Orthopaedics Flashcards
1
Q
Drugs that increase risk of tendon problems?
A
Quinolones (e.g. ciprofloxacin)
2
Q
Imaging of choice for achilles ruptures?
A
Ultrasound
3
Q
What is a risk factor for tendon xanthoma?
A
Hypercholestolaemia
4
Q
How might a patient describe an achilles tendon rupture?
A
Pop in the back of the foot
5
Q
What is Simmond’s triad?
A
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
6
Q
Adhesive capsulitis symptoms
A
Frozen shoulder causes a stiff and painful shoulder
External/internal rotation of the arm is difficult, so is abduction
Often in non-dominant hand
7
Q
Risk factors for adhesive capsulitis
A
Female gender
Diabetes
8
Q
Adhesive capsulitis treatment
A
NSAIDs
Physio
Intra-articular corticosteroid injections
Oral corticosteroids
9
Q
What causes carpal tunnel syndrome
A
Compression of the median nerve
10
Q
Symptoms of carpal tunnel
A
Numbness, weakness, pins and needles (in the thumb, index and middle finger)
Shaking hand relieves pain
11
Q
What is tinel’s sign?
A
Tap on the median nerve, causes paraesthesia in carpal tunnel
12
Q
What is phalen’s sign?
A
Flex wrists together and it reproduces symptoms of carpal tunnel
13
Q
Treatment options for carpal tunnel?
A
Wrist splint, corticosteroid injection, surgical decompression, pain relief
14
Q
What is lumbar spinal stenosis?
A
A narrowing of the spinal cord
15
Q
What causes lumbar spinal stenosis?
A
Tumours
Degenerative changes
Vertebral disc prolapse
16
Q
What are the symptoms of lumbar spinal stenosis?
A
Claudication like symptoms
Neuropathic pain
Back pain
17
Q
What relieves symptoms in lumbar spinal stenosis?
A
Positional changes, e.g. walking up a hill, riding a bike and sitting all help reduce the symptoms
18
Q
Lumbar spinal stenosis treatment
A
Laminectomy
19
Q
What is osteomyelitis?
A
Infection of the bone
20
Q
What is the most common causative organism of osteomyelitis?
A
Staph. aureus
Salmonella if the patient has sickle-cell anaemia
21
Q
What increases osteomyelitis risk?
A
DM Sickle cell anaemia IVDU Immunosuppression Alcohol excess
22
Q
How do we treat osteomyelitis?
A
Flucloxacillin (6 weeks)
Clindamycin if pen allergic
23
Q
Where is osteomyelitis most commonly found?
A
Epiphysis in adults
Metaphysis in children
(due to changing blood supply)
24
Q
What is compartment syndrome?
A
Raised pressure within a closed anatomical space (compartment)
25
Features of compartment syndrome?
```
Pain - especially on movement (even passive)
Parasthesiae
Pallor
Paralysis of muscle group
Pulseless
```
26
Can you have a pulse in compartment syndrome?
Yes
27
How to diagnose compartment syndrome?
Intracompartmental pressure measurements
Above 20mmHg is abnormal
Above 40mmHg is diagnostic
28
Treatment of compartment syndrome
Prompt and extensive fasciotomies (death of muscle group can occur within 4-6 hours)
29
What nerve is most likely damaged during TKA?
Common peroneal nerve
30
Damage to which nerves causes foot drop?
Sciatic and common peroneal nerve
31
Which muscle dorsiflexes the foot?
Tibialis anterior and extensor hallucis longus
32
What muscle plantar flexes the foot?
Tibialis posterior
33
What movements does extensor hallucis longus control?
Extension of the big toe and dorsiflexion of the foot
34
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
35
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
36
How do you manage De Quervain's tenosynovitis?
Analgesia
Steroid injection
Immobilisation with a thumb splint (spica)
Surgical
37
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
38
Lateral epicondylitis features
Otherwise known as tenniis elbow:
Pain/tenderness
Pain worse on wrist extension against resistance (Cozen's test)
39
Management of lateral epicondylitis?
Avoid muscle overload
Simple analgesia
Steroid injectiion
Physiotherapy
40
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
41
What are the 3 main types of cell in bone?
Osteoblasts (builders of bone)
Osteoclasts (resorb bone)
Osteocytes (mature, inactive osteoblasts)
42
Which vitamin is fat soluble?
Vitamin D
43
What is the active component of vitamin D?
1,25-dihydroxy-D3
It is formed from hepatic and renal hydroxylation
44
What are the two effects of 1,25-dihydroxy-D3?
Gut: increase calcium absorption
Bone: increase mineralisation and resorption
45
What does parathyroid hormone do?
Increase plasma calcium
| Lowers plasma phosphate
46
Where does PTH act?
Gut: increases calcium absorption
Bone: Increases osteoclastic resorption of bone
Renal: Increase calcium reabsorption and phosphate excretion
47
What is osteoporosis?
Systemic skeletal disease in which one has low bone mass and deterioration of bone tissue, increasing likelihood of fracture
48
Risk factors for osteoporosis?
Maternal family history of hip fracture
Oestrogen deficiency
Corticosteroid therapy
Low BMI <19
49
How do we diagnose osteoporosis?
DEXA scan
50
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
51
T score interpretation
- 1 to 1 is normal
| - 1 to -2.5 is osteopaenia
52
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
53
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)
54
Who commonly gets greenstick fractures?
Children
55
What are fatigue/stress fractures?
Fractures without any real trauma, just progress slowly over time
56
Open fractures risk
These are considered emergencies due to the high risk of osteomyelitis
57
Open fractures treatment
Immediately photograph it and then cover it to prevent further contamination
Antibiotics
Arrange for urgent surgical:
Debridement
Lavage
58
What are the two steps involved in managing a displaced fracture
Reduction
| Fixation
59
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
60
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
61
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)
62
Complications of fractures
```
Infection
Delayed union
Non-union
Avascular necrosis
Mal-union
Shortening
Compartment syndrome
Fat embolism
```
63
What type of fracture is infection found in
Only really found in compound (open) fractures
64
Which antibiotics may be prescribed to treat infection in fracture?
Flucloxacillin and fusidic acid
65
What is delayed union
No arbitrary line, but if fracture is still freely mobile after 3-4 months it is considered a delayed union
66
How to treat delayed union
Expectant
| Surgical if it does not appear to be progressing (bone grafts)
67
What is non-union
This is where a fracture remains ununited for many months with radiological evidence to suggest that union will never occur
68
Radiological signs of non-union
Rounding of fracture edges
| Fracture line becomes more clear cut
69
What is pseudoarthrosis?
This is where a cavity appears between the fractured bones in an attempt to form a false joint
70
What is in the gap between the fractured bones in non-union?
Fibrous tissue
71
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)
```
72
How to treat a non-union?
If it doesn't cause any problems, can be untreated
| Surgical (bone grafts, prosthesis)
73
What is avascular necrosis?
Death of bone due to a deficient blood supply
74
What do bones usually develop following avascular necrosis?
Osteoarthritis
75
Which bones are particularly susceptible to avascular necrosis?
Head of femur following femoral neck fracture/dislocation of the hip
76
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)
77
What might you see on imaging in later stages of avascular necrosis?
Collapse causing shortening and a crumbled appearance
78
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
79
What is malunion
Union of fragments in an imperfect position
80
Treatment of malunion
Detach and reattach/fixate in the correct position
81
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)
82
Treatment for bone shortening?
If lower limb:
Corrective shoes
Shortening of other limb
Lengthening of shortened limb
83
What does bone shortening typically cause
Back pain
Scoliosis
Hip adduction and therefore pain/osteoporosis
84
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
85
Signs of major artery damage following fracture
Severe pain, especially on passive extension of toes/fingers
| Numbness/loss of sensibility of digits
86
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
87
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
88
What is fat embolism syndrome?
An uncommon, but potentially fatal complication of fractures in which there is an occlusion of vessels by fat globules
89
Where do you usually get occlusion of small vessels in fat embolism?
Brain and lungs
| Most common fracture site causing this is lower limbs
90
What are other common symptoms with fat embolism?
Petechial rash
SOB
Tachycardia
Confusion/other cerebal side effects
91
How to diagnose fat embolism
ABG - PO2 down
92
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
93
Ix of choice in avascular necrosis of hip?
MRI
| X-ray shows osteopenia, microfractures and crescent sign (collapse of articular surface)
94
How do we classify proximal femur fractures?
Intracapsular - neck (thinner bit)
| Extracapsular - trochanteric (large bit beneath)
95
Clinical features of a neck of femur fracture?
Hx - patient tripped and fell usually
Pain
Externally rotated leg
Shortened leg
96
How can we classify neck of femur fractures?
Garden system
97
Garden type I
Incomplete fracture
98
Garden type II
Complete fracture without displacement
99
Garden type III
Complete fracture with partial displacement
100
Garden type IV
Complete fracture with full displacement
101
Which garden types are most likely to cause blood supply disruption
III and IV
102
Management of garden types I and II
Internal fixation
| Hemiarthroplasty
103
Management of garden types III and IV
Reduction and fixation
If above >70/reduced mobility:
Hemiarthroplasty/total hip replacement
104
What does arthroplasty mean
Joint replacement
105
What views are important for imaging in NOF's?
AP
| Lateral
106
Treatment of extracapsular hip fractures?
```
Dynamic hip screw (screw through intracapsular space)
Intramedullary device (screw down femur and through intracapsular space to the head)
```
107
What is Colle's fracture?
A fracture of the lower part of the radius
108
How common is Colle's fracture?
It is the most common fracture in people, particular women, over 40 years of age
109
What is often the first sign of osteoporosis?
Colle's fracture
110
What is the mechanism of injury in a Colle's fracture?
Falling on to an outstretched hand
111
How do we treat Colle's fracture?
Manipulative reduction under local/gen. anaesthetic
| Immobile with below elbow plaster
112
What sort of appearance might you see with Colle's fracture?
Dinner fork appearance
113
Distal fragment position in Colle's fracture
Posterior displacement and tilting
114
What is a Smith's fracture?
A fracture of the radius in which the distal fragment is displaced forwards and tilted forwards
115
Mechanism of injury in Smith's fracture
Falling on to a flexed wrist
116
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
117
How can we classify ankle fractures?
Weber's classification (Danis-Weber)
118
Type A Weber's classification
```
Below level of ankle joint
The tibiofibular syndesmosis is intact
Medial malleolus often fractures
Deltoid ligament intact
Usually stable
```
119
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
```
120
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)
```
121
What is a syndesmosis
Fibrous joint between two bones linked by ligaments
122
What treatment does type C Weber's require?
Open reduction and internal fixation (ORIF)
123
When do we x-ray an ankle?
Inability to weight bear for 4 steps
Tenderness over distal tibia
Tenderness over distal fibula
124
Fracture of which bone is described by Weber's classification
Fibula
125
X-ray features in osteoarthritis
```
LOSS
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
```
