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Phase 4 Question Knowledge > T+O > Flashcards

T+O Flashcards

1
Q

Osteoarthritis (OA)

A
  • wear + tear of joints
  • loss of cartilage, osteophyte formation, inflammation
  • hips, knees, DIPJ, CMC base of thumb, lumbar spine, c-spine
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2
Q

OA Px

A
  • joint pain
  • stiffness, <30mins morning, worse after activity
  • reduced ROM
  • crepitus
  • effusions
  • bulky/bony enlargement of joint

Hands

  • Heberdens nodes - DIPJ
  • Bouchards nodes - PIPJ
  • DIPJ>PIPJ
  • Squaring at base of thumb (CMC joint)
  • weak grip, reduced ROM
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3
Q

OA Ix

A

Dx

  • > 45yo, typical pain, <30mins morning stiffness

XR - LOSS

Loss of joint space

Osteophytes

Subarticular sclerosis

Subchondral cysts

Oxford Hip Score

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4
Q

OA Mx

A
  • OT/PT, lose weight, exercise
  • topical NSAIDs
  • oral NSAIDs (+PPI)
  • weak opiates, paracetamol - short-term
  • intra-articular steroid injections
  • arthroplasty
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5
Q

Hip replacement Cx

A
  • VTE, intraoperative fracture, nerve injury, infection
  • Leg length discrepancy
  • posterior dislocation
  • aseptic loosening
  • prosthetic joint infection
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6
Q

XR interpretation

A

Initial approach

  • patient details, XR details
  • adequacy - 2 views, joint above+below, rotation, penetration
  • previous imaging

ABCS approach

  • alignment, joint space
  • bone texture
  • cortices
  • soft tissues
  • what bone, area, articular surface involvement
  • type of fracture
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7
Q

Types of fractures

A

COMPLETE – fracture extends all the way through bone

  • Closed – no break in skin
  • Open – break in skin
  • Transverse – right angle to shaft
  • Oblique – angle to shaft

· Eg Toddler’s fracture – oblique tibial fracture in infants

  • Spiral – twisting
  • Segmental – more than one fracture along bone
  • Comminuted – 2+ bone fragments
  • Compression – involving vertebrae in spine
  • Impacted – fractured bone forced together

INCOMPLETE (not all the way through cortex) – commonly children

  • Greenstick – bending of shaft, fracture on convex surface
  • Buckle (torus) – fracture of shaft of bone characterised by bulging of cortex
  • Salter-Harris – involving growth plate
  • Bowing – bend in bone shaft – plastic deformity
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8
Q

Fracture displacement

A
  • Describe in terms of distal fragment to body (eg anterior/posterior)
  • Angulation – change in axis of bone – dorsal / palmar, varus/valgus, radial/ulnar
  • Translation – movt of fractured bones away from each other – use width of bone, eg 25% - if >100% - describe as off-ended
  • Rotation – difficult to see on XR
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9
Q

Fracture causes

A
  • trauma - excessive force
  • stress-related - repetitive low velocity injury
  • pathological - abnormal bone, fractures during normal use
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10
Q

Fracture healing

A
  • Haematoma formation, dead bone removed
  • Fibrocartilaginous callus formed, then bony callus, then replaced by trabecular bone
  • Remodelled into lamellar bone
  • Fracture healing delayed if bone ends are mobile, infected, misaligned, avascular
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11
Q

Fracture Px

A
  • pain
  • deformity
  • loss of function
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12
Q

Fracture Ix

A
  • check for other injuries
  • NV status of limb
  • XR - 2 views, inc joint above + below
  • CT +/- angio maybe
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13
Q

Fracture Mx

A
  • immobilise, inc joints above + below
  • reduce if necessary
  • analgesia
  • open - IV abx, tetanus, debride + lavage <6hrs, avoid internal fixation
  • simple - fracture clinic follow up
  • complex - NBM, add to trauma list for morning
  • mechanical alignment - manipulation / surgery
  • stability - casts, wires/plates/screws, ORIF, external frame
  • rehab early
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14
Q

Fracture Cx

A

Early

  • damage to local structures
  • haemorrhage
  • compartment syndrome
  • fat embolism
  • VTE

Long-term

  • delayed union, malunion, non-union, avascular necrosis, osteomyelitis, joint instability, stiffness, arthritis, chronic pain
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15
Q

Paediatric fractures

A

Complete – both sides of cortex breached

Toddler’s fracture – oblique tibial fracture in infants

Bowing – plastic deformity, no break

Greenstick fracture – bending of shaft, fracture on convex surface

Buckle / torus fracture – incomplete cortical disruption resulting in periosteal haematoma

Growth plate fractures – fracture of growth plate – Salter-Harris classification

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16
Q

Paediatric fractures NAI

A
  • Delayed presentation
  • Delay in attaining milestones
  • Lack of concordance between proposed and actual mechanism of injury
  • Multiple injuries
  • Injuries at sites not commonly exposed to trauma
  • Children on the at risk register
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17
Q

Paediatrics pathological fractures

A

eg osteogenesis imperfecta

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18
Q

Fat embolism

A
  • fat globule released into circulation after long bone fracture
  • lodges in pulm arteries
  • causes systemic inflammatory response
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19
Q

Fat embolism Px

A
  • 24-72hrs after fracture

Gurd’s major criteria

  • Respiratory distress
  • Petechial rash
  • Cerebral involvement – confusion, agitation

Gurd’s minor criteria

  • Jaundice, thrombocytopenia, fever, tachycardia, retinal haemorrhages,, renal signs, high ESR, anaemia….
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20
Q

Fat embolism Ix

A
  • imaging may be normal
  • CTPA - may not show occlusion
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21
Q

Fat embolism Mx

A
  • supportive
  • operate early to reduce risk
  • VTE prophylaxis
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22
Q

Compartment syndrome

A
  • high pressure in fascial compartment - cuts off blood supply
  • associated with fracture / crush injury - bleeding/swelling in compartment
  • restrict capillaries, then venous, then arterial - ischaemia + necrosis
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23
Q

Compartment syndrome Px

A
  • pain - disproportionate
  • paraesthesia
  • pale - initially warm + swollen
  • pressure high
  • paralysis - late
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24
Q

Compartment syndrome Ix

A
  • clinical dx
  • needle manometry
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25
Q

Compartment syndrome Mx

A
  • remove dressings, elevate to heart level
  • emergency fasciotomy
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26
Q

Osteomyelitis

A
  • infection of bone
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27
Q

Osteomyelitis patho

A
  • S aureus most commonly (salmonella in SCA)

Haematogenous

  • from blood infection
  • eg vertebral osteomyelitis
  • RFs - SCA, IVDU, immunosuppression, IE

Contigous

  • from adjacent tissues
  • RFs - diabetic foot ulcers, pressure sores, DM, PAD

Direct inoculation

  • direct trauma / surgery
  • RFs - open fractures, surgery
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28
Q

Osteomyelitis Px

A
  • fever, rigors, sweats, malaise, N+V
  • dull pain, tender, warm, erythema, swelling
  • maybe non-healing ulcers, non-healing fractures
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29
Q

Osteomyelitis Ix

A
  • Bloods - cultures, FBC, CRP
  • XR - potential periosteal reaction, osteopenia, bone destruction
  • MRI
  • Bone cultures
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30
Q

Osteomyelitis Mx

A

Abx

  • flucloxacillin 6wks (clindamycin)
  • +/- rifampicin/fusidic acid for first 2wks
  • vancomycin/teicoplanin MRSA
  • chronic - >3mo abx

Surgery

  • debridement, hardware removal
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31
Q

Septic arthritis

A
  • infection in joint
  • rapidly destroys joint, systemic illness
  • S aureus most commonly
  • also N gonorrhoea, H influenzae, E coli

RFs

  • prosthetic joints, DM, immuno, RA, low SES, IVDU, osteomyelitis, surgery, joint injections
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32
Q

Septic arthritis Px

A
  • Single joint, often knee
  • Hot, red, swollen
  • Stiff, reduced ROM
  • Non-weight bearing
  • Fever, lethargy
  • Sepsis sx
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33
Q

Septic arthritis Ix

A
  • joint aspiration - to MC+S, gram staining, crystal microscopy
  • FBC - raised WCC, CRP
  • Blood cultures
  • STI screen, HIV
  • XR joint
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34
Q

Septic arthritis Mx

A
  • empirical IV abx, then continue for 4-6wks (oral after 2wks)
  • flucloxacillin / clindamycin
  • vancomycin - MRSA
  • ceftriaxone - gonorrhoea
  • arthroscopic lavage
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35
Q

Sarcoma

A

malignant tumour originating from mesenchymal (connective) tissue

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36
Q

Bone sarcomas

A

osteosarcoma
chondrosarcoma
Ewing’s sarcoma

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37
Q

Osteosarcoma

A
  • most common primary malignant bone tumour
  • mainly children, adolescents
  • mostly metaphyseal region of long bones
  • XR - Codman triangle, sunburst pattern
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38
Q

Chondrosarcoma

A
  • malignant tumour of cartilage
  • middle-aged
  • axial skeleton
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39
Q

Ewing’s sarcoma

A
  • small round blue cell tumour
  • children/adolescents
  • from mesenchymal stem cells
  • pelvis, long bones
  • severe pain
  • XR - onion skin appearance
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40
Q

Soft tissue sarcoma

A

Liposarcoma – from adipose

Rhabdomyosarcoma – skeletal muscle

Synovial sarcoma – from soft tissue around joints

Fibrosarcoma

Angiosarcoma – blood and lymph vessels

Leiomyosarcoma – smooth muscle

Kaposi’s sarcoma – cancer caused by HHV 8, mostly seen in end-stage HIV

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41
Q

Bone tumours patho

A
  • primary bone tumours rare - would mets to lung
  • most commonly secondary - osteolytic - mets from breast, prostate, kidney, lung, thyroid
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42
Q

Benign bone tumours

A

Osteoma

  • benign overgrowth of bone

Osteochondroma

  • cartilage-capped bony projection on external surface of bone
  • metaphysis of long bones

Giant cell tumour

  • tumour of multinucleated giant cells in fibrous stroma
  • epiphysis of long bones
  • XR - double bubble / soap bubble appearance

Osteoblastoma / osteoid osteomas

  • from osteoblasts
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43
Q

Bone tumour Px

A
  • depends on location / size
  • pain, swelling, palpable mass
  • impaired function
  • pathological fractures
  • fatigue, wt loss, fever, anaemia
  • aches/pains - hypercalcaemia
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44
Q

Bone tumour Ix

A
  • Scans - XR, CT, MRI, PET, skeletal isotope scan
  • USS for soft tissue lumps
  • Biopsy - fine needle / core / incisional
  • TNM staging
  • Bloods - high Ca, ALP
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45
Q

Bone tumour Mx

A
  • surgical resection
  • radio/chemo
  • targeted therapy
  • immunotherapy
  • hormonal therapy
  • bisphosphonates - alendronate
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46
Q

Osteochondritis dissecans (OCD)

A
  • pathological process affecting subchondral bone - secondary effects on joint cartilage
  • bone fragments, creates defect between lesion + parent bone, lack of blood supply to fragment
  • pain, oedema, free bodies, degenerative changes if untreated
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47
Q

OCD Px

A
  • subacute
  • knee pain, swelling, after exercise
  • catching, locking, giving way
  • painful click flexing / extending knee
    …
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48
Q

OCD Ix

A
  • XR - subchondral crescent sign, loose bodies
  • MRI
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49
Q

OCD Mx

A

Non-surgical

  • Modify activity
  • Partial / non-weight bearing
  • Immobilise – promote healing

Surgical

  • Arthroscopic drilling
  • Pins to secure flap
  • …
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50
Q

Rib fracture

A
  • may have underlying injury / flail chest

RFs

  • blunt trauma
  • osteoporosis, steroids, COPD
  • pathological - cancer

Px

  • severe, sharp chest wall pain, tenderness
  • bruising
  • haemopneumothorax

Ix

  • CT chest
  • CXR

Mx

  • pain control
  • surgical fixation
  • Mx cx, consider ventilation
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51
Q

Lower back pain (non-specific)

A
  • pain in lumbosacral region, no specific cause
  • aka mechanical back pain
  • may come from pathology of vertebrae, facet joints, intervertebral discs, muscles / ligaments

RFs

  • obesity, sedentary, heavy lifting, stress, depression, low SES, smoking
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52
Q

Lower back pain (non-specific) Px

A
  • Pain in lower back
  • Exacerbated by movt
  • Varies with time and posture
  • No red flag features
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53
Q

Back pain DDx

A
  • Cauda equina
  • Spinal fracture
  • malignancy
  • spinal infections - discitis, vertebral osteomyelitis, epidural abscess
  • spinal stenosis
  • radicular pain
  • radiculopathy
  • spondylolisthesis
  • OA of spine
  • facet joint pathology
  • aseptic necrosis of femoral head
  • pyelo, renal stones, prostatitis, PID, endometriosis, pancreatitism PAD, AAA
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54
Q

Back pain red flags

A
  • <20yo, >50yo
  • Hx of malignancy
  • Nocturnal pain
  • Hx of trauma
  • Systemically unwell - fever, weight loss, night sweats
  • IVDU
  • Immunocompromise - eg HIV, meds
  • Bilateral leg pain, neuro deficits
  • Urinary incontinence / retention
  • Faecal incontinence
  • Early morning stiffness or at rest
  • Current / recent infection - TB, staph etc
  • Abdo mass - malignancy
  • Acute onset in elderly - osteoporotic
  • Pain when lying down (usually resolves pain)
  • Leg claudication
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55
Q

Back pain Ix

A
  • bloods - CRP, WCC, FBC, U/E, ESR, bone, LFTs
  • urine dip
  • MRI
  • spinal XR
  • STarT back tool- bloods - CRP, WCC, FBC, U/E, ESR, bone, LFTs
  • urine dip
  • MRI
  • spinal XR
  • STarT back tool
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56
Q

Back pain Mx

A
  • exercise, heat
  • NSAIDs + PPI
  • codeine +/- paracetamol (short term)
  • diazepam - muscle spasms
  • physio
  • massage
  • CBT
  • radiofrequency denervation
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57
Q

Prolapsed L3 disc

A
  • Sensory loss anterior thigh
  • Weak hip flexion, knee extension, hip adduction
  • Reduced knee reflex
  • Positive femoral stretch test
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58
Q

Prolapsed L4 disc

A
  • Sensory loss anterior knee, medial malleolus
  • Weak knee extension, hip adduction
  • Reduced knee reflex
  • Positive femoral stretch test
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59
Q

Prolapsed L5 disc

A
  • Sensory loss dorsum of foot
  • Weakness in foot / big toe dorsiflexion
  • Reflexes intact
  • Positive sciatic nerve stretch test
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60
Q

Prolapsed S1 disc

A
  • Sensory loss posterolateral aspect of leg, lateral aspect of foot
  • Weakness in plantarflexion of foot
  • Reduced ankle reflex
  • Positive sciatic nerve stretch test
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61
Q

Disc prolapse Px

A
  • back pain
  • dermatomal leg pain
  • worse when sitting
  • sensory/motor deficit
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62
Q

Disc prolapse Mx

A
  • analgesia (NSAIDs), physio, exercises
  • if sx >4-6wks, consider MRI
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63
Q

Spinal stenosis

A
  • narrowing of central canal in spine - compresses spinal cord / nerve roots
  • from tumour, disc prolapse, degenerative changes
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64
Q

Spinal stenosis Px

A
  • gradual onset
  • lower back pain, buttock pain
  • neuropathic pain, leg weakness
  • sciatica / radiculopathy
  • sx better when sitting
  • easier walking uphill than downhill
  • struggle sitting on bike
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65
Q

Spinal stenosis Ix

A
  • MRI spine
  • R/o PAD - ABPI, CT angio
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66
Q

Spinal stenosis Mx

A
  • exercise, wt loss, physio
  • surgery - laminectomy
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67
Q

Sciatica

A
  • irritation / compression of sciatic nerve
  • eg herniated disk, spinal stenosis, spondylolisthesis, piriformis syndrome…
  • L4-S3 form sciatic, sensation to lateral lower leg, foot, motor to posterior thigh, lower leg, foot
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68
Q

Sciatica Px

A
  • unilateral shooting pain from buttock, radiating down back of thigh to knee/foot
  • paraesthesia, numbness, weakness
  • may affect reflexes
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69
Q

Sciatica Ix

A
  • sciatic stretch test
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70
Q

Sciatica Mx

A
  • physio, exercise, simple analgesia
  • consider amitriptyline, duloxetine
  • specialist mx - epidural corticosteroid injections, LA injections, radiofrequency denervation, spinal decompression
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71
Q

Cauda equina syndrome (CES)

A
  • compression of cauda equina - surgical emergency
  • spinal cord terminates L2/3

Causes

  • herniated disc
  • tumours
  • spondylolisthesis
  • abscess
  • trauma
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72
Q

CES Px

A
  • low back pain
  • bilateral sciatica / weakness, numbness, paraesthesia
  • loss of sensation in bladder/rectum
  • saddle anaesthesia
  • urinary retention / incontinence
  • faecal incontinence
  • gait disturbance / difficulty walking
  • reduced anal tone (PR)
  • reduced tone / reflexes
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73
Q

CES Ix

A
  • urgent MRI
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74
Q

CES Mx

A
  • neurosurgical - lumbar decompression surgery
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75
Q

Discitis

A
  • infection of intervertebral disc space
  • S aureus most commonly
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76
Q

Discitis Px

A
  • back pain
  • fever, rigors, sepsis
  • if epidural abscess develops - lower limb neurology
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77
Q

Discitis Ix

A
  • MRI
  • CT guided biopsy
  • bloods, inc cultures
  • ECHO - IE
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78
Q

Discitis Mx

A
  • 6-8wks IV abx
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79
Q

Osteoporotic vertebral fracture

A
  • spinal fracture in osteoporosis
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80
Q

RFs for osteoporotic fractures

A
  • older
  • post-menopause
  • Hx of fragility #
  • Hx of falls
  • steroids
  • FHx NOF
  • secondary osteoporosis
  • low BMI
  • smoking, drinking
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81
Q

Osteoporotic vertebral fracture Px

A
  • asym
  • acute back pain
  • breathing difficulties, GI problems
  • Hx fall / trauma - minority
  • loss of height, kyphosis
  • localised tenderness
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82
Q

Osteoporotic vertebral fracture Ix

A
  • XR spine
  • CT / MRI
  • DEXA, FRAX
83
Q

Osteoporotic vertebral fracture Mx

A
  • paracetamol, NSAIDs, opioids
  • bed rest, mobilisation, physio
  • Ca + vit D supplements
  • bisphosphonates
  • maybe intervention - eg vertebral augmentation
84
Q

NOF

A
  • neck of femur / hip fracture
  • head of femur has retrograde blood supply - intracapsular # can lead to avascular necrosis

RFs

  • older, osteoporosis, F>M, fall
85
Q

NOF categories

A

intracapsular

  • # in femoral neck, proximal to intertrochanteric line
  • Garden classification
  • non-displaced - may have intact blood supply
  • displaced - disrupted blood supply

Extracapsular

  • blood supply to head of femur intact

Intertrochanteric

  • # between greater + lesser trochanter

Subtrochanteric

  • distal to lesser trochanter, but <5cm
86
Q

Garden classification of intracapsular #

A

Grade I – incomplete #, non-displaced

Grade II – complete #, non-displaced

Grade III – partial displacement (trabeculae at angle)

Grade IV – full displacement (trabeculae are parallel)

87
Q

NOF Px

A
  • Pain in groin / hip, may radiate to knee
  • Unable to weight bear
  • Shortened, abducted, externally rotated leg
  • Unable to straight leg raise
  • Bruising, swelling around hip
88
Q

NOF Ix

A
  • look for fall cause - eg bloods, MI, HF, stroke, chest infection
  • Bloods…
  • CXR, ECG
  • XR hip - disruption of Shenton’s line
  • MRI / CT - if XR negative, but still ?#
  • NV status of limb
89
Q

NOF Mx

A
  • analgesia - fascia iliaca block
  • OT/PT - mobilise ASAP after op

Surgery

  • <48hrs of admission
  • intracapsular - hemiarthroplasty (limited mobility) / total hip replacement (fitter)
  • intertrochanteric - DHS
  • Subtrochanteric - IM nail
90
Q

NOF Cx

A

Malunion, blood loss, VTE, fat emboli, avascular necrosis, infection of metalwork

91
Q

Hip dislocation

A
  • more likely in total hip replacement / major trauma

Px

  • posterior - 90% - shortened, adducted, internally rotated leg
  • anterior - abducted, externally rotated leg

Ix

  • XR

Mx

  • analgesia
  • reduction <4hrs (avascular necrosis risk)
  • OT/PT

Cx

  • sciatic / femoral nerve injury
  • avascular necrosis
  • OA
  • recurrence
92
Q

Acetabular labral tear

A
  • tear to labrum (cartilage) in hip socket
  • direct trauma, sports, degenerative change
  • pain in hip / groin, locking, catching, snapping
  • MRI, arthroscopy
  • rest, physio, surgery
93
Q

Avascular necrosis of hip

A
  • death of bone tissue from lack of blood supply -> destruction + loss of joint function

Causes

  • long term steroids, chemo, alcohol, trauma

Px

  • asym
  • pain in affected joint

Ix

  • XR
  • MRI - definitive

Mx

  • surgical - joint replacement
94
Q

Iliopsoas abscess

A
  • collection of pus in iliopsoas compartment

Causes

  • primary - haematogenous - S aureus
  • Secondary - Crohn’s, diverticulitis, cancer, UTI, GU cancer, IVDU….

Px

  • fever, back/flank pain, limp, wt loss
  • flexion at hip against resistance causes pain
  • hyperextension of hip causes pain

Ix

  • CT abdo

Mx

  • abx
  • percutaneous drainage
  • surgery
95
Q

Meralgia paraesthetica

A
  • localised sensory sx of outer thigh caused by compression of lateral femoral cutaneous nerve (LFCN) - mononeuropathy
  • eg pressure, deformity, trauma - at any point along nerve

RFs

  • obesity, pregnancy, ascites, trauma, sports, iatrogenic, idiopathic
96
Q

Meralgia paraesthetica Px

A
  • abnormal sensations - dysaesthesia
  • loss of sensation - anaesthesia
  • burning, numbness, pins + needles
  • cold sensation
  • hair loss
  • sx worsened by standing/walking/hip extension
  • sx mild / persist for yrs
97
Q

Meralgia paraesthetica Ix

A
  • clinical dx
  • pelvic compression test
  • inject nerve with LA
  • NCS
  • Ix to r/o spinal/pelvic pathology
98
Q

Meralgia paraesthetica Mx

A
  • rest, loose clothing, wt loss, physio

Medical

  • paracetamol, NSAIDs
  • neuropathic pain meds
  • local steroid / anaesthetic injections

Surgical

  • decompression, nerve transection/resection
99
Q

Greater trochanteric pain syndrome

A
  • pain in outer hip from trochanteric bursitis
  • eg IT band, trauma, RA, septic bursitis
100
Q

Greater trochanteric pain syndrome Px

A
  • pain over lateral hip, may radiate down thigh
  • gradual onset
  • aching / burning
  • worse after activity / standing still / cross-legged
  • tender on palpation of GT
  • infection - warm, red, swelling, pain, fever
101
Q

Greater trochanteric pain syndrome Ix

A

Clinical examination
- pain on resisted abduction of hip
- pain on internal / external rotation of hip against resistance
- Positive Trendelenburg test

102
Q

Greater trochanteric pain syndrome Mx

A
  • Rest, ice
  • analgesia
  • physio
  • steroid injections
  • abx for infection
  • 6-9mo recovery
103
Q

Iliotibial band syndrome

A
  • common cause of lateral knee pain in runners
  • irritation of IT band
  • tenderness 2-3cm above lateral joint line at knee
  • physio, activity modification to tx
104
Q

Meniscal tear

A
  • damage to meniscus - cartilage in knee joint
  • often twisting movts, young pt, sports
105
Q

Meniscal tear Px

A
  • pop sensation
  • pain, swelling, stiffness, reduced ROM
  • pain worse straightening knee
  • locking of knee, knee instability
  • maybe referred to hip/lower back
106
Q

Meniscal tear Ix

A
  • McMurray’s test
  • Apley grind test
  • XR if Ottawa knee rules
  • MRI
  • arthroscopy
107
Q

Meniscal tear Mx

A
  • A+E / fracture clinic referral
  • RICE
  • NSAIDs
  • physio
  • surgery - arthroscopy - repair/resection of meniscus
108
Q

ACL injury

A
  • most common
  • stops tibia sliding forwards
  • typically twisting injury
109
Q

ACL injury Px

A
  • pain, swelling
  • pop sensation
  • instability of knee joint
110
Q

ACL injury Ix

A
  • anterior draw
  • Lachman’s
  • MRI
  • arthroscopy
111
Q

ACL injury Mx

A
  • RICE
  • NSAIDs
  • crutches / knee braces
  • physiotherapy
  • arthroscopic surgery - reconstruct ligament
112
Q

Patella fracture

A
  • patella protects knee, forms part of extensor mechanism
  • direct trauma - usually undisplaced crack/comminuted fracture
  • indirect - quad contracts against something, transverse patella fracture

Px

  • swelling, bruising, pain
  • palpable gap
  • if extensor mechanism injured - unable to SLR

Ix

  • XR

Mx

  • undisplaced - hinged knee brace
  • displaced - surgical - wires/screws
113
Q

Ruptured PCL

A
  • hyperextension / dashboard injuries
  • tibia lies back on femur
  • paradoxical anterior draw, positive posterior sag
114
Q

Ruptured MCL

A
  • When leg forced into valgus from force from outside
  • Knee unstable when put into valgus position
115
Q

Chondromalacia patellae

A
  • damage to cartilage at back of kneecap
  • Typically teenage girls, after injury to knee
  • Pain on going downstairs, or at rest
  • May see tenderness, quad wasting
  • Physio, analgesia
  • Rarely, surgery
116
Q

Patella dislocation

A
  • after trauma / severe quad contraction (with knee in valgus + external rotation)
  • clinically obvious, or skyline XR for sx
  • 5% have osteochondral #
  • 20% recurrence
  • reduce with analgesia
117
Q

Tibial plateau fracture

A
  • fracture of tibia just below knee
  • knee fractures before ligaments rupture
  • may need pins / plates
118
Q

Patellofemoral pain syndrome

A
  • pain in front of knee

Causes

  • injury, overuse, maltracking of patella, weak hips/foot issues, overweight

Px

  • pain around knee, intermittent
  • worse going up/down stairs
  • crepitus
  • swelling

Ix

  • clinical dx

Mx

  • physio
  • analgesia
119
Q

Prepatella bursitis

A
  • housemaid’s knee
  • inflammation of bursa in front of patella
  • injury, prolonged kneeling, infection, gout/RA

Mx

  • RICE, NSAIDs
  • abx for infection
120
Q

Baker’s cyst

A
  • fluid-filled bursa in popliteal fossa
  • primary / secondary (eg OA, meniscal tears)

Px

  • asym
  • swelling
  • pain, discomfort
  • fullness, pressure
  • rupture - can cause compartment syndrome

Ix

  • Lump biggest when standing
  • USS
  • MRI

Mx

  • tx cause
  • analgesia - NSAIDs
  • physio
  • US-guided aspiration
  • steroid injections
121
Q

Osgood-Schlatter disease

A
  • inflammation at tibial tuberosity at patella tendon insertion
  • multiple small avulsion #’s where patella ligament pulls away bits of bone -> growth of tibial tuberosity

Px

  • gradual onset
  • lump at tibial tuberosity
  • pain in ant knee
  • pain worsened by movt, kneeling, extension of knee

Mx

  • reduce activity
  • Ice
  • NSAIDs
  • stretching, physio
122
Q

Achilles tendinopathy

A
  • inflammation of achilles tendon
  • connects gastroc + soleus to calcaneus

Types

  • insertion - <2cm of insertion
  • mid-point - 2-6cm

RFs

  • sports, RA, DM, cholesterol, ciprofloxacin
123
Q

Achilles tendinopathy Px

A
  • gradual onset
  • pain / ache in heel, worse with activity
  • stiff, tender, swelling
  • nodule on palpation
124
Q

Achilles tendinopathy Ix

A
  • clinical dx
  • exclude rupture - Simmond’s
125
Q

Achilles tendinopathy Mx

A
  • rest, ice
  • analgesia
  • physio
  • insoles
  • Extracorporeal shock-wave therapy (ESWT)
  • surgery
126
Q

Achilles tendon rupture

A
  • sudden onset rupture of tendon

RFs

  • sports, older, tendinopathy, FHx, cipro, steroids
127
Q

Achilles tendon rupture Px

A
  • sudden onset pain in achilles/calf
  • snapping
  • swelling, tender
  • weak plantarflexion - cannot stand on tiptoes
  • Simmond’s positive
128
Q

Achilles tendon rupture Ix

A
  • USS
129
Q

Achilles tendon rupture Mx

A
  • same day T+O review
  • RICE
  • surgical reattachment
  • consider non-surgical….
130
Q

Ankle fracture

A
  • Involve lateral malleolus (distal fibula) or medial malleolus (distal tibia)
  • tibiofibular syndesmosis important for ankle stability - if disrupted, surgery more likely
131
Q

Ankle fracture Weber Classification

A

Type A – below ankle joint, intact syndesmosis

Type B – at level of ankle joint, syndesmosis intact / partially torn

Type C – above ankle joint – syndesmosis disrupted

132
Q

Maisonneuve fracture

A

Spiral fibular fracture which widens ankle joint, disrupts syndesmosis

133
Q

Pott’s fracture

A

Bimalleolar ankle fracture, from forced foot eversion

134
Q

Ankle fracture Mx

A
  • reduce
  • plates/screws for younger pts
  • elderly - conservative
135
Q

Ankle sprain

A
  • stretching, partial/complete tear of ligament in ankle

Types

  • low - lateral collateral ligaments (between distal fibula and talus)
  • high - syndesmosis (between tibia/fibula)
  • deltoid ligament (between tibia/talus) - maisonneuve
136
Q

Low ankle sprain

A
  • > 90%, injury to ATFL
  • inversion of foot

Px

  • pain, swelling, tenderness, bruising
  • weight bear usually

Ix

  • XR if Ottawa rules
  • MRI if persistent pain

Mx

  • RICE / MEAT (move, exercise, analgesia, tx)
  • orthosis, cast, crutches
  • surgery if unstable
137
Q

High ankle sprain

A
  • syndesmosis injury - rare
  • external rotation of foot

Px

  • pain, swelling, tenderness, bruising
  • pain weight bearing
  • pain when tibia / fibula squeezed together at mid-calf

Ix

  • XR, MRI

Mx

  • orthosis, cast
  • if diastasis - surgery
138
Q

Ottawa ankle rules

A

XR for ankle injury only necessary if – pain in the malleolar zone and one of:

  • Inability to weight bear 4 steps
  • Bony tenderness at lateral malleolar zone – tip of lateral malleolus to lower 6cm of posterior border of fibula
  • Bony tenderness in medial malleolar zone – tip of medial malleolus to lower 6cm of posterior border tibia
139
Q

Charcot foot

A
  • neuropathic joint
  • joint badly disrupted secondary to loss of sensation
  • diabetics

Px

  • some pain
  • joint swollen, red, warm
  • change in foot shape

Mx

  • keep in cast (keep still whilst recovering)
  • surgical mx
140
Q

Plantar fasciitis

A

inflammation of plantar fascia

Px

  • gradual onset pain at heel
  • worse walking / standing
  • tender on palpation

Mx

  • rest, ice
  • physio
  • analgesia
  • supportive shoes, insoles
  • consider steroid injections, shockwave therapy, surgery
141
Q

Fat pad atrophy

A
  • wasting of fat pad under calcaneus
  • older, repetitive jumping, obesity, local steroid injections

Px

  • pain, tenderness over plantar aspect of heel

Ix

  • USS - measure thickness

Mx

  • comfortable shoes, insoles
  • avoid high heels
  • lose weight
142
Q

Morton’s neuroma

A
  • dysfunction of nerve in intermetatarsal space at top of foot - usually 3-4th
  • irritation of nerve, eg high heels

Px

  • pain at front of foot
  • feels like lump in shoe
  • burning, numbness, paraesthesia in distal toes

Ix

  • deep pressure causes pain
  • metatarsal squeeze - pain
  • Mulder’s sign
  • USS / MRI

Mx

  • analgesia, insoles, wt loss steroid injections, radiofrequency ablation, surgery
143
Q

Bunions (hallux valgus)

A
  • bony lump - deformity at MTPJ base of toe
  • 1st metatarsal angles medially, big toe angles laterally
  • MTPJ inflamed, enlarged, OA over time

Px

  • +/-pain, gradual, lump

Ix

  • wt bearing XR

Mx

  • wide, comfortable shoes
  • analgesia
  • bunion pads
  • surgery
144
Q

Metatarsal fracture

A
  • 5th metatarsal - most commonly fractured - proximal avulsion fractures / Jones fractures
  • also metatarsal stress fractures (2nd most commonly)

Px

  • pain, bony tenderness
  • swelling
  • antalgic gait

Ix

  • XR
  • isotope scan / MRI
145
Q

Ottawa foot rules

A

Foot XR required if pain in midfoot zone and any one of:

  • Bony tenderness at navicular zone
  • Bony tenderness at base of 5th metatarsal
  • Inability weight bear 4 steps
146
Q

Frozen shoulder

A
  • adhesive capsulitis
  • middle-aged females
  • primary (no trigger) / secondary (trauma, surgery…)
  • inflammation + fibrosis in joint capsule -> adhesions, restriction of movt
147
Q

Frozen shoulder Px

A
  • painful shoulder, worse at night
  • stiff - active/passive - mostly external rotation
  • thawing - gradual sx improvement
  • bilateral 20%
148
Q

Frozen shoulder Ix

A
  • clinical dx
  • XR - normal
  • US / CT / MRI - thickened joint capsule
149
Q

Frozen shoulder Mx

A

Non-surgical

  • analgesia
  • physio
  • intra-articular steroid injections
  • hydrodilation

Surgical

  • manipulation under anaesthesia
  • arthroscopy
150
Q

Rotator cuff injury

A
  • Subacromial impingement / supraspinatus tendinopathy
  • calcific tendonitis
  • rotator cuff tears
  • rotator cuff arthropathy
151
Q

Subacromial impingement / supraspinatus tendinopathy

A
  • inflammation of supraspinatus - impingement where it passes between humeral head + acromion

Px

  • shoulder pain
  • painful abduction arc 60-120deg
  • tender over anterior acromion
  • empty can test

Mx

  • rest, physio, steroid injection
152
Q

Rotator cuff tears

A
  • acute injury / degenerative

Px

  • shoulder pain
  • abduction weakness
  • night pain

Ix

  • XR
  • USS / MRI

Mx

  • physio, rest, analgesia
  • surgery
153
Q

Shoulder tests

A

Neer’s impingement test

  • Anterolateral shoulder pain during forward flexion of arm whilst internally rotated

Hawkin’s test

  • Forced internal rotation of arm at shoulder height, elbow bent 90 – causes anterolateral shoulder pain

Empty can test

  • Supraspinatus
  • Abduct arm to 90, internally rotate arm, apply downward pressure – creates pain / weakness

Posterior cuff test

  • Infraspinatus
  • Weakness / pain on resisted external rotation

Gerber’s lift off test

  • Subscapularis
  • Lift hand off back, whilst resistance applied – weakness / pain with tear
154
Q

AC joint arthritis

A
  • AC joint tender
  • pain worse at extremes of shoulder abduction, 170 onwards
  • positive scarf test
155
Q

AC joint injury

A
  • eg rugby collision, fall onto shoulder, FOOSH
  • conservative/surgical mx
156
Q

Shoulder dislocation

A
  • Humeral head dislodges from glenoid cavity of scapula
  • > 90% anterior, but also posterior, inferior
  • Subluxation - partial dislocation
157
Q

Shoulder dislocation patho

A
  • anterior - arm forced backwards whilst abducted/extended at shoulder
  • posterior - arm forced back whilst outstretched, internally rotated (electrocution/seizures)

Associated damage

  • glenoid labrum tear
  • Bankart lesion
  • Hill-Sachs lesions
  • axillary nerve damage
  • fractures
  • rotator cuff tear
158
Q

Shoulder dislocation Px

A
  • beware after acute injury
  • holding arm
  • shoulder pain
  • assess NV status, fractures
159
Q

Shoulder dislocation Ix

A
  • XR - posterior (lightbulb sign)
  • MRI
  • arthroscopy
  • apprehension test
160
Q

Shoulder dislocation Mx

A
  • reduce dislocation, analgesia/sedation
  • sling
  • post-reduction XR
  • fracture clinic follow up
  • recurrent - physio, shoulder stabilisation surgery
161
Q

Cervical spondylosis

A
  • degenerative changes in spine - from OA - vertebrae + discs
162
Q

Cervical spondylosis Px

A
  • neck pain, worse on movt
  • shoulder pain
  • stiffness
  • headaches
163
Q

Cervical spondylosis Mx

A
  • gentle exercises
  • physio
  • analgesia
  • amitriptyline
164
Q

Olecranon bursitis

A
  • inflammation + swelling of bursa over elbow

Causes

  • friction/repetitive movts, trauma, RA/gout, infection
165
Q

Olecranon bursitis Px

A
  • swelling over posterior aspect of elbow
  • warm, tender, fluctuant
  • infection - hot, tender, erythema, fever, sepsis
166
Q

Olecranon bursitis Ix

A
  • if infected - aspirate - MC+S
167
Q

Olecranon bursitis Mx

A
  • RICE/MEAT
  • compression
  • analgesia
  • steroid injections
  • abx if infected
168
Q

Repetitive strain injury

A
  • soft tissue injury/strain from repetitive activities

Px

  • pain, aching, weakness, cramping, numbness, tender on palpation

Ix

  • clinical dx
  • XR to r/o OA
  • USS
  • Bloods - RA

Mx

  • RICE/MEAT
  • occie health (if work related)
  • analgesia
  • physio
  • steroid injections
169
Q

Epicondylitis

A
  • inflammation at insertion of tendons into epicondyles at elbow

Lateral

  • tennis elbow
  • pain in lateral epicondyle, insertion of wrist extensors, pain with wrist extension against resistance

Medial

  • Golfer’s elbow
  • pain in medial epicondyle, flexors, pain with wrist flexion against resistance
170
Q

Epicondylitis Px

A
  • gradual onset
  • pain in epicondyle
  • can radiate down forearm
  • weakness in grip strength
  • medial can have ulnar nerve involvement
171
Q

Epicondylitis Ix

A
  • clinical dx
172
Q

Epicondylitis Mx

A
  • rest, NSAIDs
  • physio
  • braces, straps
  • steroid injections
  • rarely, surgery, shockwave therapy, plasma injections
173
Q

Radial tunnel syndrome

A
  • compression of posterior interosseous branch of radial nerve - Overuse injury

Px

  • Similar to tennis elbow
  • Pain 4-5cm distal to lateral epicondyle
  • Pain worse extending elbow, pronating forearm
174
Q

Cubital tunnel syndrome

A
  • compression of ulnar nerve as it passes through cubital tunnel

Px

  • intermittent tingling in 4/5th finger, later numbness / weakness
  • worse with elbow flexed
  • often hx of OA/trauma

Ix

  • clinical dx
  • ?NCS

Mx

  • physio
  • steroid injections
  • surgery
175
Q

Biceps rupture

A
  • rupture of biceps tendon
  • 90% long tendon proximally, 10% distal tendon
  • proximal MOI - biceps lengthened, contracted, load applied
  • distal MOI - flexed elbow suddenly extended with biceps contracted

RFs

  • heavy lifting, shoulder overuse, smoking, steroids
176
Q

Biceps rupture Px

A
  • sudden pop/tear
  • pain, bruising, swelling
  • Proximal - Popeye deformity
  • distal - reverse Popeye
  • weakness in shoulder/elbow
177
Q

Biceps rupture Ix

A
  • examination
  • Biceps squeeze test
  • USS
  • MRI
178
Q

Biceps rupture Mx

A
  • proximal - conservative
  • distal - surgical repair
179
Q

Pulled elbow

A
  • subluxation of radial head
  • <6yo

Px

  • elbow pain
  • limited supination / extension

Mx

  • analgesia
  • passively supinate elbow whilst flexed at 90
180
Q

De Quervain’s tenosynovitis

A
  • Sheath containing extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons is inflamed
  • repetitive movt -> inflammation/swelling of tendon sheaths
181
Q

De Quervain’s tenosynovitis Px

A
  • pain on radial side of wrist
  • aching, burning, weakness, numbness, tingling
  • tender over radial styloid process
  • abduction of thumb against resistance painful
182
Q

De Quervain’s tenosynovitis Ix

A
  • Finkelstein’s test
183
Q

De Quervain’s tenosynovitis Mx

A
  • analgesia
  • steroid injection
  • immobilise
  • surgical tx - cut extensor retinaculum
184
Q

Trigger finger

A
  • Pain / difficulty moving a finger - aka stenosing tenosynovitis
  • thickening of tendon / tightening of sheath prevents tendon moving smoothly, may be nodule also
185
Q

Trigger finger Px

A
  • finger painful/tender
  • does not move smoothly
  • popping / clicking sound
  • stuck in flexed position
  • sx worse in morning, improve during day
186
Q

Trigger finger Ix

A
  • clinical dx
187
Q

Trigger finger Mx

A
  • rest
  • analgesia
  • splinting
  • steroid injections
  • surgery
188
Q

Dupuytren’s contracture

A
  • Fascia of hand becomes thickened, tight, leading to finger contractures

RFs

  • age, FHx, manual labour, epilepsy, alcoholic liver disease, smoking, phenytoin, trauma

Px

  • hard nodules on palm
  • ring/little fingers flexed

Ix

  • table top test

Mx

  • conservative
  • surgical - needle fasciotomy / fasciectomy
189
Q

Ganglion cyst

A
  • sac of synovial fluid arising from joint / tendon sheath

Px

  • Firm, well-circumscribed mass, transilluminates

Ix

  • clinical dx
  • XR
  • USS

Mx

  • conservative
  • needle aspiration / surgical excision
190
Q

Carpal tunnel syndrome (CTS)

A
  • compression of median nerve in carpal tunnel
  • swelling of tendon sheaths / narrowing of tunnel
191
Q

CTS causes

A
  • Idiopathic
  • Pregnancy
  • Oedema, eg HF
  • Lunate fracture
  • RA
  • Acromegaly - bilateral sx
  • Repetitive strain
  • Perimenopause
  • Diabetes
192
Q

CTS Px

A
  • gradual onset, intermittent, worse at night
  • pain / paraesthesia in thumb, index, middle finger
  • numbness, burning
  • shake hands for relief, at night
  • weak thumb abduction, wasting of thenar eminence
  • difficulty with fine movts / grip strength
  • Tinels / Phalens positive
193
Q

CTS Ix

A
  • clinical dx
  • NCS
  • Carpal tunnel questionnaire
194
Q

CTS Mx

A
  • corticosteroid injections
  • wrist splints
  • surgical decompression
195
Q

Midshaft humerus fracture

A

radial nerve injury, wrist drop

196
Q

Colles fracture

A
  • FOOSH, dinner-fork deformity

Features

  • transverse fracture of radius
  • 1in proximal to radiocarpal joint
  • dorsal displacement / angulation

Cx

  • median nerve injury
  • compartment syndrome
  • NV compromise
  • malunion, tendon rupture, OA
197
Q

Smith’s fracture

A
  • fall onto flexed wrist
  • volar / palmar angulation of distal radius fragment (Garden spade deformity)
198
Q

Bennett’s fracture

A
  • intra-articular fracture of metacarpal, at base of thumb
  • punching
  • XR - triangular fragment at base of metacarpal
199
Q

Monteggia’s fracture

A
  • dislocation of proximal radioulnar joint, ulnar fracture
  • FOOSH with forced pronation
  • prompt dx to avoid disability
200
Q

Galeazzi fracture

A
  • radial shaft fracture with dislocation of distal radioulnar joint
  • fall on hand + rotational force
  • bruising, swelling, tenderness over lower end of forearm
  • XR - displaced radial fracture, prominent ulnar head from dislocation
201
Q

Barton’s fracture

A
  • distal intra-articular radius fracture with radiocarpal dislocation in direction of fracture segment
  • dorsal / palmar
  • fall onto extended + pronated wrist
202
Q

Scaphoid fractures

A
  • from FOOSH
  • risk of avascular necrosis

Px

  • pain, swelling in anatomical snuffbox
  • pain on wrist movts, eg ulnar deviation
  • pain on longitudinal compression of thumb
  • loss of grip / pinch strength

Ix

  • XR - need ulnar deviation AP
  • CT
  • MRI

Mx

  • Immobilise - futuro splint / below elbow backslab
  • T+O referral
  • undisplaced - 6-8wk cast
  • displaced - surgical fixation
  • proximal scaphoid pole - surgical fixation
203
Q

Radial head fracture

A
  • usually FOOSH

Px

  • marked local tenderness over radius head
  • impaired elbow movts
  • sharp pain at lateral side of elbow at extremes of pronation / supination

Phase 4 Question Knowledge (30 decks)

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