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ORTHOPAEDICS Flashcards

1
Q

What are some risk factors for poor fracture healing?

A
  • older age
  • comorbidities (especially DM)
  • recent trauma
  • smoker
  • osteoporosis
  • corticosteroids
  • NSAIDs
  • local fracture complications
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2
Q

What are the steps involved in describing x-rays?

A
  1. Site of fracture - which bone/which part of bone
  2. Type of fracture - transverse, oblique, spiral
  3. Simple or comminuted
  4. Displaced or not
  5. Angulated or not - comment on direction of distal fracture
  6. Is bone normal consistency or is there signs of pathology?
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3
Q

What will the bone profile be like in osteomalacia/rickets?

A

Raised ALP
Ca, phosphate normal or low
- Vitamin D low by definition

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4
Q

What will the bone profile be like in bony mets?

A

Raised ALP

- Ca + phosphate raised/normal

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5
Q

What are the causes of hypercalcaemia with a raised phosphate?

A

RAISED ALP:

  • bony mets
  • sarcoidosis
  • thyrotoxicosis
  • lithium

NORMAL ALP:

  • myeloma
  • hypervitaminosis D
  • sarcoid
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6
Q

What are the causes of hypercalcaemia with a normal/low phosphate?

A
  • primary or tertiary hyperPTH
  • familial benign hypercalciuria
  • paraneoplastic-PTHrp
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7
Q

What will ECG show in hypercalcaemia?

A

short QT interval

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8
Q

How is hypercalcaemia managed?

A

Find + treat underlying cause

  1. REHYDRATE
    - 1L 0.9% NaCl over 4h
    - monitor hydration status
  2. FRUSEMIDE
    - start when pt volume replete
    - use with caution
  3. BISPHOSPHONATES
    - only if malignancy is cause
    - zolendronic acid infusion
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9
Q

What is the most common type of shoulder dislocation?

A

Anterior

- common in young males playing sport who have forced arm into abduction, extension + external rotation

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10
Q

What is a Colles’ Fracture?

A

extra-articular fracture of distal radius with dorsal displacement of distal radius
- dinner fork deformity

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11
Q

What is the most common scaphoid fracture type?

A

scaphoid

  • associated with FOOSH
  • AVN is serious complication
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12
Q

What does a shortened, externally rotated leg imply?

A

Neck of Femur Fracture

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13
Q

How do you manage an undisplaced intracapsular fracture?

A

Internal fixation with DHS

- if major illness do hemiarthroplasty

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14
Q

How do you manage a displaced intracapsular fracture?

A

If aged under 70 = internal fixation
If over 70 = total arthroplasty

If major/immobile do hemiarthroplasty

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15
Q

What are the symptoms of fat embolism? When does it tend to occur?

A

Usually 3-10 days post-long bone fracture.

  • altered mental status
  • pyrexia, SOB, tachycardia
  • petechial rash
  • subconjunctival + oral haemorrhage
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16
Q

What does pain on passive muscle stretching indicate?

A

Compartment syndrome

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17
Q

What does a positive scarf test indicate?

A

ACJ OA

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18
Q

What are the risk factors for osteoporosis? HINT: shattered.

A 
S - Steroids
H - Hyperthyroid, Hyperparathyroid, Hypercalcaemia
A - Alcohol excess
T - Thin (BMI below 22)
T - Testosterone reduced 
E - Early menopause 
R - Renal/Liver failure
E - Erosive or Inflammatory arthritis 
D - Dietary calcium low, malabsorption, T1DM
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19
Q

If some has osteoporosis, what treatment is there?

A 
LIFESTYLE
- STOP smoking + reduce alcohol
- weight bearing exercise
- balance exercises to reduce falls
- calcium + vitamin D rich diets
- falls prevention programme
PHARMACOLOGICAL
- bisphosphonates (alendronate)
- calcium + vit D 
- HRT
- strontium ranelate
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20
Q

What is the difference between rickets + osteomalacia?

A

Rickets is when growing

Osteomalacia after epiphyses have fused

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21
Q

What is the difference between osteoporosis + osteomalacia?

A

In osteoporosis, bones are brittle + porous
- mineral to collagen ratio is normal
In osteomalacia, they are soft
- mineral to collagen ratio is reduced

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22
Q

What are the typical features of Rickets?

A

knock-knee
bow leg
features of hypocalcaemia

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23
Q

How do you manage osteomalacia/rickets?

A

Calcium with vitamin D tablets

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24
Q

What is Paget’s disease?

A

Increased bone turnover

  • disorder of osteoclasts with excessive osteoclast resorption followed by increased osteoblast activity
  • common but only symptomatic in 1 in 20mins
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25
Q

What is the typical presentation of Paget’s?

A

Older male with bone pain + isolated rise in ALP

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26
Q

How do you manage Paget’s?

A

No cure - but treatment can help relieve symptoms
Bisphosphonates or calcitonin can be given
- Supportive therapies e.g. physio, OT, walking stick, orthotics, brace for spine

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27
Q

What is multiple myeloma a cancer of?

A

Plasma cells

- type of B lymphocyte that produces antibodies

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28
Q

What are the symptoms of multiple myeloma?

A
  1. Backache + bone pain
    - pathological #s + vertebral collapse
  2. BM infiltration = anaemia, neutropenia, thrombocytopenia
  3. Renal disease = AKI
    - hypercalcaemia
  4. Hyper-viscosity = easy bruising/bleeding or reduced/loss of sight
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29
Q

What investigations should be performed in multiple myeloma? What will they show?

A
  1. FBC - anaemia
  2. Raised Ca + normal ALP
  3. Raised ESR
  4. Serum electrophoresis + serum immunoglobulins
  5. Bence-jones protein on urine electrophoresis

BM Trephine biopsy is essential for diagnosis

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30
Q

What complications can arise as a result of multiple myeloma? How do you treat them?

A
  1. Hypercalcaemia
    - IV fluids, bisphosphonates, frusemide
  2. Cord Compression
    - MRI, dex + radiotherapy
  3. Hyperviscocity
    - plasmapheresis
  4. AKI
    - rehydration + dialysis
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31
Q

How do you manage mechanical back pain? What is its typical course?

A

Self-limiting, 70% recover within 3-weeks + 90% by 6-weeks

  • 50% experience another ep w/in 1 year
    1. Pain relief - paracetamol + ibuprofen
    2. Exercise to improve function, rest for only 48h
    3. Lifestyle to prevent recurrence
    4. Psychosocial issues
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32
Q

What are the most common levels of lumbar disc prolapse?

A

L4/L5 disc

L5/S1 disc

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33
Q

What is Lasegue’s sign positive? What condition does it suggest?

A

Pain on straight leg raise

- indicative of lumbar disc prolapse

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34
Q

What signs/symptoms will pts have in L4/L5 compression? HINT L5 compression

A
  • weak ankle dorsiflexion (test by having walk on heels)
  • weak foot inversion
  • Decreased sensation on dorsum of foot
  • reflexes intact!!!
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35
Q

What signs/symptoms will pts have in L5/S1 compression? HINT S1 compression.

A
  • Sensory loss sole of foot + back of calf
  • Weak plantarflexion + eversion
  • Reduced ankle reflex
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36
Q

What is the management of lumbar disc prolpase?

A

Similar to that of other mechanical back pain
= analgesia, physiotherapy, exercises
BUT if symptoms persist (e.g. after 4-6 weeks) then referral for consideration of MRI is appropriate - may need discectomy

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37
Q

What tends to cause cauda equina syndrome?

A

Usually from large prolapses or hernation of lumbar discs, but may be from extrinsic tumours, primary cord tumours, spondylosis or spinal stenosis

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38
Q

How do you diagnose cauda equina syndrome?

A

MRI!

Refer to neurosurgery URGENTLY

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39
Q

How do you diagnose + treat lumbar spine stenosis?

A

MRI

- decompressive laminectomy gives good results if NSAIDs, epidural steroid injection + corsets fail to help

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40
Q

What is spondylolisthesis? What tends to cause it?

A

Displacement of one lumbar vertebrae on another
- usually forward
- usually L5 on S1
Causes = congenital malformation, spondylosis, osteoarthritis

41
Q

What are the symptoms of spondylolithesis? What investigation is required?

A

Onset of pain usually in adolescence/early adulthood
- worse on standing, may have sciatica, hamstring tenderness, abnormal gait
PLAIN RADIOGRAPH - lateral view important

42
Q

What are the clinical features of ankylosing spondylitis?

A
  • male with low back pain, worse at night + morning stiffness more than 30mins, relieved by exercise
  • progressive loss of movements in all directions
  • can have kyphosis or neck hyperextension
  • enthesitis = achilles, plantar fasciitis
  • acute iritis
43
Q

How do you manage ankylosing spondylitis?

A
  1. Exercise, not rest
  2. NSAIDs
  3. Adalimumab (TNF-a blocker)
  4. Steroids during flares
  5. Bisphosphonates - prevent osteoporosis
  6. Surgery
44
Q

What cancers tend to metastasise to the spine?

A
  • breast
  • lung
  • prostate
  • lymphoma
  • myeloma
45
Q

What conditions may present as a monoarthritis?

A
  • septic arthritis
  • crystal arthritis
  • osteoarthritis
  • trauma = haemoarthrosis
46
Q

What can present as an oligoarthritis? (5 joints or less)

A
  • crystal arthritis
  • psoriatic arthritis
  • reactive arthritis
  • ankylosing spondylitis
  • OA
47
Q

What are causes of polyarthritis? (more than 5 joints affected)

A

SYMMETRICAL
- RA, OA, viruses e.g. Hep A, B, C, mumps
ASYMMETRICAL
- reactive arthritis
- psoriatic arthritis
EITHER
- systemic disease e.g. SLE, sarcoid, endocarditis

48
Q

What are the tests required in a pt with a hot, swollen joint?

A
  1. JOINT ASPIRATION
    - WCC, gram stain, polarised light microscopy, culture
  2. BLOODS
    - FBC, ESR, urate, U+E, CRP
    - blood culture
    - RhF, anti-CCP, ANA
    - HLA-B27
  3. RADIOLOGY
    - OA = loss of joint space, osteophytes, subchondral sclerosis + cysts
    - RA = juxta-articular osteopenia, soft tissue swelling, joint deformity, loss of joint space
    - Gout = periarticular erosions, normal joint space, soft tissue swelling
49
Q

What are the risk factors for osteoarthritis?

A
  • females more than men
  • increasing age
  • obesity
  • known joint abnormality
50
Q

What are the symptoms of osteoarthritis?

A

Affects knees, hips, DIPs, PIPs + CMC of thumb (squaring of thumb base)

  • pain worse with movement, worse at end of day
  • stiff after rest, lasts less than 30 mins
  • decreased ROM
51
Q

How do you manage osteoarthritis?

A 
CONSERVATIVE
- pt education, exercise + weight loss
- physio, OT, hold/cold, walking aids, supportive footwear, home modifications
MEDICAL
- regular paracetamol + NSAIDs
- steroid injections
SURGICAL = arthroplasty
52
Q

What are the genetic associations of RA?

A

HLA-DR4 or DR-1

53
Q

How does RA tend to present?

A
  1. ARTHRITIS - symmetrical, polyarthritis of MCPs, PIPs of hands + feet
  2. NODULES - elbows, fingers, feet, heel
  3. TENOSYNOVITIS - DeQuervain’s, atlanto-axial subluxation
  4. IMMUNE - AIHA, vasculitis, amyloidosis, lymphadenopathy
  5. CARDIAC - pericarditis + pericardial effusion
  6. CARPAL TUNNEL
  7. PULMONARY - fibrosing alveolitis, pleural effusions
  8. OPHTHALMIC - episcleritis, scleritis
  9. RAYNAUDS
  10. FELTYS - RA + splenomegaly + neutropenia
54
Q

How do you manage RA?

A
  1. CONSERVATIVE
    - rheum referral, regular exercise, physio + OT input
  2. MEDICAL
    - DMARDs, then biologicals
    - steroids for flares + for bridging treatment
    - NSAIDs for symptoms
    - manage CV risk
    - prevent osteoporosis + gastric ulcers
  3. SURGICAL
    - ulna stylectomy or joint prosthesis
55
Q

What scoring system if used in RA to monitor disease severity?

A

DAS-28

  • aim for below 3
  • above 5.1 is severe
56
Q

What is the follow-up for pts with RA?

A
  • rapid access specialist care for flares
  • R/V every 6-months after achieving treatment target
  • extensive r/v annually
57
Q

How do you differentiate seronegative spondyloarthritis (psoriatic) from RA?

A
  1. Presence of dactylitis
  2. Absence of anti-CCP
  3. DIP involvement
  4. Sacroiliitis
  5. Oligo/monoarticular joint involvement
58
Q

What are the clinical features of psoriatic arthritis?

A
  • joint pain + morning stiffness
  • enthesitis
  • dactylitis
  • psoriatic plaques
  • nail changes = onycholysis, pitting + subungal hyperkeratosis
59
Q

What investigations should be done in suspected psoriatic arthritis?

A

Complete PEST tool questionnaire - if high score refer to rheum

  1. X-Ray hands + feet
    - pencil in cup deformity
    - erosion in DIP joints
  2. ESR + CRP
    - not always raised
  3. RhF + Anti-CCP to r/o RA
  4. Uric acid level - r/o gout
  5. Lipid profile + Blood glucose
    - increased risk of metabolic syndrome in psoriasis
  6. Synovial fluid aspiration
  7. MRI sacroiliac joints - AS may be present
60
Q

What is arthritis mutilans?

A

most severe form of psoriatic arthritis, occurs in phalanxes

  • osteolysis of bones around joints in digits. Leads to progressive shortening of digit
  • gives appearance of ‘telescopic finger’
61
Q

What are the HLA-B27 associated conditions? (HINT: PAIR)

A

P - psoriasis
A - Ankylosing spondylitis/Anterior uveitis
I - IBD
R - Reactive arthritis

62
Q

What tends to trigger reactive arthritis?

A

Gastroenteritis

STI - Chlamydia (most common) or gonorrhoea (more common to cause septic arthritis)

63
Q

What are the typical features of reactive arthritis?

A

Can’t see, pee or climb a tree

  • bilateral conjunctivitis
  • anterior uveitis
  • circinate balanitis (dermatitis of head of penis)
  • asymmetrical lower limb oligoarthritis (knee)
  • mouth ulcers and/or enthesitis
64
Q

How do you manage reactive arthritis?

A

Treat according to hot swollen joint policy until SA excluded

  1. NSAIDs + treat underlying cause e.g. STI
  2. Steroid injection
  3. Systemic steroids
    - most resolve within 6-months + do not recur.
65
Q

What are risk factors for septic arthritis?

A
  • pre-existing joint disease
  • DM
  • immunosuppression
  • CKD
  • recent joint surgery
  • prosthetic joints
  • IVDU
  • aged over 80y
66
Q

How do you treat septic arthritis?

A

Follow SEPSIS 6

  • start Abx once aspirate taken. Flucloxacillin (or clindamycin)
  • obtain orthopaedic opinion for lavage, arthrocentesis, debridement
67
Q

What are the causes of hyperuricaemia? HINT: can be impaired excretion or impaired production

A
  1. IMPAIRED EXCRETION
    - chronic renal disease
    - drugs = thiazides, aspirin
    - HTN
    - lead toxicity
    - primary hyperPTH or hypothyroid
    - raised lactic acid from alcohol, exercise, starvation
    - G6PD deficiency
  2. INCREASED PRODUCTION
    - increased purine synthesis
    - increased turnover of purines
68
Q

What are the typical joints affected by gout?

A
  • base of big toe (1st MTP)
  • wrists
  • base of thumb (1st MCP)
69
Q

What investigations are performed in suspected gout? What do they show?

A

Must r/o septic arthritis

  1. JOINT ASPIRATION
    - MC+S to r/o SA
    - polarised light microscopy shows crystals that are negatively birefringent needle-shaped crystals
  2. SERUM URATE
    - usually raised but not useful in acute setting
  3. X-RAY
    - punched out erosions in juxta-articular bone
    - flecked calcification
    - WCC + ESR often raised
70
Q

How do you manage an acute attack of gout?

A
  1. NSAIDs
  2. Colchicine - if NSAIDs contraindicated
    - diarrhoea v. common SE
  3. Steroids
71
Q

How to you manage gout prophylactically?

A
  1. LIFESTYLE = weight loss, stay hydrated, minimise purine intake (alcohol, meat, seafood)
  2. URATE LOWERING THERAPY
    - allopurinol or febuxostat
    - wait until 3wks after acute ep to start + cover with NSAID/cochicine for 6wks
72
Q

What are the indications to start urate lowering therapy?

A
  • more than 1 attack in 12 months
  • tophi
  • renal stones
  • CKD stage 2+
    Aim is to reduce attacks + limit damage from crystal stones
73
Q

What investigations should be performed in suspected pseudogout? What will they show?

A
  1. JOINT ASPIRATION
    - no bacterial growth
    - calcium pyrophosphate crystals
    - positively birefringent rhomboid shaped crystals
  2. X-RAY
    - chrondrocalcinosis
74
Q

How do you manage pseudogout?

A

Symptoms usually resolve spontaneously.
Symptomatic management with:
- NSAIDs, colchicine, joint aspirate, steroid injection etc.

75
Q

What medications can cause drug-induced lupus? What antibody will pts have?

A 
COMMON = procainamide or hydralazine
OTHERS = isoniazid, minocycline, phenytoin, penicillamine

Anti-histone antibody

76
Q

What organs can SLE affect? What clinical features does it cause?

A
  1. Arthritis - symmetrical small joint arthralgia
  2. Renal - proteinuria + HTN. Lupus nephritis (nephrotic syndrome)
  3. Skin - butterfly malar rash, Discoid rash, photosensitive, Raynaud’s
  4. Lungs - pleurisy + pleural effusions, pulmonary fibrosis
  5. Eyes - retinal vasculitis, 2ndary sjogrens
  6. Neuro - seizures, psychosis, depression
  7. CV - pericarditis, increased risk IHD + stroke
  8. Haem = AIHA, low WCC, low platelets
77
Q

What are the most important investigations for SLE?

A
  1. Anti-dsDNA titres
  2. Complement C3 + C4 - reduced
  3. ESR
  4. Urinalysis + PCR
    - blood + protein denotes lupus nephritis
78
Q

If someone has a multisystemic disorder with raised ESR + normal CRP, what should you be thinking of?

A

SLE

79
Q

What antibody will majority of SLE pts be positive for?

A

ANA

80
Q

What antibody is most specific for SLE?

A

Anti-dsDNA

- anti-smith is also specific but not very sensitive

81
Q

What antibodies are associated with Sjogren’s?

A

Anti-Ro + La

82
Q

What antibodies are associated with diffuse systemic sclerosis?

A

Anti-Scl70

83
Q

What antibodies are associated with dermatomyositis?

A

Anti-Jo1

84
Q

How do you manage SLE?

A
  1. SEVERE FLARES e.g. AIHA, nephritis, pericarditis or CNS disease
    - IV cyclophosphamide
    - high dose prednisolone
  2. JOINTS
    - hydroxychloroquine
    - NSAID
    - prednicolone
  3. SKIN
    - sunscreen, avoid sun
    - hydroxycholorquine or methotrexate
  4. LUPUS NEPHRITIS
    - cyclophosphamide/tacrolumus/ciclosporin
85
Q

What antibodies are associated with antiphospholipid syndrome?

A
  • lupus anticoagulant
  • anti-cardiolipin antibodies
  • anti-beta-2-glycoprotein 1 antibodies
86
Q

What are the clinical features of antiphospholipid syndrome? (HINT: CLOT)

A

C - coagulation defect
L - livedo reticularis (purple lace-like rash gives skin mottled appearance)
O - obstetric (miscarriages)
T - thrombocytopenia (reduced platelets)

87
Q

How do you manage anti-phospholipid syndrome?

A

Long term warfarin

- use LMWH + aspirin in pregnancy

88
Q

What are examples of (i) Large vessel (ii) medium vessel vasculitis?

A

(i) GCA/PMR or Takayasu

(ii) polyarteritis nodosa or Kawasaki disease

89
Q

What are causes of small vessel vasculitis?

A 
P-ANCA
- MPA, glomerulonephritis, EGPA
C-ANCA = GPA
ANCA negative
- HSP
- goodpasture's
- cryoglobulinaemia
90
Q

Who does polyarteritis nodosa tend to affect?

A

Middle aged men

Hep B infection

91
Q

What are the features of PAN?

A
  • fever, malaise, arthralgia
  • weight loss
  • hypertension
  • mononeuritis multiplex, sensorimotor polyneuropathy
  • testicular pain
  • livedo reticularis
  • haematuria, renal failure
92
Q

What are the buzzwords for Takayasu’s? How is it managed?

A 
Buzzwords:
- South –east Asia
- 20-40 FEMALE
- Pulseless disease
- Dizziness
Raised ESR/CRP
TREAT:
Reduce BP (high due to Renal artery stenosis) + steroids
93
Q

What can cause secondary sjogren’s?

A

SLE or RA

94
Q

How do you manage Sjogren’s?

A

Artificial tears and saliva
Vaginal lubricants
Hydroxychloroquine to halt progression of disease

95
Q

What are the symptoms of diffuse cutaneous systemic sclerosis?

A

Features of CREST plus:

  • CV = HTN + CAD
  • Lungs = pulmonary HTN + fibrosis
  • Kidneys = GN + scleroderma renal crisis
96
Q

How do you manage fibromyalgia?

A

BIOPSYCHOSOCIAL

  • educate pt, exercise, CBT, acupunture, hydrotherapy, mindfulness
  • screen for anxiety + depression
  • Medications = duloxetine, pregabalin, tramadol, venlafaxine, amitriptyline
97
Q

What are polymyositis + dermatomyositis commonly associated with?

A

MALIGNANCY

  • lung
  • breast
  • ovarian
  • gastric
98
Q

What are the skin features of dermatomyositis?

A
  • gottron lesions on knuckles, elbows, knees
  • photosensitive rash on back, shoulders + neck
  • purple rash on face + eyelids
  • periorbital oedema
  • subcutaneous calcinosis

FINALS (14 decks)

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