ORTHOPEDICS Flashcards
What is the most common cause of posterior heel pain?
Achilles tendon disorders
What are the presentations of achilles tendon disorders?
- tendinopathy - tendonitis
- partial tear
- complete rupture achilles tendon
What are the risk factors to achieve;;es tendon disorders?
quinolone use - e.g. ciprofloxacin
hypecholestrerolaemia - tendon xanthomata
What is the onset like for achilles tendinopathy/ tendonitis?
gradual
Where is the pain in achilles tendinopathy?
posterior heel pain
When is the heel pain worse in achilles tendinopathy?
worse following activity
At what time of the day is the pain worse in achilles tendinopathy?
morning - stiffness
What is the management of achilles tendinopathy?
SUPPORTIVE
- simple analgesia
- reduction in precipitating activities
3.calf muscle eccentric exercises - physio
When should a achilles tendon rupture be suspected?
audible pop in the ankle
sudden onset significant pain in the calf or ankle
inability to walk
all whilst doing sport or running
What is the Simmond’s triad?
an examination used to exclude achilles tendon rupture.
lie prone with feet over bed
look for abnormal ankle of declination
squeeze calf and ankle will stay in neutral position
What is the imaging of choice for achilles tendon rupture?
US
When should a referral be made to oath regarding achilles tendon rupture?
Acutely
What is adhesive capsulitis?
frozen shoulder
Who does adhesive capsulitis most commonly affect?
middle aged females
What is the aetiology of adhesive capsulitis?
not understood
What is adhesive capsulitis associated with?
diabetes
What rotation is affected in adhesive capsulitis?
external rotation
What movement is affected in adhesive capsulitis? (active or passive)
both active and passive
What phases do patient’s have in adhesive capsulitis?
- painful freezing phases
- Adhesive phase
- recovery phase
What percentage of people have bilateral adhesive capsulitis?
20%
How long does an episode of adhesive capsulitis last?
6 months and 2 years
How is a diagnosis of adhesive capsulitis made?
clinical
What is the management of adhesive capsulitis?
NSAIDs
Physio
Oral corticosteroids
Intra-articular corticosteroids
What is the Ottawa ankle rule?
criteria for ankle injuries and X-ray
When is an ankle X-ray require according to Ottawa ankle rule?
An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:
bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)
bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)
inability to walk four weight bearing steps immediately after the injury and in the emergency department
What is a sprain?
stretching, martial or complete tear of a ligament
What does a high ankle sprain involve?
syndesmosis
What does a low ankle sprain involve?
lateral collateral ligaments
What is the presentation of a low ankle sprain?
most common (>90%) with injury to the ATFL
the most common offender
inversion injury most common mechanism
pain, swelling, tenderness over affected ligaments and sometimes bruising
patients usually able to weight bear unless severe
What is a grade I low ankle sprain?
mild ankle sprain
How is the ligament disrupted in a grade I ankle sprain?
stretch or micro tear
In a grade I ankle sprain what degree of bruising and swelling is there?
minimal
In a grade I ankle sprain is there any pain on weight bearing?
none
What isa grade II ankle sprain?
a moderate low ankle sprain
How is the ligament disrupted in grade II ankle sprain?
Partial tear
What degree of bruising and swelling is there is a grade II low ankle sprain?
moderate
Is there any pain on weight bearing in a grade II ankle sprain?
minimal
What is a grade III ankle sprain?
severe low ankle sprain
How is the the ligament disrupted in a grade III ankle sprain?
complete tear
What is the degree of bruising like in a grade III ankle sprain?
severe
Is there any pain on weight bearing in a grade III ankle sprain?
severe
Investigations of low ankle sprains
radiographs - 15% associated with fractures
MRI if resistant pain - useful for evaluating perineal tendons
What is the management for a low ankle sprain?
RICE
removable orthosis, cast +/- crutches shrt term
surgical and MRI intervention is rare - only if persistent
What are high ankle sprains and how common are they?
injuries to the syndesmosis
rare
What is the mechanism of injury in high ankle sprains?
external rotation - causes the talus t pus the fibula laterally
How do patients find weight bearing in high ankle sprains?
painful
What is the Hopkins Squeeze Test?
in relation to high ankle sprains
pain when the tibia and fibula are squeezed together at the level of the mid calf
What re the investigations of high ankle sprains?
Radioraphs - show widening of the tibiofibular joint (diastatsis) or ankle mortise
MRI - if high suspicion of syndesmotic injury but normal plain films
What is the management for high ankle sprains?
if no diastasis - non- WB orthosis or cast until pain subsides
if diastasis or failed non-operative management then operative fixation
When should one look out for Maisonneuve fracture of the proximal fibula in high ankle sprains?
deltoid ligament isolated injuries - which are rare
When can treatment of a high ankle sprain be as per low ankle sprain?
provided the ankle mortise is anatomically reduced
What is a boxer fracture?
a minimally displaced fifth metacarpal
after punching
What is found on examination in carpal tunnel syndrome?
weakness of thumb abduction - abductor policies brevis
wasting of theanar eminences - not hypothenar
tinels sign
phalens sign - flexion of wrists
What re the accuses of carpal tunnel?
idiopathic
pregnancy
oedema e.g. heart failure
lunate fracture
rheumatoid arthritis
What is the electrophysiology behind carpal tunnel’s syndrome?
motor + sensory: prolongation of the action potential
What is the treatment of carpal tunnel’s syndrome
a 6-week trial of conservative treatments if the symptoms are mild-moderate:
corticosteroid injection
wrist splints at night
if there are severe symptoms or symptoms persist with conservative management:
surgical decompression (flexor retinaculum division)
What is cubital tunnel syndrome?
Cubital tunnel syndrome occurs due to compression of the ulnar nerve as it passes through the cubital tunnel.
What are the features of cubital tunnel syndrome?
Tingling and numbness of the 4th and 5th finger which starts off intermittent and then becomes constant.
Over time patients may also develop weakness and muscle wasting
Pain worse on leaning on the affected elbow
Often a history of osteoarthritis or prior trauma to the area.
What are the investigations of cubital tunnel syndrome?
clinical
however, in selected cases nerve conduction studies may be used
What is the management of cubital tunnel syndrome?
Avoid aggravating activity
Physiotherapy
Steroid injections
Surgery in resistant cases
What is de quervain tenosynovitis?
the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed.
Who does de quervain’s tenosynovitis typically affect?
females aged 30 - 50 years old.
De Quervain’s tenosynovitis - where is the pain and tenderness ?
Radial side of the wrist
tenderness over the radial styloid process
What movement of the thumb is painful in de quervains?
abduction of the radial styloid process
What is Finkelstein test in de quervains tenosynovitis?
the examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction.
In a patient with tenosynovitis this action causes pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus
What is the management of de quervain’s tenosynovitis?
analgesia
steroid injection
immobilisation with a thumb splint (spica) may be effective
surgical treatment is sometimes required
What is discitis?
Discitis is an infection in the intervertebral disc space. It can lead to serious complications such as sepsis or an epidural abscess.
What are the features of discitis?
Back pain
General features
-pyrexia,
-rigors
-sepsis
Neurological features
e.g. changing lower limb neurology
if epidural abscess develops
What are the causes of disci tis?
Bacterial
-Staphylococcus aureus is the most common
cause of discitis
Viral
TB
Aseptic
How is discitis diagnosed?
Imaging: MRI has the highest sensitivity
CT guided biopsy may be required to guide antimicrobial treatment
What is the management of discitis?
The standard therapy requires six to eight weeks of intravenous antibiotic therapy
Choice of antibiotic is dependent on a variety of factors.
The most important factor is to identify the organism with a positive culture (e.g. blood culture, or CT guided biopsy)
What are the complications of discitis?
sepsis
epidural abscess
What are the further investigations of discitis?
Assess the patient for endocarditis e.g. with transthoracic echo or transesophageal echo.
Who is a dupuytren’s contracture most common in?
older males
60-70% have posiive family history
Causes of duputytrens contracture
manual labour
phenytoin treatment
alcoholic liver disease
diabetes mellitus
trauma to the hand
Which fingers are commonly affected in dupuytren’s contracture?
the ring finger and little finger
What is the management of dupuytren’s contracture?
surgery
What is lateral epicondylitis?
tennis elbow
Weher is the pain and tenderness in lateral epicondylitis?
localised to the lateral epicondyle
When is the pain worse in lateral epidondylitis?
resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended
How long does lateral epicondylitis last for?
between 6 months and 2 years
How long do people with lateral epicondylitis have acute pain for?
6-12 weeks
What is medial epicondylitis?
golfer’s elbow
Where is the pain in medial epicondylitis?
medical epicondyle
How is the pain aggravated in medial epicondylitis?
wrist flexion and pronation
what are the symptoms of medial epicondylitis?
numbness and tingling in the 4 th and 5tth finger due to ulnar nerve involvement
What is radial tunnel syndrome?
compression of the posterior interosseous branch of the radial nerve
as a results of overuse
What are the symptoms of radial tunnel syndrome similar to?
lateral epicondylitis
where is the pain in the radial tunnel syndrome?
around 4-5cm distal to the lateral epicondyle
how are the symptoms worsened in radial tunnel syndrome?
extending elbow and pronating forearm
What is olecranon bursitis?
swelling over the posterior aspect of the elbow
associated with pain, warmth and erythema
who does olecranon bursitis typically affect?
middle aged male patients
What types of hip dislocation are there?
posterior dislocation - most common, leg shortened, adducted and internally rotated
What is the management of hip dislocation?
ABCDE approach.
Analgesia
A reduction under general anaesthetic within 4 hours to reduce the risk of avascular necrosis.
Long-term management: Physiotherapy to strengthen the surrounding muscles.
What are the complications of hip dislocation?
Sciatic or femoral nerve injury
Avascular necrosis
Osteoarthritis: more common in older patients.
Recurrent dislocation: due to damage of supporting ligaments
What are the complications of hip dislocation?
Sciatic or femoral nerve injury
Avascular necrosis
Osteoarthritis: more common in older patients.
Recurrent dislocation: due to damage of supporting ligaments
What is the prognosis of hip dislocation?
It takes about 2 to 3 months for the hip to heal after a traumatic dislocation
the prognosis is best when the hip is reduced less than 12 hours post-injury and when there is less damage to the joint.
What is a intracapsular or sub capital fracture of the hip?
from the edge of the femoral head to the insertion of the capsule of the hip joint
What is an extra capsular fracture?
these can either be trochanteric or subtrochanteric
(the lesser trochanter is the dividing line)
What is the garden system and how is it classified?
Type I: Stable fracture with impaction in valgus
Type II: Complete fracture but undisplaced
Type III: Displaced fracture, usually rotated and angulated, but still has boney contact
Type IV: Complete boney disruption
In the garden system which type is blood supply disruption most common in regards to a hip fracture?
types III and IV
What is the management for an undisplaced intracapsular fracture?
internal fixation, or hemiarthroplasty if unfit.
what is the management of an intracapsular displaced hip fracture?
arthroplasty (total hip replacement or hemiarthroplasty) to all patients with a displaced intracapsular hip fracture
total hip replacement is favoured to hemiarthroplasty if patients:
were able to walk independently out of doors with no more than the use of a stick and
are not cognitively impaired and
are medically fit for anaesthesia and the procedure.
What is the management of an extra capsular hip fracture?
stable intertrochanteric fractures: dynamic hip screw
if reverse oblique, transverse or
subtrochanteric fractures: intramedullary device
How is development dysplasia of the hip picked up?
barrows test
ortolani’s
What is transient synovitis (irritable hip)?
acute hip pain with oral infection
COMMONEST cause of hip pain in kids
What is the typical age group affected by transient synovitis?
2-10 years
What is transient synovitis also known as?
irritable hip
What is perthes disease?
a degenerative condition affecting the hip joints of children, typically between the ages of 4-8 years. It is due to avascular necrosis of the femoral head
Is perthes disease more common in boys or females?
males
is perthes disease of the hip bilateral or unilateral?
unilateral
Over what period of time does perthes disease develop?
hip pain: develops progressively over a few weeks
what are the symptoms of perthes disease?
limp
stiffness and reduced range of hip movement
what are the xray changes seen in perthes disease?
early changes include:
widening of joint space,
later changes include decreased femoral head size/flattening
what age range is typically affected by perthes disease?
4-8 years
what age range is a slipped upper emoral epiphysis
10-15 years
in whom is a slipped upper femoral epiphysis most common in?
obese children and boys
what direction is the displacement of the femoral head epiphysis in slipped upper femoral epiphysis?
postero-inferiorly
is a slipped upper femoral epiphysis usually bilateral or unilateral?
unilateral
bilateral in 20%
what are the features of a slipped upper femoral epiphysis? (pain and movement affected)
knee or distal thigh pain
loss of internal rotation of the leg in flexion
what is juvenile idiopathic arthritis?
describes arthritis occurring in someone who is less than 16 years old that lasts for more than three months.
What does pauciartciular Jia refer to and how many joints are affected and how may cases does it account for?
where 4 or less joints are affected. It accounts for around 60% of cases of JIA
what are the signs and symptoms of JIA?
joint pain and swelling: usually medium sized joints e.g. knees, ankles, elbows
limp
Are you ANA positive with JIA and what other condition is it associated with ?
maybe - associated with anterior uveitis
What is iliotibial band syndrome?
common cause of lateral knee pain in runners
What is the main sign/symptom of iliotibial band syndrome?
tenderness 2-3cm above the lateral joint line
What is the management of iliotibial band syndrome?
activity modification
iliotibial band stretches
if not improving physio
What causes a meniscal tear?
twisting injuries
When is the pain worse with a meniscal tear?
when straightening the knee
What are the signs and symptoms of meniscal tear?
knee locking
knee giving way
tender alone joint line
What is Thessaly’s test?
investigate meniscal tear
weight bearing at 20 degrees knee flexion
patient supported by doctor
positive pain on twisting knee
