Surgery - Orthopaedics (too much to learn for me) Flashcards
In the major haemorrhage protocol, what baseline bloods should be taken pre-transfusion?
FBC
Group and save
Clotting
Clauss fibrinogen assay (measures function of fibrinogen)
In which major haemorrhage scenarios can tranexamic acid be given, and how should it be prescribed?
If trauma within 3 hours
Dose is 1g bolus over 10 mins followed by 1g infusion over 8 hours
When examining a joint, what 3 things should you assess for?
Pain
Effusion
Temperature
What are the 3 main tests to do when examining any joint?
Look
Feel
Move
Describe the tests for each muscle of the rotator cuff
Supraspinatus tendon: Empty can test
Infraspinatus: External rotation against resistance
Teres minor: Hornblower test
Subscapularis: Internal rotation against resistance
What 2 special tests can be doe on examination for carpel tunnel syndrome? Describe them
Tinel’s test: tap along nerve from index finger down through wrist towards antecubital fossa, is positive if tingling or paraesthesia down median nerve as is tapped
Phalen’s test: put hands in like a downwars pray position with backs of hands together, positive if tingling/ paraesthesia in distribution of median nerve
What does the Trendelenburg test assess?
Abductor (gluteus medius and minimus) abnormality
What is a positive trendelenburg test?
Dip in hip when lifting GOOD side leg
How do you perform Thomas’ test, and what does it assess?
Ask pt to lie down, and to bring their knee up to their chest to ‘hug’ it
Positive test = other leg lifts off bed
Tests for fixed flexion deformities eg iliopsoas tightness, ACL tear, osteoarthritis…
How can you identify if leg shortening is tibial or femoral in nature?
Galeazzi test
Get pt to lie down, flex hips to 45 degrees and knees to 90 degrees
Test is positive when knees are a different heights
If lower knee displaced towards foot = shortened tibia, if displaced towards body = shortened femur
What can you do on examination to test for Achilles tendon rupture?
Simmond’s test
Calf squeeze –> foot movement
What can you do on examination to test for Morton’s neuroma?
Mulden’s test
Clasp metatarsals and poke plantar side of foot - positive test will be pain/ tingling
After an orthopaedic examination in PACES, what can you say you would like to do to finish your examination?
Assess neurovascular status
Assess joints above and below
Test the contralateral joint
What % of bone matrix is organic vs inorganic?
40% osteoid (organic matrix)
60% inorganic
What is osteoid matrix made up of?
Protein mix secreted by osteoblasts
Recall the 2 subtypes of lamellar bone
Cortical (compact)
Trabecular (cancellous)
What is woven bone?
Disorganised bone that forms the embryonic skeleton and fracture callus
What are the 2 types of bone formation?
- Intramembranous ossification - direct ossification of mesenchymal bone models formed during embryonic development (skull bones, mandible and clavicle for example)
- Endochondral ossification - mesenchyme –> cartilage –> bone: most bones ossify this way
What are the 4 stages of fracture healing and how long does each one last?
- Reactive: first 48 hours
Reparative phase = 2 days - 2 weeks - Proliferation (reparative phase part 1)
- Consolidation (reparative phase part 2)
- Remodelling = 1 week - 7 years
Describe the reactive phase of fracture healing
Bleeding into the fracture site –> haematoma
Inflammation –> cytokine release –> recruitment of leukocytes and fibroblasts –> granulation tissue
Describe the reparative phase of fracture healing
Proliferation of osteoblasts/ fibroblasts –> cartilage and woven bone forms –> callus formation
Consolidation = endochondrial ossification of woven bone to turn it into lamellar bone
Recall the approx healing time for different types of fracture
Closed/ paediatric/ metaphyseal/ upper limb = 3 weeks
Open/ adult/ diaphyseal/ lower limb = 6 weeks
Recall some examples of traumatic, stress and pathological fracture
Traumatic: direct (assault with metal bar), Indirect (fall on outstretched hand, clavicle #), avulsion
Stress: Foot fracture in marathon runners (particularly 2nd metatarsal)
Pathological: local (tumours), general (osteoporosis, Cushing’s, Paget’s)
What is an avulsion fracture?
When small chunk of bone attached to a tendon/ligament gets pulled away from the main part of the bone. Common in young athletes
What radiographs do you need to image a fracture properly?
Orthogonal radiographs (at right angles) –> request AP and lateral films
What is an open vs closed fracture?
Open breaks the skin, closed doesn’t
What is an extraarticular fracture?
One that doesn’t cross the surface of a joint
What is fracture angulation?
Where the normal axis of the bone has been altered such that the distal portion of the bone points off in a different direction
What is fracture translation?
Movement of the fractured bones away from each other
What are the 4 elements of fracture ‘deformity’ you might comment on?
Translation (‘translocation’)
Angulation
Rotation
Impaction
What are the ‘four Rs of fracture management?
Resuscitation
Reduction
Restriction
Rehabilitation
Recall the principles of resuscitation in fracture management
- ATLS - Trauma assessed in primary survey (C spine, chest, pelvis) with secondary survey addressing #
- Assess neurovascular status and look for dislocations
- Stabilise BEFORE imaging
Recall the ‘6 As’ of managing open fractures
Analgesia
Assess: NV status, soft tissues, photograph
Alignment: align # and splint
Anti-sepsis: wound swab, copious irrigation, cover with betadine-soaked dressing
Anti-tetanus: check status (booster lasts 10 years)
Antibiotics: flucloxacillin 500mg IV/IM, benzylpenicillin 600mg IV/IM)
What system can be used to classify open fractures?
Gustilo classification
Differentiate the 3 types of fracture in the Gustilo classification in terms of size
Type 1: <1cm
Type 2: 1-10cm
Type 3: >10cm
Which of the Gustilo classifications of fracture might involve periosteal stripping?
Type 3
If a fracture has been exposed to salt/fresh water, what extra antibiotic coverage will be needed and why?
Ciprofloxacin for pseudomonas exposure
Recall the principles of reduction in fracture management
- Displaced fractures should be reduced unless no effect on outcome (eg ribs)
- Aim for anatomical reduction (especially if articular surfaces involved)
- Alignment is more important than opposition
What are the principles of restriction in fracture management
Based on Wolff’s law
Tissue formed at fracture site depends on strain it experiences
Fixation –> less strain –> bone formation
Also
Fixation –> less pain –> increased stability –> ability to fx
What is the difference between internal and external fixation?
Internal: Physically reconnecting bones with screw/plates etc
External: Fragments held in place by pins/ wires connected to an external frame
For open soft tissue injuries, which sort of fixation is best?
External
When describing the possible complications of fracture management, under what sub-headings can you classify them? Name some complications under each subheading
Anaesthetic - anaphylaxis, damage to teeth, aspiration
Intra-operative - bleeding, damage to local structures (eg neurovascular injury), treatment failure
Early post-operative - compartment syndrome, infection (surgical site, UTI, bed sores), VTE, ABx colitis
Late post-operative - scarring, fx loss, neuropathy, pain, myositis ossificans
What is myositis ossificans?
A condition where bone tissue forms inside muscle or other soft tissue after an injury at sites of haematoma formation
Recall 3 possible neurological complications of fracture surgery
Neuropraxia (axon preserved, conduction interrupted)
Axonotomesis (Wallerian degeneration of axon, interruption of axon)
Neurotmesis (axon transected - requires surgery)
What is Wallerian degenration?
An active process of retrograde degeneration of the distal end of an axon that is a result of a nerve lesion
Describe how compartment syndrome develops
Oedema from fracture –> increased pressure –> decreased venous drainage –> increased pressure –> ischaemia
What are the signs and symptoms of compartment syndrome?
Pain on passive stretching
Warmth, erythema, swelling, weak pulses, increased CRT
Recall 2 fracture sites that are most associated with compartment syndrome
Suprachondylar fractures
Tibial shaft fractures
How should compartment syndrome be managed?
Elevate limb, remove all bandages/ splint etc – fasciotomy
Recall the ‘5 Is’ that may cause non-union
Ischaemia (poor blood supply/ AVN) Interfragmentory strain Intercurrent disease (eg malignancy) Infection Interposition of tissue between fragments
Into what 2 types can non-union fractures be classified?
Hypertrophic (bone end rounded, dense + sclerotic)
Atrophic (osteopaenic bone)
What is Pelligrini-Stieda disease?
A form of myositis ossificans where the superior MCL attachment on knee calcifies following trauma
How should myositis ossificans be managed?
Excision
What are the previous names for the 3 different types of complex regional pain syndrome?
Type 1 = Reflex Sympathetic Dystrophy/ Sudek’s atrophy
Type 2 = Causalgia (persistent pain following injury to a nerve)
Type 3 = Type NOS
Recall 2 criteria that can be used to diagnose complex regional pain syndrome
Budapest criteria
IASP criteria
What are the signs and symptoms of complex regional pain syndrome?
Affects a NEIGHBOURING area to the area affected by trauma
Hyperalgesia
Allodynia
Vasomotor disturbance (may be hot + sweaty or cold + cyanosed)
Swollen, atrophic and shiny skin
Hyperreflexia/ contractures/ dystonia
Recall some medical and surgical options for managing complex regional pain syndrome
Medical: amitriptyline + gabapentin
Surgical: regional nerve block
Recall the signs and symptoms of fat embolism
Looks like a PE but with neurological signs
Onset of dyspnoea, hypoxia and tachypnoea within 24 hours of multiple fractures
CNS signs: confusion, agitation, retinal haemorrhage
Dermatological: 25-50% develop a petechial rash
How should fat embolism be managed?
DVT prophylaxis
What is the Salter-Harris classification used for, and what are the criteria?
It's used to classify the degree of disruption to the growth plate caused by a fracture SALT-C Straight across Above Lower Through CRUSH Type 1-5 = increasing risk of growth plate injury
What are the Ottawa rules used for?
To decide if an x ray is needed
Recall the 4 criteria of the Ottawa knee rule
- Over 55 years old
- Isolated patellar tenderness
- Cannot flex to 90 degrees
- Inability to weight bear both immediately and in A&E for >4 steps
Recall the Ottawa ankle rule (much more complicated than knee!)
LMN FUN
Malleolar zone pain +
- Lateral malleolus posterior edge tenderness
- Medial malleolus posterior edge tenderness
- No weight bearing - both immediately and for 4 steps in A&E
Mid foot zone +
- Fifth metatarsal base pain
- Unable to weight bear immediately or for 4 steps in A&E
- Navicular tenderness
Recall the risk factors for #NOF
SHATTERED Steroids Hyperthyroidism/hyperparathyroidism Alcohol/ smoking Thin (BMI<22) Testosterone LOW Erosive bone disease (eg RhA, MM) Renal failure Early menopause Dietary calcium low, DM
What is the key examination finding in #NOF?
Leg is shortened with external rotation
What is the most common form of intracapsular #NOF?
Sub-capital NOF#
What is the most common form of extracapsular #NOF?
Intertrochanteric NOF#
If someone’s leg is shortened and internally rotated, what is this indicative of?
Posterior dislocation of the hip
What are the 3 types of intracapsular NOF#?
Subcapital
Transcervical
Basicervical
What are the 3 types of extracapsular NOF#?
Intertrochanteric
Subtrochanteric
Reverse oblique
What is the best analgesia for a #NOF?
Iliofascial nerve block
What is the surgical management of intertrochanteric #NOF?
Dynamic hip screw
How should extracapsular NOF# be managed?
ORIF (although intertrochanteric # can be managed with a DHS)
How can the degree of displacement of an intracapsular NOF# be classified?
Using Garden classification (grades I-IV)
How should intracapsular NOF# be managed?
Garden 1 + 2 = ORIF with cancellous or cannulated screws
Garden 3 + 4 =
- <55 years: ORIF with cancellous or cannulated screws
- 55 - 75 years: total hip replacement
- >75 years: hemiarthroplasty
What is the difference between a total hip replacement and a hemiarthroplasty?
THR = replaces femoral head and acetabulum Hemiarthroplasty = replaces femoral head
What is the 1 year mortality for NOF#?
30%
What type of NOF# is most likely to be complicated by osteonecrosis and why?
Transcervical fracture
Retinacular artery is disrupted from medial circumflex femoral artery
What are the signs and symptoms of osteonecrosis of the hip?
Anterior hip pain on climbing the stairs
Insidious onset
What imaging needs to be requested in suspected osteonecrosis of the hip?
XR (AP, frog-lateral, contralateral)
MRI (double density appearance)
Bone scan
How can osteonecrosis of the hip be medically managed?
Bisphosphonates
Recall some surgical options for managing osteonecrosis of the hip
Core-decompression Rotational osteotomy Free-fibula transfer Total hip resurfacing/ replacement Hip arthrodesis
What is the ‘modified Kerboul angle’ used to determine?
Risk of femoral head collapse in osteonecrosis of the hip
How should femoral shaft fractures be managed?
Immediately: traction
1st line: intramedullary nailing
2nd line: ORIF
Recall 4 options for managing humeral fracture and the general indications for each one
Collar & cuff: 2 parts, minimally displaced, high surgical risk
ORIF: >2 parts but not highly comminuted
Arthroplasty: large displacement of humeral head and high risk of non-union
Reverse arthroplasty - irreprable rotator cuff/ previous unsuccessful replacement
What is the most common type of paediatric elbow fracture?
Suprachondylar humeral #
How will a suprachondylar humeral # appear on examination?
Elbow swollen and hand semi-flexed
What is the difference between the extension and flexion types of suprachondylar humeral #?
Extension = distal fragment displaces posteriorly (most common) Flexion = distal fragment displaces anteriorly
What is the most likely artery to be severed by a suprachondylar humeral #?
Brachial artery (by sharp edge of proximal humerus)
What is the most likely nerve to be damaged by a suprachondylar humeral #?
Median nerve
Recall the principles of reducing a suprachondylar humeral # if it is undisplaced vs if it is displaced
Undisplaced: Collar and cuff with fully flexed arm
Displaced: Manipulation under anaesthetic + K-wire fixation THEN collar and cuff for 3 weeks with fully flexed arm
What is the most common early sign of compartment syndrome following a suprachondylar humeral #?
Pain on passive extension of fingers
What is the aetiology of subluxation of the humeral head?
In children the distal attachement of the annular ligament covering the radial head is weaker so is at higher risk of subluxation
What are the signs and symptoms of subluxation of the humeral head?
Elbow pain and limited supination and extension of the elbow
How should subluxation of the humeral head be managed?
Analgesia
Passively supinate elbow joint whilst elbow flexed
What is the ‘dinner fork’ deformity associated with?
Colle’s #
What is Colle’s #?
Posterior displacement and angulation of the distal radius fragment
What is Smith’s #?
Anterior displacement and angulation of the distal radius fragment
What is the typical history of Colle’s vs Smith’s #?
Colle’s = fall on an extended wrist
Smith’s fall on a flexed wrist
What are the Barton’s and Reverse Barton’s fractures?
Both are oblique intra-articular #s with dislocation at the radio-carpal joint
Barton’s: Dorsal (posterior)
Reverse Barton’s: Volar (anterior)
A Monteggia # is a type of fracture of which bone?
Ulnar
A Galeazzi # is a type of fracture of which bone?
Radius
Describe how the location of a radius/ulnar fracture guides how the cast should be applied
Proximal #: supination
Mid-shaft #: neutral
Distal #: pronation
How are intraarticular fractures of the radius/ulnar managed?
ORIF
How are extraarticular fractures of the radius/ulnar managed?
MUA + k wire
If unsuitable for k wire –> ORIF
Recall 5 signs of scaphoid fracture
[1] Pain in the anatomical snuffbox [2] Wrist joint effusion [3] Pain on telescoping thumb [4] Tenderness on scaphoid tubercle [5] Pain on ulnar deviation of wrist
Why are scaphoid fractures particularly vulnerable to avascular necrosis?
Retrograde blood supply
80% is from the dorsal carpal branch of the radial artery
What is the use of CT in tibial plateau #?
To assess whether non-operative management can be used
What is the most common long bone fracture?
Tibial
Which bone articulates with the tibia and fibula at the ankle joint?
Talus
What is Pott’s fracture?
Bimalleolar #
What is a Cotton’s fracture?
Trimalleolar #
What is a pilon fracture?
A fracture of the distal tibia involving the articular surfaces
What classification system is used to assess the extent of syndesmotic ligament damage at the tibiotalar joint?
Weber
Name 2 techniques that can be used to repair syndesmotic tears at the ankle
Syndesmotic screws
Tightrope technique
What is a Lisfranc injury?
An injury of the foot in which one or more of the metatarsal bones are displaced from the tarsus
Recall some signs and symptoms of Lisfranc injury
Medial plantar bruising
Unable to weight bear
Gross midfoot swelling with severe pain
What is the most common metatarsal to be fractured in children vs adults?
Children: 1st
Adults: 5th
Into which 3 categories can pelvic fractures be places?
- Lateral compression (hit from side)
- AP compression (Dashboard injury)
- Vertical shear (falling from height)
Recall 3 signs/symptoms of fractured patella
- Palpable patellar defect
- Significant haemarthrosis
- Loss of straight leg raise
What 3 x ray views are recommended to image a patellar fracture?
AP
Lateral
Skyline (inferior-superior)
How should patellar # be managed if the # is comminuted and ORIF is not possible?
Partial patellectomy, or total patellectomy if no salvage potential
How is ORIF performed for patellar fractures?
Tension Band Wiring
Cerclage wiring
Screw fixation
What is compartment syndrome?
Raised pressure in closed space –> compromised tissue perfusion
What are the main signs and symptoms of compartment syndrome?
Excessive use of breakthrough analgesia due to significant pain
Why might arterial pulses still be palpable in compartment syndrome?
Necrosis occurs as a result of microvascular compromise
How can a manometer be used to help diagnose compartment syndrome?
Can use to measure intracompartmental pressure (ICP)
Normal pressure = 0-10mmHg
Delta pressure <30mmHg = compartment syndrome
Absolute pressure >30mmHg = compartment syndrome
What is the ‘delta pressure’ of a compartment?
Diastolic pressure - measured intracompartmental pressure
Recall some non-operative options for managing compartment syndrome
- Fluid resuscitation to ensure normotension (as hypoperfusion accelerates tissue injury)
- Remove circumferential bandages and casts
- Maintain limb at level of heart
How can compartment syndrome be managed operatively?
Fasciotomy
Which tendon is impinged in ‘subacromial impingement’?
Supraspinatus tendon
What is Hawkin’s test used to diagnose, and how is it performed?
For shoulder impingement
90 degrees shoulder and elbow flexion
Passive internal rotation of the arm –> pain
Recall some differentials for subacromial impingement
Adhesive capsulitis
Supraspinatus tear
Osteoarthritis/ Rheumatoid/ Septic arthritis
Gout/ Pseudogout
Which x ray views are needed to investigate the aetiology of a subacromial impingement?
True AP
30 degrees caudal tilt (subacromial spurring)
Supraspinatus outlet (acromial morphology)
Recall some management options for subacromial impingement under the headings of ‘conservative’, ‘medical’ and ‘surgical’
Conservative: rest, phyisio
Medical: NSAIDs, subacromial bursa steroid
Surgical: athroscopic acromioplasty
Describe the aetiology of subcoracoid impingement
Narrowing at the coracohumeral interval impinges the ligaments of:
- Subscapularis
- Long head of biceps
- Middle glenohumeral ligament
What are the signs and symptoms of subcoracoid impingement?
Pain at the anterior shoulder when arm held adducted/ extended
Maximal pain at 120 degrees flexion + internal rotation
What are the 3 stages of calcific tendonitis of the shoulder?
- Pre-calcific (pain-free fibrocartilaginous metaplasia of tendon)
- Calcific (phases of varying levels of pain)
- Post-calcific
What imaging is useful in calcific tendonitis of the shoulder?
XR (shows deposits on AP)
US (shows extend of calcification and targets therapy)
Recall some non-operative and operative options for managing calcific tendonitis of the shoulder
Non-operative: analgesia, physio, extra-corporeal shockwave therapy, US-guided injections
Operative: Surgical decompression
What are the 4 muscles of the rotator cuff?
Supraspinatus
Infraspinatus
Subscapularis
Teres minor
Recall 4 risk factors for a rotator cuff tear
Age >60
Smoking
Family history
Hypercholesterolaemia
Recall some possible causes of a rotator cuff tear
Chronic degeneration
Chronic impingement
Acute avulsion injury
How can you differentiate between a partial and complete rotator cuff tear?
Partial –> painful arc
Complete –> shoulder tip pain, FULL RANGE of passive movement but with inability to abduct arm. Active abduction IS possible following passive abduction to 90 degrees. ‘Drop arm’ sign (lowering arm beneath 90 degrees abduction –> sudden drop)
Recall some operative options for managing rotator cuff tears
Shoulder arthroscopy (to debride rotator cuff and subacromial decompression)
Rotator cuff repair (can be open or laparoscopic)
Tendon transfer
Reverse total shoulder arthroplasty
What is the aetiology of rotator cuff arthropathy?
Rotator cuff tear –> loss of joint congruence –> abnormal glenohumeral wear –> specific degeneration
Describe the signs and symptoms of rotator cuff arthropathy
Night pain with weakness and stiffness
Supra/infraspinatus atrophy
Limited ROM +/- crepitus and inability to abduct
Recall which muscles are involved in each stage of arm abduction
0-15 degrees = supraspinatus
15-90 degrees = deltoid
>90 degrees = serratus anterior + trapezius
In which direction does the humeral head migrate in rotator cuff arthropathy?
Superiorly
What test can be used to test teres minor and how is it performed?
Hornblower’s test
Shoulder in 90 degrees abduction and elbow in full flexion
Positive test = pain/ inability to maintain
What is adhesive capsulitis?
Condition characterised by loss of active AND passive movement with no clear cause
Recall the stages of adhesive capsulitis
Stage 1: Freezing - gradual onset of diffuse pain
Stage 2: Frozen - decreased ROM
Stage 3: Thawing - gradual return of ROM
What is the main associated condition with adhesive capsulitis?
Diabetes
What score is used to assess hypermobility syndrome?
Beighton score
What % of shoulder dislocations are anterior vs posterior vs inferior?
Anterior: 90%
Posterior: 6%
Inferior: 2-4%
Which direction of shoulder dislocation is associated with seizures?
Posterior
How does acromioclavicular joint dislocation appear on examination?
‘Step’ deformity and prominent clavicle
What are the signs of glemohumeral dislocation on examination?
Shoulder contour lost (‘square shoulder’)
Bulging infraclavicular fossa
What must you assess before manipulating a glenohumeral dislocation?
Neurovascular status - especially axillary nerve in chevron area
What is the management of glenohumeral dislocation?
Reduction with sedation
Rest in sling for 3-4 weeks
Physio
What is a Hill Sachs defect?
Damage to humeral head following shoulder dislocation
Where do the short and long tendons of the biceps attach?
Long tendon: glenoid
Short tendon: coracoid process
Which tendon of the biceps is much more likely t get ruptured?
Long
What is a ‘popeye deformity’?
Caused by proximal biceps tendon rupture - muscle bulk results in a bulge in the middle of the upper arm
How can you test for biceps tendon rupture on examination?
Biceps squeeze test –> supination if tendon is intact
What is the best form of imaging for initial assessment of a proximal biceps tendon rupture?
USS
What is the best form of imaging for initial assessment of a distal biceps tendon rupture?
MRI - it’s a difficult clinical diagnosis and requires surgery
What are the 2 forms of traumatic anterior shoulder instability?
TUBS - Traumatic Unilateral dislocations with a Bankart lesion - often requires Surgery
AMBRI (“born loose”) = atraumatic Multidirectional Bilateral shoulder dislocation is treated with Rehabilitation, but may require Inferior capsular shift
What are the colloquial names for lateral vs medial epicondylitis?
Lateral = tennis Medial = golfer's
What is the aetiology of lateral epicondylitis?
Microtear at origin of ERB +/- ERCL and ECU from repetitive wrist extension/ forearm pronation
What is the aetiology of lateral epicondylitis?
Microtear at insertion of flexor-pronators from repetitive wrist activity
Which movements will worsen pain in lateral vs medial epicondylitis?
Lateral: worse on wrist extension
Medial: worse on wrist flexion
What is the best form of imaging to investigate epicondylitis?
USS
Is there a better success rate for conservative management of lateral or medial epicondylitis?
Lateral (95%)
What is the main symptom of olecranon bursitis?
Swelling over posterior aspect of elbow
Which nerve is compressed in radial tunnel syndrome, and what symptoms does this nerve compression produce?
Posterior interosseous branch of radial nerve
Symptoms very similar to lateral epicondylitis (pain in lateral epicondyle, worse on wrist extension, decreases grip strength)
Recall 6 associations with carpal tunnel syndrome
People who play DA HARP
Diabetes
Acromegaly
Hypothyroidism
Amyloidosis
Rheumatoid arthritis
Pregnancy
Which nerve is entrapped in carpal tunnel?
Median
Which digits get paraesthesia in carpal tunnel syndrome?
1st, 2nd and medial half of 3rd
What is the best investigative test for carpal tunnel syndrome?
EMG
Which muscles are supplied by the median nerve (and are weakened in carpal tunnel syndrome)?
Lateral 2 lumbricals
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
How can carpal tunnel be managed conservatively?
Wrist splints at night
How can carpal tunnel be managed if conservative management is unsuccessful?
Corticosteroid injection –> surgical decompression
What are the contents of the carpal tunnel?
Median nerve
FPL, FCR, FDP and FDS tendons
What is cubital tunnel syndrome?
Ulnar nerve entrapment at elbow
What is Guyon canal syndrome?
Ulnar nerve entrapment at wrist
Recall some risk factors for both Cubital Tunnel Syndrome and Guyon Canal Syndrome
Cubital tunnel: cycling, ganglion cyst pressure
Guyon canal: leaning on elbow
What are the signs and symptoms of ulnar nerve entrapment?
Pins and needles in 4th and 5th digit
Claw hand
How should suspected ulnar nerve entrapment be investigated?
Nerve conduction studies
Recall some conservative and surgical options for managing ulnar nerve entrapment
Conservative: wrist splints at night
Surgical: Corticosteroid injection –> surgical decompression
What is the aetiology of De Quervain’s Tenosynovitis?
Sheath containing extensor pollicis brevis + abductor pollicis longus tendons becomes inflamed
Recall some signs and symptoms of De Quervain’s Tenosynovitis
Tenderness over radial styloid and radial side of wrist
Abduction of thumb is painful
What is Finkelstein’s test used to investigate and how is it performed?
Used to investigate De Quervain’s Tenosynovitis
Examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction –> pain in the radial styloid and along the length of EPB and APL
How can De Quervain’s Tenosynovitis be managed?
Analgesia + activity modification
Steroid injections + thumb splint –> surgery (if conservative measures have failed after 6 months)
What is Dupuytren’s contracture?
Progressive, painless and fibrotic thickening of the palmar fascia
What is the aetiology of Dupuytren’s contracture?
Fibroblasts replaced by myofibroblasts which produce a contractile element
Recall the associations of Dupuytren’s contracture
BAD FIBRES
Bent penis (Peyronie’s)
AIDS
Diabetes mellitus
Family history Idiopathic (most common) Booze (ALD) Riedel's thyroiditis Epilepsy and anti-epileptics Smoking
Recall some options for managing Dupuytren’s contracture
- Percutaneous needle fasciotomy
- Collagenase injection followed by MUA 24 hours later
- Partial fasciectomy (if hand can’t be placed flat on table)
What is a trigger finger?
Tendon nodule which catches on proximal side of tendon sheath –> triggering on forced extension
How can a trigger finger be managed?
Steroid injection (high recurrence) Surgical release of 1st pulley
What is a ganglion?
Smooth, multilocular cystic swellings
What is the aetiology of ganglions?
Mucoid degeneration of joint capsule / sheath which may communicate with joint capsules/ tendons
What are the signs and symptoms of ganglion?
Subdermal swellings, fixed to deeper structures + limits planes of movement +/- pain on nerve pressure symptoms
How should ganglions be managed?
50% disappear spontaneously
Aspiration +/- steroid and hyaluronidase injection
Surgical excision
If someone has the symptom of knee locking, what are the differentials?
Obstructive causes:
- Meniscal/ cruciate tear
- Osteochondritis dissecans
- Osteophytes
What is the O’Donoghue Unhappy Triad?
Describes 3 soft tissue injuries that commonly occur together following a lateral blow to the knee on a fixed foot (eg football/ rugby)
- Ruptured ACL
- Ruptured MCL
- Damaged medial meniscus
Describe the typical presentation of ACL rupture
Rotational sports injury
Loud crack with pain
Rapid swelling due to haemarthrosis
Recall 2 signs of PCL rupture
- Tibial lies posterior to femur
2. Paradoxical anterior draw test
What is the key sign of MCL rupture
Knee unstable in valgus stress test
What are the signs and symptoms of a torn meniscus in the knee?
- DELAYED knee swelling (immediate more likely to be ACL rupture)
- Joint locking
- Recurrent pain/ effusions
- McMurray’s test positive
What cause of knee pain typically affects teenage girls?
Chondromalacia patellae
What classification system is used for tibial plateau fractures?
Schatzker system
Why would a visible fluid level in the knee (lipohaemarthrosis) on X ray lead you to perform an MRI?
It is either a # or a cruciate ligament tear
How should an isolated cruciate ligament tear be managed?
Specialised quadriceps physiotherapy
If a cruciate ligament tear is paediatric or concurrent, how can it be managed?
Reconstruction
Gold standard is an autograft repair
What is the best conservative management for a medial/ lateral cruciate ligament tear?
Hinged knee brace
What is the most obvious sign on examination of a medial/ lateral cruciate ligament tear
Extreme valgus/ varus
What movement produces the most pain in a meniscal tear?
When loading knee in flexion (going downstairs)
What imaging should be done for a meniscal tear?
XR to exclude # followed by MRI
How can meniscal tears be managed?
Arthroscopic debridement or repair (depends on site)
How does site of meniscal tear affect nanagement?
Lateral 1/3 tears might be able to be managed conservatively as they have a very rich blood supply
Medial tears 2/3 tears may need a meniscectomy as poor supply of blood
What is Osgood-Schlatter’s disease?
Tibial tuberosty apophysitis and patellar tendonitis
Can Osgood-Schlatter’s disease be bilateral?
Yes, it is in 25-50%
How is Osgood-Schlatter’s disease diagnosed?
Clinical diagnosis + XR
What would an X ray show in Osgood-Schlatter’s disease?
Fragmentation of tibial tubercle and overlying soft tissue swelling
What are the signs and symptoms of osgood schlatter’s?
Knee pain after exercise with gradual onset
Localised tenderness and swelling over the tibial tuberosity
Hamstring tightness
How should Osgood-Schlatter’s disease be managed?
Analgesia, ice packs
Reassure –> should resolve at end of growth spurt
What is meralgia paraesthetica?
Syndrome of paraesthesia/ anaesthesia in distribution of the lateral femoral cutaneous nerve
What is the aetiology of meralgia paraesthetica?
As the lateral femoral cutaneous nerve curves medioinferiorly around the ASIS it may be subject to repetitive trauma –> compression leads to symptoms
In what age group does meralgia paraesthetica typically develop?
30-40y
What are the signs and symptoms of meralgia paraesthetica?
Upper lateral thigh burning, tingling, coldness or shooting pain
NO MOTOR WEAKNESS
Symptoms usuallya ggravated by standing and relieved by sitting
How can you reproduce symptoms of meralgia paraesthetica on examination?
Deep palpation beneath ASIS
What is the main symptom of chondromalacia patellae?
Patellar aching after prolonged sitting or climing stairs
How can you investigate for chondromalacia patellae?
Clarke’s test
Pain on patellofemoral compression
What would be seen on XR in chondromalacia patellae?
Normal film
How can symptoms of chondromalacia patellae be improved?
Vastus medialis strengthening
What is a ‘Baker’s cyst’?
Popliteal extensions of the gastrocnemius-semimembranosus bursa (not a true ‘cyst’)
If Baker’s cysts are secondary, what are they likely to be secondary to?
Osteoarthritis
What are the signs and symptoms of Baker’s cysts?
Swelling in popliteal fossa
What is the cause of bipartite patella?
Congenital failure of patella to fuse
What are the 3 classifications of bipartite patella, and which is most common?
Type 1: inferior pole
Type 2: lateral margin
Type 3: superloateral (most common)
What are the 3 elements of the ankle syndesmosis?
- Anterior inferior tibiofibular ligament
- Posterior inferior tibiofibular ligament
- Interosseous ligament and membrane
What is the mainstay of management for low ankle sprain?
RICE (rest, ice, compression, elevation)
What is the most common type of low ankle sprain?
Inversion injury affecting the ATFL
How can high ankle sprains be managed?
If there is diastasis (separation of fibula and tibia) –> surgical fixation
OR
No diastasis –> non weight-bearing orthosis
Which prescription drug is highly associated with achilles tendon rupture?
Quinolones (eg ciprofloxacin)
What is Simmond’s triad?
100% sensitive in combination for picking up an Achilles’ tendon rupture
- Thomas test does not elicit plantarflexion
- Angle of declination (greater dorsiflexion of injured foot)
- Gap in tendon path
Which type of imaging is diagnostic of Achiles tendon rupture?
USS
What are the signs and symptoms of Morton’s neuroma?
‘Walking on a marble’
Shooting pain in the ball of the foot
Numb toes
Where is the most common site of Morton’s neuroma?
Between 3rd and 4th tarsal bones
What form of imaging can confirm a diagnosis of Morton’s neuroma?
USS
What is the management of Morton’s neuroma?
Orthotics –> steroid injections –> surgical resection
What is plantar fasciitis?
Inflammation of the plantar aponeurosis
What would make plantar fasciitis better or worse?
Exercise makes it better
Inactivity makes it worse
What test on examination can be used to identify plantar fasciitis?
Windlass test
What is the management for plantar fasciitis?
Orthotics Physiotherapy Analgesia Steroid injection Refer to orthopaedics
What is the proper name for a bunion?
Halux valgus
How can bunions be manages conservatively?
Bunion pads
Plastic wedge between great and 2nd toes
What surgery can be used to fix bunions?
Metatarsal osteotomy
What are the signs and symptoms of charcot foot?
Deformity Debris Density change Destruction Dislocation
What are the signs and symptoms of cervical spondylosis?
Neck pain and headaches
What are the signs and symptoms of lumbar spine stenosis?
Back pain that is worse when standing Leaning forward relieves it Neuropathic pain Neurogenic claudication Preserved distal pulses
What is the most common pathogen implicated in discitis?
Staph aureus
What is the most common pathogen implicated in iliopsoas abscess?
Staph aureus
What is the difference between the investigation of choice for discitis vs iliopsoas abscess?
Discitis: MRI (if S aureus –> echo)
Iliopsoas abscess: CT
What is the difference between the management of choice for discitis vs iliopsoas abscess?
Discitis: IV Abx
Iliopsoas abscess: Abx and percutaneous drain
What is Brown-Sequard syndrome?
Hemisected spinal cord
What are the signs and symptoms of Brown-Sequard syndrome?
Ipsilateral paralysis
Ipsilateral loss of proprioception & fine touch
Contralateral loss of pain & temperature
A prolapsed disc at which levels could cause quadriceps weakness?
L3 and L4
What are the 1st and 2nd line pain management for non-specific lower back pain?
1st line: NSAID and PPI
2nd line: codeine + paracetamol
What is the management of developmental dysplasia of the hip in a child <6 months old?
Pavlik harness for 6 months
What is Perthes’ disease?
Avascular necrosis of the proximal femoral epiphysis from interruption of supply –> revascularisation and reossification over 18-36 months
What test can you perform on examination to test for Perthes?
Roll test
Roll affected hip internally and externally –> guarding or spasm
Recall the management protocol for Perthes disease
If <6 years: analgesia, traction, crutches, physio to improve ROM
If >6 years: pelvic/ femoral osteotomy
What is SCFE?
Slipped Capital Femoral Epiphysis
Displaced of epiphysis of femoral head postero-inferiorly
What are the 2 main key examination findings in SCFE?
Loss of internal rotation of a flexed hip
Trendelenburg gait positive
How is SCFE managed?
Percutaneous internal fixation at growth plate
Recall some 5 prescription drug classes that can predispose to osteoporosis
Steroids SSRIs PPIs Glitazones Anti-epileptics
Which prognostic scoring systems are useful in osteoporosis?
FRAX
QFracture
Estimate a patient’s 10 year risk of developing a fragility fracture
When assessing osteoporosis risk, what would count as ‘long term steroids’?
> 7.5mg/day for >3months
Recall the treatment indications for bisphosphonates
- Fragility fracture + age >75
- Fragility fracture + T score 65y and on/ about to start longterm steroids
When should you give immediate bisphosophonates to patients who are on or about to start longterm steroids?
- If they are over 65
- If under 65 then do a DEXA - give bisphosphonates if
What treatments should you give alongside bisphosphonates?
Always vitamin D
Calcium supplements IF low levels
What are some contrainidications to bisphosphonates?
eGFR <30
Severe GORD
Recurrent gastric ulcer
Recall the instructions for administration of PO bisphosphonates
Take on empty stomach in the morning
Full glass of water
Stay upright for 30 minutes
If PO bisphosphonates are not tolerated, what alternative is there?
Annual IV zoledronate
What is the 2nd line for bisphosphonates if they are not contra-indicated?
SC denosumab
Recall some abnormalities that might be seen in the hands in osteoarthritis?
Heberden’s nodes (DIPJ)
Bouchard’s nodes (PIPJ)
WHat are the 4 indications of osteoarthritis on X ray?
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchindral cysts
Recall some options for managing osteoarthritis
Wt loss
Physiotherapy
1st line: PO paracetamol w/ topical NSAID
2nd line: PO NSAIDs + PPI or weak opioids or capsaicin cream
3rd line: intra-articular corticosteroids
Surgical: joint replacement
What is the most likely (i) vascular and (ii) nerve injury caused by a knee replacement?
Vascular: superficial femoral artery
Nerve: common peroneal
Recall some immediate, early and late complications of T knee replacements
Immediate: vascular/ nerve injury
Early: DVT, prosthesis infection
Late: Loosening, instability from los ACL
Recal some possible complications of anterolateral vs posterior approaches for THR
Anterolateral: superior gluteal nerve injury –> Trendelenburg gait
Posterior: sciatic nerve injury –> foot drop
What is osteochondritis?
Idiopathic condition in which bony centres of paediatric bones become temporarily softened due to osteonecrosis
What would be seen on X ray in osteochondritis?
Increased density/ sclerosis –> patchy appearance
Which variation of osteochondritis affects the vertebral ring epiphyses?
Scheuermann’s disease
Which variation of osteochondritis affects the navicular bone in toddlers?
Kohler’s disease
Which variation of osteochondritis affects the lunate bone in adults?
Kienbochs disease
Which variation of osteochondritis affects the 2nd and 3rd metatarsals at puberty?
Friedberg’s disease
Which variation of osteochondritis affects the capitulum of the humerus?
Panner’s disease
What is the aetiology of osteochondritis dissecans?
Reduced blood flow –> cracks in articular cartilage and subchondral bone –> AVN –> fragmentation of bone and cartilage with free movement of fragments –> activity-related joint pain
What is the management for osteochondritis dissecans?
Arthroscopic removal
What is necrotising fasciitis?
Life-threatening infection that spreads across soft-tissue planes
What is pre-patellar bursitis?
It’s an infection of the potential space in front of the patella
What should you ask about in the history if you are querying pre-patellar bursitis?
History of kneeling (eg builders)
How should pre-patelllar bursitis be managed?
Analgesia, compression, aspiration
Recall the risk factors for septic arthritis, and split them into modifiable and non-modifiable
Modifiable:
crystal arthropathies
Non-modifiable:
Age >90, rheumatoid arthritis, chronic renal failure, prosthetic joints
What investigations should be done to investigate septic arthritis?
XR
USS and MC&S joint aspirate
Bloods
Blood cultures
How should septic arthritis be managed?
IV antibiotics
Joint washout
Recall some risk factors for osteomyelitis
Vascular disease, trauma, SCD, immunosuppression
What is the investigation of choice in suspected osteomyelitis?
MRI
What is the management for osteomyelitis?
IV antibiotics and radical debridement to living bone
What is the most likely pathogen in a prosthetic joint infection within 6 weeks of infection and after that?
<6 weeks: S. aureus
>6 weeks: S. epidermidis
What is the gold-standard management of prosthetic joint infection?
Two-stage revision
Antibiotics whilst joint spacer is in
Re-implant with antibiotic-impregnated cement
What are the 2 main types of non-neoplastic bone tumours?
Fibrous dysplasia
Simple bone cyst
Which bone tumour produces a ‘shepherd’s crook deformity’ on X ray?
Fibrous dysplasia
Recall the names of 3 types of benign cartilaginous neoplasms
Osteochondroma
Endochondroma
Chondroblastoma
What is the most common benign bone tumour?
Osteochondroma
What is the most likely location of an osteochondroma?
Knee
What is a chondrosarcoma?
A malignant cartilaginous neoplasm
What are the most common sites of chondrosarcomas?
Pelvis
Axial skeleton
Which form of tumour produces the appearance of ‘popcorn calcification’ on x ray?
Chondrosarcoma
Recall the 4 main different types of benign bone-forming neoplasms
Osteoma
Osteoid osteoma
Osteoblastoma
Osteoclastoma (giant cell tumour)
Which bone tumour typically produces severe nocturnal pain in young adults?
Osteoid osteoma
Which bone tumour produces a ‘soap bubble’ appearance on X ray?
Giant cell tumour/ osteoclastoma
What are the 2 main forms of malignant bone-forming neoplasms?
Osteosarcoma
Ewing’s sarcoma
What is the most common malignant primary bone tumour?
Osteosarcoma
Which bone tumour is associated with onion-skinning of the periosteum on X ray?
Ewing’s sarcoma
In which dermatomes is sensation lost in Erb’s palsy?
C5 C6
In which dermatomes is sensation lost in Klumpke’s?
C8 T1
What muscle groups would be paralysed in Erb’s palsy?
Abductors and external rotators –> waiter’s tip
What muscle groups would be paralysed in Klumpke’s?
Small muscles of hand –> claw hand
