Orthopaedics Flashcards
risk factors for OA?
- obesity
- ageing
- occupation
- trauma
- female sex
- FHx
which joints are commonly affected in OA?
- hips
- knees
- sacro-iliac joints
- DIPs
- CMC (base of thumb)
- wrist
- cervical spine (gives spondylosis)
LOSS: X-ray changes seen in OA?
- loss of joint space
- osteophytes
- subarticular sclerosis
- subchondral cysts
presentation of OA?
- joint pain and stiffness
- worse after use / end of the day
- bulky enlargement of joints
- reduced ROM
- crepitus on passive movement
- effusion around joint
hand signs seen in OA?
- bouchard’s nodes (PIPs)
- heberden’s nodes (DIPs)
- squaring of base of thumb
- weak grip
- reduced ROM
how is OA diagnosed?
does not require investigations if:
- age >45
- typical pain w/ activity
- no morning stiffness (or <30 mins of morning stiffness)
management of OA?
- weight loss
- physiotherapy
- OT
- orthotics (e.g. knee braces)
- analgesia
- joint replacement if severe
analgesic ladder in OA?
- PO paracetamol + topical NSAIDs
- add PO NSAIDs (+PPI)
- weak opioids (codeine)
other options:
- topical capsaicin
- intra-articular steroids
what is a compound fracture?
when skin is broken and the broken bone is exposed to air
what is a stable fracture?
when sections of the bone remain in alignment at the fracture
what is a pathological fracture?
when a bone breaks due to underlying bone abnormalities
give some causes of pathological fractures
- bony mets
- osteoporosis
- paget’s disease of the bone
which cancers commonly metastasise to the bone?
- prostate
- renal cell carcinomas
- thyroid
- breast
- lung
what is a colle’s fracture?
transverse fracture of the distal radius
which fractures are commonly caused by falling onto an outstretched hand (FOOSH)?
- colle’s fracture
- scaphoid fracture
main complication of a pelvic fracture?
intra-abdominal bleeding, which can then cause shock / death
common sites for pathological fractures?
- femur
- vertebral bodies
what is a fragility fracture? commonest cause?
- fracture due to weakness of bone
- osteoporosis
what is the FRAX score?
risk of fragility fracture within the next 10 years
how can bone mineral density be calculated?
using a DEXA scan
which T-score range means there is osteopenia?
-1 to -2.5
which T-score range means BMD is normal?
more than -1
T-score range indicating osteoporosis?
less than -2.5
WHO criteria for severe osteoporosis?
T-score < -2.5 AND a fracture
prophylaxis of fragility fractures in osteoporotic pts?
- calcium
- vitamin D
- bisphosphonates (e.g. alendronic acid)
key side effects of bisphosphonates?
- reflux, oesophageal erosions
- atypical fractures (esp femoral)
- osteonecrosis of the jaw
- osteonecrosis of external auditory canal
what are the 3 key goals of fracture management?
- pain management
- mechanical alignment
- relative stability (so that it can heal)
2 methods of achieving mechanical alignment in fracture management?
- closed reduction (manipulating the limb)
- open reduction (surgery)
complications of a fracture?
- damage to local structures (e.g. tendons, muscle)
- haemorrhage
- compartment syndrome
- fat embolism
- VTE
presentation of fat embolism syndrome?
- onset is typically 24-72h after a fracture
- respiratory distress
- petechial rash
- cerebral involvement
how can fat embolism syndrome be prevented?
by operating early on the fracture
RFs for hip fracture?
- ageing
- osteoporosis
how can hip fractures be classified?
- intra-capsular
- extra-capsular
describe the capsule of the hip joint
- strong fibrous structure
- surrounds head and neck of femur
- attaches to rim of acetabulum on pelvis and intertrochanteric line
describe the blood supply to the hip joint
- retrograde blood supply
- supplied by medial and lateral circumflex femoral arteries
when is a hip fracture classed as intra-capsular?
- when there is a break in the femoral neck
- this is proximal to the intertrochanteric line
how can intra-capsular hip fractures be classified?
using Garden classification:
- grade I = incomplete
- grade IV = fully displaced
main complication of an intra-capsular hip fracture?
avascular necrosis
how can non-displaced intra-capsular hip fractures be treated?
interval fixation with screws
describe a hemiarthroplasty. which pts get offered this?
- replacing the head of femur but leaving the acetabulum in place
- pts with limited mobility / lots of comorbidities
describe a total hip replacement. which pts get offered this?
- replacing both head of femur and acetabulum
- pts who are independently mobile and fit for surgery
which is worse: extra-capsular or intra-capsular hip fracture?
- intra-capsular
- in an extra-capsular fracture, the blood supply is left intact, so the head of femur doesn’t need to be replaced
types of extra-capsular hip fracture?
- intertrochanteric
- subtrochanteric
how are intertrochanteric (extra-capsular) hip fractures treated?
dynamic sliding hip screw
how are subtrochanteric (extra-capsular) hip fractures treated?
intramedullary nail
presentation of a hip fracture?
- typically pts aged >60
- groin / hip pain
- might radiate to knee
- shortened, abducted and externally rotated leg
investigations for a hip fracture?
- initially: X-ray in 2 views (AP and lateral)
- MRI / CT where X-ray is -ve but fracture still strongly suspected
what might be seen on an AP view X-ray in a hip injury? what does this indicate?
- shenton’s line
- indicates #NOF
management of a hip fracture?
- analgesia
- X-ray in 2 views
- VTE risk assessment
- bloods, ECG for pre-op assessment
- operate within 48h (improves prognosis)
- orthogeriatrics input
recovery time following a hip replacement surgery?
pt should be able to bear weight immediately!
what is compartment syndrome?
when the pressure in a fascial compartment is too high
what is acute compartment syndrome? how is it treated?
- surgical emergency usually associated with an acute injury or bleed
- needs fasciotomy
5Ps: presentation of acute compartment syndrome?
- typically following bone fracture / crush injury
- pain
- paraesthesia
- pale
- pressure (high)
- paralysis (late, worrying)
describe the pain felt in acute compartment syndrome. which areas might be affected?
- disproportionate to initial injury (fracture / crush)
- unresponsive to analgesia
- worse on passive stretching of muscles
- legs are most common, but also: forearms, feet, thighs
how can acute compartment syndrome be differentiated from acute limb ischaemia?
in compartment syndrome, pulses remain present (whereas there’s pulselessness in ALI)
investigation for acute compartment syndrome?
needle manometry (measures pressure in compartment)
initial management of acute compartment syndrome?
- escalate to ortho
- remove external dressings / bandages
- elevate leg to heart level
- maintain good BP, avoid hypotension
definitive management of acute compartment syndrome?
emergency fasciotomy
what is chronic compartment syndrome typically associated with?
exertion
presentation of chronic compartment syndrome?
- pain
- numbness
- paraesthesia
- typically comes on with exercise
- goes away with rest
investigation and management of chronic compartment syndrome?
- needle manometry
- may offer fasciotomy
what is osteomyelitis?
bacterial infection of the bone and bone marrow
how can ostemyelitis occur?
- haematogenous spread of a bacterium
- direct contamination (e.g. from a fracture / surgery)
commonest causative organism of osteomyelitis?
staph aureus
RFs for osteomyelitis?
- open fractures
- orthopaedic surgery, esp with prosthetic joints
- PAD
- IVDU
- immunosuppression
presentation of osteomyelitis?
- fever
- pain
- tenderness
- erythema
- swelling
- lethargy
- nausea
- muscle aches
investigations for osteomyelitis?
- X-ray
- MRI (gold standard)
- bloods
- blood cultures
- bone cultures
signs on X-ray in osteomyelitis?
- NAD early on
- periosteal reaction
- localised osteopenia
- bone destruction
which bloods are relevant in osteomyelitis?
- WCC
- inflamm markers (CRP, ESR)
management of osteomyelitis?
- surgical debridement of infected bone / tissue
- ABx
ABx of choice in acute osteomyelitis? how long is the course of these?
- flucloxacillin for 6w
- may add on rifampicin / fusidic acid after week 2
- clindamycin if pen allergic
ABx of choice in osteomyelitis caused by MRSA?
either: vancomycin or teicoplanin
how long are ABx taken for in chronic osteomyelitis?
3+ months
management of osteomyelitis caused by an infected prosthetic joint?
complete revision surgery (replacing the joint again)
what are the 3 types of bone sarcoma?
- osteosarcoma
- chondrosarcoma
- ewing sarcoma
which organism causes kaposi’s sarcoma? which condition is this associated with?
- HHV 8
- end-stage HIV (it is an AIDS-defining illness)
commonest type of bone Ca?
osteosarcoma
presentation of sarcoma?
- soft tissue lump which is growing / painful
- bone-swelling
- persistent bone pain
investigations for sarcoma?
- X-ray if bony lump / bone pain
- USS if soft tissue lump
- CT / MRI to visualise and look for spread
- biopsy and histology
which CT scan is particularly important in sarcoma? why?
- CT thorax
- lungs are most common place for it to spread to
management of sarcoma?
- MDT care
- surgical resection
- radiotherapy
- chemo
- palliative
what is sciatica?
irritation of the sciatic nerve
how long does acute lower back pain last?
should improve within 1-2 weeks
average recovery time after sciatica?
4-6 weeks
causes of mechanical back pain?
- muscle / ligament sprain
- facet joint dysfunction
- sacroiliac joint dysfunction
- herniated disc
- spondylolisthesis
- scoliosis
- degenerative changes
causes of neck pain?
- muscle / ligament strain
- torticollis
- whiplash
- cervical spondylosis
describe torticollis
- waking up with unilateral neck stiffness
- caused by muscle spasm
red flag causes of back pain?
- spinal fracture
- cauda equina
- spinal stenosis
- ankylosing spondylitis
- spinal infection
causes of back pain not directly related to the spine?
- pneumonia
- ruptured aortic aneurysm
- renal stones
- pyelonephritis
- pancreatitis
- prostatitis
- PID
- endometriosis
which nerves make up the sciatic nerve?
L4 - S3
presentation of sciatica?
- unilateral buttock pain
- shoots down the leg, “electric shock” like
- pins and needles
- numbness
- motor weakness
- loss of reflexes
main causes of sciatica?
things that compress the lumbosacral nerve:
- herniated disc
- spondylolisthesis
- spinal stenosis
what is spondylolisthesis?
when one vertebra is out of alignment with the rest
why is bilateral sciatica a red flag?
could indicate cauda equina syndrome
findings O/E in back pain? what could each of these indicate?
- localised tenderness (spinal fracture, Ca)
- bilateral motor / sensory loss (cauda equina)
- bladder distension (cauda equina)
- reduced anal tone on PR (cauda equina)
what test can be performed to diagnose sciatica?
sciatic stretch test
describe the sciatic stretch test
- pt lies on their back with leg straight
- lift one leg from ankle to 90 degs
- then dorsiflex ankle
- if sciatic pain felt, then there’s sciatica
- symptoms improve on flexing knee
main cancers that metastasise to bone?
- prostate
- kidney
- thyroid
- breast
- lung
investigations for spinal fractures?
X-ray / CT spine
investigation for suspected cauda equina?
emergency MRI (within hrs of presentaion)
investigations for suspected ankylosing spondylitis?
- inflamm markers (CRP, ESR)
- X-ray of spine and sacrum
- MRI spine
key finding on X-ray in late-stage ankylosing spondylitis?
- “bamboo spine”
- everything is fused together
finding on MRI spine in early stages of ankylosing spondylitis?
bone marrow oedema
analgesic ladder for lower back pain?
- NSAIDs (first line)
- codeine
- BDZs (diazepam) for spasms
- specifically avoid opioids and neuropathic agents
management of sciatica?
- initially same as acute lower back pain
- either amitriptyline or duloxetine (NOT gabapentin)
- epidural corticosteroid injections
- radiofrequency denervation
- spinal decompression
pathophysiology of cauda equina syndrome?
compression of nerve roots at L2 - L3
causes of cauda equina syndrome?
- herniated disc
- tumours (primary or mets)
- spondylolisthesis
- abscess
- trauma
red flags for cauda equina syndrome?
LMN signs:
- saddle anaesthesia
- loss of sensation in bladder and rectum
- urinary retention / incontinence
- faecal incontinence
- bilateral sciatica
- bilateral / severe motor weakness
- reduced anal tone on PR
management of cauda equina syndrome?
- immediate hosp admission
- emergency MRI spine
- neurosurg referral (for lumbar decompression)
key features of metastatic spinal cord compression to differentiate it from cauda equina syndrome?
- UMN signs instead of LMN
- back pain that is worse on coughing or straining
management of metastatic spinal cord compression?
- high-dose dexamethasone
- analgesia
- surgery
- radio
- chemo
pathophysiology of spinal stenosis?
narrowing of spinal canal causing compression on spinal cord and nerve roots
typical age group affected by spinal stenosis?
pts aged 60+
causes of spinal stenosis?
- congenital
- degenerative changes
- herniated disc
- spinal fracture
- spondylolisthesis
presentation of spinal stenosis?
- cauda equina syndrome if severe
- lower back pain
- buttock, leg pain
- leg weakness
investigations for spinal stenosis?
- MRI = first line
- ABI to r/o PAD
management of spinal stenosis?
- weight loss if needed
- analgesia
- physio
- decompression surgery
which nerve is affected in meralgia paraesthetica?
lateral femoral cutaneous nerve
presentation of meralgia paraesthetica?
- NO motor symptoms!!!
- burning
- numbness
- pins and needles
- cold sensations
- localised hair loss
… all on upper outer thigh region
which action worsens the pain felt in meralgia paraesthetica?
hip extension
presentation of trochanteric bursitis? (incl. O/E)
- middle-aged pt with outer hip pain
- radiates down thigh
- no swelling
- positive trendelenburg test
- pain on resisted abduction
what are the 4 ligaments of the knee?
- anterior cruciate
- posterior cruciate
- lateral collateral
- medial collateral
presentation of a meniscal tear?
- young pt who heard a “pop” after doing a twisty movement
- pain, referred to hip / back
- swelling
- stiffness, reduced ROM
- knee locking
- knee “gives way”
tests done O/E for suspected meniscal tear?
- mcmurray’s test
- apley grind test
according to the ottawa rules, which pts require a knee x-ray (after a knee injury)?
high suspicion of bony fracture in these cases:
- aged 55+
- patellar tenderness
- fibular head tenderness
- can’t flex past 90 degs
- can’t weigh bear
investigation for meniscal tear?
- MRI knee
- arthroscopy of knee = gold standard
management of meniscal tear?
- conservative
- NSAIDs for pain relief
- keyhole (arthroscopic) surgery
RICE: conservative management of meniscal tears?
- rest
- ice
- compression
- elevation
demographic affected by osgood-schlatter disease?
pts aged 10-15 years old
pathophysiology of osgood-schlatter disease?
inflamed tibial tuberosity, where patellar tendon goes in
presentation of osgood-schlatter disease?
- unilateral, gradual onset knee pain
- visible / palpable lump at tibial tuberosity (permanent!)
management of osgood-schlatter disease?
- rest
- ice
- NSAIDs
where do baker’s cysts present?
popliteal fossa
conditions associated with baker’s cysts?
- meniscal tears
- OA
- RA
- knee injuries
presentation of baker’s cyst?
- pain / discomfort / pressure in popliteal fossa
- palpable lump
- reduced ROM if large
differentials for a lump in the popliteal fossa?
- baker’s cyst
- DVT
- abscess
- popliteal artery aneurysm
- ganglion cyst
- lipoma
- varicose vein
- tumour
investigation for baker’s cyst?
USS knee
which bone does the achilles tendon attach to?
calcaneus bone
RFs for achilles tendinopathy?
- sports (basketball, tennis, athletics)
- RA, ank spon
- DM
- high cholesterol
- fluoroquinolones (cipro, levofloxacin)
presentation of achilles tendinopathy?
- pain / stiffness in achilles tendon
- brought on by activity
- nodule on palpation
- swelling
management of achilles tendinopathy?
- exclude tendon rupture using simmonds calf squeeze test
- conservative (rest, ice, anaglesia)
- physio
- orthotics (shoe insoles)
- extracorporeal shock-wave therapy (ESWT)
- surgery to remove nodules
presentation of achilles tendon rupture?
- sudden onset achilles / calf pain
- snapping sound / sensation
- feeling like someone hit them in the back of the leg :(
- positive simmonds calf squeeze test (no plantar flexion)
how is achilles tendon rupture diagnosed?
on USS
management of achilles tendon rupture?
- urgent review by ortho
- rest, immobilisation, ice, elevation, pain relief
- VTE prophylaxis
- non-surgical (boot)
- surgical (tendon reattachment)
presentation of plantar fasciitis?
- pain in heel of foot
- worse with pressure (walking, standing for a long time)
- tender on palpation
management of plantar fasciitis?
- rest
- ice
- NSAIDs
- physio
how can the extent of deformity in a bunion be assessed?
weight-bearing X-ray
commonest cause of shoulder pain and stiffness?
adhesive capsulitis
