Orthopaedics Flashcards
Runners knee
lateral pain
worse on 30o flexion
relieved by rest
what is it?
Iliotibial band syndrome
(tenderness 2-3cm above the lateral joint line)
tibial apophysitis, would typically cause pain and swelling over the tibial tubercle
more common in kids
Osgood-Schlatter disease
locking and swelling of the knee joint as well as tenderness.
Osteochondritis dissecans
pain at patella site of knee
pain post exercise
Patellar tendonitis
management of ITB syndrome
activity modification and iliotibial band stretches
if not improving then physiotherapy referral
shortened and internally rotated leg
POSTERIOR hip dislocation
common In RTC
pain on walking or palpation, instability, neurovascular deficits in the limb and signs of damage to pelvic organs e.g. haematuria or PR bleeding.
Pelvic fractures
abducted and externally rotated leg. There may be a palpable bulge of the femoral head. They are less common than posterior dislocations but are classically associated with hip prostheses.
No leg shortening.
Anterior hip dislocations
management of hip dislocation
ABCDE approach.
Analgesia
A reduction under general anaesthetic within 4 hours to reduce the risk of avascular necrosis.
Long-term management: Physiotherapy to strengthen the surrounding muscles.
(takes 2-3 months to heal)
complications of hip dislocation
Sciatic or femoral nerve injury
Avascular necrosis
Osteoarthritis: more common in older patients.
Recurrent dislocation: due to damage of supporting ligaments
Scaphoid fracture:
management (1)
when to fix (2)
cast 6 weeks
Sugircal fiction if:
-proximal pole fracture (as –> avascular necrosis)
- displaced
ulnar deviation of the wrist PAIN indicates
scaphoid fracture
telescoping of the thumb (pain on longitudinal compression)
scaphoid fracture
when to do CT for scaphoid fracture
CT»_space;> Xray
ongoing clinical suspicion, planning operative management, or to determine the extent of fracture union during follow-up.
MRI definitive:
NICE guidance from 2016 suggested the MRI should be considered the first-line imaging following clinical examination. However, this is still not common practice in the UK
however, MRI is much more commonly used second-line when radiographs are inconclusive
complications scaphoid fracture (2)
non-union → pain and early osteoarthritis
avascular necrosis
Achilles tendonitis management
rest, NSAIDs, and physio if symptoms persist beyond 7 days
ibuprofen and asthma
Avoid !
most common cause of posterior heel pain
Achilles tendon disorders
Possible presentations include tendinopathy (tendinitis), partial tear and complete rupture of the Achilles tendon.
risk factors Achilles tendon disodrers:
drug (1)
blood test (1)
Quinolone (ciprofloxacin)
Hypercholesterolaemia (predisposes to tendon xanthomata)
gradual onset of posterior heel pain that is worse following activity
morning pain and stiffness are common
achilles tendinopathy (tendinitis)
Simmond’s triad
for achilles tendon rupture
lie prone with their feet over the edge of the bed. The examiner should look for an abnormal angle of declination; Achilles tendon rupture may lead to greater dorsiflexion of the injured foot compared to the uninjured limb. They should also feel for a gap in the tendon and gently squeeze the calf muscles if there is an acute rupture of the Achilles tendon the injured foot will stay in the neutral position when the calf is squeezed.
achilles tendon rupture imaging of choice
US
suspected achilles tendon rupture mnagement
An acute referral should be made to an orthopaedic specialist following a suspected rupture.
cauda equina late sign
urinary incontinence
A positive sciatic stretch test just tells you that the patient has some irritation or compression of the sciatic nerve. It does not indicate spinal cord compression.
cauda equina- bilateral or unilateral pain
BILATERAL sciatica
typically an overweight adolescent boy with knee / hip problems, pain in the thigh (which can be referred from the hip), and pain worse with activity
Slipped upper femoral epiphysis -limited and painful internal rotation of the hip whilst maintaining flexion is particularly characteristic of SUFE
children (aged 3-8 years), relatively acutely, and is often preceded by an upper respiratory tract infection
Transient synovitis
Often picked up on newborn examination
Barlow’s test, Ortolani’s test are positive
Unequal skin folds/leg length
Development dysplasia of the hip
a degenerative condition affecting the hip joints of children, typically between the ages of 4-8 years. It is due to avascular necrosis of the femoral head
Features
hip pain: develops progressively over a few weeks
limp
stiffness and reduced range of hip movement
x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening
Pethers disease
5x more common in boys
10% bilateral
painful arc of abduction of arm
pain around the midpoint of shoulder abduction describes a painful arc (classically causing pain between 60 to 120 degrees of abduction) which indicates subacromial impingement as the cause of his pain.
Rotator cuff injury
pain worse on straightening the knee
knee may ‘give way’
displaced meniscal tears may cause knee locking
tenderness along the joint line
Thessaly’s test - weight bearing at 20 degrees of knee flexion, patient supported by doctor, postive if pain on twisting knee
meniscal tear
red flag features for back pain
thoracic back pain, age > 50 years or <18 , unexplained weight loss, local spinal tenderness and focal neurology (e.g. urinary or faecal incontinence or lower leg weakness).
age < 20 years or > 50 years
history of previous malignancy
night pain
history of trauma
systemically unwell e.g. weight loss, fever
Usually gradual onset
Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as ‘aching’, ‘crawling’.
Relieved by sitting down, leaning forwards and crouching down
Clinical examination is often normal
Requires MRI to confirm diagnosis
spinal stenosis
Typically a young man who presents with lower back pain and stiffness
Stiffness is usually worse in morning and improves with activity
Peripheral arthritis (25%, more common if female)
Ankylosing spondylitis
pain on walking, relieved by rest
Absent or weak foot pulses and other signs of limb ischaemia
Past history may include smoking and other vascular diseases
PAD
loss of foot dorsiflexion + sensory loss dorsum of the foot
L5
Prolpased disc
leg pain usually worse than back
pain often worse when sitting
Disc compression: L3 nerve root compression
Sensory loss over anterior thigh
Weak hip flexion, knee extension and hip adduction
Reduced knee reflex
Positive femoral stretch test
L4 nerve root compression
Sensory loss anterior aspect of knee and medial malleolus
Weak knee extension and hip adduction
Reduced knee reflex
Positive femoral stretch test
L5 nerve root compression
sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
S1 nerve root compression
Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
when to refer disc prolapse for MRI?
pain after 4-6weeks
direct blow to the medial knee, which this man has not experienced. The injury will result in an acute onset of lateral knee pain and cessation of activity. On examination, there is swelling of the knee and tenderness over the lateral joint line.
lateral collateral ligament
usually caused by a hyperextension injury or by a direct blow to the proximal tibia with the knee in flexion. Typical features are posterior knee pain, mild swelling, and a reduced range of knee flexion.
POSTERIOR cruciate
In discitis due to Staphylococcus look for..
Endocarditis (ECHO)
The most common cause is septic emboli from endocarditis and systemic bacteraemia with Staphylococcus aureus has a high rate of development of endocarditis due to the bacterial ability to attach to structures and form biofilms. Therefore an echocardiogram must be performed to look for evidence of valvular injury or vegetations in all cases of Staphylococcus aureus-positive cultures.
Discitits can lead to..
can lead to serious complications such as sepsis or an epidural abscess.
best imaging for discitits
MRI
CT-guided biopsy may be required to guide antimicrobial treatment
Spinal stenosis- best imaging? (1)
management (1)
MRI - MRI scanning is the best modality for demonstrating the canal narrowing. Historically a bicycle test was used as true vascular claudicants could not complete the test.
Laminectomy
Degenerative disease is the commonest underlying cause. Degeneration is believed to begin in the intervertebral disk where biochemical changes such as cell death and loss of proteoglycan and water content lead to progressive disk bulging and collapse. This process leads to an increased stress transfer to the posterior facet joints, which accelerates cartilaginous degeneration, hypertrophy, and osteophyte formation; this is associated with thickening and distortion of the ligamentum flavum. The combination of the ventral disk bulging, osteophyte formation at the dorsal facet, and ligamentum flavum hyptertrophy combine to circumferentially narrow the spinal canal and the space available for the neural elements. The compression of the nerve roots of the cauda equina leads to the characteristic clinical signs and symptoms of lumbar spinal stenosis.
rheumatoid nodule
hard, painless and rarely in isolation
Olecranon bursitis AKA
students elbow
trauma, infection, or systemic conditions such as rheumatoid arthritis or gout
ACL/ PCL tear vs meniscus tear: how quick does the swelling come on?
Gradual swelling of the knee is suggestive of effusion which often occurs due to meniscal injury. An ACL or PCL tear would more commonly present with rapid joint swelling due to bleeding within the joint capsule (haemarthrosis).
ACL = RAPID swelling (haemjoarthrosis)
ACL vs PCL mechanism
ACL= TWISTING injury
PCL= hyperextension, Paradoxical anterior draw test
Occur in the elderly (or following significant trauma in young)
Mechanism: knee forced into valgus or varus, but the knee fractures before the ligaments rupture
Varus injury affects medial plateau and if valgus injury, lateral plateau depressed fracture occurs
Classified using the Schatzker system (see below)
Tibial plateau fracture
right ring finger when she flexes it. On one occasion she reports it became ‘stuck’. Clinical examination is unremarkable other than a palpable nodule at the base of the finger. What is the most likely diagnosis?
trigger finger
trigger finger management
steroid injection is successful in the majority of patients. A finger splint may be applied afterwards
surgery should be reserved for patients who have not responded to steroid injections
compression of the ulnar nerve and can present with tingling/numbness of the 4th and 5th finger
Cubital tunnel syndrome
positive straight leg test
can be spinal disc prolapse
digital mucous cysts, are benign lesions that typically occur on the fingers or toes, particularly around the nail bed. A/W osteoarthritis and degenerative joint diseases
Myxoid cyst
a cyst commonly found on the face, neck or trunk and they often contain keratinous material
epidermoid cyst
infectious condition caused by a parapoxvirus that primarily affects sheep and goats. Humans can contract it through direct contact with infected animals or contaminated fomites
off
firm subcutaneous nodules that commonly occur in patients with severe RA; they are typically found over pressure points such as elbows or knuckles rather than toes
rheumatoid nodule
meralgia paraesthetica
lateral cutaneous nerve of thigh compression
Risk factors 3
Obesity
Pregnancy
Tense ascites
Trauma
Iatrogenic, such as pelvic osteotomy, spinal surgeries, laparoscopic hernia repair and bariatric surgery. In some cases, may result from abduction splints used in the management of Perthe’s disease.
Various sports have been implicated, including gymnastics, football, bodybuilding and strenuous exercise.
Some cases are idiopathic.
De Quervain’s tenosynovitis
pain on the radial side of the wrist
tenderness over the radial styloid process
abduction of the thumb against resistance is painful
Finkelstein’s test: the examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction. In a patient with tenosynovitis this action causes pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus
Rotator cuff syndrome vs adhesive capsulitis
rotator cuff = painful on ACTIVE movement
Adhesive capsulitis= ACTIVE AND PASSIVE
adhesive capsulitis RF
A bit random.
diabetes, MI, lung disease, neck disease
female
40-60yr
non-dominant hand
The nerve most likely to be injured during knee arthroplasty
common peroneal nerve
dupuytrens contracture RF
manual labour
phenytoin treatment
alcoholic liver disease
diabetes mellitus
trauma to the hand
deformity with little and ring fingers are slightly flexed, with no apparent weakness
dupuytrens contracture
pain/pins and needles in thumb, index, middle finger
unusually the symptoms may ‘ascend’ proximally
patient shakes his hand to obtain relief, classically at night
carpal tunnel syndrome
carpal tunnel Mx
NICE recommends a 6-week trial of conservative treatments if the symptoms are mild-moderate
corticosteroid injection
wrist splints at night: particularly useful if transient factors present e.g. pregnancy
if there are severe symptoms or symptoms persist with conservative management:
surgical decompression (flexor retinaculum division)
morning stiffness in joints- how long to be cocnerning
> 2 hr (inflammatory arthritis)l
plantar fascitis
Pain is worse when you ask them to walk on their toes.
the most common reason for total hip replacement revision. This often presents with pain in the hip or groin region radiating down to the knee.
aseptic loosening
Inverted + plantar flexed foot which is not passively correctable.
club foot
‘housemaid’s knee’,
pre patellar bursa inflammation
Foucher’s sign
They are more likely to develop in patients with arthritis or gout and following a minor trauma to the knee. Foucher’s sign describes the increase in tension of the Baker’s cyst on extension of the knee.
Infrapatellar bursitis
(Clergyman’s knee)
Associated with kneeling
Tennis and golfers elbow
Golfer’s elbow or medial epicondylitis produces tenderness over the medial epicondyle and medial wrist pain on resisted wrist pronation.
Tennis elbow or lateral epicondylitis produces tenderness over the lateral epicondyle and lateral elbow pain on resisted wrist extension.
intertrochanteric proximal femur fracture
Dynamic hip screws
osteomyelitis most common bacteria
exception (1)
imaging (1)
Staph. aureus is the most common cause except in patients with sickle-cell anaemia where Salmonella species predominate
MRI
hip fracture
Intracapsular femoral fracture - hemiarthroplasty
extracapsular femoral fracture - dynamic hip screw
painful arc of abduction
Subacromial impingement
women >75 with osteoporosis management
treat regardless of DEXA scan
Osteoporosis T score definition
-2.5 or less
–> bisphosphonates, adequate Ca and vit D
what medications cause osteoporosis
anticonvulstants
andogren deprivation therapy
glucocorticoids
Thyroxine (thyroid disorders –> osteoporosis)
FBC in rheumatoid arthritis
thrombocysotis
leukoenia
raised ferritin
normocytic normochromic anaemia
genetic susceptibility in RA
HLA DR4 and DR1
LFTs in RA
can have mild elevation of ALP and GGT
reduced ROM, weakness/ crepitus and tenderness over the cuff insertions and subacrominal area
rotator cuff tear
lesion to spinal cord (usually penetrating trauma)
ipsilateral loss of proprioception and motor function
contralateral loss of pain and temperature sensaiotn
Brown-Sequard syndrome
(incomplete spinal cord lesion)
difference cauda equina and conus medullaris syndrome
cauda equina = only LMN
(medullaris is UMN and LNN)
adhesive capsulitis is also called
frozen shoulder
= progressive shoulder pain
CONSTANT (pain at rest)
lasts 1-2 years before subsiding
commonest cause of pain beneath the heel
plantar fasciitis
(normally conservative management but be aware it can be associated with inflammatory cause e.g. psoriatic and reactive arthritis)
what drugs make raynauds worse
BB, pseudoephedrine, triptans, methylphenidate, ergotamine, cocain etc
allopurinol during gout flare
can PRECIPITATE acute gout flare
but don’t need to discontinue it if already ongoing
OTTAWA knee rules
knee XR if any of:
>55 years
isolated tenderness of patella
isolated head of fibula tenderness
inability to flex 90o
inability to weight bare immediately and in ED (4 steps)
nerve susceptible to injury from dislocation of shoulder of fracture of neck of humerus
axillary nerve
(anterior branch supplies deltoid)
indication for DEXA scan
<75 with low trauma fracture
XR incidental finding of osteopenia or vertebral collapse
postmenopausal with Hx hip fracture
BMI <19
steroids long term
oestrogen deficiency (premature menopause)
other conditions–> secondary osteoporosis
e.g,
malabsorption (coeliads, IBD)(
long term anticonvulsants
RA
chronic renal failure
HYPERthyroidism
primary HYPERPTH
cushing
immobilisation prolonged
60 F
low back pain
radiates to legs
a/w walking and relieved by rest
when she bends forward pain diminishes
radiating leg pain RELIEVED BY REST
spinal stenosis
–> urgent intervention spinal cord compression
most common cancers to metastasis to bone
breast
prostate
lung
colon
stomach
malunion
healing of a fracture in an abnormal (non anatomical) position
–> most common in phalangeal fracture
best way to see overlap in phalanges
ask pt to make fist and see if they overlap
segmental limb pain after a (usually) relatively minor injury to a limb but is more severe and lasts much longer than would usually be expected
complex regional pain syndrome
POSITIVE birefringent crystals
PSEUDOgout
Gout= negative50
M struck on lateral side of knee
severe brusiing
worse on lateral size
limits examination
tibial plateau fracture
Klein line
used to detect SUFE
draw to neck of femur
SUFE position of hip
foot lies externally rotated and hip flexed, abducton and medial rotation are limited
–> SURGERY
what causes adhesive capsulitis / frozen shoulder
usually no precipitating factors
risk factors of chronic back pain
smoking
psychological
low income
CVD
poor working conditiions
large numbers of children
Vit D deficiecny causes… (2)
osteomalacia and rickets
also –> low calcium and phosphate –> SECONDARY hyperparathyroidism
Biochemistry in vit D deficiency
low calcium , phoshpate
low vit D
raised ALP
13-16 years old
pain and swelling of joint
XR= radiolucent lesion with mottled radio density and il margins
most common non haematological primary malignant neoplasm of bone
osteosarcoma of the femur
hyperextension of interphalangeal joint
fixed flexion and subluxation of metacarpophalangeal
of THUMBS
Z deformity
(always thumbs)
fixed flexion deformity at proximal interphalangeal joint
hyperextension of distal interphalangeal joint
of fingers
Bouronniere deformity
(looks a bit like swan IMO)
RA:
bilateral subcutaneous swellings on extensor surfaces of forearms just distal to elbow joints
rheumatoid nodules
several bilateral pain and morning stiffness of the shoulder, neck and pelvic girdle
Polymyalgia rheumatica
(Raised ESR)
needle aspiration of join on people on warfarin..
NOT contraindicated
SUFE 1st line management
in situ screw fixation
CREST syndrome is also know as..
limited cutaneous systemic sclerosis
anti-nuclear
anti-centromere antibodies
AND
anti-Scl-70
CREST syndrome (limited cutaneous systemic sclerosis)
management CREST syndrome (2)
most common cause of death (1)
immunosuppressants
anti-fibrinotic therapy
–> deaths from pulmonary HTN if not treated
Colles fracture
distally displaced radius fracture
FOOSH
older postmenopausal women
Dinner fork deformity
if non displaced just immobilization
if displaced–> closed reduction and immobilisation
(surgical management if unstable)
Gout: 1st line is NSAID and cholchicine. When to avoid colchicine?
it has narrow therapeutic index –> avoid in:
- blood disorders
- eGFR <10
- renal impairment
- hepatic imparment
- pregnant / breatfeeding
- P-glycoprotein inhibitors (clarithromycin/ -avirs)
Lupus Sx
NUCLEAR
anti-nuclear antibodies and vasculitis
malar rash
discoid lupus
photosensitivity
oral ulcers
non erosive arthritis
pericarditis
pleruitis
renal involement
seizures
haemolytic aenamia
anti-DNA or anti-Sm or antiphospholipid
positive antinuclear
Child FOOSH fracture
supracondylar fracture
painful swollen elbow
hesitant to move
McMurray test
evaluate tear of meniscus of the knee
reactive arthritis triad
urethritis, conjunctivitis, and arthritis
a waxy yellow rash pathognomonic for reactive arthritis.
REACTIve arthritis
keratoderma blennorrhagicum
The recent travel history is relevant as reactive arthritis typically occurs 2-4 weeks after a triggering infection, commonly gastrointestinal (such as Campylobacter, Salmonella, Shigella) or genitourinary (Chlamydia trachomatis).
meralgia paraesthetica
lateral cutaneous nerve of thigh compression
burning thigh pain
(entrapment mononeuropathy)
—> management= Injection of the nerve with local anaesthetic will abolish the pain. Using ultrasound is effective both for diagnosis and guiding injection therapy in meralgia paraesthetica
Nerve conduction studies may be useful.
foot drop nerve
Common peroneal nerve
A 22-year-old male presents to the emergency room with pain in the left knee following a twisting injury during a rugby match. He states that it has gradually swollen over the past 24 hours, and he is unable to fully extend it. On examination you note tenderness over the medial joint line, a joint effusion, and the joint is held in a flexed position. There is no laxity on valgus stress test.
medial meniscal tear
ACL and PCL more RAPID join swelling (due to bleeding in joint capsule aka haemarthrosis)
Paradoxical anterior draw test
Mechanism: hyperextension injuries
Tibia lies back on the femur
PCL
scaphoid fracture: when does it need surgical fixation?
PROXIMAL or DISPLACED
as risk of avascular necrosis
if non displaced and distal then can be managed with cast
dupuytrens causes
manual labour
phenytoin treatment
alcoholic liver disease
diabetes mellitus
trauma to the hand
alteranttive to alendornate for osteoporosis if not tolerated GI side effects
risedronate or etidronate
Transient idiopathic osteoporosis
An uncommon condition sometimes seen in the third trimester of pregnancy
Groin pain associated with a limited range of movement in the hip
Patients may be unable to weight bear
ESR may be elevated
Antihistone antibodies are associated with
drug induced lupus
