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Year 5 > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

What 5 things should be covered in the ‘look’ section of REMS hand and wrist?

A 
Skin/nail changes
Muscle wasting
Swelling 
Joint deformity 
Scars
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2
Q

What is a swan neck deformity?

A

PIP hyperextension

DIP flexion

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3
Q

What is a boutonniere deformity?

A

PIP flexion

DIP hyperextension

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4
Q

How is sensation tested in REMS hand and wrist?

A

Radial - web space
Median - thenar eminence
Ulnar - little finger

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5
Q

What nerves are responsible for thumb abduction, wrist extension and finger abduction?

A

Thumb abduction - median
Wrist extension - radial
Finger abduction - ulnar

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6
Q

What is the most important thing to consider when assessing a fracture?

A

Soft tissue injury

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7
Q

What investigation is best for assessing intra-articular fractures?

A

CT

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8
Q

What 7 things are involved in fracture assessment?

A 
Soft tissue injury 
Location 
Configuration
Displacement 
Stability 
Open fractures
Intra-articular fractures
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9
Q

What are the 9 types of fracture configuration?

A 
Transverse
Oblique
Spiral 
Comminuted 
Segmental
Avulsion
Compression
Torus/buckle
Greenstick
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10
Q

What is meant by the angulation of a fracture?

A

Position of distal relative to proximal

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11
Q

What is meant by the translation of a fracture?

A

Medio-lateral/antero-posterior position

Expressed in percentage

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12
Q

Describe the Gustilo-Anderson grading for open fractures

A

Grade I - <1cm, mild contamination
Grade II - 1-10cm, moderate contamination
Grade IIIA - minimal periosteal stripping
Grade IIIB - significant periosteal stripping
Grade IIIC - associated vascular injury

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13
Q

What are the risks of an intra-articular fracture?

A

Pain
Stiffness
Post-traumatic OA

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14
Q

Give 4 types of conservative immobilisation

A

Cast
Splint
Sling
Traction

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15
Q

Give 4 types of surgical immobilisation

A

Smooth wires
Intramedullary nail
Plates and screws
External fixator

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16
Q

How can malunion be managed?

A

Osteotomy and refixation

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17
Q

What are the types and causes of non-union?

A

Atrophic - smoking, malnutrition, immunocompromised

Hypertrophic - immobilisation

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18
Q

What are the 3 main principles of fracture management?

A

Reduce
Retain
Rehabilitate

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19
Q

What is the difference in management between an intracapsular and extracapsular hip fracture?

A

Intracapsular - blood supply likely disrupted; needs replacement
Extracapsular - blood supply likely preserved; can be fixed with dynamic hip screw

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20
Q

What are the complications of a hip fracture/replacement?

A

Mortality (10% at 1 month, 30% at 1 year)
DVT
Chest infection
Dislocation of femoral head

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21
Q

What are the main concerns with a high energy pelvic fracture?

A

Damage to pelvic structures/organs

Damage to major blood vessels causing internal bleeding

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22
Q

How is a high energy pelvic fracture managed?

A

ATLS
Immobilisation - pelvic binder
Fixation - plates and screws

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23
Q

How is a low energy pelvic fracture managed?

A

Conservatively - usually heal spontaneously

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24
Q

What fracture is associated with hip dislocation?

A

Acetabular

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25
Q

What are the risks of hip dislocation?

A

Nerve damage - sciatic nerve
AVN
Post-traumatic arthritis
Recurrence (if artificial)

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26
Q

What artery is at risk of damage in knee dislocation?

A

Popliteal artery

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27
Q

How is a knee dislocation managed?

A

Reduce and splint
Angiogram
Ligamental reconstruction

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28
Q

What is the main concern with a femur fracture?

A

Massive haemorrhage causing hypovolaemic shock

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29
Q

How is a femur fracture managed?

A

Thomas-type splint

Intramedullary nail

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30
Q

What is the significance of the syndesmosis between the distal tibia and fibula in ankle fracture?

A

Determines management via Weber classification

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31
Q

What should be checked in an ankle fracture and why?

A

Subluxation/dislocation - needs to be reduced and splinted if present; soft tissue and articular surface can be damaged otherwise

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32
Q

What is a Lisfranc fracture?

A

Dislocation of midfoot between tarsal bones and base of metatarsals
Pitfall of foot fractures which is commonly missed but needs reduction and fixation

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33
Q

What are the causes of secondary OA in the hip?

A 
Trauma 
Infection 
AVN
DDH
SUFE
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34
Q

Give 3 features of OA of the hip elicited from examination

A 
Pain in buttock/groin/thigh/knee
Antalgic/Trendelenberg gait
Reduced ROM (internal rotation)
Contractures
\+ve Thomas's test
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35
Q

What are the radiological features of OA?

A

Joint space narrowing
Subchondral sclerosis
Subchondral cysts
Osteophyte formation

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36
Q

What are the management options for OA of the hip?

A

Conservative - weight loss, walking stick, NSAIDs, PT

Surgical - hip arthroplasty

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37
Q

Which side of the knee is more frequently affected in OA?

A

Medial

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38
Q

Give 3 features of OA of the knee elicited from examination

A 
Pinpoint pain, particularly when climbing stairs
Varus malalignment 
Effusion in supra-patellar pouch
Contractures 
Reduced ROM
Crepitus on movement
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39
Q

How is OA of the knee managed surgically?

A

Tibial osteotomy
Unicompartmental joint replacement
Total knee replacement

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40
Q

What is a tibial osteotomy?

A

Removal of a wedge of bone from the lateral side of the tibia to allow redistribution of load across knee joint and away from damaged medial side

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41
Q

What are the traumatic and non-traumatic causes of hip AVN?

A

Traumatic - femoral head/neck fracture, hip dislocation, SUFE
Non-traumatic - alcohol abuse, steroids, irradiation, haematological disease, decompression sickness, hyper-coaguable state, CTD, viral, idiopathic

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42
Q

By what mechanism do traumatic and non-traumatic AVN occur?

A

Traumatic - ischaemia

Non-traumatic - intra-vascular coagulation

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43
Q

What classification system is used for hip AVN?

A 
Ficat classification 
1 - minor osteopenia
2 - sclerosis and cysts
3 - loss of round shape
4 - secondary OA
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44
Q

Give 3 signs/symptoms of hip AVN

A

Insidious onset buttock/groin/hip/thigh pain
Limping patient
Stiff joint

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45
Q

What imaging is used for hip AVN in early and advanced disease?

A

X-ray - advanced disease

MRI - early disease

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46
Q

How is hip AVN managed?

A

Conservative - symptom control, bisphosphonates

Surgical - core decompression +/- bone grafting, rotational osteotomy, total hip resurfacing, total hip replacement

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47
Q

Why would a core decompression +/- bone grafting be performed for hip AVN?

A

Revacularisation of bone

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48
Q

What is a SUFE?

A

Slipped upper femoral epiphysis - fracture through the capital femoral physis, causing the epiphysis to ‘slip’ posteriorly and inferiorly

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49
Q

Who is most likely to present with SUFE?

A

10-16 year olds (rapid growth)
Males
African Americans
Obese

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50
Q

How does SUFE present?

A

Acute or insidious

Limp and groin pain (may be referred to thigh/knee)

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51
Q

Give 3 features of SUFE elicited on examination

A

Limp
Externally rotated and shortened leg
Tenderness
Reduced ROM

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52
Q

How is the stability of a SUFE judged?

A

Stable if able to weight bear

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53
Q

What 2 views are essential for SUFE x-ray?

A

AP

Frog leg lateral

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54
Q

What features of SUFE are seen on a frog leg lateral x-ray?

A

Disrupted Shenton’s line
Steel sign
Apparent widening of physis and decreased epiphysis height
Prominent lesser trochanter (external rotation)
Klein’s line fails to intersect lateral superior femur

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55
Q

What is Steel sign?

A

Additional shadow behind superior femoral neck

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56
Q

What is Klein’s line?

A

Line drawn along the superior edge of the femoral neck

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57
Q

What is DDH?

A

Developmental dysplasia of the hip - abnormal development of the hip resulting in shallow underdeveloped acetabulum +/- subluxation and hip dislocation

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58
Q

Give 3 risk factors for DDH

A 
Female
First born 
Left hip 
Breech position 
FH 
Other MSK abnormalities
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59
Q

How is DDH identified and managed in neonate to 3 months?

A

Identified - deep thigh creases, +ve Ortolani test, +ve Barlow test, reduced abduction, hip USS
Managed - splint in abduction and flexion using Pavlik harness

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60
Q

How is DDH identified and managed from 3-18 months?

A

Identified - leg length discrepancy, limited abduction, x-ray from 6 months
Managed - closed/open reduction under anaesthesia and immobilisation in spica cast for 3 months

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61
Q

How is DDH identified and managed from 1 year to walking age?

A

Identified - difficulty walking, lumbar lordosis, Trendelenberg gait, toe-walking
Managed - reduction and spica cast for 3 months +/- femoral/acetabular osteotomy

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62
Q

How is DDH identified and managed in later childhood/adolescence?

A

Identified - leg length discrepancy, large ROM, early OA on x-ray
Managed - osteotomy, total hip replacement if OA

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63
Q

What makes up the extensor mechanism of the leg and what is its function?

A

Quadriceps tendon, patella and patellar tendon

Allows extension of the leg at the knee joint

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64
Q

What patient type is likely to rupture their quadriceps tendon?

A

Elderly male with pre-existing tendinopathy

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65
Q

Give 3 signs/symptoms of quadriceps tendon rupture

A 
Pain 
Bruising 
Swelling 
Tenderness 
Inability to extend knee against resistance 
Inability to SLR (total)
Effusion
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66
Q

What is seen on x-ray of a quadriceps tendon rupture?

A 
Effusion 
Patella baja (low lying patella)
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67
Q

What patient type is likely to rupture their patellar tendon?

A

Young males

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68
Q

Give 3 signs/symptoms of patellar tendon rupture

A 
Infra-patellar pain
Popping sensation at time of incident 
Elevated patella with haemarthrosis
Tenderness
Inability to SLR or extend knee (total)
Reduced ROM 
Difficulty weight bearing
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69
Q

What is seen on x-ray of a patellar tendon rupture?

A

Proximal migration of patella (patella alta)

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70
Q

How is a quadriceps tendon rupture managed?

A

Open repair with cast/splint in extension

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71
Q

How is a patellar tendon rupture managed?

A

Conservative for partial = immobilisation in extension with PT
Surgical for complete - open repair

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72
Q

Give 3 risk factors for quadriceps and patellar tendon rupture

A

Previous tendon rupture
Corticosteroid injections
Steroid use
Co-morbidities (SLE, RA, diabetes)

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73
Q

What is the commonest mechanism of injury for a meniscal tear?

A

Twisting the knee while weight bearing

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74
Q

What are the signs/symptoms of a meniscal tear?

A 
Pain 
Instability (stairs)
Swelling 
Tenderness 
Reduced ROM
Locking 
\+ve McMurray's test
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75
Q

What is McMurray’s test?

A

Compressing and twisting knee joint reproduces pain (meniscal tears)

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76
Q

What imaging is most useful for meniscal tears?

A

MRI

Diagnostic arthroscopy

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77
Q

Injury to which ligament in the knee makes up 75% of haemarthroses caused by sport?

A

ACL

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78
Q

What other structures are likely to be injured in an ACL tear?

A

Medial meniscus

Medial collateral ligament

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79
Q

What is the mechanism of injury of an ACL tear?

A

Forced flexion or hyperflexion, twisting injury or direct blow behind upper tibia

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80
Q

What are the signs/symptoms of an ACL tear?

A 
Snapping sound/sensation 
Large rapid haemarthrosis
Tenderness
\+ve anterior drawer test 
\+ve Lachman's test
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81
Q

Give 3 complications of ACL/PCL tears

A

Instability
Loss of function
Meniscal tears
Early OA

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82
Q

What is the mechanism of injury of an PCL tear?

A

Hyperextension or forced displacement of upper tibia from femur
Falling onto an object

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83
Q

What are the signs/symptoms of a PCL tear?

A

Large haemarthrosis
Posterior sag
Tenderness
+ve posterior drawer test

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84
Q

What is the mechanism of injury of an MCL tear?

A

Twisting injury

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85
Q

What are the signs/symptoms of a MCL tear?

A

Bruising medially
Swelling
Tenderness
Laxity on valgus stress

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86
Q

Are MCL or LCL tears more common?

A

MCL

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87
Q

What is the mechanism of injury of an LCL tear?

A

Stretching/tearing when varus force applied to knee

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88
Q

What are the signs/symptoms of a LCL tear?

A

Brusing laterally
Swelling
Tenderness
Laxity on varus stress

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89
Q

What are the complications of a MCL injury?

A

Chronic valgus instability

Avulsion

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90
Q

What are the complications of a LCL injury?

A

Avulsion fracture at fibular head

Common peroneal nerve injury

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91
Q

What scoring systems are used for major trauma?

A

Injury severity score
Abbreviated injury scale
Revised trauma score

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92
Q

What is the golden hour in major trauma?

A

Period of time following an injury with the highest likelihood that prompt treatment will prevent death

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93
Q

How is c-spine stabilisation achieved in ATLS?

A

Triple immobilisation - hard collar, tape and blocks

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94
Q

Give 3 sources of major haemorrhage in trauma

A 
Chest
Abdomen
Pelvis
Retroperitoneum
Long bones
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95
Q

What is shock?

A

A life-threatening condition of circulatory failure resulting in cellular injury and inadequate tissue function

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96
Q

Outline the features of a class I acute haemorrhage

A

Blood loss - <750cc (0-15%)

Fluids - crystalloids

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97
Q

Outline the features of a class II acute haemorrhage

A 
Blood loss - 750-1500cc (15-30%)
HR - increased
PP - decreased 
Mental state - anxious
Fluids - crystalloids
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98
Q

Outline the features of a class III acute haemorrhage

A 
Blood loss - 1500-2000cc (30-40%)
HR - increased
PP - decreased 
BP - decreased
Urine output - decreased
Mental state - confused
Fluids - crystalloids and blood
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99
Q

Outline the features of a class IV acute haemorrhage

A 
Blood loss - >2000 (>40%)
HR - increased
PP - decreased 
BP - decreased
Urine output - negligible
Mental state - lethargic
Fluids - crystalloids and blood
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100
Q

In general, how is a major trauma managed?

A

ATLS

Primary survery and secondary survey

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101
Q

What might be done as part of a secondary survey in major trauma?

A

Focused history
Complete systematic examination
Further imaging

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102
Q

Give 3 complications of major trauma

A 
ARDS
SIRS
MOD
Fat embolism syndrome 
Compartment syndrome
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103
Q

What causes fat embolism syndrome?

A

Pelvis/long bone fracture

Significant soft tissue injury

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104
Q

Give 3 symptoms of fat embolism syndrome

A 
Hypoxia
Low platelets
Anaemia
SOB
Confusion 
Delirium
Petechial rash
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105
Q

What is the mortality from fat embolism syndrome?

A

20%

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106
Q

What is a Volkmann’s contracture?

A

Irreversible muscle and nerve damage caused by compartment syndrome

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107
Q

Why might colloids be unsuitable for a post-operative patient?

A

Variable effect on haemostasis

Some reduce platelet function

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108
Q

Give 3 signs/symptoms of a surgical site infection

A

Purulent discharge
Erythema
Pain
Swelling

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109
Q

What is the difference between a superficial and deep surgical site infection?

A

Superficial - skin and subcutaneous tissue

Deep - fascia and muscle

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110
Q

What is the most common organism involved in hip arthroplasty infection?

A

Coagulase negative staphylococcus

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111
Q

What route of administration is best for post-operative analgesia?

A

Oral < IV < IM

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112
Q

Give 3 ways in which analgesia may be given post-operatively

A

Local anaesthetic
Regional via nerve catheter
Regional nerve block

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113
Q

What factors increase the risk of an AKI post-operatively?

A

Hypovolaemia
Reduced vascular resistance
Nephrotoxic agents
Prophylactic antibiotics

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114
Q

How is AKI managed post-operatively?

A

Loop diuretics only if overloaded

Ensure fluid balance is adequate

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115
Q

What are the risk factors for compartment syndrome?

A 
Crush injury 
Rhabdomyolysis
Long bone fracture 
Vascular limb injury 
Tissue ischaemia 
Coagulopathy
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116
Q

In which 2 patient populations do you need to beware of compartment syndrome?

A

Ventilated ITU patients

Regional/spinal anaesthesia

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117
Q

Why are orthopaedic patients at risk of thromboembolic disease?

A 
Blood stasis (immobilisation)
Endothelial injury (surgical position/manipulation)
Hypercoagulability (increased blood loss and thromboplastins)
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118
Q

Give 2 methods of mechanical VTE prophylaxis

A

Early mobilisation
Graduated compression stockings
Intermittent pneumatic compression devices

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119
Q

Give 2 methods of pharmacological VTE prophylaxis

A

Aspirin
Warfarin
Apixaban
Clexane

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120
Q

How long after discharge can hypercoagulability last for a hip fracture?

A

6 weeks

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121
Q

What is the most common mechanism of injury of a clavicle #?

A

FOOSH

Direct blow to shoulder

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122
Q

How are clavicle # managed?

A

Usually conservative

ORIF if shortened/comminuted/Z pattern

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123
Q

Give 3 complications of clavicle #

A 
Malunion
Non-union
Bump
Stiffness
Infection
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124
Q

How are clavicle # classified?

A

Lateral (15%)
Middle (80%)
Medial (5%)

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125
Q

What is the most common type of shoulder dislocation?

A

Anterior

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126
Q

What are proximal humerus # and brachial plexus injuries associated with?

A

Shoulder dislocation

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127
Q

How is shoulder dislocation managed?

A

Urgent reduction

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128
Q

Give 2 complications of anterior shoulder dislocation seen on x-ray

A

Bankhart lesion

Hill-Sachs lesion

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129
Q

What is a Bankhart lesion?

A

Anterior shoulder dislocation complication - injury to anterior glenoid

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130
Q

What is a Hill-Sachs lesion?

A

Anterior shoulder dislocation complication - depression in posterolateral head of humerus

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131
Q

What must be assessed in older patients who have a shoulder dislocation before discharge?

A

Rotator cuff injury

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132
Q

What is the most common mechanism of action of ACJ dislocation?

A

Direct blow to shoulder

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133
Q

How are ACJ dislocations classified?

A

Rockwood type 1-6

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134
Q

How are ACJ dislocations managed?

A

Grade 1-3 - conservative PT

Grade 4-6 - reconstruction/ORIF with hook plate

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135
Q

How are proximal humerus # classified?

A

Neer classification

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136
Q

How are proximal humerus # managed?

A

Depends on number of fragments and their displacement

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137
Q

In what type of # is axillary nerve palsy a complication?

A

Proximal humerus #

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138
Q

How are humeral shaft # classified?

A

Location - proximal, middle, distal

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139
Q

What is a Holstein-Lewis #?

A

Spiral fracture of distal 1/3 of humeral shaft associated with radial nerve palsy

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140
Q

How are humeral shaft # managed?

A

Usually conservative - humeral brace

Open, vascular injury, plexus injury, forearm fracture (floating elbow), polytrauma - ORIF

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141
Q

Is radial nerve palsy due to humeral shaft # an indication for surgery?

A

Only if palsy has occurred due to manipulation/intervention

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142
Q

What is the most common elbow #?

A

Radial head #

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143
Q

What is the most common mechanism of injury for radial head #?

A

FOOSH with pronated forearm

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144
Q

How are radial head # classified?

A

Mason types 1-4

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145
Q

What is an Essex-Lopresti injury?

A

Interossesous membrane disruption and distal radial ulnar joint (DRUJ) injury

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146
Q

How are radial head # managed?

A

Type 1 - conservative
Type 2 - conservative unless block to rotation
Type 3/4 - ORIF, excision or replacement

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147
Q

Give 2 complications of radial head #

A

Soft tissue injury - DRUJ, interosseous membrane, MCL, LCL, elbow dislocation
Loss of forearm movements

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148
Q

What is the ‘terrible triad’ of radial head # complications?

A

Elbow dislocation
Coronoid #
Radial head #

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149
Q

What is the most common type of elbow dislocation?

A

Posterolateral

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150
Q

What is the most common mechanism of elbow dislocation?

A

Axial loading, supination and valgus force

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151
Q

How are elbow dislocations classified?

A

Location of olecranon in relation to humerus - simple or complex

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152
Q

What is the ‘terrible triad’ of elbow dislocation?

A

Elbow dislocation (lateral ulnar collateral ligament injury)
Radial head #
Coronoid process #

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153
Q

How are elbow dislocations managed?

A

Closed reduction or ORIF with soft tissue repair

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154
Q

Give 2 complications of elbow dislocation

A

Stiffness
Instability
Heterotrophic ossification
Neurovascular injury

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155
Q

Give 3 features to look for on x-ray of an elbow dislocation

A

Alignment - anterior humeral line, radiocapitellar line
Fat pads - anterior may be normal, posterior always abnormal
Cortices

156
Q

What is the most common mechanism for forearm (both bones) #?

A

Direct trauma

157
Q

How are forearm (both bones) # managed?

A

Conservative - minimal displacement

ORIF

158
Q

What is a Monteggia #?

A

Proximal 1/3 ulnar # with associated radial head dislocation/instability

159
Q

At what age is a Monteggia # most likely to occur?

A

4-10 years

160
Q

What is a Galeazzi #?

A

Distal 1/3 radial shaft # with associated DRUJ injury

161
Q

Give 3 signs of DRUJ injury

A

Ulnar styloid #
Widening of joint on AP view
Dorsal/volar displacement on lateral view
Radial shortening (>5 mm)

162
Q

Give 2 upper limb # associated with osteoporosis

A

Proximal humerus #

Distal radius #

163
Q

How are distal radius # classified?

A

Intra/extra-articular
Shortened
Displaced
Comminuted

164
Q

How are distal radius # managed?

A

Extra-articular, simple - MUA and plaster, K wires

Intra-articular, complex - ORIF

165
Q

Give 2 complications of distal radius #

A

Complex regional pain syndrome
Stiffness
Extensor pollicis longus rupture

166
Q

What is the most common type of scaphoid #?

A

Waist (65%)
Proximal (25%)
Distal (10%)

167
Q

Describe the blood supply of the scaphoid and its significance

A

Retrograde blood supply from branches of radial artery - risk of AVN increases with proximity of fracture

168
Q

How are scaphoid # managed?

A

Usually conservative

ORIF for proximal pole # or displaced waist #

169
Q

How are scaphoid # imaged?

A

X-ray
Repeat x-ray in 2 weeks if negative
MRI for occult fracture

170
Q

Give 2 complications of scaphoid #

A

Non-union
SNAC wrist
AVN

171
Q

What is SNAC wrist?

A

Scaphoid non-union advanced collapse - progressive degenerative arthritic changes in the wrist

172
Q

What is the mechanism of perilunate dislocation?

A

Wrist extended with ulnar deviation = intercarpal supination
Scapholunate ligament, capitolunate articulation and lunotriquetral articulation disruption -> failure of dorsal radiocarpal ligament -> lunate dislocates

173
Q

How are perilunate dislocations classified?

A

Mayfield classification 1-4

174
Q

How are perilunate dislocations managed??

A

Urgent reduction and fixation with K wires +/- ligament reconstruction +/- carpal tunnel release

175
Q

What metacarpals are most commonly #?

A

5th MC

MC neck

176
Q

How are metacarpal/phalanx # managed?

A

Conservative - good movement

ORIF or K wires - rotational deformity

177
Q

Give 2 complications of metacarpal/phalanx #

A

Stiffness
OA
Deformity

178
Q

How can major trauma and polytrauma be defined?

A

Major - injury with the potential to cause prolonged disability or death; injury severity score >15
Poly - multiple severe injuries which may cause dysfunction/failure of organs/systems

179
Q

What scoring systems can be used for trauma?

A

Injury severity score
Abbreviated injury scale
Revised trauma score

180
Q

What is a primary survey?

A

Initial assessment of trauma patient to detect and treat imminent threats to life
A-E (with c-spine control as part of A and haemorrhage control as part of C)

181
Q

Give 2 sources of major haemorrhage

A 
Chest 
Abdomen
Pelvis 
Retroperitoneum
Long bones
182
Q

What are the 3 types of pelvic fracture?

A

Lateral compression
AP compression
Vertical shear

183
Q

How can the pelvis be stabilised in trauma?

A

Pelvic binder

184
Q

Outline the major haemorrhage protocol

A

Assess - major haemorrhage
Restore volume - wide bore cannulae, fluids, oxygen, monitor BP
Summon help and stop bleeding - 2222 call for major haemorrhage, call surgery/anaesthetics
Bloods - emergency crossmatch, FBC, clotting screen, calcium
Give blood products as necessary

185
Q

How is major haemorrhage defined?

A

50% blood loss in 3 hours OR rate of loss >150ml/minute

186
Q

What is a secondary survey?

A

Complete head-to-toe systematic examination once patient is stable
Focused history

187
Q

What are the differential diagnoses for back pain?

A 
Mechanical back pain 
Osteoarthritis of the spine
Prolapsed intervertebral disc 
Spinal stenosis
Spondylolithesis
Discitis 
Inflammatory causes 
Malignancy 
Fracture 
Referred pain from - abdomen, hip, pelvis, SI joints
188
Q

How should mechanical back pain be investigated?

A

No investigation unless more sinister cause suspected or history >6 weeks
Check - FBC with differential WCC, EST, LFTs, bone profile, myeloma screen, CRP

189
Q

How should mechanical back pain be managed?

A

Patient education
Simple analgesia
Early return to normal activities
Self-referral to physiotherapy

190
Q

Give 5 red flags for back pain

A 
Thoracic pain
Fever and unexplained weight loss
Bladder or bowel dysfunction
History of carcinoma
Ill health or presence of other medical illness
Progressive neurological deficit
Disturbed gait, saddle anaesthesia
Age of onset <20 years or >55 years
Immunocompromised/prolonged steroid use 
Limb weakness
Bilateral radicular pain
191
Q

What is the most common cause of nerve root impingement causing back pain?

A

Intervertebral disc herniation (L4/5 or L5/S1)

192
Q

What pattern does pain follow in nerve root impingement?

A

Radicular pain which extends below the knee, is equal to/worse than the back pain and follows the dermatome of the involved nerve root

193
Q

Give 2 clinical signs of nerve root impingement

A

Leg pain in dermatomal distribution extending below the knee

Pain on straight leg raise

194
Q

What imaging is used to diagnose nerve root impingement and what are the indications?

A

MRI
Radicular pain >6 weeks and failure of conservative measures
Neurologic deficit
Bilateral lower limb deficit/peroneal symptoms (CES)

195
Q

How is nerve root impingement managed?

A

Non-surgical - PT, NSAIDs, muscle relaxants, acupuncture

Surgical - decompression

196
Q

What are the absolute and relative indications for surgical intervention in nerve root impingement?

A

Absolute - CES, progressive neurological deficit
Relative - intractable radicular pain, neurological deficit not improving despite conservative measures, recurrent sciatica following successful conservative measures

197
Q

What are the 3 main clinical features of cauda equina syndrome?

A

Bilateral parasthesia/muscle weakness
Saddle parasthesia
Bladder and bowel dysfunction

198
Q

Give 2 red flags for cauda equina syndrome on history taking

A 
Back pain with sciatica 
Lower limb weakness
Altered perianal sensation 
Faecal incontinence
Acute urinary retention/incontinence
199
Q

Give 2 red flags for cauda equina syndrome on examination

A

Limb weakness
Other neurological deficit/gait disturbance
Hyper-reflexia/clonus/up-going plantars
Urine retention
DRE - saddle anaesthesia, loss of anal tone

200
Q

How is CES managed?

A

History and examination (including DRE)
Bladder scan pre and post void
Urgent MRI
Refer to neurosurgery for decompression

201
Q

What are discitis and vertebral osteomyelitis?

A

Discitis - infection of the disc space

Vertebral osteomyelitis - infection of the vertebral body

202
Q

What are discitis/vertebral osteomyelitis associated with?

A

IV drug use
Sepsis from another source
Post-spinal surgery

203
Q

What organisms most commonly cause discitis/vertebral osteomyelitis?

A

Staphylococci and streptococci
Strep and haemophilus in children
Tuberculosis should also be considered

204
Q

How does discitis/vertebral osteomyelitis present?

A

Fever
Generally unwell
Unrelenting back pain
Spinal deformity (late)

205
Q

How should discitis/vertebral osteomyelitis be investigated?

A

Bloods - WCC, ESR, CRP

Imaging - XR, MRI

206
Q

How is discitis/vertebral osteomyelitis managed?

A

CT guided biopsy
IV antibiotics (6 weeks)
Surgical - stabilisation, abscess drainage

207
Q

What is the most common type of spinal tumour?

A

Metastatic

208
Q

How are spinal tumours investigated?

A

MRI spine
Bone scan
Serum calcium

209
Q

What is malignant spinal cord compression?

A

Patients with spinal metastatic disease present with compression of the spinal cord - oncolocy/neurosurgery emergency

210
Q

How is malignant spinal cord compression managed?

A

Emergency radiotherapy or surgical decompression

211
Q

What type of spinal fractures are stable/unstable?

A

Isolated anterior column
fractures (wedge compression) tend to be stable
Both column (burst fractures) or associated ligament injuries tend to be unstable

212
Q

How should a patient with a suspected spinal injury be assessed?

A

Log roll with C-spine control
Examination - bony midline tenderness, clinical deformity/palpable step, boggy swelling/bruising, neurological compromise
ASIA chart documentation of neurological deficits
Spinal shock - bradycardia, hypotension

213
Q

How can different imaging modalities be used to investigate spinal injuries?

A

XR - c-spine, T and L spine
CT - high energy, >1 column, SC or ligament injury
MRI - SC or ligament injury

214
Q

How should spinal injuries be managed?

A

Stable - cervical (collar, analgesia), thoracolumbar (early mobilisation, brace)
Unstable - cervical (HALO, collar, ORIF), thoracolumbar (ORIF, brace, bed rest)

215
Q

How are spinal cord injuries managed?

A

Surgical decompression and stabilisation

216
Q

Define scoliosis

A

Lateral deviation/rotational deformity of the spine

217
Q

What are the causes of scoliosis?

A

Idiopathic
Neuromuscular
Congenital
Secondary

218
Q

How is scoliosis managed?

A

Mild - conservative, brace if risk of progression

Moderate/severe - surgical correction

219
Q

Give 2 common causes of shoulder pain?

A

Subacromial impingement
Rotator cuff tears
Dislocation
Arthritis

220
Q

What is subacromial impingement?

A

First stage of rotator cuff disease
Most common cause of shoulder pain
Inflammation of the subacromial bursa due to abutment of the greater tuberosity/RC and the acromion/coraco-acromial ligament/acromioclavicular joint

221
Q

What 3 things are associated with subacromial impingement?

A

Hook shaped acromion
Greater tuberosity fracture malunion
Shoulder instability

222
Q

How does subacromial impingement present?

A

Insidious onset shoulder pain
Exacerbated by overhead activities
Night pain

223
Q

What signs of subacromial impingement can be seen on examination?

A 
Positive painful arc test (60-120 degrees)
Neer impingement sign (pain on passive forward flexion >90 degrees) 
Hawkins test (pain on passive forward flexion to 90 degrees and internal rotation)
224
Q

What features may be seen on XR of a patient with subacromial impingement?

A

Type 3 hooked acromion
ACJ osteoarthritis
Sclerosis/cystic changes in greater tuberosity

225
Q

How is subacromial impingement managed?

A

Non-operative - PT, NSAIDs, corticosteroid injections

Operative - arthroscopic subacromial decompression and acromioplasty

226
Q

What are the risk factors for rotator cuff tears?

A

Age
Smoking
Hypercholesterolaemia
Thyroid disease

227
Q

How can rotator cuff tears be categorised?

A

Mechanism - chronic degenerative tear, acute traumatic avulsion
Size - small, medium, large, massive (>=2 tendons)

228
Q

What are the 2 main symptoms of rotator cuff tears?

A

Pain - acute/insidious, deltoid region, worse on overhead activities, night pain
Weakness - loss of active ROM

229
Q

What sign is seen on physical examination of rotator cuff tears if the supraspinatus is involved?

A

Jobe’s/empty can test

230
Q

What sign is seen on physical examination of rotator cuff tears if the infraspinatus is involved?

A

External rotation lag
(Arm is placed in maximal ER; patients with a massive RC tear will be unable to maintain the arm in that position and the arm will swing toward neutral rotation)

231
Q

What sign is seen on physical examination of rotator cuff tears if the teres minor is involved?

A 
Hornblower sign 
(The patient is asked to bring the hands to the mouth; if teres minor is torn, will do it, but only with the elbow in a high position on the affected side)
232
Q

What sign is seen on physical examination of rotator cuff tears if the subscapularis is involved?

A

Lift-off and belly-press tests

233
Q

What imaging modalities are used for rotator cuff tears?

A

USS

MRI

234
Q

How are rotator cuff tears managed?

A

Non-operative - PT, NSAIDs, steroid injections
Operative - repair (young), debridement (elderly, irreparable), tendon transfer (young, irreparable), reverse total shoulder arthroplasty (massive tear with advanced arthritis)

235
Q

What is the most common joint dislocation and why?

A

Shoulder - the head of humerus is larger than the shallow glenoid fossa

236
Q

How are shoulder dislocations classified?

A

Anterior (95%)
Posterior (4%)
Inferior (1%)

237
Q

What is the usual mechanism of injury in posterior shoulder dislocation?

A

Seizure

Electric shock

238
Q

Give 2 clinical features of shoulder dislocation

A

Severe pain
Inability to move
Empty glenoid fossa (palpable lump)
Arm held in external rotation and slight abduction

239
Q

Give 2 complications of shoulder dislocation

A 
Axillary nerve damage 
Brachial plexus injury 
Axillary artery/vein injury 
Avulsion fracture of tuberosities 
Recurrent shoulder instability (<30 years)
Rotator cuff injury (>45 years)
240
Q

What is a Bankhart lesion?

A

Injury of the anterior inferior lip of the glenoid labrum due to traumatic anterior shoulder dislocation

241
Q

How are shoulder dislocations managed?

A

Emergency - sling immobilisation, analgesia
Conservative - closed reduction
Surgical - reduction of humeral head and repair of labrum

242
Q

What are the indications for surgical management of shoulder dislocation?

A

Unsuccessful closed reduction
Displaced Bankhart lesion
Recurrent dislocation
Young and active to prevent recurrence

243
Q

What are the 2 types of shoulder OA?

A

Primary

Secondary - fracture/dislocation, RA/gout, AVN, massive RC tear leading to arthritis

244
Q

What are the signs/symptoms of shoulder OA?

A

Shoulder pain
Loss of ROM (especially external rotation - anterior capsule contraction), pain at night
Crepitus

245
Q

What are the XR features of shoulder OA?

A

Joint space narrowing
Subchondral sclerosis
Subchondral cysts
Osteophytes

Circumferentially at humeral head “goat’s beard”
Posterior glenoid wear

246
Q

How is shoulder OA managed?

A

NSAIDs, PT, steroid injections

Shoulder replacement

247
Q

Give 3 common causes of elbow pain

A 
OA
RA
Tennis elbow
Golfer's elbow
Olecranon bursitis
248
Q

How is elbow OA managed?

A

NSAIDs, steroid injections

Debridement (removal of osteophytes and capsular release), arthroplasty

249
Q

What is tennis elbow?

A

Overuse injury at origin of common extensor tendon (ECRB) leading to tendinosis and inflammation

250
Q

What are the clinical features of tennis elbow?

A

Pain with gripping and resisted wrist extension
Point tenderness at lateral epicondyle (ECRB origin)
Exacerbation of pain on resisted extension of long finger

251
Q

What feature of tennis elbow may be seen on XR?

A

Calcifications at extensor origin

252
Q

How is tennis elbow managed?

A

NSAIDs, PT, steroid injections

Release and debridement of ECRB origin

253
Q

Define golfer’s elbow

A

Overuse of flexor-pronator origin - medial epicondylitis

254
Q

What are the clinical features of golfer’s elbow?

A

Pain on gripping and resisted wrist flexion
Point tenderness distal to medial epicondyle
Pain on resisted forearm pronation and wrist flexion

255
Q

What features of golfer’s elbow may be seen on XR/MRI?

A

XR - calcifications at flexor origin

MRI - rule out ulnar collateral ligament injury in overhead throwers

256
Q

What is the main differential for golfer’s elbow?

A

Ulnar collateral ligament injury

257
Q

How is golfer’s elbow managed?

A

NSAIDs, PT, steroid injection

Debridement and reattachment of flexor-pronator origin

258
Q

What are the causes of olecranon bursitis?

A 
Trauma 
Prolonged pressure 
Infection 
RA
Gout
259
Q

How does olecranon bursitis present?

A 
Swelling 
Pain
Redness 
Warmth 
Fever and malaise if infective
260
Q

How is olecranon bursitis investigated?

A 
FBC 
Uric acid level 
CRP
XR - olecranon spur 
Aseptic needle aspiration - GS, C&S, crystals
261
Q

How is olecranon bursitis managed?

A

Non-infective - ice, elevation, NSAIDs, treat cause
Infective - broad spectrum antibiotics
Recurrent - interval bursectomy

262
Q

What is the differential diagnosis for tingling fingers?

A

Peripheral nerve entrapment (carpal tunnel syndrome or cubital tunnel syndrome)
Central nerve entrapment
Peripheral neuropathy

263
Q

What are the 3 key features of peripheral nerve entrapment?

A

Pain/paraesthesia in the distribution of the nerve
Altered sensation in the distribution of the nerve
Reduced muscle function supplied by the nerve

264
Q

What forms the carpal tunnel?

A

Bones of the carpus roofed by the transverse carpal ligament (flexor retinaculum)

265
Q

What passes through the carpal tunnel?

A 
10 structures, 4 components
Median nerve 
4 x FDS (flexor digitorum superficialis)
4 x FDP (flexor digitorum profundus)
1 x FPL (flexor pollicis longus)
266
Q

What conditions are associated with CTS?

A 
Diabetes
Hypothyroidism
RA
Acromegaly
Wrist fracture
Pregnancy 
Use of heavy vibrating machinery
267
Q

How does CTS present?

A

Nocturnal waking with tingling (relieved by shaking/running under water)
Altered/reduced sensation in median nerve distribution
Difficulty manipulating small objects
Clumsiness

268
Q

What signs are seen on examination of CTS?

A

Reduced/altered sensation in median nerve distribution
Reduced power of median nerve innervated muscles of the hand - thumb abduction
Thenar muscle wasting
Positive Tinel’s test
Positive Phalen’s test

269
Q

How is CTS managed?

A 
Wrist splints (night)
Steroid injections (pregnancy)
Decompression surgery - division of flexor retinaculum longitudinally
270
Q

What causes cubital tunnel syndrome?

A

Compression of ulnar nerve in cubital tunnel behind medial epicondyle of elbow

271
Q

What forms the cubital tunnel?

A

Cubital tunnel retinaculum

Ulnar nerve travels underneath between 2 heads of FCU

272
Q

How does cubital tunnel syndrome present?

A

Nocturnal wakening with tingling in ulnar nerve distribution
Altered/reduced sensation in ulnar nerve distribution

273
Q

What signs may be seen on examination of cubital tunnel syndrome?

A

Altered/reduced sensation in ulnar nerve distribution
Reduced power of ulnar nerve innervated muscles - finger abduction
Claw posture (severe)
Hypothenar muscle wasting
Interosseous muscle wasting
Positive Tinel’s sign at elbow

274
Q

How is cubital tunnel syndrome managed?

A

Soft elbow splints (night)

Decompression surgery

275
Q

Why are steroid injections not used to treat cubital tunnel syndrome?

A

Risk of ulnar nerve injury

276
Q

What is the differential diagnosis for sticking fingers?

A

Trigger finger

Extensor tendon subluxation

277
Q

What causes trigger finger?

A

Constriction and thickening of A1 pulley

Nodule on tendon

278
Q

How does trigger finger present?

A

Finger stuck in flexion and clicks painfully when extended

Worse in morning

279
Q

Patients with what condition are at higher risk of trigger finger?

A

Diabetes

280
Q

How is trigger finger managed?

A

Splint
Steroid injection
Surgical release of A1 pulley

281
Q

What causes extensor tendon subluxation?

A

Weakness of sagittal bands which hold extensor tendon centrally over MCPJ

282
Q

Patients with what condition are at higher risk of extensor tendon subluxation?

A

RA

283
Q

How does extensor tendon subluxation present?

A

On flexion, tendon subluxes into ulnar gutter and flicks back in extension so needs to be straightened manually

284
Q

How is extensor tendon subluxation managed?

A

Splint

Surgical recontruction/repair

285
Q

What is the differential diagnosis for stuck fingers?

A

Dupuytren’s disease
Radial nerve/posterior interosseous nerve injury
Locked trigger finger
Subluxed MCPs

286
Q

What causes Dupuytren’s disease?

A

Autosomal dominant genetic condition with variable penetrance
Proliferation of myofibroblasts in palmar fascia producing nodules and cords

287
Q

What are the ectopic manifestations of Dupuytren’s disease?

A

Plantar fascia of feet (Ledderhose disease)
Knuckle pads on dorsal aspect of PIPJs (Garrod’s disease
Dartos fascia of penis (Peyronie’s disease)

288
Q

How does Dupuytren’s disease present?

A

Fixed flexion deformity of MCP and PIP joints

Difficulty with ADLs

289
Q

How is Dupuytren’s disease managed?

A

Needle aponeurectomy (hypodermic needle used to cut cords)
Collagenase injections (digests collagen and allows snapping by extension 24-72 hours later)
Fasciectomy (surgical excision of cords)
Dermofasciotomy (as above including overlying skin and application of skin graft)

290
Q

What are the causes of radial/interosseus nerve palsy?

A

Trauma
RA elbow
Compression neuropathy

291
Q

How does radial/interosseus nerve palsy present?

A

Weakness of active wrist/finger and thumb extension
Wrist drop
Normal passive movement

292
Q

How is radial/interosseus nerve palsy managed?

A 
Repair nerve (laceration)
Treat inflammation (synovitis)
Surgical decompression (compression)
293
Q

What causes subluxed MCPs?

A

RA

294
Q

How do subluxed MCPs present?

A

Swollen painful MCPs
Inability to extend
Obvious deformity

295
Q

How are subluxed MCPs managed?

A

Joint replacement

296
Q

What are the differentials for radial sided wrist pain?

A 
De Quervain's stenosing tenovaginitis 
Scaphoid fracture 
Radial styloid fracture 
Thumb CMC joint OA
Scaphotrapezotrapezoid OA
297
Q

What causes De Quervain’s stenosing tenovaginitis?

A

Stenosis at 1st dorsal extensor compartment (APL and EPB tendons pass through)

298
Q

How does De Quervain’s stenosing tenovaginitis present?

A

Pain on wringing/removing stiff lids
Pain on resisted abduction
Positive Eichoff’s test

299
Q

What is Eichoff’s test?

A

Positive if pain over De Quervain’s tendons on ulnar deviation with thumb in fist

300
Q

How is De Quervain’s stenosing tenovaginitis managed?

A

Splint
Steroid injection
Surgical release of 1st dorsal compartment

301
Q

Give 2 features of scaphoid fractures

A

Young people
FOOSH
Difficult to see on XR
Treated with plaster cast

302
Q

Give 2 features of radial styloid fracture

A

May be associated with other carpal injuries

Treated with immobilisation in splint or plaster cast

303
Q

How does thumb carpo-metacarpal OA present?

A

Pain and stiffness
Pain on wringing/removing stiff lids
Positive grind test
Often noticed after a fall

304
Q

How is thumb carpo-metacarpal OA managed?

A

Analgesia, splint, steroid injection

Surgery - excise, fuse, replace

305
Q

What are the differentials for lumps and bumps on the hand and wrist?

A 
Ganglion
Giant Cell Tumour
Heberden’s and Bouchard’s nodes
Skin lesions
Gouty Tophi
Rheumatoid Nodules
Inclusion cysts
Osteochondroma
Enchondroma
306
Q

What are the most common sites for ganglions in the hand?

A

Dorsal wrist
Volar wrist
Finger flexor sheath
DIP joint

307
Q

How are ganglions managed?

A

None - most will spontaneously regress

Can aspirate or excise

308
Q

What is a giant cell tumour of the tendon sheath and how is it managed?

A

Benign but aggressive slow growing tumour which can become very large
Excision

309
Q

What are the 2 complications of gouty tophi?

A 
Skin ulceration 
Tendon infiltration (difficult excision)
310
Q

What is an enchondroma and how is it managed?

A

Commonest bony tumour in hand which is benign

Observation, curretage and bone graft

311
Q

Define osteoporosis

A

Low BMD and microarchitectural deterioration of bone leading to increased risk of fractures

312
Q

Give 3 risk factors for reduced BMD

A 
Oestrogen deficiency in females
Androgen deficiency in males 
Endocrine disease (diabetes, hyperthyroidism)
Malabsorption (Crohn's, UC, coeliac disease)
CKD
COPD
Immobiliry 
Low BMI
313
Q

Give 3 risk factors for osteoporosis

A 
Age 
Oral steroids 
Smoking
Alcohol
Previous fragility fracture
RA
Parental hip fracture
Drugs - SSRIs, PPIs
314
Q

What do T- and Z-scores show?

A

T - compares BMD with normal adult

Z - compares BMD with age-matched controls

315
Q

How are T-scores used in diagnosis of osteoporosis

A

Normal > -1
Osteopenia between < -1 and > -2.5
Osteoporosis < -2.5

316
Q

What is a fragility fracture?

A

Caused by low energy mechanism which would not normally cause a fracture (e.g. fall from standing height)

317
Q

What 2 assessment tools can be used to determine fracture risk?

A

FRAX

QFracture

318
Q

Who should undergo assessment of fragility fracture/osteoporosis risk, according to NICE?

A

All women 50-64 years and all men 50-74 years with: previous fragility fracture, current/frequent use of oral steroids, history of falls, low BMI, smoking, alcohol >14 units/week, secondary cause of osteoporosis
All patient <50 years with: steroids, menopause, previous FF
All patients <40 years with: steroids, previous/multiple FF

319
Q

What conditions causing fragility fractures should be excluded in suspected osteoporosis?

A

Metastatic disease
Myeloma
Osteomalacia
Paget’s

320
Q

How is osteoporosis managed non-pharmacologically?

A

Exercise (weight-bearing)
Reduce fizzy drinks (phosphoric acid)
HRT for menopause <40 years
Vitamin D and calcium

321
Q

What are the pharmacological options for managing osteoporosis?

A

Bisphosphonates (e.g. alendronate) - reduce resorption
SERM (e.g. raloxifene)
Calcitonin - inhibits resorption
Monoclonal (e.g. denosumab) - inhibits formation
Recombinant PTH (e.g. teriparatide) - anabolic

322
Q

What is osteomalacia/Rickets?

A

Defective mineralisation of osteoid most commonly due to vitamin D deficiency
Osteomalacia - after skeletal maturity
Rickets - before (children)

323
Q

How is bone morphology affected in Rickets?

A

Fraying and widening of metaphysis (cupping)
Increased physeal width and cortical thinning/bowing
Large physes most prominent (e.g. knee, wrist)

324
Q

What are the causes of vitamin D dependent forms of osteomalacia/Rickets?

A 
Low UV radiation exposure 
Low oral intake 
Low intestinal absorption (e.g. CF, pancreatitis, coeliac) 
Drugs 
Alcoholism 
Renal/hepatobiliary disease 
Tumours
325
Q

What are the causes of vitamin D independent forms of osteomalacia/Rickets?

A 
Renal dysfunction (e.g. renal tubular acidosis, Fanconi anaemia)
Drugs - bisphosphonates, fluoride, antacids
326
Q

Give 3 clinical features of Rickets

A 
Bowed legs 
Rachitic rosary (ribs)
Kyphosis
Flattened skull
Deformity and pain
327
Q

How is osteomalacia/Rickets managed?

A 
Vitamin D 
Calcium
Calcitriol
Phosphate 
Surgical correction
328
Q

Give 3 clinical features of osteomalacia

A

Bone and muscle pain
Waddling gait (proximal muscle weakness)
Fractures
Looser’s zones, trefoil pelvis, biconcave vertebral fracture, protusio acetabuli on XR

329
Q

What is Paget’s disease? What are the 3 phases?

A

Disorder of bone remodelling in which there is increased osteoclast activity
Phases - lytic, mixed, sclerotic

330
Q

What are the clinical features of Paget’s disease?

A 
Localised pain and tenderness
Increased temperature (hyperaemia)
Increased bone size 
Bowing deformity 
Kyphosis of spine 
Decreased ROM 
75% asymptomatic
331
Q

What are the complications of Paget’s disease?

A 
Deformity 
Pathological fracture 
OA risk 
Hearing loss 
Neural compression 
Malignant transformation 
High output congestive cardiac failure 
Hyperparathyroidism 
Extramedullary haematopoeisis
332
Q

What signs of Paget’s disease can be seen on skull XR?

A

Osteoporosis circumscripta - a large, well-defined lytic lesion
Cotton wool appearance - mixed lytic and sclerotic lesions of the skull
Diploic widening - both inner and outer calvarial
tables are involved, with the former usually more extensively affected
Tam O’Shanter sign - frontal bone enlargement, with the
appearance of the skull falling over the facial bones, like a Tam O’Shanter hat

333
Q

What signs of Paget’s disease can be seen on pelvic XR?

A

Cortical thickening and sclerosis of the iliopectineal and ischiopubic lines
Acetabular protrusion
Enlargement of the pubic rami and ischium

334
Q

What signs of Paget’s disease can be seen on long bone XR?

A

Blade of grass/candle flame sign - begins as a subchondral area of lucency with advancing tip of V-shaped osteolysis, extending towards the diaphysis
Lateral curvature (bowing) of the femur
Anterior curvature of the tibia - sabre

335
Q

What signs of Paget’s disease can be seen on spine XR?

A

Picture frame sign - cortical thickening and sclerosis encasing the vertebral margins
Squaring - flattening of the normal concavity of the anterior margin of the vertebral body also adds to the rectangular appearance
Vertical trabecular thickening

336
Q

How is Paget’s disease managed?

A

Bisphosphonates
Calcitonin
Surgical correction of deformities/fractures

337
Q

What are the compartments of the leg?

A

Anterior - deep peroneal nerve, dorsiflexors
Lateral - superficial peroneal nerve, evertors
Superficial and deep posterior - tibial nerve, plantarflexors

338
Q

Name 3 lesser toe deformities

A

Mallet toe
Hammer toe
Claw toe

339
Q

What is metatarsalgia and what is the differential?

A

Pain under forefoot

Tight calf, fracture, Morton’s neuroma, Freiberg’s infraction

340
Q

What conditions can affect the lateral and medial ankle?

A

Lateral - peroneal tendon pathology, lateral ligament, subtalar joint arthritis
Medial - deltoid ligament injury, tibialis posterior tendinopathy, OA

341
Q

What conditions can affect the anterior and posterior ankle?

A

Anterior - osteophyte impingement, OA, loose bodies

Posterior - Achilles tendon rupture/tendinopathy, os trigonum, sub talar OA

342
Q

How is hallux valgus managed?

A

Accommodative shoes, orthotics

Osteotomy (failed non-operative management, pain, skin compromise)

343
Q

What is hallux rigidus?

A

1st MTPJ OA

Pain, stiffness, prominent bump

344
Q

How is hallux rigidus managed?

A

Accommodative shoes, Rocker sole, orthotics

Cheilectomy (mild, bump trimming), fusion (Gold standard)

345
Q

How is ankle arthritis managed?

A

Analgesia, activity modification, splint, injection

Fusion, replacement

346
Q

What are the signs/symptoms of a growing bone tumour?

A 
Pain
Swelling
Joint swelling and stiffness
Limping
Fever
Generally unwell
Weight loss
Anaemia
347
Q

What basic investigations can be done in suspicion of bone/soft tissue lesions?

A 
XR - appearance 
Bloods - alkaline phosphatase
CT - size 
MRI - soft tissue 
Biopsy - definitive diagnosis
348
Q

What is an osteoid osteoma?

A

Benign bone tumour arising from osteoblasts which tend to be <1.5cm in size and are more common in long bones

349
Q

What is an osteochondroma?

A

Most common benign tumour

Cartilage capped bony projections/outgrowths on the surface of bones

350
Q

What is an enchondroma?

A

Benign bone tumour of cartilage

351
Q

What is a simple bone cyst?

A

AKA unicameral bone cyst (UBC)

Benign cavity filled with yellow fluid which may be active or latent

352
Q

What is fibrous dysplasia?

A

Uncommon bone disorder in which fibrous tissue develops in place of bone which leads to weakness and deformity/fracture
Commonly affects a single bone - skull or long bones

353
Q

What is a lipoma?

A

Benign tumour made of fat tissue which may be superficial (back, thigh, buttocks, shoulders, arms) or deep (muscles)

354
Q

What is osteosarcoma?

A

Most common malignant bone tumour which peaks during growth spurts
Mostly from metaphysis of distal femur, proximal tibia or proximal humerus

355
Q

What is chondrosarcoma?

A

Malignant tumour of cartilaginous origin arising from diaphyseal-metaphyseal region of long bones most commonly in males aged 30-50
Mostly femur, pelvis or scapula

356
Q

What is Ewing’s sarcoma?

A

Highly malignant tumour occurring in children which arises from mesenchymal cells of medullary cavity
Mostly diaphysis of long bones or pelvis

357
Q

What is the most common cause of a destructive bone lesion in an adult?

A

Metastatic bone disease

358
Q

What cancers commonly spread to bone?

A 
Breast
Prostate
Thyroid
Renal 
Lung
359
Q

Give 3 things to consider regarding fluid management and blood loss in orthopaedic patients

A 
Type of injury (trauma cases)
Amount of fluid loss during operation 
Type of fluid loss (blood, insensible, third space)
Level of dehydration/overload 
Age
Comorbidities
360
Q

How is fluid balance assessed?

A

Clinical examination
Urine output
(CVP monitoring)

361
Q

What are the 3 types of post-operative infection?

A

Surgical site
Superficial - within 30 days, skin and subcutaneous tissue
Deep - within 30 days (no implant) or 90 days (implant), fascia/muscle involved

362
Q

What are the 3 most common organisms causing post-operative infection in hip arthroplasty?

A

Coagulase negative staphylococcus (67%)
Staphylococcus aureus including MRSA (13%)
Streptococcus (9%)
E.coli (6%)

363
Q

What are the risk factors for post-operative infection?

A 
Trauma case 
Open wounds 
Diabetes
Obesity 
Vascular disease 
Prolonged procedure time
Older patients 
Immune impairment 
Nutritional deficiencies (e.g. low albumin)
364
Q

How should post-operative infection be managed?

A

Refer to treating team/on call orthopaedics
Take wound swab, tissue culture and bloods
Do not commence antibiotics without swabs/cultures and senior input

365
Q

Why should antibiotics not be given until adequate samples and senior input obtained?

A

Prosthetic joint infection can be difficult to identify and organisms difficult to culture
Best chance to isolate infection is at first presentation before antibiotic therapy

366
Q

Give 2 considerations for pain management in post-operative patients

A 
Pre-operative education 
Use oral over IV administration 
Avoid IM administration 
IV patient controlled analgesia recommended if parenteral route needed
Monitor sedation 
Local infiltration is useful 
Regional anaesthesia (e.g. nerve catheter or regional nerve block) can be effective but may hide signs of compartment syndrome
Be aware of toxicity
367
Q

Define AKI

A

Elevated creatinine

Reduced urine output

368
Q

How does AKI occur in post-operative patients?

A

Hypotension leads to pro-inflammatory state –> increase in vasoconstrictive mediators –> tubular ischaemia and injury

369
Q

What are the procedure related risk factors for AKI in post-operative patients?

A

Hypovolaemia
Reduced systemic vascular resistance (anaesthesia)
Nephrotoxic agents (NSAIDs, contrast)
Prophylactic antibiotics (gentamicin, flucloxacillin)

370
Q

What are the patient related risk factors for AKI in post-operative patients?

A 
Older patients 
Pre-existing CKD
Diabetes
Liver disease
Hypertension 
ACEi
371
Q

How should post-operative AKI be managed?

A

Loop diuretics only for fluid overload

Aim to maintain optimal haemodynamic state to perfuse kidneys

372
Q

What is compartment syndrome?

A

Occurs when the pressure within a fascial compartment exceeds the capillary perfusion pressure of that compartment leading to a state of ischaemia
Orthopaedic emergency that requires immediate attention.

373
Q

What are the risk factors for compartment syndrome?

A

Trauma cases with crushing injury to tissues
Trauma cases with long lie (rhabdomyolysis)
Long bone fractures
Patients with vascular injury to limb
Ischaemia of tissues (eg prolonged tourniquet time)
Patients with coagulopathy

374
Q

What are the clinical features of compartment syndrome?

A 
Pain (disproportionate to injury)
Paraesthesia
Pallor
Pulselessness
Paralysis
Perishingly cold
375
Q

What 3 features make orthopaedic patients at higher risk of thromboembolic disease?

A

Virchow’s triad

Blood stasis - immobilisation, tourniquet
Endothelial injury - surgical position, limb manipulation
Hypercoagulability - trauma increases thromboplastins, blood loss

376
Q

What are the risk factors for thromboembolic disease?

A 
Older patients
Obesity
Varicose veins
Family history of VTE
Thrombophilia
Combined OCP / HRT
Immobility
Immobility due to travel
Lower limb fracture
Spinal cord injury
Lower limb surgery
377
Q

What are the options for VTE prophylaxis?

A

Mechanical - early mobilisation, graduated compression stockings, intermittent pneumatic compression devices
Pharmacological - aspirin, vitamin K antagonists (warfarin), unfractionated heparin (clexane), newer oral anticoagulants (rivaroxaban/apixaban)

378
Q

For how long does hypercoagulability persist after hip fracture?

A

Up to 6 weeks

379
Q

How should hand amputations be assessed?

A 
Level - tip, distal to FDS, proximal to FDS, hand, forearm, arm 
Vascularity
Time from injury 
Bone, tendon and nerve injury 
Nail and skin loss
380
Q

How are partial and complete finger tip amputations managed?

A

Partial - preserve and suture back on if viable
Complete - usually not suitable for replant
Try to preserve as much length as possible and insertion of FDP

381
Q

How are finger tip injuries managed?

A

Dressing only or trimming of bone and dressing
Primary closure
Local advancement or transposition flap

382
Q

How does amputation in relation to FDS change management?

A

Distal to FDS but proximal to DIPJ - ideal for replant

Proximal to FDS - unlikely to be replanted

383
Q

What structures are at risk in self-harm?

A

Palmaris longus

Median nerve

384
Q

How should tendon and nerve injuries be assessed?

A

Vascular assessment - CRT, pulses, emergency if able to replant
Neurological assessment - radial and ulnar
Tendon assessment - FDS and FDP tendons

385
Q

How should tendon and nerve injuries be managed in A&E?

A

Local anaesthetic and irrigation
Tetanus
Dressing and back slab
Low threshold for surgical exploration

386
Q

How should tendon and nerve injuries be managed in theatre?

A

Exploration and repair
Balance mobilisation and immobilisation
Tendon and nerve repair

Year 5 (10 decks)

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