Orthopaedics (Unit 1 - Joint Conditions) Flashcards
What cells are involved in acute disease?
Polymorphonuclear leucocyte (polymorph)
Why is a polymorph called a polymorph?
Because it’s nucleua is in many sections and it appears white
What cells are involved in chronic disease?
Lymphocytes
Where are lymphocytes produced
Bone marrow and the spleen
What is osteoarthritis?
Breakdown of the balance between the wear and repair processes in the joint
What is a congenital cause of secondary OA?
Congenital dislocation of the hip
What are childhood causes of secondary OA?
Perthe’s disease
Infection
What is a traumatic cause of secondary OA?
Fracture in a joint
What are metabolic causes of secondary OA?
Gout
Crystal arthropathy
What is an infective cause of secondary OA?
TB
What is a chronc inflammatory cause of secondary OA?
Rheumatoid
Clinical presentation of OA
pain & associated loss of function
Worse with activity
Joint stiffness
Conservative management options for OA
Weight loss
Use of a stick
Rest
Physio
Surgical options for OA
Arthrodesis
Osteotomy
Arthroplasty
What is arthrodesis?
Surgical stiffening of a joint in a position of function
What is a good surgical option in a young person with painful OA and a limited range of movement
Arthrodesis
What is the long term disadvantage of arthrodesis?
Puts stress on adjacent joints
What can be done to try and reduce stress on other joints following arthrodesis in a young person?
“Unpick” and convert to arthroplasty in their 50’s
Which joints in particular are well suited to arthrodesis?
Wrist and ankle
What is osteotomy?
Surgical realignment of a joint
What is the aim of osteotomy?
To more evenly distribute the load to which the joint is subjected
In a young person with OA when would osteotomy be most useful and why?
If they have maintained a good range of movement despite the pain. If severely limited osteotomy won’t work as useful function cannot be restored
What is arthroplasty?
Surgery which creates a new joint or changes the shape of a joint
Why does arthroplasty not work as well for the upper limb?
Loads are low but need a large range of movement
Which is the most successful and common joint replacement?
Hip
What are specific early complications of joint replacement?
Dislocation
DVT
Infection
What are the most likely causative organisms in an early infection following joint replacement?
Staph Aureus
Commensals (e.g. staph albus)
What are specific late complications of joint replacement?
Infection
Loosening and wear
What is the likely route of infection if late after joint replacement?
Blood steam (bacteraemias)
Symptoms of RA
Severe pain. swelling and deformity of joints
Symmetrical small joint involvement
Stiffness worse in the morning
What soft tissue surgery can affect sufferers of RA?
Synovectomy (particularly at the wrist)
In what patients is synovectomy particularly valuable?
Young person, who retains movement, but has pain
What often accompanies a synovectomy for RA at the elbow & wrist?
Excision arthroplasty
What is AVN?
Bone tissue death through loss of blood supply
What are the causes of AVN?
Trauma
Spontaneous
Which areas are at risk for post traumatic AVN?
Femoral head
Proximal part of the scaphoid in the wrist
Proximal part of the talus
Which 2 sites does spontaneous AVN tend to occur?
Femoral head
Lunate
In what individuals is AVN of the head of femur seen?
Chronic alcohol abuse
High dose steroid therapy
Caisson’s disease
What is Caisson’s disease?
Decompression sickness in deep sea divers
How does a patient with AVN of the femoral head present?
Acute severe joint pain
Made worse by movement
To some degree relieved by rest
How can AVN be reversed?
If blood supply is restored naturally (however bone is soft and prone to distort)
What is the role of surgery in the management of AVN?
Surgical restoration of blood supply not possible
Sometimes joint replacement
What are crystal arthopathies?
Crystals of the by products of body metabolism are deposited in the joints, on the surface of articular cartilage and within synovial fluid
Why do crystal arthropathies occur?
Abnormality of metabolism causing excess production or kidneys failing to eliminate them
Which crystal is deposited in gout?
Urate
What is urate?
A waste product of cell metabolism
What are the causes of gout?
Dehydration
Chemo
Diuretic overuse
Clinical presentation of gout
Hot, tender swollen joint
Which condition can mimic gout?
Infection
Where is gout most commonly seen?
Knee
First MTP
How is gout diagnosed?
High level of uric acid in the blood or urate cystals in joint fluid
What crystals are deposited in pseudogout?
Pyrophosphate
What is the prognosis of pseudogout?
Symptoms can be controlled by anti-inflammatory drugs but long-term degeneration is likely
What effect does chronic pseudogout have on joints?
Calcification of joint surfaces and menisci in the knee
What is acute septic arthritis?
Infection caused bacteria spread to the joint via the blood from a site of trivial infection
How does acute septic arthritis present in children?
Unpleasant acute illness
High temperature
Stiff hot and tender joint
How does acute septic arthritis present in adults?
Less acute illness
chronically abnormal joint may give false impression of minor upset
Unwell for days before presenting with blood poisoning
What is the most likely causative organism in a young adult with septic arthritis with little constitutional upset?
Gonococcus
How is acute septic arthritis managed?
Surgical washing
IV antibiotics
What is the first guess antibiotic in kids with acute septic arthritis?
Anti-staphylococcal agent
What is the cause of chronic septic arthritis?
TB spread to joints via the blood
How does chronic septic arthritis present?
Chronic ill health
Weight loss
Muscle wasting around affected joint
What is seen on an x-ray of chronic septic arthritis?
Marked thinning of the bone
How is chronic septic arthritis treated?
Combo of antibiotics (streptomycin, ethambutol, rifampricin)
Symptoms of a meniscal lesion
Pain
Effusion
Locking and/or giving way
Generalised discomfort
What is the main cause of meniscal lesions?
Twisting injury (femur twists over stationary tibia)
Which meniscus is more frequently torn?
Medial
Describe a cleavage lesion
Meniscus splits horizontally
Common in old age
Can act like flap valves and allow build up of synovial fluid within the meniscus (cyst)
List 3 different types of meniscal tear
Bucket handle (vertical split anchored at both ends)
Parrot beak (split off one
end of the lateral meniscus)
Degenerate tear
How are patients with a suspected meniscal tear investigated?
Arthroscopy
How can peripheral meniscal tears be managed?
Sutures
How should tears within the substance of the meniscus be managed?
Torn peripheral part should be removed
What is the advantage of arthroscopic over open meniscectomy?
Patients recover quickly (within days)
What is a loose body?
When fragments of cartillage and bone are sheared off in a shearing injury and knee swells up from associated bleeding into the joint
How do loose bodies present?
First incident settles
Months or years later patient presents with lock, pain and giving way, often with effusion
Describe osteochondritis dissecans
Adolescents
Osteochondral fragments occur spontaneously
Tends to settle spontaneously
Loose bodies may require removal
How are cruciate ligaments injured?
Hyperextension or twist
Why are cruciate ligaments not capable of spontaneous healing?
If torn blood supply is lost
In what situation might cruciate ligament retain its blood supply after an injury?
If cruciate ligament pulled off with a fragment of bone at one end and put back within a few hours
Clinical presentation of cruciate injury
Acute swelling (haemarrthrosis)
Feel a “pop”
Antero-posterior instability
Rotational instability
Management of cruciate ligament injuries
Left untreated for a while
Knee muscle rehab
Only offer treatment if interfering with daily life or wanting to return to sport
What are the surgical treatment options for cruciate ligament injuries?
Synthetic ligament
Why is a prosthetic ligament more likely to fail?
Has no sensory receptors to indicate the brain that ligament is being overstretched (no muscle action to protect joint)
What is dislocation of the patella usually associated with anatomically?
Malformation of either the patella or lateral femoral condyle
How does dislocation of the patella usually present clinically?
Failure of quads to act as extensor so patient falls to the ground
How are minor degrees of patellar dislocation treated?
Surgical splitting of vastus lateralis muscle insertion into th patella, allows the patella to fall back into a normal relationship with the femur
How is recurrent and severe patellar dislocation treated?
Medial tightening (plication) of the vastus medialis muscle In childhood patellar tendon may be re-sited more medially
