Orthopaedics Part 2 Flashcards
What is De Quervain’s tenosynovitis?
- sheath containing extensor pollicis brevis and abductor pollicis longs tendons inflamed
- females 30-50yo
Features of De Quervain’s tenosynovitis:
- pain on radial side of wrist
- tenderness over radial styloid process
- abduction of thumb against resistance painful
- Finkelstein’s test
What is Finkelstein’ test?
- pull thumb in ulnar deviation and longitudinal traction
- pain over radial styloid process along length of extensor pollicis brevis and abductor pollicis longus
Management De Quervain’s tenosynovitis:
- analgesia
- steroid injection
- immobilisation with thumb splint
- surgical treatment sometimes
What is discitis and what are the features?
- infection in intervertebral disc space
- can lead to serious complications such as sepsis or epidural abscess
- back pain, pyrexia, riggers, sepsis
- neurological features: e.g. changing lower limb neurology, if epidural abscess develops
Causes of discitis:
- bacterial: staph aureus most common
- viral
- TB
- aseptic
Diagnosis and Treatment of discitis:
- MRI has highest sensitivity
- CT guided biopsy may be required
- 6-8 weeks IV Abx
- identify organism with positive culture with bloods or CT guided
Further investigation required when someone has discitis:
assess for endocarditis e.g. with trans thoracic echo or transesophageal echo
In whom is dupuytren’s contracture most common?
older male patients with 60-70% positive family history
Specific causes of dupuytren’s contracture:
- manual labour
- phenytoin treatment
- alcoholic liver disease
- diabetes mellitus
- trauma to hand
Management of Dupuytren’s contracture:
consider surgical treatment when metacarpophalangeal joints cannot be straightened and thus the hand cannot be placed flat on the table (fasciectomy)
can recur and risks neuromuscular damage
Features of lateral epicondylitis (tennis elbow):
- pain localised to lateral epicondyle
- worse on resisted wrist extension with albow extended or supination of forearm with elbow extended
- episodes 6 months - 2 years
- acute pain 6-12 weeks
Features of medial epicondylitis (golfer’s elbow):
- pain and tenderness localised to medial epicondyle
- aggravated by writs flexion and pronation
- numbness/tingling in 4th and 5th finger due to ulnar nerve involvement
What is radial tunnel syndrome and what are the features?
- compression of posterior interosseous branch of radial nerve
- result of overuse
- symptoms similar to lateral epicondylitis
- pain 4-5cm distal to lateral epicondyle
- worsened by extending elbow and pronating forearm
What is cubital tunnel syndrome and what are the features?
- compression of ulnar nerve
- initially intermittent tingling in 4th and 5th finger
- worse when elbow on firm surface for extended periods
- later numbness in 4th and 5th finger with weakness
What is olecranon bursitis?
swelling over posterior aspect of elbow - pain, warmth, erythema (middle aged males)
What is a Smith’s fracture?
- reverse Colles
- volar angulation of distal radius fragment (garden spade deformity)
- by falling backwards onto palm of outstretched hand or falling with wrists flexed
What is a Bennett’s fracture?
- intra-articular fracture of first carpometacarpal joint
- impact on flexed metacarpal, caused by fist fights
- x-ray: triangular fragment at ulnar base of metacarpal
What is a Monteggia’s fracture?
- dislocation of proximal radioulnar joint in association with an ulna fracture
- fall on outstretched hand with forced pronation
- needs prompt diagnosis to avoid disability
What is Galeazzi fracture?
- radial shaft fracture with associated dislocation of distal radioulnar joint
- direct blow
What is a Pott’s fracture?
- bimalleolar ankle fracture
- forced foot eversion
What is a Barton’s fracture?
- distal radius fracture (Colles/Smith) with associated radoiocarpal dislocation
- fall onto extended and pronated wrist
Fat embolism in respiratory system features:
- early persistent tachy
- tachypnoea, dyspnoea, hypoxia 72 hours post injury
- pyrexia
Fat embolism in dermatological system features:
- red/brown impalpable petechial rash
- subconjunctival and oral haemorrhage/petechiae
Fat embolism in CNS features:
- confusion and agitation
- retinal haemorrhages and intra-arterial fat globules on fundoscopy
Treatment fat embolus:
- prompt fixation of long bone fractures
- DVT prophylaxis
- general supportive care
Fracture types:
- oblique
- comminuted
- segmental
- transverse
- spiral
Gustilo and Anderson classification system:
1: low energy wound <1cm
2: greater than 1cm wound with moderate soft tissue damage
3: high energy wound >1 cm with extensive soft tissue damage
3A: adequate soft tissue coverage
3B: inadequate soft tissue coverage
3C: arterial injury
Management of fractures:
- immbolise including proximal and distal joints
- monitor neuromuscular status
- tetanus prophylaxis
- IV broad spec antibiotics for open injuries
- debride thoroughly if open
- open fractures constitute an emergency and should be lavage within 6 hours
What is a ganglion?
- cyst arising from joint or tendon sheath
- most commonly around back of wrist and 3 times more common in women
- often disappear spontaneously after several months
What is greater trochanteric pain syndrome?
- trochanteric bursitis
- repeated movement of fibroelastic iliotibial band
- most common 50-70yo
- pain over lateral hip/thigh
- tenderness on palpation of greater trochanter
What is Dupuytren’s contracture?
- fixed flexion of hand
- underlying ontractures of palmar aponeurosis
- progresses slowly ad painlessly
What is the aim of carpal tunnel syndrome surgery?
- decompression
- division of flexor retinaculum
What are Osler’s nodes?
- painful, red, raised lesion on hands and feet
- deposition of immune complexes
What are Bouchard’s nodes?
- hard, bony outgrowths or gelatinous cysts
- proximal interphalangeal joints
- osteoarthritis
- formation of calcific spurs of articular cartilage
What are Heberden’s nodes?
- middle age
- chronic swelling of affected joints or sudden painful onset of redness, numbness and loss of dexterity
- symptoms usually subside
- permanent bony outgrowth
Types of hip dislocations:
- posterior: 90%, affected leg is shortened, adducted and internally rotated
- anterior: affected leg abducted and externally rotated, no leg shortening
- central dislocation
Management of hip dislocation:
- ABCDE
- analgesia
- reduction under general anaesthetic within 4 hours to reduce the risk of avascular necrosis
- long term management: physiotherapy to strengthen muscles
Complications of hip dislocations:
- sciatic or femoral nerve injury
- avascular necrosis
- osteoarthritis
- recurrent dislocation: due to damage of supporting ligaments
Prognosis of hip dislocation:
- 2-3 months for hip to heal after traumatic dislocation
- prognosis best when hip is reduced less than 12 hours post injury
Features of hip fracture:
- pain
- shortened and externally leg
- non-displaced or incomplete neck of femur fractures may be able to weight bear
What is an intracapsular hip fracture:
from edge of femoral head to insertion of capsule of hip joint
What is an extra capsular hip fracture:
trochanteric or subtrochanteric
Garden system of hip fracture classification:
- type I: stable fracture with impaction in valgus
- type II: complete fracture but undisplaced
- type III: displaced fracture, usually rotated and angulated but still has boney contact
- type IV: complete boney disruption
In which hip fractures is blood supply disruption most common?
types III and IV
Management of undisplaced intracapsular hip fracture:
internal fixation or hemiarthroplasty if unfit
Management of displaced intracapsular hip fracture:
- arthroplasty (total hip replacement or hemiarthroplasty)
- total is favoured if patients were able to walk independently, are not cognitively impaired and are medically fit for anaesthesia
Management of extra capsular hip fracture:
- dynamic hip screw
- if reverse oblique, transverse or subtrochanteric: intramedullary device
What is development dysplasia of the hip?
- often picked up on newborn examination
- Barlow’s test, Ortolani’s test positive
- unequal skin folds/leg length
What is transient synovitis (irritable hip):
- typical age group: 2-10 years
- acute hip pain associated with viral infection
- commonest cause of hip pain in children
What is Perthes disease:
- degenerative condition affecting hip joints of children (4-8yo)
- avascular necrosis of femoral head
- 5 times more common boys
- 10% bilateral
- limp, stiffness, reduced range of movement
X ray findings of Perthes disease:
- early changes including widening of joint space
- later changes include decreased femoral head size/flattening
How does a slipped upper femoral epiphysis present?
- 10-15yo
- more common in obese and boys
- displacement of femoral head epiphysis postern-inferiorly
- bilateral in 20%
- may present following trauma or more commonly chronic
- knee or distal thigh pain
- loss of internal rotation of leg in flexion
What is juvenile idiopathic arthritis:
- arthritis occurring in someone who is less than 16yo for more than 3 months
- pauciarticular JIA refers to cases where 4 or less joints are affected
- 60% of JIA
Features of JIA:
- joint pain and swelling (knees, ankles, elbows)
- limp
- ANA may be positive - associated with anterior uveitis
What is an iliopsoas abscess?
collection of pus in iliopsoas compartment
Primary causes iliopsoas abscess:
- haematogenous spread of bacteria
- staphylococcus aureus most common
Secondary causes of iliopsoas abscess:
- Crohn’s
- Diverticulitis, CRC
- UTI, GU cancers
- vertebral osteomyelitis
- femoral catheter, lithotripsy
- endocarditis
- IV drug use
Mortality rates of iliopsoas abscess:
- primary: 2-4%
- secondary: 19-29%
Features iliopsoas abscess:
- fever
- back/flank pain
- limp
- weight loss
Clinical examination iliopsoas abscess:
- supine with knee flexed and hip mildly externally rotated
- place hand proximal to patient’s ipsilateral knee and ask patient to lift thigh against your hand - pain due to contraction of poses muscle
- lie patient on normal side and hyperextend the affected hip - pain as muscle is stretched
Investigation and management of iliopsoas abscess:
- CT abdomen
- Abx
- percutaneous drainage
- surgery if failure to drain or presence of another intra-abdominal pathology which requires surgery
What is iliotibial band syndrome?
- common cause of lateral knee pain in runners
- 1 in 10 runners
- tenderness 2-3cm above the lateral joint line
Management of iliotibial band syndrome:
- activity modification and iliotibial band stretches
- if not improving - physiotherapy
What is the unhappy triad?
commonly seen following lateral blow to knee:
- anterior cruciate ligament
- medial collateral ligament
- meniscus
How is the ACL commonly damaged and what tests are positive?
- from twisting injuries (sports)
- anterior drawer test: knee at 90 degrees
- Lachman test: knee at 30 degrees
What damage commonly results in PCL injury and tests?
- following dashboard injuries
- hyperextension
- tibia lies on back of femur
- paradoxical anterior draw test
What damage commonly results in MCL injury and what test?
- skiing and following valgus stress
- causes abnormal passive abduction of knee
- leg forced into valgus via force outside leg
How common is lateral collateral ligament injury?
isolated injury uncommon
How can the menisci be damaged and symptoms?
- twisting injuries
- locking and giving way
- rotation sporting injuries
- delayed knee swelling
- recurrent pain and effusions common (often following minor trauma)
Presentation of ruptured ACL:
- loud crack
- pain and rapid joint swelling (haemoarthrosis)
- poor healing
Chondromalacia patellae:
- teenage girls following injury to knee e.g. dislocation patella
- typical history of pain going downstairs or at rest
- tenderness, quadriceps wasting
How does dislocation of patella come about?
- most commonly due to trauma or severe contraction of quadriceps with knee stretched in valgus and external rotation
- genu valium, tibial torsion and high riding patella risk factors
- skyline x-ray views of patella required
- osteochondral fracture in 5%
- 20% recurrence rate
2 types of fracture of patella:
- direct blow to patella causing undisplaced fragments
- avulsion fracture
Tibial plateau fracture:
- elderly
- knee forced into valgus or virus, but knee fractures before ligaments rupture
- varus affects medial plateau and if valgus, lateral plateau depressed fracture
- classified using Schatzker system
Test for meniscal tear:
Thessaly’s test: weight bearing at 20 degrees at knee flexion, patient supported, positive if pain on twisting knee
What is infra patellar bursitis associated with?
- also Clergyman’s knee
- kneeling
What is prepatellar bursitis associated with?
- housemaid’s knee
- upright kneeling
