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Y3 surgery old > T&O round 2 > Flashcards

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

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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.

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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.

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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.

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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.

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6
Q

Define osteomalacia

A

Softening of bone due to vitamin D deficiency. This increases the risk of bone fractures in older adults.

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7
Q

Describe the four features of OA on XRAY

A

Subchondral sclerosis, narrowing of joint space, osteophytes, bony cysts (SNOB)

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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.

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9
Q

Define OA

A

Degeneration of joint cartilage and underlying bone

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10
Q

Name categories of secondary OA

A

post-traumatic, post-operative, inflammation/infection related, miscellaneous

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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

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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

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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.

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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

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15
Q

Define a Colles fracture

A

Extra-articular distal radius fracture with dorsal angulation and dorsal displacement. Within 2cm of articular surface.

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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.

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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

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18
Q

What are the five signs of compartment syndrome?

A

5Ps. —> Pain, Pallor, Parasthesia, Pulselessness, Paralysis

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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.

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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.

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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.

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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.

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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

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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.

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25
Q

What are RF for CT syndrome?

A

Female, increasing age, obesity, previous injury, RSI, DM, RA, Hypothyroidism

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26
Q

What complications of CT (carpal tunnel) surgery would you make a patient aware of?

A

Persistent CTS symptoms. Infection. Scar formation. Nerve damage. Trigger thumb.

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27
Q

If CTS was untreated, what complications would it lead to?

A

Increased MN damage, impairment, disability.

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28
Q

What condition involves painless (sometimes painful) clicking or snapping of the finger when trying to extend?

A

Trigger finger

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29
Q

What may be present in PMH of pt with trigger finger?

A

Flexor tenosynovitis

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30
Q

How is trigger finger managed?

A

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.

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31
Q

What are risk factors for getting trigger finger?

A

Having occupation/hobby involving prolonged gripping and use of hand. PMH of RA, DM. Female. Increasing age

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32
Q

What can form as a complication of trigger finger surgery?

A

Adhesions

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33
Q

What are adhesions (with regard to being a complication of repair/surgery)?

A

Fibrous bands. They can cause obstruction.

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34
Q

What are risk factors for Dupytren’s disease?

A

Being male, FHx, alcohol use, PMH of DM or seizures, increasing age.

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35
Q

What are complications of surgically treating dupytren’s?

A

Pain, scarring, injury to surrounding N and BV, wound infection, stiffness, loss of sensation, loss of finger (v v rare).

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36
Q

What condition can predispose to a Baker’s cyst?

A

OA

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37
Q

Which abx prescribed for a UTI can increase the risk of Achilles tendinopathy and tendon rupture?

A

Ciprofloxacin

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38
Q

Numbness in the ring and little fingers may mean there is involvement of which nerve?

A

Ulnar nerve

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39
Q

Define cubital tunnel syndrome

A

Compressive neuropathy of the ulnar nerve

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40
Q

How would you conduct a Tinel’s test for cubital nerve syndrome?

A

Tap over space between medial epicondyle of humerus and the olecranon process of the ulna

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41
Q

What type of emboli is at risk of forming with a femoral shaft fracture?

A

Fat emboli

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42
Q

Fat emboli gives a classic triad of signs. What are they?

A

Hypoxaemia, neurological abnormalities, petechial rash

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43
Q

Herniation at which level of the spinal discs can lead to caudal equine syndrome?

A

Lumbar discs

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44
Q

What does Neer’s test assess?

A

Shoulder impingement

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45
Q

A patient comes in with tendonitis of the rotator cuff muscles. You are worried about shoulder impingement. What test could you do?

A

Neer’s test

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46
Q

Describe a positive Neer’s test

A

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.

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47
Q

What findings would you see on an XR of a child with Perthes’ disease?

A

Femoral head collapse and fragmentation which suggests osteonecrosis.

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48
Q

Osteogenesis imperfecta affects 4 parts of the body - what are they?

A

B = bones
I = eyes
T =.teeth
E = ears

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49
Q

What is Saturday night palsy?

A

Wrist drop and paralysis of the radial nerve - get weakness of hand and finger extensors

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50
Q

What is first line (surgical) management for pre-patellar bursitis if conservative management has not been successful?

A

Steroid injection

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51
Q

Name the rotator cuff muscles and identify their function

A

Suprspinatus- abduction
Infraspinatus- external rotation
Teres minor- external rotation
Subscapularis- internal rotation

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52
Q

Where is the attachment of rotator cuff muscles?

A

Greater tuberosity- Suprspinatus, Infraspinatus and Teres minor
Lesser tuberosity- Subscapularis

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53
Q

What is the mechanism of injury for anterior shoulder dislocation

A

FOOSH, playing sport, trauma, ?recurrent trauma

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54
Q

How would the patient look on examination with an anteriorly dislocated shoulder?

A

Shoulder is tender, loss of roundness of the deltoid, held externally rotated , swelling

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55
Q

What are you worried about in an anterior shoulder dislocation?

A

Rotator cuff injuries, associated fractures, potential nerve injuries

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56
Q

What views of an X-ray would you request for an anterior shoulder dislocation and what would you see?

A

AP and Y Lateral, you would see the head towards the corocoid process in a Y lateral view

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57
Q

What is a Bankart lesion?

A

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

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58
Q

How do you manage an anterior shoulder dislocation?

A

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

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59
Q

What is the mechanism of injury for a posterior shoulder dislocation?

A

Electrocution or epileptic seizure

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60
Q

Why and what do we need to be aware of with posterior shoulder dislocations?

A

EASILY MISSED! The arm will be held in an internally rotated position, therefore we need to ask them to externally rotate

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61
Q

How would you investigate a posterior shoulder dislocation? What would you find?

A

XRAY- AP- light bulb sign
Y lateral- head of humerus towards the acromion

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62
Q

How do you manage posterior shoulder dislocation?

A

Surgical reduction, potentially a humeral head replacement or partial replacement

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63
Q

How would a patient with an inferior shoulder dislocation present?

A

Arm abducted with hand running down

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64
Q

What is the most important thing to notice in ankle fractures?

A

Talar shift

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65
Q

What is talar shift?

A

The talus usually sits in the mortiste, if moved from here, talar shift- unequal joint space around the talus

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66
Q

Explain the anatomy of the ankle joint

A

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.

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67
Q

What types of fractures can occur at the ankle?

A

Lateral malleolus ( most common), medial malleolus, bimalleolar, trimalleolar

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68
Q

What are the mechanism of injuries of lateral and medial malleolus fractures?

A

Lateral- inversion of foot
Medial- eversion of foot

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69
Q

What is the weber classification?

A

For lateral malleolar fractures.
A- below the syndamosis
B- at the syndamosis
C- Above the syndamosis

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70
Q

When would you use conservative management for malleolar fractures?

A

Weber A, weber B without talar shift
Non-displaced medial malleolus fractures

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71
Q

When would you use surgical management for malleolar fractures?

A

Weber B with talar shift, weber C, bimallerolar or trimalleolar fractures and open fractures

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72
Q

What is a pilon fracture?

A

Usually high impact, talus drives into distal tibia

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73
Q

What is De Quervain’s tenosynovitis?

A

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

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74
Q

How does a patient with De Quervain’s tenosynovitis present?

A

Pain localised over the dorsal radial side of the wrist. Pain is exacerbated by work, and relieved by rest

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75
Q

What test would you carry out in a patient with suspected De Quervain’s tenosynovitis, and what does positive test show?

A

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).

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76
Q

What is the mechanism of action of bisphosphonates?

A

Inhibition of osteoclasts

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77
Q

What are risk factors for plantar fasciitis

A

Running, obesity, prolonged standing

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78
Q

What is a recognised complication of a total hip replacement?

A

Posterior hip dislocation

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79
Q

Which area of the leg does the saphenous nerve provide sensation to?

A

Medial aspect of lower leg and foot§

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80
Q

Where does the tibial nerve provide sensation?

A

Posterolateral side of the leg, lateral side of the foot and the sole.

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81
Q

Describe the five stages of healing in fracture healing

A
  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.
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82
Q

How does achilles tendonitis present?

A

Gradual onset posterior ankle pain, tenderness over the tendon and swollen tendon

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83
Q

How would you manage achilles tendonitis

A

NSAIDS, avoid precipitating exercise and RICE

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84
Q

How does achilles tendon rupture present?

A

Sudden onset of sharp pain with a popping sound and feeling as though something ‘went’

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85
Q

What are the risk factors for achilles tendonitis/ rupture

A

Tendonitis: someone unfit who suddenly increases exercise frequency, male, poor footwear, obesity .
Rupture is associated with recent use of flouroquinolones

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86
Q

How would you manage an achilles tendon rupture

A

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

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87
Q

When is surgery indicated in achilles tendon rupture?

A

When there is a delayed presentation of greater than 2 weeks or when there is a re-rupture

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88
Q

How do you perform the Simmonds test

A

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

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89
Q

When would you perform the Simmonds test aka thompson test?

A

To test for achilles tendon rupture

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90
Q

What is hallux valgus?

A

Characterised by the medial deviation of the first metatarsal and the lateral deviation of the hallux +/- rotation of the hallux with associated joint sublaxation

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91
Q

How does hallux valgus present ?

A

painful medial prominence
aggravated by walking, weight bearing activities and narrow fitting shoes

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92
Q

What are the risk factors for hallux valgus?

A

female
Hyper-mobility conditions
Connective tissue disorders
flat feet

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93
Q

What should you assess on examination for a patient that presents with hallux valgus

A

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

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94
Q

Why do we Xray in hallux valgus?

A
  • 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
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95
Q

What makes up the syndesmosis between the tibia and fibula?

A

Anterior inferior tibiofibular ligament, Posterior inferior tibiofibular ligament and the intra-osseous membrane.

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96
Q

What part of the ankle anatomy is involved in a trimalleolar ankle fracture?

A

medial malleolus fracture, lateral malleolus fracture and posterior malleolar fracture

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97
Q

How do you manage an ankle fracture?

A

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.

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98
Q

What is the main complication after an ankle fracture?

A

Post traumatic arthritis. This is rare with appropriate reduction and fixation.

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99
Q

What are risk factors following an ORIF surgery?

A

Surgical site infection, DVT or PE, NV injury, non-union, metalwork prominence.

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100
Q

Definition of cauda equina syndrome?

A

A prolapsed intervertebral disc fills the spinal canal. This compresses the lumbar and sacral nerve roots within the spinal canal

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101
Q

How does CES present? What are red flags?

A

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

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102
Q

What is the investigation for suspected CES?

A

Emergency lumbar-sacral MRI

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103
Q

What does MRI of CES show?

A

Cauda equina nerves being compressed. Shows cause of compression

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104
Q

How do you manage CES?

A

Surgical decompression within 48hrs of onset of sphincter symptoms

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105
Q

Name 2 risk factors for CES?

A

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.

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106
Q

Name a complication of CES

A

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.

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107
Q

Define spinal stenosis

A

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).

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108
Q

How may spinal stenosis present?

A

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

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109
Q

What investigation would you order for suspected spinal stenosis?

A

MRI of the whole spine

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110
Q

How is spinal stenosis managed?

A

Analgesia, exercise, weight loss. If a malignancy is present, high dose corticosteroids, chemo and radiotherapy. Spinal cord decompression.

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111
Q

What are risk factors for spinal stenosis?

A

Malignancy, trauma, infection, disc prolapse.

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112
Q

What complications can arise from spinal stenosis?

A

CES

113
Q

A child sustains a supracondylar fracture of the elbow following a FOOSH. What structures could be damaged and what can this lead to?

A

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
Q

What would be the management for an intertrochanteric NOF fracture?

A

This is an extracapsular break off the femur between the greater and lesser trochanters. Needs DHS.

115
Q

What tendons hold the patella in place?

A

Quadriceps tendon and the patella tendon

116
Q

What do fractures of the olecranon result in?

A

Result in the sudden pull of the triceps (and brachialis) muscle.

117
Q

What do olecranon fractures present with on examination?

A

Tenderness when palpating over posterior aspect of the elbow. Inability to extend the elbow against gravity, as triceps mechanism is disrupted.

118
Q

What XR views would you request for suspected olecranon fracture?

A

Plain AP and lateral of affected joint (+/- joint above and below).

119
Q

In a Weber’s fracture, what other features may be present?

A

Talar shift and shortening.

120
Q

How do you treat NOF?

A

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
Q

What movements are preserved and weakened in the Short head of biceps rupture?

A

Flexion is weakened but supination is preserved

122
Q

What is frozen shoulder?

A

Stiff painful shoulder due to adhesive capsulitis

123
Q

How does the pain from frozen shoulder present?

A

Gradual onset pain and stiffness of the shoulder with reduced movement, most notably external rotation. Pain worsens initially and persists for weeks- months

124
Q

How is frozen shoulder managed?

A

Analgesia(NSAIDS), Physiotherapy and exercise and local intraarticular steroid injection

125
Q

What are the causes of cauda equina?

A

Lumbar disc herniation at L4/5 and L5/S1 level, neoplasms, abscesses, iatrogenic causes

126
Q

How does cauda equina present?

A

Lower back pain with alternating or bilateral radicular pain, saddle parasthesia, urinary retention, urinary incontinence, bowel incontinence or retention

127
Q

How do you manage cauda equina?

A

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
Q

What does an xray of a frozen shoulder look like?

A

Normal

129
Q

What is the mechanism of injury of a scaphoid fracture

A

FOOSH

130
Q

What are the symptoms of a scaphoid fracture?

A

Pain on palpation of the anatomical snuffbox

131
Q

A patient presents to the ED with a suspected scaphoid fracture, on xray there is no abnormality, what would your next steps be?

A

Immobilisation of the wrist in a thumb spica cast (beer glass position) and arrange a repeat xray in 10-14 days

132
Q

What does common peroneal nerve injury cause?

A

Foot drop, due to paralysis of foot extensor.

Foot eversion may also occur.

133
Q

How is common peroneal nerve injury treated?

A

Conservatively.

Surgical intervention is indicated in those who do not have improved neurological function within 2-3 months

134
Q

What is the mechanism of injury of a hook of hamate fracture?

A

Typically in athletes- FOOSH or direct blow to volar proximal palm e.g. athletes who grip hard and big force -hockey stick

135
Q

How does hook of hamate fracture present?

A

tenderness over the hypothenar eminence/ ulnar side wrist pain/ Flexion of thumb whilst palpating the hypothenar eminence also causes pain in that area

136
Q

How are hook of hamate fractures diagnosed?

A

Plain x-ray with ‘carpal tunnel’ view the most useful for visualisation.

137
Q

What muscle is tested by the empty can test?

A

Supraspinatus

138
Q

How do you test for subscapularis function?

A

Gebers lift off test

139
Q

Causes of OA?

A

Idiopathic, infection, inflammation, trauma

140
Q

Name two risk factors for OA?

A

Increasing age, genetic factors, female, obesity, low bone density, previous joint injury, occupational or recreational stress, joint laxity, malignancy, surgery.

141
Q

How does OA present in the knee?

A

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
Q

Describe a ACL tear

A

Anterior cruciate ligament is torn.

143
Q

What is role of ACL?

A

Stops tibia from sliding out in front of femur (i.e. stops anterior translation). Provides rotational stability to the knee

144
Q

How does an ACL tear present?

A

Loss/impaired function.
Hx of twisting the knee.
Rapid joint swelling.
Pain!
Joint feels unstable.

145
Q

What tests would you do for suspected ACL tear?

A

Lachman’s test. Anterior draw test.

146
Q

How is an ACL tear managed?

A

RICE.
NSAIDs
Crutches, knee brace.
Rehab to strengthen quads to stabilise the know. Surgical reconstruction - tendon or artificial Grat used.

147
Q

What is a complication of ACL injury?

A

OA

148
Q

What do the menisci in the knee act as?

A

Shock absorbers
Stabalise knee joint
Allow for distribution of synovial fluid through joint

149
Q

How do meniscal injuries/tears present?

A

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
Q

What tests would you do for suspected meniscal injury?

A

McMurray’s - would be positive.

151
Q

How are meniscal tears managed?

A

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
Q

How does quadriceps tendon rupture present?

A

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
Q

Difference in presentation of meniscal tear and ACL tear - with regard to joint swelling?

A

ACL = rapid joint swelling!!!
Meniscal = slow joint swelling

154
Q

What imaging would you do for quadriceps tear?

A

XR - rule out fracture of patella. USS to measure degree of rupture.

155
Q

You do an examination of a pt with suspected quadriceps tendon tear. What do you find on examination if this is true?

A

Can’t complete a straight leg raise. Can’t extend the knee. (or can only do these movements partially if only partially torn).

156
Q

A pt has a partial quadriceps tendon tear. What is your management plan?

A

Immobilise knee in brace, rehab.

157
Q

A pt has a complete quadriceps tendon rupture. What is your management?

A

Surgery needed! Then need immobilisation in brace for 6 weeks. THEN need strengthening and flexibility exercises.

158
Q

How does patella fracture present?

A

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
Q

What XR is needed for patella fracture?

A

AP, lateral, skyline.

160
Q

What surgical management options are available for patella fracture?

A

Open reduction and internal fixation WITH tension band wiring.

161
Q

When is surgery discussed as an option for a patellar fracture?

A

When there is significant displacement of the patella or a compromise to the extensor mechanism.

162
Q

How does patella tendon rupture present?

A

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
Q

How do presentations of patella tendon rupture and quadriceps tendon rupture differ?

A

Patella - defect is palpable inferior to the patella. Quadriceps - defect is palpable superior to the patella.

164
Q

What imaging would you do for suspected patella tendon rupture?

A

XR to rule out fracture. USS to measure degree of rupture. MRI can be used.

165
Q

How are patella tendon ruptures managed?

A

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
Q

Define a patella dislocation

A

Patella is displaced out of the patellofemoral groove, normally held in place by vistas medius obliques.

167
Q

How do patella dislocations present?

A

Hx of high force trauma on patella/sudden forceful twisting of the knee. Laterally displaced patella

168
Q

What XR would you ask for, for a patella dislocation?

A

AP, lateral, skyline.

169
Q

How is patella dislocation managed?

A

Extend knee and reduce patella. Immobilise to allow healing. Physio to strengthen Vastus Medialis Obliques (VMO)

170
Q

What can be involved in aetiology of compartment syndrome?

A

Reduced compartment size e.g. Tight dressing/cast. Increased compartment content e.g. fracture (increase bleeding) or trauma/burns (increase capillary permeability)

171
Q

What is most common cause of compartmnt syndrome?

A

Fracture

172
Q

How is compartment syndrome diagnosed in a traumatised limb?

A

History, check for 6Ps when examining the limb (tight compartment, shiny), do compartment pressure measurement, CK, myoglobin

173
Q

What clincial parameters do you see in compartment syndrome?

A

Pain, exaggerated by stretch, parasthesia and pressure. These are the first three you see out of 6Ps

174
Q

What is difference between spinal and epidural analgesia?

A

Spinal - injection that starts within mins and lasts 2-3 hours.
Epidural - cannula type medication can be given over longer time 24-48hrs

175
Q

A pt has compartment syndrome. What analgesia should you be aware of that a pt may be on?

A

Epidural analgesia, long acting nerve blocks or controlled IV opiate analgesia as can mask compartment syndrome

176
Q

How is pressure measured in suspected compartment syndrome?

A

Stryker STIC monitor

177
Q

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?

A

Up to 5cm, as further distance affects pressure measurements. Usually within 5cm of fracture site

178
Q

How is compartment syndrome managed?

A

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
Q

Define a fasciotomy

A

Cut skin subcutaneously, cut through fascia to relieve pressure of muscle

180
Q

What is a contraindication of a fasciotomy?

A

Compartment syndrome over 24hours as muscle and nerves are both damaged. No point now as muscle is dead - can lead to systemic effects.

181
Q

What are 4 fascial compartments in leg?

A

Lateral, posterior superficial, posterior deep, anterior

182
Q

What are three fascial compartments of forearm?

A

Posterior, anterior and lateral

183
Q

Within how many hours after confirmed compartment syndrome can you carry out a fasciotomy?

A

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
Q

What is main complication of fasciotomy?

A

Altered sensation within margin of the wounds

185
Q

What is usual presentation of chronic compartment syndrome?

A

Pain, parasthesia over 20-30 mins of exercise, symptoms go away after 15mins rest. Younger patient

186
Q

How does OA of hip present?

A

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
Q

What would you find on examination of pt with OA of hip?

A

Antalgic gait, tenderness round hip. Passive movements are often painful, crepitus. reduced range of movement. Fixed flexion deformity on Thomas test. Trendelenberg gait.

188
Q

What investigations would you order for suspected OA of hip?

A

XR. May want MRI too.

189
Q

What are risk factors for OA of hip?

A

Primary - female, obesity, manual handling occupation, increasing age. Secondary - connective tissue disorders - RA, Marfans, Trauma, Infiltrative diseases

190
Q

What is involved in conservative management of OA of hip?

A

Lose weight. Minimise aggravating activity. Use walking aids. Meds - NSAIDs (remember to give PPI!), corticosteroid injection, Acetminophen.

191
Q

What surgical options would you offer for OA of hip?

A

Total hip replacement, hip resurfacing

192
Q

What are some complications of hip surgery?

A

Anaesthetic complications
Infection
Loosening of the joint
Hip dislocation
Leg length disparity
Thrombosis
Nerve damage

193
Q

Name a differential for OA of hip presentation

A

Teach me surgery: trochanteric bursitis, radiculopathy, spinal stenosis, iliotibial band syndrome

Sciatica, trochanteric bursitis, femoral NOF, gluteus medias tendinopathy

194
Q

What do we mean by an inter-trochanteric fracture?

A

Between lesser and greater trochanter

195
Q

What is a sub-trochanteric fracture?

A

Fracture from lesser trochanter to 5cm distal to this point

196
Q

How does an extra capsular NOF fracture present?

A

Hx of trauma - high energy or low energy if more elderly. Pain. can not weight bear.

197
Q

What would you see on examination of an extra capsular NOF fracture/intracapsular NOF?

A

Shortened and externally rotated leg. Pain on pin rolling the leg or axial loading.

198
Q

What investigations would you do a suspected extracapsular NOF fracture?

A

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
Q

What are RF for extra capsular NOF fracture?

A

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
Q

What is initial management for NOF fracture?

A

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
Q

What is surgical management for intertrochanteric NOF extracap fracture?

A

DHS - dynamic hip sore. Here - screw into the NOF and side plate fixed screw - compress to cause bone healing.

202
Q

What is surgical management for subtrochanteric NOF extracap fracture?

A

Intramedullary femoral nail - titanium rod is placed through medullary cavity of the demur to help stabilise it.

203
Q

Name 2 immediate post op NOF fracture surgery complications

A

Pain, bleeding, leg length discrepancy, NVS damage

204
Q

What are long term complications of NOF fracture surgery?

A

Joint dislocation, aspect loosening, peri-prosthetic fracture, deep infection, prosthetic joint infection

205
Q

What is level of mortality increased by, at one year post NOF fracture?

A

Up to 30%

206
Q

Define intracapsular NOF fracture

A

Fracture in sub capital region of the femoral head to the basocervical region

207
Q

What surgical management would you consider with a displaced sub capital inter capsular NOF fracture?

A

Hip hemiarthorplasty or total hip arthroplasty if independence and systemically well

208
Q

Pt has non displaced intracapsular NOF fracture that needs to be treated surgically. What surgery would be considered?

A

Cannulated hip screws or a total hip arthroplasty

209
Q

What type of surgery would be done for a basocervical intracap NOF fracture?

A

DHS or total hip arthroplasty if systemically well and independent.

210
Q

How can rotator cuff tears be classified?

A

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
Q

How do rotator cuff tears present?

A

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
Q

What tests could you do for suspected rotator cuff tear?

A

Jobe’s test, Gerber’s lift off test and Posterior cuff test.

213
Q

Describe Jobe’s test

A

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

214
Q

Which rotator cuff muscles does Jobe’s test test for?

A

Supraspinatus

215
Q

Describe Gerber’s lift off test

A

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
Q

Which rotator cuff muscles does Gerber’s lift off test test for?

A

Subscapularis

217
Q

Which rotator cuff muscles does posterior cuff test test for?

A

Infraspinatus and teres minor

218
Q

Describe the Hawkins test

A

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
Q

What imaging would you want to do for a patient with pain on lateral aspect of scapula?

A

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
Q

How are rotator cuff tears managed ?

A

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
Q

What are RF for rotator cuff tears?

A

Age, trauma, overuse, repetitive overhead shoulder movements, BMI above 25, smoking, DM

222
Q

How does clavicle fracture present?

A

Sudden onset, severe localised pain, on active movement. On examination, have deformity, focal tenderness, crepitus, tenting of skin.

223
Q

How is clavicle fracture managed?

A

Conservative - broad arm sling. Open fracture need surgical intervention.

224
Q

What is a major complication of clavicle fracture?

A

Non-union. Also could have NV injury and puncture injury i.e haemothorax or pneumothorax

225
Q

How does proximal humeral fracture present?

A

Tenderness, swelling and decreased motion of the arm. May have eccymossis around area.

226
Q

How is proximal humeral fracture managed?

A

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
Q

How does humerus shaft fracture present?

A

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
Q

What is a Holstein-Lewis fracture?

A

Fracture of distal 3rd of humerus, get radial nerve trapped - get loss of sensation in radial nerve distribution and wrist drop deformity.

229
Q

What are RF for humerus shaft fracture?

A

Older age, osteoporosis, pathological fracture.

230
Q

What is an open fracture?

A

Direct communication between fracture haematoma and the external environment

231
Q

What may cause an open fracture?

A

Hx of high energy trauma

232
Q

What investigations would you do for a presentation of an open fracture?

A

FBC, Clotting screen, Group and Save, skin swabs, XR, CT if highly comminuted.

233
Q

What classification system is used for open fractures?

A

Gustilo Anderson

234
Q

How are open features managed initially?

A

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
Q

How are open fractures managed surgically?

A

Wound/fracture site debridement. Saline wash. Skeletal stabilisation. Soft tissue coverage - plastics, vascular surgeons if needed.

236
Q

What are complications of open fracture?

A

Fracture site infection, Osteomyelitis, Compartment syndrome, NV injury

237
Q

What is compartment syndrome?

A

Critical pressure within a confined compartmental space.

238
Q

Why is compartment syndrome so serious?

A
  • 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
Q

How does compartment syndrome present?

A
  • 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
Q

How is compartment syndrome managed?

A
  • Remove cast, splints, dressings.
  • **Immediate fasciotomy !!!! **
  • Give analgesia.
  • Keep limb neutral.
  • Improve O2 delivery, augment BP with a fluid bolus.
241
Q

Name a complication of compartment syndrome

A

Rhabdomyolysis, repercussion injury, check kidney function as good damage kidneys.

242
Q

Define septic arthritis

A

Infection of a joint caused by (usually) Staphylococcus aureus. Can cause irreversible articular damage. Can also be caused by Neisseria Gonorrhoea

243
Q

How does septic arthritis present?

A

A single, hot, swollen, painful joint.

244
Q

What investigations might you want to do for suspected septic arthritis?

A

Bloods - see raised WCC and CRP. ESR, urate. May want to aspirate the joint - send off for microscopy and culture.

245
Q

How is septic arthritis managed?

A

Abx - flucloxacillin for 2-3weeks IV then 2-4 after as oral tablets. Joint revision surgery if prosthetic joint is in pt.

246
Q

What is pseudo gout?

A

Deposition of calcium pyrophosphate within the joint space which causes inflammatory arthritis

247
Q

How does pseudo gout present?

A

Acute onset joint swelling. Usually in knee or wrist.

248
Q

What is seen on XR of knee with pseudo gout?

A

Cloudy appearance in the joint space.

249
Q

What is seen in aspirate of joint with pseudo gout ?

A

Rhomboid shape crystals

250
Q

How is pseudo gout managed?

A

NSAIDs and treat underlying cause

251
Q

What are the three principles of fracture management?

A
  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
Q

Why do we restore the anatomical alignment of a fracture or dislocation?

A

To restrict/stop bleeding at the fracture site. AND to reduce traction on soft tissues, nerves and blood vessels.

253
Q

Why do we rehabilitate in fracture management?

A

To improve clinical outcome for patient. Reduce stiffness, strengthen muscles.

254
Q

What is the most common type of of hip dislocation?

A

Posterior (90%)

255
Q

What is the mechanism of action of a posterior hip dislocation?

A

Dashboard injury

256
Q

How does a posterior hip dislocation present?

A

Internally rotated and slightly flexed and abducted

257
Q

How does an anterior hip dislocation present?

A

Externally rotated, slightly flexed and abducted

258
Q

What is trochanteric bursitis?

A

Inflammation of the bursa overlying the greater trochanter

259
Q

How does trochanteric bursitis present?

A

Lateral hip pain (worse with activity and at night)
Swelling
Positive trendelenburg test

260
Q

What scoring tool could you use for back pain?

A

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
Q

How would you treat a patient who received a LOW RISK score on the Keele STarT Back scoring tool?

A

Self-management / Education
Reasurrance
Stay as active as possible
Analgesia

262
Q

How would you treat a patient who received a MEDIUM / HIGH RISK score on the Keele STarT Back scoring tool?

A

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
Q

NICE 2020 guidance for drug medication for sciatica:

  1. What drugs should you NOT USE?
  2. Which neuropathic can use if worsening / persisting symptoms ?
A

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
Q

Examination findings for meniscal injury?

A

Reduced/restricted range of motion
Localised tenderness to the joint line
Swelling

265
Q

Investigations for suspected meniscal injury?

A

MRI - first line for establishing Dx.
Arthroscopy - gold standard for meniscal tear.

266
Q

Ottawa ankle rules?

A

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
Q

osteomyelitis on xray findings?

A

regional osteopenia, focal cortical loss, periosteal changes

268
Q

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
A
  1. Lung, breast, thyroid, kidney, colon cancer, myeloma
  2. Prostate, breast
  3. breast, prostate, lymphoma
269
Q

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?

A

If the radial nerve is involved, complain of reduced sensation over the dorsal 1st webspace and weakness in wrist extension.

270
Q

Risk factors for developing septic arthritis?

A

Intravenous drug use, diabetes mellitis (immunocompromise; ulcerations as a source of bacteraemia), prosthetic joint, osteoarthritis. Chronic kidney disease

271
Q

What scoring system can be used to classify severity of knee OA?

A

The Kellgren and Lawrence system

272
Q

What does the The Kellgren and Lawrence system for knee OA entail?

A

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
Q

Compare OA and RA based on Aetiology

A

OA :
Mechanical - wear & tear with localised loss of cartilage, remodelling of adjacent bone and
associated inflammation

RA :
Autoimmune

274
Q

Compare OA and RA based on gender it affects

A

OA: similar incidence in men and women

RA: more common in wormn

275
Q

Compare OA and RA based on Age of pt effected

A

OA: elderly

RA: adults of all ages

276
Q

Compare OA and RA based on typical affected joints

A

OA : Large weight-bearing joints (hip, knee)
Carpometacarpal joint
DIP, PIP joints

RA: MCP / PIP joints

277
Q

Compare OA and RA based on typical Hx

A

OA : Pain following use, improves with rest
Unilateral symptoms
No systemic upset

RA: Morning stiffness, improves with use
Bilateral symptoms
Systemic upset

278
Q

Compare OA and RA based on X ray findings

A

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

Y3 surgery old (6 decks)

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