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Year 4 > Orthopaedics > Flashcards

Orthopaedics Flashcards

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1
Q

What is the most superior landmark on the bony pelvis?

A

Iliac crest

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2
Q

The obturator foramen is positioned … to the acetabulum

A

Inferior

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3
Q

List some features of the male pelvis

A 
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
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4
Q

List some features of the female pelvis

A 
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
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5
Q

When does the ischial rams fuse to the inferior ramus of the pubis?

A

Between 5-8 years of age

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6
Q

When does the acetabulum fuse?

A

Between 11-15 years of age

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7
Q

What are the three primary centres of ossification associated with?

A

The ilium
The ischium
The pubis

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8
Q

How many secondary centres of ossification are there?

A

5

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9
Q

Where is the primary ossification centre of the femur located?

A

The midshaft

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10
Q

When does the primary ossification centre of the femur appear?

A

7th-8th week in utero

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11
Q

How many secondary ossification centres are there in the femur, and where are they?

A

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

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12
Q

What structure is attached around the margin of the acetabulum, but can not be seen on radiographs?

A

Acetabular labrum

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13
Q

What are the proximal and distal attachments of the iliofemoral ligament?

A

Proximal: anterior inferior iliac spine & margin of the acetabulum
Distal: intertrochanteric line

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14
Q

Name the 3 ligaments associated with the hip joint

A

Iliofemoral
Ischiofemoral
Pubofemoral

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15
Q

In what position is the hip most unstable, and why?

A

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’

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16
Q

What is the embryological role of the ligament teres?

A

Transmits blood vessels to the femoral head

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17
Q

Recent research has suggested that the ligamentum treres plays a role in preventing …?

A

Dislocation of the femoral head, and initiating a reflex response to prevent excessive movements

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18
Q

Where does the major blood supply to the head of the femur enter?

A

The capsule at the base of the femoral neck

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19
Q

An intra-capsular fracture of the femoral head disrupts femoral head vessels and can result in…

A

Avascular necrosis

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20
Q

How is an intra-capsular fracture of the femoral head treated?

A

Replacement of the entire femoral head (usually a heme-arthroplasty), to prevent bleeding and avascular necrosis

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21
Q

Which action des iliopsoas perform?

A

Hip flexion

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22
Q

What gluteus muscles are involved in abduction?

A

Gluteus medius and Gluteus minimus

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23
Q

What action does gluteus maximums perform?

A

Hip extension

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24
Q

What action does performis perform?

A

Lateral rotation

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25
Q

What is the nerve supply of gluteus medius?

A

Superior gluteal nerve

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26
Q

Why is the superior gluteal nerve clinically important?

A

It is vulnerable during hip surgery. Injury to the nerve and resulting paralysis of gluteus medium results in a positive Trendelenburg sign

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27
Q

Action of rectus femurs?

A

Hip Flexion

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28
Q

Action of adductor longs, adductor braves and the adductor portion of adductor magnus?

A

Hip Flexion and adduction

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29
Q

Action of gracilis?

A

Adduction

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30
Q

Action of hamstring portion of adductor magnus?

A

Adduction and hip flexion

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31
Q

Action of the hamstrings?

A

Hip Extension

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32
Q

Action of gluteus medium and minimum?

A

Abduction

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33
Q

Nerve supply of rectus femurs?

A

Femoral nerve

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34
Q

Nerve supply of adductor longs, adductor braves, adductor portion of adductor Magnus and gracilis?

A

Obturator nerve

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35
Q

Nerve supply of the hamstring portion of adductor Magnus?

A

Tibial nerve

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36
Q

nerve supply of the hamstrings?

A

Sciatic nerve

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37
Q

Which 3 muscles make up the true hamstring group?

A

Biceps femoris
Semitendonous
Semimembranous

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38
Q

Which muscle is considered a partial hamstring, and why?

A

Adductor magnus

A section inserts on the ischial tuberosity, and assists in hip extension

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39
Q

When does the primary ossification centres for the tibia appear?

A

7-8 weeks in utero

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40
Q

Where are the 3 secondary ossification centres in the tibia?

A

1) Proximal epiphysis - around birth
2) Distal epiphysis - 3-10 months old
3) Ischial tuberosity - 10 years old

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41
Q

When does the primary ossification centre of the fibula appear?

A

8 weeks in utero

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42
Q

Where are the 2 secondary centres of ossification in the fibula?

A

1) Distal epiphysis - 1-2 years old

2) Proximal epiphysis - 3-5 years old

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43
Q

Describe the difference in shapes between the 2 menisci?

A

Medial meniscus - C-shaped

Lateral meniscus - circular

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44
Q

Describer the differences between attachments of the medial and lateral menisci?

A

Medial - blends into the ACL and the medial collateral ligament
Lateral - not attached to lateral collateral ligament

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45
Q

How is the knee joint ‘unlocked’ after standing?

A

Contraction of popliteus laterally rotates the femur on the tibia

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46
Q

What is the clinical importance of the ‘unhappy triad of the knee’

A

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

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47
Q

What is the function of the quadriceps muscles?

A

Knee extension

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48
Q

What is the function of gastrocnemius?

A

Knee flexion

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49
Q

What is the function of the hamstrings?

A

Knee flexion

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50
Q

What is the function of sartorial?

A

Flexion

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51
Q

What is the function of popliteus?

A

Lateral rotation

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52
Q

Nerve supply of the quadriceps?

A

Femoral nerve

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53
Q

Nerve supply of gastrocnemius?

A

Tibial nerve

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54
Q

Nerve supply of the hamstrings?

A

Sciatic nerve

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55
Q

Nerve supply of sartorial?

A

Femoral nerve

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56
Q

Nerve supply of popliteus?

A

Tibial nerve

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57
Q

Which 4 muscles make up the quadriceps group?

A

1) Rectus femoris
2) Vastus lateralis
3) Vastus intermedius
4) Vastus medialis

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58
Q

When does the external iliac artery become the femoral artery?

A

When it passes deep to the inguinal ligament

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59
Q

When does the femoral artery become the popliteal artery?

A

As it passes through the adductor hiatus and enters the popliteal fossa

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60
Q

What is the fovea capitis?

A

A small depression on the femoral head which is the site of attachment for the ligamentum teres

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61
Q

What are the attachment points of the ischiofemoral ligament?

A

Ischium to the inner aspect of the intertrochanteric crest

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62
Q

Name the 3 internal supporting structures of the hip

A

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

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63
Q

What the functions of the superior and inferior gemellus?

A

Rotation

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64
Q

What are the attachment points of the superior gemellus?

A

Ischial spine to femur

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65
Q

What are the attachment points of the inferior gemellus?

A

Ischial tuberosity to femur

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66
Q

Which muscle is largely associated with sciatica and why?

A

Piriformis - the sciatic nerve passes right next to/through it

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67
Q

What is the nerve supply of the anterior thigh compartment?

A

Femoral nerve

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68
Q

What muscles make up the anterior thigh compartment?

A

Quadiceps Femoris muscles (rectus femoris, vastus lateralis, vastus intermedius and vastus medialis)
Iliopsoas (formed from posts major, minor and iliac)
Sartorius
Pectineus

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69
Q

Which nerve supplies the medial thigh compartment?

A

Obturator nerve

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70
Q

Which muscles make up the medial thigh compartment?

A

Adductor longus
Adductor brevis
Adductor magnus
Gracilis

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71
Q

Which nerve supplies the posterior compartment of the thigh?

A

Sciatic nerve

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72
Q

Which muscles make up the posterior thigh compartment?

A

Biceps femoris
Semitendonous
Semimembranous

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73
Q

Where do all three hamstrings originate from?

A

Ischial tuberosity

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74
Q

Name the 3 borders of the femoral triangle

A

Inguinal ligament
Medial border of sartorial
Medial border of adductor longus

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75
Q

What structures pass through the femoral triangle?

A

Femoral artery
Femoral nerve
Femoral vein

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76
Q

Which branch of the femoral artery appears in the femoral triangle?

A

Profundus femoris

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77
Q

What is the clinical relevance of the femoral artery branch point in the femoral triangle?

A

Site of femoral hernias

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78
Q

MSK disorders account for about ??% of GP consultations

A

25%

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79
Q

What is the biggest cause of disability?

A

Limb trauma

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80
Q

How does NICE define OA?

A

“a syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life”

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81
Q

OA affects women to men in a ??:1 ratio

A

1.7

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82
Q

What percentage of over 45 year olds suffer from hip OA?

A

11

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83
Q

What percentage of over 45 year olds suffer from knee OA?

A

18

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84
Q

Name some of the risk factors for primary OA

A

Age
Genetics
Female sex
Obesity

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85
Q

Name some of the risk factors for secondary OA

A 
Trauma
Infection
SUFE
Perthe's
inflammation (RA)
Gout
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86
Q

Describe articular cartilage

A

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.

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87
Q

Describe chondrocytes

A

Chondrocytes are avascular cells which are exclusive to articulate cartilage, nourished via the synovial fluid. Their function is to produce the ECM and enzymes.

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88
Q

Name 3 functions of articular cartilage

A

Structure
Load bearing
Reduce friction

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89
Q

Describe the pathology of OA

A

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

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90
Q

Describe the 2 layers and functions of hyaline cartilage

A

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.

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91
Q

What are the 4 cardinal signs of OA on an x-ray

A

1) Joint space narrowing
2) Osteophytes
3) Subchondral sclerosis
4) Bone cysts

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92
Q

A working diagnosis of OA can be made without an x-ray if the patient meets the following criteria:

A

1) Age >45
2) Chronic joint pain (>3 months) which worsens with use
3) Morning stiffness <30 minutes
4) An alternative diagnosis is unlikely

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93
Q

About ?/? of OA patients develop progressive disease

A

1/3

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94
Q

Conservative management of OA includes…

A 
Patient education
Physiotherapy and exercise
Lifestyle changes - weight loss, smoking cessation
Walking aids
Simple analgesia
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95
Q

Surgical management of OA includes…

A

Joint arthroplasty
Joint arthrodesis (in joints which require little movement)
Osteotomy
Cartilage procedures

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96
Q

List some differences between paediatric and adult fractures

A

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
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97
Q

Why are physeal plate injuries important before skeletal maturity?

A

They can stunt growth

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98
Q

Describe the management of forearm fractures in children

A
  1. Controlled in cast
  2. Manipulation under anaesthesia
  3. K-wires/flexible nails
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99
Q

Describe the management of femoral fractures in children

A
  1. Bed traction

2. Flexible nails (in those who can’t tolerate bed traction)

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100
Q

When would a tibial or femoral fracture be a red flag symptom in a child?

A

If the child is not mobilising

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101
Q

What age do the physeal growth plates usually fuse?

A

12-14 years old

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102
Q

List some of the complications of a physical growth plate fracture?

A
  1. Increased risk of growth problems
  2. Partial/complete growth arrest - can lead to angular deformities (varus/valgus legs) or leg length differences
  3. Intra-articular involvement can predispose to arthritis
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103
Q

How are physical fractures classified?

A

Salter-Harris Classification system

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104
Q

How would you manage a Salter-Harris type I or II fracture?

A

Conservative management e.g. cast or MUA

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105
Q

How would you manage a Salter-Harris type III or IV fracture?

A

Surgical reduction and fixation

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106
Q

What structures do you need to avoid when placing a screw in a Salter-Harris fracture?

A

Growth plate

Intra-articular structures

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107
Q

What type of Salter-Harris fracture is most common?

A

Type II

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108
Q

What neurovascular structures would you be concerned about in a supracondylar fracture of the humerus?

A

Brachial artery
Median nerve
Ulnar nerve

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109
Q

What would be your 4 main differential diagnoses in a limping child under 2 years old?

A

Infection
Malignancy
Non-accidental injury
Developmental Dysplastic Hip

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110
Q

What would be your 4 main differential diagnoses in a limping child between 3 and 8 years old?

A

Infection
Malignancy
Non-accidental injury
Perthes Disease

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111
Q

What would be your 4 main differential diagnoses in a limping child between 9 and 15 years old?

A

Infection
Malignancy
Non-accidental injury
Slipped Capital Femoral Epiphysis

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112
Q

What is the most common musculoskeletal disorder in newborns?

A

Developmental hip dysplasia

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113
Q

What is the incidence of hip dysplasia in newborns?

A

1 in 1000

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114
Q

The hips are bilaterally affected in ..% of hip dysplasia cases

A

20

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115
Q

List the risk factors for hip dysplasia

A 
Female
First born
Family history
Breech birth
Oligohydramnios
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116
Q

What tests can be used to screen babies for DDH?

A

Barlow’s test
Ortolani’s test
Leg length difference testing
Hip abduction testing (limited in DDH)

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117
Q

What imaging should you perform in a baby who is at high risk of DDH?

A

Ultrasound

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118
Q

Describe the pathophysiology of DDH

A

DDH is a disorder of abnormal development resulting in acetabular dysplasia, leading to subsequent laxity or dislocation of the hip.

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119
Q

Describe the management options for DDH

A
  1. Spica casting (in those 6-18 months)
  2. Open reduction and case (in those >18 months or where closed reduction has failed)
  3. 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)
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120
Q

What is the incidence rate of SUFE?

A

10 in 100000 children affected

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121
Q

When are children likely to present with SUFE?

A

Normally just before their pubertal growth spurt/skeletal maturity - girls usually present at 12.2 and boys at 13.4

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122
Q

Describe the risk factors associated with SUFE

A 
Obesity
Endocrine disorder
Males (male: female 3:2)
African Americans
Pacific Islanders
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123
Q

Describe the pathophysiology of SUFE

A

SUFE is a weakness of the proximal femoral physics, which leads to slippage of the epiphysis relative to the femoral neck

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124
Q

Describe how SUFE would typically present

A

In an 8-15 year old
Commonly with obesity and//or endocrinopathy
Shortened external rotation of hip
Loss of internal rotation and abduction

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125
Q

What imaging would you perform in a child with suspected SUFE?

A

‘Frog leg’ lateral X-ray - have child sit cross legged

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126
Q

The line of ….. is useful in detecting an early SUFE

A

Klein

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127
Q

What are some of the complications of an undetected SUFE?

A

Avascular necrosis
Femoral head collapse
Death of the femoral head

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128
Q

Describe the management options for a child with SUFE

A
  1. Pin in situ without attempt to reduce

2. Open realignment if screw can’t be inserted

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129
Q

In Edinburgh, it is routine practice to prophylactically fix the other hip in a child with SUFE (true or false)

A

True - 50% of children with SUFE will slip on the contralateral side within 1 year

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130
Q

What is the incidence of Perthes disease?

A

1 in 1000 children affected

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131
Q

The hips are bilaterally affected in ..% cases of Perthes disease

A

12%

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132
Q

List the risk factors for Perthes disease

A

Positive family history
Low birth weight
Exposure to second hand smoke
Male (5:1 male: female)

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133
Q

Describe the pathophysiology of Perthes disease

A

Idiopathic avascular necrosis of the proximal femoral epiphysis - disruption of the femoral head blood supply which leads to bone collapse and subsequent remodelling

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134
Q

Which factors would make the prognosis of Perthes disease worse?

A

Age >6 at presentation
Female sex
Decreased hip range of motion at presentation

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135
Q

Describe the typical clinical features of Perthes disease

A

Insidious limp (Trendelenburg gait)
Hip and/or knee pain
Loss of internal rotation and abduction
Leg length differences (in advanced disease)

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136
Q

What imaging test would you perform in a child with suspected Perthes?

A

X-ray to view bone collapse. An MRI can be used if nothing is seen on x-ray to rule out other pathologies.

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137
Q

Describe the management of Perthes disease

A
  1. Observation alone - most cases are self-limiting and tend to get better with skeletal maturity
  2. Femoral and/or pelvic osteotomy (in children >8, more severe disease and cases of femoral head collapse)
138
Q

??% of cases of septic arthritis present in children under 2

A

50%

139
Q

Which joint is most commonly affected in cases of septic arthritis?

A

Hip

140
Q

Describe 3 routes of potential inoculation of the joint in septic arthritis

A
  1. Haematogenous spread (most common)
  2. Extension from adjacent bone
  3. Direct inoculation from trauma or surgery
141
Q

…. criteria is used to diagnose septic arthritis?

A

Kocher’s - there is a 90% chance of a child having septic arthritis is 3/4 criteria are met

142
Q

List the 4 Kocher’s criteria

A
  1. WBC >12,000 cells/ul
  2. Inability to bear weight
  3. Fever >38.5oC
  4. ESR > 40mm/h OR CRP >20
143
Q

List 4 poor prognostic indicators for septic arthritis

A
  1. Age <6 months
  2. Associated osteomyelitis
  3. Hip joint affected
  4. Delay of >4 days until presentation
144
Q

Describe the management of septic arthritis in a child

A
  1. Ultrasound
  2. Urgent synovial fluid aspiration
  3. Emergency surgical drainage of the joint
  4. IV antibiotics for at least 2 weeks
145
Q

Describe the differences between transient synovitis and septic arthritis

A

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.

146
Q

What is osteomyelitis?

A

An infection of the bone

147
Q

Why are paediatric patients art high risk of osteomyelitis?

A

They have a rich metaphysic blood supply and an immature immune system - osteomyelitis is usually spread haematogenously

148
Q

How will osteomyelitis typically present clinically?

A 
Joint pain
Inability to bear weight
Fever
Elevated WBC and CRP
Normal x-ray
149
Q

How would you manage osteomyelitis in a child?

A

IV antibiotics

150
Q

What are the red flag symptoms for malignancy in a child?

A

Night bone pain
Systemic symptoms
Joint swelling

151
Q

What features would make you suspect a non-accidental injury?

A

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)

152
Q

..% of children who present with an NAI will undergo further abuse, and ..% will die as a result?

A

50% of children who present with an NAI will undergo further abuse, and 15% will die as a result?

153
Q

Define an open fracture

A

A fracture where there is direct communication between the external environment and the fracture

154
Q

Describe the Gustily Classification classes

A

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

155
Q

How would you manage an open fracture

A

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

156
Q

What is the surgical management of open fractures protocol?

A

1) Wound debridement
2) Skeletal stabilisation - IM nailing or external fixation
3) Tissue inspection and further debridement
4) Wound closure

157
Q

List 3 causes of dysvascular limb

A

1) Kinking of a major vessel
2) Disruption of major vessel
3) Artery spasm

158
Q

List 6 symptoms of dysvascular limb

A

1) Pain
2) Parasthesia
3) Pulseless
4) Perishingly cold
5) Pale
6) Paralysis

159
Q

Describe the management of critical limb ischaemia

A

1) Resuscitate patient
2) Realign and splint limb
3) Check vascular status
4) Surgical referral if no improvement

160
Q

Define neurapraxia

A

Nerve ischaemia from contusion/traction, but structure intact –> once cause is removed, ion pump works again and nerve is normal

161
Q

Define axonotemesis

A

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.

162
Q

Define neurotemesis

A

Complete nerve division, irreversible without surgical repair

163
Q

Which structure is at risk with a hip dislocation, and what signs would you see?

A

Sciatic nerve injury

Foot drop, numb foot

164
Q

Which structure is at risk with a knee dislocation and what signs would you see??

A

Common peroneal nerve injury

Foot drop

165
Q

Which structure is at risk with a shoulder dislocation, and what signs would you see?

A

Axillary nerve injury

Reduced abduction

166
Q

Which structure is at risk with a humeral shaft fracture, and what signs would you see?

A

Radial nerve injury

Wrist drop
Decreased sensation over 1st dorsal web space

167
Q

Which structure is at risk with a distal radial fracture, and what signs would you see?

A

Median nerve

168
Q

Describe compartment syndrome

A

Results from increased pressure inside a fixed fascial compartment, which results in reduced tissue perfusion –> causes severe pain and ischaemia and irreversible damage

169
Q

Name 3 causes of compartment syndrome

A
  1. Fracture
  2. Prolonged lie
  3. Extreme exercise
170
Q

List the signs and symptoms of compartment syndrome

A

Pain on passive stretching
Pain refractory to analgesia
Parasthesia
Muscle feels tight

NORMAL PULSES

171
Q

Describe the management of compartment syndrome

A

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

172
Q

Define cellulitis

A

Infection of the skin and subcutaneous fat

173
Q

Define an abscess

A

Closed collection of pus

174
Q

What is the overall mortality of septic arthritis in adults?

A

10%

175
Q

What joints are most commonly affected in septic arthritis?

A

Knee - 50%
Hip - 20%
Shoulder - 8%

176
Q

What is the most common route of infection in septic arthritis?

A

Haematogenous

177
Q

What organisms would you be worried about, and in what group, in a patient with septic arthritis?

A

Adults:
S. Aureus
Streptococcus

Newborns/young children
Haemophilus influenzae

Young, sexually active adults:
Gonococcal

IVDU:
Pseudomonas aeruginosa

Immunocompromised patients:
Candida/fungus

178
Q

What signs would you see on examination of a patient with septic arthritis?

A

Systemically unwell
No passive movement of affected joint

Turbid synovial fluid on joint aspiration

179
Q

How would you manage a patient with septic arthritis?

A

1) Joint aspiration
2) IV antibiotics –> Flucloxacillin or Vancomycin
3) Emergency surgical washout

180
Q

How would you change your management plan of septic arthritis in a patient with a prosthetic infection?

A

Longer courses of antibiotic and multiple surgical washout

Consider joint replacement or review

181
Q

What results would you see in the blood test of a patient with necrotising fascitits?

A

High CRP
High WBC
High Creatinine (due to muscle breakdown)
High lactate

182
Q

What are the signs and symptoms of necrotising fasciitis?

A 
Rapid progression of rash
Systemically unwell
Swollen and discoloured limb
Extreme pain
Crepitations
183
Q

What is the management protocol for necrotising fascitits?

A

Mark area to monitor spread
Broad spectrum antibiotics
Sepsis 6
Emergency surgical debridement

184
Q

Define a fracture

A

Disruption in bone continuity

185
Q

Describe a greenstick fracture

A

Paediatric injury where bone fractures on one side but not other, so bends

186
Q

Describe a buckle injury

A

Paediatric injury which allows bone to ‘buckle’ and bulge outwards instead of fracturing

187
Q

Describe the Salter-Harris classification

A

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

188
Q

Which is the most common type of Salter Harris fracture?

A

2

189
Q

List 3 key causes of fracture

A

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

190
Q

Describe primary fracture healing

A

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

191
Q

Describe secondary fracture healing

A

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)

192
Q

List patient factors which slow fracture healing

A 
Smoking
Alcohol
Malnutrition
NSAIDs
Diabetes
Vascular Insufficiency
193
Q

List fracture-related factors which slow fracture healing

A

Injury energy transfer
Fracture morphology
Blood supply to fracture
Associated soft tissue injury

194
Q

List fixation-related factors which slow fracture healing

A

Inadequate fixation
Soft tissue dissection
Infection

195
Q

Define a stable fracture

A

Fracture which remains in place under minimal physiological load

196
Q

Define an unstable fracture

A

Fracture which does not remain in place under minimal physiological load

197
Q

List the absolute indications for operative management of a fracture

A

Displaced intra-articular fracture
Open fracture
Pathological fracture
Polytrauma –> stabilise long bones

198
Q

List the relative indications for operative management of a fracture

A

Failure of conservative management
Fractures with high risk of complications
Morbidity associated with conservative fractures

199
Q

After a hip fracture, ??% return to previous function, ??% lose their independence and ??% die within a year

A

33%
33%
33%

200
Q

Describe the Garden classification of hip fractures

A

1) undisplaced, incomplete, including valgus impacted fracture
2) undisplaced complete fracture
3) Complete fracture, incompletely displaced
4) Complete fracture, completely displaced

201
Q

How would you manage an undisplaced intra-capsular hip fracture?

A

Cannulated hip screws

202
Q

How would you manage an displaced intra-capsular hip fracture in a young patient?

A

Cannulated hip screws –> high failure rate, 1/3 need hip replacement

203
Q

How would you manage an displaced intra-capsular hip fracture in an older patient with dementia and a low level of functional demand?

A

Hemi arthroplasty

204
Q

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?

A

Total hip replacement

205
Q

How would you manage an intertrochanteric hip fracture?

A

Dynamic hip screw

206
Q

How would you manage a subtrochanteric hip fracture?

A

IM nail

207
Q

How would you manage an acceptable positioned and stable wrist fracture?

A

Cast

208
Q

How would you manage an unacceptable position but stable wrist fracture

A

Trial manipulation and cast

ORIF if fracture slips

209
Q

How would you manage an unacceptable and unstable wrist fracture

A

ORIF

210
Q

Describe the Weber classification of ankle fractures

A

A) distal to syndesmosis
B) at level of syndesmosis
C) proximal to syndesmosis

211
Q

How would you manage a Weber class A fracture?

A

Moon boot

212
Q

When would you consider surgery in an ankle fracture?

A

Weber class C
Unacceptable position/unstable
Bimalleolar
Talar shift

213
Q

Describe the presentation of impingement syndrome

A

Pinching pain on raising arm above shoulder
Painful/reduced internal rotation and abduction - positive Hawkin’s test
Other movements unaffected
Normal passive movement

214
Q

Describe the management algorithm for impingement syndrome

A

1) NSAIDs
2) Physiotherapy
3) Sub-acromial corticosteroid injections

215
Q

Describe the presentation of adhesive capsulitis

A

Presents in middle aged people, diabetics
Global pain and stiffness
Global reduced ROM - external rotation is first to be lost
LIMITED PASSIVE movement

216
Q

What investigation would you do in someone with suspected adhesive capsulitis and why?

A

X-ray to rule out arthritis and shoulder dislocation

217
Q

Describe the management algorithm for adhesive capsulitis

A

1) Physiotherapy
2) NSAIDs
3) Distention arthrogram

218
Q

Describe the presentation of rotator cuff disease

A

Usually occurs after trauma
Constant dull ache
Weak and painful abduction and external rotation - struggle to reach above shoulder height
Normal passive movement

219
Q

Which rotator cuff muscles are usually affected in rotator cuff disease?

A

Supraspinatus or infraspinatus

220
Q

How would you investigate a suspected rotator cuff tear?

A

MRI

221
Q

How would you manage rotator cuff damage?

A

Young, active people –> rotator cuff repair

222
Q

What percentage of shoulder dislocations are anterior?

A

90%

223
Q

When might you suspect a posterior shoulder dislocation?

A

Electrocution

Epileptic fit

224
Q

Describe the presentation of GH arthritis

A

Globally irritable shoulder

Pain improves with analogies

225
Q

Describe the presentation of ACJ arthritis

A

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

226
Q

Describe epicondylitis

A

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

227
Q

What is the most common nerve entrapment neuropathy?

A

Carpal tunnel syndrome

228
Q

Symptoms of carpal tunnel

A

Clumsiness
Aching wrist
Numbness/tingling in thumb and radial fingers
Symptoms worse at night

229
Q

Management of carpal tunnel

A

1) Wrist splints
2) Hydrocholothiazide
3) NSAIDs
4) Corticosteroid injection
5) Surgical release (1st line in severe disease

230
Q

Describe Dupuytren’s contracture

A

Inherited disease of progressive fibrous tissue contracture of the plantar fascia

231
Q

Risk factors for Dupuytren’s

A 
Northern European 
Men
>40
Smoking
Alcohol
Diabetes
232
Q

Management of Dupuytren’s

A

Corticosteroid injections
Collagenase injections
Surgery

233
Q

Describe De Quervain’s

A

Painful tenosynovitis of tendons in wrist and lower thumb, causing pain in base of thumb and wrist

234
Q

Describe Finkelsteins test

A

Stretch thumb across palm and make fist - positive if painful

235
Q

Management of De Quervains

A

1) Analgesia
2) Splint + physiotherapy
3) Steroid injections

236
Q

Describe the presentation of hip OA

A

Deep-seated groin pain
Globally stiff/irritable hip
Limited passive and active movement
Pain worse on movement

Positive Thomas test

237
Q

Describe the management of hip OA

A

1) Paracetamol
2) Oral NSAIDs
3) Physiotherapy
4) Total hip replacement

238
Q

Describe the grading system for OA

A

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

239
Q

What investigation would you request in a patient with acute knee injury and pain?

A

Knee X-ray

240
Q

What investigation would you request in a patient with suspected knee OA?

A

AP and lateral X-rays

241
Q

Management of knee OA

A

1) Paracetamol
2) Topical NSAIDs
3) Oral NSAIDs
4) Physiotherapy
5) Intra-articualr steroids
6) Knee replacement/high tibial osteotomy

242
Q

When would a tibial osteotomy be indicated?

A

<60s

Isolated OA deformity

243
Q

Describe the presentation of trochanteric bursitis

A

Point tenderness over the greater trochanter, with normal passive movement

More common in females

244
Q

Management of trochanteric bursitis

A

1) Standard OA management if OA present too
2) Steroid injections
3) Bursa excisions

245
Q

Describe the presentation of a collateral ligament knee injury

A 
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

246
Q

Management of collateral ligament knee injury

A

Physiotherapy

Surgery in multiple ligament injury

247
Q

Describe the presentation of an ACL injury

A

Twisting injury round a fixed foot
Immediate haemarthrosis/swelling - can’t carry on

Large haemarthrosis
Anterior draw

248
Q

Describe the diagnosis and management of ACL injury

A

Outpatient MRI

Rehabilitation
Elective ACL reconstruction for those indicated

249
Q

Indications for elective ACL reconstruction

A

Young
Physically active
Ongoing instability after rehab
Multi-ligament damage

250
Q

Describe the presentation of a meniscal injury

A

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

251
Q

When you should acutely x-ray a meniscal injury?

A

If the patients leg is locked in flexion - trapped meniscus

252
Q

Management of meniscal injury

A

Conservative in degernative tears

Arthroscopic debridement or meniscal repair

253
Q

Describe the presentation of PCL injury

A

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

254
Q

Management of PCL injury

A

Physiotherapy

Surgical reconstruction in multi-ligament injury or chronic instability

255
Q

What constitutes an extensor mechanism injury?

A

Quadriceps tendon rupture >40
Patellar ligament rupture <40
Patellar fracture

256
Q

How are extensor mechanism injuries diagnosed?

A

Acute ultrasound - need to diagnose them before tendons contract and wither.

257
Q

What percentage of people experience non-specific lower back pain at some point?

A

50-80%

258
Q

List the red flag symptoms for back pain

A

Neurological signs
Immunosuppressed patient
Malignancy
Trauma

259
Q

Management of non-specific lower back pain

A

Physiotherapy to mobilise lower back
Analgesia
Reassurance

260
Q

What vertebral level does degenerative disc disease occur at?

A

L5/S1

261
Q

Presentation of degenerative disc disease

A

Back pain radiating to hip/buttock/thigh
Pain worse on walking or axial loading
No neurological symptoms or radicular symptoms or LMN symptoms

262
Q

Management of degenerative disc disease

A 
Conservative:
Activity modification
Analgesia
Physiotherapy
Delayed MRI scan

Surgery
Discectomy
Laminectomy

263
Q

Presentation of spinal stenosis

A

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

264
Q

What investigation would you do if you suspect spinal stenosis?

A

MRI

265
Q

Management of spinal stenosis

A

Lumbar decompression if symptoms are severe

266
Q

Define spondylolysis

A

Defect in the pars interarticularis of the vertebral arch

267
Q

Define spondylolithesis

A

Anterior translocation of a vertebrae

268
Q

Risk factors for adult pyogenic vertebral osteomyelitis/discitis?

A

Immunosuppression:

  • IVDU
  • Diabetes
  • Recent systemic infection
  • Obesity
  • Malignancy
  • Medication
  • Malnutrition
  • Smoking
269
Q

Most common pathogens causing discitis?

A

S. Aureus

S. Epidermis

270
Q

Presentation of discitis

A 
Fever
Pain:
- severe
- insidious onset
- unrelenting, worse with activity
- waking at night
Neurological symptoms (10-20%)
- Radiculopathy or myelopathy
271
Q

What investigations would you do in a patient with suspected discitis?

A

Inflammatory markers
MRI (bone scan/CT if unable to tolerate MRI)
Blood cultures

272
Q

Management of discitis

A

Long-term IV flucloxacillin or Vancomycin

Decompression, debridement or stabilisation occasionally required

273
Q

Define an epidural abscess

A

Collection of pus or inflammatory granulation tissue between dura and adipose tissue

274
Q

Causes of Cauda Equine Syndrome

A

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
275
Q

Presentation of cauda equine syndrome

A

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

276
Q

What investigation would you do in a patient with suspected cauda equine syndrome?

A

Emergency MRI

277
Q

Management of cauda equina syndrome

A

Emergency decompression

278
Q

What precautions should be taken in a patient with suspected spinal injury?

A

Lie patient flat
Log roll
Catheterise
Maintain airway with jaw thrust (not head tilt, chin lift)

279
Q

Management protocol for any spinal injury includes

A
  1. Decompress spinal cord
  2. Stabilise any fractures
  3. Steroids within 8 hours
  4. Extensive rehab
280
Q

Define tetraplegia

A

Caused by cervical spine injury, impairment to arms, trunk, legs and pelvic organs

281
Q

Define paraplegia

A

Caused by thoracic/lumbar/sacral spine injury, impairment of trunk, legs and pelvis

282
Q

Define neurogenic shock

A

Loss of sympathetic trunk activity with profound shock

283
Q

Define complete spinal injury

A

Injury with no sparing of motor or sensory function below injury level

284
Q

Define incomplete spinal injury

A

Injury with some preserved motor or sensory function below injury level

285
Q

Define dysplasia

A

Abnormal ratio of differentiated: undifferentiated cells

286
Q

Define metaplasia

A

Abnormal change of one differentiated tissue into another

287
Q

Define neoplasia

A

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

288
Q

Define lytic

A

Removes bone

289
Q

Define blastic

A

Deposits bones

290
Q

Define expansile

A

Expands normal bone contour

291
Q

What are the red flag symptoms for malignant tumours

A

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
292
Q

Describe the differences between benign and malignant tumours

A 
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
293
Q

What investigations would you perform in a patient with suspected malignancy?

A

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

294
Q

What are the symptoms of metastatic hypercalcaemia?

A 
Renal or biliary stones
Bone pain
Abdominal pain, nausea and vomiting
Polyuria
Constipation
Psychiatric disturbance
295
Q

How would you manage metastatic hypercalacemia?

A

1) Hydration

2) Bisphosphonates

296
Q

What is the most common cause of bony tumours

A

Metasasis

297
Q

What is the most common reasons for a destructive bone lesion in adults?

A

Metastasis

298
Q

Which carcinomas commonly spread to the bone?

A 
Prostate
Breast
Kidney
Thyroid
Lung
299
Q

What is the most common primary bone malignancy in adults >40

A

Multiple myeloma

300
Q

What is the 5 and 10 year survival rate of multiple myeloma?

A

5 year - 30%

10 year - 11%

301
Q

How is multiple myeloma diagnosed?

A

Urine or plasma electrophoresis - myeloma is neoplastic proliferation of the plasma cells which produce immunoglobulins

302
Q

Presentation of multiple myeloma

A

Skeletal lesions

303
Q

What investigations would you do in a patient with suspected multiple myeloma?

A

Urine/plasma electrophoresis

Skeletal survey - bone scans (cold in 30% of patients), X-ray (show punched out lesions)

304
Q

Management of multiple myeloma

A

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

305
Q

What is the most common primary tumour of the bone?

A

Osteosarcoma

306
Q

When does osteosarcoma usually occur?

A

Children and young adults, but can occur in elderly patients with Paget’s disease

307
Q

Presentation of osteosarcoma

A

Usually affects knee

Presents with rapidly progressive pain, fever and swelling. A mass may be felt on examination

308
Q

What investigations would you do in a patient with suspected osteosarcoma?

A

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

309
Q

What malignancy would presence of Codman’s triangle on X-ray indicate?

A

Osteosarcoma

310
Q

Management of osteosarcoma

A

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

311
Q

What precent of osteosarcoma patients will have long term survival?

A

76%

312
Q

What are the poor prognostic factors for osteosarcoma?

A

Tumour site and size
Advance disease stage
Response to chemotherapy

313
Q

What is the most common benign bone tumour?

A

Osteochrondroma

314
Q

What is the risk of osteochondroma undergoing malignant change?

A

<1%

315
Q

What radiological features would you see in Osteochrondoma?

A

Sessile or pedunculated lesion on bone surface

Pedunculated lesions growing away from involved joint - continuous with cortex and medullary cavity of the bone

316
Q

What investigations would you use to characterise lesions in a patient with suspected osteochonrdoma?

A

MRI/CT

317
Q

Management of Osteochondroma

A

Observation - asymptomatic/minimally symptomatic patients

Marginal resection at base of stalk, including cartilage cap

318
Q

Indications for operative management of osteochondroma

A

Symptomatic lesions
Lesions causing inflammation in surrounding tissue
Lesions which are cosmetically displeasing

319
Q

Surgical management of osteochondroma should be delayed until skeletal maturity. (True/False)

A

True

320
Q

What is the 2nd most common benign cartilage lesion?

A

Enchondroma

321
Q

What age group does Enchondroma occur most commonly in?

A

20-50 year olds

322
Q

Where is enchondroma most commonly found?

A

In the diaphysis or metaphysis of long bones

In the hand (60%)

323
Q

Presentation of enchrondroma

A

Usually asymptomatic

Can present with pathological fracture or pain

324
Q

How would an enchondroma appear on X-ray?

A

Well-defined, lucent, central medullary lesions that calcify over time

325
Q

Management of enchondroma

A

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

326
Q

Risk of malignant transformation of enchrondroma

A

1% in single enchondroma

25-30% in Ollier’s disease

327
Q

Where is chondrosarcoma typically found?

A

In elderly patients

In the pelvis, proximal femur and scapula

328
Q

Presentation of chondrosarocoma

A

Pain
Slow-growing mass
Symptoms of bladder/bowel dysfunction
Pathological fracture (50% of de-differentiated chondrosarcomas)

329
Q

What features will be present on an X-ray of a Chondrosarcoma?

A

Lytic or blastic lesion with reactive thickening of the cortex and intra-lesinal ‘popcorn’ mineralisation

330
Q

What is the 2nd most common bone tumour in children?

A

Ewing’s Sarcoma

331
Q

Where is Ewing’s Sarcoma usually found?

A

Patients age 5-25
~50% in diaphysis of long bones
Most common locations are pelvis, distal femur, proximal tibia, femoral diaphysis and proximal humerus

332
Q

Presentation of Ewing’s sarcoma

A

Pain accompanied by fever (mimic infection)

Swelling and local tenderness

333
Q

What features would be seen on an X-ray of Ewing’s Sarcoma?

A

Large destructive lesion in the diaphysis or metaphysis with a ‘moth eaten’ appearance.

Periosteal reaction may give an onion skin or sunburst appearance

334
Q

What investigations would you do in a patient with suspected Ewing’s sarcoma?

A

X-ray
Bone scan - to stage, will show a very hot lesion
MRI - large soft tissue involvement
CT - to look for pulmonary metastasis

335
Q

What malignancy is associated with ‘onion skin’ or sunburst appearance on the periosteum?

A

Ewing’s sarcoma

336
Q

Presentation of Soft tissue sarcoma

A

Enlarging painless mass

337
Q

Where does soft tissue sarcoma most commonly metastasise to?

A

Lung

338
Q

What are the basic principles of management in malignancy?

A

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

339
Q

Presentation of osteogenesis imperfecta

A 
Fractures
Blue tinge to sclera
Easy bruising
Short height
Loose joints
Hearing loss
Breathing problems
Problems with teeth
340
Q

How would you diagnose osteogenesis imperfecta?

A

Clinical features
X-ray
Genetic testing

341
Q

Management of osteogenesis imperfecta

A 
Lifestyle changes
Analgesia
Physiotherapy
Wheelchairs
Bisphosphonates
Surgery

Year 4 (11 decks)

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