Orthopaedics 5 Flashcards
Osteochondritis Dissecans
- What is it?
- What clinical features are seen?
- What is seen on investigation?
- pathological process affecting subchondral bone - most commonly the knee in children and young adults
- knee pain and swelling especially after exercise
- knee locking / catching / giving way - more constant and severe symptoms if loose bodies
- ‘clunk’ when flexing and extending the knee implies lateral femoral condyle involvement
O/E:
- joint effusion
- tenderness on palpation of medial femoral condyle cartilage
- Wilson’s sign: flex knee at 90 degrees with internally rotated tibia, gradually extend knee, at about 30 degrees patient feels pain, at this point external rotation of tibia relieves the pain
- XR - crescent sign or loose bodies
Osteomyelitis
- a) What is the most common cause?
b) What is the most common cause in sickle cell? - Who is most likely to get:
a) haematogenous spread
b) non-haematogenous spread
NOTE: non-haematogenous often polymicrobial
- What is the investigation of choice?
- How is it managed?
- a) staph aureus
b) salmonella - a)
age: more common type in children
RFs:
- sickle cell
- immunosuppression (HIV or medication)
- infective endocarditis
- IVDU
THINK: sickle cell has own subtype of bacteria, IE and IVDU go together
b)
age: most common type in adults
RFs:
- diabetes
- PAD
- MRI
- flucloxacillin for 6 weeks (think about most causative bacteria!)
clindamycin if penicillin allergic
Osteoporotic Fracture
- What are the RFs for osteoporotic fracture?
- What clinical features can be seen for osteoporotic vertebral fractures?
- a) What is the investigation of choice?
b) What appearance would old fractures have?
- history of fragility fracture
- family history of hip fracture
- low BMI
- history of falls
- smoking
- alcohol
- long term steroid use
- secondary osteoporosis: cushing’s disease, hyperthyroidism, chronic renal disease
mnemonic: think of in pairs
- acute back pain
- breathlessness / GI symptoms due to compression of organs
O/E:
- loss of height
- kyphosis
- tenderness on palpation of fracture site
also remember can be asymptomatic presenting as incidental finding on XR
- a) XR
b) sclerotic appearance
Osteoporosis: Assessing risk
- What do the FRAX and QFracture scores assess?
- What should be done if a patient is assessed as
a) low risk
b) medium risk
c) high risk?
- 10 year risk of fracture
- a) reassure + lifestyle advice
b) bone mineral density test
c) offer bone protection treatment
(bisphonates [always end …dronic acid] +/- calcium and vitamin D)
Paediatric fractures
- What is meant by the following fracture types
a) complete fracture
b) toddler’s deformity
c) plastic deformity
d) greenstick fracture
e) Buckle or torus fracture - Salter-Harris system assesses growth plate fractures. State what is meant by
a) Type I
b) Type II
c) Type III
d) Type IV
e) Type V
- a) typical fracture where both sides of bone are breached causing bone to be in 2 separate pieces
b) oblique tibial fracture in infants
c) stress on bone causing deformity without cortical disruption
d) unilateral cortical disruption - I.e. bone cracked +/- bent but not in 2 separate pieces
e) (similarly to greenstick) incomplete cortical disruption (similarly to greenstick) which causes periosteal heamatoma appearing as bulge on XR
- a) involves physis
b) involves metaphysis + physis
c) involves physis + epiphysis (therefore involves joint - intraarticular)
d) involves metaphysis, physis + epiphysis
e) crush fracture of physis (so therefore XR appears as type I or normal)
What should you suspect if lack of differentiation between cortex and medulla (“marble bone”) is seen on XR?
autosomal recessive osteoporosis
Osteogenesis imperfecta
- What is it?
- What is seen on radiology?
- defective production of osteoid and collagen
- multiple fractures
- irregular patches of ossification “workman bones”
- translucent bones
- trefoil pelvis - softening of pelvis causes acetabuli to indent further
mnemonic: need to be wrapped in a MITT as they’re so likely to fracture
Planter Fasciitis
- What is it?
- What clinical feature is seen?
- How is it managed?
- inflammation of band of tissue running along bottom of foot
- foot pain worst at medial calcaneal tuberosity
- rest feet where possible
- wear shoes with good arch support + cushioning
Facet joint pain
- Is it acute or chronic?
- What clinical features are seen?
- can be BOTH!
- pain worse on:
- standing
- extending the back
- the morning
Rib Fracture
- What clinical features are seen?
- What investigation is done?
- How is it managed?
- Flail chest
a) What is it?
b) How is it managed?
1.
- sharp chest wall pain worse on deep breathing or coughing
- chest wall tenderness at fracture site
remember: may have associated lung injury
2. CT
- good analgesia so that breathing is not effected by pain
- > inadequate ventilation could predispose to chest infection
- a) two or more rib fractures along 3 or more consecutive ribs with flail segment moving paradoxically during inspiration
b) can cause serious lung injury so therefore often requires invasive ventilation and surgical fixation
Rotator Cuff Injury
- State the spectrum of disease of rotator cuff injury?
- What clinical feature is seen (and how is it seen in different types)?
- impingement
- calcific tendonitis
- rotator cuff tears / arthropathy
- shoulder pain worse on abduction
- pain in first 60 degrees = rotator cuff tear
- pain between 60-120 degrees likely impingement syndrome
Scaphoid Fracture
- What causes it?
- What neuromuscular structure is most likely to be damaged?
- What clinical features are seen?
- When and what investigations are carried out?
- How is it managed?
- What are the complications of scaphoid fracture?
- FOOSH
- dorsal carpal branch of radial artery (which also give scaphoid 80% of its blood supply
- pain:
- at radial aspect of wrist at thumb base
- on longitudinal compression of the thumb “telescoping”
- on ulnar deviation of the wrist
tenderness
- maximal over anatomical snuff box
- over scaphoid tubercle (volar aspect of wrist)
wrist joint effusion
(may be absent if injury <4hrs old or >4 days old)
loss of grip / pinch strength
- AP + lateral XRs (80% sensitive)
MRI or CT 7-10 days later if XR normal but clinical suspicion continues - initial: immobilisation with Futuro splint or standard below elbow backslab
undisplaced fracture: cast for 6-8 weeks
displaced or proximal pole fractures: surgical fixation
- non-union (pain and OA)
avascular necrosis
Shoulder Dislocation
- What is by far the most common type?
- When can reduction be attempted without analgesia / sedation?
- anterior
2. if dislocation is recent
Proximal humerus fractures
- Where normally is the fracture?
- When is there a risk of avascular necrosis to the humeral head?
- surgical neck
2. anatomical neck fractures displaced by >1cm
Anterior shoulder dislocation
- What is the mechanism of injury?
- In what percentage of patients will it be recurrent ?
- What is it associated with?
- violent force in external rotation + abduction
- 35-40%
- Bankhart lesion: tear in anterior inferior glenoid labrum
- Hill Sachs lesion: bony indent at back of humeral head as when it exits cavity collides with glenoid cavity
- greater tuberosity fracture
