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Orthopaedics Flashcards

1
Q

What is the most common pathogen causing septic arthritis? What are some others?

A

Staph aureus!

Staph epidermis, Neisseria gonorrhoea in young sexually active. Pseudmonas in IVDU

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2
Q

What organism is the cause of septic arthritis in children with sickle cell disease ?

A

Salmonella

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3
Q

What are some symptoms of septic arthritis?

A

Red, hot, swollen, tender joint, reduced ROM, systemic symptoms- fever

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4
Q

What is the initial treatment of a patient presenting with septic arthritis? (including investigations)

A

Sepsis 6- BUFALO - blood cultures and bloods- raised WCC, urine output so catheter, IV fluids, IV Abx, lactate, oxygen
IV Abx- flucloxacillin
X ray joint
Joint aspiration and send to lab for gram stain

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5
Q

What is the definitive treatment of septic arthritis?

A

Joint drain and washout in surgery

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6
Q

You are the F1 in A&E. A patient has come in with an open fracture in their leg and crying out in pain. What initial 4 very things are you going to do?

A

ABCDE primary survey- within take bloods- FBC, U&E, clotting, G&S
Analgesia
Trauma CT if needed
X ray affected bone

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7
Q

Your patient with the open fracture has had their very initial assessment and X ray has been done which confirms a long bone fracture. No treatment has been started, what will you do? (6)

A 
IV Abx + tetanus
Re-align and splint fracture
Photograph
Remove gross contamination eg, branch
Cover with saline gauze and dressing
Surgical debridement
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8
Q

A patient has come into A&E with back pain. On further questioning he says it came on suddenly and the pain goes down the back of his legs. He has noticed he cannot feel any sensation when he sits on the toilet and admits to being incontinent once. Given the likely diagnosis, what is the immediate investigations and treatment needed?

A

MRI full spine
PR

Tx: dexamethasone high dose.
urgent spinal surgery.

This is cauda equina

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9
Q

What are some causes of cauda equina? 3

A 
Malignancy -metastases to spine 
Trauma - vertebral fracture
Disc herniation 
Infection
Inflammatory disorders- RA, ank spons
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10
Q

What are the symptoms of cauda equina?

A 
Back and leg pain 
Bowel incontinence - loss of anal tone 
Saddle anesthesia
Urinary retention 
LMN signs - lower limb weakness, loss of lower limb reflexes
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11
Q

What action does the anterior compartment muscles of the leg do?

A

Dorsiflex’s the foot

eg. tibias anterior

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12
Q

What action does the posterior compartment muscles of the leg do?

A

Plantarflex’s the foot and inversion of foot

eg. gastrocnemius, coleus

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13
Q

What action does the lateral compartment muscles of the leg do?

A

Plantarflexion and eversion of foot

eg. peroneus

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14
Q

What are some causes of compartment syndrome? (3)

A 
Trauma- fractures, crush injuries
Burns
Constricting casts/ dressings
infection 
post-ischaemia swelling
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15
Q

What are the symptoms of compartment syndrome?

A

6P’s
pain out of proportion, pain on passive stretch (dorsiflex- anterior compartment, plantarflex- posterior, evert foot- lateral), not relieved by analgesia
paraesthesia (anterior compartment = deep peroneal nerve, posterior compartment= tibial nerve, lateral compartment= superficial perineal nerve)
pallor
pulselesness
paralysis
perishingly cold

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16
Q

What is the treatment for compartment syndrome? (4)

A

Anaglesia
Split casts and dressings on skin
Elevate limb
Fasciotomy is definitive

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17
Q

What are some complications of compartment syndrome?

A 
Rhabdomyolysis --> AKI 
Volkamn's ischaemic contracture- tissue necrosis of flexor muscles in arm causing them to shorten --> claw like deformity 
Pain 
Amputation 
Infection
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18
Q

What signs may you see in a patient with a pelvic fracture?

A

Leg length discrepancy

Blood at the rectum, urethra and sacrum due to bladder/urethral rupture

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19
Q

An elderly patient has come into A&E because she has had a fall. You rule out a head injury but she is in a lot of pain and after examination you suspect a pelvic fracture. How will you initially treat and investigate this? (6)

A

Put out trauma call
Bloods- FBC, U&E, cross match, clotting, LFTs
Analgesia
IV fluids- permissive hypotension
Blood transfusion
Pelvic binder - across greater trochanters
CT pelvis

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20
Q

What does the first C stand for in a trauma primary survey?

And how would you treat?

A

Catastrophic haemorrhage- pressure, tourniquets, may need transexamic acid

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21
Q

What does the A stand for in a trauma primary survey? And how would you treat?

A

Airway.
Immoblise C-spine
Speak to them- is the airway patent? If not - maneovures eg jaw thrust, chin lift. Use artificial airways eg. LMA
High flow O2
Intubate and ventilate if patient not breathing/ GCS <8

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22
Q

What does the B stand for in a trauma primary survey? And how would you identify and treat the following problems: tension pneumothorax, haemothorax, flail chest

A

Breathing.
Listen to chest - breath sounds- equal?, RR, sats. Look for equal chest expansion.
Tension pneumothorax- deviated trachea, unequal chest expansion. Tx: Urgent needle decompression and chest drain.
Haemothorax- hyporesonant (dull to percussion). Tx: blood transfusion, chest drain
Flail chest- paradoxical chest abdo breathing. Tx: analgesia, high flow O2, may need ventilation

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23
Q

What does the C stand for in a trauma primary survey? And how would you identify and treat the following problems: bleeding in the abdomen (haemoperitoneum), pelvic fracture, long bone fracture, cardiac tamponade

A

Circulation
Listen to heart sounds, pulse rate, cap refill, blood pressure, urine output, PERIPHERAL pulses
Bloods- FBC, U&E, G &S/ crossmatch, clotting, glucose
IV fluids- permissive hypotension- only if systolic <90
Bleeding in abdo (haemoperitoneum): feel abdo- liver, spleen. FAST scan- bedside US and CT
Pelvic fracture- pelvic binder and analgesia
Long bone fracture- splint, X ray + analgesia.
Cardiac tamponade: Beck’s triad- muffled heart sounds, hypotension, distended JVP. Classic in penetrating chest trauma. Tx: needle pericardiocentesis

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24
Q

What does the D stand for in a trauma primary survey?

A

Disability
GCS, pupils, glucose, temperature
Look for head injuries and any peripheral neuro signs

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25
What does E stand for in a trauma primary survey?
Exposure Check for full body injuires- log roll Keep patient warm
26
What is the function of the periosteum in bone? And what happens to the periosteum and so to the bone in osteomyelitis?
Adheres to the bone to provide nutrients | The infection in the bone causes the periosteum to strip away pulling the blood supply away and causing necrosis
27
What are some risk factors for osteomyelitis (4)
Extremes of age: children (highly vascular bones and incompletely developed immune systems) and elderly Diabetics eg. diabetic foot infection spreading Vascular disease eg. patients with PVD Immunosuppresed patients Trauma
28
What is the most common pathogen implicated in osteomyelitis?
Staph aureus | IVDU- pseudomonas
29
What are the signs and symptoms of osteomyelitis?
Joint- red, hot, painful, effusion | Systemic symptoms- fever, malaise
30
What investigations would you do in a patient with suspected osteomyelitis? (4)
Bloods- FBC, CRP, U&E, LFTs Blood cultures Local cultures- of pus Imaging- definitive: MRI (x ray wouldn't show much early on)
31
What treatment would you provide for osteomyelitis? (4)
``` If septic - sepsis 6 Analgesia High dose IV antibiotics- fluclox/vancomycin if suspect MRSA Immobilisation of limb May need surgical drainage ```
32
What do lytic lesions look like on X ray?
Dark- bone is being destroyed and the X ray is shining through eg. lung cancer mets to bone = lytic
33
What do sclerotic lesions look like on X ray?
Bright - solid bone forming eg. secondary prostate cancer
34
Which age and gender group is osteoid osteoma (primary bone tumour) most common in?
Young males- 15-25
35
What are the symptoms of osteoid osteoma?
Commonly affects long bones- femur, spine | Severe dull pain, worse at night. Relived by NSAIDs and aspirin
36
What investigations and treatment would you do in a young man with osteoid osteoma?
X rays- see radiolucent nidus (releases prostaglandins) CT Tx: NSAIDs and aspirin- blocks the prostaglandins and helps pain Surgical excision of tumour
37
Is osteochondroma benign or malignant?
Benign- most common benign bone tumour
38
What is the presentation of osteochondroma?
Painful mass usually associated with trauma. Mainly affects knee, femur and humerus
39
How would you investigate and treat osteochondroma?
X ray. Surgical excision if symptoms/ continues to grow bigger.
40
What symptoms might you get in a osteosarcoma?
Bone pain, swelling ,erythema.
41
Which part of bone is affected in osteosarcoma which helps differentiate from Ewing's sarcoma? What test would you have to do to differentiate?
Osteosarcoma: metaphysis of long bone Ewing's: diaphysis of long bone (shaft) MRI
42
What investigations are done in osteosarcoma (2) and what would you see on imaging?
X ray- see lytic destruction, periosteum stripping away (Coddman's triangle) and new bone formation throughout (Sunray spicules) Biopsy
43
How do you treat osteosarcoma?
Surgical resection of tumour + chemotherapy
44
What symptoms would you get in Ewing's sarcoma?
Pain, swelling, fever - classically in pelvis and spine
45
What investigations would you do in Ewing's sarcoma (3) and what would you see on imaging?
X ray- lytic lesions - dark areas due to bone destruction MRI- to differentiate from osteosarcoma Bone biopsy
46
How do you treat Ewing's sarcoma?
Surgical excision, chemo, radio
47
What age group is typically affected by chondrosarcoma?
Middle aged adults
48
What is the classic sign seen on X ray in chondrosarcoma?
Popcorn sign- the tumour look like popcorn + lytic lesions
49
What symptoms do you get in myeloma?
CRAB- hypercalcaemia, renal failure, anaemia, bone pain
50
What investigations would you do to confirm a diagnosis of myeloma?
Bloods- FBC, U&E & paraprotein band Urine- Bence Jones Protein X ray - punched out lesions and pathological fractures
51
What are the treatment options for myeloma?
Bone marrow transplant - only definitive Chemo + radio Supportive- bisphosphonates, dialysis if renal failure, EPO for anaemia Surgical fixation for pain relief
52
What are the cancers that metastasise to bone?
``` Lung Prostate Breast Renal Thyroid Skin ```
53
Main blood supply of lower limb? starting with abdominal aorta and down to calf
Abdo aorta --> common iliac--> external and internal iliac External iliac becomes common femoral artery Common femoral artery becomes superficial femoral artery (main artery of lower limb) Superficial femoral becomes popliteal once passes through popliteal fossa In the calf - anterior tibial, posterior tibial and peroneal
54
What is the basic classification of hip fractures?
Intracapsular | Extracapsular then split into intertrochanteric and subtrochanteric
55
Which type of hip fracture is worse- intracapsular or extra-capsular and why?
Intracapsular- especially if displaced: disrupts the inter medullary blood supply that goes through the bone into the femoral head whereas this is not disrupted by an extracapsular fracture
56
What are some symptoms/signs of hip fracture? How might the patient be sitting with their leg?
Pain in outer thigh/groin which can radiate to knee Inability to weight bear Affected leg shortened and externally rotated Painful rotating the leg
57
What investigations would you do in a patient with a hip fracture? Also thinking about what might've caused the fall leading to hip fracture
Bloods- FBC, U&E, clotting, G&S, Creatinine kinase CXR, urine dip- look for a source of fall? infection? ECG- arrythmia? X RAY
58
An elderly patient has come in and has had a confirmed hip fracture on X ray. She has been given no treatment whatsoever, what are 4 things you will do initially?
Analgesia IV fluids Blood transfusion if Hb low Laxatives and anti-emetics
59
What is the definitive treatment of a displaced intracapsular fracture?
Hemiarthroplasty (femoral head replaced but not acetabulum) or total hip replacement (both replaced). Because of risk of avascular necrosis
60
What is the definitive treatment of a non- displaced intracapsular fracture?
Internal fixation with screws
61
What is the definitive treatment of an inter-trochanteric extra-capsular fracture?
Dynamic hip screw
62
What is the definitive treatment of an sub-trochanteric extra-capsular fracture?
Intramedullary nail
63
What part of hand does median nerve supply? What movement would you ask a patient to do to test it? What part of hand would you tap to check sensation?
On palm: Thumb, first and 2nd finger and half of 3rd On back: tips of 1st, 2nd and half of 3rd finger Clench fist Thenar eminence
64
What part of hand does ulnar nerve supply? What movement would you ask a patient to do to test it? What part of hand would you tap to check sensation?
On palm: half of 4th finger and 4th finger on back: same spread fingers and don't let me push them back in Hypothenar eminence
65
What part of hand does radial nerve supply? What movement would you ask a patient to do to test it? What part of hand would you tap to check sensation?
Only on back: thumb, half of first, second and third fingers Cock wrists back and don't let me push them down Anatomical snuffbox
66
A patient has come into A&E with severe pain in their hand. He says he was playing football as a goalie and tried to stop the ball and landed on his hand. It immediately started hurting and you see swelling over the palm nearer the wrist. He struggles to grip your fingers when asked and is particularly tender in the anatomical snuffbox. What is the likely diagnosis?
Scaphoid fracture
67
What symptoms occur with a scaphoid fracture?
Pain and swelling over the area of scaphoid in palm Tender in anatomical snuffbox Difficulty gripping fingers Difficulty turning over hands
68
What investigation would be done in a suspected scaphoid fracture?
X ray
69
If the scaphoid fracture is visible on X ray, what management would you do? What would you do if it was displaced and why?
Analgesia, scaphoid splint and review in 10 days | Surgical fixation to stop risk of avascular necrosis
70
A 60 year old woman comes into A&E with a painful hand. She describes loosing balance and falling onto her outstretched hand. Examination of the hand , you can see a dinner fork deformity and swelling. What is the likely diagnosis?
Colles fracture - distal radius fracture
71
What are the risk factors for a colles fracture?
Post- menopausal women Long term steroid use increasing age smoking/alcohol use
72
How do you investigate and treat a Colles fracture? How would management differ if the fracture was displaced?
``` X ray Analgesia Splint to immoblise Elevate with sling Undisplaced: send home and follow up in fracture clinic Displaced: reduction of fracture ```
73
What bones make up the ankle?
Tibia, fibula, talus and calcaneus
74
What investigation would you do in a patient with an ankle fracture?
X ray
75
How do you treat an ankle fracture?
Fracture reduction to re-align immediately Cast If displaced- surgical fixation
76
What are the complications of rib fractures? (4)
Pneumothorax Flail chest- rib fractures in 2 or more ribs in 2 or more places leads to paradoxical breathing Haemothorax Surgical emphysema - air gets under skin Abdo injuries- spleen ,liver Pneumonia- not breathing in properly over time due to pain
77
What are the main two symptoms of a rib fracture?
Pain in ribs | Shortness of breath- short, shallow breaths
78
How do you treat a rib fracture? What main thing do you need to tell patients with rib fractures?
Analgesia and supportive | Take deep breaths every so often to reduce risk of pneumonia
79
What are the rotator cuff muscles and their functions?
``` SITS Supraspinatus- abduction Infraspinatus- external rotation Teres minor- external rotation Subscapularis- internal rotation ```
80
How do you test for rotator cuff pathology in shoulder exam?
Supraspinatus: abduction. Abduct arm to 90, bring it forward, turn so thumb down and resist pressure. Infraspinatus and trees minor: external rotation. Bend elbow into body and bring arm out against pressure Subscapularis- internal rotation: lift off test- hand behind back and push out against resistance
81
What symptoms/signs may a person with rotator cuff pathology have?
Pain | Pain on abducting arm
82
What imaging is required to identify a rotator cuff tear?
US / MRI
83
How do you treat a rotator cuff tear?
Conservative- analgesia- paracetamol, NSAIDs. If they need- steroid injections. Physiotherapy. If 2 weeks of symptoms/not improving/large tear= surgeons
84
A patient has come in with pain in their shoulder. He is a young man that is a professional pitcher in baseball. He describes the pain coming on suddenly while he was playing and was very painful and hasn't settled. On examination, he describes pain on abduction of shoulder between 60-120. What is the likely pathology?
Rotator cuff tear
85
What are the signs/symptoms of subacromial impingement?
Pain - worse on abduction, relieved by rest. Painful arc | Weakness and stiffness.
86
How do you treat subacromial impingement?
conservative: physio, NSAIDs/paracetamol, steroid injections if needed Surgery after 6 months of conservative treatment
87
A patient has attended your clinic with shoulder pain. On further questioning he says its a deep pain that is always there and can often radiate to his arm and elbow. The pain is dull and is worsened by brushing hair/activity. There is marked reduced range of active and passive movement on shoulder examination. What is the likely diagnosis?
Adhesive capsulitis / frozen shoulder
88
How is adhesive capsulitis/frozen shoulder treated?
Physio, analgesia- paracetamol/NSAIDs, steroid injections | Surgery if 3 months of no improvement.
89
What is the function of the Achilles tendon?
Inserts into the calcaneus to produce plantar flexions of the ankle
90
What are the risk factors for achilles tendonitis?
Overuse- high intensity running and jumping inappropriate footwear Obesity Gender Recent fluoroquinolone use eg ciprofloxacin
91
A patient has come into practice with pain in her foot. It has been present for a while but has got a lot worse recently, notably worse after she had a very bad UTI and was treated with anbitiotics. The pain is localised at the heel and on pressing down at the back of the heel , this causes pain. She is a professional netball player and is keen to get back to sport. What is the likely diagnosis?
Achilles tendonitis
92
What symptoms and signs would you get in achilles tendonitis and what would you get in achilles rupture?
Tendonitis: pain of gradual onset, worsened by movement. Pain on pressing the achilles tendon Rupture: sudden onset pain, audible popping sound, loss of plantar flexion.
93
What test can you do to help diagnose achilles rupture?
Simmonds test- patient lies prone, squeeze calf: normally foot should plantar flex, if rupture: foot will not.
94
How do you treat achilles tendinitis and how do you treat achilles rupture?
Tendonitis: stop exercise, ice, anti-inflammatories, physio | Rupture- analgesia, splint ankle in plaster/weight bearing boot
95
A girl in her 20's presents with a painful knee. This happened a few days ago. In the history, you find out she was playing football when her knee twisted and gave way. Immediately it was really painful but it's settled since and she's able to walk on it. However, she has noticed it locking every so often which is why she has come to see you. On examination- you notice some swelling around the knee and its particularly tender on the medial joint line. She is also unable to fully extend her leg on the bed. What is the likely diagnosis?
Meniscus tear- medial
96
What are the signs and symptoms of a meniscus tear?
``` Twisting in flexion Acute pain which settles Gradual effusion Able to weight bear Localised tenderness to joint line Knee catching/locking ```
97
What is the treatment of a meniscus tear?
Rest, ice, elevation, analgesia If it's a large tear/symptoms continue: repair the tear May eventually need meniscus removal
98
What type of trauma usually causes an MCL tear?
Lateral force to knee
99
What symptoms and signs would you see with a MCL tear?
Immediate pain medially Swelling - due to bleeding Hear a pop Laxity on knee abduction - valgus stress test
100
How do you investigate and treat a MCL tear?
MRI | usually always conservative- analgesia, physio, knee brace
101
What symptoms and signs would you see with an ACL tear (and on examination)?
``` Swelling Pain Feels unstable Unable to weight bear 'Felt a snap' Lachman's test- increased displacement of tibia compared to femur Anterior draw - increased laxity ```
102
How do you investigate and treat an ACL tear?
MRI Sporty, young, unstable with ADLs= ACL reconstruction Conservative: physio, brace, activity modification
103
What is the most common cause of a PCL tear?
Knee hyperextension
104
What are the signs and symptoms of a PCL tear?
``` Immediate posterior knee pain Swelling Instability of joint Struggling to weight bear Positive posterior draw test ```
105
How do you investigate and treat a PCL tear?
MRI Rest, ice, analgesia Knee brace and physio If repeatedly symptomatic- surgery

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