Orthopedics Flashcards
What is non specific low back pain?
Tension, soreness and/or stiffness in the lower back region for which it isn’t possible to identify a specific cause of the pain
Diagnosis is dependent on the clinician being satisfied that there is not a specific cause for their patient’s pain
May include referred pain in the upper leg
What is radicular pain?
Pain caused by irritation or compression of nerve roots
Typically pain/numbness in a dermatomal distribution
Describe the epidemiology of low back pain
Annual incidence of first episode: 6%-15%
Annual incidence of any episode: 1% - 36%
Lifetime prevalence: Estimates up to 84%
Name some specific causes of low back pain
Infection Fracture Malignancy Inflammatory disorders: ankylosing spondylitis Cauda equina compression Non-spinal causes of back pain
How common is infection as a cause of low back pain? And how would you go about diagnosing it?
Account for
Where is the lower back?
Area bounded by the bottom of the 12th ribs, the buttock creases and the mid-axillary line
What investigations would you do in a patient that you suspected had an infective cause for their lower back pain?
Imaging, blood count, inflammatory markers
In whom are osteoporotic fractures a more likely cause of their lower back pain?
Older people, female, low body mass, taking glucocorticoids, past history of fragility fracture, Cushing’s syndrome, alcohol intake, smoking, regular falls
How do you diagnose osteoporosis?
Measure bone mineral density using a DEXA scan
Normal: t score >-1
Osteopenia: >-2.5
Osteoporosis:
What is the specific treatment for osteoporosis? What is the mechanism of action?
Bisphosphonates: encourage osteoclasts to undergo apoptosis so reducing bone resorption
Examples: alendronate, risendronate, zoledronic acid
What are the most common malignancies which may present as lower back pain?
Primary: Myeloma, Intra-abdominal disease
Metastatic disease: Breast, Prostate, Lung
What malignant cause of back pain do you suspect in a patient who presents with >60, back pain, weight loss + other abdominal symptom or new onset diabetes?
Pancreatic cancer
What malignancy might you suspect in a patient who presents as >60 with persistent back pain?
Multiple myeloma
What investigations would you do for a patient who you suspect has multiple myeloma?
Bloods; FBC, Calcium, Plasma viscosity/ESR
What investigation would you do for a patient with suspected pancreatic cancer as a cause of their back pain?
Urgent direct access CT
What are the nice guidelines on patients with cancer with back pain in whom you should act urgently (
Pain in the thoracic or cervical spine Progressive lumbar spinal pain Severe unremitting lower spinal pain Spinal pain aggravated by straining (for example, at stool, or when coughing or sneezing) Localised spinal tenderness Nocturnal spinal pain preventing sleep
How does Ankylosing spondylitis typically present?
Young men
Gradual onset
Relieved by exercise
Morning stiffness
What are extra articular symptoms of Ankylosing spondylitis?
Uveitis: inflammation of uvea, pigmented layer between inner retina and outer fibrous layer of sclera and cornea
Enthesitis: inflammation of the entheses, sites where tendons or ligaments insert into bone
What might you see on an X-ray of an Ankylosing spondylitis spine?
Bamboo spine: vertebral body fusion by marginal syndesmophytes
Typically involves thoracolumbar and/or lumbosacral junctions and predisposes to unstable vertebral fractures
Outer fibres of annulus fibrosis of IV discs ossify which results in the formation of the syndesmophytes between adjoining vertebral bodies
What is inflammatory back pain?
Chronic back pain >3 months Onset of symptoms before age 45 yrs Back pain at night Morning stiffness (>30 mins) Improvement with exercise
When should you consider Ankylosing spondylitis as opposed to inflammatory back pain?
If several factors present together: Inflammatory back pain Alternating buttock pain Response to NSAIDs Onset of symptoms before age 45 Peripheral disease manifestations (arthritis, dactylitis, enthesitis) Confirmed acute anterior uveitis Positive family history HLA-B27 positive Sacroiliitis/spondylitis by imaging
What is cauda equina syndrome and what key symptoms would you ask a patient about?
Compression of nerve roots below level of spinal cord termination: caused by central disc prolapse, tumour
Weakness / numbness in legs
Bowel or bladder dysfunction
Saddle / perineal anaesthesia
What is the nice guidance on suspected cauda equina
compression in people with cancer?
Immediate referral metastatic spinal cord compression co-ordinator if: neurological symptoms including radicular pain,
any limb weakness, difficulty in walking, sensory loss or bladder or bowel dysfunction
Name some non spinal causes of low back pain
Abdominal aortic aneurysm Pancreatitis / pancreatic cancer Renal pain (stone/infection) Peptic ulcer Gynaecological disorders: fibroids Shingles
List some red flags which you want to ask about in a patient presenting with lower back pain
Age >50 Bladder dysfunction Cancer history Immune suppression Rest/night pain Trauma Saddle anaesthesia Lower extremity neurological deficit Weight loss Recent infection Fever/chills
What is Lasègue’s sign?
Straight leg raise: determine whether patient with low back pain has a herniated disk, often at L5
Patient experiences sciatic pain when straight leg raised between 30 and 70 degrees
What is Kernig test?
Thigh flexed at the hip, knee at 90 degrees
Subsequent extension in knee is painful and often resisted
May indicate sub arachnoid haemorrhage or meningitis
What is bragards test?
Used to determine whether a source of lower back pain is nervous or muscular
Straight leg raise is done, if positive, leg lowered just below point of pain and then ankle is dorsiflexed
If pain increases, pain is likely nervous in origin
If no increase in pain, source is likely muscular
When is imaging of spine needed for low back pain?
Investigation for specific cause of back pain: Metastatic Disease, Bloods may be more appropriate and easier to organise
When surgery is being considered: Suspected cauda equina compression - Immediate, Radicular pain that is not resolving, To identify those with operable lesions congruent with symptoms, Selected patients who might be considered for spinal fusion
What is non specific low back pain?
Tension, soreness and/or stiffness in lower back region for which it isn’t possible to identify a specific cause of the pain
Diagnosis is dependent on the clinician being satisfied that there is not a specific cause for their patient’s pain
May include referred pain in the upper leg
What different durations of back pain might present?
Acute: 3 months: Prevalent cases, Major health burden
Describe the management of acute low back pain
Exclude serious causes of back pain: Ask about micturition
Avoid bed rest
Encourage activity
Adequate analgesia: Paracetamol, NSAIDs, mild opioids, Muscle relaxants if indicated
Specific treatment not required: No evidence of effectiveness
What do you do to manage sub acute Radicular pain?
Consider imaging or surgical opinion: Test clinically for nerve root compression, Sensitive but not specific
Delayed surgery less likely to reduce any neurological deficit: Many still improve without surgery, Remember risks of surgery
Describe the care pathway for persistent low back pain which goes on for more than 12 months
GP advice and analgesia, if no improvement then choice of acupuncture, exercise or manual therapy
If continuing problems, try one or more further course of treatment
If continuing pain and disability, then combined physical and psychological therapy of 100 contact hours
If continuing pain and disability, consider surgical referral
What choice of physical therapies are available to treat back pain?
Acupuncture: up to a maximum of 10 sessions over a period of up to 12 weeks
Exercise: up to a maximum of eight sessions over a period of up to 12 weeks, aerobic activity, movement instruction, muscle strengthening, postural control, stretching
Manual Therapy: up to a maximum of nine sessions over a period of up to 12 weeks
What are problems with chronic non-specific low back pain?
90% of costs, Vast majority of health care usage Unlikely to ever get better Major impact on quality of life (DALYs) Variable course Treatment only modest benefit
What factors indicate a poor prognosis in a patient with chronic low back pain?
Widespread pain, severity, duration, previous episodes, anxiety and/or depression, higher somatic perceptions and/or distress, adverse coping strategies, low social support, older age, higher baseline disability, and greater movement restriction
What are Patient expectations for treatment of back pain?
Clear diagnosis Pain relief Physical examination Confirmation that pain is real Confidence based association: understanding, listening, respect, and shared decision making
What factors concern patients most at a pain clinic?
Spoiled identity: more important than pain or disability
Unmet expectations: GP don’t take their pain seriously, appear not to care
Making sense of pain: doctors don’t help them make sense of pain; just provide a medical interpretation
The future: acceptance / accommodation
Describe the fear avoidance model in regards to pain
Pain experience leads to fear of pain, which leads to avoidance of the activity, which then leads to disuse, disability and depression, this then exacerbates the pain experience
The way for patients to avoid this cycle is that they don’t experience fear about their pain, so they confront it and therefore more likely to recover
What acute treatments are available for back pain?
Pain killers: Paracetamol, NSAIDs (Oral, Topical), Opioids (Weak, Strong) Muscle relaxants (acute pain only): Benzodiazepines (diazepam)
What opioids can be used to treat back pain?
Weak opioids: Codeine, Dihydrocodeine
Strong opioids: Morphine, Buprenorphine, Tramadol (some consider to be weak), Oxycodone, Fentanyl (patches)
What are some problems with using strong opioids to treat back pain?
Addiction, sedation, depression, black market
Describe the use of antidepressants to treat back pain
Specific effect on chronic pain Tricyclics – amitriptyline, nortriptyline Best evidence for higher doses Side effects: Sedation, constipation, dry mouth, blurred vision Duloxetine – pain specific evidence Not Other SSRIs or SNRIs May help depression – if present Night time sedation may be helpful Allow 4-6 weeks for effect Back pain specific evidence base weak
What anti epileptic drugs can be used for back pain?
Gabapentin / pregabalin
Used widely for chronic pain
Back pain specific evidence very limited
What is osteopetrosis?
Congenital condition: failure of bone reabsorption
No differentiation between cortex and medulla, multiple cortical layers
Bones are brittle and prone to fracture
No room for marrow to grow so marrow failure, peripheral cytopenias
Bones expand and cause neural compression symptoms
What is osteogenesis imperfecta?
Congenital condition of brittle bones, susceptible to fractures due to mutation in type 1 collagen
Autosomal dominant
Blue sclera and neural deafness from bone overgrowth
X-rays show reduced bone density and cortical disorganisation
What are 4 common differentials for shoulder problems?
Frozen shoulder: Global restriction of all shoulder movements
Glenohumeral OA: Global restriction of all shoulder movements
Impingement syndrome+/- rotator cuff tear: Pain on overhead activities; weakness and inability to actively abduct shoulder
Instability: patients in teens or twenties with a hx shoulder dislocation
How can the location of shoulder pain help you to decide what the problem is?
Frozen shoulder and OA painis mainly anterior: over glenohumeral joint
Impingement and cuff tear pain usually laterally in subacromial region or on lateral aspect of the arm
What are the components of a shoulder examination?
Look: Swelling/wasting/scars/sinuses
Feel: mass/crepitus/Temperature/ Tenderness over the SC joint, clavicle, AC joint, spine of scapula, subacromial space, glenohumeral joint
Move: Active then passive
Special Tests: specific to the findings from the history, neers test for shoulder impingement (passively forward flex shoulder, pain in anterior shoulder), Hawkins Kennedy test
What is the lightbulb sign on an AP radiograph of a shoulder?
Posterior glenohumeral joint dislocation
What is the mechanism for a posterior glenohumeral joint dislocation?
Axial loading of the adducted internally rotated arm
Forward fall on the point of the elbow
Seizure could cause sudden contraction of the internal rotators of the shoulder which can cause a posterior dislocation
What injuries are associated with posterior glenohumeral joint dislocation?
Glenoid rim fracture
Labral tear
Compression fracture of humeral head
What is perthes disease?
Childhood hip disorder initiated by a disruption of blood flow to the femoral head
Osteonecrosis or avascular necrosis occurs and the bone stops growing
What is slipped capital femoral epiphysis?
Fracture through growth plate which results in slippage of the overlying end of the femur
The epiphysis remains in the acetabulum while the metaphysis moves in an anterior direction with external rotation
Usually causes groin pain and a painful limp
Occurs in obese adolescent males
Which muscles form the rotator cuff?
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
What is a drop arm test?
Abduct patients arm to 90 degrees then ask them to lower it slowly. Positive test- arm will drop
Test for supraspinatus damage
Which muscles form the rotator cuff?
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
What is a drop arm test?
Abduct patients arm to 90 degrees then ask them to lower it slowly. Positive test- arm will drop
Test for supraspinatus damage
What are nice guidelines on arthroplasty in patients with NOF fractures?
Total hip replacements should be given to patients who are:
able to walk independently out doors with no more than the use of a stick
Not cognitively impaired
Fit for anaesthesia
If they are less fit a hemiarthroplasty is performed
How are extracapsular hip fractures managed?
Reduction
Internal fixation, usually with a dynamic hip screw
How do you test supraspinatus?
Ask patient to elevate the arm at 30 deg of abduction, while the
examiner resists it by downward pressure
If there is a tear in the supraspinatus, the patient will not be able to elevate the arm
How do you test infraspinatus?
Ask patient to externally rotate the shoulder with elbows at 90 deg. The examiner resists it
If there is a tear, the patient will be weak compared to the opposite side
How do you test subscapularis?
Ask the patient to push backwards against resistance with arm behind back
If there is a tear this would be weak compared to the other side
What clinical features and examination finding differences would there be between OA and frozen shoulder?
Frozen shoulder and OA both have global restriction of all
movements.
Crepitus may be present in OA but not in frozen shoulder
Radiographs are normal in frozen shoulder not in OA
What examination findings might make you suspect impingement syndrome / rotator cuff tear?
Pain on overhead activities; sometimes weakness and
inability to actively abduct the shoulder
In an elbow examination, what are you feeling for?
Tenderness over lateral,medial epicondyles
Relation between the 2 epicondyles and olecranon tip
Soft spot over radial head: Palpate radial head by rotating forearm
What findings on elbow examination would you expect in a patient with olecranon bursitis?
Swelling and inflammation superficial to the elbow joint
Usually full range of movement
What findings would you expect on elbow examination of a patient with tennis elbow?
Degenerate tear in the origin of extensor carpi radialis brevis
Tenderness just anterior to lateral epicondyle
Pain on resisted extension
What findings would you expect to find on elbow examination of a patient with golfers elbow?
Medial epicondylitis: Degenerate tear over the common flexor origin
Pain on resisted wrist flexion
What would you expect to find on elbow examination of a patient with OA?
Stiffness
Crepitus
Pain
What findings would you expect on elbow examination of a patient with cubital tunnel syndrome? How would you diagnose this condition?
Compression of ulnar nerve behind the medial epicondyle
Pain worse on elbow flexion
Diagnosis based on ulnar nerve examination (neurological) and nerve conduction studies
What characteristics would make you suspect articular vs periarticular joint problems?
Articular: joint line tenderness, Pain at the end of range of movement in all planes, Crepitus, Active and passive movement equal
Periarticular: point tenderness over involved structure, pain exacerbated by movement or stress, active movement more than passive
What characteristics make you think of inflammatory vs non inflammatory joint problems?
Inflammatory: morning stiffness >15 mins, relieved by activity, warmth, redness, swelling/bogginess
Non inflammatory: worse at end of day, relieved by rest, crepitus, restricted movement
Give an example of an asymmetrical polyarthritis
Psoriatic arthritis
What aspects of a history would you want to know to look at joint problems?
Trauma
Previous episodes
Locking or giving way
Systemic features: fever, night sweats, lymphadenopathy, weight loss, anorexia, malaise
Extra articular features: skin, nails, mucous membranes, eyes, heart, lungs, abdo organs
FH
Occupation
Medication: steroids, diuretics, COCP/HRT
Psychosocial: stress, disability
What are some reg flags to look out for with joint problems?
One hot, red, intensely painful joint, limitation of movement, systemic illness: septic arthritis
Rapid onset swelling after trauma: haemarthrosis, fracture
Sever pain at rest/night: malignancy
Systemic symptoms, fever, weight loss: inflammatory arthritis, malignancy
Children with a limp: fracture, septic arthritis, SUFE, perthes
What is SUFE?
Slipped upper femoral epiphysis
What is perthes disease?
AVN of femoral head in childhood
What are some differentials for an acute mono arthritis?
Trauma Septic arthritis Gout/pseudogout Inflammatory arthritis Gonococcal/TB Leukaemia Osteomyelitis
What are some differentials for polyarthritis?
OA RA Viral arthritis Psoriatic arthritis Seronegative spondyloarthritis SLE Chronic gout Sarcoidosis Polymyalgia rheumatica Systemic sclerosis Haemochromatosis
What crystals are present in gout and pseudogout?
Gout: urate
Pseudogout: calcium pyrophosphate
How does gout present?
1st MTP, feet or ankles Obese patients On diuretics Purines Alcohol More in males
Which joints are usually affected by pseudogout?
Knee
Wrist
Shoulder
What investigations would you do for gout?
FBC U and Es ESR Serum urate Microscopy of synovial fluid: pseudo gout - positively birefringent rhomboid crystals, gout - negative needle shaped
What is management for gout?
Analgesia - NSAIDs, colchicine
Weight loss
Avoid alcohol and purine rich foods (red meat, marmite, mussels)
Avoid thiazide diuretics
Consider prophylaxis - allopurinol (not in acute attack)
What are risk factors for OA?
Age Female Genetics Obesity Abnormal joint loading - previous fracture or instability Poor muscle function
Describe the pathophysiology of OA
Surface cracks in cartilage, bone exposed
Becomes burnished - eburnation
Bone and cartilage fragments in joint cavity
Osteophytes form
Alteration in composition of cartilage: reduce proteoglycans and collagen, increase water, chondrocyte hypertrophy
Alteration of mechanical properties
Reduced shock absorption
Describe the clinical presentation of OA
Joint pain, stiffness Swelling Deformity Crepitus Muscle weakness and wasting Reduced function Hips, knees, base of thumb, DIPs (heberdens nodes)
What investigations would you do for OA?
Consider bloods to exclude inflammatory causes: FBC, ESR
X-ray: loss of joint space, osteophytes, subchondral cysts, subchondral sclerosis
What is the management for OA?
Hollistic Education and advice Weight reduction Exercise and muscle strengthening Analgesia Aspiration of effusion and joint injections Joint replacement
What is the pathophysiology of RA?
Genetic predisposition and immunological trigger
T cell mediated immune response
RF antigen/IgG interaction
Compliment fixation
Inflammatory response
Recruitment of inflammatory cells with release of enzymes and prostaglandins
Angiogenesis in synovium and proliferation, pannus invasion
Destruction of articular cartilage and underlying bone
What is the clinical presentation of RA?
Symmetrical peripheral polyarthritis
Joint pain
Swelling
Early morning stiffness
Joint destruction and deformity: ulnar deviation, z deformity, swan neck, boutonnière, subluxation, claw toes, cervical spine pain
Extra articular features: episcleritis, scleritis, effusions, fibrosis, nodules, vasculitis, rashes, weight loss, fever, fatigue
What investigations might be done for RA?
FBC ESR and CRP RF Anti CCP antibodies X-ray: soft tissue swelling, loss of joint space, erosions, joint destruction
What is management for RA?
Refer to rheumatology Urgent referral if: small joints, >1 joint, delay of >3 months between onset and presentation Physical exercise/OT/physio NSAIDs DMARDs Monoclonal antibodies/ anti TNFa Surgery: nerve decompression, tendon repair, joint replacement Spinal fusion
What is the embryological origin of the appendicular skeleton?
Neural crest mesenchyme
What are the components of the thenar compartment of the hand?
Abductor Pollicis brevis
Flexor Pollicis brevis
Opponens Pollicis
What is a compound fracture?
Wound through adjacent or overlying soft tissues communicates with site of break
What factors may influence haemarthrosis development?
Trauma Bleeding disorders Neurological deficits: charcots joint Intra articular neoplasms Vascular abnormality: haemangioma, AV malformation, aneurysm, synovial vascular structural abnormality
What are risk factors for spinal stenosis?
Age >40 Previous back surgery Previous injury Achondroplasia Acromegaly
What are risk factors for osteoporotic spinal compression fracture?
Older age (>50 women, >65 men) Previous vertebral compression fracture Low body weight Recent weight loss Fhx osteoporosis Smoking White or Asian Post menopausal Secondary amenorrhoea Alcohol Corticosteroid use Glucocorticoid excess Hyperthyroidism Vit d deficiency Low calcium RA
What are the 5 causes of spondylolisthesis?
Dysplastic: birth defect Isthmic: Repetitive spine trauma, gymnasts and weight lifters Degenerative: joints become arthritic Traumatic: Sudden injury or trauma Pathologic: tumour or other abnormality
What are possible complications of a scaphoid fracture?
Avascular necrosis
Non Union
Arthritis
What are risk factors for hip fracture?
Osteoporosis/osteopenia Age over 65 Falls Low BMI Female sex High energy trauma
What are the Ottawa knee rules?
Decide if patient needs X-ray if any of following are present
Age over 55
Tenderness over fibular head
Discomfort confined to patella on palpation
Inability to flex knee to 90 degrees
Inability to bear weight for at least 4 steps
