Orthopaedics Flashcards
What is the most superior landmark on the bony pelvis?
Iliac crest
The obturator foramen is positioned … to the acetabulum
Inferior
List some features of the male pelvis
Male: Narrow heart-shaped pelvic inlet Wide pubic arch Everted margins of the pubic arch Narrow and deep greater sciatic notch Ischial spines project more inward Ischial spines tuberosities less everted Smaller distance between the pubic tubercles Wider acetabulum Large and oval obturator foramen Absent pre auricular sulcus Coccyx projected anteriorly and is more fixed Sacrum is long, narrow and curved throughout it's length
List some features of the female pelvis
Female: Wide circular pelvic inlet Narrow pubic arch Not everted margins of the pubic arch Wide and shallow greater sciatic notch Ischial spines project more outwardly More everted ischial tuberosities Greater distance between the pubic tubercles Narrower acetabulum Pre auricular present Straight and flexible coccyx Short, wide and straighter sacrum
When does the ischial rams fuse to the inferior ramus of the pubis?
Between 5-8 years of age
When does the acetabulum fuse?
Between 11-15 years of age
What are the three primary centres of ossification associated with?
The ilium
The ischium
The pubis
How many secondary centres of ossification are there?
5
Where is the primary ossification centre of the femur located?
The midshaft
When does the primary ossification centre of the femur appear?
7th-8th week in utero
How many secondary ossification centres are there in the femur, and where are they?
1) Proximal femur - appears before birth
2) femoral head - 4-6 months old
3) Greater trochanter - 2-5 years old
4) Lesser trochanter - 11 years
What structure is attached around the margin of the acetabulum, but can not be seen on radiographs?
Acetabular labrum
What are the proximal and distal attachments of the iliofemoral ligament?
Proximal: anterior inferior iliac spine & margin of the acetabulum
Distal: intertrochanteric line
Name the 3 ligaments associated with the hip joint
Iliofemoral
Ischiofemoral
Pubofemoral
In what position is the hip most unstable, and why?
Flexion and medial rotation - the head of the femur is mostly out of the acetabulum and capsule, and the ligaments are all unwound so are ‘loose’
What is the embryological role of the ligament teres?
Transmits blood vessels to the femoral head
Recent research has suggested that the ligamentum treres plays a role in preventing …?
Dislocation of the femoral head, and initiating a reflex response to prevent excessive movements
Where does the major blood supply to the head of the femur enter?
The capsule at the base of the femoral neck
An intra-capsular fracture of the femoral head disrupts femoral head vessels and can result in…
Avascular necrosis
How is an intra-capsular fracture of the femoral head treated?
Replacement of the entire femoral head (usually a heme-arthroplasty), to prevent bleeding and avascular necrosis
Which action des iliopsoas perform?
Hip flexion
What gluteus muscles are involved in abduction?
Gluteus medius and Gluteus minimus
What action does gluteus maximums perform?
Hip extension
What action does performis perform?
Lateral rotation
What is the nerve supply of gluteus medius?
Superior gluteal nerve
Why is the superior gluteal nerve clinically important?
It is vulnerable during hip surgery. Injury to the nerve and resulting paralysis of gluteus medium results in a positive Trendelenburg sign
Action of rectus femurs?
Hip Flexion
Action of adductor longs, adductor braves and the adductor portion of adductor magnus?
Hip Flexion and adduction
Action of gracilis?
Adduction
Action of hamstring portion of adductor magnus?
Adduction and hip flexion
Action of the hamstrings?
Hip Extension
Action of gluteus medium and minimum?
Abduction
Nerve supply of rectus femurs?
Femoral nerve
Nerve supply of adductor longs, adductor braves, adductor portion of adductor Magnus and gracilis?
Obturator nerve
Nerve supply of the hamstring portion of adductor Magnus?
Tibial nerve
nerve supply of the hamstrings?
Sciatic nerve
Which 3 muscles make up the true hamstring group?
Biceps femoris
Semitendonous
Semimembranous
Which muscle is considered a partial hamstring, and why?
Adductor magnus
A section inserts on the ischial tuberosity, and assists in hip extension
When does the primary ossification centres for the tibia appear?
7-8 weeks in utero
Where are the 3 secondary ossification centres in the tibia?
1) Proximal epiphysis - around birth
2) Distal epiphysis - 3-10 months old
3) Ischial tuberosity - 10 years old
When does the primary ossification centre of the fibula appear?
8 weeks in utero
Where are the 2 secondary centres of ossification in the fibula?
1) Distal epiphysis - 1-2 years old
2) Proximal epiphysis - 3-5 years old
Describe the difference in shapes between the 2 menisci?
Medial meniscus - C-shaped
Lateral meniscus - circular
Describer the differences between attachments of the medial and lateral menisci?
Medial - blends into the ACL and the medial collateral ligament
Lateral - not attached to lateral collateral ligament
How is the knee joint ‘unlocked’ after standing?
Contraction of popliteus laterally rotates the femur on the tibia
What is the clinical importance of the ‘unhappy triad of the knee’
Unhappy triad: ACL, medial meniscus and medial collateral ligament. If the medial collateral ligament is torn, this subsequently leads to tearing of the medial meniscus and sometimes the ACL
What is the function of the quadriceps muscles?
Knee extension
What is the function of gastrocnemius?
Knee flexion
What is the function of the hamstrings?
Knee flexion
What is the function of sartorial?
Flexion
What is the function of popliteus?
Lateral rotation
Nerve supply of the quadriceps?
Femoral nerve
Nerve supply of gastrocnemius?
Tibial nerve
Nerve supply of the hamstrings?
Sciatic nerve
Nerve supply of sartorial?
Femoral nerve
Nerve supply of popliteus?
Tibial nerve
Which 4 muscles make up the quadriceps group?
1) Rectus femoris
2) Vastus lateralis
3) Vastus intermedius
4) Vastus medialis
When does the external iliac artery become the femoral artery?
When it passes deep to the inguinal ligament
When does the femoral artery become the popliteal artery?
As it passes through the adductor hiatus and enters the popliteal fossa
What is the fovea capitis?
A small depression on the femoral head which is the site of attachment for the ligamentum teres
What are the attachment points of the ischiofemoral ligament?
Ischium to the inner aspect of the intertrochanteric crest
Name the 3 internal supporting structures of the hip
1) Transverse acetabular ligament (bridges the acetabular notch between the lunate surface)
2) Acetabular labrum - cartilage which blends with the TAL to surround the edge of the acetabulum
3) Ligamentum teres
What the functions of the superior and inferior gemellus?
Rotation
What are the attachment points of the superior gemellus?
Ischial spine to femur
What are the attachment points of the inferior gemellus?
Ischial tuberosity to femur
Which muscle is largely associated with sciatica and why?
Piriformis - the sciatic nerve passes right next to/through it
What is the nerve supply of the anterior thigh compartment?
Femoral nerve
What muscles make up the anterior thigh compartment?
Quadiceps Femoris muscles (rectus femoris, vastus lateralis, vastus intermedius and vastus medialis)
Iliopsoas (formed from posts major, minor and iliac)
Sartorius
Pectineus
Which nerve supplies the medial thigh compartment?
Obturator nerve
Which muscles make up the medial thigh compartment?
Adductor longus
Adductor brevis
Adductor magnus
Gracilis
Which nerve supplies the posterior compartment of the thigh?
Sciatic nerve
Which muscles make up the posterior thigh compartment?
Biceps femoris
Semitendonous
Semimembranous
Where do all three hamstrings originate from?
Ischial tuberosity
Name the 3 borders of the femoral triangle
Inguinal ligament
Medial border of sartorial
Medial border of adductor longus
What structures pass through the femoral triangle?
Femoral artery
Femoral nerve
Femoral vein
Which branch of the femoral artery appears in the femoral triangle?
Profundus femoris
What is the clinical relevance of the femoral artery branch point in the femoral triangle?
Site of femoral hernias
MSK disorders account for about ??% of GP consultations
25%
What is the biggest cause of disability?
Limb trauma
How does NICE define OA?
“a syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life”
OA affects women to men in a ??:1 ratio
1.7
What percentage of over 45 year olds suffer from hip OA?
11
What percentage of over 45 year olds suffer from knee OA?
18
Name some of the risk factors for primary OA
Age
Genetics
Female sex
Obesity
Name some of the risk factors for secondary OA
Trauma Infection SUFE Perthe's inflammation (RA) Gout
Describe articular cartilage
A firm, flexible connective tissue made of chondrocytes bound in an ECM. The ECM is 65-80% water, but also contains type 2 collagen and proteoglycans.
Describe chondrocytes
Chondrocytes are avascular cells which are exclusive to articulate cartilage, nourished via the synovial fluid. Their function is to produce the ECM and enzymes.
Name 3 functions of articular cartilage
Structure
Load bearing
Reduce friction
Describe the pathology of OA
Inappropriate water retained in the ECM –> water content increased –> all other cells decrease in number –> biochemical and structural changes occur –> inferior load bearing and increased friction
Describe the 2 layers and functions of hyaline cartilage
Superficial - smooth surface with parallel collagen fibres and few chondrocytes. Function: decreases joint friction
Deep - perpendicular collagen fibres with greater cell numbers. . Function: load-bearing.
What are the 4 cardinal signs of OA on an x-ray
1) Joint space narrowing
2) Osteophytes
3) Subchondral sclerosis
4) Bone cysts
A working diagnosis of OA can be made without an x-ray if the patient meets the following criteria:
1) Age >45
2) Chronic joint pain (>3 months) which worsens with use
3) Morning stiffness <30 minutes
4) An alternative diagnosis is unlikely
About ?/? of OA patients develop progressive disease
1/3
Conservative management of OA includes…
Patient education Physiotherapy and exercise Lifestyle changes - weight loss, smoking cessation Walking aids Simple analgesia
Surgical management of OA includes…
Joint arthroplasty
Joint arthrodesis (in joints which require little movement)
Osteotomy
Cartilage procedures
List some differences between paediatric and adult fractures
Paediatric fractures:
- Heal more quickly
- Have less morbidity with bed rest (e.g. no chest infection, DVT, pressure sores)
- Have a thick periosteum which allows conservative management
- Can be left malaligned due to remodelling ability
Why are physeal plate injuries important before skeletal maturity?
They can stunt growth
Describe the management of forearm fractures in children
- Controlled in cast
- Manipulation under anaesthesia
- K-wires/flexible nails
Describe the management of femoral fractures in children
- Bed traction
2. Flexible nails (in those who can’t tolerate bed traction)
When would a tibial or femoral fracture be a red flag symptom in a child?
If the child is not mobilising
What age do the physeal growth plates usually fuse?
12-14 years old
List some of the complications of a physical growth plate fracture?
- Increased risk of growth problems
- Partial/complete growth arrest - can lead to angular deformities (varus/valgus legs) or leg length differences
- Intra-articular involvement can predispose to arthritis
How are physical fractures classified?
Salter-Harris Classification system
How would you manage a Salter-Harris type I or II fracture?
Conservative management e.g. cast or MUA
How would you manage a Salter-Harris type III or IV fracture?
Surgical reduction and fixation
What structures do you need to avoid when placing a screw in a Salter-Harris fracture?
Growth plate
Intra-articular structures
What type of Salter-Harris fracture is most common?
Type II
What neurovascular structures would you be concerned about in a supracondylar fracture of the humerus?
Brachial artery
Median nerve
Ulnar nerve
What would be your 4 main differential diagnoses in a limping child under 2 years old?
Infection
Malignancy
Non-accidental injury
Developmental Dysplastic Hip
What would be your 4 main differential diagnoses in a limping child between 3 and 8 years old?
Infection
Malignancy
Non-accidental injury
Perthes Disease
What would be your 4 main differential diagnoses in a limping child between 9 and 15 years old?
Infection
Malignancy
Non-accidental injury
Slipped Capital Femoral Epiphysis
What is the most common musculoskeletal disorder in newborns?
Developmental hip dysplasia
What is the incidence of hip dysplasia in newborns?
1 in 1000
The hips are bilaterally affected in ..% of hip dysplasia cases
20
List the risk factors for hip dysplasia
Female First born Family history Breech birth Oligohydramnios
What tests can be used to screen babies for DDH?
Barlow’s test
Ortolani’s test
Leg length difference testing
Hip abduction testing (limited in DDH)
What imaging should you perform in a baby who is at high risk of DDH?
Ultrasound
Describe the pathophysiology of DDH
DDH is a disorder of abnormal development resulting in acetabular dysplasia, leading to subsequent laxity or dislocation of the hip.
Describe the management options for DDH
- Spica casting (in those 6-18 months)
- Open reduction and case (in those >18 months or where closed reduction has failed)
- Combined femoral head and/or pelvic osteotomy (surgery to shift femoral head into acetabulum, in those with failed treatment, or >24 months of age/late diagnosis)
What is the incidence rate of SUFE?
10 in 100000 children affected
When are children likely to present with SUFE?
Normally just before their pubertal growth spurt/skeletal maturity - girls usually present at 12.2 and boys at 13.4
Describe the risk factors associated with SUFE
Obesity Endocrine disorder Males (male: female 3:2) African Americans Pacific Islanders
Describe the pathophysiology of SUFE
SUFE is a weakness of the proximal femoral physics, which leads to slippage of the epiphysis relative to the femoral neck
Describe how SUFE would typically present
In an 8-15 year old
Commonly with obesity and//or endocrinopathy
Shortened external rotation of hip
Loss of internal rotation and abduction
What imaging would you perform in a child with suspected SUFE?
‘Frog leg’ lateral X-ray - have child sit cross legged
The line of ….. is useful in detecting an early SUFE
Klein
What are some of the complications of an undetected SUFE?
Avascular necrosis
Femoral head collapse
Death of the femoral head
Describe the management options for a child with SUFE
- Pin in situ without attempt to reduce
2. Open realignment if screw can’t be inserted
In Edinburgh, it is routine practice to prophylactically fix the other hip in a child with SUFE (true or false)
True - 50% of children with SUFE will slip on the contralateral side within 1 year
What is the incidence of Perthes disease?
1 in 1000 children affected
The hips are bilaterally affected in ..% cases of Perthes disease
12%
List the risk factors for Perthes disease
Positive family history
Low birth weight
Exposure to second hand smoke
Male (5:1 male: female)
Describe the pathophysiology of Perthes disease
Idiopathic avascular necrosis of the proximal femoral epiphysis - disruption of the femoral head blood supply which leads to bone collapse and subsequent remodelling
Which factors would make the prognosis of Perthes disease worse?
Age >6 at presentation
Female sex
Decreased hip range of motion at presentation
Describe the typical clinical features of Perthes disease
Insidious limp (Trendelenburg gait)
Hip and/or knee pain
Loss of internal rotation and abduction
Leg length differences (in advanced disease)
What imaging test would you perform in a child with suspected Perthes?
X-ray to view bone collapse. An MRI can be used if nothing is seen on x-ray to rule out other pathologies.
Describe the management of Perthes disease
- Observation alone - most cases are self-limiting and tend to get better with skeletal maturity
- Femoral and/or pelvic osteotomy (in children >8, more severe disease and cases of femoral head collapse)
??% of cases of septic arthritis present in children under 2
50%
Which joint is most commonly affected in cases of septic arthritis?
Hip
Describe 3 routes of potential inoculation of the joint in septic arthritis
- Haematogenous spread (most common)
- Extension from adjacent bone
- Direct inoculation from trauma or surgery
…. criteria is used to diagnose septic arthritis?
Kocher’s - there is a 90% chance of a child having septic arthritis is 3/4 criteria are met
List the 4 Kocher’s criteria
- WBC >12,000 cells/ul
- Inability to bear weight
- Fever >38.5oC
- ESR > 40mm/h OR CRP >20
List 4 poor prognostic indicators for septic arthritis
- Age <6 months
- Associated osteomyelitis
- Hip joint affected
- Delay of >4 days until presentation
Describe the management of septic arthritis in a child
- Ultrasound
- Urgent synovial fluid aspiration
- Emergency surgical drainage of the joint
- IV antibiotics for at least 2 weeks
Describe the differences between transient synovitis and septic arthritis
Transient synovitis is a reactive arthritis which typically follows a viral illness (usually an upper respiratory tract infection). The child may be mildly unwell but will be much less sick than a septic child and no pus will be present in the joint.
What is osteomyelitis?
An infection of the bone
Why are paediatric patients art high risk of osteomyelitis?
They have a rich metaphysic blood supply and an immature immune system - osteomyelitis is usually spread haematogenously
How will osteomyelitis typically present clinically?
Joint pain Inability to bear weight Fever Elevated WBC and CRP Normal x-ray
How would you manage osteomyelitis in a child?
IV antibiotics
What are the red flag symptoms for malignancy in a child?
Night bone pain
Systemic symptoms
Joint swelling
What features would make you suspect a non-accidental injury?
History inconsistent with clinical features
History changing between people or over time
Abnormal fracture patterns
Delay seeking medical attention
Atypical injury for age (e.g. 80% of long bone injuries in children <1 year are NAI)
Additional or unreported injuries
Specific injury types (e.g. posterior rib fractures, metaphyseal corner fractures)
..% of children who present with an NAI will undergo further abuse, and ..% will die as a result?
50% of children who present with an NAI will undergo further abuse, and 15% will die as a result?
Define an open fracture
A fracture where there is direct communication between the external environment and the fracture
Describe the Gustily Classification classes
Class 1: low energy, wound <1cm, simple fracture, minimal soft tissue involvement and contamination, no NV injury.
Class 2: moderate energy, wound size 1-10cm, moderate comminution of fracture, moderate soft tissue involvement and contamination, no NV injury.
Class 3a: high energy, wound size >10cm, highly comminuted/segmental fracture, soft tissue injury requires local flap, extensive contamination, no NV injury.
Class 3b: high energy, wound size >10cm, highly comminuted/segmental fracture, soft tissue injury requires free flap, extensive contamination, no NV injury.
Class 3c: requires arterial repair
How would you manage an open fracture
1) IV antibiotics:
- Cefuroxime
- Clindamycin (if allergic to penicillin)
- Gentamicin (if heavy contamination)
2) Tenetanus booster
3) Take photo of injury
4) Cover injury with saline soaked dressing
5) Reduce, restrict and rehabilitate fracture
What is the surgical management of open fractures protocol?
1) Wound debridement
2) Skeletal stabilisation - IM nailing or external fixation
3) Tissue inspection and further debridement
4) Wound closure
List 3 causes of dysvascular limb
1) Kinking of a major vessel
2) Disruption of major vessel
3) Artery spasm
List 6 symptoms of dysvascular limb
1) Pain
2) Parasthesia
3) Pulseless
4) Perishingly cold
5) Pale
6) Paralysis
Describe the management of critical limb ischaemia
1) Resuscitate patient
2) Realign and splint limb
3) Check vascular status
4) Surgical referral if no improvement
Define neurapraxia
Nerve ischaemia from contusion/traction, but structure intact –> once cause is removed, ion pump works again and nerve is normal
Define axonotemesis
Myelin sheath disruption but Schwann cells and endoneurium intact –> distal axon dies but nerve can recover as Schwann cells repair. Myelin sheath may scar and prevent full recovery.
Define neurotemesis
Complete nerve division, irreversible without surgical repair
Which structure is at risk with a hip dislocation, and what signs would you see?
Sciatic nerve injury
Foot drop, numb foot
Which structure is at risk with a knee dislocation and what signs would you see??
Common peroneal nerve injury
Foot drop
Which structure is at risk with a shoulder dislocation, and what signs would you see?
Axillary nerve injury
Reduced abduction
Which structure is at risk with a humeral shaft fracture, and what signs would you see?
Radial nerve injury
Wrist drop
Decreased sensation over 1st dorsal web space
Which structure is at risk with a distal radial fracture, and what signs would you see?
Median nerve
Describe compartment syndrome
Results from increased pressure inside a fixed fascial compartment, which results in reduced tissue perfusion –> causes severe pain and ischaemia and irreversible damage
Name 3 causes of compartment syndrome
- Fracture
- Prolonged lie
- Extreme exercise
List the signs and symptoms of compartment syndrome
Pain on passive stretching
Pain refractory to analgesia
Parasthesia
Muscle feels tight
NORMAL PULSES
Describe the management of compartment syndrome
1) Split cast down to skin
2) Lift limb to level of heart
3) Compartment monitors
4) Emergency fasciotomies of all muscles in affected limb
Define cellulitis
Infection of the skin and subcutaneous fat
Define an abscess
Closed collection of pus
What is the overall mortality of septic arthritis in adults?
10%
What joints are most commonly affected in septic arthritis?
Knee - 50%
Hip - 20%
Shoulder - 8%
What is the most common route of infection in septic arthritis?
Haematogenous
What organisms would you be worried about, and in what group, in a patient with septic arthritis?
Adults:
S. Aureus
Streptococcus
Newborns/young children
Haemophilus influenzae
Young, sexually active adults:
Gonococcal
IVDU:
Pseudomonas aeruginosa
Immunocompromised patients:
Candida/fungus
What signs would you see on examination of a patient with septic arthritis?
Systemically unwell
No passive movement of affected joint
Turbid synovial fluid on joint aspiration
How would you manage a patient with septic arthritis?
1) Joint aspiration
2) IV antibiotics –> Flucloxacillin or Vancomycin
3) Emergency surgical washout
How would you change your management plan of septic arthritis in a patient with a prosthetic infection?
Longer courses of antibiotic and multiple surgical washout
Consider joint replacement or review
What results would you see in the blood test of a patient with necrotising fascitits?
High CRP
High WBC
High Creatinine (due to muscle breakdown)
High lactate
What are the signs and symptoms of necrotising fasciitis?
Rapid progression of rash Systemically unwell Swollen and discoloured limb Extreme pain Crepitations
What is the management protocol for necrotising fascitits?
Mark area to monitor spread
Broad spectrum antibiotics
Sepsis 6
Emergency surgical debridement
Define a fracture
Disruption in bone continuity
Describe a greenstick fracture
Paediatric injury where bone fractures on one side but not other, so bends
Describe a buckle injury
Paediatric injury which allows bone to ‘buckle’ and bulge outwards instead of fracturing
Describe the Salter-Harris classification
Classification of growth plate fractures:
1) Straight through growth plate
2) Above growth plate
3) Lower than the growth plate
4) Through the physis (from above to below)
5) Ruined
Which is the most common type of Salter Harris fracture?
2
List 3 key causes of fracture
1) Injury mechanism exceeds maximum force bone can withstand –> normal bone, abnormal force
2) Co-morbidity which increases risk of fracture
- Osteogenesis Imperfecta
- Rickets/Osteomalacia
- Osteoporosis
- Tumour
3) Co-morbidity which increases risk of injury
- Alcohol/drugs
- Visual impairment
- Balance disorders
- Neuropathy
- Epilepsy
Describe primary fracture healing
Healing which occurs when bone is in direct contact and no movement occurs - absolute stability. No callus forms. This needs surgery but is important for certain fractures e.g. knee, intra-articular fractures and forearm fractures
Describe secondary fracture healing
Fracture healing occurs with callous formation in bones which are relatively stable.
3 stages:
1) Inflammation –> haematoma forms and inflammatory cells invade, granulomatous tissue forms around bone edge
2) Repair –> primary soft callous forms (2 weeks)
3) Remodelling –> woven bone is replaced with lamellar bone (several years)
List patient factors which slow fracture healing
Smoking Alcohol Malnutrition NSAIDs Diabetes Vascular Insufficiency
List fracture-related factors which slow fracture healing
Injury energy transfer
Fracture morphology
Blood supply to fracture
Associated soft tissue injury
List fixation-related factors which slow fracture healing
Inadequate fixation
Soft tissue dissection
Infection
Define a stable fracture
Fracture which remains in place under minimal physiological load
Define an unstable fracture
Fracture which does not remain in place under minimal physiological load
List the absolute indications for operative management of a fracture
Displaced intra-articular fracture
Open fracture
Pathological fracture
Polytrauma –> stabilise long bones
List the relative indications for operative management of a fracture
Failure of conservative management
Fractures with high risk of complications
Morbidity associated with conservative fractures
After a hip fracture, ??% return to previous function, ??% lose their independence and ??% die within a year
33%
33%
33%
Describe the Garden classification of hip fractures
1) undisplaced, incomplete, including valgus impacted fracture
2) undisplaced complete fracture
3) Complete fracture, incompletely displaced
4) Complete fracture, completely displaced
How would you manage an undisplaced intra-capsular hip fracture?
Cannulated hip screws
How would you manage an displaced intra-capsular hip fracture in a young patient?
Cannulated hip screws –> high failure rate, 1/3 need hip replacement
How would you manage an displaced intra-capsular hip fracture in an older patient with dementia and a low level of functional demand?
Hemi arthroplasty
How would you manage an displaced intra-capsular hip fracture in an older patient who is active, cognitively intact and has a high functional demand?
Total hip replacement
How would you manage an intertrochanteric hip fracture?
Dynamic hip screw
How would you manage a subtrochanteric hip fracture?
IM nail
How would you manage an acceptable positioned and stable wrist fracture?
Cast
How would you manage an unacceptable position but stable wrist fracture
Trial manipulation and cast
ORIF if fracture slips
How would you manage an unacceptable and unstable wrist fracture
ORIF
Describe the Weber classification of ankle fractures
A) distal to syndesmosis
B) at level of syndesmosis
C) proximal to syndesmosis
How would you manage a Weber class A fracture?
Moon boot
When would you consider surgery in an ankle fracture?
Weber class C
Unacceptable position/unstable
Bimalleolar
Talar shift
Describe the presentation of impingement syndrome
Pinching pain on raising arm above shoulder
Painful/reduced internal rotation and abduction - positive Hawkin’s test
Other movements unaffected
Normal passive movement
Describe the management algorithm for impingement syndrome
1) NSAIDs
2) Physiotherapy
3) Sub-acromial corticosteroid injections
Describe the presentation of adhesive capsulitis
Presents in middle aged people, diabetics
Global pain and stiffness
Global reduced ROM - external rotation is first to be lost
LIMITED PASSIVE movement
What investigation would you do in someone with suspected adhesive capsulitis and why?
X-ray to rule out arthritis and shoulder dislocation
Describe the management algorithm for adhesive capsulitis
1) Physiotherapy
2) NSAIDs
3) Distention arthrogram
Describe the presentation of rotator cuff disease
Usually occurs after trauma
Constant dull ache
Weak and painful abduction and external rotation - struggle to reach above shoulder height
Normal passive movement
Which rotator cuff muscles are usually affected in rotator cuff disease?
Supraspinatus or infraspinatus
How would you investigate a suspected rotator cuff tear?
MRI
How would you manage rotator cuff damage?
Young, active people –> rotator cuff repair
What percentage of shoulder dislocations are anterior?
90%
When might you suspect a posterior shoulder dislocation?
Electrocution
Epileptic fit
Describe the presentation of GH arthritis
Globally irritable shoulder
Pain improves with analogies
Describe the presentation of ACJ arthritis
Painful/reduced abduction
Tender to palpate over superior shoulder
Can be seen in younger people with jobs working above shoulder height e.g. painter, gardener
Can present simultaneously with rotator cuff degeneration - reduced abduction and weak internal rotation
Describe epicondylitis
Lateral/tennis elbow: pain during wrist and digit extension and during passive wrist flexion
Medial/golf elbow: pain during resisted forearm pronation and resisted wrist flexion
Occurs in 40-50 year olds, caused by muscle overuse.
management: 1) Rest, 2) NSAIDs 3) physiotherapy 4) injection therapy 5) surgical debridement
What is the most common nerve entrapment neuropathy?
Carpal tunnel syndrome
Symptoms of carpal tunnel
Clumsiness
Aching wrist
Numbness/tingling in thumb and radial fingers
Symptoms worse at night
Management of carpal tunnel
1) Wrist splints
2) Hydrocholothiazide
3) NSAIDs
4) Corticosteroid injection
5) Surgical release (1st line in severe disease
Describe Dupuytren’s contracture
Inherited disease of progressive fibrous tissue contracture of the plantar fascia
Risk factors for Dupuytren’s
Northern European Men >40 Smoking Alcohol Diabetes
Management of Dupuytren’s
Corticosteroid injections
Collagenase injections
Surgery
Describe De Quervain’s
Painful tenosynovitis of tendons in wrist and lower thumb, causing pain in base of thumb and wrist
Describe Finkelsteins test
Stretch thumb across palm and make fist - positive if painful
Management of De Quervains
1) Analgesia
2) Splint + physiotherapy
3) Steroid injections
Describe the presentation of hip OA
Deep-seated groin pain
Globally stiff/irritable hip
Limited passive and active movement
Pain worse on movement
Positive Thomas test
Describe the management of hip OA
1) Paracetamol
2) Oral NSAIDs
3) Physiotherapy
4) Total hip replacement
Describe the grading system for OA
0) no radiographic features
1) Possible joint space narrowing and subtle osteophytes
2) Definite joint space narrowing, defined osteophytes and some sclerosis, especially in acetabular region
3) Marked joint space narrowing, small osteophytes, some sclerosis and cyst formation and deformation the femoral head and acetabulum
4) Gross loss of joint space, large osteophytes, sclerosis and cyst formation, increased deformity
What investigation would you request in a patient with acute knee injury and pain?
Knee X-ray
What investigation would you request in a patient with suspected knee OA?
AP and lateral X-rays
Management of knee OA
1) Paracetamol
2) Topical NSAIDs
3) Oral NSAIDs
4) Physiotherapy
5) Intra-articualr steroids
6) Knee replacement/high tibial osteotomy
When would a tibial osteotomy be indicated?
<60s
Isolated OA deformity
Describe the presentation of trochanteric bursitis
Point tenderness over the greater trochanter, with normal passive movement
More common in females
Management of trochanteric bursitis
1) Standard OA management if OA present too
2) Steroid injections
3) Bursa excisions
Describe the presentation of a collateral ligament knee injury
Varus/valgus force Slower swelling (1-2 hours after injury) - may be able to carry on
Swelling over affected side
Possible effusion
Painful palpation over affected side
Pain and potential joint ‘opening’ with varus/valgus pressure
Management of collateral ligament knee injury
Physiotherapy
Surgery in multiple ligament injury
Describe the presentation of an ACL injury
Twisting injury round a fixed foot
Immediate haemarthrosis/swelling - can’t carry on
Large haemarthrosis
Anterior draw
Describe the diagnosis and management of ACL injury
Outpatient MRI
Rehabilitation
Elective ACL reconstruction for those indicated
Indications for elective ACL reconstruction
Young
Physically active
Ongoing instability after rehab
Multi-ligament damage
Describe the presentation of a meniscal injury
Twisting injury
Often occur with other ligamentous injuries
Less severe symptoms/present later
Mechanical symptoms - clicking/locking, inability to fully straighten leg
Joint line tenderness
Unable to fully extend leg
McMurray’s test
When you should acutely x-ray a meniscal injury?
If the patients leg is locked in flexion - trapped meniscus
Management of meniscal injury
Conservative in degernative tears
Arthroscopic debridement or meniscal repair
Describe the presentation of PCL injury
Direct impact to proximal/anterior tibia while knee is flexed
Immediate haemarthrosis/swelling
Hyperextension or hyeprflexion with plantar flexed foot
Haemarthrosis
Posterior sag
Posterior draw
Management of PCL injury
Physiotherapy
Surgical reconstruction in multi-ligament injury or chronic instability
What constitutes an extensor mechanism injury?
Quadriceps tendon rupture >40
Patellar ligament rupture <40
Patellar fracture
How are extensor mechanism injuries diagnosed?
Acute ultrasound - need to diagnose them before tendons contract and wither.
What percentage of people experience non-specific lower back pain at some point?
50-80%
List the red flag symptoms for back pain
Neurological signs
Immunosuppressed patient
Malignancy
Trauma
Management of non-specific lower back pain
Physiotherapy to mobilise lower back
Analgesia
Reassurance
What vertebral level does degenerative disc disease occur at?
L5/S1
Presentation of degenerative disc disease
Back pain radiating to hip/buttock/thigh
Pain worse on walking or axial loading
No neurological symptoms or radicular symptoms or LMN symptoms
Management of degenerative disc disease
Conservative: Activity modification Analgesia Physiotherapy Delayed MRI scan
Surgery
Discectomy
Laminectomy
Presentation of spinal stenosis
Back pain with leg discomfort on walking, worsened when walking up a hill (hip extension) and received by sitting (hip flexion)
Central stenosis - non-specific lower limb weakness
Foraminal stenosis - corresponding nerve root symptoms
What investigation would you do if you suspect spinal stenosis?
MRI
Management of spinal stenosis
Lumbar decompression if symptoms are severe
Define spondylolysis
Defect in the pars interarticularis of the vertebral arch
Define spondylolithesis
Anterior translocation of a vertebrae
Risk factors for adult pyogenic vertebral osteomyelitis/discitis?
Immunosuppression:
- IVDU
- Diabetes
- Recent systemic infection
- Obesity
- Malignancy
- Medication
- Malnutrition
- Smoking
Most common pathogens causing discitis?
S. Aureus
S. Epidermis
Presentation of discitis
Fever Pain: - severe - insidious onset - unrelenting, worse with activity - waking at night Neurological symptoms (10-20%) - Radiculopathy or myelopathy
What investigations would you do in a patient with suspected discitis?
Inflammatory markers
MRI (bone scan/CT if unable to tolerate MRI)
Blood cultures
Management of discitis
Long-term IV flucloxacillin or Vancomycin
Decompression, debridement or stabilisation occasionally required
Define an epidural abscess
Collection of pus or inflammatory granulation tissue between dura and adipose tissue
Causes of Cauda Equine Syndrome
Central compression
Degeneration
- Lumbar disc herniation
- Lumbar spinal canal stenosis
- Spondylolithesis
- Tarlov cysts
- Facet joint cysts
Inflammation
Trauma
- Spinal fracture or dislocation
- Epidural haematoma
Infection
- Epidural abscess
- TB
Malignancy
- Lymphoma
- Metastases
- Primary CNS malignancy
Vascular
- Aortic dissection
- Arteriovenous malformation
Presentation of cauda equine syndrome
Perianal/saddle anaesthesia
Bladder/bowel dysfunction
Reduced/absent anal tone
Lower back pain
Lower limb parasthesia and/or motor weakness (uni or bilateral)
Reduced/absent lower limb reflexes (uni or bilateral)
Sexual dysfunction
What investigation would you do in a patient with suspected cauda equine syndrome?
Emergency MRI
Management of cauda equina syndrome
Emergency decompression
What precautions should be taken in a patient with suspected spinal injury?
Lie patient flat
Log roll
Catheterise
Maintain airway with jaw thrust (not head tilt, chin lift)
Management protocol for any spinal injury includes
- Decompress spinal cord
- Stabilise any fractures
- Steroids within 8 hours
- Extensive rehab
Define tetraplegia
Caused by cervical spine injury, impairment to arms, trunk, legs and pelvic organs
Define paraplegia
Caused by thoracic/lumbar/sacral spine injury, impairment of trunk, legs and pelvis
Define neurogenic shock
Loss of sympathetic trunk activity with profound shock
Define complete spinal injury
Injury with no sparing of motor or sensory function below injury level
Define incomplete spinal injury
Injury with some preserved motor or sensory function below injury level
Define dysplasia
Abnormal ratio of differentiated: undifferentiated cells
Define metaplasia
Abnormal change of one differentiated tissue into another
Define neoplasia
An abnormal mass of tissue, the growth of which exceeds and is uncoordinated with that of the normal tissues, and persists in the same excessive manner after cessation of the stimuli which evoked the change
Define lytic
Removes bone
Define blastic
Deposits bones
Define expansile
Expands normal bone contour
What are the red flag symptoms for malignant tumours
size >5cm
Changes or rapid growth
Pain
Previous sarcoma
Associated symptoms Night pain Weight loss Night sweats Red herring events that patients attribute bony pain to
Describe the differences between benign and malignant tumours
Benign: Well differentiated Slow growth Capsulated Localised and contained
Malignant: Poorly differentiated or anapaestic Fast growth No capsulation - invades surrounding tissue Locally invasive or mestases
What investigations would you perform in a patient with suspected malignancy?
Blood tests (to find the primary):
- FBC
- ESR/CRP
- U&Es
- LFTs
- PSA
- Bone profile (Calcium, phosphate)
- Myeloma screen (serum and urine immunoelectrophoresis
X-rays of all lesions
CT chest, abdo, pelvis to look for metastasis
MRI for primary bone tumours
Biopsy
What are the symptoms of metastatic hypercalcaemia?
Renal or biliary stones Bone pain Abdominal pain, nausea and vomiting Polyuria Constipation Psychiatric disturbance
How would you manage metastatic hypercalacemia?
1) Hydration
2) Bisphosphonates
What is the most common cause of bony tumours
Metasasis
What is the most common reasons for a destructive bone lesion in adults?
Metastasis
Which carcinomas commonly spread to the bone?
Prostate Breast Kidney Thyroid Lung
What is the most common primary bone malignancy in adults >40
Multiple myeloma
What is the 5 and 10 year survival rate of multiple myeloma?
5 year - 30%
10 year - 11%
How is multiple myeloma diagnosed?
Urine or plasma electrophoresis - myeloma is neoplastic proliferation of the plasma cells which produce immunoglobulins
Presentation of multiple myeloma
Skeletal lesions
What investigations would you do in a patient with suspected multiple myeloma?
Urine/plasma electrophoresis
Skeletal survey - bone scans (cold in 30% of patients), X-ray (show punched out lesions)
Management of multiple myeloma
Non-operative:
1) Multi-agent chemotherapy & steroids
2) Bisphosphonates –> help reduce number of skeletal lesions
Operative:
1) Surgical stabilisation and irradiation –> for complete or impending fractures
What is the most common primary tumour of the bone?
Osteosarcoma
When does osteosarcoma usually occur?
Children and young adults, but can occur in elderly patients with Paget’s disease
Presentation of osteosarcoma
Usually affects knee
Presents with rapidly progressive pain, fever and swelling. A mass may be felt on examination
What investigations would you do in a patient with suspected osteosarcoma?
X-rays:
- Characteristic blastic and lytic lesions
- Periosteal reaction (Codman’s triangle)
- Large soft tissue mass
MRIs
- Must include entire involved bone
- Assesses soft tissue and neurovascular involvement
Bone scan:
- Very hot
CT:
- Pulmonary metastases
Biopsy
What malignancy would presence of Codman’s triangle on X-ray indicate?
Osteosarcoma
Management of osteosarcoma
1) Chemotherapy –> pre-op chemo given for 8-12 weeks, followed by maintenance chemo for 6-12 months after resection
2) Surgical limb salvage (where possible) or amputation
What precent of osteosarcoma patients will have long term survival?
76%
What are the poor prognostic factors for osteosarcoma?
Tumour site and size
Advance disease stage
Response to chemotherapy
What is the most common benign bone tumour?
Osteochrondroma
What is the risk of osteochondroma undergoing malignant change?
<1%
What radiological features would you see in Osteochrondoma?
Sessile or pedunculated lesion on bone surface
Pedunculated lesions growing away from involved joint - continuous with cortex and medullary cavity of the bone
What investigations would you use to characterise lesions in a patient with suspected osteochonrdoma?
MRI/CT
Management of Osteochondroma
Observation - asymptomatic/minimally symptomatic patients
Marginal resection at base of stalk, including cartilage cap
Indications for operative management of osteochondroma
Symptomatic lesions
Lesions causing inflammation in surrounding tissue
Lesions which are cosmetically displeasing
Surgical management of osteochondroma should be delayed until skeletal maturity. (True/False)
True
What is the 2nd most common benign cartilage lesion?
Enchondroma
What age group does Enchondroma occur most commonly in?
20-50 year olds
Where is enchondroma most commonly found?
In the diaphysis or metaphysis of long bones
In the hand (60%)
Presentation of enchrondroma
Usually asymptomatic
Can present with pathological fracture or pain
How would an enchondroma appear on X-ray?
Well-defined, lucent, central medullary lesions that calcify over time
Management of enchondroma
Observation - serial radiographs every 3-6 months for 1-2 years, then annually, with long-term follow up for patients with multiple Enchondroma symptoms
Intralesional curettage or bone grafting
Risk of malignant transformation of enchrondroma
1% in single enchondroma
25-30% in Ollier’s disease
Where is chondrosarcoma typically found?
In elderly patients
In the pelvis, proximal femur and scapula
Presentation of chondrosarocoma
Pain
Slow-growing mass
Symptoms of bladder/bowel dysfunction
Pathological fracture (50% of de-differentiated chondrosarcomas)
What features will be present on an X-ray of a Chondrosarcoma?
Lytic or blastic lesion with reactive thickening of the cortex and intra-lesinal ‘popcorn’ mineralisation
What is the 2nd most common bone tumour in children?
Ewing’s Sarcoma
Where is Ewing’s Sarcoma usually found?
Patients age 5-25
~50% in diaphysis of long bones
Most common locations are pelvis, distal femur, proximal tibia, femoral diaphysis and proximal humerus
Presentation of Ewing’s sarcoma
Pain accompanied by fever (mimic infection)
Swelling and local tenderness
What features would be seen on an X-ray of Ewing’s Sarcoma?
Large destructive lesion in the diaphysis or metaphysis with a ‘moth eaten’ appearance.
Periosteal reaction may give an onion skin or sunburst appearance
What investigations would you do in a patient with suspected Ewing’s sarcoma?
X-ray
Bone scan - to stage, will show a very hot lesion
MRI - large soft tissue involvement
CT - to look for pulmonary metastasis
What malignancy is associated with ‘onion skin’ or sunburst appearance on the periosteum?
Ewing’s sarcoma
Presentation of Soft tissue sarcoma
Enlarging painless mass
Where does soft tissue sarcoma most commonly metastasise to?
Lung
What are the basic principles of management in malignancy?
Non-operative:
1) Analgesia
2) Bisphosphonate
3) Radiotherapy
4) Chemotherapy
Operative management of symptoms:
1) Excision of tumour
2) Stabilisation
3) Replacement
Operative prognostic management:
1) Intra-lesional curettage/marginal excision –> benign tumours
2) Wide local excision –> most common for malignant tumours
3) Radical excision (all muscles of affected compartment) –> rarely required
4) Amputation
Presentation of osteogenesis imperfecta
Fractures Blue tinge to sclera Easy bruising Short height Loose joints Hearing loss Breathing problems Problems with teeth
How would you diagnose osteogenesis imperfecta?
Clinical features
X-ray
Genetic testing
Management of osteogenesis imperfecta
Lifestyle changes Analgesia Physiotherapy Wheelchairs Bisphosphonates Surgery
