Orthopaedics Flashcards
Risk factors for achilles tendon disorders:
- quinolone use e.g. ciprofloxacin
- hypercholesterolaemia (predisposes to tendon xanthomata)
Features of achilles tendinopathy (tendinitis):
- gradual onset of posterior heel pain worse following activity
- morning pain and stiffness common
Management of achilles tendinopathy:
- simple analgesia
- reduction in activities
- calf muscle eccentric exercises
Common presentation and investigations of achilles tendon rupture:
- ‘pop’ in ankle with sudden onset significant pain in calf or ankle and inability to walk
- Simmond’s triad
- Ultrasound
- acute referral to orthopaedic specialist
What is Simmond’s triad?
- abnormal angle of declination
- greater dorsiflexion of injured foot
- gap in tendon and gently squeeze calf muscles - if rupture, foot will stay in neutral position
How are acromioclavicular joint injuries graded?
from I to VI depending on degree of separation
- grades I and II: very common, manage conservatively, sling
- grades IV, V and VI: rare, surgical intervention
What is adhesive capsulitis and in whom does it most commonly occur?
- frozen shoulder
- middle aged females
- diabetes mellitus
Features of adhesive capsulitis:
- develop over days
- external rotation affected more than internal rotation or abduction
- passive and active affected
- painful freezing phase, adhesive phase, recovery phase
- bilateral in 20%
- episodes 6 months - 2 years
Management adhesive capsulitis:
NSAIDs, physio, oral corticosteroids, intra-articular corticosteroids
When is an ankle x-ray required for suspected fracture?
Ottawa rules:
if any pain in malleolar zone with any of the following:
-bony tenderness at lateral malleolar zone
-bony tenderness at medial malleolar zone
-inability to walk four weight bearing steps immediately after injury
Sensitivity of Ottawa rules:
100%
Ligamentous structures of ankle:
- syndesmosis binds distal tibia and fibula: anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), interosseous ligament (IOL) and interosseous membrane
- distal fibular to talus by anterior and posterior talofibular ligaments (ATFL and PTFL) and to calcaneus by calcanenofibular ligament (collectively lateral collateral ligaments)
- distal tibia to talus by deltoid ligament
What is a sprain?
stretching, partial or complete tear of ligament
- high ankle sprains involve syndesmosis
- low ankle sprains involve lateral collateral ligaments
Presentation of low ankle sprains:
- most common
- injury to ATFL most common
- inversion injury most common mechanism
- pain, swelling, tenderness sometimes bruising
- able to weight bear unless severe
Investigation low ankle sprain:
- radiographs according to ottawa ankle rule
- MRI if persistent pain and useful for evaluating perineal tendons
Treatment low ankle sprain:
- non operative: rest, ice, compression, elevation
- removable orthosis, cast, crutches
- surgery if symptoms fail to settle or significant joint instability
Presentation high ankle sprains:
- injury to syndesmosis rare and severe
- mechanism usually external rotation of foot causing talus to push fibula laterally
- weight bearing painful
- pain when tibia and fibula squeezed at mid-calf (Hopkin’s squeeze test)
Investigations high ankle sprain:
- radiographs may show widening of tibiofibular joint or ankle mortise
- MRI if high suspicion of syndesmotic injury but normal plain films
Treatment high ankle sprain:
- if no diastasic, non-weight bearing orthosis or cast until pain subsides
- if diastasic or failed non-operative management - operative fixation
What is avascular necrosis?
- death of bone tissue secondary to loss of blood supply
- most commonly affects epiphysis of long bones e.g. femur
Causes of avascular necrosis:
- long term steroid use
- chemotherapy
- alcohol excess
- trauma
Features and investigations of avascular necrosis:
- initially asymptomatic
- pain in joint
- plain X-ray: osteopenia and micro fractures early on, collapse of articular surface shows crescent sign
- MRI: investigation of choice, more sensitive
Management avascular necrosis:
joint replacement
What are Baker’s cysts?
- also popliteal cysts
- not true cysts but distension of gastrocnemius-semimembranosus bursa
- primary: no underlying pathology, typically children
- secondary: underlying condition e.g. osteoarthritis, typically adults
Features of ruptured Baker’s cyst:
- similar symptoms to DVT
- pain, redness, swelling
- majority asymptomatic
Management Baker’s cyst:
- children typically resolve so no Tx
- adults: treat underlying cause where appropriate
Tendons of biceps muscle:
- long tendon attached to glenoid
- short tendon attached to coracoid process
- inserts distally via another tendon onto radial tuberosity
What happens in biceps rupture?
- one tendon separates from attachment site or torn across full width
- most long tendon 90%
- rarely distal tendon
In whom are biceps ruptures more common?
men to women 3:1
Risk factors biceps rupture:
- heavy overhead activities
- shoulder overuse or underlying shoulder injuries
- smoking
- corticosteroids
Mechanism of injury of biceps rupture:
- proximal long tendon: when biceps lengthened and contracted and load applied e.g. descent phase of pull up
- distal tendon: flexed elbow suddenly and forcefully extended whilst biceps is contracted
Presentation and features of biceps rupture:
- sudden pop or tear at shoulder (long) or antecubital fossa (distal) with pain and swelling
- proximal tendon - popeye deformity
- distal rupture causes reverse Popeye
- weakness in shoulder and elbow follows including difficulty with supination
- some have chronic shoulder pain before
Investigating for biceps rupture:
- palpate long head and distal biceps tendon to assess neuromuscular function
- biceps squeeze test - intact then squeeze will cause forearm supination
- MSK US
- consider MRI for long head
- distal biceps rupture - urgent MRI (surgical intervention)
Features of Paget’s:
- focal bone resorption with excessive bone deposition
- affects spine, skull, pelvis and femur
- serum ALP raised
- abnormal thickened, sclerotic bone on X-ray
- risk of cardiac failure
- small risk sarcomatous change
Treatment Paget’s:
bisphosphonates
Features of osteoporosis:
- excessive bone resorption causing demineralised bone
- common in older
- increased risk of pathological fracture
- otherwise asymptomatic
- normal ALP, normal calcium
Treatment osteoporosis:
- bisphosphonates
- calcium and vit D
Features secondary bone tumours:
- bone destruction and tumour infiltration
- mirel scoring used to predict risk of fracture
- elevated serum calcium and ALP
Treatment secondary bone tumours:
- radiotherapy
- prophylactic fixation and analgesia
What is a buckle fracture?
- torus
- incomplete fractures of shaft of long bone characterised by bulging of cortex
- children 5-10 years
- self limiting - no operative intervention
- splinting and immobilisation
What is carpal tunnel syndrome and what are the symptoms?
- compression of median nerve
- pain/pins and needles in thumb, index and middle finger
- may ascend proximally
- patient shakes hand to obtain relief
Examination carpal tunnel syndrome:
- weakness of thumb abduction (abductor pollicis brevis)
- wasting of thenar eminence (not hypothenar)
- Tinel’s sign: tapping causes paraesthesia
- Phalen’s sign: flexion of wrist causes symptoms
Causes of carpal tunnel syndrome:
- idiopathic
- pregnancy
- oedema e.g. heart failure
- lunate fracture
- rheumatoid arthritis
Electrophysiology carpal tunnel syndrome:
motor and sensory: prolongation of action potential
Treatment carpal tunnel syndrome:
- corticosteroid injection
- wrist splints at night
- surgical decompression (flexor retinaculum divison)
What is cauda equina syndrome?
- lumbosacral nerve roots bowl spinal cord compressed
- may lead to permanent nerve damage resulting in long term weakness and urinary/bowel incontinence
Causes of cauda equina syndrome:
- most common is central disc prolapse: L4/5 or L5/S1
- tumours: primary or metastatic
- infection: abscess, discitis
- trauma
- haematoma
Features of cauda equina syndrome:
- low back pain
- bilateral sciatica
- reduced sensation/pins and needles in perianal area
- decreased anal tone
- urinary dysfunction
Investigation and management CES:
- urgent MRI
- surgical decompression
What is cervical spondylosis:
- common condition resulting from osteoarthritis
- most commonly presents as neck pain
- referred pain e.g. headaches
- complications: radiculopathy, myelopathy
What is a charcot joint?
- neuropathic joint
- joint which has become badly disrupted and damaged secondary to los of senation
- most commonly caused by neuropathy to syphilis (tabes dorsalis) but now diabetics
- joint swollen, red and warm
What is a colles’ fracture?
- follows FOOSH
- distal radius fracture with dorsal displacement of fragments
- dinner fork type deformity
3 classic features of colles’ fracture:
- transverse fracture of radius
- 1 inch proximal to radio-carpal joint
- dorsal displacement and angulation
What is compartment syndrome?
- complication following fractures or ischaemia repercussion injury in vascular patients
- raised pressure in anatomical space
- leads to necrosis
- two main fractures: supracondylar fractures and tibial shaft injuries
Features of compartment syndrome:
- pain, especially on movement (even passive)
- excessive use of breakthrough analgesia
- paraesthesia
- pallor
- arterial pulsation may still be felt
- paralysis of muscle group may occur
- presence of pulse does not rule out compartment syndrome
Diagnosis of compartment syndrome:
-measurement of intracompartmental pressure - excess of 20mmHg abnormal
>40mmHg diagnostic
-no pathology on x-ray
Treatment compartment syndrome:
- prompt and extensive fasciotomies
- myoglobinuria may occur following fasciotomy and result in renal failure so IV fluids
- necrotic muscles derided and amputated
- death of muscle occurs within 4-6 hours
What is cubital tunnel syndrome?
- compression of ulnar nerve
- tingling and numbness of 4th and 5th finger
- weakness and muscle wasting
- pain worse on leaning on affected elbow
- history of osteoarthritis or prior trauma to area
Management of cubital tunnel syndrome:
- avoid aggravating activity
- physiotherapy
- steroid injections
- surgery in resistant cases
