Orthopaedics Flashcards
Give an overview of shoulder pathology.
- dislocation (glenohumeral)
- humeral shaft fracture
- humeral neck fracture
- impingement syndrome
- rotator cuff tears
- frozen shoulder
GHJ dislocation
- almost always anterior, due to excessive external rotation (Bankart lesion); posterior exceptionally rare (epilepsy etc., Hill-Sachs - lightbulb sign)
- assess neurovascular status (axillary nerve - loss of sensation in regimental badge area)
- X-ray confirms diagnosis; may need multiple planes
- closed reduction under anaesthetic, followed by physiotherapy - ORIF if displacement remains
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Humeral shaft fracture
- direct trauma (e.g. RTA) with high union rate
- up to 30deg angulation is accepted
- neurovascular (radial nerve - wrist drop)
- usually humeral brace, non-operative Mx
- internal fixation/IM nails in polytrauma, and non-union requires plates/bone grafts
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Humeral neck fracture
- low injury osteoporotic FOOSH to surgical neck
- minimally displaced: sling, gradual physio
- internal fixation or joint replacement otherwise
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Impingement syndrome
- painful arc (60-120deg), +ve hawkins-kennedy
- NSAIDs, physiotherapy, then up to 3 steroid injections. subacromial decompression if these fail
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rotator cuff tears
- sudden jerk (e.g. sudden stop holding rail on bus)
- MRI/USS can visualise
- older: physio, younger: surgery
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Frozen shoulder (adhesive capulitis)
- severe, progressive shoulder pain with stiffness
- movement reduces until it is frozen
- pain -> stiffness -> thawing. loss of external rotation
- NSAIDs/steroids for pain, exercise, physio. arthroscopy speeds up recovery
Give an overview of elbow pathology.
- epicondylitis
- cubital tunnel syndrome
- olecranon fracture
- radial head & neck fracture
- elbow dislocation
Epicondylitis
- enthesitis of extensor (lateral) or flexor (medial) tendons at their insertions of the epicondyles
- self-limiting; advise rest, physio
- local steroid injection and/or brace; rarely surgery is needed for refractory cases
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Cubital Tunnel Syndrome
- compression of ulnar nerve behind medial epicondyle
- parasthaesia in ulnar 1.5 fingers
- +ve Tinel’s or Froment’s. Surgical decompression rare
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Olecranon Fracture
- fall onto point of elbow with triceps contraction
- simple transverse avulsion - tension band wiring
- any other requires ORIF to restore triceps and articular surfaces
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Radial Head & Neck Fracture
- usually due to FOOSH
- may not show up on X-ray requiring lateral views, showing fat pad sign
- conservative if nondisplaced (sling, physio)
- aspiration if effusion, surgery if displaced fragments
- ORIF if the fragment is large
—- Monteggia: proximal radial joint
—- Galeazzi: distal radial joint
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Elbow Dislocation
- usually posterior due to FOOSH
- uncomplicated: closed reduction under sedation, sling, and physio. assess neurovascular pre- & post-
- fragments may need surgery
- epicondyle fractures fixed with a screw or ORIF
Give an overview of non-traumatic hand pathology.
- carpal tunnel syndrome
- dupuytren’s contracture
- trigger finger
- ulnar/radial nerve injury
Carpal Tunnel
- median nerve compression in the carpal tunnel
- most are idiopathic; other causes: thickened ligaments, tendon sheaths, RA, bone enlargement
- numbness, tingling in thumb and radial 2.5 fingers
- +ve Tinel’s or Phalen’s
- splint overnight relieves (diagnostic)
- steroid injection or surgical decompression
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Dupuytren’s
- painless, palpable fibrosis of palmar aponeurosis
- gradual fixed flexion usually of ring/little fingers
- Caucasians, diabetics, epileptics, alcoholics, Peyronie’s or Lederhosen disease predispose
- steroid injection -> collagenase -> surgery
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Trigger Finger
- tendonitis of flexor tendon over A1 pulley
- pain and finger may lock, requiring manipulation to regain extension
- steroid injection or surgery if recurrent
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Ulnar Nerve Injury
- impairs power of wrist adduction. cannot make a fist; results in claw hand
- affects medial 1.5 fingers
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Radial Nerve Injury
- causes wrist drop, with minimal parasthesia
- intact sensation
Give an overview of traumatic hand pathology.
- colles fracture
- smith’s fracture
- barton’s fracture
- scaphoid/carpus injuries
- peri-lunate / lunate dislocation
DISTAL RADIAL FRACTURES
Colles Fracture
- extra-articular distal radius fracture, due to FOOSH with extended wrist
- minimal displacement: splintage
- past neutral angulation (10deg): manipulation. may be held with plaster cast, or percutaneous wires if unstable/ORIF
- can cause carpal tunnel (median nerve)
Smith fracture
- opposite of colles (volar). all undergo ORIF
- malunion: reduction in grip strength/extension
Barton fracture
- intra-articular fracture, 90deg to Colles/Smith. can be dorsal (colles) or volar (smith). Use ORIF
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Scaphoid & Carpus Fracture
- usually after a FOOSH. tenderness in snuff box, and pain telescoping thumb MC
- 4 x-ray views needed, may not show fracture
- splint/plaster cast if suspected/nondisplaced
- displaced: compression screw into bone
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Peri-Lunate & Lunate Fracture
- fracture of carpal bones, due to high energy hyperdorsiflexion
- emergency: closed reduction, percutaneous pinning, or open reduction
- lunate: ‘spilt cup’ sign, same treatment
Give an overview of hip pathology.
- trochanteric bursitis
- pelvic fracture
- hip fracture
- femoral shaft fracture
Trochanteric bursitis
- pain and tenderness in greater trochanter; bursa under gluteus medius tendon
- analgesia, anti-inflammatories, physio, steroid inject
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Pelvic Fracture
- younger: high energy, older: osteoporotic
- ring structure; can’t break in only one place (Polo)
- ABCDE, resus, replace blood, PR exam to exclude cauda equina syndrome or rectal tear (open fracture)
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Hip Fracture
- usually > 80yr and female
- most undergo surgery, except the very high risk who are expected to die soon
- risk of AVN of the femoral head if intracapsular
- hemi-arthroplasty used most often; THR for very active
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Femoral Shaft
- high energy, usually polytrauma
- substantial blood loss, fat embolism, confusion, risk of ARDS
- resus, analgesia, femoral nerve block, Thomas splint
- definitive: closed reduction w/ IM nail
Give an overview of leg pathology.
- tibial shaft fracture
- distal tibia (pilon) fracture
Tibial Shaft
- indirect force: bending (transverse), rotational (spiral)
- compressive force: deceleration (oblique)
- combination: comminution
- frequent cast changes, check X-rays. internal fixation alternative with faster results
- tibia takes a long time to heal (16 wks to a year)
- comminution needs ORIF - but this risks non-union and disruption to periosteal blood supply
- IM nails most common; less disruption
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Pilon Fracture
- intra-articular distal tibia fracture, high energy caused by fall from height or rapid deceleration
- pestle and mortar (distal tibia into talus)
- internal rotation if very early, otherwise temporary external rotation, CT, and planned internal rotation
Give an overview of soft-tissue knee pathology.
- meniscal tears
- ACL rupture
- PCL rupture
- MCL rupture
- LCL rupture
Meniscal Injuries
- twisting forces on a loaded knee; causes effusion and / or locking
- Steinmann test +ve. bucket handle tear - spongy block to extension, confirmed by MRI
- Schatzker system of classification
- poor arterial supply (outer 1/3 only) - surgery only in young patients with outer meniscal injury
- >90% not suitable for surgery -> steroid injection
- arthroscopic partial meniscectomy if > 3 month pain
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ACL rupture
- internal tibial rotation (lateral rotation of body on planted foot) -> pop -> haemarthrosis within 1 hr
- rule of thirds
- professional sportspersons or giving way when sedentary - reconstruction (tendon graft, semitend.)
- intensive rehab and physio
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PCL rupture
- direct blow to anterior tibia (e.g. dashboard injury)
- difficulty going down stairs
- reconstruction only in severe cases (with cadaver achilles tendon allograft)
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MCL rupture
- valgus injury (medial, along with ACL)
- most heal with no/little instability (high healing capacity). some need hinged knee brace
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LCL rupture
- varus injury (lateral, along with PCL)
- usually surgical; early - repair, late - reconstruction
Give an overview of knee fractures & tendon ruptures.
- distal femoral fracture
- extensor mechanism rupture
- patellofemoral dysfunction
- patellar instability
Distal Femoral Fracture
- usually osteoporotic fall onto flexed knee
- fragment adopts flexed position
- usually fixed with plate and screw; fracture is difficult to maintain in a cast
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Extensor Mechanism Rupture
- patellar (young) and quadriceps (old) tendon
- rapid contractile force (heavy weight, fall)
- avoid quinolones and steroid injection. patient cannot straight leg raise (SLR), obvious palpable gap
- surgical Mx with tendon-tendon repair/reattachment
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Patellofemoral Dysfunction
- anterior knee pain (encompasses chondromalacia, Osgood-Schlatter, compression)
- most common: lateral pull of patella by tendon
- pain worse after going downhill, grinding, clicking, pseudolocking
- physio (strengthen surrounding muscles), taping
- surgery last resort
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Patellar Instability
- always lateral; direct blow or sudden twist. may reduce spontaneously
- fracture may occur if patella hits lateral femoral condyle, when patellar tendon snaps
- splintage and physio; reconstruction if recurrent
Give an overview of ankle pathology.
- ankle OA
- ankle fractures
- Sever’s disease
Ankle OA
- may be idiopathic or due to football injury
- cheilectomy (removal of osteophytes) can help
- more significant: arthrodesis or replacement
- reserve replacement for older, less active patients - once failed fusion is required
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Ankle Fractures
- suspected fractures screened with Ottawa criteria
- bony tenderness (severe, local), or unable to weight bear for 4 steps -> send for X-ray
- stable: walking cast, splint 6 weeks
- unstable: X-ray shows talar shift or tilt; needs ORIF
- ORIF can be delayed 1-2 wks to allow soft tissue injury to settle
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Sever’s Disease
- traction apophysitis of the Achilles tendon
- traumatic or complicates spondyloarthopathy
- raising the heel/steroid injection can help
Give an overview of non-traumatic foot conditions.
- hallux valgus
- hallux rigidus
- morton neuroma
- tendonitis & tendon rupture
- plantar fasciitis
- pes planus & cavus
- claw & hammer toes
Hallux Valgus
- medial deviation of first MT, and lateral toe deviation
- no proof footwear is causative but may be linked
- rubbing of foot on shoe can cause bunions (inflamed bursa), rubbing of toes can cause ulcers
- surgery has poor cosmetic outcome, better functional
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Hallux Rigidus
- OA of the 1st MTPJ
- conservative: stiff soled shoe, metal bar in the shoe, or cheilectomy in early cases
- surgical: arthrodesis (fusion) gold standard
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Morton Neuroma
- trauma to interdigital nerves, swelling and inflammation causing neuroma
- burning, tingling, loss of sensation in web space
- Mulder’s click, USS shows swollen nerve
- conservative: MT pad, insole, steroid injection
- surgical: excision; may not work, or recur
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Tendonitis & Tendon Rupture
- repetitive strain (sports), degeneration (RA, gout), quinolones. causes pain
- rest, physio, heel raise; decompression, resection
- avoid steroid injection -> rupture (also from lunging; feels like being kicked in back of leg)
- Simmond’s +ve (no plantarflexion squeezing calf)
- usually conservative: equinous position casts for 8 wks - surgery scars can be problematic
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Plantar Fasciitis
- self-limiting stress/overload, or degeneration
- pain on instep, tenderness on palpation
- rest, stretching exercise, steroid injection, gel filled heel pad. surgery of dubious value
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Pes Planus, Cavus
- pes planus (flat foot), lack of medial longitudinal arch
- pes cavus - abnormally high medial arch
- higher risk of tendonitis, otherwise normal. severe cases may require arthrodesis
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Claw & Hammer Toes
- imbalance between flexor and extensor tendons
- claw: hyperext. MTPJ, hyperflex. PIPJ
- hammer: hyperflex. MTPJ, hyperext. PIPJ
- toe sleeves, corn plasters, surgery (tenotomy, tendon transfer, arthrodesis (PIPJ), amputation)
Give an overview of traumatic foot conditions.
- calcaneal fracture
- talar fracture
- metatarsal fracture (including Lisfranc and Jones)
- toe fracture
Calcaneal Fracture
- fall from height onto heel (fall from ladder)
- soft tissue swelling and risk of compartment syndrome; heel may drift into valgus
- ORIF in young, arthrodesis in chronic pain
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Talar Fracture
- forced dorsiflexion from rapid deceleration
- risk of talar AVN -> closed/open reduction, screw fixation
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Metatarsal Fracture
- may not show on X-ray until 3 wks after, until resorption or callus occurs
- Lisfranc: base of 2nd MT, Jones in 5th MT
- may be a ‘flake fracture’, may be overlooked
- grossly swollen, bruised foot, cannot weight bear, needs reduction or fixation with screws
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Toe Fracture
- rarely needs anything other than protection in a stout boot; reduction/fixation for large fragments
- open: debridement, stabilization with wire
Give an overview of non-emergency back pathology.
- mechanical back pain
- acute disc tear
- sciatica
- spinal stenosis
Mechanical Back Pain
- usually no serious underlying pathology. advice, analgesia, and/or physio often enough
- maintain normal function (no bed rest)
- if single level with OA/instability, or not improved despite physio, spinal stabilization surgery can help
- ensure no adverse factors (disability allowance appeal, compensation claim, physiological dysfunction)
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Acute Disc Tear
- classically occurs after lifting heavy object
- pain severe (rich innervation), worse on coughing, takes 2-3 mnths to settle
- analgesia, physio
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Sciatica
- herniation of IV disc impinging on exiting nerve root
- reduces muscle power in myotome and reflexes
- pain radiates down sciatic nerve distribution; burning (neuralgic) or tingling. cannot radiate past knee
- analgesia, mobility, physio. usually recovers spontaneously; very rarely discectomy (MRI + lack of response to treatment)
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Spinal Stenosis
- narrowing of cauda equina (bulging discs, ligaments, and osteophytes). may affect multiple nerve roots
- claudication (burning, lessened uphill, pedal pulses)
- surgery if no response to physio + evidence on MRI; of decompression
Give an overview of emergency back pathology.
- cauda equina syndrome
- c-spine fracture
- thoracolumbar spine fracture
- spinal shock
- central cord syndrome
Cauda Equina
- surgical emergency affecting defecation/urination
- bilateral leg pain, parasthesia, saddle anaesthesia
- MUST DO PR and MRI, then prompt discectomy
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C-Spine
- atraumatic in Down’s & RA; screen with flexion - extension x-ray for abnormal motion
- atlanto-axial subluxation in RA -> cord compression.
- high energy, may be associated with head injury
- may be missed in primary survey, and may be fatal if it affects phrenic nerve
- less severe -> collar, serious -> surgical fusion (‘halo vest’, external fixator, stabilization)
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Thoracolumbar
- usually RTA or fall from height
- full trauma evaluation and neurovascular assessment
- stable: brace. surgery: neuro deficit, unstable pattern, loss of vertebral height, displacement, ligaments
- stabilize w/ pedicle screws, rods, fusion; decompress
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Spinal Shock
- physiologic response to injury; complete loss of sensation and motor function, and reflexes
- absence of bulbocavernous reflex (contraction of anal sphincter w/ squeeze of glans penis)
- resolves in 24hrs - return reflex indicates end
- neurogenic shock -> bradycardia, priapism and hypotension, resolving within 24-48hrs
- IV fluid therapy; differentiate from hypovolaemic
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Central Cord Syndrome
- hyperextension in c-spine with OA
- often no signs on radiograph (SCIWORA); paralysis of arms due to corticospinal tracts; sacral sparing
- Brown-Sequard - hemisection of cord from penetrating injury (e.g. stab wound)
- ipsilateral paralysis, contralateral loss of pain, temperature, coarse touch sensation
Give an overview of arthritis in children.
- juvenile idiopathic arthritis
- rheumatic fever
- growing pains
- osteochondritis (osgood-schlatter)
- Perthes’ disease
- transient synovitis of the hip
JIA
- systemic: high fever, maculopapular rash, arthralgia, myalgia, lymphadenopathy. high ESR, CRP, neutrophilia, thrombocytosis, negative for abs
- oligo-: < 4 joints (knee, ankles, wrist); assess for uveitis and blindness regularly with slit-lamp
- poly RF+ve: older girls, needs aggressive Mx
- poly RF-ve: younger girls; eye exams needed
- all: NSAIDs, DMARDs (after steroids); avoid aspirin
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Rheumatic Fever
- systemic resulting from GAS infection
- autoantibodies against cardiac myosin and laminin
- major: throat culture, clinical Hx, elevated anti- streptolysin O, carditis, arthritis, chorea
- absolute bed rest, phenoxymethylpenicillin
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Growing Pains
- exclude other causes
- episodic, nocturnal, lasting 15-30 mins, waking up
- physio, analgesia, ?psychosocial problems
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Osteochondritis
- localized pain and swelling over tibial tubercle
- usually seen in athletic teenagers, responds to local Mx and changing sporting activity
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Perthes Disease
- idiopathic necrosis of proximal femoral epiphysis
- painless limp, usually in boys, usually unilateral
- loss of internal rotation -> loss of abduction, then a positive Trendelenburg gait
- x-ray observation and avoidance of physical activity
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Transient Synovitis
- irritable hip, causing painful limitation of movement
- occurs after URTI, usually in boys
- symptoms resolve in a few weeks; rest and analgesia
Give an overview of children’s development disorders.
- varus & valgum
- in-toeing
- femoral neck anteversion
- scoliosis
- spondylolisthesis
- varum at birth (normal), physiologic valgus (14 mnths, 10-15deg), then regresses to 6deg
- pathology is +/- 6deg from mean value for age
- generally resolves < 10yrs, surgery otherwise
- exclude underlying (dysplasia, tumour, OA etc)
- in-toeing is feet that point to midline
- exaggerated when running, clumsiness, wear through shoes at high rate
- excessive femoral neck anteversion gives appearance of in-toeing, knock-knees
- not usually enough to need surgery
- scoliosis is lateral curvature of the spine
- usually idiopathic, females > males
- pain needs urgent MRI (exclude infection or tumour)
- mild cases don’t need surgery; surgery used for assisting wheelchair sitting, or respiratory function
- spondylolisthesis - slippage of one vertebra over another, usually L5/S1. may have radiculopathy
- paradoxical ‘flat back’, waddling gait
- minor: observation, rest, physio
- larger: stabilization, ?reduction (risks neuro injury)
