Orthopaedics Flashcards
How would you manage an extracapsular proximal femoral fracture?
1) reduce
2) immobilise: Dynamic hip screw
3) rehab
Which nerve is most likely to be damaged during a knee arthroplasty? and what signs would the pt have?
Common peroneal nerve
difficultly dorsiflexing foot when walking (foot drop)
what is compartment syndrome?
complication following fracture where there is raised pressure in a closed anatomical space
-pain, parasthesiae, pallor, reduced pulse
what fractures is compartmental syndrome associated with?
supracondylar and tibial shaft fractures
Which movement is classically impaired in adhensive capsulitis?
External rotation (shoulder)
How would left posterior hip dislocation typically present?
Left leg shortened adducted and internally rotated
how would a left leg anterior hip dislocation typically present?
left leg abducted and externally rotated
how does slipped upper femoral epiphysis typically present?
overweight teen boy (puberty) with knee/hip problems
could have been minor trauma
progressive hip pain, limp, stiffness and reduced ROM
Locking and giving way are common symptoms of
Meniscal injury
Risk factors for hip fracture
previous hip fracture
osteoporosis
frequent falls
Types of hip fracture
1) intracapsular
- transcervical: through NOF
- subcapital: above NOF
2) extracapsular
What is the difference between intra/extracapsular fractures
Risk of necrosis in intracap because severes blood supply
in extracap the blood supply is intact
How does a hip fracutre present?
Shortened leg: reduced angle between neck and shaft of femur
external rotation
How do you describe a fracture?
1) position: displaced or not
2) completeness: complete or not
3) orientation: linear, transverse
4) skin penetration: compound (penetrates) simple (doesnt)
What are the stages of fracture healing?
1) haematoma and inflam
2) fibrocartilaginous callus formation (soft callus) - days
3) bony callus formation - weeks
4) bone remodelling - months
what happens in the first stage of healing
-haematoma and inflam
accumulation of blood causing death of bone cells, swelling and pain
what happens in the second stage of fracture healing?
-fibrocartilaginous callus formation
new blood vessels forming, meshwork from granulated tissue by chondrocyres secreting collagen and proteoglycans -> callus which rejoin the fracture
external callus also forming
What happens in the 3rd stage of fracture healing?
-bony callus formation
endochondral ossification turns soft callus into hard callus
what happens in the final stage of fracture healing?
-Bone remodelling
bony callus-> fine bone which is organised and strong. Compact bone laid down bc increased osteoblast activity
What is osteoporosis
low bone mass and deterioration of bone tissue which increases facture risk
what tool is used to assess femoral neck fractures?
Garden classification
what is garden 1 fracture
incomplete and minimally displaced
what is a garden 2 fracture
complete, non-displaced
what is a garden 3 fracture?
complete fracture and partially displaced
what is a garden 4 fracture?
completely displaced- no engagement of 2 fragements
Where do fragility fractures occur?
Distal forearm: Colles
hip: NOF
vertebrae
what factors increase pt risk of hip fracture and how would would determine risk?
FRAX
- female
- age
- personal Hx and FHx
Meds: corticosteroids
Secondary: RA, CKD, IBD, hyper/hypothyroid
How does a vertebral fracture present?
back pain
decreased height
How do you diagnose a patient with suspected osteoporosis?
DEXA scan - produces T score
if T score >-2.5 =osteoporosis
if T Score >-2.5 + fracture = severe OP
T score 1-2.5 = osteopenia
How do you manage osteoporosis?
Lifestyle
meds
- Vit D/calcium supplements
- bisphosphonates (alendronate)
- Monoclonal Antibodies (denosumab)
- Forsteo
What is pagets?
increased osteoclast activiy -> increased osteoblast activity = disordered and weaker bone
How does pagets present?
affects axial skeleton, normally asx
Bone pain
How would you investigate a pt with ?pagets?
Bone specifc alkaline phosphatase levels increased
Isotope scans - affected bones in black
X-ray
What X-ray findings would you expect to find on ?Pagets
- blade of grass lesions between healthy and diseases long bone
- cotton wool pattern in the skull
how would you manage a pt with Pagets?
NSAIDS
IV/PO bisphos (zoledronate)
surgery
What are the potential complications of pagets?
Triad: pain, deformity, fractures
Deafness: if skull affected
Myelopathy
osteosarcoma: life long monitoring required
How does Osteomalacia present?
Bone: pain, tenderness, bilat symmetrical fractures
Prox muscle weakness
Lethargy
change in gait
Which groups are at risk of Vit D deficiency?
- dark skin
- clothes covering skin
- housebound
- alcoholics
- poverty
What are the causes of Vit d def?
insufficient exposure
malabsorption
anti-c
renal failure
How do you manage osteomalacia?
Increase exposure
vit D supplements: colecalciferol or calcitriol (CKD pt)
Why do CKD patietns have to receive calcitriol instead of colecalciferol
calcitriol is the active form, needed because dont have enzyme to convert cholecalciferol -> calcitriol
*25(oh)D3-1-alpha-hydroxylase*
Typical presentation of hypercalcaemia?
Polyuria and polydipsia
Dyspepsia
Depression
cog impairment
How does very hight (>3.5mmol/L) hypercalcaemia present?
vomiting and abdo pain
dehydration
lethargy
arrhythmias
How does middle high hypercalcaemia present (<3.5)
muscle weakness
anorexia and nausea
constipation
fatigue
blood results and likely cause of hypercalcaemia?
high PTH: primary hyperparathryoidism
high albumin and urea: dehydration
high alk phos: boney mets
high plasma protein: sarcoidosis, lymphoma, thyrotoxicosis
Most common primary hyperparathyroid cause?
adenoma
4 year old child developed pain yesterday in L hip when walking. Had chest infection last week, otherwise well
Diagnosis and management
Transient synovitis of the hip
Mx: rest and physio, resolves in 2 weeks
Classic presentation of Transient synovitis of the hip?
acute onset post infection
unilateral
no pain at rest
3-10 years
Obese 7 year old boy presents with several week history of increasing pain in R hip, started limping, struggling with sports at school
investigations and diagnosis
X-ray: widening joint space and remodelling deformities
-Perthes
Classic presentation of Perthes?
insidious limp +hip/knee pain
decreased ROM
5-10 year old boys
How would you manage Perthes?
If <50% fem head affected: bed rest and NSAIds
if >50% affected: plaster cast and surgery
what is perthes?
Bone remodelling following avascular necrosis of the femoral head causes epiphysis distorsion
Overweight 14 year old limping and complaining of pain after being tackled in football yesterday
what is your suspected diagnosis and management plan?
Slipped capital femoral epiphysis
X-ray: displacement
Mx: surgical fixation
Red flags for paeds limp and condition indicated
temp>38.5
WCC>12
CRP>20
not weight bearing
If 3+ of above then BC ± aspiration for ?septic arthritis
When would you suspect osteomyelitis and what would your management plan be?
acute febrile, pain, swollen, red tender over bone
+ve BC and increased WCC
IV then PO Abx
How would you manage Lyme disease?
doxy or amox
