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Finals > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

What is compartment syndrome?

A

Raised pressure (>40 for diagnosis) within a fixed fascial space

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2
Q

Which fractures most commonly lead to compartment syndrome?

A

tibial shaft
supracondylar
crush injuries

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3
Q

How does compartment syndrome present?

A 
Pain even on passive movement
Pallor
Paraesthesia 
Perishingly cold
Pulseless
Paralysis
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4
Q

What is the management of compartment syndrome?

A

Fasciotomies

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5
Q

What is a systemic complication of compartment syndrome and its management? How can this be avoided?

A

Increased myoglobin leading to rhabdomyolysis. This can occur on reperfusion of the limb following fasciotomy.

Large amounts of fluids are given

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6
Q

What is osteomyelitis?

A

Infection of the bone marrow which can spread to the cortex and periosteum via the Harversian canals

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7
Q

What organism most commonly causes osteomyelitis?

In which group of people is another organism most often responsible?

A

staph aureus

Sickle cell patients: salmonella

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8
Q

How does osteomyelitis present?

A

Fever
Pain
Warm, red limb
Immobility of the limb

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9
Q

What is the management of osteomyelitis?

A

Flucloxacillin

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10
Q

What are the 2 types of osteomyelitis and the risk factors for these?

A

Haematogenous: IVDU, immunocompromised (HIV, diabetic), infective endocarditis

Non-haematogenous: trauma, diabetic foot ulcer, arterial disease (ulcers)

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11
Q

What is the gold standard investigation for osteomyelitis?

A

MRI

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12
Q

What is septic arthritis? What is the most common responsible organism in adults?

A

Infection of a native or prosthetic joint

Staph aureus

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13
Q

How does septic arthritis present? Which joint is most often affected?

A

Often the knee
Fever
Hot, swollen, erythematous
Limp, pain, immobile

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14
Q

How is septic arthritis managed?

A

drainage of the joint using needle aspiration

Flucloxacillin (often for 6 weeks)

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15
Q

What organism often causes septic arthritis in young adults?

A

Neisseria gonorrhoea due to disseminated gonococcal disease

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16
Q

How is septic arthritis investigated?

A

Synovial fluid sampling prior to abx

blood cultures

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17
Q

What diagnostic criteria is used to diagnose septic arthritis in children?

A 
Kocher criteria
Fever >38.5
Non-weight bearing
Raised ESR
Raised WCC
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18
Q

How does flexor tenosynovitis present?

A 
Kanavel's cardinal signs:
Fixed flexion
Pain on passive extension 
Fusiform swelling
Tender
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19
Q

What is the pathophysiology of flexor tenosynovitis?

A

A deep cut can introduce bacteria to the synovial compartment where there is no blood supply and therefore no ability to fight infection

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20
Q

What is the cauda equina?

A

The nerve roots caudal to the conus medularis

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21
Q

What causes cauda equina syndrome?

A

Hernaition at L4/L5 or L5/S1
tumour
abscess
trauma

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22
Q

How does cauda equina syndrome present?

A 
Back pain
Lower limb weakness
Saddle anaesthesia 
Reduced anal tone and faecal incontinence 
Urinary retention (painless)
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23
Q

How is suspected cauda equina syndrome investigated?

A

MRI

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24
Q

How is cauda equina syndrome managed?

A

Immediate decompression

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25
Q

Someone comes to ED with an open fracture: what needs to be done?

A 
Take a photo
Remove any obvious foreign bodies
Cover with warm saline gauze
Antibiotics
Tetanus booster 
Check the neurovascular status
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26
Q

What is the definition of an open fracture

A

Any fracture with associated breach of the overlying skin

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27
Q

What in the history would raise your suspicions for NAI?

What specific fractures are typical of NAI?

A

History and injury don’t match up
Delayed presentation to A&E
Multiple A&E visits

Metaphyseal corner fractures (occurs when a child is shaken)
Skull, rib, sternal, scapular

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28
Q

Talk through presenting a fracture x-ray

A 
TYPE:
transverse, oblique, spiral, comminuted 
DISPLACEMENT:
(movement of the distal fragment)
1. Angulation
-valgus is away from midline
-varus is towards midline
2. Rotation
3. Shortening
4. Distraction
- is there widening?
5. Impaction
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29
Q

What are the types of comminuted fracture?

A

butterfly: 2 oblique fractures leave a bone fragment like a butterfly wing
segmental: distal and proximal fracture leaving a segment inbetween

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30
Q

Describe secondary fracture healing (very briefly)

A
  1. haematoma formation
  2. fibrocartilaginous callus formation
  3. ossification to form a bony callus
  4. remodelling
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31
Q

What impairs bone healing?

A

Smoking (inhibits osteoblasts and nicotinic vasospasms reduce blood supply to heal)
Diabetes
NSAIDs
calcium and vit D deficiency

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32
Q

Compare a Buckle/Torus fracture with a greenstick fracture

A

Buckle: periosteal haematoma only. Although the cortex bulges there is no distinct fracture line

Greenstick: unilateral cortical breach

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33
Q

What is the Salter Harris classification for?

A

Describing fractures across the growth plates

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34
Q

Describe the fractures of the Salter Harris classification

A

1: S: straight across
2: A: above the plate
3: L: beLow the plate
4: T: Through all (plate, epiphysis and metaphysis)
5: R: cRush

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35
Q

At what ages do the various points at the elbow ossify?

A

CRITOL

1: capitulum
3: radial head
5: internal (medial) epicondyle
7: trochlear
9: olecranon
11: lateral epicondyle

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36
Q

What is a bakers cyst? What causes them?

A

Swelling of the gastrocnemius semi-membranous bursa
In children: idiopathic
In adults: secondary to osteoarthritis

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37
Q

How does a bakers cyst present?

A

swelling behind the knee

Rupture: can present very similarly to a DVT

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38
Q

Describe the associations of prepatella and infrapatella bursitis.

A

prepatella/ housemades - upright kneeling

infrapatella/clergymans - kneeling

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39
Q

What mechanisms lead to the 2 types of tibial plateau fracture?

A

varus force leads to medial condyl fracture

valgus forces leads to lateral condyl fracture

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40
Q

How are tibial plateau fractures classified? Briefly describe this classification.

A

Schatzer classification

1: lateral condyl
2: lateral condyl + load bearing part of condyl
3: condylar rim intact with depression of articular surface
4: medial epicondyl
5: both condyls
6: condylar + subcondylar

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41
Q

Describe the injury pattern leading to an ACL and a PCL tear

A

ACL: twisting action whilst in slight flexion
PCL: hyperextension or dashboard injuries

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42
Q

How is a PCL tear diagnosed?

A

paradoxical anterior draw test

O/E the tibia lies back on the femur

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43
Q

How does an ACL tear present?

A

Loud clunking noise
Rapid hemarthrosis and swelling
Pain
Feeling the knee will give way

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44
Q

What injury pattern leads to a meniscus tear?

A

rotational often during sport

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45
Q

How does a meniscus tear present?

A

Delayed gradual joint effusion (as opposed to ACL where rapid)
Locking of the knee (stuck in flexion)
Gives way
Pain worse when the knee is straight

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46
Q

What is McMurray’s test? What is Thessaly’s test?

A

Diagnoses a meniscus tear:

McMurrays: Clicking or pain upon rotation of the leg with the knee in flexion

Thessaly’s: pain on twisting the knee whilst weight bearing at 20 degrees flexion

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47
Q

What is a typical chrondomalacia patellae history?

A

Teenage girl
Knee pain worse on walking downstairs and at rest
Quadriceps wasting

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48
Q

What is Osgood-Schlatter disease?

A

Multiple microfractures at the point of tendon insertion to the tibial tuberosity

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49
Q

How does Osgood-Schlatter disease present?

A

Tender tibial tuberosity
Pain worse on activity
Swelling

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50
Q

What investigation is required to diagnose a dislocated patella?

A

Skyline x-ray views

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51
Q

What is the unhappy triad of knee injuries?

A

Anterior cruciate ligament
Medial collateral ligament
Meniscus (classically medial but can be lateral)

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52
Q

What is osteochondritis dissecans?

A

AVN of subchondral bone (often knee) with secondary effects on the joint cartilage

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53
Q

How does osteochondritis dissecans present?

A

Often teenagers and males

  • knee pain and swelling after exercise
  • clunk on flexing or extending the knee
  • feeling of locking or giving way
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54
Q

How is osteochondritis dissecans investigated? What are the results of these?

A

X-ray

  • subchondral crescent sign
  • loose bodies

MRI

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55
Q

Compare the presentation of an anterior vs posterior hip dislocation

A

posterior (most common): shortened, internally rotated, adducted
anterior: no change in limb length, externally rotated, abducted

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56
Q

How are hip dislocations managed?

A

Relocation with 4 hours

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57
Q

What are the complications of hip dislocations?

A

ANV of the femoral head
Damage to the sciatic or femoral nerve
osteoarthritis
recurrent dislocation due to ligament weakness

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58
Q

How does a hip fracture present?

A

Shortened and externally rotated

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59
Q

Describe the anatomical locations of various type of hip fracture

A

Intracapsular: anywhere from femoral head to point of capsular attachment

Extracapsular:

  • intertrochanteric (above the lesser trochanter)
  • subtrochanteric (below the lesser trochanter)
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60
Q

What system is used to classify hip fractures? What are the 4 types?

A

Garden system

1: incomplete
2: complete
3: displaced but still in bony contact
4: complete displacement

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61
Q

How are extracapsular hip fractures managed?

A

intertrochanteric: dynamic hip screw
subtrochanteric: intermedullary nail

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62
Q

How are intracapsular hip fractures managed?

A

young and fit: reduction and internal fixation if possible

old and generally immobile: hemiarthroplasty

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63
Q

What is a complication of a hip fracture?

A

AVN due to disruption of the medial circumflex artery

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64
Q

How does hip osteoarthritis most commonly first present?

A

inability to internally rotate the hip

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65
Q

What is greater trochanteric pain syndrome?

A

repeated friction of the iliotibial band leading to trochanteric bursitis

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66
Q

How does greater trochanteric pain syndrome present?

A

Often females age 50-70

pain on the lateral thigh over the greater trochanter

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67
Q

Aside from bony injuries and arthritis what are some other differentials for hip pain in adults? What would be some key history points for these?

A

REFERRED LUMBAR PAIN
- pain on femoral nerve stretch test

MERALGIA PARAESTHETICA
- burning sensation over antero-lateral thigh

AVN

  • history of steroid use
  • gradual onset pain

TROCHANTERIC BURSITIS
- pain over the lateral thigh and over the greater trochanter

PUBIC SYMPHYSIS DYSFUNCTION

  • often pregnancy
  • pain over pubic symphysis
  • waddling gait
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68
Q

What x-ray findings would be seen in hip AVN?

A

osteopenia
microfractures
collapse of the articular surface = crescent sign

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69
Q

What x-ray findings would be seen in hip AVN?

A

osteopenia
microfractures
collapse of the articular surface = crescent sign

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70
Q

What does superior gluteal nerve damage lead to?

A

Trendelenburg
The contralateral hip will drop as the nerve innervates the ipsilateral gluteus medius and minimus to contract and stabilise the hip

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71
Q

How does an ilipsoas abscess present?

A

fever + limp+ back pain

Pain is worse on hip extension so they lie with their hip flexed

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72
Q

What are the risk factors for iliopsoas abscess?

A

IVDU
Crohns and diverticulitis
Vertebral osteomyelitis

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73
Q

What is painful arc formerly known as? What is it?

A

supraspinatus tendinitis
It is in the spectrum of rotator cuff injuries and involves subacromial space narrowing leading to impingement of the supraspinatus tendon

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74
Q

How does supraspinatus tendonitis/painful arc present?

A

Painful abduction especially 60-120
Painful flexion
Tenderness over the anterior acromion

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75
Q

How is supraspinatus tendonitis managed?

A

NSAIDs and steroid injections

physio

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76
Q

Who does adhesive capsulitis most commonly affect?

A

Middle age females

Diabetics (20% of diabetics will get it at some point)

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77
Q

What are the stages of adhesive capsulitis? What are the symptoms at these stages?

A

Freezing:
-pain and stiffness on external rotation (+abduction)
Frozen:
- less pain but limited active and passive ROM
Thawing:
- symptoms improve over years

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78
Q

How is adhesive capsulitis managed?

A

NSAIDs and steroid injections

physio

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79
Q

Compare the pain in supraspinatus tendonitis to a rotator cuff tear.

A

supraspinatus tendonitis: 60-120
rotator cuff tear: <60
Both of them you get pain over the anterior acromion

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80
Q

How do rotator cuff tears present?

A

Painful abduction

No limitation to passive movement

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81
Q

What is a long term complication of rotator cuff injuries? Why does this happen?

A

Early shoulder OA

The humeral head migrates superiorly and therefore impacts on the glenohumeral joint leading to friction and OA

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82
Q

Where does the humerus most commonly fracture?

A

surgical neck

83
Q

What are some complications of humeral fractures?

A

proximal: axillary nerve damage, AVN (ant. humeral circumflex)
shaft: radial nerve damage

84
Q

When does the shoulder classically not dislocate anteriorly as normal?

A

epilepsy

electric shocks

85
Q

What are some concomitant injuries seen alongside shoulder dislocations?

A

avulsion of the glenoid labrum
avulsion of the glenohumeral ligament
fractures of the humerus

86
Q

What are some complications of shoulder dislocations?

A

axillary nerve damage, rotator cuff injury, greater tuberosity fracture, early arthritis

87
Q

What injury mechanism leads to anterior shoulder dislocations?

A

excessive external rotation and extension

88
Q

How do shoulder dislocations present?

A

patient will hold their arm up

Step off deformity seen at the acromion

89
Q

How does an anterior shoulder dislocation appear on x-ray? Compare this to how a posterior dislocation looks.

A

ANTERIOR:
the humeral head is overlying the glenoid i.e. it is displaced anteriorly and medially and inferiorly

POSTERIOR
lightbulb sign: the humeral head is symmetrical
widening of the joint space

90
Q

Which tendon of the biceps most commonly ruptures?

A

long

91
Q

What are the risk factors for a biceps tendon rupture?

A

heavy lifting
elderly
steroids
smoking

92
Q

How does biceps tendon rupture present?

Which movement will they have difficulty performing?

A 
audible pop
pain
- long head = pain in shoulder
- distal tendon = pain in ACF
swelling 
pop-eye deformity

difficulty in supination

93
Q

What is thoracic outlet syndrome?

A

compression of the brachial plexus (neurogenic TOS) or subclavian artery/vein (vascular TOS) at the sight of the thoracic outlet

94
Q

What factors increase the likelihood of developing thoracic outlet syndrome/what are the causes?

A

typically younger thin women with long necks
preceding neck trauma
cervical rib
scalene muscle hypertrophy

95
Q

Thoracic outlet syndrome can be neurogenic or vascular, describe how these would present?

A

neurogenic

  • wasting of the muscle of the hands
  • problems grasping
  • tingling and other sensations/sensory loss

vascular venous

  • swelling and engorgement of the arm
  • pain
  • distended veins

vascular arterial

  • arm claudication
  • ulcer, gangrene
96
Q

How is thoracic outlet syndrome managed?

A

conservatively i.e. with physio, rehab and taping

97
Q

What is the fat pad sign, which fractures is it seen in?

A

Intra-articular fracture leads to joint effusion which can be seen on the x-ray

Seen in proximal radius and supracondylar fractures

98
Q

Compare the pain associated with medial and lateral epicondylitis

A

medial: pain worse on wrist flexion and pronation
lateral: pain worse on wrist extension and supination

99
Q

Radial tunnel syndrome presents similarly to lateral epicondylitis, how could you differentiate them?

A

the pain in radial tunnel syndrome is located 4-5cm distal to the lateral epicondyl whereas in epiconylitis the pain is located directly over the epicondyl

100
Q

What is cubital tunnel syndrome and how does it present?

A

compression of the ulnar nerve within the cubital tunnel leads to tingling in the 4th and 5th digit
It is worse when the elbow is flexed or resting on a hard surface

101
Q

How does olecranon bursitis present?

A

swelling over the posterior aspect of the elbow associated with pain

102
Q

Which way does the elbow commonly dislocate? Therefore what is the structure most at risk of damage?

A

Posteriorly i.e. the ulnar sits posterior to the humerus

The ulnar nerve is stretched

103
Q

Where does the clavicle most commonly fracture?

A

the middle 1/3 segment

104
Q

What structures are at risk of being damaged in a clavicle fracture?

A

Subclavian artery and vein
Brachial plexus
lung - pneumothorax

105
Q

What is a “pulled elbow”? How does it present?

A

the radial head slips out of the annular ligament

The child will be unwilling to use their arm

106
Q

How does a supracondylar fracture present and what is seen on x-ray?

A

++ swelling
fat pad sign
The anterior humerus should normally dissect the middle 1/3 of the capitulum, in fractures this line sits anteriorly

107
Q

What are the complications of a supracondylar fracture?

A

Anterior interosseous nerve damage (check they can perform the OK sign)
Brachial artery = Volkmann’s contractures
Compartment syndrome
Median and radial nerve damage

108
Q

Describe the injury pattern leading to and resultant fracture seen in 2 types of distal radial fracture

A

Colles:

  • FOOSH with palm down
  • dorsal displacement and angulation of the distal fragment
  • also get avulsion fracture of ulnar styloid process

Smiths:

  • Fall backwards onto palm or fall forwards onto back on hand
  • volar displacement and angulation of the distal fragment
109
Q

Where does the distal radius fracture?

A

1 inch proximal to the radio-carpal joint

110
Q

What is a Bennetts fracture? and what commonly causes it?

A

Intra-articular fracture of the base of the thumb metatarsal

Due to impact on a flexed metacarpal i.e. fist fights

111
Q

What is a Monteggia’s fracture? What injury pattern leads to it?

A

“MUP”
Ulnar fracture
Proximal radio-ulnar dislocation

FOOSH with pronation

112
Q

What is a Galezzi’s fracture?

A

Radial shaft fracture
Distal radio-ulnar dislocation

FOOSH with rotational force

113
Q

How does a scaphoid fracture present?

A

Pain in the anatomical snuffbox
Pain on axial compression of the thumb
weakness of pincer grip

114
Q

How are scaphoid fractures managed?

A

plaster with a thumb spica splint

115
Q

What is a complication of a scaphoid fracture?

A

AVN and resulting non-union

116
Q

What is carpal tunnel syndrome? What are the contents of the carpal tunnel?

A

Compression of the median nerve within the carpal tunnel

Median nerve
Flexor digitorum profundus x4
Flexor digitorum superficialise x4
Flexor policis longus

117
Q

What is a typical history of someone presenting with carpal tunnel syndrome?

A

tingling over the thumb, 1st and 2nd digits

shaking the hand typically helps

118
Q

What examination findings are seen in carpal tunnel?

A

wasting of the thenar eminence
weak thumb abduction
Tinnels: tapping the nerve causes pain
Phalens: prolonged wrist flexion causes pain

119
Q

What are the risk factors for carpal tunnel syndrome?

A 
Pregnancy
Diabetes
Rheumatoid arthritis 
Trauma 
Malignancy 
Acromegaly 
Hypothyroid
120
Q

How can carpal tunnel syndrome be investigated? What would be the results?

A

Nerve conduction studies would should prolonged motor and sensory action potential

121
Q

How is carpal tunnel syndrome managed?

A

splints
steroid injections
surgery to release the flexor retinaculum

122
Q

What are the causes of Dupuytrens contractures?

A

Alcohol
Trauma
Diabetes
Phenytoin

123
Q

What is Dupuytren’s contacture?

A

fibromatosis of the palmar fascia resulting in a fixed flexion deformity normally of the 4th and 5th digits

124
Q

When and how is Dupuytren’s contracture managed?

A

When they can no longer lay their palm flat on a surface

Fasciectomy

125
Q

What is De’Quervain’s synovitis? Who does it classically present in?

A

inflammation of the sheath containing extensor pollicis brevis and abductor pollicis longus

Females age 30-50

126
Q

What are your examination findings in De’Quervain’s synvoitis?

A

pain on the radial side of the wrist
tender radial styloid process
painful abduction of the thumb against resistance
Positive Finklesteins test
- pull the thumb towards the little finger gives pain over the radial styloid process

127
Q

Describe the Weber classification of ankle fractures. How are each of them managed?

A

a: below the syndesmosis
b: at the syndesmosis
c: above the syndesmosis

a is generally stable so just immobilise but b and c need ORIF

128
Q

What are the Ottowa ankle rules?

A

Medial malleolus pain
+ can’t weight bear for 4 steps
or distal tibia pain
or distal fibular pain

129
Q

What is a sprain?

A

stretching or tear of a ligament

130
Q

Which ankle ligament is most commonly sprained? What injury pattern leads to this?

A

Anterior-talo-fibular

Due to foot inversion injury

131
Q

What are the risk factors for developing Achilles tendon disorders?

A 
Ciprofloxacin 
Hypercholesterolaemia (tendon xanthomata)
132
Q

How does achilles tendonitis present?

A

posterior heel pain worse on activity

morning stiffness

133
Q

How is achilles tendonitis managed?

A

supportive with NSAIDs, rest

eccentric calf muscle exercises

134
Q

What is a typical history of achilles tendon rupture?

A

audible pop
pain in the posterior heel and calf
inability to walk

135
Q

How would you examine a suspected achilles tendon rupture?

A

Simmonds triad:

  • whilst prone with feet hanging off bead the affected foot will be more dorsiflexed
  • feel for a gap in the tendon
  • calf squeeze test - the foot should plantarflex
136
Q

How would you investigate achilles tendon rupture? i.e. what imaging modality?

A

USS

137
Q

How does plantar fasciitis present?

A

heel pain that is worse in the morning and after rest

138
Q

When would you want to refer someone with plantar fasciitis on to ortho?

A

6 months of conservative management

139
Q

Which metatarsal most commonly fractures? What injury pattern would lead to it?

A 
5th 
Inversion injuries (therefore commonly get ankle sprains too)
140
Q

Which metatarsal most commonly sustains a stress fracture?

A

2nd

141
Q

How would you investigate a stress fracture?

A

isotope bone scan or MRI as commonly doesn’t show on x-ray

142
Q

What are the causes of AVN of bone?

A

Trauma and fractures
Steroids
Chemotherapy
Alcoholism

143
Q

What is the gold standard investigation for AVN of bone?

A

MRI

144
Q

What are the causes of gout?

A

Thiazide diuretics

Diet: oily fish and rich meats

145
Q

What is seen on examination of gout?

A

Monoarthritis typically of the MCP, DIP or PIP
Tophi (visible crystal deposits in the skin)
Painful, warm, erythematous joint

146
Q

What are the blood, synovial fluid and and x-ray findings in gout?

A

Blood: raise urate

Synovial fluid: negatively bifringent crystals

x-ray: punched out erosions of the bone with sclerotic margins

147
Q

What is the management of gout? (Immediate and long term)

If someone has co-existing HTN what anti-hypertensive should be used?

A
  1. NSAIDs and 2. colchicine
    Long term: Allopurinol

Losartan (it reduces uric acid)

148
Q

What are ADRs to be aware of for colchicine and allopurinol?

A

colchicine: diarrhoea
allopurinol: bone marrow suppression (don’t give to someone on azathioprine!)

149
Q

Who does pseudogout typically effect? i.e. what are the risk factors

A

Elderly females with OA
Phosphate disorders: hyperparathyroidism, low phoshphate, low Mg
Haemachromatosis
Wilsons

150
Q

How does pseudogout present?

A

Monoarthritis typically of the knee, wrist or shoulder

Painful, warm, swollen, erythematous joint

151
Q

What are the synovial fluid and x-ray findings in pseudogout?

A

Synovial fluid: Positively bifringent crystals

x-ray findings: calcifications of the meniscus and articular cartilage (white horizonal lines in the joint space)

152
Q

How is pseudogout managed?

A

Rule out septic arthritis

Intra-articular steroid injections

153
Q

What are the causes of lytic and sclerotic bone metastasis

A

Lytic: (paired organs) lung, breast, kidney, thyroid

Sclerotic: prostate

154
Q

What is osteoporosis, osteopenia and osteomalacia?

A

osteoporosis is reduced bone mineral density with a T score

155
Q

Who should undergo assessment for osteoporosis (including the risk factors for osteoporosis)?

How is this assessment done?

A 
Women >65
Men >75
Younger people with a risk factor: 
- prolonged steroid use
- BMI <18.5
- smoker
- excessive alcohol intake
- Cushings, hyperthyroid, CKD, RA
- FH of hip fracture
- personal history of fragility fracture

FRAX score

156
Q

What is a FRAX score? What does the FRAX score take in to consideration?

A

It assesses the 10 year risk of getting a fragility fracture

age, height, weight and risk factors for osteoporosis

157
Q

Describe the management of a low, intermediate and high FRAX score

A

low: reassure
intermediate: DEXA scan
high: treat

158
Q

A patient has a fragility fracture… what do you do next?

A

> 75 = treat
<75 = DEXA scan
If the DEXA scan gives a T score

159
Q

How is osteoporosis managed?

A

Everyone should have calcium and vit D +

  1. alendronate
  2. risedronate or etidronate
  3. specialists can start Denosumab, strontium ranelate or Raloxifene (SERM)
160
Q

What are the side effects of bisphosphonates?

A
  • gastrointestinal upset and oesophagitis
  • osteonecrosis of the jaw
  • atypical femur fractures
  • myalgia
161
Q

What is a fragility fracture?

A

fracture resulting from a force that would not normally cause a fracture

162
Q

What are the signs and symptoms of an osteoporotic vertebral fracture?

A

Acute back pain and localised tenderness
Loss of height (vertebrae collapses)
Kyphosis
Associated respiratory and gastrointestinal symptoms relating to compression with altered spine shape

163
Q

Describe the x-ray appearance of osteoporotic vertebral fractures

A

wedge shaped vertebrae where it has collapsed

sclerotic appearance indicating previous fractures

164
Q

A patient is diagnosed with PMR and is going to be on long term steroids, what do you also need to prescribe?

A

bone protection straight away do not wait for 3 months

165
Q

What is a T score and what is a Z score?

A

T score: based on bone mass of young reference population

Z score: adjusted for the patients age, gender and ethnicity

166
Q

In summary how can a patient end up on bisphosphonates for osteoporosis?

A

> 75 with a fragility fracture
<75 with a fragility fracture and positive DEXA
High risk FRAX score
Intermediate risk FRAX score and positive DEXA
Known to be on steroids for >3 months

167
Q

When does Rickets become osteomalacia?

A

When the epiphysis fuse

168
Q

What are the causes of osteomalacia?

A

Reduced Vit D (sun, diet, absorption)
CKD
Anticonvulsants

169
Q

How does osteomalacia present?

A

Bone pain
Fractures
Muscle tenderness
Proximal myopathy

170
Q

What are the blood results of osteomalacia?

A

Low calcium, vit D, phosphate

Raised ALP

171
Q

How is osteomalacia managed?

A

Vit D and calcium

172
Q

What is the pathophysiology of Pagets disease?

A

increased osteoclast and osteoblast activity = increased bone turnover = remodelling = bone enlargement, deformity and weakness

173
Q

How can paget’s disease present?

What classical blood results is seen?

A

Bone pain and deformity
If it affects the skull then CN trapping = deaf

Raised ALP

174
Q

How is Paget’s disease managed?

A

Bisphosphonates

175
Q

What is osteogenesis imperfecta?

A

AD disorder of collage metabolism

176
Q

What are the signs and symptoms of osteogenesis imperfecta?

A

Fractures
blue sclera
otosclerosis = deaf
dental imperfections

177
Q

What are the blood results of osteogenesis imperfecta?

A

PTH, Calcium, and phosphate are all typically normal

178
Q

What is an ADR of hydroxychloroquine and therefore what do you need to ask about on follow up?

A

Bull’s eye retinopathy so ask about vision

179
Q

How do bone tumours typically present?

A

deep aching bone pain that is worse at night

180
Q

What is Marfan syndrome?

A

AD defect in fibrillin protein

181
Q

What are the features of Marfan syndrome?

A 
Tall stature
Scoliosis
High arch palate
pectus excavatum
dilated aortic sinus = regurg, dissection and aneurysm
mitral valve prolapse
182
Q

What is osteoarthritis?

A

Cartilaginous loss with inflammation and periarticular bone response involving the synovial joint

183
Q

What are the x-ray findings of osteoarthritis?

A
  • reduced joint space
  • osteophytes
  • subchondral cysts
  • subarticular sclerosis (from attempts at bone repair and remodelling)
184
Q

What is the management of osteoarthritis?

A

lifestyle: weight loss, muscle strengthening exercises, general aerobic fitness

analgesia:

  1. paracetamol and topical NSAIDs
  2. oral NSAIDs, opioids, capsaicin cream

adjuvants:
intra-articular corticosteroids
TENS

185
Q

Osteoarthritis of what joints would indicate treatment with topical NSAIDs?

A

Knee and hand

186
Q

What advice is given to hip replacement patients to minimise the risk of dislocation?

A

don’t flex more than 90 degrees
lie flat on their back for 6 weeks post-op
do not cross legs

187
Q

What are the complications of joint replacement for osteoarthritis?

A 
VTE
inta-operative fractures
nerve damage
dislocation 
infection
188
Q

When would a revision of a joint replacement be indicated?

A

aseptic loosening of the joint
dislocation
infection

189
Q

How does hip OA present?

A

groin pain after exercise that is relieved by rest

restricted internal rotation

190
Q

What are some red flag features that would make you consider an alternative diagnosis to OA?

A

Morning stiffness >2 hours
Pain that wakes the patient at night
Pain at rest

191
Q

Which hand joints are most commonly affected by OA?

A

CMCs and DIPs

CMC of the thumb giving a squared off appearance and fixed adduction

192
Q

How does hand OA present?

A

Bilateral
One joint at a time with worsening over years
Pain provoked by movement and relieved by rest
Painless swellings: Bouchards (PIP) and Heberdens (DIP) nodes

193
Q

Which discs more commonly herniate?

A

L4/L5 and L5/S1

194
Q

Compare an L4/L5 disc herniation and a L5/S1 herniation

A

L4/L5 compresses L5

  • positive sciatic nerve stretch test
  • intact reflexes
  • sensation loss to dorsum of food
  • weak hip abduction and foot drop

L5/S1 compresses S1

  • positive sciatic nerve stretch test
  • loss of ankle jerk reflex
  • sensation loss to posterolateral leg/foot
  • weak plantar flexion
195
Q

How would an L3 and L4 nerve compression present?

A 
BOTH
- positive femoral nerve stretch test
- reduced knee reflex
- weak quadriceps 
L3
- reduced sensation over the knee
L4
- reduced sensation over anterior thigh
196
Q

How are disc herniations managed? At what point should referral be considered?

A

NSAIDs
physio
at 4-6 weeks of conservative management consider referral for MRI

197
Q

What can cause spinal stenosis?

How does it present?

A

Ligamentum flavum hypertrophy
osteophytes
tumour

Presentation: neurogenic claudication (relieved by walking up hill, can cycle), tingling and numbness

198
Q

What is facet joint syndrome?

A

degeneration of the facet joints

199
Q

How does facet joint syndrome present?

A

lower back pain worse on back extension

tender on palpation

200
Q

What are some differentials for lower back pain?

A

disc herniation
ankylosing spondylosis
facet joint syndrome
spinal stenosis

201
Q

What organism most commonly causes discitis?

A

staph aureus

202
Q

What are the hallmark features of discitis?

A

fever + back pain + LL neurology

203
Q

How should discitis be investigated? Aside from this imaging what else do you need to investigate?

A

MRI

Need to do echo to check for infection endocarditis as this could be the cause of the discitis

Finals (16 decks)

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