Orthopaedics Flashcards
What sort of criteria would you require to perform hip replacement on pt
Severe pain - Doesn’t respond to analgesia Tried walking aids Had physio E.g. can’t put on socks Weight loss if needed
Knee replacement, continuing problems. Ix
Xray
Aspirate
which is valgus/varus?
valgus = knock-kneed varus = bow legged
4 xray features of OA
osteophytes
reduced joint space
subchondral sclerosis
bone/ subchondral cysts
is fibula medial or lateral?
lateral
what is trochanteric bursitis
inflammation of the bursa between greater trochanter and the iliotibial band/ tensor fascia lata
describe position of leg following NOF fracture
shortened, ext rotated
describe different management between intra and extracapsular NOF fracture
intra-capsular = blood supply to head of femur affected so replace head extra = blood supply intact so able to keep own head of femur
In +ve trendelenburg, which side is abductor weakness?
Opposite to dipped side
Describe Colles and smiths fractures
Colles - dorsal angulation (fell on extended wrist)
Smiths - opposite
What age group are rotator cuff tears/injuries most common
Elderly
How do you assess axiliary nerve (can be damaged in dislocation)
Sensation in regimental badge area. Can also pinch deltoid and ask to raise arm
Mx options for PIP OA
Splint
Steroid + local inj
Joint replacement
Permanent fusion
What is Tennis elbow and how can you simulate the discomfort O/E
Lateral epicondylitis
Tender over lat epichondial + cock wrist back (uses extensors which attach lat epi)
Carpal tunnel ix + Mx
Nerve conduction study,
Surgical Decompression
First movement to go in frozen shoulder
Ext rotation
What causes Numbness of little finger
Ulnar nerve entrapment at elbow
Mechanism of frozen shoulder + mx
Tightened capsule
Hydrodilatation / endoscopic cut capsule
bowel/ gynae/ urology surgical prophylaxis Abx
co-amoxiclav
[if penicillin allergic - cefuroxime + metro/ gent + metro]
thromboprophylaxis for ortho Pt on warfarin
stop warfarin day -4, replace with a LMW heparin e.g. tinzaparin
what action is taken during surgery for patients on steroids and why
give extra hydrocort [patients can’t produce own steroids to respond to surgical stress]
any HTN meds you need to stop pre-op and why
ACE inhib + ARBs
can interact w/ anaesthetic, leading to hypoTN
factors that increase bone healing time after fracture
^age
mid shaft
lower limb
what are the 3 main principles of fracture Mx? [pneumonic RMR]
reduction
maintainence
rehab
fractures common to elderly w/ osteoporosis
colles
NOF
spinal wedge fracture
forearm fracture, ORIF, cast. Pt now experiencing severe pain, paraesthesia, swelling. diagnosis/Mx?
cast too tight or compartment syndrome.
split cast volar side. If no improvement, take the theatre and split fascia to release pressure
mx of intracapsular NOF fracture in frail 90 yr old with reduced mobility
hemiarthroplasty
mx of intracapsular NOF fracture in fit Pt
total hip replacement
[or if not displaced, can sometimes keep head with DHS, then fit enough to undergo 2nd op if AVN occurs]
Mx of extracapsular NOF fracture
DHS or 2 nails, depending on intra/subtrochanteric
non-surgical Mx options for fractures
splint/brace
cast
traction - skin/skeletal
problems with skin traction
not much weight can be applied
skin sores
priniciples of immediate ortho trauma Mx
ABC, stabilise cervical spine, rule out life-threatening.
analgesia, neurovasc status,
splint, traction,
Abx, cross match.
damage to common perineal nerve causes what clinical sign
foot drop
causes of common perineal nerve damage
varus knee = stretched nerve squashed by cast/ stirrups MS etc disc prolapse etc!
24 hrs post femur fracture. Pt presents w/ petechial rash, hypoxia, tachycardia. Whats happened
fat embolism syndrome [marrow > lung, like PE]
risk with scaphoid fractures
avn
due to poor blood supply (artery damaged with fracture)
patient falls on outstretched hand.
3 anatomical areas to examine for tenderness in suspected scaphoid fracture
anatomical snuffbox
longitudinal compression of thumb
push on scaphoid at base of thenar eminence
what are the aspects of 3 point immobilization of the neck
hard collar, sand bags, tape
alternative names for cervical vertebrae C1 and C2
C1 atlas
C2 axis
most important consequence of cervical spondylolisthesis
spinal cord compression
causes of spinal cord comporession
bone displacemnt disc prolapse local tumour abscess hameoatoma
broadly speaking , what signs are seen at the level of, and below a spinal cord compression?
LMN signs at level
UMN signs below [spastic weakness, brisk refelxes, upgoing plantars]
sensory changes below [loss of coord/ joint position sense/ vibration/ temp + pain]
how could cervical prolapsed disc present?
pain radiating to arm stiff neck muscle weakness depressed reflexes cord compression
Mx of cervical prolapsed disc
NSAIDs
collar
physio
(surg)
problems caused by cervical rib [congenital development of costal process of C7 vertebra]
+ Mx
brachial plexus compression
subclavian artery stenosis
[pain/numbness in hand/forearm, weakness/muscle wasting]
[weak radial pulse, forearm cyanosis]
physio to strengthen shoulder elevators, surg removal
whiplash Mx
reassure serious injury is rare prompt return to usual activity and occupation active mobilization prevent disuse > chronic analgesia NO collar/ rest
which intervertebral discs are most likely to rupture?
L4/L5, L5/S1
presentaiton in disc prolapse + exam features
forward flexion, extension,+/- lateral flexion limited lumbar pain, sciatica calf pain sudden severe pain on e.g. coughing weak plantar flexion/hallux ext[depends which disc] reduced ankle jerk reduced sensation cauda equina
Ix of choice in suspected disc prolapse
MRI [or ct]
Mx of disc prolapse
brief rest, early mobilizaiton
analgesia
+/- physio
discectomy in cauda equina/ progressive muscle weakness, continuing pain
what Ix.s would you do in back pain lasting >4 weeks, or red flag sx
FBC, ESR, LFT, bone profile
myeloma screen if >50
XR, CT, MRI, isotope bone scan, bone biopsy
risk factors for discitis [or other pyogenic spine infection]
DM
imm supp
urinary surg
catheter
causes of cauda equine
disc prolapse extrinsic tumour primary cord tumour spondylosis spinal stenosis
danger signs suggestive of cauda equina
poor anal tone severe back pain saddle parasthesia incontinence or retention of faeces or urine paralysis +/- sensory loss
problem with delay in cauda equine diagnosis?
permanent neuro damage to sexual, bladder and bowel fn
what is osteomyelitis?
infection of bone
common organisms for osteomyelitis
staph aureus
pseudomonas
e. coli
strep
what are the 3 routes infection can get to a bone/ 3 categories of osteomyelitis?
acute haematogenous [through the blood]
local infection
direct inoculation from trauma or surg
risk factors for osteomyelitis
DM prosthesis vasc disease imm comp sickle cell open fracture
what is the gold standard investigaiton for pathogen identification or uncertain diagnosis in osteomyelitis
bone biopsy and culture
Mx of osteomyelitis
surg - drain abscesses and remove sequestra
6 weeks vanc and cefotax
complications of osteomyelitis
septic arth
fractures
deformity
chronic osteomyelitis
in a painful shoulder, if all movements hurt what pathology do you consider? and if only some?
all - arthritis or capsulitis
some - impingement
what position might you find the arm in on examination of a posterior shoulder [glenohumeral] dislocation?
and what might you see in anterior dislocation?
internal rotation
anteromedial mass
name the 4 muscles of the rotator cuff
supraspinatus
infraspinatus
subscapularis
teres minor
describe some tests for impingement
Neers [backstroke]
Hawkins [motion in the ocean]
scarf test positive [forced adduction of arm across neck] suggests what pathology?
acromioclavicular joint disease
what imaging for rotator cuff tears
US or MRI [US quicker and cheaper and tear or no tear, MRI for quantifying muscle wasting/prognosis]
what is the pathology behind impingement syndrome/
the supraspinatus tendon catches under the acromion during abduction around 70-140 degrees
you believe pt has impingement syndrome. Give 1 other cause of painful arc
supraspinatus tendinopathy or partial rupture
calcifying tendinopathy
acromioclavicular joint arthritis
young weightlifter with painful arc. Diagnosis and management
acromioclavicular joint arthritis
rest, nsaids, steroid inj, [surg]
rupture of long head of biceps management
repair rarely indicated as function remains
disease associations of frozen shoulder
cervical spondylosis
DM
thyroid disease
so always check glucose and TFT
frozen shoulder Mx
NSAIDs
physio
steroid IA inj for pain early on
arthroscopic arthrolysis
what is usually the first movement restricted by hip disease?
int rotation
test for fixed flexion deformity
thomas test [bend good leg + fixed flexion leg will lift off couch]
special test for weak abductors + positive result
trendelenburg [sound side sags]
what causes a trendelenburg gait?
describe it
weak abductors
waddling gait, trunk tilts over weak side
causes of coxa vara [angle between neck and shaft of femur less than 125/ right angled - leading to leg shortening]
congen SCFE #NOF malunion trachanteric # rickets/pagets/osteomalacia
secondary causes of OA hip
AVN paeds hip disease age occupation trauma post-op infection malposition mechanical instab osteochondritis desicans
differentials for painful hips in children
rule out SA
then consider: perthes SUFE inflammatory arth osteomyeltis
by exclusion: transient synovitis
4 yr old presents with pyrexia and limp due to hip pain - 2 main differentials
SA
transient synov
4 prognostic clinical signs for SA [if 3 or more present, 93% chance of SA]
temp
^WCC
^CRP
non-weight bearing
if SA suspected in child w/ painful hip, 2 urgent Ix you’d do?
blood culture
US guided joint aspirate
6 yr old with acute onset hip pain, recent viral illness. Pain in extremes of movement, bloods and radiology normal. Most likely diagnosis?
what about if other joints were involved?
- transient synov
- consider JIA
6 yr old boy, hip pain and limp. All hip movements are limited, especially int. rotation + abduction. Early XR shows joint space widening, later there is small patchy femoral head. DIagnosis?
perthes disease
Mx of transient synovitis
self limiting w/ rest +/- analgesia
Mx of perthes disease
bed rest, NSAIDs
XR surveillance
+/- joint replacement
non-hip causes of limp in children
leukaemia discitis rickets reactive arthritis JIA
RFs for developmental dysplasia of hip
breech caesarean due to breech other malformations sibling w/ ^birth weight oligohydramnios primip or old postmaturity
in babies who are high risk for developmental dysplasia of hip, or if neonatal exam suggests instability, what Ix should be done?
US
treatment for developmental dysplasia of hip [remains unstable at 6 weeks]
long term splinting in Pavlik harness [in flexion-abduction]
closed reduction + immobilisation
open reduction if failed or 18 months +
other than specific hips tests for developmental dysplasia, what are some other signs
unequal leg length
asymmetrical groin creases
limited abduction in flexion
older: delay in walking, waddling gait
risk factors for elbow osteoarthritis
osteochondritis dissecans
fractures
describe the pathology of osteochondritis dissecans
subchondral bone becomes avascular, may progress to fragments of bone + cartilage breaking away to form loose bodies [osteochondral fragments]
cause is unknown
osteochondritis dissecans - typical site? and age of patient?
lateral side of medial femoral condyle
13-21
what are the colloquial terms for medial and lateral epicondylitis ?
and which is more common?
lateral = tennis elbow medial = golfers elbow
tennis
management of tennis elbow + prognosis
restrict activities which overload tendons
lasts 6-24 months, 90% recover within 1 yr
physio
[brace]
[surgical tendon release in severe unresponsive cases]
what neuropathy is occasionally associated with medial epicondylitis [golfers elbow]?
ulnar
causes of ulnar neuritis [cubital tunnel syndrome]
OA
RA
cubitus valgus
presentation of ulnar neuritis [cubital tunnel syndrome]
reduced sensation of little finger and medial half of ring finger
clumsiness of hand
weakness of hand
test and treatment for ulnar neuritis [cubital tunnel syndrome]
nerve cond studies
surgical decompression
mx of dupuytrens contracture
early disease: injectible clostridium histolyticum, percutaneous needle fasciotomy
fasciectomy
causes/ associations of dupuytrens contracture
genetic [auto dom] smoking DM antiepileptics peyronies disease
mx of ganglia
no Tx unless pain or pressure on median/ulnar nerve at wrist.
local pressure may disperse it
aspiration or surgical dissection
disease which increases chance of getting trigger finger [when tendon nodule prevents re-straightening of finger after flexing]
DM
Mx of trigger finger [when tendon nodule prevents re-straightening of finger after flexing]
rest, splinting
severe: steroid inj into region of nodule, or surgery
symptoms and signs in carpal tunnelsyndrome
sx: tingling/pain in thumb/ index /middle finger, worse @night, flicks/shakes wrist to relieve pain, clumsiness
signs: wasted thenar eminence, reduced sensation to lateral 3 digits, phalens [reverse prayer] + tinnels [tap]
what does tenderness over the lateral joint line of the knee suggest?
iliotibial band tendinitis
causes of anterior knee pain
patellofemoral pain syndrome [runners]
patella tendinopathy [jumpers]
Hoffa’s fat pad syndrome [impingement]
Bursitis [housemaid’s/clergyman’s]
osgood-schlatter disease
bipartite patella
what actions may bring on the pain of patellofemoral pain syndrome
how is it managed?
prolonged sitting
climbing/descending stairs
recent ^sport
trauma
rest
physio/strengthening exercises
NSAIDs for pain
[rarely surgery]
management of patella tendinopathy [jumpers knee]
rest
NSAIDs
steroid inj around tendon
physio/exercises
what surgical intervention in knee OA can delay a total knee replacement by 10 years
osteotomy
where does aspiration of a prosthetic joint need to occur?
orthopaedic theatre, never in ED or clinic
how would a meniscal cyst usually present ?
and how is it managed?
young man, previous trauma, pain over joint line, swelling
arthroscopic decompression
examination special test for ACL tear
anterior draw
examination special test for knee meniscal tears
McMurray’s
imaging investigation of choice for knee meniscal tears or cysts
MRI
preferred imaging technique in bakers cyst
US
patient with pagets disease, anterior calf hot on examination.
XR shows lytic central lesion, ass. w/ erosion of cortical surface of tibia + soft tissue swelling. Likely diagnosis?
osteosarcoma
when is a p value given in a study ?
can only be given if there is hypothsis testing
