Orthopaedics Flashcards
What are features of Paget’s disease and how is it managed?
Caused by focal bone resorption followed by excessive bone deposition. Simultaneous osteoblast and osteoclast activity leads to thick brittle bones
- Affects (in order): spine, skull, pelvis, femur
- Raised ALP
- Thickened sclerotic bone on XR
- risk of cardiac failure
Managed by Bisphosphonates
How is osteoporosis managed?
Bisphosphonates, Vit D and calcium supplements
What bone appearance does prostate and breast cancer metastases cause?
Prostate ca: Sclerotic appearance
Breast ca: Lytic appearance
What is scurvy?
Vitamin C deficiency
Causes defective collagen
What are features of rickets?
- Bow leg
- Hypocalcaemia
- Knock-knee
What are some of the causes of osteomalacia?
- Vit D deficiency (malabsorption, lack of sunlight)
- Renal failure
- Drug induced (anti convulsants)
What are the managements of an extra capsular NOF fracture and what is the management dependent on?
Extracapsular fractures are categorised into Intertrochanteric and Subtrochanteric
Intertrochanteric: DHS
Subtrochanteric: Intramedullary nail
What are differences in serum calcium, phosphate and ALP found in Osteoporosis, Osteomalacia and Paget’s disease?
Osteoporosis: all would be normal
Osteomalacia: Reduced calcium and phosphate, increased ALP
Paget’s: Calcium and phosphate would be normal. ALP would be increased significantly
What is pseudogout and what are its features?
Form of microcrystalline synovitis caused by deposition of calcium pyrophosphate dihydrate
Features;
- knee, wrist and shoulders mostly affected
- Weakly positive birefringent rhomboid shaped crystal
- Chrondrocalcinosis on XR
How is pseudogout managed?
- Aspiration to exclude septic arthritis
- NSAIDs or steroids
What is the birefringent of gout?
Negatively birefringent needle shaped crystals
What are features of Chronic suprspinatus tendonitis / Subacromial impingement?
Pain on abduction 6-120 degree (middle 1/3 arc)
Extremes of movement are painless
What causes shoulder pain in osteoarthritis?
Presence of osteophytes causes pain in last degrees of shoulder abduction
What is the most common type of shoulder dislocation?
Anterior dislocation
What are features of an anterior shoulder dislocation?
- Loss of shoulder contour
- Sulcus sign
- Humeral head felt anteriorly
Managed by relocation by Hippocratic/Milch/Stimson technique
What are causes of posterior shoulder dislocation and what are its features ?
- 50% trauma
- Classically post-seizure or electrocution
Features:
- arm locked in internal rotation
- XR may show lightbulb appearance
What is Bankart lesion?
Avulsion of anterior glenoid labrum with an anterior dislocation
What is the management of Subacromial impingement?
- Physio + NSAIDS
- Subacrominal steroid injection
- Arthroscopic subacromial decompression
What is calcific tendonitis/Supraspinatus tendonitis and what the 3 stages involved in this disease?
Calcific deposits within tendons, commonly in rotator cuffs causing subacromial impingement and pain, especially above 120 degrees
Stages:
- Formative phase: calcific deposits
- Resting phase: deposits are stable but presents with impingement symptoms
Resorptive phase: phagocytic resorption. Most painful stage
What is adhesive capsulitis and what are the 3 stages of disease progression?
Pain and loss of movement of shoulder join caused by fibroblastic proliferation of capsular tissue. This causes tissue scarring and contracture.
- Stage 1: Freezing and painful stage
- Stage 2: frozen and stiff stage
Stage 3: thawing stage, where shoulder movement slowly improves
Can take up to 2years to resolve
What is the Gustilo and Anderson classification?
Grade 1: Skin opening <1cm, clean, simple transverse or short oblique fractures
Grade 2: Laceration >1-10cm with extensive soft tissue damage, flaps or avulsion. simple transverse or short oblique fractures
Grade 3: >10cm laceration with extensive soft tissue damage (often high velocity injury)
- 3a: Adequate bone coverage, segmental fractures, gunshot injury - 3b: Periosteal stripping and bone exposure, associated with massive contamination. Requires soft tissue coverage - 3c: Vascular injury requiring repair
What is the management of open/compound fractures?
- Pain relief
- Abx immediately
- Splinting and immobilisation of affect bone
- Tetanus prophylaxis
- Washouts outside of theatre (e.g. in ED) are not indicated. Only handle wound for gross decontamination
- Debridement in theatre:
1) Immediately if highly contaminated or where there Is vascular compromise
2) Within 12hrs for solitary high energy fractures
3) Within 24hrs for other low energy open fractures
How is the management of an intracapsular NOF fracture divided?
Undisplaced (ANY age): Int fixation or cannulated screws
Displaced:
- <50yrs: Cannulated screws
- 50 - 60yrs: THR
- >60yrs + Mobile: THR
- >60yrs + Immobile: Hemiarthroplasty
What is the mechanism of ACL injury and how is it managed?
Sports related, High twisting force applied to flexed knee
PC: Loud crack/pop, pain and rapid joint swelling, knee giving way
Ix: Lachman test / Ant drawer test
Mx: Physio + Surgery
What is the mechanism of a PCL injury and what test is used to investigate this?
Hyperextension injuruies
Ix: Posterior drawer test
How does a meniscal tear present and what clinical test is used to investigate this?
- Delayed knee swelling
- Joint locking
- Episodes of effusions
Ix: McMurray’s test
What condition is associated with pain on walking down stairs and more commonly affects teenage girls?
Chondromalacia patellae
Is a patient able to weight bare with a fractured patella?
Yes
What is the Weber classification and management of each type?
Classification of ankle fractures
A = below syndesmosis
B = level of syndesmosis
C = above level of syndesmosis
Management:
- A: stable. WB. Ankle boot cast for 6 weeks
- B: same as A if stable and unimalleolar. If part of trimalleolar fracture, will need ORIF
- C: usually unstable. Will need ORIF
What is the difference between a Colles’ fracture and Smith’s fracture?
Both are caused by FOOSH
Colles’: dorsal displacement and angulation of radius (dinner fork deformity)
Smith’s: Volar displacement and angulation of radius
What is a Barton’s fracture?
Like a Colles’ fracture, there is displacement of the radius, however there will also be extension of the fracture to the articular surface of the radius
What is a Galeazzi fracture?
Radial shaft fracture with associated dislocation of distal radioulnar joint
What is a Monteggia’s fracture?
Ulna fracture with dislocation of proximal radioulnar joint
What occurs to the hand in Dupuytren contracture?
- Semi-flexion of ring finger and little finger
- Thickening of the overlying skin over these digits and palmar area
How is Dupuytren’s contracture managed?
Angle of deformity <30 degrees: Steroid injections and Collagenase injections
Angle of deformity >30 degrees: surgery (fasciectomy)
What fractures in paediatric patients should raise suspicion of NAI?
- Skull fractures
- Rib fractures
- Scapular fractures
- Sternal fractures
- Metaphysical fractures
- Femur fractures
What type of bone fracture pattern is most common in metastatic bone disease?
Transverse fracture
What is the Gartland classification?
Classifies types of Supracondylar fractures
Type 1: Non-displaced
Type 2: Displaced, posterior cortex and periosteal hinge intact
Type 3: Completely displaced
What is the Salter Harris Classification?
For fractures involved the growth plates in children
SALTER
Typer 1 - S: Slip - transverse fracture through the growth plate
Type 2 - A: Above - fracture through the growth plate and extends upwards in the metaphysis
Type 3 - L: Lower - fracture of growth plate extending downwards into the epiphysis
Type 4 - TE - Through everything - fracture extending through growth plate, epiphysis and metaphysis
Type 5 - R: Ruined (crushed): crush fracture of growth plate (poorest outcome)
If you are treating a tibial fracture conservatively, what cast would be used?
Groin to toe cast
OR
Above knee to toe cast
How can developmental dysplasia of the hip be detected in infancy?
By Ultrasound up to 3 months of age
- child will also have a skin crease over the groin
What is the Xray finding seen in the Perthes disease and how is it managed?
Flattened femoral head
Normally self limiting. Physio
Who is most often affected by Slipped upper femoral epiphysis and how does present?
Obese male adolescents
- limited internal rotation
- femoral head displaced inferolaterally
What is Barlow and Ortolani manoeuvre?
Barlow: Adduction of hip with posterior force on the knee to cause DISLOCATION
Otolani: Abduction of hip with anterior force on the femur to cause RELOCATION
What is the mechanism of disease of Perthe’s disease and how is it managed?
Idiopathic avascular necrosis of the femoral epiphysis of the femoral head. This leads to bone infarction. The bone either heals or subchondral fractures occur.
PC: limp + hip pain, 2-12yrs
Staged by the Catterall staging (1-4)
Mx:
- If <6yrs, observation
- >6yrs: surgical management
What pathogen is associated with septic arthritis in a sickle cell aneamic patient?
Salmonella
However, Staph aureus is still a cause of septic arthritis in patients with this condition
What is Kocher criteria?
Criteria for suspecting Septic arthritis
Criteria:
- NWB on affected side
- ESR >40
- Fever
- WBC >12,000
If 4/4 99% chance of septic arthritis
What is Still’s disease?
Systemic form of juvenile arthritis (autoimmune) causing:
- pyrexia
- salmon pink rash
- aches + pains in joints and muscles
- hepatosplenomegaly
What is Osgood-Schlatter disease?
Tibia tubercle becomes painful and swollen due to traction injury of apophysis (insertion of patellar tendon)
Mx: Rest + plaster immobilisation for 6-8 weeks
What is the typical presentation complaint of plantar fasciitis?
- Middle aged woman
- Heel pain
- Tender passive dorsiflexion of toe
- Pain while tip toeing
Where is a Morton neuroma found?
Causes pain in dorsal of foot between cleft of 3rd and 4th toes
What are the symptoms of Kohler’s disease?
Tenderness over medial longitudinal arch
Osteochondritis of navicular bone
What is pain during the Finkelstein Test a positive indicator for?
de Quervain’s syndrome
What type of bone tumour is an Osteoid osteoma and where are they usually found?
Benign tumour. Causes pain WORSE at NIGHT.
Found in cortex of long bones
Mx by NSAIDs
What are risk factors associated with osteosarcomas and how is this disease managed?
- Elderly
- <20 years old
- Paget’s disease
Affects metaphysis of long bone. Causes elevation of periosteum (Codman’s triangle)
Mx:
- Surgery
- Chemotherapy
Who does Giant cell tumours usually affect and what type of tumour is it?
Benign tumour affecting 20-40 year olds
Who is most at risk of developing Ewing’s sarcoma
Common in caucasian males:
- <15yrs
- Fever + loss of weight
- Immunocompromised
Develop onion skin appearance
What is the triad of symptoms that makes up Rieter syndrome (reactive arthritis)?
CUP
- Conjunctivitis
- Urethritis
- Polyarthritis
How many secondary ossification centres are there?
5
What structure of the cervical vertebra is commonly damaged in a hangman’s fracture?
Pedicles of C2
What is a Le Fort 2 fracture?
Fracture extending from nasofrontal suture through superior medial wall of maxillary bone, inferno-laterally through lacrimal bone and then along inferior orbital rim
How are tibial shaft fractures usually managed?
IM nail
What ion movement causes repolarisation of skeletal muscles action potentials?
K+ moving outwards
What type of anaesthesia is commonly used in hip replacements to assist with post-operative recovery?
Spinal anaesthesia
How is a stress fracture of the foot managed?
Adequate rest
Boot is not necessary as returning to normal activity can worsen stress fracture to a complete fracture
What structure is at risk of damage during insertion of the lateral port for knee arthroscopy?
Lateral meniscus
