Orthopaedics Flashcards

Question

Carpal tunnel syndrome

Answer 1

Compression of median nerve Thumb + 2.5 fingers Symptoms - thenar eminence wasting - pain, paraesthesiae, reduced sensation - reduced dexterity - comes and goes according to wrist position and activity - Tinel's and Phalen's tests exacerbate

Answer 2

Conservative - leave alone if symptoms manageable - wrist splint for 20 degrees extension, overnight - pain relief - amitriptyline, gabapentin - steroid injection into carpal tunnel, lasts 3-6 months Surgical - carpal tunnel release (ligament reheals longer) - the only reliable long-term cure

Answer 3

Compression of ulnar nerve around medial epicondyle of humerus Affects little and ring finger palmar and dorsally Sensation change, pain, affected grip strength Claw hand - hyperextension of MCP (lumbricles), fixed flexion at DIP and PIP (median nerve) Ulnar paradox - if nerve cut above elbow, 18 months to get hand sensation back. As improves beyond elbow, claw hand, but once improvement to hand then clawhand subsides. (higher lesion = less obvious injury)

Answer 4

``` Cystic swelling (synovial joint fluid) in the neighbourhood of joint or tendon Can occur anywhere in the body where there is joint or tendon, but most common in wrist or hands Out-pouchings of joint capsule, fluid forced in via trapdoor ``` Conservative treatment (resolve on their own but may take years) Surgical - Aspiration -> 90% recurrence - Excision - find root in capsule, remove and then reseal -> still 20% recurrence Interventions not normally funded (can be painful but is mainly cosmetic)

Answer 5

Stenosing tenovaginitis of the flexor tendon sheath (any digit) Inflammation of tendon, that gets stuck on sheath - very painful! Can be congenital or acquired (idiopathic, traumatic, diabetes, rheumatoid) ``` Conservative - Rest (avoid making a fist) - NSAIDs - Steroid injection (majority) Operative - Release of A1 pulley – at the base of the digit ```

Answer 6

Same as trigger finger, but in extensor compartment In anatomical snuffbox, nerves - abductor pollicis longus, extensor pollicis brevis - run in sheath Don’t get stuck because power of wrist movement too much, but is incredibly painful ``` Conservative - Rest (avoid making a fist) - NSAIDs - Steroid injection (majority) Operative - Release tendon sheath ``` Finklestein’s test to diagnose (but essentially is just causing lots of pain)

Answer 7

Nodular hypertrophy and contracture of palmar fascia = tissue shortened and thickened, brings finger in and over Familial cause - born predisposed and then something environmental triggers - Liver disease/cirrhosis (so alcohol) - Smoking - Epilepsy (if take carbamazepine) Male 10x more than female Middle age onset Leads to contracture of ring and little finger, MCP and/or IPJ, not DIP Conservative - Leave (Bill Nighy) (Stretching splinting etc not effective) Surgical (if progressive contracture (can’t know if will) and functional loss) - zigzag incisions - Fasciotomy - cut the cord in half - Fasciectomy/dermofasciectomy - cut the cord out, with or without skin - Amputation (rare) Always risk of recurrence

Answer 8

Colles' Smith's - reverse Colles', distal radius fracture with volar angulation Galleazzi - distal radius fracture with dislocation of distal radioulnar joint and intact ulnar Scaphoid fracture - FOOSH in young adults (palpatable in anatomical snuffbox with thumb hyperextended. High rate non-union)

Answer 9

- extra-articular distal radius fracture - FOOSH in elderly - dorsal angulation and displacement, radial angulation and displacement, shortening, distal fragment supinated = dinner fork deformity

Answer 10

Supracondylar fractures Monteggia fracture - #ulnar shaft with dislocation of radial head, mainly in children Midshaft humerus - brace and leave if no neurovascular involvement, no problem up to 30 degrees displacement

Answer 11

- FOOSH in children - concern re medial nerve damage (anterior interosseous branch, test with OK sign) and brachial artery damage (-> compartment syndrome) - if long term can be Volkmann’s ischaemic contracture, where permanent fixed flexion of hand and wrist - malunion common, usually need reduction and wiring

Answer 12

Rarely tibia and not fibula Fibula classified using Weber, level of syndesmosis Calcaneum fractures most common tarsal, fall from height, commonly with associated injury eg spine compression

Answer 13

Osteoporosis as diagnosis of exclusion - primary/secondary tumours/multiple myeloma/infection/trauma

Answer 14

Bone infection Common in children - vascular stasis up to growth plate Common bugs - staphylococcus - or non-specific if can't attribute to one bug Presents - continuous throbbing pain, worse at night, fever/swelling/discharge Acute/subacute/chronic Spread - haematogenous/penetrating injury/contiguous Conservative treatment - IV Abx 90% success Operative - debridement, excision to healthy bone, irrigation, dead space management (+ abx)

Answer 15

Joint infection Acute presentation - hot, painful, swollen, red, loss of function Usually s. aureus, or gram -ves in elderly/immunosupressed Risk - prosthesis, pre-existing joint disease, intra-articular steroid injections, diabetes MEDICAL EMERGENCY - need aspiration to tailor abx and joint drainage Treat with flucloxacillin initially (s. aureus)

Answer 16

What tumour does to bone - osteolysis, sclerosis What bone does to tumour - indicates how fast growing if sclerosis/boxed in Edges (demarcation) Soft tissue swelling

Answer 17

Osteochondroma - Most common - Aberrant cortical cartilage lesion - Children and adults - Usually no treatment required (1% may become malignant) - Comes from growth plate, so becomes more proximal as you grow, then stops growing after you have finished your growth Enchondroma - Cartilaginous lesion - Usually incidental finding - Often left untreated - Adults only Osteoid osteoma - Rare - Age 5-30 - Painful (needs treatment) - Self-limiting - Caused by osteoblasts

Answer 18

RARE Osteosarcoma - Mostly sporadic - Ill-defined lesion - Needs chemotherapy and limb salvage or amputation Ewing’s sarcoma - Very rare - Age 5-25 - In flat or long bones - Very malignant, can get very large - Needs chemotherapy and limb salvage or amputation - 60% survival at 5 years Chondrosarcoma - Peak at age 80 - M>F - Usually from a benign tumour, slow growing - Common in pelvis and hip - Chemo and radiotherapy less effective, needs wide excision and amputation - Low grade 90% survival at 5 years, High grade 5% survival

Answer 19

Much more likely than primary ``` MOSTLY FROM MULTIPLE MYELOMA (CRABI) or Mets from BLT with KP sauce - breast - lung - thyroid - kidney - prostate ``` Mets rarely below the knee - to spine, pelvis, ribs, proximal long bones Often only palliative care

Answer 20

Compression of lumbar spine nerve roots causing loss of sensation and function in bladder and bowel - Lower back pain - Alternating or bilateral root pain in legs - Saddle anaesthesia - Loss of anal tone on DRE - Bladder (and bowel) incontinence Due to herniated disc, tumour, fracture, narrowing of spinal canal Need MRI

Answer 21

Bilateral leg weakness Preceding back pain Bladder/anal sphincter involvement is late, manifests as hesitancy, frequency, painless retention NEUROSURGICAL EMERGENCY Signs on a motor, reflex and sensory level - Normal signs above the level of the lesion - LMN signs at the level of the lesion - UMN signs below the level of the lesion (reflexes increased) Causes - Secondary malignancy (breast, lung, prostate, thyroid, kidney) in the spine - Infection - Cervical disc prolapse - Trauma - Haematoma (warfarin) - Intrinsic cord tumour - Atlanto-axial subluxation - Myeloma

Answer 22

Fall on outstretched hand Elderly -> Colles’ Young child -> greenstick Young/middle age -> scaphoid fracture

Answer 23

Metabolic bone disease - osteoclasts and osteoblasts out of balance/control Starts with lytic bone (clasts) then becomes sclerotic (blasts) Presentation - Pain - Bony deformities - skull enlargement On radiograph - Irregular borders - Cortical thickening - Trabecular coarsening (mottled) - Bowed bone - Expanded bone size (is what causes bowing, because fixed at eg knee and ankle so has nowhere to go) Complications - Fractures - Osteoarthritis - Osteosarcoma

Answer 24

``` LOSS Loss of joint space Osteophytes Subchondral cysts Subchondral sclerosis ``` Bilateral, symmetrical ish (dominant side worse), DIPs and PIPs of hand mostly

Answer 25

``` CRITOL Capitellum - 2 Radial head - 4 Internal (medial) epicondyle - 6 Trochlea - 8 Olecranon - 10 Lateral (external) epicondyle - 12 ``` Fuse at 14-16

Answer 26

Scaphoid lunate triquetrum pisiform hamate capitate trapezoid trapezium

Answer 27

``` B ladder/bowel disfunction A naesthesia (Saddle) D rop in weight unexpectedly ``` T rauma U nrelenting non-mechanical pain N eurological abnormalities A ge of onset <20 or >55 F ever I VDU S teroid use H istory of cancer (prostate, renal, breast, lung, bowel)

Answer 28

Part of nucleus pulposus herniates through the annulus fibrosis Presents with sciatica, numbness/tingling/weakness of the foot, uncomfortable to sit and either stand/lie down BILATERAL LEG SYMPTOMS = impending cauda equina Common in manual workers after heavy lifting Need MRI Conservative management unless cauda equina syndrome (surgical emergency)

Answer 29

Discitis – Infection of the disc space Vertebral osteomyelitis – infection of the vertebral body - sinister back pain - in immunocompromised or IVDU - unwell, pyrexic, severe unrelenting back pain - staphylococcus or streptococcus - need to exclude spinal TB (unwell with TB symptoms + spondylitic, deformity, neurological deficit) - need 6 weeks IV Abx + surgical drainage of abscess if present

Answer 30

Age-related condition in which one or more of the vertebral discs deteriorate or break - pain, especially on movement + maybe numbness/tingling in extremities - not OA, but can develop into OA if bone comes into contact and rubs - clinical diagnosis + MRI

Answer 31

``` Subluxation and Dislocation of the Acromioclavicular (AC) Joint - fall laterally onto shoulder (rugby) and tear capsule, coronoid and trapezoid ligaments as acromion is forced down. Anterior Dislocation of the Shoulder - common as shallow glenohumoral joint space and wide range of motion. From FOOSH or forced abduction and external rotation. Must rule out fracture before manipulating! Rotator cuff pathology - continuum of tendinitis, bursitis, partial tearing or complete tearing of the tendons. In age, repetitive motions. Conservative management, maybe steroid injections, only operate if sudden acute tear, impingement or calcific tendonitis. Adhesive capsulitis (frozen shoulder) - loss of passive and active shoulder movement, no clear underlying cause. Insidious onset, lose external rotation first. Should improve in 3 months. ``` - axillary nerve - posteriorly around surgical neck of humerus (with posterior circumflex artery). Motor to deltoid and teres minor, sensory to superior lateral cutaneous nerve (skin over shoulder) - axillary artery

Answer 32

Axillary nerve - surgical neck fracture of the humerus Radial nerve - mid shaft fracture of the humerus, as it travels down the radial groove Brachial Artery - supracondylar fracture of the humerus, increases the risk of volkmaan's ischemic contractures Axillary artery - surgical neck fracture of the humerus, but is relatively uncommon (musculocutaneous nerve uncommonly injured)