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3b General care > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

What is the pathology of osteoporosis?

A

osteoporosis is a reduction in bone mineral density and disruption of the normal bone architecture causing increased bone fragility and fracture risk

there is an imbalance in remodelling of bone - osteoclast activity outweighs osteoblast

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2
Q

What are the risk factors for osteoporosis?

A 
S - STEROIDS
H - HYPERTHYROID, HYPERPARATHYROID
A - ALCOHOL, smoking
T - TESTOSTERONE decrease
T - THIN (BMI <22)
E - EARLY MENOPAUSE
R - RENAL DISEASE, liver disease
E - EROSIVE BOWEL DISEASE e.g. coeliac
D - DIETARY INTAKE - decreased Ca, malabsorption

+ female, age, rheumatological conditions (RA), FH of hip fractures, previous fragility fracture

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3
Q

What does osteoporosis cause?

A

FRAGILITY FRACTURES - commonly vertebral, femoral neck or wrist

(otherwise asymptomatic)

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4
Q

What is a fragility fracture?

A

fracture after falling from standing height or less

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5
Q

Which score is used after a fragility fracture in osteoporosis? what does it assess?

A

FRAX SCORE - risk score for likelihood of another fracture in the next 10 years (before doing a DXA scan)

3 PERSON (age, sex, BMI) , 3 FRACTURE (previous fracture, FH of hip fracture, low bone mineral density), 3 INPUT (smoking, alcoholism glucocorticoids), 2 CONDITIONS (RA, secondary osteoporosis)

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6
Q

Which medications may worsen osteoporosis?

A 
glucocorticoids (corticosteroids) e.g. prednisolone, budesonide
anti epileptics 
PPI
SSRI
glitazones
heparin therapy
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7
Q

After a fragility fracture or a FRAX score >10%, how is a patient assessed or diagnosed with osteoporosis?

A

DXA scan** (Dual x-ray absorptiometry) - measures bone mineral density

T score

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8
Q

How is osteoporosis managed conservatively?

A

reduce risk factors - smoking cessation, stop alcohol, BMI >22, diet rich in calcium
weight bearing exercises
fall prevention
treat secondary osteoporosis causes e.g. coeliac

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9
Q

What is the first line treatment for osteoporosis?

A

BISPHOSPHONATES e.g. oral alendronate (if experience SE try -> risedronate)
= inhibit osteoclast activity and bone resorption

+ ORAL CALCIUM AND VITAMIN D

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10
Q

What should you tell the patient when taking bisphosphonates?

A
  1. take first thing in the morning on empty stomach
  2. do not eat/ take other tabelts for 30 mins after taking
  3. do not lie down
  4. have a glass of water when taking tablet
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11
Q

What are the side effects of bisphosphonates?

A

oesophagitis *, atypical femoral fractures, gastric ulcers, osteonecrosis of jaw, hypocalcaemia

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12
Q

What are the other medical options for treating osteoporosis?

A

2nd line = STRONTIUM RANELATE
= increases deposition of new bone by osteoblasts and inhibits osteoclast

3rd line = OESTROGEN (HRT) OR SERMS e.g. raloxifene
= prevents bone loss and reduce risk of vertebral fractures

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13
Q

What is the pathology of pagets disease?

A

increased and uncontrolled bone turnover

  1. LYTIC PHASE -> increase bone resorption by osteoclasts
  2. SCLEROTIC PHASE -> rapid bone formation by osteoblasts but disorganised and mechanically WEAKER bone
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14
Q

How does pagets disease present?

A

usually in older people
bone pain - usually lumbrosacral, pelvis, femur
joint pain - secondary to bone deformity

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15
Q

What are the complications of pagets disease?

A

bowing of long weight bearing bones e.g. femur
deafness (compression of cranial nerve 8)
osteosarcoma
risks with surgery

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16
Q

How is pagets disease diagnosed?

A
  1. HIGH ALK PHOS ** - very high and also allows disease activity to be monitored
  2. x-rays - shows osteolysis and osteosclerosis
  3. isotope bone scans - identifies which bones affected
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17
Q

How is pagets disease managed?

A
  1. analgesics
  2. bisphosphonates + oral calcium + vit D
  3. joint replacements for severe joint destruction
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18
Q

What causes osteomalacia and what is it?

A

deficiency in vitamin D causes impaired mineralisation of the bone -> leads to softening of the bone (accumulation of unmineralised osteoid) -> bone becomes deformed and pseudo fractures

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19
Q

Who is at risk of osteomalacia?

A
  1. people who are housebound (lack of sun on skin)
  2. asian immigrants (lack of sun on dark skin)
  3. CKD (failure to activate vit D)
  4. liver disease e.g. cirrhosis (failure to activate vit D)
  5. malabsorption syndromes e.g. crohns, CF, coelaic, pancreatic disease (poor absorption of calcium and vitamin D)
  6. pregnancy
  7. alcohol, obesity
  8. drugs - corticosteroids, anti convulsants, rifampicin
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20
Q

How does osteomalacia present?

A

bone pain - tender, widespread
fractures
fatigue
proximal myopathy

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21
Q

How does rickets present?

A

when vit D deficiency in children affecting bone development

bone pain
impaired gait, delayed walking
bowing leg, knock knees
dental abnormalities

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22
Q

Which diseases does vitamin D deficiency cause?

A

rickets
osteomalacia
hypocalcemia
muscle weakness

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23
Q

How is osteomalacia diagnosed?

A

serum 25 (OH) D <25nmol/L
low serum calcium
high alk phos
high PTH

X-ray: translucent bands, pseudofractires

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24
Q

How is osteomalacia managed?

A
  1. calcium and vitamin D supplements
    high doses for 6-12 weeks, IM for malabsorption syndromes, active calcitriol given to CKD patients
  2. encourage sitting outside in the sun
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25
Explain vitamin D activation cycle
1. vitamin D3 (cholecalciferol) absorbed through sunlight on the skin and vitamin D2 found in dietary intake (fish oil, egg yolk) 2. it is metabolised in the liver to 25- hydroxy-vitamin D 3. it is activated in the kidneys to 1,25- hydroxy-vitamin D if low serum calcium, activated vit D can then increase calcium absorption from the small intestines or act directly on the bone to release calcium to increase serum calcium
26
Who is more likely to get fibromyalgia?
``` women age 20-50 y/o stress chronic fatigue syndrome IBS ```
27
What is the criteria of fibromyalgia?
pain at 11/18 tender points for >3 months
28
What are the symptoms and associations of fibromyalgia?
soft tissue tenderness/pain at tender points: knees, midpoint upper trapezius, supraspinatus, suboccipital muscle insertions, costochondral junction 2nd rib, upper outer gluteal, greater trochanter ``` fatigue "fibro fog" - memory problems mood difficulties - depression, anxiety stress sleep disturbance headache ```
29
How is fibromyalgia managed?
1. patient education and explanation 2. CBT 3. amitriptyline 4. regular exercise 5. gabapentin, pregabalin
30
What are the complications of mechanical back pain?
reduced quality of life depression unemployment disability
31
What is the difference between mechanical and inflammatory back pain? which points indicates each diagnosis?
mechanical = pain arising from a structure within the spine - older age - worse on movement, better with rest inflammatory = pain arising from inflammation in the vertebra, joints of spine and enthese - <40 y/o - better on movement, worse on rest, morning stiffness
32
What are the possible causes of mechanical Lower back pain?
``` trauma degenerative disease osteoarthritis of the spine scoliosis spinal stenosis herniated disc ```
33
How is mechanical back pain managed?
1. exclude inflammatory cause, spinal pathology or sciatica 2. pain relief: 1st line = NSAIDs or codeine +/- paracetamol 3. physio and encourage exercise 4. consider short course of diazepam if paraspinal muscle spasm
34
What are the differentials for inflammatory back pain?
ankylosing spondylitis psoriatic arthritis reactive arthritis IBD
35
What are the red flags for someone presenting with back pain? What are you concerned about?
"TUNA FISH" T- trauma U- unexplained weight loss N- neurological symptoms e.g. urinary retention, incontinence, weakness A- age >50 y/o or <20 y/o with new onset pain F- fever, sweats I- IVDU/ immunocompromised S- steroid use H- history of cancer concerned about: metastatic bone cancer, cauda equina, osteomyelitis, multiple myeloma, infection
36
How is sciatica caused?
90% intervertebral disc prolapse
37
What are the symptoms of sciatica?
severe pain: originating in the buttock -> upper thigh -> outer calf -> toes tingling, numbness pain worse on coughing, sneezing, lying down
38
What are the signs on examination of sciatica?
pain on straight leg raise | +ve crossover sign
39
How is sciatica managed?
1. rest (improves within 3-6 months) 2. analgesia (1st line = NSAIDS, 2nd line = gabapentin, amitriptyline) 3. physiotherapy
40
What is spinal stenosis?
degenerative changes (thickening of ligaments, osteophytes) cause narrowing of the spinal canal and can compress the nerve roots
41
Who is at risk of spinal stenosis?
manual labourers - heavy lifting | elderly
42
How does spinal stenosis present?
pain on walking pain in the buttock, calf, feet, back pain worse on extension
43
How is spinal stenosis managed?
1. x-ray or MRI shows degenerative changes and degree of stenosis 2. NSAIDs 3. weight loss, exercise, physio 4. if severe, ortho referral and surgery
44
What are the risk factors of vertebral osteomyelitis/ discitis?
IVDU immunocompromised recent sepsis surgery to spine
45
When is vertebral osteomyelitis suspected?
back pain + systemically unwell (fever) O/E: reduced movement, tenderness, red and swollen
46
How is suspected vertebral osteomyelitis investigated and managed?
1. blood cultures, high WCC, high ESR, MRI (detect abscess) | 2. IV abx (usually staph/strep) for 6 weeks
47
What are the causes of vertebral fractures?
trauma osteoporosis pathological fracture e.g. cancer, bony mets
48
What are the features of vertebral fractures?
lower back pain tingling/numbness/ weakness incontinence/ urinary retention
49
What are the causes of scoliosis?
scoliosis = lateral deviation and rotational abnormality of the spine congenital e.g. hemivertebra idiopathic e.g. adolescent idiopathic scoliosis neuromuscular e.g. cerebral palsy secondary e.g. leg length discrepancy
50
How is scoliosis managed?
1. braces if mild | 2. surgical stabilisation, fusion and correction if severe
51
What is the pathology of a prolapsed intervertebral disc?
disc prolapse occurs when part of the nucleus pulpous herniates through the annulus fibrosis and presses on a spinal nerve root commonly occurs at L4-L5 or L5-S1
52
What can a prolapsed intervertebral disc cause?
1. sciatica | 2. cauda equina
53
how does cauda equina present?
asymmetrical flaccid paralysis asymmetrical sensory disturbance LMN signs = decreased reflexes, fasciculations, weakness bladder symptoms e.g. urinary retention (later sign)
54
How is a prolapsed intervertebral disc managed?
1. MRI - if cauda equina, need surgical discectomy | 2. if sciatica, bed rest, analgesia, physiotherapy
55
What are the 3 types of wrist fracture?
1. colles fracture - fracture of the distal radius with dorsal displacement 2. smith fracture - fracture of the distal radius with volar displacement 3. scaphoid fracture - fracture of the scaphoid within the anatomical snuffbox
56
Which wrist fracture is common in osteoporosis?
colles fracture (with a fall)
57
How are scaphoid fractures caused?
fall on an outstretched hand - younger
58
With a colles fractures, what Is seen on x ray?
"dinner fork" on lateral x ray
59
With a smiths fracture, what is seen on x ray?
"garden spade" deformity
60
What are the main complications with wrist fractures?
median nerve damage!! with scaphoid fracture, at risk of AVASCULAR NECROSIS
61
How do you manage wrist fractures?
reduction and immobilisation for 6 weeks repeat x ray
62
which fractures are you concerned about avascular necrosis?
scaphoid and femoral head (intracapsular) fracture leads to joint destruction and osteoarthritis
63
list possible complications of fractures in general
1. infection 2. thromboembolism 3. compartment syndrome 4. complex regional pain syndrome 5. fat embolus (common in long bone fractures) 6. delayed union (fractures slow to unite), malunion (fracture heals in abnormal position) 7. stiffness 8. nerve damage 9. haemorrhage and shock
64
how does complex regional pain syndrome present?
usually upper limb, foot or ankle | atypical pain, red, swollen and shiny
65
Explain compartment syndrome
when there is increased pressure inside a closed anatomical space (fascial muscle compartment) -> tissue perfusion is compromised -> necrosis !!
66
When should you suspect compartment syndrome?
``` post fracture and 6 P'S: P - pain out of proportion P - pallor P - perishingly cold P - paraesthesia P - paralysis P - pulse still felt ```
67
How is compartment syndrome diagnosed?
measure the intra compartmental pressure | >40 mmHg = diagnostic
68
How is compartment syndrome managed?
urgent fasciotomy !!! | may need debridement or amputation
69
what is a complication of fasciotomy?
myoglobinuria causing renal failure -> treat with IV fluids
70
What are the key points in managing a fracture?
1. immobilise the fracture and the joint above and below 2. assess neurovascular status 3. stem bleeding by direct pressure 4. manage infection e.g. tetanus IM and treat with IV broad spec abx if open wound 5. analgesia !! - diamorphine
71
Describe the definitive management in fractures?
1. reduction of deformity = put bones into correct position closed or open reduction 2. stabilisation = maintain reduction until healing with external splitting, intraoperative fixation, external frame fixation 3. rehabilitation = rehabilitate person and limb back to normality physiotherapy
72
What type of fractures are there?
oblique - fracture is obliquely to long axis of bone comminuted- >2 fragments segmental- >1 fracture along bone transverse - perpendicular to long axis of bone spiral - fracture with rotation along long axis of bone
73
define a displaced fracture
where components are no longer in their original anatomical position
74
what is the difference between open and closed fracture?
open - break in the skin | closed - skin intact lying over fracture
75
Who is at risk of a hip fracture?
most commonly from TRAUMA or FALL: 1. elderly 2. osteoporosis 3. metastatic bone disease
76
Describe the blood supply to the femoral head
profunda femoris artery + medial femoral circumflex artery
77
define the intertrochanteric line
where the capsule attaches between the intracapular and extra capsular
78
What are the 2 types of hip fracture?
1. intra capsular fracture = fracture above the intertrochanteric line - between the blood supply and the femoral head( e.g. sub capital) -> AT RISK OF AVASCULAR NECROSIS 2. extra capsular fracture = below the intertrochanteric line and head in continuity with blood supply so no risk of asvacular necrosis
79
How are hip fractures diagnosed?
``` x ray : lateral and AP view is it extra capsular or intra capsular? displaced? angulation? type of fracture ```
80
How does a pt with a hip fracture present?
excruciating pain in upper thigh and groin (which radiates to knee) non weight bearing unable to straighten leg
81
on examination what would you find in a hip fracture?
affected leg shortened, adducted and externally rotated
82
Which classification system is used for hip fractures?
Garden classification
83
how are intracapsular hip fractures managed?
if displaced -> internal fixation if undisplaced -> hemiarthroplasty (femoral head replaced) or Total Hip Replacement (head and socket replaced)* should be fully weight bearing on day 1 of op
84
How are extra capsular hip fractures treated?
internal fixation and dynamic hip screw or intramedullary nail
85
Which pt factors determine whether a THR or hemiarthroplasty?
THR is preferred option but patient must have: 1. good mobility - walking outside with 1 stick or less 2. cognitive function intact 3. medically fit for big operation
86
what are the complications of a hip fracture that is treated conservatively as surgery not an option?
``` DVT infection malnutrition pressure ulcers muscle atrophy ```
87
If present with back pain with sensory weakness in arms, what could be the cause and how should you investigate?
three causes of this? nerve root compression Cervical spine fractures Intervertebral disc prolapse three investigations? shoulder x ray, MRI, nerve conduction studies
88
where does osteomyelitis occur in children and adults?
``` children = metaphysis adults = epiphysis ```
89
How is a T score interpreted?
< -2.5 = osteoporosis | < -1 = osteopenia
90
What is a Z score?
adjusted for age, gender, ethnicity

3b General care (4 decks)

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