Orthopaedics Flashcards
1
Q
Osteoarthritis
Aetiology (6)
A
Abnormal anatomy Intra-articular fracture Ligament rupture Meniscal injury Persistent heavy physical activity Obesity
2
Q
Osteoarthritis
Signs + symptoms of generalised disease (5)
A
Heberden's nodes (DIP) Bouchard's nodes (PIP) Joint tenderness Decreased ROM Mild synovitis
3
Q
Osteoarthritis
Signs + symptoms of localised disease (5)
A
Usually knee/hip Pain on movement Crepitus Worse at end of day and after rest Joint instability
4
Q
Osteoarthritis
X-ray findings (4)
A
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
5
Q
Osteoarthritis Differential Diagnoses (4)
A
Gout
Other inflammatory arthritides
Septic arthritis
Malignancy
6
Q
Osteoarthritis
Treatment (6)
A
Exercise (improve muscle strength)
Weight loss
Analgesia: paracetamol + NSAIDs (topical) –> codeine/oral NSAID + PPI
Intra-articular steroids or hyaluronic acid
Physiotherapy + occupational therapy
Surgery: joint replacement
7
Q
Osteomyelitis
Aetiology (8)
A
Haematogenous spread Secondary to contiguous local infection (+/- vascular disease) Direct from trauma/surgery (open fractures, surgical prostheses) Boils Abscesses Pneumonia Diabetes Pressure sores
8
Q
Osteomyelitis
Organisms (5)
A
Staph. aureus Pseudomonas E.coli Streptococci Fungi (especially in HIV/AIDS)
9
Q
Osteomyelitis
Infection sites in adults + children (2)
A
Cancellous bone typical in adults- vertebrae (IVDU), feet (diabetics)
Vascular bone in children (long bone metaphyses)
10
Q
Osteomyelitis
Pathology (4)
A
Infection ledas to cortex erosion
Exudation of pus lifts up periosteum, interrupting blood supply to underlying bone
Necrotic fragments of bone may form (sequestrum)
New bone formation created by elevated periosteum
11
Q
Osteomyelitis
Signs + symptoms (7)
A
More marked in children Pain of gradual onset Unwillingness to move Tenderness Warmth Erythema Signs of systemic infection (fever, tachycardia, malaise)
12
Q
Osteomyelitis
Investigations (4)
A
Bloods: elevated ESR, elevated CRP, elevated WCC, blood culture
Bone biopsy and culture
X-ray: changes not apparent for 10-14 days, haziness, loss of density
MRI
13
Q
Osteomyelitis Differential diagnoses (6)
A
Septic arthritis Acute inflammatory arthritis Trauma Transient synovitis Cellulitis Necrotising fasciitis
14
Q
Osteomyelitis
Treatment (2)
A
Antibiotics: vancomycin and cefotaxime
Surgery: drain abscesses and remove sequestrae
15
Q
Osteomyelitis
Complications (5)
A
Septic arthritis Pathological fractures Chronic osteomyelitis Septicaemia and death Deformity/altered growth
16
Q
Chronic Osteomyelitis
Aetiology (2)
A
Poor treatment of acute osteomyelitis
Always suspect in non-healing ulceration in vascular insufficiency
17
Q
Chronic Osteomyelitis Risk factors (3)
A
Diabetes
Immunosuppressed
Elderly
18
Q
Chronic Osteomyelitis
Investigations (1)
A
X-ray: thick irregular bone
19
Q
Chronic Osteomyelitis
Treatment (1)
A
Radical excision of sequestra and antibiotics (vancomycin and cefotaxime)
20
Q
Chronic Osteomyelitis
Complications (1)
A
Squamous carcinoma development in sinus track
21
Q
Osteochondroma
Definition (2)
A
Commonest benign bone tumour
Usually occurring about knee/proximal femure/humerus
22
Q
Osteochondroma
Signs + symptoms (2)
A
Painful mass
Associated with trauma
23
Q
Osteochondroma
Investigations (1)
A
X-ray: bony spur arising from the cortex
24
Q
Osteochondroma
Treatment (2)
A
Surgery if causing symptoms eg. pressure on adjacent structures
Any osteochondroma continuing to grow after skeletal maturity must be removed due to risk of malignancy
25
Osteoid Osteoma
| Definition (2)
Painful benign bone lesion
| Occurs most commonly in long bones of males aged 10-25
26
Osteoid Osteoma
| Investigations (2)
X-ray: local cortical sclerosis
| CT
27
Osteoid Osteoma
| Treatment (1)
CT-guided biopsy and radiofrequency ablation
28
Chondroma
| Definition (1)
Benign cartilaginous tumours
29
Chondroma
| Signs + symptoms (2)
Local swelling
| Fracture
30
Sarcoma
| Definition (1)
Any malignant neoplasm arising from mesenchymal cells (which give rise to connective and non-epithelial tissue)
31
Sarcoma
| Categories (3)
Soft tissue cancers
Primary bone cancers
Gastrointestinal stromal tumours
32
Osteosarcoma
| Aetiology (2)
Primary osteosarcoma: affects adolescents and arises in the metaphyses of long bones
Secondary osteosarcoma: may arise in bone affected by Paget's disease or after irradiation, presents age 10-20
33
Osteosarcoma
| Signs + symptoms (4)
Non-mechanical bone/joint pain
Bone pain at night
Bony swellings
Pathological fractures
34
Osteosarcoma
| Investigations (3)
X-ray: bone destruction, new bone formation, marked periosteal elevation
Staging MRI: assess intramedullary spread
HRCT: assess for pulmonary metastases
35
Osteosarcoma
| Treatment (2)
Neoadjuvant chemotherapy
| Amputation
36
Ewing's Sarcoma
| Definition (2)
Malignant round-cell tumour of long bones and limb girdles
| Typically presents in adolescents
37
Ewing's Sarcoma
| Investigations (2)
X-ray: bone destruction, new bone formation, soft tissue swelling, periosteal elevation
MRI
38
Ewing's Sarcoma
| Treatment (1)
Chemotherapy + Surgery + Radiotherapy
39
Chondrosarcoma
| Aetiology (2)
Idiopathic
| From malignant transformation of chondromas
40
Chondrosarcoma
| Signs + symptoms (3)
Pain
Lump
Presents in axial skeleton of middle-aged
41
Chondrosarcoma
| Investigations (2)
X-ray: calcification
| MRI/CT: to define tumour extent
42
Chondrosarcoma
| Treatment (2)
Unresponsive to chemotherapy + radiotherapy
| Excision
43
Fractures
| Describing an X-ray (8)
Site: bones involved and part (eg. proximal/shaft/distal)
Intra-articular involvement
Epiphyseal involvement
Obliquity: transverse/spiral
Displacement: rotation/angulation/shortening/translation
Impaction: causes shortening
Fracture pattern: simple (spiral/oblique/transverse), buckle, greenstick, comminuted (splintered), segmental (multiple breaks), avulsion (tendon/ligament pulls bone fragment away)
Soft tissues
44
Fractures
| Healing (8)
Haematoma --> Vascular granulation tissue --> Osteoblast stimulation --> Bone matrix --> Endochondral ossification --> Callus (woven bone) --> Lamellar bone --> Fracture union
45
Fractures
| Risk factors for poor healing (7)
```
Age
Recent trauma
Osteoporosis
NSAIDs
Comorbidities
Smoker
Corticosteroids
```
46
Fractures
| Gustilo Classification of Open Fractures (3)
Type I: low energy, <1cm
Type II: low energy, >1cm, moderate soft tissue damage
Type III: high energy, irrespective of wound size
47
Fractures
| Salter Harris Classification of Epiphysal Injury (5)
Type I: transverse fracture through growth plate, babies/pathological
Type II: fracture line above growth plate, most common, spares epiphysis
Type III: fracture through growth plate + epiphysis, spares metaphysis
Type IV: fracture through growth plate, metaphysis + epiphysis, interferes with growth
Type V: compression of growth plate, causes deformity and stunting
48
Fractures
| Principles of fracture management (4)
Realignment
Stabilisation to allow normal activity
Maintaining neurovasculr supply
Encouraging early rehabilitation
49
Fractures
| Management of fractures (4)
Traction (mostly children)
Conservative (splints/casts/traction)
ORIF: for intra-articular, failed conservative management, multiple fractures, open fractures (plates provide strength and stabilisation, screws, intramedullary nails, IC-wires for closed reduction and fixation)
External fixation: burns/loss of skin or if open fracture, causes less disruption to fracture site + associated sot tissue
50
Fractures
| Complications (8)
Fat embolism: released from disrupted bone marrow, usually day 2-3, altered mental state, pyrexia, SOB, tachycardia
Neurovascular injury
Infection
Delayed union: poor blood supply, systemic disease
Non-union: no healing after 6 months
Malunion: fragments not healed in anatomical positions causing loss of function
Thromboembolic events
Compartment syndrome (can lead to rhabdomyolysis then renal failure)
Complex regional pain syndromes
51
Hip Fractures
| Presentation (2)
Elderly and minor fall
| Visible shortening of leg, abduction, external rotation
52
Hip Fractures
| Investigations (6)
X-ray: AP + lateral + full length femur if querying pathological fracture
Bedside investigations to ensure haemodynamically stable, ECG + urine dip to ensure no delirium or infection
FBC: rule out anaemia
U&E: ensure pre-op optimisation
LFTs: admission baseline
Group + save: so transfusion prepared
53
Hip Fractures
| X-ray description (3)
Disruption to Shenton's line (should be smooth arch)
Extra or intra-capsular
Any displacement
54
Hip Fractures
| Treatment (6)
Analgesia + fluid resuscitation
DVT prophylaxis (LMWH)
Conservative management rare unless unfit
Surgical: depends if intracapsular (replace) or extracapsular (fix)
Intracapsular surgery: blood supply is disrupted so at risk of avascular necrosis-- hemiarthroplast/total hip replacement
Extracapsular surgery: if between the trochanters then dynamic hip screw, if subtrochanteric then intramedullary nail
55
Wrist Fractures
| Examination (2)
Vascular status: palpate radial and ulnar pulses, distal limb perfusion (temp., colour, cap refill)
Neurological status: sensation + motor function in nerve regions
56
Wrist Fractures
| X-ray description (5)
Postero-anterior for distal radius and lateral centred on wrist
State bones fractured
Intra or extra-articular
Evidence of radial shortening
Describe displacement and angulation of the distal fragment
57
Wrist Fractures
| Colle's Fracture (2)
Extra-articular transverse fracture of distal radius
| Dinner fork deformity: distal fragment displaced dorsally
58
Wrist Fractures
| Smith's Fracture (1)
Reverse Colle's fracture: displacement of distal fragment is volar (palmar)
59
Wrist Fractures
| Barton's Fracture (2)
Intra-articular
| Either dorsal or volar depending on which cortex the fracture extends into
60
Wrist Fractures
| Chauffeur's Fracture (3)
Isolated fracture of radial styloid process
Displacement of fragment uncommon
Associated with injury to the scapholunate ligament
61
Wrist Fractures
| Treatment (2)
Based on fracture pattern and stability (extension into radiocarpal joint, loss of radial height, amount of dorsal comminution and loss of volar tilt)
Non-operative: closed reduction and casting
Operative: ORIF (with volar/dorsal plate) or external fixation
62
Ankle Fractures
| Anatomy of the Ankle (6)
Ankle joint: tibia + fibula + talus
Syndesmosis joint: tibia + fibula
Movements: dorsi/plantarflexion at the tibiotalar joint, eversion and inversion at the subtalar joint, rotation
Medial soft tissue structures: delotid ligament joins medial malleolus to talus, calcaneus and navicular bones
Lateral soft tissue structures: anterior talo-fibular ligament, calcaneo-fibular ligament and posterior talo-fibular ligament
Anterior and posterior soft tissue structures: tibio-fibular ligaments
63
Ankle Fractures
| Assessment (3)
Displaced fractures should be reduced under sedation/anaesthesis
Vascular: temp., perfusion, cap refill, dorsalis pedis and posterior tib. pulses
Neurological: sensation, motor and sensory function of: superficial peroneal, deep peroneal, saphenous and sural nerves
64
```
Ankle Fractures
Ottawa Rules (2)
```
Differentiates between likely sprain or fracture
Ankle X-rays indicated if: >55, unable to weight bear for 4 steps, bony tenderness at post. edge or inf. tip of lateral malleolus, bony tenderness at posterior edge/inferior tip of medial malleolus
65
```
Ankle Fractures
Simple Classification (3)
```
Medial/lateral malleolar
Bimalleolar (both involved)
Trimalleolar (medial + lateral + posterior part of the tibia
66
Ankle Fractures
| Weber-AO System (4)
Refers to level of lateral malleolus or distal fibular fracture
Weber A: transverse fractures below syndesmosis, generally stable
Weber B: at level of syndesmosis, extending proximally (spiral or short oblique pattern), may be stable or unstable
Weber C: above tibial plafond, likely syndesmotic injury, unstable
67
Ankle Fracture
| Treatment (2)
Conservative: for stable, undisplaced fractures with minimal disruption to articular surface, displaced fractures can be manipulated and put in cast
Surgical: for unstable fractures with talar shift, displacement and fragmentation of articular surface, ORIF with plate and screws to reduce and fix fracture
68
Clavicle Fractures
| Aetiology (2)
Fall on outstretched hand
| Direct blow to clavicle
69
Clavicle Fractures
| Location (1)
Middle 1/3rd where proximal fragment is pulled superiorly by sternocleidomastoid is most common
70
Clavicle Fractures
| Treatment (3)
Broad arm sling with follow up X-rays at 6 weeks to ensure union
ORIF if fracture significantly displaced
Possibility of neurovascular injury (brachial plexus, subclavian vessels) and pneumothorax as complications
71
Compartment Syndrome
| Definition (1)
Raised pressure within a closed compartment resulting in tissue ischaemia, and if untreated, necrosis followed by fibrosis and muscle contracture
72
Compartment Syndrome
| Epidemiology (3)
<35
M>F
Most often seen in the leg, followed by the forearm
73
Compartment Syndrome
| Aetiology (2)
Decreases in compartment size (tight casts/bandages, lying on limb, burns)
Increase in compartment content (haemorrhage, post-op swelling)
74
Compartment Syndrome
| Pathology (4)
Increased compartment pressure --> Reduced capillary pressure gradient --> Reduced tissue perfusion and hypoxic injury --> Fluid diffusion into compartment
75
Compartment Syndrome
| Signs + Symptoms (6)
```
Pain (out of proportion to injury, not improving wit analgesia)
Pallor
Pressure
Paraesthesia
Paralysis
Pulseless
```
76
Compartment Syndrome
| Investigations (2)
Clinical diagnosis: severe pain on passive stretching of involved limbs' digits (fingers/toes)
Pressure monitor inserted into compartment (DELTA pressure when there is 30mmHg difference from diastolic)
77
Compartment Syndrome
| Treatment (4)
V. quick (by 8 hours- permanent damage)
Remove dressing
Hold limb at level of heart to promote arterial inflow
Fasciotomy
78
Compartment Syndrome
| Complications (2)
If untreated, necrosis of muscles leading to ischaemic contracture
Loss of limb
79
```
Knee Injuries
Patellar dislocation (5)
```
Typically lateral
Result of twisting lower leg and contraction of the quadriceps
Reduction by firm medial pressure whilst extending the knee
Post reduction: check extensor mechanism of knee and X-ray to ensure no fracture
Treatment: period of immobilisation in cast/split/brace
80
Knee Injuries
| Recurrent Patellar Subluxation (5)
Subluxation: partial dislocation, not fully out of joint
A tight lateral retinaculum causes patella to sublux laterally, giving medial pain
Commoner in girls and in those with valgus knees
Signs: increased lateral patellar movement and pain and contraction of quadriceps
May warrant surgery to strengthen medial expansion
81
Knee Injuries
| Collateral Ligament Injury (5)
Common in sport
Mechanism in medial ligament: blow to lateral aspect of knee whilst foot is fixed
Mechanism in lateral ligament: blow to medial aspect of knee whilst foot is fixed
Feel of 'crack'
Signs: effusion +/- tenderness over affected ligament
82
```
Knee Injuries
ACL tear (3)
```
Follows twisting injury of knee with foot fixed to ground
'Pop'
Signs: rapid effusion, haemarthrosis, +ve draw sign (anterior)
83
```
Knee Injuries
PCL tear (2)
```
Less frequently damaged than aCL
| +ve posterior draw test
84
```
Knee Injuries
Meniscal tears (5)
```
Medial meniscus: twist to flexed knee
Lateral meniscus: adduction + internal rotation
Extension is limited (knee locking) as displaced segments lodged between condyles
Slow swelling
Painful 'squelch'
85
Olecranon Bursitis (5)
Student's elbow
Traumatic bursitis following pressure on the elbows
Pain and swelling behind olecranon
If overlying skin cellulitis then consider antibiotics
Complications: abscess formation, septic bursitis
86
Prepatellar Bursitis (5)
Causes anterior knee pain
Following trauma or overuse (kneeling for a prolonged time- housemaid knee)
Swelling anteriorly
Treatment: aspiration +/- corticosteroid to prevent recurrence
Always consider septic arthritis of joint
87
```
Club Foot (Talipes Equinovarus)
Deformity (4)
```
Inversion
Adduction of forefoot relative to hindfoot (which is in varus)
Equinus (plantarflexion) deformity
Foot cannot be passively everted and dorsiflexed through the normal range
88
```
Club Foot (Talipes Equinovarus)
Treatment (1)
```
Ponseti method: foot manipulated and placed in a long leg plaster cast on repeated occasions (important that correction is gradual)
89
Developmental Dysplasia of the Hip
| Aetiology (9)
```
M:F 1:6
L:R 4:1
Breech birth
Other malformations
Sibling with DDH
Increased birth weight
Older mother or principarous
Postmaturity
Oligohydramnios
```
90
Developmental Dysplasia of the Hip
| Signs (5)
Widened perineum and buttock flattening on affected side
Unequal leg length
Asymmetrical groin creases
Limited abduction of hip
In older children: delay in walking and waddling gait (affected leg is shorter)
91
Developmental Dysplasia of the Hip
| Investigations (3)
Clinical diagnosis: all babies have hips examined in 1st days of life and at 6 weeks
Ultrasound (up to 4.5 months old)
Pelvic X-rays in older children
92
Developmental Dysplasia of the Hip
| Treatment (4)
Treatment delayed 2-8 weeks to allow spontaneous resolution
Unstable hips at 6 weeks: long term splinting in flexion- abduction harness
From 6-18 months: period of immobilisation in bandage
After 18 months or failure of closed techniques: open reduction
93
Slipped Upper Femoral Epiphysis (SUFE)
| Aetiology (3)
10-16
M:F 3:1
Obesity
94
Slipped Upper Femoral Epiphysis (SUFE)
| Pathology (2)
Displacement through the growth plate
| Epiphysis slips down and back
95
Slipped Upper Femoral Epiphysis (SUFE)
| Signs + Symptoms (5)
Usually presents after minor injury
Limping
Pain in groin, anterior thigh, knee
90% are able to weight bear (stable), 10% cannot (unstable)
Flexion, abduction and medial rotation are limited (eg. lying with foot externally rotated)
96
Slipped Upper Femoral Epiphysis (SUFE)
| Investigations (1)
AP + frog-leg lateral X-rays
97
Slipped Upper Femoral Epiphysis (SUFE)
| Treatment (1)
Early internal fixation to stabilise any slippage and encourage physeal closure
98
Perthes' Disease
| Aetiology (3)
Idiopathic
3-11
M:F 4:1
99
Perthes' Disease
| Pathology (3)
Avascular necrosis of femoral head
Ischaemia self heals
Subsequent bone remodelling distorts the epiphysis and generates abnormal ossification
100
Perthes' Disease
| Signs + Symptoms (2)
Pain in hip/knee causing a limp
| All movements at the hip are limited, especially internal rotation and abduction
101
```
Perthes' Disease
Radiological Findings (3)
```
Early on: joint space widening
Then: decrease in size of femoral head with patchy density
Finally: collapse and deformity of femoral head with new bone formation
102
Perthes' Disease
| Outcome (2)
Severe deformity of the femoral head risks early arthritis and likely need for joint replacement
Younger patients have better ability to remodel and greater prognosis
103
Perthes' Disease
| Treatment (2)
```
Less severe disease (<1/2 femoral head affected and joint space depth well preserved): bed rest + NSAIDs
Severe disease (>1/2 femoral head affected and joint space narrowing): surgery
```
104
```
Cervical Spondylosis
Define spondylosis (2)
```
Degenerative changes in the spine such as bone spurs and degenerating intervertebral discs between the vertebrae
Often referred to as back osteoarthritis
105
Cervical Spondylosis
| Signs + Symptoms (4)
Neck stiffness
Crepitus on moving neck
Stabbing/dull arm pain
Root compression (radiculopathy): pain/tingling in arms/fingers at level of compression and LMN signs in muscles innervated by affected root, may be UMN signs below level suggesting cord compression
106
Cervical Spondylosis
| Investigations (1)
MRI: localise lesion
107
```
Cervical Spondylosis
Differential diagnoses (3)
```
MS
Nerve root neurofibroma
Compression by bone/cord tumours
108
Cervical Spondylosis
| Treatmnet (3)
Neck collar to restrict movement and relieve pain
Surgical root decompression (laminectomy/laminoplatsy)
Transforaminal steroid injection to reduce pain
109
Spondylolisthesis
| Definition (1)
Displacement (usually forward of one lumbar vertebra upon the on below- usually L5 on S1, sometimes palpable)
110
Spondylolisthesis
| Aetiology (4)
Spondylosis (age-related degeneration resulting from joint deformity and associated with osteophyte formation)
Spondylolysis (results from a defect in pars interarticularis- could be a stress defect)
Congenital malformation of articular processes
Osteoarthritis of posterior facet joints
111
Spondylolisthesis
| Signs + Symptoms (2)
Pain +/- sciatica
| May have hamstring tightness causing a waddling gait
112
Spondylolisthesis
| Investigations (2)
X-ray
| MRI
113
Spondylolisthesis
| Treatment (2)
Temporary relief with conservative bracing and physio
| Curative treatment is spinal fusion
114
Prolapsed Disc
| Signs + Symptoms (3)
Typically acute onset of pain on coughing/sneezing/twisting a few days after back strain
Pain may radiate to buttock/leg (sciatica) if the herniated nucleus pulposus compresses a nerve root
Forward flexion and extension limited
115
Prolapsed Disc
| Signs of L4/5 Prolpase (L5 Root Compression) (2)
Weak hallus extension
| Decreased sensation on outer dorsum of foot
116
Prolapsed Disc
| Signs of L5/S1 Prolapse (S1 Root Compression) (4)
Calf pain
Weak foor plantar flexion
Reduced sensation over sole of foot and back of calf
Reduced ankle jerk
117
Prolapsed Disc
| Investigations (2)
MRI
| Make sure no cauda equina compression
118
Prolapsed Disc
| Treatment (3)
Brief rest and early mobilisation
Analgesia +/- physiotherapy is enough for most
Discectomy if cauda equina/progressive muscular weakness/continuing pain
119
Rotator Cuff Tears
| Aetiology (2)
Degeneration in elderly
| Trauma in young
120
Rotator Cuff Tears
| Signs + Symptoms (1)
Shoulder weakness + pain
121
Rotator Cuff Tears
| Investigations (2)
Ultrasound: tear or no tear
MRI: quantify muscle wasting
122
Rotator Cuff Tears
| Treatment (2)
Incomplete: surgery if symptoms persist
Complete: prompt referral for open arthroscopic repair
123
Impingement Syndrome
| Aetiology (3)
Supraspinatus tendinopathy or partial rupture of supraspinatus tendon
Calcifying tendinopathy
Acromioclavicular joint osteoarthritis
124
Impingement Syndrome
| Pathology (1)
As the tendon catches under the acromion during abduction
125
Impingement Syndrome
| Signs + symptoms (1)
On abducting 45-160 you get pain
126
Impingement Syndrome
| Treatment (3)
Supraspinatus tendinopathy: active shoulder movement with physio and pain relief, subacromial bursa injection of corticosteroid and local anaesthetic, surgery (subacromial decompression) if >6 months
Calcifying tendinopathy: physio, NSAIDs, steroid injection
Osteoarthritis: rest, NSAIDs, steroids
127
Frozen Shoulder
| Phases of symptoms (3)
1: painful phase (up to 1 year), active and passive movement range reduced, reduced abduction +/- external rotation
2: frozen phase, pain usually settles but shoulder remains stiff (6-12 months)
3: thawing phase (1-3 years), shoulder slowly regains range of movement
128
Frozen Shoulder
| Aetiology (3)
Cervical spondylosis
Diabetes
Thyroid disease
129
Frozen Shoulder
| Treatment (3)
Early physio + NSAIDs
Corticosteroid injections
Surgery: manipulation under anaesthesia or arthroscopic arthrolysis
130
```
Lateral Epicondylitis (Tennis Elbow)
Definition (1)
```
Inflammation where the common extensor tendon arises form the lateral epicondyle of the humerus
131
```
Lateral Epicondylitis (Tennis Elbow)
Signs + Symptoms (3)
```
Clear history of repetitive strain
Pain at front of lateral condyle
Exacerbated when tendon is most stretched (wrist + finger flexion with hand pronated)
132
```
Lateral Epicondylitis (Tennis Elbow)
Treatment (3)
```
Most resolve through restriction of activities which overload the tendons
Physio
Surgery: tendon release (severe cases)
133
```
Medial Epicondylitis (Golfer's Elbow)
Definition (1)
```
Inflammation of the forearm flexor muscles at their origin on the medial epicondyle
134
```
Medial Epicondylitis (Golfer's Elbow)
Signs + Symptoms (2)
```
Pain exacerbated by pronation and forearm flexion
| Occasionally associated with ulnar neuropathy as the ulnar nerve runs behind the epicondyle
135
```
Medial Epicondylitis (Golfer's Elbow)
Treatment (3)
```
Rest + restrict movement
Physio
Surgery if severe
136
Dupuytren's Contracture
| Definition (1)
Progressive, painless fibrotic thickening of the palmar fascia with skin puckering and tethering
137
Dupuytren's Contracture
| Aetiology (4)
Genetic
Smoking
Diabetes
Antiepileptics
138
Dupuytren's Contracture
| Signs + Symptoms (2)
Ring + little fingers chiefly affected, often bilateral
| As the thickening worsens, there may be MCP joint flexion
139
Dupuytren's Contracture
| Treatment (2)
Early disease: clostridium histolyticum or percutaneous needle fasciotomy
Surgery: fasciectomy to remove palmar fascia and release contractures (refer if cannot lay palm flat on table)
140
Ganglia
| Definition (1)
Smooth multilocular swellings are cysts containing jelly-like fluid in communication with joint capsules or tendon sheaths
141
Ganglia
| Treatment (4)
Not needed unless they cause pain or pressure (eg. on the median/ulnar nerve)
May disappear spontaneously
Local pressure (eg. Bible)
Aspiration or surgical dissection
142
Carpal Tunnel Syndrome
| Definition (2)
Commonest mononeuropathy and cause of hand pain at night
| Compression of the median nerve as it passes under the flexor retinaculum
143
Carpal Tunnel Syndrome
| Signs + Symptoms (4)
Tingling and pain in thumb, index and middle fingers
Relieved by dangling and shaking hand
Wasted thenar eminence
Weakness of abductor pollicis brevis
144
Carpal Tunnel Syndrome
| Median Nerve Anatomy (4)
Arises from C5-T1 from lateral and medial cords of brachial plexus
Jut distal to elbow, gives off anterior interosseous branch (motor to FPL, FDP, index finger and pronator quadratus)
Just proximal to wrist gives off palmar cutaneous branch (sensory to thenar skin), over lies flexor retinaculum
Recurrent motor branch to the thenar muscles arises at distal end of carpal tunnel
145
Carpal Tunnel Syndrome
| Carpal Tunnel Function (2)
Motor: pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, and LOAF (Lateral 2 lumbricals, Opponens pollicis, Abductor pollicis brevis, Flexor pollicis brevis)
Sensation: radial 3.5 digits
146
Carpal Tunnel Syndrome
| Investigations (4)
Nerve conduction studies to confirm lesion site and severity
Phalen's: maximal wrist flexion for 1 minute
Tinel's: tapping over nerve at wrist --> tingling
Ultrasound/MRI: identifies lesions
147
Carpal Tunnel Syndrome
| Associations (4)
Hypothyroidism
Pregnancy
Diabetes and obesity
RA
148
Carpal Tunnel Syndrome
| Treatment (4)
Treat associations
Rest, reduce weight and wrist splints 1st line
Corticosteroids for pain relief
Surgery: carpal tunnel decompression
149
De Quervain's Disease
| Definition (1)
Stenosing tenosynovitis (thickening and tightening) of the 1st extensor compartment, abductor pollicis longus and extensor pollicis brevis tendons (at anterior border of anatomical snuffbox) as they cross the distal radial styloid
150
De Quervain's Disease
| Signs + Symptoms (2)
Pain is worst when tendons are stretched (eg. lifting a teapot)
Finkelstein's sign: pain elicited by gripping the thumb into the palm of the same hand with passive ulnar deviation
151
De Quervain's Disease
| Treatment (3)
Rest (thumb splint), ice + NSAIDs
Corticosteroid injection
Surgery: decompression of the tendons by splitting the tendon sheaths
152
Trigger Finger
| Pathology (4)
Caused by a swelling of the flexor tendon or tightening of the sheath
Ring + middle fingers most commonly affected
Swelling of tendon sheath, tendon nodule formation, AI pulley prevents tendon gliding smoothly and instead 'catches' causing the finger to lock in flexion
As extension occurs, nodule moves with the flexor tendon and becomes jammed and has to be flicked straight, producing triggering
153
Trigger Finger
| Treatment (3)
Rest + splintage
If severe, steroid injection into nodule region
Surgery may be needed in recurrence (which is high)
154
Kyphosis
| Definition (1)
Excessive curvature of the spine in the sagittal plane, typically the thoracocervical spine
155
Kyphosis
| Aetiology (5)
```
Congenital
Osteoporosis
Spina bifida
Paget's disease
Ankylosing spondylitis
```
156
Kyphosis
| Complications (1)
Dislocations of the spinal column into cord can cause cord compression and paraplegia
157
Scoliosis
| Definition (1)
Lateral spinal curvature with secondary vertebral rotation
158
Scoliosis
| Classification (4)
Idiopathic (most common adolescent)
Neuromuscular (neuropathic or myopathic)
Syndromic (eg. Marfan's)
Other (eg. tumour, osteoporosis)
159
Scoliosis
| Signs + Symptoms (3)
Complications (pain, cosmesis, impaired lung function) occurs as they grow
Double curves progress more than single curves
Scoliosis in girls more likely to progress
160
Scoliosis
| Investigations (2)
X-ray
| Cobb angles to measure deformity
161
Scoliosis
| Treatment (3)
Cobb angle 1/6 requires treatment
Braces to prevent progression
Surgery: deformity correction with spinal fusion and stabilisation
162
Spinal Stenosis
| Definition (1)
Generalised narrowing of the spinal canal or its lateral recesses causes nerve ischaemia
163
Spinal Stenosis
| Aetiology (2)
Facet joint OA (only synovial joints in back)
| Osteophytes
164
Spinal Stenosis
| Signs + Symptoms (4)
Pain worse on walking with aching and heaviness in one/both legs causing the person to stop walking (spinal claudication)
Pain on extension
Negative straight leg raising test
Few CNS signs
165
Spinal Stenosis
| Investigations (2)
```
MRI
Myelography (injection of contrast into subarachnoid space) if MRI contraindicated
```
166
Spinal Stenosis
| Treatment (4)
Decompressive laminectomy
NSAIDs
Epidural steroid injection
Corsets (prevent exaggerating the lumbar lordosis)
167
Spinal Tumours
| Origin (2)
May be of spinal cord, meninges, nerves or bone
| Primary or secondary (metastases tend to affect cancellous bone)
168
Spinal Tumours
| Signs + Symptoms (7)
Cord compression: pain, LMN signs at level, UMN signs + sensory loss below, or bladder and bowel dysfunction
Peripheral nerve impairment: pain along course of nerve, weakness, hyporeflexia and reduced sensation
Cauda equina involvement
If tumour in spinal canal with no bone involvement, there may just be long tract signs
When bones involved, progressive pain and local bone destruction
Muscle spasm + tenderness to percussion
Bone collapse: deformity, cord/nerve compression
169
Spinal Tumours
| Investigations (8)
```
Bloods: FBC, ESR, LFT
Bone profile
Myeloma screen if age >50
Plain X-rays
CT
MRI
Isotope bone scans
Bone biopsy
```
170
Cauda Equina Syndrome
| Anatomy (3)
Cord tapers to its end (conus medullaris) at L1 in adults
Lumbar and sacral nerve roots arising from the conus medullaris form the cauda equina
These spinal nerve roots separate in pairs, exiting laterally through the nerve root foramina, providing motor and sensory to the legs and pelvic organs
171
Cauda Equina Syndrome
| Aetiology (5)
```
Compression is most frequently from large prolapses or herniation of lumbar discs
Extrinsic tumours
Primary cord tumours
Spondylosis
Spinal stenosis
```
172
Cauda Equina Syndrome
| Signs + Symptoms (6)
```
LMN lesion
Poor anal tone
Severe back pain
Saddle-area (perianal) reduced sensation
Incontinence/retention of faeces/urine
Paralysis +/- sensory loss
```
173
Transient Synovitis
| Definition (1)
Inflammation in the hip joint (chief cause of hip pain in children aged 4-10)
174
Transient Synovitis
| Aetiology (2)
Viral illness preceded by recent viral URTI
| Autoimmune
175
Transient Synovitis
| Signs + Symptoms (4)
Most are self limiting
Pain (particularly at extremities of movement)
Refusal to weight bear
Investigations all come back normal but consider JIA if other joints are involved)
176
Hallux Valgus
| Definition (1)
The big toe deviates laterally at the metatarsophalangeal joint
177
Hallux Valgus
| Signs + Symptoms (3)
Typically present bilaterally
Pressure of MTP against shoe leads to bunion formation
Secondary OA of the joint
178
```
Hallux Valgus
Risk Factors (6)
```
```
Female
Age
Type of footwear
+ve family history
Conditions causing joint hypermobility
Neuromuscular disease
```
179
Hallux Valgus
| Treatment (4)
Education on appropriate footwear (wide and low heeled)
Foot exercises to strengthen musculature around big toe
Bunion pads and plastic wedges may relieve pain
Painful bunions affecting lifestyle considered for surgery
180
Hallux Valgus
| Complications (3)
Chronic pain
Recurrence
Joint stiffness
181
```
Lesser Toe Deformities
Hammer Toes (3)
```
Definition: extended at the MTP joint, hyperflexed at the PIP joint and extended at the DIP joint (toes look curled)
Associated with contracture of flexor digitorum longus tendon
2nd toes most commonly affected
182
```
Lesser Toe Deformities
Claw Toes (2)
```
Definition: extended at the MTP joint but flexed at PIP and DIP joints giving a clawed appearance where the toe digs into the sole of the foot
Treatment: same for hammer toes, metatarsal shortening (flexible deformity) or PIP joint arthrodesis (fixed deformity)
183
```
Lesser Toe Deformities
Mallet Toes (2)
```
Definition: flexion deformity of DIP joint in isolation
Treatment: flexor tenotomy (flexible deformity) or DIP joint arthrodesis (fixed deformity)
184
Morton's Neuroma
| Definition (1)
Common cause of metatarsalgia (forefoot pain) in women
185
Morton's Neuroma
| Pathology (1)
Degenerative and inflammatory changes tot he interdigital nerve resulting in entrapment neuropathy
186
```
Morton's Neuroma
Risk Factors (5)
```
```
High BMI
High heels
Toe deformities
High impact sports
Inflammatory arthritis
```
187
Morton's Neuroma
| Signs + Symptoms (2)
Pain is from pressure from an interdigital neuroma between the metatarsals (eg. from tight shoes)
Pain usually radiates tot he lateral side of one toe, and the medial side of its neighbour
188
Morton's Neuroma
| Investigations (1)
MRI/ultrasound
189
Morton's Neuroma
| Treatment (1)
Neuroma excision
190
Plantar Fasciitis
| Pathology (3)
The plantar fascia supports the arch of the foot
Most common cause of plantar heel pain
Arises from degenerative changes from microtrauma
191
```
Plantar Fasciitis
Risk Factors (3)
```
Obesity
Inactivity
Excessive walking
192
Plantar Fasciitis
| Treatment (3)
Stretching achilles tendon
Orthotics
Shockwave therapy
193
Osteogenesis Imperfecta
| Definition (2)
An inherited disorder of type 1 collagen
| Results in joint laxity and fragile, low-density bones which recurrently fracture
194
Osteogenesis Imperfecta
| Types (4)
1- mildest and most common, autosomal dominant, blue sclera and hearing loss, normal life expectancy, pre-puberty fractures
2- lethal perinatal form with many fractures, blue sclera and dwarfism, autosomal recessive
3- severe form, autosomal recessive, fractures at birth with progressive spinal and limb deformity with resultant short stature, decreased life expectancy
4- moderate form, autosomal dominant, fragile bones
195
Osteogenesis Imperfecta
| Signs + Symptoms (6)
```
Growth deficiency
Defective tooth formation
Hearing loss
Blue sclerae
Scoliosis
Easy bruising
```
196
Osteogenesis Imperfecta
| Investigations (2)
X-ray: many fractures, osteoporotic bones, bowing deformity of long bones
Histology: immature unorganised bone with abnormal cortex
197
Osteogenesis Imperfecta
| Treatment (4)
Prevent injury
Physio, rehab, OT
Osteotomies may correct deformity
Bisphosphonates to increase cortical thickness
198
Joint Replacement
| Types (3)
Total hip replacement: both articular surfaces of femur and acetabulum are replaced
Hip hemiarthroplasty: only articular surface of femoral head is replaced
Knee replacement: resection of articular surfaces of knee, then resurfacing with metal and polyethylene components
199
```
Joint Replacement
Early complications (7)
```
VTE
Dislocation (increased risk if revision surgery due to existing weakness surrounding)
Deep infection (if caught early- debridement and antibiotics, if late- removal)
Fracture
Nerve palsy
Limb-length discrepancy
Death
200
```
Joint Replacement
Joint Survival (2)
```
Knee: 90% last 15 years
Hip: by 9-10 years 11% of implants have been revised
201
Mallet Finger
| Aetiology (1)
Sudden blow to an extended finger which leads to rupture of the extensor tendon at the distal phalanx
202
Mallet Finger
| Treatment (3)
Splint for 6 weeks (in slight hyperextension)
If untreated, may develop swan-neck deformity
Surgery if splint fails or there is a large evulsion fracture
203
Achilles Tendon Rupture
| Signs + Symptoms (5)
Sudden pain at back of ankle running/jumping
Walk with limp
Some plantar flexion but impossible to raise heel from floor when stood on affected side
Gap may be palpated in tendon course
Squeeze test: kneel on chair and squeeze both calve, if Achilles ruptured there's less plantar flexion on affected side
204
Achilles Tendon Rupture
| Treatment (2)
Tendon repair for young and athletic
Conservative (casting in equinus position, brought to neutral over 6-8 weeks with no weight bearing) for smokers/diabetics/>50s
205
Brachial Plexus Injuries
| Anatomy (3)
C5-T1
Roots leave vertebral column between scalenus anterior and medius
Divisions occur under the clavicle
206
Brachial Plexus Injuries
| Aetiology (2)
Direct: eg. shoulder girdle fracture, penetrating/iatrogenic injury
Indirect: eg. avulsion/traction injuries
207
Brachial Plexus Injuries
| Erb's Palsy- C5/6 (3)
Abductors and external rotators paralysed
Waiters tip position
Loss of sensation in C5/6 dermatomes
208
Brachial Plexus Injuries
| Klumpke's Paralysis- C8/T1 (3)
Paralysis of small hand muscles
Claw hand
Loss of sensation in C8/T1 dermatomes
209
Brachial Plexus Injuries
| Radial Nerve Injury (3)
```
C5-T1
Low lesions (fracture around elbow/forearm): loss of extension of CMC joints causing finger drop
High lesions (fracture at humerus shaft where nerve is in radial groove): wrist drop, loss of sensation over snuff box
```
210
Brachial Plexus Injuries
| Ulnar Nerve Injury (5)
C8-T1
Intrinsic hand muscle paralysis --> claw hand
Weakness of finger ad/abduction (interossei)
Sensory loss over little finger
Test: can't cross fingers for luck
211
Brachial Plexus Injuries
| Median Nerve Injury (3)
C5-T1
Carpal tunnel syndrome
Can cause loss of sensation in median distribution
212
Soft Tissue Tumours
| Pathology (1)
Arise in any mesenchymal tissue, origination from fat, muscle etc.
213
```
Soft Tissue Tumours
Risk Factors (2)
```
Neurofibromatosis type 1
| Previous radiotherapy
214
Soft Tissue Tumours
| Signs + Symptoms (1)
Painless enlarging mass
215
Soft Tissue Tumours
| Red Flag Symptoms (4)
>5cm
Increased size
Deep to the deep fascia
Painful
216
Soft Tissue Tumours
| Investigations (2)
MRI
| Needle Biopsy
217
Soft Tissue Tumours
| Treatment (2)
Excision with wide margins followed by radiotherapy
| Adjuvant chemotherapy may be appropriate
218
Paget's Bone Disease
Aetiology (2)
Pathology (3)
Aetiology:
- >40
- genetics
Pathology:
- localised disorder of bone turnover
- increased bone resorption and formation
- bone becomes bigger, more vascular and more susceptible to deformity and fracture
219
Paget's Bone Disease
Signs + symptoms (5)
Treatment (1)
Signs + symptoms:
- bone pain
- excessive heat over bone
- neurological complications such as nerve deafness
- elevation of serum alkaline phosphatase bone deformity/fracture
Treatment:
- IV bisphosphonate therapy
