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3rd year MDEMO > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

Bone purpose and make up

A

ORGAN
Functions - stability for locomotion, haematopoeisis, calcium homeostasis

Organic - cells and type I collagen (to resist tension like fibrocartilage - type II is hyaline cartilage)
Inorganic - hydroxyapatite and calcium phosphate to resist compression

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2
Q

Structure of bone

A

Metaphysis - proximal to growth plate (good blood supply, heals well)
Epiphysis - distal to growth plate
Diaphysis - rest of the shaft

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3
Q

Types of bone

A

Lamellar - mature, regular arrangement of collagen, strong, few cells - cortical and cancellous bone
Woven - immature, disorganised, in children or adults pathologically/fracture repair

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4
Q

Describing a fracture

A
  • mechanism of injury (trauma, stress, pathological)
  • which bone, what part
  • closed/compound
  • simple/comminuted
  • displaced (angulated/shortened - according to distal fragment, no. of cortical widths by if lateral) or not displaced
  • intra/extra-articular
  • fracture pattern (transverse/spiral/oblique/segmental/greenstick/avulsion)
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5
Q

4 needs in bone healing

A 
CASS
Contiguity
Alignment
Stability
Stimulation
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6
Q

Primary bone healing

A

Abnormal in real life, needs intervention for absolute stability
Cutting cones formed by osteoclasts for intramembranous ossification
Without callus - haematoma, inflammation and proliferation, cutting cones, consolidation

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7
Q

Secondary bone healing

A

With callus - haematoma, inflammation and proliferation, soft callus, hard callus, remodelling
Endochrondral ossification
Needs micromotion

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8
Q

Fracture time to heal

A

Perkin’s principles

Upper limb

  • if under 12yo, 3-4 weeks
  • in adult, 6-8 weeks

Lower limb (double)

  • in child, 6-8 weeks
  • in adult, 12-16 weeks

Axial skeleton
- 8-12 weeks (rare in children)

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9
Q

Factors affecting bone healing

A

Biological

  • energy transfer
  • neurovascular status
  • infection
  • the patient - age, smoking, diabetes, alcohol

Mechanical

  • degree of displacement/reduction
  • degree of movement
  • mode of infection
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10
Q

Non-union of fracture

A

If not healed in double the time expected, will never heal naturally

  • host factors
  • injury factors
  • treatment factors

Hypertrophic - excessive strain/movement at site, callus forms but fracture line persists
Atrophic - host + injury factors, absence of callus

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11
Q

Wolff’s law

A

Form follows function

Bent bone will reform straight according to where the pressure is

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12
Q

Secondary signs of fracture

A

Lipohaemarthosis

  • if intra-articular, commonly in knee
  • fat and blood from bone marrow into joint
  • leg must be elevated to show fluid level on imaging

Haemarthrosis

  • less serious
  • haemorrhage into joint space
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13
Q

Principles of treatment of fractures

A

Aim to restore normal function

REDUCE
IMMOBILISE
REHABILITATE

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14
Q

Reduction of fractures

A

Only necessary if

  • pressure on surrounding tissues
  • intra-articular (synovial fluid washes away haematoma so can’t heal)
  • multiple fractures (to get patient mobilising sooner)

To restore length, alignment, rotation in extra-articular fracture

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15
Q

Immobilisation of fractures

A

Non-operative

  • plaster of paris cast
  • splint
  • traction

Operative

  • K-wires (still callus formation, just to stabilise slightly, secondary healing)
  • screws/plates (holds in absolute stability, primary healing)
  • intramedullary nail (callus so secondary healing - need weight bearing 24h after surgery to get micromotion necessary)
  • external fixator (secondary healing, for compound fractures, bridging plate so allows micromotion)
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16
Q

Rehabilitation of fractures

A

The earlier to move the better

MDT - physio, OT, GP, district nurse
Analgesia
Social worker (adapting housing)
Work assessment
Repeat risk management - falls, malignancy, epilepsy, osteoporosis
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17
Q

Fractures in children

A

Commonest in the areas of rapid growth – distal humerus, radius and around the growth plate

Greenstick - break on tension side, buckling on compression side (single cortical #, eg FOOSH)
Torus - 360degree buckling, bulge ‘donut’ around
Growth plate - Salter-Harris

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18
Q

Salter-Harris classification

A

For fractures of the growth plate in children, or commonly in adolescents (lots of growth, lots of cartilage)
- 90% type II

I - Straight across
II - Above
III - Lower
IV - Two 
V - ERasure (crush)
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19
Q

Blood supply to NOF

A

Abdominal aorta -> common iliac

-> internal iliac
- obturator artery to head
- superior gluteal artery to greater trochanteric head
- inferior gluteal artery to lesser trochanter
All not enough to keep head of femur alive

-> external iliac -> femoral -> profunda femoris
-> LCFA + MCFA -> extracapsular anastomotic ring
Blood supply to femoral head

So if in fracture, cut the retinacular/ascending arteries, all blood supply cut off and avascular necrosis

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20
Q

Intracapsular NOF fractures

A

Shortened, internally rotates (ileopsoas to lesser trochanter pulls up)
Rare than extracapsular
Displaced or undisplaced
Garden’s classification - 1/2 give it a screw, 3/4 hip no more

NEED SURGERY within 36h (avascular necrosis will not heal alone)

  • if under 55/undisplaced - cannulated screws
  • if 55-75 - THR
  • if 75+ - hemiarthroplasty
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21
Q

Extracapsular NOF fractures

A

More common than intracapsular, and better prognosis and blood supply not compromised

NEED SURGERY (for secondary healing, micromotion)

  • intertrochanteric - DHS
  • subtrochanteric (needs more support, closer to moment) - long intermedullary nail
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22
Q

Hip problems in children by age

A

Newborn - developmental dysplasia, dislocatable hips
First year - Tom-Smiths arthritis (septic)
Toddler - irritable hip, spontaneous improvement
Age 5-9 - Legg-Calve-Perthes
Age 10-14 - SUFE (limp, external fixation deformity)
Age 15-30 - early arthritis secondary to childhood problems
Age 50+ - impingement (CAM if cup too shallow, pincer if cup too big)
Old age - osteoarthritis

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23
Q

Contraindications to hip arthroplasty

A

ABSOLUTE

  • active infection
  • Charcot (proprioception loss)
  • flail/neuromuscular impairment
  • hypovascular
  • inadequate soft tissue cover

RELATIVE

  • young patient
  • heavy demand
  • obese
  • poor compliance
  • poor mental state
24
Q

Carpal tunnel anatomy

A
  • floor - scaphoid, lunate, triquetrum
  • roof - flexor retinaculum (transverse carpal ligamentum)

Contains

  • median nerve
  • 9 tendons (4x flexor digitorum superficialis, 4x profundus, flexor pollucis longus)
  • NO artery
25
Q

Carpal tunnel syndrome

A

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
26
Q

Treatment of carpal tunnel syndrome

A

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

27
Q

Cubital tunnel syndrome

A

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)

28
Q

Ganglia

A 
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)

29
Q

Trigger fingers

A

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
30
Q

De Quervain’s

A

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)

31
Q

Dupuytren’s contracture

A

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

32
Q

Wrist fractures

A

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)

33
Q

Colles’ fracture

A
  • extra-articular distal radius fracture
  • FOOSH in elderly
  • dorsal angulation and displacement, radial angulation and displacement, shortening, distal fragment supinated
    = dinner fork deformity
34
Q

Humeral fractures

A

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

35
Q

Supracondylar fractures

A
  • 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
36
Q

Ankle fractures

A

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

37
Q

Vertebral fractures

A

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

38
Q

Osteomyelitis

A

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)

39
Q

Septic arthritis

A

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)

40
Q

Bone tumours (four things to consider)

A

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

41
Q

Benign bone tumours

A

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
42
Q

Malignant primary bone tumours

A

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
43
Q

Malignant secondary bone tumours

A

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

44
Q

Cauda equina syndrome

A

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

45
Q

Spinal cord compression

A

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
46
Q

FOOSH

A

Fall on outstretched hand

Elderly -> Colles’
Young child -> greenstick
Young/middle age -> scaphoid fracture

47
Q

Paget’s disease of bone

A

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
48
Q

Osteoarthritis on radiology

A 
LOSS
Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis

Bilateral, symmetrical ish (dominant side worse), DIPs and PIPs of hand mostly

49
Q

Elbow ossification centres by age

A 
CRITOL
Capitellum - 2
Radial head - 4
Internal (medial) epicondyle - 6
Trochlea - 8
Olecranon - 10
Lateral (external) epicondyle - 12

Fuse at 14-16

50
Q

Bones in wrist

A

Scaphoid lunate triquetrum pisiform hamate capitate trapezoid trapezium

51
Q

Back pain red flags

A 
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)

52
Q

Intervertebral disc prolapse

A

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)

53
Q

Discitis/Vertebral Osteomyelitis

A

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

54
Q

Degenerative disc disease

A

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
55
Q

Unplanned care in shoulder pathology

A 
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
56
Q

Humoral fractures and associated structures

A

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)

3rd year MDEMO (6 decks)

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