Orthopaedics Flashcards
What is Ottawa rules ??
Ankle x-ray is required only if there is any pain in the Malleolar zone + any 1 of the following
- Lateral malleoli bony tenderness (from tip of LM to lower 6cm of posterior border of fibula)
- Medial M bony tenderness (from tip of MM to lower 6 cm of Tibial posterior border)
- Not able to walk 4 wt. bearing steps immediately after injury & in A-E dept
What action causes severe pain in Tennis elbow ??
- Pain worse on Resisted wrist extension with elbow extended/ supination of forearm with the elbow extended
- lasts for 6 months to 2 years
- acute pain for 6 to 12 wks
House painting/ playing Tennis
What action worsens Golfer’s elbow ??
- Wrist flexion & Pronation
- may be a/w numbness/tingling in 4th & 5th finger (ulnar involved)
What is Radial tunnel syndrome ??
Posterior Interosseous branch of Radial nerve compression
- due to overuse
- C/F are similar to Lateral Epicondylitis BUT pain tends to be 4-5 cm DISTAL to lateral epicondyle
- pain worse on Elbow extension & Pronation of forearm
What is Cubital tunnel syndrome ??
ULNAR Nerve compression
- Initial: 4th & 5th finger tingling
- Worse when elbow is resting on a firm surface/ flexed for extended periods
- Later: Numbness a/w weakness
Ix. & Rx. of Cubital Tunnel Synd. ??
Clinical dx.; but is selected cases- NCS
- Avoid aggravating activities
- Physiotherapy
- Steroid injections
- Surgery in resistant cases
What is Olecrenon bursitis ??
Swelling over posterior aspect of elbow
- a/w pain, warmth, erythema
- Typical in middle aged MALE pat.
What is Greater Trochanteric pain synd. ??
aka Trochanteric bursitis
- due to repeated movt. of fibroelastic ILIOTIBIAL band
- MC in 50 to 70 yrs old WOMAN
- Pain over lateral side of hip/ thigh
- Tenderness on greater trochanter palpation
Features of Inflammatory arthritis ??
- Morning pain
- Systemic features
- Raised Inflammatory markers
Which nerve compression causes Referred Lumber spine pain ??
Femoral nerve compression
- FN Stretch test is positive
Hallmark features of Meralgia Paraesthetica ??
Lateral Cutaneous nerve of Thigh compression
- BURNING pain over antero-lateral aspect of thigh
What is Pubic Symphysis dysfunction ??
Pain over pubic symphysis which radiates to groin & medial aspect of thighs
- Common in PREGNANCY (ligament laxity increases due to hormonal changes)
- WADDLING gait may be seen
What is Transient Idiopathic Osteoporosis ??
Seen in 3rd Trimester of pregnancy
- Groin pain + limited range of Hip movement
- Unable to bear weight
- ESR may be elevated
Hallmark features of Devt. Dysplasia of Hip ??
- Barlow’s & Ortolani’s test (+)ve
- Unequal gluteal skin folds
- Unequal leg length
What is Transient sinovitis ??
Irritable hips
- Common in 2- 10 yrs old
- Acute hip pain a/w Viral infection
- MCC of hip pain in children
MCC of hip pain in children ??
Transient Synovitis
Hallmark features of Perthes disease ??
AVASCULAR Necrosis of FEMORAL Head
- Typical in 4 to 8 yrs old
- 5x MC in BOYS
- 10% cases are B/L
X-ray features of Perthe’s disease ??
Early: Joint space widening
Late: Decreased Femoral head size/ Flattening
- Hip pain (progressive over few wks.)
- Limp & Stiffness
What is Slipped Upper Femoral Epiphysis ??
POSTERO-INFERIOR displacement of Femoral head Epiphysis
- Typical in 10 to 15 yrs old
- MC in OBESE kids & Boys
- Knee or Distal thigh pain is normal
LOSS of Internal Rotation of Leg in flexion
Which antibody is Juvenile Idiopathic Arthritis a/w ??
ANA
- when (+)ve, it is a/w Anterior Uveitis
Rx. of Tennis elbow ??
Typical among 45 to 55 yrs old; affects the Dominant arm
- Avoid muscle overload
- Simple analgesia
- Steroid injection
- Physiotherapy
Hallmark features of ILIOPSOAS Abscess ??
Collection of pus in Iliopsoas compartment (Iliopsoas + Iliacus)
2 types
- Primary: MCC is Staph. aureus infection (Haematogenous spread)
- Secondary: MCC is Crohn’s disease
IoC for Iliopsoas abscess & which type has the highest mortality ??
CT abdomen
Secondary (19-20%)»Primary (2.3%)
Rx. of Iliopsoas Abscess ??
- Antibiotics
- Percutaneous drainage (initial approach)
SURGERY indicated if: - PC drainage fails
- Presence of another intra-abdominal pathology requiring Sx.
What is Chondromalacia patellae ??
Patellar cartilage softening
- Common in Teenage GIRLS
- Anterior Knee pain on walking up & down the stairs & rising after prolonged sitting
Rx. Physiotherapy
What is Osgood-Schlatter disease ??
aka Tibial Apophysitis
- common in Sporty Teenagers
- Pain, Tenderness & Swelling over Tibial tubercle
What is Osteochondritis dessicans ??
Bone underneath the cartilage of a joint dies due to a lack of blood supply
- Common among Kids & Adolescents who are active in Sports
- Pain after Exercise
- Intermittent swelling & Locking
What is Patellar Subluxation ??
Lateral subluxation of patella causing Medial knee pain
- Knee may give away
Hallmark of Patellar Tendonitis ??
Chr. anterior knee pain => worsens post- running
- MC in athletic Teenage BOYS
- O/E: Tender below patella
Hallmark features of Carpel Tunnel Synd. ??
Median N compression in Carpel T
- Pain/pins & needles in Thumb, Index & Middle finger
- C/F may ASCEND Proximally
- Pt. SHAKES his hand for relief; classic at night
What are the O/E features & Causes of CTS ??
Weakness of Thumb ABDUCTION (Abductor pollicis brevis)
THENAR muscles wasting
- Tinel’s sign (+)ve : Paraesthesia on Tapping
- Phalen’s sigh (+)ve : Wrist FLEXION causes c/f
Causes: Idiopathic, PREGNANCY, Oedema (eg. HF), RA
Ix. & Rx. of CTS ??
Electrophysiology [Motor + Sensory] : Prolongation of Action Potential
Rx.
- Mild to Moderate: 6 wks trial of conservative Rx.; Corticosteroids injection, Wrist splint at night
- Severe symptoms/ Failed conservative Rx. : Surgical Decompression (Flexor retinaculum division)
Which bone # causes CTS ??
LUNATE #
What is De Quervain’s Tenosynivitis ??
Inflammation of the SHEATH containing Extensor pollicis brevis & Abductor pollicis longus tendons
- FEMALES, 30 to 50 yrs old
- Pain on radial side of wrist
- Tenderness over Radial Styloid process
- ABDUCTION of thumb against resistance is painful
Hallmark features & Rx. of De Quervain’s Tenosynovitis ??
Finkelstein’s test (+)ve: Examiner pulls the Thumb of the pt. in Ulnar deviation & Longitudinal traction => causes pain over Radial styloid process along the whole of EPB & APL
- Analgesia
- Steroid injection
- Immobilization : Thumb SPICA
- Surgical Rx.
What are Rotator cuff muscles ??
“S I t S”
-Supraspinatus: aBDucts arm before deltoid
- Infraspinatus: MC injured
- teres minor: Rotates arm Laterally
- Subscapularis: aDDucts & rotates arm Laterally
What are the Red Flags in Lower Back pain ??
- Age: < 20 yrs / > 50 yrs
- H/o previous Malignancy
- Night pain
- H/o Trauma
- Systemically unwell (eg. Wt. loss, Fever)
Name the cause for the following type of pain-
- Pain worse in morning, on walking & Back extension ??
- Pain worse on walking; relieved when sits/ leans forward/ crouches down (aching/ crawling type of pain)??
- Pain on walking; relieved by Rest; absent / weak foot pulses
- Leg pain worse»back pain; worse when sitting; clear dermatological leg pain ??
- Facet joint damage
- Spinal canal Stenosis
- PAD
- Prolapsed disc
IoC for Spinal Canal Stenosis ??
MRI to confirm dx. (as clinical examination is normal)
Rx. of Disc prolapse ??
- Analgesia, Physiotherapy, Exercises
- If c/f persists (after 4-6 wks => referral for MRI consideration
What is the hallmark feature of Ank. Spon. with respect to different gender ??
Peripheral arthritis (25% more common in Females than in males)
Features of L3 nerve root compression ??
Sensory loss over Anterior thigh
Weak Quadriceps
Reduced Knee reflex
(+)ve Femoral Stretch test
Features of L4 nerve root compression ??
- Sensory loss over Anterior aspect of Knee
- Weak Quadriceps
- Reduced Knee reflex
- (+)ve Femoral Stretch test
Features of L5 nerve root compression ??
- Sensory loss over Dorsum of foot
- Weakness of Foot & Big toe Dorsiflexion
- Reflexes INTACT
- (+)ve Sciatic nerve stretch test
S1 nerve root compression ??
- Sensory loss over Posterolateral leg & Lateral foot
- Weakness of Plantar flexion of foot
- Reduced Ankle reflexes
- (+)ve Sciatic nerve stretch test
What is AVN of Hip ??
Death of bone tissue secondary to loss of blood supply => Bone destruction & loss of joint func.
- EPIPHYSIS of long bones (eg. Femur) are most commonly affected
Mention the following about AVN hip
- Causes ??
- Ix. ??
- Rx. ??
Long term Steroids, Chemotherapy, Alcohol excess, Trauma
Ix.
- Plain x-ray may be initially NORMAL
- Osteopenia & Micro# may be seen early on; Crescent sign (Collapse of articular surface)
- MRI is the IoC
Rx.- Joint replacement
What is Osteopetrosis ??
Marble bone disease
- FAILURE of Osteoclast mediated bone resorption => overly Dense, Thick, Brittle bones
A R (Infantile form): SEVERE, presents in infancy with Pancytopenia & #
A D (Adult form): MILDER, presents late with # & minimal systemic c/f
Features of Marble Bone Disease ??
- Bone pain (due to overgrowth & micro#)
- Recurrent #
- Neuropathy (bone encroachment on CNs- Facial palsy, vision, hearing loss)
- Pancytopenia: Due to BM cavity obliteration => Anemia, Thrombocytopenia & Leukopenia
Ix. & Dx. of Osteopetrosis ??
NORMAL- Ca2+, PO4, ALP
X-Ray:
- Diffuse Skeletal Sclerosis (‘Bone within Bone’ or Erlenmeyer Flask deformity)
- Dense vertebrae (‘Sandwich vertebrae’)
Rx. of Osteopetrosis ??
- Stem Cell Transplantation (Curative)
- IFN- Gamma Therapy: improves Immune func. & Bone remodeling
- Vit. D supplements
- Low-Ca2+ diet in HyperCa2+ cases
What is Osteoporosis ??
Reduced bone mineral density & deteriorated bone microarchitecture
- Predominantly Postmenopausal woman & Older adults
Pathophysiology of Osteoporosis ??
Bone remodelling = Osteoclast mediated resorption & Osteoblast-driven formation
- An imbalance favouring resorption => Osteoporosis
- RANKL + [RANK on Osteoblast] =+=> Resorption
- OPG =(-)=> RANKL => reduces Osteoclast activity
PM oestrogen deficiency, increases RANKL & reduces OPG
What causes the following in Osteoporosis
- Height loss ??
- Kyphosis ??
- Back pain ??
- Vertebral Compression #
- Vertebral #
- May indicate Vertebral #
How to Dx. Osteoporosis ??
- DEXA Scan (for BMD assessment)
- FRAX tool (calculates 10-yr. probability of maj. osteoporotic #)
- Lab. Tests: basic Ix. + PTH, 25-OH vit. D, Urine Ca2+ excretion
- Imaging
Types of Imaging used in Osteoporosis ??
- X-ray: for Vertebral # dx.
- Quantitative CT: Differentiates b/w Cortical & Trabecular bone
- Quantitative USS: Peripheral bone density
Which Ix. should be done when DEXA scan is inconclusive ??
Quantitative CT (QCT)
What is T-score & Z-score ??
- T-score compares the pt.’s BMD to the Mean peak BMD of a young healthy adult of the same sex.
- Z-score: Comparative measure that adjusts BMD for- age, gender, ethnicity ie. compares to the average of their peers.
Difference b/w T-score & Z-score ??
T- Score: Critical for dx. of Osteoporosis & guiding Rx. in older adults
Z- Score: For identifying ABNORMAL bone loss pattern in younger populations & distinguishing b/w physiological & pathological changes
In which group of people do we do the following tests
- T- score
- Z- scores
- Older adults, PM woman
- Children, PM woman, Men < 50yrs
Z-score of [< -2] indicates SECONDARY cause of osteoporosis & warrants further Ix.
T score values ??
Normal : > [-1]
Osteopenia : -1.0 to -2.5
Osteoporosis : < [- 2.5]
What is FRAX tool ??
Calculates 10-yrs probability of maj. osteoporotic #
- integrates [Clinical Risk Factor + Femoral neck BMD]
Rx. options for Osteoporosis ??
Anti-Resorptive Agents
- Bisphosphonates (1st line)
- RANKL inhibitors (Denosumab)
- SERMs (Raloxifene)
- HRT
Anabolic Agents
- PTH analogues (Teriparatide, Abaliparatide)
- Sclerostin inhibitor (Romosozumab)
Sequential Therapy
Which Osteoporosis Rx. should not be used for > 24 months & Why ??
PTH analogues (Teriparatide, Abaloparatide)
- risk of Osteosarcoma
Which Osteoporotic Rx. is CI in recent MI cases ??
Sclerostin inhibitors
- NOT used in recent cases both MI & Stroke
Which Rx. of Osteoporosis is considered in Young PM woman with high risk of Vertebral # ??
SERMs
- Reduces Vertebral # risk & also lowers breast cancer risk
Which Rx. of Osteoporosis requires U & E monitoring ??
Bisphosphonates
- Monitor U&E before starting
- CI in Severe Renal impairment
Describe Sequential Therapy used in Osteoporosis ??
Post- Teriparatide (PTH analogue)
- Follow with Bisphosphonates to maintain BMD
Post- Romosozumab (Sclerostin I)
- Use Anti-resoptive therapy to sustain gains
Post- Denosumab
- Avoid abrupt discontinuation to prevent rapid BMD loss
Ca2+ & Vit. D supplements dose in Osteoporosis ??
Ca2+ : 1000 to 1200 mg/ day
Vit. D : 800 to 1000 IU/ day
What is Glucocorticoid-Induced Osteoporosis (GIOP) & its Rx. ??
Prednisolone >= 7.5 mg/day for >= 3 months can cause GIOP
- >= 65 yrs or Prior fragility # : Start bone protection immediately
- < 65 yrs : DXA-guided management
TREATMENT
- 1st line: Alendronate
- Ensure Ca2+ & Vit. D sufficiency
Tailor Rx. based on Cumulative Steroid dose
In what age group is DXA scan recommended ??
Regular DXA for
- PM woman
- Men > 70yrs old.
What is Osteogenesis Imperfecta ??
aka Brittle Bone Disease
- Group of disorders of Collagen metabolism resulting in Bone Fragility & #
- MC & Milder form is OI type 1
Features of Brittle Bone Disease ??
A D
- Decreased synthesis of Pro-alpha 1 or Pro-alpha 2 polypeptides => abnormal Type 1 collagen
- # by Mild trauma + Blue Sclera + Deafness (Otosclerosis) + Dental Imperfections
- Seen in Childhood
Adjusted Ca2+, PO4, PTH, ALP are
usually normal
How is Osteomyelitis subclassified ??
Infection of Bone
Haematogenous OM
- Due to Bacteraemia
- MONOMICROBIAL
- Vertebral OM is the MC form of haematogenous OM in adults
- RF: Sickle Cell, IVDU, Immuno-suppression by medication/ HIV, Infective Endocarditis
Non-Haematogenous OM
- Spread of infection from adjacent Soft tissue to bone or Direct trauma
- POLYMICROBIAL
Name the following about OM
- MC route of spread in Children
-MC route of spread in Adults
- MC site of blood borne OM in adults
- Haematogenous OM
- Non- haematogenous
- Vertebral OM
MCC of OM ??
IoC in OM ??
- Staph. aureus except in SCD
- SALMONELLA species predominates in Sickle Cell disease pts
- MRI scan
Rx. of OM ??
Flucloxacillin for 6 wks
Clindamycin if penicillin allergic
Septic arthritis causes ??
- MC overall cause: Staph. aureus
- MC in Young, sexually active: N gonorrhoea (disseminated gonococcal infection)
- MC route is Haematogenous spread (from distant bacterial infection eg.- abscess)
- MC site in adults: KNEE Joint
Features of Septic arthritis ??
Acute, Swollen joint
- Restricted movt. in 80% cases
- Warm to touch & is fluctuant
FEVER
Rx. of Septic Arthritis ??
IV Antibiotics which cover Gram (+)ve cocci
- Flucloxacillin
- Clindamycin if penicillin allergic
Given for 4 to 6 weeks
- Pts. are switched to Oral Abx. after 2 wks of IV abx.
- Arthroscopic lavage may be required
Ix. done in Septic arthritis ??
Synovial Fluid sampling
- Prior to Abx. administration
- Under radiological guidance
Blood culture
Joint imaging
What is Osteogenesis imperfecta ??
It is a collagen disease due to defect in Type 1 collagen
There are 8 subtypes
Type 1: Normal quality + Insufficient Quantity
Type 2: Poor Quantity & Quality
Type 3: Collagen poorly formed, Normal quantity
Type 4: Poor quality & Sufficient Quantity
Bone # easily, loose joint & multiple other defects depending upon which subtype they suffer from
Ehler-Danlos syndrome ??
- Multiple subtypes
- Abnormality of Types 1 & 3 collagen
- Hypermobility, prone to dislocations, Pelvic organ prolapse + Many other diseases related to connective tissue defects
