Orthopaedics Flashcards
What is used to assess fracture risk
FRAX tool
What is squaring of thumbs seen in
OA
Presentation of a prolapsed disc
Back pain worse on sitting
Leg pain worse than back pain
Associated relevant sensory and motor deficit
Management of prolapsed disc
1st line- physio, exercise, NSAID with PPI
If no response after 6 weeks do MRI
What predisposes people to tendon problems
High cholesterol forming tendon xanthomata
Quinolones
Eccentric vs concentric movements
Eccentric lengthens a joint like elbow extension
Concentric shortens like elbow flexion
Presentation of achilles tendonitis
Pain in heel worse after exercise
Like in inflammatory disorders
- morning pain and stiffness
Achilles tendonitis management
Supportive
- analgesia
- physio if persists beyond 7 days
Presentation of Achilles heel rupture
Feel pop when playing sport
Debilitating pain in heel/calf-
Examination findings of achilles rupture
Simmonds positive
Greater dorsiflexion of that foot
First line imaging for suspected achilles rupture
USS
Management of achilles rupture
Ortho referral immediately
Management of ganglion cyst
Will resolve in a few months
Surgery if severe sx or neurovascular compromise
Presentation of ganglion cyst
Lump on dorsal aspect of wrist
Firm and transilluminates
More common in women
Examination finding of ganglion cyst
Firm and transilluminable cyst most commonly
What is a ganglion
Cyst arising from tendon
What exercises used for achilles tendonitis
Eccentric stretching of achilles
What do if achilles tendonitis fails to respond to analgesia
If no improvement after 7 days refer for physio
What is phalens sign
Carpal tunnel sx worsened by flexion of wrist
What is tinels sign
Tapping on median nerve leads to parasthesia
What nerve compressed in carpal tunnel
Median
Carpal tunnel presentation
Pain or pins and needles in the median nerve distribution- middle finger to thumb
Shaking hand to relieve sx especially at night
Electrophysiology findings of carpal tunnel
Prolongation of motor and sensory action potentials
What are exam findings in carpal tunnel
Wasting of thenar eminence
Reduced thumb abduction
Sensory loss middle finger to thumb
Tinels and phalens signs
What can cause carpal tunnel
Idiopathic
RA
Oedema
Pregnancy
Acromegaly
Amyloidosis
Management of carpal tunnel
Mild/moderate- options include wrist splint (especially if transient cause like pregnancy), corticosteroid injections
Severe- decompression by dividing flexor retinaculum
Management of carpal tunnel if pregnant
Wrist splint as only transient
Presentation of stress fractures
Prolonged usage of that limb
Sudden onset severe pain
X ray finding of stress fracture
Callous formation at site of pain
Management of stress fractures
If very severe pain then immobilisation
What is tibial stress syndrome
Constant pressure in legs seen in athletes and military personnel leads to pain and tenderness over the tibia
Management of tibial stress syndrome
Rest and recovery
Do an x ray to rule out a stress fracture
Causes of cauda equina syndrome
Most common- central disc prolapse
Tumours
Haematomas
Abscesses
Trauma
Presentation of cauda equina
Back pain
Bilateral sciatica
Saddle paraesthesia/ pins and needles
Reduced anal tone
Incontinence is a late sign
What is a late sign of cauda equina
Urinary incontinence
Management of patient with cauda equina
Urgent MRI
Surgical decompression
What does positive straight leg test indicate
sciatic nerve pain from prolapsed disc
Knee pain which worse after exercise in teenager, causes knee to lock and clunk
Osteochondritis dissecans
When urgently do MRI in sciatica
Weakness or parasthesia
Bladder or bowel dysfunction
Bilateral symptoms
Second line options for prolapsed discs
Neuropathic analgesiacs
What do if prolapsed discs fail to respond to NSAIDs, physio and neuropathic options
Injections or a surgery
What causes a colles fracture
Falling on outstretched hands
What causes a smiths fracture
Falling onto posterior side of hand/wrist
How investigate compartment syndrome
Intracompartmental pressure measurements
Above 40 is diagnostic
Key presentation features of compartment syndrome
Pain on movement
Pallor
Swelling
Paralysis
Parasthesia
What are risk factors for compartment syndrome
Supracondylar fractures
Tibial shaft injuries
Fixation with intramedullary nails
What use to determine if ankle x ray needed for suspected fracture
Ottowa rules
When need to use x ray for suspected ankle fracture
If pain in ankle area plus 1 of
- bony tenderness in lateral malleolar zone
- bony tenderness in medial malleolar zone
- unable to walk 4 steps after injury and in ED
What are the medial and lateral malleolus zone
Medial- within 6 cm upwards from medial malleolus
Lateral- within 6cm upwards from lateral malleolus
What is cubital tunnel syndrome
Compression of the ulnar nerve
Presentation of cubital tunnel syndrome
Tingling and numbness in the 4th and 5th fingers
May develop weakness and muscle wasting in that area
Pain worse when lean on elbow
Management principals of cubital tunnel syndrome
Physio, steroid injections
Surgery if resistant
How differentiate avascular necrosis of hip from osteoarthritis of hip
Avascular necrosis may present with night pain
Exacerbated by exercise too
No stiffness
Causes of avascular necrosis of hip
Steroids use
Chemo
Alcohol xs
How image avascular necrosis of hip
Plain x ray most likely will be normal but can see crescent sign
MRI investigation of choice
Management of avascular necrosis of hip
Joint replacement may be necessary
What is pathology in colles fracture and which nerve at risk of being damaged
Falling onto an outstretched hands causing distal radial fracture with dorsal displacement of fragments
Median nerve vulnerable
What is dinner fork type deformity seen in
Colles fracture
Plantar fasciitis presentation
Heel pain worse when walking
Most commonly affected under the back of heel on bony part
Management of plantar fasciitis
Rest
Shoes with good arch and cushioned heels
Weight loss
In which metatarsal are stress fractures most commonly seen in
2nd
What is immediate management of an ankle fracture
Prompt closed reduction to prevent damage to skin
What factors make more likely to operate on ankle fractures
Young
Proximal injury
High velocity
Unstable
What is most common reason for having to revise a total hip replacement
Aseptic loosening of the implant
What does tibia displacing posteriorly on application of force suggest
PCL rupture
Imaging for spinal canal stenosis
MRI
Management of lumbar spinal stenosis
Laminectomy- removes part of vertebral bone
What is de quervains tenosynovitis
Inflammation of the sheath surrounding the extensor pollicis and abductor pollicis longus
Presentation of de quervains tenosynovitis
Pain on radial side of wrist
Abduction of thumb painful
Positive finkelsteins test
What is finkelsteins test
Put the wrist in ulnar deviation-pull the thumb in abduction movement and will recreate pain over radial styloid process
What does positive finkelsteins test show
De quervains tenosynovitis
Management of de quervains tenosynovitis options
Analgesia
Steroid injection
Thumb splint
Management of rib fractures
Conservative- ensure good analgesia to make sure breathing not affected by pain, physio too
What are complications of rib fractures
Pneumothorax
Haemothorax
Poor ventilation leading to chest infections
Flail chest
Management of flail chest from rib fractures
Discuss with cardiothoracics
What can be used if simple analgesia does not work for rib fractures
Intercostal nerve blocks
When consider surgery for rib fractures
12 weeks and no healing
Flail chest
What imaging need to do for rib fractures
CT following CXR
Why give analgesia and physio after a rib fracture
To ensure good ventilation thus reducing infection risk
How does leg appear in hip fracture
Short and externally rotated
Garden classification of hip fractures
Type I: Stable fracture with impaction in valgus
Type II: Complete fracture but undisplaced
Type III: Displaced fracture, usually rotated and angulated, but still has boney contact
Type IV: Complete boney disruption
stage I and II are stable fractures and can be treated with internal fixation (head-preservation)
stage III and IV are unstable fractures and treated with arthroplasty (either hemi- or total arthroplasty)
Intra vs extra capsular hip fractures
Intra capsular= the angled capsule
Extracapsular= top part of femur
How are extracapsular hip fractures classified
Intertrochanteric
Subtrochanteric
Dividing line is horizontal to the the lesser trochanter
Management of intracapsular fractures in elderly
Undisplaced= internal fixation
Displaced= arthroplasty- total preferred if able to walk independantly with stick or more, cognitively functional and medically fit for anaesthesia
Management of extracapsular hip fractures
Dynamic hip screw
- stable intertrochanteric
Intramedullar device
- subtrochanteric
What undergoes wasting in carpal tunnel
Thenar eminence
What is a greenstick fracture
Bending of bone leads to break in cortex
What is a buckle fracture
Caused by pressure leading to buckle or shortening
What is the meniscus
Cartilage sitting on the knee joint
Presentation of meniscal tear
Twisting injuries
- knee may give way
- pain worse on straightening knee
- locking
Twisting injury that leads to pain on extension of knee
Meniscal tear
Imaging for meniscal tear
MRI
What is thessalys test
Weight bearing at 20 degrees of knee flexion, supported by doctor leas to pain on twisting
What does positive thessalys test indicate
Meniscal tear
What does a positive mcmurrays test reveal
Meniscal tear
What is mcmurrays test
Patient lies down
Flex hip and knee holding sole and knee with either hand
Internally rotate whilst extending the knee
Positive test shown by click or pain on movement
What organism causes osteomyelitis in sickle cell patients
Salmonella
Fall mechanism in posterior cruciate ligament injuries
Hyperextension injuries
Fall mechanism in anterior cruciate ligaments
Twisting force applied to a bent knee
Presentation of ACL injuries
Cracking sound
Pain
Rapid swelling
Meralgia parasthetica presentation
Pain and burning sensation over upper lateral aspect of thigh
Symptoms worsened by standing up and relieved by sitting
Presentation of fat embolism
CNS
- confused
- retinal haemorrhages
Petechial rash
Tachycardia
Fever and dyspnoea
Iliotibiral band syndrome presentation
Tenderness above lateral joint line
Lateral knee pain in runners
Management of iliotibial band syndrome
Activity modification and iliotibial band stretches
2nd line physio
What is a bakers cyst
Popliteal cysts which develop as part of a bursa behind the knee
Causes of bakers cysts
In children- idiopathic
Adults- osteoarthritis
Mechanism of fall in saphoid fracture
Falling onto outstretched hand
Presentation of scaphoid fracture
Falling onto an outstretched hand
Pain along radial aspect of wrist
Loss of grip and pinch strength
Investigations for suspected scaphoid fractures
Plain X rays in PA, lateral, PA with ulnar and oblique views first line
MRI gold standard and used if x rays inconclusive
Immediate management of scaphoid fracture
Immobilisation with futuro splint or below elbow backslab
Refer to orthopaedics, if radiographs inconclusive then review in 7-10 days
What do if initial radiographs are inconclusive for scaphoid fracture
Review in 10 days
Put in futuro splint in meantime
Ortho management of scaphoid fractures
Undisplaced scaphoid waist fractures
- cast for 6-8 weeks
Displaced waist fracture
- surgical fixation
Proximal scaphoid pole fractures
- surgical fixation
What is the most concerning type of scaphoid fracture
Proximal due to avascular necrosis risk
Metatarsal fractures causes
Runners
Women who wear heels consistently
What is an iliopsoas abscess
Collection of pus in the iliopsoas compartment
Most common organism in iliopsoas abscess
S.aureus
Secondary causes of iliopsoas abscess
Crohns
Diverticulitis
Endocarditis
IVDU
Investigation of choice for iliopsoas abscess
CT abdomen
Management of iliopsoas abscess
Abx
Percutaneous drainage
Surgery indicated if fails
Presentation of iliopsoas abscess
Fever
Flank pain
Weight loss
Limp
Pain on extension of hip
Where in bone does osteomyelitis most typically affect children
Metaphysis
Causes of dupuytrens contracture
Alcohol
Trauma
Manual labour
Phenytoin
DM
What drug can cause dupuytrens contracture
Phenytoin
Management of dupuytrens
In GP use analgesia
Refer to ortho when
- function severely affected
- unable to place hand straight on table
Options from ortho include surgery or corticosteroid injections
In anterior shoulder dislocations, what nerve needs to be checked
Axillary
What causes posterior shoulder dislocation
Electrocution
Seizure
Management of posterior shoulder dislocation
Refer to orthopaedic surgeons
Management of anterior shoulder dislocation
Reduction, analgesia
2 principles in management of an open fracture
Wound debridement+ IV abx
External fixation device
When debride an open fracture wound
Contaminated- immediately
High speed- within 12 hours
Other- within 24 hours
Where is an open fracture wound debrided
Theatre
What is a charcot joint
Neuropathic joint where feet joint over time have disrupted and damaged. Can get dislocation, disfigurement
Causes of charcot joint
DM most common
Used to be syphilis
Presentation of charcot joint
Swollen
Red and warm
Moderate pain
Joint remodelled and appears abnormal
What is an acetabular labral tear
Tear in acetabulum surrounding hip joint
Causes of acetabular labral tear
Young- trauma
Older- degenerative changes
Presentation of acetabular labral tear
Hip/groin pain
Snapping sensation
Locking sensation
Young man with hip pain following rugby match with snapping and locking sensation
Acetabular labral tear
Initial management in ED of open fracture
IV abx
Photography
Apply saline soaked gauze with impermeable dressing
Discitis presentation
Back pain
Pyrexia
Sepsis
Neuro features
Most common cause of discitis
S. aureus
Best imaging for discitis
MRI
Complications of discitis
Sepsis
Epidural abscess
Treatment of discitis
IV abx
To echo to look for vegetations
What need to do for all patients with discitis
TTE
What can help guide antibiotics choice in discitis
Blood culture or CT guided biopsy
What analgesia used for NOF
Iliofascial nerve block
After a intramedullary nail when can weight bear
ASAP as tolerated
Difference in blood work between metastatic bone disease and primary bone tumours
In metastases- ALP and calcium raised
When does hip dislocation most commonly occur
RTA
Falling from height
What are the types of hip dislocation and how do they present on examination
Anterior- abducted and externally rotated
Posterior- shortened, adducted and internally rotated
What is most common type of hip dislocation
Posterior
Management of hip dislocation
Analgesia
Reduction under GA within 4 hours
Physio long term
Which nerves are often injured in hip dislocation
Sciatic and femoral nerve
What is main function of the patella
Knee extension
Management of patella fractures
Non displaced and extensor mechanisms intact- hinged knee brace
Displaced or extensor mechanisms affected- surgical repair
Classifying ankle fractures
Weber A- distal to syndesmosis
Weber B- at level of syndesmosis
Weber C- proximal to syndesmosis
What is a maisonneuve fracture
combination of a spiral fracture of the proximal fibula together with an unstable ankle injury
Management of maisonneuve fracture
Surgery
If not operating on an ankle fracture, what do
Analgesia, weightbearing as tolerated, CAM boot
What is the ulnar nerve paradox
Injuries at level of elbow produces better deformity.
In lower lesions the hand muscles are weak but the long flexors which are supplied by the ulnar nerve just below the elbow are not affected.
In the high lesion both are weak and the clawing is more mild.
Trauma to knee followed by swelling, x ray shows no fractures
Patella dislocation
Presentation of patella dislocation
Traumatic injury to knee
Lots of swelling and tense due to haemoarthrosis
What is in simmonds triad
Calf squeeze
Observation of the angle of declination
Palpation of the tendon
What can cause rotator cuff injuries
Subacromial impingement
Calcific tendonitis
Rotator cuff tears
Arhtropathy
What does pain in first 60 degrees of abduction suggest
Rotator cuff tear
What is within painful arc syndrome
Conditions where get painful abduction between 60-120 degrees
- subacromial impingement
- supraspinatus tendonitis
Supraspinatus tendonitis presentation
Pain and tenderness over lateral shoulder
Painful arc syndrome
Things to think about in shoulder pain
Frozen shoulder
Subacromial impingement
Rotator cuff tear- weakness and pain, pain in first 60 degrees of abduction
Supraspinatus tendonitis- tender on lateral part of shoulder
What is a hill sachs lesion seen in
Glenohumeral fracture
What is acromioclavicular dislocation
Where clavicles comes out of its joint into the shoulder
Examination finding of acromioclavicular dislocation
Loss of shoulder contour
Clavicle more prominent
Step deformity visible where clavicle appears out
Management of ankle fractures in a young person
Unstable or proximal = surgery with compression plate
Stable= if Weber A or B use below knee plaster to include midfoot
Differentiating medial from lateral meniscal tear
Which side of knee pain and tenderness
What is crescent sign/sub chondral curved lucency seen in
Avascular necrosis- can see curved dark bit where arrows are
Management of ankle fractures in elderly
Ideally avoid surgery
Popping in knee, swelling and instability of joint being unable to stand
ACL injury
Management of acromicoclavicular joint injuries
Grade 1-2= conservative
Grade 3 and above= surgery
What tends to cause acromioclavicular injuries
High contact sports
Falling onto outstretched hands
Parts of bone in a child (the physis’)
Painful swelling over posterior elbow with erythematous tended swelling
Olecranon bursitis
Flank pain which radiates to back differentials
Pyelonephritis
Stone
Psoas abscess
Ruptured AAA
Presentation of osteoporotic vertebral fracture
Acute back pain
GI problems from compression of bowel
SOB from compressing lungs
Signs on examination of osteoporotic vertbral fractue
Loss of height
Kyphosis
Tenderness on back
Investigation for osteoporotic vertebral fracture
X ray
What do if patient develops suspected avascular necrosis of hip
Refer for MRI
Differences between trigger finger and dupuytrens contracture
Trigger finger
- flexion starts in fingers
- mainly affects middle and index
Dupuytrens
- flexion starts in palm
- mainly affects pinky and ring fingers
Causes of trigger finger
Idiopathic- common in women
RA
DM
Management of trigger finger
Steroid injection then put in splint
Surgery if resistant
How does trigger finger present
Pain when flexing
Nodule at base of finger
Finger flexed- typically middle and index
Elbow fracture after falling onto outstretched hand
Fracture of radial head
Fracture of radial head presentation
Falling onto outstretched hand
Tenderness over elbow point
Restricted pronation and supination
What type of motor neurone signs does CES present with
Lower
Presentation of cauda equina
Low back pain
Bilateral sciatica
Decreased anal tone
Reduced perianal sensation
Urinary dysfunction
Examination features of scaphoid fractures
Tenderness over snuffbox
Effusion in wrist
Pain on longitudal compression of thumb
Pain on ulnar deviation
What is a supracondylar fracture
Fracture of the humerus just above the elbow
What fractures are most commonly associated with compartment syndrome
Supracondylar
Tibial shaft
What is vessel affected in scaphoid fracture
Dorsal carpal arch of radial artery
What heel pain is worse when walk on toes
Plantar fasciitis
What is a bennetts fracture
Caused by punching
Fracture in thumb of first carpometacarpal joint
What is a potts fracture
Bimalleolar ankle fracture from forced foot eversion
How does stimson method work
Lie patient face down
Place weights in affected hand
Difference in fractures causing dislocation of radio-ulnar joint
Ulnar fracture- monteggia
Radial fracture- galeazzi
Remember as UM and GRRR
Risks for bicep rupture
Heavy overhead exercises
Shoulder overuse
Smoking
Steroids
Presentation of biceps rupture
Sudden pop followed by burising and pain
Subsequent weakness
Popeye sign where bulge present in middle of arms
What are 2 types of bicep rupture
Long tendon- proximal insertion to shoulder
Short tendon- distal insertion to elbow
What to do with bicep ruptures
Diagnosis should be made clinically
MRI if uncertainty or suspected distal rupture
Management of bicep ruptures
Conservative typically
Severe cases may require surgery
What tendon is harvested in ACL surgery
Semitendinosus tendon
First line for OA
If knee or hand- topical NSAID
If hip- oral NSAID and PPI
Management of trochanteric bursitis
Simple- NSAIDs, rest, ice, physio
Injections may be required
If red, inflamed and fever very indicative is infected as rarely causes inflamed normally unlike other bursitis- admit for abx and assessment
What is the blood supply to femoral head
Retrograde flow from lateral and medial circumflex femoral artery
Is why femoral head needs replacing in displaced intracapsular fractures
