Orthopaedics 2 Flashcards
Red flags back pain (5)
<20yo >50yo
Hx of malignancy
Night pain
History of trauma
Systemically unwell
Stiffness usually worse in the morning and improves with activity. Young man with lower back pain =
Ank spond
Spinal stenosis
Sx (3)
Gradual onset
Unilateral or bilateral leg pain
Numbness and weakness
Spinal stenosis
Worse when?
Relieved by?
Worse on walking/downhill
Relieved by sitting/ leaning forwards/ crouching/ walking uphill
Spinal stenosis examination
Ix
Rx
NAD
MRI
Rx laminectomy
PAD sx
Pain on walking, relieved by rest
Absent or weak pulses
Lower back pain (non specific)
Ix (2)
Lumbar spine XR
MR
Lower back pain
When should an MR be offered?
If it will change management OR if malignancy/ infection/ fracture/ cauda equina or ank spond is suspected
Lower back pain Mx
1st line mx
NSAIDs with PPI if >45yo
Lower back pain
Should paracetamol be offered?
Paracetamol should not be offered as monotherapy
Features of prolapsed disc (2)
Leg pain worse than back pain
Clear dermatomal leg pain
L3 nerve root compression features (4)
Sensory
Motor
Reflexes
Stretch test
Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
L4 nerve root compression
Sensory loss ?
Weak ?
Reflexes
Stretch test
Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
L5 nerve root compression
Sensory
Motor
Reflexes
Stretch test
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
S1 nerve root compression
Sensory
Motor
Reflexes
Stretch test
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
Mx prolapsed disc (2)
Analgesia, physio
Prolapsed disc - when to refer for MR?
If symptoms persist after 4-6 weeks
Femoral nerve
Motor
Sensor
Mechanism of injury
M knee extension, hip flexion
S Anterior and medial aspect of thigh and lower leg
Hip and pelvic fractures/ stab and gun shot wounds
Obturator nerve
Motor
Sensory
Mechanism of injury
Thigh adduction
Medial thigh
Anterior hip doslocation
Lateral cutaneous nerve of the thigh
Motor
Sensory
Mechanism of injury
M - none
S Lateral and posterior thigh
Compression of the nerve can lead to meralgia paraesthetica
Tibial nerve
Motor
Sensory
Mechanism of injury
Plantarflexion and inversion
Sole of the foot
Not commonly injured, popliteal lacerations and posterior knee dislocations
Common peroneal nerve
Motor
Sensory
Mechanism of injury
Dorsiflexion and eversion + Extensor hallucis longus
Dorsum of the foot and lower lateral part of the leg
Neck of fibula injury
Tight lower limb cast
Foot drop
Superior gluteal nerve
Motor
Sensory
Mechanism of injury
M Hip abduction
S None
Misplaced IM injection/ hip surgery, pelvic fracture, posterior hip dislocation
Positive Trendelenburg
Inferior gluteal nerve
Motor
Sensory
Mechanism of injury
M hip extension and lateral rotation
S None
Injury to sciatic nerve
Difficult in rising from seated position.
Cannot jump or climb stairs.
Lumbar spinal stenosis can be caused by? (3)
Degenerative changes
Prolapsed disc
Tumour
pain and tenderness localised to the medial epicondyle
pain is aggravated by wrist flexion and pronation
symptoms may be accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement
Golfers elbow/ Medial epicondylitis
Meralgia paraesthetica originated from which L segment
Age range
Gender
Unilat versis bilat
More common in those with which condition?
L2/L3
30-40
M>F
Can be bilat
DM
Meralgia paraesthetica
RF (7)
DM
Obesity
Pregnancy
Tense ascites
Trauma
Surgery
Sports
Meralgia paraesthetica aggravated by/ relieved by
Aggravated Standing, extension of the hip
Relieved Sitting
Ix meralgia paraesthatica
Rx
Pelvic compression test
Rx local anaesthetic
What is Morton’s neuroma?
Neuroma most commonly in the third inter-metatasophalangeal space
Morton’s neuroma
Gender
Sx (4)
F>M
Sx
Forefoot shooting or Burning pain
Worse on walking
Pebble in the shoe feeling
Loss of sensation in the toes
Morton’s neuroma
Ix
Mx (2)
When to refer?
US
Mx - avoid high heels, metatarsal pads
If symptoms persist for >3 months
RF OA hand (3)
Previous trauma
Obesity
Hypermobility
How does stiffness in OA hand differ from RA
OA hand - stiffness after periods of inactivity, which resolves after a few minutes unlike RA
Heberden’s and Bouchard’s locations?
DIP, PIP (osteophyte formation)
XR findings OA (2)
Osteophytes
Joint space narrowing
Red flags for hip pain
Rest pain
Night pain
Morning stiffness >2 hours
Hip pain Ix
Mx (3)
Clinical if typical features
Otherwise XR
Mx analgesia, injections, THR
Posterior dislocation rotation
Internal rotation and shortening
Most common type of hip replacement?
How long will sticks/ crutches be used after op?
Cemented hip replacement
6 weeks
Advice to give post hip replacement (4)
Avoiding flexing the hip > 90 degrees
Avoid low chairs
Do not cross your legs
Sleep on your back for the first 6 weeks
Osteochondritis dissecans impact what age group?
Children and young adults
Knee pain and swelling after exercise
Catching and locking/ giving away
Clunk on flexing or extending knee (involvement of lateral femoral condyle)
Joint effusion
Tenderness on palpation of the articular cartilage medial femoral condyle when knee is flexed
osteochondritis dissecans
Osteochondritis dissecans Ix (2) + finding on each
Mx (1)
XR subchondral crescent sign or loose bodies
MR cartilage evaluation, loose bodies
Mx ortho referral
Who should be assessed for osteoporosis?
F age
M age
Then how often after that?
F >=65yo
M >=75yo
Then 2 yearly after this
Which younger people should be assessed for fragility fractures? (7)
Younger if
- previous fragility fracture
- steroid use
- hx of falls
- FH hip fracture
- low BMI
- smoking
- ETOH >14units
Risk assessment for osteoporosis tool
When to do a DEXA? (2)
FRAX or QFracture
Before starting treatments which have an effect on bone density e.g hormone deprivation
> 40yo with a major risk fracture
Interpretation of FRAX without a BMD (DEXA)
Low risk: lifestyle advice and reassure
Intermediate risk: offer BMD
High risk: bone protection treatment
Ewing’s sarcoma
Gender
Age of onset
Commonest site
Mets
Rx (2)
M>F
10-20yo
Femoral diaphysis
Blood
Rx chemo and surgery
Osteosarcoma
Gender
Age
Rx (2)
20% of all primary bone tumours
M >F
Age 15-30
Limb preserving surgery + chemo
Liposarcoma
Age
Location
Growth speed
> 40yo
Retroperitoneum
Slow growing
Most common sarcoma in adults
Malignant Fibrous Histiocytoma
What is talipes equinovarus?
Club foot - inverted and plantar flexed foot
Talipes equinovarus
Gender
When is it diagnosed?
M>F
Newborn examination
Talipes equinovarus
Mx
Resolves by:
What is normally required under local?
Ponseti method - soon after birth, normally corrected by week 6-10 + night time braces until aged 4yo
Achilles tenotomy
