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Yr3 - General Surgery > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

Principles of fracture management

A

Reduce
Hold
Rehabilitate

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2
Q

Pathophysiology of osteoarthritis

A

Degradation of cartilage and remodelling bone due to active chondrocytes
Release of enzymes break down collagen and proteoglycans destroying articular cartilage
Exposure of underlying subchondral bone -> sclerosis
Reactive remodelling -> formation of osteophytes and subchondral bone cysts
Loss of joint space

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3
Q

Risk factors for OA

A 
Primary
Secondary
- trauma
- infiltrative disease
- connective tissue disease
Obesity 
Advancing age
Female gender
Manual labour occupations
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4
Q

Clinical features of OA

A

Small joints of hands and feet, hip joint and knee joint
Insidious, chronic and gradually worsening
Pain and stiffness - worsened with activity
Deformity and reduced range of movement
Bouchard nodes - swelling of PIPJs
Heberden nodes - swelling of DIPJs

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5
Q

X-ray features of OA

A

Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis

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6
Q

Management of OA

A 
Conservative
- education
- weight loss
- physiotherapy
Medical
- simple anagesics
- topical NSAIDs
- intra-articular steriod injections
Surgical
- osteotomy
- arthrodesis
- arthroplasty
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7
Q

Outcomes of open fractions

A

Skin
Soft tissues
Neurovascular injury
Infection

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8
Q

Management of open fractures

A 
Urgent realignment and splinting of limb
Broad spectrum antibiotic cover
Tetanus vaccination
Photograph wound
Remove gross debris
Dress in saline-soaked gauze
Debridement of wound and fracture site
Skeletal stabilisation
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9
Q

Define compartment syndrome

A

Critical pressure increase within a confined compartmental space

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10
Q

Pathophysiology of compartment syndrome

A

Fluid deposition in compartment -> intra-compartmental pressure
Increase in hydrostatic pressure
Compression of traversing nerves - paraesthesia
Arterial inflow compromised

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11
Q

Clinical features of compartment syndrome

A 
Usually present within hours
Severe pain
- disproportionate to injury
- worse by passively stretching muscle bellies of muscles
- not improved by analgesia
Parasthesia
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12
Q

Investigations for compartment syndrome

A

Diagnosis is clinical
Intra-compartmental pressure monitor
Creatine kinase

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13
Q

Management of compartment syndrome

A

Keep limb at neutral level
Improve oxygen delivery with high flow oxygen
Augment blood pressure with bolus of IV crystalloid fluids
Remove all dressings/splints/casts
Treat symptomatically
Surgical fasciotomy
Monitor renal function - rhabdomyolysis or reperfusion injury

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14
Q

Main causative organisms of septic arthritis

A

S.aureus
Streptococcus spp
Gonorrhoea
Salmonella

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15
Q

Risk factors for septic arthritis

A 
Age > 80yrs
Pre-exisiting joint disease
DM 
Immunosuppression
Chronic renal failure
Hip or knee joint prosthesis
IV drug use
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16
Q

Clinical features of septic arthritis

A

Single swollen joint causing severe pain
Pyrexia
Red, swollen warm joint that’s painful on active and passive movements

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17
Q

Investigations for septic arthritis

A

Routine bloods - FBC, CRP, ESR
Blood cultures
Joint aspiration
Plain radiograph

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18
Q

Management of septic arthritis

A

Empirical antibiotic treatment

Surgical irrigation and debridement

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19
Q

Complications of septic arthritis

A

Osteoarthritis

Osteomyelitis

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20
Q

Define osteomyelitis

A

Infection of bone

- caused by haematogenous spread, direct inoculation or direct spread from nearby infection

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21
Q

Common causative organisms of osteomyelitis

A 
S. aureus
Streptococci
Enterobacteur spp
H.influnzae
P.aeruginosa
Salmonella spp.
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22
Q

Risk factors for osteomyelitis

A

Diabetes mellitus
Immunosuppression
Alcohol excess
IV drug use

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23
Q

Clinical features of osteomyelitis

A

Severe pain
- constant
- worse at night
Low grade pyrexia

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24
Q

Investigations for osteomyelitis

A 
Routine bloods
Blood cultures
Plain film radiographs
- osteopaenia
- periosteal thickening
- endosteal scalloping
- focal cortical bone loss
Culture from bone biopsy at debridement
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25
Q

Management of osteomyelitis

A 
Long-term IV antibiotic therapy >4 weeks
Surgical management
- pt deteriorates
- evidence of deterioration
- progressive bone destruction
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26
Q

Complications of osteomyelitis

A

Overwhelming sepsis
Mortality
Growth disturbance in children
Chronic osteomyelitis

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27
Q

Name bone forming tumours

A 
Benign
- osteoma
- osteoid osteoma
- osteoblastoma
Malignant
- osteosarcoma
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28
Q

Name cartilage forming tumours

A 
Benign
- condroma
- osteochondroma
- chondroblastoma
Malignant
- chondrosarcoma
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29
Q

Name fibrous tissue tumours

A 
Benign
- fibroma
- fibromatosis
Malignant
- fibrosarcoma
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30
Q

Name giant-cell tumours

A

Benign
- benign osteoclastoma
Malignant
- malignant osteoclastoma

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31
Q

Name marrow tumours

A

Malignant

  • Ewing’s tumour
  • myeloma
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32
Q

Common primary sites for metastatic bone cancers

A 
Renal
Thyroid
Lung
Prostate
Breast
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33
Q

Common site of metastatic bone cancers

A

Spine

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34
Q

Management of metastatic bone cancer

A

Rarely surgical
Systemic therapies - often palliative
Prophylactic nailing of long bones - high risk of pathological fractures

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35
Q

Risk factors for primary bone cancer

A 
Genetic association
- RB1 and p53 - osteosarcomas
- TSC1 and TSC2 mutation - chondroma
Previous exposure to radiation of alkylating agents in chemotherapy
Benign bone condition
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36
Q

Clinical features of bone tumours

A

Pain

  • not associated with movement
  • worse at night
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37
Q

What is achilles tendonitis

A

Inflammation of calcaneal tendon
Repetative action -> microtears leading to localised inflammation
Can lead to tendon rupture

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38
Q

Risk factors for achilles tendonitis

A 
Unfit individual who has sudden increase in exercise frequency
Poor footwear choice
Male gender
Obesity
Recent fluoroquinoline use
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39
Q

What is an achilles tendon ruputure

A

Complete loss of function of ipsilateral calf muscle

- commonly occurs during athletic activity

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40
Q

Clinical features of achilles tendonitis

A

Gradual onset of pain and stiffness

  • worse with movement
  • improved with mild exercise of heat application
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41
Q

Clinical features of achilles tendon rupture

A

Sudden-onset severe pain in posterior calf
Audible popping sound
Loss of power of ankle plantarflexion

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42
Q

Describe Simmond’s Test

A

For Achilles tendon rupture

Squeeze affected calf - if rupture present foot won’t plantar flex

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43
Q

Management of achilles tendonitis

A 
Supportive measures
- stop precipitating exercise
- ice
- anti-inflammatory medication regularly
Chronic cases
- rehabilitation
- physiotherapy
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44
Q

Management of achilles tendon rupture

A

Analgesia and immobilisation
- ankle splinted in plaster in full equinus or moon boot with large heal raise insert
- after 2 weeks bring to semi-equinus
- after 4 weeks brought to neutral position and held for another 4 weeks
Delayed presentation or re-rupture requires surgical fixation - end to end tendon repair

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45
Q

Classification of ankle fractures

A

Type A = below syndesmosis
Type B = at syndesmosis
Type C = above syndesmosis

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46
Q

Ottawa Ankle Rules

A

Used when diagnostic uncertainty where patient is able to mobilise and no deformity
- bone tenderness at posterior edge/tip of lateral/medial malleolus
- inability to bear weight both immediately and in A&E for 4 steps
If any then plain radiograph taken

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47
Q

Immediate management of ankle fractures

A

Immediate fracture reduction

  • below knee back slab
  • plain film radiograph
  • neurovascular examination
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48
Q

When is conservative management of an ankle fracture suitable

A

Non-displaced medial malleolus fractures
Weber A or Weber B without talar shift
Those unfit for surgical intervention

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49
Q

When in surgical management of an ankle fracture suitable

A

Displaced bimalleolar or trimalleolar fractures
Weber C fractures
Weber B with talar shift
Open fractures

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50
Q

Describe ankle sprain

A 
Ligamentous injury
High ankle sprain
- injury to syndesmosis
Low ankle sprain
- injury to ATFL or CFL
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51
Q

Presentation of ankle fracture

A

Inversion injury on plantarflexed ankle
Significant swelling and pain
Fingertip tenderness to distal malleoli

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52
Q

Management of ankle sprain

A

Conservative

  • ice
  • analgesia
  • elevation
  • early mobilisation
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53
Q

Define hallux valgus

A

Medial deviation of first metatarsal and lateral deviation/rotation of hallus with associated joint subluxation

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54
Q

Risk factors for hallux valgus

A

Female
Connective tissue disorders
Hypermobility syndromes

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55
Q

Clinical features of hallux valgus

A

Painful medial prominence - aggrevated by

  • walking
  • weight-bearing
  • narrow toed shoes
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56
Q

Management of hallux valgus

A

Conservative
- analgeisa
- adjust footwear
- physiotherapy
Surgical
- chevron - remove V shape and shift laterally to normal alignment and pin - common for mild deformities
- scarf - longitudinal osteotomy made within shaft for distal portion to be moved laterally and fixed
- lapidus - base of 1st metatarsal and medial cuneiform fused
- keller - open joint capsule, remove diseased joint surfaces, joint stabilised by suturing of surrounding tissue and scar tissue - common when arthritis severe

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57
Q

Describe plantar fasciitis

A

Inflammation of plantar fascia

- micro-tears

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58
Q

Risk factors for planatar fasciitis

A 
Anatomical features 
- excessive pronation
- pes cavus (high arches)
Weak plantar flexors or tights gastrocnemius or soleus
Prolonged standing or excessive running
Leg length discrepancy
Obesity
Unsupportive footwear
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59
Q

Clinical features of plantar fasciitis

A

Sharp pain across plantar aspect of foot

  • worse at heel
  • radiate down arch
  • worse in first few steps
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60
Q

Management of plantar fasciitis

A

Activity moderation and regular analgesics
Physiotherapy
Corticosteriod injections
Plantar fasciotomy

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61
Q

Causes of talar fracture

A 
High-energy trauma
- fall from height
- RTC
Ankle forced in dorsiflexion
Commonly talar neck
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62
Q

Clinical features of talar fracture

A

Immediate pain and swelling
Clear deformity
Unable to dorsiflex or plantarflex ankle

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63
Q

Management of talar fracture

A

Undisplaced - conservative in weight-bearing orthosis

Displaced - immediate reduction and surgical repair

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64
Q

Complications of talar fracture

A

Avascular necrosis

Osteoarthritis

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65
Q

Stabilisers of the elbow joint

A 
Static 
- humeroulnar joint
- medial ligaments
- collateral ligaments
- radiocapetellar joint
- joint capsule
- extensor origin tendons
Dynamic
- surrounding musculature - anconeus, brachialis and triceps brachii
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66
Q

Clinical features of elbow dislocation

A

High energy fall
Painful and deformed joint
Swelling and decreased function
Sensory deficit in ulnar nerve

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67
Q

Management of elbow dislocation

A 
Closed reduction
- sufficient analgesia/sedation
- above elbow backslab to keep elbow at 90 degrees
Simple dislocation
- 5-14 days immobilisation 
- early rehabilitation
Complicated dislocation
- operative fixation - open reduction and internal fixation (ORIF)
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68
Q

Criteria for complicated elbow dislocation

A

Fracture present
Open injury
Neurovascular compromise

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69
Q

Complications of elbow dislocation

A

Early stiffness - loss of terminal extension
Stretching of ulnar nerve
Recurrent instability

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70
Q

Features of terrible triad

A

Elbow dislocation with

  • lateral collateral ligament injury
  • radial head fracture
  • coronoid fracture
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71
Q

Define epicondylitis

A

Chronic symptomatic inflammation of the forearm tendons at the elbow

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72
Q

Another term for lateral epicondylitis

A

Tennis elbow

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73
Q

Another term for medial epicondylitis

A

Golfer’s elbow

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74
Q

What attaches to lateral epicondyle

A

Common extensor tendon

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75
Q

What attaches to medial epicondyle

A

Pronator teres tendon

Flexor carpi radialis tendon

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76
Q

Risk factors for lateral epidcondylitis

A

Occupations and hobbies that are a/w excessive use of extensive forearm muscles

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77
Q

Clinical features of lateral epicondylitis

A

Pain

  • affects elbow
  • radiates down forearm
  • worsens over weeks-months
  • most often affects dominant arm
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78
Q

Management of lateral epicondylitis

A

Modify activities - reduce repetitive actions causing condition
Simple analgesics and topical NSAIDs
Corticosteriod injections
Physiotherapy
Refer to surgery if symptoms not controlled

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79
Q

Causes of olecranon bursitis

A

Repetitive flexion-extension movements -> irritation of bursa
Gout
RA
Infection through skin abrasion or puncture

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80
Q

Clinical features of olecranon bursitis

A

Pain and swelling over olecranon

ROM preserved

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81
Q

Investigations of olecranon bursitis

A 
Routine bloods - FBC and CRP
Serum urate levels
X-ray
Aspiration of fluid
- symptomatic
- microscopy and culture
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82
Q

Clinical features of olecranon fracture

A 
FOOSH
Elbow pain, swelling and lack of mobility
Bi-modal age distribution
- young = high energy injury
- old = low energy direct injury
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83
Q

Management of olecranon fracture

A 
Adequate analgesia
Non-operative
- immobilisation in 60-90 degrees
- early introduction of ROM at 1-2 weeks
Operative
- tension band wiring
- olecranon plating
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84
Q

Criteria for operative management of olecranon fracture

A

Displacement > 2mm

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85
Q

Complications of olecranon fracture

A

Loss of ROM
- elderly often non-operative management as loss no functional loss
High rate of removal of metalwork

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86
Q

Clinical features of radial fracture

A

FOOSH
Elbow pain
- on supination/pronation
Swelling and bruising at elbow

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87
Q

Management of radial head fracture

A 
Adequate analgesia
Non-operatively
- immobilisation with sling for less than 1 week 
- early mobilisation
Surgery
- ORIF
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88
Q

Peak incidence of supracondylar humeral fractures

A

5-7 years

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89
Q

Clinical features of supracondylar humeral fractures

A 
Recent fall or trauma - FOOSH
Sudden onset severe pain 
Reluctance to move arm
Gross deformity and swelling
Reduced ROM
Ecchymosis of anterior cubital fossa
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90
Q

Management of supracondylar fracutres

A

Conservative
- above elbow cast in 90 degrees flexion
Surgical
- closed reduction and percutaneous K-wire fixation
- open reduction with percuatneous pinning if open fracture

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91
Q

Complications of supracondylar fractures

A 
Nerve palsies
- anterior interosseous nerve
Malunion
- cubitus varus deformity - extended forearm deviates towards midline
Volkmann's contracture
- wrist/hand held in permanent flexion
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92
Q

Common causes of femoral shaft fracturs

A

High-energy trauma
Fragility fractures in elderly - low-energy
Pathological fractures
Bisphosphonate-related fractures

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93
Q

Clinical features of femoral shaft fractures

A

Pain in thigh, hip or knee
Unable to bear weight
Obvious deformity

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94
Q

Management of femoral shaft fractures

A 
Stabilise patient
Adequate analgesia
Immediate reduction and immobilisation
In-line traction
Surgically fixed if complicated
- antegrade intramedullary nail
- external fixation
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95
Q

Complications of a femoral shaft fracture

A 
Nerve or vascular injury
- pudendal or femoral nerve
Mal-union, delayed union or non-union
- risk increased with smoking and post op NSAIDs
Infection
Fat embolism
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96
Q

Clinical features of neck of femur fracture

A

Trauma - often low energy in elderly
Pain
- groin, thigh or referred to knee
Inability to bear weight

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97
Q

Investigations for neck of femur fracture

A 
X-ray
Routine bloods
- FBC
- U&Es
- Group and save
- creatinine kinase - rhabdomyolysis
Urine dip
Chest x-ray
ECG
98
Q

Management of neck of femur fracture

A 
Displaced subcapital
- hip hemiarthroplasty
Inter-trochanteric and basocervical 
- dynamic hip screw
Non-displaced intra-capsular 
- cannulated hip screws
Sub-trochanteric
- intramedullary femoral nail
99
Q

Post operative complications of NOF patients

A 
Immediate
- pain
- bleeding
- leg-length discrepancies
- neurovascular damage
Long-term
- joint dislocation
- aseptic loosening
- peri-prosthetic fracture
- deep infection/prosthetic joint infection
100
Q

Define osteoarthritis

A

Degenerative joint disease

Characterised by loss of articular cartilage

101
Q

Risk factors for OA of the hip

A 
Systemic
- increasing age - > 45 years
- obestiy
- female gender
- genetic factors
- vitamin D deficiency
Local
- history of trauma
- anatomic abnormalities
- muscle weakness
- joint laxity
- participation in high impact sports
102
Q

Clinical features of OA of the hip

A 
Pain
- felt in groin
- aggrevated by weight-bearing
- improved on rest
Stiffness
- improves with mobility
- associated grinding or crunching
Antalgic gait
Pain on passive movement
Reduced ROM
Flexed flexion deformity and Trendelenburg gait
103
Q

Signs of OA on x-ray

A

Loss of joint space
Subchondral sclerosis
Bony cysts
Osteophytes

104
Q

Management of OA of the hip

A 
Pain control
- WHO analgesic ladder
Lifestyle modification
- weight loss
- regular exercise
- smoking cessation
Physiotherapy - slows disease progression and improves joint mechanics
Total hip replacement
105
Q

Complications of hip replacement

A 
Revision hip arthroplasty - prosthesis designed for 15-20 years
Thromboembolic disease
Bleeding
Dislocation
Infection
Loosening of prosthesis
Leg length discrepancy
106
Q

Aetiology of ACL tear

A

History of twisting knee whilst weight bearing

  • usually athletes
  • without contact
  • landing from jumpt
107
Q

Clinical features of an ACL tear

A

Rapid joint swelling and significant pain

Lachman’s and anterior drawer test

108
Q

Investigations for ACL tear

A

X-ray

MRI scan of knee

109
Q

Managment of ACL tear

A 
RICE
Conservative
- rehabilitation - strengthen quadriceps to stabilise knee
Surgical
- tendon or artificial graft
110
Q

Complications of an ACL tear

A

Post-traumatic osteoarthritis

111
Q

Clinical features of PCL tear

A

High-energy trauma
Posterior knee pain
Instability of the joint
Positive posterior drawer test

112
Q

Management of PCL

A

Conservatively
- knee brace
- physiotherapy
Surgery

113
Q

Define iliotibial band syndrome

A

Inflammation of iliotibial band - longitudinal fibres form shared aponeurosis of tensor fasicae latae and gluteus maximus

114
Q

Risk factyors of ITBS

A 
Regular exercise - repetitive flexion and extension of the knee 
- weightlifters, runners, cyclists
Anatomical
- genu varum
- excessive internal tibial torsion
- foot pronation
- hip abductor weakness
115
Q

Clinical features of ITBS syndrome

A

Lateral knee pain

- exacerbated by exercise

116
Q

Management of ITBS syndrome

A 
Modify activity
Regular simple analgesics
Local steriod injections
Physiotherapy
Surgical release of iliotibial band
117
Q

Grades of MCL tear

A 
1 - mild injury
- minimally torn fibres
- no loss of MCL integrity
2 - moderate injury
- incomplete tear
- increased laxity of MCL
3 - severe injury
- complete tear
- gross laxity of MCL
118
Q

Clinical features of MCL tear

A

Trauma to lateral aspect of knee
Immediate medial joint pain
Swelling
Increased laxity of MCL - valgus stress test

119
Q

Investigations of MCL tear

A

X-ray

MRI

120
Q

Management of MCL tear

A 
Grade I
- RICE
- analgesia 
- strength training - full exercise in 6 weeks
Grade II
- analgesia
- knee brace
- weight-bearing/strength training - full exercise in 10 weeks
Grade III
- analgesia
- knee brace and crutches
- surgery if distal avulsion
- full exercise in 12 weeks
121
Q

Complications of MCL tear

A

Instability of joint

Damage to saphenous nerve

122
Q

PAthophysiology of meniscal tears

A 
Trauma or degernerative disease
- twisted knee
Different types of tear
- longitudinal - most common
- degenerative
- vertical
- transverse
123
Q

Clinical features of meniscal tears

A 
Tearing sensation
Intense sudden onset pain
Swellig
Locked in flexion
Tenderness
Significant joint effusion
Limited knee flexion
124
Q

Investigations of meniscal tears

A

X-ray

MRI

125
Q

Management of meniscal tears

A

RICE
Arthroscopic surgery for large tears
- surture
- trimmed

126
Q

Complications of meniscal tears

A

OA
Knee arthroscopy risks
- DVT
- damage to local structures

127
Q

Clinical features of tibial plateau fractures

A 
History of trauma
- axial loading
- high-impact injury
Sudden onset pain
Unable to weight-bear
Swelling of knee
Ligament instability
128
Q

Investigations of tibial plateau fractures

A 
X-ray
- lipohaemarthrosis
CT 
- assess severity
- surgical planning
129
Q

Management of tibial plateau fractures

A 
Non-operative
- hinged knee brace
- non/partial weight-bearing for 8-12 weeks
- physiotherapy
- suitable analgesia
Operative
- ORIF
- hinged knee brace
- non/partial weight-bearing for 8-12 weeks
- physiotherapy
130
Q

Causes of adhesive capsulitis

A 
Primary
- idoipathic
Secondary
- rotator cuff tendinopathy
- subacromial imingement syndrome
- biceps tendinopathy
- previous surgical intervention or trauma
- inflammatory conditions
- diabetes mellitus
131
Q

Stages of adhesive capsulitis

A

Initial painful stage
Freezing stage
Thawing stage

132
Q

Clinical features of adhesive capsulitis

A

Generalised deep and constant pain of shoulder
- often disturbs sleep
Stiffness
Reduced function

133
Q

Investigations for adhesive capsulitis

A

Usually clinical diagnosis
X-ray unremarkable
MRI imaging
- thickening of glenohumeral joint capsule

134
Q

Management of adhesive capsulitis

A 
Self-limiting condition
Education and reassurance
- physiotherapy
- shoulder exercises
Management of pain
- paracetamol and NSAIDs
- steriod injections and oral corticosteriods
Surgical intervention
- if no improvement after 3 months
- joint manipulation under GA to remove capsular adhesions to humerus
- arthographic distension
- surgical release of glenohumeral joint capsule
135
Q

Complications of adhesive capsulitis

A

Proportion of patients will never regain full ROM
- regain movement beyond that required to perform activities of daily living
Symptoms persist beyond 2 years
Recur in contralateral shoulder

136
Q

Define biceps tendinopathy

A

Pathological change - typically due to overuse

- painful, swollen and structurally weaker tendon that is at risk of rupture

137
Q

Aetiology of biceps tendinopathy

A

Occurs in both proximal and distal biceps tendon
Younger individuals
- sports with repetitive flexion movements - tennis, cricket
Older individuals
- degenerative

138
Q

Clinical features of biceps tendinopathy

A 
Pain
- worsened by stressing tendon
- weakness - flexion and supination
- stiffness
Disuse atrophy
139
Q

Investigations for biceps tendinopathy

A

Clinical
Blood tests and X-ray to rule out other differentials
USS - thickened tendons
MRI

140
Q

Management of biceps tendinopathy

A 
Conservative
- analgesia
- ice therapy
- physiotherapy
- USS steriod injections
Surgical
- arthroscopic tenodesis
- tenotomy
141
Q

Describe biceps tendon rupture

A

Complete or partial

Sudden forced extension of flexed elbow

142
Q

Risk factors for biceps tendon rupture

A 
Biceps tendinopathy
Steriod use
Smoking
Chronic kidney disease
Fluoroquinolone antibiotics
143
Q

Clinical features of biceps tendon rupture

A

Sudden onset pain and weakness
- pop feeling
Marked swelling and bruising in antecubital fossa
Reverse Popeye sign
- buldge in arm as proximal belly retracts

144
Q

Management of biceps tendon rupture

A 
Conservative - lower demand patients
- analgesia
- physiotherapy
Surgical
- occur within a few weeks
145
Q

Classification of clavicle fractures

A 
Type 1 - most common
- middle third
Type 2
- lateral third
Type 3
- medial third
146
Q

Pathophysiology of a clavicle fracture

A 
Direct or indirect trauma
Medial fragment -> superiorly
- pull of SCM
Lateral fragment -> inferiorly
- weight of arm
147
Q

Managment of clavicle fracture

A

Conservatively
- sling - support elbow and improve deformity
- early movement of shoulder - prevent frozen shoulder
Surgical
- open fractures
- comminuted fractures or shortened
- ORIF 2-3 months post injury if fail to unite

148
Q

Clinical features of humeral shaft fractures

A

Pain and deformity
Falling onto outstreached limb or laterally onto adducted limb
If radial nerve involved
- reduced sensation of dorsal 1st webspace
- weakness in wrist extension

149
Q

Management of humeral shaft fractures

A 
Re-alignment of the limb
Conservative
- humeral brace
Surgical
- ORIF
- intramedullary nails if pathological fractures, polytrauma or severely osteoporotic bones
150
Q

Complications of humeral shaft fractures

A

Non-union
Mal-union
Varus angulation - transverse fractures
Radial nerve injury

151
Q

Classification of rotator cuff tears

A

Acute - < 3 months
Chronic - > 3 months
Partial or full thickness

152
Q

Name the rotator cuff muscles and their function

A

Supraspinatus - abduction
Infraspinatus - external rotation
Subscapularis - internal rotation
Teres minor - external rotation

153
Q

Risk factors for rotator cuff tears

A 
Age
Trauma
Overuse
Repetitive overhead shoulder movements
Overweight
Smoking
Diabetes mellitus
154
Q

Clinical features of rotator cuff tears

A

Pail over lateral aspect of shoulder
Inability to abduct arm above 90 degrees
Tenderness over greater tuberosity and subacromial bursa region
Supra and infraspinatus atrophy

155
Q

Investigations for rotator cuff tears

A 
X-ray
- unremarkable
- exclude fracture
USS 
- presence and size
MRI
- size, characteristics and location
156
Q

Managment of rotator cuff tears

A 
Conservative
- present within 2 weeks injury
- analgesia
- physiotherapy
- corticosteriod injections
Surgical
- present after 2 weeks post injury or remain symptomatic
- large tears
- arthroscopically or open approach
157
Q

Complications of a rotator cuff tear

A

Adhesive capsulitis

Enlargement of tear

158
Q

Types of shoulder dislocation

A

Anterior
- force applied to extended, abducted externally rotated humerus
Posterior
- seizures or electrocution
- direct blow to anterior shoulder or force through flexed adducted arm

159
Q

Clinical features of shoulder dislocation

A

Painful shoulder
Reduced mobility
Feeling instable
Loss of shoulder contours and anterior buldge

160
Q

Associated injuries of a shoulder dislocation

A

Bony Bankart lesion
- fracture of anterior inferior glenoid bone
- common in recurrent dislocations
Hill-Sachs defects
- impaction injuries on the chondral surface of posterior and superior portions of the humeral head
Fractures of greater tuberosity and surgical neck of humerus
Soft Bankart lesion
- avulsions of anterior labrum and inferior glenohumeral ligament
Glenohumeral ligament avulsion
Rotator cuff injuries

161
Q

Investigations for shoulder dislocation

A 
X-ray
- anterior-posterior, Y-scapular and axial views
Anterior dislocations
- AP view - head out of glenoid fossa
Posterior dislocation
- light bulb sign
162
Q

Management of shoulder dislocation

A

Appropriate analgesia
Reduction, immobilisation and rehabilitation
Broad-arm sling - typically 2 weeks
Physiotherapy

163
Q

Complications of shoulder dislocation

A 
Chronic pain
Limited mobility
Stiffness
Recurrence
Adhesive capsulitis
Nerve damage
Rotator cuff injury
Degenerative joint disease
164
Q

Define subacromial impingement syndrome

A

Inflammation and irritation of the rotator cuff tendons as they pass through the subacromial space

165
Q

Pathophysiology of impingement syndrome

A 
Intrinic mechanisms
- rotator cuff muscle weakness - humerus shifts proximally towards body
- overuse of shoulder - repetitive microtrauma
- degenerative tendinopathy
Extrinsic mechanisms
- anatomic features
- scapular musculature
- glenohumeral instability
166
Q

Clinical features of SAIS

A

Progressive pain in anterior superior shoulder
- exacerbated by abduction
Elicited by Neers Impingement or Hawkins test

167
Q

Differential diagnosis of SAIS

A

Muscular tear
Neurological pain
Frozen shoulder syndrome
Acromioclavicular pathology

168
Q

Management of SAIS

A 
Conservative
- analgesia - NSAIDs
- regular physiotherapy
- corticosteriod injecitons
Surgical
- 3 months without response
169
Q

Complications of SIAS

A

Rotator cuff degeneration or tear
Adhesive capsulitis
Cuff tear arthropathy
Complex regional pain syndrome

170
Q

Differential diagnosis of rotator cuff tear

A

Fracture
Persistent glenohumeral subluxation
Brachial plexus injury
Radiculopathy

171
Q

Differential diagnosis of clavicle fracture

A

Sternoclavicular dislocation

ACJ seperation

172
Q

Differential diagnosis of biceps tendinopathy

A

Inflammatory arthropathy
Radiculopathy
OA
Rotator cuff disease

173
Q

Differential diagnosis of adhesive capsulitis

A 
Acromioclavicular pathology
- injury
- arthritis
Subacromial impingement syndrome
Muscular tear
Autoimmune disease
174
Q

Differential diagnosis of achilles tendonitis

A

Ankle sprain
Stress fracture
OA

175
Q

Differential diagnosis of hallux valgus

A 
Gout
Septic arthritis
Hallux rigidus
OA
RA
176
Q

Differential diagnosis of plantar fasciitis

A

Achilles tendonitis
Morton neuroma
Calcaneal stress fracture
Inflammatory artropathy

177
Q

Differential diagnosis of lateral epicondylitis

A

Cervical radiculopathy
Elbow osteoarthrits
Radial carpal tunnel syndrome

178
Q

Differential diagnosis of olecranon bursitis

A

Inflammatory arthropathies
Gout
Cellulitis
Septic arthritis

179
Q

Differential diagnosis of OA of the hip

A

Trochanteric bursitis
Gluteus medius tendinopathy
Sciatica
Femoral neck fracture

180
Q

Differential diagnosis of ACL tear

A

Fracture
Meniscal tear
Collateral ligament tear
Quadriceps or patellar ligament tear

181
Q

Differential diagnosis for swollen knee following trauma

A

Fracture
Cruciate ligament tear
Collateral ligament tear
Osteochondritis dissecans

182
Q

Describe cauda equina syndrome

A

Surgical emergency

Caused by compression of the cauda equina

183
Q

Causes of cauda equina syndrome

A

Disc herniation - L5/S1 and L4/L5
Trauma - vertebra fracture and subluxation
Neoplasm
Infection
Chronic spinal inflammation - ankylosing spondylitis
Iatrogenic

184
Q

Clinical features of cauda equina

A 
Saddle anaesthesia
Bilateral sciatica
Painless urinary retention
Urinary and faecal incontinence
Erectile dysfunction
185
Q

Consequences of untreated cauda equina syndrome

A

Chronic neuropathic pain
Impotence
Perform intermittent self-catheterisation
Faecal incontinence requiring manual evacuation
Loss of sensation
Lower limb weakness -> wheelchair

186
Q

Differential diagnosis of cauda equina syndrome

A

Radiculopathy
- radiating back pain
- no faecal, urinary or sexual dysfunction
Cord compression
- characterised by upper motor neurone signs

187
Q

Investigations for cauda equina syndrome

A

Whole spine MRI

188
Q

Management of cauda equina syndrome

A

Early neurosurgical review for urgent decompression
High dose steriods - dexamethasone
Surgical decompression

189
Q

Define radiculopathy

A

Conduction block in the axons of a spinal nerve or its roots

- causing weakness and paresthesia/anaesthesia

190
Q

Define radicular pain

A

Pain deriving from damage or irritation of the spinal nerve tissue
- particularly dorsal root ganglion

191
Q

Causes of radiculopathy

A 
Intervertbral disc prolapse
- repeated minor stresses 
Degenerative diseases
- neuroforaminal or spina canal stenosis
Fracture
Malignancy
Infection
192
Q

Clinical features of radiculopathy

A

Pareasthesia and numbess
Weakness
Radicular pain - burning, deep, strap-like pain

193
Q

Red flag symptoms to identify causes of radiculopathy

A 
Cauda equina syndrome
- faecal incontinence
- painless urinary retention
- saddle anaesthesia
Infection
- immunosuppression
- IV drug user
- unexplained fever
Fracture
- chronic steriod use
- significant trauma
- osteoporosis
Malignancy
- new onset after 
Metastatic disease
- history of malignancy
194
Q

Differential diagnosis of radiculopathy

A 
Referred pain
Myofascial pain
Thoracic outlet syndrome
Greater trochanteric bursitis
Iliotibial band syndrome
Meralgia paraesthetica
Piriformis syndrome
195
Q

Management of radiculopathy

A 
Depends on underlying cause
Symptomatic management
- analgesia - WHO ladder 
- neuropathic pain medications - Amitriptyline
- physiotherapy
196
Q

Causes of spinal cord compression

A 
Neoplastic
- metastatic from thyroid, lung, breast, renal, prostate
- primary bone tumours
- haematological - myeloma
Traumatic
- vertebral fracture
- facet joint dislocation
Infective
Disc prolapse
197
Q

Clinical features of spinal cord compression

A 
Sensation and proprioception impaired
Pain
Weakness
Presence of upper motor neurone signs
- hypertonia
- hyperreflexia
- clonus
198
Q

Differential diagnosis of spinal nerve compression

A 
Lumbago
- pain in lumbar region with no radiation
Sciatica
- radiates to buttocks/lower limb
Cauda equina
- lower motor neurone signs
199
Q

Investigations for spinal cord compression

A

MRI of whole spine

200
Q

Management of spinal cord compression

A

High dose corticosteriods
- PPI for gastric protection
Surgical decompression

201
Q

What is carpal tunnel sydrome

A

Compression of median nerve within the carpal tunnel of the wrist

202
Q

Risk factors for carpal tunnel syndrome

A 
Female gender
Age
Pregnancy
Obesity
Previous injury
Repetitive hand or wrist movements
203
Q

Clinical features of carpal tunnel syndrome

A 
Throughout distribution of median nerve - thumb and radial 2.5 fingers
- Pain
- Numbness
-Paraesthesia
- palm usually spared due to palmar cutaneous branch
Worse at night
Later stages
- weakness of thumb abduction
- wasting of thenar eminence
204
Q

Differential diagnosis for carpal tunnel syndrome

A

Cervical radiculopathy
Pronator teres syndrome
Flexor carpi radialis tenosynovitis

205
Q

Investigations for carpal tunnel syndrome

A

Clinical diagnosis

  • Tinel’s test
  • Phalen’s test
206
Q

Management of carpal tunnel syndrome

A 
Conservatively
- wrist splint
Medically
- corticosteriod injections
Surgical
- carpal tunnel release surgery - cut through flexor retinaculum
207
Q

Complications of carpal tunnel surgery

A 
Persistent CTS symptoms - incomplete ligament release
Infection
Scar formation
Nerve damage
Trigger thumb
208
Q

Complications of carpal tunnel syndrome

A

Permanent neurological impairment

209
Q

What is De Quervain’s tenosynovitis

A

Inflammation of the tendons within the first extensor compartment of the wrist -> pain and swelling

210
Q

Risk factors forDe Quervain’s tenosynovitis

A

Age - 30-50
Female
Pregnancy

211
Q

Clinical features of De Quervain’s tenosynovitis

A

Pain near base of thumb

Associated swelling

212
Q

Differential diagnosis for De Quervain’s tenosynovitis

A

Arthritis of carpometacarpal joint
Intersection syndrome
Wartenber’s syndrome

213
Q

Management of De Quervain’s tenosynovitis

A 
Conservative
- lifestyle modification - avoid repetitive actions
- wrist splint
Medically
- steriod injections
Surgically
- surgical decompression
214
Q

Pathophysiology of distal radius fracture

A

FOOSH

Increase with age - osteoporosis

215
Q

Classification of distal radius fractures

A 
Colles'
- dorsal displacement of distal fragment
Smiths'
- volar displacement of distal fragment
Barton's
- intra-articular fracture
216
Q

Risk factors for distal radius fractures

A 
Increasing age
Female
Early menopause
Smoking
Alcohol excess
Prolonged steroid use
217
Q

Clinical features of distal radial fractures

A

Episode of trauma
Immediate pain +/- deformity
Swelling

218
Q

Differential diagnosis of distal radial fractures

A

Forearm fracture
Carpal bone fractures
Tendonitis or tenosynovitis
Wrist dislocation

219
Q

Investigations for distal radial fractures

A

Wrist plain radiograph

  • radial height < 11mm
  • radial inclination < 22 degrees
  • radial volar tilt > 11 degrees
220
Q

Management of distal radial fracture

A

Closed reduction
Below elbow backslab - repeat radiographs after 1 week
Surgical intervention in significantly displaces or unstable
- ORIF
- K-wire fixation
- external fixation

221
Q

Complications of distal radial fracture

A

Malunion
Median nerve compression
OA

222
Q

Define Dupuytren’s contracture

A

Contraction of longitudinal palmar fascia
Painless nodule -> fibrous cords -> flexion contractures
- limits digital movement

223
Q

Risk factors for Dupuytren’s contracture

A 
Smoking
Alcoholic liver disease
Cirrhosis
Diabetes mellitus
Occupational exposures
- vibration tools or heavy manual work
224
Q

Clinical features of Dupuytren’s contracture

A

Reduced ROM
Nodular deformity
Complete loss of movement

225
Q

Management of Dupuytren’s contracture

A 
Conservative
- hand therapy
Medical
- injectable collagenase clostridum histolyticum
Surgical
- excision of disease fascia
226
Q

Define ganglionic cysts

A

Non-cancerous soft tissue lumps that occur along any joint or tendon
Arise from degeneration within joint capsule/tendon sheath
Filled with synovial fluid

227
Q

Risk factors for ganglionic cysts

A

Female
OA
Previous joint or tendon injury

228
Q

Clinical features of ganglionic cysts

A

Smooth spherical painless lump adjacent to affected joint

Soft and able to transilluminate

229
Q

Differential diagnosis for ganglionic cysts

A 
Tenosynovitis
Giant cell tumour of tendon sheath
Lipoma
OA
Sarcoma
230
Q

Management of ganglionic cysts

A

Monitor - most disappear spontaneously
If causes pain or reduced ROM
- aspiration
- cyst excision

231
Q

Clinical features of scaphoid fracture

A

Following trauma - high energy
Sudden onset pain and bruising
Tenderness on floor of anatomic snuffbox

232
Q

Investigations for scaphoid fracture

A

Plain radiograph - scaphoid series
Wrist immobilisation and repeat radiographs
MRI scan of wrist

233
Q

Management of scaphoid fracture

A 
Undisplaced
- strict immobilisation
Displaced
- surgical
- percutaneous variable pitched screw
234
Q

Complications of scaphoid fractures

A 
Avascular necrosis
- risk increases the more proximal the fracture
Non-union
- most commonly due to poor blood supply
- internal fixation and bone grafts
235
Q

Define trigger finger

A

Finger or thumb click or lock when in flexion - preventing return to extension

236
Q

Pathophysiology of trigger finger

A

Flexor tenosynovitis - repetitive movements leading to inflammation of tendon and sheath
Nodal formation

237
Q

Risk factors for trigger finger

A 
Prolonged gripping or use of hand
RA
DM
Female
Age
238
Q

Clinical features of trigger finger

A

Painless clicking/snapping/catching when trying to extend finger
May become painful over time

239
Q

Differential diagnosis of trigger finger

A

Dupuytren’s contracture
Acromegaly
Infection
Ganglion

240
Q

Management of trigger finger

A 
Conservative
- avoid painful activities
- small splint at night
Medical
- steroid injections
Surgical
- percutaneous trigger finger release

Yr3 - General Surgery (17 decks)

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