Orthopaedics Flashcards
What is a compound fracture?
Skin is broken and the broken bone is exposed to the air
What is a Colle’s fracture?
Transverse fracture of the distal radius
Distal portion displaces posteriorly (upwards)
‘dinner fork deformity’
Fall onto an outstretched hand FOOSH
What bones have vulnerable blood supplies?
Scaphoid
Femoral head
Humeral head
Talus, navicular and fifth metatarsal in the foot
What is the Weber classification?
For fractures of the lateral malleolus, described in relation to the distal syndesmosis (fibrous join between the tibia and fibular), which is essential for stability and function of the ankle joint
Type A - below the ankle joint - syndesmosis intact
Type B - at the level of the ankle joint - syndesmosis intact or partially torn
Type C - above the ankle joint - syndesmosis is disrupted
What cancers metastasise to bone?
Prostate
Renal
Thyroid
Breast
Lung
What are the key side effects of bisphosphonates?
Reflux and oesophageal erosions
Atypical fractures
Osteonecrosis of the jaw
Osteonecrosis of the external auditory canal
How do you prevent the side effects of bisphosphonates?
Taken on an empty stomach sitting upright for 30 mins before moving or eating to prevent this
What is an alternative to bisphosphonates when they can’t be used?
Denosumab
What is a fat embolism?
Fat globules released into the circulation following a fracture, often of the long bones
This can cause a systemic inflammatory response
Presents 24-72 hrs after
Use Gurd’s criteria for diagnosis
What is Gurd’s major criteria for fat embolism syndrome
Respiratory distress
Petechial rash
Cerebral involvement
What are the two types of hip fractures?
Intra-capsular
Extra-capsular
What are the two arteries that supply the femoral head?
Medial and lateral circumflex femoral arteries
Join the femoral neck just proximal to the intertrochanteric line
How do you know whether a fracture is intra-capsular or extra-capsular?
Break in the femoral neck, within the capsule
Area proximal to the intertrochanteric line
What is the Garden classification for intra-capsular neck of femur fractures?
Grade I - incomplete fracture and non-displaced
Grade II - complete fracture and non-displaced
Grade III - partial displacement (trabecular are at an angle
Grade IV - full displacement (trabeculae are parallel)
Grade III and IV have disrupted blood supply
How do you decide between a hemiarthroplasty or a total hip replacement in avascular necrosis of the femoral head?
Hemiarthroplasty - for those with limited mobility or significant co-morbidities
Total hip replacement - patients who can walk independently
Which type of hip fracture can disrupt the blood supply to the femur?
Intra-capsular
How are non-displaced intra-capsular #NOF treated?
Internal fixation with screws
How are intertrochanteric fractures treated?
Dynamic hip screw through the neck into the head of the femur
Plate with barrel that holds the screw is screwed to the outside of the femoral shaft
How are subtrochanteric fractures treated?
Intramedullary nail - through the greater trochanter into the central cavity of the shaft of the femur
How do hip fractures present?
History of older patient with a fall
Pain in the groin or hip, which may radiate to the knee
Not able to weight bear
Shortened, abducted and externally rotated leg
What is Shenton’s line?
Seen on AP x-ray
One continuous curving line formed by the medial border of the femoral neck and continues to the inferior border of the superior pubic ramus.
Disruption = #NOF
What can cause compartment syndrome?
Bone fractures
Crush injuries
What are the 5 Ps of acute compartment syndrome?
Pain - disproportionate, worsened by passive stretching
Paraesthesia
Pale
Pressure - high
Paralysis (a late and worrying feature)
What can be used to measure compartment pressure?
Needle manometry
What is the management for acute compartment syndrome?
Escalation
Remove external dressings or bandages
Elevating the leg to heart level
Maintaining good BP
Emergency fasciotomy
What are the features of chronic compartment syndrome?
Associated with exertion, improves with rest
Pain, numbness and paraesthesia
What are the three types of canal stenosis?
Central stenosis - central spinal canal
Lateral stenosis - nerve root canals
Foramina stenosis - intervertebral foramina
What can cause the spinal canal to narrow?
Congenital
Degenerative changes in the facet joints, discs and bone spurs
Herniated discs
Thickening of the ligaments lava or posterior longitudinal ligament
Spinal fractures
Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
Tumours
How does lumbar central stenosis present?
Intermittent neurogenic claudication on standing or walking, worse standing straight
Lower back pain
Buttock and leg pain
Leg weakness
What type of spinal stenosis causes sciatica?
Lateral stenosis and foramina stenosis
How do you differentiate between spinal stenosis and PAD?
In PAD, the peripheral pulses or the ankle-brachial pressure index are abnormal
What is the management for spinal stenosis?
Exercise and weight loss
Analgesia
Physiotherapy
Decompression surgery if above fail (this has variable results)
What is a laminectomy?
Removal of part or all of the lamina from the affected vertebra.
What is a meniscal tear?
Knee injury involving the cartilage in the knee joint
What are the menisci of the knee?
Medial and lateral meniscus in between the femur and the tibia.
Shock absorber
Distribute weight
Stabilise joint
How do meniscal tears often occur?
Twisting movements in the knee
What is the presentation of meniscal tear?
Pop sound or sensation
Pain
Swelling
Stiffness
Restricted range of motion
Locking of the knee
Instability of the knee ‘giving way’
Localised tenderness on the joint line
Swelling
Restricted range of motion
What is McMurray’s test?
Lying supine, knee is flexed
Internal rotation of the tibia and outward pressure to the inside of the knee, extend the knee - pain or restriction = lateral meniscal damage
Vice versa for medial
Not used due to risk of worsening tear
What is Apley Grind Test?
Patient prone with knee flexed to 90 degrees
Downward pressure applied through the leg into knee, tibia is internally and externally rotated at the same time. Pain suggests meniscal damage.
Not used due to risk of worsening tear
What are the Ottawa knee rules?
X ray of acute knee injury if any of the following:
Age 55 or above
Patella tenderness with no tenderness elsewhere
Fibular head tenderness
Cannot flex knee to 90 degrees
Cannot weight bear
What is the gold standard investigation for meniscal tears?
Arthroscopy
What are the features of achilles tendinopathy?
Damage
Swelling
Inflammation
Reduced function
What are the two types of achilles tendiopathy?
Insertion tendinopathy: within 2cm of insertion point of the calcaneus
Mid-portion tendinopathy: 2-6cm above the insertion point
What are risk factors for achilles tendinopathy?
Sports
Inflammatory conditions
Diabetes
Raised cholesterol
Fluroquinolone antibiotics (e.g. ciprofloxacin and levofloxacin)
How does achilles tendinopathy present?
Gradual onset of pain/aching in achilles or heel
Stiffness
Tenderness
Swelling
Nodularity
How do you exclude achilles tendon rupture?
Simmonds calf squeeze test
Prone/kneeling with feet hanging freely
Intact achilles = plantar flexion
Ruptured = none
Management of achilles tendinopathy
Rest
Ice
Analgesia
Physio
Orthotics
Extracorporeal shock-wave therapy
Surgery to remove nodules or adhesions
How does achilles rupture present?
Sudden onset of pain in the achilles or calf
Snapping sound/sensation
Feeling as though something has hit them in the back of the leg
What are the signs of achilles rupture?
Dorsiflexed when dangled
Tenderness
Palpable gap
Weakness of plantar flexion
Unable to stand on tiptoes
Positive Simmonds’ calf squeeze test
How do you manage achilles rupture?
Non surgical: specialist boot to immobilise the ankle and with foot in full plantar flexion of the ankle - gradually altered to move from full plantar flexion to a neutral position (6-12 weeks)
Surgical is basically the same but with surgical reattachment of the achilles
What is the presentation of plantar fasciitis?
Gradual onset of pain on the plantar aspect/heel
Worse with pressure and tender to palpation
Steroid injections can be used in plantar fasciitis, but what are they at risk of causing?
Pain
Rupture
Fat pad atrophy under the heel
What is the specialist management of plantar fasciitis?
Extracorporeal shockwave therapy
Surgery
What can cause fat pad atrophy?
Age
Inflammation due to repetitive impact
What are the symptoms of fat pad atrophy?
Pain and tenderness over the heel
Worse with activity and barefoot on hard surfaces
Very similar to plantar fasciitis - can be seen on US
What is Morton’s neuroma?
Dysfunction of the nerve in the inter metatarsal space
Irritation of the nerve relating to the biomechanics of the foot
High heels or narrow shoes can irritate it further
What are the typical symptoms of Morton’s neuroma?
Pain at the location of the lesion
Sensation of a lump in the shoe
Burning/numbness/pins and needles
What are the tests for Morton’s neuroma?
Deep pressure on it
Metatarsal squeeze test with pressure on the affected area
Mulder’s sign: painful click on manipulation of the metatarsal heads to rub the neuroma.
What is the management of Morton’s neuroma?
Adapting activities
Insoles
Analgesia
Weight loss
Steroid injections
Radiofrequency ablation
Surgery
What is the medical name for bunions?
Hallux valgus
How are bunions managed?
Wide, comfortable shoes with bunion pads
Surgery to realign the bones
What is seen on joint fluid aspiration in gout?
No bacterial growth
Needles shaped crystals which are negatively birefrigent of polarised light
Crystals are made of monosodium urate
Why should you not start allopurinol during an acute flare of gout?
Can worsen it
What is the medical name for frozen shoulder?
Adhesive capsulitis
What are the key risk factors for adhesive capsulitis (frozen shoulder)?
Middle age
Diabetes
Trauma,surgery or immobilisation (although it can occur spontaneously without any trigger)
What is the pathophysiology in adhesive capsulitis?
Inflammation and fibrosis in the joint capsule lead to adhesions, restricting movement
What are the phases in adhesive capsulitis?
Painful phase - shoulder pain worse at night
Stiff phase - shoulder stiffness and affects both active and passive
Thawing phase - gradual improvement in stiffness and return to normal.
6 months to a year in each phase but 50% have persistent symptoms
What differentials do you need to think about in adhesive capsulitis?
Supraspinatus tendinopathy
Acromioclavicular joint arthritis
Glenohumeral joint arthritis
Septic arthritis
Inflammatory arthritis
Malignancy (e.g. osteosarcoma or bony metastases)
If preceded by trauma or injury:
Shoulder dislocation
Fractures (E.g. proximal humerus, clavicle or scapula)
Rotator cuff tear
What test is used to assess for supraspinatus tendiopathy?
The empty can test with pressure down on the arm and resistance
What tests are used to assess for acromioclavicular joint arthritis?
Tenderness to palpation of the AC joint
Worse at extremes of the shoulder abduction about 170 degrees
Positive scarf test
What is the management of adhesive capsulitis?
Continue movement, physio
Analgesia
Intra-articular steroid injecitons
Hydrodilation injections to stretch the capsule
Surgery can also be used to either forcefully stretch the capsule or to cut the adhesions
What are the four muscles of the rotator cuff?
SITS
Supraspinatus - abducts the arm
Infraspinatus - externally rotates the arm
Teres minor - externally rotates the arm
Subscapularis - internally rotates the arm
How does rotator cuff tears present?
Shoulder pain and weakness with specific movements
What is the management for rotator cuff tears?
Usually surgery unless unfit for surgery
What is subluxation?
Partial dislocation of the shoulder
What is the name of the socket in the shoulder joint?
Glenoid cavity of the scapula
What type of dislocation are the majority of shoulder dislocations?
Anterior dislocations - the arm is forced backwards whilst abducted and extended at the shoulder
What are posterior dislocations of the shoulder associated with?
Electric shocks and seizures
What associated damage can happen during shoulder dislocation?
Glenoid labrum (cartilage) tear
Bankart lesions (anterior tears of the labrum)
Hill-Sachs lesions - compression fractures of the posterolateral part of the head of the humerus
Axillary nerve damage*** key - comes from C5 and C6 nerve roots
Fractures of the humerus, scapula or clavicle
Rotator cuff tears
What are the signs of axillary nerve damage?
Loss of sensation in the regimental badge area over the lateral deltoid
Motor weakness int he deltoid and tires minor muscles
What do you need to assess in someone with a shoulder dislocation
Fractures
Vascular damage (e.g. pulses, CRT, pallor)
Nerve damage
What is the apprehension test?
Tests for shoulder instability, particularly in the anterior direction
Patient lies supine
Shoulder abducted to 90 degrees with elbow flexed to 90 degrees
Shoulder slowly externally rotated
As it approaches 90 degrees, the patient becomes anxious and apprehensive, even thought there is no pain
Why should you try to relocate the shoulder as soon as safely possible?
Muscle spasm occurs over time making it harder and increasing risk of neuromuscular injury during relocation
What happens in bursitis?
Thickening of synovial membrane and increased fluid production due to inflammation
Inflammation can be caused by: friction/repetitive movements, leaning on elbow, trauma, inflammatory conditions, infections
How does olecranon bursitis present?
Young/middle aged man with an elbow that is:
Swollen
Warm
Tender
Fluctuant
What characteristics of an activity increase risk of repetitive strain injury?
Small repetitive activities
Vibration
Awkward positions
What are the symptoms of repetitive strain injury?
Pain, exacerbated by using the associated joints, muscles and tendons
Aching
Weakness
Cramping
Numbness
The tendon that inserts into medial epicondyle acts to do what?
Flex the wrist
The tendon that inserts into the lateral epicondyle acts to do what?
Extend the wrist
Lateral epicondylitis is often called what?
Tennis elbow
What is Mill’s test?
Stretching the extensor muscles of the forearm while palpating the lateral epicondyle.
Elbow extended, forearm pronated and wrist flexed.
(showing off an engagement ring position)
Testing for tennis elbow
What is Cozen’s test?
Elbow extended, forearm pronated, wrist deviated in the direction of the radius, hand in a fist
Pressure on the lateral epicondyle and resistance to the back of the hand while patient extends the wrist
What is the medical name for golfer’s elbow?
Medial epicondylitis
Pain often radiates down forearm and leads to weakness in grip strength
What is the golfer’s elbow test?
Elbow extended, forearm supinated, wrist and fingers extended
Pressure on the medial epicondyle
What is De Quervain’s tenosynovitis?
Swelling and inflammation of the tendon sheaths in the wrist. Affects:
Abductor pollicis longus tendon
Extensor pollicis brevis tendon
Type of repetitive strain injury
What is the presentation of Der Quervain’s tenosynovitis?
Pain in the radial aspect of the wrist
- radiating to the forearm
- aching
- burning
- weakness
- numbness
- tenderness
Bilateral is often due to new parents lifting up baby
What is the pathophysiology of De Quervain’s tenosynovitis?
Repetitive movement of the tendon sheaths of APL and EPB tendons under the extensor retinaculum cause inflammation of the tendon sheaths
What is Finkelstein’s test for De Quervain’s tenosynovitis?
Patient makes a fist with thumb inside fingers
Fist is abducted to ulnar sign
What is the medical name for trigger finger?
Stenosing tenosynovitis
What is the pathophysiology of trigger finger?
Thickening of the tendon or tightening of the sheath in finger tendons.
Causes pain, stiffness, catching
Often affects First annular pulley at the MCP joint - often by a nodule which gets stuck in the bent position
What is the presentation for trigger finger?
Painful and tender finger usually at MCP joint
Doesn’t move smoothly
Makes a popping or clicking sound
Gets stuck in flexed position
Worse in mornign
What are the risk factors for trigger finger?
Middle age
Women
Diabetes
What is the management for trigger finger?
Splinting
Steroid injections
Surgery
