Orthopaedics Flashcards
What is meant by a pathological fracture
Fracture through an abnormal bone e.g. osteoporosis, tumour/mets, osetemalacia, Pagets disease
How many points are allocated to each aspect of GCS
Eyes 4
Voice 5
Motor 6
Describe GCS assessment of eyes
1 - wont open
2 - open to pain
3 - open to voice
4 - spontaneously open
Describe the GCS assessment of voice
1 - no voice 2 - incomprehensible 3 - inappropriate 4 - confused 5 - orientated
Describe the GCS assessment of motor
1 - none 2- abnormal extension (decerebrate) 3 - abnormal flexion (decorticate) 4 - flexion to withdraw from pain 5 - moves to localise pain 6 - obeys commands
Early complications of a fracture
DVT/PE Avascular necrosis Wound infection Osteomyelitis Compartment syndrome
Late complications of a fracture
Mal-union, Non-union Delayed union Infection Stiffness Instability
Delayed union of a fracture is classed as non-union how long after the injury?
6 months
Risk factors for incomplete bone healing
Joint instability Infection Segmental fracture Areas of low blood supply - scaphoid, distal tibia, 5th MTP DM Smoker HIV Steroids
What are the 6 Ps of critical limb ischaemia
Pain Pallor Pulseless Paralysis Paraesthesia Perishingly cold
Signs/symptoms of a fracture
Pain, swelling, tenderness Mobile at fracture site Loss of limb function Neurovascular compromise distally Crepitus
What are the 3 types of nerve injury from fractures
Neuropraxia
Axonotmesis
Neurotmesis
Management of a fracture
Wound care and analgesia
- Reduction (closed/open)
- Stabilisation/fixation (internal/external)
- Rehabilitation
What are the 2 broad types of hip fracture
Intracapsular
Extracapsular
Describe the Garden classification of intracapsular hip fractures
1 - undisplaced + incomplete
2 - undisplaced + complete
3 - partly/incompletely displaced
4 - completely displaced
Management of Garden hip fractures type 1 and 2
Dynamic hip screw (internal fixation)
Management of Garden hip fractures type 3 and 4
Hemi/total arthoplasty
When describing fractures what are the 3 main questions you need to think about
Which bone
Which bit of that bone
How is it broken
When describing how a bone is broken what descriptive categories can you use
Complete/incomplete Transverse/spiral/oblique Non-displaced/angulated/displaced Distracted/impacted Simple/segmental/comminuted Open/closed
OA affects mostly which joints
Hip, knee, hand, spine, shoulder
Secondary causes of OA
Metabolic: gout/pseudogout, haemochromatosis, Wilsons
Neuropathic: DM, syphilis
Anatomical: slipped epiphysis, Perthes disease
Traumatic: injury, fracture, surgery
Inflammatory arthritis
Clinical features/symptoms of OA
Pain and stiffness that gets worse with activity
Sometimes swelling
Giving way/locking
Decreased ROM
Bony deformities - heberdens nodes, bouchards nodes, squaring of the thumb base
Crepitus
Joint line tenderness
Heberdens nodes affect which joint
DIP
Bouchards nodes affect which joint
PIP
X-ray findings of OA
Loss of joint space
Subchondral sclerosis
Subchondral cysts
Osteophytes
Management of OA
Conservative: weight loss, exercise, physio Analgesia - NSAIDs + paracetamol + PPI Intra-articular steroid injections Orthoses Surgery
Bone density T score for osteopenia
-1 to -2.5
Normal bone density T score
Over -1
Osteoporosis bone density T score
Less than -2.5
Risk factors for osteoporosis
Female Low BMI Maternal FH Steroid use Aromatase inhibitors Smoking Alcohol
Diseases that can cause osteoporosis
Hyperthyroidism
Hyperparathyroidism
Cushings
Vitamin D deficiency
Management of osteoporosis
Falls prevention
Bisphosphonates (Alendronic acid)
Ca/Vit D replacement
Differentials of childhood leg pain
Transient synovitis of the hip Perthes disease Slipped upper femoral epiphysis Developmental dysplasia of the hip Juvenile idiopathic arthritis Tumour Referred pain - malignancy, testicular, appendix NAI Joint sepsis/osteomyelitis
Classic findings of a fractured neck of femur
Classically the affected leg is shortened, ABducted and externally rotated
Exacerbation of pain on palpation of the greater trochanter
Pain is exacerbated by rotation of the hip
Typical presentation and management of transient synovitis of the hip
Boy aged around 5
Acute mild/moderate hip pain and limp following recent URTI or gastroenteritis
Limited movement, positive leg roll, sometimes abducted and externally rotated
Usually resolves after 7-10 days, management is supportive with analgesia and activity restriction
What is Perthes disease
Decreased blood supply to femoral epiphysis –> avascular necrosis, remodelling, deformity, secondary OA
Typical presentation of Perthes disease
Boys aged around 5
Painless limp, usually unilateral, decreased ROM, short stature, pain worse with activity, asymmetrical limb length
Typical presentation of slipped upper femoral epiphysis
Adolescent/puberty
Associated obesity, hypothyroidism or metabolic disorder
Pain, limp, external rotation upon flexion of the hip
Restricted range of movement
Typical presentation of developmental dysplasia of the hip
Newborn girls
Hip subluxation/dislocation
Asymmetrical leg folds, asymmetrical hip abduction, delayed crawling
Back pain differentials
Mechanical Disc herniation Spinal stenosis Fracture Discitis/osteomyelitis/spinal abscess Malignancy Inflammatory arthropathy Cauda equina syndrome Referred: peptic ulcer, AAA, pyelonephritis
At what level does the spinal cord end and cauda equina start
T12/L1
Sciatic nerve root levels
L4 + L5
S1,2,3
Back pain red flags
Thoracic pain Leg weakness Incontinence Fever Saddle anaesthesia History of cancer
Typical presentation of spinal stenosis
Neurogenic claudication - Leg/back pain, weakness, numbness bought on by walking
Differential diagnosis of shoulder pain
Subachromial impingement Bursitis Referred pain from neck Rotator cuff tear RA OA Frozen shoulder
Typical symptom complaint of shoulder impingement
Pain and weakness with overhead movements
Risk factors for bursitis
Occupation with repetitive mechanical stress Nearby joint infection OA RA Gout/pseudogout
Typical symptom complaint of bursitis
Localised pain, worse with movement, over months and has flare ups
Risk factors for frozen shoulder
Female Shoulder injury or surgery DM Thyroid disease Previous frozen shoulder
Describe the 4 typical stages of frozen shoulder (adhesive capsulitis)
1 - lateral shoulder pain, worse at night, only slight reduction to range of movement
2 - pain and ROM get worse
3 - pain only on extremes of movement but loss of ROM really bad
4 - negligible pain but profound loss of ROM
How long does frozen shoulder typically take to resolve
18-24 months
How long after intra-articular steroid injections do you have to wait before you could have implant/prosthesis surgery
3 months
What are the muscles of the rotator cuff
Supraspinatus
Infraspinatus
Subscapularis
Teres minor
What action does the supraspinatus muscle facilitate
Abduction of the shoulder
What action does the subscapularis muscle facilitate
Internal rotation of the shoulder
The infraspinatus muscle and teres minor facilitate which movement
External rotation of the shoulder
Which nerve supplies the supraspinatus muscle
Suprascapular nerve
Which nerve supplies the subscapularis muscle
Upper and lower subscapular nerves
Which nerve supplies the infraspinatus muscle
Subscapular nerve
Which nerve supplies teres minor
Axillary nerve
What does pain upon the Hawkins-Kennedy test suggest
Supraspinatus impingement
What are the two tests for shoulder impingement
Hawkins-Kennedy
Scarf test
What are the three tests for the rotator cuff
Empty can test
External rotation against resistance
Gerber’s lift-off test
Which muscle does Gerbers lift off test assess
Subscapularis
Which muscles does external rotation of the shoulder against resistance assess
Infraspinatus and teres minor
Which muscle does the empty can test assess
Supraspinatus
Low arc pain on abduction of the shoulder suggests what
Supraspinatus impingement
High arc pain on abduction of the shoulder suggests what
ACJ injury/pathology
Loss of shoulder external rotation is common in which disease process
Frozen shoulder
Winging of the scapula suggests damage to which nerve
Long thoracic nerve
Typical clinical features of meniscal tears
Knee pain worse on weight bearing or activity Joint line tenderness Restricted knee extension Locked knee Clicking/popping/locking of knee joint Intermittent joint effusion
What special test in examination can assess for knee meniscal tears
McMurray’s test
What aspects of the history can be used to differentiate meniscus tear from knee ligament injuries
Meniscal tears - axial loading and rotation with fixed foot or degenerative changes are mechanism of injury. You get delayed slow onset effusion. There is palpable popping/clicking/locking of the knee with maneuvers
Knee ligaments - varus or valgus stress is mechanism of injury. Rapid onset effusion. Absent popping sensation.
Features of L3 nerve root compression
Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
Features of L4 nerve root compression
Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
Features of L5 nerve root compression
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
Features of S1 nerve root compression
Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
Describe the femoral stretch test
This is a test for irritation of higher nerve roots - L4 and above.
The patient is positioned lying face downwards, and with the knee flexed, the hip is lifted into extension. Lumbar root irritation tension may cause pain to be felt in the front of the thigh and the back.
An elderly man with bone pain, raised ALP but normal Ca and PO4 is typical of which diagnosis
Pagets disease
If a FRAX score shows intermediate risk what should you do
Arrange a bone mineral density scan
Describe a Colle’s fracture
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 of distal fragment
Describe a Smiths fracture
Palmar 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 Bennetts 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
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
Describe Galeazzi fracture
Radial shaft fracture with associated dislocation of the distal radioulnar joint
Direct blow
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
