Orthopaedics Flashcards
What is a hemiarthroplasty?
Replacing only half the joint e.g. head of femur in the hip joint only as opposed to a total hip replacement
What is given to patient before/during a joint replacement surgery?
Prophylactic antibiotics
Tranexamic acid
VTE prophylaxis
What types of fracture typically only occur in children?
Greenstick, buckle, salter-harris
What is a comminuted fracture?
Multiple fragments of bone
A fall on an outstretched hand is likely to result in what two kinds of fracture?
Colle’s fracture and scaphoid fracture
What is a Colle’s fracture?
Transverse fracture of the distal radius near the wrist causing the distal portion to displace posteriorly
What is a key sign of a scaphoid fracture?
Tenderness in the anatomical snuffbox
Why do displaced scaphoid fractures require surgical fixation?
They have a retrograde blood supply which can result in avascular necrosis
What are the Ottawa criteria for ankle x-rays following ankle injury?
Pain is present in the malleolar zone and one of the following:
1. Inability to walk four steps
2. Bony tenderness at the medial malleolar zone
3. Bony tenderness at the lateral malleolar zone
Can you break you pelvis in only one place?
No due to it being a ring you have to break it in two locations
What are the most common sites for pathological fractures?
Femur and vertebral bodies
How can you achieve mechanical alignment of a fracture?
Closed reduction via manipulation of the limb OR open reduction via surgery
How can you provide relative stability to a joint in order to allow it to heal?
External casts, K wires, intramedullary wires, screws, plates
What is a fat embolism?
Occur 24-72 hours following a fracture in a long bone, fat globules are released and becomes lodged in blood vessels
Where are intracapsular fractures located?
Break in the femoral neck, affect the area proximal to the intertrochanteric line
How is a non-displaced intracapsular fracture treated?
Internal fixation
How is a displaced intracapsular fracture treated?
If older/frail = hemiarthroplasty
Otherwise = total hip replacement
How are intertrochanteric fractures managed?
Dynamic hip screw
How are subtrochanteric fractures treated?
Intramedullary nail
What is the presentation of hip fracture?
Pain in groin/hip, fall, not able to weight bear, shortened, abducted and externally rotated leg
What is the imaging of choice for a hip fracture?
AP and lateral view XR
How long following surgery should patients be encouraged to weight bear?
Immediately
What is compartment syndrome?
Where the pressure within the fascial compartment is abnormally elevated cutting off the blood flow to the contents of that compartment
What causes acute compartment syndrome?
Acute injury where bleeding or tissue swelling leads to the increased pressure
What are the symptoms of compartment syndrome?
Disproportionate pain to the underlying injury, worse pain on passive stretching, pale, paraesthesia, paralysis
What is the management of compartment syndrome?
Emergency fasciotomy
What is the most common cause of osetomyelitis?
Staph aureus
What are the modes of infection in osteomyelitis and which is most common?
Haematogenous (most common)
Direct (fracture or during surgery)
What is the presentation of osteomyelitis?
Fever, pain, erythema, swelling, non-specific
What is the best imaging modality for diagnosing osteomyelitis?
MRI scans
How is osteomyelitis managed?
Surgical debridement, 6 weeks of IV flucloxacillin (+ rifampicin or fuscidic acid)
What are the red flags for back pain?
Non-mechanical back pain, history of previous malignancy/HIV, night pain, systemically unwell, thoracic back pain, widespread neurological symptoms
What are the red flag causes of back pain?
Cauda equina, spinal fracture, spinal stenosis, ankylosing spondylitis, spinal infection, malignancy
Where does the sciatic nerve supply sensory and motor innervation to?
Sensation to lateral lower leg and foot
Motor function to posterior thigh, lower leg and foot
What are the symptoms of sciatica?
Unilateral pain from buttock radiating down the back of the thigh to knee/foot - electric/shooting pain
Paraesthesia, numbness, motor weakness, absent or reduced reflexes
What is the initial management for sciatica and what is the chronic management?
NSAIDs
Amitriptyline or duloxetine for persisting pain
What do the nerves of the cauda equina supply?
Sensation - lower limbs, perineum, bladder and rectum
Motor - lower limbs, anal and urethral sphincters
Parasympathetic innervation of bladder and rectum
What are the causes of cauda equina?
Herniated disc - most common
Tumours
Spondylolisthesis
Abscess
Trauma
What are the red flag symptoms in cauda equina?
Saddle anaesthesia, loss of sensation in bladder and rectum, urinary retention or incontinence, faecal incontinence, bilateral sciatica, bilateral motor weakness in legs, reduced anal tone on PR exam
What is the management of cauda equina?
Emergency MRI and lumbar decompression surgery
What is the management of metastatic spinal cord compression?
High dose dexamethasone
May require surgery or radiotherapy/chemotherapy
What is spinal stenosis?
Narrowing of part of the spinal cord resulting in compression of the spinal cord or nerve roots (most commonly lumbar spine)
What are the causes of spinal stenosis?
Congenital, degenerative, herniated disc, thickening of the ligamenta flava, spinal fractures, spondylolisthesis, tumours
What is the presentation of spinal stenosis?
Intermittent neurogenic claudication - lower back/buttock/leg pain, leg weakness, numbness
Symptoms are worse on standing/walking and are relieved by leaning forward (e.g. cycling)
What is the management of spinal stenosis?
Exercise, weight loss, physio, analgesia
Laminectomy can be performed
What are the features of L3 nerve root compression?
Sensory loss over anterior thigh, weak hip flexion and knee extension, reduced knee reflex
What are the features of L4 nerve root compression?
Sensory loss over anterior aspect of knee and medial malleolus, weak knee extension and hip adduction, reduced knee reflex
What are the features of L5 nerve root compression?
Sensory loss over dorsum of foot, foot drop, intact reflexes
What are the features of S1 nerve root compression?
Sensory loss over posterolateral aspect of leg and lateral aspect of foot, weakness in plantar flexion of foot, reduced ankle reflex
What is in initial investigation of choice in bony lumps and soft tissue swellings?
Bony lumps = x-ray
Soft tissue swellings = USS
What is meralgia paraesthetica?
Mononeuropathy - sensory symptoms of the outer thigh due to compression of the lateral femoral cutaneous nerve
What are the presenting symptoms of meralgia paraesthetica?
Abnormal or loss of sensation in the outer thigh, aggravated by walking or standing for a long duration and improve when sitting down, symptoms worse with extension of the hip
What are the management options for meralgia paraesthetica?
Physio, analgesia, surgical decompression
What is discitis and what is the most common causative agent?
Infection of the intervertebral disc space
Staph aureus is most common cause
What is the management of discitis?
MRI spine
6-8 weeks of IV antibiotics (e.g. IV flucloxacillin)
What is trochanteric bursitis?
Also known as greater trochanteric pain syndrome
Bursa because inflamed due to repetitive movements, trauma or inflammatory conditions such as RA
What are the symptoms of trochanteric bursitis?
Gradual onset lateral hip pain, worse with activity, may disrupt sleep, pain on resisted movement but ROM should be normal
What is the management of trochanteric bursitis?
Rest, ice, analgesia, physio and steroid injections
What kind of knee injury results in a meniscal tear?
Twisting movement in the knee - common in sporting injuries
In older age the meniscus becomes more prone to injury and tears can occur with very minor twisting movements
What is the presentation of meniscal tear?
Popping sensation, pain, swelling, stiffness, restricted ROM, locking of the knee, knee giving way
What is the 1st line and gold standard imaging investigation in meniscal tears and ACL injuries?
1st line = MRI
Gold = arthroscopy
What is the management of meniscal tears?
NSAIDs, physio, arthroscopy with repair or resection of the meniscus
What are the Ottawa knee rules for determining whether a patient requires a knee XR after acute injury?
Age 55 or above
Patella tenderness (not anywhere else)
Fibular head tenderness
Cannot flex the knee to 90 degrees
Cannot weight bear
What is the presentation of an ACL injury?
Damaged during twisting injury
Pain, swelling, popping of the knee, instability of the knee
What is the management of ACL injury?
NSAIDs
RICE
Arthroscopic surgery to reconstruct knee
Crutches and knee braces required to protect knee while mobilising
What are the causes of a baker’s cyst?
Most common = degenerative changes in the knee
Meniscal tears, knee injuries, inflammatory arthritis, osteoarthritis
What is the presentation of a baker’s cyst?
Pain, fullness, pressure, lump/swelling, restricted ROM
Lump is most obvious when patient stands with their knees fully extended
What is the presentation of a ruptured baker’s cyst?
Pain, swelling and erythema of the knee and calf muscle
(need to exclude DVT as differential)
What imaging investigations can be done in Baker’s cyst?
USS (diagnose but also rules out DVT)
MRI can evaluate cyst further if required
What is the management of baker’s cyst?
Analgesia, physio, USS guided aspiration, steroid injections
What are the causes of achilles tendinopathy?
Sports that stress the achilles, inflammatory conditions, diabetes, raised cholesterol, fluoroquinolone antibiotics
What is the presentation of achilles tendinopathy?
Gradual onset of pain or aching in the achilles tendon or heel with activity, stiffness, tenderness, swelling
What is the management of achilles tendinopathy?
Exclude rupture, RICE, physio, orthotics (insoles), surgery to remove nodules and adhesions
Do not do steroid injections as increases risk of rupture
What are the risk factors for achilles tendon rupture?
Sports that stress the achilles, increasing age, existing achilles tendinopathy, family history, fluoroquinolone antibiotics, systemic steroids
What is the presentation of of achilles tendon ruputre?
Sudden onset of pain in achilles or calf, snapping sound, something has hit them in the back of the leg, rest in a more upright position
What is the Simmond’s calf squeeze test?
Positive result in achilles tendon rupture
Squeezing the calf muscles will not cause plantar flexion of the ankle
What investigation is used in achilles tendon rupture?
USS
What are the management options of achilles tendon rupture?
Non-surgical - specialist boot to immobilise the ankle
Surgical - surgery followed by boot to immobilise ankle
What is the presentation of plantar fasciitis?
Gradual onset of pain on the plantar aspect of the heel, worse with pressure and standing for prolonged periods
How is plantar fasciitis managed?
RICE, NSAIDs, physio
What is fat pad atrophy and what are the symptoms?
Fat pad over heel atrophies due to age or inflammation (measured with USS), pain and tenderness over plantar aspect of heel
What is the management of fat pad atrophy?
Comfortable shoes, custom insoles, weight loss
What is Morton’s neuroma and what are the symptoms?
Dysfunction of the nerve between the toes towards the top of the foot, pain at the foot of the foot, sensation of lump in shoe, burning/numbness/paraesthesia
What is the management of Morton’s neuroma?
USS/MRI to confirm
Analgesia, insoles, weight loss, steroid injections
What is a bunion and what are the symptoms?
Bony lump created by deformity at base of big toe, first MTP becomes angled medially and toe is angled laterally
Pain in the area when walking and wearing tight shoes
What are the management options for bunions?
Conservative = wide shoes, analgesia
Surgical correction
What is the presentation of frozen shoulder/adhesive capsulitis?
Painful phase, followed by stiff phase (external rotation most affected), gradual improvement and return to normal
What are the differential diagnoses for shoulder pain not preceded by trauma?
Supraspinatus tendinopathy (tested with empty can test), acromioclavicular joint arthritis (tested with scarf test), frozen shoulder, glenohumeral joint arthritis
What are the differential diagnoses for shoulder pain preceded by trauma?
Shoulder dislocation, fractures, rotator cuff tear
What is the management of frozen shoulder?
Continue to use arm but do not make pain worse, NSAIDs, physio, steroid injection
What are the causes of rotator cuff tears?
Acute injuries such as falling on outstretched hand, degenerative, overhead activities such as playing tennis
What 4 muscles make up the rotator cuff?
Supraspinatus, infraspinatus, teres minor, subscapularis
What imaging is done in suspected rotator cuff tears?
USS/MRI
What is the management of rotator cuff tears?
Rest, analgesia, physio
Can have surgery if young or full thickness tear
Which is more common anterior or posterior should disclocations?
Anterior - posterior are caused by electric shocks and seizures
Which nerve is commonly damaged in shoulder discloations and what symptoms occur as a result?
Axillary nerve - loss of sensation over lateral deltoid, motor weakness in deltoid
What is the apprehension test?
Test for shoulder instability due to previous anterior shoulder dislocation - won’t allow you to do movement due to fear of shoulder popping back out
What imaging is done for shoulder dislocations?
X-rays are used in acute scenarios
Arthroscopy
What is the management of shoulder dislocations?
Relocated as soon as possible as the muscle spasms over time making it more difficult followed by immobilisation
What is olecranon bursitis and what are the symptoms?
Inflammation and swelling of bursa over elbow due to repetitive movements or leaning on elbow, infection
Symptoms = swollen, warm, tender and fluid filled elbow
What is the management of olecranon bursitis?
Aspirate the fluid for MC+S (rule out infection as a cause)
RICE, analgesia, protect elbow from pressure, aspirate the fluid to relieve pressure, steroid injections if problematic
What is lateral epicondylitis?
Tennis elbow, pain and tenderness at the lateral epicondyle (outer elbow) - type of RSI
What is medial epicondylitis?
Golfer’s elbow, pain and tenderness on inner elbow - type of RSI
How do you manage epicondylitis?
Self-limiting, NSAIDs, physio, steroid injections, rest
What is De Quervain’s tenosynovitis?
RSI –> swelling and inflammation of tendon sheaths of abductor pollicis longus and extensor pollicis brevis
What are the symptoms of De Quervains’s tenosynovitis?
Symptoms at the radial aspect of the wrist near the thumb - aching, burning, weakness, numbness, tenderness
What is the test for De Quervains’s tenosynovitis?
Finkelstein’s test - make fist with thumb inside fist and deviate wrist towards ulnar
Positive test = pain on this movement
What is the management of De Quervains’s tenosynovitis?
Rest, splints, analgesia, physio, steroid injections
What is the presentation of trigger finger?
Painful finger around MCP joint, does not move smoothly, makes popping noise, gets stuck in flexed position
What is the management for trigger finger?
Rest, analgesia, splinting, steroid injection, surgery
What are the risk factors for carpal tunnel?
Repetitive strain, obesity, perimenopause, RA, diabetes, acromegaly, pregnancy, hypothyroidism
What is the presentation of carpal tunnel?
Sensory symptoms in palmar aspects of thumb, index, middle and lateral half of ring finger, shaking hands may relieve symptoms, difficulty with fine movements of thumb
What special tests can be done to help aid diagnosis of carpal tunnel?
Phalen’s test - reverse prayer sign
Tinel’s test - tapping of the wrist
What is the management of carpal tunnel?
Rest, wrist splints at night for 4 weeks, steroid injections, surgery
What investigations are done for ganglionic cysts?
USS can confirm and exclude other causes - usually a clinical diagnosis
How can ganglionic cysts be managed?
Conservatively
Needle aspiration, surgical excision
How can you differentiate between meniscal tear and ACL/PCL injury?
Meniscal tear will gradually swell and have pain on the joint line
ACL/PCL will swell immediately will have pain above/below the joint line where the ligament inserts
When should you refer to orthopaedic surgeons in trauma cases?
If there is any neurovascular deficit
How do c-spine fractures present?
Severe pain in neck/chest/back, may have neuro findings in hands/arms
What is the best imaging modality for C-spine fractures?
CT scan neck
What initial imaging investigation should be done in someone with persistent/red flag back pain?
Plain x-ray (followed by MRI)
Compression of the T1 nerve leads to …
Intrinsic hand muscle wasting and loss of sensation over the ulnar aspect of the forearm
