Orthopaedics Flashcards
What is the sural nerve?
A cutaneous nerve, providing only sensation to the posterolateral aspect of the distal third of the leg and the lateral aspect of the foot, heel, and ankle.
Originates from S1-S2
It is in close proximity to the short saphenous vein
What nerve supplies the gluteus maximus?
Inferior Gluteal Nerve
What nerve roots does the Superior Gluteal Nerve arise from?
L4-S1
What muscles does the Superior Gluteal Nerve supply?
Gluteus minimus and maximus
What nerve supplies the quadriceps muscles?
Femoral nerve
What are the boundaries of the anatomical snuff box?
Medial - Extensor pollicus longus
Lateral - Extensor pollicus brevis and abductor pollicus longus
What muscles does the musculocutaneous nerve innervate?
Coracobrachialis
Biceps Brachii
Brachialis
What are the nerve roots for the musculocutanous nerve?
C5-C7
Which branch of the brachial plexus innervates the deltoid and teres minor?
Axillary Nerve
What muscle separates the subclavian artery and subclavian vein?
Scalene anterior
What are the 3 thenar muscles?
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
What are the 3 hypothenar muscles?
Opponens digiti minimi
Abductor digiti minimi
Flexor digiti minimi brevis
What nerve innervates the hypothenar muscles?
Ulnar nerve
What are the other muscles of the hand that are not in the thenar or hypothenar eminences?
Lumbricals
Interossei
Palmaris brevis
Adductor pollicis
Which muscles of the hand are supplied by the median nerve?
Lateral 2 lumbricals
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
What nerve innervates the deep muscles of the anterior compartment of the forearm?
Anterior interosseous branch of the median nerve
What muscles make up the superficial layer of muscles in the anterior compartment of the forearm (Medial to Lateral)?
Flexor carpi ulnaris
Palmaris longus
Flexor carpi radialis
Pronator teres
(FPFP)
What are the origins and insertions of the flexor carpi ulnaris?
Origins - medial epicondyle of the humerus and olecranon of the ulnar
Insertions - pisiform, hook of hamate, base of 5th metacarpal
Which is the only muscle in the anterior compartment which is not innervated by the median nerve?
Flexor carpi ulnaris - ulnar nerve
Which is the only muscle to flex the distal interphalangeal joints of the fingers?
Flexor digitorum profundus
Which nerve roots does the ankle reflex test?
S1-S2
What muscles lie in the deep posterior compartment of the lower leg?
Tibialis posterior
Flexor hallicus longus
Flexor digitorum longus
Popliteus
What nerve are the muscles in the deep posterior compartment of lower leg supplied by?
Tibial nerve
Which structure usually herniates in a vertebral disc prolapse?
nucleus pulposus
What is a Colle’s fracture?
Distal radial metaphyseal transverse fracture with dorsal angulation.
Dinner fork deformity
Fall onto outstretched hand
Cast immobilisation with wrist flexion and ulnar deviation
What is a Smith’s fracture?
Distal radial metaphyseal transverse fracture with volar angulation.
Garden spade deformity
Fall onto proned hand or blow to back of wrist
Cast immobilisation with forearm supinated and wrist extended
What is a Barton’s fracture?
Distal radial fracture similar to colle’s or smith’s but with intra-articular involvement. Can be volar (more common) or dorsal dislocation
Radio-ulnar dislocation common.
What do you call base of thumb fracture due to forced abduction of metacarpal?
Bennett’s fracture
Intra-articular
What are the differential diagnoses of a Bennett’s fracture?
Rolando - comminuted
Pseudo-Bennett - extra-articular
Name of ulnar shaft fracture with dislocation of proximal radial head?
Monteggia’s fracture
What classification system is used for Monteggia fractures?
Bado classification
What is the name of a radial shaft fracture with dislocation of radio-ulnar joint?
Galeazzi fracture
What are the 2 types of galeazzi fractures?
Type 1 - dorsal displacement
Type 2 - volar displacement
What is a Hutchinson fracture?
Also known as chauffeur fracture
Intra-articular fracture of styloid process of distal radius
Due to forced dorsiflexion or direct blow
Unstable - requires percutaneous lag screw fixation
What is a Holstein-Lewis fracture?
Simple spiral fracture of distal humerus with radial dispalcement of the distal humeral fragment
Due to fall in elderly or RTC
Requires reduction and functional humeral brace
What nerve is likely to be damaged in a Holstein-Lewis fracture?
Radial nerve
What is an Essex-Lopresti fracture?
Fracture of radial head, dislocation of distal radio-ulnar joint and rupture of the antebrachial interosseus membrane.
Due to fall from height or high energy trauma.
Requires ORIF +/- prosthetic radial head
What defect in the humeral head occurs as a result of anterior glenohumeral dislocation?
What is the lesion of the infraglenoid labrum?
Hill-Sach’s defect - depression fracture of posterolateral humeral head
Bankart lesion
What classification is used to classify ankle fractures?
Weber classification
What nerve innervates the deltoid muscle?
Axillary
What muscles make up the anterior compartment of the upper arm and what nerve supplies them?
Coracobranchialis
Brachialis
Biceps Brachii
Musculocutaneous Nerve (C5-C7)
What muscles make up the posterior compartment of the upper arm and what nerve supplies them?
Triceps brachii only
Radial nerve
What nerve root is tested with the biceps reflex?
C6
What are the attachments of the biceps brachii?
Long head - supraglenoid tubercle of the scapula
Short head - coracoid process of the scapula
Insertion - Radial tuberosity and fascia of forearm via the bicepital aponeurosis
What are the attachments of the triceps brachii?
Long head - infraglenoid tubercle of the scapula
Lateral head - humerus, superior to the radial groove
Medial head - humerus, inferior to the radial groove
Insertion - Olecranon of the ulnar
What staging system is used for perthes disease?
Catterall staging
What is perthes disease?
idiopathic avascular necrosis of femoral head
What blood vessels supply the femoral head and neck?
Medial and lateral femoral circumflex arteries
What blood vessel supplies the humeral head?
Anterior humeral cirumflex artery
Disrupted in 80% of proximal humeral head fractures with risk of avascular necrosis and therefore fractures of the anatomical neck of humerus require hemiarthroplasty
What are some causes of avascular necrosis?
P - pancreatitis
L - lupus
A - alcohol
S - steroids
T - trauma
I - idiopathic, infection
C - caisson disease, collagen vascular disease
R - radiation, rheumatoid arthritis
A - amyloid
G - gaucher disease
S - sickle cell disease
Name the superficial muscles in the posterior compartment of the forearm
Brachioradialis
Extensor Carpi Radialis Brevis and Longus
Extensor Digitorum Communis
Extensor Digiti Minimi
Extensor Carpi Ulnaris
Anconeus
Name the deep muscles of the posterior compartment of the forearm
Supinator
Extensor Pollicis Brevis
Extensor Pollicis Longus
Abductor Pollicis Longus
Extensor Indicis
What would aspirated joint fluid show for pseudogout?
calcium pyrophosphate crystals
What would a raised transferrin saturation level indicate in the context of pseudogout?
Haemochromatosis
Tenderness over anatomical snuffbox and tenderness of longitudinal compression of thumb indicate what?
Scaphoid fracture
How do you manage spiral fracture of tibia?
Intramedullary nail
What classification system is used for open fractures?
Gustilo and Anderson Classification
What are the features of a radial head fracture?
Fall onto outstretched hand, tenderness on pronation and supination, tenderness over proximal forearm
What part of the humerus does the radial head articulate with?
Capitulum
What part of the hip does psoas major insert into?
Lesser trochanter of femur
What is Froment’s test?
Holding a piece of paper between thumb and finger without flexing IP joint.
Assesses adductor pollicis and therefore for ulnar nerve palsy
Which artery provides blood supply to scaphoid?
dorsal carpal branch vessels via retrograde flow
What muscles make up the anterior compartment of the lower leg? What nerve are the innervated by?
Tibialis anterior
Extensor digitorum longus
Extensor hallucis longus
+/- Peroneus tertius
Deep peroneal nerve
What are the 3 ligaments stabilising the hip joint?
Iliofemoral ligament
Pubofemoral ligament
Ischiofemoral ligament
Weakness of which muscle causes the patella to track laterally?
Vastus medialis
What ligament is most likely injured with an ankle inversion injury?
Anterior talofibular ligament
Which muscles make up the anterior compartment of the thigh?
Rectus femoris
Vastus lateralis
Vastus intermedius
Vastus medialis
Sartorius
Pectineus
+/- iliopsoas
What is the innervation of the anterior component of the thigh?
Femoral nerve L2-L4
What vessels provide blood supply to anterior compartment of the thigh?
Femoral artery
Medial circumflex femoral artery
Lateral circumflex femoral artery
Profunda femoris artery
Which nerve innervates the posterior compartment if the thigh?
Tibial part of the sciatic nerve
Where do the heads of the biceps femoris originate and insert?
Long head - ischial tuberosity
Short head - linea aspera of femus
Insert together onto lateral head of fibula
Which muscle of the posterior compartment of the thigh is most lateral?
Biceps femoris
Which muscle lies deeper; semitendinosis or semimembranosus?
Semimembranosus
Where do the semitendinosus and semimembranosus originate and insert?
Semitendinosus
- originates from ischial tuberosity
- inserts to medial surface aspect of tibia
Semimembranosus
- originates from ischial tuberosity
- inserts to medial tibial condyle
Which muscles insert onto the pes anserinus?
Semitendinosus
Gracilis
Sartorius
Which nerves innervate to adductor magnus?
Adductor part - Obturator nerve (L2-L4)
Hamstring part - tibial part of the sciatic nerve (L4-S3)
Where does the adductor longus originate and insert?
Originates from pubis and attaches to linea aspera of femur
Where does the adductor brevis originate and insert?
Originates from body of pubis and inferior pubic rami and inserts to linea aspera
Other than adductor magnus, longus and brevis, what muscles make up the adductor muscles?
Gracilis
Obturator externus
What is the origin and insertion of obturator externus?
Origin is membrane of the obturator foramen.
Passes posteriorly to neck of femur and inserts onto posterior aspect of the greater trochanter.
What 6 muscles insert onto the greater trochanter?
Gluteus medius
Gluteus minimus
Obturator externus
Obturator internus
Piriformis
Gemelli
What muscles cross both the hip and the knee?
Rectus Femoris
Gracilis
Sartorius
Where does the gracilis muscle originate and insert?
Inferior pubic rami to medial surface of tibial shaft
Which is the most superficial and deep out of adductor maganus, longus and brevis?
Deepest - adductor magnus
Superficial - adductor longus
Which nerve innervates the medial compartment of the thigh?
Obturator nerve (L2-L4)
What is the blood supply to the adductor muscles?
Obturator artery
What are the origins of the muscles within the anterior compartment of the thigh?
Psoas muscle - lumbar spine
Iliacus - ilium of plevis
Rectus Femoris - Anterior inferior iliac spine
Vastus lateralis - Greater trochanter
Vastus intermedius - Anterior and lateral femoral shaft
Vastus medialis - intertrochanteric line and medial lip of the linea aspera
What is the blood supply and innervation of the 4 compartments of the lower leg?
Anterior - tibial artery and deep peroneal nerve (L4-S1)
Lateral - fibula artery and superficial peroneal nerve
Deep posterior - posterior tibial artery and tibial nerve (L4-S3)
Superficial posterior - posterior tibial artery and tibial nerve (L4-S3)
Muscles in superficial posterior compartment of the lower leg and their function
Gastrocnemius
Soleus
Plantaris
Plantarflexion
Muscles in deep posterior compartment of the lower leg and their function
Popliteus- unlock knee
Flexor digitorum longus - flex digits
Flexor hallicus longus - flex great toe
Posterior tibialis - plantarflexion and inverson
Injury to what nerve causes foot drop and how is it most commonly injured?
Common fibular nerve
Fracture to proximal fibula
Muscles in lateral compartment of the lower leg and their function
Fibularis longus
Fibularis brevis
Eversion
Muscles in anterior compartment of the lower leg and their function
Tibialis anterior
Extensor digitorum logus
Extensor hallicus longus
Dorsiflexion
What are the nerve roots of the sciatic nerve?
L4-S3
What nerve innervates the biceps femoris?
Long head innervated by the tibial part of the sciatic nerve, whereas the short head is innervated by the common fibular part of the sciatic nerve.
What structure separates the ulnar artery and the median nerve in the proximal forearm?
Pronator teres
What are the contents of the popliteal fossa?
Popliteal artery and vein
Small saphenous vein
Common peroneal nerve
Tibial nerve
Posterior cutaneous nerve of the thigh
Genicular branch of the obturator nerve
Lymph nodes
Which nerve lies lateral to the brachial artery in the upper arm?
Median
What tough ligamentous structure lies anterior to the spinous processes?
Ligamentum Flavum
What are the branches of the lumbar plexus and what vertebrae do they arise?
Iliohypogastric T12-L1
Ilioinguinal L1
Genitofemoral L1-L2
Lateral cutaneous L2-L3
Femoral L2-L4
Obturator L2-L4
What muscles does the anterior interosseous nerve supply? and what does damage to this nerve look like?
Muscles of the deep anterior compartment:
Flexor pollicus longus
Lateral aspect of the flexor digitorum profundus
Pronator quadratus
Loss of pincer grip between thumb ad index finger and inability to pronate
Which nerve supplies sensory innervation to skin of anterolateral thigh?
Lateral cutaneous nerve of the thigh
What structures run posterior to the medial malleolus?
T ibialis posterior tendon
flexor Digitorum longus
A rtery (posterior tibial artery)
N erve (tibial nerve)
H allucis longus (flexor)
Tom Dick And Nervous Harry
How do sarcomas metastasise and where to?
Haematogenous route
Lung
What is osteopetrosis?
Marble bone disease
Defective osteoclast function resulting in failure of normal bone resorption
due to deficiency in carbonic anhydrase isoenzyme II
Stem cell transplant and interferon-gamma have been used for treatment
Radiology reveals a lack of differentiation between the cortex and the medulla.
Which childhood hip disorder is associated with short stature and hyperactivity?
Perthes
What bone tumour shows multiple lytic and lucent areas (Soap bubble) appearances on xray?
Osteoclastoma (giant cell tumor of bone)
What is klein’s line?
Radiographic finding used to detect SUFE
A line is drawn along the superior border of the femoral neck. In a normal hip, the line intersects the lateral part of the superior femoral epiphysis.
What are the risk factors for DDH?
Breech
Family history
Female
Firstborn
Oligohydramnios
Swaddling
What does perthe’s disease show on xray?
Widening of femoral neck
Flattening of femoral head
Patchy density
Cause of hip pain in children aged 4-10 following viral URTI
Transient synovitis of the hip
What type of benign bone tumour shows thickened reactive bone area 1cm radiolucent core?
Osteoid osteoma
Affects males > females, ages 10-25 yrs
Usually occurs in femur or tibia
Presents with dull ache which responds to NSAIDs
What benign bone tumour presents with painless bony lump?
Osteochondroma
Affects ages 10-30
Abnormal growth on surface of the bone near growth plate
Rarely needs treatment - excised if compresses a nerve or vessel
How do chondromas present?
Found incidentally, usually in hands or feet
Made from cartilage
What type of bone tumour has soap bubble appearance on x-ray?
Giant cell tumour of bone (osteoclastoma)
What solid organ tumours most commonly metastasise to bone?
Breast
Thyroid
Lung
Prostate
Kidney
How does Ewing’s sarcoma appear histologically?
Small blue cells
Where do osteosarcomas most commonly metastasise to?
Lung
What is a chordoma?
Neoplasm originating from noctocord - therefore found in axial skeleton only
Accounts for 50% of sacral tumours
Presents in ages 50-70
Causes of carpal tunnel
Myxoedema
Edema premenstrually
Diabetes
Idiopathic
Acromegaly
Neoplasm
Trauma
Rheumatoid arthritis
Amyloidosis
Pregnancy
What lab test is used to test for HIV?
P24 antigen test
What are lining cells?
Dormant osteoblasts
What are the most common causes of hypercalcaemia in hospital and in the community?
Hospital - metastatic malignancy
Community - Primary hyperparathyroidism
What is the radiological finding of a greenstick fracture?
Unilateral cortical breach only
+ periosteal haematoma
Symptoms of fat embolism?
Triad of symptoms:
Respiratory - reduced sats, breathless
Neurological - agitated, confused
Petechial rash (tends to occur after the first 2 symptoms)
What treatments does metastatic bone pain respond to?
Paracetamol and NSAIDs are first line
Bisphosphonates
Radiotherapy if drugs are not working
In the supracondylar area, where does the radial nerve lie in relation to the humerus?
Anterolateral
Where does the common peroneal nerve divide into the deep and superficial peroneal nerves?
Just lateral to the neck of the fibula
Remember that when there is a proximal fibular fracture there is risk of common peroneal nerve damage and results in footdrop
What artery does the gluteal arteries arise from?
internal iliac artery
What are sharpey’s fibres?
Collagenous fibres that attach the periosteum to bone
At what level is a cervical rib most likely to arise from?
C7
What nerve innervates the trapezius?
Spinal accessory nerve
Which nerve provides cutaneous innervation of the 1st webspace of the foot?
Deep peroneal nerve (L4-5)
What are the nerve roots of the sciatic nerve?
L4-S3
What structures pass through both the greater and lesser sciatic foramen?
Pudendal nerve
Internal pudendal artery
Nerve to obturator internus
What is De Quervain’s Tenosynovitis?
Inflammation of the tendons in compartment 1:
Abductor pollicis longus
Extensor pollicis brevis
Pain and swelling at base of the thumb with associated difficulty with grasping and pinching
What nerve is most likely to be damaged if the sternocleidomastoid is mobilised during surgery?
Accessory
Where is the radial nerve relative to the humerus at the supracondylar level?
Anterolateral
Where does the common peroneal nerve bifircate?
Lateral to the neck of fibular
Which ligament keeps the head of the radius connected to the radial notch of the ulna?
Annular (Orbicular) ligament
What are the contents of the adductor canal?
Saphenous nerve
Superficial femoral artery
Superficial femoral vein
Where does the sciatic nerve bifurcate?
Apex of the popliteal fossa
What nerve supplies sensory innervation to the skin on the back of the knee?
posterior cutaneous nerve of the thigh
(S1-S2)
Branch of the sacral plexus
What is Lachman’s test?
used to determine ACL injury
similar to anterior draw test but the knee is only flexed to 15-20 degrees
Which nerve supplies sensory innervation to the medial aspect of the lower leg and foot?
Saphenous nerve
Branch of femoral nerve
L3-L4
What is pes planus?
Flat foot
Due to dysfunction of posterior tibialis muscle
What nerve innervates the teres minor? And what are the attachments of this muscle?
Axillary
Inferior facet of the greater tubercle of the humerus and lateral border of scapula
Which nerves accompany the cephalic and basilic veins in the forearm?
Basilic - Medial cutaneous nerve of the forearm
Cephalic - Lateral cutaneous nerve
What is the axillary sheath?
An extension of the prevertebral fascia.
Contains the axillary artery and the 3 cords of the brachial plexus
Divided in to 3 parts according to pectoralis minor
Where do the two heads of the flexor carpi ulnaris arise from?
Humeral head from the medial epicondyle of the humerus
Ulnar head from the olecranon and posterior border of the ulnar
What does the dorsal scapular nerve innervate?
C5
Rhomboid minor and major and levator scapular
Causes retraction and elevation of the scapula
What is the canal of guyon?
Where the ulnar nerve enters the hand
Superficial to the flexor retinaculum, lateral to the pisiform bone
Ulnar nerve lies medial to the artery within the guyon canal.
What nerve innervates teres major?
What other muscle does this nerve innervate?
Lower subscapular nerve
Subscapularis
What are the contents of the cubital fossa (lateral to medial)?
Radial nerve
Biceps tendon
Brachial artery
Median Nerve
What is the annular ligament?
Encircles the head of the radius
Allows for pronation and supination
Where do all the muscles in the superficial compartment of the anterior forearm originate?
Medial epicondyle of humerus
Which nerve supplies the brachioradialis muscle?
Radial nerve
Where do the two heads of the extensor carpi radialis brevis an longus arise from?
Long - Lateral supracondylar ridge of the humerus
Short - Lateral epicondyle of the humerus
Which branch of the median nerve is responsible for innervation of the thenar muscles?
Recurrent branch
What are the contents of the anatomical snuffbox?
Cephalic vein
Radial artery
Radial nerve - superficial branch
What is a bankart lesion?
Injury of the anterior (inferior) glenoid labrum of the shoulder due to anterior shoulder dislocation.
