orthopedics Flashcards
golfers vs tennis elbow
golfers (medial epicondyle)
tennis (lateral epicondyle)
Fever/back pain with pain on extension of the hip
iliopsoas abscess
what is the FRAX score?
FRAX estimates the 10-year risk of fragility fracture for 40-90year olds based on various risk factors such as age, sex, weight etc and bone mineral density measurements
FRAX score >10% needs a DEXA scan
scores for fracture risk
FRAX or QFracture
knee pain and swelling after exercise, locking and ‘clunking’
Osteochondritis dissicans
shortened and externally rotated leg
hip fracture
open fracture management
After primary wound debridement of an open fracture with or without temporary fixation (e.g. external fixation), a secondary inspection and debridement after 24-48 hours is warranted before definitive surgical fixation.
causes of fracture
trauma (Excessive force applied to healthy bone)
stress (repetitive low velocity injury)
pathological (minimal force to abnormal bone)
open fractures classification
Gustilo and Anderson classification
falls on outstretched hands cause fractures where?
scaphoid colles fracture (distal radius)
risk factors for Baker’s cysts
arthritis or gout and following a minor trauma to the knee
what is Foucher’s sign?
the increase in tension of the Baker’s cyst on extension of the knee. the cyst becomes hard as the pressure changes
Mx non-specific lower back pain
- NSAIDS eg Ibuprofen (paracetamol is ineffective!)
- proton pump inhibitors should be co-prescribed for patients over the age of 45 years who are given NSAIDs!!!
- physio, rest etc
Pencil in cup appearance X ray
psoriatic arthritis
X ray changes osteoarthritis
Loss of joint space (narrowing),
osteophytes,
Subchondrol sclerosis
Subchondrol cysts
DIPs, base of thumb, glenohumeral shoulder
X ray changes RA
soft tissue swelling
joint effusions
bony erosions
secondary osteoarthritis
light bulb sign x ray
posterior shoulder dislocation
nerve roots affected most commonly affected areas for cauda equina syndrome
L4, L5, S1
what is the most common cause is septic emboli/ septicaemia from Staphylococcus aureus?
endocarditis
investigations for discitis
MRI - gold standard diagnosis
CT guided biopsy - to target treatment
echocardiogram - look for source (endocarditis)
Mx scaphoid fracture
undisplaced fractures of the scaphoid waist
cast for 6-8 weeks — union is achieved in > 95%
displaced scaphoid waist fractures: requires surgical fixation
proximal scaphoid pole fractures: require surgical fixation
what is charcot joint?
aka. neuropathic joint
weight bearing joint which has become badly disrupted and damaged (midfoot remodelling) secondary to a loss of sensation (repeated damage to foot)
causes: ***diabetes, alcohol, syphillis, leprosy, spinal cord injury
signs: months of swollen, red, warm joint (not as painful to patient because of sensory damage)
complications of discitis
sepsis, epidural abscess
definitive management of compartment syndrome
fasciotomy.
Twisting sporting injuries followed by delayed onset of knee swelling. diagnosis?
meniscal tear
high twisting force is applied to a flexed knee. Rapid joint swelling
Anterior cruciate ligament rupture
classification of tibial plateau fractures? how many levels are there?
Schatzker
6
azathioprine + allopurinol interaction
bone marrow suppression
azathioprine is metabolised into mercaptopurine which inhibits purine synthesis
allopurinol inhibits xanthine oxidase which normally inactivates mercaptopurine
so with allopurinol, higher levels of mercaptopurine which incorporates into DNA and causes pancytopenia
before starting azathioprine
thiopurine methyltransferase (TPMT) for individuals prone to azathioprine toxicity
sjogrens antibodies
anti-Ro, anti-La
Leriche syndrome
claudication of buttocks and thicks
atrophy of the musculature of the legs
impotence
due to atherosclerotic disease of the abdominal aorta and iliac arteries
what nerve at risk in shoulder dislocation/ fracture
axillary nerve
patient fell off roof and held onto gutter for a few seconds. which nerve is damaged?
Klumpke’s paralysis
brachial trunks c8-T1 – weakness of hand muscles
T1 – horner’s syndrome
abducted arm pulled away from body in traction
new name for waiter’s tip palsy and which nerves are damaged
erb’s palsy
C5-6 brachial
pronated arm that is medially rotated
Neck of femur fracture - what do you look for on x ray
Shenton’s line
Mcdonalds
Ankle X rays
AP
Lateral
Mortise - turn ankle AP 10* so you can see space between fibula and tibia
types of gait
antalgic - reduce stance due to pain
trendelenberg -
waddling gait - BOTH abductor muscles are weak
swinging gait - ankylosis of hip results in patient needing to swing the lower limb forwards and backwards from the lumbar spine
unevent gait - leg length discrepency
high stepping gait - sciatic nerve/ peroneal nerve injury
why does apparent leg shortening happen
posture problem
- adduction contracture at the hip
- compensatory lordosis at the spine
where do you look with the sweep test?
medial gutter
lateral ligament tests
to test medial aspect - abduct stress
to test lateral aspect - adduction stress on knee
test is positive with knee flexed to 30* but negative on straight knee, it implies the medial collateral ligament has been damaged
if test is positive in both positions it means the the cruciate and the medial colateral ligament has been damaged
Mcmurray’s test explanation
test the menisci (posterior or middle thirds)
flex the knee
external rotation + abduction — extend
internal rotation + adduction — extend
painful click = positive test
Apley’s grind test
patient prone
hip extended and knee flexed to 90*
internally and externally rotate the knee while compressing downwards and then an upward contraction
pain on downwards = meniscal tear
pain on upward traction = ligament injury
structure for MSK pathology
infection
- septic arthritis
- lyme arthritis
- hep B,C
- rheumatic fever
joints
- osteoarthritis
- crystal arthritis: gout, pseudogout
- RA
- spondyloarthritis (ank spond, psoriatic, IBD, reactive arthritis following GI/GUM)
multisystem
- connective tissue: SLE, sjreogens, sclerosis, idiopathic polymyositis
- vasculitis
Bone/Soft tissue
- metabolic bone: osteoporosis, osteomalacia
- inherited (ehler’s danlos, marfans)
- soft tissue: bursitis, tendinopathy
- fibromyalgia
osteoarthritis
definition
signs
treatment
Osteoarthritis = degenerative joint disorder in which there is progressive loss of hyaline cartilage + inflammation with synovitis and effusions + new bone formation at the joint surface and its margin.
- RFs: age, obesity, joint abnormality
- ## 1ary vs 2ary (underlying cause e.g. obesity)Sxs: pain (++ by movement/end of day), stiffness/ gelling (esp after rest – lasts around 30min), deformity (genu varu), reduced
Ix
inspection - squaring of the 1st CMC, nodes in the hands, valrus/ valgus, effusions, fixed flexion
antalgic gait
palpation - cool bony swelling, +/- joint line tendernes
ROM
+ crepitus (knee, 1sr carpometacarpal joint)
reduced function
Mx: (MDT – GP, physio, OT, dietitian, orthopod) - Modification of ADLs
o Stop smoking (osteoblasts inhibited by smoking), reduce weight, incr exercise
o OT: walking aids, supportive footwear, home modifications
Physiotherapy - Muscle strengthening
o WHO analgesic ladder > paracetamol, NSAIDs (check renal function), weak opioid, strong opioid - Steroid injection
- topical capsaicin cream, NSAID gel, lignocaine patches
o Do not inject steroids if there is metal work (i.e. had a replacement)
Surgery: Arthroplasty (OA) – hemi or total, arhroscopy
telescoping of fingers
arthritismultilans - psoriatic arthritis
causes of gout
- diet, alcohol
- higher BMI — Hx osteoarthritis
- drugs eg. thiazides, loop diuretics
- familial - polymorphisms in URAT1 affecting urate resorption in kidney tubules
presentation of gout
1st MTP (podagra) severe inflammation, pain, red, swelling
may spontaneously settle over a week
future presentations involving other large joints and become polyarticular
tophi deposits in tissues
Ix. gout/ pseudogout
serum uric acids (may not be raised during acute attack)
raised ESR/ CRP
synovial fluid aspiration and microscopy- negatively birefringent for gout and positively birefringent for pseudogout
+ cytology to rule out septic arthritis
X rays - may show joint erosions + calcinosis in pseudogout
renal functions - renal impairment may cause hyperuricaemia
fasting lipids, and glucose and BP
Mx of gout
review drugs - thiazides, loop diuretics
weight loss, low purine diet (low meat, alcohol, liver, sardines)
acute: analgesia, NSAIDs, colchicine, prednisolone, steroid injections, splint joint
long term (recurrent episodes) - after acute attacks start allopurinol (xanthine oxidase inhibitor)
simmond’s test
squeeze calves
should cause plantar flexion
detects achilles rupture
how to diagnose joint prosthesis infection
X ray periprosthetic lucency (infection or prosthetic loosening) bone destruction
mx of prosthetic infection and likely organisms
excisional arthroplasty
debridement/ implant retention or removal and replacement in one or two stage revision
causes staph and strep
mx of prosthetic infection and likely organisms
excisional arthroplasty
debridement/ implant retention or removal and replacement in one or two stage revision
causes staph and strep
fixed flexion deformities causes
osteoarthritis
NOF
finkelstein’s test positive causes
De Quervain's tenosynovitis scaphoid fracture (FOOSH)
name the fingers
thumb, index, middle, ring, little
carpal bones
sally left the party to take cathy home
***scaphoid - fracture lunate triquetrum pisiform trapezium trapezoid capitate hamate
scaphoid blood supply
radial blood supply enters through the waist
retrograde blood supply
fracture of the proximal pole –> avascular necrosis of the proximal pole
- 70% of the fractures occur through the waist
Mx. colles’ fracture
reduction under local/regional anaesthesia
set in plaster
pseudogout aka acute calcium pyrophosphate crystal arthritis
- which crystals
- risk factors
- x ray images
calcium pyrophosphate crystals
form in joint carilage
more common in elderly, osteoarthritis, hyperparathyroid, haemochromatosis
the crystals are visible “whifts/ bands” of hyper- white calcinosis on X rays
presentation of acute calcium pyrophosphate crystal
acute calcium pyrophosphate crystal arthritis (pseudogout)
- acute monoarthritis
- severe hot swollen joint
- wrist/ knee
- DDx septic arthritis
osteoarthritis WITH calcium pyrophosphate
- inflammation with OA joint due to crystal deposition
Mx of pseudogout
same as acute mx of gout
NSAIDs, colchicine, splint joint, intraarticular steroid injections, prednisolone
no long-term prevention
rheumatoid arthritis defintion/ classification
ACR/ EULAR 2010 classification
synovitis in at least one joint without alternative explanation
+ at least 6 points to make a diagnosis
assigned for number of joints involved, >6 weeks of symptoms, acute phase response (CRP/ ESR), sero positive for RF or CCP
if sero-negative for RF/CCP need at least 10 joints (at least 1 small) for RA diagnosis
what is a Reactive arthritis
A sterile joint inflammation which occurs due to a bacterial infection taking place elsewhere in the body.
The infection will result in cross-reactivity resulting in a warm, painful and swollen joint.
Often there will be multiple extra-articular features such as conjunctivitis or urethritis which are also due to cross-reactivity.
pathogenesis of RA
synovial membrane invaded by lymphocytes
activation of synoviocytes
synovial proliferation (pannus) –> ++ synovial fluids (joint effusion)
pannus may invade bode causing erosion
inflammation damages cartilage –> 2* osteoarthritis
3 signs of RA + other features
- joint pain - MCP, PIPs — NEVER DIP!
- stiffness/ worse after rest
- joint swelling and effusions
malaise, fatigue, fevers, sweats, Interstial lung disease
chronic disease = joint deformity
serological test for RA
Rheumatoid factor (antibody for IgG Fc) - 60% sensitive & specific for RA
anti-cyclic citrullinated peptide antibody - 60% sensitive, 95% specific
RA disease activity scoring
what is the target?
DAS28 score
points for number of tender, swollen joints, patient global assessment of disease and ESR
score >5.1 is a high disease activity score
treat to target = regular monitoring and disease activity scoring with esclation of drug treatment to achieve a target DAS 28 (2.6 is remission or 3.2 is low disease activity)
causes of carpal tunnel syndrome
signs
causes: idiopathic, pregnancy, hypoT, cardiac failure, previous wrist trauma, RA, OCP
signs - sensory + pins and needles to first three fingers palmar aspect + wasting in thenar eminence
assessing X rays of C-cervical spine
need to be able to see all the way down to T1
draw 3 vertical lines - anterior vertebral, posterior vertebral, spinolaminar (anterior spinous processes) to check for alignment
what is a Hangman’s fracture
bilateral spondylothiesis (fracture) of C2 (axis)
complications of intravenous drug injectors into thighs
Management
abscess formation
crepitus if gas forming organism (e.coli, klebsiella, c. perfringes)
- DVTs –> PEs –> pulmonary infarctions
- false aneurysm (arteriography)
- osteomyelitis
- infective endocarditis
- hep B/C –> cirrhosis
- sepsis
Mx
treat with IV Abx, surgical excision
treat withdrawal
treat complications - Infective endocarditis
treat likely other eg. TB, HIV, hepatiits
borders of anatomical snuff box
extensor policus longus
extensor policus brevis
abductor policus longus
