Orthopaedics Unit 1 Flashcards
what is acute disease characterised by
polymurphonuclear leucocyte or polymorph
what is chronic disease characterised by
lymphocytes produced by bone marrow and the spleen
when is “…..octomy” and “….ectomy” used in surgery
otomy - when surgeons operate and open something up
ectomy - when something is removed in operation
what is most joint replacement surgery aimed at
pain relief
what is gout caused by
uric acid crystal deposited on the cartilaginous surface of the joints
what are the 2 principles symptoms of orthopaedics
pain
stiffness
what is OA and what causes this
wear and tear of the joints leading to degeneration
breakdown of the balance between wear and repair processes in the joint
what are causes of secondary OA
congenital - CDH
childhood - Perthe’s disease, infection
trauma - fracture into a joint
metabolic - gout
infection - TB
chronic inflammatory - rheumatoid
Sx of OA
Pain
Stiffness
Loss of function
Limitation of movement
when is secondary care sought in OA
when sleep is disturbed
what is important to remember about OA in regards to limitation of movement
better ROM when under anaesthetic (patient not feeling pain)
successful surgeries are related to adequacy of pain relief rather than improving mobility of joint
what are conservative Tx for OA
weight loss
- modest reduction in weight can have significant reduction in total loads
use of a stick
- used in opposite hand, means shoulder girdle can help in tilting the pelvis
- reduces work of abductor muscles and reduces load on the hip
rest
physio
what joints are particularly affect by obesity
lower limb joints
- e.g. hip joint = joint loading during the stance phase of walking can reach 3x body weight and during activities of greater hip muscle exertion joint loading can reach 5x body weight
why is physiotherapy controversial in Tx for OA
Over-exercise issues
some exercise does relieve stiffness and muscle spasm and therefore pain.
what should young and old be told in relation to physio
Young - should be advised against excessive activity
Elderly - Total rest is however equally counterproductive, maintenance of the activities of daily living is essential.
surgical Tx for OA
Nothing
Arthrodesis
Osteotomy
Arthroplasty
why is nothing an option for Tx of OA
if risks outweigh the benefits
patient needs to be allowed to decided for themselves
what is arthrodesis
surgical stiffening of a joint in a position of function
when is arthrodesis an appropriate operation
for a young person with a painful and limited ROM
what is done in arthrodesis
stiff and painful joint is cut out and the remaining raw bone ends are held together either by an external splint or screws until they heal with a bony bridge
what is the position the hip joint is fused in and who dislike this position
30 degrees in flexion and some adduction
disliked in females as it can interfere with sexual activity
what is the recovery period of arthrodesis
6 months
what are the disadv of arthrodesis
puts stress of adjacent joints
e.g. in the hip, it causes extra stress on the lumbar spine
what procedure can be done on the hip joint to avoid the disadv of arthrodesis
fuse the joint until the fifth decade and then performing a second operation to “unpick” the arthrodesis and convert it to an arthroplasty
what joints can undergo arthrodesis with good response
ankle
wrist
what is osteotomy and what is the aim of the operation
surgical alignment of a joint
redirect forces across a joint so that they more evenly distribute the load to which the joint is subjected.
when is osteotomy normally used
joint is deformed and the loads crossing it are distorted by the deformity
what is the disadv of osteotomy
seen as a temporary measure lasting from 1 to 2 years to around 10
rarely tackles underlying cause
when is osteotomy used in arthritis
young patient who have maintained a good ROM, despite the pain and preservation of articular cartilage
which is typical of the early stages of osteoarthritis
what joints are suitable for osteotomy and how is the operation carried out
hip
knee
performed on the femoral side by altering the angle of the femoral neck to change the attitude of the femoral head relative to the acetabulum.
what is arthroplasty
surgery that creates a new joint or changes the shape of a joint
what is the aim of arthroplasty
reduce pain and the restricted ROM pain brings
not likely to alleviate disability due to stiffness
what is important to remember about the artificial joints
From the moment it is put in, it begins to wear out, whereas a natural joint has the capacity to regenerate.
for the knee and hip joint, what is the current success rates
knee joint - very successful
hip joint - more successful in the elderly
why has there been difficulty in joint replacements in the arm
loads involved are low but the ROM of the elbow and shoulder required are quire large
why does arthroplasty improve pain related Loss of function but does less for intrinsic stiffness
due to soft tissue distortion of the capsule and ligaments remaining even after replacing articular surfaces
what angle must the elbow be able to flex to to permit eating
90 degrees
what is the functional range of hip motion required
30-50 degrees flexion
10-15 degrees extension
few degrees of abduction and rotation
what is the functional range of knee motion required
90 degrees flexion
what is essential for the surgeon to ensure in a knee joint replacement and how is this achieved
stability in extension so that we can support the full weight of the body on a single straight leg
accurate soft tissue balance
how does the surgeon achieve accurate soft tissue balance
must balance the collateral ligaments
ensure the medial and lateral collateral ligaments are under equal tension
surgeon cuts ligaments and puts in artificial surface replacements of sufficient thickness to re-tighten the ligament
what are 3 requirements for any joint replacement
functional and pain-free range of movement
stability and resistance to forces
wear and loosening
what are general complications post surgery
chest infection
UTI
DVT
PE
what are specific early complications of joint replacement surgery
dislocation
DVT
infection
why is the hip at a period of risk of dislocation after surgery
[when is the period of risk]
prosthesis will not be fully supported by the surrounding soft tissues.
muscles and proprioceptors out of action due to surgery and pain inhibition
[before the effects of anaesthesia wears off]
what movement of the leg can particularly cause a hip dislocation
twisting the leg into extreme flexion with adduction and internal rotation
what are prophylaxis of DVT
heparin
stockings [prevent blood pooling in the legs]
what organisms most commonly infect the hip joint
staph aureus
commensals - staph albus [found on the skin]
what measures are taken to try prevent infection
antibiotic prophylaxis
ultra-clean air operating environment
when does late specific surgical complications occur
what are the late specific surgical complications
may occur as late as 10 years post surgery
infection
loosening and wear
what are the ways an artificial joint can become infected
bacteria being introduced at the time of insertion
blood borne (bacteraemia) i.e. after tooth extraction
what Sx of RA
severe pain
swelling
deformity of the joints
F > M
what are the principal joints affected in RA
small joints of hands and feet that are affected symmetrically
how does RA differ from OA Sx
RA - first notice stiffness, worse in the morning and improves during the day
OA - stiffness worse after activities
what are operations that can be done to tackle RA
soft tissue surgery
- synovectomy = helps with damage to tendon sheath and tendons.
joint surgery
- excision arthroplasty
what synovectomy surgery is successful in RA and what can it relieve
at the wrist
- clears up damage around extensor tendons
can reduce pain and stiffness
- good for younger patents who retains movement, but who has pain
what is the adv and disadv of excision arthroplasty
relieves pain
but as part of joint has been removed, there can never be full return of function
what is the surgeons role in RA
salvage joint
pain relief
return of function
what is AVN
bone tissue death through loss of blood supply
can be caused by trauma or be spontaneous
what areas are at risk of AVN after trauma
femoral head
proximal part of the scaphoid
proximal part of the talus
what areas are at risk of AVN spontaneously
lunate of the wrist
femoral head
when is AVN of the femoral head seen
chronic alcohol abuse
high dose steroid therapy
deep sea divers [Caisson’s disease]
Sx of AVN
acute, severe joint pain
worse on movement
relieved a little by rest
patients tend to be younger
over time becomes indistinguishable from OA
why is AVN difficult to diagnose
no changes are seen on an x-ray
Mx of AVN
may be reversed if blood supple is re-established naturally
Tx underlying cause
joint replacement if needed
what causes gout
urate crystal
- urate = waste product of cell metabolism normally passed in the urine
causes of gout
dehydration [i.e. post-op]
after chemo
overuse of diuretics
Sx of gout
hot, tender, swollen joint
seen in 1st metatarsophalangeal joint and knee joint
Ix of gout
high level of uric acid in the blood
extract joint fluid and test for the presence of urate crystals
Mx of gout
NSAID
what is the cause of pseudogout
calcium pyrophosphate crystals on the articular surface of the joint
causes calcification of joint surfaces and menisci of the knee
what is the consequences of pseudo gout and gout
long term degeneration
what causes acute septic arthritis
infection which has spread to the joint via the blood
Sx of acute septic arthritis
in children
- acute illness
- high temperature
- joint is stiff, hot and tender
in adults
- can have less acute illness
- present with blood poisoning
- can be easy to miss septic arthritis
if a young adult presents with acute septic arthritis, what is the likely organism
gonococcus
Mx of acute septic arthritis
surgery - open and wash the joint
IV antibiotics
- first guess IV anti-staphylococcal agent in children [most likely organism]
what is the consequences of septic arthritis if not managed adequately
septicaemia
articular cartilage may disintegrate, may cause fibrous or bony fusion of the joint
what causes chronic septic arthritis
TB
- chronic SA seen commonly in AIDS patients
if there is TB in the joints, where else is it likely to be
Kidneys
Sx of chronic septic arthritis
chronic ill health
weight loss
muscle wasting around the joint
thinning of the bone
Mx of chronic septic arthritis
streptomycin, ethambutol and rifampicin
what are the Sx of mechanical knee problems
swelling
locking
giving way
pain
Sx of meniscal lesions
M > F
pain
effusion
locking
giving way
abnormality poorly localised O/E
MOI of meniscal lesions
twisting injury
- foot gets stuck on the ground, femur twists over stationary tibia cause a wrench to the meniscus
- may be torn or pulled off the bone
- seen in football, skiing
what menisci is more likely to be injury
medial more than lateral
what are the different types of meniscal lesions
cleavage lesion
- meniscus splits horizontally
- common in old age
- can cause the formation of a cyst due to build up of synovial fluid
bucket handle tear
- vertical split, which is anchored at both ends
parrot beak tear
- split off ones end of the lateral meniscus
degenerate tear
- tear due to generation
consequence of meniscal tear
torn part can become jammed in the joint
- stops the joint extending
why is your menisci important
shock absorber
helps distribute loads between femur and tibia
Mx of menisci tear
peripheral tears
- reattached with sutures
- have ability to heal due to good blood supply
tears within centre of menisci
- no ability to heal
- should be removed by arthroscopic meniscectomy
- patients recover quicker with arthroscopic
Ix of menisci tear
arthroscopy
what are osteochondral fragments
small fragments of cartilage and bone sheared off in injury a.k.a loose body
causes haemarthrosis (bleeding into the joint) and swelling
why can osteocondral fragments be difficult to diagnoses
invisible on x-ray
Sx of osteocondral fragments
after first incident may settle
months/years later
- locking
- pain
- giving way
- effusion
Mx of osteocondral fragments
removed with arthroscope
what is osteochondritis dissecans.
osteochondral fragments occurring spontaneously in adolescents
can settle spontaneously
why do collateral ligaments of the knee injuries heal by themselves but injuries to the cruciate do not
collateral ligaments have an excellent blood supply
when cruciate ligament is torn, blood supply is lost
how is the cruciate ligament commonly injured
by hyperextension or twist, often with the foot being anchored
Sx of ACL rupture
haemarthrosis
- knee swells quickly
- caused by bleeding from artery in cruciate
loss of antero-posterior stability
- particular flexion
loss of rotatory stability
- when twisting and turning
patients may report feeling a “pop”
what activities will cause the patient to experience Sx in ACL rupture
descending stairs
twisting or turning
Mx of ACL rupture
Tx offered when Sx interfere with daily life or if patients wishes to return to sport
replace torn ligament with synthetic one
why are synthetic ligaments more likely to fail compared to a natural ligament
it has no sensory receptors to let the brain know if the ligament is being overstretched
The brain is therefore unable to initiate muscle action to protect the joint.

what is patella dislocations associated with and what is the clinical presentation
malformation of the patella or lateral femoral condyle
- leads to patella moving on the femur (mal-tracking)
- painful and associated muscle spasm present
- spontaneous dislocation
- failure of quads to act as an extensor = person falls to the ground
Mx of patella dislocation
minor mal-tracking
- surgical splitting of the vastus laterals muscle insertion into the patella
- allows patella to fall back into a normal
recurrent/severe mal-tracking
- medial tightening (PLICATION) of the vastus medialis muscle
what can patella dislocation be confused with
anterior knee pain often seen in adolescent girls
