Orthopaedics Flashcards
vitamin D normal serum value
75-250 nanomole/L
Normal BMD T-score
> -1
osteopenic BMD T-score
-1 to -2.5
Osteoporotic BMD T-score
< -2.5
NEXUS Criteria
Finkelstein’s test
De Quervain tenosynovitis
Tinel sign
Carpal tunnel syndrome
Fromenr’s sign
Ulnar nerve injury
Thompsons test
Achilles tendon lesion/rupture
Lachmans test
ACL
Drawers test
anterior: ACL
posterior: PCL
Bulb sign
Posterior dislocation of shoulder
most useful test for evaluation of osteoporosis
- DEXA
- 25-hydroxy vitamin D
corticosteroid use in osteoporosis
at least 3 months
Back pain without neurological symptoms
pulled muscle/muscle spasm
- analgesia + normal activity
Back pain classification
1- Acute low back pain lasts less than 6 weeks.
2- Sub-acute low back pain lasts between 6 and 12 weeks.
3- Chronic low back pain persists for more than 12 weeks.
Back pain diagnosis
chronic back pain persisting longer than 3 months, have to exclude:
- central canal stenosis
- nerve root compression
Signs of cauda equina compression
- loss of bladder
- loss of bowel control
- paraparesis/paraplegia
bilateral leg pain + worse on erect posture + responds to exercise
Spinal stenosis
Back pain around the anus, scrotum or vagina
saddle anaesthesia
- investigate by MRI
Acute herniation of an intervertebral disk that will require emergency surgery
crushed cauda equina
shooting radiating pain through the posterior thigh and posterior leg to little toe + anterior + posterior motor symptoms
Sciatica
pain radiating to the hip + anterior thigh + medial aspect of knee + calf + diminished knee jerk
L4 radiculopathy
posterolateral buttock + posterior thigh + lateral leg +
L5 radiculopathy
posterolateral buttock + posterior thigh + lateral leg posterior calf + lateral foot + diminished Ankle jerk
L5-S1 radiculopathy
pain radiates through posterior buttock + posterior calf +
lateral foot + diminished Ankle jerk
S1 radiculopathy
weakness of eversion and dorsiflexion + sensory loss of dorsum of foot + hc of colon cancer surgery
Common peroneal nerve damage
weakness of foot plantar flexion + inversion
Tibial nerve
Hip pain management
- walking stick on the contralateral hand
hip joint degeneration affected movement
Internal rotation
osteoporosis most common site fracture
Vertebrae
Osteoporosis risk factors
– Menopause
– Age over 70
– Corticosteroid use longer than three months
– Rheumatoid arthritis
– Alcoholism
– Smoking
– Anorexia nervosa.
– Inflammatory Bowel Disease
pain in the distal interphalangeal joints + carpometacarpal joints + hard/bony swelling + evening stiffness
Osteoarthritis (OA)
Osteoarthritis treatment
symptomatic pain treatment
Osteoarthritis not responding to pain
Severe
- orthopaedic consult for knee replacement
Osteoporosis treatment
- Alendronate, risedronate and zoledronic acid: first-line therapy in **postmenopausal osteoporosis **
and prevent vertebral, Non-vertebral and hip fractures. - bisphosphonates: primary prevention of fractures in px who never had minimal trauma fracture, secondary prevention of fractures
- Strontium ranelate: primary prevention of osteoporosis in women
- bisphosphonates and raloxifene: secondary prevention of fractures in women who have had minimal trauma fractures
Osteoporosis treatment not going to plan, what to do
Biphosponate not working
- BMD T-score of =<-3
- > 1 symptomatic new
fracture after at least 12-months of
continuous therapy - > 2 minimal trauma fractures despite being on sufficient doses of bisphosphonates.
switch to teriparatide for 18 months
Most common pelvic bone tumour in young adult
Metastatic tumor
non-healing diabetic foot ulcer concern
osteomyelitis
- Do MRI
child + fever + limp + raised ESR
Acute osteomyelitis
osteomyelitis in children
- S aureus
- secondary to deep cellulitis
-MRI investigation
pain in the proximal interphalangeal joints + carpometacarpal joints + soft/tender swelling + morning stiffness > 30 minutes
Rheumatoid arthritis (RA)
Diagnosis of rheumatoid arthritis (RA)
-Persistent joint pain and swelling affecting at least three joint areas
2-Symmetrical involvement of the MCP or MTP joints
3-Morning stiffness lasting more than 30 minutes.
(if there’s a rash: Psoriatic arthritis)
Rheumatic arthritis treatment
NSAIDs + DMARDS
asymmetrical large joint monoarthritis/oligoarthritis + rash + uveitis + enthesitis
Reactive arthritis
Distal interphalangeal joints are most commonly seen in
Psoriatic arthritis
septic arthritis
septic arthritis management
- IV antibiotics (flucloxacillin) for 2 weeks
- Oral antibiotics after 6 weeks
positive rhomboid-shaped birefringent crystals
Pseudogout
Negative needle shaped birefringent crystals
Gout
Gout causes
- Alcohol (increase urate)
Gout investigation
Diagnostic: joint aspiration
sclerosis of sacroiliac joint
sacroiliitis
sacroiliitis ddx
– Psoriasis.
– Reactive arthritis.
– Ankylosing spondyloarthropathy.
– Arthritis related to inflammatory bowel disease
sacroiliitis causes
1-HLA-B27
2-Chlamydia and Gonorrhoea serology
3-RA factor, anti-ccp to rule out Rheumatoid arthritis
4-Inflammatory markers such as ESR and C-reactive protein
Ankylosing spondylitis features
- Sacroilitis is the earliest manifestation
- In only 5% cases, onset is after the age of 40 years
- Median age of onset is 23 years of age
- More than 40% patients present with unilateral ocular pain, lacrimation and
photophobia - Limited chest expansion
- Limitation of movement of lumbar spine in both sagital and frontal planes
- inflammatory back pain
Ankylosing spondylitis management
1st line: NSAIDs
2nd: TnF alpha inhibitors
- Infliximab
- Adalimumab
- rituximab
Bisphosphonates prerequisites
Vitamin D level (symptomatic hypocalcaemia)
renal function test (creatinine > 35mL)
Bisphosphonates side-effects
- oesophagitis
- jaw osteonecrosis
Scaphoid fracture
- proximal pole fracture 20%
- Distal pole fractures are 10%
- Most common site of fracture is waist of the bone 70%
Most common type of scaphoid fracture
proximal pole fracture 20%
blood supply to the scaphoid
distal to proximal
Scaphoid fracture complication
– Non-union.
– Avascular necrosis.
– Carpal instability.
– Osteoarthritis.
Scaphoid fracture investigation
CT scan
Summary:
• Initial Step: X-ray (including specific scaphoid views). • If X-ray is negative but suspicion remains: Consider MRI or CT. • Alternative: Immobilization and follow-up X-rays after 10-14 days.
Scaphoid fracture prognosis
distal pole fractures is better than proximal pole because of low risk of vascular compromise
- may take up to 1-2 weeks to become visible radiologically
age 3-8 + viral illness + acute hip/thigh Pain + limp + hip decreased range decreased range of motion
transient synovitis transient synovitis (TS),
transient synovitis transient synovitis (TS) management
ibuprofen
medial deviation of the forefoot with a normal neutral position of the hindfoot
Metatarsus adductus (MA)
- corrects spontaneously;
rigid positioning + medial/upward deviation of forefoot & hindfoot + hyperplantar flexion of foot
congenital clubfoot
congenital clubfoot management
serial manipulation and casting
-surgery if dire
knee X-ray is required when a child presents after an injury
– Isolated patellar tenderness.
– Tenderness at the head of the fibula.
– Inability to flex at 90 degrees.
– Inability to bear weight immediately after trauma and in an emergency.
subluxed, dislocated femoral heads + knees are at unequal heights when hips and knees are flexed + asymmetric skin folds + limited abduction
Developmental dysplasia of the hip
Developmental dysplasia of the hip risk factors
- female
- breech presentation
- positive family history of hip dysplasia
Developmental dysplasia of the hip screening
- < 6 months: Hip examination (Ortolani), US
- > 6 months: X-ray
athlete + overuse apophysitis of the tibial tubercle + pain upon quadriceps contraction
Osgood-Schlatter disease
4-10 years + avascular necrosis of the femoral head
Legg-Calve-Perthes Disease
Overweight adolescent + limping + hip stiffness + hip pain radiating to antero-medial thigh and knee
Slipped capital femoral epiphysis
Slipped capital femoral epiphysis management
Percutaneous pin fixation
injuries warranting knee X-ray in children
– Isolated patellar tenderness.
– Tenderness at the head of the fibula.
– Inability to flex at 90 degrees.
– Inability to bear weight immediately after trauma and in an emergency
by trauma, as a result of a fall, or by the direct pressure and friction of repetitive kneeling
Acute prepatellar bursitis (housemaid’s knree)
Acute prepatellar bursitis management
- NSAIDs
- glucocorticoid injection
Absolute contraindication to total knee
replacement
Septic knee
‘pop’ at time of knee injury + severe pain + effusion (hemarthrosis) + instability of the knee changing direction
anterior cruciate ligament (ACL) injury
‘twinge’ or sudden pain + Medial Joint line tenderness + able to continue activity with some discomfort
Medial meniscus tear
Medial meniscus tear investigation
- barefooted with the knee flexed to 20 degrees and rotates the body
and knee three times internally and externally (Thessaly test) most useful
Flexion/rotation test (McMurray test) for screening
hx of type 2 DM + severe global passive movement restriction affecting all planes of movement + bilateral pain
Adhesive capsulitis (Frozen shoulder)
adhesive capsulitis movement restriction
all planes of movement but especially internal rotation
Adhesive capsulitis features
- bilateral 20%
- Diabetic 80%
- painful freezing phase, adhesive phase and a recovery phase 6months-2years
Adhesive capsulitis management
– 1st line: NSAIDS.
– 2nd line: - Intra-articular steroids
- Physiotherapy /Occupational Therapy
– Oral steroids (prednisolone) if NSAIDs not working
Winging of the scapula nerve impingmeent
Long thoracic nerve
shoulder pain + shoulder abduction weakness + external roation weakness
suprascapular nerve entrapment (SNE)
- shoulder abduction (supraspinatus)
- external rotation (infraspinatus)
Muishaft humeral fracture will cause what nerve injruy
radial nerve
prominent acromion + loss of deltoid contour + slightly abducted and externally rotated
anterior shoulder dislocation
anterior shoulder dislocation nerve injury
Axillary nerve
Adhesive capsulitis management
prednisolone 30 mg daily for 3 weeks
- wean after 6 weeks
most common complication of Colles
fracture
Malunion
earliest complication of Colles fracture
Ischemic Volkmann contracture
Most common elbow fracture in children
supracondylar fracture
most serious complication of supracondylar fractures
Volkmann ischemic contracture
- permanent damage to nerves and muscles of the forearm leading to contractures
Radial nerve injury
wrist drop
- decreased or absent thumb extension and abduction
- Decreased sensation over dorsum of the hand (thumb, index, middle and half of the ring fingers)
Median nerve injury
- Colles fracture
- acute carpal tunnel syndrome
- impaired thumb abduction
- paraesthesia
Colles fracture nerve injury
median nerve
Colles fracture cast management
the wrist should be in 10° flexion and 10° ulnar deviation 4-6 weeks
lower limbs trauma or surgery + 24 to 72 hours after injury + altered mental state + dyspnoea + petechiae + eye/torso haemorrhage
fat embolism
sudden onset of severe calf pain + limping + absent plantar reflex
Achilles tendon rupture
Achilles tendon rupture investigation
Thompson Test
- absent plantar reflex
Calcaneal fracture can give rise to what injury
spinal injury
- do Spinal x-ray series
A calcaneal fracture, also known as a heel bone fracture, is a break in the calcaneus, which is the largest bone in the foot and forms the heel. Calcaneal fractures are often caused by high-energy trauma, such as falls from height or motor vehicle accidents. These fractures can have significant impact on foot function and mobility, making prompt diagnosis and appropriate management crucial.
serious complication after cast application
compartment syndrome
compartment syndrome diagnostic symptom
throbbing pain increasing after wiggling fingers/toes
compartment syndrome complications
permanent nerve damage or loss of limb due to decreased circulation and oxygen to the tissue
bone pain + tibia bowing + enlarged skull with frontal bossing
Paget’s disease
Paget’s disease features
-Elevated alkaline phosphatase (early finding)
- bone pain (most common symptom)
Paget’s most common location
Pelvis 70%
Paget’s disease management
IV Zoledronic acid
Bisphosphonate, Alendronate
- paracetamol, NSAIDs
- vitamin D and calcium supplementation (prevent hypocalcaemia and secondary hyperparathyroidism)
wrist movements is most likely to reproduce the pain in a patient with lateral epicondylitis
Resisted extension
lateral epicondylitis management
Band support below the elbow
pain worsens on thumb and wrist + grasping + tenderness on proximal to radial styloid
De Quervain tenosynovitis
thickened fascia of 4th digit + joint stiffness + a loss of full extension
Dupuytren’s contracture
Dupuytren’s contracture cause
- Alcohol
- DM
- epilepsy
- male
Dupuytren’s contracture management
depends on severity
low/moderate: Steroid injection
severe: Open fasciectomy
pain and numbness in the fingers + HIV + multiple loose bodies in the ulnar bursal fluid
Mycobacterial tenosynovitis due to Mycobacterium avium complex
volleyball and baseball injury + flexion deformity + inability to actively extend finger
Mallet finger
Mallet finger management
Maintain hyper-extension of the distal interphalangeal joint for 6-8 weeks
most common joint affected in diabetic neuropathy
tarsus and tarsometatarsal joints(midfoot)
severe burning pain between the third and fourth toe + gets better walking barefoot + gets worse on weight bearing + localised tenderness
Morton Neuroma
Heel pain + medial tuberosity tenderness + worse getting out of bed + relieved by walking
Plantar Fasciitis
treatment for plantar fasciitis
- stretching exercises for the plantar fascia and calf muscles
- Avoid flat shoes and barefoot walking
- arch supports
and/or heel cups - Decreasing causative or aggravating exercise
- NSAIDs
- glucocorticoids and a local anesthetic
Major Branches of Brachial Plexus
- MUSCULOCUTANEOUS NERVE ( C5,C6,C7) - REMEMBER IT SUPPLIES- BICEPS
BRACHII, BRACHIALIS - AXILLARY NERVE ( C5,C6)- it wraps around the neck of humerus. REMEMBER DELTOID AND REGIMENTAL BADGE SIGN
- MEDIAN NERVE ( C5-T1)- REMEMBER - ALL FLEXORS OF FOREARM EXCEPT 1.5
- RADIAL NERVE (C5-T1) - REMEMBER ALL THE EXTENSORS
- ULNAR NERVE (C8-T1)- 1.5 FLEXORS + ALL THE INTRICATE MUSCLES OF THE Hand
