T&O Flashcards
What is the biggest sesamoid bone in the body?
patella
What bones make up the knee joint?
femur
tibia
patella
NOT fibula!!!
What are menisci?
fibrocartilagenous structures between the bones in the knee joint
there is a medial and a lateral one
they are shock absorbers and stabilise the joint
they also have a role in distribution of synovial fluid
Ligaments of the knee
- lateral collateral ligament
- medial collateral ligament
- patella ligament
- transverse ligament
- Anterior Cruciate Ligament
- posterior Cruciate Ligament
- posterior meniscofemoral ligament
Which structures does the patellar ligament arise from?
quadriceps tendon which is formed by the rectus femoris and the vastus muscles
Where does the patellar ligament attach distally?
tibial tuberosity
bursae of the knee
- suprapatellar
- prepatellar
- infrapatellar (deep and superficial, there are 2)
bursae can get inflamed (usually the latter 2)
role of the transverse ligament of the knee
joins the anterior part of the medial and lateral meniscus
it supposedly prevents the meniscus from moving forwards
Where do the ACL and the PCL attach?
named after where they attach on the tibial bone
ACL: from back of femur to anterior tibia (prevents the tibia from sliding out in front of the femur)
PCL: from the medial femur to posterior tibia (prevents knee from hyperextending, tibia from going behind the femur)
LAMP:
lateral (ACL) -> moves medially
medial (PCL) -> moves laterally
What is the pes anserie?
anterior medial knee
made up of three tendons (semitenosus, gracilis, sartorius; behind it sits the pes anserine bursa)
you can have bursitis there
Iliotibial band
runs laterally over the lateral condyle and attaches to anterior lateral tibia; helps stabilise and move the knee joint.
formed from: fascia of gluteus maximus, gluteus medius and tensor fasciae later muscles
can get irritated at the lateral condyle
can cause iliotibial band syndrome
What are the borders of the popliteal fossa?
inferiomedially: lateral head of gastrocnemius AND plantaris
inferolaterally: medial head of the gastrocnemius
superomedially: biceps femoris
superolaterally: semimembranosus
What is inside the popliteal fossa?
- tibial nerve (branches into the common perineal (fibular) nerve and wraps around head of fibular bone)
- popliteal vein (cont of femoral V)
- popliteal artery (cont of femoral A)
What is inside the popliteal fossa?
- tibial nerve (branches into the common perineal (fibular) nerve and wraps around head of fibular bone)
- popliteal vein (cont of femoral V)
- popliteal artery (cont of femoral A)
Baker cyst
does not usually require surgery
causes swelling in the popliteal fossa
Causes of popliteal swelling
baker cyst
popliteal aneurysm (also check for AAA, present in 50%) -> popliteal aneurysm requires surgery!!
What should you check for if you diagnose someone with a popliteal aneurysm?
AAA, present in 50%
What occurs clinically if there is damage to the common perineal nerve?
foot drop
What is foot plantarflexion?
Pushing down on a pedal
What is foot dorsiflexion?
Extend your feet backwards like you’re trying to point them up towards your head
Weber Classification
A - below the stndesmosis; stable, no surgery.
B - at the level of syndesmosis. Variable stability. May need surgery.
C - above the syndesmosis; unstable; requires surgery
Signs of OA on radiograph
- narrowing of joint space
- subchondral cysts
- osteophyte formation
- subchondral sclerosis
What is a hemiarthroplasty?
Half joint replacement
When do you see green stick fractures? What are they?
In children
Shenton’s Line
If there is a discontinuity in Shenton’s line there is probably a fracture
How much blood loss would you see in a broken femur?
1.5 L
a lot of blood is lost
acronym for describing fractures on radiographs
STAR
S - shortening
T - translation
A - angulation
R - rotation
What does ‘compound’ refer to in the context of fractures?
It is an old term for open fractures
What are the principles of managing a fracture?
- reduce deformity
- immobilise to let the # heal
- rehab
Management of osteomyelitis
- Abx for 6 weeks
a. Flucloxacillin
b. clindamycin if allergic to penicillin
c. If MRSA osteomyelitis is suspected, vancomycin or
teicoplanin.
For all these, consider adding rifampicin/fusidic acid for the first 2 weeks.
- Surgery
debridement
if there is an abscess - Pain management (paracetamol, NSAIDs, if there is need for stronger perhaps morphine)
If there is chronic osteomyelitis or if there are prostheses involved, seek further advice.
Blood supply to the neck of femur
- retrograde from medial and lateral femoral circumflex arteries
- artery of the ligamentum teres (foveolar artery - branch of the Obturator A)
- femur itself (bone marrow)
- synovial intracapsular arterial ring
double check this
When do you replace the hip and when do you fixate with screws?
It is a matter of blood supply
if the fracture is intracapsular, likely to need to replace the hip because of AVN
in extracapsular fractures the blood supply should be intact and therefore screw fixation in preferable
? double check this
Septic arthritis definition
Septic arthritis is defined as the infection of 1 or more joints caused by pathogenic inoculation of microbes. It occurs either by direct inoculation or via haematogenous spread.
What are the sx of septic arthritis?
- red, hot, swollen and painful joint
- limited range of movement
- acute presentation
Also likely:
- fever
- large joint
- single joint
- prosthetic joint
- sexual activity (can indicate gonococcal infection)
What are risk factors for septic arthritis?
- immunosuppression
- prosthetic joint
- age: >80 (but can happen at any age)
- underlying joint disease (e.g. RA or OA)
- contiguous spread
- exposure to ticks (lyme disease)
Incidence of septic arthritis in the population and in individuals with prosthetic joints
6 in 100 000 generally (0.006%)
70 in 100 000 in people with prosthetic joints (10x increased risk; 0.07% incidence)
What pathogens can cause septic arthritis?
- staphylococci and streptococci make up 91%
- gonococcal (in sexually active poeple)
- anaerobes do not usually cause SA (unless there was perforating trauma)
tuberculous arthritis can be suspected in immunocompromised people or people from areas where TB is prevalent.
when are gram -ve organisms causing septic arthritis more common?
in older people and immunocompromised individuals they are more common than in healthier/younger people. However, in this population staphylococcal and streptococcal infections are still more common.
How do you manage septic arthritis
a) Inpatient admission
b) IV antibiotics (refer to local guidelines; start after cultures, joint aspirate, swabs if possible, unless this were to cause delays); after 2 weeks can usually be switched to oral abx
c) therapeutic joint aspiration (call ortho!) - this will help clear out the pathogen and decrease pain caused by pressure
d) Analgesia (e.g. paracetamol or NSAIDs)
What bones make up the elbow joint?
What bones make up the shoulder joint?
What bones make up the wrist joint?
wrist joint = radiocarpal joint
marking the area of transition between the forearm and the hand.
Bones: radius + lunate + scaphoid
NOT ulna
Key differences in adult and paediatric orthopaedics
1) elasticity
2) physes
3) speed of healing
4) remodelling
What fractures do you more commonly see in kids rather than adults?
- greenstick ( tension side breaks, compression side does not)
- buckle
- plastic deformity
How would you define a greenstick fracture?
fracture on the tension side
intact on the compression side
(tension side breaks, compression side does not)
How can you describe a pediatric radiograph
This is a radiograph of a skeletally immature/ mature individual
What is a buckle fracture?
- more common in children because of higher elasticity
- It is a minor fracture which heals with minimal intervention
- incomplete #
- small area of compressed bone
What is tennis elbow and golfer’s elbow?
epicondylitis
in tennis elbow its the lateral epicondyle
in golfers elbow its the medial epicondyle
What can cause damage to the physis?
trauma
infection
malignancy
iatrogenic causes (e.g. OPs)
How do you manage fractures?
4 R’s
- resuscitation
- reduce (get the bones as close to the anatomical position as possible for optimal healing)
- restrict movement (e.g. cast)
- rehabilitation
How do you manage fractures?
4 R’s
- resuscitation
- reduce (get the bones as close to the anatomical position as possible for optimal healing)
- restrict movement (e.g. cast)
- rehabilitation
How do you remember Salter Harris classification?
I - S for separation (the epiphysis slips)
II - A for above (metaphyseal #)
III - L for lower (through the epiphysis)
IV - T for through both together (# through metaphysis and epiphysis)
V - compression
How do you remember Salter Harris classification?
I - S for separation (the epiphysis slips)
II - A for above (metaphyseal #)
III - L for lower (through the epiphysis)
IV - T for through both together (# through metaphysis and epiphysis)
V - compression
What is the Salter Harris classification used for?
fractures at the physis
Why are we worried about injuries to the physis?
- can cause growth arrest or slow down growth
- this can cause limb length discrepancies
- can also cause angular deformities (coronal: valgus and varus; sagittal: ?term)
When do bones stop to grow?
14-15 for girls (or 2 years post menarche)
15-16 for boys
What does bone remodelling depend on?
- age (the younger the child the faster)
- location of the # (different blood supply to diffreent areas, i.e. 9mls/min to proximal tibia so will heal faster than 5mls/min to distal tibia or 3 mls/min for proximal femur)
- nutrition can also influence but not as much as age and location
What does bone remodelling depend on?
- age (the younger the child the faster)
- location of the # (different blood supply to diffreent areas, i.e. 9mls/min to proximal tibia so will heal faster than 5mls/min to distal tibia or 3 mls/min for proximal femur)
- nutrition can also influence but not as much as age and location
How long does a # take to heal in adults?
6 weeks
(usually - 6w is the golden time in orthopedics, many things take 6 weeks)
PAID acronym for describing #
- pattern (horizontal? transverse? greenstick? oblique? spiral? comminuted?)
- anatomy (which part of the bone? proximal/middle/distal 1/3?)
- Intra or extraarticular?
- displacement (STAR)
PAID acronym for describing #
- pattern (horizontal? transverse? greenstick? oblique? spiral? comminuted?)
- anatomy (which part of the bone? proximal/middle/distal 1/3?)
- Intra or extraarticular?
- displacement (STAR)
+/- Salter Harris if affecting the physis
PAID acronym for describing #
- pattern (horizontal? transverse? greenstick? oblique? spiral? comminuted?)
- anatomy (which part of the bone? proximal/middle/distal 1/3?)
- Intra or extraarticular?
- displacement (STAR)
Supracondylar #
- in children
- typically 5-7 yo u
- falls onto elbow
worried about the neurovascular status because the brachial artery or the median nerve could be damaged.
Gartland classification
used to classify supracondylar #
I - non-displaced; can manage conservatively
IIA - angulated with an intact posterior cortex (hinged in extension; no rotation or translation)
IIB - angulated with an intact posterior cortex (hinged in extension with some degree of rotational displacement or translation)
III - completely displaced
IV - complete periosteal disruption
II-IV require surgical management
Gartland classification
used to classify supracondylar #
I - non-displaced; can manage conservatively
IIA - angulated with an intact posterior cortex (hinged in extension; no rotation or translation)
IIB - angulated with an intact posterior cortex (hinged in extension with some degree of rotational displacement or translation)
III - completely displaced
IV - complete periosteal disruption
II-IV require surgical management
How does a child position their hip in septic arthritis of the hip and why?
external rotation
flexion
abduction
because this maximizes the space around the hip joint where the abscess is -> less painful
How do you test the neurovascular status in the hand of a child?
motor:
- ok sign (median N)
- thumbs up (radial N)
- starfish/cross fingers (ulnar N)
sensory:
- touch between thumb and index finger
- touch outside of index finger
- touch outside of little finger
vascular:
- radial pulse
- brachial A
Kocher classification in septic arthritis
To identify SA (differentiate from transient synovitis)
criteria:
- ESR
- fever
- weight bearing
- WBC
0/4 - 0.2%
1/4 - 3%
2/4 - 40%
3/4 - 93%
4/4 - 99%
% probability that it is septic arthritis
Child with a limp - what must you exclude?
septic arthritis
(could be ankle, knee, hip or spine)
Transient synovitis
- common (mainly between age 2-12, m>f)
- presents acutely with mild - moderate pain and limp
- ddx SA - must exclude!
- sterile arthritis
- can weight bear
- supportive treatment (e.g. NSAIDs, activity restrictions; sometimes abx are given if already initiated)
Can be a degree of uncertainty. Some children may be admitted because there may be ?SA, in that case sometimes you do not want to risk surgical management because it seems unlikely to be SA but you cannot really exclude it, or they may have MRI scan to check.
- '’like mesenteric adenitis of the joints’’
Commonest cause of malignant hyperthermia?
AD mutation in ryanodine receptor 1
(increasing Ca levels in the sarcoplasmic reticulum and increasing metabolic rate)
caused by inhalation anesthetics or suxamethonium
What causes winging of the scapula?
- deficit in the serratus anterior muscle
OR
- damage to the long thoracic nerve (which innervates the serratus anterior muscle)
fancy term for shoulder joint
glenohumeral joint
What does axillary nerve damage cause?
paralysis of the deltoid muscle
loss of sensation over the regimental badge
paralysis of deltoid and loss of sensation over regimental badge - which nerve is damaged?
axillary
BS of shoulder
anterior circumflex humeral A (axillary A)
posterior circumflex humeral A (axillary A)
Branches of suprascapular A (branch of the thyrocervical trunk)
Which dislocations of the shoulder can you get and how common are they?
anterior (95%)
posterior (4%)
inferior (1%)
Superior displacement of the humeral head is generally prevented by the coraco-acromial arch.
What structures do you palpate on examination of the knee?
- quadriceps tendon (any gaps?)
- anterior patella
- medial patella
- lateral patella
- medial joint space (at 90 dg flexion)
- lateral joint space (at 90dg flexion)
- patellar tendon
- tibial tuberosity
You also do the sweep test and the other fluid movement test and special tests
check if everything is included in this FC
What does pain in the join spaces indicate?
meniscal injury
How does ACL rupture present?
- twisting injury at the knee
- plopping sound
- immediate swelling of the affected knee
- instability on anterior draw test
- often seen with meniscal rupture/injury (-> pain over the joint space)
How does ACL rupture present?
- twisting injury at the knee
- plopping sound
- immediate swelling of the affected knee
- instability on anterior draw test
- often seen with meniscal rupture/injury (-> pain over the joint space)
How can you recognise meniscal rupture on examination?
tenderness on the joint space
What special tests do you do on knee examination
- anterior/posterior draw test
- Lachmann’s
- …..
What type of joint is the shoulder joint?
a synovial ball and socket joint
What makes the shoulder joint unstable?
the head of the humerus is relatively large whereas the glenoid fossa of the scapula is rather shallow
this relationship makes it very mobile
Movements of the shoulder joint
- flexion
- extension
- adduction
- abduction
- internal/medial rotation
- external rotation
- circumflexion (mix of ab/duction and flex/extension)
Which muscles add stability to the shoulder joint?
- deltoid
- pec major (ant)
- long head of biceps brachii
- long head of triceps brachii (post)
- rotator cuff muscles
- theres major
- latissimus dorsi
What is the (glenoid) labrum?
- surrounds/line the glenoid fossa
- fibrocartilagenous collar/structure
- also adds some depth to the glenoid cavity
Which tendon is continuous with the glenoid labrum?
biceps brachia tendon
the tendon runs over the glenohumeral joint and adds some stability to it
What does the join capsule of the shoulder joint consist of?
- fibrous membrane (wraps around GH-joint, outside the glenoid labrum and encloses the origin of the long head of biceps brachii tendon)
- synovial membrane (lines the fibrous membrane;
Which tendon encloses the tendon biceps brachii (and the synovial membrane of the joint capsule around it) within the inter tubercular groove/sulcus?
transverse humeral ligament
What is the function of the synovial sheath lining the biceps brachii tendon in the inter tubercular sulcus?
reduces friction
ligaments of the shoulder joint
3 glenohumeral
- superior
- middle
- inferior
they attach onto lesser tubercle and originate own the margin of the glenoid cavity
transverse humeral ligament
coracohumeral ligament
where does the transverse humeral ligament attach?
from lesser tubercle to greater tubercle
(lies over biceps tendon)
Where do the glenohumeral ligaments attach and originate
they attach onto lesser tubercle and originate own the margin of the glenoid cavity
Where does the coracohumeral ligament originate and attach?
From the coracoid process to the humerus
Where does the coracohumeral ligament originate and attach?
From the coracoid process to the humerus
How are bursae of the shoulder formed?
The joint capsule is made out of a fibrous and synovial layer
synovial membrane protrudes through the fibrous membrane to form bursae
Shoulder dislocation + humeral # - when would you use broad arm sling and when collar and cuff?
collar and cuff for humeral #
broad arm sling for shoulder dislocation
