Orthopaedics Flashcards
What are the LOAF muscles?
Lateral two lumbricals
Opponens pollis
Abductor pollis brevis
Flexor pollis brevis
What’s another name for frozen shoulder?
Adhesive capsulitis
Who does adhesive capsulitis normally affect and what conditions is it associated with?
Middle aged women (50s)
- Diabetes mellitus: up to 20% of diabetics may have an episode of frozen shoulder
- Trauma
- steroids
- endocirnopathies
What are the features of adhesive capsulitis?
- external rotation is affected more than internal rotation or abduction
- both active and passive movement are affected
- patients typically have a painful freezing phase (6 months), an adhesive phase/stiff phase (1 year) and a recovery phase (6-12 months)
- bilateral in up to 20% of patients
- the episode typically lasts between 6 months and 2 years
What’s the management for frozen shoulder?
- no single intervention has been shown to improve outcome in the long-term
- treatment options include NSAIDs, physiotherapy, oral corticosteroids and intra-articular corticosteroids
- reassure that it is self resolving
What’s the management for dupuytren’s contracture?
Consider surgical treatment or injectable enzyme therapy when the metacarpophalangeal joints cannot be straightened and thus the hand cannot be placed flat on the table
- needle fasciotomy
- fasciectomy
- collagenase
What is the pathophysiology of dupuytren’s contracture?
What is it associated with?
- Painless thickening of the skin/fascia with skin puckering and tethering on palmar aspect
- particularly affects the little and ring fingers
- often bilateral and symmetrical
- MCP joints can be affected
- manual labour
- phenytoin treatment
- alcoholic liver disease
- trauma to the hand
What’s the prevalence of dupuytren’s contracture? Who is normally affected?
5%. It is more common in older male patients and around 60-70% have a positive family history
What is cauda equina and what causes it?
- compression of cauda equina
- abcess
- central lumbar disc prolapse
- extrinsic/intrinsic tumours of spine/cord
- spondylosis
- spinal stenosis
- trauma
- spinal SAH
- vertebral collapse
What are the symptoms of cauda equina?
- back pain
- lower limb weakness/sensory loss
- altered perineal/perianal sensation
- sphincter disturbance (incontinence or retention)
How do you manage back pain?
Advice to people with low back pain
- try to encourage self-management
- stay physically active and exercise
Analgesia
- NSAIDS are now recommended first-line for patients with back pain. This follows studies that show paracetamol monotherapy is relatively ineffective for back pain
- proton pump inhibitors should be co-prescribed for patients over the age of 45 years who are given NSAIDs
- NICE guidelines on neuropathic pain should be followed for patients with sciatica
What should you do if you suspect cauda equina?
- DRE
- MRI within 4 hours
Which neurovascular structure that is compromised in a scaphoid fracture?
The dorsal carpal branch of the radial artery
A scaphoid fracture typically occurs as a result of which injury?
- fall onto an outstretched hand (FOOSH)
- contact sports
- during a road traffic accident due to the patient holding the steering wheel
resulting in axial compression of the scaphoid, with the wrist hyper-extended, and radially deviated.
Who is most likely to get a scaphoid fracture?
- Males are at increased risk of fracture (7M:1F).
- The average age of the patient is 22 years old (9 to 35 years old).
- The reported incidence for fracture of the scaphoid is 12.4 per 100,000.
If you have all the symptoms of a hip fracture but it doesn’t show on Xray what should you do?
MRI
What are the features of a hip fracture?
- pain
- shorter and externally rotated leg
How do you classify hip fractures?
Location
- intracapsular (subcapital): from the edge of the femoral head to the insertion of the capsule of the hip joint
- extracapsular: these can either be trochanteric or substrochanteric (the lesser trochanter is the dividing line)
The Garden system is one classification system in common use.
- Type I: Stable fracture with impaction in valgus
- Type II: Complete fracture but undisplaced
- Type III: Displaced fracture, usually rotated and angulated, but still has boney contact
- Type IV: Complete boney disruption
Blood supply disruption is most common following Types III and IV.
How do you treat a hip fracture?
Intracapsular hip fracture:
- Undisplaced Fracture:
- internal fixation (DHS), or hemiarthroplasty if unfit. 10% chance of head dying. - Displaced Fracture:
- young and fit i.e. <70 years- Reduction (still using own femoral head) and internal fixation (DHS/cannulated hip screws)(if possible). 40% chance of head dying
- older and reduced mobility- Hemiarthroplasty or total hip replacement (10% chance of dislocation with THR. If this is too great then do a hemiarthroplasty as ball is much bigger).
Extracapsular hip fracture
- dynamic hip screw
- if reverse oblique, transverse or subtrochanteric: intramedullary device
What’s the condition?
The x-ray shows extensive bone remodeling / fragmentation involving the midfoot. In combination with the presence of a swollen, red, warm joint in a patient with a history of poorly controlled diabetes is highly suggestive of ….
a Charcot’s joint (neuropathic joint)
It describes a joint which has become badly disrupted and damaged secondary to a loss of sensation.
What’s the most common cause of a Charcot joint?
In years gone by they were most commonly caused by neuropathy secondary to syphilis (tabes dorsalis) but are now most commonly seen in diabetics.
Describe Colles’ fracture
(dinner fork deformity)
Fall onto extended outstretched hand
Classical Colles’ fractures have the following 3 features:
- Transverse fracture of the radius
- 1 inch proximal to the radio-carpal joint
- Dorsal displacement and angulation
Describe Smith’s fracture
(reverse Colles’ fracture)
- Volar angulation of distal radius fragment (Garden spade deformity)
- Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed
Describe Bennett’s fracture
- Intra-articular fracture of the first carpometacarpal joint
- Impact on flexed metacarpal, caused by fist fights
- X-ray: triangular fragment at ulnar base of metacarpal
Describe Monteggia’s fracture
mont- a- ga
- Dislocation of the proximal radioulnar joint in association with an ulna fracture
- Fall on outstretched hand with forced pronation
- Needs prompt diagnosis to avoid disability
MUgGeR:
MonteggiA= ulnar, A= proximal
GaleaZzi= radial, Z= distal
Describe Galeazzi fracture
gil-e-art-zi
The opposite of a Monteggia fracture
- Radial shaft fracture with associated dislocation of the distal radioulnar joint
- Direct blow
MUgGeR:
MonteggiA= ulnar, A= proximal
GaleaZzi= radial, Z= distal
Describe Pott’s fracture
- Bimalleolar ankle fracture
- Forced foot eversion
Describe Barton’s fracture
- Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation
- Fall onto extended and pronated wrist
Which nerve is at risk in the Lloyd-Davies position?
Peroneal
Inguinal hernia repair can damage which nerve?
Ilioinguinal nerve
What are the muscles in the anterior compartment of the lower leg? Which nerves innervate them and what is their function?
Tibialis anterior
- Deep peroneal nerve
- Dorsiflexes ankle joint, inverts foot
Extensor digitorum longus
- Deep peroneal nerve
- Extends lateral four toes, dorsiflexes ankle joint
Peroneus tertius
- Deep peroneal nerve
- Dorsiflexes ankle, everts foot
Extensor hallucis longus
- Deep peroneal nerve
- Dorsiflexes ankle joint, extends big toe
What are the muscles in the peroneal compartment of the lower leg? Which nerves innervate them and what is their function?
Peroneus longus
- Superficial peroneal nerve
- Everts foot, assists in plantar flexion
Peroneus brevis
- Superficial peroneal nerve
- Plantar flexes the ankle joint
What are the muscles in the superficial posterior compartment of the lower leg? Which nerves innervate them and what is their function?
Gastrocnemius
- Tibial nerve
- Plantar flexes the foot, may also flex the knee
Soleus
- Tibial nerve
- Plantar flexor
What are the muscles in the deep posterior compartment of the lower leg? Which nerves innervate them and what is their function?
Flexor digitorum longus
- Tibial
- Flexes the lateral four toes
Flexor hallucis longus
- Tibial
- Flexes the great toe
Tibialis posterior
- Tibial
- Plantar flexor, inverts the foot
What actions do the lumbricals do?
flex the metacarpal phalangeal joints (MCPJ) and extend the interphalangeal joints (IPJ)
What causes clawing of the medial two fingers?
When the ulnar nerve is damaged at the wrist, the medial two lumbrical muscles are affected (the lateral two being supplied by the median nerve). Denervation of the lumbricals, which flex the metacarpal phalangeal joints (MCPJ) and extend the interphalangeal joints (IPJ), causes unopposed extension of the MCPJ by extensor digitorum longus and flexion of the IPJ by flexor digitorum profundus and superficialis. This gives the hand a claw like appearance.
What’s the function of the femoral nerve?
From what is it derived?
Motor functions: Innervates the anterior thigh muscles that:
- flex the hip joint (pectineus, iliacus, sartorius)
- extend the knee (quadriceps femoris: rectus femoris, vastus lateralis, vastus medialis and vastus intermedius)
Sensory functions: Supplies cutaneous branches to the:
- anteromedial thigh (anterior cutaneous branches of the femoral nerve)
- medial side of the leg and foot (saphenous nerve).
Derived from the anterior rami of nerve roots L2, L3 and L4
Where does the femoral nerve divide and what are the branches?
4cm below the inguinal ligament
Anterior division of the femoral nerve
- Anterior cutaneous branches
- Branch to sartorius
- Branch to pectineus
Posterior division of the femoral nerve
- Saphenous nerve (travels through the adductor canal)
- Branches to quadriceps femoris
What are the features of a prolapsed disc and how do you manage it?
Features
- leg pain usually worse than back
- pain often worse when sitting
- similar to that of other musculoskeletal lower back pain: analgesia, physiotherapy, exercises
- if symptoms persist then referral for consideration of MRI is appropriate
What is chondromalacia patellae? Who normally gets it? What are the presenting features?
- damage to the cartilage at the back of the kneecap (patella)
- Teenage girls, following an injury to knee e.g. Dislocation patella
- Typical history of pain on going downstairs or at rest
- Tenderness, quadriceps wasting
How do knee dislocations normally occur? What are the risk factors?
Most commonly occurs as a traumatic primary event:
- direct trauma
- severe contraction of quadriceps with knee stretched in valgus and external rotation
Risk factors:
- Genu valgum (knock knee)
- tibial torsion
- high riding patella
What x ray is needed for a knee dislocation?
Skyline view
What’s the recurrence rate of knee dislocation?
20%
What are the types of patella fracture?
i. Direct blow to patella causing undisplaced fragments
ii. Avulsion fracture
Who normally gets a tibial plateau fracture? What’s the mechanism? How are they classified?
- Occur in the elderly (or following significant trauma in young)
- Mechanism: knee forced into valgus or varus, but the knee fractures before the ligaments rupture
- Varus injury affects medial plateau and if valgus injury, lateral plateau depressed fracture occurs
- Classified using the Schatzker system
A 45-year-old man presents with a painful swelling on the posterior aspect of his elbow. There is no history of trauma. On examination an erythematous tender swelling is noted. What is the most likely diagnosis?
Olecranon bursitis
What are the features of lateral epicondylitis?
- aka tennis elbow
- pain and tenderness localised to the lateral epicondyle
- pain worse on resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended
- episodes typically last between 6 months and 2 years
- patients tend to have acute pain for 6-12 weeks
What are the features of medial epicondylitis?
- aka golfers elbow
- pain and tenderness localised to the medial epicondyle
- pain is aggravated by wrist flexion and pronation
- symptoms may be accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement
What are the features of radial tunnel syndrome?
- Most commonly due to compression of the posterior interosseous branch of the radial nerve. It is thought to be a result of overuse.
- symptoms are similar to lateral epicondylitis making it difficult to diagnose
however, the pain tends to be around 4-5 cm distal to the lateral epicondyle - symptoms may be worsened by extending the elbow and pronating the forearm
What are the features of cubital tunnel syndrome?
- Due to the compression of the ulnar nerve.
- initially intermittent tingling in the 4th and 5th finger
- may be worse when the elbow is resting on a firm surface or flexed for extended periods
- later numbness in the 4th and 5th finger with associated weakness
What’s the diagnosis?
left leg is shortened, adducted and internally rotated compared to the right
Left posterior hip dislocation
What are the complications of a posterior hip dislocation?
- Sciatic nerve injury (occurs in 10-20% of posterior dislocations, normally affects the part containing the common peroneal nerve)
- Femoral nerve injury
- Avascular necrosis
- Osteoarthritis: more common in older patients.
- Recurrent dislocation: due to damage of supporting ligaments
What’s the diagnosis?
The affected leg is usually abducted and externally rotated. No leg shortening
Anterior hip dislocation
What’s the most common type of hip dislocation?
Posterior 90%
How do you manage hip dislocation?
- ABCDE approach.
- Analgesia
- A reduction under general anaesthetic within 4 hours to reduce the risk of avascular necrosis.
- Long-term management: Physiotherapy to strengthen the surrounding muscles.
What’s the prognosis for hip dislocation?
- It takes about 2 to 3 months for the hip to heal after a traumatic dislocation
- the prognosis is best when the hip is reduced less than 12 hours post-injury and when there is less damage to the joint.
How do you detect DDH?
- Often picked up on newborn examination
- Barlow’s test, Ortolani’s test are positive
- Unequal skin folds/leg length
What are the features of transient synovitis?
- Typical age group = 2-10 years
- Acute hip pain associated with viral infection
- Commonest cause of hip pain in children
What is Perthes disease? Who gets it? What are the features?
- Perthes disease is a degenerative condition affecting the hip joints of children, typically between the ages of 4-8 years. It is due to avascular necrosis of the femoral head
- Perthes disease is 5 times more common in boys. Around 10% of cases are bilateral
Features
- hip pain: develops progressively over a few weeks
- limp
- stiffness and reduced range of hip movement
x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening
What is SUFE? Who typically gets it? Which way is the displacement? How common is bilateral slip? What are the features? How do you treat it?
- Slipped upper femoral epiphysis
- Typical age group = 10-15 years
- More common in obese children and boys
- Displacement of the femoral head epiphysis postero-inferiorly
- Bilateral slip in 20% of cases
- May present acutely following trauma or more commonly with chronic, persistent symptoms
Features
- knee or distal thigh pain is common
- loss of internal rotation of the leg in flexion
Percutaneous in situ fixation with a single cannulated screw.
What is JIA?
Juvenile idiopathic arthritis (JIA)
Arthritis occurring in someone who is less than 16 years old that lasts for more than three months.
Pauciarticular JIA refers to cases where 4 or less joints are affected. It accounts for around 60% of cases of JIA
What are the features of JIA?
- joint pain and swelling: usually medium sized joints e.g. knees, ankles, elbows
limp - ANA may be positive in JIA - associated with anterior uveitis
What are the associations and features of adhesive capsulitis?
Associations
- diabetes mellitus: up to 20% of diabetics may have an episode of frozen shoulder
Features typically develop over days
- external rotation is affected more than internal rotation or abduction
- both active and passive movement are affected
- patients typically have a painful freezing phase, an adhesive phase and a recovery phase
- bilateral in up to 20% of patients
- the episode typically lasts between 6 months and 2 years
What system is used to classify paediatric fractures? What are the categories?
Salter- Harris system
I Fracture through the physis only (x-ray often normal)
II Fracture through the physis and metaphysis (above)
III Fracture through the physis and epiphyisis to include the joint (below)
IV Fracture involving the physis, metaphysis and epiphysis (through)
V Crush injury involving the physis (x-ray may resemble type I, and appear normal)
What are the frequencies of Salter-Harris fracture types?
I 5% II 75% III 10% IV 10% V uncommon
III-V will usually require surgery
What are the signs of NAI?
- Delayed presentation
- Delay in attaining milestones
- Lack of concordance between proposed and actual mechanism of injury
- Multiple injuries
- Injuries at sites not commonly exposed to trauma
- Children on the at risk register
What is a buckle fracture?
Incomplete cortical disruption resulting in periosteal haematoma only
What are the red flags for lower back pain?
- age < 20 years or > 50 years
- history of previous malignancy
- night pain
- history of trauma
- systemically unwell e.g. weight loss, fever
What are the features of facet joint pain?
- May be acute or chronic
- Pain worse in the morning and on standing
- On examination there may be pain over the facets.
- The pain is typically worse on extension of the back
What are the features of spinal stenosis?
- Usually gradual onset
- Unilateral or bilateral leg pain (with or without back pain)
- numbness, and weakness which is worse on walking. Resolves when sits down.
- Pain may be described as ‘aching’, ‘crawling’
- Relieved by sitting down, leaning forwards and crouching down
- Clinical examination is often normal
- Requires MRI to confirm diagnosis
What are the features of ankylosing spondylitis?
- Typically a young man who presents with lower back pain and stiffness
- Stiffness is usually worse in morning and improves with activity
- Peripheral arthritis (25%, more common if female)
What are Baker’s cysts? Who are they more common in? How do you test for it on examination?
a fluid-filled swelling that develops at the back of the knee
They are more likely to develop in patients with:
- arthritis
- gout
- following a minor trauma to the knee
Foucher’s sign describes the increase in tension of the Baker’s cyst on extension of the knee.
A 22-year-old woman sustains a closed tibial shaft fracture following a road traffic accident. This is managed with an intramedullary nail. On the ward you are called to see her 6 hours post-op as she has a heart rate of 118 beats per minute and a respiratory rate of 26 breaths per minute with oxygen saturations of 100%. She has used 60mg of oral morphine in the past 3 hours on top of her regular analgesia.
What complication are you most worried about? What’s the most sensitive clinical sign?
Excessive use of breakthrough analgesia should raise suspicion for compartment syndrome
On examination, pain on passive stretch of compartments is the most sensitive sign but clinical examination cannot definitively rule in or out the diagnosis.
What are the features of fat embolus syndrome?
- typically presents between 12 and 72 hours
- classic triad of respiratory distress, cerebral signs and a petechial rash
Which fractures are most commonly associated with compartment syndrome?
- supracondylar fractures in the arm
- tibial shaft fractures in the lower leg
What are the signs and symptoms of compartment syndrome?
- Pain, especially on movement (even passive)
- Parasthesiae
- Pallor may be present
- Arterial pulsation may still be felt as the necrosis occurs as a result of microvascular compromise
- Paralysis of the muscle group may occur
How do you diagnose and treat compartment syndrome?
Diagnosis
- Is made by measurement of intracompartmental pressure measurements. Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic.
Treatment
- This is essentially prompt and extensive fasciotomies
- In the lower limb the deep muscles may be inadequately decompressed by the inexperienced operator when smaller incisions are performed
- Myoglobinuria may occur following fasciotomy and result in renal failure and for this reason these patients require aggressive IV fluids
- Where muscle groups are frankly necrotic at fasciotomy they should be debrided and amputation may have to be considered
- Death of muscle groups may occur within 4-6 hours
What are the name of the nodules that occur as part of OA on the PIP and DIP joints?
PIP Bouchard’s nodes (caused by formation of calcific spurs of the articular cartilage)
DIP Heberden’s nodes
What is carpal tunnel syndrome and how would it present?
Trapping of the median nerve due to tightening of the flexor retinaculum.
- numbness/tingling/pain in lateral 3.5 fingers
- pain radiating to forearm
- pain often worse at night and after repetitive movements
- atrophy of thenar muscles when long standing
- flicking hand may relieve pain
What are the risk factors of carpal tunnel syndrome?
Acromegaly Rheumatoid Mixodema (hypothyroidism) Pregnancy Idiopathic Trauma (vibrating tools)
Gout DM Obesity Amyloidosis Use of some breast cancer drugs
How do you diagnose and treat carpal tunnel?
- test opponens pollicis (touch thumb and little finger) and abductor pollicis brevis (lift thumb to ceiling)
- tinel’s sign (tap over tunnel)
- Phalen’s manoeuvre (hold in hyperflexion)
- no need for nerve conduction studies if hx an exam anre conclusive
- treat associations
- splint holding in dorsiflexion ON, rest, weight reduction
- steroid injection
- surgical decompression (flexor retinaculum division)
What’s the diagnosis and how do you treat it?
Twisting sporting injuries followed by delayed onset of knee swelling and locking are strongly suggestive of…..
a menisceal tear. Arthroscopic menisectomy is the usual treatment.
What’s the diagnosis?
Twisting injury, rapid joint swelling and a pop
Rupture ACL
When should rotator cuff tears be repaired?
When more than 2cm
What is Parsonage - Turner syndrome?
aka also known as acute brachial neuropathy and neuralgic amyotrophy
This is a peripheral neuropathy that may complicate viral illnesses and usually resolves spontaneously.
What’s the most common site for proximal humeral fractures?
- Through the surgical head
- It is rare to have fractures through the anatomical neck.
- Anatomical neck fractures which are displaced by >1cm carry a risk of avascular necrosis to the humeral head.
How do you treat a proximal humeral fracture?
- Impacted fractures of the surgical neck are usually managed with a collar and cuff for 3 weeks followed by physiotherapy.
- More significant displaced fractures may require open reduction and fixation or use of an intramedullary device.
What are the types of shoulder dislocation?
- Glenohumeral dislocation (commonest): anterior shoulder dislocation most common
- Acromioclavicular dislocation (12%): clavicle loses all attachment with the scapula
- Sternoclavicular dislocation (uncommon)
What are the types of glenohumeral dislocation and what are their features?
Anterior shoulder dislocation
- External rotation and abduction
- 35-40% recurrent (it is the commonest disorder)
- Associated with:
- 90 % Bankart lesion (injury of the anterior (inferior) glenoid labrum of the shoulder, can’t see on x-ray
- 5% bony Bankart lesion (if a bit of bone fragments off)
- 35-40% Hill-Sachs defect (back of humeral head/posterior lateral strikes against the glenoid and causes an indentation fracture)
- 10% greater tuberosity fracture,
Inferior shoulder dislocation
- Luxatio erecta (arm above head)
Posterior shoulder dislocation
- Associated with convulsive seizures
- Rim’s sign= distance between medial border of humeral head and anterior glenoid rim >6mm
- Light bulb sign= humeral head held in internal rotation, appearing bulb like on AP
- Associated with Trough sign (reverse Hill-Sachs)= compression fracture of anteromedial humeral head
Superior shoulder dislocation
- Rare and usually follow major trauma.
What are the risk factors for shoulder fractures during dislocation?
- > 40 years
- traumatic injury
- first dislocation
If present order shoulder x rays (AP, oblique, axillary, Y view)
Y should intersect humeral head
How do you treat shoulder dislocations?
- Prompt reduction is the mainstay of treatment and is usually performed in the emergency department.
- Neurovascular status must be checked pre and post reduction and x-rays should be performed again post reduction to ensure no fracture has occurred.
In recurrent anterior dislocation there is usually a Bankart lesion and this may be repaired surgically. Recurrent posterior dislocations may be repaired in a similar manner to anterior lesions but using a posterior (or arthroscopic) approach.
What is the initial imaging modality of choice for suspected Achilles tendon rupture?
Ultra sound
What are the risk factors for achilles tendon disorders?
- quinolone use (e.g. ciprofloxacin) is associated with tendon disorders
- hypercholesterolaemia (predisposes to tendon xanthomata)
What are the features of achilles tendinopathy and how would you manage it?
- gradual onset of posterior heel pain that is worse following activity
- morning pain and stiffness are common
- simple analgesia
- reduce precipitating activities
- calf muscle eccentric exercises - this may be self-directed or under the guidance of physiotherapy
What would you expect to see when examining a patient with a ruptured achilles tendon?
Simmonds’ triad
- calf squeeze (foot doesn’t move)
- altered angle of declination (greater dorsiflexion of the injured foot compared to the uninjured limb)
- palpable gap
A 67-year-old woman who is taking long-term prednisolone for polymyalgia rheumatica presents with progressive pain in her right hip joint. On examination movement is painful in all directions but there is no evidence of limb shortening or external rotation.
An x-ray of the hip shows osteopenia and microfractures.
What is the most likely diagnosis?
Long-term steroid use (such as in this patient taking prednisolone for polymyalgia rheumatica) is a key risk factor for the development of avascular necrosis of the femoral head.
What are the risk factors for avascular necrosis?
- long-term steroid use
- chemotherapy
- alcohol excess
- trauma
How would you investigate suspected avascular necrosis of the femoral head?
- MRI is the investigation of choice. It is more sensitive than radionuclide bone scanning
- plain x-ray findings may be normal initially. Osteopenia and microfractures may be seen early on. Collapse of the articular surface may result in the crescent sign
