Orthopaedics Flashcards
Which nerve is compressed in Carpal Tunnel Syndrome?
= median nerve
Risk factors to consider in patient’s who present with bilateral carpal tunnel syndrome? (4)
- rheumatoid arthritis
- DM
- acromegaly
- hypothyroidism
Sensory symptoms associated with Carpal Tunnel Syndrome?
= numbness, parasthesia, burning sensation OR, pain in the following distributions
palmar aspects and full fingertips of the thumb, index, middle finger, and lateral half of ring finger
What the Phalen’s test? and what is it used for?
= involves fully flexing wrists and holding it in this position – backs of their hands together
This position triggers numbness and paraesthesia in the median nerve distribution if patient has Carpal Tunnel
What the Tinel’s test? and what is it used for?
= involves tapping wrist at location where median nerve travels through carpal tunnel
Triggers numbness + paraesthesia in the medial nerve distribution associated with Carpal Tunnel Syndrome
Primary investigation for establishing a diagnosis of Carpal Tunnel Syndrome?
= nerve conduction studies
Lateral epicondylitis is also known as…
- ‘tennis elbow’
- ‘golfer’s elbow’
- ‘tennis elbow’
Medial epicondylitis is also known as…
- ‘tennis elbow’
- ‘golfer’s elbow’
- ‘golfer’s elbow’
Stenosing tenosynovitis is also known as?
= trigger finger
Is trigger finger more coming in women or men?
= women
Management options for trigger finger? (4)
- rest + analgesia
- splinting
- steroid injections
- surgery to release A1 pulley
What is De Quervain’s Tenosynovitis?
= condition where there is swelling + inflammation of the tendon sheaths in the wrist. It is a type of repetitive strain injury and results in pain on the radial side of the wrist
De Quervain’s Tenosynovitis: Describe the Finkelstein’s test
= patient making a fist with their thumb inside their fingers. Then, wrist is adducted (ulnar deviation), causing a strain on the APL and EPB tendons
If this movement causes pain at the radial aspect of the wrist > test is +ve, indicating De Quervain’s tenosynovitis
What is Trochanteric Bursitis?
= refers to the inflammation of a bursa over the greater trochanter on the outer hip
Which special tests can be performed to help establish a diagnosis of trochanteric bursitis? (2)
- Trendelenburg test
- Resisted movements (abduction, internal and external rotation of the hip)
Describe the Trendelenburg Test?
= ask patient to stand one-legged on the affected leg
Normally, the other side of the pelvis should remain level or tilt upwards slightly
Positive test is when the other side of the pelvis drops down, suggesting weakness in affected hip
2 types of Achilles tendinopathy
- insertion tendinopathy (within 2 cm of the insertion point on the calcaneus)
- mid-portion tendinopathy (2-6cm above the insertion point)
Which type of antibiotics are risk factors for tendinopathies?
= fluoroquinolone antibiotics (e.g., Ciprofloxacin and Levofloxacin)
What is important to exclude in patient with suspected Achilles tendinopathy?
= Achilles tendon rupture
What imaging is used to diagnose Achilles tendon rupture?
= USS
Why are steroid injections avoided in Achilles tendons?
= risk of tendon rupture
Which nerve is most likely to be damaged in a humerus fracture?
= radial nerve
‘RATS’ mnemonic for describing an orthopaedic x-ray
R - rotation
A - angulation
T - translation
S - shortening
4 R’s in management of a fracture
Resuscitate
Reduce (closed or open)
Retain (operative or non-operative)
Rehabilitate
Most common nerve to be damaged in an extension type supracondylar fracture?
= terminal branch of the median nerve (anterior interosseous nerve)
Most common nerve to be injured in a head of radius fracture?
= terminal branch of the radial nerve (posterior interosseous)
Most common nerve to be injured in an anterior shoulder dislocation?
= axillary nerve
What is the function of Tranexamic acid in an elective joint replacement?
= minimise blood loss during procedure
What is a compound fracture?
= skin is broken, and broken bone is exposed to air
What is a stable fracture?
= sections of the bone remain in alignment in the fracture
What is a pathological fracture?
= bone break due to an abnormality within the bone
What is a Colle’s fracture?
= transverse fracture of the distal radius, near the wrist
What kind of fracture can cause a ‘dinner fork deformity’?
= Colle’s fracture
What are scaphoid fractures at a higher risk of avascular necrosis?
= scaphoid bone has retrograde blood supply
What is Weber classification used for?
= classifying lateral malleolar fractures
Main cancers that metastasise to the bone
HINT: PoRTaBLe
P - prostate
R - renal
T - thyroid
B - breast
L - lung
What is fat embolism?
= complication of fractures. Fat globules are released into the circulation following a fracture, these can become lodged in blood vessels and cause blood flow obstruction
What is compartment syndrome?
= orthopaedic emergency
Pressure within a fascial compartment is abnormally elevated, cutting off the blood flow to contents of that compartment
5P’s of how acute compartment syndrome presents
P - pain disproportionate to underlying injury
P - parasthesia
P - pale
P - pressure (high)
P - paralysis - late and worrying sign
Specific test to check for compartment syndrome if you suspect this?
= pain worsened by passive stretching of the muscles in that compartment
What can be used to measure compartment pressure (in suspected compartment syndrome)?
= needle manometry
Definitive treatment in acute compartment syndrome?
= emergency fasciotomy
What is a fasciotomy?
= involves surgical operation to cut through the fascia, down the entire length of the compartment, and release the pressure
What is chronic compartment syndrome pain made worse by?
= increased activity, it is exertional
What is Cauda Equina Syndrome?
= surgical emergency where the nerve roots of the cauda equina at the bottom of the spine are compressed
Most common cause of Cauda Equina Syndrome?
= herniated disc
Red flags of Cauda Equina (7)
- saddle anaesthesia
- loss of sensation in bladder or rectum (not knowing when full)
- urinary retention or incontinence
- faecal incontinence
- bilateral sciatica
- bilateral or severe motor weakness in legs
- reduced anal tone on PR
What scan is required to diagnose Cauda Equina Syndrome?
= emergency MRI scan
Treatment of Cauda Equina Syndrome?
= lumbar decompression surgery
How to differentiate between Cauda Equina Syndrome and Metastatic Spinal Cord Compression (MSCC)?
= Cauda Equina presents with LMN signs (reduced tone and reflexes), whereas Metastatic spinal cord compression shows UMN signs
Chondrosarcoma is cancer originating from where?
= cartilage
Leiomyosarcoma is cancer originating from where?
= smooth muscle
Kaposi’s sarcoma is most often seen in which type of patients?
= end-stage HIV
Initial investigation for bony lumps in suspected sarcoma?
= x-ray
Initial investigation for soft tissue lumps in suspected sarcoma?
= USS
Where is the most common location for sarcoma to metastasise to?
= lungs
What is spondylolisthesis?
= anterior displacement of vertebrae out of line with the one below
What is ‘lumbago’?
= another term for low back pain
What is sciatica?
= refers to symptoms associated with irritation of the sciatic nerve
Which spinal nerves come together to form the sciatic nerve?
= spinal nerves L4-S3
Main pharmacological choices to manage sciatica (2)
- Amitriptyline
- Duloxetine
First-line option for managing acute lower back pain
= NSAIDs
What is the STarT Back Screening Tool used for?
= used to stratify the risk of a patient presenting with acute back pain developing chronic back pain
What is spinal stenosis?
= narrowing of part of the spinal canal, resulting in compression of the spinal cord or nerve roots
Intermittent neurogenic claudication is a key presenting feature in which condition?
= spinal stenosis
What does radiculopathy refer to?
= compression of the nerve roots as they exit the spinal cord + spinal column (leading to motor + sensory problems)
Patient presents with symptoms of peripheral arterial disease however, ABPI are normal, and he is experiencing back pain? What is the most likely differential?
= spinal stenosis
Imaging used to investigate spinal stenosis?
= MRI
Management options for spinal stenosis (4)
- weight loss + exercise
- analgesia
- physiotherapy
- decompression surgery (where conservative treatment fails)
What is laminectomy?
= removal of part of all of the lamina from the affected vertebra
What is the laminae?
= bony part that form the posterior part of the vertebral foramen + attaches to the spinous process
What is osteomyelitis?
= inflammation in a bone and bone marrow
What is haematogenous osteomyelitis?
= refers to when a pathogen is carried through the blood and seeded in the bone
Most common causative organism of osteomyelitis?
= Staphylococcus aureus
Best imaging option for establishing a diagnosis of osteomyelitis?
= MRI scan
Which antibiotics are recommended to treat acute osteomyelitis (2), and for how long?
= Flucloxacillin for 6 weeks, possibly with Rifampicin or Fusidic acid added for the first 2 weeks
How long is the course of Abx for chronic osteomyelitis?
= usually requires 3 months or more
Imaging used to identify avascular necrosis?
= MRI (more sensitive then x-rays, in early detection)
What is a Baker’s cyst?
= AKA, popliteal cyst is a fluid-filled sac originating from an extension of the knee synovium
Important differential to rule out in potential baker’s cyst?
= DVT (d-dimer + USS or venography of leg)
What is a Bennett Fracture?
= base of thumb (first metacarpal bone) intra-articular fracture - results in a 2-piece fracture dislocation
Bennett Fractures are often the result of which of the following,
- forced adduction + flexion
- forced abduction + extension
- forced abduction + extension
Gold standard imaging in diagnosing biceps tendon injuries (e.g., bicep tendon tear)?
= MRI scan
‘Popeye sign’ is a sign of?
= bicep tendon tear
Which of the following types of bone malignancy typically presents with warm, painful swelling, often around the knee?
- osteosarcoma
- ewing’s sarcoma
- chondrosarcoma
- osteosarcoma
Which of the following types of bone malignancy typically presents with painful, warm, enlarging mass along long bone diaphysis?
- osteosarcoma
- ewing’s sarcoma
- chondrosarcoma
- ewing’s sarcoma
Which of the following types of bone malignancy typically occurs in older patients (>40), often presents with pain + lump?
- osteosarcoma
- ewing’s sarcoma
- chondrosarcoma
- chondrosarcoma
Which of the following x-ray findings is seen in Osteosarcoma?
- sunburst appearance
- ‘onion skin’ periosteal reaction
- lytic lesion with ‘fluffy popcorn’ calcification
- sunburst appearance
Which of the following x-ray findings is seen in Ewing’s sarcoma?
- sunburst appearance
- ‘onion skin’ periosteal reaction
- lytic lesion with ‘fluffy popcorn’ calcification
- ‘onion skin’ periosteal reaction
Which of the following x-ray findings is seen in chondrosarcoma?
- sunburst appearance
- ‘onion skin’ periosteal reaction
- lytic lesion with ‘fluffy popcorn’ calcification
- lytic lesion with ‘fluffy popcorn’ calcification
What is a boxer’s fracture?
= refers to a fracture of the neck of the 4th or 5th metacarpal
Which of the following brachial plexus injuries is characterised by shoulder adduction, elbow extension, forearm pronation, and wrist flexion (‘waiter’s tip sign’) + dermatomal sensory loss in C5-6 distribution?
- Erb’s palsy
- Klumpke’s palsy
- Erb’s palsy
Which of the following brachial plexus injuries is characterised by dermatomal sensory in the C8-T1 distribution + weakness of the intrinsic muscles of the hand
- Erb’s palsy
- Klumpke’s palsy
- Klumpke’s palsy
Gold standard imaging for a suspected calcaneal fracture?
= computed tomography (CT)
How long should a non-displaced fracture be non on ‘no-weight bearing’?
= 6-12 weeks
What nerve is compressed in Carpal Tunnel Syndrome (CTS)?
= median nerve
Most common mononeuropathy encountered in clinical practice
= Carpal Tunnel Syndrome (CTS)
Primary investigation for Carpal Tunnel Syndrome
- electromyography (EMG)
Carpal Tunnel Syndrome: conservative management (4)
- wrist splitting
- NSAIDs
- corticosteroid injections
- modifying activities that exacerbate symptoms
At what vertebral level does the spinal cord end (conus medullaris)?
= around L1
Most common cause of cauda equina?
= lumbar disc herniation (L4/5, and L5/S1)
Gold standard imaging for cauda equina?
= urgent whole-spine MRI
Main goal in management of cauda equina?
= surgically decompress affected area within 48 hours
Cauda equina: If malignancy is identified on MRI, or clinical suspicion is high what can be given?
= Dexamethasone 16mg faily in divided doses (with PPI cover)
Foot drop and foot eversion is seen in which type of nerve injury?
= common peroneal nerve injury
What is Complex Regional Pain Syndrome (CRPS) AKA, Sudek’s Atrophy?
= complex, chronic pain disorder that arises even in the absence of nerve injury
Most common cause of Complex Regional Pain Syndrome (AKA, Sudek’s Atrophy)?
= post-trauma particularly from fractures + orthopaedic procedures
How long after insult does Complex Regional Pain Syndrome become symptomatic?
= presents weeks to months after initial insult
(usually affecting neighbouring areas)
What is allodynia?
= pain from a non-painful stimulus
What is hyperalgesia?
= increased pain response
Medications which are used in Complex Regional Pain Syndrome (CRPS)? (2)
Amitriptyline or Gabapentin
Which cruciate ligament is more likely to be injured due to sudden deacceleration or change in direction?
= ACL
Which cruciate ligament is more likely to be injured due to a direct blow to the proximal tibia when the knee is flexed?
= PCL
Tests for a posterior cruciate ligament injury? (2)
- posterior drawer test
- posterior sag test
Describe the Phalen’s test, and what is is used for
= press the back of your hands and fingers together with your wrists flexed in completion and your fingers pointed down. You will stay in that position for at least one or two minutes
The test is positive (abnormal) if the patient experiences characteristic symptoms of carpal tunnel syndrome (pain and paresthesias along the distribution of the median nerve, i.e., thumb, index finger, and middle finger)
