Orthopaedics Flashcards
1
Q
What is compartment syndrome?
A
Raised pressure (>40 for diagnosis) within a fixed fascial space
2
Q
Which fractures most commonly lead to compartment syndrome?
A
tibial shaft
supracondylar
crush injuries
3
Q
How does compartment syndrome present?
A
Pain even on passive movement Pallor Paraesthesia Perishingly cold Pulseless Paralysis
4
Q
What is the management of compartment syndrome?
A
Fasciotomies
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
6
Q
What is osteomyelitis?
A
Infection of the bone marrow which can spread to the cortex and periosteum via the Harversian canals
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
8
Q
How does osteomyelitis present?
A
Fever
Pain
Warm, red limb
Immobility of the limb
9
Q
What is the management of osteomyelitis?
A
Flucloxacillin
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)
11
Q
What is the gold standard investigation for osteomyelitis?
A
MRI
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
13
Q
How does septic arthritis present? Which joint is most often affected?
A
Often the knee
Fever
Hot, swollen, erythematous
Limp, pain, immobile
14
Q
How is septic arthritis managed?
A
drainage of the joint using needle aspiration
Flucloxacillin (often for 6 weeks)
15
Q
What organism often causes septic arthritis in young adults?
A
Neisseria gonorrhoea due to disseminated gonococcal disease
16
Q
How is septic arthritis investigated?
A
Synovial fluid sampling prior to abx
blood cultures
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
18
Q
How does flexor tenosynovitis present?
A
Kanavel's cardinal signs: Fixed flexion Pain on passive extension Fusiform swelling Tender
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
20
Q
What is the cauda equina?
A
The nerve roots caudal to the conus medularis
21
Q
What causes cauda equina syndrome?
A
Hernaition at L4/L5 or L5/S1
tumour
abscess
trauma
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)
23
Q
How is suspected cauda equina syndrome investigated?
A
MRI
24
Q
How is cauda equina syndrome managed?
A
Immediate decompression
25
Someone comes to ED with an open fracture: what needs to be done?
```
Take a photo
Remove any obvious foreign bodies
Cover with warm saline gauze
Antibiotics
Tetanus booster
Check the neurovascular status
```
26
What is the definition of an open fracture
Any fracture with associated breach of the overlying skin
27
What in the history would raise your suspicions for NAI?
What specific fractures are typical of NAI?
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
28
Talk through presenting a fracture x-ray
```
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
```
29
What are the types of comminuted fracture?
butterfly: 2 oblique fractures leave a bone fragment like a butterfly wing
segmental: distal and proximal fracture leaving a segment inbetween
30
Describe secondary fracture healing (very briefly)
1. haematoma formation
2. fibrocartilaginous callus formation
3. ossification to form a bony callus
4. remodelling
31
What impairs bone healing?
Smoking (inhibits osteoblasts and nicotinic vasospasms reduce blood supply to heal)
Diabetes
NSAIDs
calcium and vit D deficiency
32
Compare a Buckle/Torus fracture with a greenstick fracture
Buckle: periosteal haematoma only. Although the cortex bulges there is no distinct fracture line
Greenstick: unilateral cortical breach
33
What is the Salter Harris classification for?
Describing fractures across the growth plates
34
Describe the fractures of the Salter Harris classification
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
35
At what ages do the various points at the elbow ossify?
CRITOL
1: capitulum
3: radial head
5: internal (medial) epicondyle
7: trochlear
9: olecranon
11: lateral epicondyle
36
What is a bakers cyst? What causes them?
Swelling of the gastrocnemius semi-membranous bursa
In children: idiopathic
In adults: secondary to osteoarthritis
37
How does a bakers cyst present?
swelling behind the knee
| Rupture: can present very similarly to a DVT
38
Describe the associations of prepatella and infrapatella bursitis.
prepatella/ housemades - upright kneeling
| infrapatella/clergymans - kneeling
39
What mechanisms lead to the 2 types of tibial plateau fracture?
varus force leads to medial condyl fracture
| valgus forces leads to lateral condyl fracture
40
How are tibial plateau fractures classified? Briefly describe this classification.
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
41
Describe the injury pattern leading to an ACL and a PCL tear
ACL: twisting action whilst in slight flexion
PCL: hyperextension or dashboard injuries
42
How is a PCL tear diagnosed?
paradoxical anterior draw test
| O/E the tibia lies back on the femur
43
How does an ACL tear present?
Loud clunking noise
Rapid hemarthrosis and swelling
Pain
Feeling the knee will give way
44
What injury pattern leads to a meniscus tear?
rotational often during sport
45
How does a meniscus tear present?
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
46
What is McMurray's test? What is Thessaly's test?
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
47
What is a typical chrondomalacia patellae history?
Teenage girl
Knee pain worse on walking downstairs and at rest
Quadriceps wasting
48
What is Osgood-Schlatter disease?
Multiple microfractures at the point of tendon insertion to the tibial tuberosity
49
How does Osgood-Schlatter disease present?
Tender tibial tuberosity
Pain worse on activity
Swelling
50
What investigation is required to diagnose a dislocated patella?
Skyline x-ray views
51
What is the unhappy triad of knee injuries?
Anterior cruciate ligament
Medial collateral ligament
Meniscus (classically medial but can be lateral)
52
What is osteochondritis dissecans?
AVN of subchondral bone (often knee) with secondary effects on the joint cartilage
53
How does osteochondritis dissecans present?
Often teenagers and males
- knee pain and swelling after exercise
- clunk on flexing or extending the knee
- feeling of locking or giving way
54
How is osteochondritis dissecans investigated? What are the results of these?
X-ray
- subchondral crescent sign
- loose bodies
MRI
55
Compare the presentation of an anterior vs posterior hip dislocation
posterior (most common): shortened, internally rotated, adducted
anterior: no change in limb length, externally rotated, abducted
56
How are hip dislocations managed?
Relocation with 4 hours
57
What are the complications of hip dislocations?
ANV of the femoral head
Damage to the sciatic or femoral nerve
osteoarthritis
recurrent dislocation due to ligament weakness
58
How does a hip fracture present?
Shortened and externally rotated
59
Describe the anatomical locations of various type of hip fracture
Intracapsular: anywhere from femoral head to point of capsular attachment
Extracapsular:
- intertrochanteric (above the lesser trochanter)
- subtrochanteric (below the lesser trochanter)
60
What system is used to classify hip fractures? What are the 4 types?
Garden system
1: incomplete
2: complete
3: displaced but still in bony contact
4: complete displacement
61
How are extracapsular hip fractures managed?
intertrochanteric: dynamic hip screw
subtrochanteric: intermedullary nail
62
How are intracapsular hip fractures managed?
young and fit: reduction and internal fixation if possible
old and generally immobile: hemiarthroplasty
63
What is a complication of a hip fracture?
AVN due to disruption of the medial circumflex artery
64
How does hip osteoarthritis most commonly first present?
inability to internally rotate the hip
65
What is greater trochanteric pain syndrome?
repeated friction of the iliotibial band leading to trochanteric bursitis
66
How does greater trochanteric pain syndrome present?
Often females age 50-70
| pain on the lateral thigh over the greater trochanter
67
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?
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
68
What x-ray findings would be seen in hip AVN?
osteopenia
microfractures
collapse of the articular surface = crescent sign
69
What x-ray findings would be seen in hip AVN?
osteopenia
microfractures
collapse of the articular surface = crescent sign
70
What does superior gluteal nerve damage lead to?
Trendelenburg
The contralateral hip will drop as the nerve innervates the ipsilateral gluteus medius and minimus to contract and stabilise the hip
71
How does an ilipsoas abscess present?
fever + limp+ back pain
| Pain is worse on hip extension so they lie with their hip flexed
72
What are the risk factors for iliopsoas abscess?
IVDU
Crohns and diverticulitis
Vertebral osteomyelitis
73
What is painful arc formerly known as? What is it?
supraspinatus tendinitis
It is in the spectrum of rotator cuff injuries and involves subacromial space narrowing leading to impingement of the supraspinatus tendon
74
How does supraspinatus tendonitis/painful arc present?
Painful abduction especially 60-120
Painful flexion
Tenderness over the anterior acromion
75
How is supraspinatus tendonitis managed?
NSAIDs and steroid injections
| physio
76
Who does adhesive capsulitis most commonly affect?
Middle age females
| Diabetics (20% of diabetics will get it at some point)
77
What are the stages of adhesive capsulitis? What are the symptoms at these stages?
Freezing:
-pain and stiffness on external rotation (+abduction)
Frozen:
- less pain but limited active and passive ROM
Thawing:
- symptoms improve over years
78
How is adhesive capsulitis managed?
NSAIDs and steroid injections
| physio
79
Compare the pain in supraspinatus tendonitis to a rotator cuff tear.
supraspinatus tendonitis: 60-120
rotator cuff tear: <60
Both of them you get pain over the anterior acromion
80
How do rotator cuff tears present?
Painful abduction
| No limitation to passive movement
81
What is a long term complication of rotator cuff injuries? Why does this happen?
Early shoulder OA
| The humeral head migrates superiorly and therefore impacts on the glenohumeral joint leading to friction and OA
82
Where does the humerus most commonly fracture?
surgical neck
83
What are some complications of humeral fractures?
proximal: axillary nerve damage, AVN (ant. humeral circumflex)
shaft: radial nerve damage
84
When does the shoulder classically not dislocate anteriorly as normal?
epilepsy
| electric shocks
85
What are some concomitant injuries seen alongside shoulder dislocations?
avulsion of the glenoid labrum
avulsion of the glenohumeral ligament
fractures of the humerus
86
What are some complications of shoulder dislocations?
axillary nerve damage, rotator cuff injury, greater tuberosity fracture, early arthritis
87
What injury mechanism leads to anterior shoulder dislocations?
excessive external rotation and extension
88
How do shoulder dislocations present?
patient will hold their arm up
| Step off deformity seen at the acromion
89
How does an anterior shoulder dislocation appear on x-ray? Compare this to how a posterior dislocation looks.
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
Which tendon of the biceps most commonly ruptures?
long
91
What are the risk factors for a biceps tendon rupture?
heavy lifting
elderly
steroids
smoking
92
How does biceps tendon rupture present?
Which movement will they have difficulty performing?
```
audible pop
pain
- long head = pain in shoulder
- distal tendon = pain in ACF
swelling
pop-eye deformity
```
difficulty in supination
93
What is thoracic outlet syndrome?
compression of the brachial plexus (neurogenic TOS) or subclavian artery/vein (vascular TOS) at the sight of the thoracic outlet
94
What factors increase the likelihood of developing thoracic outlet syndrome/what are the causes?
typically younger thin women with long necks
preceding neck trauma
cervical rib
scalene muscle hypertrophy
95
Thoracic outlet syndrome can be neurogenic or vascular, describe how these would present?
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
How is thoracic outlet syndrome managed?
conservatively i.e. with physio, rehab and taping
97
What is the fat pad sign, which fractures is it seen in?
Intra-articular fracture leads to joint effusion which can be seen on the x-ray
Seen in proximal radius and supracondylar fractures
98
Compare the pain associated with medial and lateral epicondylitis
medial: pain worse on wrist flexion and pronation
lateral: pain worse on wrist extension and supination
99
Radial tunnel syndrome presents similarly to lateral epicondylitis, how could you differentiate them?
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
What is cubital tunnel syndrome and how does it present?
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
How does olecranon bursitis present?
swelling over the posterior aspect of the elbow associated with pain
102
Which way does the elbow commonly dislocate? Therefore what is the structure most at risk of damage?
Posteriorly i.e. the ulnar sits posterior to the humerus
| The ulnar nerve is stretched
103
Where does the clavicle most commonly fracture?
the middle 1/3 segment
104
What structures are at risk of being damaged in a clavicle fracture?
Subclavian artery and vein
Brachial plexus
lung - pneumothorax
105
What is a "pulled elbow"? How does it present?
the radial head slips out of the annular ligament
| The child will be unwilling to use their arm
106
How does a supracondylar fracture present and what is seen on x-ray?
++ swelling
fat pad sign
The anterior humerus should normally dissect the middle 1/3 of the capitulum, in fractures this line sits anteriorly
107
What are the complications of a supracondylar fracture?
Anterior interosseous nerve damage (check they can perform the OK sign)
Brachial artery = Volkmann's contractures
Compartment syndrome
Median and radial nerve damage
108
Describe the injury pattern leading to and resultant fracture seen in 2 types of distal radial fracture
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
Where does the distal radius fracture?
1 inch proximal to the radio-carpal joint
110
What is a Bennetts fracture? and what commonly causes it?
Intra-articular fracture of the base of the thumb metatarsal
| Due to impact on a flexed metacarpal i.e. fist fights
111
What is a Monteggia's fracture? What injury pattern leads to it?
"MUP"
Ulnar fracture
Proximal radio-ulnar dislocation
FOOSH with pronation
112
What is a Galezzi's fracture?
Radial shaft fracture
Distal radio-ulnar dislocation
FOOSH with rotational force
113
How does a scaphoid fracture present?
Pain in the anatomical snuffbox
Pain on axial compression of the thumb
weakness of pincer grip
114
How are scaphoid fractures managed?
plaster with a thumb spica splint
115
What is a complication of a scaphoid fracture?
AVN and resulting non-union
116
What is carpal tunnel syndrome? What are the contents of the carpal tunnel?
Compression of the median nerve within the carpal tunnel
Median nerve
Flexor digitorum profundus x4
Flexor digitorum superficialise x4
Flexor policis longus
117
What is a typical history of someone presenting with carpal tunnel syndrome?
tingling over the thumb, 1st and 2nd digits
| shaking the hand typically helps
118
What examination findings are seen in carpal tunnel?
wasting of the thenar eminence
weak thumb abduction
Tinnels: tapping the nerve causes pain
Phalens: prolonged wrist flexion causes pain
119
What are the risk factors for carpal tunnel syndrome?
```
Pregnancy
Diabetes
Rheumatoid arthritis
Trauma
Malignancy
Acromegaly
Hypothyroid
```
120
How can carpal tunnel syndrome be investigated? What would be the results?
Nerve conduction studies would should prolonged motor and sensory action potential
121
How is carpal tunnel syndrome managed?
splints
steroid injections
surgery to release the flexor retinaculum
122
What are the causes of Dupuytrens contractures?
Alcohol
Trauma
Diabetes
Phenytoin
123
What is Dupuytren's contacture?
fibromatosis of the palmar fascia resulting in a fixed flexion deformity normally of the 4th and 5th digits
124
When and how is Dupuytren's contracture managed?
When they can no longer lay their palm flat on a surface
Fasciectomy
125
What is De'Quervain's synovitis? Who does it classically present in?
inflammation of the sheath containing extensor pollicis brevis and abductor pollicis longus
Females age 30-50
126
What are your examination findings in De'Quervain's synvoitis?
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
Describe the Weber classification of ankle fractures. How are each of them managed?
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
What are the Ottowa ankle rules?
Medial malleolus pain
+ can't weight bear for 4 steps
or distal tibia pain
or distal fibular pain
129
What is a sprain?
stretching or tear of a ligament
130
Which ankle ligament is most commonly sprained? What injury pattern leads to this?
Anterior-talo-fibular
| Due to foot inversion injury
131
What are the risk factors for developing Achilles tendon disorders?
```
Ciprofloxacin
Hypercholesterolaemia (tendon xanthomata)
```
132
How does achilles tendonitis present?
posterior heel pain worse on activity
| morning stiffness
133
How is achilles tendonitis managed?
supportive with NSAIDs, rest
| eccentric calf muscle exercises
134
What is a typical history of achilles tendon rupture?
audible pop
pain in the posterior heel and calf
inability to walk
135
How would you examine a suspected achilles tendon rupture?
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
How would you investigate achilles tendon rupture? i.e. what imaging modality?
USS
137
How does plantar fasciitis present?
heel pain that is worse in the morning and after rest
138
When would you want to refer someone with plantar fasciitis on to ortho?
6 months of conservative management
139
Which metatarsal most commonly fractures? What injury pattern would lead to it?
```
5th
Inversion injuries (therefore commonly get ankle sprains too)
```
140
Which metatarsal most commonly sustains a stress fracture?
2nd
141
How would you investigate a stress fracture?
isotope bone scan or MRI as commonly doesn't show on x-ray
142
What are the causes of AVN of bone?
Trauma and fractures
Steroids
Chemotherapy
Alcoholism
143
What is the gold standard investigation for AVN of bone?
MRI
144
What are the causes of gout?
Thiazide diuretics
| Diet: oily fish and rich meats
145
What is seen on examination of gout?
Monoarthritis typically of the MCP, DIP or PIP
Tophi (visible crystal deposits in the skin)
Painful, warm, erythematous joint
146
What are the blood, synovial fluid and and x-ray findings in gout?
Blood: raise urate
Synovial fluid: negatively bifringent crystals
x-ray: punched out erosions of the bone with sclerotic margins
147
What is the management of gout? (Immediate and long term)
If someone has co-existing HTN what anti-hypertensive should be used?
1. NSAIDs and 2. colchicine
Long term: Allopurinol
Losartan (it reduces uric acid)
148
What are ADRs to be aware of for colchicine and allopurinol?
colchicine: diarrhoea
allopurinol: bone marrow suppression (don't give to someone on azathioprine!)
149
Who does pseudogout typically effect? i.e. what are the risk factors
Elderly females with OA
Phosphate disorders: hyperparathyroidism, low phoshphate, low Mg
Haemachromatosis
Wilsons
150
How does pseudogout present?
Monoarthritis typically of the knee, wrist or shoulder
| Painful, warm, swollen, erythematous joint
151
What are the synovial fluid and x-ray findings in pseudogout?
Synovial fluid: Positively bifringent crystals
x-ray findings: calcifications of the meniscus and articular cartilage (white horizonal lines in the joint space)
152
How is pseudogout managed?
Rule out septic arthritis
| Intra-articular steroid injections
153
What are the causes of lytic and sclerotic bone metastasis
Lytic: (paired organs) lung, breast, kidney, thyroid
Sclerotic: prostate
154
What is osteoporosis, osteopenia and osteomalacia?
osteoporosis is reduced bone mineral density with a T score
155
Who should undergo assessment for osteoporosis (including the risk factors for osteoporosis)?
How is this assessment done?
```
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
What is a FRAX score? What does the FRAX score take in to consideration?
It assesses the 10 year risk of getting a fragility fracture
age, height, weight and risk factors for osteoporosis
157
Describe the management of a low, intermediate and high FRAX score
low: reassure
intermediate: DEXA scan
high: treat
158
A patient has a fragility fracture... what do you do next?
>75 = treat
<75 = DEXA scan
If the DEXA scan gives a T score
159
How is osteoporosis managed?
Everyone should have calcium and vit D +
1. alendronate
2. risedronate or etidronate
3. specialists can start Denosumab, strontium ranelate or Raloxifene (SERM)
160
What are the side effects of bisphosphonates?
- gastrointestinal upset and oesophagitis
- osteonecrosis of the jaw
- atypical femur fractures
- myalgia
161
What is a fragility fracture?
fracture resulting from a force that would not normally cause a fracture
162
What are the signs and symptoms of an osteoporotic vertebral fracture?
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
Describe the x-ray appearance of osteoporotic vertebral fractures
wedge shaped vertebrae where it has collapsed
| sclerotic appearance indicating previous fractures
164
A patient is diagnosed with PMR and is going to be on long term steroids, what do you also need to prescribe?
bone protection straight away do not wait for 3 months
165
What is a T score and what is a Z score?
T score: based on bone mass of young reference population
| Z score: adjusted for the patients age, gender and ethnicity
166
In summary how can a patient end up on bisphosphonates for osteoporosis?
>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
When does Rickets become osteomalacia?
When the epiphysis fuse
168
What are the causes of osteomalacia?
Reduced Vit D (sun, diet, absorption)
CKD
Anticonvulsants
169
How does osteomalacia present?
Bone pain
Fractures
Muscle tenderness
Proximal myopathy
170
What are the blood results of osteomalacia?
Low calcium, vit D, phosphate
| Raised ALP
171
How is osteomalacia managed?
Vit D and calcium
172
What is the pathophysiology of Pagets disease?
increased osteoclast and osteoblast activity = increased bone turnover = remodelling = bone enlargement, deformity and weakness
173
How can paget's disease present?
What classical blood results is seen?
Bone pain and deformity
If it affects the skull then CN trapping = deaf
Raised ALP
174
How is Paget's disease managed?
Bisphosphonates
175
What is osteogenesis imperfecta?
AD disorder of collage metabolism
176
What are the signs and symptoms of osteogenesis imperfecta?
Fractures
blue sclera
otosclerosis = deaf
dental imperfections
177
What are the blood results of osteogenesis imperfecta?
PTH, Calcium, and phosphate are all typically normal
178
What is an ADR of hydroxychloroquine and therefore what do you need to ask about on follow up?
Bull's eye retinopathy so ask about vision
179
How do bone tumours typically present?
deep aching bone pain that is worse at night
180
What is Marfan syndrome?
AD defect in fibrillin protein
181
What are the features of Marfan syndrome?
```
Tall stature
Scoliosis
High arch palate
pectus excavatum
dilated aortic sinus = regurg, dissection and aneurysm
mitral valve prolapse
```
182
What is osteoarthritis?
Cartilaginous loss with inflammation and periarticular bone response involving the synovial joint
183
What are the x-ray findings of osteoarthritis?
- reduced joint space
- osteophytes
- subchondral cysts
- subarticular sclerosis (from attempts at bone repair and remodelling)
184
What is the management of osteoarthritis?
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
Osteoarthritis of what joints would indicate treatment with topical NSAIDs?
Knee and hand
186
What advice is given to hip replacement patients to minimise the risk of dislocation?
don't flex more than 90 degrees
lie flat on their back for 6 weeks post-op
do not cross legs
187
What are the complications of joint replacement for osteoarthritis?
```
VTE
inta-operative fractures
nerve damage
dislocation
infection
```
188
When would a revision of a joint replacement be indicated?
aseptic loosening of the joint
dislocation
infection
189
How does hip OA present?
groin pain after exercise that is relieved by rest
| restricted internal rotation
190
What are some red flag features that would make you consider an alternative diagnosis to OA?
Morning stiffness >2 hours
Pain that wakes the patient at night
Pain at rest
191
Which hand joints are most commonly affected by OA?
CMCs and DIPs
| CMC of the thumb giving a squared off appearance and fixed adduction
192
How does hand OA present?
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
Which discs more commonly herniate?
L4/L5 and L5/S1
194
Compare an L4/L5 disc herniation and a L5/S1 herniation
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
How would an L3 and L4 nerve compression present?
```
BOTH
- positive femoral nerve stretch test
- reduced knee reflex
- weak quadriceps
L3
- reduced sensation over the knee
L4
- reduced sensation over anterior thigh
```
196
How are disc herniations managed? At what point should referral be considered?
NSAIDs
physio
at 4-6 weeks of conservative management consider referral for MRI
197
What can cause spinal stenosis?
| How does it present?
Ligamentum flavum hypertrophy
osteophytes
tumour
Presentation: neurogenic claudication (relieved by walking up hill, can cycle), tingling and numbness
198
What is facet joint syndrome?
degeneration of the facet joints
199
How does facet joint syndrome present?
lower back pain worse on back extension
| tender on palpation
200
What are some differentials for lower back pain?
disc herniation
ankylosing spondylosis
facet joint syndrome
spinal stenosis
201
What organism most commonly causes discitis?
staph aureus
202
What are the hallmark features of discitis?
fever + back pain + LL neurology
203
How should discitis be investigated? Aside from this imaging what else do you need to investigate?
MRI
| Need to do echo to check for infection endocarditis as this could be the cause of the discitis
