Orthopaedics Flashcards
1
Q
3 parts of the bone
A
diaphysis (shaft)
metaphysis (neck)
epiphysis (end)
2
Q
Pain asymbolia
Congenital analgesia
A
pain is experienced without unpleasantness
inability to feel pain
3
Q
abnormal gaits?
A
- trenedelenburg : compensating bending on the opposite side
- antalgic
4
Q
Antalgic gait?
A
It is a form of gait abnormality where the stance phase of gait is abnormally shortened relative to the swing phase.
5
Q
hip replacement, small vs bigger heads?
A
Small: wears off more slowly
Big: wears off more quickly, gives better range of movement
6
Q
Complications of a hip replacement?
A
Infection 1-2%
Blood clot formation 1 in 1000
Stroke
Heart attack
Others such as fracture, damage to the neurovasculature, change in length of the leg
7
Q
Why fractures in metaphysis heal more quickly?
A
Bigger cross-sectional area
Better blood supply
8
Q
Why being intra-articular matters for a fracture?
A
Most likely cartilage is also damaged
Limits movement at the joint
Needs to be immobilised to try to achieve 1^ bone formation and not secondary
9
Q
Descriptions of a fracture:
- Side
- Location
- Pattern
- No of fragments
- relation to joint
- relation to skin
- Displacement of the bone
A
- Proximal, middle, distal 1/3 // shaft, head neck
- transverse, oblique (>30 degrees), spiral (when oblique on 2 plains)
- Multi or simple or segmental
- intra or extra articular
- open or close
- Translation
Shortened
Angulated
Rotated
10
Q
Management of fracture/dislocation?
A
Operatively or non-operatively
1. Reduce ( open or close)
- Immobilise
I. Non-surgical
Cast: first backslab to avoid compartment syndrome by build up of pressure (inflam), then plaster cast for chronic use
II. Surgical
- Intramedullary: fixation with intramedullary nail or K wires
- Extramedullary: screws and plate or external fixation (allows treatment of the wound at the same time) - Rehabilitate
11
Q
Difference between subluxed and dislocated
A
sublux: partial
dis: complete loss of contact
12
Q
Non-union risk factors
A
Patient: Old, smoker, alcoholic
Fracture: Open, multi-fragmented
Treatment: poor reduction
13
Q
Valgus vs varus
A
vaLgus: distal bone points Laterally, apex medially
varus: distal bone points medially
14
Q
secondary vs primary bone healing?
A
2: Callus formation, relative stability
1: absolute stability (rigid fixation), tunneling resorption
15
Q
3 important compartments of the knee joint?
A
Medial femorohumeral joint Lateral femorohumeral joint Femoropatellar joint (skyline view) (pain on walking down the stairs)
–> 1/3 narrowing partial replacement, 2/3 complete
16
Q
Why infection is important during knee replacement?
A
if infected, abx cant reach, so has to be taken out
17
Q
virchow’s triad for blood clots?
A
- hyper coagulity
- immobility
- injury to vessels
18
Q
Sesamoid bone in knee?
A
fabella, within lateral head of gastrocnemius
acts as a lever to increase the power
19
Q
Treatment of injury to menisci within knee?
A
made of fibrocartilage, not much blood supply
the middle 2/3 gets no blood, so damage –> disected out
Outside 1/3 small blood supply, fixed with sutures
20
Q
Gout vs pseudogout x-ray differences?
A
psuedo :calcified meniscus on knee
gout: tophus on x ray, (most common on big toe)
21
Q
Why ask for a rosenberg radiograph of knee?
A
On supine or standing ones cartilage loss/narrowing of joint may not be visible and are only visible when knee is at 45 degress
22
Q
Avulsion fracture?
A
bone fragment pulled away by muscle
23
Q
Normal soft tissue width anterior to cervical vertebrae on a lateral radiograph?
A
C1 to c3 : 1/3 of vertebral body
C4 to c7: width of vertebral body
bigger than that may be due to bleeding
24
Q
Difference in growth plate of thumb and and other digits metacarpals?
A
thumb: proximal plate
others: distal
25
What features would make an intra-articular fracture require surgical attention? Why?
Step off >2mm
Split >2mm
One part of cartilage gets more loaded: increased weight on one side is not tolerable by the cartilage: risk of arthritis
26
What are the white lines on the surface of the bone?
Trabeculae: shows the direction of spread of the weight
27
Which articular surface of calcaneous gets the most pressure?
posterior articular facet
28
Classifications of the ankle fractures?
Their management?
How else can you describe them?
Webbers A: Distal to syndesmoses (tibia and fibula touching distally)
Webbers B: At the syndesmoses
Webbers C: Above syndesmoses
A no fix
b fix if unstable
c always fix
Bimaleolar, trimaleolar (posteriro side)
29
2 types of bone?
```
1. Woven
laid down in disorganised manner
2. Lamellar
a. cortical:
-dense, concentric rings
- mostly around diaphysis, little around metaphysis
b. cancellous
- laid along the stress linse (tabeculae)
```
30
Bone cell and matrix types?
Oosteocyte (90%, Ca hoemostasis), oesteoblast and oesteoclast
Matrix:
a. inorganic (60%)
made of Ca
resists compressive load
b. organic (40%)
- type I collagen
- resists extensile force
31
Bone blood supply
1. in children
2. in mature bone
- how is everything connected in 2?
1.
Metaphyseoepipheal system and diaphyseal system separated by growth plate
2.
a. Nutrient artery:
- Ascending and descending limbs
- high pressure, flow from inside to outside
- supplies the inner 2/3
b. perosteal a
- low pressure, from muscle blood supply
- supplies the outer third
- Volkmanns canal (transverse) , haversian canal (within a concentric ring)
32
Pereosteum 2 layers?
```
Outer fibrous
Inner vascular (Oesteoblastic activity, helps with bone healing)
```
33
Shenton line
is an imaginary line drawn along the inferior border of the superior pubic ramus (superior border of the obturator foramen) and along the inferomedial border of the neck of femur. This line should be continuous and smooth
34
Lipohaemarthrosis?
- Intra-articular fracture ,
- with escape of fat and blood from the bone marrow into the joint
- seen on horizontal beam radiograph, lateral view of knee, fat superior to blood
35
Difference between gout and pseudogout crystals UNDER THE MICROSCOPE?
Gout: needle-shaped
Pseudo: cuboid crystals
36
Ewing's sarcoma?
- cancer cells are found in the bone or in soft tissue
- most common areas in which it occurs are the pelvis, the femur, the humerus, the ribs and clavicle (collar bone)
- genetic
Fuzzy bone tissue seen
37
Most common sites of fractures on an extended arm?
Triquetrum
Scaphoid
medial/lateral epicondyl
suprachondylar fossa
38
3 stages of walking?
Foot strike
Flat foot
Toe off
39
Greenstick fracture
a fracture of the bone, occurring typically in children, in which one side of the bone is broken and the other only bent.
40
Shoulder examination?
```
1- Look:
scars, inflammation, muscle wasting
2. Feel:
Acromioclavicular, sternoclavicular, acromion
3. Move:
I. non-specific tests:
abduction, rotation, flexion
combined touch c7 and t6
II. specific
a. Dislocation
Apprehension test (flexed elbow 90, flex shoulder, abduction) :
Sulcus sign (pulling down arm, prone to dislocation)
b. Impingement test
Neer's test: thumb down, put fingers posterior superior to AC joint, flex shoulder
--> pain at low elevation
c. rotator cuff tear
supra: thumbs down, resist elevation
infra: elbow 90 flexed, external rotation
subcapsularis: put your hands behind you, dont let me push them towards your belt, internal rotation,
d. AC joint pain/arthritis
SCARF
pain at high elevation
e. OA
X-ray
```
41
5 common shoulder problems?
Age?
```
Dislocation 20-40 yo
Impingement 40-60
Rotator cuff tear 45-65
OA >60
Frozen shoulder 40-80
```
42
Structures posterior to medial malleolus
```
Tom dick and very naughty harry
Tibialis posterior
Flexor Digitorum longus
Tibial artery
Tibial vein
Tibial nerve
Flexor hallucis longus
```
43
Structures anterior to medial malleolus
Extensor hallucis longus
Extensor digitorum longus
Dorsalis pedis
44
Foot and ankle exam?
a. Look
1. Look at nail beds for psoriatic arthritis
2. sunshine sign (sausage like toes)
3. scars between toes
4. flat foot.
5. Look at sole for calluses
6. Achilles tendon (plantar flex: varus toes, landing :valgus toes)
7. gait
b. Feel
Go from medial to lateral to feel joints
Dorsalis pedis and post. tibialis
c. Move: both passive and active
1. Extend,flex big toe
2. Invert-exvert
3. dorsiflex, plantar flex
4. Thomas test: squeezing gastrocnemious to see achilles tendon moving normally (rupture otherwise)
5. Squeez MTP joints to check for pain/ sign of OA
45
Things to consider on a fracture x-ray?
```
Name, date, side
The most obvious abnormality is...
JOAST
Joint
Outline : break along outline?
Arthritis : displaced?
Soft tissue : open/close?
Texture of the bone : trabeculae?
```
46
2 ossification centres?
1. primary:
- develops first
- starts at diaphysis
2. Secondary:
- ends of long bone
these 2 separated by epiphyseal plates
47
2 types of ossification?
1. Endochondral
- bone laid on cartilage
- eg long bones
2. Intramembranous
- bone laid on bone
eg skull and clavicle
48
2 types of bone healing?
Which one better for intraarticular fracture?
1. primary
Cutting cone model:
- Oclasts cut bone, Oblasts lay bone, followed by vascularisation
- no cartilage formation
- Aim of surgical fixation by plate and screw ( needs to have very little strain on the fractured part of the bone to achieve this)
2. secondary
4 stages:
1. inflammation (fibroblasts form granulation tissue)
2. Soft callus formation (granulation tissue -> fibrocartilage (chondrocytes) (3rd week)
3. hard callus (fibrocartilage -->woven bone) ( 6th week, appears on x-ray)
4. Remodelling (Woven --> lamellar bone , several yrs)
Primary, no callus formation, doesnt limit ROM
49
2 types of non-union
Either stability or blood supply is impaired:
1. hypertrophic non-union:
new bone forms, but no bridges at fracture site, shows blood supply intact, but lack of stability
2. atrophic non-union:
soft edges of bone shows lack of blood supply
50
Hip examination
STANDING UP::
LOOK
- Gait (trendelenburg/antalgic)
- Trendelenburg test
- Spinal screening test (lumbar flexion for AS, crossing arms and twisting both ways, sliding palms down to knees)
Anterior, lateral and posterior sides:
- skin ( scars, erythamatous) +
- soft tissue (swelling, muscle wasting)
- bone (pelvic obliquity)
- coronal view abnormalities such as fixed flexion, sagittal: scoliosis
LYING SUPINE::
LEG LENGTH:
- apparant : umbilicus to med malleolus
- true leg length – ASIS to the tip of medial malleolus
FEEL
- Skin (temp, erythema, distal sensation)
- Bone (ASIS, greater trochantar, hip joint halfway between ASIS and trochantar)
MOVE:
- Thomas test (also tests active flex/extend)
- abduct/adduct (hand and elbow and ASIS)
- internal/external rotation, knee at 45
- FABER and FADIR for acetabular impingement
LYING PRONE
- test extension
TO COMPLETE:
- x-ray of hip
- examine joints above and below
- full neurovascular test
51
Plastering of tibial fracture?
above knee for 6 weeks, followed by sarmiento (patellar tendon bearing plaster) which allows movement of the knee
52
Which fractures are intra-articular on femur? How treated?
capsule is between greater and lesser trochantar, anything proximal is intra.
Either screws or hemiarthroplasty
53
Which joint(s) need(s) to be involved in a plaster of extra articular fracture?
above and below
54
Colle's fracture
what?/where?
4 features?
- extra-articular fractures of distal radius
- dorsal angulation
- radial displacement
- dorsal displacement
- shortening
55
Action of interossei muscles?
DAB PAD
Dorsal interpssei abduction
Palmar interossei adduction
56
Hand examination
LOOK
1. Deformities:
- 4 signs of RA
2. Scars:
- carpal tunnel? trigger finger release?
3. Lumps:
- Dupuytren's contracture? ganglions?
4. Muscle wasting
FEEL
1. Painful swellings
2. Characteristics of lump (6 Ss and P:
- Site (and underlying structures),
- Size,
- Shape,
- Surface and edges,
- Structure (soft or hard),
- Sensation (tenderness, temperature),
- Pulsatile
3. Pulses (ALANS TEST: hold both ulnar and radial arteries, pump their fist, relax hand, let go of ulnar, should slowly go pink)
Motor
1. Grips:
- Power: lift a heavy object
- Tripod: hold a pen
- Key: thumb and index, unlocking motion
2. Nerve function- motor and sensory
- Radial: S: 1st interweb space, M: flex their wrist, ask to extend finger
- Median: S: tip of index finger, M: ask to point upwards with thumb, dont let you push it down
- Ulnar: S: tip of little finger, M: piece of paper between fingers dont let me pull it out
57
Nerve supply of various muscles in hand?
```
Median (LOAF) :
-Lumbricals
-Opponens pollicis,
-Abductor pollicis brevis
-Flexor pollicis brevis
Radial:
- Extensors of digits, thumb and wrist
Ulnar:
- everything else
```
58
Dupuytren's contracture
1. Def?
2. Cause?
3. Sx?
4. Management?
5. complication?
DEF: flexion contracture of MCP or PIP,
Cause: caused by palmar fascia thickening
Sx: little finger and ring finger slightly flexed
Mx: if interfering with function, excised
Complication: nerve damage
more common in men
59
Ganglion
1. def
2. cause
3. where?
4. Mx?
1. non-painful lump in hand
2. myxoid degeneration of fibrous tissue
3. most common on the back of the hand (medial to snuffbox), A1 pulley and DIP digits
4. aspirate (refills) or excision if affecting function
60
Trigger finger
1. def
2. Mx
1. thickening of flexor tendon of a finger (most commonly ring finger),
2. trigger finger release surgery (cutting the A1 pulley, to allow extension of the digits)
61
Positive Carpal tunnel test?
Hyperextend wrist, press on carpal tunnel. Painful is a positive test
62
Knee examination
LOOK (anterior , lateral, posterior)
Gait
Skin: redness, scars
Soft tissue: swelling (Baker's cyst), muscle wasting (disc prolapse)
Bone: Valgus (7 degrees of valgus normal)/ varus - hyperextension
SIT UP on bed (legs hanging)
Extend leg: normal patellar traction laterally? Feel for creptations
FEEL (always keep an eye on the patient to look for pain)
1. Temperature
2. From tibial tuborisity->go proximal -> and medial to patella to feel the medial joint line -> after reaching the joint space go away from midline medially to feel the medial joint line
3. From tibial tuborisity->go proximal and lateral to patella to feel the medial joint line -> after reaching the joint space go away from midline laterally to feel the lateral joint line
4. Go proximal from tibial tuborisity, feeling patellar tendon, patella and quadriceps
5. Feel the medial collateral ligament by pressing on the medial epicondyle
6. Feel the lateral collateral ligament by pressing on the lateral epicondyle (move proximal from head of fibula)
7. Popliteal fossa
8. Sweep test:
put a hand on suprapatellar pouch, other hand go up on the medial side, then start distally moving proximally on the lateral side, If positive parapatellar fossa fills with fluid.
MOVE (passuve and active)
1. Flex and extend
2. At 20 degrees, check the collaterals
3. At 90, sit on toes and perform the draw test for ACL and PCL (thumps on the fossa, rest of the hand wraps around the back)
4. Loss of tibial step off at 90 degrees means PCL injury
NVS exam
Joint above and below
63
Examination of elbow
LOOK
- wasting
- scar
- asymmetry
FEEL
4 bony prominences:
- olecranon
- medial epicondyl
- lateral epicondyl
- radial head (felt on supination/pronation)
Feel for tenderness, heat, rheumatoid nodules
MOVE
Flex 140 degrees
Extend 0 degrees
Supinate 90 degrees
Pronate 80 degrees (radial head doesnt go all the way next to ulna)
64
Tendonopathy vs tendonitis
pathy:
- more chronic
- wear and tear
itis:
- acute inflammation
65
Funtional elbow range of movement?
30 (wipe back passage) to 140 (feed)
50 % of Supination (put clothes on)/ pronation (operate computer)
Sup/pron less important as shoulder can compensate
66
Elbow diagnosis
I. Tennis elbow
1. def
2. examination 3
3. treatment
II. OA/RA
1. examination
2. treatment
III. Ulnar nerve neuropathy
1. on examination (3)
2. investigation
3. treatment
IV. Olecranon bursitis
1. examination ( 2)
2. treatment (4)
I. Tennis elbow
1. affects lateral epicondyle
2. On exam:
- tender lateral epicondyle at 90 degrees
- Mills test: passively extend elbow, flex wrist, radial deviate wrist. pain on lateral epicondyle
- limited extension of elbow
3. Tx:
- clasp below elbow, rests the long extensors
- ------------------------------------------
II. OA
1. symmetrical loss of movement in all different moves
2.
Conservative: maintain mobility + NSAIDs + DMARDs, + biological agents
Surgical: replace
-------------------------------------------
III. Ulnar nerve neuropathy
```
1.
Muscle wasting
- hypothenar muscle,
- interossei wasting (guttering of hand)
Clawing :
- lumbricals vs long flexors
Tinnel sign:
- tapping lateral to medial epicondyle, on the nerve, brings on symptoms
```
2. nerve conduction study
60 m/s normal nerve conduction
40 m/s in neuropathy
3. surgical decompression
- ------------------------------------------
IV. Olecranon bursitis
```
1.
ROM unaffected
Swelling in the normally loose skin on the posterior side of elbow
2.
- rest
- ice
- compression
- cut out
```
67
Keinbocks disease
def
Sx
Tx
- avascular necrosis of lunate bone,
- pain and discomfort in wrist, reduced ROM
- surgical fusion of the wrist
68
Developmental dysplasia of the hip (DDH)
1. Def
2. 3 clinical features?
3. 2 special tests?
4. Ix?
5. Mx?
1. failure of normal development of the acetabulum leading to excessive joint laxity
2.
- loss of abduction
- leg length discrepancy
- asymmetrical posterior skin crease
3. screened at 24hrs/6mo post birth
Barlow test:
- attempts to dislocate a reduced hip, by pulling down and adduction of a hip at 90 degrees
Ortolani's test:
- attempts to reduce a dislocated hip, by abducting a 90 flexed hip
4. ultrasound younger babies, x-ray older children
5.
conservative:
- Palvik harness
Surgery:
- close/open reduction
69
Perthe's disease
1. def?
2. presentation?
3. Ix
4. Mx
5. what happens to the femoral head after bone death
1. segmental avascular necrosis of femoral head of unknown aetiology
2. gradual hip/knee pain with impaired abduction
3. X-ray:
- fragmentation
- subluxation
- loss of epiphyseal height
4.
- 75% require no treatment
- rest treated by surgical osteotomy
5.
- initially collapses & fragments
- then repairs and remodels over years
70
Slipped upper femoral epiphysis (SUFE)
1. def?
2. how does the slip look like on the x-ray?
3. Mx?
1. displacement of epiphysis due to failure of growth plate, associated with endochondral abnormalities and obesity
2. epiphysis looks inferior and posterior to femoral neck
3.
- slip fixed in situ immediately to avoid further displacement
- cant be reduced due to risk of avascular necrosis
71
Congenital talipes equinovarus (club foot)
1. presentation
2. 2 main sings?
3. Mx?
1. calf wasting and inward pointing of the feet
2.
fixed varus
fixed equinous (plantar flexed)
3. Ponseti casting:
- slowly corrects the varus deformity
- weekly changes in cast (external rotation)
- treatment can last up to 4 years (3mo norm)
72
Back pain causes?
I. Mechanical
a. non-specific: Muscle or ligamentous strains
b. trauma: Vertebral fractures, intervertebral disc prolapse (PID)
c. degenerative: Spondylosis, intervertebral disc prolapse, spinal stenosis, spondylolisthesis, scoliosis, kyphosis, spina bifida
II. Non-mechanical
a. Inflammatory: Spondyloarthropathy, rheumatoid arthritis, polymyalgia rheumatica
b. Metabolic: Osteoporosis (vertebral collapse), Paget's disease, Osteomalacia
c. neoplasm
d. Infection: Osteomyelitis, paravertebral abscess, discitis, TB
III. Referred
a. GI/GU: biliary colic, renal colic, pancreatitis
b. Visceral organs: endometriosis and prostatitis, atopic pregnancy
73
Spine
1. development of spinal curves?
2. movements of different regions?
3. what level cauda equina comes out?
4. 4 important bony parts of vertebra
5. 2 parts of disc
1. --when born--> thoracic kyphosis--> cervical lordosis ---when they walk--> lumbar lordosis
2.
- flexion/extension in lumbar spine
- rotation in thoracic
- lateral flexion(abduction) in cervical
3. L1/L2
4. spinous and transverse processes, facets, pedicle (aka, foot) and body
5. annulus fibrosis and nucleus pulposis
74
4 lines to look at on a c-spine x-ray?
- anterior vertebral line
- posterior vertebral line
- spinolamilar line
- posterior spinous line
75
Red flags for back pain
I. cauda equina
II. Malignancy
III. infection
```
I. Cauda equina
- saddle anaesthesia
- incontinence/ absent anal tone
II. Malignancy
- Night pain
- constitutional symptoms
- <20yo or >50
III. infection
- IVDU
- immunosuppressed
```
76
Spondylolisthesis
1. def
2. Ix
3. Mx
1. slipping of one vertebra onto another
NOTE: DIFFERENT FROM SPONDYLOLYSIS (defect in pars interarticularis)
2. X-ray changes:
- scottie dog appearance
3.
conservative:
- reduction in activity may allow it to heal
surgical:
- fusion if pain is really bad
77
Gibbus?
A Gibbus deformity is a form of structural kyphosis, where one or more adjacent vertebrae become wedged.
78
Cauda equina syndrome
Def?
Sx?
1.
- the cauda equina, located below the level of L2, becomes compressed
- This condition is a surgical emergency, requiring immediate referral.
2.
- Sphincter disturbance leading to bladder or bowel dysfunction
- saddle anaesthesia
79
Metastasis to spine
```
Breast
Bronchus
Prostate
Kidney
Thyroid
```
80
Neck of femur fracture
1. abductor attachment?
2. capsule attachment?
3. Different classification of intracapsular fracture?
4. blood supply to neck of femur?
5. Sx of NOF? 4
6. Ix? 3
7. conservative Mx?
1.
Abductors attach at greater trochanter
2.
Inter-trochanteric line on the anterior side
Mid-neck of femur on the posterior side
3.
- Subcapital
- Midcervical
- Basicervical
( + sub trochanteric)
4.
Medial and lateral trochanteric arteries which form the trochanteric anastemosis
5.
- Shortened leg: gluteus maximus and abductors pull up the femur
- Externally rotated
- Groin/hip pain
- neurovascular impairment
```
6.
I. Blood (G+S, FBC, U&E, CRP, Ca, troponin, ABGs, Thyroid function test, blood glucose)
II. Urine dip
III. X-ray:
- CXR
- AP pelvis
- horizontal beam of the affected hip
```
7.
- ABC: high O2, IV fluids
- Analgesia: oral, IV + femoral nerve block
- identify co-morbidities and treat
- thromboprophylaxis
- MDT management
81
Surgical management of NOF fracture
1. what factors does method of surgery depend on?
2. 3 different treatments?
I. elderly, poor mobility
II. elderly, high level of mobility
III. young patient
3. mortality at 30 days, 3 months and 1 yr post op?
1. type of fracture, age of patient, pre-mobility status, skills of the surgeon
```
2.
I. hemiarthroplasty
II. full hip replacement
III.
In-situ fixation: with dynamic hip screws or intermedullary nail
```
3. 10%, 20%, 33.3 %
82
Post op management of NOF fracture
I. Short term 6
II. long term 4
Short term:
1. Abx prophylaxis
2. DVT prophylaxis (stocking)
3. Analgesia
4. IV fluid resus (bleeding)
5. monitor urine output, temperature, FBC, U&E
6. X-RAY
II. long term
1. physio
2. nutritional status
3. orthogeriatric liason
4. 2ndary prevention: ca supplements
83
Spine examination
I. Look
Ant: symmetry in head, neck and shoulders
Side: kyphosis or lordosis
Back: scoliosis
II. Feel
- spinous processes
- paravertebral muscles
```
III. Move
A. Cervical
- Lateral flexion
- Flexion/extension
- rotation
B. Thoracic
- Rotation
C. Lumbar
- lateral flexion
- extension/flexion
```
Special test:
A. Schober test:
- Lumbar flexion
B. Sciatic stretch test (straight leg raise)
- tests sciatica ( sciatic root impingement)
- Supine position, flex hip to max possible, Dorisflex
- remarkable: posterior thigh/ buttock
