Orthopaedics Passmed Flashcards
what is the first line medication for lower back pain
If malignancy has been ruled out:
NSAIDs
PPI should be co-prescribed for adults >45 taking NSAIDs
what is the initial management for a suspected or confirmed scaphoid fracture?
- Immobilisation with a future splint or below elbow back slab
- Referral to orthopaedics
Further imaging 7-10 days if initial radiographs are inconclusive
What is the orthopaedic management of a scaphoid fracture
- Undisplaced fracture of waist = 6-8 weeks in cast
- Displaced fracture of waist = Surgical fixation
- Proximal pole fracture = surgical fixation
what are the first signs of compartment syndrome
- pain on movement (even passive)
- excessive use of breakthrough analgesia
- parasthesia
- pallor
- paralysis
- pulse MAY or MAY NOT be present
what is the intracompartmental pressure in compartment syndrome?
> 20mmHg is abnormal
> 40mmHg is diagnostic
which fractures most commonly cause compartment syndrome?
supracondylar and tibial shaft injuries
what is the treatment for open fractures?
Treated as an emergency - should be derided and lavage within 6 hours of injury.
Definitive management of open fractures should be delayed until soft tissues have recovered - external fixation devices can be used as an interim while soft tissue coverage is achieved (should be done within 72 hours).
what are the signs of adhesive capsulitis
- stiffness and pain on active and passive movement - external rotation affected more than internal rotation
- pain on coracoid palpation
what are the risk factors for adhesive capsulitis
- female
- thyroid disease
- diabetes
- middle aged
what is de quervains tenosynovitis
The sheath containing tendons is inflamed:
- Extensor pollicis brevis
- Abductor pollicis longus
what test is done in de quervains tenosynovitis
Finkelstein’s test - Pulling thumb in ulnar deviation causes pain over radial styloid process
what are the complications of discitis?
epidural abscess
sepsis
what organism most commonly causes discitis?
staphylococcus aureus
what is the treatment for discitis?
- 6-8 weeks of IV antibiotics
- transthoracic echo (screen for endocarditis)
what imaging should be done for a suspected achilles tendon rupture?
Ultrasound
what are risk factors for achilles tendon ruptures?
ciprofloxacin
hypercholesterolaemia
what is Simmonds triad?
Triad for achilles rupture:
Patient should lie prone with their feet over the edge of the bed
- Greater dorsiflexion of injured foot
- Gap felt in tendon
- Foot will stay in neutral position despite the calf being squeezed
what is the Weber classification for ankle fractures?
Type A - Below the syndesmosis
Type B - Starts at the level of the tibia and pay extend proximally to involve the syndesmosis
Type C - Above the syndesmosis
Syndesmosis (between distal tibia and fibula)
what are the Ottawa rules regarding ankle fractures?
A fracture should only be x-rayed if:
There is pain in the malleolar zone AND
- Inability to weight bear for 4 steps
- tenderness over the distal tibia
- Bone tenderness over distal fibula
what is carpal tunnel syndrome?
idiopathic median neuropathy at the carpal tunnel
what is cubital tunnel syndrome?
Compression of the ulnar nerve.
Tingling in 4th and 5th finger - later develops into numbness and weakness
worse when elbow is flexed or resking on a firm surface
what is the treatment for an extra capsular hip fracture?
Stable intertrochanteric fractures = Dynamic hip screw
If reverse oblique, transverse or subtrochanteric fractures = intramedullary device
what is the treatment for intra capsular hip fractures?
Undisplaced = Intramedullary nail or hemiarthroplasty if unfit
Displaced = arthroplasty (or hemiarthroplasty)
what is the advice regarding hip fractures and weight bearing?
Immediate weight bearing is encouraged
what classification system is used to classify neck of femur fractures?
Garden
what are the clinical features seen in femoral nerve injuries?
- weak knee extension
- loss of patella reflex
- numbness of thigh
what is the definition of flail chest
Two or more rib fractures along three or more consecutive ribs
Usually anteriorly
which metatarsal is most likely to be fractured
5th metatarsal = most likely to be fractured overall
2nd metatarsal = most likely to be fractured due to stress
what is the most common cause of osteomyelitis
staphylococcus aureus
what are the signs of hip dislocation
posterior dislocation most common (>90%)
Leg is shortened, adducted and internally rotated
what are the features of L5 lesions?
Loss of foot dorsiflexion
Sensory loss dorsum of foot
Reflexes intact
what are the main features of subacromial impingement
Painful arc of abduction - worst between 90 and 120 degrees.
what is the management of simple rib fractures
- the majority are managed conservatively with good analgesia
- if the pain isn’t controlled by normal analgesia then nerve blocks can be considered
(inadequate ventilation may predispose to chest infections)
what are specific causes of dupuytrens contracture?
Manual labour
phenytoin treatment
alcoholic liver disease
diabetes mellitus
trauma to the hand
what is the treatment for osteomyelitis
Flucloxacillin for 6 weeks
clindamycin if penicillin allergic
what is the treatment for shoulder dislocation?
- recent dislocation = reduction without any analgesia
- HOWEVER - some patients may need analgesia or sedation to ensure the rotator cuff muscles are relaxed
what is the fouchers sign regarding a bakers cyst?
Theres an increase in tension of the bakers cyst on extension of the knee
what are the causes of avascular necrosis of the hip
Long term steroid use
chemotherapy
alcohol excess
trauma
what are the main features of caudal equine syndrome?
lower back pain
sciatica (bilateral)
reduced perianal sensation
reduced anal tone
faecal incontinence
Late sign - urinary incontinence
what is caudal equine syndrome?
a condition where the lumbosacral nerve roots that extend below the spinal cord are compressed
what are the causes of caudal equine?
Most common = central disc prolapse (L4/5 or L5/S1)
Tumour
Infection (abscess, discitis)
Trauma
haematoma
what is the most common organism causing a poses abscess
staphylococcus aureus
what are complications of ANY staphylococcal infection
endocarditis
psoas abscess
what is the management of a posts abscess?
Antibiotics
1st line = Percutaneous drainage
2nd line = surgery
what are the signs and symptoms of trochanteric bursitis?
Caused by repeated movement of the fibroelastic iliotibial band.
Most common in women aged 50-70.
Pain over lateral hip/thigh.
Tenderness on palpation of greater trochanter.
What is the treatment for trochanteric bursitis?
physiotherapy
Anti-inflammatory drugs
corticosteroid injections
what are the features of hand osteoarthritis?
usually bilateral
carpometacarpal joints and distal interlpahalgeal joints are affected more than the proximal interphalangeal joints.
heberdens nodes at the DIP joints
Bouchards nodes at the PIP joints
squaring of the thumb
weak grip
reduced ROM
which joints does rheumatoid arthritis spare
the DIP joints
what are the x ray changes seen in osteoarthritis
Loss of joint space
osteophytes
subarticular sclerosis (increased density of bone along the joint line)
Subchondral cysts (fluid filled holes in the bone)
what does the sciatic nerve divide into?
It divides into the tibial and common perineal nerves
what is the most characteristic cause of foot drop
a peroneal nerve lesion
which nerve roots make up the sciatic nerve
L4, L5, S1, S2, S3
what is the treatment for club foot
Ponseti method:
- manipulation and progressive casting starting soon after birth
what are the signs of carpal tunnel syndrome?
- compression of the median nerve
- altered sensation of the lateral 3 fingers (pins and needles)
- associated with RA
- commoner in females
- symptoms worst at night
- wasting of thenar muscle
what are the tests done fro carpal tunnel syndrome?
Formal diagnosis = Electrophysiological studies
Phalens test
Tinnels test
what is the difference between carpal tunnel and cubital tunnel?
Carpal tunnel = pinching of the nerve at the level of the wrist.
Cubital tunnel = Pinching of the nerve at the level of the elbow
what are the signs of cubital tunnel syndrome?
- compression of the ulnar nerve
- tingling and numbness of 4th and 5th finger
- pain worse when leaning on affected elbow
what is the treatment for carpal tunnel syndrome?
Initial:
- 6-week trial of conservative management of symptoms are mild to moderate (corticosteroid injections, wrist splints at night)
Severe or persistent symptoms:
- surgical decompression (flexor retinaculum division)
what are signs and symptoms of fat embolisms?
- fever
- breathlessness
- hypoxia
- tachycardia
- petechial rash
- retinal haemorrhage
- Symptoms can occur up to 3 days after the trauma
- confusion and agitation
what is the imaging that should be done for suspected osteomyelitis?
MRI
What are the symptoms of discitis?
- back pain
pyrexia
rigors
sepsis
neurological features
what is the treatment for pages disease
bisphosphonates
what is the treatment for osteoporosis
Calcium and vitamin D replacement (first)
bisphosphonates (second)
which test is best for avascular necrosis of the hip
MRI is the investigation of choice
what are the features of a prolapsed disc?
- A prolapsed lumbar disc usually produces clear dermatomal leg pain
- leg pain worse than back pain
- pain worse when sitting
what is the management of a disc prolapse?
First line:
- NSAIDs +/- PPI
If symptoms persist (after 4-6 weeks) then refer for an MRI
what are the symptoms of sciatica
- unilateral pain from the buttock radiating down the back of the thigh to the knee or feet
- pain might be electric or shooting
- pins and needles
- numbness
- weakness
*BILATERAL sciatica is a red flag for caudal equine syndrome
what is the diagnostic test for caudal equine syndrome?
MRI
what are the signs of an L3 nerve root compression
sensory loss over anterior thigh
weak - hip flexion, knee extension and hip adduction
reduced knee reflex
what are the signs of spinal stenosis
back pain, neuropathic pain and symptoms mimicking claudication:
- sitting better than standing
- walking uphill is better than downhill
what is the investigation and treatment for spinal stenosis
investigation - MRI
Treatment - laminectomy
what is Charcot joint
Also known as a neuropathic joint = a joint which has become badly disrupted and damaged secondary to a loss of sensation.
what are the characteristic features of different knee injuries
ACL or PCL - rapid joint swelling (suggestive of haemoarthrosis)
ACL - positive lachman test
LCL - Direct blow to medial side. Slow development of joint effusion and lateral joint line tenderness
MCL - Direct blow to the lateral side. Classical symptoms would be a slow developing joint effusion and medial joint line tenderness.
Meniscal tears - Twisting injuries, delayed knee swelling and joint locking.
what is the most common problem after a hip replacement?
Aseptic loosening of the hip replacement
which movements aggravate medial epicondylitis
Wrist flexion and pronation
What is the treatment of ankle fractures?
Weber A + Minimally displaced = Weight bear as tolerated in a CAM boot
Weber B = Needs careful investigation. If involving the ankle ligaments - same as C. If not involving ankle ligaments - same as A.
Weber C = ORIF (open reduction and internal fixation).
