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Orthopaedics > Orthopaedics Part 3 > Flashcards

Orthopaedics Part 3 Flashcards

1
Q

What is Leriche syndrome?

A
  • atheromatous disease involving iliac vessels
  • blood flow to pelvic viscera compromised
  • buttock claudication and impotence
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2
Q

Diagnosis Leriche syndrome:

A
  • angiography

- iliac occlusions usually treated with endovascular angioplasty and stent insertion

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3
Q

Red flags for lower back pain:

A
  • <20yo or >50yo
  • history previous malignancy
  • night pain
  • history trauma
  • systemic symptoms
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4
Q

Spinal stenosis onset, symptoms, examination and diagnosis:

A
  • gradual
  • unilateral or bilateral leg pain (with or without back pain)
  • numbness, weakness worse on walking and resolves when sitting
  • relieved by sitting, leaning forwards and crouching
  • examination normal
  • MRI diagnosis
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5
Q

Presentation of ankylosing spondylitis:

A
  • young man with LBP and stiffness
  • worse in morning and improves with activity
  • peripheral arthritis
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6
Q

Peripheral arterial disease lower back pain presentation:

A
  • pain on walking, relieved by rest
  • absent or weak foot pulses
  • limb ischaemia
  • past history: smoking and other vascular disease
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7
Q

Back pain management:

A
  • NSAIDs
  • co-prescribe PPI for >45yo
  • exercise and manual therapy
  • epidural injections of local anaesthetic and steroid for acute and severe sciatica
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8
Q

Investigation lower back pain:

A
  • lumbar spine x-ray
  • MRI if non-specific back pain and malignancy, infection, fracture, cauda equina or ankylosing spondylitis suspected
  • no other imaging can see neurological/soft tissue structures
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9
Q

L3 nerve root compression features:

A
  • sensory loss anterior thigh
  • weak quadriceps
  • reduced knee reflex
  • positive femoral stretch test
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10
Q

L4 nerve root compression features:

A
  • sensory loss anterior knee
  • weak quadriceps
  • reduced knee reflex
  • positive femoral stretch test
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11
Q

L5 nerve root compression features:

A
  • sensory loss dorsal of foot
  • weakness in foot and big toe dorsiflexion
  • reflexes intact
  • positive sciatic nerve stretch test
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12
Q

S1 nerve root compression features:

A
  • sensory loss posterolateral leg and lateral foot
  • weakness plantar flexion of foot
  • reduced ankle reflex
  • positive sciatic nerve stretch test
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13
Q

Management prolapsed disc:

A
  • analgesia, physio, exercises

- if symptoms persists, referral for consideration MRI

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14
Q

Motor and sensory supply of femoral nerve:

A

motor: knee extension, thigh flexion
sensory: anterior and medial aspect of thigh and lower leg

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15
Q

Typical mechanism of injury femoral nerve:

A
  • hip and pelvic fractures

- stab/gunshot wounds

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16
Q

Motor and sensory supply of obturator nerve:

A

motor: thigh adduction
sensory: medial thigh

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17
Q

Typical mechanism of injury of obturator nerve:

A

anterior hip dislocation

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18
Q

Motor and sensory supply of lateral cutaneous nerve of thigh:

A

no motor

sensory: lateral and posterior surfaces of thigh

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19
Q

Typical mechanism of injury of lateral cutaneous nerve of thigh:

A

compression of nerve near the ASIS - meralgia paraesthetica, condition characterised by pain, tingling and numbness in distribution of lateral cutaneous nerve

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20
Q

Motor and sensory supply tibial nerve:

A

motor: foot plantar flexion and inversion
sensory: sole of foot

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21
Q

Typical mechanism of injury of tibial nerve:

A

not commonly injured as deep

popliteal lacerations, posterior knee dislocation

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22
Q

Motor and sensory supply common peroneal nerve:

A

motor: foot dorsiflexion and eversion, extensors hallucinate longus
sensory: dorsal of foot and lower lateral part of leg

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23
Q

Typical mechanism of injury common peroneal nerve:

A
  • injury at neck of fibula
  • tightly applied lower limb plaster cast
  • foot drop
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24
Q

Motor and sensory supply superior gluteal nerve:

A

motor: hip abduction
sensory: none

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25
Q

Typical mechanism injury superior gluteal nerve:

A
  • misplaced IM injection
  • hip surgery
  • pelvic fracture
  • posterior hip dislocation
  • positive Trendelenburg sign
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26
Q

Motor and sensory supply inferior gluteal nerve:

A

motor: hip extension and lateral roatation
sensory: none

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27
Q

Typical mechanism of injury inferior gluteal nerve:

A
  • association with sciatic injury
  • difficulty rising from seated position
  • can’t jump, can’t climb stairs
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28
Q

Muscles of anterior compartment and innervation:

A

-tibialis anterior
-extensor digitorum longus
-peroneus tertius
-extensor hallucis longus
all supplied by deep peroneal nerve

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29
Q

Action of tibias anterior:

A
  • dorsiflexion ankle

- inversion

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30
Q

Action of extensor digitorum longus:

A
  • extends lateral four toes

- dorsiflexes ankle joint

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31
Q

Action of peroneus tertius:

A
  • dorsiflexes ankle

- eversion

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32
Q

Action of extensor hallucinate longus:

A
  • dorsiflexion ankle

- extends big toe

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33
Q

Muscles of peroneal compartment and innervation:

A

-peroneus longus
-peroneus brevis
supplied by superficial peroneal nerve

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34
Q

Action of peroneus longus:

A
  • eversion

- assists in plantar flexion

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35
Q

Action of peroneus brevis:

A

plantar flexion ankle

36
Q

Muscles of superficial posterior compartment and innervation:

A

-gastrocnemius
-soleus
innervated by tibial nerve

37
Q

Action of gastrocnemius:

A

plantar flexion foot (may also flex knee)

38
Q

Action of soleus:

A

plantar flexor

39
Q

Muscles of deer posterior compartment and innervation:

A

-flexor digitorum longus
-flexor hallucis longus
-tibialis posterior
tibial nerve

40
Q

Action of flexor digitorum longus:

A

flexes lateral four toes

41
Q

Action of flexor hallucis longus:

A

flexes great toe

42
Q

Action of tibialis posterior:

A
  • plantar flexor

- inversion

43
Q

Presentation lumbar spinal stenosis:

A
  • back pain
  • neuropathic pain
  • symptoms mimicking claudication
  • sitting better than standing and may find it easier to walk uphill rather than downhill
44
Q

Most common underlying cause of lumbar spinal stenosis:

A
  • degenerative disease
  • begins in intervertebral disc where cell death and loss of proteoglycan and water content leads to progressive disc bulging and collapse
  • increased stress transfer to posterior face joints - cartilaginous degeneration, hypertrophy, osteophyte formation
  • thickening and distortion of ligaments flavum
45
Q

Diagnosis and treatment lumbar spinal stenosis:

A
  • MRI scanning

- laminectomy

46
Q

What is meralgia paraesthetica:

A
  • entrapment mononeuropathy of lateral femoral cutaneous nerve
  • can also be iatrogenic post surgery or neuroma
47
Q

What nerve is affected in meralgia paraesthetica and how?

A
  • lateral femoral cutaneous nerve
  • originates from L2/3
  • runs beneath iliac fascia as it crosses surface of iliac muscle and exits through or under lateral inguinal ligament
  • as it passes inferiorly to anterior superior iliac since, repetitive trauma or pressure
48
Q

Risk factors meralgia paraesthetica:

A
  • obesity
  • pregnancy
  • tense ascites
  • trauma
  • iatrogenic
  • sports
  • idiopathic
49
Q

Symptoms meralgia paraesthetica:

A
  • burning, tingling, coldness, shooting pain
  • numbness
  • deep muscle ache
  • aggravated by standing and relieved by sitting
  • can be mild and resolve spontaneously
50
Q

Signs of meralgia paraesthetica:

A
  • may be reproduced by deep palpation below ASIS and extension of hip
  • altered sensation upper lateral thigh
  • no motor weakness
51
Q

Investigations meralgia paraesthetica:

A
  • pelvic compression test highly sensitive
  • injection with local aesthetic abolishes pain
  • US
  • nerve conduction studies
52
Q

Which metatarsal is most and least commonly fractured?

A
  • 5th most common

- 1st least common

53
Q

5th metatarsal fractures:

A
  • proximal avulsion fractures (Pseudo-Jones) - proximal tuberosity, associated with lateral ankle sprain often follow inversion injuries of anlke
  • Jones fractures - less common, transverse fracture at metaphysical-diaphyseal junction
54
Q

Metatarsal stress fractures:

A
  • healthy athletes

- most common site of metatarsal stress fractures is 2nd metatarsal shaft

55
Q

Features and investigations of metatarsal fractures:

A
  • pain and bony tenderness, swelling, antalgic gait
  • x-rays to distinguish between displaced and non-displaced fractures (periosteal reaction seen 2-3weeks later)
  • isotope scan or MRI
56
Q

What is Morton’s neuroma?

A
  • benign neuroma affecting inter metatarsal plantar nerve
  • most commonly 3rd metatarsophalangeal space
  • more common female
57
Q

Features Morton’s neuroma:

A
  • forefoot pain
  • worse on walking
  • Mulder’s click
  • loss of sensation distally in toes
58
Q

Diagnosis and management of Morton’s neuroma:

A
  • clinical diagnosis but US helpful
  • metatarsal pad
  • referral if persistent for >3 months
  • corticosteroid injection and neurectomy of involved interdigital nerve and neuroma
59
Q

What is Froment’s sign?

A
  • asses for ulnar nerve palsy
  • adductor pollicis muscle function
  • hold piece of paper between thumb and index finger - object then pulled away
  • if palsy, unable to hold paper and will flex flexor pollicis longus to compensate
60
Q

What is Phalen’s test?

A
  • assess carpal tunnel syndrome
  • more sensitive than Tinel’s
  • hold wrist in maximum flexion and test positive if numbness in median nerve distribution
61
Q

What is Tinel’s sign?

A
  • assess for carpal tunnel syndrome

- tap median nerve at wrist and test positive if tingling over distribution of median nerve

62
Q

What is an open fracture defined as?

A
  • disruption of bony cortex

- associated with breach in overlying skin

63
Q

Features osteoarthritis of the hand:

A
  • bilateral
  • carpometacarpal joints, distal interphalangeal joints affected more than proximal interphalangeal joints
  • episodic joint pain
  • stiffness worse after inactivity, only few minutes in morning compared to RA
  • painless nodes: Heberden’s at DIPJ and Bouchard’s at PIPJ
  • squaring of thumbs - fixed adduction
64
Q

X-ray findings of osteoarthritis in hands:

A

osteophytes and joint space narrowing

65
Q

Most common location of OA:

A

knee

66
Q

Second most common location OA:

A

hip

67
Q

Features osteoarthritis of hip:

A
  • chronic history groin ache relieved by rest

- red flag: rest pain, night pain, morning stiffness >2 hours

68
Q

What scoring system is used for OA of hip?

A

Oxford hip score

69
Q

Management OA of hip:

A
  • oral analgesia
  • intra articular injections
  • total hip replacement definitive treatment
70
Q

Complications OA of hip and reasons for total hip:

A
  • VTE, intraoperative fracture, nerve injury

- total hip: aseptic loosening, pain, dislocation, infection

71
Q

Patients who have had a hip replacement operation should receive basic advice to minimise the risk of dislocation:

A
  • avoid flexing hip >90 degrees
  • avoid low chairs
  • no leg crossing
  • sleep on back for 6 weeks
72
Q

Complications joint replacement:

A
  • wound and joint infection
  • thromboembolism (LMWH for 4 weeks)
  • dislocation
73
Q

What is osteochondritis dissecans?

A
  • pathological disease affecting subchondral bone
  • most often knee
  • also effects on joint cartilage, pain, oedema, free bodies and mechanical function
  • affects children and adolescents with open growth plates (juvenile OCD) and adults with closed (adult OCD)
74
Q

Risk factors OCD:

A
  • trauma
  • male
  • genetic
75
Q

Features OCD:

A
  • knee pain and swelling, typically after exercise
  • knee catching, locking and/or giving way
  • feeling a painful clunk when flexing or extending knee - involvement of lateral femoral condyle
76
Q

Signs OCD:

A
  • joint effusion
  • full range movement without signs of ligamentous instability
  • external tibial rotation when walking
  • tenderness on palpation of cartilage of medial femoral condyle when knee flexed
  • Wilson’s sign
77
Q

What is Wilson’s sign?

A
  • for detecting medial condyle lesion
  • with knee at 90 degrees and tibia internally rotated, gradual extension leads to pain at 30 degrees (external rotation of tibia relieves)
78
Q

Investigations OCD:

A
  • x-ray: subchondral crescent sign or loose bodies
  • MRI: to evaluate cartilage, loose bodies, stage and assess stability of lesion
  • CT: preoperative planning
  • scintigraphy: sign of osteoblastic activity
79
Q

2 types osteomyelitis:

A
  • haematogenous

- non-haematogenous

80
Q

What is haematogenous osteomyelitis?

A
  • from bacteraemia
  • monomicrobial
  • most common in children
  • vertebral most common from in adults
  • risk factors: sickle cell, IV drugs, immunosuppression due to meds or HIV, infective endocarditis
81
Q

What is non-haematogenous osteomyelitis:

A
  • contiguous spread of infection or from direct injury
  • polymicrobial
  • most common in adults
  • risk factors: diabetic foot ulcers/pressure sores, diabetes, peripheral arterial disease
82
Q

Most common organism in osteomyelitis:

A
  • staph aureus

- sickle cell: salmonella

83
Q

Investigation and management of osteomyelitis:

A
  • MRI
  • flucloxacillin for 6 weeks
  • or clindamycin
84
Q

Typical presentation osteoporotic vertebral fractures:

A
  • asymptomatic
  • acute back pain
  • breathing difficulties
  • gastrointestinal problems due to compression of organs
  • minority have history of trauma
85
Q

Signs and investigation of osteoporotic vertebral fracture:

A
  • loss of height
  • kyphosis
  • localised tenderness on palpation of spinous processes at fracture site
  • x-ray of spine first line - wedging of vertebra due to compression (old fractures have sclerotic appearance)
86
Q

How to calculate 10-year risk of osteoporotic fracture:

A

QFRacture tool or FRAX

Orthopaedics (4 decks)

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