Orthopaedics Flashcards
1
Q
Describe the causes of Achilles tendon rupture?
A
- Middle aged man;
- Infrequent sports goer;
- Repetitive jumping motion.
2
Q
Describe the Simmond’s triad for the diagnosis of Achilles tendon rupture?
A
Patient in prone position:
- Affected leg rests in a dorsiflexed position;
- Palbable gap at the heel;
- No plantar flexion when calf is squeezed.
3
Q
What is the management of Achilles tendon rupture?
A
Same day referral to orthopaedics.
4
Q
What medications can contribute to Achilles tendon rupture?
A
Fluoroquinolones
- Increases the risk of tendinitis and tendon rupture.
Ex: ciproflocxacin.
5
Q
Describe the Thompson test for Achilles tendon rupture?
A
Calf is squezeed ➝ reduced/absent plantar flexion.
Indication of tendon discontinuity.
6
Q
What are the muscles group affected in Achilles tendon rupture?
HIGH YIELD
A
- Gastrocnemius
- Soleus
7
Q
Describe the presentation of Baker’s cyst / popliteal cyst.
A
- Popliteal mass;
- Occasional pain;
- Cyst rupture ➝ calf sweeling and pain.
8
Q
A
9
Q
How is the diagnosis of Baker’s cyst / popliteal cyst done?
A
Ultrasound.
10
Q
A
11
Q
What are the symptoms of frozen shoulder / adhesive capsulitis?
A
- Pain;
- Stiffness of the shoulder;
- Restriction of active and passive shoulder movements;
- Inability of doing passive external rotation.
12
Q
What is the cause of frozen shoulder / adhesive capsulitis?
A
- Thickened and contraction of the glenohumeral joint capsule;
- Formation of adhesions.
13
Q
What is the Rx of frozen shoulder / adhesive capsulitis?
A
- Paracetamol and NSAIDs
- Physiotherapy
- Steroid injection
14
Q
What is the commonest cause of shoulder pain?
A
Rotator cuff disorders.
15
Q
Name the 4 rotator cuff muscles.
A
- Supraspinatus;
- Infraspinatus;
- Teres minor;
- Subscapularis.
16
Q
What is the cause of Rotator cuff disorders?
A
- Rotator cuff tears;
- Calcific tendonitis;
- Subacromial impingement.
17
Q
What is the Rx of rotator cuff disorders?
A
- Pain relief;
- Physiotherapy;
- Steroid injections (max 2);
- Surgery.
18
Q
What are the symptoms of shoulder impingement syndrome?
A
- Pain on shoulder movement ;
- Weakness on shoulder movement;
- Restriction of activity;
19
Q
What is the cause of shoulder impingement syndrome?
A
- History of repetitive overhead activity or of carrying heavy objects;
- It will cause narrowing of the subacromial space leading to supraspinatus tendinitis.
20
Q
DDx between:
- Supraspinatus tendinitis
- Adhesive capsulitis
A
Supraspinatus tendinitis
- Difficulty lifting arm above shoulder;
- Painful arc test positive;
- Associated with injury of heavy lifting;
Adhesive capsulitis (stiff shoulder)
- Reduced active movements;
- Reduced passive glenohumeral joint movements;
- Difficulty to put on a jacket (external rotation impaired);
- Associated with DM.
21
Q
What is the presentation / symptoms of Colles fracture?
A
- Radial fracture (with or w/out ulnar fracture);
- Dinner-fork deformity:
Distal fragment of radius deviated backwards and laterally.
➔ Elderly patient who has fallen on an outstretched hand.
22
Q
What is the management & Rx of Colles fracture?
A
- X-ray;
- Analgesia: haematoma block with lidocaine;
- Closed reduction and immobilisation with a cast;
- X-ray post reduction.
23
Q
Describe the presentation of Smith’s fracture.
A
- Reverse colles fracture;
-
Garden spade deformity; - Anterior displacement of the distal fragment.
Garden spade = pá de jardinagem/machamba.
24
Q
Describe the presentation of scaphoid fracture.
A
➜ Most common carpal bone fracture.
- Fall on an outstreched hand;
- Tenderness on the anatomical snuffbox.
25
Describe the `complications` of **scaphoid fracture**.
High risk of avascular necrosis.
26
What are the `investigations` done in **scaphoid fracture**?
**X-ray**
- One immediately
- One in 10-14 days if the first one doesn't show the fracture line.
27
What is the **`Rx`** done in **scaphoid fracture**?
**Fracture visible on x-ray**
- Scaphoid cast for 6 weeks;
**Fracture not visible:**
- Cast of the wrist for 2 weeks, review with x-ray.
28
**DDx between:**
- Galeazzi fracture;
- Monteggia fracture.
**Galeaz`z`i fracture**
- `Z is distal` ➝ fracture of distal 1/3 of radius shaft;
- Distal radioulnar joint dislocation;
**Monteggi`a` fracture**
- `A is proximal` ➝ fracture of proximal 1/3 of ulna.
- **`Radial nerve damage`**;
- Dislocation of the head of radius.
29
What are the **complications** of `fracture`?
➔ **Fat embolism syndrome**
- Fracture of long bones;
- Petechial rash;
- Chest pain & dyspnoea;
- Oliguria & haematuria;
➔ **Compartment syndrome**
➔ **Gunstock deformity**
- Cubitus varus following supracondylar fracture of the humerus;
➔ **Myositis ossificans**
- Formation of new bone in muscle after the fracture.
30
What are the `symptoms` of **osteosarcoma**?
- Knee pain worse at night;
- Fracture even with minor trauma;
- Swelling
➔ Distal femur & proximal tibia commonly affected.
➔ Adolescents & old adults.
31
What are the `investigations` done in **osteosarcoma**?
◉ **X-ray:**
- Sunburst appearance;
- Codman's triangle.
◉ **CT scan**
◉ **Bone biopsy**
32
What is the `Rx` of **osteosarcoma**?
Radical resection of the tumour.
33
**DDx between**:
- Osteosarcoma
- Ewing sarcoma
**Osteosarcoma**
- Teenage boy with knee pain
**Ewing sarcoma**
`Teenage boy with:`
- Bone pain;
- Tiredness;
- Fever;
- Weight loss.
34
What are the `symptoms` of **osteoid osteoma**?
- Unilateral leg pain;
- Worse at night;
- Relieved by NSAID.
35
What are the `symptoms` of **transient synovitis**?
- Acute onset hip pain;
- Limp;
- Fever (mild).
36
DDx of **elbow fracture**.
`◆ Child` ⟶ radial neck.
`◆ Adult` ⟶ radial head.
37
What is the **most common type** of `ELBOW fracture in children`?
Supracondylar fracture of humerus.
38
What are the `structures damaged` in **elbow fracture**?
**Most likely:**
- Brachial artery
**Others:**
- Median nerve
- Ulnar nerve
- Radial nerve
39
What is the most commom origin of a `bone metastasis`?
`◆ Male` ⟶ Prostate > lung.
`◆ Female` ⟶ Breast > lung.
40
What is the **most common type** of `childhood fracture`?
- Torus fracture / buckling fracture;
- Distal radius.
41
What are the `symptoms` of **Ewing sarcoma**?
- Bone pain;
- Fever;
- Weight loss;
- Fractures;
➔ Common in the `2nd decade` of life;
➔ `Location:` diaphysis of femur, pelvis, tibia.
42
What is the `Rx` of **Ewing sarcoma**?
**Highly metatastic**
- Chemo
&
- Surgery
or
- Radiotherapy
&
- Surgery
43
What are the `symptoms` of **sciatica**?
- Shooting pain from buttocks down the leg;
- Pain ↓ on lying down and ↑ on sitting or walking;
- Numbness;
- Paraesthesia;
- Weakness;
- +/- loss of tendon reflexes.
44
What is the `cause` of **sciatica**?
➜ Disk prolapse:
- L4
- L5
- S1
➜ Large herniation can cause cauda equina syndrome
45
What is the `management` of **sciatica**?
- NSAIDs
- Amitriptyline
➜ **Avoid gabapentinoids.**
46
Describe the **unhappy triad** of `knee injuries`.
**Injury to:**
- Anterior cruciate ligament;
- Medial collateral ligament;
- Medial meniscus.
47
What is **`investigation`** done in **unhappy triad** of `knee injuries`?
**Gold standard:** MRI.
48
What is **`management / treatment`** done in **unhappy triad** of `knee injuries`?
- Protect
- Rest
- Ice
- Compression
- Elevation
- Rehabilitation
➔ **Complete ligament tear:** Arthroplasty.
49
Describe the **mechanism of knee injury** in `medial collateral ligament`.
- Direct blow / twisting injury to lateral side of knee.
- Associated to meniscal tears.
50
Describe the **mechanism of knee injury** in `lateral collateral ligament`.
- Direct blow / twisting injury to medial side of knee with the foot planted.
51
Describe the **mechanism of knee injury** in `anterior cruciate ligament`.
- Foot is fixed + rotational force + POP sound.
- Deceleration movement.
52
Describe the **mechanism of knee injury** in `posterior cruciate ligament`.
- Direct impact on the shin (proximal tibia) with bent knee.
53
What are the tests done **for knee injury**?
**Medial collateral ligament:**
- `Valgus stress test`.
**Lateral collateral ligament:**
- `Varus stress test`.
**Anterior cruciate ligament:**
- Anterior drawer test, Lachman test.
**Posterior cruciate ligament:**
- Posterior drawer test.
54
What are the tests done **for meniscal tears**?
- McMurray test;
- Apley test.
55
Describe the **mechanism of injury** in `meniscal tears`.
- Twisting / pivoting + POP sound;
- Associated with ACL injury.
56
Describe the `types and symptoms` of **knee bursitis**.
| `Housemaid's knee`.
**Prepatellar bursitis**
- Localized swelling `anterior` to patella;
- Fluctuant / movable and compressible.
**Infrapatellar bursitis**
- Localized swelling `inferior` to patella;
- Fluctuant / movable and compressible.
57
Which `nerve injury` is associated to **Traction injury at birth**?
Brachial plexus.
58
Which `nerve injury` is associated to:
**- Fracture of humeral neck**
**- Shoulder dislocation**?
Axilliary nerve.
59
Which `nerve injury` is associated to **fracture of humeral neck (Spiral groove)**?
Radial nerve.
60
Which `nerve injury` is associated to **elbow dislocation**?
- Ulnar nerve
OR
- Median nerve.
61
Which `nerve injury` is associated to **Monteggia fracture**?
| Fracture of proximal 1/3 of the ulna.
Radial nerve (wrist drop).
62
Which `nerve injury` is associated to **fibular neck fracture**?
Common peroneal nerve (foot drop).
63
Which `nerve injury` is associated to:
**- Femoral neck / acetabular fracture**;
**- Hip dislocation**?
Sciatic nerve.
64
**DDx between:**
- Radial nerve palsy;
- C7 nerve root injury.
**Radial nerve palsy**
`Numbness/tingling:`
- Dorsolateral aspect of the hand;
- Thumb;
- Index finger;
- Dorsal aspect of the middle finger;
`Wrist:`
- Weakness
- Wrist drop
**C7 nerve root injury**
`Numbness:`
- Middle finger
65
**DDx between:**
- High ulnar nerve palsy;
- Low ulnar nerve palsy.
**High ulnar nerve palsy**
- Weakness in flexion of 4th and 5th finger;
- `Ulnar claw hand`;
- Sensory loss on the medial one and half finger anterior and posterior.
**High ulnar nerve palsy**
- Pins and needles in the medial one and half finger anterior and posterior
- Seen in cyclists.
66
What are the `symptoms` of **carpal tunnel syndrome**?
- Tingling & numbness (median nerve area);
- Weakness on hand grip and opposition of the thumb.
67
What are the `causes` of **carpal tunnel syndrome**?
- Pregnancy;
- Wrist trauma;
- Obesity;
- Hypothyroidism;
- Renal failure.
68
What are the `tests` to diagnose **carpal tunnel syndrome**?
**Gold standard:** electroneurography
**Others**
- Tine's sign;
- Carpal tunnel compression test;
- Phalen's test.
69
What is the `Rx` of **carpal tunnel syndrome**?
- Activity modification;
- Local steroid injection;
- Release of flexor retinaculum.
70
What is the `risk factor` of **developmental dysplasia of the hip**?
- Vaginal birth of a breeched baby.
- Female infant.
71
What are the `symptoms` of **developmental dysplasia of the hip**?
- Asymetrical gluteal or thigh skin folds;
- Limb lenghts discrepancies;
- Limitation of hip abduction;
72
What are the `tests` done in **developmental dysplasia of the hip**?
◆ **Barlow test**
- Attempts to dislocate the femoral head;
◆ **Ortolani test**
- Attempts to relocate a dislocated femoral head;
◆ **Ultrasound scan of the hip**
- In `infants < 4.5 months old`.
◆ **X-ray**
- Older than 4.5 months.
73
What is the `Rx` of **developmental dysplasia of the hip**?
◆ **< 6 months**
- Pavlik harness;
◆ **> 6 months**
- Surgery.
74
Describe what is `Legg-Calve-Perthes' disease`.
Avascular necrosis of the femoral head.
75
What are the `symptoms` of **Legg-Calve-Perthes' disease**?
| Avascular necrosis of the femoral head.
- Limping;
- Pain on the hip or knee;
- Limited internal rotation;
- Common in: 4-8 YO boys.
76
What is the `investigation` done in **Legg-Calve-Perthes' disease**?
- **X- ray**: joint space widening
- **MRI** of the hip
77
What is the `Rx` of **Legg-Calve-Perthes' disease**?
- Conservative;
- Crutches;
- Plasters;
- Physiotheraphy.
78
Describe what is **Paget's disease (BONE)**.
Bone turnover (bone makig process) becomes faster and out of control with disorganised new bone formation.
79
What are the `symptoms` of **Paget's disease (BONE)**?
- Bone pain;
- Pathological fractures;
- Deafness & Tinittus (compression of CN VIII).
80
What are the `investigations` done in **Paget's disease (BONE)**?
**Labs**
- ⬆︎ alkaline phosphatase.
- Normal: Ca²⁺, PTH, phosphate.
**X-ray**
- `Skull: Cotton wool sclerotic pattern;`
- Osteolytic lesions;
- Thickened cortices.
81
What is the `Rx` of **Paget's disease (BONE)**?
- Biphosphonates (zolendrainc acid) ➝ to ↓ bone resortion.
- Paracetamol & NSAIDs ➝ pain.
82
**DDx between:**
- Paget's disease (BONE);
- Osteomyelitis.
**Paget's disease**
- Bowing of long bones due to remodelling deformities;
- ⬆︎ ALP;
- Warm skin;
**Osteomyelitis**
- Localised bone pain;
- Swelling over the affected area;
- Systemic infection: fever, malaise.
- Mild raised ALP.
- Warm skin.
83
What are `symptoms/presentation` of **fracture neck of femur**?
- H/o of fall in elderly patient
- H/o of osteoporotic bone
- Pain in the upper thigh or bone
- Inability to bear weight
- High risk of avascular necrosis of femoral head.
84
What are the `investigations` of **fracture neck of femur**?
1. **X-ray**
- Broken shento's line
2. **MRI**
- If x-ray is normal
85
What is the `Pain Rx` of **fracture neck of femur**?
| **High yield**
➜ `Most initial`
- IV Morphine (5 mg in elderly patient to start)
➜ `Most aproppriate`
- Fascia iliaca compartment block.
86
What is `definitive management` of **fracture neck of femur**?
- Internal fixation of the femoral head;
- Total hip replacement if AVN.
87
What are the `symptoms` of **osteoarthritis**?
- ⬆︎ Joint pain during activity that ⬇︎ at rest.
- Commonly affects hip and knees;
- Joint crepitus and tenderness;
◆ **Bone swelling:**
`HD: BP`
- `H`eberdern's nodes ➝ `D`istal interphalangeal joints
- `B`ouchard's nodes ➝ `P`roximal IP joints
88
What is the `investigation` done in **osteoarthritis**?
**X-ray**
`➜ LOSS`
- `L`oss of joint space;
- `O`steophytes;
- `S`ubchondral cysts;
- `S`ubchondral sclerosis.
89
What is the `treatment` of **osteoarthritis**?
- Weight reduction & physiotherapy;
- Joint replacement surgery (last resort)
**Pain management:**
`➔ Newly diagnosed + Pain`
- Paracetamol
- Topical NSAID's
`➔ Already on paracetamol + topical NSAIDs`
- Codeine *(before tramadol)*
- Oral NSAIDs *(if no risk of GI bleeding)*
90
**DDx between:**
- Osteoarthritis
- Rheumatoid arthritis
**Osteoarthritis**
- > 50 YO
- `Unilateral` monoarthritis;
- Hip and knee joints
- `DIP joint can be affected`
- Pain gets worse with movement `(worse at the end of the day)`
**Rheumatoid arthritis**
- 30-50 YO
- Symetrical polyarthritis
- DIP sparred
- Pain and stiffness early in the morning and after a period of inactivity;
| DIP: Distal interphalangeal joint
91
What is the `cause` of **Mallet finger**?
Rupture of extensor tendon of finger.
92
What are the `symptoms` of **Mallet finger**?
- Fixed flexion deformity at DIP joint;
- Swelling and ecchymosis;
- H/O of trauma.
93
What is the `management` of **Mallet finger**?
- **Partial tear:** splint;
- **Complete tear:** Surgical fixation.
94
Describe **Gamekeeper's / skier's thumb**?
- Rupture of ulnar collateral ligament;
- Thumb is hyperextended and deviated laterally.
95
Describe the bone mineral density of **Osteoporosis**.
Bone mineral density ⩽ -2.5 from mean.
96
What are the `risk factors` for **Osteoporosis**?
- ⬆︎ age;
- Female sex *(postmenopausal)*
- Corticosteroid use
- Cushing's syndrome
- Primary hyperparathyroidism
97
What are the `symptoms ` of **Osteoporosis**?
Fracture with even low trauma.
98
What are the `investigations` done in **Osteoporosis**?
- Dexa scan;
- Normal calcium;
- Normal PTH.
99
What is the `management` of **Osteoporosis**?
- **Biphosphonates:** alendronate
- Vit D
- Calcium
- Denosumab
100
In **osteoporosis**, what is the step by step management for `assessment and prevention`?
**Risk of osteoporosis**
1. Fracture risk assessment;
2. If risk ≥10% of osteoporotic; fracture than step 3;
3. Dexa scan;
4. T-score <-2.5 ➝ offer Rx.
**≥ 50 years & has a fragility fracture**
- Dexa scan;
- T-score <-2.5 ➝ offer Rx.
101
What is the `management` when **DEXA scan's reading** `< -2.5`:
- Spine
- Hip
- Neck of femur?
Biphosphonates.
102
What are the `symptoms` of **tennis elbow / lateral epicondylitis**?
- Pain and tenderness at the lateral epicondyle of the humerus;
- Positive cozen's test (pain on resisted extension of the wrist).
103
What is the `Rx` for **tennis elbow / lateral epicondylitis**?
- `Physiotherapy`
- Activity modification;
- NSAIDs
- Local steroid injection
- Surgery (last resort)
104
What are the `symptoms` of **golfer's elbow / medial epicondylitis**?
- Pain and tenderness at the medial epicondyle of the humerus;
- Pain ⬆︎ on wrist flexion and pronation.
105
What is the `Rx` for **golfer's elbow / medial epicondylitis**?
- Physiotherapy
- Activity modification;
- NSAIDs
- Local steroid injection
- Surgery (last resort)
106
What are the **common organisms** that `cause` **`septic arthritis`**?
- **General:** S. Aureus
- **Sexually active adults:** N. gonorrhoea
107
What are the `symptoms` of **`septic arthritis`**?
- Common swollen and red joint;
- Pain on active and passive movement;
- Fever and rigors;
- Common joint: knee.
108
What is the **investigation** done in **septic arthritis**?
- Synovial fluid aspiration
- Blood culture
109
What is the **Rx** done in **septic arthritis**?
- Flucloxacillin for 4-6 weeks
- Gonococcal arthritis: cefotaxime or ceftriaxone.
110
DDx between:
- Septic arthritis
- Reactive arthritis
**Septic arthritis**
- *Organism*: S. aureus or N. Gonorrhoeae
- *Arthritis*: Monoarthritis (knee)
- *Synovial fluid aspiration*: growth of causative organism
**Reactive arthritis**
- *Organism*: C. Trachomatis, C. pneumoniae
- *Arthritis*: Migratory oligoarthritis
- *Synovial fluid aspiration*: raised WBC
111
What is the **causative organism** for **osteomyelitis**?
S. Aureus.
112
What are the **risk factors** for **osteomyelitis**?
- Recent trauma
- Recent surgery
- Open fractures
- Immunocompromised state
- DM
113
What are the **symptoms** for **osteomyelitis**?
- Acute onset of pain in the affected bone;
- Swelling
- Warmth
- Fever
114
What are the **investigations**
done for **osteomyelitis**?
**Gold standard**: MRI
**Other**: Blood cultures
115
What is the **management** of **osteomyelitis**?
IV flucloxacillin.
116
What are the **symptoms** of **slipped capital femoral epiphysis**?
- Pain/discomfort in the groin or knee
- Limp on the affected side
- Common in obese teens
117
What is the **investigation** done in **slipped capital femoral epiphysis**?
**X-ray**: widening of the epiphyseal line or displacement of the femoral head.
118
What is the **Rx** of **slipped capital femoral epiphysis**?
Surgery.
119
Describe what is **Toddler’s fracture**.
Mid-tibial spiral fracture on toddlers 1-3 years old.
120
What are the **features** of **Toddler’s fracture**?
- Not walking after a fall
- Mid-tibial tenderness
- Suspect even if X-ray is normal.
121
Management of **Toddler’s fracture**?
- Analgesia
- Review in outpatient fracture clinic after 1-2 weeks.
122
Describe the **limps rule** in **children**.
**< 3 years**
- Developmental dysplasia of the hip
- Septic arthritis
- Toddler’s fracture
**3 - 9 years**
- *Acute:* transient synovitis
- *Chronic:* Perthes disease
**> 9 years**
- Slipped upper femoral epiphysis
123
Describe **foot fractures** and the bones affected.
**Vertical fall on feet:** Calcaneus.
**Stress fracture:** Metatarsals
124
When to apply a **below elbow back slab**?
- Colles fracture
- Distal radius and ulnar fractures.
125
What are the **Symptoms** of **lumbar stenosis**?
- Neurogenic claudication (improves on sitting and bending forward and cycling).
- Pain on dermatome distribution
- Unilateral or bilateral
- With or without back pain
126
What are the **investigations** for **lumbar spinal stenosis**?
**Initial:** X-ray (degenerative changes)
**Gold-standard:** MRI
127
What is the **treatment** of **lower back pain**?
**1st line:** NSAIDs
**2nd line:** Paracetamol.
128
What are the **symptoms** of **reactive arthritis**?
Reiter’s triad:
- **Can’t see**: conjunctivitis
- **Can’t pee**: urethritis
- **Can’t climb a tree**: arthritis
129
What is the **cause** of **reactive arthritis**?
One of the following:
- Urogenital infection
- Gastrointestinal infection
