Orthopaedics Flashcards
FRACTURES
i) what are growth plates? what do they sit between? at what age do they dissapear and what do they become?
ii) which type of fracture are children more likely to have? how are growth plate fractures graded?
iii) what is the first thing that needs to be done? which two ways may this be achieved?
iv) what is the second thing that needs to be done? name four ways the bone can be fixed in place?
v) what is the first line pain relief? whats second line? which two pain relief drugs are not used in children?
i) epiphyseal plates at the end of long bones that allows bones to grow in length - made of hyaline cartilge and sit etween epiphysis and metaphysis
eph and meta fuse during teenage years and epiph lines are left
ii) more likely to have greenstick fracture (one side of the bone breaks and the other side stays in tact)
growth plate fraactures are graded using salter harris classification
iii) first need to mechanically align - by closed reduction (manipulation of the joint), open reduction (surgery)
iv) then need to provide relative stability to allow healing - fix bone in correct position while it heals by external casts, k wires, intra medullary nails/witres, screws
v) first line paracetamol and ibuprofen
second line morphine
dont use codeine and tramadol due to unpredictable mechanism
HIP PAIN
i) name three common causes in 0-4 years? name three common causes 5-10 years? name three causes 10-16 years?
ii) name 6 red flags for hip pain
iii) name five criteria for urgent referral?
iv) what two things can inflammatory markers show? what two things can xray diagnose? what is joint aspiration used to dx? what is MRI used to dx?
i) 0-4 - septic arthritis, dev dysplasia of hip, transient synovitis
5-10yrs - septic arth, transient synovitis, perthes disease
10-16yrs - spetic arth, slipped uper fem epiphysis (SUFE), juvenile idiopathic arthritis
ii) red flags - <3yrs, fever, waking at night, weight loss, anorexia, night sweats, fatigue, persistent pain, stiffness in am, swollen hot joint
iii) urgent refer - <3yrs, >9 with restricted hip, not able to weight bear, evidence of NV compromise, severe pain, abuse suspicion
iv) inflammatory markers raised in juvenile idiopathic arth or septic arth
xray - dx fractures or SUFE
US - joint effusion
joint aspiration - septic arth
MRI for osteomyelitis
SEPTIC ARTHRITIS
i) what is it? who is it most common in? what is it a common complication of?
ii) which joint is most commonly affected? name four symptoms what maay be seen?
iii) what is the most common causative organism? name two other bac that can cause it?
iv) name three DDs? what should first be done for any suspicion of septic arth?
v) what should be done prior to giving abx? what type of abx should be given initially? how long are abx continued for once dx confirmed? what is done in severe cases?
i) infection inside a joint most common in children under 4 years
common compliction of joint replacement
ii) most common in knee or hip
rapid onset hot/swollen/painful, refusing to weight near, stiff with reduced range of motion, systemic symp eg fever, lethargy
iii) staph aureus or neiss gonnorea, group A strep (strep pyog), haemoph influenza, e coli
iv) transient synovitis, perthes disease, slipped upper fem ephyphisis, juvenile idiopathic arth
v) aspirate joint before abx where possible and send for gram stain, crystal microscopy, culture and abx
give IV abx until microbial sensitivies are known and continue abx for 3-6 weeks
severe - surgical drainage and washout to clear the infection
TRANSIENT SYNOVITIS
i) what is it caused by? between which age is it common? what infection is it commonly associated with? do pts present with a fever?
ii) name three symptoms? will they be systemically well?
iii) what should be done for general management? what needs to be ruled out?
iv) what safety net advice shold be given? when should they be followed up?
v) how long do symptoms usually take to improve? resolve?
i) transient irritation and inflammtion of synovial membrne common between 3-10 years
often assoc with viral URTI and patients do not typically have a fever
ii) limp, refusal to weight bear, groin or hip painm mild low grade temp
will be systemically well
iii) general mx is symptomatic - analgesia
need to rule out septic arth
iv) safety net - if they develip a fever
follow up at 48 hrs and 1 week to ensure symptoms fully resolve
v) improve in 24-48 hours and resolve in 1-2 weeks
PERTHES DISEASE
i) what is it? what area of the bone does it affect? which ages is it most common? which sex is it most common?
ii) what happens to the joint over time? what is the main complication?
iii) name four presenting features? will there be a history of trauma?
iv) what is the imaging of choice? name three other investigations that may be done?
v) what is initial mx when young andd less severe? (3) what can be done to retain range of movement? how is healing assesed? what can be done in severe cases?
i) disruption of blood flow to the femoral head causing avascular necrosis of the bone (affecting ephiphysis of femur)
common between 5-8 years and in boys
ii) over time there is revasc/neovasac and healing of the femoral head
main complication is soft and deformed femoral head > early hip OA
iii) pain in hip/groin, limp, restricted hip movement, referred pain to the knee
no hx of trauma (if trigg by trauma think SUFE)
iv) initial ix is an xray (can be normal)
bloods (usually normal), technetium bone scan, MRI scan
v) conservative if less severe - maintain healthy position and alignment of joint with bed rest, traction, crutches, analgesia
physio to retain range of movment
regular x rays to assess healing
surgery if severe or not healing
SLIPPED UPPER FEMORAL EPIPHYSIS
i) what happens? who is it most common in? (2)
ii) what may there be a history of that triggers the symptoms? name four presenting symptoms?
iii) which position will the patient prefer to keep their hip in? which movement is most likely to be restricted?
iv) what is the imaging of choice? name three other scans that may be done?
v) how is it managed?
i) head of the femur is displacced along the growth plate
most common in 8-15yrs, boys, obese
ii) minor trauam may trigger symptoms
hip/groin/thigh/knee pain, restricted hip movement, paainful limp
iii) prefer to keep hip in external rotation and limited movement espec restricted internal rotation
iv) imaging = xray
may do bloods, tecnetium bone scan, CT scan, MRI scan
v) needs to be managed with surgery
OSTEOMYELITIS
i) what is it? where does it typically occur? wht is the most common bacteria? what is chronic osteomyelitis?
ii) name two ways a bacteria may be introduced to the joint? under what age is it most common? name four risk factors
iii) name three signs or symptoms?
iv) what imaging is usually done initially? what imaging is best to establish aa diagnosis? what will bloods show? what other test needs to be done?
v) how is it treated? what may also need to be done?
i) infection in bone and bone marrow occuring at the metaphysis of long bones
most common bac is staph aureus
chronci OM is deep seated slow growing infection
ii) directly to bone via an open fracture or through the blood
more common in boys under 10
RF are open bone fracture, orthopaedic surgery, immunocomp, SCA, HIV, TB
iii) px with refusal to weight beaar, pain, swelling, tenderness
may be afebrile or have a low frade fever
iv) do x ray initially
MRI is best for establishing a dx
bloods will show raised inflam markers and WBC
also do culture to establish causative
v) treat with prolonged abx
may need surgery for drainage and debridement
OSTEOSARCOMA
i) when does it usually present? which bone is it most common in? name two other bones?
ii) what is the most common px feature? when does this happen? name two other symptoms
iii) what imaging needs to be done urgently? what may be seen? what is the sun burst appearance?
iv) what blood marker may be raised?
v) how is it managed? what is the most common complication?
i) presents in adolescents 10-20years
usually affects femur (can also affect tibia, humerus)
ii) px feature is persistent bone pain which can be worse at night (can disturb or wake from sleeo)
also get bone swelling, palpable mass, restricted joint movement
iii) do urgent x ray within 48hours for children px with unexplained bone pain or swelling
may show a poorly defined lesion which destruc of normal bone and a fluffy appearance
may be a periosteal reaction - irritation of bone lining that has a sun burst appearance
iv) raised ALP
v) mx with surgical resention (often amputation), adjuvant chemo and MDT approach
TALIPES
i) what is it? what is it aka? when is it usually identified?
ii) what position is the ankle in tlaipes equinovarus? in talipes calcaneovalgus?
iii) what is the ponseti method? when is it started?
iv) what is positional talipes? what needs to be done for this?
i) fixed abnormal ankle position aka clubfoot
usually identified at birth or on newborn exam
ii) equino - plantar flexion and supination
valgus - dorsiflexion and pronation
iii) ponseti method is a way to treat without surgery
start immed after birth
foot manip towards a normal position and cast applied to hold it in position > repeat until foot in correct position
then do achilles tenotomy to relaase tension in the achilles tendon
ater tx - cast finished in a brace
iv) positional - resting position of the ankle is in planrar flexiona and supination but not fixed and there are no bony/struc abnormalities
muscles are tight around the ankle - need referal to physio and will resolve with time
DDH
i) what is it? what are the hips prone to? when is it picked up?
ii) name three risk factors? what needs to be looked for on exam? name three things that may suggest DDH?
iii) which two tests are used to test? explain each? what is another common exam finding?
iv) what is the imaging of choice? which other imaging can be done?
v) what is given to children under 6m of age? what does this do? when may surgery be done?
i) structural abnormality in hips caused by abnormal dev of fetal bones during pregnancy
leaads to potention for subluxation or dislocation > may persist to adulthood > weakness, recurrent disloc, abnormal gait, early degen changes
ii) RG are first degree family hx, breech from 36 weeks, multiple pregnancy
screen on neonatal exam at 6-8 weeks old
look for symmetry in hips, leg length, skin folds and hip movements
DDH: different leg lengths, restricted hip abduc to kne side, signific bulat restriction in abduc, diff in knee level when hips re clexed, clunking of hips on special tests
iii) ortolani and barlow test
iv) US is imaging of choice - may do x ray on older children
v) pavlik harness under 6m - can be fitted and kept on permanently > holds the femoral head in position to allow hip socket to dev a normaal shape (keeps hips flexed and anducted)
surgery can be done if harness fails or dx after 6, (then use hip cast to immobilise hip for a prolonged period)
RICKETS
i) what is defective? what does it lead to? what is the same process called in adults?
ii) what causes it? (2) which rare form of rickets is genetic? whta is the inheritance pttern?
iii) name four potential symptoms? name four bone deformities that occur?
iv) what is the lab investigation for vitamin D? what result establishes a diagnosis? which imaging is required to diagnose?
v) what is the best management? which type of feeding puts babies at higher risk of vit D defic? how can children with vit D defic be treated?
i) defective bone mineralisation leading to soft deformed bones
osteomalacia in adults
ii) caused by vitamin D or calcium deficiency
rare genetic form - herediatry hypophosphatemic rickets (x linked dominant)
iii) may not have any symptoms - may have lethargy, bone pain, swollen wrists, bone deform, poor growth, dental problems, muscle weakness
deformities - bowing of legs, knock knees, delayed teeth
iv) serum 25 hydroxyvitamin D is the lab test
results of <25nmol/L
x ray is required to dx
v) best mx is prevention
breastfed babies are more at risk as formula is fortiified with vitamin D - all breastfeeding women and children should take vitamin D supplement
treat with vitamin D (ergocalciferol) > refer to paediatrician and supplement with vit D and calcium
ACHONDROPLASIA
i) what is it the most common cause of? which gene is mutated on which chromosome? what is the inheritance pattern? what does this mutation cause?
ii) which areas of the body are most affected? is the spine affected? is intelligence and life expectancy affected?
iii) name three features of the condition? how does the skull grow? how does the cranial vault grow? what does this lead to?
iv) name four associations
v) what type of sx may be done?
i) most common cause of disproprotionate short stature
mutation in FGFR3 on chromosome 4 > auto dominant inheritance
causes abnormal function of epiphyseal plaates that restrits bone growth in length > short bones and short stature
ii) mostly affects limbs > reduced bone length (femur and humerus) spine is less affected and normal intelligence and life expectancy
iii) short difits, bow legs, disproportionate skull, foramen magnum stenosis
skull grows by endochondral ossification (affected in achon > flattened mid face and nasal bridge)
cranial vault grows and fuses by membranous ossification (unaff in achon > normal sized vault and frontal bossing - prominent forehead)
iv) assoc with recurrent otitis media due to cranial abnorms, kyphpscoliosis, spinal stenosis, OSA, obesity, foramen magnum stenosis ccna leaad to cervical cord compression and hydrocephalus
v) may do leg lengthening surgeru > cut the bone and create a gap and over time new bone will form between the two parts creating a long bone
OSGOOD SCHLATTERS DISEASE
i) what is it caused by? what is it a common cause of? what age does it usually occur? is it usuaally unilateral or bilateral?
ii) what can cause the patella ligament to pull away from bone? what does this lead to in the knee?
iii) are symptoms sudden or graduall? name three symptoms?
iv) what is initial management? name three ways this caan be done? what can be done once symptoms settle?
v) what is the patient usually left with? what is a rare complication?
i) caused by inflammation at the tibial tuberosity where patella ligament inserts > common cause of anterior knee pain
typicaally occurs in 10-15 years and more common in males
usually unilateral but can be bilateral
ii) stress from running, jumping can result in inflam of tibial epiphseal plate > multiple small avulsion fractures where pat ligament pulls away from bone > growth of tibial tuberosity > visible lump below knee (initially tender then heals and becomes hard and non tender)
iii) gradual onset - visible/palp hard nd tender lump at tib tub, anterior knee pain, exac by physical activity, kneeling or knee extension
iv) initial mx is reduce pain and inflam with reduction in physical activity, ice and NSAIDs
once symptoms settle > stretching and physio
v) patients usually left with hard boney lump on knee
rare complication is an avulsion fracture where tibial tub is sep from tibia > needs surgical intervention
OSTEOGENESIS IMPERFECTA
i) what is it and what does it result in? what protein is affected?
ii) how does it usually present? how may the joints appear? how may the sclera appear?
iii) name two medical treatments?
i) genetic condition that results in brittle bones that are prone to fracures > mutations affect the formation of collagen
ii) present with recurrent and inappropriate fractures
joints may be hypermobile and blue grey sclera
iii) bisphos to help bone desnity and vitamin D supplementation
