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Orthopaedics Flashcards

1
Q

What is ankylosis?

A

Stiffening of a joint with fibrous/bony union across it

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2
Q

What is arthrodesis?

A

Surgical fusion of a joint

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3
Q

What is arthroplasty?

A

Creation of an artificial joint

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4
Q

What is arthroscopy?

A

“Keyhole” joint inspection/surgery

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5
Q

What is osteotomy?

A

Surgical cutting/wedging and realignment of bone

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6
Q

What is spondylolisthesis?

A

Slippage of one vertebra over another

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7
Q

What is spondylolysis?

A

Defect in pars interarticularis of a vertebra

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8
Q

What is spondylosis?

A

Degenerative disease of the spine

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9
Q

What is valgus deformity?

A

Deformity of limb laterally from its normal axis

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10
Q

What is varus deformity?

A

Deformity of limb medially from its normal axis

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11
Q

Which movements test bones/muscles in the neck? Which joints are responsible for these movements?

A 
Flexion, extension (atlanto-occipital joint)
Rotation (atlanto-axial joint)
Lateral flexion (cervical spine)
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12
Q

Which type of XR is used to investigate the cervical spine?

A

Cross-table lateral XR

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13
Q

What is assessed on a cross-table lateral XR of the cervical spine?

A 
Alignment: of vertebral bodies, spinous processes, spinal canal
Bone contours
Cartilages
Soft tissues
All 7 cervical vertebrae should be seen!
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14
Q

What is cervical spondylosis?

A

Degeneration of the cervical spine (annulus fibrosis degenerates, bony spurs form)

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15
Q

List clinical features of cervical spondylosis

A

Slow-onset neck stiffness
Pain, radiating to shoulders/occiput
Radicular pain

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16
Q

Outline treatment for cervical spondylosis

A

Pain relief
Physiotherapy
Surgical decompression of nerve impingement

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17
Q

List clinical features of a prolapsed cervical disc

A

Stiff neck
Arm pain
Dermatomal distribution of symptoms if nerve root compression

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18
Q

Which cervical joint is the most unstable?

A

Atlanto-axial joint

Very prone to subluxation

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19
Q

What is cervical rib?

A

Congenital development of the costal process of C7 produces a rib-like deformity

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20
Q

List clinical features of cervical rib

A 
Pain
Numbness in hand/forearm
Muscle wasting
Thoracic outlet compression
Weak radial pulse
Forearm cyanosis
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21
Q

Outline treatment for cervical rib

A

Physiotherapy to strengthen shoulder elevators

Surgical removal of rib

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22
Q

What is torticollis?

A

Dystonia due to sternocleidomastoid and trapezius muscle spasm

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23
Q

List clinical features of torticollis

A

Tilted head
Retarded facial growth
Thickened muscle
Nodding spasms

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24
Q

Respectively, what is the most likely shoulder pathology if a patient presents with generalised pain on movement vs. pain on specific movement?

A

Generalised pain: arthritis, capsulitis

Specific pain: impingement, muscle tear

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25
Which rotator cuff is responsible for shoulder abduction?
Supraspinatus
26
Which rotator cuff is responsible for shoulder extension?
Teres minor
27
Which rotator cuff is responsible for shoulder internal rotation?
Subscapularis
28
Which rotator cuff is responsible for shoulder external rotation?
Infraspinatus
29
Which shoulder pathologies are the following tests used for: Jobe's test, Hawkin's test, apprehension test, scarf test?
Jobe's test for impingement/supraspinatus tear Hawkin's test for impingement Apprehension test for instability Scarf test for acromioclavicular joint disease
30
List aetiology/risk factors for shoulder instability
Atraumatic (5%): ligamentous laxity, teenagers | Traumatic: usually anterior subluxation/dislocation
31
What is biceps tendonitis?
Inflamed long head of biceps causes anterior shoulder pain
32
List clinical features of biceps tendonitis
``` Resisted biceps contraction causes pain Popeye deformity (bulky biceps) ```
33
Outline treatment of biceps tendonitis
Pain relief Physiotherapy Surgical division of tendon with attachment to humerus
34
What is painful arc syndrome?
Rotator cuff tendons (mainly supraspinatus) become compressed in tight subacromial space during abduction (45-160')
35
List aetiology/risk factors for painful arc syndrome
``` Tendonitis Subacromial bursitis Acromioclavicular osteoarthritis (osteophytes) Hooked acromion rotator cuff tear Calcification ```
36
List clinical features of painful arc syndrome
Pain on abduction up to 160' Tenderness Cervical radiculopathy
37
Outline treatment of painful arc syndrome
Physiotherapy Pain relief IA steroid Surgical decompression
38
List aetiology/risk factors for rotator cuff tears
Degeneration Trauma Sudden jerky movements
39
List clinical features of rotator cuff tear
Weak initation of abduction Muscle wasting Full-range passive movement Shoulder tip pain
40
Outline treatment of rotator cuff tear
Open/arthroscopic repair if complete tear | Otherwise physiotherapy and pain relief
41
What is adhesive capsulitis?
Frozen shoulder occurring over long period of time, usually in elderly
42
List aetiology/risk factors for adhesive capsulitis
``` Elderly Innoccuous trigger Post-surgery Diabetes Hypercholesterolaemia Dupuytren's contracture ```
43
Which muscles are responsible for elbow flexion and extension?
Flexion: biceps, brachialis Extension: triceps
44
Which muscles are responsible for forearm supination and pronation?
Supination: supinator, biceps Pronation: pronator teres
45
What is lateral epicondylitis?
"tennis elbow" | Inflammation of lateral common extensor tendon
46
List aetiology/risk factors for lateral epicondylitis
Repetitive strain injury involving extension | Degenerative enthesopathy
47
List clinical features of lateral epicondylitis
Painful tender lateral epicondyle | Pain on resisted middle finger + wrist extension
48
Outline treatment of lateral epicondylitis
``` Self-limiting Rest from activity Pain relief Physiotherapy IA steroid Elbow brace if unresolving, surgical division/excision of fibres ```
49
What is medial epicondylitis?
"golfer elbow" Inflammation of medial common flexor tendon Less common than lateral epicondylitis
50
Which nerve must you be wary of when giving IA steroid for medial epicondylitis?
Ulnar nerve
51
What is olecranon bursitis?
"student elbow" | Inflammation of bursae due to repetitive/prolonged pressure on elbow
52
List aetiology/risk factors for olecranon bursitis
Studying medicine Gout Septic joint
53
What investigation should you do for olecranon bursitis?
Aspirate swelling and send for Gram stain + microscopy
54
Outline treatment for olecranon bursitis
Injected hydrocortisone Drain septic bursa + antibiotics Self-limiting
55
What is cubital tunnel syndrome?
Compression/irritation of ulnar nerve as it passes behind medial epicondyle
56
List aetiology/risk factors for cubital tunnel syndrome
Osteoarthritis, rheumatoid arthritis (narrowing of ulnar groove) Tight band of Osborne fascia Tight IM septum between flexor carpi ulnartis Fluid overload
57
List clinical features of cubital tunnel syndrome
Paraesthesia over medial 1.5 digits Clumsy, weak hand Tinel's sign (percuss over ulnar nerve illicits symptom) Froment's sign (weak adductor pollicis)
58
Outline treatment of cubital tunnel syndrome
Surgical decompression +/- transposition of nerve to front of elbow
59
If someone has a total elbow replacement, what is the maximum weight they can lift?
2.5 kg
60
What is Dupuytren's contracture?
Progressive painless fibrotic thickening of palmar fascia due to type 3 collagen deposition (instead of type 1) Normal fascial bands form nodules and cords, causing contractures of fingers
61
List aetiology/risk factors for Dupuytren's contracture
``` Genetic (autosomal dominant) Smoking Antiepileptics (phenytoin) Liver disease Males Cirrhosis ```
62
List clinical features of Dupuytren's contracture
``` Puckered skin Usually ring + little finger affected MCP + PIP flexion Peyronie's disease of penis Ledderhose's disease (plantar fibromatosis) ```
63
Outline treatment of Dupuytren's contracture
Fasciectomy if PIP joint stiffening Fasciotomy Amputation Steroid injection for short-term symptom relief
64
What is trigger finger?
Disproportion of tendon to its sheath causes fixed flexion deformity Nodular tendon enlargement distal to fascial pulley over metacarpal head (usually A1 pulley) causes intermittent locking of finger
65
Outline treatment for trigger finger
Steroid injection into region of nodule | Surgical fixation
66
What is a ganglion cyst?
Common mucinous cyst found adjacent to tendon or synovial joint
67
List clinical features of ganglion cyst
Localised pain Firm/smooth/rubbery swelling Transilluminates
68
Outline treatment of ganglion cyst
Needle aspiration | Surgery if painful but not for cosmesis
69
What is De Quervain's tenosynovitis?
Thickened tendons of abductor pollicis longus and extensoru pollicis brevis
70
List clinical features of De Quervain's tenosynovitis
Pain over radial styloid process Worse on stretching (lifting teapot) Finkelstein's sign (sharply pull relaxed thumb to cause ulnar deviation)
71
Outline treatment of De Quervain's tenosynovitis
NSAID Hydrocortisone injection Tendon decompression surgery
72
What is carpal tunnel syndrome?
Compression/irritation of median nerve within the carpal tunnel
73
List aetiology/risk factors for carpal tunnel syndrome
``` Arthritis Fluid overload (pregnancy, renal failure) Diabetes Tendonitis Swelling Fractures (Colles) ```
74
List clinical features of carpal tunnel syndrome
``` Paraesthesiae over lateral 3.5 digits Worse at night, need to "shake it off" Weak, clumsy hand Thenar wasting Tinel's sign Phalen's sign (hold wrist hyperflexed to reproduce symptoms) ```
75
Outline treatment of carpal tunnel syndrome
Wrist splints Pain relief Steroid injection Surgical decompression by dividing transverse carpal ligament
76
List aetiology/risk factors for exaggerated kyphosis/lordosis
``` Osteoporosis Spina bifida Cancer Wedge fractures Tuberculosis Ankylosing spondylitis Paget's disease ```
77
List clinical features of exaggerated kyphosis/lordosis
Increased anterior curvature of spine (hump-back) | Paraplegia
78
List aetiology/risk factors of scoliosis
``` Idiopathic Congenital Genetics Neuromuscular Marfan's Neurofibromatosis ```
79
List clinical features of scoliosis
Greater than 10' lateral curvature of spine Pain Impaired lung function Rib deformity
80
List aetiology/risk factors for mechanical back pain
``` Obesity Poor diet/nutrition Poor posture Poor lifting technique Lack of exercise Psych disorder Degenerative discs Osteoarthritis Spondylosis ```
81
List clinical features of mechanical back pain
Pain worse on movement Muscle spasms Recurrent "flares"
82
Outline treatment of mechanical back pain
Conservative pain relief | Physiotherapy
83
What is disc prolapse?
Herniation of nucleus pulposis through disc and impingement of nerve
84
List clinical features of disc prolapse
Radiculopathic pain Burning, tingling pain +ve straight leg raise
85
List clinical features of L3/L4 prolapse
L4 entrapment causes pain to medial ankle, reduced knee jerk, reduced quadriceps power
86
List clinical features of L4/L5 prolapse
L5 entrapment causes pain to dorsum foot, reduced power of knee extension, reduced power of leg extension
87
List clinical features of L5/S1 prolapse
S1 entrapment causes pain to sole of foot, reduced power of plantarflexion, reduced ankle jerk
88
Outline treatment of disc prolapse
``` Analgesia Physiotherapy Early mobilisation Discectomy if unresolving Neuropathic pain meds (gabapentin) ```
89
What is lumbar spinal stenosis?
Narrowing lumbar spinal canal, causing nerve root irritation/compression
90
List aetiology/risk factors for lumbar spine stenosis
Facet joint OA Osteophytes Disc prolapse Ligamentum flavum bulge
91
List clinical features of lumbar spine stenosis
``` Neuropathic claudication (pain in legs on walking, usually uphill, burning pain) -ve straight leg raise ```
92
Outline treatment of lumbar spine stenosis
``` Weight loss Pain relief Physiotherapy Spinal canal decompression Surgery ```
93
What is cauda equina syndrome?
Compression of all lumbar and sacral nerve roots arising from conus medullaris (L1)
94
List aetiology/risk factors for cauda equina syndrome
``` Extrinsic tumour, cord tumour Spondylosis Spinal stenosis Disc prolapse Subarachnoid haemorrhage Fracture of vertebra Trauma ```
95
List clinical features of cauda equina syndrome
Bilateral leg pain Paraesthesiae, typically "saddle anaesthesia" Urinary and bowel incontinence
96
What investigations would you do for cauda equina syndrome?
PR exam | Urgent MRI
97
Outline treatment of cauda equina syndrome
Discectomy | Surgical decompression
98
List red flags for back pain
``` New onset back pain Less than 20 yo Over 55 yo Bilateral Associated weakness Constant, unremitting Worse at night Weight loss Systemic upset (fever, night sweats, malaise) ```
99
What is the difference between "total hip replacement" and "total hip arthroplasty"?
Arthroplasty is a broader term encompassing resurfacing technique that does not replace the entire femoral head, so technically not a full hip replacement
100
What is the gold-standard material used for hip replacement?
Cemented metal-polyethylene
101
List aetiology/risk factors for avascular necrosis
``` Idiopathic Alcohol abuse Steroid abuse Hypercholesterolaemia Thrombophilia ```
102
What would an MRI and XR of avascular necrosis of the femoral head show?
Patchy sclerosis Lytic zone Granulation tissue "hanging rope" sign on XR
103
Outline treatment of avascular necrosis of the femoral head
Decompression via drill hole if detected pre-collapse | Otherwise total hip replacement
104
What is trochanteric bursitis?
Tendonitis and degeneration of insertion of abductor muscles (mainly gluteus medius)
105
List clinical features of trochanteric bursitis
Pain and tenderness near greater trochanter | Pain on resisted abduction
106
Outline treatment of trochanteric bursitis
Analgesia Physiotherapy Steroid injection
107
What is chondromalacia patellae?
Patellar aching/weakness associated with dislocation
108
Who typically gets chondromalacia patellae?
Young women/girls | Service men
109
List clinical features of chondromalacia patellae
Pain after prolonged sitting/climbing stairs Retropatellar tenderness Clarke's test: pain on patellofemoral compression with tense quadriceps
110
Outline treatment of chondromalacia patellae
Vastus medialis strengthening NSAID's Arthroscopic lateral retinacular release if ongoing
111
Why might recurrent patellar subluxation occur?
Tight retinaculum causes patella to sublux laterally, causing medial pain
112
Who typically gets recurrent patellar subluxation?
Girls Valgus knees Joint/ligamentous laxity High patella
113
Which part of the knee is typically affected by osteoarthritis?
Posteromedial knee, causing varus deformity
114
Who typically gets meniscal cysts?
Young men | Usually lateral
115
What is osteochondritis dissecans?
Osteochondral fragment separates from underlying bone | Usually occurs on lateral side of medial femoral epicondyles in young adults
116
List clinical features of osteochondritis dissecans
Pain after exercise Intermittent knee swelling Locking
117
Where does bursitis in the knee typically occur?
Pre-patellar (housemaid's knee) | Infra-patellar (clergyman's knee)
118
Outline treatment of knee bursitis
Aspiration Hydrocortisone injection Topical NSAID Antibiotic if suppurative exudate
119
What is hallux valgus?
Deviation of big toe laterally at metatarsophalyngeal joint
120
List aetiology/risk factors for hallux valgus
``` Biomechanical forces Pointed/poorly fitting shoes Heels Rheumatoid NM disease ```
121
List clinical features of hallux valgus
Painful | Inflamed bursa over 1st medial metatarsal head (bunion)
122
Outline treatment of hallux valgus
Bunion pads Plastic wedges between toes Metatarsal osteotomy Arthrodesis
123
What is hallux rigidus?
Osteoarthritis of the first MTP joint
124
Outline treatment of hallux rigidus
Wear stiff-soled shoe to limit motion Remove osteophytes Arthrodesis is gold-standard
125
Women can't wear high-heel shoes after arthrodesis for hallux rigidus. True/False?
True
126
What are claw toes?
Hyperextension at the MTP joint | Hyperflexion at the PIP joint and DIP joint
127
What are hammer toes?
Hyperextension at the MTP joint Hyperflexion at the PIP joint Hyperextension at the DIP joint
128
What are mallet toes?
Hyperflexion at the DIP joint
129
Outline treatment of toe deformities
``` Toe sleeves Plasters Surgical tenotomy Arthrodesis Tendon transfer ```
130
What is pes planus?
Flat feet - medial long arch of foot is low
131
List aetiology/risk factors of pes planus
Physiological Familial Ligamentous laxity Tibialis posterior tendon stretch
132
Outline treatment of pes planus
Hindfoot fusion if painful | Generally not for surgery
133
What is pes cavus?
Abnormally high arch of foot that does not flatten on weight bearing
134
List aetiology/risk factors for pes cavus
``` Idiopathic Neuro disorder (spina bifida, cerebral palsy, muscular dystrophy) ```
135
List clinical features of pes cavus
``` Pain Claw toes Foot fatigue Ankle instability Reduced mobility If foot used to be normal, refer to neurologist ```
136
Outline treatment of pes cavus
``` Orthoses Custom footwear Soft tissue release/tendon transfer Calcaneal osteotomy Arthrodesis if severe ```
137
What is Morton's neuroma?
Pressure/trauma to plantar interdigital nerves nerves overlying intermetatarsal ligaments Irritated nerves become inflamed and swollen (neuroma)
138
List clinical features of Morton's neuroma
``` Burning/tingling pain radiating laterally Women with high heels Usually 3rd webspace Reduced sensation Mulder's click test ```
139
Outline treatment of Morton's neuroma
Metatarsal pads Offloading insole Steroid injection Excise neuroma
140
List aetiology/risk factors of Achilles tendonitis
Repetitive strain Quinolones Inflammatory arthritis Gout
141
Outline treatment of Achilles tendonitis
``` Rest Physiotherapy Splinting Tendon decompression/repair If rupture, cast in plantarflexion ```
142
List aetiology/risk factors of plantar fasciitis
Diabetes Hard floors Poor support
143
List clinical features of plantar fasciitis
Pain in instep of foot | Local tenderness
144
Outline treatment of plantar fasciitis
Rest Stretching exercises Gel-filled heel pad Steroid injection
145
List "high-energy" incidents that can result in a fracture
RTA Fall from height Gunshot
146
List "low-energy" incidents that can result in a fracture
Trip Fall Sports injury Pathological (osteoporosis)
147
List clinical features of fractures
``` Pain, tenderness Loss of function Deformity, abnormal position/movement Swelling Trapped air/foreign body ```
148
What is a tranverse fracture?
Bending force causes split in the bone
149
What is an oblique fracture?
Shearing force causes diagonal break in bone
150
What is a spiral fracture?
Rotational force causes diagonal break in bone
151
What is a comminuted fracture?
3 or more fragments break off from bone
152
What is a segmental fracture?
Fracture in 2 separate places of a bone
153
How is a fracture described?
Site: bone fractured, part of bone affected Angulation: direction in which distal fragment points towards Displacement: direction of translation of distal fragment
154
What is first intention healing of bone?
Less than 1mm gap (hairline fracture) filled by osteoblasts
155
What is second intention healing of bone?
Macrophages and osteoclasts remove debris and resorb bone ends Granulation tissue forms Chondroblasts form soft callus (2-3 weeks) Osteoblasts lay down new bone matrix Calcium mineralisation forms hard callus (6-12 weeks) Remodelling occurs
156
Outline initial management of a fracture
Correct shock Give blood if 1.5 L lost, monitor BP regularly Analgesia (IV morphine) Splinting/immobilisation Reduce a grossly open fracture, sterile covering over protruding bone Prevent infection (IV flucloxacillin + benzylpenicillin)
157
Outline definitive management of a minimally displaced, stable fracture
Non-operative Splinting/immobilisation (cast, orthosis, plaster) Rehabilitation and physiotherapy
158
Outline definitive management of a displaced, angulated fracture
Reduction under anaesthetic Close + cast or surgery
159
Outline definitive management of an unstable intra/extra -articular diaphyseal fracture
Open reduction, internal fixation | If soft tissues too swollen or risk of blood loss, external fixation instead
160
Outline definitive management of an open fracture
Assess, anti-sepsis, align, anti-tetanus, antibiotic, analgesia Early and thorough debridement Prompt internal/external fixation
161
List early local complications of fractures
``` Compartment syndrome Vascular injury/ischaemia Nerve compression Skin necrosis Bleeding ```
162
List early systemic complications of fractures
``` Hypovolaemia Shock ARDS AKI Sepsis Far embolism ```
163
List late local complications of fractures
``` Stiffness Loss of function Malunion/non-union Chronic regional pain syndrome DVT ```
164
List late systemic complications of fractures
PE Pneumonia Renal stones
165
What is compartment syndrome?
Limb and life -threatening complication where swollen muscles bound tight in fascial compartments Bleeding and inflammatory exudate compresses venous system, causing congestion, and arterial supply cannot supply area, causing necrosis
166
List clinical features of compartment syndrome
``` Severe intense pain outwith anticipated severity Swelling Tenderness Reduced/absent pulses Pain on passive muscle stretching ```
167
Outline treatment of compartment syndrome
Prompt fasciotomy Remove tight bandages/dressings Monitor fluid loss and renal function (dialysis may be needed)
168
What is complex regional pain syndrome?
``` Heightened chronic pain response following injury Type 1 (no nerve injury) Type 2 (nerve injury) ```
169
List clinical features of complex regional pain syndrome
``` Lancinating pain with/without trigger point Weeks or months following injury/surgery Allodynia Cold/cyanotic or hot/sweaty limb Vasomotor instability ```
170
Outline treatment of complex regional pain syndrome
Refer to pain clinic, physiotherapy, OT Encourage optimism and mobilisation Neuropathic painkillers (gabapentin, antidepressants, lidocaine)
171
What is neurapraxia?
Temporary loss of nerve conduction usually resolving within 28 days Due to compression/ischaemia of a nerve
172
What is axonotmesis?
Damage to nerve but with intact epineural tube Due to higher force/trauma Axons regenerate 1mm per day
173
What is neurotmesis?
Complete transection of a nerve Due to closed/penetrating injury No nerve recovery unless surgery
174
List aetiology/risk factors for nerve injury
Fractures: Colles (median), humeral shaft (radial) Dislocation: ant shoulder (axillary), post hip (sciatic), lat knee (common peroneal)
175
What is the difference between non-union and delayed union of a fracture?
Non-union: no evidence of progression towards healing | Delayed union: fracture not healed within expected time
176
List aetiology/risk factors of non-union and delayed union
``` Instability Excessive motion Rigid fixation Lack of blood supply Chronic disease Infection ```
177
List clinical features of non-union and delayed union
Ongoing pain and oedema Bridging callus on XR Scaphoid, distal clavicle, subtrochanteric of femur, 5th metatarsal notorious for non-union Tibia and femur notorious for delayed union
178
Outline treatment of non-union and delayed union
Remove dead/infected bone Fracture stabilisation Optimise blood supply
179
Outline treatment of cervical spine fractures
ABCDE + C-spine approach C-spine immobilisation using collar and bags Clinically clear a C-spine if conscious, cooperative, and ALL of: no history of LOC GCS 15 no significant injury no neurological signs no midline tenderness on palpation no pain on gentle active neck movement Firm cervical collar External fixation "halo vest" if unstable
180
Outline treatment of a thoracolumbar spine fracture
Brace to limit flexion if stable Plaster jacket Surgical stabilisation with pedicle screws and rods Spinal fusion
181
What is complete spinal cord injury?
No sensory or motor function below the level of the injury
182
What is spinal shock?
Physiological loss of sensory and motor function below the level of injury which usually resolves in 24 hours
183
What clinical test can detect spinal shock?
Absent bulbocavernous reflex
184
What is neurogenic shock?
Hypotension, bradycardia +/- priapism due to temporary shutdown of T1-L2 outflow (unopposed parasympathetic stimulation)
185
Outline treatment of spinal cord injury
Immobilise, traction IV fluids Surgical decompression IV steroid
186
What is the clinical pattern of involvement in central cord syndrome?
Paralysis of arms more than legs
187
What is the clinical pattern of involvement in anterior cord syndrome?
Loss of motor and spinothalamic function
188
What is the clinical pattern of involvement in Brown-Sequard syndrome?
Ipsilateral motor and dorsal column loss | Contralateral spinothalamic loss
189
Which neck of the humerus - anatomical or surgical - is most likely to fracture?
Surgical neck with medial displacement of humeral shaft due to pul of pectoralis major
190
Outline management of a humeral neck fracture
Sling and conservative if minimally displaced Manipulation/ORIF if displaced upper humeral epiphysis in kids If comminuted, may need head replacement
191
List clinical features of anterior shoulder dislocation
``` Loss of shoulder contour Flattened deltoid Anterior bulge Pain Axillary nerve damage (badge-patch numbness) ```
192
What is a Bankart lesion?
Detachment of anterior glenoid labrum in anterior shoulder dislocation
193
What is a Hill-Sachs lesion?
Posterior humeral head impacts on anterior glenoid
194
Outline management of anterior shoulder dislocation
Relieve pain - anaesthesia, parenteral opioid, entonox Closed reduction under sedation Sling for 2-4 weeks and physiotherapy ORIF if displaced/fracture of greater tuberosity
195
How does posterior shoulder dislocation usually arise?
Posterior force on adducted, internally rotated arm
196
Outline management of posterior shoulder dislocation
Closed reduction and immobilisation with physiotherapy
197
How do acromioclavicular joint injuries arise?
Fall onto point of shoulder
198
List clinical features of acromioclavicular joint injury
Prominence over acromioclavicular joint Reproducible subluxation Abduct shoulder and flex elbow and passively flex + extend arm - failure of outer end of clavicle to follow acromion suggests coracoclavicular ligament rupture
199
Outline management of acromioclavicular joint injury
Conservative, sling, physiotherapy | Reconstruct ligaments if chronic pain/young
200
Which nerve is at risk of damage in a humeral shaft fracture?
Radial nerve | May cause wrist drop and reduced sensation in 1st webspace
201
Outline management of a humeral shaft fracture
Splint with humeral brace and immobilise for 8-12 weeks | Internal fixation with IM nail/plate + screws if polytraumatic
202
How does an olecranon fracture occur?
Fall onto point of elbow with reflex contraction of triceps
203
Outline management of olecranon fracture
ORIF to restore triceps function | Tension band wiring if simple transverse avulsion
204
Outline management of supracondylar elbow fractures
Keep elbow in extension, correct valgus/varus Reduce under GA ORIF may be more stable Dunlop traction, olecranon traction
205
What sign may be seen on XR in a radial head/neck fracture?
Fat pad "triangular sail" sign at elbow
206
Outline management of radial head/neck fracture
Collar and cuff sling if undisplaced + physiotherapy | ORIF if large fragment/displaced
207
Outline management of elbow dislocation
Closed reduction under anaesthetic if uncomplicated | ORIF if associated fractures of radius/epicondyles/coronoid process
208
What happens in "pulled elbow"
Radial head slips out of annular ligament due to pull on arms
209
Outline management of pulled elbow
Elbow rotation - forced supination | Immobilise for a few days
210
What is a nightstick fracture?
Fracture of the ulnar shaft
211
What is a Monteggia fracture?
Fracture of ulna with dislocation of radial head at elbow
212
What is a Galeazzi fracture?
Fracture of radius with dislocation of ulna at radioulnar joint
213
Outline management of Monteggia/Galeazzi fractures
Lateral XR of wrist/elbow | ORIF
214
What is a Colles fracture?
Extra-articular dorsal displacement of distal radius
215
List aetiology/risk factors for Colles fracture
Fall on outstretched hand Osteoporosis Post-menopausal
216
Outline management of a Colles fracture
Splint if minimal displacement Reduction + plaster if displaced ORIF if particularly unstable Treat median nerve compression if unresolving
217
What is a Smith's fracture?
Extra-articular volar displacement of distal radius
218
What is a Barton's fracture?
Intra-articular fracture of dorsal radius (dorsal or volar)
219
Outline management of a scaphoid fracture
XR lateral AP and 2 x oblique views Splint and further XR in 2 weeks if unsure Plaster for 6-12 weeks Compression screw if displaced/non-union
220
Volar injury to the hand risks damage to which tendons?
Flexor tendons
221
Dorsal injury to the hand risks damage to which tendons?
Extensor tendons
222
What is mallet finger?
Avulsion of extensor tendon from terminal phalanx, causing flexion of the DIPJ
223
What are the 3 main types of pelvic fracture and their patterns of injury?
Lateral compression: half of pelvis displaced medially Vertical shear: half of pelvis displaced superiorly Anteroposterior compression: disrupted pubic symphysis
224
Outline management of pelvic fracture
PR exam is mandatory Relieve pain and replace blood ORIF/external fixation
225
List features of a pelvic radiograph that would be reassuring following a fracture
Less than 1cm pubic symphysis separation Symmetrical Integrity of superior pubic rami, acetabula and femoral necks
226
List clinical features of hip fractures
External rotation, adduction Limb shortening Antalgic/abnormal gait
227
Nearly all patients undergo surgery for hip fracture. True/False?
True
228
Where do intracapsular hip fractures occur?
Occur just below femoral head | Risk of disruption to arterial supply and AVN
229
Outline management of intracapsular hip fracture
Hemiarthroplasty/total hip replacement | Treat shock and relieve pain
230
Outline management of extracapsular hip fracture
Dynamic hip screw
231
Outline management of proximal femoral fractures
Intramedullary nailing
232
Outline management of femoral shaft fractures
Femoral nerve block Thomas splint Closed reduction and stabilisation with IM nail
233
The patella usually dislocates laterally. True/False?
True
234
Outline management of patellar dislocations
Temporary splintage and physiotherapy | Vastus muscle strengthening
235
What is a tibial plateau fracture?
Proximal tibia intra-articular fracture with either a split in bone or depression of articular surface
236
What is a pilon fracture?
Intra-articular fracture of distal tibia where talus driven into tibia
237
When is an ankle fracture stable and unstable?
Stable: distal fibular fracture with no medial fracture of rupture of deltoid ligament Unstable: distal fibular fracture with rupture of deltoid ligament
238
What is a Lisfranc fracture?
Fracture of base of 2nd metatarsal with dislocation of 2nd metatarsal and dislocation of other metatarsals
239
Which meniscal tear - medial or lateral - is more common?
Medial (it's more fixed and less mobile)
240
List clinical features of a meniscal tear
Localised pain to medial/lateral joint line Steinmenn's test +ve Effusion after 24h Catching/"locking" sensation if bucket-handle tear True lock = mechanical block to full extension
241
Outline management of meniscal tear
Arthroscopic menisectomy | Leave if asymptomatic
242
What is the soft tissue injury triad of the knee?
ACL rupture Medial meniscus tear Medial collateral ligament tear
243
How does ACL rupture usually occur?
High rotational force (twisting injury) | Posterior blow to tibia
244
List clinical features of ACL rupture
``` Rotatory instability Initial "pop" sound Give way on turning Deep pain Knee effusion Anterior translation of tibia (anterior draw test) ```
245
Outline management of ACL rupture
3 weeks' rest and physiotherapy Pain relief 1/3 compensate, 1/3 avoid movement, 1/3 persistent symptoms ACL reconstruction with tendon grafts
246
How does medial collateral ligament (MCL) rupture occr?
Valgus stress injury
247
How does lateral collateral ligament (LCL) rupture occr?
Varus stress injury
248
MCL rupture is more common than LCL rupture. True/False?
True
249
Which nerve is at risk in LCL rupture?
Common fibular nerve
250
What is a sequestrum in osteomyelitis?
Dead fragment of bone that breaks off
251
What is an involucrum in osteomyelitis?
New bone formation around an area of necrosis
252
Who typically gets acute osteomyelitis?
Children (sluggish blood supply) Post-surgery Trauma
253
What is a Brodie's abscess?
Subacute osteomyelitis where bone walls off abscess with a rim of slcerotic bone
254
List organisms that typically cause osteomyelitis
``` Staph aureus Pseudomonas E. coli Streptococci Salmonella (esp sickle cell patients) ```
255
Outline management of osteomyelitis
Drain abscess, surgical debridement Vancomycin + cefotaxime IV (empirical) for 6-12 weeks Flucloxacillin IV typically used Stabilise bone with internal/external fixation
256
List patients who are particularly susceptible to osteomyelitis of spine
Poorly controlled diabetes IV drug users Immunocompromised
257
List clinical features of osteomyelitis of the spine
``` Usually lumbar spine Insidious pain, constant, unremitting Paraspinal muscle spasm Tenderness Systemic upset Neuro deficit Epidural abscess Kyphosis ```
258
Which organisms typically cause surgical implant infections?
Staph aureus E. coli Staph epidermidis Enterococci
259
What happens in osteochondritis?
Softening of bony centres following necrosis
260
List aetiology/risk factors for osteochondritis
Children, adolescents Repetitive stress Trauma Familial predisposition
261
Outline management of osteochondritis
Osteotomy if joint damage | Casting of large joints
262
What is osteochondritis dissecans?
Segment of subchondral bone and cartilage becomes avascular and separates from underlying bone, resulting in a loose body
263
List clinical features of osteochondritis dissecans
``` Early aching Adolescents Knee, elbow, hip, ankle Sudden painful locking Effusions ```
264
What is avascular necrosis?
Ischaemic necrosis of bone due to disrupted blood supply
265
Which areas are susceptible to avascular necrosis?
``` Femoral head Humeral head Capitellum Proximal pole of scaphoid Talus ```
266
List aetiology/risk factors for avascular necrosis
``` Fractures Alcoholism Steroid abuse Hyperlipidaemia Thrombophilia Sickle cell disease ```
267
Outline management of avascular necrosis
Decompression via drill if not collapsed | Joint replacement if collapsed
268
What is the commonest benign primary bone tumour?
Osteochondroma
269
Describe osteochondroma
Bony outgrowth on external surface | Usually on knee, proximal femur, proximal humerus
270
Which benign tumour is an intramedullary cartilagenous tumour caused by failure of normal endochondral ossification at the metaphysis?
Enchondroma
271
Describe enchondroma
Lucency in bone that may mineralise to give patchy sclerotic appearance
272
Which benign tumour is a nidus of immature bone surrounded by a sclerotic halo?
Osteoid osteoma
273
List clinical features of osteoid osteoma
Intense constant pain worst at night relieved by NSAID's
274
Which benign tumour looks like a Shepherd's crook deformity at the femur?
Fibrous dysplasia
275
Which benign tumour has a soap-bubble appearance on XR?
Giant cell tumour
276
What is the most common primary malignant bone tumour?
Osteosarcoma
277
List clinical features of most primary malignant bone tumours
Unexplained, non-mechanical pain Constant severe pain Systemic upset Swelling
278
Which malignant bone tumour looks like popcorn calcification on XR?
Chondrosarcoma
279
Which malignant bone tumour usually affects adolescents and has the poorest prognosis?
Ewing sarcoma
280
List typical sources of metastatic tumours to bone
``` Breast Prostate Lung Renal Thyroid ```
281
What is osteoporosis?
Reduced bone mineral density with increased bone mineral porosity i.e. good quality bone, just not enough of it
282
What are the cut-offs for bone mineral density for osteopenia and osteoporosis?
Osteopenia: 1.5-2.5 standard deviations below mean peak Osteoporosis: greater than 2.5 standard deviations below mean peak
283
List aetiology/risk factors for osteoporosis
``` Type 1 (post-menopausal) Smoking Alcohol abuse Lack of exercise Poor diet Reduced sun exposure Chronic disease Immunosuppression ```
284
Ca and phosphate are low/normal/high in osteoporosis
Ca and phosphate are normal in osteoporosis
285
Outline management of osteoporosis
``` Exercise, good diet Vit D supplements Calcium supplements Bisphosphonates Monoclonal antibody Strontium ranelate if unresponsive/intolerant ```
286
What is osteomalacia?
Softening of bone due to deficient mineralisation | i.e. poor quality bone but plenty of bone
287
List aetiology/risk factors for osteomalacia
``` Malabsorption of Ca and vit D Reduced sunlight exposure Hypophosphataemia Chronic kidney disease Anticonvulsant use ```
288
Ca and phosphate are low/normal/high in osteomalacia
Ca and phosphate are low in osteomalacia
289
What is Paget's disease?
Increased osteoclastic activity with inefficient osteoblastic activity results in impaired remodelling of bone
290
List clinical features of Paget's disease
Thickened, brittle, fragile, mis-shapen bone | Usually affects pelvis, femur, skull, tibia, ear ossicles
291
Ca and phosphate are low/normal/high in Paget's disease
Ca and phosphate are normal in Paget's disease
292
What is osteogenesis imperfecta?
Defect of maturation and organisation of type 1 collagen
293
List clinical features of osteogenesis imperfecta
``` Brittle-bone disease Fragile bones Multiple fractures Short stature Deformities Blue sclerae Loss of hearing ```
294
Outline management of osteogenesis imperfecta
Splint/traction/surgical stabilisation of fractures | Sofield procedure for progressive deformity
295
What is achondroplasia?
Skeletal dysplasia/short stature involving reduced growth of cartilagenous bone due to mutations in fibroblast growth factor receptor 3 (FGR3)
296
List clinical features of achondroplasia
``` Disproportionately short limbs Short stature Prominent forehead Wide nose Joint laxity Large head Increased lumbar lordosis Bow legs Learning difficulty Organ dysfunction ```
297
Outline management of achondroplasia
Correct deformities Growth hormone Limb lengthening
298
What is Marfan's syndrome?
Ligamentous laxity due to defect in collagen synthesis, causing hypermobility
299
Which gene is mutated in Marfan's syndrome?
Fibrillin
300
List clinical features of Marfan's syndrome
``` Tall stature Lig laxity Long limbs High-arched palate Scoliosis Pectus excavatum Eye problems (retinal detachment) Aortic aneurysm Valve incompetence ```
301
What is Ehlers-Danlos syndrome?
Abnormal collagen-elastin formation/ratio causes profound joint hypermobility
302
What is cerebral palsy?
Insult to immature brain causes reduced/impaired function | Onset usually before 2-3 years of age
303
List aetiology/risk factors for cerebral palsy
``` Insult to brain around/during/after birth Genetics Brain malformations Intrauterine infections Prematurity Intracranial haemorrhage Hypoxia at birth Meningitis ```
304
List clinical features of cerebral palsy
``` Weakness Paralysis Delayed milestones Seizures Language/speech difficulty Depends on area of brain affected ```
305
What is the difference between monoplegic, diplegic, hemiplegic and quadriplegic cerebral palsy?
Monoplegic: one limb Hemiplegic: ipsilateral upper + lower limb Diplegic: lower limbs Quadriplegic: all four limbs
306
Which area is affected in spastic cerebral palsy?
Injury to precentral gyrus/UMN/corticospinal tract
307
Which area is affected in ataxic cerebral palsy?
Cerebellum
308
Which area is affected in athetoid cerebral palsy?
Basal ganglia/extrapyramidal tract/pyramidal tract
309
Outline management of cerebral palsy
``` Physiotherapy Splintage/orthotics Baclofen, botox for spasticity Hip excision/replacement Correct severe scoliosis/joint contractures ```
310
What is spina bifida?
Two halves of posterior verebral arch fail to fuse
311
List clinical features of spina bifida occulta
``` Mild form: some develop tethering of spinal cord and roots Pes cavus Clawed toes Neuro deficit Tell-tale dimple Tuft of hair ```
312
List clinical features of spina bifida cystica
``` Severe form: vertebral canal contents herniate through defect If meningocele (herniation of meninges), usually no neuro deficit If myelomeningocele (herniation of meninges and cord), usually neuro deficit below level of lesion ```
313
Outline management of spina bifida
Treat hydrocephalus Scoliosis correction Contracture release/correction Avoid formation of sores
314
List clinical features/examples of limb malformations
Syndactyly - two digits fused Polydactyly - extra digit Fibular hemimelia - partial/complete loss of fibula
315
Outline management of limb malformations
``` Surgical separation/amputation Limb lengthening External fixation Prosthetic limb Surgical reconstruction Deformity correction ```
316
List aetiology/risk factors for obstetric brachial plexus palsy
Macrosomia Twin delivery Shoulder dystocia
317
What are the features of Erb's palsy?
C5 + C6 damage Loss of innervation to deltoid, supraspinatus, infraspinatus, biceps, brachialis Results in internal rotation of humerus, "waiter's tip" posture
318
What are the features of Klumpke's palsy?
C8 + T1 damage Paralysis of intrinsic hand muscles with/without finger/wrist flexors Results in flexed fingers, Horner's syndrome
319
Outline management of obstetric brachial plexus injury
Physiotherapy to prevent contractures Surgical release of contractures Tendon transfers if no recovery
320
Define pathological genu varus/valgus
Greater than/less than 6' of angulation from mean
321
List conditions where genu varus is typically seen
Osteochondroma Skeletal dysplasia Trauma
322
List conditions where genu valgus is typically seen
``` Idiopathic Ricket's Enchondromas Trauma Neurofibromatosis ```
323
What is in-toeing?
Feet that point towards midline
324
List aetiology/risk factors for in-toeing
Femoral neck anteversion Internal tibial torsion Forefoot adduction
325
When would surgery be considered for in-toeing?
Only consider after 7-8 years of age as most resolve
326
What is pes planus?
Flat footedness due to loss of medial plantar arch
327
What is the difference between mobile/flexible pes planus and rigid/fixed pes planus?
Mobile: flattened medial arch forms on dorsiflexion of great toe, present on weight-bearing only, usually due to lig laxity Rigid: persistently flat medial arch, with/without weight bearing, usually due to tarsal coalition
328
What is developmental dysplasia of the hip (DDH)?
Dislocation/subluxation of femoral head during perinatal period results in abnormal hip joint
329
List aetiology/risk factors for DDH
``` Females Left hip usually affected Family history Breech presentation First-born Down's syndrome Increased birth weight Oligohydramnios ```
330
List clinical features of DDH
``` Unstable hips Shallow acetabulum Arthritis early on False acetabulum may develop, causing limb shortening Asymmetrical groin/thigh skin creases Delayed walking, waddling gait ```
331
What are the clinical tests for DDH?
Ortolani: reduce dislocated hip with abduction and elevation of femur Barlow: dislocate hip with adduction and flexion
332
When would you scan for suspected DDH?
USS before 6 months | XR after 6 months
333
Outline management of DDH
Serial observation if relocated Pavlik harness (splint in abduction) for 3 months if unstable Open reduction if persistent dislocation over 18 months
334
What is transient synovitis of the hip?
Chief cause of hip pain in kids | Self-limiting inflammation of synovium, usually post-URTI
335
List clinical features of transient synovitis of the hip
Limp Reluctant to weight bear Restricted motion Low-grade fever
336
What investigations would you do for transient synovitis of the hip?
Need to EXCLUDE septic arthritis, Perthes, juvenile arthritis, SUFE Aspirate/surgical drainage if uncertain
337
Outline management of transient synovitis of the hip
NSAID short-course | Rest
338
What is Perthes disease?
Idiopathic osteochondritis of femoral head in aged 4-9
339
List clinical features of Perthes disease
``` Pain Limp Loss of internal rotation, loss of abduction +ve Trendelenberg Restricted motion ```
340
Outline management of Perthes disease
``` Avoid physical activity Rest Radiographic surveillance Osteotomy of femur/acetabulum if subluxation/dislocation Hip replacement if collapse ```
341
What is slipped upper femoral epiphysis (SUFE)?
Femoral head epiphysis slips inferiorly in relation to femoral neck
342
List aetiology/risk factors for SUFE
Overweight prepubertal adolescent boys Hypothyroidism Renal disease
343
List clinical features of SUFE
Limping Pain in growin/thigh/knee Loss of internal rotation Limited motion
344
Outline management of SUFE
Urgent surgery to pin femoral head Hip replacement Femoral osteotomy
345
What is talipes equinovarus?
Clubfoot - congenital deformity due to in utero malalignment of joints between talus, calcaneus and navicular
346
List clinical features of clubfoot
Contracture of soft tissue Plantarflexion Supination Varus alignment of forefoot
347
Outline management of clubfoot
Early splintage - Ponseti technique | Surgery may be required
348
Describe Salter Harris physeal fracture I and II
I: pure physeal separation II: physeal separation with metaphyseal fragment
349
Describe Salter Harris physeal fracture III and IV
III: intra-articular with physis split IV: Intra-articular with physis and metaphysis split
350
Describe Salter Harris physeal fracture V
Compression injury to physis

4MB Surgery (3 decks)

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