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PHASE 3B > Trauma and Orthopaedics > Flashcards

Trauma and Orthopaedics Flashcards

1
Q

Things to ask about in orthopaedic history?

A

PC: traumatic/ non-traumatic, acute/ chronic, congenital/ acquired, night pain, relieving/ exacerbating factors
Pain, stiffness, swelling, sensory disturbance, weakness/ loss of function, tx for a current complaint, effectiveness, SEs + compliance
Past hx- ops, illnesses/ injuries, pre-morbid function
SHx + functional status
ADLs
Social hx
PMHx
FHx
Tx history and drug allergies
System review

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2
Q

Components to examination?

A

Look: scars, skin changes, swelling, deformity, gait, balance, posture, muscle wasting

Feel: temperature, pain on palpation, joint effusion, abnormal movement, measure (limb length discrepancy,) regional lymph nodes, distal pulses

Move: active + passive movement, abnormal movement, power, joint stability, functional assessment e.g. gait, simple tasks with hands, neuro exam if indicated in MSK disorder

X-ray

Compare with other side
Assess function- dressing, gripping objects
Specific tests- movements, stability, functional status, pain
Systemic examination- co-morbidities

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3
Q

Most common X-ray requests are what? When assessing what should be included? What to look for on an X-ray?

A

In 2 planes at 90 degrees to each other
Joint above and below the fracture, AP film and lateral projection
OLD ACID: Open/ closed
Location
Degree: complete/ incomplete
Articulation involvement
Comminution: simple, wedge, multi-fragmentary (comminuted,) pattern (transverse, oblique, spiral, avulsion)
Intrinsic bone quality
Displacement, angulation, rotation
Type: traumatic, pathological, stress

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4
Q

What is a simple transverse fracture from?

A

Bending force
Small extrusion wedge on compression side of bone- break is perpendicular to shaft of the bone

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5
Q

What is a wedge fracture? What does an extrusion wedge not retain?

A

Most common type of compression fracture usually in the front of a cylinder- shaped vertebra causing the front to collapse
It’s soft tissue attachment- poor blood supply

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6
Q

What is an oblique fracture?

A

Fracture is at an angle to the shaft- extrusion wedge remains attached

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7
Q

What causes a spiral fracture? What happens with a spiral wedge?

A

Twisting force
Wedge fragment is fairly large and retain their soft tissue attachment

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8
Q

What is a segmental fracture?

A

Occurs in the diaphysis at two levels, leaving a ‘floating segment’

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9
Q

Causes of pathological fractures?

A

Osteoporosis, tumours: benign, malignant: metastasis, primary, Paget’s disease, metabolic bone disease: osteomalacia/ rickets, hyperparathyroidism, osteogenesis imperfecta, lymphoma, myeloma, RA, infection

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10
Q

Things important to note with a fracture? Suspected spinal injuries need to have what?

A

Skin condition, peripheral nerve function, vascular status: peripheral pulse + CRT
Log-rolled for examination and full peripheral nervous system examination performed

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11
Q

What are CT scans helpful for? Thinner sectioned CTs are used to detect what? Thicker slices? Applications for CT scans? When are MRI scans used? What are CIs for MRIs?

A

To plan surgery in severe multi-fragmentary intra-articular fractures
Subtle pathology/ large lesions e.g. IC haematoma
High energy spine injuries+ areas difficult to visualise with X-ray, intra-articular fractures- whether fractures are displaced and if so whether surgery will improve fracture fragment positions, tumour surgery- detecting metastases
To diagnose a fracture where doubt exists + follow-up of certain fractures to look for avascular necrosis
Pacemakers, internal hearing devices, IC aneurysm clips, metal fragments in eyes, joint replacements and spinal implants= generally safe

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12
Q

How to describe a fracture?

A

Name + age of the patient and date of X-ray- ABC
A= adequacy and alignment
B= bone: which bone, where i.e. metaphysis etc, fracture pattern, deformity: displacement, angulation, shortening, rotation, joint: intra-articular, dislocation
C= soft tissues: look for air, may indicate open fracture, swelling/ joint fluid
Also: general condition, skin= open/ closed, neurovascular status

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13
Q

Basic principles of fracture management?

A

Resuscitation
Stabilisation- does the fracture need reducing? (yes- displacement in functionally vital area e.g. articular surface or significant displacement, no- undisplaced, risk of anaesthesia outweigh risk of deformity)
Types of reduction: MUA, open reduction

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14
Q

What you need to refer to T&O?

A

How did it happen, when did it happen, pain, PMH= T&O surgery, cancer, osteoporosis, Paget’s disease, SH= mobility (before + after fracture,) frailty
Examination: NV status, open, swelling

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15
Q

When is doing a FBC useful? When is ESR useful? When is it abnormal?

A

If surgery is likely to lead to sizeable blood loss, hx of significant blood loss or CR disease, infection suspected
When it’s normal, when it’s abnormal

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16
Q

What does prothrombin time measure? Increased with what? Activated partial thromboplastin time(APTT)? Increased with what?

A

Measures the extrinsic pathway components- when on warfarin, in liver disease and DIC
Intrinsic pathway components- in haemophilia, DIC + in patients on heparin

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17
Q

When are U&Es measured?

A

In all patients over 65, those with known cardiopulmonary, renal or hepatic disease
Those taking diuretics, steroids or cardiac drugs

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18
Q

In metabolic disorders affecting bone it is always important to measure levels of what in the serum? What serum levels are sometimes indicated?

A

Calcium, phosphate and ALP
Vitamin D levels and urinary calcium levels

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19
Q

What is dark in T1 weighted MRI scans? Bright? T2 weighted scans? MRI scans indications?

A

Water e.g. CSF fluid, bone, air/ fat
Cartilage, bone, air/ water
Spine- prolapsed discs, stenosis, tumours, infection, cord pathology, knee- ligament injuries, meniscal injuries, cartilage studies, hip- labral pathology, avascular necrosis, undisplaced fractures, shoulder- rotator cuff anatomy, hand + wrist- scaphoid fractures, ligament injuries, AVN, others= tumours + infection in all sites

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20
Q

What is the neonatal skeleton investigated by? Why? What is often needed to perform an MRI scan in children under 5 y/o?

A

USS- cartilage is radiolucent, joints often incompletely seen on X-rays as they have not fully ossified- especially relevant with elbow fractures
Sedation or general anaesthetic

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21
Q

Indications for CNS and EMG?

A

Localised weakness or altered sensation, generalised weakness/ altered sensation, weakness alone- MND, NM disease, motor neuropathy, myopathy

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22
Q

Non-operative management options?

A

Rest: reduction in normal activity and avoidance of strain
Splintage and traction
Physiotherapy and occupational therapy
Medications- analgesics, DMARDs, bisphosphonates
Local injections
Radiotherapy
Continuous passive motion

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23
Q

Indications for synovial fluid aspiration?

A

Suspected sepsis, gout/ pseudogout, inflammatory arthropathy
Therapeutic: osteoarthritis/ inflammatory arthropathy, acute haemarthrosis

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24
Q

When is a broad arm sling useful? Collar and cuff?

A

Shoulder injuries- ACJ disruption in particular, clavicular fractures
Non-op management of humeral shaft and neck fractures

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25
Q

What is used for a tibial shaft fracture? Conversion to what permits weight bearing across the fracture encouraging axial micromotion stimulating healing?

A

An above-knee cast to maintain length and alignment by hydrostatic soft tissue pressure and 3-point moulding against the deformity; including the joint above
Patella-tendon bearing or Sarmiento cast(functional brace)

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26
Q

Ix during pre-operative assessment? How long for pre-op fasting?

A

FBC, cross-match or order blood, U&Es, clotting studies, ECG, CXR in deteriorated lung function, cervical spine XR in patients with RA with persistent neck pain or neuro S&S
ECHO, coronary perfusion scan or coronary angiogram may be required
6h for solid food, infant formula or other milk/ 4h breast milk/ 2h clear fluids + non-carbonated fluids

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27
Q

What drugs are usually omitted on the day of surgery? Regional anaesthesia how long after LMWH? What isn’t stopped for regional anaesthesia?

A

ACE-i- can exacerbate hypotension during regional + general anaesthesia, administer IV steroid on long-term steroid use
12 hours- often prescribed at 6pm
Aspirin

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28
Q

What should be supplemented for 3 postoperative nights? Other things to consider?

A

Oxygen- often when CV complications occur
Perfusion- if compromised consider blood loss during surgery to maintain adequate circulating volume with appropriate replacement fluid
Pain + analgesia
Confusion- excess opiates, diabetic control, possible MI/ CVA
Urinary retention- follow hospital protocol if catheterisation required after prosthetic joint replacement for ABx prophylaxis
Compartment syndrome
NV status

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29
Q

Intermediate inpatient ward tx?

A

Prevention of atelectasis or pneumonia- physio, sit up and mobilise if possible, likewise for constipation
Be vigilant for DVT/ PE; embolus= classically 10 days post-operatively
Mobilisation with physio
Wound care- nurses
Definite splintage once post-op swelling receding
Ongoing and step-down analgesia
Discharge planning- ward nurses, physios and OTs

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30
Q

Long-term post-op management?

A

Ongoing occupational and physio
Monitor wound healing- in collab with GP within 6 weeks
Radiographs- indicated/ surveillance

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31
Q

Cancers that have pre-disposition to metastasise to bone? Factors indicating a malignant lump? Blood Ix and urinalysis?

A

Breast, bowel, lung, thyroid, kidney and prostate
Size>5cm, pain at night, increase in size, deep to deep fascia
FBC + film for leukaemia, ESR+ CRP, bone chemistry- calcium/ phosphate, liver enzymes + ALP, acid phosphatase, TFTs, PSA, serum protein electrophoresis + urinalysis for Bence- Jones protein

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32
Q

Common sites for bone tumours? Further imaging?

A

Distal femur, proximal tibia, proximal humerus- metaphyseal and intramedullary
MRI- characterisation + staging, CT- further characterisation, USS- to guide biopsy, assess soft tissue mass or look for abdominal secondaries, CXR or CT chest- mets or primary if bone mets, bone scan- for skeletal measures, abdominal US- visceral mets, angiography/ MRA for surgical planning/ preop embolisation

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33
Q

Bone tumour biopsy for what?

A

Histological diagnosis and grade

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34
Q

Neoadjuvant chemo commonly used to reduce tumour mass and vascularity in what? After surgery what can be given once soft tissues healed? Comps? How can radiotherapy be used? Comps?

A

Osteosarcoma and Ewing’s sarcoma- re-stage post-therapy and assess tumour ‘kill rate’ which is prognostic for patient survival
Further chemo- physeal damage, osteoporosis, AVN, malignancy and organ toxicity
Preoperatively to reduce tumour mass or as adjuvant therapy to kill residual microscopic disease- reduce rates of local recurrence, facilitating limb salvage surgery
Joint + soft tissue stiffness, inflammation of bladder, bowel and liver, hair loss and lymphoedema

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35
Q

Given to reduce bone pain palliatively?

A

Radiotherapy and bisphosphonates- early opiate analgesia with appropriate antiemetics and aperients

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36
Q

Pre-operative RFs for PE and DVT? Intraoperative technique? Post-op measures? Meticillin-resistant S.aureus usually treated with what?

A

Proposed major surgery, previous thromboembolism, advanced age, malignancy, obesity, varicose veins, congestive HF, pre-existing thrombophilia
Regional anaesthesia, minimal soft tissue damage, meticulous haemostasis, compression devices for calves

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37
Q

Post-operative measures for preventing PE + DVT?

A

Mechanical- TED stockings, pneumatic foot compression devices, early mobilisation
Chemical- aspirin, factor XA inhibitors, LMWH, unfractionated heparin/ warfarin
Combinations- better effects achieved when combined
Vancomycin, teicoplanin or rifampicin

38
Q

Ways of preventing infection in trauma and orthopaedics?

A

Prophylactic antibiotics, keep operating time to a minimum, cover instruments when not in use, minimise theatre traffic and operate in laminar flow, 4% chlorhexidine skin prep with spirit in contact for 2 minutes
Minimise use of diathermy + suture material, ensure haemostasis and eliminate dead space, theatre rituals
Post-op ABx, no-touch technique of wound dressing, inspection of wounds and prompt action for discharging wounds, good general hygiene, in particular hand washing

39
Q

Common comps of orthopaedic surgery?

A

Wound infection, resp infection + UTI, MI, local NV injury, DVT, PE, compartment syndrome, bleeding, paralysis, bleeding, periprosthetic fracture, malposition of implants, malunion/ non-union of fractures, joint stiffness, heterotropic ossification, chronic regional pain syndrome

40
Q

Only when can long bone fracture non-union be determined? What is hypertrophic non-union? Tx?

A

6-9 months post-injury
Non-union secondary to mechanical instability of fracture; excessive motion prevents biological union- hypertrophic bone ends, exuberant callus formation, ‘elephant’s foot’ appearance of bone ends
Seen when mobilised too early/ insufficient rigidity of fixation to allow union e.g. metacarpal + metatarsal fractures tx by IM nailing, ulnar nightstick fractures
Stabilisation of the fracture and/ or rigid internal or circular external fixation

41
Q

What is atrophic non-union? Classical cause of what? Most usually seen in what? Management strategies?

A

Non-union due to lack of biological activity in fracture site- most commonly seen in high-energy, open or infected fractures, in smokers and with use of NSAIDs
Failure of internal fixation- in midshaft humerus, clavicle and scaphoid fractures, and internally fixed tibial shaft fractures
Surgical debridement of bone ends, autologous or allogeneic bone grafting, rigid compression and stability with compression plating or circular external fixation

42
Q

What is oligotrophic non-union? Tx?

A

Non-union secondary to excessive fracture gap distraction, post-infection segmental defect, extruded fracture fragments/ interposed avascular comminuted fragments, most commonly seen in the tibia
Similar to atrophic

43
Q

What is fibrous union?

A

Synonymous with non-union- asymptomatic non-union with dense fibrous tissue bridging the fracture and giving some stability

44
Q

End result of non-union? How subdivided? Often what? Tx for symptomatic?

A

Pseudoarthrosis; mobile non non-union site develops synovial characteristics with membrane
Stiff(hypertrophic) or lax (atrophic) types
Painless
That of atrophic non-union

45
Q

A potent cause of non-union? Pattern may be what or what? Tx?

A

Infection- atrophic or hypertrophic
Excision and sampling of all infected tissue, with reconstruction using external fixation(Ilizarov method)

46
Q

Phases of wound healing? Time for suture removal?

A

Inflammatory= 0-5 days
Proliferation= 3-14 days
Maturation= 7 days- 1 year
Face= 5-7 days, limbs= 10-14 days, trunk= 10 days

47
Q

How to treat contaminated wounds?

A

Debride to ensure all foreign material removed, irrigate thoroughly with solution of chlorhexidine in saline, leave open with a saline-soaked gauze wick or pack
Check tetanus status, administer prophylactic ABx tailored to likely contaminants
Plan second look at 48 hours +/- 48h further debridement and irrigation- if clean at this stage can appose skin edges with interrupted sutures

48
Q

What does arthroplasty mean? Operative options for RA? OA?

A

Surgical reconstruction or replacement of a malformed or degenerated joint
Synovectomy, soft tissue realignment and arthroplasty
Arthroplasty for severe OA in the knee + hip- also indicated in the ankle and shoulder
Arthrodesis in the ankle and DIPJs of hand and foot + in spine
Osteotomy, cartilage transplantation + joint distraction= limited indications

49
Q

How do osteoid sarcomas present? Ix? Tx?

A

Pain, especially at night characteristically eased by aspirin- can cause a limp/ tenderness depending on the site
CT/ MRI
NSAIDs with high recurrence risk or ablative
Radiofrequency ablation= less invasive than excision- does not yield specimen if Ix is in doubt

50
Q

How does osteoblastoma present? Tx?

A

Larger with more aggressive appearances may mimic osteosarcoma radiologically and histologically- usually between 10 and 30 y/o, M>F, mostly in posterior elements of spine
Pain of insidious onset, partial response from NSAIDs
Observation, curettage or marginal excision with bone grafting

51
Q

What is an osteosarcoma?

A

Tumour of young adult at metaphyseal sites of rapid growth- mets= present at Ix in 10-20% and determine survival
Primary= seen in 10-20 year olds- genetic link to Li-Fraumeni syndrome, retinoblastoma, Rothmund Thomson syndrome, Bloom syndrome, Werner syndrome

52
Q

Osteosarcoma lesion may be what? Secondary osteosarcoma seen where? Tx?

A

Intramedullary, parosteal, periosteal, telangiectatic
In areas of pagetic bone or fibrous dysplasia, or sites of previous radiotherapy, in de-differentiated chondrosarcoma
MDT often with neoadjuvant chemo, surgical= local disease control

53
Q

What is an enchondroma? Ix? Tx? Ass w/? Stages?

A

2nd most common benign cartilage lesion- osteochondroma= most common
Proliferation of hyaline cartilage in metaphysis/ diaphysis- common in hands and feet, between ages of 20-50 y/o
Well-defined lucent, central medullary lesion that is 1-10cm often ass w/ pop-corn stippling, arcs, whorls, or rings
Observation- most are asymptomatic
Solitary enchondroma, Ollier’s disease, Maffucci’s syndrome
Latent, active, aggressive lesions

54
Q

What is an osteochondroma? Growth after skeletal maturity suggest what? Ix? Tx?

A

Benign chondrogenic lesions from aberrant cartilage from the perichondrial ring commonly on bone surface and at sites of tendon insertion–> solitary osteochondroma or Multiple Hereditary Exostosis- most grow away from the joint except in Trevor’s disease= towards the epiphysis
Between ages 10-30 y/o w/ a painless mass
With MRI or US- sessile or pedunculated lesions found on bone surface
Observation/ surgical resection in progressive + severe pain

55
Q

What is a chondroblastoma? Typical patient? Ix? Tx? May have genetic mutations on what chromosomes?

A

Benign lesion with low met potential- commonly found in the epiphysis of the proximal tibia and distal femur
Between the ages of 10-20 y/o with regional pain, M:F= 2:1
Biopsy–> chondroblasts arranged in cobblestone or chickenwire pattern with focal areas of chondroid matrix
Extended intralesional curettage and bone grafting
5 and 8

56
Q

C3 radiculopathic sx? C4? C5? C5? C6? C7? C8? In early stages? What test is positive + pain where?

A

Pain in back of neck and mastoid area and pinna and trapezius
Pain and numbness in back of neck, anterior
Pain side of neck to top of shoulder, weak deltoid, no reflex change
Pain lateral arm, forearm and thumb, weak biceps and biceps reflex
Pain middle forearm and middle finger, weak triceps and triceps reflex
Pain medial forearm/ little finger, intrinsic hand atrophy, normal reflexes
Paraesthesia, Spurling’s test, axial neck pain mainly to the side of the pain

57
Q

Myelopathic symptoms?

A

Gait disturbance, spasticity, decreased manual dexterity, paraesthesia and weakness

58
Q

Myelopathy signs?

A

Hypertonia, hyperreflexia, weakness, positive Hoffman’s test, L’Hermitte’s sign= 25%, up-going plantar response, paradoxical/ inverted brachial reflex= C6 involvement, urinary disturbance, abnormal gait, decreased dexterity, sensory disturbance, spasticity, clonus, Babinski’s sign

59
Q

Red flags for back pain?

A

<20 y/o, >50 y/o at onset, non-mechanical pain, nocturnal pain, fever, night sweats, weight loss, thoracic pain, severe/ progressive neurological deficit, sphincter disturbances, immunosuppression, hx of infection of malignancy, significant trauma or deformity

60
Q

PP of spondylosis? Spinal canal stenosis–>? More laterally?

A

Dehydration + decreased elasticity of IV disc occur with age and cracks and fissures appear in IV discs, surrounding ligaments–> less elasticity and thicken, collapse of IV discs, annuli of discs bulge outward, uncinate processes over-ride and hypertrophy and facets over-ride and hypertrophy–> marginal osteophytes
Myelopathy, radiculopathy

61
Q

C5/C6 pathology affects what nerve root? IV joints involved in decreasing order of frequency? T1 radiculopathy usually arises due to what?

A

C6
C5/C6, C5/C6/T1, C6/C7, C4/C5
Pancoast tumour at the lung apex

62
Q

DDx of myelopathy?

A

MS, acute disc prolapse, neurofibroma of nerve root or subacute combined degeneration of the cord

63
Q

Thoracic spondylosis presents how? Roots exit where? Lumbar spondylosis? Ix? Tx?

A

Pain often triggered by flexion and hyperextension
Below the vertebrae(unlike the cervical vertebrae)
Asymptomatic–> symptomatic with impingement, disc disease or spinal stenosis
Plain XRs including obliques, CT + MRI
Medical, immobilisation/ brace, collar, decompression/ fusion may be considered

64
Q

Ix of disciitis?

A

Hx, inflammatory markers, urine/ blood cultures, XR- disc space narrowing, endplate erosions, increased uptake on bone scan, MRI= gold standard, disc aspiration

65
Q

Which lumbar disc herniates most often? Ix?

A

L4/L5 disc followed by L5/S1 disc
MRI

66
Q

What is discogenic pain?

A

Back pain without a radicular component with no evidence of neural compression or segmental instability- plain XR= normal or show degenerative changes

67
Q

Sx of spinal stenosis usually develop in what decades? Pathology? Types?

A

5th and 6th decades
Disc dehydration–> loss of disc height and increases loading of the facets–> hypertrophy and w/ bulging annulus and thickening of ligamentum flavum–> stenosis= narrowing of the spinal canal/ neural foramina–> root ischaemia and neurogenic claudication
Central, lateral and foraminal

68
Q

Presentation, Ix and tx of spinal stenosis?

A

Usually >60 y/o, unilateral/ bilateral leg pain with or without back pain on walking upright with or without back pain on walking upright
Often preceded by longstanding low back pain
O/E= loss of lumbar lordosis, decreased lumbar movements and occasionally nerve root tension signs/ motor or sensory deficit
MRI= gold standard
Operative= laminotomy or laminectomy and decompression of nerve roots

69
Q

What does the coccyx consist of? Articulates with the sacrum how? Who is coccydynia more common in?

A

Four or more bones fused together
A vestigial disc and ligaments
Females- coccyx= rotated and facing backwards which makes it more susceptible to trauma, female broader pelvis places sitting pressure on the coccyx in addition to the ischial tuberosities

70
Q

What are osteoid osteomas? When do patients present? How is Ix made? What is tx with?

A

Small, benign osteogenic bone lesions most commonly found in the proximal femur
Between ages 5 and 25 with regional pain that is worse at night + improves with NSAIDs
Radiographically by a characteristic lesion that is <1.5cm in diameter with a sclerotic margin and radiolucent nidus
Non-operative w/ observation + NSAID for pain control- radiofrequency ablation or surgical resection may be indicated

71
Q

Epidemiology and location of osteoid osteomas? Stages?

A

M:F= 3:1 ratio
>50%= lower extremity- proximal femur> tibia diaphysis usually within bone cortex
Spine- thoracic + lumbar > cervical + sacral
Hand- scaphoid + proximal phalanx
Talar neck
3 stages: latent, active or aggressive lesions

72
Q

What are intramedullary osteosarcomas? They’re most commonly found where? Typical patients? Ix made how? Tx?

A

Malignant, aggressive, osteogenic bone tumours commonly found in distal femur or proximal tibia
Children/ young adults that present with rapidly progressive pain and swelling
Biopsy–> malignant mesenchymal cells with significant atypia + presence of lacey osteoid
Neo-adjuvant chemo, wide surgical resection, followed by adjuvant chemo

73
Q

What is a parosteal osteosarcoma? Ix? Tx? Main DDx?

A

Malignant low-grade osteosarcoma occurring on the surface of the metaphysis of long bones
Typically between 30 and 40 y/o with painless mass, F>M
Heavily ossified, lobulated mass arising from the cortex with biopsy showing cellular atypia seen between regularly arranged osseous trabeculae
Wide surgical resection
Fibrous dysplasia

74
Q

What are periosteal osteosarcomas? Typical patient? Ix? Tx?

A

Rare, malignant intermediate- grade surface osteosarcomas commonly on the diaphysis of the femur and tibia
15-25 y/o w/ regional pain and swelling
Lesion that has a classic sunburst or hair on end periosteal reaction with biopsy showing cellular atypia with areas of osteoid and chondroblastic matrix
Neo-adjuvant chemo, limb salvage surgical resection followed by adjuvant chemo

75
Q

What are telangiectatic osteosarcomas? Most commonly found where? Ix how? Tx?

A

Rare, malignant high-grade osteosarcomas most commonly in proximal humerus, femur and proximal tibia between ages 5-25 y/o w/ regional pain + swelling, M>F
Biopsy–> high grade sarcoma with mitotic figures seen in intervening cellular areas, lakes of blood mixed with malignant cells
Neo-adjuvant chemo, limb salvage surgical resection followed by adjuvant chemo

76
Q

Inheritance of multiple hereditary exostosis (osteochondroma)? Presentation?

A

AD of EXT1, EXT2 and EXT3 genes- EXT1= more severe presentation
Limb deformities- knee, forearm and ankle, joint pain, ulnar shortening + radial bowing, radial head dislocation, ulnar deviation of the hand

77
Q

Complications of osteochondroma?

A

Pseudoaneurysm of the popliteal artery in the popliteal fossa, nerve compression- sciatic/ common peroneal/ radial nerve, tendon compression, chondrosarcoma, bursa formation, recurrence after resection

78
Q

What are chondromyxoid fibromas? Typical presentation? Ix? Tx?

A

Rare, benign chondrogenic lesions characterised by variable amounts of chondroid, fibromatoid and myxoid elements most commonly in metaphysis of long bones, pelvis, feet or hands
Between ages of 10 and 30 y/o with regional pain + swelling, M>F
Biopsy–> hypercellular area with lobules of fibromyxoid tissue and myxoid stroma with stellate cells
Intralesional curettage and bone grafting/ PMMA

79
Q

What are chondrosarcomas? Typical presentation? Ix? Tx?

A

Malignant bone tumours composed of chondrocytes with variable degrees of malignancy most commonly in pelvis and proximal femur, typically after 40 y/o with progressively painful mass, M>F
Biopsy–> hypercellular stroma “blue-balls” of cartilage lesion which permeate bone trabeculae
Chemo + radiation, intra-lesional curettage, wide surgical resection

80
Q

What is Ewing’s sarcoma? Ix? Tx?

A

2nd most common primary malignant bone tumour in children- distinctive small round cell sarcoma ass w/ t(11:22) translocation most commonly occurs in diaphysis of long bones in patients <25 with regional pain, swelling + fevers, M>F
Biopsy–> sheets of monotonous small round blue cells with prominent nuclei and minimal cytoplasm + immunostaining +ve for CD99
Neo-adjuvant chemo and limb salvage surgical resection followed by adjuvant chemo +/- radiation

81
Q

Presentation of Ewing’s sarcoma? Comps?

A

> 50%= sx for >6 months before Ix- delayed more common in pelvis and axial skeleton
Pain- often worsen at night, swelling, erythema, mass, fever, weight loss
Swelling, local tenderness
Limp + decreased ROM depending on tumour location
Secondary neoplasms, haematologic malignancy, recurrence/ progression, metastases, radiation therapy comps, VTE

82
Q

Most common place for sarcoma to metastasise to?

A

Lungs

83
Q

What is a leiomyosarcoma? Presentation? Ix? Tx?

A

An aggressive sarcoma thought to arise from the smooth muscle cells lining small blood vessels
5th and 6th decades of life with pain and palpable mass- most commonly metaphysis of long bones
Biopsy–> spindle cell neoplasm with similar characteristics shared between the osseous and soft tissue forms, immunostains= +ve for actin and vimentin
Chemo, radiation, wide surgical resection with radiation

84
Q

What are rhabdomyosarcomas? Presentation? Ix? Tx?

A

Malignant tumours of the primitive mesenchyme coming in 4 sub-types: embryonal, alveolar, botryoid and pleomorphic- most common sarcoma in children
Embryonal + botryoid= young children, alveolar= young adults, pleomorphic= older patients
Rapidly growing painless mass- most in head/ neck, GU system or retroperitoneum
Biopsy, immunostains= +ve for desmin, myosin and vimentin, CT for staging + MRI for tx planning
WSE with chemo for paed + not chemo for adult, WSE with radiation for adult pleomorphic

85
Q

What are lipomas? Presentation? Ix? Tx?

A

Benign tumours of mature fat which may be SC, extramuscular or intramuscular
40-60 y/o with stable, mobile and painless mass, M>F, >sedentary individuals
Superficial= common in upper back, thighs, buttocks, shoulders and arms, deep= affixed to surrounding muscle, thighs, shoulders and arms
MRI- homogenous lesion with signal intensity matching adipose tissue on all image sequencing
Observation, marginal surgical resection for symptomatic/ rapidly growing, deep to fascia or in retroperitoneum, spindle cell/ pleomorphic= marginal resection

86
Q

Common variants of lipoma? Sx?

A

Spindle cell, pleomorphic, angiolipoma, intramuscular lipoma, hibernoma
Painless mass present for a long time, angiolipoma= painful when palpated

87
Q

What are liposarcomas? Presentation? Ix? Tx?

A

Heterogeneous class of sarcomas with differentiation towards adipose tissue- 2nd most common form soft tissue in adults, 5 sub-types: well-differentiated, myxoid, round cell, pleomorphic, undifferentiated
50-80 y/o- slow-growing, painless mass, M>F
Lower>upper extremity, tend to occur deep to fascia, common in retroperitoneum
Biopsy- immature lipoblasts various cellular atypia depending on sub-type
Marginal excision for well-differentiated, WSE for intermediate and high-grade liposarcomas

88
Q

What are angiosarcomas? Presentation? Ix? Tx?

A

Malignant, aggressive tumours from endothelium of blood vessels
Typically in elderly patients with regional pain and overlying skin changes, M>F
Biopsy= malignant cells ass w/ vascular structures, MRI evaluate soft tissue mass
WSE w/ radiation, amputation

89
Q

What is a synovial sarcoma? Presentation? Ix? Tx? Check for what?

A

A malignant soft tissue sarcoma caused by a t(X;18) chromosomal translocation mutation most commonly found near joints, but rarely within the joint
15-40 y/o with growing mass in proximity to a joint, may be painful/ painless, M>F, most common malignant sarcoma of the foot
Biopsy- classic biphasic appearance with atypical spindle cells and epithelial cells, immunostaining= +ve for epithelial membrane antigen + vimentin
WSE with radiation pre or post surgery, chemo
Regional lymphadenopathy

90
Q

Sarcomas which can metastasise to lymph nodes? Can stage how? More common with what?

A

Angiosarcoma, clear cell sarcoma, rhabdomyosarcoma, epitheloid sarcoma
Lymph node biopsy- not as bad as lung mets
Large, deep, and high grade sarcomas

91
Q

What is Kaposi’s sarcoma caused by? Most often seen in who? Ix? 3 elements in staging? Tx?

A

Human herpes virus 8
Patients with end-stage HIV–> typical red/ purple raised skin lesions- commonly around the mouth, nose and throat, also other body parts
May involve internal organs e.g. lungs–> dyspnoea
May be superimposed bacterial infection
Spindle cells, highly vascular, may be surrounding inflammation, detection of LANA confirms, CXR
TIS- extent of tumour, status of immune system, extent of organ involvement/ systemic illness
Palliative tx

92
Q

Syringomelia presentation?
Ix?

A

“Cape-like” loss of pain and temp sensation, light touch & position and vibration sensation usually not affected, upper limbs affected first, occipital headache, central cord syndrome
FBC, U&Es, LFTs, B12, ESR/ CRP, aquaporin 4/ MOG antibody screens

PHASE 3B (11 decks)

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