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D3 > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

Bone Composition

A

Cells - osteoblasts, osteoclasts, osteocytes, OPCs

Matrix
Organic (osteoid 40%)
 Collagen Type I
 Resists tension, twisting and bending

Inorganic (60%)
 Calcium hydroxyapatite
 Resists compressive forces

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2
Q

Classification

A

Woven Bone - disorganised structure forms embryonic skeleton and fracture callus

Lamellar bone - mature bone (2 types)

  • cortical/compact - dense outer layer
  • Cancellous/trabecular - porous central layer
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3
Q

Intramembranous Ossification

A

Direct ossification of mesenchymal bone models - formed during embryonic development

skull bones, mandible + clavicle

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4
Q

Endochondral Ossification

A

Mesenchyme → cartilage → bone

Most bones ossify this way

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5
Q

Fracture Healing

A

Reactive Phase (injury - 48h)

  1. bleeding into # site - haematoma
  2. inflammation - granulation tissue by leukos + fibroblasts

Reparative phase (2 days- 2weeks)

  1. proliferation - osteoblasts + fibroblasts > cartilage + woven bone production > callus formation
  2. Consolidation (endochondral ossification) of woven bone > lamellar bone
Remodelling Phase (1wk - 7yrs)
5. Remodelling of lamellar bone to cope w mechanical forces applied to it
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6
Q

healing time

A

Closed, paediatric, metaphyseal, upper limb: 3wks

“Complicating factor” doubles healing time
 Adult
 Lower limb
 Diaphyseal
 Open
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7
Q

Fracture Classification

A

Traumatic #

  • direct (eg assault w metal bar)
  • indirect (FOOSH > clavicle #)
  • avulsion

Stress #

  • bone fatigue due to repetitive strain
  • eg foot # in marathon runners

Pathological #
- normal force, diseased bone
 Local: tumours
 General: osteoporosis, Cushing’s, Paget’s

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8
Q

Describing Fractures

A

Radiographs must be orthogonal
Need Images below and above joint #

D PAID S S

Demographics
 Pt. details
 Date radiograph taken
 Orientation and content of image

Pattern
 Transverse
 Oblique
 Spiral
 Multifragmentary
 Crush
 Greenstick
 Avulsion

Anatomical Location

Intra/extra-articular (dislocation or subluxation)

Deformity (distal relative to proximal)
 Translation
 Angulation or tilt
 Rotation
 Impaction (→shortening)

Soft tissues
 Open or closed
 Neurovascular status
 Compartment syndrome

Specific # classification type
 Salter-Harris
 Garden
 Colles’, Smith’s, Galeazzi, Monteggia

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9
Q

Management

A 
4 Rs 
Resuscitation 
Reduction
Restriction
Rehabilitation
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10
Q

Mx 1. Resuscitation

A

ATSL guidelines
Trauma series in 1mary survey: C-spine, chest and pelvis
# usually assessed in 2ndary survey
Assess neurovascular status + look for dislocations

Consider reduction + splinting before imaging
 ↓ pain
 ↓ bleeding
 ↓ risk of neurovascular injury

X-ray once stable

Open frature requires urgent attention

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11
Q

Open fracture urgent attention

A

6As
 Analgesia: M+M
 Assess: NV status, soft tissues, photograph
 Antisepsis: wound swab, copious irrigation, cover with
betadine-soaked dressing.
 Alignment: align # and splint
 Anti-tetanus: check status (booster lasts 10yrs)
 Abx
 Fluclox 500mg IV/IM + benpen 600mg IV/IM
 Or, augmentin 1.2g IV

Mx: debridement and fixation in theatre

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12
Q

Gustillo Classification of Open #s

A
  1. Wound <1cm in length
  2. Wound ≥1cm c¯ minimal soft tissue damage
  3. Extensive soft tissue damage
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13
Q

Fracture Mx 2. Reduction

A

Displaced #s should be reduced (unless no effect on outcome - ribs)
Aim for anatomical reduciton (esp if articular surfaces)
Alignment more important than opposition

Methods
- Manipulation/closed reduction
 Under local, regional or general anaesthetic
 Traction to disimpact
 Manipulation to align
-Traction
 Not typically used now.
 Employed to overcome contraction of large
muscles: e.g. femoral #s
 Skeletal traction vs. skin traction
- Open reduction (+ internal fixation)
 Accurate reduction vs. risks of surgery
 Intra-articular #s
 Open #s
 2 #s in 1 limb
 Failed conservative Rx
 Bilat identical #s
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14
Q

Fracture Management 3. Restriction

A

Interfragmentary strain hypothesis > tissue formed at # site depends on strain it experiences
Fixation → ↓ strain → bone formation
Fixation also → ↓ pain, ↑ stability, ↑ ability to function

Methods
Non-Rigid - slings, elastic supports

Plaster - POP
- in first 24-48h use back slab or split cast (risk of compartment syndrome)

Functional bracing - joints free to move but bone shafts support in cast segments

Continuous traction (collar + cuff)

Ex-fix

  • Fragments held in position by pins/wires > connected to external frams
  • intervention is away from field of injury
  • useful in open #s, burns, tissue loss to allow wound access + ↓ infection risk.
  • risks pin site infections

Internal fixation

  • pins, plates, screws, IM nales
  • usually perfect anatomical alignment
  • increase stability
  • aid early mobilisation
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15
Q

Mx 4. Rehabilitation

A

 Immobility → ↓ muscle and bone mass, joint stiffness
 Need to maximise mobility of uninjured limbs
 Quick return to function ↓s later morbidity

Methods
 Physiotherapy: exercises to improve mobility
 OT: splints, mobility aids, home modification
 Social services: meals on wheels, home help

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16
Q

Complications (General)

A

Tissue Damage

  • haemorrhage + shick
  • infection
  • muscle damage - rhabdomyolysis

Anaesthesia

  • anaphylaxis
  • damage to teeth
  • aspiration

Prolonged Bed rest

  • chest infection, UTI
  • Pressure sores + muscle wasting
  • DVT, PE
  • ↓ BMD
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17
Q

Complications (Specific)

A

Immediate

  • neurovascular damage
  • visceral damage

Early

  • Compartment syndrome
  • infection
  • fat embolism - ARDS

Late

  • problems w union
  • AVN
  • growth disturbance
  • Post-traumatic osteoarthritis
  • Complex regional pain syndromes
  • Myositis ossificans
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18
Q

Neuro complications

A

severance is rare, stretching over bone edge more common

Seddon classification - 3 types
neuropraxia
axonotmesis
neurotmesis

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19
Q

Neuropraxia

A

temporary interruption of conduction w/o loss of axonal continuity

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20
Q

Axonotmesis

A

disruption of nerve axon > distal wallerian

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21
Q

neurotmesis

A

disruption of entire nerve fibre

surgery required and recovery usually incomplete

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22
Q

complications - Common Palsies

Ant shoulder dislocation, humeral surgical neck

A

> Axillary nerve Palsy

Test/result
Numb chevron - weak abduction

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23
Q

humeral shaft

complications - Common Palsies

A

Radial Nerve

Waiter’s tip

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24
Q

complications - Common Palsies

Elbow dislocation

A

Ulnar nerve

Claw hand

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25
Q

complications - Common Palsies

Hip dislocation

A

Sciatic nerve

foot drop

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26
Q

complications - Common Palsies

# neck of fibula 
knee dislocation
A

fibular nerve

foot drop

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27
Q

Compartment Syndrome

A

Osteofacial membranes divide limbs into separate
compartments of muscles.

Oedema following # → ↑ compartment pressure → ↓
venous drainage → ↑ compartment pressure

If compartment pressure > capillary pressure → ischaemia

Muscle infarction →
 Rhabdomyolysis and ATN
 Fibrosis → Volkman’s ischaemic contracture

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28
Q

Compartment syndrome Presentation + Rx

A

 Pain > clinical findings
 Pain on passive muscle stretching
 Warm, erythematous, swollen limb
 ↑ CRT and weak/absent peripheral pulses

Rx

  • elevate limb
  • remove all bandages + split/remove cast
  • fasciotomy
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29
Q 
# complications 
Problems with union

Causative factors 5 Is

A

Delayed union/Non-union of fracture

Causative factors - 5 Is

  • Ischaemia (poor blood supply or AVN)
  • Infection
  • ↑ interfragmentary strain
  • Interposition of tissue between fragments
  • intercurrent disease - eg malignancy or malnutrition
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30
Q

complications

Non-union classifcation

Mx

Malunion

A

Non-union classification

  • hypertrophic - bone end rounded, dense and slerotic
  • atophic - bone looks osteopenic

Management
 Optimise biology: infection, blood supply, bone graft, BMPs
 Optimise mechanics: ORIF

Malunion - #healed in imperfect position
 Poor appearance and/or function
 E.g. Gunstock deformity

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31
Q

Avascular necrosis

A

Death of bone due to deficient blood supply.

Sites: femoral head, scaphoid, talus

Consequence: bone becomes soft and deformed
→ pain, stiffness and OA.

X-ray: sclerosis and deformity.

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32
Q

Myositis Ossificans

A

Heterotopic ossification of muscle at sites of haematoma formation
> restricted painful movements
> commonly elbows + quadriceps
> can be excised surgically

Pellegrini-Stieda disease

  • form of MO
  • calcification of superior attachment of Medial Collateral Ligament at knee following trauma
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33
Q

Hip fracture RF

A

Osteoporosis w minor trauma
Major trauma

RF - Age + SHATTERED

Steroids
Hyper-para/thyroidism
Alcohol + Cigarrettes 
Thin (BMI <22)
Testosterone low
Early Menopause
Renal/Liver Failure
Erosive/inflamed bone disease (RA, myeloma)
Dietary Ca Low/ Malabsorption, DM
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34
Q

Hip Fracture Presentation

A

O/E shortened and externally rotated

Qs 
 Mechanism
 RFs for osteoporosis / pathological #
 Premorbid mobility
 Premorbid independence
 Comorbidities
 MMSE
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35
Q

Hip Fracture Initial Mx

A

Resuscitate: dehydration, hypothermia

Analgesia: M+M

Assess neurovascular status of limb

Imaging: AP and lateral films

Prep for theatre 
 Inform Anaesthetist and book theatre
 Bloods: FBC, U+E, clotting, X-match (2u)
 CXR
 DVT prophylaxis: TEDS, LMWH
 ECG
 Films: orthogonal X-rays
 Get consent
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36
Q

Hip fracture Imaging

A 
 Ask for AP and lateral film
 Look @ Shenton’s lines
 Intra- or extra-capsular?
 Displaced or non-displaced
 Osteopaenic?
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37
Q

Hip fracture Key Anatomy

A

Capsule attaches proximally to acetabular margin and
distally to intertrochanteric line.

Blood supply to fem head:

  1. Retinacular vessels, in capsule, distal → prox
  2. Intramedullary vessels
  3. Artery of ligamentum teres.

If retinacular vessels damaged there is risk of AVN of the femoral head → pain, stiffness and OA

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38
Q

Hip Fracture Classification

(Garden classification

A

Intracapsular: subcapital, transcervical, basicervical

Extracapsular: Intertrochanteric, subtrochanteric

Garden Classification of Intracapsular Fractures

  1. Incomplete #, undisplaced
  2. Complete #, undisplaced
  3. Complete #, partially displaced
  4. Complete #, completely displaced
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39
Q

Hip Fracture Surgical Mx

A

Intracapsular
 1,2: Open Reduction Internal Fixation w cancellous screws

 3,4:
<55: ORIF c¯ screws.
 f/up in OPD and do arthroplasty if AVN
develops (in 30%)

55-75: total hip replacement

> 75: hemiarthroplasty
 Mobilises: cemented Thompson’s
 Non-mobiliser: uncemented Austin Moore

Extracapsular
 ORIF c¯ DHS

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40
Q

Hip # Surgical Discharge

complications
Prognosis

A

Involve OT + physio
Discharge when mobile + social circumstances permit

Spec complications

  • AVN of femoral head if displaced #
  • Non/malunion
  • Infection
  • Osteoarthritis

Prgn
- 30% mortality at 1 year
- 50% never regain premorbid function
10+% unable to return to premorbid residence
- majority will have residual pain/disability

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41
Q

Colle’s Fracture

A

Falling onto outstretched hands
elderly females w osteoporosis
dinner fork deformity

Radiology
xtra-articular # of dist. radius (w/i 1.5” of joint)
Dorsal displacement of distal fragment
Dorsal angulation of distal fragment
Normally 11 degrees volar tilt
↓ radial height (norm =11mm)
↓ radial inclination (norm=22degrees)
± avulsion of ulna styloid
± impaction
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42
Q

Colle’s# Mx

A

Examine neurovascular injuries - median nerve
and radial artery lie close.

If displaced a lot > reduce
 Under haematoma block, IV regional anaesthesia
(Bier’s block) or GA.
 Disimpact and correct angulation.
 Position: ulnar deviation + some wrist flexion
 Apply dorsal backslab: provide 3-point pressure

Re- XR - ortho review if not satisfactory position (MUA w K wires)
- if ok - home + #clinic w/i 48 hours for completion of POP (plaster)

If comminuted, intra-articular or re-displaces
- surgical fixation w ex-fix, kirschner wires or ORIF + plates

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43
Q

Colle’s # Spec Complications

A 
 Median N. injury
 Frozen shoulder / adhesive capsulitis
 Tendon rupture: esp. EPL
 Carpal tunnel syn.
 Mal- /non-union
 Sudek’s atrophy / CRPS
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44
Q

Smith’s / Reverse Colles’

A

 Fall onto back of flexed wrist
 Fracture of distal radius c¯ volar displacement and
angulation of distal fragment.
 Reduce to restore anatomy and POP for 6wks

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45
Q

Barton’s Fracture

A

Oblique intra-articular # involving the dorsal aspect of distal radius and dislocation of radio-carpal joint

Reverse Barton’s involves the volar aspect of the radius

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46
Q

Scaphoid #s

A

Clinical features
FOOSH (fall onto outstretched hand)
Pain in anatomical snuffbox
pain on telescoping thumb

Mx
- Request scaphoid XR view
- If hx and exam > scaphoid #, initially treat even if XR normal
 # may become apparent after 10d > localised decalcification.
- Place wrist in scaphoid blaster (beer glass position)

  • if initial XR negative, pt returns to clinic after 10 days for re-XR
     # visible → plaster for 6 wks
     No visible # but clinically tender → plaster for 2
    wks
     # not visible and not clinically tender → no plaster
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47
Q

Scaphoid # complications

A

AVN of scaphoid - supply runs distal to proximal

> stiffness + pain at wrist

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48
Q

Radial + Ulna Shaft #

Classification

A

Monteggia
 # of proximal 3rd of ulna shaft
 Anterior dislocation of radial head at capitellum
 May → palsy of deep branch of radial nerve →
weak finger extension but no sensory loss

Galleazzi
 # of radial shaft between mid and distal 3rds
 Dislocation of distal radio-ulna joint

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49
Q

Radial + Ulna Shaft #

A

Spec Mx
Unstable fractures
 Adults: ORIF
 Children: MUA + above elbow plaster

Fractures of forearm should be plastered in most stable
position:
 Proximal #: supination
 Distal #: pronation
 Mid-shaft #: neutral
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50
Q

Shoulder Dislocation Classification

A

Anterior
 95% of shoulder dislocations.
 Direct trauma or falling on hand
 Humeral head dislocates antero-inferiorly

Posterior
 Caused by direct trauma or muscle contraction
(seen in epileptics).

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51
Q

Shoulder dislocation associated lesions

A

Bankhart Lesion - damage to anteroinferior glenoid labrum

Hill-Sachs Lesion

  • cortical depression in posterolateral part of humeral head following impaction against glenoid rim during anterior dislocation
  • 35-40% anterior dislocation
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52
Q

Shoulder dislocation presentation

A

 Shoulder contour lost: appears square
 Bulge in infraclavicular fossa: humeral head
 Arm supported in opposite hand
 Severe pain

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53
Q

Shoulder dislocation specific Mx

A

assess neurovasc deficit (esp axillary nerve)
 Sensation over “chevron” area before and after
reduction.
 Occurs in 5%

XR - AP and transcapular view

Reduction under sedation (propafol)
 Hippocratic: Longitudinal traction c¯ arm in 30O
abduction and counter traction @ the axilla
 Kocher’s: external rotation of adducted arm,
anterior movement, internal rotation

Rest Arm in sling 3-4 weeks
Physio

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54
Q

Shoulder Dislocation Complications

A

Recurrent dislocation
- 90% pt <20yr with traumatic dislocation

Axillary Nerve Injury

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55
Q

Recurrent Shoulder instability

A

TUBS - Traumatic Unilateral dislocations w Bankhart lesion oft require Surgery

AMBRI - Atraumatic Multidirectional Bilateral shoulder dislocation treated w Rehabilitation - may require inferior capsular shift

56
Q

Impingement Syndrome/Painful arc

A

Entrapment of supraspinatus tendon + subacromial bursa betw acromnion + greater tuberosity of humerus

> subacromial bursitis +/or supraspinatous tendonitis

57
Q

Impingement Syndrome/Painful arc

Presentation + Ix

A

Presents
 Painful arc: 60-120 degrees
 Weakness and ↓ ROM
 +ve Hawkin’s test

Ix
 Plain radiographs: may see bony spurs
 US
 MRI arthrogram

58
Q

Impingement Syndrome/Painful arc

Rx

A

Conservative
 Rest
 Physiotherapy

Medical
 NSAIDs
 Subacromial bursa steroid ± LA injection

Surgical
 Arthroscopic acromioplasty

59
Q

Impingement Syndrome/Painful arc

DDx

A

 Impingement
 Supraspinatous tear or partial tear
 AC joint OA

60
Q

Frozen shoulder - Adhesive capsulitis

A

Progressive ↓ active and passive ROM
 ↓ ext. rotation <30O
 ↓ abduction <90O
 Shoulder pain, esp night (can’t lie on affected side)

Cause - unknwon, may follow trauma in elderly (assw DM)

Rx - conservative - rest, physio
- Medical - NSAIDs, subacromial bursa steroid +/- LA injection

61
Q

Rotator Cuff Tear

A

2ndary to degen or sudden jolt/fall
Partial Tears > painful arc

Complete tear > shoulder tip pain

  • full range of passive movement
  • inability to abduct arm
  • active abduction possible following passive abduction to 90 degrees
  • lowering arm beneath this > sudden drop (DROP ARM SIGN)
62
Q

Supracondylar fractures of the humerus

Presentation

A

 Common in children after FOOSH
 Elbow very swollen and held semi-flexed.
 Sharp edge of proximal humerus may injure brachial artery which lies anterior to it.

63
Q

Supracondylar fractures of humerus

Classification

A

Extension
- Commonest type
- Distal fragment displaces posteriorly
- Gartland further classified extension type
Gartland further classified extension type:
 Type 1: non-displaced
 Type 2: angulated c¯ intact posterior cortex
 Type 3: displaced c¯ no cortical contact

Flexion

  • less common
  • distal fragment displaces anteriorly
64
Q

Supracondylar fractures of humerus

Spec Mx

A

Ensure no neurovascular damage
 If radial pulse absent or damage to brachial
artery suspected, URGENT theatre for reduction ± on-table angiogram.
 Median nerve is also vulnerable

Restore anatomy

No displacement → flex the arm as fully as
possible and apply a collar and cuff for 3wks –
triceps acts as sling to stabilise fragments.

Displacement → MUA + fixation with K-wires +
collar and cuff with arm flexed for 3wks.

65
Q

Supracondylar fractures of humerus

Specific Complications

A

Neurovascular Injury
- Brachial artery
- Radial nerve
- Median nerve - esp anterior interosseus branch
>supplies deep forearm felxors (FPL, lateral half of FDP and pronator quadratur)

Compartment Syndrome
 Monitor closely first 24h
 Pain on passive extension of the fingers (stretches
flexor compartment) is early sign.
 Mx: try extension of the elbow, surgical Rx may be
needed.
 Volkmann’s ischaemic contracture can result → fibrosis of flexors → claw hand.

Gunstock Deformity
 Valgus, varus and rotational deformities in the coronal plane do not remodel and → cubitus varus.
 Cubitus varus deformity is referred to as a “gunstock”
deformity.

66
Q

Femoral + Tibial Fractures

A 
Spec Mx 
- Resus + Mx life-thretening 
- X-match
 Tibial #: 2 units
 Femoral #: 4 units
  • Assess neurovascular status (esp distal pulses)

If Open

  • abx + ATT (tetanus?)
  • theatre for urgent debridement + washout + stabilisation

Fixation methods

  • IM nail
  • Ex- fix
  • plates + screws
  • MUA (manipulation under anaethesia) w fixed traction for 3-4m
67
Q

Femoral + Tibial Fractures

Spec Complications

A

Hypovolaemic shock

Neurovascular
 SFA: swelling and check pulses
 Sciatic nerve

Compartment syndrome

Respiratory complications
 Fat embolism
 ARDS
 Pneumonia

68
Q

Ankle Injury

Ligament Strains

A

Typically twisting inversion injury
 Strains anterior talofibular part of lateral collateral
ligament

Medial deltoid ligament strains are rare.

May be assw malleolar avulsion #s

69
Q

Ankle Fracture

Ottowa ankle rules

A

X-ray ankle if pain in malleolar zone + in any of:

 Tenderness along distal 6cm of posterior tib / fib
including posterior tip of the malleoli.

 Inability to bear weight both immediately and in
ED

70
Q

Ankle Fracture

Weber Classification

A

Relation of fibula # to joint line
 A: below joint line
 B: at joint line
 C: above joint line

Weber’s B and C represent possible injury to the syndesmotic ligaments between tib and fib → instability

71
Q

Ankle Fracture Mx

A

Weber A
 Boot or below-knee POP

Non-displaced Weber B/C
 Below-knee POP

Displaced Weber B/C
 Closed reduction and POP if anatomical reduction achieved
 ORIF if closed reduction fails

72
Q

Knee Injury Hx

A

Mechanism

Swelling
 Immediate = haemarthrosis = # or torn cruciates
 Overnight = effusion = meniscus or other lgt

Pain / tenderness
 Joint line = meniscal
 Med/lateral margins = collateral lgts.

Locking: meniscal tear → mechanical obstruction

Giving way: instability following lgt. injury

73
Q

Knee haemarthrosis

A

Primary Spont Bleeding
- coagulopathy, warfarin, haemophilia

Secondary trauma

  • ACL injury 80%
  • Patella Dislocation 10%
  • Meniscal injury 10% - outer third where its vascularised
  • osteophyte
74
Q

Unhappy triad of O’Donoghue

A

ACL
MCL
Medial Meniscus

75
Q

Mx of acutely injured knee

A

Full examination of acutely swollen knee after injury is
difficult.
 Take x-ray to ensure no #s

Fluid level indicates a lipohaemarthrosis and
indicates either a # or torn cruciate.

If no # → RICE + later re-examination for pathology

If meniscal or cruciate injury suspected → MRI

76
Q

Arthoroscopy

A

 Direct vision of inside of knee joint by arthroscope
 Can examine knee under anaesthesia (↓ muscle tone)
 Meniscal tears can be trimmed or repaired.

77
Q

Mx of Ruptured ACL

A

Conservative
 Rest
 Physio to strengthen quads and hamstrings
 Not enough stability for many sports

Surgical
 Gold-standard is autograft repair
 Usually semitendinosus ± gracilis (can use patella
tendon)
 Tendon threaded through heads of tibia and femur and
held using screws

78
Q

Osteoarthritis

A

Degenerative Joint disorder - progressive loss of hyaline cartilage + new bone formation at joint surface and its margin

RF Age, obesity, joint abnormality

Classification

  • Primary - no underlying cause
  • Secondary - obesity, joint abnormality
79
Q

Osteoarthritis Sx + Signs

A

Sx
 Affects: knees, hips, DIPs, PIPs, thumb CMC
 Pain: worse c¯ movement, background rest/night pain,
worse @ end of day.
 Stiffness: especially after rest, lasts ~30min (e.g. AM)
 Deformity
 ↓ ROM

Signs
 Pouchards (prox), Heberdips (dist.)
 Thumb CMC squaring
 Fixed flexion deformity

80
Q

Osteoarthritis Hx

A 
 Pain severity, night pain
 Walking distance
 Analgesic requirements
 ADLs and social circumstances
 Co-morbidities
 Underlying causes: trauma, infection, congenital
81
Q

Osteoarthritis Path

A

Softening of articular cartilage → fraying and fissuring of smooth surface → underlying bone exposure.

Subchondral bone becomes sclerotic c¯ cysts.

Proliferation and ossification of cartilage in unstressed
areas → osteophytes.

Capsular fibrosis → stiff joints.

82
Q

Osteoarthritis XR changes

A 
 Loss of joint space
 Osteophytes
 Subchondral cysts
 Subchondral sclerosis
 Deformity
83
Q

Osteoarthritis Bloods

A

 CRP may be mildly elevated

 Ca, PO4 and ALP all normal

84
Q

Osteoarthritis Rx

Conservative + Medical

A

MDT: GP, physio, OT, dietician, orthopod

Conservative
Lifestyle: ↓ wt., ↑ exercise
Physio: muscle strengthening
OT: walking aids, supportive footwear, home mods

Medical
Analgesia (paracetamol, NSAIDs, Tramol)
Joint injection - local anaesthetic + steroids

85
Q

Osteoarthritis Surgical Rx

A

Arthroscopic Washout
>Mainly knees
>Trim cartilage
>Remove loose bodies.

Realignment Osteotomy
>Small area of bone cut out
>Useful in younger (<50yrs) pts. w medial knee OA
>High tibial valgus osteotomy redistributes wt. to lateral part of joint.

Arthroplasty: replacement (or excision)

Arthrodesis: last resort for pain management

Novel Techniques
Microfracture: stem cell release → fibro-cartilage
formation
Autologous chondrocyte implantation

86
Q

Back pain (Mechanical Pain)

A

Soft tissue injury > dysfunction of whole spine > muscle spasm > pain
May have incited event (lifting)
Younger pt w no sinister features

Mx
- Conservative
 Max 2d bed rest
 Education: keep active, how to lift / stoop
 Physiotherapy
 Psychosocial issues re. chronic pain and disability
 Warmth: e.g. swimming in a warm pool

Medical
 Analgesia: paracetamol ± NSAIDs ± codeine
 Muscle relaxant: low-dose diazepam (short-term)

87
Q

Disc Prolapse definition + presentation

A

Herniation of nucleus pulposus through annulus fibrosus

Presents
 L5 and S1 roots most commonly compressed by prolapse of L4/5 and L5/S1 discs.
 May present as severe pain on sneezing, coughing or twisting a few days after low back strain
 Lumbago: low back pain
 Sciatica: shooting radicular pain down buttock and thigh

88
Q

Disc Prolapse Signs

A

 Limited spinal flexion and extension
 Free lateral flexion
 Pain on straight-leg raise: Lesague’s Sign
 Lateral herniation → radiculopathy
 Central herniation → corda equina syndrome

89
Q

L4/5 disc prolapse > L5 root compression

A

Weak hallux extension ± foot drop
 In foot drop due to L5 radiculopathy, weak
inversion (tib. post.) helps distinguish from
peroneal N. palsy.

↓ sensation on inner dorsum of foot

90
Q

L5/S1 disc prolapse → S1 Root Compression

A

 Weak foot plantarflexion and eversion
 Loss of ankle-jerk
 Calf pain
 ↓ sensation over sole of foot and back of calf

91
Q

Disc Prolapse Ix + Rx

A

Ix: MRI (emergency if cauda equina)

Rx
 Brief rest, analgesia and mobilisation effective in ≥90%
 Conservative: brief rest, mobilisation/physio
 Medical: analgesia, transforaminal steroid injection
 Surgical: discectomy or laminectomy may be needed in cauda-equina syndrome, continuing pain or muscle
weakness.

92
Q

Lumbar Microdisectomy

A

 Commonest procedure for disc prolapse
 Microscopic resection of the protruding nucleus pulposus
 Posterior approach c¯ pt. in prone position.
 May be performed endoscopically

93
Q

Spondylolisthesis

A

Displacement of one lumbar vertebra on another
- usually forward
- usually L5 on S1
May be palpable

Causes - congen malf, spondylosis, OA

Presentation - onset of pain usually in adolescence or early adulthood > worse on standing
+/- sciatica, hamstring tightness, abn gait

Dx - Plain Radiography

Rx - Corset, nerve release, spinal fusion

94
Q

Spinal Stenosis

A

Dev predisposition +/- facet joint OA > generalised narrowing of lumbar spinal canal

Presents
Spinal Claudication - aching or heavy buttock and lower limb pain on walking
- Rapid onset
- May c/o paraesthesiae/numbness 
- Pain eased by leaning forward

Pain on spine extension

Ix - MRI

Rx - Corsets
NSAIDs
Epidural steroid injection
Canal decompression surgery

95
Q

Neurosurgical Emergencies

Acute Cord Compression

A

 Bilateral pain: back and radicular
 LMN signs at compression level
 UMN signs and sensory level below compression
 Sphincter disturbance

96
Q

Neurosurgical Emergencies

Acute Cauda Equina Compression

A

Alternate or bilateral radicular pain in legs

Saddle anaesthesia

Loss of anal tone

Bladder +/- bowel incontinence

97
Q

Neurosurgical emergencies

Rx

Acute cord compression and Acute cauda equina compression

A

Large prolapse - laminectomy/disectomy

Tumours - radiotherapy and steroids

Abscesses - decompression

98
Q

Osteochondritis

A

idiopathic condition > bony centres of children/adolescents become temporarily softened due to osteonecrosis

Pressure > deformation

Bone hardens in new deformed position

Radiography - intially ^density/sclerosis
- then patchy appearance

99
Q

Osteochondritis

Scheuermann’s Disease

A

Vertebral ring epiphyses
AD
Vertebral Tenderness + kyphosis

XR - wedge-shaped thoracic vertebra

100
Q

Osteochondritis

Kohler’s Disease

A

Navicular Bone
Children 3-5 years
Pain in mid-tarsal region > limp

101
Q

Osteochondritis

Kienbochs Disease

A

Lunate bone
Adults
Pain over lunate, esp on active movement

impaired grip

102
Q

Osteochondritis

Friedberg’s Disease

A

2nd/3rd metatarsal heads
around puberty
forefoot worse w pressure

103
Q

Osteochondritis

Panner’s Disease

Perthe’s Disease

A

Panner’s - Capitulum of humerus

Perthe’s - hip

104
Q

Traction Apophysitis

Osgood-Shlatter’s

A

Tibial tuberosity apophysitis + patellar tendonitis
Children 10-14 years M>F 3:1
Assw physical activity

Sx - pain below knee, esp w quads contraction

XR - tuberosity enlargement +/- fratmentation

Rx - rest, consider POP

105
Q

Traction Apophysitis

Sinding Larsen’s Disease

A

 Tranction tendinopathy with calcification of proximal
attachment of patellar tendon
 Children 8-10yrs

106
Q

Traction Apophysitis

Sever’s Disease

A

Calcaneal apophysitis
8-13 years

Sx - pain behind heal + limping

Rx - physio

107
Q

Osteochondritis Dissecans

A

Piece of bone + overlying cartilage dissects off into joint space

Commonly knee (Med fem condyle), also elbow, hip , ankle

Young adult/adolescent

Sx - pain, swelling, locking, decreased ROM

XR - loose bodies, lucent crater

Mx arthroscopic removal

108
Q

Avascular necrosis

A 
# or dislocation 
SCD, thallassaemia 
SLE
Gaucher's 
Drugs - steroids, NSAIDs
109
Q

Acute Osteomyelitis

Pathophysiology

A

Source - local or haematogenous

RF
Vascular disease
Trauma
SCD (sickle cell)
Immunosuppression (e.g. DM)
Children
 Rich blood supply to growth plate
 :. usually affects metaphysis 
Organisms
 Staph
 Strep
 E. coli
 Pseudomonas
 Salmonella (in SCD)
110
Q

Acute Osteomyelitis

Sx + Signs
Ix
Mx

A

Symptoms and Signs
 Pain, tenderness, erythema, warmth, ↓ROM
 Effusion in neighbouring joints
 Signs of systemic infection

Investigations
 ↑ESR/CRP, ↑WCC
 +ve blood cultures in 60%

X-ray:
 Changes take 10-14d
 Haziness + ↓ bone density
 Sub-periosteal reaction
 Sequestrum and involucrum

MRI is sensitive and specific

Management
 IV Abx: Vanc + cefotaxime until MCS known
 Drain abscess and remove sequestra
 Analgesia

111
Q

Septic Arthritis

Pathyphysiology

A

Source: local or haematogenous.

RFs
 Joint disease (e.g. RA)
 CRF
 Immunosuppression (e.g. DM)
 Prosthetic joints
Organisms
 Staph: 60%
 Streps
 Gonococcus
 Gm-ve bacilli
112
Q

Septic Arthritis Sx + Ix

A

Symptoms
 Acutely inflamed tender, swollen joint.
 ↓ROM
 Systemically unwell

Investigations
 Joint aspiration for MCS
 ↑↑ WCC (e.g. >50,000/mm3) : mostly PMN
 ↑ESR/CRP, ↑WCC, Blood cultures
 X-ray
113
Q

Septic Arthritis Mx + Complications

A 
Management
 IV Abx: vanc + cefotaxime
 Consider joint washout under GA
 Splint joint
 Physiotherapy after infection resolved

Complications
 Osteomyelitis
 Arthritis
 Ankylosis: fusion

114
Q

High (C5/6): Erb’s Palsy

A

abductors + external rotators paralysed
waiter’s tip position
Loss of sensation in C5/6

115
Q

Low C8/T1: Klumpke’s Paralysis

A

Paralysis of small hand muscles
Claw hand
Loss of senstaion in C8/T1 Dermatomes

116
Q

Radial Nerve C5-T1 injury

A

Low lesions - posterior interosseous nerve
 Site: # around elbow or forearm (eg #head of radius)
 Loss of extension of CMC joints (finger drop)
 No sensory loss

High Lesions
 Site: # shaft of humerus where N. is in radial groove.
 Wrist drop
 Loss of sensation to dorsum of thumb root (snuff box)
 Triceps functions normally

Very High Lesions
 Site: axilla – e.g. crutches or Sat night palsy
 Paralysis of triceps and wrist drop

117
Q

Ulnar nerve C8-T1 injury

A

Site
 Elbow: cubital tunnel
 Wrist: in Guyon’s Canal

Effects
 Intrinsic hand muscle paralysis → claw hand
 Ulnar paradox: lesion at elbow has less clawing as
FDP is paralysed, decreasing flexion of 4th/5th digits.
 Weakness of finger ad/abduction (interossei)
 Sensory loss over little finger

Tests
 Can’t cross fingers for luck
 Froment’s Sign: flexion of thumb IPJ when trying to
hold onto paper held between thumb and finger.
 Indicates weak adductor policis.

118
Q

Median Nerve C5-T1 Damage

A

Injury Above the Antecubital Fossa
 Can’t flex index finger IPJs (e.g. on clasping hands)
 Can’t flex terminal thumb phalanx (FPL)
 Loss of sensation in median distribution

Injury at the Wrist
 Typically affects abductor pollicis brevis

Carpal Tunnel Syndrome

119
Q

Carpal Tunnel Syndrome

Anatomy

A

Carpal tunnel formed by flexor retinaculum and carpal
bones.

Contains
 4 tendons of FDS
 4 tendons of FDP
 1 tendon of FPL
 Median N.

 Median N. supplies LLOAF (aBductor pollicis brevis)
 Palmer cutaneous branch travels superficial to flexor
retinaculum → spares sensation over thenar area

120
Q

Causes of carpal tunnel syndrome

A

F>M
Primary/idiopathic

Secondary 
 Water: pregnancy, hypothyroidism
 Radial #
 Inflammation: RA, gout
 Soft tissue swelling: lipomas, acromegaly,
amyloidosis
 Toxic: DM, EtOH
121
Q

Carpal Tunnel Sx + Signs

A

Symptoms
 Tingling / pain in thumb, index and middle fingers
 Pain worse @ night or after repetitive actions
 Relieved by shaking / flicking
 Clumsiness

Signs
 ↓ sensation over lateral 3½ fingers
 ↓ 2-point touch discrimination
 Early sign of irreversible damage
 Wasting of thenar eminence 
> Late sign of irreversible damage
 Phalen’s flexing and Tinel’s tapping
122
Q

Carpal Tunnel Syndrome Ix, Non-surgical Mx

A

Ix
 Not usually performed
 Nerve conduction studies
 US

Non-surgical Mx
 Mx of underlying cause
Wrist splints
 Neutral position
 Esp. @ night
Local steroid injections
123
Q

Carpal Tunnel Syndrome Surgical Mx + complications

A

Carpal tunnel decompression by division of the flexor retinaculum

Complications
 Scar formation: high risk for hypertrophic or keloid
 Scar tenderness: up to 40%

Nerve injury
 Palmar cutaneous branch of the median nerve
 Motor branch to the thenar muscles

Failure to relieve symptoms

124
Q

Carpal Tunnel Syndrome

Other Locations of Median Nerve Entrapment

A

Pronator syndrome
 Entrapment between two heads of pronator teres

Anterior interroseous syndrome
> Compression of the anterior interosseous
branch by the deep head of pronator teres
> Muscle weakness only
 Pronator quadratus
 FPL (flexor pollicis longus)
 Radial half of FDP

125
Q

Dupuytren’s Contracture

A

Progressive, painless fibrotic thickening of palmar
fascia.

The Patient
 M>F
 Middle age / elderly
 Skin puckering and tethering
 Fixed flexion contracture of ring and little fingers
 Often bilateral and symmetrical
 MCP and IP joint flexion
126
Q

Dupuytren’s Contracture Associations

A 
BAD FIBERS
 Bent penis: Peyronies (3%)
 AIDS
 DM
 FH: AD
 Idiopathic: commonest
 Booze: ALD
 Epilepsy and epilepsy meds (phenytoin)
Reidel’s thyroiditis and other fibromatoses
 Ledderhose disease
    >Fibrosis of plantar aponeurosis
    >5% c¯ dupuytren’s
 Retropitoneal fibrosis

 Smoking

127
Q

Dupuytren’s Contracture Mx

A

Conservative: e.g. physio / exercises

Fasciectomy
 e.g. when hand can’t be placed flat on the table.
 Z-shaped scars: prevent contracture
 Can damage ulnar nerve
 Usually recurs
Differential
 Skin contracture: old laceration or burn

Differential
 Skin contracture: old laceration or burn
 Tendon fibrosis, trigger finger
 Ulnar N. palsy

128
Q

Trigger Finger

A

 Tendon nodule which catches on proximal side of
tendon sheath → triggering on forced extension.
 → Fixed flexion deformity
 Usually ring and middle fingers
 assw RA

 Rx: steroid injection (high recurrence) or surgery

129
Q

Ganglion definition + presentation

A

 Smooth, multilocular cystic swellings
 Mucoid degeneration of joint capsule or tendon sheath
 May be in communication w joint capsules / tendons

Presentation
 90% located on dorsum of wrist.

Subdermal, fixed to deeper structures.
 Limits planes of movement

May cause pain or nerve pressure symptoms

130
Q

Ganglion Mx + differential

A

Management
 50% disappear spontaneously
 Aspiration ± steroid and hyaluronidase injection
 Surgical excision

Differential
 Lipoma
 Fibroma
 Sebaceous cyst

131
Q

Meralgia paraesthetica

A

Entrapment of lat cutaneous nerve of thigh betw ASIS + inguinal ligament

Pain +/- paraesthesia on lateral thigh

No motor deficit

↑ risk w obesity: compression by belts, underwear
 Relieved by sitting down

Can occasionally be damaged in lap hernia repair

132
Q

Chondromalacia Patellae

A

Predominantly young women

Patellar aching after prolonged sitting or climbing stairs

Pain on patellofemoral compression: Clarke’s test

Ix: no abnormality on X-ray

Rx: vastus medialis strengthening

133
Q

Baker’s Cyst

A

Popliteal swelling arising betw the medial head of
gastrocnemius and semimembranosus muscle

Herniation from joint synovium
 Usually 2ndary to OA

Rupture: acute calf pain and swelling
 DVT differential

134
Q

Hallux Valgus

A

Great toe deviates laterally @ MTP joint
Pressure of MTP against shoe → bunion

↑ wt. bearing @ 2nd metatarsal head
 → pain: “Transfer metatarsalgia”
 → hammer toe

Aetiology
 Pointed shoes
 Wearing high heals

Mx
 Conservative: bunion pads, plastic wedge between
great and second toes.
 Surgical: metatarsal osteotomy

135
Q

Morton’s Metatarsalgia/neuroma

A

Pain from pressure on an interdigital neuroma between the metatarsals.

Pain radiates to medial side of one toe and lateral side of another.

Rx: neuroma excision

D3 (14 decks)

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