Orthopaedics Flashcards
What is a compound fracture?
When the skin is broken and the broken bone is exposed to the air.
What is a stable fracture?
Refers to when the sections of bone remain in alignment at the fracture.
What fractures are common in children?
Greenstick and buckle fractures typically occur in children rather than adults. Salter-Harris fractures only occur in children (adults do not have growth plates).
What is Colles’ Fracture?
A Colles’ fracture refers to a transverse fracture of the distal radius near the wrist, causing the distal portion to displace posteriorly (upwards), causing a “dinner fork deformity”. This is usually the result of a fall onto an outstretched hand (FOOSH).
What cancers commonly metastasise to bone?
Prostate
Renal
Thyroid
Breast
Lung
What is a FRAX tool?
It can be used to calculate a patient’s risk of a fragility fracture over the next 10 years.
What does T-score of more than -1 represent?
Normal Bone Mineral Density
What does a T-score of -1 to -2.5 represent?
Osteopenia
What does a T-score of less than -2.5 represent?
Osteoporosis
What does a T-score of less than -2.5 plus a fracture represent?
Severe Osteoporosis
Why might a Fat Embolism occur?
They can occur following the fracture of long bones (e.g., femur) as fat globules are released into the circulation following a fracture
What is the investigation of choice for osteomyelitis?
MRI (with a sensitivity of 90-100%)
What is McMurrays test used for?
A positive McMurrays points toward a meniscal tear
What is the most common pathogen causing discitis?
Staphylococcus Aureus
What is Discitis?
It is an infection of the intervertebral disc space
How do you diagnose Discitis?
Imaging: MRI has highest sensitivity
CT-guided biopsy may be required to guide antimicrobial treatment
How does a Scaphoid fracture present?
- Fall on outstretched hand
- Tenderness in the anatomical snuffbox dorsally
- Tenderness in the scaphoid tubercle volarly
What is cancellous bone?
Also known as spongy bone or trabecular bone, which is characterised by its spongy, porous, honeycomb-like structure and is typically found at the ends of long bones.
What criteria is used for diagnosis of fat embolism?
Gurd’s criteria
What are Gurd’s major criteria?
Respiratory distress
Petechial rash
Cerebral involvement
What are some of Gurd’s minor criteria?
Jaundice
Thrombocytopaenia
Fever
Tachycardia
Why does osteoarthritis occur?
Occurs in the synovial joints and results from genetic factors, overuse and injury. It is thought to result from an imbalance between cartilage damage and the chondrocyte response
What do chondrocytes do?
They proliferate and secrete extracellular matrix to maintain and sustain cartilage. They response to outside stimuli and tissue damage.
What X-Ray changes do you see with osteoarthritis?
L-oss of joint space
O-steophytes (bone spurs)
S-ubarticular sclerosis (increased density of the bone along the joint line)
S-ubchondral cysts (fluid-filled holes in the bone)
When is the pain of osteoarthritis worse?
Worsens with activity and at the end of the day
What are ganglion cysts?
Sacs of synovial fluid that originate from the tendon sheaths or joints
What is carpal tunnel syndrome?
Caused by compression of the medial nerves as it travels through the carpal tunnel in the wrist
What could be linked to bilateral carpal tunnel syndrome?
Acromegaly
What are the two special tests for carpal tunnel syndrome?
Phalen’s test
Tinel’s test
What is a contracture?
Shortening of the soft tissues that leads to restricted movement in a joint.
What are some causes of contractures?
Motor neuron disease
Radiculopathy
Muscular Dystrophies
What is the pathophysiology of Dupuytren’s contracture?
The palmar fascia of the hand forms a triangle of strong connective tissue on the palm.
In Dupuytren’s contracture, the fascia of the hands becomes thicker and tighter and develops nodules. Cords of dense connective tissue can extend into the fingers, pulling the fingers into flexion and restricting their ability to extend (contracture).
What is De Quervain’s tenosynovitis?
It is a condition where there is swelling and inflammation of the tendon sheaths in the wrist.
What tendons does De Quervain’s tenosynovitis usually affect?
Abductor pollicis longus (APL) tendon
Extensor pollicis brevis (EPB)
What is the most commonly involved organism in prosthetic joint infection?
Staphylococcus aureus
Weakness and loss of bulk in which muscle group occurs with carpal tunnel syndrome?
Thenar Muscles
What is tennis elbow otherwise known as?
Lateral epicondylitis
What artery is at high risk of compromise in NOF
Medial femoral circumflex artery
What is a Galeazzi Fracture?
A radial fracture with ulnar dislocation
What is a Monteggia fracture?
An ulnar fracture with radial dislocation
Causes of a positive Trendelenburg test
- Pain on weight bearing
- Weakness of hip ABductors
- Shortening of the femoral neck
- Dislocation/subluxation of the hip
A patient loses the ability to plantarflex and invert his foot is a stereotypical history for an injury to which nerve/structure?
Tibial nerve
What is the unhappy triad and when is it seen?
Unhappy triad is commonly seen following a lateral blow to the knee and consists of damage to the:
- Anterior cruciate ligament
- Medial collateral ligament
- Meniscus (classically the medial meniscus but recent evidence shows that the lateral meniscus is more commonly injured)
Foot drop is caused by an injury to which nerve?
Common Peroneal nerve
A positive Trendelenburgs sign indicates injurt to what structure?
Superior gluteal nerve
What is a Type 1 Hip fracture on the Garden System?
Stable fracture with impaction in valgus
What is a Type 2 Hip fracture on the Garden System?
Complete fracture but undisplaced
What is a Type 3 Hip fracture on the Garden System?
Displaced fracture, usually rotated and angulated, but still has boney contact
What is a Type 4 Hip fracture on the Garden System?
Complete boney disruption
What surgery is required for an undisplaced intracapsular hip fracture?
Internal fixation or hemiarthroplasty if unfit
What surgery is required for a displaced intracapsular fracture?
Replacement arthroplasty. Total hip replacement favourable
What surgery is required for a stable intertrochanteric fracture?
Dynamic hip screw
What surgery is required for a reverse oblique hip fracture
Intramedullary device
What surgery is required for a transverse hip fracture
Intramedullary device
What surgery is required for a subtrochanteric hip fracture
Intramedullary device
Injury of what nerve results in a winged scapula?
Long thoracic nerve
Injury of what nerve may result in a ‘claw hand’
Ulnar nerve
What injuries may result in the knee from a twisting injury?
Anterior cruciate ligament
Meniscal tear
Injury to what nerve will cause a wrist drop?
Radial nerve
What are ganglionic cysts?
They are non-cancerous soft tissue lumps that occur along any joint or tendon.
What are the risk factors for developing a ganglionic cyst?
- Female
- Osteoarthritis
- Previous joint or tendon injury
What is the management of a ganglionic cyst?
If it does not cause any pain, the usual recommended treatment is to simply monitor, as cysts often disappear spontaneously without further intervention.
If causing pain
- Aspiration
- Cyst excision
What are the risk factors for developing Carpal tunnel syndrome?
- Female
- Increasing age
- Pregnancy
- Obesity
- Previous injury to the wrist
- DM, RA, Hypothyroid
What antibiotic is associated with Achilles Tendinitis?
Ciprofloxacin
What are some major risk factors for a C-Spine injury?
Motor vehicle collisions
Falls from height
Diving accidents
Contact sports
Direct impact to the head or neck
What is the NEXUS criteria used for?
Used to identiy patients at low risk of C-Spine injury
What is included in the NEXUS criteria?
Normal level of alertness
No evidence of intoxication
No painful distracting injuries
No focal neurological deficit
Absence of midline cervical tenderness
If all of the crietria are met, the C-Spine may be ‘cleared’ and imaging may not be required.
What is the imagineg used in C-Spine injury?
CT C-Spine
Who does Avascular necrosis commonly impact?
Can affect individuals at any age, it commonly affects those in their 30-60s.
Has a male preponderance, likely due to higher incidence of risk factors such as trauma and alcohol abuse.
What are some causes of Avascular necrosis?
- Trauma: Fractures or dislocations
- Intravascular coagulation: Thrombi can obstruct blood flow
- Fat Emboli: Fat particles can block blood vessels
- Steroid therapy: Long term or high dose can be associated with AVN.
They reduce blood flow, leading to ischaemic, osteocyte necorsis and the loss of structural integrity
How do patients with AVN present?
- Gradual onset of joint pain, often worsened by weight bearing
- Reduced range of motion in the affected joint
- If untreated, it can progress to severe pain and joint instability, leading to collapse of the subchondral bone
How do you diagnose AVN?
- Plain X-ray: The early changes may not be evident, but later stages show lucent areas representing bone resorption, and sclerotic areas representing both living reparative bone and dead trabeculae.
- MRI: More sensitive than X-rays in early detection, it can demonstrate bone marrow oedema and other early changes.
- Bone scans: May be used in some cases for assessment of the extent of disease.
WHahat is the management of AVN?
- NSAIDs
- Surgical intervention with options including core decompression, osteotomy, bone grafting and joint replacement
How do patients with axillary nerve dysfunction present?
- Weakness of the deltoid and teres minor muscles
- Diminished or absent sensation over the lateral deltoid skin
Where do Baker’s cysts typically occur?
They typically develop in the popliteal space between the medial head of the gastrocnemius muscle and the semimembranosus muscles
What are the signs and symptoms of a Baker’s cyst?
- Swelling or lump behind the knee, which may be more noticeable when standing
- Knee pain
- Stiffness and reduced range of movement
What population are more at risk of developing a biceps tendon tear?
They are more common in the elderly, particularly in individuals with pre-existing degenerative shoulder disease.
Can also occur in younger patients who have excessive strain or trauma to the muscle
What are the symptoms of biceps tendon tear?
- Sudden, sharp pain in the upper arm, which may subside into a dull ache over time
- Audible “pop” at the time of injury
- Weakness in elbow flexion and supination
- Difficulty in turning the arm from palm down to palm up
What are the signs of a biceps tendon tear?
- Bruising on the upper arm
- A palpable or visible bulge in the upper arm (“Popeye sign”)
What is the main form of imaging for diagnosing a biceps tendon tear?
Magnetic Resonance Imaging
What is the management for a biceps tendon tear?
- Conservative treatment: Rest, Ice, Compression, Elevation, NSAIDs for pain and inflammation
- Physiotherapy
- Surgery in more severe cases, surgical intervention may be necessary to reattach the tendon
What is the usual presentation of an osteosarcoma?
Typically presents with a warm, painful swelling, often around the knee
What is the typical presentation of Ewing’s Sarcoma?
- Presents as a painful, warm, enlarging mass along long bone diaphysis.
- Can have systemic symptoms such as fever and anaemia.
- Raised ESR and WCC
What is the typical presentation of Chondrosarcoma?
- Occurs in older patients (>40) with pain and a lump
What would you see on an Xray of Osteosarcoma?
- Periosteal reaction with Codman’s triangle and a sunburst appearance
What would you see on an XRay of Ewing’s sarcoma?
‘Onion skin’ periosteal reaction
What would you see on a XRay of Chondrosarcoma?
Lytic lesions with ‘fluffy popcorn’ calcification
What is a Boxer’s fracture?
A break in the neck of the 4th or 5th metacarpal, typically caused by punching a hard object
What are the indications for surgery in a Boxer’s fracture?
- Significant rotation or angulation of the affected fingers
- Articular involvement of the fracture
- Multiple metacarpal fractures
- Open fractures
What nerve roots are damaged in Erb’s palsy?
Damage to the C5-C6 nerve roots
What nerve roots are damaged in Klumpke’s palsy?
Damage to the C8-T1 nerve roots
What are the main causes of brachial plexus injury and what specific type of palsy do they cause?
- Trauma, especially during childbirth (more associated with Erb’s palsy)
- High-impact accidents
- Axillary radiotherapy (more likely to cause Klumpke’s palsy)
What are the signs and symptoms of Erb’s Palsy?
- Dermatomal sensory loss in the C5-6 distribution
- “Waiter’s tip” sign: characterized by shoulder adduction, elbow extension, forearm pronation and wrist flexion
What are the signs and symptoms of Klumpke’s Palsy?
- Dermatomal sensory loss in the C8-T1 distribution
- Weakness of the intrinsic muscles of the hand
- Potential ipsilateral Horner’s syndrome if T1 involvement occurs
What are the signs and symptoms of a calcaneal fracture?
- Heel pain which may be severe and acute
- Swelling in the heel region
- Bruising
- Difficulty or inability to weight bear on the affected side
What is the gold standard investigation for a calcaneal fracture?
CT
When might the symptoms of Carpal tunnel syndrome be worse?
Worse at night
Worse after activities involving wrist flexion
What are the primary investigations for Carpal Tunnel Syndrome?
- Electromyography (EMG): to assess the electrical activity of the muscles at rest and during nerve contraction
- Nerve conduction studies (NCS): to measure the speed and strength of signals travelling through the median nerve
What is the most common cause of cauda equina syndrome?
Lumbar disc herniation at the L4/5 and L5/S1 levels
What are the presenting symptoms of cauda equina syndrome?
- Lower back pain
- Alternating or bilateral radicular pain
- Saddle anaesthesia, often manifesting as an inability to feel toilet paper when wiping
- Bladder and bowel disturbances
What is the gold-standard investigation for Cauda Equina syndrome?
Urgent Whole-Spine MRI
What is the management of Cauda Equina Syndrome?
- The goal should be to surgically decompress the affected area within 48 hours
- If malignancy is identified on MRI, or clinical suspicion is high, administration of Dexamthasone 16mg daily is indicated
What is the most common cause of discitis?
Staphylococcus aureus
What causes Greater Trochanteric pain syndrome?
Repeated movement of the fibroelastic iliotibial band
What is associated with Adhesive capsuilitis?
Diabetes mellitus
What relieves spinal stenosis?
Often relieved by sitting down or leaning forward
What are the red flag symptoms for lower back pain?
- Age < 20 years or > 50 years
- History of previous
- Malignancy
- Night pain
- History of trauma
- Thoracic pain
- Systemically unwell e.g. weight loss, fever
What are the Ottawa rules for an ankle X Ray?
Recommend an ankle X-Ray if following an ankle injury, a patient has pain the malleolar zone and one of the following
1) Inability to weight bear immediately after the injury and on examination
2) Bony tenderness along the distal 6cm of the posterior edge of the fibula or tip of the lateral malleolus
3) Bony tenderness along the distal 6cm of the posterior edge of the tibia or tip of the medial malleolus
What are the two main fractures carrying a risk of compartment syndrome?
Supracondylar fractures and tibial shaft injuries
What classification system is used in paediatric fractures?
Salter-Harris system
What is the most common type of shoulder dislocation?
Anterior shoulder dislocations account for >95% of cases
