Orthopaedics Flashcards
Drugs that increase risk of tendon problems?
Quinolones (e.g. ciprofloxacin)
Imaging of choice for achilles ruptures?
Ultrasound
What is a risk factor for tendon xanthoma?
Hypercholestolaemia
How might a patient describe an achilles tendon rupture?
Pop in the back of the foot
What is Simmond’s triad?
A triad of signs that one gets with achilles rupture.
Lie the patient down with their feet off the bed.
There will be more dorsiflexion in the ruptured foot
A gap in the tendon on ruptured foot
Squeezing the calf won’t move the foot in the ruptured leg
Adhesive capsulitis symptoms
Frozen shoulder causes a stiff and painful shoulder
External/internal rotation of the arm is difficult, so is abduction
Often in non-dominant hand
Risk factors for adhesive capsulitis
Female gender
Diabetes
Adhesive capsulitis treatment
NSAIDs
Physio
Intra-articular corticosteroid injections
Oral corticosteroids
What causes carpal tunnel syndrome
Compression of the median nerve
Symptoms of carpal tunnel
Numbness, weakness, pins and needles (in the thumb, index and middle finger)
Shaking hand relieves pain
What is tinel’s sign?
Tap on the median nerve, causes paraesthesia in carpal tunnel
What is phalen’s sign?
Flex wrists together and it reproduces symptoms of carpal tunnel
Treatment options for carpal tunnel?
Wrist splint, corticosteroid injection, surgical decompression, pain relief
What is lumbar spinal stenosis?
A narrowing of the spinal cord
What causes lumbar spinal stenosis?
Tumours
Degenerative changes
Vertebral disc prolapse
What are the symptoms of lumbar spinal stenosis?
Claudication like symptoms
Neuropathic pain
Back pain
What relieves symptoms in lumbar spinal stenosis?
Positional changes, e.g. walking up a hill, riding a bike and sitting all help reduce the symptoms
Lumbar spinal stenosis treatment
Laminectomy
What is osteomyelitis?
Infection of the bone
What is the most common causative organism of osteomyelitis?
Staph. aureus
Salmonella if the patient has sickle-cell anaemia
What increases osteomyelitis risk?
DM Sickle cell anaemia IVDU Immunosuppression Alcohol excess
How do we treat osteomyelitis?
Flucloxacillin (6 weeks)
Clindamycin if pen allergic
Where is osteomyelitis most commonly found?
Epiphysis in adults
Metaphysis in children
(due to changing blood supply)
What is compartment syndrome?
Raised pressure within a closed anatomical space (compartment)
Features of compartment syndrome?
Pain - especially on movement (even passive) Parasthesiae Pallor Paralysis of muscle group Pulseless
Can you have a pulse in compartment syndrome?
Yes
How to diagnose compartment syndrome?
Intracompartmental pressure measurements
Above 20mmHg is abnormal
Above 40mmHg is diagnostic
Treatment of compartment syndrome
Prompt and extensive fasciotomies (death of muscle group can occur within 4-6 hours)
What nerve is most likely damaged during TKA?
Common peroneal nerve
Damage to which nerves causes foot drop?
Sciatic and common peroneal nerve
Which muscle dorsiflexes the foot?
Tibialis anterior and extensor hallucis longus
What muscle plantar flexes the foot?
Tibialis posterior
What movements does extensor hallucis longus control?
Extension of the big toe and dorsiflexion of the foot
What is De Quervain’s tenosynovitis?
A common conditiion in which the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed
What are the features of De Quervain’s tenosynovitis?
Pain on radial side of the wrist
Tenderness over radial styloid process
Abduction of the thumb against resistance is painful
How do you manage De Quervain’s tenosynovitis?
Analgesia
Steroid injection
Immobilisation with a thumb splint (spica)
Surgical
What is Finkelstein’s test?
Examiner pulls the thumb of patient in ulnar deviation. A positive test will cause pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus
Lateral epicondylitis features
Otherwise known as tenniis elbow:
Pain/tenderness
Pain worse on wrist extension against resistance (Cozen’s test)
Management of lateral epicondylitis?
Avoid muscle overload
Simple analgesia
Steroid injectiion
Physiotherapy
How do we manage osteoporosis?
Vitamin D and calcium supplementation
Bisphosphonates: Alendronate
Risedronate (if patients can’t tolerate alendronate due to upper GI problems [usually])
Strontium ranelate/raloxifene/denosumab if patient can’t tolerate bisphosphonates
What are the 3 main types of cell in bone?
Osteoblasts (builders of bone)
Osteoclasts (resorb bone)
Osteocytes (mature, inactive osteoblasts)
Which vitamin is fat soluble?
Vitamin D
What is the active component of vitamin D?
1,25-dihydroxy-D3
It is formed from hepatic and renal hydroxylation
What are the two effects of 1,25-dihydroxy-D3?
Gut: increase calcium absorption
Bone: increase mineralisation and resorption
What does parathyroid hormone do?
Increase plasma calcium
Lowers plasma phosphate
Where does PTH act?
Gut: increases calcium absorption
Bone: Increases osteoclastic resorption of bone
Renal: Increase calcium reabsorption and phosphate excretion
What is osteoporosis?
Systemic skeletal disease in which one has low bone mass and deterioration of bone tissue, increasing likelihood of fracture
Risk factors for osteoporosis?
Maternal family history of hip fracture
Oestrogen deficiency
Corticosteroid therapy
Low BMI <19
How do we diagnose osteoporosis?
DEXA scan
What are the Z and T scores in DEXA scans?
These tell you the relative bone mineral densities
T score is compared with young mean
Z score is compared with someone of your age and gender
T score interpretation
- 1 to 1 is normal
- 1 to -2.5 is osteopaenia
Open vs closed fracture
Open fracture there is communication between the site of fracture and the exterior of the body
(This does NOT include if there is a wound at the site, it is ONLY if the wound goes to the level of the fractured bone)
Closed fracture there is no communication between the two
What are the six common patterns of fracture?
Transverse fracture (horizontal across)
Oblique fracture (diagonal across)
Spiral fracture (spirals)
Comminuted (lots of pieces)
Compression fracture
Greenstick fracture (bent on one side and broken the other)
Who commonly gets greenstick fractures?
Children
What are fatigue/stress fractures?
Fractures without any real trauma, just progress slowly over time
Open fractures risk
These are considered emergencies due to the high risk of osteomyelitis
Open fractures treatment
Immediately photograph it and then cover it to prevent further contamination
Antibiotics
Arrange for urgent surgical:
Debridement
Lavage
What are the two steps involved in managing a displaced fracture
Reduction
Fixation
What does reduction involve?
First, you move the bone in the same direction as the original fracture force
Then, use the periosteum as a hinge to guide the two pieces back into their correct position
Why do we first move the bone in the direction of the fracture force when reducing?
Allows the fracture pieces to be separated without causing further damage to the capsule or the periosteum
What does fixation involve?
You need to hold the fracture in its correct place:
Simple sling
Plate and screws (if lots of fragments I guess?)
Plaster of Paris (in children sometimes)
Complications of fractures
Infection Delayed union Non-union Avascular necrosis Mal-union Shortening Compartment syndrome Fat embolism
What type of fracture is infection found in
Only really found in compound (open) fractures
Which antibiotics may be prescribed to treat infection in fracture?
Flucloxacillin and fusidic acid
What is delayed union
No arbitrary line, but if fracture is still freely mobile after 3-4 months it is considered a delayed union
How to treat delayed union
Expectant
Surgical if it does not appear to be progressing (bone grafts)
What is non-union
This is where a fracture remains ununited for many months with radiological evidence to suggest that union will never occur
Radiological signs of non-union
Rounding of fracture edges
Fracture line becomes more clear cut
What is pseudoarthrosis?
This is where a cavity appears between the fractured bones in an attempt to form a false joint
What is in the gap between the fractured bones in non-union?
Fibrous tissue
Risk factors for non-union
Infection Dead bone ends Unfavourable mechanical environment (e.g. excessive shearing) Soft tissue between fragments Loss/dissolution of fracture haematoma NSAIDs/other non-steroidal drugs Destruction of bone (as by a tumour)
How to treat a non-union?
If it doesn’t cause any problems, can be untreated
Surgical (bone grafts, prosthesis)
What is avascular necrosis?
Death of bone due to a deficient blood supply
What do bones usually develop following avascular necrosis?
Osteoarthritis
Which bones are particularly susceptible to avascular necrosis?
Head of femur following femoral neck fracture/dislocation of the hip
How do we diagnose avascular necrosis?
When fractured, bones tend to go through some osteoporosis due to disuse. If a bone has gone through avascular necrosis, it does not lose bone density like the vascularised bone. It therefore sticks out on x-ray (usually after 1-3 months)
What might you see on imaging in later stages of avascular necrosis?
Collapse causing shortening and a crumbled appearance
What is the treatment for avascular necrosis?
Surgery, early (ie before collapse)
Drilling of the avcascular bone to promote vascularisation
Excision of the avascular bone
What is malunion
Union of fragments in an imperfect position
Treatment of malunion
Detach and reattach/fixate in the correct position
What are the 3 causes of bone shortening?
Mal-union
Crushing/actual loss of bone
Interference with the growth epiphysial cartilage (growth plate - only in children)
Treatment for bone shortening?
If lower limb:
Corrective shoes
Shortening of other limb
Lengthening of shortened limb
What does bone shortening typically cause
Back pain
Scoliosis
Hip adduction and therefore pain/osteoporosis
Important major vessel damages to know about
Axillary artery in fracture/dislocation of the shoulder
Brachial artery from supracondylar fracture of humerus
Popliteal artery from dislocation of the knee/upper tibia
Signs of major artery damage following fracture
Severe pain, especially on passive extension of toes/fingers
Numbness/loss of sensibility of digits
Treatment of major vessel damage from fracture
Depends on whether primary or secondary (i.e. if it was caused by the fracture itself or by fixation
1 - removal of external splint/bandage
2 - reduction of any fractures
3 - if steps 1/2 fail to work <30 mins: Surgery
Three types of nerve injury complicating fractures
Neurapaxia - transient physiological block. Recovery spontaneous within 3 weeks
Axonotmesis - axons badly damaged. Peripheral degen. occurs. Recovery takes months
Neurotmesis - structure of the nerve is destroyed. Requires excision and bridging with nerve graft
What is fat embolism syndrome?
An uncommon, but potentially fatal complication of fractures in which there is an occlusion of vessels by fat globules
Where do you usually get occlusion of small vessels in fat embolism?
Brain and lungs
Most common fracture site causing this is lower limbs
What are other common symptoms with fat embolism?
Petechial rash
SOB
Tachycardia
Confusion/other cerebal side effects
How to diagnose fat embolism
ABG - PO2 down
Treatment of fat embolism
Spontaneously reversible if the patient makes it past the O2 deprivation period
100% O2
Methylprednisolone can reduce risk of fat embolism
Heparin can be helpful as well
Ix of choice in avascular necrosis of hip?
MRI
X-ray shows osteopenia, microfractures and crescent sign (collapse of articular surface)
How do we classify proximal femur fractures?
Intracapsular - neck (thinner bit)
Extracapsular - trochanteric (large bit beneath)
Clinical features of a neck of femur fracture?
Hx - patient tripped and fell usually
Pain
Externally rotated leg
Shortened leg
How can we classify neck of femur fractures?
Garden system
Garden type I
Incomplete fracture
Garden type II
Complete fracture without displacement
Garden type III
Complete fracture with partial displacement
Garden type IV
Complete fracture with full displacement
Which garden types are most likely to cause blood supply disruption
III and IV
Management of garden types I and II
Internal fixation
Hemiarthroplasty
Management of garden types III and IV
Reduction and fixation
If above >70/reduced mobility:
Hemiarthroplasty/total hip replacement
What does arthroplasty mean
Joint replacement
What views are important for imaging in NOF’s?
AP
Lateral
Treatment of extracapsular hip fractures?
Dynamic hip screw (screw through intracapsular space) Intramedullary device (screw down femur and through intracapsular space to the head)
What is Colle’s fracture?
A fracture of the lower part of the radius
How common is Colle’s fracture?
It is the most common fracture in people, particular women, over 40 years of age
What is often the first sign of osteoporosis?
Colle’s fracture
What is the mechanism of injury in a Colle’s fracture?
Falling on to an outstretched hand
How do we treat Colle’s fracture?
Manipulative reduction under local/gen. anaesthetic
Immobile with below elbow plaster
What sort of appearance might you see with Colle’s fracture?
Dinner fork appearance
Distal fragment position in Colle’s fracture
Posterior displacement and tilting
What is a Smith’s fracture?
A fracture of the radius in which the distal fragment is displaced forwards and tilted forwards
Mechanism of injury in Smith’s fracture
Falling on to a flexed wrist
Treatment of Smith’s fracture
Reduction/immobilisation with cast including elbow
Weekly check radiographs for the first 3 weeks to ensure position stays correct
Plaster for at least 6 weeks
How can we classify ankle fractures?
Weber’s classification (Danis-Weber)
Type A Weber’s classification
Below level of ankle joint The tibiofibular syndesmosis is intact Medial malleolus often fractures Deltoid ligament intact Usually stable
Type B Weber’s classification
At the level of the ankle joint Syndesmosis intact or partially torn Medial malleolus may be fractured Deltoid may be torn Variable stability
Type C Weber’s classification
Above the level of the ankle joint Syndesmosis disrupted Medial malleolus fractured Widening of tibiofibular articulation Deltoid ligament injury Unstable (requires ORIF)
What is a syndesmosis
Fibrous joint between two bones linked by ligaments
What treatment does type C Weber’s require?
Open reduction and internal fixation (ORIF)
When do we x-ray an ankle?
Inability to weight bear for 4 steps
Tenderness over distal tibia
Tenderness over distal fibula
Fracture of which bone is described by Weber’s classification
Fibula
X-ray features in osteoarthritis
LOSS Loss of joint space Osteophytes Subchondral sclerosis Subchondral cysts
