Orthopaedics Flashcards
Which blood vessels are at risk of damage in intracapsular hip #
Retinacular arteries from the femoral artery
Name the main hip abductors
Gluteus minimums and maximis
Tensor fasciae lattea
What is the main action of gluteus maximums?
Extension and external rotation
Describe the appearance of a -ve Trendelenberg test. What is the clinical significance?
Normal = pelvis falls on the side of the stance leg
Abnormal = pelvis rises on the side of the stance leg —> abductor muscle paralysis
Name the main hip flexors
Psoas major and iliacus
Quad muscles innervated by the femoral nerve. What muscles make up the quad group?
Rectum femoris
Vastus lateralis, medialis and intermedious
Hamstrings are supplied by sciatic nerve. What muscles make up hamstrings?
Biceps femoris
Semimembranosus
Semitendinosis
The adductors are supplied by the obturator nerve. Name the adductor muscles
Adductor longus
Adductor brevis
Adductor Magnus
Gracious
Which meniscus is most likely to be torn? Why?
Medical meniscus is most likely to be torn as it is fixed. The lateral meniscus is mobile so tears are less likely
Role of medial meniscus?
To resist virus stress
Role of PCL?
To resist posterior subluxation of the tibia e.g. going down stairs - can also think of resisting anterior subluxation of femur
Role of lateral meniscus
To resist varus stress and external rotation of the knee
What is our average anatomical axis of the hip and knee?
6 degrees valgus —> knee and ankle aligned perfectly
Which nerve supplies the anterior compartment of the lower leg?
Deep peroneal (or fibular) nerve
E.g. tibialis anterior and extensor digitorum
Act to dorsiflex and invert the foot
Which nerve supplies the lateral compartment of the leg?
Superficial perineal (fibular) Act to evert the foot E.g. fibularus longus and brevis
Which nerve supplies the posterior compartment of the leg?
Tibial nerve
Acts to plantarflex the foot
E.g. gastrocnemius, soles, tibialis posterior etc
Which 2 structures contribute to the medial arch of the foot?
Posterior tibial and plantar fascia
Difference between hammer and claw toe?
Claw = flexion at proximal and distal interphalangeal joint
Hammer = flexion at PIP but extension and DIP
Both due to an imbalance between flexors and extenders
Cartilage is made of water, collagen, proteoglycans and chondorcytes. What do chondrocytes do?
Make collagen
What is osteochondritis dissecans?
Subchondral bone becomes avascular —> cartilage +/- bone fragmenting
Usually medial epicondyle of femur in adolescence
Typically pain with swelling and locking after exercise
Treat conservatively, with pinning or removal of fragment
Good surgical option for builder with valgus alignment and early medical compartment OA?
Osteotomy
surgical cutting of bone to alllow realignment
In a well selected patient, how long does a TKR last?
15-20 years
Don’t forget that 50% of ACL tears often have a meniscal tear too
Medial meniscus 10x more common that lateral
Why do radial meniscal tears not heal?
They involve the central surface of the meniscus - only the peripheral 1/3 has a blood supply
Most likely diagnosis in a patient with an acute locked knee
Bucket handle meniscal tear
Requires urgent surgery
MCL tear usually heals well. Brace, early motion and physio
ACL tear is more worrying. Repair does not work - needs reconstruction from graft e.g. patellar tendon or Achilles
1/3 compensate well
1/3 can avoid instability by avoiding actively
1/3 cannot compensate and get instability
What structures are relatively likely to be damaged in a knee dislocation?
1) Common peroneal nerve
2) Popliteal artery
—> potential for compartment syndrome
Patient can’t do a straight leg raise and there is a palpable gap on examination. Diagnosis and management?
Extensor mechanism rupture
Needs surgical repairs
Most likely knee injury after hitting dashboard in RTA?
PCL tear
Most likely knee injury from getting up from squat?
Meniscal
Diagnosis in footballer who twisted and heard a pop. Generalised pain and rotator instability?
ACL rupture
Recurrent catching and locking after sudden pain which occurred when getting up from squatting?
Meniscal tear
What 3 examination tests are done if suspected ACL tear?
1) Lachman (knee at 20 degree flexion)
2) Anterior drawer (knee at 90 degree flexion)
3) Pivot shift (knee externally rotated)
LOSS on x-ray
Loss of joint space
Osteophytes
Subchondrol sclerosis
Subarticualr cysts
+ve McMurray test. Likely diagnosis?
Probably a meniscal problem
Position of a leg with an intracapsular hip fracture?
Shortened, externally rotated and adducted
Need to do AP and lateral view
Intracapsular # occur within the joint capsule and as there is poor blood supply - malunion is common
Extracapsular fracture occur outwith the joint capsule so malunion is less likely
Management of intracapsular hip #
Undisplaced —> internal fixation and dynamic hip screw
Discplaced —> hemiarthroplasty (exicse head and insert prosthesis)
Management of extra-capsular #
Usually a dynamic hip screw
femoral shaft # requires stabilisation and then insertion of intra-medullary nail
What does loss of Shenton’s line suggest?
Hip #
It is formed by the inferior edge of the superior pubic ramis and medial edge of femoral neck
What are the 5 types of hip # ?
Intra-capsular:
- subcapital
- transcervical
- basicervical
Extra-capsular:
- intertrochanteric
- sub-trochanteric
What is Garden’s classification?
Tool for assessing the severity of hip #
1 - incomplete or impacted
2 - complete
3 - partially displaced
4 - completely displaced
Remember a hip # is EXTRA bad so the leg is EXTERnally rotated
Hip dislocations are not too bad so the leg is internally rotated
Key things to mention when discussing a #
Site - e.g. shaft of femur
Direction of # e.g. transverse/ oblique/ spiral
Displacement - always describe in relation to distal bone fragment e.g. lateral displacement eith shortening and valgus angulation
Soft tissue - open/ closed, NVB? Compartment syndrome?
What does comminuted # mean?
> 2 bone fragment s
In every patient with back pain you must ask about causes equina and any history of malignant
In every patient with back pain you must ask about causes equina and any history of malignant
Knee pain worse on walking up or down stairs?
Classically patellofemoral pain
Always look at medication list in a patient with gout. They may have just started a thiazide diuretic which often precipitates attacks
Always look at medication list in a patient with gout. They may have just started a thiazide diuretic which often precipitates attacks
Differential diagnosis of neck pain?
- mechanical
- trauma
- cervical spondylosis, prolapse or discitis
- OA
- bony mets
Features of complex regional pain syndrome?
Pain, hypersensitivity and autonomic dysfunction e.g. excess sweating
Often following trauma
Distal forearm and hand usually involved
Carpal tunnel = radial 3.5 fingers affected
Cubical tunnel = ulnar 1.5 fingers affected
Differential for widespread musculoskeletal pain
PMR Polymyositis Fibromyalgia RA Psoriatic arthritis Ank spon SLE Metabolic bone disease
Differential for ‘acute hot swollen joint’
Septic arthritis Gout RA Transient synovitis Haemarthrosis - common in patients on warfarin or with a bleeding disorder (if haemarthrosis is suspected, a clotting screen should be done and INR should be checked)
Differential for an unwell child with joint pain?
Septic arthritis
Idiopathic juvenile arthritis
How will a child with a SUFE typically stand?
With the affected leg in external rotation
What does Thomas’s test test for?
A fixed flexion disorder (the contralateral leg comes off the bed)
If you suspect a SUFE, which x-ray should you order?
Frog leg lateral x-ray
What are the hand manifestations of RA?
Swan neck deformity
Boutonnière deformity
Ulnar drift
In any skin lump/ swelling, consider it sinister if >5cm in diameter
In any skin lump/ swelling, consider it sinister if >5cm in diameter
List some causes of a secondary arthritis
Perthes SUFE AVN Trauma Previous infection RA
HLA DR4 is very important in the development of RA
HLA DR4 is very important in the development of RA
Rheumatoid factor is in serum of 80% of patients with RA
High levels —> severe disease and extra-articulate features
Which joints are typically affected by rheumatoid arthritis?
Small and medium sized joints in a symmetrical
Synovitis is the cardinal feature of RA. It usually affects the small joints of the wrist and hand except…
DIPJ -almost always spared
Extra-articular of RA
Rheumatoid nodules Teno synovitis/ bursitis Carpal tunnel - due to synovitis Lung nodules/ pulmonary fibrosis Eye - keratoconjunctivitis sicca, episcleritis, scleritis
What are the 2 serological tests associated with RA.
Rh factor
Anti- CCP
Name some biological therapies
Anti-TNF —> infliximab, adalimumab and etanercept (monoclonal antibodies)
Other biologics —> ritixumab and abatacept
People with RA should be on a DMARD asap
Steroids are often given to relieve symptoms short term while the DMARD takes effect
What is the major side effect of ciclosporin, other than bone marrow suppression?
Renal disease —»HT
In any fracture, what must you consider other than the actual bone?
1) Overlying skin
2) Distal blood supply - pulses?
3) Nerve involvement - weakness/ sensation
Describe the salter Harris classification of growth plate #
1 = through growth plate only 2 = mainly epiphysis but part of metaphysis is also involved 3 = growth plate and epiphysis e.g. intra-articular 4 = though epiphysis, growth plate and metaphysis —> most severe 5 = crush injury —> unusual and only detected when bone growth stops later
Most common type of salter-Harris fracture
Type 2
Through growth plate and epiphysis
Operative treatment i.e open reduction is always required for open fractures and displaced intra-articulate fracture
Operative treatment i.e open reduction is always required for open fractures and displaced intra-articulate fracture
Patient develops hypoxia and sudden onset SOB 2 days after femoral #. Differential?
PE
Fat embolus - never forget!
First step in management of an open #
ABCDE Cover in an iodine soaked swab Splint Start ABx prophylaxis e.g. IV co-amoxiclav (amoxicillin and clavulanic acid) Tetanus prophylaxis De-bride in theatre ASAP.
What must be considered if there is blood at the urethral meatus/ blood or boggy prostate on PR?
Pelvic fracture
Scaphoid # are notoriously tricky. You need to get a lateral (scaphoid) view. What are the complications?
Non-union Malunion AVN Reduced grip strength Increased risk o OA
Patient with FOOSH and pain in anatomical snuffbox. Suspected scaphoid # but x-ray normal. What to do?
Immobilise wrist and re-do x-ray in 2 weeks
If still normal but tenderness remains then do an MRI
Cole’s #
Fracture of the distal radius with dorsal displacement (dinner fork appearance)
Most common in old ladies who fall and have osteoporosis
Names of bone ends and growth plates
Epiphysis = bone end e.g. beyond growth plate Physis = growth plate Metaphysis = between physis and diaphysis Diaphysis = bone shaft
Most likely mechanism for a posterior shoulder dislocation?
Epileptic shoulder
Views for shoulder dislocation?
AP and axillary
Which rotator cuff muscles insert into greater tuberosity?
Supraspinatous (Jobe’s -thumb down)
Infraspinatous and Teres minor (external rotation)
Which rotator cuff muscle inserts onto lesser tuberosity?
Subscapularis
Internal rotation - push against hand
Popeye sign
Ruptured biceps tendon
What are the 3 recognised stages of adhesive capsulitis?
Painful - often at night
Frozen - reduced ROM, especially external rotation
Thawing - progressive improvement in ROM
Galeazzia = radial shaft # with dislocation of DRUJ
Monteggia = proximal ulnar # with dislocation of radial head
remember its the ulnar head which forms the elbow joint
Bennet’s = intra-articulation # of the base of the thumb
Boxers # = 5th metacarpal neck fracture (little finger)
Always volar angulation
Remember trascervical is an intracapsular fracture
Basicervical is an extracapsular fracture
Positive anterior draw and Lachman’s test?
ACL rupture
The Danis-Weber classification is used for ankle fractures. Describe it
A = below syndesmosis B = at level of syndesmosis C = above syndesmosis
Ankle # need reduced in A&E
Any degree of talar shift needs operative fixing
Commonest cause of Baker’s cyst?
OA
Bone bone which resolves with aspirin?
Osteoid osteoma
benign
Soap bubble appearance of bone tumour?
Giant cell tumour
Onion skin appearance of bone tumour?
Ewing sarcoma
t(11;22) translocation
Popcorn appearance of bone tumour?
Chondrosarcoma
