Orthopeadics Flashcards
What causes a transverse fracture?
From pure bending force
What causes an oblique fracture?
Shear force (fall from height)
What causes a spiral fracture?
Torsional forces
What is a comminuted fracture?
Fracture with 3+ fragments
Due to high energy trauma or poor bone quality
What is a segmental fracture?
Bone fracture sin two separate places
What is the order of fracture healing?
Fracture healing order:
1. Haematoma
2. Inflammation
3. Soft callus
4. Hard callus
5. Remodelling
What is the px and mx of compartment syndrome?
Px – severe pain, tensely swollen, loss of distal pulse and numbness
Mx - emergency fasciotomy
When do fat embolisms occur?
After long bone fractures where fat globules are released into circulation
-> Systemic inflammatory response 24-72hrs after fracture
Px of fat embolism?
Respiratory distress, petechial rash, cerebral involvement, jaundice, thrombocytopenia, fever
What is a Colle’s fracture?
- FOOSH -> transverse fracture of distal radius with dorsal angulation
- Displacement posteriorly (upwards) causing a “dinner fork deformity”
- Extra-articular
What is a smith fracture?
- Falling onto back of outstretched wrist -> transverse fracture of distal radius with volar angulation
- Reverse Colle’s fracture
- Extra-articular
What is the risk of a scaphoid fracture?
Only one blood supply so fracture can result in avascular necrosis & non-union
What is a Monteggia fracture-dislocation?
Ulna fracture + dislocation of radial head at elbow
Age 4-10 years commonly
What is a Galeazzi fracture-dislocation?
Radius fracture + dislocation of radioulnar joint
What nerve is at risk if a humeral shaft fracture?
Radial nerve risk
What nerve is at risk in a proximal humerus fracture?
Axillary nerve risk
Is an intertrochanteric hip fracture intra- or extra- capsular?
Extracapsular
Is a subcapital hip fracture intra- or extra- capsular?
Intracapsular
Is a subtrochanteric hip fracture intra- or extra- capsular?
Extracapsular
What is osteochondritis dissecans?
Inflammation of bone and cartilage which occurs in young adults due to increased physical activity and body weight
o Recurrent impact trauma -> bleeding + oedema in bone -> capillary compression -> bone necrosis -> bone fragmentation
Px & Mx of osteochondritis dissecans?
Px - Poorly localised pain, effusion, locking
Mx - Pinning or removal of unstable fragments
Who does osteoporosis affect?
Occurs – post-menopause, old age, steroid/alcohol use, malnutrition
What is used to Dx osteoporosis?
DEXA scan
T-scores of osteoporosis?
More than -1 Normal
-1 to -2.5 Osteopenia
Less than -2.5 Osteoporosis
Less than -2.5 plus a fracture Severe Osteoporosis
Mx of osteoporosis?
Calcium + Vitamin D
Bisphosphonates - Alendronate, Zoledronic acid
Others:
- Denosumab - blocks osteoclasts
- Strontium ranelate - stimulates osteoblasts, blocks osteoclasts
- Raloxifene (secondary prevention only)
- HRT (if early menopause)
Mx of osteoporosis?
Calcium + Vitamin D
Bisphosphonates - Alendronate, Zoledronic acid
Others:
- Denosumab - blocks osteoclasts
- Strontium ranelate - stimulates osteoblasts, blocks osteoclasts
- Raloxifene (secondary prevention only)
- HRT (if early menopause)Wha
What is osteomalacia?
Abnormal softening of bone due to deficient mineralisation
o Due to insufficient calcium absorption
Px of osteomalacia?
Bone pain, soft bone deformities, fractures, hypocalcaemia signs
Biochemistry markers seen in osteomalacia?
Low calcium
Low serum phosphate
High serum ALP
Mx of osteomalacia?
Vitamin D + calcium + phosphate supplementation
What is Paget’s disease?
Thickened, brittle and mishappen bones due to osteoclasts / osteoblasts speeding up
Px - constant dull bone pain
Mx of paget’s disease?
Bisphosphonates
What is impingement syndrome?
Compression of rotator cuff muscles in subacromial space -> thinning / tearing of tendons
Causes:
Injury or overuse causing thicker & swollen tendon (swimmer’s shoulder)
Abnormal acromion – curved bony growth
Px of impingement syndrome?
Painful arc between 60-120° of abduction, radiates to deltoid & upper arm
Hawkins-Kennedy test (internally rotating flexed shoulder) recreates pain
Px of adhesive capsulitis?
Progressive pain & stiffness of shoulder. Pain becomes negligible when shoulder is fully stiff.
Resolves in 18-24mo where the shoulder ‘thaws’ out
Mx of adhesive capsulitis?
Physio, NSAIDs, corticosteroid injection, manipulation under anaesthesia (teras capsule)
What is the Px of acute calcific tendonitis?
Acute, severe shoulder pain due to calcium deposits in the supraspinatus tendon
Where / when is the pain with lateral epicondylitis?
Extensor region (outside of elbow)
Pain on wrist extension
Where / when is the pain with medial epicondylitis?
Flexion region (inside of elbow)
Pain on wrist flexion, tingling in digits
Mx of epicondylitis?
Resolves with rest, physio, NSAIDs in meantime
Steroid injections in lateral (risk to ulnar nerve in medial)
Ix & Mx of olecranon bursitis?
Ix – Aspirate -> microscopy + culture
Mx:
- Non-infectious -> RICE + analgesia
- Infection -> antibiotics (flucloxacillin)
What is dupuytren’s contracture?
Contractures at MCP and PIP joint
What is trigger finger?
- Tendonitis of flexor tendon
- Nodular enlargement
- Catches on tendon sheath
What is the px of trigger finger?
F>M, >40yrs
* Middle & ring finger
* ‘Clicking’ sensation
* Pain at base
* Worse in morning
What is a ganglion cyst?
Fluid filled swelling near a joint or tendon
Red flag back pain px?
Pain – constant, severe, worse at night, lasting >6 weeks
Worse on coughing – herniated disc
Systemic upset – fever, night sweats, weight loss, fatigue, malaise
What is scoliosis?
Lateral curvature of spine
Can be congenital, idiopathic or due to tumour, infection
- If painful -> urgent MRI
What is kyphosis?
Abnormal rounding of upper back
Can be due to osteoporosis compression fractures
What is cervical spondylosis?
Degenerative changes in cervical spine
+/- radiculopathy
What are the spine levels?
Cervical 7
Thoracic 12
Lumbar 5
Sacrum 5
Coccyx 4
What is spondylolysis?
Stress fracture in the pars interarticularis
What is spondylolisthesis?
Slippage of one vertebra over another (L4-S1)
Who suffers from spondylolysis?
Younger patients with sport
Who is at rx of spondylolisthesis?
> 50, F>M
Spondylolysis in adolescence
What are common causes of radiculopathy?
Nerve root entrapment due to:
- A herniated disc (bulged, slipped or ruptured)
- Osteophyte formation (OA), spinal stenosis, bone spurs
Mx of acute disc tear?
Analgesia + NSAIDs + physio [pain settles after 2-3 mo]
What is sciatica?
Shooting, burning pain from buttocks radiating down the back of the thigh to below the knee or feet [L4-S3]
Px of L3/4 prolapse?
L4 root entrapment
Pain down to medial ankle (L4)
Px of L4/5 prolapse?
L5 root entrapment
Pain down dorsum of foot
Px of L5/S1 prolapse?
S1 root entrapment
Pain to sole of foot
Mx of sciatica?
Analgesia, physiotherapy [90% recover <3mo]
- Neuropathic pain drugs (gabapentin)
- If severe – surgery (discectomy)
What is cauda equina?
Emergency
Large disc prolapses compressing lumbar nerve roots (L2-L5)
What is cauda equina?
Emergency
Large disc prolapses compressing lumbar nerve roots (L2-L5)
Px of cauda equina?
Px:
- Bilateral leg pain
- Saddle anaesthesia (numbness around sitting area)
- Altered bladder / bowel function
Ix & Mx of cauda equina?
Ix – PR exam, urgent MRI (call ortho on-call)
Mx – urgent discectomy (untreated -> permanent nerve damage)
Px of spinal stenosis?
Lumbar pain which is relieved sitting forward (flexion)
Ix & Mx of spinal stenosis?
Ix - MRI
Mx - Analgesia + physiotherapy [surgery if severe]
4 features of osteoarthritis?
L - Loss of joint space
O - Osteophytes
S - subchondral sclerosis
S - subchondral cysts
Mx for hip osteoarthritis?
- Topical analgesia
- Injections
- THA / THR
Rx for avascular necrosis?
M>F
35-50
Rx – alcohol, steroids, injury
Px of hip avascular necrosis?
Insidious dull ache, throbbing pain in groin
What is avascular necrosis of the hip?
Blood supply lost to femoral head -> collapse
Px of trochanteric bursitis?
Sharp pain at hip point with ache spreads across thigh
- Worse at night
What is FAI?
Femoracetabular impingement syndrome (FAI)
Extra bone at hip joint
- Pincer = above
- Cam = below
Px & Mx of FAI?
Px - Groin pain on flexion / extension -> OA
Mx - Osteotomy (remove bone)
What is and the steps of ITOH?
Idiopathic transient necrosis of the hip (ITOH)
- Local hyperaemia
- Marrow oedema
- ^Pressure
- Osteoporosis + osteolysis
Who is at rx of ITOH?
Female in third trimester
Px & Mx of ITOH?
Sudden progressive onset of pain -> worse walking
Resolves in 6-9months
- Avoid stress fracture
What is perthe’s disease?
Femoral head disease involving necrosis, collapse, repair & remodelling
Who is at rx of perthes disease?
M>F [5:1]
4-9yo
Px & Mx of perthes disease
Px:
- Pain
- Loss of internal rotation / abduction
Mx:
- Self-limiting
- Keep hip in socket and rest
Who is at rx of SUFE?
Fat, pre-pubescent teenage boys
What is SUFE?
Growth plate in hip can’t hold weight, so slips
Px & Mx of SUFE?
Px:
- Pain in hip
- Radiates to knee
Mx:
Urgent surgery to pin femoral head
Are medial or lateral meniscus tears more common?
Medial tears > lateral tear [10:1]
Mechanism of action of meniscal tears?
MOA – twisting, getting up from squatting
Px of meniscal tears?
Pain, effusion, locking, joint line tenderness
Ix for meniscal tear?
Steinman test
Mx for meniscal tears?
rest + physio
Locked knee = urgent arthroscopic surgery
> 3mo symptoms = consider surgery
Degenerative tear (elderly) = no surgery
Grades of ligament injuries?
Grade 1 = Sprain
Grade 2 = Partial tear
Grade 3 = Complete tear
MOA / px of ACL tear?
Twisting, ‘pop’ heard
anterior drawer test + lachman test
MOA / px of PCL tear?
Hyperextension / car crash
MOA / px of MCL tear?
Pain on valgus stress
MOA / px of LCLtear?
Pain on varus stress (uncommon)
ACL tear mx?
Physio, 40% have reconstruction
Knee dislocation mx?
Emergency reduction (<6 hour window)
+
Check neurovascular status before and after reduction
What way does a patella dislocate?
Laterally
Rx for extensor mechanism rupture?
Steroids, tendonitis, CKD, ciprofloxacin, DM
Age and what tendon ruptures in extensor tendon rupture?
<40 – patellar tendon ruptures
> 40 – quadriceps tendon rupture
Px of extensor mechanism rupture?
Palpable gap
Can’t straight leg raise
What is tibialis posterior dysfunction and who is at rx?
Acquired flat foot in adults as inflamed tibialis posterior tendon can’t support arch of foot
Obese, middle-aged female
Px and Ix for plantar fascitiis?
Px – Pain with walking at plantar aspect of heal
Ix – Tinnel’s test +ve for Baxter’s nerve
What is hallux valgus?
Bunions
Medial deviation of the 1st metatarsal
Pain due to joint incongruence & widened foot
What is Morton’s neuroma?
Degenerative fibrosis of digital nerve
Forefoot pain, burning and tingling in toes (high heels)
o “small stone under foot” [between 3rd/4rth toes]
MOA & Px of achille’s rupture?
MOA - ‘lunging at squash’ in weak tendon
Px – sudden pain, palpable gap, can’t weight bear
Ix for achille’s rupture?
Ix – Simmonds test – squeezing the calf -> no plantarflexion
What are the ottawa rules for an ankle sprain?
X-ray required if pain in malleolar zone +:
- Bone tenderness at lateral malleolar zone
- Bony tenderness at medial malleolar one
- Inability to weight bear
MOA for lateral and medial ankle tear?
Inversion -> lateral tear [calcaneofibular]
Eversion -> medial tear [deltoid ligament]
What is pes cavus?
Abnormal high arched foot (+toe clawing) – can be neuromuscular or idiopathic
What is pes planus?
low arched foot (flat foot) – can be developmental or acquired
What is hallux rigidus?
OA of the first MTPJ
What are claw & hammer toes?
Imbalance between flexors and tendons
Mx of shoulder dislocation?
Reduction and immobilisation in a broad arm sling for 2 weeks
Check for axillary nerve damage
What does Jobe’s test tell us?
Tests the supraspinatus - loss of abduction >90 degrees
Mx of rotator cuff tear?
Within 2 weeks - conservative (physio, NSAIDs, steroid injection)
> 2 weeks or failed conservative mx:
- Tendon repair
- Acromial decompression
Nerve injury in supracondylar fracture?
Most common - Anterior interososseus nerve (branch of median)
2nd most common - Radial nerve
Radial nerve palsy px?
Wrist drop - unable to extend wrist
Mx of Gartland type 1 or minimally displaced type 2 fracture? (elbow)
Conservatively with an above elbow cast in 90o flexion
Mx of elbow fracture with compromise or displacement?
Closed reduction and K wire placement (removed after 4w)
Garden classification of hip fracture?
1 - incomplete, un-displaced
2 - complete, un-displaced
3 - complete, incompletely displaced
4 - complete, completely displaced
Ix for developmental dysplasia of hip?
- US
- If baby >4.5m -> x-ray
Mx of developmental dysplasia of hip?
<4-6 months: Pavlik harness
6-18 months or failure of Pavlick harness: closed reduction and hip spica casting
>18months: open reduction and hip spica casting
>2 years: open reduction femoral/pelvic osteotomy
Mx of Perthe’s disease?
<8 y/o: NSAIDS for pain, physiotherapy to restore range of motion
>8y/o: femoral/pelvic osteotomy
Ix & Mx of SUFE?
Ix - AP and lateral frog leg x rays
Mx - Internal fixation using a single cannulated screw
Medial sensation down leg to foot?
Saphenous nerve
