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Year 6 - Surgery > Surgery: Ortho > Flashcards

Surgery: Ortho Flashcards

1
Q

The general principles of T&O

A

Trauma: Resus, Reduce, Restrict, Rehabilitate

Ortho: Look, Feel, Move, Special Tests

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2
Q

What are the clinical signs of a fracture?

A

Pain, swelling, crepitus, deformity, adjacent structural injury

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3
Q

How would you describe a fracture?

A

Location, pieces, pattern, displacement, plane

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4
Q

Outline translation and angulation

A

Coronal Plane:

  • Medial/Lateral
  • Varus/Valgus

Sagittal Plane:

  • Anterior/Posterior
  • Dorsal/Volar

Axial Plane:

  • Proximal/Distal
  • Internal/External
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5
Q

When is external fixation most commonly used?

A

Large amount of soft tissue damage inc risk of infection and also as a quick fix to save life

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6
Q

Where is Shenton’s line?

A

Imaginary curved line drawn along the inf border of the superior pubic ramus and inferomedial border of NOF

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7
Q

What is the % risk of AVN in a displaced intracapsular #?

A

25-30%

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8
Q

Hemi vs THR

A

If young, fit, mobile -> THR

If older and less fit -> hemiarthroplasty

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9
Q

Why don’t you give everyone a THR?

A

Lower mobility, multiple comorbidities, risk of dislocation, requires specialist hip surgeons

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10
Q

Important points in an OA hx

A

Pain (exertional, rest, night)

Disability (walking distance, stairs, giving way)

Deformity

Prev hx of trauma or infection

Tx given physio, injections, ops

Other joints affected

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11
Q

What is the angle of flexion if the leg is straight?

A

0°

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12
Q

The mx of OA

A

Conservative: analgesics, physio, walking aids, avoidance of exacerbating activity, infections

Operative: replace, realign, excise, fuse, synovectomy, denervate

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13
Q

RA vs OA

A

RA - inflammatory - worse in the morning

OA - degenerative - worse w activity

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14
Q

Look

A

Scars
Swellings
Deformities
Redness

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15
Q

Feel

A

PET: pain, effusion, temp

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16
Q

Move

A

Active -> Passive

Active ❌ Passive ✅
Think muscle, tendon, neuro

Active ❌ Passive ❌
Think mechanical block

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17
Q

Why do osteophytes form?

A

They’re outgrowths of bone to try spread the SA and dec friction

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18
Q

What are the special tests?

A

Knee - C’s - collaterals, cruciates, cartilages

Hip - T’s - Trendelenburg’s and Thomas’s

Shoulder - I SITS - impingement, supraspinatus, infraspinatus, teres minor, subscapularis

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19
Q

What should you always ask for before performing Thomas’s test?

A

If they have a hip replacement

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20
Q

How does a frozen shoulder present?

A

Extremely painful, global dec ROM, normal xray

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21
Q

Bone growth in width and length?

A

Width - intramembranous ossification

Length - endochondral ossification

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22
Q

What are the two types of bone healing?

A

Primary/Direct - by direct union and cutting cone where haematoma has been disturbed - slow

Secondary/Indirect - by callus formation where haematoma has NOT been disturbed - fast

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23
Q

Which type of bone healing can the union be evaluated by xray?

A

Secondary

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24
Q

Which type of bone healing is fastest?

A

Secondary

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25
Q

The prerequisites for bone healing

A

Blood supply and periosteum, minimal fracture gap and movement, optimum pH/nutrients/growth factors

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26
Q

How many planes must you ensure you xray a fracture in?

A

Two

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27
Q

What are the biggest RFs for poor bone healing that you should always elicit from the hx?

A

Diabetes

Smoking

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28
Q

How does movement affect bone healing?

A

If direct bony contact there shouldn’t be any movement vs if indirect up to 10% can be helpful

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29
Q

What should you avoid when using k wires in children?

A

The physis i.e. growth plate

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30
Q

The principles of fracture mx

A

Save Life -Then- Save Limb

Resus, Reduce, Restrict, Rehabilitate

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31
Q

What are the benefits of reducing the fracture?

A

Helps to prevent malunion

Places the soft tissues under less direct stress, inc blood flow to skin, red secondary damage

Red pain and risk of carpal tunnel syndrome etc

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32
Q

PWB vs TWB

A

Partial - a % of BW is placed on the injured limb

Touch - the injured limb is used only for balance

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33
Q

Methods of restriction

A

Non-Op: casts (backslab or full POP/fibreglass), splints, traction

Operative: external/percutaneous/internal fixation + replacement

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34
Q

When would you immobilise just that joint or both above/below?

A

If near epiphysis then below vs midshaft above

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35
Q

The ALTS principles

A 
Primary Survey
A - C spine control w manual inline stabilisation
B - ?pneumothorax
C - ?haemorrhage
D - GCS, spine, log roll
Secondary Survey
E - top to toe
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36
Q

What is a pathological fracture?

A

When there was no trauma, assess fragility, ask FLAWS/hx of cancer

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37
Q

What is the most sensitive marker of blood loss?

RR, UO, HR, BP

A

Clinically RR>HR>BP + objectively fall in urine output but not immediate

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38
Q

What is the least sensitive marker of blood loss?

RR, UO, HR, BP

A

Fall in BP

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39
Q

What is the most important marker of resus?

A

Lactate

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40
Q

Classification for open fractures

A

Gustillo Anderson:

I - puncture wound <1cm

II - 1-10cm w mod soft tissue injury

IIIa - >10cm but able to close skin

IIIb - either extensive tissue injury or needs flap/graft to close overlying skin

IIIc - vascular injury

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41
Q

How are supracondylar fractures classified?

A

Gartland:

I - undisplaced

II - displaced w intact posterior cortex

IIIa - completely displaced posteromedially

IIIb - completely displaced posterolaterally

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42
Q

What is the typical cause of a supracondylar fracture?

A

Child falling on an outstretched elbow fracturing the narrowest part of the humerus

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43
Q

Def of compartment syndrome

A

Sustained inc pressure within a myofascial compartment leading to reduced perfusion which if left untreated may lead to permanent tissue necrosis

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44
Q

What is the main give away for compartment syndrome?

A

Pain out of proportion w clinical picture and worse on passive stretching eg wriggling toes

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45
Q

Which blood supply is occluded first in compartment syndrome?

A

Venous

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46
Q

Mx of suspected compartment syndrome

A

Take everything off the limb dressings/casts and give analgesia, go back and see them in ~15mins, emerg fasciotomy if lower leg two incision four compartment decomp, excise necrotic tissue, re-exploration <48hrs, early involvement of plastics

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47
Q

What should you do w any erythema you see?

A

Mark the outline

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48
Q

How long does nec fas take to spread?

A

Hrs NOT days

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49
Q

What should you always do before sticking a needle into a joint w septic arthritis?

A

Xray before aspirating before abx

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50
Q

What are vital parts of an ortho examination?

A

Neurovascular status on both sides + examine the joint above/below

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51
Q

Which blood supply to the bone inc if the nutrient artery is impaired?

A

The periosteum therefore important not to take too much away during surgery

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52
Q

What is Wolff’s law?

A

The bone density changes in response to functional force

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53
Q

The two broad categories of a fracture

A

Simple and comminuted

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54
Q

Why do you straighten and apply pressure to a break before op?

A

Pain relief, better for the surrounding soft tissue, makes the op easier

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55
Q

When would you measure the compartment pressure?

A

If the pt is unconscious

NB: compartment syndrome is otherwise a clinical dx

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56
Q

What are the four compartments of the lower leg?

A

Anterior, lateral and deep/superficial posteriors

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57
Q

What inserts onto the greater trochanter?

A

Gluteus medius and minimus - hip aBductors

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58
Q

What inserts onto the lesser trochanter?

A

Psoas - hip flexor

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59
Q

How do you categorise NOF fractures?

A

Intracapsular - undisplaced (Garden I+II) and displaced (Garden III+IV)

Extracapsular - intertrochanteric and subtrochanteric

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60
Q

The blood supply to the NOF

A

Major supply - medial and lateral circumflex femoral arteries from profunda femoris and subsequent trochanteric anastomosis w branches of gluteal arteries

Minor supply - ligamentum teres from obturator artery/internal iliac + intramedullary

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61
Q

Mx of NOF#

A

Upon admission MMSE, seen by orthogeris, operate within 36hrs

Intracapsular: 1,2,Screw + 3,4,Austin-Moore

Extracapsular: inter DHS + sub nail

Mobilise early w physio and minimise risk of future falls and osteoporosis

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62
Q

What is the NOF# give away on inspection?

A

Shortened + externally rotated leg

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63
Q

What do you do if clinically it suggests NOF# but not present on xray?

A

MRI>CT

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64
Q

What is non union?

A

Failure of bone healing within an expected timeframe

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65
Q

What is malunion?

A

The bone heals but outside normal parameters of alignment: limp, gait, arthritis

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66
Q

The two types of non union

A

Atrophic - infection, gap, too stiff

Hypertrophic - too much movement

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67
Q

How do you describe a fracture? (3)

A

Type
Location
Displacement

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68
Q

How do you describe displacement? (3)

A

In relation of the distal to the proximal: translation, angulation, rotation

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69
Q

Which cells make up the cutting cone?

A

The osteoClasts lead + osteoBlasts follow that lay osteoids

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70
Q

When would you favour external > internal fixation?

A

Poor soft tissues and quicker

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71
Q

How do you describe angulation?

A

Coronal - varus (apex lateral) or valgus (apex medial)

Sagittal - recurvartum (apex posterior) or procurvatum (apex anterior)

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72
Q

Why are some fractures not fixed?

A 
Infection
Bleeding
VTE
NV Injury
Nonunion
Malunion
Stiffness
CRPS
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73
Q

Outline the mx of open fractures

A 
Save life first w ATLS
Document NV status
Photo of soft tissue
Cover w gauze and saline
IV abx co-amoxiclav and tetanus
Splint w backslab POP cast
Xrays and plan for theatre
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74
Q

What is the general approach to interpreting a MSK radiograph?

A

The usual details + whether the pt is skeletally mature/immature

The ABCS Approach

Alignment: sublux or discl

Bones: cortex, fragments, quality

Cartilage: joint spaces, contour, arthritic/gout changes

Soft Tissues: disruption, swelling, foreign bodies

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75
Q

What does a fat pad on x-ray indicate?

A

An occult fracture that has caused swelling: ant can be normal but post is abnormal

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76
Q

What is a Jefferson #?

A

Multiple fractures at different points in C1 ring due to compressing vertical force

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77
Q

What is a Hangman’s #?

A

Fractures of both pedicles of C2 due to hyperextension injury

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78
Q

Colles v Smiths v Bartons

A

Colles Type - extension # of distal radius w dorsal angulation

Smiths Type - flexion # of distal radius w volar angulation

Bartons Type - intra articular distal radius #

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79
Q

Monteggia v Galeazzi

A

MUgGeR

Monteggia - ulna # w dislocation of radial head

Galeazzi - radius # w dislocation of distal radioulnar joint

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80
Q

What are the clinical signs of a scaphoid #?

A

Any tenderness in the anatomical snuffbox, scaphoid tubercle, thumb telescoping

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81
Q

What if there’s no visible fracture on xray but there’s clinical suspicion of a scaphoid #?

A

Treat and repeat xray in 10 days

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82
Q

Why is it important not to miss scaphoid fractures?

A

Retrograde blood supply and avasc necrosis risk

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83
Q

What is the Weber classification of lateral malleolus fractures?

A

A - below ankle joint

B - at ankle joint

C - above ankle joint

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84
Q

What is the Salter-Harris grading for growth plate fractures?

A 
I - Separated
II - Above
III - beLow
IV - Through
V - Rammed
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85
Q

Mx of OA

A

Confirm dx w hx, exam, ix

Take an MDT approach w PT, OT, podiatrist

Consrv: manage RFs ie optimise weight, diet, low impact exercise, ensure other medical conditions are well controlled + consider applying warm/ice packs and use of arthritis gloves if the hands are affected

Med: analgesia up WHO pain ladder + intra-articular steroid injections

Surg: referral to ortho for osteotomy, arthrodesis and more likely arthroplasty

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86
Q

OA: DISGAPMMSSP

A

A multifactorial degenerative disease process involving degradation of articular cartilage, cellular changes and biomechanical stresses

It’s the sixth most prevalent cause of disability globally affecting predominantly elderly females esp from low income countries

Usually 1° but can be 2° to infection, inflam RA, trauma #/meniscal tear

Sx: pain, stiffness, swelling; Signs: tenderness, crepitus, dec ROM, Heberden’s, Bouchard’s; Ix: x-ray

The prognosis depends on the joints affected and disease severity and surgical mx appears to yield the best long term outcome

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87
Q

What are the features of OA on an x-ray?

A

LOSS: loss of joint space (trendelenburg), osteophytes, subchondral sclerosis, subchondral cysts (late sign)

If it’s a WB joint take the x-ray standing

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88
Q

What is the unhappy triad?

A

ACL, MCL, medial meniscus

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89
Q

Which nerve innervates the gluteus medius/minimus and tensor fascia lata?

A

Superior Gluteal Nerve

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90
Q

Which nerve innervates the gluteus maximus?

A

Inferior Gluteal Nerve

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91
Q

What is a crude way of assessing A-E in ATLS?

A

Ask for their name + to wiggle their fingers/toes

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92
Q

What are the types of lamellar bone?

A

Cortical: hard concentric Haversian systems that communicates w medullar canal

Cancellous: soft trabecular honeycomb structure around metaphysis oriented in direction of most stress which allows for meta/epiphyseal vessels

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93
Q

What happens to the blood supply to a bone after fracture?

A

The nutrient artery is disrupted and inc supply to periosteum unless open

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94
Q

What are the stages of secondary bone healing?

A
  1. Haematoma 0-2w
  2. Soft Callus 2-3w
  3. Hard Callus 3-6w
  4. Remodelling <2yr
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95
Q

When do you try and operate on a #?

A

Within 2wks before callus formation makes the procedure more difficult

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96
Q

Which clinical situation would 2° bone healing be problematic?

A

Intra-Articular + Displaced #: operate to promote 1° bone healing and minimise the joint surface becoming uneven

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97
Q

How do you dx a fracture?

A

Hx, o/e (tenderness + swelling), xray

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98
Q

Why might a fracture displacement in a cast?

A

As the swelling reduces therefore we take xrays to ensure it remains in place

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99
Q

: Replace>Fix

A

Comminuted
Intra-Articular
Avasc Necrosis

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100
Q

: ExFix>Cast

A

If you’re worried about infection

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101
Q

: Backslab>Full Cast

A

Allow for swelling therefore red risk of compartment syndrome

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102
Q

: Full Cast>Backslab

A

When seen in 2wk # clinic, more stable, if fibreglass also lighter weight

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103
Q

When would traction be used?

A

Midshaft femur # before operating where a cast would be inappropriate

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104
Q

How long do you have if there’s damage to the blood supply?

A

Check pulses, cap refill, doppler -> limited 3-6hrs to revascularise

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105
Q

What needs immobilising in a midshaft fracture?

A

The joint either side so above knee/elbow casts required

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106
Q

Why do pts die following a RTA?

A

Immediate: brain injury + catastrophic bleeding

Early: bleeding, DIC, ARDS

Late: comps from surgery

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107
Q

Mx of Open Fracture

A 
ATLS
NV Status
Photograph
Soaked Gauze
Abx + Tetanus
Restrict
Xrays
Theatre
Rehab
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108
Q

What muscles sit in the lateral compartment of the lower leg? (2)

A

Peroneal Longus + Brevis

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109
Q

What muscles sit in the posterior compartments of the lower leg?

A

Deep: tibialis posterior, popliteus, flexor hallucis longus, flexor digitorum longus

Superficial: gastrocnemius, soleus, plantaris

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110
Q

What muscles sit in the anterior compartment of the lower leg? (4)

A

Tibialis anterior, fibularis tertius, extensor hallucis longus, extensor digitorum longus

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111
Q

What are the 6P’s of compartment syndrome?

A

Pain x6

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112
Q

Dx of Compartment Syn

A

Clinical

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113
Q

When would you measure the pressure of a compartment?

A

Unconscious or pt w severe learning disabilities to see if delta p >30 (within 30mmHg of diastolic pressure or absolute pressure above 40mmHg)

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114
Q

Why do pts die following a NOF#?

A

Mechanical fall due to slow decline and degeneration of reflex pathways

Plus stroke, MI, UTI

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115
Q

Workup for NOF#

A

Full/collateral hx to identify cause inc pre-injury mobility, DHx, SHx

Examination inc NV status, cvs, resp

Special tests inc bloods, G+S, ECG, CXR, AP pelvis and lateral hip

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116
Q

What bones make up the acetabulum?

A

Ileum, Ischium, Pubis

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117
Q

Why don’t we mx NOF# non-operatively?

A

Dec Pain, VTE, Pneumonia, UTI, Sepsis

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118
Q

Which group of elderly pts would you worry about giving a THR to?

A

Alcoholics or demented pts who forget to follow the restrictions and result in dislocation

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119
Q

Hemi vs Total

A

The risk of dislocation is less for a hemi because of the larger head but initial immobilisation isn’t as good and it won’t last as long due to wearing of the acetabulum

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120
Q

Which OA is most common in the hip, knee, ankle?

A

Hip 1°, Knee 1°, Ankle 2°

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121
Q

Which pts classically get valgus knee OA?

A

RA

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122
Q

Why would you perform a unicondylar knee replacement > TKR?

A

Operatively: quicker op + preserve as much native bone making future revisions easier w less comps

Postop: faster recovery, less pain, feels more like a real knee

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123
Q

What are the main comps specific to a THR?

A

Immediate - bleeding + nerve injury

Early - infection + VTE

Late - leg length discrepancy, dislocation, loosening

124
Q

What is a potential cause for a trendelenburg gait?

A

An anterolateral approach to hip surgery resulting in superior gluteal nerve injury

125
Q

What are the hip approaches? (3)

A

Anterior, Anterolateral (hemi), Posterior (total)

126
Q

Where does AVN typically occur? (3)

A

Scaphoid, Navicular, NOF

127
Q

What are the most common causes or AVN? (5)

A 
Idiopathic
Trauma
Alcohol
Steroids
Sickle Cell
128
Q

Mx of AVN

A

Dx: exclude other causes and xray/MRI

Tx: remove cause, revascularise, arthroplasty

129
Q

Where does the spinal cord end? And what is a useful landmark?

A

L1 @ bottom of ribcage

130
Q

Cord Compression vs Cauda Equina Syndrome

A

CC: presynaptic, inc tone, red power, brisk reflexes, clonus, upgoing plantars, reduced PR tone, incontinence, sensory level loss of sensation

CES: postsynaptic, dec tone, red power, red reflexes, no clonus, downgoing plantars, reduced PR tone, incontinence, patchy loss of sensation

131
Q

Myelopathy vs Radiculopathy

A

Compression of cord + root

132
Q

What happens if CES is left untreated?

A

Lower limb weakness and paralysis + long term incontinence

133
Q

Where is the T10 sensory level?

A

Umbilicus

134
Q

Where is the T4 sensory level?

A

Nipples

135
Q

What are the causes of cord compression?

A

Tumour (Mets)

Trauma

Infection (Epidural Abscess + Discitis)

Disc Prolapse

Degeneration (Spondylolisthesis)

Congenital (Scoliosis + Syringomyelia)

136
Q

What are the causes of CES?

A

The same pathology as for cord compression however it’s the level where it occurs that’s differs as does the order of most common causes: disc prolapse, degeneration, infection, tumour

137
Q

What is the most common cause of CC + CES?

A

CC: Tumour + CES: Central Disc Prolapse

138
Q

What are the red flags for impending CES?

A

Bilateral sciatica, progressive evolving neurology, saddle anaesthesia, urinary/bowel sx, sexual dysfunction

139
Q

Mx of CES

A

Confirm dx w urgent MRI + emerg discectomy/laminectomy within 48hrs of onset of sx

140
Q

What joins the lamina to the vertebral body?

A

Pedicle

141
Q

How do you reduce a patella that’s dislocated laterally?

A

Extend the knee

142
Q

Paeds: Septic Arthritis vs Transient Synovitis

A

The hx and symptomatology are similar: not moving, ?temp/tachy, ?recent viral illness, use Kocher criteria

143
Q

Why do children w an inflam hip find externally rotating their hip and flexing the knee more comfortable?

A

It puts the least amount of tension on the capsule

144
Q

What are the Kocher criteria for a child w an inflamed hip?

A

NWB
Temp >38.5°
ESR >40mm/hr
WBC >12,000cells/mm^3

It’s a point for each w more points making septic arthritis and need for aspiration/surg drainage more likely: 1=3%, 2=40%, 3=93%, 4=99%

145
Q

What would you do if a child’s limping and only has one of the Kocher criteria?

A

Start NSAIDs to see if it settles down as an irritable hip is self limiting

If there’s no improvement consider US looking for an effusion +/- aspiration

146
Q

What is Perthes disease?

A

Idiopathic transient AVN of the hip usually 4-8yo w the older they px the worst the prognosis as less potential for remodelling

147
Q

What should you consider if a suspected transient synovitis is not improving after a few days?

A

Perthes

148
Q

Mx of Perthes

A

Dx: initially w MRI and may be found later on xray

Tx: aim to preserve shape of femoral head until revascularisation to red future arthritis

Consrv: avoid contact sports and consider crutches during painful stages

Surg: when older osteotomy/THR left as late as possible

149
Q

What are the stages of Perthes disease? (3)

A

Precollapsed, Collapsed, Remodelling

150
Q

What is a SUFE?

A

Idiopathic head of femur slips backwards usually 9-15yo undergoing puberty px w groin or referred knee pain

151
Q

What should you consider as a potential cause of a pre-pubertal boy px w SUFE?

A

Likely to be due to hormonal changes: obesity, hypogonadal, thyroid disease

Also more likely to end up w bilateral disease and could be a ~yr b/w each px

152
Q

Mx of SUFE

A

Dx: have a low threshold to ask for AP pelvis and frog lateral xrays

Tx: aim to fix epiphysis in current position w a screw to prevent further slippage and development of 2° AVN, nonunion, arthritis +/- prophylactically tx other side in young pts

153
Q

What are the DDH screening tests for all children?

A

Barlow -> Ortolani

154
Q

Which children are at a high risk of DDH? (3)

A

FHx
Breech
Oligohydramnios

155
Q

Mx of DDH

A

Dx: initially w US if RF/pos screening and may be found later on xray

Tx: aim to keep the hip joint in place

Consrv: Pavlick harness + serial USS

Surg: MUA, spica cast, open reduction, when older osteotomy/THR

156
Q

What results in a break in shentons line?

A

DDH

NOF#

157
Q

How do you describe translation?

A

The fixed point is your proximal bone and it’s the lateral bone that’s described

158
Q

What NV can be damaged following a supracondylar fracture?

A

Median Nerve + Brachial Artery

159
Q

What is the indication for urgent surg tx of a supracondylar fracture?

A

Absent radial pulse, clin signs of impaired perfusion, evidence of threatened skin viability

160
Q

What is the surg tx of a supracondylar fracture according to BOAST?

A

Stabilise w bicortical wire fixation: crossed wires lower risk of loss of fracture reduction + divergent lateral wires lower risk of ulnar nerve injury

Postop radiographs @ 4-10d + wire removal and mobilisation @ 3-4w

161
Q

Which rotator cuff muscle does the axillary nerve innervate?

A

Teres Minor

162
Q

What is Sir Herbert Seddon’s classification of peripheral nerve injury?

A

Mild-Sev: neurapraxia, axonotmesis, neurotmesis

163
Q

Why is it so important to clinically distinguish b/w CC + CES?

A

To MRI the correct part of the spine to confirm dx vs the wrong part of the spine and falsely reassure

164
Q

What is a crude way to examine the peripheral nerves of the upper limb in a child?

A

Play rock (median), paper (radial), scissors (ulnar)

165
Q

What are the comps of a distal radius fracture?

A

Immediate: soft tissues, haemorrhage, shock

Early: infection, compartment syn, VTE, ARDS

Late: malunion, nonunion, scarring, stiffness, CRPS

166
Q

Fat Embolism vs PE

A

You have a petechial rash w fat embolism

167
Q

Where is true hip pain?

A

Groin

168
Q

What are the three compartments of the knee joint?

A

Patellofemoral
Medial Femorotibial
Lateral Femorotibial

169
Q

What is the ASIA score?

A

The minimal elements of neurological assessment for all pts w spinal injury: strength of 10 muscle groups each side + pin prick discrimination at 28 sensory locations each side

170
Q

Mnemonic to remember the carpus: thumb + pinky

A

Here Comes The Thumb: Hamate Capitate Trapezoid Trapezium

Straight Line To Pinky: Scaphoid Lunate Triquetrum Pisiform

171
Q

What are the boundaries of the anatomical snuffbox? (3)

A

EPL + EPB/APL

172
Q

What passes through the anatomical snuffbox? (3)

A

Radial artery, cephalic vein, superficial branch of the radial nerve

173
Q

What passes through the carpal tunnel? (4)

A

FDSx4, FDPx4, FPL, Median Nerve

174
Q

What are the boundaries of the carpal tunnel? (2)

A

Superficial flexor retinaculum + deep carpal arch

175
Q

What are the boundaries of Guyon’s canal? (4)

A

Volar and transverse carpal ligaments, pisiform, hook of hamate

176
Q

What passes through Guyon’s canal? (3)

A

Ulnar artery, vein, nerve

177
Q

What is the sensory distribution of the median + ulnar nerves?

A

Median: lateral three 1/2 digits inc nail beds + palmar cutaneous

Ulnar: medial one 1/2 digits, palmar cutaneous, dorsal branch

178
Q

What does the anterior interosseous branch of the median nerve supply?

A

FDP, FPL, Pronator Quadratus

179
Q

What is the Kapandji score?

A

Assessment of thumb opposition: 1 (radial side of proximal phalanx of index finger) to 10 (distal palmar crease)

180
Q

How does conus medullaris syndrome differ to CC + CES?

A

It presents w a mixture of UMN + LMN signs

181
Q

What is the vertebral level of the inferior angle of scapula?

A

T7

182
Q

What are the borders of the femoral triangle? (3)

A

Inguinal ligament, adductor longus, sartorius

183
Q

Where in the ankle do the long + short saphenous veins pass?

A

Long: in front of the medial malleolus

Short: behind the lateral malleolus

184
Q

Ddx for a hot swollen knee

A 
Trauma
Septic
Gout
Bursitis
Reactive
Haemarthrosis
Flare up of RA
185
Q

What are hints that the joint could be septic?

A

RIG: recent replacement, infection risk (elderly, diabetic, immunocomp), gonococcal

186
Q

Septic Arthritis vs Bursitis

A

ROM

187
Q

Where are the diff eponymous bursitis in the knee?

A

Housemaids - Prepatella

Clergymans - Infrapatella

Bakers Cyst - Semimembranous

188
Q

What are the potential consequences of septic arthritis? (2)

A

Septic Shock + OA

189
Q

What’s the most common culprit for septic arthritis?

A

Staph Aureus

Plus ivdu mrsa, sickle cell salmonella, sexually active gonococcal

190
Q

What is a red hot swollen joint until proven otherwise?

A

Septic Arthritis

191
Q

What is a bakers cyst usually on the background of?

A

OA or RA

192
Q

Workup for a hot swollen knee

A

Full hx inc recent surg/diabetic/sexual, examination inc mcmurrays/hands/obs, special tests inc bloods (wcc crp esr urate clotting) + aspiration (MCS and crystals) only if native joint

193
Q

Tx of Septic Arthritis

A

Washout + IV Empirical Abx

194
Q

What are the two causes of a trendelenburg gait in OA?

A

Loss of joint space + pain inhibition

195
Q

What can result in ulnar nerve palsy? (3)

A

Dysfunction at cervical spine, cubital tunnel syndrome at elbow, guyons canal syndrome at wrist

196
Q

Which muscles in the forearm does the ulnar nerve supply?

A

Flexor capri ulnaris + the medial half of flexor digitorum profundus

197
Q

What are the subtypes of osteomyelitis?

A

Acute: initially nidus of infection which can spread under the periosteum

Subacute: brodies abscess in children

Chronic: walled off abscess w sequestrum (necrotic bone) inside and involucrum (reactive bone) outside +/- sinus

198
Q

What are the majority of osteomyelitis you see in the community?

A

Chronic: young/old, immunocomp, diabetic

199
Q

Tx of Osteomyelitis

A

Aggressive IV abx if acute + surgical drilling if sequestrum

200
Q

CIs of FIB

A

Absolute: clinical suspicion of compartment syndrome + local anaesthetic allergy

Relative: associated crush injury, infection/burn of overlying skin at injection site, easy bruising

201
Q

What is the vertebral level of the iliac crest?

A

L4

202
Q

Most common sources of bone mets

A 
Breast
Prostate
Lung
Kidneys
MM
Lymphoma
203
Q

Most common sites of bone mets

A 
Spine
Ribs
Pelvis
Proximal Femur
Proximal Humerus
204
Q

When does periprosthetic lucency occur?

A

Prosthetic loosening or infection

205
Q

What is the imaging modality of choice in diagnosing a joint prosthesis infection?

A

X-rays

206
Q

What xray changes are indicative of joint prosthesis infection?

A

Wideband of radiolucency at the cement/metal bone interface & bone destruction

207
Q

Mx options for periprosthetic infection

A

Excisional arthroplasty, debridement and implant retention, single/two stage revision

208
Q

What is arthroplasty?

A

The surgical creation or reshaping of a new joint to relieve pain and/or restore movement

209
Q

Where is excision arthroplasty commonly performed?

A

The hip (Girdlestone), first carpometacarpal joint/trapezium & to correct severe hallux valgus deformity (Keller)

210
Q

What is the Trendelenburg’s sign?

A

The pelvis drops on the side of the lifted foot during the step

211
Q

When is the Trendelenburg’s sign positive?

A

Contralateral aBductor weakness, superior gluteal nerve palsy, subluxation or dislocation of the hip, shortening of the femoral neck, any painful hip disorder

212
Q

Draw out the carpus

A

https://teachmesurgery.com/wp-content/uploads/2018/10/21.jpg

See iPad Photos

213
Q

Draw out the tarsus

A

https://teachmeanatomy.info/wp-content/uploads/The-Tarsal-Bones-of-the-Foot.jpg

See iPad Photos

214
Q

What are the most causative organisms of infected hip replacement?

A

Staph aureus & coagulase negative strept

215
Q

What are the primary aBductors of the hip?

A

Gluteus medius & minimus

216
Q

Intracapsular hip fractures

A

Femoral head & neck

217
Q

Extracapsular hip fractures

A

Trochanteric, intertrochanteric and subtrochanteric

218
Q

Branches of which artery can be damaged in intracapsular fractures?

A

The medial femoral circumflex artery

219
Q

What is a/w femoral neck fractures?

A

Limb shortening, external rotation, fracture non-union, avascular necrosis

220
Q

What is fracture non-union?

A

It fails to heal

221
Q

Which fracture increases the risk of septic arthritis?

A

Compound

222
Q

Mx of displaced intracapsular fractures

A

Replacement arthroplasty or total hip replacement

223
Q

Mx of extracapsular fractures

A

Intramedullary pin and plate or extramedullary sliding hip screw for trochanteric fractures above and including the lesser trochanter & internal fixation for subtrochanteric fractures

224
Q

Mx of non-displaced intracapsular fractures

A

Internal fixation

225
Q

What are Tinel’s + Phalen’s signs?

A

Both test the MEDIAN nerve

Tinel’s: tapping over the median nerve causes paraesthesia

Phalen’s: downward prayer position results in flexion at the wrist producing sx

226
Q

What are the Ottawa ankle rules?

A

Ankle x-ray is only required if there’s any pain in the malleolar zone and one of: inability to WB for four steps or bony tenderness over distal tibia or fibula

227
Q

Outline the Weber classification

A

A: infrasyndesmotic

B1-3: usually starting at level of tibial plafond and extending proximally

C1-3: suprasyndesmotic +/- tibiofibular syndesmosis disruption, medial malleolus #, deltoid ligament injury

228
Q

Mx of Weber A + C

A

A: remain WB as tolerated in CAM boot for 6wks

C: open reduction + external fixation

229
Q

What radiographic signs are a/w POSTerior shoulder dislocation?

A

Rim’s: widened glenohumeral joint >6 mm

Light Bulb: fixed internal rotation of the humeral head

Trough Line: dense vertical line in the medial humeral head

230
Q

What position does ANTerior shoulder dislocation result in?

A

Ext rotation and aBduction

231
Q

What radiographic signs are a/w ANTerior shoulder dislocation?

A

Bankart Lesion: injuries specifically at the anteroinferior aspect of the glenoid labral complex

Hill-Sachs Defect: posterolateral humeral head depression fracture resulting from the impaction with the anterior glenoid rim

Greater Tuberosity #

232
Q

Which #s are most commonly a/w compartment syndrome?

A

Supracondylar + Tibial Shaft

233
Q

What is the most common site of metatarsal stress #s?

A

Second metatarsal shaft as it’s the longest

234
Q

Fifth Metatarsal #s: Pseudo-Jones vs Jones

A

Pseudo: most common, avulsion # at proximal tuberosity, a/w lateral ankle sprain and often follow inversion injuries

Jones: less common, transverse # at metatarsal base, a/w sig aDduction force to forefoot w ankle in plantar flexion

235
Q

Outline the Gustilo + Anderson classification

A

Open #s

1 - low energy wound <1cm

2 - >1cm w mod soft tissue damage

3 - high energy wound >1cm w extensive soft tissue damage
A: adequate ST coverage
B: inadequate ST coverage
C: associated arterial injury

236
Q

How soon should open #s be debrided and lavaged?

A

<6hrs of injury + IV broad spec abx and tetanus prophylaxis

237
Q

: Trauma v Stress v Patho

A

XS forces, repetitive low velocity injury, abnormal bone w normal use

238
Q

Pt w snuffbox tenderness but neg x-rays next step?

A

Ideally MRI before discharging w splint/cast plus thumb immobilisation + 2wk review in # clinic to repeat x-ray

239
Q

What are the scaphoid views?

A

PA
Ziter
Lateral
Oblique

240
Q

What is the mx of undisplaced scaphoid #s?

A

Immobilisation in below elbow cast for 6-8wks

241
Q

Which scaphoid #s require surgical fixation?

A

Displaced OR proximal scaphoid pole #s

242
Q

What are the comps of discitis? (2)

A

Sepsis + Epidural Abscess

243
Q

What other ix do you need to perform alongside spine MRI for pt w discitis?

A

Assess for signs of infective endocarditis

244
Q

What is the FRAX score?

A

Estimates the 10yr risk of fragility fracture for pts 40-90yo: low reassure and lifestyle advice, med offer BMD, high offer boje protection tx

245
Q

Ddx for sx ruptured bakers cyst

A

DVT

246
Q

What is the most common 1° + 2° cause of iliopsoas abscess?

A

1°: staph aureus + 2°: crohns disease

247
Q

Iliopsoas abscess ix + mx

A

CT abdomen + IV abx and percutaneous drainage

248
Q

Tx for NOF

A

Intracapsular - internal fixation, hemi (immobile), total (mobile)

Extracapsular - DHS (intertrochanteric) or intramedullary nail (subtrochanteric)

249
Q

What is the Garden classification?

A

NOF

I: stable w impaction in valgus

II: complete but undisplaced

III: displaced but still has boney contact

IV: complete boney disruption

250
Q

Tests for DDH

A

Barlow -> Ortolani

251
Q

Perthes vs SUFE

A

Perthes: 4-8yo boy, hip pain stiffness red rom, widening of hip joint space due to avasc necrosis w flattening of femoral head on x-ray

SUFE: 10-15yo obese boys, distal thigh or knee pain w loss of int rotation of leg in flexion, displacement of femoral head epiphysis postero-inferiorly on x-ray

252
Q

Aetiology of Dupuytren’s contracture

A

Manual labour, trauma, alcoholic liver disease, diabetes mellitus, phenytoin

253
Q

What is Simmond’s triad?

A

Helps to exclude Achilles tendon rupture: palpation of tendon, angle of declination at rest, Thompson test ie calf squeeze test

254
Q

De Quervain’s tenosynovitis vs Wartenberg’s syndrome

A

De Quervains: inflam of EPB and APL tendon sheath causing radial styloid process pain w no sensory deficit

Wartenbergs: entrapment of superficial branch of radial nerve causing rest pain regardless of position over distal radial forearm w paraesthesia over dorsal radial aspect of the hand

255
Q

How long should you wait to weight bear following the placement of an intramedullary nail?

A

You don’t need to wait as WB is tolerated and prolonging it would just inc risk of VTE and decline in physical function

256
Q

The red flags for lower back pain (5)

A

Age <20 or >50, night pain, sys unwell, hx of trauma, prev malignancy

257
Q

What does the light bulb sign on x-ray suggest?

A

Posterior dislocation of the shoulder

258
Q

Elbow: Golfers vs Tennis

A

Middle of the fairway vs sides of the court

Golfers: tenderness over MEDIAL epicondyle + medial wrist pain on resisted wrist pronation/flexion

Tennis: tenderness over LATERAL epicondyle + lateral elbow pain on resisted wrist supination/extension

259
Q

What is Finkelstein’s test?

A

Pulling the thumb in ulnar deviation and longitudinal traction will cause pain over the styloid process and along EPB+APL in pts w tenosynovitis

260
Q

Mx of Open #

A

Consrv: examine extent of injury, monitor and document NV status, image, dressing

Med: IV broad spec abx + tetanus prophylaxis

Surg: primary debridement within 6hrs of injury +/- temp external fixation followed by secondary debridement after 24-48hrs to ensure soft tissue recovery before def fixation

261
Q

What is the main NV structure that is compromised in a scaphoid #?

A

Dorsal carpal arch of the radial artery

262
Q

What is long term steroid use a key RF for the development of?

A

Avascular necrosis of the femoral head

263
Q

What are the causes of AVN of the hip? (4)

A

Steroids, chemo, xs alcohol, trauma

264
Q

What causes of lower back pain are worst in the morning?

A

Facet Joint + Ank Spond

265
Q

What causes of lower back pain are relieved by rest?

A

Spinal Stenosis + Peripheral Arterial Disease

266
Q

What does the straight leg raise test?

A

If a pt w lower back pain has an underlying lumbosacral nerve root sensitivity

267
Q

How is the straight leg raise performed?

A

Pt lying supine raise the straight leg, place hand under the lumbar spine to ensure no compensatory lordosis, dorsiflex the foot to exacerbate the signs

268
Q

What are RFs for haematogenous osteomyelitis? (5)

A

Sickle cell anaemia, immunosuppression, HIV, infective endocarditis, IVDU

269
Q

What are RFs for non-haematogenous osteomyelitis? (4)

A

Diabetic foot ulcers, diabetes mellitus, peripheral arterial disease, pressure sores

270
Q

What are the most common causative organisms of osteomyelitis? (2)

A

Staph aureus except in pts w sickle cell where salmonella predominate

271
Q

What are the possible features of cauda equina syndrome? (5)

A

Lower back pain, bilateral sciatica, red perianal sensation, dec anal tone, urinary dysfunction

272
Q

What should you check in pts with new onset back pain?

A

Anal Tone

273
Q

Comps of cauda equina syndrome (2)

A

Paralysis + Incontinence

274
Q

CES: ix + mx

A

Urgent MRI within 6hrs + surg decompression

275
Q

What is the most common cause of cauda equina syndrome?

A

Central disc prolapse

Plus: infection, malignancy, trauma

276
Q

What is the initial imaging modality for suspected Achilles tendon rupture?

A

USS

277
Q

RFs for Achilles tendon disorders (2)

A

Quinolone + Hypercholesterolaemia

278
Q

What is the first line tx for back pain?

A

NSAIDs +/- PPI

279
Q

Typical LCL + MCL injuries

A

LCL: direct blow to MEDIAL aspect w slow developing effusion and lateral joint line tenderness

MCL: direct blow to LATERAL aspect w slow developing effusion and medial joint line tenderness

280
Q

What are meniscal tears a/w? (3)

A

Twisting injuries, delayed knee swelling, joint locking

281
Q

What does the Schatzker system classify?

A

Tibial plateau fractures

282
Q

What is the incidence of different shoulder dislocations?

A

Ant >95%
Post 2-4%
Inf <1%

283
Q

How is acromioclavicular joint injury graded?

A

Based on degree of separation: I+II conv rest w sling and IV-VI surg

284
Q

What is Thessaly’s test?

A

Used to assess meniscal tear: weight bear at 20° knee flexion and pos if pain on twisting knee

285
Q

How does lumbar spinal stenosis px?

A

Back pain, neuropathic pain and sx mimicking claudication however sitting>standing and uphill>downhill

286
Q

Mx of lumbar spinal stenosis

A

MRI + Laminectomy

287
Q

Adhesive Capsulitis vs Subacromial Impingement

A

AC: restriction of both active and passive ROM w ext rotation most marked

SI: pain on overhead activities w painful arc at the top of aBduction o/e and worse when lying on affected side

288
Q

Osgood-Schlatter Disease vs Chondromalacia Patellae

A

OSD: inflam of insertion into tibial tuberosity worst w activity and better w rest

CMP: inflam of underside of patella typically teenage girl w knee pain on walking down the stairs + o/e wasting of quads and pseudolocking of knee

289
Q

Osteochondritis Dissecans: DISGAPMMSSP

A

Affects subchondral bone w 2° pain, oedema, free bodies, mechanical dysfunctions

Young males
RFs trauma+genetics

Loose piece separates from end of bone

Sx: knee pain and swelling typically after exercise, locking/giving way a/w loose bodies

Signs: effusion, tenderness, Wilson’s sign

Left untx can develop degen arthritis

290
Q

What is Wilson’s sign?

A

Used for detecting medial condyle lesion: knee at 90° flexion and tibia int rotated gradual extension leads to pain at about 30° relieved by tibia ext rotation

291
Q

Ddx of Painful Arc

A

45-120°: Glenohumeral

170-180°: Acromioclavicular

292
Q

Which group of pts typically get posterior shoulder dislocations?

A

Epileptics

293
Q

Mx of Frozen Shoulder

A

Relieve Pain + Restore ROM: consrv physio, meds NSAIDs codeine steroid injections, surg MUA

294
Q

What are the origins + insertions of the rotator cuff muscles?

A

Scapula + Humerus

295
Q

What position does POSTerior shoulder/hip dislocation result in?

A

Int rotation and aDduction

296
Q

What are the common injuries following a FOOSH?

A

Fractures: scaphoid, colles type, clavicle + ant shoulder dislocation

297
Q

Mx of Radial Head Sublux

A

Analgesia and passive supination in 90° flexion

298
Q

Which nerve is compressed in meralgia paresthetica?

A

Lateral Femoral Cutaneous

299
Q

What are Kanavel’s signs of flexor tendon sheath infection?

A

Fixed flexion, fusiform swelling, tenderness on passive extension

300
Q

Which digits are more responsible for the pincer + power grips?

A

Pincer: index + middle

Power: ring + little

301
Q

Which knee ligament is isolated injury uncommon?

A

LCL

302
Q

What is the sx triad of a fat embolism?

A

Resp, Neuro, Petechial Rash

303
Q

Which biceps tendon rupture requires urgent MRI and often surgical intervention?

A

Distal

304
Q

Achilles Tendon RFs

A

Ciprofloxacin + Hypercholesterolaemia

305
Q

What are the key features of a ACJ dislocation?

A

Loss of shoulder contour and a prominent clavicle

Year 6 - Surgery (6 decks)

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