Orthopaedics Flashcards
1
Q
What is Lachman’s test?
A
tests ACL integrity - leg external rotated, knee flexed to 30 degrees; lower leg pulled forward whilst stabilising thigh, finger should be on tibial tuberosity. positive sign - moves forward >2mm compared with other side, soft endpoint
2
Q
What is McMurray’s test?
A
tests for Meniscal tear - maximally flex hip + knee; then extend -if click/catch, is positive
3
Q
Which patient group is typically affected by Perthes disease?
A
Boys (M:F 5:1) age 4-8 years
4
Q
What are the typical X-ray findings in Perthes disease?
A
=avascular necrosis of femoral head - early changes include widening of joint space, later changes include decreased femoral head size/flattening
5
Q
Which age group is affected by SUFE?
A
10-15 years (males, obese)
6
Q
What happens in SUFE?
A
Displacement of femoral head epiphysis posterior-inferiorly
7
Q
What is pauciarticular JIA?
A
Arthritis affecting 4 or fewer joints, usually medium size - knees, ankles, elbows. Joint pain and swelling, limp
8
Q
What is another name for lateral epicondylitis?
A
tennis elbow
9
Q
What is lateral epicondylitis / tennis elbow?
A
pain over lateral epicondyle of humerus - worse with wrist extension against resistance when elbow is extended OR supination of forearm with elbow extended
10
Q
What activities may cause lateral epicondylitis?
A
tennis (tennis elbow); house painting
11
Q
What is the classic examination finding in lateral epicondylitis (tennis elbow)?
A
pain on resisted wrist extension when elbow is extended
12
Q
How long do episodes of lateral epicondylitis typically last?
A
6 months - 2 years (acute pain for 6-12 weeks)
13
Q
What are 4 treatment options for tennis elbow (lateral epicondylitis)?
A
- avoid excessive loading
- simple analgesia
- intraarticular steroids
- physiotherapy
14
Q
What is Simmonds triad?
A
For Achilles tendon rupture -
- when patient prone on examination couch with feet over edge, injured foot more dorsiflexed
- feel for gap in Achilles tendon
- when calf gently squeezed there is no plantarflexion
15
Q
What is the imaging modality of choice for Achilles tendon rupture?
A
Ultrasound
16
Q
What is the management of Achilles tendon rupture?
A
Urgent referral orthopaedics
17
Q
What is the clinical presentation of iliotibial band syndrome?
A
Keen runners - knee pain after exercise; sharp pain to palpation over lateral epicondyle of femur (2-3 cm above lateral join margin)
18
Q
What is the management of SUFE?
A
stop weight bearing, surgical fixation ASAP (in situ internal screw fixation) +- prophylactic for contralateral side
19
Q
What predisposes patients to SUFE?
A
weakness in proximal femoral growth plate (physis) - allows displacement of capital femoral epiphysis
20
Q
Which ethnicity is SUFE commoner in?
A
African Caribbean
21
Q
What proportion of SUFE cases are bilateral?
A
20%
22
Q
What are 3 risk factors for SUFE?
A
- excessive weight or obesity
- family history
- endocrine disorder - e.g. hypothyroidism, hypopituitarism, hyperparathyroidism, renal osteodystrophy (outside typical age range)
23
Q
What type of growth plate injury is SUFE?
A
Type I Salter-Harris growth plate injury (due to repeated trauma on BG mechanical / hormonal predisposing factors)
24
Q
What is a key examination finding in SUFE?
A
obligatory external rotation on hip flexion
25
What is the key imaging finding on pelvic radiographs in SUFE?
Klein lines - drawn along superior cortex of femoral neck - if normal should intesect the epiphysis, if abnormal doesn't intersect
26
When is CT used in SUFE?
should not be used unless absolutely necessary due to radiation - allows multi-plane reconstruction to assess femoral head with relation to metaphysis
27
When is MRI used in SUFE?
examine contralateral hip (high incidence of bilateral slip)
28
Why is prophylactic pinning of the unaffected side in SUFE recommended by some?
sometimes stabilisation of affected side can precipitate slip on contralateral side
29
What are 5 complications of SUFE?
1. long term degenerative OA
2. avascular necrosis of femoral head
3. chondrolysis or acute cartilage necrosis
4. deformity + limb length discrepency
5. femoroacetabular impingement
30
What is de Quervain's tenosynovitis?
sheath containing **extensor pollicis brevis** and **abductor pollicis longus** tendons becomes thickened and inflamed
| more common in women 30-50y
31
What is the classical presentation of de Quervain's tenosynovitis?
* unaccustomed or excessive activity e.g. rose pruning
* pain on radial side of wrist
* swelling + tender along thumb tendons / thickened tendon sheath
* tender over tip of radial styloid
* finkelstein's test positive
32
What are the treatment options for de Quervain's tenosynovitis?
* coricosteroid injection if diagnosed early
* splint at wrist
* chronic: operation - slitting thickened lateral wall of tendon sheath
33
What is a Colles' fracture?
**dorsally** displaced distal radius fracture (mechanism = FOOSH) causes dinner fork deformity
34
What imaging is needed in Colles fracture?
posteroanterior and lateral radiographs (+- oblique radiographs of injured forearm to reveal intra-articular involvement not apparent on other views)
35
What is the management of a Colles fracture?
1. **immobilisation** without fracture manipulation if non-displaced
2. displaced: **closed reduction + immobilisation** in plaster splint
3. **surgical** treatment for unstable fractures
36
In which patients do supracondylar fractures classially occur?
children falling onto outstretched hand - present with painful swollen elbow, hesitant to move it
37
What is the presentation of a supracondylar fracture?
* painful swollen elbow
* may appear angulated and upper extremity shortened (open wounds in 30% of patients)
* neuropraxias common - generally resolve with restoration of normal alignment
38
How long may it take for neuropraxias to recover after a supracondylar fracture has been restored to normal alignment?
up to 18 months
39
What investigations should be performed to diagnose a supracondylar fracture?
* AP and lateral films
* if complicated - CT
* if vascular compromise - arteriograms
40
What is the management of a supracondylar fracture with arterial disruption present?
vascular surgery consultant + immediate ORIF for skeletal stability + support of vascular reconstruction
41
What is the most frequently gractures caarpal bone?
scaphoid (71%)
42
What is the primary mechanism of injury for scaphoid fracture?
FOOSH
43
What are 5 clinical features of scaphoid fracture?
1. snuff box tenderness
2. tenderness of palmar and dorsal aspect of scaphoid
3. pain on compressing thumb longitudinally
4. pain on gentle flexion + ulnar deviation of wrist
44
What is done if scaphoid fracture is suspected but is not apparent on xray?
cast for 7-10 days, then second set of xrays taken (hairline fracture healing may be apparent)
CT or MRI can provide more information
45
What is the management of scaphoid fractures?
6-12 weeks of casting
46
What is a common complication of scaphoid fractures?
avascular necrosis
| if missed scaphoid fracture suspected - urgent ortho assessment in ED
47
What are 3 investigations indicated in transient synovitis?
1. WBC + inflammatory markers - mildly elevated
2. Plain films - exclude fractures, tumours and Perthes disease
3. US - demonstrates fluid in joint capsule (not always present), helps distinguish from septic arthritis
| if need to r/o septic arthritis - US guided needle aspiration of fluid
48
What is the most common cause of acute hip pain in children aged 3-10 years?
transient synovitis
49
What is the management of transient synovitis?
* rest + appropriate analgesia
* keep leg flexed + some external rotation
* aspiration of effusion if present
| surgical washout not necessary
50
What is the commonest form of shoulder dislocation?
anterior - 95%
51
What are 3 types of shoulder dislocation in addition to anterior?
1. inferior
2. superior
3. intrathoracic
52
What is the usual mechanism causing anterior shoulder dislocation?
traumatic - abduction, extension & posteriorly directed force on the arm; & fall on outstretched hand common in elderly
53
What happens anatomically in anterior shoulder dislocation?
humeral head forced anteriorly out of glenohumeral joint, tearing shoulder capsule & detaching labrum from glenoid
| note #humeral head / neck / greater tuberosity can also occur
54
What is the presentation of anterior shoulder dislocation?
* h/o trauma, inability to move shoulder
* arm held at side of body in external rotation
* shoulder loses usual roundness, anterior bulge may be seen
* humeral head palpable anteriorly
* abduction and internal rotation resisted
55
Where should sensation and vascular damage be assessed in anterior shoulder dislocation?
* regimental badge - axillary nerve
* radial pulse
56
What investigations should be performed for suspected anterior shoulder dislocation?
* **AP XR** - humeral head under coracoid process
* **Axillary or transcapular 'Y' view**
* in **axillary** - head of humerus anterior to glenoid
* **Y view**: humeral head anterior to Y (glenoid at centre of Y)
57
What is the management of anterior shoulder dislocation?
* without fracture - closed reduction
* fracture dislocation - surgery
58
What is the most common muscle involved in a rotator cuff tear?
supraspinatus
59
What typically leads to rotator cuff tear?
chronic rotator cuff disease in patients <40 years old. may follow trauma e.g. fall with hyperabduction or hyperextension of shoulder
60
What is the presentation of rotator cuff tear?
* reduced **range of motion**
* **weakness**
* **crepitus** and **tenderness** over cuff insertions and subacromial area
* **supraspinatus** strength usually reduced (test by resistance to abduction)
61
What may xray show in rotator cuff tear?
bony avulsions
62
What is the management of a rotator cuff tear?
analgesia, broad arm sling, physio at 2 weeks
younger patients with complete tear: may require surgical repair
63
What is the commonest mechanism of clavicle fracture?
* violent upward and backward force
* e.g. landing on outstretched hand after being thrown from a horse / over handlebards of a bicycle
* less common: blows or falls on the point of the shoulder or by direct violence
64
What are the commonest locations for the clavicle to fracture?
**middle 1/3**: most common at junction of middle third and outer third
65
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What is the management of a clavicle fracture?
* accurate closed reduction
* sling for 10 days (pain relief)
* operative reduction if severely displaced outer one-third (untreated caused marked deformity + shoulder weakness)
66
How long does it usually take a for a clavicle fracture to heal?
heal quickly - 6 weeks in adult, return of function in 3 weeks; 3 weeks in child
67
What are 5 specific causes of Dupuytren's contracture?
1. manual labour
2. **phenytoin** treatment
3. alcoholic liver disease
4. diabetes mellitus
5. trauma to the hand
| 60-70% have a positive family history
68
When is surgical treatment considered for dupuytren's contracture?
metacarpophalangeal joints can't be straightened and thus hand can't be placed flat on the table
69
What is the next best action if a suspected missed scaphoid fracture is diagnosed?
urgent ortho assessment in ED/urgent ortho clinic due to risk of avascular necrosis
70
Why is the scaphoid bone susceptible to avascular necrosis?
the tubercule receives part of the flexor retinaculum; the only part of the scaphoid available for entry of blood vessels.
71
How are fractured NOFs divided anatomically?
- intracapsular
- extracapsular - divided into trochanteric and subtrochanteric
72
What is an eponymous classification system for fractured NOF?
Garden system
73
What divides intertrochanteric from subtrochanteric extracapsular fractures?
Lesser trochanter is the dividing line
74
What are the 4 types of fractured NOFs based on the Garden system?
1. Stable fracture with impaction in valgus
2. Complete fracture but undisplaced
3. Displaced fracture, usually rotated and angulated, but still has bony contact
4. Complete bony disruption
75
Which type of fractured NOFs is blood supply disruption most common with?
Garden type III and IV
76
What is the management of an undisplaced intracapsular hip fracture?
Internal fixation; hemiarthroplasty if unfit
77
What is the management of a displaced intracapsular hip fracture?
Replacement arthroplasty (THR or hemiarthroplasty)
78
What are 3 factors that favour THR over hemiarthroplasty?
1. able to walk independently outdoors with no more than stick
2. No CI
3. Medically fit for anaesthesia
79
What is the management of stable intertrochanteric (extracapsular) fractures?
Dynamic hip screw
80
What is the management of reverse oblique, transverse or subtrochanteric extracapsular hip fractures?
Intramedullary device
81
What is the gold standard for diagnosis of degenerative cervical myelopathy?
MRI (disc degeneration, ligamentous hypertrophy and cord signal change)
82
In the GP setting what is the next step in management if DCM is suspected?
Urgent referral for specialist spinal services (orthopaedics or neurosurgery) - early treatment important
83
How soon should treatment of DCM be?
Within 6 months of diagnosis
84
What is the only effective treatment for DCM?
Decompressive surgery
85
What are the Ottawa rules ot determine if ankle x-ray is required after ankle injury?
Any pain in the malleolar zone AND one of the following:
* bony tenderness at lateral malleolar zone (from tip of lateral malleolus to include lower 6cm of posterior border of fibula)
* bony tenderness at medial malleolar zone (top of medial malleolus to lower 6cm of posterior border of tibia)
* inability ot walk 4 weight-bearing steps immediately after injury and in the ED
86
What is the most common joint affected by septic arthritis in adults?
knee
87
What is the commonest organism involved in septic arthritis overall?
Staphylococcus aureus
| Neisseria gonorrhoeae in young adults
88
What investigations are warranted in septic arthritis?
* synovial fluid sampling (prior to abx if possible)
* blood cultures
* joint imaging
89
What is the commonest cause of septic arthritis?
haematogenous spread
90
Which abx are indicated for septic arthritis and for how long?
flucloxacillin (clindamycin if pen allergic) - 4-6 weeks (switch to oral after 2)
91
What are 3 aspects of management of septic arthritis?
1. IVABx
2. needle aspiration to decompress joint
3. arthroscopic lavage may be required
92
What is the value of radiographs in diagnosing DCM?
No value - MRI required for diagnosis
93
What are the features of posterior vs anterior hip dislocation?
* **posterior** dislocation: affected leg shortened, adducted, internally rotated
* **anterior** dislocation: affected leg abducted and externally rotated. no leg shortening
94
What are 3 types of hip dislocation and which is most common?
**posterior** (90%), anterior, central
95
What is the management of hip dislocation?
reduction under GA in <4h to reduce risk of avascular necrosis
long term - physio
96
What are 4 complications of hip dislocation?
1. sciatic or femoral nerve injury
2. avascular necrosis
3. OA - in older patients
4. recurrent dislocation (damage of supporting ligaments)
97
How long does it take the hip to heal after traumatic dislocation?
2-3 months
98
What gives the best prognosis following hip dislocation?
when hip reduced <12h post injury, and when there is less damage to the joint
99
When do NICE guidelines suggest a presumptive diagnosis of transient synovitis can be made and managed in primary care?
if child is 3-9 years, well, afebrile, mobile but limping, symptoms <72h
100
What is the stepwise management for osteoarthritis?
* **topical NSAIDs** - first line
* **oral NSAIDs** - second line (+PPI)
* non-pharmacological: **walking aids** for knee + hip OA
* **intra-articular steroid** if standard treatment ineffective
* if conservative methods fail: refer for consideration of **joint replacement**
101
What drugs are NOT recommended for pain relief in OA?
* paracetamol
* weak opioids
(unless used only infrequently in short-term or other options contraindication)
* glucosamine
* strong opioids
102
How long is benefit derived from intra-articular steroid injections in OA?
2-10 weeks - short-term relief only
103
What is often the first sign on examination in hip OA?
reduction in internal rotation
104
What sign may be positive in referred lumbar spine pain to the hip joint, leading to femoral nerve compression?
femoral nerve stretch test - patient lies prone, hip joint extended with straight leg, then knee bent - +Ve if pain
105
What causes trochanteric bursitis (greater trochanteric pain syndrome)?
repeated movement of the fibroelastic ilitibial band
106
Which patient group is trochanteric bursitis most common in?
women 50-70y
107
What causes pubic symphysis dysfunction?
common in pregnancy - ligament laxity increases in response to hormonal changes of pregnancy
108
What is the presentation of pubic symphysis dysfunction?
pain over pubic symphysis with radiation to the groins and medial aspects of thighs, waddling gait
109
What patient group is transient idiopathic osteoporosis seen in?
uncommonly seen in third trimester of pregnancy
110
What is the presentation of transient idiopathic osteoporosis?
groin pain associated with limited range of movement of hip, unable to weight bear, raised ESR
111
In which patient group does femoroacetabular impingement present?
young, active adults
112
What is the presentation of femoroacetabular impingement?
* hip/groin pain with prolonged sitting
* snapping, clicking or locking of the hip
* associated with prior hip pathology e.g. Perthes
113
What is cubital tunnel syndrome?
Compression of the ulnar nerve as it passes through the cubital tunnel causing tingling and numbness of 4th and 5th fingers
114
What is the typical presentation of cubital tunnel syndrome?
* **tingling and numbness 4th and 5th digits**
* starts **intermittent** then **becomes constant**
* weakness and muscle wasting over time
* pain worse **leaning on affected elbow**
* history of OA or trauma
115
Which 2 things may be in the history of someone with cubital tunnel syndrome?
- OA
- previous trauma
116
How is a diagnosis of cubital tunnel syndrome made?
Clinical diagnosis - NCS in selected cases
117
What are 4 aspects of the management of cubital tunnel syndrome?
* avoid aggravating activity
* physiotherapy
* steroid injections
* surgery in resistant cases
118
What are the 2 classes that osteomyelitis can be grouped into?
1. haematogenous
2. non-haematogenous
119
What is the most common form of haematogenous osteomyelitis in adults?
vertebral osteomyelitis
120
What are 4 risk factors for haematogenous osteomyelitis?
1. sickle cell anaemia
2. IVDU
3. immunosuppression due to medication or HIV
4. infective endocarditis
121
Which type of osteomyelitis is most common in adults?
non-haematogenous (haematogenous in children)
122
What organism is the commonest cause in non-sickle cell related osteomyelitis?
Staph. aureus
123
What organism is the commonest cause in sickle cell related osteomyelitis?
salmonella species
124
What is the imaging modality of choice for osteomyelitis?
MRI
125
What is the management of ostemyelitis?
flucloxacillin for 6 weeks (clinda if pen allergy)
126
What is the commonest reason for revision operation of total hip replacement?
aseptic loosening of the implant
127
What score can be used to work out severity in hip OA?
Oxford Hip Score
128
What are 4 perioperative complications of total hip replacement?
1. venous thromboembolism
2. intraoperative fracture
3. nerve injury
4. surgical site infection
129
What are 4 complications of total hip replacement?
1. leg length discrepency
2. posterior dislocation
3. aseptic loosening
4. prosthetic joint infection
130
What are the features of prosthetic hip (THR) posterior dislocation?
* may occur during extremes of hip flexion
* typically presents acutely with 'clunk', pain and inability ot weight bear
* internal rotation + shortening of affected leg
131
What can exacerbate the symptoms of cubital tunnel syndrome?
leaning on the affected elbow
132
What are 5 types of paediatric fractures?
1. **complete fracture** - both sides of cortex breached
2. **Toddlers fracture** - oblique tibial fracture in infants
3. **plastic deformity** - stress on bone resulting in deformity without cortical disruption
4. **Greenstick fracture** - unilateral cortical breach only
5. **Buckle (torus) fracture** - incompete cortical disruption resulting in periosteal haematoma only
133
What classification system is used for paediatric growth plate fractures?
Salter-Harris system
134
What are the 5 grades of the Salter-Harris grading system?
1. fracture through physis only (xray may be normal)
2. fracture through physis and metaphysis
3. fracture through physis and epiphysis to include joint
4. fracture involving physis, metaphysis and epiphysis
5. crush injury involving physis (xray may resemble type 1 / appear normal)
135
Which types of Salter-Harris growth plate fractures usually require surgery?
III, IV, V
136
Which type of Salter-Harris growth plate injury is often associated with disruption to growth?
type V
137
What are 2 genetic conditions that may predispose to pathological fractures in children?
1. osteogenesis imperfecta
2. osteopetrosis
138
What is osteogenesis imperfecta?
* Defective **osteoid** formation due to congenital inability to produce adequate intercellular substances like **osteoid, collagen and dentine**
* Failure of maturation of **collagen** in all the connective tissues.
139
What are the 4 subtypes of osteogenesis imperfecta?
* Type I - The collagen is normal quality but insufficient quantity.
* Type II - Poor collagen quantity and quality.
* Type III - Collagen poorly formed. Normal quantity.
* Type IV - Sufficient collagen quantity but poor quality
140
What is the inheritance pattern of osteopetrosis?
autosomal recessive
141
What is osteopetrosis?
common in young adults - bones become harder and more dense
142
What is seen on x-rays in osteogenesis imperfecta?
* **translucent** bones
* multiple **fractures**, particularly of the long bones
* **wormian** bones (irregular patches of ossification)
* **trefoil** pelvis
143
What does radiology show in osteopetrosis?
**lack of differentiation** between the cortex and the medulla described as **marble bone**
144
What is thought to be the effect of obesity on joint replacement?
only slight increase in short-term complications, no difference in long-term joint replacement survival
145
What is the commonest surgical procedure for hip OA?
cemented hip replacement - metal femoral component cemented into femoral shaft, accompanied by cemented acetabular polyethylene cup
146
What are 2 alternative procedures for hip OA to cemented hip replacement?
1. uncemented replacements - expensive, popular in young acite patients
2. hip resurfacing - metal cap over femoral head, younger patients, preserves femoral neck
147
What are 3 key aspects of the post-operative recovery following hip replacement?
1. physiotherapy
2. home-exercises
3. walking sticks or crutches used up to 6 weeks after hip / knee replacement surgery
148
What are 4 key pieces of advice to give to patients who have had a hip replacement to avoid dislocation?
1. avoid flexing hip >90 degrees
2. avoid low chairs
3. do not cross legs
4. sleep on back for first 6 weeks
149
What is done to reduce the risk of VTE after hip replacement?
LMWH for 4 weeks
150
Is Perthe's disease painful? What are the clinical features?
no - usually painless limp and restricted range of movement
151
What patients are classically affected by adhesive capsulitis?
middle-aged females, associated with diabetes mellitus
152
What features are characteristic of adhesive capsulitis on examination?
* limited external rotation - affected more than internal rotation or abduction
* active and passive movement affected
153
What are the 3 typical phases of adhesive capsulitis?
1. freezing phase - painful
2. adhesive phase
3. recovery phase
154
How long does an episode of adhesive capsulitis typically last for?
6 months - 2 years
155
What are 3 options for the management of adhesive capsulitis?
1. NSAIDs
2. physiotherapy
3. oral corticosteroids / intra articular steroids
156
What is patellofemoral pain syndrome?
aka chondromalacia patellae - softening of cartilage of patella
157
What is the classic presentation fo patellofeoramol pain syndrome?
teenage girls - anterior knee pain on walking up and down stairs, rising from prolonged sitting
158
What is the management of patellofemoral pain syndrome?
physiotherapy
159
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What are 4 diseases on the spectrum of rotator cuff injury?
1. subacromial impingement
2. calcific tendonitis
3. rotator cuff tears
4. rotator cuff arthropathy
160
What are the classic examination findings in subacromial impingement?
painful arc 60 -120 degrees
161
Where is the painful arc in rotator cuff tears?
first 60 degrees
162
What is Osgood-Schlatter disease?
small avulsion fractures within tibial tuberosity are caused by traction of the patellar tendon on the immature tibial tuberosity during forceful contractions of the quadriceps muscle
163
Which patients get Osgood-Schlatter disease?
children who do sports -overuse syndrome associated with physical exertion before skeletal maturity - strength of quadripceps may exceed ability of tibial tuberosity to resist that force
164
How may Osgood-Schlatter disease present?
tibial tubercle may enlarge - pain and swelling below knee relieved by reset, worst on activity
165
What is the management of Osgood-Schlatter disease?
conservative - rest from painful activities
166
What is a Maisonneuve fracture?
**spiral fracture of upper third of fibula** + tear of distal tibiofibular syndesmosis and the interosseous membrane, with associated **fracture of medial malleolus**, or rupture of deep deltoid ligament
167
Who is affected by stress fracture of the metatarsals (March fracture)?
individuals who undertake repetitie walking or running e.g. army recruits, runners
168
What is the presentation of a stress fracture of the metatarsals?
usually 2nd metatarsal shaft - tender lump on dorsum of foot, palpable just medial to mid-sharf of a metatarsal bone
169
What is the management of metatarsal stress fracture / march fracture?
analgesia, elevation, rest, modified daily activity
