Orthopaedics Flashcards
1
Q
What are the 3 types of joint?
A
- Fibrous - connected by dense connective tissue, no joint cavity eg skull sutures
- Fibrocartilagenous - where the body of one bone meets the body of another (aka symphysis), found in vertebral column and pubic symphysis
- Synovial - connected with a fibrous cavity filled with synovial fluid eg. ball and socket joints (hip), hinge joints (interphalangeal)
2
Q
What is a Bennett’s fracture?
A
- Intraarticular two part fracture of the base of the first metacarpal
3
Q
What is a Rolando fracture?
A
- Three part/comminuted intra-articular fracture-dislocation of the 1st metacarpal
4
Q
What is mallet finger?
A
- Injury to the externsor mechanism of the finger at the DIP
- Most prevalent finger tendon injury in sport
- Will often have triangular avulsion fraction at insertion of the common extensor tendon on dorsel aspect of distal phalynx at DIP joint
5
Q
What is Gamekeeper’s thumb?
A
- aka Skiers thumb
- Avulsion of rupture of the ulnar collateral ligament of the first metacarpophalangeal joint
6
Q
What is a Boxer’s fracture?
A
- Minimally comminuted, transverse fracture of the 5th metacarpal neck
- Most common metacarpal fracture
- Often treated conservatively with closed reduction and splintage +/- K-wire
7
Q
What is contained in the extracellular matrix?
A
Collagens
Elastins
Glycoproteins/proteoglycans
8
Q
What is an oblique fracture?
A
Angled
9
Q
What is a segmental fracture?
A
A fracture composed of at least two fracture lines that isolate a segment of bone
10
Q
What is an incomplete fracture?
A
A fracture in which the bone doesn’t break completely - often occurs in the long bones of paediatric patients
11
Q
What is a greenstick fracture? What is the usually mechanism of injury?
A
Incomplete fracture of the long bones - usually during infancy and childhood due to a child falling
12
Q
What is a compression fracture?
A
aka Crush fracture
A fracture of the vertebrae (cancellous spongy bone), often due to osteoporosis
13
Q
What is an intra-articular fracture?
A
A fracture in which the break crosses into the surface of a joint causing cartilage damage - may cause secondary OA
14
Q
What is a stress fracture? Where is it commonly found?
A
Tiny fractures formed through repetitive overuse - common in runners and soldiers in the tibia, metatarsals, fibula and navicular bones.
V common in 2nd metatarsal!!!
15
Q
What is a pathological fracture?
A
Fracture due to disease, such as osteoporosis, osteomalacia, Paget’s, osteitis and malignancy
16
Q
What are the requirements for bone healing?
A
- Viability (intact blood supply)
- Mechanical rest (immobilisation)
- Absence of infection
17
Q
What are the 2 mechanisms of bone healing?
A
PRIMARY - healing without formation of callus, bone ends must be touching, osteoclasts traverse line and form lamellar bone to form a compression plate (high risk)
SECONDARY - healing with callus formation and remodelling triggered by responses in periosteum and external soft tissues (low risk)
18
Q
When assessing a patient with a fracture, what injuries may be identified?
A
Bones - fractures, pain
Skin - open fractures, devolving injuries, ischaemic necrosis
Muscles - crush and compartment syndromes
Blood vessels - vasospasm, arterial laceration
Nerves - nerve laceration, neuropraxia
Ligaments - joint instability ad dislocation
19
Q
What investigations should be done in a fracture patient?
A
BEDSIDE: Obs, ECG
BLOODS: FBC, ESR, U&E, bone profile, myeloma screen
IMAGING: x-rays (2 views, 2 joints), MRI, CT, bone scan, US
(may need to investigate cause of fall)
20
Q
What are the 3 principles of fracture management?
A
- Reduce (open or closed)
- Hold (external or internal)
- Rehabilitation
21
Q
What are the indications for closed reduction?
A
- Extra-articular features
- Closed fractures
- Simple fractures
- Stable configuration
- Children
22
Q
What are the indications for open reduction?
A
- Failed closed reduction
- Displaced intra-articular fractures
- Open fractures
- Nerve/vessel injuries
- Multiple injuries
- Pathological fractures
23
Q
What are some methods of external fixation?
A
- Plaster
- Traction (steady, pulling action, often preliminary)
- Brace
- Percutaneous wires
- External fixator
24
Q
What are some methods of internal fixation?
A
- Extra-medullary (plates, screws)
- Intra-medullary (nails)
25
How do you manage an open fracture?
1. Inspect, clean and cover wound
2. Give immediate IV co-amoxiclav/cefuroxime
3. Give tetanus prophylaxis
4. Operate within 6 hours (excise wound edges and dead tissue, irrigate, stabilise)
26
What are some early local complications of fractures?
- Visceral/vascular injury
- Compartment syndrome
- Nerve injury
- Haemarthrosis
- Infection
- Plaster sores
27
What are some late local complications of fractures?
- Delayed/non/mal union
- Joint stiffness
- Avascular necrosis
- Complex regional pain syndrome
- Osteoarthritis
- UTI/LRTI
28
What are some general complications of fractures?
- Shock
- ARDS
- Fat embolism
- Crush syndrome
- Tetanus
- Gas gangrene
29
What is compartment syndrome?
High pressure within a closed fascial space which reduces capillary blood supply so that there is an insufficient level to support tissue --> tissue death
Presents in early stage as passive stretch pain, late stage as numbness and loss of pulses
Diagnosis is pressure >40mmHg
30
How is compartment syndrome managed?
Occlusive dressing and urgent fasciotomy to decompress muscle compartment - prevents ischaemia and rhabdomyolysis
Requires aggressive IV fluids as risk of myoglobinuria and renal failur after fasciotomy
They will need morphine!!
31
What is a Colle's fracture?
Complete fracture of the radius, causing posterior displacement of the radius (looks like a fork) - common in elderly female patients from falling on an outstretched hand
NB - this is equivalent to a greenstick fracture in children
32
How is a Colle's fracture managed?
Internal/external fixation - usually 6 weeks in a cast
May need prior reduction if poor bone alignment
33
What is a Smiths fracture?
- Fracture of the distal radius after falling onto a flexed wrist or due to a direct blow to the back of the wrist
- Reverse Colles fracture
- Causes volar angulation
34
What is a Barton's fracture?
- Intraarticular distal radius fracture with dislocation of the radiocarpal joint
35
Describe the Garden classification of NOFs?
THIS IS A CLASSIFICATION FOR INTRACAPSULAR HIP FRACTURES
Stage 1 - undisplaced, incomplete
Stage 2 - undisplaced, complete
Stage 3 - incompletely displaced (some continuity between fracture ends), complete
Stage 4 - completely displaced, complete
36
How are NOFs managed?
INTRACAPSULAR:
1. Internal fixation with a DHS (if undisplaced/extracapsular)
2. Replacement arthroplasty (total/hemi - if displaced)
Also give analgesia, nerve block, thromboprophyalxis, antibiotics, MDT involvement
EXTRACAPSULAR:
1. Stable > DHS
2. Reverse oblique, transver or subtrochanteric > intramedullary device
37
What is a Thomas splint?
A splint applied in A&E that keeps the leg still if broken before surgical management
38
What is ORIF?
Open reduction internal fixation - procedure to realign bone in the case of a severe fracture
39
What are the complications of a NOF?
- Leg deformity, mobility issues
| - Avascular necrosis of the femoral head and collapse (more likely in intracapsular garden 3/4)
40
How is avascular necrosis of the hip managed?
1. Do MRI to look at extent of AVN
2. Core decompression (drill holes into femoral head)
3. Osteochondral grafting
4. Total arthroplasty (if collapse has already occurred)
41
What are the symptoms of a scaphoid fracture?
Pain and swelling in the anatomical snuffbox
42
What is the main complication of a scaphoid fracture?
Avacular necrosis of the scaphoid - may need a vascularized bone graft
43
How is a scaphoid fracture managed?
Immobilisation in a thumb cast for 8-12 weeks
If displaced may need surgical reduction and fixation
44
What are osteporotic spinal compression fractures? How are they managed?
Isolated failure of anterior spinal column - usually stable flexion fractures and heal conservatively with bracing for 8-12 weeks and rehab. Maybe have lordosis and kyphosis.
Usually in postmenopausal women and those on long term corticosteroids. Exclude malignancy!
45
What are the different types of pelvic fracture?
1. Stable - only one break in pelvic ring, bones line up adequately
2. Unstable - multiple breaks with displacement. high energy event
46
What is a ganglion cyst?
Smooth, soft benign non-tender mass located on the wrist with one or more communicating stalks into the wrist joint or surrounding structures.
47
What are the RF for a ganglion cyst?
Female
Age 10-30 years
Trauma
Scapholunate instability
48
How should a ganglion cyst be managed?
Without neurovascular compromise:
1. Observe (often resolve spontaneously)
2. Cyst aspiration and steroid injection
3. Surgical resection
With neurovascular compromise:
1. Surgical resection
49
What is tenosynovitis tendonopathy?
Inflammation of the extrinsic tendons of the hand and wrist, manifesting as:
1. Trigger fingers
2. De Quervains disease
Result from overuse of hand and degeneration
50
What are the symptoms of trigger finger?
Pain, stiffness and locking when you bend or straighten finger. Tendon can catch in the tendon sheath causing characteristic appearance.
Most commonly affects ring finger (4th)
Manage with steroid injection and finger splint
51
What are the symptoms of De Quervains disease?
- Pain, stiffness and locking of tendons on the THUMB side of the wrist.
- Due to inflammation of the sheath containing the extensor pollicis brevis and abductor pollicis longus
Positive Finkelstein test - pain on ulnar deviation
52
How should tenosynovitis be investigated and managed?
1st line - high res USS shows effusion, tendon sheath thickening and hyperaemia (excess blood vessels)
Manage with NSAIDS, splinting, steroid injection and surgery if necessary - in trigger finger incise the A pulley and DQ incise the first dorsal compartment
53
Describe the sensory supply to the hand
ULNAR - half of fourth digit and entire fifth digit on dorsal and palmar aspects
MEDIAN - tips of first second and third digits and half of the fourth digit
RADIAL - remaining dorsal surface of these digits, extending proximally to the wrist
54
What is Dupytrens contracture, what are the risk factors and how is it managed?
Inherited disease involving progressive fibrous tissue contracture of the palmar fascia. May have contracture of 4th/5th digits. May have Garrods nodes and involvement of penis.
More common in men, northern europe, smokers/alcohol. Phenytoin use. Autosomal dominant.
Diagnose with US, give steroids. If significant MCP/PIP joint contracture (over 30 degrees), give collagenase injection, needle aponeurotomy and percutaneous fasciotomy
High rate of recurrence.
55
What spinal nerve roots supply the brachial plexus?
C5, C6, C7, C8, T1
56
Which nerves come off the brachial plexus?
```
Musculocutanous (C5,C6,C7)
Axillary (C5, C6)
Radial (all)
Median (all)
Ulnar (C8, T1)
```
57
What is Dupytrens contracture, what are the risk factors and how is it managed?
Inherited disease involving progressive fibrous tissue contracture of the palmar fascia and aponeuroses. May cause flexion of proximal and middle phalanx on ring and little finger. May have Garrods nodes and involvement of penis.
More common in men, northern europe, smokers/alcohol. Autosomal dominant.
Diagnose with US, give steroids. If significant MCP/PIP joint contracture (over 30 degrees), give collagenase injection, needle aponeurotomy and percutaneous fasciotomy
High rate of recurrence.
58
Describe the sensory supply to the hand
ULNAR - half of fourth digit and entire fifth digit on dorsal and palmar aspects
MEDIAN - tips of first second and third digits and half of the fourth digit
RADIAL - remaining dorsal surface of these digits, extending proximally to the wrist
59
What are the clinical features of radial nerve palsy?
- Numbness over posterior arm, forearm and radial hand distribution
- Wrist drop (weak extensor muscles)
- Absent triceps, supinator reflexes
60
What might cause injury to the radial nerve?
- Humeral/radial fracture
- Stab wounds to antecubital fossa, forearm, wrist
- Crutch palsy
- Saturday night palsy
- Honeymoon palsy
61
What are the clinical features of medial nerve palsy?
- Sensory loss over thenar eminence and tips of fingers
| - HAND OF BENEDICTION (1/2/3 digits remain upright when trying to make a fist)
62
What might cause injury to the medial nerve?
- Supracondylar fracture (just above elbow) of humerus
- Stab wounds to antecubital fossa, forearm, wrist
- Self harm
- Carpal tunnel syndrome
63
What are the clinical features of an ulnar nerve palsy?
- Sensory loss over hypothenar eminance and ulnar side of hand
- CLAW HAND (patient cannot extend IPJs of ring or little fingers causing fixed flexion of IPJs and hyperextension of CMPJs, at REST)
64
What are the clinical features of medial nerve palsy?
- Sensory loss over thenar eminence and tips of fingers
- HAND OF BENEDICTION (1/2/3 digits remain upright when trying to make a fist)
- Positive froments sign (reduced functionality of pincer grip)
65
What is cubital tunnel syndrome?
- Compression of the ulnar nerve
- Presents as tingling and numbess of 4th and 5th fingers
- May develop weakness and muscle wasting over time
- Pain worse on leaning on affected elbow
66
How is cubital tunnel syndrome managed?
- Usually a clinical diagnosis but may use NCS
- Manage conservatively with physio
- Steroid injections + surgery if refractory
67
What is the flexor retinaculum?
Thick connective tissue that forms the roof of the carpal tunnel
68
What is carpal tunnel syndrome?
Numbness, tingling in the thumb and fingers and aching wrist due to COMPRESSION OF THE MEDIAN NERVE IN THE CARPAL TUNNEL
Symptoms are intermittent, gradual onset and worse at night time. Wasting of thenar eminence
69
What are the RF for carpal tunnel syndrome?
```
High BMI
Female
Age over 30
Smoking
Pregnancy
Diabetes, thyroid dysfunction, autoimmune, RA
Occupational hazards
```
70
How is carpal tunnel syndrome investigated?
1st line - EMG (electromyogram), slowed nerve conduction (also phanlen and tinels test!)
2nd line - wrist US/MRI, if suspect space occupying lesion such as ganglion cyst
71
How is carpal tunnel syndrome managed?
1. Wrist splint worn nightly and steroid injections
| 2. Surgical release through flexor retinaculum division (as risk of permanent nerve damage)
72
What are phalen and tinel tests?
PHALEN - flex wrists (backwards prayer) for 60s
TINEL - tap over transverse carpal ligaments
Positive test gives pain, anaesthesia and parasthesia
73
What is epicondylitis?
Tennis elbow (lateral epicondylitis) - lads play tennis:
- Pain worse on resisted wrist extension or supination of forearm with elbow extended
- Acute pain for 6-12 weeks
Golfers elbow (medial epicondylitis) - men play golf:
- Pain worse with wrist felexion and pronation
- May have parasthesia in 4/5 fingers due to ulnar involvemet
74
Describe the shoulder joint
Ball and socket - made up of humerus, scapula and clavicle.
Acromion and coracoid process of scapula exend laterally over the shoulder joint, forming the subacromial space.
Joint kept in place by rotator cuff muscles, with an underlying bursa allowing the tendons to glide freely on arm movement
75
What are the 4 rotator cuff muscles?
1. Supraspinatus
2. Infraspinatus
3. Subscapularis
4. Teres minor
76
What is the function of the supraspinatus muscle?
Elevates the shoulder joint out to the side
77
What is the function of the infraspinatus and teres minor muscle?
Externally rotate the shoulder joint
78
What is the function of the subscapularis muscle?
Allows the humerus t omove freely during arm elevation
79
What are some DDs for shoulder pathology?
- Shoulder impingement
- Subacromial bursitis
- Rotator cuff syndrome/tendonitis
- Trauma
- Adhesive capsulitis
80
What is subacromial impingement?
AKA impingement syndrome, painful arc syndrome
- Presents as shoulder pain worse on abduction
- Painful arc of abduction between 60 and 120 degrees
- Tenderness over anterioer acromion
81
What is a rotator cuff tear? How is it managed?
Pain, weakness and loss of ROM around the shoulder, due to trauma or attritional damage. Will usually have pain on initial 60 degrees of abduction
CONSERVATIVE: exercise, physio
MEDICAL: analgesia, subacromial steroid injection or nerve block (dont give more than 2 with 6 weeks in between as risk of tendon damage)
SURGICAL: open, arthroscopic repair (if no response after 6weeks medical therapy)
(nb - refer to secondary care if red flags, no benefit after 6 weeks or injury caused by trauma)
82
What is adhesive capsulitis? How is it caused?
Frozen shoulder - insidious, progressive severe restriction of active and passive shoulder motion. Initial pain but worsening stiffness.
Exact mechanism unknown, but may be due to scar tissue formation, causing thickening of joint capsule.
RF include age, DM/thyroid, prior hx, recent traumatic injury
83
What tests are done to diagnose adhesive capsulitis?
Coracoid pain test - pain elicited by direct pressure on coracoid
Shoulder shrug test - inability to abduct arm to 90 degrees in to plane of body
External rotation more affected than internal rotation or abduction
84
How is adhesive capsulitis managed?
The condition is generally self-limiting - should resolve within a year after passing through 3 phases (painful, stiff, recovery)
CONSERVATIVE - analgesia, activity modification, physiotherapy (sleeper stretch), hot packs
MEDICAL - glenohumeral steroid injection
85
How is acute shoulder dislocation managed?
- Do x-ray to confirm and exclude fracture
- Patients over 40 should have further US/MRA to look for rotator cuff tear
- Reduction under anaesthesia (abduction and external rotation and axial traction)
- Immobiliation in a sling for 3 weeks
- Repeat x-ray to exclude further iatrogenic fractures and confirm placement
86
What are the complications of joint dislocation?
- Soft tissue injury
- Articular surface injury
- Neurovascular compromise
87
What is a subluxtation and how is it managed?
Partial/incomplete dislocation. Treat with shoulder strengthening exercises, closed reduction and surgery if multiple occurences.
88
What is a subluxation and how is it managed?
Partial/incomplete dislocation. Treat with shoulder strengthening exercises, closed reduction and surgery if multiple occurences.
89
How are strains (muscle or tendon) /sprains (ligaments) managed?
PRICE!!
```
Protection
Rest
Ice
Compression
Elevation
```
Advise to avoid HARM (heat, alcohol, running, massage) in first 72hours after injury.
May need immobilization and cruthc.
90
How are strains (muscle or tendon) /sprains (ligaments) managed?
PRICE!!
```
Protection
Rest
Ice
Compression
Elevation
```
Advise to avoid HARM (heat, alcohol, running, massage) in first 72hours after injury.
May need immobilization and crutch.
91
What investigations should be considered in arthritis?
BEDSIDE: obs, joint aspiration and fluid analysis
BLOODS: FBC, U&E, CRP, ESR, RF, anti-CCP, urate, AST/ALT (if<6 weeks, check for hepatitis), HLA-B27, virology
IMAGING: x-ray, MRI (affected and contralateral joint)
92
What are the features of osteroarthritis?
Pain and stiffness in large joints, pain worse at the end of the day.
May have crepitus
93
What are the features of osteoarthritis on x-ray?
1. Loss of joint space
2. Subchondral sclerosis
3. Osteophyte
4. Subchondral cysts
94
How is OA managed?
CONSERVATIVE - weight loss, physiotherapy, analgesia, TENS, weight bearing exercise, orthotics, OT/PT
MEDICAL - may need opiods, steroid injections
(can use topical NSAIDs for knee and hand OA)
SURGICAL - osteotomy, joint replcaement or fusion, arthoscopic lavage and debridement to help locking
95
What are Bouchards and Heberdens nodes?
Bouchards nodes - bony enlargements on PIP joints
Heberdens nodes - bony enlargements on DIP joints (outer hebrides)
96
What are the complications of joint replacement?
- Aseptic loosening
- Pain
- Dislocation
- Infection
- Fracture
97
What may cause early onset OA?
- Previous trauma
- Juvenile idiopathic arthritis
- Metabolic disease eg. acromegaly, haemochromatosis
- Late avascular necrosis
- Neuropathic joint
98
What are the features of RA?
Pain and inflammation in multiple small joints. Pain and stiffness worse in the morning, symmetrical. Fatigue.
Presence of systemic features - ILD, pericarditis, skin nodules, cervical myelopathy, mononeuritis multiplex, scleritis
May have recurrent soft tissue problems (frozen shoulder, carpal tunnel, DQ)
99
What are the features of RA on x-ray?
1. Juxta-articular osteopenia
2. Soft tissue swelling
3. Joint deformity
4. Joint space narrowing
5. Ill-defined marginal erosions
100
Describe some hand findings in a patient with RA?
- Z-neck swan deformity
- Ulnar deviation
- Boutonniere deformity - bent PIP
101
How is RA diagnosed and monitored?
Diagnosis is clinical but bloods may show raised RF (poor prognosis), anti-CCP, CRP, ESR.
DAS28 score can be used to monitor disease activity.
102
How is RA managed?
CONSERVATIVE Smoking/alcohol cessation, PT/OT, podiatry, pain team, flu vaccines
MEDICAL
1st - DMARD eg. methotrexate, sulfasalazine, start within 3 months (plus short course oral prednisolone)
2nd - add on DMARDS (dual, triple therapy)
3rd - biologics TNFa infliximab/adalimumab (if inadequate response to at least 2 DMARDS including methotrexate)
Manage flares with oralglucocorticoid
SURGICAL
Only if septic arthritis, tendon rupture, nerve compression, stress fracture, persistent pain
103
What parameters are measured in a patient taking DMARDs?
Methotrexate - exclude pregnancy before treatment, FBC, GFR, LFT before. During therapy need these tests every 1-2 weeks until stabilised then every 3 months.
Hydroxychloroquine - no routine monitoring, eye assessment every 5 years as risk of retinopathy
Sulfasalazine - FBC (pancytopenia), GFR, LFTs
104
When can patients with RA try biologics?
They must have tried low-dose glucocorticoids and two trials of six months of traditional DMARD monotherapy or combination therapy.
DMARDS - azothiaprine, ciclosporin, hydroxychloroquine, methotrexate
BIOLOGICS - infliximab, ritxuimab
105
What are seronegative spondyloarthropathys?
Conditions with overlapping clinical manifestations and association with HLA-B27. negative RhF
eg, ank spon, psoriatic arthritis, enteropathic arthritis, reactive arthritis
106
What are the features of ankylosing spondylitis?
- Affects sacroiliac joints and axial spine, question mark posture (thoracic kyphosis and neck hyperextension), radiates to hip
- Insidious onset pain, worse in morning, improves with exercise
- Fatigue
- Extra articular (eg. uveitis)
107
How is ank spon diagnosed?
- Clinical diagnosis is key!
- Positive HLA-b27
- Bamboo spine on x-ray (vertebral body fusion due to inflammation, only in advanced disease)
- Schobers test <5cm (reduced forward flexion) and reduced lateral flexion of lumbar spine
- MRI (most sensitive)
- Enthesitis on US
108
How is ank spon managed?
CONSERVATIVE - physio, osteoporosis assessment every 2 years. manage CVS RF (asociated with aortic valve incompetence)
MEDICAL - NSAIDS, corticosteroid injections, DMARD (sulfasalazine), TNFa inhibitors
SURGICAL (if hyperkyphosis or severe hip involvement)
109
How can you differentiate psoriatic arthritis from RA?
- Associated psoriatic rash
- Dactylitis (swelling of entire digit)
- Sacrioilitis
- Frequent oligoarticular/monoarticular pattern (not poly)
- Asymmetrical compared to symmetrical in RA
- DIP involvement
- Coexistence of erosive changes and new bone formation, sausage finger and pencil deformity on x-ray
- Negative RhF
110
How is psoriatic arthritis managed?
1st line - NSAIDS and splint affected joints
2nd line - DMARDS/steroid injection, usually methorexate
3rd line - monoclonal antibodies (ustekinumab, secukinumab)
111
What is enteropathic arthritis?
Chronic inflammatory arthritis associated with IBD
112
What are the features of reactive arthritis?
- Assymetrical oligoarticular arthritis affecting large joints
- Systemic symptoms
- GI/urinary/chlamydial infection 1-4 weeks before onset
- Enthesitis (inflammation where tendon inserts into bone) and dactylitis, conjuctivitis, iritis
- Skin lesions (painfull vesciles on penis, lesions on palms/soles)
'Can't see, pee or climb a tree'
113
What is Reiters syndrome?
Classical triad in reactive arthritis:
1. Conjunctivitis
2. Urethritis
3. Arthritis
114
What bloods are raised in reactive arthritis?
Raised - ESR, CRP, HLA-DR4
| Not raised - ANA, RF
115
How is reactive arthritis managed?
- Give symptomatic relief with NSAIDS, steroids, should resolve.
- DMARDS if persistent arthritis
116
What are the features of septic arthritis?
Red hot inflamed joint, usually affecting the knee.
RF include pre-exisiting joint disease, DM, immunosuppresion, renal, IV drug use
117
How is septic arthritis diagnosed?
Urgent joint aspiration with microscopy and culture - may need to do nucleic acid test and serological lab tests for certain pathogens
118
How is septic arthritis managed?
IV antibiotics - flucloxacillin, vancomuycin (MRSA), cefotaxime (covers gram neg)
Treatment is time-critical as can cause irreversible damage within 24h.
119
What are the features of gout?
- Acute monoarthropathy, often in MTP joint of big toe
- Raised urate (>450)
- Punched out erosions in bone
- May have tophi (white) if chronic
RF - hereditary, dietary purines, alcohol, diuretics, cytotoxics, associated CVS/HTN/DM/CKD
120
What does aspirate show in gout?
Negatively birefringent urate crystals
121
How is acute gout managed?
High dose NSAID or colchicine, symptoms should reside in 3-5 days, continue 1-2 days post symptom resolution
2nd line - prednisolone
If pt is already on allopurinol prophylaxis, continue at current dose alongside acute treatment
Renal impairment - colchicine
122
How is gout prophylaxis managed?
1st line - allopurinol 100mg OD
2nd line - febuxostat
3rd line - uricase, pegloticase
Start after acute attack has resolved
Consider startnig alongside colchicine cover
Aim urate <360
Consider stopping precipitants (such as thiazides) - give losartan instead
Increase vitamin C intake
Avoid food high in purines (seafood, organs, oily fish, yeast products)
123
What is pseudogout?
Deposits of calcium pyrophosphate crystals (CPPD) causing an acute monoarthropathy in larger joints (wrist, shoulder) of elderly patients. May be triggered by surgery, dehydration, ilness.
Risk factors include haemochromatosis, hyperparathyroidism, low magnesium/phosphate, acromegaly, Wilsons
Manage with NSAIDS and colchicine.
124
What so investigations show in pseudogout?
Aspirate - polarized light microscopy of synovial fluids shows weakly psoitively birefringent crystals.
XR - chondrocalcinosis
125
What are some DDs for back pain?
Prolapsed disc, trauma, fractures, ank spon, pregnancy, malignancy, paget's, cauda equina, osteoporotic vertebral collapse, spinal infection
126
What are the indications for surgery in the upper limb?
Any radial or ulnar fracture - usually needs operating
Distal radius fracture - reduce and cast/splint
Humeral fractures - don't need operation unless significantly displaced/open fracture
127
What are the indications for surgery in the lower limb?
NOF - always operate, DHS (extracapsular) or hemiarthroplasty (intracapsular)
Tibial/fibula fracture - only operate if displacement by 5-10mm
Fracture of medial malleolus - often needs plating
128
What is the medical name for bunion and how is it managed?
Hallux valgus - surgery aims to return the toe to its anatomical position using nails and arthrodesis (surgical immobilisation of the 1st MTP joint
129
How are ankle injuries classified?
Weber Classification (describes in relation to where the tibia and fibula join)
A - infrasyndesmotic
B - transsyndesmotic
C - suprasyndesmotic
130
In what instances is surgery indicated for ankle injury?
Depends on stability - generally Weber A is quite stable.
Fracture of lateral malleolus - often nonsurgical adequate
Fracture of medial mallelous - may need surgery even if stable as risk of nonunion
Fracture of posterior malleolus - will need surgery if out of place or unstable, risk of developing arthritis
Bimalleolar - ankle not stable, ligaments often injured, may have dislocation, need surgery.
Trimalleolar - as bimalleolar
131
Where does arthritis commonly affect the ankle joint?
OA - mortice
| RA - subtalar
132
What investigation is indicated if a fracture is sustained falling from standing height?
DEXA scan looking at bone mineral density - fragility fracture
133
What is an avulsion fracture?
An injury to the bone in a location where a tendon or ligament attaches to the bone
134
What are the common sites of tendinopathy?
- Rotator cuff (supraspinatus tendon)
- Wrist extensors (lateral epicondyle)
- Wrist pronators (medial epicondyle)
- Patellar and quadriceps tendon
- Achilles tendon
135
How is achilles tendinopathy managed?
CONSERVATIVE - physio, analgesia, night splints, heel lifts
MEDICAL - glyceryl trinitrate patch
SPECIAL - laser, shockwave therapy
136
What is an achilles tendon rupture and how is it managed?
Complete or partial tear, due to forceful jumping or sudden acceleartions.
Sx - Causes sudden pain and audible snap.
Ix - Ask pt to lie prone with feet over edge of bed; positive simmonds calf squeeze test, no plantar flexion on squeeze due to the gastrocnemius-soleus complex no longer being connected to foot
Mx - VTE risk assessment, virtual fracture clinic, functional bracing in most cases, surgical repair
137
What is osteomalacia? What are the symptoms?
Incomplete mineralisation of underlying mature osteroid following growth plate closure, due to vit D deficiency
Sx - Proximal muscle weakness, spinal tenderness, pseudofractures and skeletal deformities
138
What is rickets?
Equivalent underlying pathological process to osteomalacia but in children, due to defective mineralisation of the epiphyseal growth plate cartilage
139
What are some RF for osteomalaica?
- Calcium and vit D deficiency
- Anticonvulsant therapy (due to above defieicnies)
- CKD
- Some mesenchymal tumours
140
How is osteomalaica investigated?
BEDSIDE: 24h urinary calcium (low)
BLOODS: calcium (low), 25-hydroxy vitD (low), phosphate (low), U&E, PTH (high), LFTs (ALP high)
IMAGING: bone x-rays shows translucent bands (Looser's zones or psuedofractures)
MANAGEMENT: vitamin D and calcium supplementation
141
When should osteoporosis risk be assessed?
1. All women over 65 and men over 75
2. Younger patients with risk factors incl smoking, alcohol >14u, fam hx, low BMI, steroids, previous fragility fracture
Use FRAX or QFracture
If in intermediate risk group, assess every 2 years
142
When should you skip risk assessment and go straight to DEXA?
1. Before starting treatments that may have a rapid adverse effect on bone density
2. Patients <40yo with history of multiple fragility fractures, major osteoporotic fracture, high dose steroids
143
What is osteoporosis?
Low bone density resulting in increased bone fragility
Sx - often asymptomatic until fracture occurs
(NB - osteopenia is a precursor!)
144
How is osteoporosis diagnosed?
Do FRAX score to calculate whether to perform a DEXA or to start bisphosphonate
T score <2.5 on DEXA scan
145
What factors predispose to osteoporosis?
- Family history
- Female, age
- Low BMI or recent weight loss
- Androgen deprivation (eg. for testicular cancer) or aromatase inhibitor treatment (breast cancer)
- Steroid use
- Smoking
- Renal calculi
146
How is osteoporosis managed?
CONSERVATIVE: fall prevention, smoking cessation, BMI/exercise
MEDICAL:
- Bisphosphonates (start with alendronate and change to risedronate, etidronate if GI side effects)
- Calcium/vit D supplementation
- Denosumab - monoclonal antibody, given SC every 6, EXPENSIVE!
- Raloxifene (SERM) - risk of worse menopause, VTE
- Strontium ranelate - only by specialist due to risk of CVS/VTE/skin reaction
- Teriparatide - form of PTH
- HRT - only if also suffering vasomotor symptoms
Following fragility fracture:
- If >75 start oral bisphosphonate without need for a DEXA
- If <75 do FRAX score
147
How are bisphosphonates taken?
In the morning on an empty stomach (30 min before eating), stand upright, with water.
148
How do bisphosphonates work? What are the side effects?
Inhibit bone resorption by osteoclasts
SE - GI irritation, hypocalcemia, jaw osteonecrosis, atypical femur fracture (bones become harder but more shatter-prone)
149
How does teriparatide work? What are the side effects?
Synthetic form of PTH, when given in short bursts it activates osteoblasts to increase bone density, give SC
SE - increased risk of osteosarcoma so only give for 24 months
150
How does denosumab work? What are the side effects?
Human monoclonal antibody prevents development of osteoclasts
SE - atypical femoral fractures, hypocalcemia, jaw osteonecrosis, abdo discomfort
151
What is osteomyelitis? What are the symptoms?
Bone infection, usually due to staph aureus
Sx - non-specific pain, malaise, fatigue, local inflammation, fever, reduced ROM/sensation
152
What are the RF for osteomyelitis?
- Penetrating injuries
- Surgical contamination
- IV drug use
- Diabetes mellitus
- Immunocompromise
153
What are the sources of osteomyelitis?
1. Haematogenous (from bacteraemia)
- usually monomicrobial
- usually staph aureus
- sickle cell anaemia pts will have salmonella infection
- more common in children
2. Non-haematogenous:
- usually polymicrobial
- due to contiguous spread from adjacent soft tissue from direct injury/trauma
- more common in adults
154
How should osteomyelitis be investigated and managed?
Investigations:
- MRI
Management:
- Flucloxacillin for 6w
- Clindamycin if pen allergic
- Surgery if bone necrosis/sequestrum/biofilm (means it is chronic) - debridement, reconstruction
Compliactions:
- Secondary amyloidosis, Marjolins ulcer (malignancy at site of discharging skin ulcer)
155
What are the sciatic and femoral stretch tests?
Sciatic stretch aka straight leg raise:
- Lie supine and lift leg
- Pain in posterior thigh or buttock on SLR suggests sciatica
Femoral stretch:
- Lie prone and bend knee back then lift leg up
- Pain in aterior thigh or inguinal region suggests femoral nerve impingement
156
What are the indications for further investigation for back pain?
- 6 weeks duration
- Extremes of age
- Constant, progressive pain
- Thoracic
- PMH cancer, TB, HIV, osteoporosis
- Steroid use
- Major trauma
- Saddlae anaesthesia
157
What are the features of spinal stenosis?
- Leg discomfort relieved by rest (pseudocaludication)
- Can be unilateral or bilateral
- Characterisitc simian posture with forward stoop
- Clinical examnation usually normal
- Caused by Pagets/OA
- Refer for MRI to confirm diagnosis
158
What are the features of disc prolapse?
- Nerve root pain
- Sensory/motor changes
- Asymmetrical reflexes
- Positive femoral (L3,L4) and sciatic (L5,S1 - aka SLR) stretch test
L3 compression -thigh hips and knee
L4 compression - knee and medial malleolus
L5 compression - foot
S1 compression - posterolateral leg and lateral foot
Management:
- NSAIDS and physio and refer after 4-6 weeks
159
What are the features of spondylolisthesis (slipped vertebrae)?
- Back pain aggravated by standing/walking
- Usually congenital, post-trauma or degenerative
Mx - muscle-strengthening, posture exercises. May need surgical fusion or decompression if cauda equina
160
What are the features of arachnoiditis?
- Chronic severe lower back pain
- Inflammation of nerve root sheath in spinal canal due to meningitis or spinal surgery
MX - chronic pain relief, physio
161
What are the features of PMR?
- Pain and morning stiffness in the neck, shoulder girdle and pelvic girdle
- Age >50yo
- Comorbid giant cell arteritis
- Raised ESR >40
- Note normal CK and EMG
162
How is PMR managed?
1. Low dose corticosteroids (pred 15), NSAIDs
2. Methotrexate plus folic acid
3. Tocilizumab
Should start pts on bisphosphonate (don't need a FRAX/DEXA)
163
What are the different types of bone sarcomas (malignant) and their features?
Osteosarcoma
- Local pain, swelling and tenderness
- Common in children and adolescents
- Occurs in metaphyseal region of long bones
- XR shows sunburst pattern and codman triangle
- Mesenchymal cells with osteoblastic differentiation
Ewings sarcoma
- Small round blue cell tumour
- Pelvis and long bones, severe pain
- Assoc with t(11;22) translocation
- XR shows onion skin appearance
Chondrosarcoma
- Chondrocyte (cartilage) malignancy
- Axial skeleton
- More common in middle age
164
What investigations are ordered in osteosarcoma?
BLOODS: raised ALP, LDH
IMAGING: xray shows expansion of bone and surrounding soft tissue mass, CT/MRI for staging, PET, bone biopsy
165
How is osteosarcoma managed?
Surgical resection, chemo and radio - excellent prognosis if non-metastatic/not related to Pagets
166
What are the benign tumours of the bone?
Osteoma:
- Benign bone overgrowth
- Typically in skull
- Assoc with Gardners syndrome
Osteochondroma:
- Most common
- Cartilage capped bony projection on external surface of bone
Giant cell tumour:
- Tumour of multinuclated giant cells
- Long bones
- XR shows double bubble appearance
167
What are the features of Pagets disease of bone?
- Disorder of osteoclasts involving focal areas of increased and disorganized bone remodelling
- Leads to osseus deformities, nerve compressions and pathological fractures
- Mutation in SQSTM1 gene
- Often asymptomatic, may have bone pain, deformity, deafness, pathological fractures
168
How is Pagets diagnosed?
- Clinical features
- Family history
- Raised ALP with normal Ca and phosphate
- Bone expansion on x-ray
169
How is Pagets managed?
Treat with bisphosphonate if bone pain, skull or long bone deformity, fracture, periarticular Pagets
Complications:
- Deafness (cranial nerve entrapment)
- Bone sarcoma
- Fractures
- Skull thickening
- High output cardiac failure
170
What is osteogenesis imperfecta?
Rare genetic disorder of collagen metabolism involving:
- multiple bone fractures
- blue-grey sclera
- normal calcium, phosphate and PTH
171
Why do you get an AKI in compartment syndrome?
Tibial fracture - increased pressure in fascial compartment - muscle breakdown - myoglobin release into bloodstream
This causes AKI and dark urine that dips positively for blood
172
What is flail chest? How is it managed?
Paradoxical movement of the flail segment of the chest during respiration - caused by two or more rib fractures along 3 or more consecutive ribs
Must have invasive ventilation and surgical fixation as risk of serious contusional injury
173
How should an undisplaced intracapsular fracture be managed?
Healthy - internal fixation
Comorbidities - hemiarthroplasty
174
How should a displaced intracapsular fracture be managed?
Age<70 - internal fixation if possible or hemiarthroplasty
Age>70, major comorbidities, not v mobile - hemiarthroplasty
Age>70, independently mobile - total hip replacement
175
How should an extracapsular fracture be managed?
Non special type - DHS
Reverse oblique, transverse or subtrochanteric - intramedullary device
176
What are the features of a psoas abscess?
- Non-specific presentation, back pain
- Positive psoas sign (pain in left hip and back when hip is hyperextended)
- Associated with IV drug use and bacterial endocarditis
- Staph aureus
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How are psoas abscesses managed?
- Diagnose with CT and bloods
| - Percutaneous drainage and IV antibiotics
178
What causes a positive psoas sign?
- Psoas abscess
- Retrocaecal appendix
(patient lies on left side with knee extended and hip is passively extended by examiner)
179
What causes a positive obturator sign?
- Acute appendicitis
| patient lies on back and flexes knees 90 degrees, examiner internally rotates the hip
180
What is the most common type of shoulder dislocation?
Anterior glenohumeral dislocation - causes external rotation and abduction of the upper limb. May cause a weak deltoid muscle and no sensation in sergeants patch due to axillary nerve palsy
181
What are the features of a posterior shoulder dislocation?
- Rims sign, trough sign and lightbulb sign on X-ray
| - Uncommon but associated with convulsive disorders/electrocution
182
What is luxatio erecta?
Form of inferior shoulder dislocation - loss of articulation with glenoid fossa causing severe arm hyperabduction
183
What is a Bankart lesion?
Injury of the anterior glenoid labrum due to anterior shoulder dislocation
Makes shoulder joint unstable and prone to further dislocation
184
What management is essential in rib fractures?
Adequate analgesia - ensures breathing not affected by pain
Adequate ventilation - otherwise increased likelihood of chest infection
Prophylactic antibiotics not used routinely!
185
What is a Galeazzi fracture?
Dislocation of the distal radioulnar joint with an associated radial fracture
GRIMUS (Galeazzi radial inferior, Monteggia ulnar superior)
186
What is a Monteggia fracture?
Dislocation of the proximal radioulnar joint and associated fracture of the proximal ulna
GRIMUS (Galeazzi radial inferior, Monteggia ulnar superior)
187
What is a Boxers fracture?
Fracture of the neck of the 4th/5th metacarpal with displacement of the metacarpal head
188
What is plantar fasciitis? How is it managed?
Heel pain around the medial calcaneal tuberosity, associated with walking
Mx - weight loss, stretch exercises, NSAIDS, orthotics
189
What are the features of a ruptured ACL?
- Sport injury
- Mechanism: high twisting force applied to a bent knee
- Typically presents with: loud crack, pain and RAPID joint swelling (haemoarthrosis)
- O/E: positive anterior drawer test
- Investigations: Do MRI arthroscopy
- Management: Poor healing, intense physiotherapy or surgery
190
What are the features of a ruptured posterior cruciate ligament?
- Mechanism: hyperextension injuries, blow to front of knee
- Tibia lies back on the femur
- Paradoxical anterior draw test
- Do MRI arthroscopy
191
What are the features of a ruptured medial collateral ligament?
- Mechanism: leg forced into valgus via force outside the leg
- Knee unstable when put into valgus position
192
What are the features of a menisceal tear?
Features:
- Rotational sporting injuries
- Delayed knee swelling
- Joint locking (Patient may develop skills to 'unlock' the knee
- Localised pain over joint line (anteromedial or anterolateral)
- Positive Thessaly's test - pain on twisting knee whilst weight bearing at 20 degrees of knee flexion
- Recurrent episodes of pain and effusions are common, often following minor trauma
Management:
- Do x-ray and MRI arthroscopy
- Management: RICE, physiotherapy, arthroscopic surgery if no improvement but avoid
193
How are osteoporotic vertebral fractures with no neurological symptoms managed?
Conservatively with assessment of future risk using FRAX tool
(x-ray may show vertebral wedging due to bone compression)
194
What is the first line analgesic for back pain?
NSAIDS (provided no contraindication)
195
How should open fractures be managed?
- Immobilise the fracture including the proximal and distal joints
- Carefully monitor and document neurovascular status, particularly following reduction and immobilisation
- Manage infection including tetanus prophylaxis
- IV broad spectrum antibiotics for open injuries
- As a general principle all open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution)
- Open fractures constitute an emergency and should be debrided and lavaged within 6 HOURSof injury
196
What are the Ottawa rules for ankle x-ray?
Ankle x-ray required if pain and malleolar zone and any one of:
1. Bony tenderness at lateral malleolar zone
2. Bony tenderness at medial malleolar zone
3. Inability to walk 4 weight bearing steps
197
How should fractures be immobilised?
Immobilise the joint above and below!
- Below knee stabilisation for isolated ankle injury
- Above knee stabilisation for mid-shaft tibial injuries
- Walked boot for stable ankle injuries where weight bearing is permitted (Weber A)
198
Which imaging is used in back injury?
X-ray - suspected osteroporotc fracture
CT - spine fracture with no hx of osteoporosis or signs of instability on x-ray
MRI - any neurological involvement (non contrast if trauma, contrast if any suspicion of malignancy)
199
Describe the features of lower limb nerve pathology
Femoral nerve - Weakness in knee extension, loss of the patella reflex, numbness of the thigh
Lumbosacral trunk - Weakness in ankle dorsiflexion, numbness of the calf and foot
Sciatic nerve -Weakness in knee flexion and foot movements, pain and numbness from gluteal region to ankle
Obturator nerve - Weakness in hip adduction, numbness over the medial thigh
200
What are the features of greater trochanteric pain syndrome?
- AKA trochanteric bursitits
- Due to repeated movement of the fibroelastic iliotibial band
- Pain and tenderness over lateral side of thigh
- Most common in women aged 50-70yo
201
What are the features of meralgia paraesthetica?
- Caused by compression of lateral cutaneous nerve of thigh
- Causes burning sensation over antero-lateral aspect of thigh
202
What are the features of pubic symphysis dysfunction?
- Common in pregnancy
- Ligament laxity increases in response to hormonal changes of pregnancy
- Pain over the pubic symphysis with radiation to the groins and medial aspects of thighs
- May see waddling gait
203
What are the features of transient idiopathic osteoporosis?
- Uncommon condition seen in third trimester of pregnancy
- Groin pain associated with a limited range of movement in hip
- May be unable to weight bear
- May have elevated ESR
- Self-limiting
204
What are the DDx for hip pain in children?
DDH:
- Picked up on newborn test
- Positive Barlow's and Ortolani's
Transient synovitis:
- 2-10yr olds
- Acute hip pain post viral infection
Perthes disease:
- 4-8yr olds, boys
- Due to AVN of femoral head
- Progressive hip pain, limp and stiffness
- XR shows widening of joint space and later decreased femoral head size and flattening
SUFE:
- 10-15yr olds
- Obese children and boys
- Displacement of femoral head epiphysis postero-inferiorly
- May be acute and traumatic or chronic
- Loss of internal rotation of leg in flexion
JIA:
- <16yo
- Joint pain, swellling and limp
- Positive ANA + anterior uveitis
Septic arthritis
205
What is iliotibial band syndrome?
- Common cause of lateral knee pain in runners
- Tenderness 2-3cm above lateral joint line
- Manage with stretches/physio referral
206
What is Osgood-Schlatter disease?
- AKA tibial apophysitis
- Pain and swelling over tibial tubercle
- Caused by small avulsion fractures which form from traction of the patellar tendon on the immature tibial tuberosity
207
What is osteochondritis dissecans?
- Condition in which bone undeneath the joint cartilage dies due to poor blood flow
- This can break loose causing pain and hindering joint motion
- Locking/swelling of joint
208
What is a myxoid cyst?
Benign lesion that occurs on the fingers or toes - usually associated with OA or degenerative joint disease
209
What is talipes equinovarus?
- AKA club foot, inverted plantar flexed foot
- Usually idiopathic but may be associated with spina bifida, cerebral palsy, trisomy 18
- Manage with Ponseti method (manipulation and casting) +/- achilles tenotomy
210
What are the features and management of hip dislocation?
Features:
- Usually after RTA?fall from height
- Posterior dislocation (90%) - shortened, internally rotated leg
Management:
- ABCDE
- Reduce under GA within 4h to reduce risk of AVN
211
What is meralgia paraesthetica?
- Parasthesia in the distribution of the lateral femoral cutaneous nerve (thigh)
- Can be due to entrapment, iatrogenic or from a neuroma
- Investigate with pelvic compression test (symptoms reproduced by deep palpation just below the ASIS)
- Treat by injecting nerve with LA
212
What is femoroacetabular impingement?
- Common cause of hip pain in active young adults
- Presents with hip/anterior groin pain worse on prolonged siting
- Associated with snapping, clicking or locking of the hip
- Association with Perthes
213
What are the features of radial tunnel syndrome?
- Common in gymnasts, racquet players and golfers
- Presents similary to lateral epicondylitis however pain is distal to epicondyle and worse on elbow extension/forearm pronation
- May have hand paraesthesia or wrist ache
214
What are the features of clubfoot?
aka taliped equinovarus
Invertd, plantar flexed foot which is NOT PASSIVELY CORRECTABLE
Managed with Ponseti method +/- achilled tenotomy
215
What is Morton's neuroma?
-Irritation of interdigital nerve by compression between metatarsal heads (usually 3rd and 4th) +/- inflamed bursa
- Exacerbated by tight fitting footwear
- Squeezing MT heads will elicit a painful click (Mulder's click)
- Management is conservative and with US guided procedures
216
What is Freiberg's disease?
- Oestochondrosis affecting toes
- Pain on WB in girls aged 12-15 years
- Manage with rest and surgery
217
What is a Maisonneuve fracture?
- Spiral fracture of the upper third of the fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseus membrane
- Due to pronation-external rotation force
- Associated fracture of the medial malleolus
Must examine proximal fibular in all ankle injuries and perform x-rays if locally tender !!!
218
What is a March fracture?
- Stress fracture of the metatarsals seen in people who undertake repetitive walking or running
- Commonest site is 2nd MT shaft
- Pt will present with a tender lump on the dorsum of the foot
219
What is an Orbital floor/blow out fracture?
- Occur when a blunt object strikes the eye
- Globe does not rupture so the force is transmitted throughout the orbit causing a fracture of the orbital floor
- Presents with bruising, diplopia, enopthalmos, hypo-ophthalmia and reduced sensation on the cheek
