T&O round 2 Flashcards
1
Q
Name three functions of bone
A
Mechanical - protect delicate tissues and organs, a framework for the shape of the human body, form a basis for movement.
Synthetic - haemopoiesis.
Metabolic - mineral storage (ca2+, po4-), fat storage (yellow bone marrow), acid-base homeostasis by absorbing salts to regulate blood pH
2
Q
What is the difference between endochondral ossification and intra-membranous ossification?
A
Endochondral - form long bones from cartilage templates. Have continued lengthening by ossification at the epiphyseal plates. Intra-membranous ossification - the formation of bone from clusters of mesenchymal stem cells in the centre of bone.
3
Q
Describe a coronal section of mature bone
A
Compact/cortical bone on the outside/external surface. Cancellous bone/spongy on the inside - combines strength with lightness.
4
Q
Name a factor which affects bone stability
A
Activity of osteocytes (can act as osteoblasts or osteoclasts).
Activity of osteoblasts (stimulated by calcitonin, GH, oestrogen, testosterone, thyroid hormones, vit A)
Activity of osteoclasts (increased by PTH).
Nutrition - vit D, C, K and B12.
5
Q
In a fracture repair, first comes hematoma formation. Next comes ______(1)_______, followed by bony callus formation and ______(2)________.
A
(1) - fibrocartilaginous callus formation - here, the pro callus of granulation tissue is replaced by a fibrocartilaginous callus where bony trabecular are developing.
(2) - bone remodelling - cancellous bone is replaced by compact, cortical bone until bone remodelling is complete.
6
Q
Define osteomalacia
A
Softening of bone due to vitamin D deficiency. This increases the risk of bone fractures in older adults.
7
Q
Describe the four features of OA on XRAY
A
Subchondral sclerosis, narrowing of joint space, osteophytes, bony cysts (SNOB)
8
Q
How may OA present?
A
Deep aching pain in the joint which is exacerbated by use. Reduced range of motion. Grinding sensation/sound. Stiffness during rest - morning stiffness usually lasts less than an 30mins.
9
Q
Define OA
A
Degeneration of joint cartilage and underlying bone
10
Q
Name categories of secondary OA
A
post-traumatic, post-operative, inflammation/infection related, miscellaneous
11
Q
What may you find on examination of someone with OA?
A
Swelling of joint, joint deformity, tenderness on palpation, joint effusions, restricted/reduced movements, joint instability, weakness or wasting
12
Q
To be considered for a knee replacement, what three features need to be present during a knee examination?
A
Correctable varus, full extension of the leg (at the knee), and flexion of at least 100 degrees
13
Q
What management options are available for OA?
A
Analgesia (e.g. NSAIDS - ibuprofen 200mg, naproxen 500mg initially, then 250mg every 6-8 hours as required). Steriodal injection. Weight loss. Use of walking stick. Surgery - partial or total knee replacement.
14
Q
Define a Smiths fracture
A
Fracture of the distal radius with palmar angulation of the distal fracture fragments. Have volar (anterior) displacement of the distal fragment of the radius. AKA a reverse Colles fracture. Usually occurs on fall on back of flexed wrist
15
Q
Define a Colles fracture
A
Extra-articular distal radius fracture with dorsal angulation and dorsal displacement. Within 2cm of articular surface.
16
Q
Describe presentation (Hx and examination) of Colles fracture
A
Hx of trauma, FOOSH. Immediate pain, tenderness, swelling, bruising. Elderly woman or young adult. PMH of osteoporosis, post menopause. Dinner fork deformity. Unable to grasp object. Increased angulation of distal radius.
17
Q
Describe presentation of Smiths fracture
A
Hx of falling on back of hand, or direct blow to the dorsal aspect of the wrist. Young male after high energy fall or elderly female after low energy fall.
Present with pain, swelling on anterior side. Reduced ROM, distal forearm deformity
18
Q
What are the five signs of compartment syndrome?
A
5Ps. —> Pain, Pallor, Parasthesia, Pulselessness, Paralysis
19
Q
What management options are available for fractures of the distal radius?
A
Reduction - external and/or internal fixation, percutaneous pinning, bone substitiutes. Immobilisation. Physiotherapy to restore range of movement, motion and function.
20
Q
What are the risk factors for Smiths or Colles fractures?
A
Age (older than 60 increases risk), being female, osteoporosis, menopause, smoking, alcohol use, prolonged steroid use.
21
Q
Why does prolonged steroid use increase the risk of fractures?
A
Steroids decrease osteoblast activity and increase osteoclast activity. This reduces bone density and increases risk of osteoporosis. Increased risk of osteoporosis = increased risk of fracture.
22
Q
Describe the presentation Dupytren’s disease
A
Hx of slow progression over years. Nodules present on palm of hands. Nodules are fixed. Nodules have thickened and can form tough cords under skin, fingers are pulled inwards towards palm. May also present with thickened skin on the feet or penis.
23
Q
How does Carpal tunnel syndrome present?
A
Pain, numbness and parasthesia in the lateral 3.5 digits. Worse during the night. Pain subsides on shaking wrist. Wasting of thenar eminence, weakness of thumb abduction
24
Q
What initial investigations would you do for suspected CT?
A
Tinel’s test - percuss over median N. Phalen’s test - hold wrist in full flexion for a minute. Both tests bring on symptoms.
25
What are RF for CT syndrome?
Female, increasing age, obesity, previous injury, RSI, DM, RA, Hypothyroidism
26
What complications of CT (carpal tunnel) surgery would you make a patient aware of?
Persistent CTS symptoms. Infection. Scar formation. Nerve damage. Trigger thumb.
27
If CTS was untreated, what complications would it lead to?
Increased MN damage, impairment, disability.
28
What condition involves painless (sometimes painful) clicking or snapping of the finger when trying to extend?
Trigger finger
29
What may be present in PMH of pt with trigger finger?
Flexor tenosynovitis
30
How is trigger finger managed?
Conservatively - give splint to hold finger in extension at night. Steriod injections. Surgical decompression of tendon tunnel or surgery via percutaneous trigger finger release via needle.
31
What are risk factors for getting trigger finger?
Having occupation/hobby involving prolonged gripping and use of hand. PMH of RA, DM. Female. Increasing age
32
What can form as a complication of trigger finger surgery?
Adhesions
33
What are adhesions (with regard to being a complication of repair/surgery)?
Fibrous bands. They can cause obstruction.
34
What are risk factors for Dupytren's disease?
Being male, FHx, alcohol use, PMH of DM or seizures, increasing age.
35
What are complications of surgically treating dupytren's?
Pain, scarring, injury to surrounding N and BV, wound infection, stiffness, loss of sensation, loss of finger (v v rare).
36
What condition can predispose to a Baker's cyst?
OA
37
Which abx prescribed for a UTI can increase the risk of Achilles tendinopathy and tendon rupture?
Ciprofloxacin
38
Numbness in the ring and little fingers may mean there is involvement of which nerve?
Ulnar nerve
39
Define cubital tunnel syndrome
Compressive neuropathy of the ulnar nerve
40
How would you conduct a Tinel's test for cubital nerve syndrome?
Tap over space between medial epicondyle of humerus and the olecranon process of the ulna
41
What type of emboli is at risk of forming with a femoral shaft fracture?
Fat emboli
42
Fat emboli gives a classic triad of signs. What are they?
Hypoxaemia, neurological abnormalities, petechial rash
43
Herniation at which level of the spinal discs can lead to caudal equine syndrome?
Lumbar discs
44
What does Neer's test assess?
Shoulder impingement
45
A patient comes in with tendonitis of the rotator cuff muscles. You are worried about shoulder impingement. What test could you do?
Neer's test
46
Describe a positive Neer's test
Hand is positioned in the empty can position. Arm is passively raised into full flexion. When arm is raised = subacromial space narrows = impinge tendon and cause pain.
47
What findings would you see on an XR of a child with Perthes' disease?
Femoral head collapse and fragmentation which suggests osteonecrosis.
48
Osteogenesis imperfecta affects 4 parts of the body - what are they?
B = bones
I = eyes
T =.teeth
E = ears
49
What is Saturday night palsy?
Wrist drop and paralysis of the radial nerve - get weakness of hand and finger extensors
50
What is first line (surgical) management for pre-patellar bursitis if conservative management has not been successful?
Steroid injection
51
Name the rotator cuff muscles and identify their function
Suprspinatus- abduction
Infraspinatus- external rotation
Teres minor- external rotation
Subscapularis- internal rotation
52
Where is the attachment of rotator cuff muscles?
Greater tuberosity- Suprspinatus, Infraspinatus and Teres minor
Lesser tuberosity- Subscapularis
53
What is the mechanism of injury for anterior shoulder dislocation
FOOSH, playing sport, trauma, ?recurrent trauma
54
How would the patient look on examination with an anteriorly dislocated shoulder?
Shoulder is tender, loss of roundness of the deltoid, held externally rotated , swelling
55
What are you worried about in an anterior shoulder dislocation?
Rotator cuff injuries, associated fractures, potential nerve injuries
56
What views of an X-ray would you request for an anterior shoulder dislocation and what would you see?
AP and Y Lateral, you would see the head towards the corocoid process in a Y lateral view
57
What is a Bankart lesion?
When the labrum is pulled from the glenoid (injury to anterior part of the glenoid labrum). This needs urgent repair as it makes the shoulder unstable
58
How do you manage an anterior shoulder dislocation?
If NO ASSOCIATED FRACTURE- reduce it in ED- traction and counter traction.
Immobilise in sling- 2 weeks in elderly as stiffness is an issue, longer in young people.
Physio
Follow up and assess for any rotator cuff injuries
59
What is the mechanism of injury for a posterior shoulder dislocation?
Electrocution or epileptic seizure
60
Why and what do we need to be aware of with posterior shoulder dislocations?
EASILY MISSED! The arm will be held in an internally rotated position, therefore we need to ask them to externally rotate
61
How would you investigate a posterior shoulder dislocation? What would you find?
XRAY- AP- light bulb sign
Y lateral- head of humerus towards the acromion
62
How do you manage posterior shoulder dislocation?
Surgical reduction, potentially a humeral head replacement or partial replacement
63
How would a patient with an inferior shoulder dislocation present?
Arm abducted with hand running down
64
What is the most important thing to notice in ankle fractures?
Talar shift
65
What is talar shift?
The talus usually sits in the mortiste, if moved from here, talar shift- unequal joint space around the talus
66
Explain the anatomy of the ankle joint
Tibia- medial, Fibula- laterally, syndamosis joining the two bones. Medial malleolus at the base of the tibia with the deltoid ligaments and lateral malleolus at the base of the fibula and lateral ligaments.
67
What types of fractures can occur at the ankle?
Lateral malleolus ( most common), medial malleolus, bimalleolar, trimalleolar
68
What are the mechanism of injuries of lateral and medial malleolus fractures?
Lateral- inversion of foot
Medial- eversion of foot
69
What is the weber classification?
For lateral malleolar fractures.
A- below the syndamosis
B- at the syndamosis
C- Above the syndamosis
70
When would you use conservative management for malleolar fractures?
Weber A, weber B without talar shift
Non-displaced medial malleolus fractures
71
When would you use surgical management for malleolar fractures?
Weber B with talar shift, weber C, bimallerolar or trimalleolar fractures and open fractures
72
What is a pilon fracture?
Usually high impact, talus drives into distal tibia
73
What is De Quervain’s tenosynovitis?
Inflammation of abductor policies longus and extensor policies brevis tendons as they pass through the first dorsal compartment of the wrist at the radial styloid process
74
How does a patient with De Quervain’s tenosynovitis present?
Pain localised over the dorsal radial side of the wrist. Pain is exacerbated by work, and relieved by rest
75
What test would you carry out in a patient with suspected De Quervain's tenosynovitis, and what does positive test show?
Finkelstein's test. Positive - pain induced by ulnar deviation of the wrist with the thumb clasped in the palm. (Get tenderness over the styloid process too).
76
What is the mechanism of action of bisphosphonates?
Inhibition of osteoclasts
77
What are risk factors for plantar fasciitis
Running, obesity, prolonged standing
78
What is a recognised complication of a total hip replacement?
Posterior hip dislocation
79
Which area of the leg does the saphenous nerve provide sensation to?
Medial aspect of lower leg and foot§
80
Where does the tibial nerve provide sensation?
Posterolateral side of the leg, lateral side of the foot and the sole.
81
Describe the five stages of healing in fracture healing
1. Haematoma: tissue damage and bleeding occur at the fracture site; bone ends die back a few mms.
2. Inflammatory reaction: inflammation cells appear in the haematoma.
3. Callus formation: cell population changes to osteoblasts and osteoclasts; dead bone is mopped up and woven bone appears in the fracture callus.
4. Consolidation: woven bone is replaced by lamellar bone - fracture has united.0
5. Remodelling: newly formed bone is remodelled to resemble the normal structure.
82
How does achilles tendonitis present?
Gradual onset posterior ankle pain, tenderness over the tendon and swollen tendon
83
How would you manage achilles tendonitis
NSAIDS, avoid precipitating exercise and RICE
84
How does achilles tendon rupture present?
Sudden onset of sharp pain with a popping sound and feeling as though something 'went'
85
What are the risk factors for achilles tendonitis/ rupture
Tendonitis: someone unfit who suddenly increases exercise frequency, male, poor footwear, obesity .
Rupture is associated with recent use of flouroquinolones
86
How would you manage an achilles tendon rupture
Initial management: analgesia, immobilisation, in a plastered splint in full equines and no weight bearing, then 2 weeks later, held in a splint in semi equines and then 4 weeks later held in splint in neutral position
If delayed presentation, surgical intervention
87
When is surgery indicated in achilles tendon rupture?
When there is a delayed presentation of greater than 2 weeks or when there is a re-rupture
88
How do you perform the Simmonds test
Patient kneeling on chair with affected ankle hanging off the end of the chair. Squeeze the calf on affected side. If there is ankle plantar flexion, the tendon is intact, if there is no ankle plantar flexion then the tendon is not intact
89
When would you perform the Simmonds test aka thompson test?
To test for achilles tendon rupture
90
What is hallux valgus?
Characterised by the medial deviation of the first metatarsal and the lateral deviation of the hallux +/- rotation of the hallux with associated joint sublaxation
91
How does hallux valgus present ?
painful medial prominence
aggravated by walking, weight bearing activities and narrow fitting shoes
92
What are the risk factors for hallux valgus?
female
Hyper-mobility conditions
Connective tissue disorders
flat feet
93
What should you assess on examination for a patient that presents with hallux valgus
Position and lateral deviation of hallux
Check for inflammation and skin breakdown over the prominence at the base of the hallux
Check for worsening prominence when weight bearing
Check for active and passive range of movement. Check for crepitus and pain associated with crepitus
94
Why do we Xray in hallux valgus?
* To assess the degree of lateral deviation and joint subluxation
* Measure the angle between the first metatarsal and the first proximal phalanx- greater than 15 degrees, indicative of hallux valgus
95
What makes up the syndesmosis between the tibia and fibula?
Anterior inferior tibiofibular ligament, Posterior inferior tibiofibular ligament and the intra-osseous membrane.
96
What part of the ankle anatomy is involved in a trimalleolar ankle fracture?
medial malleolus fracture, lateral malleolus fracture and posterior malleolar fracture
97
How do you manage an ankle fracture?
Immediate fracture reduction to realign the fracture. Place ankle in a 'below knee back slab'. Repeat NV examination after reduction. Management after this can be conservative or surgical depending on type of fracture sustained.
98
What is the main complication after an ankle fracture?
Post traumatic arthritis. This is rare with appropriate reduction and fixation.
99
What are risk factors following an ORIF surgery?
Surgical site infection, DVT or PE, NV injury, non-union, metalwork prominence.
100
Definition of cauda equina syndrome?
A prolapsed intervertebral disc fills the spinal canal. This compresses the lumbar and sacral nerve roots within the spinal canal
101
How does CES present? What are red flags?
Recent PMH of disc prolapse. Age 40-50yrs. LMN signs and symptoms,
Red flags: (from Z2F)
Saddle anaesthesia
Loss of sensation in rectum and bladder (unsure how full they are)
Urinary incontinence or retention
Fecal incontinence
Bilateral sciatica
Bilateral weakness in LL (including ED)
Reduced anal tone in PR exam
102
What is the investigation for suspected CES?
Emergency lumbar-sacral MRI
103
What does MRI of CES show?
Cauda equina nerves being compressed. Shows cause of compression
104
How do you manage CES?
Surgical decompression within 48hrs of onset of sphincter symptoms
105
Name 2 risk factors for CES?
Disc herniation L5/S1 or L4/L5. Trauma.
Neoplasm - tumour affecting vert column or meninges.
Spinal stenosis - usually 2y to arthritis
Spinal infection or abscess.
Chronic spinal inflammation - ankylosing spondylitis (late stage). Iatrogenic - haematoma secondary to spinal anaesthesia.
106
Name a complication of CES
Chronic neuropathic pain. Impotence. Need to do self catheterisation. Fecal incontinence. Impaction of faeces. Loss of sensation and motor weakness of LL. Requirement of lifelong wheelchair.
107
Define spinal stenosis
Degenerative in nature. Narrowing of the spinal canal or other nerve pathways in the spinal column. This puts pressure on nerves travelling through the spine. (Can affect spinal cord, or N roots).
108
How may spinal stenosis present?
Gradual onset. Over 60 years old (as it is due to degenerative changes in spine).
Intermittent neurogenic claudication below level: usually bilateral
- lower back pain
- buttock and leg pain
- leg weakness.
Absent at rest or sitting.
Present when walking/standing.
Bend = Better
Straight = Symptoms
Note: ^ for central spinal stenosis - most common. Lateral stenosis and foramina stenosis = present w Sciatica
109
What investigation would you order for suspected spinal stenosis?
MRI of the whole spine
110
How is spinal stenosis managed?
Analgesia, exercise, weight loss. If a malignancy is present, high dose corticosteroids, chemo and radiotherapy. Spinal cord decompression.
111
What are risk factors for spinal stenosis?
Malignancy, trauma, infection, disc prolapse.
112
What complications can arise from spinal stenosis?
CES
113
A child sustains a supracondylar fracture of the elbow following a FOOSH. What structures could be damaged and what can this lead to?
Brachial artery affected by direct damage from fracture. This can lead to ischaemia —> Volkmann's ischaemic contracture. Can affect radial, medial or ulnar nerve. In children, supracondylar fracture can lead to 'pale, pulseless' limb —> need emergency surgery
114
What would be the management for an intertrochanteric NOF fracture?
This is an extracapsular break off the femur between the greater and lesser trochanters. Needs DHS.
115
What tendons hold the patella in place?
Quadriceps tendon and the patella tendon
116
What do fractures of the olecranon result in?
Result in the sudden pull of the triceps (and brachialis) muscle.
117
What do olecranon fractures present with on examination?
Tenderness when palpating over posterior aspect of the elbow. Inability to extend the elbow against gravity, as triceps mechanism is disrupted.
118
What XR views would you request for suspected olecranon fracture?
Plain AP and lateral of affected joint (+/- joint above and below).
119
In a Weber's fracture, what other features may be present?
Talar shift and shortening.
120
How do you treat NOF?
Garden 1/2- ORIF and cancellous screws
Garden 3/4- depends on age--> <55--> ORIF and screws
>75--> hemiarthroplasty
55-75- total hip replacement
EXTRACAPSULAR- ORIF and DHS
121
What movements are preserved and weakened in the Short head of biceps rupture?
Flexion is weakened but supination is preserved
122
What is frozen shoulder?
Stiff painful shoulder due to adhesive capsulitis
123
How does the pain from frozen shoulder present?
Gradual onset pain and stiffness of the shoulder with reduced movement, most notably external rotation. Pain worsens initially and persists for weeks- months
124
How is frozen shoulder managed?
Analgesia(NSAIDS), Physiotherapy and exercise and local intraarticular steroid injection
125
What are the causes of cauda equina?
Lumbar disc herniation at L4/5 and L5/S1 level, neoplasms, abscesses, iatrogenic causes
126
How does cauda equina present?
Lower back pain with alternating or bilateral radicular pain, saddle parasthesia, urinary retention, urinary incontinence, bowel incontinence or retention
127
How do you manage cauda equina?
Suspicion of cauda equina should have whole spine MRI and surgical decompression within 48 hours
If malignancy is suspected or shown then administer dexamethasone 16mg daily in divided doses with PPI cover
128
What does an xray of a frozen shoulder look like?
Normal
129
What is the mechanism of injury of a scaphoid fracture
FOOSH
130
What are the symptoms of a scaphoid fracture?
Pain on palpation of the anatomical snuffbox
131
A patient presents to the ED with a suspected scaphoid fracture, on xray there is no abnormality, what would your next steps be?
Immobilisation of the wrist in a thumb spica cast (beer glass position) and arrange a repeat xray in 10-14 days
132
What does common peroneal nerve injury cause?
Foot drop, due to paralysis of foot extensor.
Foot eversion may also occur.
133
How is common peroneal nerve injury treated?
Conservatively.
Surgical intervention is indicated in those who do not have improved neurological function within 2-3 months
134
What is the mechanism of injury of a hook of hamate fracture?
Typically in athletes- FOOSH or direct blow to volar proximal palm e.g. athletes who grip hard and big force -hockey stick
135
How does hook of hamate fracture present?
tenderness over the hypothenar eminence/ ulnar side wrist pain/ Flexion of thumb whilst palpating the hypothenar eminence also causes pain in that area
136
How are hook of hamate fractures diagnosed?
Plain x-ray with 'carpal tunnel' view the most useful for visualisation.
137
What muscle is tested by the empty can test?
Supraspinatus
138
How do you test for subscapularis function?
Gebers lift off test
139
Causes of OA?
Idiopathic, infection, inflammation, trauma
140
Name two risk factors for OA?
Increasing age, genetic factors, female, obesity, low bone density, previous joint injury, occupational or recreational stress, joint laxity, malignancy, surgery.
141
How does OA present in the knee?
Pain around knee. Pain can radiate to hip/thigh. Made worse by walking/exercise. Better when resting. Stiff in knee joint, swollen, crepitus, reduced range movement, bilateral.
142
Describe a ACL tear
Anterior cruciate ligament is torn.
143
What is role of ACL?
Stops tibia from sliding out in front of femur (i.e. stops anterior translation). Provides rotational stability to the knee
144
How does an ACL tear present?
Loss/impaired function.
Hx of twisting the knee.
Rapid joint swelling.
Pain!
Joint feels unstable.
145
What tests would you do for suspected ACL tear?
Lachman's test. Anterior draw test.
146
How is an ACL tear managed?
RICE.
NSAIDs
Crutches, knee brace.
Rehab to strengthen quads to stabilise the know. Surgical reconstruction - tendon or artificial Grat used.
147
What is a complication of ACL injury?
OA
148
What do the menisci in the knee act as?
Shock absorbers
Stabalise knee joint
Allow for distribution of synovial fluid through joint
149
How do meniscal injuries/tears present?
Knee twisted while flexed or weight bearing. Sensation of tearing. Intense sudden onset pain. Swells slowly. Tender along joint line. Effusion in the joint. Limited knee flexion.
Z2F:
Young patient - sports related injury
"pop" sound or sensation
Pain
Swelling
Stiffness
Restricted range of motion
Locking knee
Instability - knee "gives way"
150
What tests would you do for suspected meniscal injury?
McMurray's - would be positive.
151
How are meniscal tears managed?
RICE. Small tears <1cm- heal by themselves. Large, symptomatic tears - need arthroscopic surgery. Sutures may be needed if tear is in outer 1/3rd. Sutures need to be trimmed if in inner third, as can cause locking of the knee.
Z2F:
RICE
NSAIDs
Physio after initial pain and swelling settled
Surgery may be needed - arthroscopy - repair meniscus or remove affected part of meniscus
152
How does quadriceps tendon rupture present?
Hx of landing from jump/height and putting excessive load on quads - hear popping sensation/tearing.
Pain in anterior knee or thigh. Hard to weight bear. Swelling. Palpable defect over superior patella.
153
Difference in presentation of meniscal tear and ACL tear - with regard to joint swelling?
ACL = rapid joint swelling!!!
Meniscal = slow joint swelling
154
What imaging would you do for quadriceps tear?
XR - rule out fracture of patella. USS to measure degree of rupture.
155
You do an examination of a pt with suspected quadriceps tendon tear. What do you find on examination if this is true?
Can't complete a straight leg raise. Can't extend the knee. (or can only do these movements partially if only partially torn).
156
A pt has a partial quadriceps tendon tear. What is your management plan?
Immobilise knee in brace, rehab.
157
A pt has a complete quadriceps tendon rupture. What is your management?
Surgery needed! Then need immobilisation in brace for 6 weeks. THEN need strengthening and flexibility exercises.
158
How does patella fracture present?
Hx of direct trauma to patella/strong contraction of the quadriceps. Anterior knee pain, which is worse on movement. Patella defect is palpable. Swollen and bruised.
159
What XR is needed for patella fracture?
AP, lateral, skyline.
160
What surgical management options are available for patella fracture?
Open reduction and internal fixation WITH tension band wiring.
161
When is surgery discussed as an option for a patellar fracture?
When there is significant displacement of the patella or a compromise to the extensor mechanism.
162
How does patella tendon rupture present?
Direct blow or jumping action which is followed by a tearing or popping sensation. There is a palpable defect interior to the patella. Swelling. Pain in anterior knee.
163
How do presentations of patella tendon rupture and quadriceps tendon rupture differ?
Patella - defect is palpable inferior to the patella. Quadriceps - defect is palpable superior to the patella.
164
What imaging would you do for suspected patella tendon rupture?
XR to rule out fracture. USS to measure degree of rupture. MRI can be used.
165
How are patella tendon ruptures managed?
Depends on degree of rupture. If partial = immobilise in brace and rehab. If complete = surgical intervention followed by immobilisation in brace for 6 weeks before strengthening and flexibility exercises.
166
Define a patella dislocation
Patella is displaced out of the patellofemoral groove, normally held in place by vistas medius obliques.
167
How do patella dislocations present?
Hx of high force trauma on patella/sudden forceful twisting of the knee. Laterally displaced patella
168
What XR would you ask for, for a patella dislocation?
AP, lateral, skyline.
169
How is patella dislocation managed?
Extend knee and reduce patella. Immobilise to allow healing. Physio to strengthen Vastus Medialis Obliques (VMO)
170
What can be involved in aetiology of compartment syndrome?
Reduced compartment size e.g. Tight dressing/cast. Increased compartment content e.g. fracture (increase bleeding) or trauma/burns (increase capillary permeability)
171
What is most common cause of compartmnt syndrome?
Fracture
172
How is compartment syndrome diagnosed in a traumatised limb?
History, check for 6Ps when examining the limb (tight compartment, shiny), do compartment pressure measurement, CK, myoglobin
173
What clincial parameters do you see in compartment syndrome?
Pain, exaggerated by stretch, parasthesia and pressure. These are the first three you see out of 6Ps
174
What is difference between spinal and epidural analgesia?
Spinal - injection that starts within mins and lasts 2-3 hours.
Epidural - cannula type medication can be given over longer time 24-48hrs
175
A pt has compartment syndrome. What analgesia should you be aware of that a pt may be on?
Epidural analgesia, long acting nerve blocks or controlled IV opiate analgesia as can mask compartment syndrome
176
How is pressure measured in suspected compartment syndrome?
Stryker STIC monitor
177
A pt has a fracture which has been fixed. They now have compartment symdrome and you are going to measure the compartment pressure. How far away from the fracture can you insert the monitor?
Up to 5cm, as further distance affects pressure measurements. Usually within 5cm of fracture site
178
How is compartment syndrome managed?
Based on clinical suspicion. Ensure they have normal Bp. IV crystalloid fluids to improve perfusion of limb. Remove any bandages, cast. Keep limb at a neutral level (don’t elevate or lower). High flow 02. Use ice packs. IV opiate analgesia for symptoms. Organise theatre asap for fasciotomy.
179
Define a fasciotomy
Cut skin subcutaneously, cut through fascia to relieve pressure of muscle
180
What is a contraindication of a fasciotomy?
Compartment syndrome over 24hours as muscle and nerves are both damaged. No point now as muscle is dead - can lead to systemic effects.
181
What are 4 fascial compartments in leg?
Lateral, posterior superficial, posterior deep, anterior
182
What are three fascial compartments of forearm?
Posterior, anterior and lateral
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Within how many hours after confirmed compartment syndrome can you carry out a fasciotomy?
Within 8 hours. After this, need supportive treatment for acute renal failure. If more than 12 hours, need to leave skin intact and do a later reconstruction.
184
What is main complication of fasciotomy?
Altered sensation within margin of the wounds
185
What is usual presentation of chronic compartment syndrome?
Pain, parasthesia over 20-30 mins of exercise, symptoms go away after 15mins rest. Younger patient
186
How does OA of hip present?
Chronic worsening sx, pain, stiffness, grinding sensation, relieved by rest, aggravated by activity. Pain in hip can radiate to groin, anterior thigh or can present as pain in the knee (referred).
187
What would you find on examination of pt with OA of hip?
Antalgic gait, tenderness round hip. Passive movements are often painful, crepitus. reduced range of movement. Fixed flexion deformity on Thomas test. Trendelenberg gait.
188
What investigations would you order for suspected OA of hip?
XR. May want MRI too.
189
What are risk factors for OA of hip?
Primary - female, obesity, manual handling occupation, increasing age. Secondary - connective tissue disorders - RA, Marfans, Trauma, Infiltrative diseases
190
What is involved in conservative management of OA of hip?
Lose weight. Minimise aggravating activity. Use walking aids. Meds - NSAIDs (remember to give PPI!), corticosteroid injection, Acetminophen.
191
What surgical options would you offer for OA of hip?
Total hip replacement, hip resurfacing
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What are some complications of hip surgery?
Anaesthetic complications
Infection
Loosening of the joint
Hip dislocation
Leg length disparity
Thrombosis
Nerve damage
193
Name a differential for OA of hip presentation
Teach me surgery: trochanteric bursitis, radiculopathy, spinal stenosis, iliotibial band syndrome
Sciatica, trochanteric bursitis, femoral NOF, gluteus medias tendinopathy
194
What do we mean by an inter-trochanteric fracture?
Between lesser and greater trochanter
195
What is a sub-trochanteric fracture?
Fracture from lesser trochanter to 5cm distal to this point
196
How does an extra capsular NOF fracture present?
Hx of trauma - high energy or low energy if more elderly. Pain. can not weight bear.
197
What would you see on examination of an extra capsular NOF fracture/intracapsular NOF?
Shortened and externally rotated leg. Pain on pin rolling the leg or axial loading.
198
What investigations would you do a suspected extracapsular NOF fracture?
XR AP and lateral. FBC< U+E, Coag screen, group and save, CK is suspect rhabdomyolysis . In elderly pt, do urine dip, egg, cxr.
199
What are RF for extra capsular NOF fracture?
Being elderly (osteoporotic), stress fractures, trauma. Pathological fractures (have underlying disease meaning bone is brittle) - Paget's disease, osteomalacia, osteoporosis, osteogenesis imperfecta, bone cancer
200
What is initial management for NOF fracture?
A-E assessment + stabilise. Analgesia - opiod or regional fascia - iliac block. if elderly - need to have assessment by ortho-geriatricians. Need to be seen by physio and occupy therapists.
201
What is surgical management for intertrochanteric NOF extracap fracture?
DHS - dynamic hip sore. Here - screw into the NOF and side plate fixed screw - compress to cause bone healing.
202
What is surgical management for subtrochanteric NOF extracap fracture?
Intramedullary femoral nail - titanium rod is placed through medullary cavity of the demur to help stabilise it.
203
Name 2 immediate post op NOF fracture surgery complications
Pain, bleeding, leg length discrepancy, NVS damage
204
What are long term complications of NOF fracture surgery?
Joint dislocation, aspect loosening, peri-prosthetic fracture, deep infection, prosthetic joint infection
205
What is level of mortality increased by, at one year post NOF fracture?
Up to 30%
206
Define intracapsular NOF fracture
Fracture in sub capital region of the femoral head to the basocervical region
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What surgical management would you consider with a displaced sub capital inter capsular NOF fracture?
Hip hemiarthorplasty or total hip arthroplasty if independence and systemically well
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Pt has non displaced intracapsular NOF fracture that needs to be treated surgically. What surgery would be considered?
Cannulated hip screws or a total hip arthroplasty
209
What type of surgery would be done for a basocervical intracap NOF fracture?
DHS or total hip arthroplasty if systemically well and independent.
210
How can rotator cuff tears be classified?
Based on time: Acute (<3months) or chronic (>3months). Based on thickness of tear: Partial or full thickness. Based on size of the FULL thickness tear: small <1cm, medium 1-3cm, large 3-5cm, massive >5cm.
211
How do rotator cuff tears present?
Pain over the lateral aspect of the shoulder. Can't abduct over 90 degrees. On examination, there is tenderness over the greater tuberosity and subacromial bursa area.
212
What tests could you do for suspected rotator cuff tear?
Jobe's test, Gerber's lift off test and Posterior cuff test.
213
Describe Jobe's test
AKA empty can test. Get pt to place shoulder in 90deg abduction and 30deg forward flexion. Internally rotate fully. Look as though you are emptying a can. Gently push down on arm, ask pt to resist push. Positive test = weakness on resistance.
Checking function of: supraspinatus
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Which rotator cuff muscles does Jobe's test test for?
Supraspinatus
215
Describe Gerber's lift off test
For subscapularis dysfunction
Internally rotate arm so dorsal surface of hand rests on lower back.
Ask pt to lift hand away from back against your resistance.
Positive test is weakness in actively lifting hand away from back.
216
Which rotator cuff muscles does Gerber's lift off test test for?
Subscapularis
217
Which rotator cuff muscles does posterior cuff test test for?
Infraspinatus and teres minor
218
Describe the Hawkins test
For shoulder impingement
Arm is at pt's side. Flex elbow to 90deg. Ask pt to externally rotate arm against resistance. Positive test if weakness on resistance.
219
What imaging would you want to do for a patient with pain on lateral aspect of scapula?
This could be rotator cuff tear. Need urgent plain film radiograph to ensure it is not a fracture. Need USS to establish size of rotator cuff tear. Maybe MRI to establish size, characteristic and location of tear.
220
How are rotator cuff tears managed ?
Depends on size of tear and functional status. Conservatively - analgesia, physio. Corticosteriods in subacromial space can be given. If presenting within 2 weeks since injury or if symptomatic despite conservative treatment - refer for surgical intervention.
221
What are RF for rotator cuff tears?
Age, trauma, overuse, repetitive overhead shoulder movements, BMI above 25, smoking, DM
222
How does clavicle fracture present?
Sudden onset, severe localised pain, on active movement. On examination, have deformity, focal tenderness, crepitus, tenting of skin.
223
How is clavicle fracture managed?
Conservative - broad arm sling. Open fracture need surgical intervention.
224
What is a major complication of clavicle fracture?
Non-union. Also could have NV injury and puncture injury i.e haemothorax or pneumothorax
225
How does proximal humeral fracture present?
Tenderness, swelling and decreased motion of the arm. May have eccymossis around area.
226
How is proximal humeral fracture managed?
Conservative - collar and cuff sling. Need surgery if greater tuberosity is displaced more than 0.5cm or there are more than 2 part breaks. Fixed with screws or nails. Shoulder replacement may be necessary.
227
How does humerus shaft fracture present?
Younger patient - high energy trauma. Elderly - low impact. Pain and deformity. Reduced sensation over dorsal 1st webspace and weakness in wrist extension if radial nerve is involved.
228
What is a Holstein-Lewis fracture?
Fracture of distal 3rd of humerus, get radial nerve trapped - get loss of sensation in radial nerve distribution and wrist drop deformity.
229
What are RF for humerus shaft fracture?
Older age, osteoporosis, pathological fracture.
230
What is an open fracture?
Direct communication between fracture haematoma and the external environment
231
What may cause an open fracture?
Hx of high energy trauma
232
What investigations would you do for a presentation of an open fracture?
FBC, Clotting screen, Group and Save, skin swabs, XR, CT if highly comminuted.
233
What classification system is used for open fractures?
Gustilo Anderson
234
How are open features managed initially?
A-E, stabilise, evaluate poly trauma, NV assessment, realign, splint, give Tetanus booster if not up to date or anti serum if not had Tetnus jab. Give broad spec abx. Remove gross debris and dress with saline soaked gauze
235
How are open fractures managed surgically?
Wound/fracture site debridement. Saline wash. Skeletal stabilisation. Soft tissue coverage - plastics, vascular surgeons if needed.
236
What are complications of open fracture?
Fracture site infection, Osteomyelitis, Compartment syndrome, NV injury
237
What is compartment syndrome?
Critical pressure within a confined compartmental space.
238
Why is compartment syndrome so serious?
* Fasical compartments can not be distended —> vascular injury causes pressure to increase in the compartment
* —> this increases hydrostatic pressure in veins as they are compressed —> this forces fluid out the veins —> nerves traversing get compressed —> compartment pressure then reaches diastolic BP so arterial inflow is compromised = get ischaemia.
239
How does compartment syndrome present?
* Within hours of high energy trauma with vascular injury or surgery.
* Pain experienced is disproportionate to the injury. The compartment may feel tense. Parasthesia. Stretching compartment affected will worsen pain.
* If there is arterial insufficiency, there will be the 6Ps - pain, pallor, perishingly cold, parasthesia, pulselessness, paralysis (v late).
240
How is compartment syndrome managed?
* Remove cast, splints, dressings.
* **Immediate fasciotomy !!!! **
* Give analgesia.
* Keep limb neutral.
* Improve O2 delivery, augment BP with a fluid bolus.
241
Name a complication of compartment syndrome
Rhabdomyolysis, repercussion injury, check kidney function as good damage kidneys.
242
Define septic arthritis
Infection of a joint caused by (usually) Staphylococcus aureus. Can cause irreversible articular damage. Can also be caused by Neisseria Gonorrhoea
243
How does septic arthritis present?
A single, hot, swollen, painful joint.
244
What investigations might you want to do for suspected septic arthritis?
Bloods - see raised WCC and CRP. ESR, urate. May want to aspirate the joint - send off for microscopy and culture.
245
How is septic arthritis managed?
Abx - flucloxacillin for 2-3weeks IV then 2-4 after as oral tablets. Joint revision surgery if prosthetic joint is in pt.
246
What is pseudo gout?
Deposition of calcium pyrophosphate within the joint space which causes inflammatory arthritis
247
How does pseudo gout present?
Acute onset joint swelling. Usually in knee or wrist.
248
What is seen on XR of knee with pseudo gout?
Cloudy appearance in the joint space.
249
What is seen in aspirate of joint with pseudo gout ?
Rhomboid shape crystals
250
How is pseudo gout managed?
NSAIDs and treat underlying cause
251
What are the three principles of fracture management?
1. Reduce - restore anatomical alignment of the fracture or dislocation.
2. Hold - immobilise the fracture using splint/plaster cast etc.
3. Rehabilitate - intensive period of physio.
252
Why do we restore the anatomical alignment of a fracture or dislocation?
To restrict/stop bleeding at the fracture site. AND to reduce traction on soft tissues, nerves and blood vessels.
253
Why do we rehabilitate in fracture management?
To improve clinical outcome for patient. Reduce stiffness, strengthen muscles.
254
What is the most common type of of hip dislocation?
Posterior (90%)
255
What is the mechanism of action of a posterior hip dislocation?
Dashboard injury
256
How does a posterior hip dislocation present?
Internally rotated and slightly flexed and abducted
257
How does an anterior hip dislocation present?
Externally rotated, slightly flexed and abducted
258
What is trochanteric bursitis?
Inflammation of the bursa overlying the greater trochanter
259
How does trochanteric bursitis present?
Lateral hip pain (worse with activity and at night)
Swelling
Positive trendelenburg test
260
What scoring tool could you use for back pain?
Keele STarT Back scoring tool
Evaluates the risk of acute back pain becoming chronic and intital interventions - CBT, group therapy, physio, exercises.
Qus focus on pts function and psychological response to pain. There are 9 questions in total. 4/ 9 are psychological questions
You get 2 scores - a total score (out of 9) and subscore (out of 4) for the psychological score
TOTAL SCORE = 3 or less - LOW risk
SUBSCORE = 3 or less - LOW risk
TOTAL SCORE = more than 3 - MEDIUM RISK
SUBSCORE = 3 or less - MEDIUM RISK
TOTAL SCORE =more than 3 - HIGH RISK
SUBSCORE = more than 3 - HIGH RISK
261
How would you treat a patient who received a LOW RISK score on the Keele STarT Back scoring tool?
Self-management / Education
Reasurrance
Stay as active as possible
Analgesia
262
How would you treat a patient who received a MEDIUM / HIGH RISK score on the Keele STarT Back scoring tool?
LOW RISK : Self-management / Education / Reasurrance / Stay as active as possible /Analgesia
PLUS ADD in :
Non drug:
CBT
Physiotherpay
Group exercise
Drug:
NSAID
Codeine (NSAID alternative)
Benzos - diazepam for muscle spasm (short term e.g. 5 days)
tell to look for red flag symptoms e.g. saddle parathesia
DO NOT use opiods / gabapentin / amytriptyline / pregabalin for lower back pain
263
NICE 2020 guidance for drug medication for sciatica:
1. What drugs should you NOT USE?
2. Which neuropathic can use if worsening / persisting symptoms ?
p. 263 of Z2F
1. No opiates, gabapenitn, pregabalin, oral corticosteroids, diazepam.
2. Amitriptyline or Duloextine
(Specialist management can include : Epidural corticosteroid injections / local anaesthetic injections / spinal decompression )
264
Examination findings for meniscal injury?
Reduced/restricted range of motion
Localised tenderness to the joint line
Swelling
265
Investigations for suspected meniscal injury?
MRI - first line for establishing Dx.
Arthroscopy - gold standard for meniscal tear.
266
Ottawa ankle rules?
Ankle x-ray is required only if there is pain in the malleolar zone and any of:
Bone tenderness at the posterior edge or tip of the lateral malleolus
Bone tenderness at the posterior edge or tip of the medial malleolus
Inability to bear weight both immediately and in emergency department for four steps.
Foot x-ray is only required if there is midfoot zone pain and any of the below:
Bone tenderness at base of the fifth metatarsal.
Bone tenderness at navicular bone.
Inability to bear weight both immediately and in emergency department for four steps.
267
osteomyelitis on xray findings?
regional osteopenia, focal cortical loss, periosteal changes
268
Give examples of primary cancers that commonly metastasise to bone and cause (Capsule ortho 462):
1. Osteolytic bony mets
2. Osteoblastic bony mets
3. Mixed bony mets
1. Lung, breast, thyroid, kidney, colon cancer, myeloma
2. Prostate, breast
3. breast, prostate, lymphoma
269
Pt had a FOOSH or fell laterally on an adducted arm gets a mid humeral shaft fracture where might she get reduced sensation and weakness and why?
If the radial nerve is involved, complain of reduced sensation over the dorsal 1st webspace and weakness in wrist extension.
270
Risk factors for developing septic arthritis?
Intravenous drug use, diabetes mellitis (immunocompromise; ulcerations as a source of bacteraemia), prosthetic joint, osteoarthritis. Chronic kidney disease
271
What scoring system can be used to classify severity of knee OA?
The Kellgren and Lawrence system
272
What does the The Kellgren and Lawrence system for knee OA entail?
Grade 0 – no radiographic features of OA are present
Grade 1 – unclear joint space narrowing and possible osteophytic lipping
Grade 2 – definite osteophytes and possible joint space narrowing on AP weight-bearing views
Grade 3 – multiple osteophytes, definite joint space narrowing, evidence of sclerosis, and possible bony deformity
Grade 4 – large osteophytes, marked joint space narrowing, severe sclerosis, and definite bony deformity
273
Compare OA and RA based on Aetiology
OA :
Mechanical - wear & tear with localised loss of cartilage, remodelling of adjacent bone and
associated inflammation
RA :
Autoimmune
274
Compare OA and RA based on gender it affects
OA: similar incidence in men and women
RA: more common in wormn
275
Compare OA and RA based on Age of pt effected
OA: elderly
RA: adults of all ages
276
Compare OA and RA based on typical affected joints
OA : Large weight-bearing joints (hip, knee)
Carpometacarpal joint
DIP, PIP joints
RA: MCP / PIP joints
277
Compare OA and RA based on typical Hx
OA : Pain following use, improves with rest
Unilateral symptoms
No systemic upset
RA: Morning stiffness, improves with use
Bilateral symptoms
Systemic upset
278
Compare OA and RA based on X ray findings
OA: Loss of joint space
Subchondral sclerosis
Subchondral cysts
Osteophytes forming at joint margins
RA: Loss of joint space
Juxta-articular osteoporosis
Periarticular erosions
Subluxation
