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Year 3 Semester 2 > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

What is subluxation?

A

Incomplete or partial dislocation

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2
Q

What three injuries comprise the unhappy triad?

A
  1. ACL tear
  2. MCL tear
  3. Medial meniscal tear
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3
Q

Why is the medial meniscus more commonly injured than the lateral meniscus?

A

It is relatively immobile, being attached to the MCL and joint capsule

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4
Q

Why is the ACL more commonly torn than the PCL?

A

The PCL is shorter and stronger

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5
Q

On physical examination, what manoeuvre will reproduce the pain of Osgood-Schlatter disease?

A

Knee extension against resistance

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6
Q

Explain the pathophysiology of Osgood-Schlatter disease

A
  1. The tibial tuberosity develops separately from the proximal tibia
  2. Normally it ossifies with the tibia
  3. With repeated tension on the patellar ligament, the tuberosity avulses
  4. This avulsed fragment continues to grow and the intervening space fills with new bone or connective tissue
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7
Q

What is osteochondritis dissecans?

A

Necrosis of subchondral bone in which a bone-cartilage fragment detaches and becomes displaced in the joint space

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8
Q

A popping and locking sensation in the knee is characteristic of an injury to which structure?

A

Menisci

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9
Q

What is the most sensitive and specific test for meniscal tears?

A

Thessaly test

Clicking/locking/catching with rotation

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10
Q

What is the characteristic MRI finding of a meniscal tear?

A

Hyperdense line

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11
Q

What are the 6 P’s of acute limb ischaemia?

A
  1. Pain
  2. Pallor
  3. Paraesthesias
  4. Poikilothermia (inability to regulate temperature)
  5. Pulselessness
  6. Paralysis
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12
Q

What is the major complication of acute forearm compartment syndrome?

A

Volkmann contracture

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13
Q

What upper limb injury is particularly prone to the development of a Volkmann contracture?

A

Fractures around the elbow, particularly supracondylar humeral fractures due to compression of the brachial artery

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14
Q

Which nerve is most commonly affected by compartment syndrome in the lower limb?

A

Deep peroneal nerve

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15
Q

What are the 5 types of Salter-Harris fractures?

A
  1. S - straight across
  2. A - above
  3. L - lower
  4. T - through/two
  5. ER - Erasure
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16
Q

When in a child’s life are Salter-Harris fractures most common?

A

Growth spurts at the beginning of puberty

11-12 for females

12-14 for males

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17
Q

Where on a bone is the metaphysis, epiphysis and physis?

A
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18
Q

What is the difference between adult and child periosteum and what is the clinical significance of this in terms of fractures?

A

Children have thicker and stronger periosteum

  • Limits fracture displacement
  • Reduces the likelihood of open fractures
  • Maintains fracture stability
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19
Q

What type of collagen predominates in bone?

A

I

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20
Q

What is an avulsion fracture?

A

Injury to the bone in a location where a tendon or ligament attaches to bone

The tendon or ligament pulls of a piece of the bone

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21
Q

What is a comminuted fracture?

A

More than 2 fracture fragments

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22
Q

What is a segmental fracture?

A

A type of comminuted fracture in which a completely separate segment of bone is bordered by fracture lines

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23
Q

What is a greenstick fracture?

A

Bone that is bent with a fracture line that does not extend completely through the width of the bone

(common in children)

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24
Q

What is a torus/buckle fracture?

A

Incomplete fractures of the shaft of a long bone that is characterised by bulging of the cortex. They result from trabecular compression from an axial loading force along the long axis of the bone.

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25
Q

List 3 potential complications of a fracture at the surgical neck of the humerus

A
  1. Axillary nerve damage
  2. Posterior circumflex humeral artery damage → necrosis of the humeral head
  3. Suprascapular nerve damage
  4. Adhesive capsulitis
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26
Q

What is the major complication of humeral shaft fractures?

A

Radial nerve damage

(triceps muscle is spared)

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27
Q

What is a Galeazzi fracture?

A

Radius fracture + dislocation of the distal radioulnar joint

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28
Q

What is a Smith fracture?

A

Palmar displacement of the distal radius fragment

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29
Q

What is a Monteggia fracture?

A

Ulna fracture + dislocation of the radial head

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30
Q

What test is used the assess the function of the supraspinatus?

A

Empty can test/Jobe’s test

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31
Q

What test is used to assess the function of the infraspinatus?

A

External rotation against resistance

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32
Q

What test is used to assess the subscapularis?

A

Internal rotation against resistance

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33
Q

What test can be used to assess the function of the teres minor?

A

Position the arm in 90° of abduction and bend the elbow to 90°

Passively externally rotate the shoulder to its maximum degree

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34
Q

During shoulder abduction, pain through during which arc is suggestive of glenohumeral impingement?

A

60-120 degrees

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35
Q

During shoulder abduction, pain through during which arc is suggestive of acromioclavicular impingement?

A

170-180

May also be due to osteoarthritis

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36
Q

Which two test can be used to assess a biceps tendon rupture?

A

Speed’s test - elbow flexion against resistance

Yergason’s test - forearm supination against resistance

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37
Q

What is the sail sign?

A

Wide anterior fat pad

Suggests an occult fracture (hidden, does not appear clearly on x-ray)

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38
Q

What is the significance of a posterior fat pad on an x-ray of the elbow?

A

Suggests an effusion caused by significant trauma

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39
Q

What is neuropraxia?

A

Temporary loss of nerve function due to compression/stretch of the nerve. There is no structural damage to the nerve, but to the myelin sheath

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40
Q

Which branch of the median nerve is most commonly injured in supracondylar humeral fractures?

A

Anterior interosseous (AION)

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41
Q

What are the features of an injured anterior interosseous nerve?

A

No sensory changes (AION lacks a superficial sensory component)

Hand weakness, weak “OK” sign

Proximal forearm pain

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42
Q

How are supracondylar humeral fractures graded?

A

I. Undisplaced

II. Angulated with intact posterior cortex

III. Displaced distal fragment posteriorly with no cortical contact

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43
Q

What does radial head malalignment on x-ray suggest?

A

Radial head should point towards the capitellum

Lateral condylar fracture

Monteggia fracture

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44
Q

What is the significance of the anterior humeral line in x-rays of supracondylar humeral fractures?

A

In a normal elbow, a line drawn through the anterior cortex of the humerus intersects the capitellum in its middle third

The anterior humeral line passes through the anterior third of the capitellum or fails to intersect it if the humerus is posteriorly displaced

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45
Q

How are ligamentous injuries of the knee graded?

A
  1. No tear, no instability
  2. Partial tear, reduced stability
  3. Complete tear, poor stability
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46
Q

Which tendons are most commonly used as native grafts for ACL tears?

A

Patellar tendon

Hamstring tendon

Quadriceps tendon

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47
Q

How do you differentiate rotator cuff impingement from a tear?

A

Tears are associated with weakness

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48
Q

What are the 5 Ottowa knee rules?

A

A knee x-ray series is only required for knee injury patients with any of these findings:

  1. Age 55 or older
  2. Isolated tenderness of the patella

(No bone tenderness of knee other than patella)

  1. Tenderness of the head of the fibula
  2. Cannot flex to 90 degrees
  3. Unable to bear weight both immediately and in the emergency room department for 4 steps

(Unable to transfer weight twice onto each lower limb regardless of limping)

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49
Q

What is the management for a rotator cuff tear < 50% of the tendon’s thickness?

A

Arthroscopic debridement

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50
Q

What is the management for a rotator cuff tear >50% of the tendon’s thickness?

A

Arthroscopic repair (sutures)

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51
Q

How do you perform the Hawkin’s Kennedy test?

A

The clinical stabilises the shoulder with one hand and, with the patient’s elbow flexed at 90 degrees, internally rotates the shoulder using the other hand

Pain = positive test

Assesses shoulder impingement

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52
Q

What are 3 potential complications of a proximal humeral fracture?

A
  1. Avascular necrosis of the humeral head (circumflex artery)
  2. Axillary nerve palsy
  3. Suprascapular nerve palsy
  4. Adhesive capsulitis
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53
Q

What is a floating shoulder injury?

A

Fracture of the clavicle and glenoid neck

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54
Q

Which two conditions are most strongly associated with adhesive capsulitis?

A
  1. Diabetes mellitus
  2. Thyroid disease
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55
Q

What is a bankart lesion?

A

Detachment of the anterior inferior labrum from the glenoid due to an anteriorly dislocated humeral head

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56
Q

What’s the difference between a strain and a sprain?

A

Strain: overstretching/tearing of LIGAMENTS

Sprain: overstretching/tearing of MUSCLES or TENDONS

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57
Q

Which shoulder conditions may cause pain at night?

A

Impingement

Adhesive capsulitis

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58
Q

What is the conservative treatment of proximal humeral fractures?

A

Immobilisation with a sling (no splinting needed)

Ice, analgesia, mobilisation

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59
Q

What is the Neer classification of proximal humeral fractures?

A

Fractures are classified according to how many of the four major segments of the proximal humerus are displaced

  1. Anatomical neck
  2. Surgical neck
  3. Greater tuberosity
  4. Lesser tuberosity

Displacement exists when a segment is angulated more than 45 degrees or displaced more than one centimetre from a normal anatomic position.

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60
Q

What is the management of non-complicated clavicular fractures of the middle third?

A

Sling for 2 weeks (children)

Figure 8 can be used but they may be less comfortable and there is little evidence to show increased efficacy

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61
Q

What is the most common complication of a scaphoid fracture?

A

Avascular necrosis

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62
Q

Pain with pressure on the anatomic snuffbox suggests what injury?

A

Scaphoid fracture

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63
Q

How are femoral neck fractures classified?

A

Garden classification

64
Q

Which muscle tendons are affected by De Quervain’s tenosynovitis?

A

Extensor pollicis brevis

Abductor pollicis longus

65
Q

What are two causes of de Quervain’s tenosynovitis?

A
  1. Repeated hand and thumb movements
  2. Rheumatoid arthritis
66
Q

Which test is used to confirm de Quervain’s tenosynovitis?

A

Finkelstein test

67
Q

Which injury is classically seen in cyclists due to constant pressure on the wrist/hand from the handlebars?

A

Guyon canal syndrome

(ulnar tunnel syndrome)

68
Q

Damage to which two important structures is most important to consider in a mid-shaft humeral fracture?

A
  1. Radial nerve
  2. Profunda brachii artery
69
Q

Damage to which four important structures is most important to consider in a supracondylar humeral fracture?

A
  1. Brachial artery
  2. Median nerve (particularly the anterior interosseous branch)
  3. Ulnar nerve
  4. Ulnar collateral artery
70
Q

Damage to which two important structures is most important to consider in a fracture of the medial epicondyle of the humerus?

A
  1. Ulnar nerve
  2. Ulnar collateral artery
71
Q

Where is pain from greater trochanteric pain syndrome felt?

A

Lateral hip

72
Q

What exacerbates pain from greater trochanteric pain syndrome?

A

Lying on the affected side

Weight-bearing

Palpation of the greater trochanter

73
Q

What causes greater trochanteric pain syndrome?

A

Gluteus medius or minimus tendinopathy (may also include trochanteric bursa)

Associated with knee OA, high BMI, low back pain, females

74
Q

What is Legg-Calve-Perthes disease?

A

Idiopathic osteonecrosis of the femoral head in children 2-12 years of age

75
Q

What are 3 radiologic signs of avascular necrosis of the femoral head?

A
  1. Femoral head lucency
  2. Subchondral sclerosis
  3. Subchondral collapse (crescent sign - photo)
  4. Flattening of the femoral head
76
Q

How do you manage undisplaced intracapsular fractures?

A

Internal fixation with a dynamic hip screw or multiple cannulated screws

77
Q

How do you manage a displaced intracapsular hip fracture?

A

< 60 - ORIF

>60 - arthoplasty

78
Q

What is the management of intertrochanteric hip fractures?

A

Internal fixation with a dynamic hip screw or intramedullary nail

79
Q

What antibiotic prophylaxis is used for orthopaedic surgery?

A

Cephazolin

+/- vancomycin if at risk of MRSA

80
Q

What displaces intertrochanteric femoral fractures?

A

Iliopsoas pulls on the lesser trochanter and the major external rotators and abductors pull on the greater trochanter

81
Q

A positive Trendelenburg gait suggests what?

A

Weakness of the gluteus medius and minimus

Superior gluteal nerve

82
Q

What is the FABER test? What does a positive result mean?

A

FABER: flexion, abduction, external rotation

Groin pain: iliopsoas strain, intra-articular hip disorder

SI pain: SI joint disorder

Posterior pain: posterior hip impingement

83
Q

What is the FADIR test?

A

FADIR: flexion, adduction, internal rotation

Causes:

  1. Hip impingement (FAI)
  2. Hip labral tear
  3. Hip loose bodies
  4. Hip chondral lesion
84
Q

What two deformities are associated with femoroacetabular impingement?

A

Cam

Pincer

85
Q

What is piriformis syndrome?

A

Compression of the sciatic nerve

Piriformis strain

86
Q

Referred pain from which region is felt in the hip?

87
Q

Transient synovitis in the hip affects people of which age?

88
Q

Perthes disease affects people of what age?

A

5-10 years

89
Q

Slipped capital femoral epiphysis (SCFE) affects people of what age?

A

10-15 years

90
Q

What is the Thomas test?

91
Q

What is the special test for lateral epicondylitis (tennis elbow)?

A

Wrist extension against resistance

92
Q

What is the special test for medial epicondylitis (Golfer’s elbow)?

A

Wrist flexion against resistance

93
Q

What is a hairline fracture?

A

Fracture from minimal trauma, not involving fracture displacement

Commonly stress fractures

Often in foot or lower leg

94
Q

If you suspect a fracture but cannot visualise it, what should you do regarding imaging?

A
  1. Ask for more oblique views
  2. Re-image in 7-10 days as there will be decalcification at the site
95
Q

How does osteoporosis affect trabecular and cortical bone differently?

A

Trabecular bone is lost before cortical bone

Fractures occur bones with a high proportion of trabecular bone e.g. vertebrae as opposed to long bones

96
Q

What are the stages of fracture healing?

A
  1. Inflammation
  2. Repair
  3. Remodelling
97
Q

Which bursa is most commonly affected in “housemaid’s knee”?

A

Prepatellar

98
Q

What are the Ottawa foot rules?

A

Required: pain in the midfoot

Major (1 required)

  1. Inability to walk 4 steps
  2. Bone tenderness at the navicular or the base of the fifth metatarsal
99
Q

What are the Ottowa ankle rules for the malleolar zone?

A

Bone tenderness at the posterior edge or tip of the lateral malleolus

OR

Bone tenderness at the posterior edge or tip of the medial malleolus

OR

An inability to bear weight both immediately and in the emergency department for four steps

100
Q

Which nerve is affected in tarsal tunnel syndrome?

101
Q

What is the pattern of sensory loss in carpal tunnel syndrome?

A

Loss on the palmar surface of the thumb, index and middle finger, and radial half of the ring

Sensation on the thenar eminence is preserved (affected in more proximal injuries)

The sensory innervation of this area is supplied by the superficial branch of the median nerve, which arises 5–7 cm proximal to the carpal tunnel and is therefore not compressed.

102
Q

What is the most commonly fractured carpal bone?

103
Q

What is “Saturday Night Palsy”?

A

Compression of the radial nerve in the axilla

104
Q

Which nerve can be damaged following a fall onto an outstretched that results in fracture to the hook of the Hamate?

A

Ulnar

FOOSH puts tension on the transverse carpal ligament and causes avulsion of the hook from the body

105
Q

Why are fractures to the scaphoid prone to avascular necrosis?

A

Retrograde blood supply from the palmar carpal branch of the radial artery

Proximal end at higher risk of AVN

106
Q

What are the risk factors for a baker’s cyst?

A

Inflammatory knee disease e.g. rheumatoid arthritis

Degenerative knee disease

Knee trauma e.g. meniscal lesions

Inflammation of the synovium stimulates excess production of synovial fluid

107
Q

What is the most commonly fractured long bone?

108
Q

Which forces cause displacement of a clavicular fracture?

A

Lateral fragment: downward displacement (gravity), adduction (shoulder adductors)

Medial fragment: elevation (sternocleidomastoid)

109
Q

What are the implications of the insertion of the pronator teres on the management of radial fractures?

A

Inserts mid-shaft

Fractures proximal to this point will be supinated by the unopposed action of the biceps brachii

Fractures must be splinted in a supinated position

110
Q

Why are elbow effusions most prominent anteriorly and posteriorly?

A

The capsule is weakest anteriorly and posteriorly

(Lateral and medial ligaments are thickenings of the capsule)

111
Q

When does damage to the radial nerve not cause wrist drop?

A

Damage to the posterior interosseous nerve

The extensor carpi radialis longus is spared

112
Q

Why does wrist drop impair grip?

A

Grip strength is weak in wrist flexion

The flexors must be stretched

113
Q

What is the area of anaesthesia in a radial nerve injury?

A

Dorsum of the hand between the 1st and 2nd metacarpals

114
Q

Which structure is affected in Dupuytren’s contracture?

A

Palmar aponeurosis

The 4th and 5th digits are disproportionately affected

115
Q

How is apparent leg length measured?

A

Umbilicus to medial malleolus

116
Q

How is true leg length measured?

A

ASIS to medial malleolus

117
Q

What is the main purpose of the FABER test?

A

Differentiating sacroiliac from hip joint pathology

Buttock pain = sacroiliitis

Groin pain = hip joint

118
Q

Why is both true and apparent leg length measured?

A

True - anatomical shortening

Apparent - functional shortening e.g. joint contracture, ligament laxity, muscle tension

119
Q

In general terms, how good is the sensitivity and specificity of the anterior drawer test?

A

Sensitivity: poor (27-88%)

Specificity: good (91-99%)

120
Q

In general terms, how good is the sensitivity and specificity of Lachman’s test?

A

Good sensitivity (60-100%)

High specificity (up to 100%)

121
Q

How is the patellar swipe test performed and what constitutes a positive result?

A

The examiner “milks” fluid into the lateral compartment of the knee

If a wave of fluid can be seen heading back towards the medial side of the knee the test is positive

122
Q

What is the difference in clinical value between the patellar tap and swipe test?

A

Tap - large effusions

Swipe - small effusions

Both have very variable sensitivity and specificity

123
Q

How do you perform McMurray’s test?

A

Medial meniscus:

One hand of the examiner is placed on the posteromedial edge of the joint, while the other hand holds the foot and externally rotates it with the knee still exed. The knee is then extended

Reverse for lateral meniscus

124
Q

How do you perform the patellar apprehension test?

A

The patient lies supine with the knee slightly exed (usually to 20–30°). The examiner then applies pressure with both hands, pushing from medial to lateral on the patella, while the patient is instructed to contract the quadriceps muscle. The test is said to be positive if pain occurs or if the anticipation of pain or subluxation.

Dislocated patellofemoral joint, patellar instability, patellofemoral pain syndrome

125
Q

What is a positive shoulder apprehension test and what does it suggest?

A

Positive: patient feels apprehension that the shoulder may dislocate NOT if there is pain

Associations: humeral head subluxation/dislocation, rotator cuff damage, anterior rim damage, detachment of the joint from ligaments

126
Q

What is the sulcus sign?

A

Pulling down of a relaxed, hanging arm causes dimpling of the skin below the acromion

Suggests glenohumeral laxity

127
Q

What is subacromial decompression?

A

Removal of the acromial spur and acromioclavicular ligament

Can be used for shoulder impingement

128
Q

What is being tested in the lift-off test?

A

Subscapularis/internal rotation

129
Q

How is a digital nerve block performed?

A

Injection into the web space, just distal to the MCP joint

130
Q

What does the Hawkins Kennedy test assess?

A

Subacromial impingement

131
Q

Which special manoeuvre can be used to assess the acromioclavicular joint?

A

Crossbody adduction

132
Q

What causes radial head subluxation and who is affected?

A

Sudden axial traction on a pronated and extended forearm

Affects people aged 1-5 years almost exclusively

The radial head is still cartilaginous and the annular ligament is not strong

133
Q

What is a snapping or popping sound in association with a knee injury suggestive of?

A

Ligamental tear, often ACL

Teenagers and young adults may also hear an audible pop with meniscal tears

134
Q

What is immediate swelling in association with a knee injury suggestive of?

A

Haemarthrosis

Significant injury e.g. ACL tear

135
Q

What is locking of the knee suggestive of?

A

Meniscal injury

136
Q

What is a segond fracture?

A

Avulsion fracture of the knee that involves the lateral tibial plateau

Commonly associated with an ACL tear

137
Q

How are ACL tears diagnosed?

A

MRI

Arthroscopy is the gold standard but is not commonly used

138
Q

How long following injury do ACL reconstructions occur?

A

2-12 weeks after the injury

Patients should be pain and swelling free, have an almost normal range of motion and normal gait

Prehabilitation exercises should be done

139
Q

What is Neer’s test?

A

Passive test of subacromial impingement

https://www.youtube.com/watch?v=bXA8cblZUok

140
Q

What questions do you ask on history following a fracture?

A

A - allergies

M - medications

P - past MHx

L - last meal

E - events surrounding injury

141
Q

When is open reduction indicated?

A

NO CAST

N: non-union

O: open fracture

C: neurovascular compromise

A: intra-articular fracture (involve the joint space)

S: Salter-Harris 3, 4, 5

T: polytrauma

Other: failure closed reduction, cannot cast site e.g. hip, infection, non-union

142
Q

List 3 ways fractures can be externally fixated

A
  1. Splints
  2. Casts
  3. Traction
  4. External fixator
143
Q

List 3 ways in which fractures can be internally fixated?

A
  1. Percutaneous pinning
  2. Extramedullary fixation (screws, plates, wires)
  3. Intramedullary fixation (rods)
144
Q

What occurs in the inflammatory stage of bone healing?

A

Haematoma formation

Facilitates the migration of acute inflammatory mediators and cells

Bone resorption, swelling, inflammation

Phagocytes and osteoclasts remove dead or damaged tissue

145
Q

What occurs during the reparative stage of bone healing?

A

Callus formation (fibroblasts and chondroblasts) - begins to stabilise the bone

146
Q

What occurs during the remodelling phase of bone healing?

A

Endochondral callus is replaced by bone

Osteoclasts resorb the hard callus and osteoblasts deposit lamellar bone

147
Q

How are Gartlant type I fractures managed?

A

Immobilisation with above-elbow backslab in 90 degrees of flexion

148
Q

How are Gartland type II fractures managed?

A

Closed reduction (push anteriorly on the distal fragment as the elbow is flexed at 90 degrees)

Immobilisation with above-elbow backslab with 90 degrees flexion

149
Q

How are Gartland type III fractures managed?

A

ORIF with percutaneous K wires

Splinted with a collar and cuff

150
Q

How are Gartland type II fractures reduced?

A

Anteriorly push the olecranon while the hand flexes the humerus

151
Q

How are posterior elbow dislocations reduced?

A

Apply traction of slightly flexed forearm while someone else applies traction on the humerus

152
Q

How are type II gartland fractures reduced?

A

Push the distal fragment anteriorly as the elbow is flexed at 90 degrees

153
Q
A

Subcapital femoral neck fracture

154
Q
A

Transcervical hip fracture

155
Q
A

Intertrochanteric hip fracture

156
Q

List the order in which ossification of the epiphyses in the elbow occurs

A

CRITOE

Capitulum

Radial head

Internal (medial) epicondyle

Trochlea

Olecranon process

External (lateral) epicondyle

Year 3 Semester 2 (7 decks)

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