Orthopaedics Flashcards
1
Q
3 parts of the bone
A
diaphysis (shaft)
metaphysis (neck)
epiphysis (end)
2
Q
abnormal gaits?
A
- trenedelenburg : compensating bending on the opposite side
- antalgic
3
Q
Antalgic gait?
A
stance phase shorter than the swing phase.
4
Q
hip replacement, small vs bigger heads?
A
Small: wears off more slowly
Big: wears off more quickly, gives better range of movement
5
Q
Complications of a hip replacement?
A
fracture
damage to the neurovasculature
change in length of the leg
6
Q
Why fractures in metaphysis heal more quickly?
A
Bigger cross-sectional area
Better blood supply
7
Q
Why being intra-articular matters for a fracture?
A
Most likely cartilage is also damaged
Limits movement at the joint
Needs to be immobilised to try to achieve 1^ bone formation and not secondary
8
Q
Descriptions of a fracture:
- Side
- Location
- Pattern
- No of fragments
- relation to joint
- relation to skin
- Displacement of the bone
A
- Proximal, middle, distal 1/3 // shaft, head neck
- transverse, oblique (>30 degrees), spiral (when oblique on 2 plains)
- Multi or simple or segmental
- intra or extra articular
- open or close
9
Q
Types of displacement
A
Translation
Shortened
Angulated
Rotated
10
Q
Management of fracture/dislocation?
A
- Reduce ( open or close)
- Immobilise
- Rehabilitate
11
Q
Non-surgical immobilsation methods
A
Cast:
first backslab to avoid compartment syndrome by build up of pressure (inflam),
then plaster cast for chronic use
12
Q
Surgical methods of immobilisation
A
Intramedullary
Extramedullary
13
Q
Intramedullary fixation methods
A
Intramedullary nail
K wires
14
Q
Extramedullary fixation methods
A
screws and plate
external fixation (allows treatment of the wound at the same time)
15
Q
Difference between subluxed and dislocated
A
sublux: partial
dis: complete loss of contact
16
Q
Non-union risk factors
A
Patient: Old, smoker, alcoholic
Fracture: Open, multi-fragmented
Treatment: poor reduction
17
Q
Valgus vs varus
A
vaLgus: distal bone points Laterally, apex medially
varus: distal bone points medially
18
Q
Primary bone healing?
A
absolute stability (rigid fixation)
tunneling resorption
19
Q
Secondary bone healing
A
Callus formation
Relative stability
20
Q
3 important compartments of the knee joint?
A
Medial femorohumeral joint
Lateral femorohumeral joint
Femoropatellar joint
21
Q
Femoropatellar joint arthrtitis pain
A
pain on walking down the stairs
22
Q
Femoropatellar joint arthritis mx
A
Knee skyline view
1/3 narrowing partial replacement
2/3 narrowing complete replacement
23
Q
Why infection is important during knee replacement?
A
if infected, abx cant reach, so has to be taken out
24
Q
virchow’s triad for blood clots?
A
- hyper coagulity
- immobility
- injury to vessels
25
Sesamoid bone in knee?
fabella, within lateral head of gastrocnemius acts as a lever to increase the power
26
Treatment of injury to menisci within knee?
made of fibrocartilage, not much blood supply
the middle 2/3 gets no blood, so damage --\> disected out
Outside 1/3 small blood supply, fixed with sutures
27
pseudogout x-ray differences?
calcified meniscus on knee
28
Gout x-ray changes
tophus on x ray, (most common on big toe)
29
Why ask for a rosenberg radiograph of knee?
On supine or standing ones cartilage loss/narrowing of joint may not be visible and are only visible when knee is at 45 degress
30
Avulsion fracture?
bone fragment pulled away by muscle
31
Normal soft tissue width anterior to cervical vertebrae on a lateral radiograph?
C1 to c3 : 1/3 of vertebral body
C4 to c7: width of vertebral body
bigger than that may be due to bleeding
32
Difference in growth plate of thumb and and other digits metacarpals?
thumb: proximal plate
others: distal
33
What features would make an intra-articular fracture require surgical attention? Why?
Step off \>2mm
Split \>2mm
One part of cartilage gets more loaded: increased weight on one side is not tolerable by the cartilage: risk of arthritis
34
What are the white lines on the surface of the bone?
Trabeculae: shows the direction of spread of the weight
35
Which articular surface of calcaneous gets the most pressure?
posterior articular facet
36
Classifications of the ankle fractures?
Webbers A: Distal to syndesmoses (tibia and fibula touching distally)
Webbers B: At the syndesmoses
Webbers C: Above syndesmoses
37
Mx of ankle fracture
A no fix
B fix if unstable
C always fix Bimaleolar, trimaleolar (posteriro side)
38
2 types of bone?
1. Woven: laid down in disorganised manner
2. Lamellar a. cortical b. cancellous
39
Cortical bone
dense, concentric rings
mostly around diaphysis, little around metaphysis
40
Cancellous bone
laid along the stress linse (tabeculae)
41
Bone cell types
Oosteocyte (90%, Ca hoemostasis)
Oesteoblast
Oesteoclast
42
Matrix types
Inorganic (60%) aka calcium ; resists compressive load
Organic (40%) aka type 1 collagen: resists extensile force
43
Bone blood supply in children
Metaphyseoepipheal system and diaphyseal system separated by growth plate
44
Adult bone blood supply
Nutrient artery
Periosteal artery
Volkmanns canal (transverse)
Haversian canal (within a concentric ring)
45
Nutrient artery fx
- Ascending and descending limbs
- high pressure, flow from inside to outside
- supplies the inner 2/3
46
Periosteal artery fx
low pressure, from muscle blood supply
supplies the outer third
47
Pereosteum 2 layers?
Outer fibrous
Inner vascular (Oesteoblastic activity, helps with bone healing)
48
Shenton line
is an imaginary line drawn along the inferior border of the superior pubic ramus (superior border of the obturator foramen) and along the inferomedial border of the neck of femur.
This line should be continuous and smooth
49
Lipohaemarthrosis?
- Intra-articular fracture
- with escape of fat and blood from the bone marrow into the joint
- seen on horizontal beam radiograph, lateral view of knee, fat superior to blood
50
Difference between gout and pseudogout crystals UNDER THE MICROSCOPE?
Gout: needle-shaped
Pseudo: cuboid crystals
51
Ewing's sarcoma?
- cancer cells are found in the bone or in soft tissue
- most common areas in which it occurs are the pelvis, the femur, the humerus, the ribs and clavicle (collar bone)
52
Most common sites of fractures on an extended arm?
Triquetrum
Scaphoid
medial/lateral epicondyl
suprachondylar fossa
53
3 stages of walking?
Foot strike
Flat foot
Toe off
54
Greenstick fracture
a fracture of the bone, occurring typically in children, in which one side of the bone is broken and the other only bent.
55
5 common shoulder problems?Age?
Dislocation 20-40 yo
Impingement 40-60
Rotator cuff tear 45-65
OA \>60
Frozen shoulder 40-80
56
Structures posterior to medial malleolus
Tom dick and very naughty harry
Tibialis posterior
Flexor Digitorum longus
Tibial artery
Tibial vein
Tibial nerve
Flexor hallucis longus
57
Structures anterior to medial malleolus
Extensor hallucis longus
Extensor digitorum longus
Dorsalis pedis
58
Foot and ankle exam?
a. Look
1. Look at nail beds for psoriatic arthritis
2. sunshine sign (sausage like toes)
3. scars between toes
4. flat foot. 5. Look at sole for calluses
6. Achilles tendon (plantar flex: varus toes, landing :valgus toes)
7. gait
b. Feel Go from medial to lateral to feel joints
Dorsalis pedis and post. tibialis
c. Move: both passive and active
1. Extend,flex big toe
2. Invert-exvert
3. dorsiflex, plantar flex
4. Thomas test: squeezing gastrocnemious to see achilles tendon moving normally (rupture otherwise)
5. Squeez MTP joints to check for pain/ sign of OA
59
Things to consider on a fracture x-ray?
Name, date, side
The most obvious abnormality is... JOAST
Joint
Outline : break along outline?
Arthritis : displaced?
Soft tissue : open/close?
Texture of the bone : trabeculae?
60
Primary ossification centres?
develops first
starts at diaphysis
61
Secondary ossification centre
ends of long bone
these 2 separated by epiphyseal plates
62
2 types of ossification?
1. Endochondral - bone laid on cartilage- eg long bones
2. Intramembranous- bone laid on bone eg skull and clavicle
63
2 types of bone healing?
1. primary Cutting cone model
2. secondary
64
Primary bone healing
Oclasts cut bone, Oblasts lay bone, followed by vascularisation
- no cartilage formation
- Aim of surgical fixation by plate and screw ( needs to have very little strain on the fractured part of the bone to achieve this)
65
Secondary bone healing
4 stages:
1. inflammation (fibroblasts form granulation tissue)
2. Soft callus formation (granulation tissue -\> fibrocartilage (chondrocytes) (3rd week)
3. hard callus (fibrocartilage --\>woven bone) ( 6th week, appears on x-ray)
4. Remodelling (Woven --\> lamellar bone , several yrs)
66
2 types of non-union
Either stability or blood supply is impaired:
1. hypertrophic non-union:new bone forms, but no bridges at fracture site, shows blood supply intact, but lack of stability
2. atrophic non-union: soft edges of bone shows lack of blood supply
67
Plastering of tibial fracture?
above knee for 6 weeks, followed by sarmiento (patellar tendon bearing plaster) which allows movement of the knee
68
Which fractures are intra-articular on femur? How treated?
capsule is between greater and lesser trochantar, anything proximal is intra.
Either screws or hemiarthroplasty
69
Which joint(s) need(s) to be involved in a plaster of extra articular fracture?
above and below
70
Colle's fracturewhat?/where?4 features?
- extra-articular fractures of distal radius-
dorsal angulation
- radial displacement
- dorsal displacement
- shortening
71
Action of interossei muscles?
DAB PAD
Dorsal interpssei abduction
Palmar interossei adduction
72
Nerve supply of various muscles in hand?
Median (LOAF) :
- Lumbricals
- Opponens pollicis,
- Abductor pollicis brevis
- Flexor pollicis brevis
Radial: - Extensors of digits, thumb and wrist
Ulnar:- everything else
73
Dupuytren's contracture def
DEF: flexion contracture of MCP or PIP,
74
Dupuytrens cause
caused by palmar fascia thickening
75
Dupuytrens sx
little finger and ring finger slightly flexed
76
Dupuytrens mx
if interfering with function, excised
77
Ganglion def
non-painful lump in hand
78
ganglion contracture cause
myxoid degeneration of fibrous tissue
79
Ganglion site
most common on the back of the hand (medial to snuffbox),
A1 pulley
DIP digits
80
Ganglion mx
aspirate (refills) or excision if affecting function
81
Trigger finger def
thickening of flexor tendon of a finger (most commonly ring finger)
82
Trigger finger mx
trigger finger release surgery (cutting the A1 pulley, to allow extension of the digits)
83
Positive Carpal tunnel test?
Hyperextend wrist, press on carpal tunnel. Painful is a positive test
84
Tendonopathy vs tendonitis
pathy: - more chronic- wear and tear
itis: - acute inflammation
85
Funtional elbow range of movement?
30 (wipe back passage) to 140 (feed)
50 % of Supination (put clothes on)/ pronation (operate computer)
Sup/pron less important as shoulder can compensate
86
Tennis elbow
affects lateral epicondyle
87
Tennis elbow examination
tender lateral epicondyle at 90 degrees
- Mills test: passively extend elbow, flex wrist, radial deviate wrist. pain on lateral epicondyle
- limited extension of elbow
88
Tinnel sign
tapping lateral to medial epicondyle, on the nerve, brings on symptoms
89
Tennis elbow mx
clasp below elbow, rests the long extensors
90
Ulnar nerve neuropathy examination
Muscle wasting : hypothenar muscle, interossei wasting (guttering of hand)
Clawing : lumbricals vs long flexors
Tinnel sign
91
Ulnar nerve neuropathy ix
nerve conduction study
60 m/s normal nerve conduction
40 m/s in neuropathy
92
Ulnar nerve neuropathy mx
surgical decompression
93
Olecranon bursitis examination
ROM unaffected
Swelling in the normally loose skin on the posterior side of elbow
94
Olecranon bursitis mx
- rest
- ice
- compression
- cut out
95
Keinbocks disease
- avascular necrosis of lunate bone,
- pain and discomfort in wrist, reduced ROM
96
Keinbocks rx
- surgical fusion of the wrist
97
Developmental dysplasia of the hip (DDH) Def
failure of normal development of the acetabulum leading to excessive joint laxity
98
DDH sx
loss of abduction
leg length discrepancy
asymmetrical posterior skin crease
99
DDH Dx
screened at 24hrs/6mo post birth
Barlow test:- attempts to dislocate a reduced hip, by pulling down and adduction of a hip at 90 degrees
Ortolani's test:- attempts to reduce a dislocated hip, by abducting a 90 flexed hip4. ultrasound younger babies, x-ray older children
100
DDH mx
Conservative: Palvik harness
Surgery: close/open reduction
101
Perthe's disease def
segmental avascular necrosis of femoral head of unknown aetiology
102
Perthe's X-ray results
X-ray:
- fragmentation
- subluxation
- loss of epiphyseal height
103
Perthe's sx
gradual hip/knee pain with impaired abduction
104
Perthes mx
75% require no treatment (initially collapses & fragments, then repairs and remodels over years)
- rest treated by surgical osteotomy
105
Slipped upper femoral epiphysis (SUFE) def
displacement of epiphysis due to failure of growth plate, associated with endochondral abnormalities and obesity
106
RFs for SUFE
Obesity
Endochondrial abnormalities
107
SUFE x ray
epiphysis looks inferior and posterior to femoral neck
108
SUFE mx
slip fixed in situ immediately to avoid further displacement
cant be reduced due to risk of avascular necrosis
109
Congenital talipes equinovarus (club foot) presentation
calf wasting and inward pointing of the feet
110
Club foot signs
fixed varusfixed equinous (plantar flexed)
111
Club foot mx
Ponseti casting:
- slowly corrects the varus deformity
- weekly changes in cast (external rotation)
- treatment can last up to 4 years (3mo norm)
112
Development of spinal curves
--when born--\> thoracic kyphosis--\> cervical lordosis ---when they walk--\> lumbar lordosis
113
movements of different spinal regions
- flexion/extension in lumbar spine
- rotation in thoracic
- lateral flexion(abduction) in cervical
114
what level cauda equina comes out?
L1/L2
115
4 important bony parts of vertebra
spinous and transverse processes, facets, pedicle (aka, foot) and body
116
4 lines to look at on a c-spine x-ray?
- anterior vertebral line
- posterior vertebral line
- spinolamilar line
- posterior spinous line
117
2 parts of vertebral disc
annulus fibrosis and nucleus pulposis
118
Spondylolisthesis1. def2. Ix3. Mx
slipping of one vertebra onto another
119
SPONDYLOLYSIS
defect in pars interarticularis
Intervertebral disc degeneration
OA of facet joints
Commonly cervical and lumbar spine
Support, NSAIDs, surgery (spinal fusion or decompression)
120
Spondylolithiasis X ray
Scottie dog appearance
121
Spondylolithiasis mx
conservative: - reduction in activity may allow it to heal
surgical: - fusion if pain is really bad
122
Gibbus?
A Gibbus deformity is a form of structural kyphosis, where one or more adjacent vertebrae become wedged.
123
Cauda equina syndrome def
the cauda equina, located below the level of L2, becomes compressed
- This condition is a surgical emergency, requiring immediate referral
124
Metastasis to spine
Breast
Bronchus
Prostate
Kidney
Thyroid
125
Abductor attachment?
Abductors attach at greater trochanter
126
Hip capsule attachment
Inter-trochanteric line on the anterior side
Mid-neck of femur on the posterior side
127
Blood supply to neck of femur
Medial and lateral trochanteric arteries which form the trochanteric anastemosis
128
Different classification of intracapsular fracture
- Subcapital
- Midcervical
- Basicervical
( + sub trochanteric)
129
NOF X ray?
X-ray:
- CXR
- AP pelvis
- horizontal beam of the affected hip
## Footnote
7.
130
Sx of NOF?
- Shortened leg: gluteus maximus and abductors pull up the femur
- Externally rotated
- Groin/hip pain
- neurovascular impairment
131
3 different surgical procedures for NOF
hemiarthroplasty
full hip replacement
In-situ fixation: with dynamic hip screws or intermedullary nail
132
Back pain causes?
I. Mechanical
a. non-specific: Muscle or ligamentous strains
b. trauma: Vertebral fractures, intervertebral disc prolapse (PID)
c. degenerative: Spondylosis, intervertebral disc prolapse, spinal stenosis, spondylolisthesis, scoliosis, kyphosis, spina bifidaII.
Non-mechanical
a. Inflammatory: Spondyloarthropathy, rheumatoid arthritis, polymyalgia rheumatica
b. Metabolic: Osteoporosis (vertebral collapse), Paget's disease, Osteomalacia
c. neoplasm
d. Infection: Osteomyelitis, paravertebral abscess, discitis, TB
III. Referred
a. GI/GU: biliary colic, renal colic, pancreatitis
b. Visceral organs: endometriosis and prostatitis, atopic pregnancy
133
Knee examination
LOOK (anterior , lateral, posterior)GaitSkin: redness, scars Soft tissue: swelling (Baker's cyst), muscle wasting (disc prolapse)Bone: Valgus (7 degrees of valgus normal)/ varus - hyperextensionSIT UP on bed (legs hanging) Extend leg: normal patellar traction laterally? Feel for creptationsFEEL (always keep an eye on the patient to look for pain)1. Temperature2. From tibial tuborisity-\>go proximal -\> and medial to patella to feel the medial joint line -\> after reaching the joint space go away from midline medially to feel the medial joint line3. From tibial tuborisity-\>go proximal and lateral to patella to feel the medial joint line -\> after reaching the joint space go away from midline laterally to feel the lateral joint line4. Go proximal from tibial tuborisity, feeling patellar tendon, patella and quadriceps5. Feel the medial collateral ligament by pressing on the medial epicondyle 6. Feel the lateral collateral ligament by pressing on the lateral epicondyle (move proximal from head of fibula)7. Popliteal fossa8. Sweep test: put a hand on suprapatellar pouch, other hand go up on the medial side, then start distally moving proximally on the lateral side, If positive parapatellar fossa fills with fluid.MOVE (passuve and active)1. Flex and extend 2. At 20 degrees, check the collaterals3. At 90, sit on toes and perform the draw test for ACL and PCL (thumps on the fossa, rest of the hand wraps around the back) 4. Loss of tibial step off at 90 degrees means PCL injuryNVS examJoint above and below
134
Examination of elbow
LOOK-wasting-scar-asymmetry FEEL4 bony prominences: - olecranon - medial epicondyl- lateral epicondyl- radial head (felt on supination/pronation) Feel for tenderness, heat, rheumatoid nodulesMOVEFlex 140 degreesExtend 0 degreesSupinate 90 degreesPronate 80 degrees (radial head doesnt go all the way next to ulna)
135
Shoulder examination?
1- Look:scars, inflammation, muscle wasting
2. Feel:Acromioclavicular, sternoclavicular, acromion
3. Move:
I. non-specific tests:abduction, rotation, flexioncombined touch c7 and t6
II. specific
a. Dislocation Apprehension test (flexed elbow 90, flex shoulder, abduction) : Sulcus sign (pulling down arm, prone to dislocation)
b. Impingement test Neer's test: thumb down, put fingers posterior superior to AC joint, flex shoulder --\> pain at low elevation
c. rotator cuff tear supra: thumbs down, resist elevationinfra: elbow 90 flexed, external rotationsubcapsularis: put your hands behind you, dont let me push them towards your belt, internal rotation,
d. AC joint pain/arthritis: SCARFpain at high elevation
136
Hand examination
LOOK
1. Deformities: - 4 signs of RA
2. Scars: - carpal tunnel? trigger finger release?
3. Lumps: - Dupuytren's contracture? ganglions?
4. Muscle wasting
FEEL
1. Painful swellings
2. Characteristics of lump (6 Ss and P: - Site (and underlying structures), - Size, - Shape, - Surface and edges, - Structure (soft or hard), - Sensation (tenderness, temperature),- Pulsatile
3. Pulses (ALANS TEST: hold both ulnar and radial arteries, pump their fist, relax hand, let go of ulnar, should slowly go pink)
Motor
1. Grips:- Power: lift a heavy object- Tripod: hold a pen- Key: thumb and index, unlocking motion
2. Nerve function- motor and sensory
- Radial: S: 1st interweb space, M: flex their wrist, ask to extend finger
- Median: S: tip of index finger, M: ask to point upwards with thumb, dont let you push it down
- Ulnar: S: tip of little finger, M: piece of paper between fingers dont let me pull it out
137
Hip examination
STANDING UP::
LOOK- Gait (trendelenburg/antalgic)
- Trendelenburg test
- Spinal screening test (lumbar flexion for AS, crossing arms and twisting both ways, sliding palms down to knees)
Anterior, lateral and posterior sides:- skin ( scars, erythamatous) + - soft tissue (swelling, muscle wasting)
- bone (pelvic obliquity)
- coronal view abnormalities such as fixed flexion, sagittal: scoliosis
LYING SUPINE:: LEG LENGTH:
- apparant : umbilicus to med malleolus
- true leg length
– ASIS to the tip of medial malleolus
FEEL
- Skin (temp, erythema, distal sensation)
- Bone (ASIS, greater trochantar, hip joint halfway between ASIS and trochantar)
MOVE:
- Thomas test (also tests active flex/extend)
- abduct/adduct (hand and elbow and ASIS)
- internal/external rotation, knee at 45
- FABER and FADIR for acetabular impingement
LYING PRONE- test extension
TO COMPLETE:
- x-ray of hip
- examine joints above and below
- full neurovascular test
138
Spine examination
I. LookAnt: symmetry in head, neck and shouldersSide: kyphosis or lordosis Back: scoliosis II. Feel- spinous processes - paravertebral muscles III. MoveA. Cervical- Lateral flexion - Flexion/extension - rotationB. Thoracic - RotationC. Lumbar - lateral flexion- extension/flexionSpecial test:A. Schober test:- Lumbar flexionB. Sciatic stretch test (straight leg raise) - tests sciatica ( sciatic root impingement) - Supine position, flex hip to max possible, Dorisflex - remarkable: posterior thigh/ buttock
139
Albrights Hereditary Osteodystrophy
Brachydactyly
Short stature
Mental retardation
140
Arthrodesis
Surgical fusion of joint
Cartilage removes and exposed surfaces compressed
Pain relief - but LOM
141
Arthroplasty bearing surfaces
Metal on polyethylene (UHMWP)
Ceramic on polyethylene
Metal on metal - fluid film lubrication
Ceramic on ceramic
142
Bisphosphonates mech of action
Analogues of normal bone pyrophosphate
Adhere to hydroxyapatite and inhibit osteoclasts
Suppress bone resorption
Exclusively act on calcified tissue
143
When to take bisphosphonate
Poor oral bioavailability - take on empty stomach
Remain upright 30 mins after taking
144
Bisphosphonate eg
Alendronate, risedronate, pamidronate, zoledronate, ibandronate
145
Blood test for osteoprosis
normal
146
Systemic Bone homeostasis regulatory hormones
- PTH
- Vit D
- Oestrogen
- GH
147
Local Bone homeostasis regulatory hormones
OSF (osteoclast regulation)
Wnt signalling (osteoblast regulation)
148
PTH produced where
parathyroid glands following fall in plasma ionised calcium
149
PTH effect
Increases plasma calcium
Reduces plasma phosphate
Increases calcium reabsorption in kidneys
Bone resorption
150
Calcitonin produced where
c cells of thyroid
151
Calcitonin action
inhibits osteoclast
152
Calcium distribution
Bound to protein (mainly albumin)
Complexed with citrate and phosphate (\<10%)
Free ions (\>50%)
153
Calcium normal ranges
2.25 - 2.60 mmol/L
154
Corrected calcium level
Takes into account albumin level
155
Recommended daily calcium intake
1000 mg
1500 mg post menopause
156
Common causes of hypercalcaemia
hyperparathyroid
malignancies
157
Presentation of hypercalcaemia
"Bones, stones, abdo groans and psychic moans"
Bone pain/fracture
Renal stones
Constipation
Abdo pain/duodenal ulcer/pancreatitis
Confusion and depression
Thirst
158
Investigations for hypercalcaemia
Check PTH
If high due to hyperparathyroidism - scintogram (identify site of parathyroid adenoma)
If malignancy - bone isotope (identify bone metastases)
159
Skeletal complications of hypercalcaemia
Osteoporosis
Fractures
Osteolytic lesions (Brown tumours)
Pepper pot skull
160
Management of hypercalcaemia
Treat underlying cause
Rehydrate with IV fluids
IV pamidronate (bisphosphonate) - if malignant cause
161
Causes of hypocalcaemia
Vit D deficiency
Hypoparathyroidism - Di George syndrome, autoimmune, surgery
Pseudohypoparathyroidism - resistance to PTH
162
Clinical features of hypocalcaemia
Tetany
Carpo-pedal spasm
Perioral paraesthesiae
Arrhythmias
Convulsions
163
Causes of osteomalacia and rickets
Vit D deficiency
Impaired vit D hydroxylation
Vit D resistance
164
Vitamin D action
Increases gut absorption of calcium and phosphate
Increases kidney reabsorption of calcium and phosphate
Bone resorption
165
Impaired vit D hydroxylation causes
chronic renal/liver failure
166
Vit D resistance
- Hypophosphataemic
- Renal tubular disorders
- Sex linked (X chromosome)
- Oncogenic osteomalacia
- Drugs (eg. epiliptics)
167
Clinical features of Osteomalacia
Bone pain
Proximal muscle weakness
Waddling gait
Skeletal deformity
Increased fractures
168
Common joint arthrodesed
1st MTP joint
Ankle
Wrist
Spine
169
Common Osteomyelitis causing organisms in UK
Staph aureus
E. coli
Pseudomonas
Proteus
170
Common sites of osteoporotic fractures
Vertebrae
NOF
Distal radius
171
Dowager's hump
Kyphotic deformity following osteoporotic fracture of vertebra
172
DEXA scan
Bone mineral density measured at femur and lumbar spine
Given T and Z scores
Investigation for diagnosis of osteoporosis
T score \< -2.5 = osteoporosis
-2.5 \< T score \< -1 = osteopenia
T score \> -1 = normal
173
Indications to request DEXA scan
Low trauma fracture
Oral glucocorticoids \> 3 months
Osteopenia on radiograph
Predisposing condition - eg. malabsorption, thyroid disease
FH osteoporosis
Low lifetime oestrogen exposure
174
Management of osteoporosis
Improve diet
Stop smoking
Reduce alcohol
Encourage regular weight bearing exercise
Increase calcium and vit D
Start medications to decrease bone resorption:
- Bisphosphonates
175
Raloxifene
SERM
Exert oestrogen like skeletal effects
Protect against breast cancer
Reduce risk of vertebral fractures
Used for osteoporosis
176
Strontium ranelate
Mechanism unclear
Stimulates osteoblasts and inhibits osteoclasts
Reduces fracture risks
Used for osteoporosis
177
Teriparatide
Recombinant PTH
Treats refactory osteoporosis
178
Define Osteoarthritis
Chronic irreversible degenerative disease to articular cartilage.
Non-inflammatory
Synovial joints
Attempted repair and new bone formation
179
OA history
Gradual increasing asymetrical joint pain over several years
Worsened by activity
Relieved by rest
Night pain at later disease stage
One or multiple joint involvement
180
Classification of OA
Primary OA (no underlying cause found)
Secondary OA (secondary to a cause):
1) Congenital
2) Acquired
181
Common OA affected joints
Knee
Hip
Hands (thumb CMC)
Fingers (DIP)
Spine
Shoulder
Elbow
Wrists
182
Congenital secondary OA
Developmental dysplasia of the hip
Perthes disease
Slipped upper femoral epiphysis
183
RFs for OA
Age
F
Low Oestrogen stuff
Low Ca/vit D
Smoking
184
OA radiological changes
Loss of joint space
Osteophytes
Sclerosis
Subchondral cysts
185
OA conservative mx
wt loss
walking aids
physio
186
medical mx of OA
analgesia
steroid injection
187
Surgical options for OA
Debridement (open/arthroscopic)
Synovectomy
Cheilectomy
Osteotomy
Arthrodesis (fusion)
Arthroplasty
188
Cheilectomy
Surgical excision of osteophytes
Reduces painful impingement
Used in 1st MTP joint and ankle
189
Dermatome of lower limb
190
Paget's disease pathophysiology
Increased bone turnover - leads to bone remodelling, enlargement, deformity and weakness
191
Pagets affects where
skull, pelvis, vertevrae and long bones
192
Clinical features of Paget's disease
Bone pain
Bone swelling and deformity
Increased head circumference
193
Investigations for Paget's disease
Calcium and phosphate normal
Alkaline phosphatase high
Isotope bone scan - extent of disease
194
Pagets X ray
- Bone enlargement
- Patchy cortical thickening
- Sclerosis
- Osteolysis
- Deformity
195
Complications of Paget's disease
Long bone fractures
Osteosarcomas
Nerve compression - can cause deafness
OA
196
Management of Paget's disease
Bisphosphonates:
- Oral (eg. risedronate 30 mg daily)
- IV (eg. pamidronate)
Monitor response by clinical response and ALP
197
Clinical features of Rickets
Bone pain
Skeletal deformity
Muscle weakness
Widened and irregular epiphyses
Bowing of long bones
Rib deformities - diaphragm pull produces groove in rib cage
198
X ray for rickets
- Looser's zones
- Bowed long bones
- Widened epiphyses (larger gap)
199
Bloods for rickets
- Corrected calcium low or borderline
- Secondary hyperparathyroidism (low PO4, high PTH, high ALP)
200
Rickets vs Osteomalacia
Rickets - childhood vitamin D inadequacy
Osteomalacia - adult vit D inadequacy
201
Management of osteomalacia and rickets
Depends on cause
Dietary deficiency - oral cholecalciferol (vit D)
Malabsorption - parenteral cholecalciferol
Renal failure - alfacalcidol (1 alpha hydroxy vitamin D)
202
RA pathology
Synovitis
Synovium infiltrated with inflammatory cells
Chronically inflammed tissue (Pannus) extends from joint margins - erosion of articular cartilage and bone
203
Joints commonly affected in RA
PIPs
MCPs
Wrists
Elbow
Shoulder
Knees
Ankles
MTPs
204
RA x ray
Loss of joint space
Juxta-articular osteopenia
Bone erosions
Deformity
205
Pannus
Granulation tissue
Stimulates release of IL-1 and PDGF
Cartilage destruction and bone erosion
206
Modes of Arthroplasty fixation
Cemented - PMMA bone cement supports prosthesis
Uncemented - prosthesis larger than hole and coated so bone bonds to prosthesis
207
Osteogenesis imperfecta
Hx of multiple fracturs from early childhood
Blue sclerae
208
Polyethylene
Low friction and cheap
209
Radiograph changes in vertebral osteomyelitis
No changes first few weeks
Intervertebral disc space narrowing
Localised osteopenia
Sclerosis
Soft tissue swelling
Later development of vertebral collapse and kyphosis
