Orthopaedics Flashcards
At what level does the spinal cord terminate
Inferior border of L1
A patient presents to A&E with :
- Lower back pain
- Bilateral sciatica
- Urinary retention
- Faecal incontinence
- Saddle parasthesia
- Sexual dysfunction
- Bilateral weakness in the legs
What is the most likely diagnosis
Cauda equina
Does cauda equina present with LMN or UMN signs
LMN - the nerves being compressed have already exited the spinal cord
Does cervical myelopathy cause UMN or LMN signs ?
- UMN
- Myelopathy involves compression of the spinal cord and therefore compression of the nerves occurs before they leave the spine.
A patient presents with nondermatomal numbness and tingling, bilateral weakness and decreased manual dexterity and gait instability
What is the most likely differential?
Cervical myelopathy
What UMN signs are sign in cervical myelopathy ?
- Hyperreflexia
- +ve Hoffmann’s sign
- Sustained clonus
- +ve Babinski
A patient presents with unilateral arm pain, numbness and tingling in a dermatomal distribution in the hand, and weakness in specific muscle groups.
What is the most likely differential ?
Cervical radiculopathy
What is the 3 step management approach to cervical radiculopathy ?
- Mobilise and analgesia
- Selective nerve root corticosteroid injections
- Surgery (decompression +/- microdisectomy).
What medications are used in back pain caused by radiculopathy ?
- Duloxetine
- Amitriptyline
Less used :
- Pregablin
- Gabapentin
A patient presents with intermittent lower back pain, buttock and leg pain and leg weakness. The symptoms are worse on standing and better on sitting. Walking uphill > downhill.
What is the most likely differential
Lumbar spine stenosis
What movements relieve pressure in lumbar spine stenosis ?
- Bending forward as it expands the spinal canal.
- Standing straight can worsen the symptoms
What is the stepwise management of lumbar spine stenosis ?
- NSAIDs and physical therapy
- Surgical laminectomy and discectomy indicated for progressive disabling pain.
what is an important differential in lumbar spine stenosis ?
Differentiating neurogenic claudication from vascular claudication
Where do cervical nerve roots exit the spine ?
- Above the bone
- A C5/6 compression would affect cervical nerve root 6 as the root comes out above
Where do thoracic and lumbar nerve roots leave the spine?
- Underneath the vertebrae
- An L4/5 compression would affect nerve root 4.
An elderly patient presents following a fall from which they were unable to get up. They are complaining of groin pain radiating to the knee. They are unable to weight bear, what is the most likley cause ?
NOF fracture
What would be seen on physical examination in a NOF fracture ?
- Shortened, abducted and externally rotated leg on affected side.
- Pain on pill rolling and axial loading.
- Unable to straight leg raise
What is an intra-capsular NOF fracture and what classification system is used for them ?
- Break in the femoral neck, within the hip joint.
- Proximal to the intertrochanteric line.
- Garden classification
what are garden type I and II NOF and how are they treated treated?
- Grade I : incomplete and non displaced
- Grade II : cpomplete and non-displaced
- Internal fixation with screws or hemiarthroplasty if unfit
what are garden type III and IV NOF and how are they managed. ?
- Grade III : partially displaced (trabeculae at an angle)
- Grade IV : full displacement (trabeculae are parallel).
Replaced (either total or hemiarthroplasty)
what is an intertrochanteric extra-capsular hip fracture?
Occurs between the greater and lesser trochanter
how is an intertrochanteric hip fracture managed ?
DHS - dynamic hip screw (sliding hip screw)
what is a subtrochanteric extra-capsular hip fracture ?
Occurs distal to lesser trochanter but proximal to shaft of femur
How is a subtrochanteric hip fracture managed (and intertrochanteric if reverse or transverse)
Intramedullary nail
what 5 cancers commonly metastasise to bone ?
BLT Ketchup Please
- Breast
- Lung
- Thyroid
- Kidney
- Prostate
what kind of blood supply does the hip receive and what blood vessels are involved ?
- Retrograde : head of femur is at risk of avascular necrosis
- Medial and lateral circumflex artery from the deep femoral artery
Give 5 RF for OA
- Increasing age
- FHx
- Trauma
- Occupation
- Obesity
What are the 4 signs of OA on X-ray
- Loss of joint space
- Osteophytes
- Subchondral cysts
- Subarticular sclerosis
When is OA diagnosed ?
- Without investigation IF :
- > 45, Joint pain and stiffness worse with activity and no morning stiffness / less than 30 minutes
what are can OA cause in the hands ?
- Bouchards nodes : PIPs
- Haberdens nodes : DIPs
- Squaring at the CMC joint
- Reduced grip
- Reduced range of motion in the fingers
what is the stepwise management of OA ?
- Lifestyle + physio
- Analgesia
- Intra-articular steroid injections
- Joint replacement
What is the stepwise analgesic management of OA?
- Paracetamol / topical NSAIDs / topical capsaicin
- Oral NSAIDs (Ibuprofen/naproxen)
- Opiates (codeine/morphine)
what is the most common causative agent of a prosthetic joint infection
- Staph aureus
what is the most common first sign of OA in the hip?
Reduction in internal rotation
what is acute compartment syndrome ?
- Trauma (fracture/crush injury) to a limb leads to an increase in pressure within the limb compartments.
- This increase in pressure causes swelling and compromises circulation leading to tissue necrosis and death.
what are the 6 P’s of compartment syndrome ?
- P : pain (disproportionate to injury).
- P : parasthesia
- P : pale
- P : Pulse present
- P : paralysis (late sign)
- P : pressure (high)
How is compartment syndrome managed ?
- Surgical fasciotomy to relieve pressure
A patient presents with extreme pain in lower limb following a RTC causing tibial fracture. He describes a deep burning pain. Foot pulses are still present but patient reports numbness in his foot. On examination, the leg looks swollen and feels ‘wood like’. The pain is worsened by foot dorsiflexion. What is the diagnosis ?
- Compartment syndrome
- Posterior compartment effected as pain worsening by dorsiflexion (stretching the muscle worsens the pain).
3 features of a colle’s fracture and what it is often caused by?
- Transverse fracture of the distal radius
- 1 inch proximal to radio-carpal joint
- Dorsal displacement and angulation
FOOSH
What other kind of fracture is often caused by a FOOSH ?
- Scaphoid fracture
Key sign of a scaphoid fracture
- Maximal tenderness over the anatomical snuffbox
Deformity seen in a Colle’s fracture
- Dorsally Displaced Distal radius -> Dinner fork Deformity
what is an important complication of a scaphoid fracture ?
-> Avascular necrosis : there is retrograde blood supply (80% of blood supply comes from dorsal carpal branch of radial artery).
What is the Weber classification used for and what does it consist of ?
- Describe fractures of the lateral malleolus (Distal fibula)
- Type A : below syndesmosis
- Type B : at level of ankle joint (syndesmosis intact or partially torn)
- Type C : above syndesmosis which may also be damaged
what are the 2 principes to fracture management ?
- Achieve mechanical alignment via close or open reduction
- Provide relative stability by fixing the bone in the correct position whilst it heals
what is the initial investigation of choice for a NOF?
AP and lateral hip X-ray
what is osteomyelitis and most common cause ?
- Infection of bone and bone marrow, usually caused by bacterial infection
- Staph aureus
- Salmonella species -> sickle cell anaemia
investigation of choice for osteomyelitis
MRI
Management of osteomyelitis
- Surgical debridement
- Flucloxacillin 6wks
- Clindamycin if penicillin -allergic
what is the primary investigation for diagnosing spinal stenosis ?
- MRI
what is meralgia parasthetica
- Mononeuropathy caused by compression of the lateral femoral cutaneous nerve
How does meralgia parasthetica present ?
- Dysaesthesia and anaesthesia of the upper-outer thigh
- Burning / numbness / pins and needles / cold sensation
- Localised hair loss
How can the abnormal sensations experienced with meralgia paraesthetica be elicited on examination
- Extension of the hip on the affected side
How does trochanteric bursitits usually present ?
- Middle-aged man with gradual onset lateral hip pain
- Worse : activity, standing after sitting for a prolonged period and trying to sit cross legged.
What is seen on examination in trochanteric bursitits and what special tests can be used for diagnosis
- Examination : tenderness over the greater trochanter
- Pain over lateral side of hip / thigh
- Common in women aged 50-70 yrs
What is the common presentation of a meniscal tear ?
- Typically result from twisting injury
- Pain worse on straightening the knee
- Knee may ‘give way’
- Knee locking
- Tenderness along the joint line
2 tests for diagnosing meniscal tear
-> McMurray’s test
-> Apley test
1st line imaging for diagnosing meniscal tear
MRI
Management options of meniscal tears
- Conservative : RICE (Rest, Ice, Compression, Elevation).
- NSAIDs
- Physio
- Surgery : arthroscopy (repair / resection)
what 2 tests are used to diagnose ACL injuries
- Anterior drawer test
- Lachman test
What causes Osgood-Schlatter Disease
Inflammation of the tibial tuberosity
Explain the presentation of Osgood-Schlatter disease
Usually - 10 to 15 y/o male
- Visible or palpable hard and tender lump at the tibial tuberosity
- Pain in the anterior aspect of the knee
- The pain is exacerbated by physical activity, kneeling and on extension of the knee
Rare complication of Osgood-Schlatter disease
Avulsion fracture
what is a sign seen on examination in a baker’s cyst?
- Foucher’s sign = the lump will get smaller / disappear when the knee is flexed to 45 degrees (it is more apparent when knee is fully extended)
How is a baker’s cyst diagnosed ?
- USS (also done to rule out DVT)
Presentation of achilles tendinopathy
Gradual onset of :
-> Pain or aching in the Achilles tendon or heel, with activity
-> Stiffness
-> Tenderness
-> Swelling
-> Nodularity on palpation of the tendon
why are steroid injections into the achilles tendon avoided in achilles tendinopathy
risk of achilles rupture
RF for achilles tendon rupture
- Sports that stress the Achilles (e.g., basketball, tennis and track athletics)
- Increasing age
- Existing Achilles tendinopathy
- Family history
- Fluoroquinolone antibiotics (e.g., ciprofloxacin and levofloxacin)
- Systemic steroids
what medications can cause spontaneous achilles tendon rupture within 48 hours ?
-> Fluoroquinolone antibiotics (e.g. ciprofloxacin / levofloxacin).
Typical presentation of achilles tendon rupture
- Sudden onset of pain in the Achilles or calf
- A “snapping” sound and sensation
- Feeling as though something has hit them in the back of the leg
Signs on examination seen in achilles tendon rupture
- Weakness of plantar flexion of the ankle (dorsiflexion is unaffected)
- Unable to stand on tiptoes on the affected leg alone
- Positive Simmonds’ calf squeeze test : lack of plantar flexion when squeezing the calf muscle
Investigation for achilles tendon rupture
USS
key risk factor for frozen shoulder
Middle aged diabetics
Key presentation of frozen shoulder
- Shoulder pain is first symptom and is worse at night
- Shoulder becomes stiff
- Limited ROM in all directions (Loss of external rotation and abduction in 50% pts)
Non surgical management of frozen shoulder
-> Analgesia (e.g., NSAIDs)
-> Physiotherapy
-> Intra-articular steroid injections
-> Hydrodilation (injecting fluid into the joint to stretch the capsule).
Surgical options to treat frozen shoulder
- Manipulation under anaesthesia – forcefully stretching the capsule to improve the range of motion
- Arthroscopy – keyhole surgery on the shoulder to cut the adhesions and release the shoulder
Sign of supraspinatus tendinopathy on examination
- Painful arc of abduction between 60 and 120 degrees
- Empty can test (jobe test) : Resisted shoulder abduction = pain/arm gives way is +ve
Sign of acromioclavicular (AC) joint arthritis on examination
- Tenderness to palpation of the AC joint
- Pain is worse at the extremes of the shoulder abduction, from around 170 degrees onwards when the arm is overhead
- Positive scarf test – pain caused by wrapping the arm across the chest and opposite shoulder
What muscles make up the rotator cuff muscles and what action are they responsible for ?
SITS
- S : Supraspinatus : abducts arm
- I : Infraspinatus : externally rotates
- T : Teres minor : externally rotates
- S : Subscapularis : internally rotates
Distinguish betwen anterior and posterior shoulder dislocations
- Anterior = MOST COMMON. Arm forced backwards whilst abducted and extended
- Posterior = occur in electric shocks and seizures
Key complication of shoulder dislocation
- Axillary nerve damage (C5/6)
- Causes loss of sensation in “regimental badge” area over the lateral deltoid
- Also causes weakness in deltoid and teres minor muscles
Typical presentation of Olecranon Bursitis
- Swollen, warm, tender and fluid-filled elbow
what features would suggest the bursitis is caused by infection ?
Hot to touch
More tender
Erythema spreading to the surrounding skin
Fever
Features of sepsis (e.g., tachycardia, hypotension and confusion)
What is done if infection of the bursae is suspected ?
- Fluid aspiration :
- Pus indicates infection
- Straw-coloured fluid indicates infection is less likely
- Blood-stained fluid may indicate trauma, infection or inflammatory causes
- Milky fluid indicates gout or pseudogout
antibiotics for bursitis caused by infection
Flucloxacillin
Explain the tendons in the elbow and what movements they are responsible for
- > Tendons at the medial epicondyle = FLEX the wrist
-> Tendons at the lateral epicondyle = EXTEND the wrist
- Name for lateral epicomdyltitis and its features
- Tennis elbow
- Tenderness over lateral epicondyle
- Pain worse on resisted wrist extension
- Name for Medial epicondylitis and its features
- Golfer’s elbow
- Tenderness of medial epicondyle
- Pain aggravated by wrist flexion and pronation
What 2 tendons are primarily involved in De Quervain’s Tenosynovitis nd what is it
- Abductor pollicis longus (APL)
- Extensor pollicis brevis (EPB)
Inflammation of sheath containing these 2 tendons
what test can be used to diagnose De Quervain’s Tenosynovitis ?
- Finkelstein’s = make a fist with thumb inside fingers. Deviate the wrist down = if this causes pain -> test is +ve.
RF for Dupuytren’s contracture
- Age
- Family history (autosomal dominant pattern)
- Male
- Manual labour, particularly with vibrating tools
-Diabetes (more with type 1, but also type 2) - Epilepsy
- Smoking and alcohol
Risk factors for carpal tunnel syndrome
- Repetitive strain
- Obesity
- Perimenopause
- Rheumatoid arthritis
-Diabetes - Acromegaly : commonly causes bilateral carpal tunnel
- Hypothyroidism
what fingers are involved in carpal tunnel syndrome ?
- Thumb
- Index and middle
- Lateral half of ring
Involves compression of the median nerve
Primary Ix for carpal tunnel ?
Nerve conduction studies
what movement aggravates medial epicondylitis (golfer’s elbow)
Wrist flexion and pronation
what is the mechanism of injury for anterior and posterior shoulder dislocations ?
- Anterior = FOOSH
- Posterior = seizures and electric shock
what location would be a red flag in presenting back pain ?
Thoracic region
Clinical features of a fat embolism
Traumatic injury
- Resp : early & persistent tachycardia, tachypnoea, SOB, Hypoxia (72 hrs after injury), fever.
- Derm : red/brown petechial rash, subconjunctival and oral haemorrhage/petechiae
- CNS : confusion, agitation, retinal haemorrhages on fundoscopy.
common cause of bilateral carpal tunnel syndrome
RA
Management of weber A ankle fractures
patients with minimally displaced, stable fractures = analgesia and weight-bear as tolerated with controlled ankle motion (CAM) boot
what are the Ottawa ankle rules
- Screening tool used to assess need for ankle x-ray
- Bone tenderness at the posterior edge or tip of the lateral malleolus, OR
- Bone tenderness at the posterior edge or tip of the medial malleolus, OR
- An inability to bear weight both immediately and in the emergency department for four steps
X-ray finding in avascular necrosis of femoral head
Crescent sign
History suggesting avascular necrosis of femoral head
- Hip pain, worse on weight bearing
- Limited active and passive range of movement in all planes
- Pain upon abduction and internal rotation of hip
- Palpation of the joint exacerbates the pain.
what medication is associated with avascular necrosis of femoral head
Corticosteroids
When is a total hip replacement favoured over a hemiarthroplasty in a displaced intracapsular NOF
- Were able to walk independently out of doors with no more than the use of a stick and
- Are not cognitively impaired and
- Are medically fit for anaesthesia and the procedure
4 RF for OA of the hip
- Increasing age
- Female gender (twice as common)
- Obesity
- Developmental dysplasia of the hip
5 complications of a total hip replacement
- Leg length discrepancy
- Posterior dislocation
- Prosthetic joint infection
- Aseptic loosening (most common reason for revision)
- Peri-operative (VTW, nerve injury, surgical site infection, intraoperative fracture)
How is compartment syndrome diagnosed ?
- Measurement of intracompartmental pressure measurements
- Excess of 20mmHg = abnormal. >40mmHg = diagnostic
Early complications of a colles’ fracture
- Median nerve injury -> Carpal tunnel
- Compartment syndrome
- Vascular comprimise
- Malunion
- Rupture of extensor pollicis longus tendon
2 late complications of a Colles’ fracture
- OA
- Complex regional pain syndrome
Definitive investigation to confirm or exclude scaphoid fracture
MRI
Initial management of suspected or confirmed scaphoid fracture
- Immobilisation with a Futuro splint or standard below-elbow backslab
- Referral
Orthopaedic management of undisplaced scaphoid fracture
- Cast for 6-8 weeks
Management of displaced waist or proximal scaphoid pole fractures
Surgical fixation
what are the ottawa ankle rules
x-rays are only necessary if there is pain in the malleolar zone and:
1. Inability to weight bear for 4 steps
2. Tenderness over the distal tibia
3. Bone tenderness over the distal fibula
Features of De Quervain’s tenosynovitis
- Pain on radial side of the wrist
- Tenderness over radial styloid process
- Abduction of the thumb against resistance is painful
Signs of carpal tunnel on exmination.
- Weakness of thumb abduction
- Wasting of thenar eminence
- Tinel’s sign: tapping causes paraesthesia
- Phalen’s sign: flexion of wrist causes symptoms
Management of carpal tunne l
- 6 wk trial of conservative methods (steroid injections, splint at night)
- If severe / persitent = surgical decompression
- Splint is first line if pregnanct
Most cost bacteria invoved in primary IIiopsoas abscess
Staphylococcus aureus
Key secondary cause of IIopsoas abscess
IVDU
4 clinical features of IIiopsoas abscess
Fever
Back/flank pain
Limp
Weight loss
Key findings on examination in a IIipsoas abscess
- Pt will often be found laid in supine position with knee flexed and hip mildly externally rotated.
- Hyperextention of affected hip whilst pt is laid on normal side should elicit pain
- Raising affected leg against resitance should cause pain
Management of IIiopsoas abscess
- Antibiotics
- Percutaneous drainage
- Surgery is indicated if failure of percutaneous drainage
Investigation of choice for IIiopsoas abscess
CT abdomen
give 4 causes of avascular necrosis of the hip
Long term steroids use
Chemotherapy
Alcohol excess
Trauma
investigation of choice for avascular necrosis of the hip
MRI
what are buckle fractures and who do they typically occur in
- Incomplete fractures of the shaft of a long bone
- Children aged 5-10 yrs
features of discitis
- Back pain
- General : fever, rigors, sepsis
- Neurological : changing lower limb neurology if an epidural abscess develops
4 causes of discitis
- Bacterial (staph aureus most common)
- Viral
- TB
- Aseptic
what should all pts with discitis receive
Transthoracic echi - echo for endocarditis
Features of L3 nerve root compression
- Sensory loss over anterior thigh
- Weak hip flexion, knee extension and hip adduction
- Reduced knee reflex
- Positive femoral stretch test
Features of L4 nerve root compression
- Sensory loss anterior aspect of knee and medial malleolus
- Weak knee extension and hip adduction
- Reduced knee reflex
- Positive femoral stretch test
Features of L5 nerve root compression
- Sensory loss dorsum of foot
- Weakness in foot and big toe dorsiflexion
- Reflexes intact
- Positive sciatic nerve stretch test
Features of S1 nerve root compression
- Sensory loss posterolateral aspect of leg and lateral aspect of foot
- Weakness in plantar flexion of foot
- Reduced ankle reflex
- Positive sciatic nerve stretch test
Investigation of choice for rib fractures
CT scan
Common presentation of plantar fasciitis
Diffuse tenderness over heel
Aggravated by being on feet all day
Worse when asked to walk on toes
Presentation of a ganglion
Soft fluctuant swelling
Common on dorsal aspect of wrist
More prominent on making a fist
what should be considered in pts with rib fractures whos pain is not controlled by maximum medication options
- Regional nerve block
- Pain can cause pts to stop breathing effectively which can predispose to chest infections and atelectasis
Common mechanism of injury for 5th metatarsal fracture
Forced inversion of the ankle
What is cubital tunnel syndrome and how does it present
- Compression of the ulnar nerve
- Tingling / numbness of the 4th and 5th finger
