Orthopaedics, Joint Exams, Fractures & Xrays Flashcards
What are the normal angle values for hip flexion and extension?
Hip flexion - 120 degrees
Hip extension - 20 degrees
Hip exam - what are the normal angles for hip abduction and adduction?
Hip abduction - 60 degrees
Hip adduction - 45 degrees
Hip exam - normal angle values for internal and external rotation?
Internal rotation - 30 degrees
External rotation - 60 degrees
Knee exam - What are the two tests to check for a joint effusion in the knee?
- Patellar tap
2. Sweep test (aka swipe test) sweep up medially.
What is the proper name for a bunion?
Explain how it forms.
Hallux Valgus
Great toe becomes abducted at the MTP metatarsophalangeal joint. Excessive pressure on the medial side can lead to formation of a bursa, called a bunion.
How is Mallet toe different to Hammer toe?
Mallet toe - flexion at DIP only
Hammer toe - extension at MTP, flexion at PIP and DIP
How is claw toe different to hammer toe?
Both - extension at MTP, flexion at PIP Claw toe - extension at DIP
Hammer toe - flexion at DIP
Shoulder exam - what type of problem is indicated by normal passive movement, with painful or restricted active shoulder movements?
Muscle or tendon problem
Shoulder exam - what would indicate adhesive capsulitis?
Adhesive capsulitis / frozen shoulder
Loss of passive external rotation and abduction (doctor doing it for patient)
What causes winged scapula? Muscle and nerve
Serratus anterior dysfunction
Damage to the long thoracic nerve
Shoulder exam - What does a painful arc indicate?
- Middle?
- Top?
- Throughout?
- Painful arc - pain on shoulder abduction 60-120 degrees, which reduces past 120 degrees
Indicates supraspinatus tendon impingement or subacromial bursitis
- If patient reports pain at the end of the test it’s more likely to be a problem in the acromiocalvicular joint such as OA
- If patient reports pain throughout the arc, it could be OA of the glenohumeral joint or frozen shoulder
Elbow exam - where will there be pain in golfer’s elbow?
Medial epicondyle
Elbow exam - where will there be pain in tennis elbow?
Lateral epicondyle
Elbow exam - how to examine for medial epicondylitis?
Medial epicondylitis - Golfer’s elbow
Palpate medial epicondyle
Active wrist flexion against resistance
Elbow exam - how to check for lateral epicondylitis?
Lateral epicondylitis - Tennis elbow
Palpate lateral epicondyle
Make a fist, Active wrist extension against resistance - patient is pushing down
What are the risk factors for osteoporosis?
Supraspinatus muscle is innervated by what nerve?
Also what movement and test
Suprascapular nerve
Abduction up to 15 degrees
Empty can test
Infraspinatus muscle is innervated by what nerve?
Also what movement and test
Suprascapular nerve (same as supraspinatus)
External rotation
Active external rotation against resistance
What nerve supplies subscapularis?
Also what movement and test
Upper subscapular nerve
Internal rotation
Lift-off test
For what disorders would you prescribe bisphosphonates?
Paget’s disease of bone Osteoporosis Bone metastases (with or without Hypercalcemia) Multiple myeloma Primary Hyperparathyroidism Osteogenesis imperfecta Hypercalcemia
How do bisphosphonates work?
Bisphosphonates inhibit bone resorption by osteoclasts. Preventing loss of bone density.
Fuller explanation: Bisphosphonates bind hydroxyapatite in bone, inducing apoptosis in osteoclasts
Name 2 Risk factors for sciatica
Options: Older age Obesity Occupation Sedentary lifestyle Diabetes Previous sciatica
Describe the characteristic pain of sciatica
Radiating pain down back of leg, made worse by some movements, numbness, pins and needles
Sciatica - describe 2 findings on examination
Reduced straight leg raise / positive sciatic nerve stretch test
Reduced ankle reflex (areflexia)
Sensory loss
(Normal looking leg)
Name 2 risk factors for osteoarthritis
Older age Occupation (eg. Sports people) Previous joint injury Obesity Female gender Family history Inflammatory arthritis
Describe the characteristic pain of osteoarthritis
Dull ache, worse at the end of the day and during exercise, progressive, chronic, can be referred pain eg hip OA presenting as knee pain
Osteoarthritis - Findings on joint examination
Normal temperature Deformity May or may not have effusion Pain on movement Reduced range of movement Crepitus Muscle wasting
Red flags for back pain
What suggests cancer?
What suggests cauda equina?
What sign is shown in this X-ray and what does it indicate?
‘Winking owl’ sign
Occurs when the pedicle (circle) is destroyed due to metastasis
What drug class (give an example) can cause spontaneous Achilles rupture?
CIPROFLOXACIN
Quinolones eg ciprofloxacin
What are the differential diagnoses for pain in the back or hip?
What are differential diagnoses for knee pain?
What are the differential diagnoses for neck pain?
What are the differential diagnoses for shoulder pain?
What are the differential diagnoses for elbow pain?
What are the differential diagnoses for wrist and hand pain?
How are ankle fractures classified?
Weber’s A, B and C.
The Weber ankle fracture classification is a system for classifying lateral malleolar fractures, relating to the level of the fracture in relation to the distal tibiofibular syndesmosis. It has a role in determining the treatment.
A - fracture is below the level of the syndesmosis. Usually transverse. Medial malleolus sometimes fractured too. Usually stable.
B - fracture is at the level of the syndesmosis. some fibres of the syndesmosis may be torn. usually spiral. Variable stability, may require ORIF.
C - above the level of the syndesmosis. Medical malleolus fracture or deltoid ligament injury often present. Fibular neck fracture may be present - must check all the way up the fibular. Unstable - usually requires ORIF.
How would you class a fibular fracture at the level of the tibiofibular syndesmosis?
Weber’s type B.
What classification system would you use to describe fractures through a growth plate?
Can you describe the different types?
Salter-Harris classification - fractures through a growth plate in a child’s long bones.
How are the different Salter-Harris fractures type I - V treated?
Which is the most/least common?
I - cast or boot
II - cast or boot + closed reduction if misalignment
III - usually ORIF, sometimes Just cast
IV - ORIF
V - Usuallt delayed diagnosis, because X-ray may appear normal. May present with growth arrest. Surgery sometimes needed.
Type II is most common by far (75%)
Type V least common (<1%)
What classification system can be used to further describe intracapsular hip fractures?
Describe the stages
Garden classification
Garden stage I - undisplaced, incomplete. Includes valgus impacted fractures.
Garden stage II - undisplaced, complete
Garden stage III - partially displaced, complete
Garden stage IV - completely displaced, complete
Generally stage I and II are stable fracture and are treated with internal fixation with cannulated hip screw with femoral head preservation, and generally stage III and IV are unstable and treated with either hemiarthroplasty or total arthroplasty, because these stages are more likely to result in avascular necrosis.
What ‘line’ can you look for on X-ray to help diagnose a hip fracture ?
Shenton’s line - an imaginary curved line drawn along the inferior border of the superior ramus, along the inferomedial border of the neck of femur. It should be continuous and smooth.
How would the different types of Garden fracture be fixed?
Which types are at risk of avascular necrosis?
Garden stage I - undisplaced, incomplete
Garden stage II - undisplaced, complete
Garden stage III - partially displaced, complete
Garden stage IV - completely displaced, complete
Generally stage I and II are stable fracture and are treated with internal fixation with cannulated hip screws with femoral head preservation, and generally stage III and IV are unstable and treated with either hemiarthroplasty or total arthroplasty, because these stages are more likely to result in avascular necrosis.
How would you decide what patients to offer a total arthroplasty to verses a hemiarthroplasty?
NICE advise that THR offered to patients who:
- are able to walk independently outdoors with no more than a stick, and
- are not cognitively impaired, and
- are medically fit for anaesthesia and the procedure
What blood vessels supply the femoral head?
- Retinacular vessels - main blood supply. Originates from an arterial ring supplied by the medial and lateral circumflex arteries.
- Foveal artery, only in younger people
- Metaphyseal vessels, not a major source.
How are intracapsular, extracapsular and subtrochanteric hip fractures treated
Intracapsular - usually hemiarthroplasty (because blood supply to femoral head is compromised)
Extracapsular - usually dynamic hip screw
Subtrochanteric - usually intra-medullary (IM) nail
What are the Ottawa ankle rules?
Ottawa ankle rules help differentiate which ankle injuries require X-ray.
They state that an ankle radiograph series is only required if there is pain in the malleolar zone (highlighted turquoise in below image) and one or more of the following is found:
- Boney tenderness at the posterior edge or tip of the lateral malleolus OR
- Boney tenderness at the posterior edge or tip of the medial malleolus OR
- Inability to weight bear immediately and in the A+E department for four steps
What is a Colles fracture?
Caused by?
What other fracture is commonly seen alongside this?
Fracture of the distal radius with dorsal angulation of the distal fragment.
Caused by FOOSH - fall on outstretched hand, with wrist extended
50% of colles fractures are associated with a fracture of ulna styloid
What type of fracture is this?
Colles fracture
A Colles fracture is also called a ‘what’ deformity?
Dinnerfork deformity
What is a Smith’s fracture?
How is it sustained?
Distal radial fracture with palmar angulation of wrist joint
Falling on outstretched hand with wrist flexed
(Aka reverse Colles fracture)
What is a Monteggia fracture?
Fracture of the proximal 1/3 ulna + proximal radial head dislocation
This problem is often missed in children - radial head dislocation might not be obvious on X-ray
Paediatrics - closed reduction of both
Adults - Closed reduction of radial head, ORIF ulna
Posterior interosseous nerve could be injured - check finger extension
(Monteggia pronounced ‘mont-asia’)
P’s - Proximal injury, Posterior interosseous nerve
What is a Galeazzi fracture?
What branch of what nerve might be damaged and what is the sign of that damage?
Fracture of distal 1/3 of radius and dislocation of distal radioulnar joint
Anterior interosseous nerve can be damaged (terminal branch of median nerve, motor function only no sensory) - when asked to make a fist may show the Hand of Benediction (unable to flex 2nd & 3rd digits) also unable to make the ‘ok’ circle sign - index finger stays straight
