Orthopaedics Flashcards
State 4 commonly affected joints in osteoarthritis
Hips
Knees
Distal interphalangeal (DIP) joints in the hands
Carpometacarpal (CMC) joint at the base of the thumb
Lumbar spine
Cervical spine (cervical spondylosis)
what are the x-ray findings in osteoarthritis?
L – Loss of joint space
O – Osteophytes (bone spurs)
S – Subarticular sclerosis (increased density of the bone along the joint line)
S – Subchondral cysts (fluid-filled holes in the bone)
what are hand signs of osteoarthritis?
Heberden’s nodes (in the DIP joints)
Bouchard’s nodes (in the PIP joints)
Squaring at the base of the thumb (CMC joint)
Weak grip
Reduced range of motion
what lifestyle changes can be advised in osteoarthritis?
Therapeutic exercise
Weight loss if overweight
Occupational therapy
what is the medical management of osteoarthritis?
Topical NSAIDs first-line for knee osteoarthritis
Oral NSAIDs where required and suitable (co-prescribed with a proton pump inhibitor for gastroprotection)
Intra-articular steroid injections
Joint replacement
what are the 3 main options for joint replacement?
Total joint replacement – replacing both articular surfaces of the joint
Hemiarthroplasty – replacing half of the joint (e.g., the head of the femur in the hip joint)
Partial joint resurfacing – replacing part of the joint surfaces (e.g., only the medial joint surfaces of the knee)
what is a compound fracture?
skin is broken and the broken bone is exposed to the air
what is a stable fracture?
sections of bone remain in alignment at the fracture
what is a Colle’s fracture?
transverse fracture of the distal radius
fall onto an outstretched hand
what are some early complications of fractures?
Damage to local structures (e.g., tendons, muscles, arteries, nerves, skin and lung)
Haemorrhage leading to shock and potentially death
Compartment syndrome
Fat embolism (see below)
Venous thromboembolism (DVTs and PEs) due to immobility
what are some long term complications of fracture?
Delayed union (slow healing)
Malunion (misaligned healing)
Non-union (failure to heal)
Avascular necrosis (death of the bone)
Infection (osteomyelitis)
Joint instability
Joint stiffness
Contractures (tightening of the soft tissues)
Arthritis
Chronic pain
Complex regional pain syndrome
how long after a fracture does a fat embolism typically present?
24-72 hours
What criteria is used to diagnose a fat embolism?
Gurd’s criteria
major criteria:
Respiratory distress
Petechial rash
Cerebral involvement
how long after a hip fracture should you aim to perform surgery?
within 48 hours
Hip fractures can be categorised into:
Intra-capsular fractures
Extra-capsular fractures
what classification is used for Intra-capsular neck of femur fractures?
Garden classification
what is an intra-capsular fracture?
break in the femoral neck, within the capsule of the hip joint. This affects the area proximal to the intertrochanteric line
how is an intertrochanteric fracture treated?
dynamic hip screw
how is a subtrochanteric fracture treated?
intramedullary nail
what are the 3 surgical options for managing an intra-capsular fracture?
Internal fixation
Hemiarthroplasty
Total hip replacement
what are the presenting features of a hip fracture?
Pain in the groin or hip, which may radiate to the knee
Not able to weight bear
Shortened, abducted and externally rotated leg
what is a key sign of a fractured neck of femur on x-ray?
Disruption of Shenton’s line
what is compartment syndrome?
pressure within a fascial compartment is abnormally elevated, cutting off the blood flow to the contents of that compartment.
what are the presenting features of acute compartment syndrome? (5)
P – Pain “disproportionate” to the underlying injury, worsened by passive stretching of the muscles
P – Paresthesia
P – Pale
P – Pressure (high)
P – Paralysis (a late and worrying feature)
what can be used to measure the compartment pressure in compartment syndrome?
Needle manometry
what is the initial management of acute compartment syndrome?
Escalating to the orthopaedic registrar or consultant
Removing any external dressings or bandages
Elevating the leg to heart level
Maintaining good blood pressure (avoiding hypotension)
what is the definitive management of acute compartment syndrome?
Emergency fasciotomy
what is the most common cause of osteomyelitis?
Staphylococcus aureus
State 4 risk factors for osteomyelitis
Open fractures
Orthopaedic operations, particularly with prosthetic joints
Diabetes, particularly with diabetic foot ulcers
Peripheral arterial disease
IV drug use
Immunosuppression
how does osteomyelitis present?
Fever
Pain and tenderness
Erythema
Swelling
what are the potential signs of osteomyelitis on x-ray?
Periosteal reaction (changes to the surface of the bone)
Localised osteopenia (thinning of the bone)
Destruction of areas of the bone
what is the best imaging option for diagnosing osteomyelitis?
MRI
what is the management of osteomyelitis?
Surgical debridement of the infected bone and tissues
Antibiotic therapy e.g. 6w flucloxacillin
what are the presenting symptoms of sarcoma?
A soft tissue lump, particularly if growing, painful or large
Bone swelling
Persistent bone pain
State 3 causes of mechanical back pain
Muscle or ligament sprain
Facet joint dysfunction
Sacroiliac joint dysfunction
Herniated disc
Spondylolisthesis
Scoliosis
Degenerative changes (arthritis)
what do the nerves of the cauda equina supply?
Sensation to the lower limbs, perineum, bladder and rectum
Motor innervation to the lower limbs and the anal and urethral sphincters
Parasympathetic innervation of the bladder and rectum
Name 3 causes of cauda equina
Herniated disc (the most common cause)
Tumours, particularly metastasis
Spondylolisthesis
Abscess (infection)
Trauma
what are some red flags for cauda equina ?
Saddle anaesthesia
Loss of sensation in the bladder and rectum
Urinary retention or incontinence
Faecal incontinence
Bilateral sciatica
Bilateral or severe motor weakness in the legs
Reduced anal tone on PR examination
what is the management of cauda equina?
Immediate hospital admission
Emergency MRI scan
Neurosurgical input to consider lumbar decompression surgery
what are the typical symptoms of spinal stenosis
gradual onset
Lower back pain
Buttock and leg pain
Leg weakness
How is spinal stenosis diagnosed?
MRI
what is the management of spinal stenosis?
Exercise and weight loss (if appropriate)
Analgesia
Physiotherapy
Decompression surgery where conservative treatment fails
Meralgia paraesthetica is caused by compression of what nerve ?
lateral femoral cutaneous nerve
what are the symptoms if meralgia paraesthetica?
sensory changes to skin of upper-outer thigh
Burning
Numbness
Pins and needles
Cold sensation
may also be localised hair loss
Symptoms are aggravated by walking or standing for a long duration and improve when sitting down
Symptoms are often worse with extension of the hip
what is the management of meralgia paraesthetica?
Conservative -> rest, looser clothing, weight loss, physio
Medical -> Paracetamol, amitriptyline, NSAIDs
Surgical -> decompression, transection, resection
what is trochanteric bursitis?
inflammation of a bursa over the greater trochanter on the outer hip
How does trochanteric bursitis present?
gradual-onset lateral hip pain (over the greater trochanter) that may radiate down the outer thigh
worse with activity, standing after sitting for a prolonged period and trying to sit cross-legged
tenderness over the greater trochanter
what special tests should you do to diagnose trochanteric bursitis?
Trendelenburg test
Resisted abduction of the hip
Resisted internal rotation of the hip
Resisted external rotation of the hip
what is the management of trochanteric bursitis?
Rest
Ice
Analgesia (e.g., ibuprofen or naproxen)
Physiotherapy
Steroid injections
what are the 4 ligaments of the knee?
Anterior cruciate ligament
Posterior cruciate ligament
Lateral collateral ligament
Medial collateral ligament
what type of movement often causes meniscal tears?
twisting movements
what are the symptoms of a meniscal tear?
Pain
Swelling
Stiffness
Restricted range of motion
Locking of the knee
Instability or the knee “giving way”
what are the examination findings of a meniscal tear?
Localised tenderness on the joint line
Swelling
Restricted range of motion
Name 2 special tests for meniscal tears
McMurray’s test
Apley Grind test
what are the Ottawa knee rules?
used to determine whether a patient requires an x-ray of the knee after an acute knee injury to look for a fracture
Age 55 or above
Patella tenderness (with no tenderness elsewhere)
Fibular head tenderness
Cannot flex the knee to 90 degrees
Cannot weight bear (cannot take 4 steps – limping steps still count)
what is the 1st line investigation for meniscal tears?
MRI scan
what are the management options for meniscal tears?
Conservative -> Rest, ice, compression, elevation
NSAIDs
Physio
Surgery
what does the ACL attach to what?
anterior intercondylar area on the tibia
what type of injury damages the ACL?
twisting
what are the symptoms of ACL injury?
Pain
Swelling
“Pop” sound or sensation
what 2 special tests can be done to assess for ACL injury?
Anterior draw test
Lachman test
what is the 1st line investigation for ACL injury?
MRI
what is the management of an ACL injury?
Conservative (RICE)
NSAIDs
Crutches and knee braces
Physio
Arthroscopic surgery
What causes Osgood-Schlatter disease?
inflammation at the tibial tuberosity where the patella ligament inserts
what are the presenting features of Osgood-Schlatter disease?
Visible or palpable hard and tender lump at the tibial tuberosity
Pain in the anterior aspect of the knee
The pain is exacerbated by physical activity, kneeling and on extension of the knee
what is the management of Osgood-Schlatter disease?
Reduction in physical activity
Ice
NSAIDS (e.g., ibuprofen) for symptomatic relief
what is a rare complication of Osgood-Schlatter disease?
avulsion fracture
what is a Baker’s cyst?
fluid-filled sac in the popliteal fossa, causing a lump
what are bakers cysts commonly associated with?
Meniscal tears
Osteoarthritis
Knee injuries
Inflammatory arthritis
what are the presenting symptoms of a bakers cyst?
Pain or discomfort
Fullness
Pressure
A palpable lump or swelling
Restricted range of motion in the knee (with larger cysts)
what is the 1st line investigation for a Baker’s cyst?
Ultrasound
what is the management of a bakers cyst?
Modified activity to avoid exacerbating symptoms
Analgesia (e.g., NSAIDs)
Physiotherapy
Ultrasound-guided aspiration
Steroid injections
what are the 2 types of Achilles tendinopathy
Insertion tendinopathy (within 2cm of the insertion point on the calcaneus)
Mid-portion tendinopathy (2-6 cm above the insertion point)
what are the risk factors for Achilles tendinopathy ?
Sports that stress the Achilles (e.g., basketball, tennis and track athletics)
Inflammatory conditions (e.g., rheumatoid arthritis and ankylosing spondylitis)
Diabetes
Raised cholesterol
Fluoroquinolone antibiotics (e.g., ciprofloxacin and levofloxacin)
what are the presenting features of Achilles tendinopathy?
Pain or aching in the Achilles tendon or heel, with activity
Stiffness
Tenderness
Swelling
Nodularity on palpation of the tendon
what are the management options for Achilles Tendinopathy?
Rest and altered activities
Ice
Analgesia
Physiotherapy
Orthotics (e.g., insoles)
Extracorporeal shock-wave therapy (ESWT)
Surgery, to remove nodules and adhesions or alter the tendon, may be used where other treatments fail
what is the presentation of Achilles tendon rupture?
Sudden onset of pain in the Achilles or calf
A snapping sound and sensation
Feeling as though something has hit them in the back of the leg
what are the signs on examination of Achilles tendon rupture?
When relaxed in a dangled position, the affected ankle will rest in a more dorsiflexed position
Tenderness to the area
A palpable gap in the Achilles tendon (although swelling might hide this)
Weakness of plantar flexion of the ankle (dorsiflexion is unaffected)
Unable to stand on tiptoes on the affected leg alone
Positive Simmonds’ calf squeeze test
what is the investigation of choice for Achilles tendon rupture?
Ultrasound
what is the management of Achilles tendon rupture?
Rest and immobilisation
Ice
Elevation
Analgesia
Non-surgical management involves applying a specialist boot to immobilise the ankle
Surgical management involves surgically reattaching the Achilles
what are the presenting features of plantar fasciitis?
gradual onset of pain on the plantar aspect of the heel. This is worse with pressure, particularly when walking or standing for prolonged periods. There is tenderness to palpation of this area.
what is the management of plantar fasciitis?
Rest
Ice
Analgesia (e.g., NSAIDs)
Physiotherapy
what is the management of fat pad atrophy?
comfortable shoes, custom insoles, adapting activities (e.g., avoiding high heels) and weight loss if appropriate
what are the presenting features of Morton’s Neuroma?
Pain at the front of the foot at the location of the lesion
The sensation of a lump in the shoe
Burning, numbness or “pins and needles” felt in the distal toes
Name 3 ways to test for Morton’s neuroma
Deep pressure applied to the affected intermetatarsal space on the dorsal foot causes pain
Metatarsal squeeze test – squeezing the forefoot with one hand to create a concave shape to the plantar aspect while using the other hand to press the affected area on the plantar side of the foot causes pain
Mulder’s sign – a painful click is felt when using two hands on either side of the foot to manipulate the metatarsal heads to rub the neuroma
what is a key risk factor of frozen shoulder?
Diabetes
what is the difference between primary and secondary frozen shoulder?
Primary – occurring spontaneously without any trigger
Secondary – occurring in response to trauma, surgery or immobilisation
what are the 3 phases of symptoms in frozen shoulder?
Painful phase – shoulder pain is often the first symptom and may be worse at night
Stiff phase – shoulder stiffness develops and affects both active and passive movement (external rotation is the most affected) – the pain settles during this phase
Thawing phase – there is a gradual improvement in stiffness and a return to normal
what is the management of frozen shoulder (adhesive capsulitis)
Continue using the arm but don’t exacerbate the pain
Analgesia (e.g., NSAIDs)
Physiotherapy
Intra-articular steroid injections
Hydrodilation (injecting fluid into the joint to stretch the capsule)
Surgery in persistent/severe cases
what are the 4 muscles of the rotator cuff and their specific action?
S – Supraspinatus – abducts the arm
I – Infraspinatus – externally rotates the arm
T – Teres minor – externally rotates the arm
S – Subscapularis – internally rotates the arm
what are 90% of shoulder dislocations ?
anterior dislocations
how will axillary nerve damage present?
loss of sensation in the “regimental badge” area over the lateral deltoid. It also leads to motor weakness in the deltoid and teres minor muscles.
the axillary nerve comes from what nerve roots?
C5 and C6
It is important to assess patients with a shoulder dislocation for:
Fractures
Vascular damage (e.g., absent pulses, prolonged capillary refill time and pallor)
Nerve damage (e.g., loss of sensation in the “regimental patch” area)
what is the acute management of a shoulder dislocation ?
Analgesia, muscle relaxants and sedation as appropriate
Gas and air (e.g., Entonox) may be used
A broad arm sling can be applied to support the arm
Closed reduction of the shoulder (after excluding fractures)
Dislocations associated with a fracture may require surgery
Post-reduction x-rays
Immobilisation for a period after relocation of the shoulder
what are the symptoms of lateral epicondylitis?
pain and tenderness at the lateral epicondyle (outer elbow). The pain often radiates down the forearm. It can lead to weakness in grip strength.
what are the 2 tests for lateral epicondylitis?
Mill’s test
Cozen’s test
what are the symptoms of medial epicondylitis?
pain and tenderness at the medial epicondyle (inner elbow). The pain often radiates down the forearm. It can lead to weakness in grip strength.
what is the test for medial epicondylitis?
golfer’s elbow test
what 2 tendons does De Quervain’s tenosynovitis primary affect?
Abductor pollicis longus (APL) tendon
Extensor pollicis brevis (EPB) tendon
what are the symptoms of De Quevain’s tenosynovitis?
symptoms at the radial aspect of the wrist near the base of the thumb
Pain, often radiating to the forearm
Aching
Burning
Weakness
Numbness
Tenderness
Name a specialist test for De Quervain’s tenosynovitis
Finkelstein’s test
what is the management of De Quervain’s tenosynovitis?
Rest and adapting activities
Using splints to restrict movements
Analgesia (e.g., NSAIDs)
Physiotherapy
Steroid injections
Surgery may be required to release (cut) the extensor retinaculum
State 3 risk factors for trigger finger
In their 40s or 50s
Women (more often than men)
People with diabetes (more with type 1, but also type 2)
how does trigger finger present?
Is painful and tender (usually around the MCP joint on the palm-side of the hand)
Does not move smoothly
Makes a popping or clicking sound
Gets stuck in a flexed position
Symptoms are typically worse in the morning and improve during the day.
what is the management of trigger finger?
Rest and analgesia (a small number resolve spontaneously)
Splinting
Steroid injections
Surgery to release the A1 pulley
what is Dupuytren’s contracture?
fascia of the hand becomes thickened and tight, leading to finger contractures.
state 3 risk factors for Dupuytren’s contracture
Age
Family history (autosomal dominant pattern)
Male
Manual labour, particularly with vibrating tools
Diabetes (more with type 1, but also type 2)
Epilepsy
Smoking and alcohol
what nerve is affected in Carpal tunnel syndrome?
median nerve
state 4 risk factors for carpal tunnel syndrome
Repetitive strain
Obesity
Perimenopause
Rheumatoid arthritis
Diabetes
Acromegaly
Hypothyroidism
what aspect of the hand experiences sensory symptoms in carpal tunnel syndrome?
Thumb
Index and middle finger
The lateral half of ring finger
what are the motor symptoms of carpal tunnel syndrome?
Weakness of thumb movements
Weakness of grip strength
Difficulty with fine movements involving the thumb
Wasting of the thenar muscles (muscle atrophy)
Name 2 special tests for carpal tunnel syndrome
Phalen’s test
Tinel’s test
what is the primary investigation for establishing a diagnosis of carpal tunnel syndrome?
Nerve conduction studies
when are symptoms of carpal tunnel syndrome typically worse?
At night
what is the management of carpal tunnel syndrome?
Rest and altered activities
Wrist splints that maintain a neutral position of the wrist can be worn at night (for a minimum of 4 weeks)
Steroid injections
Surgery
what are the features of a ganglion cyst on examination?
Range in size from 0.5 to 5cm or more (most are 2cm or less)
Firm and non-tender on palpation
Well-circumscribed
Transilluminates
what are the active management options for ganglion cysts?
Needle aspiration
Surgical excision
