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PLAB 1 August 2024 > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

Describe the causes of Achilles tendon rupture?

A
  • Middle aged man;
  • Infrequent sports goer;
  • Repetitive jumping motion.
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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.

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3
Q

What is the management of Achilles tendon rupture?

A

Same day referral to orthopaedics.

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4
Q

What medications can contribute to Achilles tendon rupture?

A

Fluoroquinolones
- Increases the risk of tendinitis and tendon rupture.

Ex: ciproflocxacin.

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5
Q

Describe the Thompson test for Achilles tendon rupture?

A

Calf is squezeed ➝ reduced/absent plantar flexion.

Indication of tendon discontinuity.

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6
Q

What are the muscles group affected in Achilles tendon rupture?

HIGH YIELD

A
  • Gastrocnemius
  • Soleus
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7
Q

Describe the presentation of Baker’s cyst / popliteal cyst.

A
  • Popliteal mass;
  • Occasional pain;
  • Cyst rupture ➝ calf sweeling and pain.
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8
Q
A
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9
Q

How is the diagnosis of Baker’s cyst / popliteal cyst done?

A

Ultrasound.

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10
Q
A
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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.
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12
Q

What is the cause of frozen shoulder / adhesive capsulitis?

A
  • Thickened and contraction of the glenohumeral joint capsule;
  • Formation of adhesions.
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13
Q

What is the Rx of frozen shoulder / adhesive capsulitis?

A
  • Paracetamol and NSAIDs
  • Physiotherapy
  • Steroid injection
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14
Q

What is the commonest cause of shoulder pain?

A

Rotator cuff disorders.

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15
Q

Name the 4 rotator cuff muscles.

A
  • Supraspinatus;
  • Infraspinatus;
  • Teres minor;
  • Subscapularis.
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16
Q

What is the cause of Rotator cuff disorders?

A
  • Rotator cuff tears;
  • Calcific tendonitis;
  • Subacromial impingement.
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17
Q

What is the Rx of rotator cuff disorders?

A
  • Pain relief;
  • Physiotherapy;
  • Steroid injections (max 2);
  • Surgery.
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18
Q

What are the symptoms of shoulder impingement syndrome?

A
  • Pain on shoulder movement ;
  • Weakness on shoulder movement;
  • Restriction of activity;
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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.
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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.

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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.

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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.
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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.

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24
Q

Describe the presentation of scaphoid fracture.

A

➜ Most common carpal bone fracture.
- Fall on an outstreched hand;
- Tenderness on the anatomical snuffbox.

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25
Q

Describe the complications of scaphoid fracture.

A

High risk of avascular necrosis.

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26
Q

What are the investigations done in scaphoid fracture?

A

X-ray
- One immediately
- One in 10-14 days if the first one doesn’t show the fracture line.

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27
Q

What is the Rx done in scaphoid fracture?

A

Fracture visible on x-ray
- Scaphoid cast for 6 weeks;

Fracture not visible:
- Cast of the wrist for 2 weeks, review with x-ray.

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28
Q

DDx between:
- Galeazzi fracture;
- Monteggia fracture.

A

Galeazzi fracture
- Z is distal ➝ fracture of distal 1/3 of radius shaft;
- Distal radioulnar joint dislocation;

Monteggia fracture
- A is proximal ➝ fracture of proximal 1/3 of ulna.
- Radial nerve damage;
- Dislocation of the head of radius.

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29
Q

What are the complications of fracture?

A

➔ 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.

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30
Q

What are the symptoms of osteosarcoma?

A
  • Knee pain worse at night;
  • Fracture even with minor trauma;
  • Swelling

➔ Distal femur & proximal tibia commonly affected.

➔ Adolescents & old adults.

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31
Q

What are the investigations done in osteosarcoma?

A

◉ X-ray:
- Sunburst appearance;
- Codman’s triangle.

◉ CT scan
◉ Bone biopsy

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32
Q

What is the Rx of osteosarcoma?

A

Radical resection of the tumour.

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33
Q

DDx between:
- Osteosarcoma
- Ewing sarcoma

A

Osteosarcoma
- Teenage boy with knee pain

Ewing sarcoma
Teenage boy with:
- Bone pain;
- Tiredness;
- Fever;
- Weight loss.

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34
Q

What are the symptoms of osteoid osteoma?

A
  • Unilateral leg pain;
  • Worse at night;
  • Relieved by NSAID.
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35
Q

What are the symptoms of transient synovitis?

A
  • Acute onset hip pain;
  • Limp;
  • Fever (mild).
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36
Q

DDx of elbow fracture.

A

◆ Child ⟶ radial neck.
◆ Adult ⟶ radial head.

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37
Q

What is the most common type of ELBOW fracture in children?

A

Supracondylar fracture of humerus.

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38
Q

What are the structures damaged in elbow fracture?

A

Most likely:
- Brachial artery

Others:
- Median nerve
- Ulnar nerve
- Radial nerve

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39
Q

What is the most commom origin of a bone metastasis?

A

◆ Male ⟶ Prostate > lung.
◆ Female ⟶ Breast > lung.

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40
Q

What is the most common type of childhood fracture?

A
  • Torus fracture / buckling fracture;
  • Distal radius.
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41
Q

What are the symptoms of Ewing sarcoma?

A
  • Bone pain;
  • Fever;
  • Weight loss;
  • Fractures;

➔ Common in the 2nd decade of life;
➔ Location: diaphysis of femur, pelvis, tibia.

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42
Q

What is the Rx of Ewing sarcoma?

A

Highly metatastic
- Chemo
&
- Surgery

or

  • Radiotherapy
    &
  • Surgery
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43
Q

What are the symptoms of sciatica?

A
  • Shooting pain from buttocks down the leg;
  • Pain ↓ on lying down and ↑ on sitting or walking;
  • Numbness;
  • Paraesthesia;
  • Weakness;
  • +/- loss of tendon reflexes.
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44
Q

What is the cause of sciatica?

A

➜ Disk prolapse:
- L4
- L5
- S1
➜ Large herniation can cause cauda equina syndrome

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45
Q

What is the management of sciatica?

A
  • NSAIDs
  • Amitriptyline
    ➜ Avoid gabapentinoids.
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46
Q

Describe the unhappy triad of knee injuries.

A

Injury to:
- Anterior cruciate ligament;
- Medial collateral ligament;
- Medial meniscus.

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47
Q

What is investigation done in unhappy triad of knee injuries?

A

Gold standard: MRI.

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48
Q

What is management / treatment done in unhappy triad of knee injuries?

A
  • Protect
  • Rest
  • Ice
  • Compression
  • Elevation
  • Rehabilitation

➔ Complete ligament tear: Arthroplasty.

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49
Q

Describe the mechanism of knee injury in medial collateral ligament.

A
  • Direct blow / twisting injury to lateral side of knee.
  • Associated to meniscal tears.
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50
Q

Describe the mechanism of knee injury in lateral collateral ligament.

A
  • Direct blow / twisting injury to medial side of knee with the foot planted.
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51
Q

Describe the mechanism of knee injury in anterior cruciate ligament.

A
  • Foot is fixed + rotational force + POP sound.
  • Deceleration movement.
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52
Q

Describe the mechanism of knee injury in posterior cruciate ligament.

A
  • Direct impact on the shin (proximal tibia) with bent knee.
53
Q

What are the tests done for knee injury?

A

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
Q

What are the tests done for meniscal tears?

A
  • McMurray test;
  • Apley test.
55
Q

Describe the mechanism of injury in meniscal tears.

A
  • Twisting / pivoting + POP sound;
  • Associated with ACL injury.
56
Q

Describe the types and symptoms of knee bursitis.

Housemaid's knee.

A

Prepatellar bursitis
- Localized swelling anterior to patella;
- Fluctuant / movable and compressible.

Infrapatellar bursitis
- Localized swelling inferior to patella;
- Fluctuant / movable and compressible.

57
Q

Which nerve injury is associated to Traction injury at birth?

A

Brachial plexus.

58
Q

Which nerve injury is associated to:
- Fracture of humeral neck
- Shoulder dislocation?

A

Axilliary nerve.

59
Q

Which nerve injury is associated to fracture of humeral neck (Spiral groove)?

A

Radial nerve.

60
Q

Which nerve injury is associated to elbow dislocation?

A
  • Ulnar nerve
    OR
  • Median nerve.
61
Q

Which nerve injury is associated to Monteggia fracture?

Fracture of proximal 1/3 of the ulna.

A

Radial nerve (wrist drop).

62
Q

Which nerve injury is associated to fibular neck fracture?

A

Common peroneal nerve (foot drop).

63
Q

Which nerve injury is associated to:
- Femoral neck / acetabular fracture;
- Hip dislocation?

A

Sciatic nerve.

64
Q

DDx between:
- Radial nerve palsy;
- C7 nerve root injury.

A

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
Q

DDx between:
- High ulnar nerve palsy;
- Low ulnar nerve palsy.

A

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
Q

What are the symptoms of carpal tunnel syndrome?

A
  • Tingling & numbness (median nerve area);
  • Weakness on hand grip and opposition of the thumb.
67
Q

What are the causes of carpal tunnel syndrome?

A
  • Pregnancy;
  • Wrist trauma;
  • Obesity;
  • Hypothyroidism;
  • Renal failure.
68
Q

What are the tests to diagnose carpal tunnel syndrome?

A

Gold standard: electroneurography

Others
- Tine’s sign;
- Carpal tunnel compression test;
- Phalen’s test.

69
Q

What is the Rx of carpal tunnel syndrome?

A
  • Activity modification;
  • Local steroid injection;
  • Release of flexor retinaculum.
70
Q

What is the risk factor of developmental dysplasia of the hip?

A
  • Vaginal birth of a breeched baby.
  • Female infant.
71
Q

What are the symptoms of developmental dysplasia of the hip?

A
  • Asymetrical gluteal or thigh skin folds;
  • Limb lenghts discrepancies;
  • Limitation of hip abduction;
72
Q

What are the tests done in developmental dysplasia of the hip?

A

◆ 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
Q

What is the Rx of developmental dysplasia of the hip?

A

◆ < 6 months
- Pavlik harness;

◆ > 6 months
- Surgery.

74
Q

Describe what is Legg-Calve-Perthes' disease.

A

Avascular necrosis of the femoral head.

75
Q

What are the symptoms of Legg-Calve-Perthes’ disease?

Avascular necrosis of the femoral head.

A
  • Limping;
  • Pain on the hip or knee;
  • Limited internal rotation;
  • Common in: 4-8 YO boys.
76
Q

What is the investigation done in Legg-Calve-Perthes’ disease?

A
  • X- ray: joint space widening
  • MRI of the hip
77
Q

What is the Rx of Legg-Calve-Perthes’ disease?

A
  • Conservative;
  • Crutches;
  • Plasters;
  • Physiotheraphy.
78
Q

Describe what is Paget’s disease (BONE).

A

Bone turnover (bone makig process) becomes faster and out of control with disorganised new bone formation.

79
Q

What are the symptoms of Paget’s disease (BONE)?

A
  • Bone pain;
  • Pathological fractures;
  • Deafness & Tinittus (compression of CN VIII).
80
Q

What are the investigations done in Paget’s disease (BONE)?

A

Labs
- ⬆︎ alkaline phosphatase.
- Normal: Ca²⁺, PTH, phosphate.

X-ray
- Skull: Cotton wool sclerotic pattern;
- Osteolytic lesions;
- Thickened cortices.

81
Q

What is the Rx of Paget’s disease (BONE)?

A
  • Biphosphonates (zolendrainc acid) ➝ to ↓ bone resortion.
  • Paracetamol & NSAIDs ➝ pain.
82
Q

DDx between:
- Paget’s disease (BONE);
- Osteomyelitis.

A

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
Q

What are symptoms/presentation of fracture neck of femur?

A
  • 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
Q

What are the investigations of fracture neck of femur?

A
  1. X-ray
    - Broken shento’s line
  2. MRI
    - If x-ray is normal
85
Q

What is the Pain Rx of fracture neck of femur?

High yield

A

➜ Most initial
- IV Morphine (5 mg in elderly patient to start)

➜ Most aproppriate
- Fascia iliaca compartment block.

86
Q

What is definitive management of fracture neck of femur?

A
  • Internal fixation of the femoral head;
  • Total hip replacement if AVN.
87
Q

What are the symptoms of osteoarthritis?

A
  • ⬆︎ Joint pain during activity that ⬇︎ at rest.
  • Commonly affects hip and knees;
  • Joint crepitus and tenderness;

◆ Bone swelling:
HD: BP
- Heberdern’s nodes ➝ Distal interphalangeal joints
- Bouchard’s nodes ➝ Proximal IP joints

88
Q

What is the investigation done in osteoarthritis?

A

X-ray
➜ LOSS
- Loss of joint space;
- Osteophytes;
- Subchondral cysts;
- Subchondral sclerosis.

89
Q

What is the treatment of osteoarthritis?

A
  • 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
Q

DDx between:
- Osteoarthritis
- Rheumatoid arthritis

A

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
Q

What is the cause of Mallet finger?

A

Rupture of extensor tendon of finger.

92
Q

What are the symptoms of Mallet finger?

A
  • Fixed flexion deformity at DIP joint;
  • Swelling and ecchymosis;
  • H/O of trauma.
93
Q

What is the management of Mallet finger?

A
  • Partial tear: splint;
  • Complete tear: Surgical fixation.
94
Q

Describe Gamekeeper’s / skier’s thumb?

A
  • Rupture of ulnar collateral ligament;
  • Thumb is hyperextended and deviated laterally.
95
Q

Describe the bone mineral density of Osteoporosis.

A

Bone mineral density ⩽ -2.5 from mean.

96
Q

What are the risk factors for Osteoporosis?

A
  • ⬆︎ age;
  • Female sex (postmenopausal)
  • Corticosteroid use
  • Cushing’s syndrome
  • Primary hyperparathyroidism
97
Q

What are the symptoms of Osteoporosis?

A

Fracture with even low trauma.

98
Q

What are the investigations done in Osteoporosis?

A
  • Dexa scan;
  • Normal calcium;
  • Normal PTH.
99
Q

What is the management of Osteoporosis?

A
  • Biphosphonates: alendronate
  • Vit D
  • Calcium
  • Denosumab
100
Q

In osteoporosis, what is the step by step management for assessment and prevention?

A

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
Q

What is the management when DEXA scan’s reading < -2.5:
- Spine
- Hip
- Neck of femur?

A

Biphosphonates.

102
Q

What are the symptoms of tennis elbow / lateral epicondylitis?

A
  • Pain and tenderness at the lateral epicondyle of the humerus;
  • Positive cozen’s test (pain on resisted extension of the wrist).
103
Q

What is the Rx for tennis elbow / lateral epicondylitis?

A
  • Physiotherapy
  • Activity modification;
  • NSAIDs
  • Local steroid injection
  • Surgery (last resort)
104
Q

What are the symptoms of golfer’s elbow / medial epicondylitis?

A
  • Pain and tenderness at the medial epicondyle of the humerus;
  • Pain ⬆︎ on wrist flexion and pronation.
105
Q

What is the Rx for golfer’s elbow / medial epicondylitis?

A
  • Physiotherapy
  • Activity modification;
  • NSAIDs
  • Local steroid injection
  • Surgery (last resort)
106
Q

What are the common organisms that cause septic arthritis?

A
  • General: S. Aureus
  • Sexually active adults: N. gonorrhoea
107
Q

What are the symptoms of septic arthritis?

A
  • Common swollen and red joint;
  • Pain on active and passive movement;
  • Fever and rigors;
  • Common joint: knee.
108
Q

What is the investigation done in septic arthritis?

A
  • Synovial fluid aspiration
  • Blood culture
109
Q

What is the Rx done in septic arthritis?

A
  • Flucloxacillin for 4-6 weeks
  • Gonococcal arthritis: cefotaxime or ceftriaxone.
110
Q

DDx between:
- Septic arthritis
- Reactive arthritis

A

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
Q

What is the causative organism for osteomyelitis?

A

S. Aureus.

112
Q

What are the risk factors for osteomyelitis?

A
  • Recent trauma
  • Recent surgery
  • Open fractures
  • Immunocompromised state
  • DM
113
Q

What are the symptoms for osteomyelitis?

A
  • Acute onset of pain in the affected bone;
  • Swelling
  • Warmth
  • Fever
114
Q

What are the investigations
done for osteomyelitis?

A

Gold standard: MRI

Other: Blood cultures

115
Q

What is the management of osteomyelitis?

A

IV flucloxacillin.

116
Q

What are the symptoms of slipped capital femoral epiphysis?

A
  • Pain/discomfort in the groin or knee
  • Limp on the affected side
  • Common in obese teens
117
Q

What is the investigation done in slipped capital femoral epiphysis?

A

X-ray: widening of the epiphyseal line or displacement of the femoral head.

118
Q

What is the Rx of slipped capital femoral epiphysis?

119
Q

Describe what is Toddler’s fracture.

A

Mid-tibial spiral fracture on toddlers 1-3 years old.

120
Q

What are the features of Toddler’s fracture?

A
  • Not walking after a fall
  • Mid-tibial tenderness
  • Suspect even if X-ray is normal.
121
Q

Management of Toddler’s fracture?

A
  • Analgesia
  • Review in outpatient fracture clinic after 1-2 weeks.
122
Q

Describe the limps rule in children.

A

< 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
Q

Describe foot fractures and the bones affected.

A

Vertical fall on feet: Calcaneus.

Stress fracture: Metatarsals

124
Q

When to apply a below elbow back slab?

A
  • Colles fracture
  • Distal radius and ulnar fractures.
125
Q

What are the Symptoms of lumbar stenosis?

A
  • Neurogenic claudication (improves on sitting and bending forward and cycling).
  • Pain on dermatome distribution
  • Unilateral or bilateral
  • With or without back pain
126
Q

What are the investigations for lumbar spinal stenosis?

A

Initial: X-ray (degenerative changes)

Gold-standard: MRI

127
Q

What is the treatment of lower back pain?

A

1st line: NSAIDs
2nd line: Paracetamol.

128
Q

What are the symptoms of reactive arthritis?

A

Reiter’s triad:
- Can’t see: conjunctivitis
- Can’t pee: urethritis
- Can’t climb a tree: arthritis

129
Q

What is the cause of reactive arthritis?

A

One of the following:
- Urogenital infection
- Gastrointestinal infection

PLAB 1 August 2024 (32 decks)

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