Trauma and Orthopaedics Flashcards
1
Q
What are the three parts of the femoral head when talking about fractures?
A
Femoral Neck
Intertrochanteric
Subtrochanteric
2
Q
What are the four red flags for cauda equina?
A
Saddle anaesthesia
Lower back pain
Bowel or urinary incontinence or retention
Leg weakness
3
Q
What are the motor tests for the ulnar, radial and median nerve?
A
Cross fingers
Wrist cocked back
Pincer grip finger to thumb
4
Q
What is Schober’s Test?
A
Measures extent of lumbar flexion - measure 10cm above and 5cm below L5, ask patient to lumbar flex, this distance should increase by >5cm
5
Q
What is the cancer referral time for children?
A
48-hours
6
Q
What are common causative organisms of septic arthritis?
A
Staph aureus
7
Q
What is Koscher’s Criteria?
A
Non-weight bearing of affect side
Fever >38.5
ESR >40
WCC >12
8
Q
What are risk factors for septic arthritis?
A
Prosthetic joints, diabetes, immunodeficiency, IVDU
9
Q
What investigations should be done in suspected septic arthritis?
A
Blood culture, Joint aspiration, Bloods (urate to rule out gout, WCC)
XR will not always show changes for a while
10
Q
How is septic arthritis treated?
A
IV antibiotics
Surgery - irrigation and debridgement
11
Q
What are 3 features of osteomyelitis?
A
Sequestrum - development of dead bone
Involcrum - formation of new bone
Brodie’s abscess - abscess surronded by thick fibrous tissue and sclerotic bone
12
Q
What is osteomyelitis treated with?
A
IV cefuroxime
Surgical drainage and debridement
13
Q
What types of sarcomas exist?
A
Rhabdomyosarcoma (soft and connective tissue)
Osteosarcoma (15-19 years old)
Ewing’s Sarcoma
Chondrosarcoma
14
Q
What are some key and red flag features of sarcoma?
A
Non-mechanical pain, pain at night
Weight loss
Swelling, lump >5cm, fever
15
Q
What are some causes of hypercalcaemia?
A
Hyperparathyroidism (parathyroid adenoma, high PTH)
Malignancy (breast, prostate, thyroid metastasise to bone, PTH will be normal)
16
Q
How is high calcium managed?
A
Fluids, bisphosphonates (pamidronate IV)
17
Q
What is tetany and what is it a sign of?
A
A clawing of the hand, commonly seen in hypocalcaemia
18
Q
Where is 25-OH vitamin D found and where is it converted?
A
Found in the liver, converted in the kidneys
19
Q
What is osteomalacia?
A
This is under-mineralisation and bone softening. In childhood it is known as rickets.
Serum biochem will show low serum calcium, raised ALP (raised in bone destruction), treat with vitamin D
20
Q
What are some classic features of rickets?
A
Bowed legs, splayed metaphysis, limb deformity, #, slow growth
21
Q
What is a clinical presentation of osteoporosis?
A
A fall from standing resulting in a Collies or Hip #
22
Q
What are risk factors for osteoporosis?
A
Post-menopausal, early menopause Family history of hip fractures Current smoker Steroid use Obesity, low BMI
23
Q
What T-Score on a DEXA scan would indicate osteoporosis?
A
-2.5 osteoporosis
T-score is the standard deviation score compared to adult men or woman at 30 years old
24
Q
What is a blood marker of bone turnover?
A
PN1P
25
How is osteoporosis treated?
Bishosphonates
| HRT in woman
26
What are some clinical features of Paget's Disease?
An increase in bone turnover (increased osteoblasts and osteoclasts)
Bone pain
Bone remodelling, enlargement and deformity
27
What are some complications of Paget's Disease?
Deafness
| Myelopathy
28
What is Paget's Disease treated with?
Bisphosphonates
29
Name five types of fracture
```
Transverse
Linear
Oblique
Spiral
Comminuted
```
30
What are the three parts to a bone?
Diaphysis (shaft), metaphysis, epiphysis (end)
31
How is displacement described in fractures?
In relation of the distal part to the proximal part, the angulation (valgus or varus), if there is rotation, shortening or translation
32
What are the three classifications of joint involvement?
A - away from the joint
B - one part of the joint
C - lack of joint continuity
33
What are some factors that influence fracture healing?
Age, nutrition, smoking, drugs, site, diabetes, infection
34
How is an open fracture managed? (six points) (A)
```
Assessment
Antisepsis
Alignment
Anti-tetanus
Antibiotics
Analgesia
```
35
What is the main blood supply to the femoral head?
Deep femoral artery - medial and lateral circumflex artery
Intraosseous blood supply
Disruption of these can lead to avascular necrosis of the femoral head
36
What nerves are at risk in shoulder and elbow dislocations and how is this tested for?
Shoulder - axillary, test axillary patch
| Elbow - ulnar, test finger crossing
37
Low calcium, phosphate and vitamin D with a raised ALP and raised PTH indicates...?
Osteomalacia - Vitamin D3 deficiency
Treat with Vitamin D3 supplements
38
Pain in the anatomic snuffbox indicates...
Scaphoid #
39
What is a Colles and Barton's #?
Colles - a # of the distal radius, occurs after a fall onto an outstretched hand
Barton's - a fracture of the distal radius, but intraarticular
40
Describe the typical presentation of compartment syndrome and the definitive management?
Recent #, sudden severe pain, worsened by passive movement, pallor
Requires analgesia and a fasciotomy
The presence of a pulse does not rule out compartment syndrome.
41
What is the typical presentation of slipped upper femoral epiphysis?
An overweight adolescent boy with hip or knee pain
42
What is the first line management of ankylosing spondylitis?
NSAIDs + exercise regime
| If NSAIDs fail and disease moderate-severe then infliximab
43
What is a Goleazzi #?
Radial shaft fracture with associated dislocation of the distal radioulnar joint
Direct blow
44
What is Pott's #?
Bimalleolar fracture of the ankle
| Forced foot eversion
45
What is Bennet's #?
Intra-articular fracture of the first carpometacarpal joint, occurs when flexed trauma, often when punching, on x-ray a triangular fragment at ulnar base of metacarpal
46
Monteggia's #?
Dislocation of the proximal radioulnar joint in association wtih an ulnar fracture
Fall on outstretched hand with forced pronation
47
What is a Galeazzi's fracture?
Wrist fracture with distal radio-ulnar dislocation
| Occurs when falling onto an outstretched hand with wrist in flexion
48
What is the blood supply to the femoral head?
Deep femoral artery - medial and lateral circumflex artery
| Intraosseous blood supply
49
A patient presents with swelling of the digits, holds the fingers in strict flexion and there is pain on palpation and passive digit extension. What are these symptoms known as and what does it indicate?
Kanavel's sign
| Flexor tendon sheath infection
50
Dupuytrens Contracture is often associated with which diseases?
What is the presentation?
Liver cirrhosis and alcoholism
Fixed flexion contracture of the hand where the fingers bend towards the hand and cannot be fully extended
51
What nerve causes Carpal Tunnel Syndrome and what symptoms might a patient have?
Median Nerve
Altered sensation in lateral 3 fingers - finger, thumb and middle finger
Wasting of thenar eminence muscles
Tinel's test positive
Flexion of the wrist reproduced symptoms (phalen's)
52
What are some differentials for lumps on the hand?
Osler's nodes - immune complex deposits, Endocarditis
Bouchards nodes - OA, proximal joints
Heberdens nodes - distal, OA
Ganglion - swelling in association with a tendon sheath near a joint
53
How might a meniscal tear present?
Effusion - gradual swelling over knee
Tenderness of joint line
Following a twisting mechanism
Joint locking
54
What is chondrolamalacia patella?
Occurs in teenage girls following a knee injury
History of pain going downstairs or at rest
Tenderness, quadriceps wasting
55
What does a raised APTT and normal PT indicate?
Antiphospholipid syndrome with a history of miscarriage, thrombocyopenia
Heparin can cause prolonged APTT
Autoimmune thrombocytopenia can cause low platelets
VWD - APTT prolonged, no effect on platelets
Haemophilia - APTT prolonged, no effect on platelets
56
What is avascular necrosis of the hip?
Death of bone tissue secondary to loss of the blood supply leading to bone destruction and loss of joint function. Causes include long-term steroid use, chemotherapy, alcohol excess and trauma
57
What investigations should be done in suspected avascular necrosis?
Plain XR: may be ormal, may show articular surface collapse in a crescent sign
MRI: Investigation of choice
58
What is a blue sclera in a child associated with?
Osteogenesis Imperfecta
This is a collagen disorder characterised by multiple fractures and deafness (otosclerosis)
59
How should you manage plantar fasciitis?
Conservatively
Rest, weight loss, stretching exercises
NSAIDs appropriate but not immediate
60
How do you treat pseudogout?
NSAIDs
61
What is your management for acute reactive arthritis?
Chronic?
NSAIDs
Intra-articular steroids
Sulfasalazine or Methotrexate for chronic
62
What should you give patients on long-term steroids?
Bisphosphonate
Calcium + Vitamin D replacement
PPI
63
What is Osgood Schlatters disease?
Occurs in athletic teenagers
Worse on activity, settled with rest
Multiple micro fractures at tendon insertion into tibial tuberosity
Most settle with physio and rest
Tenderness overlying the tibial tuberosity and associated swelling at site
64
What is your investigation of choice for suspected osteomyelitis?
MRI
65
What is adhesive capsulitis and what is a common group it presents in?
Frozen shoulder
Diabetics
66
Give some differentials for shoulder pain and key movement problems these patients experience?
Adhesive capsulitis - painful stiff should with restriction of active and passive range of motion in abduction, internal and external rotation (goes first)
Acromioclavicular degeneration - popping, swelling, clicking or grinding, positive scarf test
Subacromial impingement - pain on overhead activities and painful arc of abduction
Rotator cuff tears - specific trauma or chronic impingement
Calcific tendinopathy - tenderness of palpation of the affect area, reluctance to move the arm
67
What is Erb-Duchenne Paralysis?
Damage to C5 and 6 nerve roots
Occurs in breech presentation
Winged scapula
68
Which nerves are responsible for a knee jerk and ankle jerk?
L4 - knee jerk
| S1 - ankle jerk
69
How is a shoulder dislocation managed?
Prompt reduction
Check neurovascular status
X-rays to check no #
70
A pain in the back of the calf and a positive Simmond's sign indicates?
Achilles tendon rupture
| Common when playing sports, 'pop in ankle' and significant pain in ankle or calf, inability to walk
71
What are your main differentials for elbow pain?
Lateral epicondylitis (tennis elbow) - lateral pain, worse on resisted wrist extension with elbow extended
Radial tunnel syndome - similar to above, but pain doesn't originate from epicondyl
Medial epicondylitis (golfer's elbow) - medial pain, worse on wrist flexion and pronation
Cubital tunnel syndrome - 4th5th finger tingling, may be worse when elbow resting
Olecron bursitis - swelling over posterior aspect of the elbow, middle-aged male patients, maybe pain, warmth, erythema
72
What are some causes or risk factors for avascular necrosis of the hip?
Long-term steroid use
Chemotherapy
Alcohol excess
Trauma
MRI investigation of choice
73
When describing fractures on X-Ray what method can you use to describe them?
Adequacy and Alignment
Bones
Cartilage
Soft Tissue
```
Open or Closed
Location - proximal/mid/distal
Degree - complete or incomplete
Articular involvement/Angulation
Communion & Pattern
Intrinsic Bone Quality
Displcement/Rotation
```
74
What is your management of an open fracture?
Saline soaked gauze
IV antibiotics
Tetanus booster
Analgesia
Reduction and splint
Surgical debridement and later fixation
75
What is Weber’s ankle classification for fractures?
A – below syndesmosis – conservative mx
B – at level of syndesmosis – cast or XR weight bearing and ORIF
C – unstable, ORIF
76
How do you manage an intertrochanteric and subtrochanteric fracture?
```
Intertrochanteric = dynamic hip screw (DHS) weight bearing immediately as it aids healing
Subtrochanteric = intramedullary nail (IM nail AKA Gamma nail)
```
77
What are your different managements for an undisplaced intracapsular NOF#? How does a displaced fracture change your management?
Young – ORIF
| Old – hemiarthroplasty (in a displaced fracture consider THR)
78
What nerve is at risk in elbow dislocations?
Ulnar
79
Which kind of humeral fracture is more common – the surgical neck or anatomical neck?
The surgical neck
80
What nerve is most at risk in an anterior shoulder dislocation? Are anterior or posterior dislocations more common?
Axillary nerve
| Anterior – posterior requires high impact trauma
81
What pre-op bloods should be done before fracture surgery?
Pre-op bloods – G&S, U&E, FBC, Coag, ECG, if old CXR, cannula
82
A young patient, unable to weight bear, pulses present, fibula fracture on XR – management?
Open reduction and internal fixation
83
In the elderly those with a hip fracture, usually independent and fracture proven to be intracapsular are treated with…?
Total hip replacement
84
What antibiotic do you use for septic arthritis and what route is it given?
IV Flucloxacillin
85
Explain how vitamin D is supplied to the body?
Supplied in diet
Precursor in skin following UV exposure
Liver - hydroxylation to active form 25(OH)D => calcidiol
Kidneys - produced 1,25-dihydroxyvitamin D3 = calcitriol
86
Give some reasons for vitamin D deficiency? (4)
```
Reduced sunlight exposure
Poor diet (oily fish, liver, egg yolks)
Renal disease
Dark / pigmented skin
Vegetarianism
GI surgery or diseases
```
87
What is the function of PTH?
- Parathyroid hormone
- Increases osteoclast activity - releases Ca and PO4
- Increases Ca2+
- Decreases PO4 reabsorption in kidney
Stimulates calcitriol production in kidney
88
What is the underlying pathophysiology of osteomalacia?
Lack of vitamin D means there is a lack of calcitriol produced
Low levels of calcitriol means low levels of calcium
Low calcium means osteoclast activity increases, taking calcium from bone and causing bones to become undermineralised
= osteomalacia
89
What can you give someone in osteomalacia?
```
Vitamin D
Calcium supplements
Increased sunlight exposure
Better diet - oily fish, milk
Bisphosphonate
```
90
What are some triggers for gout?
Infection
Dehydration
Alcohol
Diuretics - thiazide
91
Which vasculitits is associated with pANCA?
Churg Strauss Syndrome – eosinophilic granulomatosis with polyangiitis, asthma history, petechial rash, nasal polyps, impaired kidney function
Wegener’s - cANCA
92
Give some potential causes for arm and hand numbness and weakness
Cervical spine fracture
Nerve root compression
Intervertebral disk prolapse
93
What are important things to assess in fractures?
Open or closed?
Neurovascular status
Is it displaced?
Stable or non-stable?
94
How do you go about describing fractures?
Radiograph: position, type, who
Type: complete or incomplete? Transverse, oblique, spiral, communicated, bowing, buckle, greenstick, Salter Harris (if growth plate involvement)
Where: bones involved, part of the bone
Displaced or not displaced? Angulation, translation, rotation
Joint involvement?
95
What is the Salter-Harris Classification?
| What are the different classifications?
```
Classification of fractures when there is growth plate involvement
I – Straight through
II – Above
III – Lower
IV – Through everything
V – cRush
```
96
What mechanism can result in a medial malleolus fracture?
Forced inversion or eversion of the foot
97
What is a classic sign of a hip fracture?
Leg is shortened and externally rotated
98
What are the 2 main locations a hip fracture can occur?
Intracapsular
| Extracapsular – can be trochanteric or substrochanteric
99
What is your management for Intracapsular hip fractures?
Undisplaced – internal fixation or hemiarthroplasty if unfit
Displaced – young and fit – reduction and internal fixation
Older and reduced mobility – hemiarthroplasty or THR
100
What is your management for an extracapsular hip fracture?
Dynamic hip screw, intramedullary device
