Semester 1: Orthopaedic Medicine Flashcards
How has the field of orthopaedics changed over time?
Historically deals with musculoskeletal abnormalities occurring at birth or in children. Far less common now due to better nutrition, health of pregnant women, use of antibiotics, immunisation programmes, decreased incidence of TB and Polio.
Nowadays, the field has grown to encompass a whole range of musculoskeletal conditions.
Define acute
Strikes the patient suddenly. Characterised by polymorphonuclear leukocytes (Neutrophils, Eosinophils and Basophils)
Define chronic
Takes a long time to develop and may last a long time. Characterised by lymphocytes (T and B Cells)
What is the difference between the suffix “…-otomy” and “…-ectomy”?
“…-otomy” - opening something up i.e. Arthrotomy is opening up a joint
“…-ectomy” - removing something i.e. Meniscectomy is removal of a meniscus
List the professionals that make up the orthopaedic management team
Orthopaedic surgeon, theatre nurses, porters, orthopaedic nurses, GPs, anaesthetists, rheumatologists, general surgeons, physiotherapists, occupational therapists, technicians
What is the goal of treating musculoskeletal disorders?
Symptom relief i.e. relieve pain or stiffness
What are the causes of congenital abnormalities?
Familial
Genetic
Insult to child within the womb
What is Osteoarthritis?
A condition of pain and limitation of movement of joints associated with excessive wear of articular cartilage resulting from a breakdown of the balance between the wear and repair processes in the joint.
What is the difference between primary and secondary osteoarthritis?
Primary - unknown aetiology (more common)
Secondary - known aetiology
Give an example of a Congenital cause of secondary osteoarthritis
Congenital dislocation of the hip
Give an example of a Childhood cause of secondary osteoarthritis
Perthe’s disease, Infection
Give an example of a Traumatic cause of secondary osteoarthritis
Fracture especially intra-articular
Give an example of a Metabolic cause of secondary osteoarthritis
Gout or other crystal arthropathies
Give an example of an infective cause of secondary osteoarthritis
TB
Give an example of a Chronic Inflammatory cause of secondary osteoarthritis
Rheumatoid
What are the conservative management options for Osteoarthritis?
Weight loss, Use of walking aids, Rest and Physiotherapy
Use of Analgesia in parallel with these measures
During normal walking when the weight is on the right leg which muscle groups are activated to tilt the pelvis
Right gluteal abductors
How do walking aids help reduce pain in hip osteoarthritis?
When a stick is held in the opposite hand it reduces the work required of the weight bearing abductor muscles
What are the 4 surgical options available to arthritis patients ?
Nothing
Arthrodesis
Osteotomy
Arthroplasty
What is the goal in an osteotomy procedure?
To more evenly distribute the load to which the joint is subjected
Which knee compartment is under excessive stress in a Genu Varum presentation?
Medial
Which knee compartment is under excessive stress in a Genu Valgum presentation?
Lateral
In which surgeries are people particularly at risk of Deep Vein Thrombosis and Pulmonary Embolism?
Hip and Knee Surgery. Also any surgery in and around the pelvis.
List general complications of surgery
Chest Infection Urinary Complications Pressure Sores Deep Vein Thrombosis Pulmonary Embolism
What is the difference between early and late specific surgical complications?
Early - complications specific to the operation that arise soon after the operation
Late - complications specific to the operation that arise months to years later
List some specific early complications of joint replacement surgery
Dislocation
Deep Vein Thrombosis
Infection
List some specific late complications of joint replacement surgery
Infection
Loosening and wear
Why is dislocation a common early complication following arthroplasty?
Prosthesis will not be fully supported by the surrounding soft tissues. Muscles and their proprioceptors may be temporarily out of action i.e. through surgical trauma and pain inhibition. A capsule of scar tissue will not yet have formed around the prosthesis.
What measures can be taken to protect against deep vein thrombosis?
Heparin
Stockings
Symptoms of Rheumatoid Arthritis
Severe pain, swelling and deformity of the joint
What are the principle joints affected in Rheumatoid Arthritis?
Small joints of the hands and feet
Describe the clinical picture as seen in Rheumatoid Arthritis
Severe pain, swelling and deformity of the smaller joints particularly in the hands and feet in an often symmetrical pattern. Morning stiffness in affected joints which improve throughout the day. Affects females more than males.
Which surgical procedure may be offered to someone with Rheumatoid Arthritis?
Synovectomy - removal of the synovial membrane
Define avascular necrosis
Bone tissue death through loss of blood supply
Which areas are at particular risk of avascular necrosis following trauma and why?
Femoral head - supplied by a single end artery (Artery to head of Femur)
Proximal part of Scaphoid - retrograde arterial supply
Proximal part of Talus - retrograde arterial supply
Causes of non-traumatic avascular necrosis of the head of Femur
Chronic Alcohol abuse
High dose steroid therapy
Caisson’s Disease - following a quick ascent after scuba diving
Signs of avascular necrosis of the femoral head on X-ray
Initially - nothing
Later - dense crescent-shaped bone, reflecting the absence of blood vessels
What causes Gout?
Urate crystal deposition
What is the most common cause of Gout in the west?
Overuse of diuretics
Which serious condition may mimic the gout presentation?
Septic Arthritis - also presents with a hot, tender and swollen joint
How is Gout diagnosed?
High levels of uric acid in the blood
Gold Standard - joint aspiration and microscopy
What is the difference between the presentation of Gout and Pseudogout?
Pseudogout tends to be less acute
What crystals are deposited in a joint with Pseudogout?
Pyrophosphate
What happens to menisci in knees affected by pseudogout?
Calcification
What is Acute Septic Arthritis?
An infection caused by bacteria, which have spread to the joint via the blood from a site of trivial infection. Rarely occurring from direct penetration of the joint by a sharp object.
Presentation of Acute Septic Arthritis in children
Pyrexia, joint stiffness, joint erythema and joint tenderness
What is the most common infective organism responsible for Septic Arthritis in young adults with little constitutional upset?
Gonococcus
Treatment of Septic Arthritis
Surgical wash and debridement
Antibiotic therapy - “first-guess” will be an anti-staphylococcal agent
Who are at particular risk of joint Tuberculosis?
AIDS patients
Clinical presentation of Chronic Septic Arthritis
Chronic ill health (weight loss and muscle wasting - particularly around the affected joint)
Radiography will show marked thinning of affected bone surfaces
Symptoms of Meniscal lesions
Pain, joint effusion and sometimes locking and/or giving way
What is the mechanism of injury most commonly associated with meniscal tears?
Twisting injuries - particularly where the foot is planted in the ground and the Femur twists over the stationary Tibia
Which meniscus is most commonly torn?
Medial
Which two types of meniscal injury are common in old age?
Cleavage lesion (Horizontal tear) Degenerative tear
What is the role of the meniscus?
Help distribute the load between the femur and tibia
What is the benefit of an arthroscopic meniscectomy over an arthrotomy to perform an open meniscectomy?
Arthroscopic meniscectomy - quicker recovery
How are osteochondral fragments in the synovial fluid often managed?
Removal via arthroscopy
Which adolescent condition is characterised by spontaneous osteochondral fragmentation?
Osteochondritis dissecans
What is the mechanism of injury most commonly associated with cruciate ligament tears?
Hyperextension or Twisting
What are the possible causes of patella dislocation?
Malformation of the patella or lateral femoral condyles
What are the possible surgical options for recurrent patella dislocation?
Surgical splitting of the vastus lateralis muscle insertion into the patella +/- medial tightening (plication) of the vastus medialis muscle
What term is used for non-nervous tissues in the spine?
Spondylitides
What are localising signs of nerve root pain?
Loss of sensation or muscle weakness
What structures are located in front of and behind the nerve root?
Intervertebral disc infront
Facet joint behind
What is spondylosis?
Degeneration of the intervertebral disc leading to increased loading of the facet joints, which then develop secondary osteoarthritis
Define spondylolisthesis
Slippage of one vertebra relative to the one below, commonly seen in the lumbar spine
What does a fatigue fracture of the pars interarticularis (spondylolysis) predispose to?
Spondylolisthesis (slippage)
Which surgical option is available for severe cases of spondylolisthesis?
Spinal fusion
How does the pain in a prolapsed intervertebral disc differ from referred backache?
Pain from a prolapsed intervertebral disc is felt down the back of the thigh, leg and foot
Referred backache rarely extends beyond the knee or upper calf
What type of imaging is used to localise the site of an intervertebral disc prolapse prior to surgery?
Myelography - radio-opaque material injected into spinal fluid, X-ray is then captured and the location is identified as the fluid will not be able to flow past the site of the prolapse
Describe the difference between the likely sufferers of disc prolapse compared with bony root entrapment
Disc prolapse - under forty, more common in men, may follow a single event of straining/lifting or occur spontaneously
Bony root entrapment - over forty with history of previous mechanical backache, that have recently developed pain radiating to the legs and feet, which worsens with exercise
Define spinal claudication
Backache that radiates down the leg, usually made worse by exercise
By what age does the average child normally sit?
9 months
By what age does the average child normally stand?
12 months
By what age does the average child normally walk?
20 months
What is the normal alignment of the knees?
Valgus
By which age should children have developed normal knee alignment?
7 years
When is In-toeing exaggerated?
Whilst running
What is the wear pattern seen on the soles of shoes worn by children with in-toeing?
Worn down quick at the heels
What are the three main causes of in-toeing?
Femoral neck anteversion
Tibial Torsion
Abnormal Forefeet
By which age does femoral neck anteversion normally correct itself?
10 years
Is tibial torsion a normal variation that should be ignored?
Yes
What are the two types of flat feet?
Rigid and Mobile
At which age does the arch in feet form?
May not form until aged 7
In which sex is pain around the knee more common?
Female
Define Osgood Schlatter’s disease
Inflammation of the attachment of the patellar tendon to the growing tibial epiphysis caused by excess traction by the quadriceps
Who is at particular risk of Osgood Schlatter’s disease?
Active children
Is the pain from Osgood Schlatter’s disease better or worse following exercise?
Worse
When does Osgood Schlatter’s disease become asymptomatic?
Middle adolescence when the epiphysis fuses
What is Chondromalacia patellae?
Erosion of the patellar cartilage seen arthroscopically in some cases of adolescent knee pain
How common is Congenital Dislocation of the Hip?
1-2/1000 live births
When are children screened for Congenital Dysplasia of the Hip?
Birth
3 months
6 months
12 months
What are the clinical signs of Congenital Dysplasia of the Hip?
Shortening of the limb, asymmetrical skin creases, limited abduction and a limp
Early diagnosed management of Congenital Dysplasia of the Hip
Splintage
Late but before weight bearing diagnosed management of Congenital Dysplasia of the Hip
Period of gentle traction followed by open or closed manipulation. It is then splinted in plaster for three months.
Very late diagnosed Congenital Dysplasia of the Hip management
Major surgery - usually involving deepening the acetabulum and re-angulation of the femoral neck
What are the two types of Talipes Equino Varus?
Postural - mild (associated with breech position)
Fixed - severe (associated with developmental abnormalities of the nerves and muscles)
What is the initial treatment of Talipes Equino Varus?
Gentle stretching to correct the hindfoot equinus followed by the correction of the mid and forefoot varus
What is the treatment of mild Talipes Equino Varus?
Stretching and strapping in place for 6 weeks
What is the treatment severe Talipes Equino Varus?
Initial stretching and strapping (6 weeks) followed by surgery if unsuccessful
At which age do children’s feet stop growing?
14 years
What are the long-term risks of Talipes Equino Varus?
Affected foot may be significantly smaller
What are the two types of Spina bifida?
occulta and cystica
What percentage of the population are affected by Spina bifida occulta?
2%
What is the main symptom of Spina bifida occulta?
Mechanical back pain
What is diastamatomyelia?
Tethering of the spinal cord to the higher lumbar vertebrae during growth
What are the two types of Spina bifida cystica?
Meningocele and Meningomyelocele
What is the difference between Meningocele and Meningomyelocele ?
Meningocele - Nervous tissue covered by a cyst
Meningomyelocele - Nervous tissue incorporated in the cyst wall
What is common comorbidity of children with spina bifida cystica?
Hydrocephalus
Define Cerebral Palsy
Abnormality of the brain often caused by damage during birth
Are spinal reflexes affected in Cerebral palsy?
No
Define Hemiparesis Cerebral palsy
One arm and one leg on the same side affected
Define Paraparesis Cerebral palsy
Both legs affected
Define Quadparesis Cerebral palsy
All four limbs affected
What is toe-walking in adolescence a sign of?
Minor spasticity
Which condition in children is characterised by osteochondritis of the femoral head epiphysis?
Perthe’s disease
Why may pain from the hip joint radiate to the knee?
The sensory distribution follows the path of the obturator nerve
What is an enthesopathy of the origin of the forearm flexors called?
Golfer’s Elbow
What is an enthesopathy of the origin of the forearm extensors called?
Tennis Elbow
Is the common extensor origin located on the medial or lateral side of the forearm?
Lateral
Is the common flexor origin located on the medial or lateral side of the forearm?
Medial
What two options are available to speed up the recovery of an enthesopathy?
Course of anti-inflammatory agents
Local steroid injections
Define neuropraxia
Nerve injury caused by compression or stretching
What are the common sites of nerve entrapments?
Median nerve at the wrist
Ulnar nerve at the elbow and the wrist
Posterior tibial nerve at the ankle
Which condition is known as housemaid’s knee?
Pre-patellar bursitis
Define Hallux valgus
Turning away of the phalanges of the big toe from the mid-line, usually because of a deformity at the joint line
Define Hallux rigidus
Osteoarthritis of the first metatarsophalangeal joint
What is the main cause of hallux rigidus in adolescents?
Osteochondral fracture
What is the management of mild hallux rigidus?
Surgical removal of the osteophytes with an osteotomy of the proximal phalanx
What is the Keller’s procedure?
Excision of the metatarsophalangeal joint
What is a common cause of claw foot?
Weak or denervated small muscles of the feet, often associated with minor spinal abnormalities i.e. Spina bifida occulta
What is the surgical management of hammer toes?
Fusion of the interphalangeal joints in a straight position
What is a Morton’s Neuroma?
Trapped cutaneous nerves to the toes become irritated between the metatarsal heads giving rise to a neuroma
What is the plantar fascia?
Tough fibrous layer which runs from the os calcis to each toe base
Describe the pattern of pain felt in plantar fasciitis
Soreness of the instep, often worse first thing in the morning and after sitting for a few hours
Symptoms may be relieved slightly by walking
What is the main cause of Achilles tendinitis and rupture in middle age?
Degeneration thought to be caused by a poor blood supply to lower part of tendon which is considered a point of weakness
Why must steroids injections never be used in Achilles tendinitis?
May lead to rupture
How is Achilles rupture treated?
Equinus plaster for a minimum of 8 weeks
Some opt for surgical suturing
Which two conditions is tenderness under active movement within a painful arc suggestive of?
Supraspinatus tendon inflammation
Subacromial bursitis
Why should repetitive shoulder steroid injections be avoided?
May cause degeneration of rotator cuff
What determines the positions of the proximal and distal bone fragments after a fracture?
Proximal - determined by muscles
Distal - determined by gravity
What can be done initially to reduce swelling after injury?
Elevate injured part
How can the colour of bruising help diagnose age of injury?
Initial dark bruises occur due to deoxygenated blood loss into soft tissues, then as haemoglobin begins to breakdown the colour changes to green and then to yellow
Which cells carry haemoglobin degradation products from the site of bruises to the liver?
Scavenger Cells
Describe the technique used in radioisotope scanning
Small quantity of radioactive substance is injected into the blood. The substance attaches to phosphate molecules which is actively taken up by bone. An Xray plate is then exposed under the affected body part and a very sensitive radiograph is obtained.
Which of Spiral, Oblique and Transverse fractures are associated with low energy mode of injury?
Spiral - low energy twisting mechanism of injury
Describe the displacement of a fracture
Position of the distal fragment described relative to the proximal one
Which three terms are used when describing the position of the distal fragment of a fracture?
Displacement
Angulation
Rotation
How much blood is expected to be lost into soft tissues following a femoral fracture?
2-3 units
How much blood is expected to be lost into soft tissues following a tibial fracture?
Around 1 unit
What management is acceptable if there is any doubt whether a wound created from an open fracture can be closed without any skin tension?
Wounds are better left open and closed as a secondary procedure after a few days. Patients meanwhile should receive broad spectrum antibiotics and tetanus protection
How much blood is expected to be lost into soft tissues following a pelvic fracture?
Around 6 units
Restoration of a bone after fracture to normal position is achieved by the process of…
Reduction
Describe the difference between unity and consolidation of a fracture site during stages of healing
United - bone has become strong enough to support itself
Consolidation - bone has become strong enough to bear some load
Give an example of an internal fixator that works via apposition
K-wires
Give an example of an internal fixator that works via interfragmentary compression
Screws or Tension band wires
Give an example of an internal fixator that works via an onlay device
Plate and screws
Give an example of an internal fixator that works via an inlay device
Intramedullary nail
What is the difference between traction used to reduce a fracture and traction used to hold a reduced fracture?
Traction may be used to hold a reduced fracture by exerting a small weight to the limb. Which exerts a pull along the axis of the broken limb, causing muscles to contract thus holding the fracture site.
Traction may be used to achieve reduction by using a relatively large force to overcome muscle resistance to achieve alignment.
Give an example of a static traction device
Thomas splint
What is the difference between static traction and balanced traction?
Static - pull achieved against another part of the body
Balanced - pull against a body part os balanced with a counterweight at the other side
How is dynamic traction achieved?
Joints are still permitted to move but by means of pulleys and a pull along the fracture site is maintained throughout movement
What is the difference between early primary and early secondary complications of fractures?
Early primary - as a consequence of injury
Early secondary - as a consequence of treatment
Give examples of early primary fracture complications
Blood loss Infection for open fractures Fat embolism Renal failure Soft tissue injury Compartment syndrome
Give examples of early secondary fracture complications
Plaster disease Renal stones Immobility Infection Compartment syndrome
What is the difference between Late primary and early secondary complications of fractures?
Late primary - as a consequence of injury
Late secondary - as a consequence of treatment
Give examples of Late primary fracture complications
Non-union Delayed union Mal-union Growth arrest Arthritis
Give examples of Late secondary fracture complications
Mal-union
Infection
What is the treatment of an infected unstable open fracture?
Stabilisation via external fixation followed by surgical wound cleansing and later bone grafting
How might a fat embolism present post-fracture?
Usually in younger men under twenty years old, 2-5 days post-injury present with tachypnoea and mild confusion
What is the main symptom presentation in compartment syndrome?
Disproportional pain to the injury
What is a useful diagnostic test for compartment syndrome?
Stretch the muscles in the affected compartment, this should precipitate extreme pain
What complications may arise from late mobilisation?
Osteoporosis Renal stone formation Stiffness Muscle wasting Skin sores
What percentage of fractures go on to non-union?
2%
What is the most common site of fracture non-union?
Tibia
List the potential causes of non-union
Excessive movement
Too little movement - as a result of rigid internal fixation
Soft tissue interposition (between bone ends)
Poor blood supply
Infection
Excessive traction - bones too far apart
Intact adjacent bone
When are upper limb fractures considered to be non-union?
At 10 weeks
When are lower limb fractures considered to be non-union?
At 20 weeks
Define mal-union
Fracture has been allowed to heal in a position that precludes normal function
How are mal-unions treated?
Open reduction - internal fixation
