Trauma & orthopaedics Flashcards
1
Q
Hip anatomy
A
Ball + socket from acetabulum to HoF, capsule just proximal to intertrochanteric line (flat, anterior). Intertrochanteric crest is deeper + posterior
Ligaments: intracapsular (lig of HoF) and extra capsular (continuous with capsule; iliofemoral (strongest), pubofemoral and ischiofemoral
Supplied by medial circumflex femoral a and lateral circumflex (less), branches of profunda femoris
Stabilised by acetabular labrum, extra capsular ligaments, muscles
Movement: stability and weight bearing
2
Q
Hip OA
A
Articular wear - particles swept to side - synovial irritation - loss of articular cartilage - subchondral bone exposed - grooves in joint surfaces - cysts
RF: >45, female, vit D deficiency, obesity, h/o trauma, high impact sports
CF: dull aching pain around hip/anterior thigh/groin, worse with activity, stiff after immobility, may have quad/gluteal wasting + reduced power, may have leg length discrepancy (adduction deformity) or fixed flexion deformity (corrected for by lumbar hyperextension), antalgic or Trendelenberg gait, crepitus, reduced ROM, referred pain in knee, loss of movement from osteophytes
XR: may see the LOSS signs
M: pain control WHO ladder (NSAIDs first), weight loss, physiotherapy slows progression + improves joint mechanics, hip replacement
3
Q
Hip RA
A
FH gradually eroded/suddenly collapses - true shortening
Joint replacement only good treatment
4
Q
Trochanteric bursitis
A
TB between greater trochanter + insertion of abductors. Causes point tenderness at GT, passive movement full but active abduction + adduction painful, pain is in lateral side, may see calcification on XR. Steroid injection
5
Q
Septic arthritis of hip
A
Rare in adults unless debilitated/DM/steroids
Need IV AB + exploration
Gonoccal sometimes seen
6
Q
Transient synovitis
A
Irritable hip after a viral URTI, exclude SA + Perthe’s, settles 2-3d
7
Q
Snapping hip
A
Iliotibial tract snaps across GT when stands while flexing + extending knee
Normal
8
Q
NoF classification
A
By fracture line IRT joint capsule (just prox to intertrochanteric line):
- Intracapsular: blood supply usually affected unless small/undisplaced. Specific types are sub capital (through junction of head + neck) and basocervical (through base of neck)
- Extracapsular: blood supply intact. Intertrochanteric/trochanteric, or subtrochanteric (<5cm distal to the LT)
Garden classification for intracapsular # (just academic really): I (incomplete) II (complete #, undisplayed) III (complete #, partial displacement) IV (complete #, fully displaced)
9
Q
NoF presentation
A
H/o recent fall
Shortened, externally rotated (pull on short external rotators), non-weight bearing
Unable to SLR
Distal NV deficits rare but obv check
10
Q
NoF XRs
usually AP + lateral hip + AP pelvis. full length of femur if suspecting pathological #
A
- View, body part, date/time, demographics
- IC or EC (above or below ITL). # is the dark area, if can’t see it then follow cortex until looks different to the rest
- Displaced (surfaces not in good contact) or undisplaced - STAR: Shortening (LT higher), Translation (moved side to side), Angulation (tilted, compare to other side), Rotation (in ER see more of the LT)
- Shortened? ER (see more of the LT?)
- Type of #
- Blood supply: in elderly generally treat as disrupted, but for EXAM extracapsular=intact and intracapsular=compromised
- How to fix it
- Other signs of a pathological # e.g. thinned cortex and medulla ‘moth-eaten appearance’. E.g. mets from breast/bronchus/RCC/prostate
Other investigations: routine, G&S, CK (long lie-rhabdomyolysis), INR, urine dip, CXR, ECG - often an underlying reason why elderly people fall
11
Q
NoF management
A
Always surgical (unless literally going to die within next 24h)!
For analgesia initially iliofascial nerve block v useful
Device must go perpendicular to the # line to have a good hold in both main fragments
- Intracapsular - hemiarthroplasty, unless younger/fit THR (better ROM); but in young patients the lifespan of prosthesis means better to preserve own hip with reduction + fixation w cannulated screws for future THR (so do in intracapsular non-displaced)
- Extracapsular - for intertrochanteric (and basocervical non-displaced) dynamic hip screw (vertical # as device goes horizontally). Subtrochanteric may use intramedullary nail for a horizontal # as these go vertically
Post-op: physio (everyone should be fully weight bearing by default as helps remodelling / will fall again from being unsteady), complications of surgery manage, OT for home, medical review by geris, bone protection (bisphosphonates, Ca and vit D)
12
Q
NoF complications
A
Bleeding, VTE, infection, risks of anaesthetic, nerve + muscle damage
Intracapsular # - AVN + non-union (reduced re-ossification) due to interrupted blood supply
Leg length discrepancy, dislocation, peri-prosthetic #, joint dislocation, aseptic loosening
13
Q
Hip dislocation
A
Rare as hip is v stable, usually in high-energy trauma
Majority are posterior forcing hip flexed + adducted to dislocate – hip + leg in slight F, Ad and IR. Can’t weight bear, deformity.
Anterior - hip in F, Ab and ER
On XR Shenton’s line broken
M: closed reduction if no #, ORIF if have #
C: post-traumatic arthritis, FH osteonecrosis, sciatic n injury, recurrent dislocations
14
Q
Perthe’s disease
A
Osteochondritis of upper femoral epiphysis - FH softens then reforms - due to interference with venous drainage - reformed head is flatter and bigger
M>F, seen in 5-10yos
M: contain FH within acetabulum until it reforms, usually using splints
15
Q
Slipped upper femoral epiphysis
A
Childhood equivalent of intracapsular # femoral neck, most often in adolescent growth spurt in chubby boys
M + P displacement of epiphysis - rolls limb into ER. Due to a Salter 1 # or insidious onset - weaker epiphyseal plate + soft tissue cos of hormones of adolescence
CF: pain referred to knee, leg short + ER
Comp: AVN, early arthritis, stiff painful hip
M: fixation with pins to prevent further slip (not manipulation/traction), osteotomy
16
Q
Hip replacement
A
Total hip replacement-replace articular surfaces of femur + acetabulum. Take out a cup of acetabulum, femoral head replaced with a metal ball attacked to a stem inserted into femoral shaft. Usually do this when there is pain + disability due to degenration/inflammation, or # proximal femur
Hemiarthroplasty - just replace femoral head not the acetabulum. More in older people with poor general health/frail when they’ve had a #NoF, as results in lower range of movement
Cemented prosthesis most common, and posterior approach most common as adductors preserved (but greatest risk of sciatic n damage).
Complications: VTE, bleeding, infection, loosening of prosthesis (it is strong in compression but weak in scar), leg length discrepancy
Results good in 98%
17
Q
Knee anatomy
A
Hinge, F&E, tibiofemoral (M + L condyles of femur to tibial condyles - weight bearing) and patellofemoral (anterior femur-patella, for quadriceps tendon insertion)
NV: genicular anastomoses from femoral + popliteal arteries; femoral tibial + common fibular nerves
Menisci: fibrocartilage, type I cartilage, deepen articulating surface of tibia, shock absorbers, C-shaped, MM less mobile, LM smaller + more mobile
Bursae: suprapatellar, prepatellar, infrapatelar + semimembanosus
Ligaments - patellar (continuation of QF tendon distally, attaches to TT), medial and lateral collateral ligaments (prevent excessive M/L movement), cruciate ligaments (prevent anterior/posterior dislocation of tibia wrt femur resp)
M: E (QF), F (H, G, S, P), LR + MR when knee is flexed
18
Q
ACL tear
A
ACL limits anterior movement of tibia + helps rotational stability esp IR.
In twisting injury
Rapid joint swelling + haemarthrosis, instability ‘giving way’, half also have meniscal tear (usually lateral).
Test with Lachman and anterior drawer
M: RICE, physio to strengthen quadriceps, surgical repair with tendon (need physio for months before)
C: post-traumatic OA
19
Q
PCL tear
A
PCL prevents hyperflexion and reduces posterior tibial movement
In high-energy trauma e.g. direct blow in RTA, or low-energy trauma when knee hyper flexed + foot plantarflexed
Causes immediate posterior pain, instability, positive posterior drawer test w posterior sag
M: often conservative, if recurrent instability surgery
20
Q
MCL tear
A
Most common ligament injury. Is values stabiliser so injured when external rotational forces applied to lateral knee e.g. a tackle
Graded 1-3
May hear a ‘pop’ with immediate pain in medical joint line, swelling after a few hours/sooner if there is haemarthrosis, increased laxity. Do valgus stress test
M: grade 1 conservative RICE NSAIDs strength training, grade 2 analgesia knee brace strength training, grade 3 conservative, crutches + surgery if distal avulsion
21
Q
LCL tear
A
Isolated injury v rare - instability near full extension, hard to use stairs or pivot, lateral joint line pain
22
Q
Meniscal tears
A
Usually due to trauma (twisted flexed weight bearing knee) or degenerative disease. Commonest is ‘bucket handle’ tear where central tear gets separated. MM more common than LM, except in acute ACL tear
CF: tearing sensation, intense sudden onset pain (localising to affected side), swells slowly, may be locked in flexion (if get free body within the knee), may have clicking, joint line tenderness, knee effusion. Test with Apley’s Grind and McMurray’s
M: acutely RICE + NSAIDs, if larger/symptomatic do arthroscopic surgery: outer 1/3 often can be sutured together as good blood supply, if in inner 1/3 often trim the tear
23
Q
Meniscal cysts
A
Local collection fluid in/next to collection, ass w tears, asymptomatic or pain/locking/clicking/swelling/weakness if NV impingement, popliteal mass, crepitus. MRI. Need rest, NSAIDs, may need aspiration + steroids …
24
Q
Discoid meniscus
A
Abnormal developed so large and discoid-shaped, usually LM, pain, clicking, locking
25
Unhappy triad
Lateral force to extended knee - ruptured MCL, MM (as attached to MCL) + ACL
26
Iliotibial band syndrome
ITB - fibres forming aponeurosis of TFL + gluteus maximus, from iliac tubercle to tibia
Inflammation - repetitive F+E - gets impinged
CF: lateral knee pain, worse with exercise
M: modify activity, analgesia in acute pain
27
Bursitis
Pre-patellar = housemate's knee, anterior to patella, commonest, 20% septic, may occur with crystal arthropathies and RA
Infrapatellar bursitis = Clergyman's knee
Semimembranous bursa inflammation = popliteal cyst (different to Baker's cyst)
28
Hoffa's fat pad syndrome
Anterior knee pain + hyper mobility due to maltracking of patella
Due to hyper-extension e.g. lifting weight with locked knees or awkward fall
29
Osgood-Schlatter disease
Traction apophysitis of tibial tuberosity, M>F, jumping/sprinting in teenagers
Pain on anterior knee worse kneeling, may have enlarged TT
M: RICE, NSAIDs, modify activity, strapping, when skeletally mature if not resolved may need surgery
Resolves when stop growing
30
Sinding-Larsen-Johannson syndrome
Overuse injury at inferior pole of patella, like OS disease but at distal attachment
More in teenagers/chronic injury
Pain anterior knee during/after activity, pain over inferior patella, swelling
31
Osteochondritis dissecans
Lesion of articular cartilage and subchondral bone - juvenile (common in 8-12y, M>F) + adult forms
Fragment from medial femoral condyle dissects out
Various causes, but leads to softening of articular cartilage + early cartilage separation, pain related to activity (worse on hyperextension), recurrent effusions, mechanical symptoms, locking, instability
Conservative, diagnostic arthroscopy, may need fixation by drilling holes + uniting with screws/pins
32
Chondromalacia patallae
Softening of articular cartilage of patella
In teenage girls is common
Anterior knee pain with stairs and rising from sitting
Physio
33
Bipartite patella
Congenital fragmentation of patella
34
Patellofemoral syndrome
Common in runners
| LL malalignment, muscle imbalance, patella issues -- aching after recent increase in exercise
35
Patella tendinopathy
Jumper's knee
Patella tendon tears
Settles with rest + NSAIDs
36
Bakers cyst
Primary often asymptomatic, may be from chronic effusions of OA, posterior swelling + aching
37
Patellar dislocation and subluxation
Usually lateral. Reduce it with medial pressure whilst extending knee
Recurrent dislocation may be issue in adolescents due to looser ligaments + smaller bones, patient usually aware of this
Recurrent subluxation may be developmental issue
38
Patella #
Fall on flexed knee or dashboard injury
| Non-displaced can manage conservatively
39
Knee OA
V common
Medical worse than lateral, get varus deformity, osteophytes, cysts, crepitus
M: conservative (NSAIDs, walking aids, physio, WL), arthroscopic debridement (diagnosis + removing debris), tibial/low femoral osteotomy (adjust line of weight bearing so healthy bit gets the weight), TKR (harder than THR, placement of prosthesis must be v accurate), revision of knee replacement, arthrodesis (lasts a lifetime, can walk comfortably but hard to sit/climb out of car etc)
40
Internal knee derangements
Meniscal lesions - cause locking + collapsing, different types e.g. discoid meniscus
Loose bodies - float around and obstruct movement, may become a medium for infection
Osteochondral lesions - #, chondral flaps and separations, osteochondritis dissecans
41
Popliteal cysts
Swelling in PF, uncomfortable, limits flexion, worse on walking
Indicate pathology in knee e.g. RA, gout
Not 'Bakers cysts'
May disappear, rupture or become so tense that need excision
42
Ligament instability of knee
ACL - knee swelled then went away after twisting injury, now knee collapses when put weight on + twist, may need ACL reconstruction (patellar/hamstring graft, iliotibial tract)
Meniscal lesions: low speed movement with knee bent, lock knee + blocks extension
Chronic PCL instability: unsteady going down slopes or weight bearing on flexed knee, from blow at front of knee in flexion
Medial ligament instability
43
Knee haemarthrosis
Bleeding into knee
Most ligament injury (usually ACL), patella dislocation or osteochondral #
If not removed blood clots - adhesions - limits mobility + causes synovitis
Need arthroscopy + removal
44
Foot and ankle anatomy
Read this in notes
45
Ankle sprain
Partial/complete tears in ligaments from excessive inversion of PF + weight bearing foot. Lateral more likely as weaker
46
Ottawa ankle rules?
Indications for XR with an ankle injury:
| Inability to weight bear, MM/LM point tenderness, 5 MT base tenderness, navicular tenderness
47
Standard XR views for ankle?
AP, lateral and mortise
48
Metatarsal #
Direct blow from heavy object, stress # (incomplete #), excessive inversion causing avulsion
49
Calcaneal #
Crush-type injury, may be comminuted, made of cancellous bone so gets crushed
Causes chronic problems like subtalar joint arthritis
50
Talus #
Malleoli hold fragments together so little displacement
51
Tibia and fibula #
Tibial shaft commonest location, superficial so prone to open #
Types: fibula alone (if undisplaced don't need immobilisation as doesn't weight bear, may just be tender/bruised), tibia alone or tibia + fibula (common esp in twisting + RTCs)
M: stable (cast immobilised), unstable (internal fixation), contaminated + unstable (External rotation). Spiral # always unstable. Reduction. Place in backstab. Monitor for compartment syndrome. Definitive management is for skeletal stability
Comps: compartment syndrome, NV compromise, infection as lots of open #, malunion (can lead to OA), non-union (slow healing), joint stiffness, soft tissue damage
52
Weber classification of ankle #
Type A - below syndesmosis, usually stable
Type B - at level of syndesmosis
Type C - above level of syndesmosis
53
What is a syndesmosis?
A slightly moveable fibrous joint where bones are connected by connective tissue
54
Ankle injury mechanisms
Abduction - tear deltoid lig or pull MM away, lots of swelling
Adduction - rare as usually also have rotation e.g. in a sprained ankle
External rotation - pushes talus against LM, may tear deltoid lig or avulse MM, v unstable
Vertical compression or hyperextension - comminuted crush fracture
55
Pott's fracture-dislocaiton
Bimalleolar (MM + LM) or trimalleolar (MM, LM + distal tibia) #
Due to forced eversion - pulls on medial lies - avulses MM - talus moves laterally - breaks of LM - if tibia forced anteriorly shears off the posterior distal tibia
56
Hallux valgus
Deformity of 1st MTPJ - 'bunions' (though bunions are actually a bunion over a prominent first metatarsal head i.e. can have B w/o HV), subluxation
CF: painful medial prominence, gets worse, crepitus indicates cartilage degeneration, may see contracture of EHL tendon, abnormal weight distribution
M: conservative e.g. orthosis, surgery if QoL significantly impacted
57
Plantar fascitis
Inflammation of the plantar fascia (thick fibrous band of CT), v common, b/l suggests systemic cause
RF: excess pronation, per cavus, tight calf muscles, prolonged standing, excess running, leg length discrepancy, obesity, unsupportive footwear
CF: sharp pain across plantar aspect esp in heel, examine for over-pronation, high arches, leg length. Intra-calcaneal region often tender on palpation
M: activity moderation ,physio stretching, NSAIDs, adjust footwear e.g. well cushioned heel, steroid injections if not working, plantar fasciotomy ...
Recovery takes up to 12m
58
Achilles tendon rupture
Forward lunging
Swelling, squeeze test positive as fascial sheath ruptured (Simmonds test). Operation preferred for athletes, conservative need cast immobilisation in full flexion, physio
In partial rupture squeeze test is negative
59
Achilles tendinitis
Irritation by repeated friction
60
OA of ankle
From damage to any joint e.g. #, minor trauma, infection
Dorsiflexion usually first affected by the osteophytes
Shoes, NSIADs, osteophyte excision, arthrodesis
61
Tarsal tunnel syndrome
Like CTS but v rare
Medial plantar nerve compressed by tendon swelling/ganglia/arthritis/post-trauma
Pain + paraesthesia in distribution of medial plantar nerve
62
Kohler's disease
Vascular osteochondritis causing collapse of navicular
63
Sever's disease
Traction apophysitis at insertion of calcaneal tendon , Like OGS and SLJ
64
Ingrowing toenail
Most common medial edge of big toenail
| Soft tissue damage - chronic infection w granulomatous tissue
65
Hallux rigidus
Stiff big toe due to OA of 1st MTPJ
66
Pes cavus
```
High arches (medial longitudinal arch abnormally high)
Less ability to shock-absorb when walking so more stress on ball + heel
```
67
Pes planus
Flat footed
Common, lose longitudinal arches (they develop age 2-3 so this is normal in infants), mostly don't get symptoms but feet may ache after prolonged activity
Arch-supporting shoe inserts
68
Shoulder dislocation
Commonest joint dislocation. Usually antero-lateral (described as anterior) from force on E, Ab and ER humerus; posterior more likely in seizures/electrocution
CF: pain, reduced mobility, instability, asymmetry, loss of shoulder contours, may see high anterior bulge from HoH, axillary + suprascapular n injury, bony Bankart lesions (# of glenoid), Hill-Sachs defect (impaction of chondral surface), # of GT, soft Bankart lesions (avulsion of labrum + lies), ligament avulsion, rotator cuff injuries
Anterior can usually see on AP XR, Y scapular view convirms
M: closed reduction, may need it done under GA, immobilisation, rehabilitation
Recurrence is fairly common with trivial trauma due to ligament laxity, patients can reduce their own shoulder
69
Adhesive capsulitis
Frozen shoulder
F>M, 40-70y commonest. GH joint capsule becomes contracted and adheres to HoH. Can be idiopathic or associated with inflammation, DM, previous surgery/trauma, subacromial impingement
Deep generalised constant pain, often disturbs sleep, stiffness, may have loss of arm swing, atrophy of deltoid, tender on palpation, limited ROM esp F and ER. XR rules out ACJ issues or #.
M: recover over months - years, keep active, physio, pain relief, GH joint injections if not improving, v bad may need surgery to remove adhesions
70
Subacromial impingement syndrome
Inflammation + irritation of rotator cuff tendons as they pass through the subacromial space, includes rotator cuff tendinopathy and subacromial bursitis.
Supraspinatous tendinitis - causes SAIS/painful arc, pain on active movement 60-120 deg Ab, passive movement fine as pressure relieved, leads to oedema + tear. May be calcified or rupture.
Causes: tension on RC tendons (e.g. muscle weakness, overuse), degeneration, extrinsic compression, glenohumeral instability
CF: progressive pain, worse abduction improved with rest, may have weak/stiff due to pain. Test subacromial impingement with Neers impingement and Hawkins tests
M: most conservative with NSAIDs physio and poss steroid injection, if >6m and reduced ROM potentially surgery
71
OA of shoulder
Not very common as its non-weight bearing
72
Brachial plexus injury
Supraclavicular lesions: trauma, obstetric palsy (upper cords damaged) - Erb's palsy (C5-6, weak supinator, deltoid, wrist extensors + elbow flexors - Waiter's tip)
Infraclavicular: trauma e.g. anterior shoulder dislocation, birth trauma (lower cords) - Klumpke's palsy (C8-T1, weak finger flexors + intrinsic muscles)
If lesion is pre-ganglionic (between SC + DRG, if have Horner's syndrome indicates this) no recovery, if post-ganglionic (distal to DRG) it can recover
See if issue is in R, T, D, C or B.
First branches go to elevator scapulae + rhomboids so test these, if intact lesion is distal to this origin.
73
Clavicle injury
clavicle v common, mid shaft (can lead to malunion, damaged vessels, PT or deformity), outer end (displaced or undispalced)
Mostly at junction of middle and distal thirds
M: figure of eight device/sling to pull back shoulders + align bone
74
Proximal humerus injury
Avulsion of GT - usually unites well
# surgical neck - can be displaced or not, common to be impacted, sharp ends can damage NV
Proximal epiphyseal separation - common in children and in NAI, treat in sling
Fracture dislocations - v unstable
Humeral shaft # - spiral, transverse, segmented or pathological
75
What actually is the elbow articulation?
Trochlea notch of ulna + trochlea of humerus
Head of radius + capitulum of humerus
Olecranon + trochlea of humerus (posterior)
Proximal radioulnar joint is in the elbow joint capsule but is separate articulation (between HoR and radial notch of ulna)
76
Paediatric elbow ossification centres
CRITOL
Capitulum, Radial head, Internal (medial) condyle, Trochlea, Olecranon, Lateral condyle
Ossify at 1, 4, 6, 8, 10, 12
Fuse at 12, 15, 17, 12, 15, 12
77
Pulled elbow
Subluxation of radial head (partially slips out of annular ligament) because in young kids this is lax
78
Elbow dislocations
From FOOSH in extension
| May # coronoid process
79
Epicondylitis
Tennis elbow - lateral. Small tear near insertion of common extensor tendon from overuse, sharp flexion of wrist with extension of elbow. Tender, stressing extensor origin causes symptoms, rest.
Golfer's elbow - medial. Less common, small tear in common flexor attachment. Less precise area of tenderness
80
Loose bodies
Fragments form a #, cartilage or OD causing mechanical locking
81
Olecranon #
are intra-articular. May be avulsion due to pull of triceps brachii or from direct impact
CF: pain, swelling, reduced ROM, tender posteriorly, can't extent, check NV etc
M: immobilise in flexion, operative if >2mm displaced
82
Radial head #
Commonest elbow #, usually arm E and pronated. Often from FOOSH with swelling, bruising, tenderness over lateral elbow
Sail sign-elbow effusions on lateral projection
Short immobilisation <1w then mobilisation if no/v minimal displacement, if more displaced/comminuted need ORIF
83
Supracondylar #
Common in kids FOOSH
complications:
Brachial artery damage
Compartment syndrome-may compress median n and radial a
Volkmann's ischaemic contracture - muscle necrosis from vascular insufficiency, necrotic tissue in flexor compartment pulls fingers into flexion + wrist into pronation+flexion
Median n damage - anterior interosseous branch most likely to be affected
Malunion
Myositis ossificans
m: undisplaced-backslab, displaced need reduction
84
Epicondylar #
Medial epicondyle or lateral condyle avulsion
85
Ulna and radius #
GRUM-Galeazzi radius, Ulna monteggia
Galeazzi: isolated radius # with subluxation of inferior radioulnar joint
Monteggia: # of ulna with dislocation of the radial head
```
Radius and ulna # : easily broken together in a twisting injury
Isolated radius (direct trauma) or ulna (direct blow when protecting face common) #
```
86
Articulations of the wrist?
Scaphoid, lunate and triquetrium to the distal end of the radius
87
Nerves of the wrisT?
Anterior interosseous branch of median n
Posterior interosseous branch of radial n
Deep + dorsal branches of ulnar n
88
Distal radius #
Colle's #: dorsal angulation + displacement and avulsion of the ulnar styloid. Dinner fork deformity
Smiths #: volar angulation of distal fragment, from landing on dorsal surface of wrist, v unstable
Bartons #: intra-articular # + dislocation of radio-carpal joint, radius displaced proximally
Greenstick #: only in children, bone continuity maintained, can't manipulate into perfect appearance
RF: osteoporosis
M: closed reduction, stabilise in backstab, if v unstable ORIF/K-wire fixation
89
Scaphoid #
Most common carpal #
More common in younger patients, usually hyper-extended radially-deviated wrist sustains force
Part of blood is received distally, so if # is distal risk cutting of blood supply so AVN of proximal end is a risk.
Often missed on XR due to twisting
If suspect # immobilise it immediately because of the risk of AVN with displacement
90
Lunate dislocation
Falling on a DF wrist, lunate goes anteriorly and compresses the carpal tunnel causing the symptoms of CTS, may undergo AVN
91
Metacarpal #
Bennet's of 1st metacarpal base from forced hyperabduction of thumb
Boxer's of 5th metacarpal neck usually clenched first striking hard object
92
Carpal tunnel syndrome
Compression of median n due to raised pressure. RF include female, older, pregnant, obese, previous injury, DM, RA, hypothyroidism, repetitive hand/wrist movement
CF: pain, paraesthesia in median distribution, palm often spared (palmar cutaneous branch is proximal to flexor retinaculum so goes over top of CT), worse at night. Sx may be reproduced by tapping over median n (Tinel's test - due to axon regrowth so takes a while of having condition to be demonstrated), or holding wrist in full flexion for 1 min (Phalen's test), later may get denervation atrophy of thenar muscles causing weak thumb abduciton
M: wrist splint to stop flexion at night, physio, steroid injections, surgical release in v limiting cases
93
De Quervain's tenosynovitis
Inflammation of tendons in first extensor compartment of wrist (containing EPB and APL).
CF: pain near base of thumb, swelling from thickened tendon sheath, pain on grasp/pinch, Finkelstein's test often positive (thumb flexed across palm, moving wrist into flexion cause pain)
M: modify movement, wrist splint, steroid injection, surgical decompression
94
Ganglionic cysts
Benign soft tissue lumps along any joint or tendon due to degeneration in joint capsule/tendon sheath, filled with synovial fluid.
More in females, 20-40y, OA, previous injury
CF: smooth spherical painless lump, soft, sudden or insidious, will transluminate, may cause mechanical restriction of movement or impinge on nerves causing pain/paraesthesia/weakness
M: monitor if no pain as often go away, if reduced ROM aspirate (risk of infection and recurrence) or cyst excision (remove cyst capsule + some of sheath)
95
Trigger finger
Finger/thumb clicks/locks in flexion, node doesn't pass back under pulley and prevents return to extension. Often preceded by flexor tenosynovitis from repetitive movement causing inflammation, or RA/amyloid/DM inflammation.
Normally the pulley systems (palmar aponeurosis, annular ligaments + cruciate ligaments) ensure tendons remain in the joint's axis of motion.
CF: painless clicking/snapping on extension, may be painful, graded based on if it locks, if they can move it back actively, passively, or not at all
M: mild splint etc, surgery-percutaneous trigger finger release by cutting the tunnel (not the tendon)
96
Dupuytren's contracture
Begins at base of ring/little finger, pulls into extreme flexion due to contracture of palmar fascia, often symmetrical, M>F, often hereditary
97
RA of wrist
Usual pattern, large amount of synovium around wrist makes it particularly susceptible - destroys small joints of the hand
May get swan neck deformity-tight intrinsic muscles
98
OA of wrist
Usually due to trauma like # scaphoid
2x as common as hip/knee OA
Pain on gripping and twisting, tender, limited abduction
99
Neurological examination for distal radius #
Median n - thumb abduction, sensation on radial surface of distal 2nd digit
Anterior interosseous n - opposition of thumb + index finger
Ulnar n - thumb adduction, sensation on ulnar surface of distal 2nd digit
Radial n - IPJ of thumb extension, sensation of dorsal surface of 1st webspace
100
Vertebrae types
Cervical: bifid SP except C7 (longer SP non bifid), transverse foramina for VAs, triangular VF. C1 atlas (no VB or SP, articular facet to dens of axis, lateral masses either side), C2 axis (dens superiorly)
Thoracic: demi-facets for ribs, TP have costal facets for ribs, circular VF
Lumbar: large VB which is kidney-shaped, triangular VF, no TF/costal facets
Sacrum: 5 fused, lateral facets for sacro-iliac joints
Coccyx: 4 fused, articulates w sacrum
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Intervertebral disc
Fibrocartilage
| Nucleus pulposus central gel-like, annulus fibrosis surrounds and is collagenous
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Ligaments of spine
ALL (thick, prevents hyperextension) + PLL (prevents hyeprflexion)
Ligament flavum - between lamina (the bits leading to the SP)
Interspinous and supraspinous - join SP of adjacent vertebra (processes/tips respectively)
Intertransverse - between the TPs
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Meninges of SC
Dura mater - external, has loose CT + venous plexus, surrounds nerve root - SNs pierce it to exit. Fuses with epineurium
AM - middle
PM - innermost, thin, covers SN roots
SAS - between AM + PM, expands distal to conus medullaris as lumbar cistern - CSF obtained from here in LP + spinal anaesthesia performed
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Nerve roots
Mixed nerves, originate from SC to form the PNS. Begin as a motor (anterior) and sensory (posterior) NR in SC - unite at intervertebral foramina as a single spinal nerve - leave and divide into posterior (to synovial joints, deep muscles of back + overlying skin) and anterior (M+S to most of body) rami
L2-S5 are from cauda equina
All nerves rest above the pedicle in the cervical spine, then go below at C8. But still the same, e.g. in an L3/4 herniation, traversing NR gets damaged so L4 symptoms
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L3 nerve root compression
Sensory loss anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test (prone, flex knee, extend hip)
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L4 nerve root compression
Sensory loss anterior knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
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L5 nerve root compression
Sensory loss dorsum of foot
Weakness in foot and big toe DF
Reflexes intact
Positive sciatic n stretch test (SLR with DF of foot)
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S1 nerve root compression
Sensory loss posterolateral leg + lateral foot
Weak PF of foot
Reduced ankle reflex
Positive sciatic n stretch test
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Myotomes
C5 – elbow flexion (biceps)
C6 – wrist extension (radial)
C7 – elbow extension (triceps)
C8 – finger flexion (median, long flexors of forearm)
T1 – finger abduction (dorsal interossei – PAD DAB. Ulnar)
L2 – hip flexion (iliopsoas, inserts on greater trochanter)
L3 – knee extension (3=knee)
L4 – ankle DF (tibialis anterior, may also test peroneal compartment by pushing laterally to evert as mixed nerve root)
L5 – great toe extension (extensor hallucis longus)
S1 – ankle PF (gastro-soleus complex)
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Dermatomes
C2 top of neck/back of head, C3 more down, C4 across clavicular area
C5 – upper lateral arm, regimental badge
C6 – radial side forearm to thumb and index (shooter)
C7 – middle finger (7 up)
C8 – ulnar fingers and forearm side
T1 – ulnar side forearm
T2 – axilla borders
T3-T12 downwards in strips. T4=nipple, T10=umbilicus.
L1 – hands in pocket area
L2 – across thigh
L3 – across knee
L4 – down shin to foot more medial
L5 – down to include big toe and some of shin
S1 – lateral foot and sole, coming up lateral calf
S2 – up back
S3, 4, 5 – saddle area
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Reflexes
S1/2-ankle
L3/4-knee
C5/6-biceps
C7/8-triceps
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Red flags for cauda equina syndrome
Severe progressive b/l neuro deficit in LL
Recent onset urinary retention/incontinence
Perianal/perineal sensory loss
Unexpected laxity of anal sphincter
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Red flags for spinal #
Sudden onset severe central spinal pain
H/o trauma (minor in osteoporotic)
Structural deformity
Point tenderness or pathological #
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Red flags for malignant or infection in spine
```
>50 or <20
Pain remains when supine, aching, night pain, thoracic pain
H/o cancer
Fever, chills, weight loss
IVDU
Recent infection
Immunocompromise
```
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Red flags for spondyloarthropathy
Early morning stiffness >45m
Night pain
Easier w moving, worse after rest
'Gelling'
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Cauda equina syndrome
Basically knocks out below L1
Saddle paraesthesia, urinary retention (painless), faecal incontinence (loss of fullness sensation, test resting tone + ask to squeeze)
Timely decompression within 24-48h, high dose dexamethasone to reduce localised swelling
Causes: disc herniation (esp L4/5 and L5/S1), infection like discitis, chronic inflammation, iatrogenic e.g. haematoma from spinal anaesthesia, neoplasia
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Herniated disc
```
NP ruptures & breaks through the AF
Usually PL (PLL stops it squeezing out P)
If P, pressure on SC may cause neuro + muscular symptoms
```
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Spinal stenosis
Degeneration of facet joints (LOSS) - nerves clumped together
Claudication pain, worse walking downhill as more pressure
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Radiculopathy
Conduction block in axons of a SN/roots
Causes: IV disc prolapse, degenerative disease causing stenosis, #, malignancy, infection e.g. extradural abscess
CF: paraesthesia, numbness, motor weakness, radicular pain (burning, deep, often intermittent), SLR (drag on Sciatic n roots to cause tension, DF foot to increase tension, see if get sciatica symptoms)
M: depends on cause. Analgesia with WHO/amitriptyline/pregabalin/gabapentin, physio, surgery of IV disc if progressive weakness etc
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Anterior + central cord syndromes predominant symptom location?
Upper limb > lower limb
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Spinal stroke
Infarction from arterial issue - nerves die
CF: muscle weakness, paralysis, loss of reflexes
Causes: vertebral #, vasculitis, atheroma, external compression
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Abnormal spine morphology
Kyphosis: excessive thoracic curative (hunchback)
Lordosis: excessive lumbar curvature (swayback)
Scoliosis: lateral curvature
Cervical spondylosis: reduced size of IV foramina, usually degeneration of joints of spine, pressure on exiting nerves causing pain
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Acute SC compression
Causes include mets, NHL, myeloma, vertebral #, RA, AS, spinal stenosis
CF: impaired sensation + proprioception at dermatomes below compression, can have pain, bi/unilateral weakness, UMN signs (cf LMN in CES)
M: surgical emergency
If present unable to walk only 1/3 will be able to walk again
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Low back pain
Typical in 30-50s, v common, majority non-specific muscular strain or degenerative changes (e.g. causing vertebral #).
Rule out red flags, ask about expectation for recovery (yellow flags e.g. belief that activity is harmful, over-reliance on analgesia, passive treatments)
M: get on w life within limits of pain. Pain relief to break the pain-spasm cycle, manage yellow flags, exercise to improve function, lifestyle like WL
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Specific causes of low back pain
Facet joint: acute or chronic, worse in morning and standing, pain over facets, worse on extension
Spinal stenosis: gradual onset, u/l or b/l leg pain, +/- back pain, numbness, weakness, worse on walking, relieved sitting down/leaning forward
Ankylosing spondylitis: typically young man w LBP and stiffness, improves w activity, peripheral arthritis common
Peripheral arterial disease: pain on walking, relieved by rest, absent/weak foot pulses, signs of ischaemia
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What are the layers from superficial down to get to the SAS for LP?
Skin - supraspinous lig - interspinous lig - ligamentum flavum - epidural space (epidural here) - subarachnoid membrane into SAS
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Neurological claudication in spine
Continuous constriction centrally/through existing foramina, cramping sensation in LL when walk over a certain period, better when resting, starts in buttocks as large muscles need more stimulation (cf vascular claudication starts in smaller vessels so more distal muscles), worse downhill as more pressure
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How would you test motor function for a wrist or elbow #?
Rock - median n (finger flexion)
Paper - radial n (finger extension)
Scissors - ulnar n (ab and adduction)
Okay sign - anterior interosseous branch of median n
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What are the different types of fracture morphology?
Transverse - direct blow, usually aligned
Spiral - twisting, long bones, more likely to damage NV/be open
Oblique - usually actually spiral, truly oblique rare e.g.
Knight-fracture of ulna from holding arm to protect face
Comminuted-bone splintered into more than 2 fragments
Crush-squash cancellous bone, hard as no fragments to manipulate, have to pack space with bone graft / external fixation
Greenstick - # long bone in children causing compressed cortex to buckle to produce 'buckle' #, if force continues cortex will #, bone continuity is maintained but # can't be manipulated back into perfect position but result is usually good-just give a protective plaster
also open vs closed - open when skin open
displaced vs undisplaced
impacted - cancellous bone compressed together - seen as increased density on XR
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What is the Salter-Harris classification system?
Description of # involving growth plate in children, important as epiphyseal injury may cause deformity in later life
1. Slipped (# along epiphyseal line, good prognosis)
2. Above (commonest, separation of epiphysis with triangular bit of shaft attached, # line above GP)
3. Lower (# of epiphysis, part remains attached to shaft, displaced fragment has # line through GP)
4. Through (# through epiphysis + shaft, union across GP may interfere w bone growth)
5. Ruined (crushing/axial compression, deformity + stunting)
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What are the parts of a bone?
Epiphysis
Physis/epiphyseal plate - only in children
Metaphysis - thick, below GP
Diaphysis - shaft
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How fast do bones heal?
8w for most
Double for LL
Half for children
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Describe how fractures heal
1. Inflammation: haematoma (contains cells to make growth factors), macrophages/neutrophils/platelets release cytokines, fibroblasts migrate + form granulation tissue, osteoblasts + fibroblasts proliferate due to COX-2 (so NSAIDs repress)
2. Repair: primary callus within 2w, if bone ends not touching get bridging soft callus, endochondral ossification converts converts to hard callus of woven bone, type II collagen (for cartilage) and then type I collagen (for bone), fusiform callus around fracture forms
3. Remodelling: continuous long after clinical union! Cartilaginous calcification, VEGF forms new vessels, woven bone remodels in response to mechanical stress
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What improves remodelling potential of bone?
```
Younger age
# closer to the GP
# in the plane of normal movement of the joint e.g. wrist # from FOOSH heals well as wrist flexed which is a normal movement whereas a rotatory wrist movement heals worse
```
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What influences # healing?
Blood supply
Mechanical: bony soft tissue attachments, mechanical strain, location, amount of bone loss, pattern (segmental or fragmentS)
Patient: diet (low vit D and calcium slow), gastric bypass (less Ca absorption), DM (slower ossification, fewer cells), nicotine (slows as inhibits blood vessel growth), NSAIDs
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Immediate fracture complications (hours)
Haemorrhage from bone or surrounding structure (esp pelvic and hip #)
Arterial damage e.g. brachial a in supracondylar # - Volkmann's ischaemic contracture if prolonged
Damage to other things e.g. # rib - pneumothorax or liver rupture
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complications within days-weeks (early)
Wound infection - sepsis, tetanus, gas gangrene
Fat embolism - hypoxia, CXR shows patchy consolidation, low O2, low platelets, raised lipase, tachypnoea, petechial rash
Shock lung - ARDS
Chest infection
DIC from disturbed clotting
Exacerbation of generalised illness
Compartment syndrome
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Late complications (m-y)
Malunion - unite in wrong position
Delayed union - slow
Non-union - don't unite
Defomirty
OA - esp if joint surfaces broken but also in other joints from having more weight bearing
AVN - often takes 2y to develop, esp in FH, scaphoid (distal entry of blood) and head of talus (blood enters at neck so if neck) - bone appears denser due to bone collapse, disuse osteoporosis + calcium deposition
Traumatic chondromalacia - articular cartilage softens and disintegrates, pain + crepitus, likely to lead to OA - esp in patella injury
Reflux sympathetic dystrophy - skip feels cold, goes blue, v tender, skin thin and shiny, patchy osteoporosis on XR
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General # management = reduce, immobilise, rehabilitate
1. Reduce - restore anatomical alignment
This helps stop bleeding, reduces traction on soft tissues/NV to reduce swelling/damage/less neuropraxia, correct deforming forces that caused injury. Usually closed in emergency, some open. Need analgesia, usually some conscious sedation, someone to reduce + someone for counter-traction. If not badly displaced can do closed reduction
2. Hold - immobilise
Traction sometimes need when muscle pull strong + # unstable. In first 2w plaster not circumferential to allow swelling (backslab), if axial instability plaster should cross joint above and below
3. Rehabilitate
Physio as stiff after immobilisation, ensure move non-immobilised joints from the outset, help cope at home
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What are the common causes of anterior knee pain in adolescents?
Chondromalacia patellae: softened articular cart of patella, reversible or arthroscopy to smooth if causing crepitus
Lateral pressure syndrome: lateral pain as patella doesn't fit properly in femoral trochlea
Synovial shelf syndrome: plica. Fold of synovial (shelf) irritated by trauma/pressure
Jumper's knee: at insertion of patellar tendon onto lower pole, can't jump properlyy. similar to tennis elbow
Bipartite patella: separate fragment of patella, usually just leave
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Developmental dysplasia of the hip
CF: limbs unequal length, asymmetrical ROM, asymmetrical skin creases, lurching gait, instability, Barlow's test
RF: 1st born female, FH, oligohydroamnios, small for dates, breech presentation
M: within 1st week nearness to hold hips adducted + flexed, 3-6m abduction splinting e.g. Pavlik harness, if not early diagnosed affects their walking + need surgery
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Bowlegs and knock knees?
Bowleg - genu varum. Normal up to age 3, if persists usually Blount disease (abnormal tibia development)
Knock knee - genu values. Normal age 4-8
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Talipes equinovarus
Club foot
Seen at birth but Can be postural, idiopathic or part of a syndrome
Feet turned inward, PF ankle, inverted foot, adducted forefoot, IR of tibia
Need serial plaster casts to prevent bony deformity + keep foot in position to be placed flat - Ponseti treatment
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Perthes disease
AVN of upper femoral epiphysis
Idiopathic
Limping, decreased hip motion, hip/knee pain, antalgic gait, guarded passive movement - insidious onset
Treat w casting + crutching to keep FH within acetabulum until it heals
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Slipped upper femoral epiphysis (SUFE)
Orthopaedic emergency
Typical patient chubby teenage boy
Groin/knee pain, limping, when sit w legs dangling the sole of affected leg points towards other foot, limited movement
Surgery to pin Fh back into place, can develop AVN
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Osteogenesis imperfecta
Often sporadic but can be inherited - defective type I collagen so can't make enough osteoid - failure of maturation of collagen in all the CTs
XR may show translucent bones, multiple #, wormian bodies (irregular patches of ossification)
CF: bones more plastic than normal e.g. bowing, prone to #, teeth often thick + discoloured, ground substance in sclera may be abnormal causing it to look blue (retinal pigmentation)
V severe in utero may not survive , or few # in childhood or multiple # in childhood (may lead to scoliosis, pigeon chest)
M: IV pamidronate can reduce # rate, surgical implants/osteotomies may help. saw child having to have big cast on legs for weeks cos of #
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Rickets
Vitamin D, calcium and/or phosphorus deficiency - mineralisation at epiphyses is inadequate
CF: bone pain, short, limb angulation, exaggeration of varus/valgus, flattened skull, dorsal kyphosis, rachitic rosary, hypotonia, dental disease, pathological #, waddling gait, lax ligaments
Histology: widened osteoid seams, Swiss cheese trabeculae
XR: brittle bones, physeal widening + cupping, codfish vertebrae
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Types of ligament injury
Sprain - stable as partial tear, tender, bruised, treat symptomatically + reduce stress
Partial rupture - some loss of stability but some fibres intact, occ need immobilisation but most cons
Complete rupture - loss of stability, never heal properly as scar never as strong as original
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Types of nerve injury
Stretching - deforming force continues after the #
Spasm
Crushing
Neuropraxia - transient loss of function from external compression, early recovery
Axonotmesis - loss of function from severe compression, still continuity, recovery in w-m
Neurotmesis-divison of nerve, no recovery
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Types of muscle damage
Crush - heals w fibrous tissue
Laceration - won't hold structures enough to stop muscle contraction pulling edges apart
Ischaemia - replaced w fibrous tissue
Ectopic ossification - can't haematomas in the muscle belly limiting joint movement
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Types of skin damage
Direct
Stretching - transient ischaemia leads to fracture blisters (infection risk)
Undermining at op
Degloving - skin peeled back over bones
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Septic arthritis
Infection of a JOINT
- top differential in single painful swollen joint
Causes: S aureus, Strep, N gonorrhoea (young sexually active), Salmonella (sickle cell) --> bacteria go to joint haematogenously, from adjacent osteomyelitis or direct inoculation from open wound
CF: single swollen joint with severe pain, pyrexia in 60%, red swollen warm, can't weight bear, often rigid, pain on A+P movement (in DM may not be systemically ill may just have unexplained effusion!)
Kocher's criteria: elevated CRP, ESR, WCC + can't weight bear = likely septic arthritis
Ddx - crystal arthropathies like gout, RA ,reactive arthritis, Lyme disease, osteomyelitis
M: sepsis management, ABs IV 2w then PO 4w, surgical irrigation + drainage for source control
C: necrosis of articular cartilage (doesn't heal - joint fused), osteomyelitis, sepsis, angulation if at GP
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Compartment syndrome
Increased pressure in confined fascial compartment - impaired venous drainage (lower pressure system) then capillaries then occluded arterial input - ischaemia, necrosis, permanent disability, limb loss, sepsis. Most in LL
C: after trauma/vascular injury, post-op tight casts etc.
CF: PAIN disproportionate to injury/worsening esp in passive movement, paraesthesia from compressed n, generalised muscle tenderness + swelling, subsequently the 6Ps of acute arterial insufficiency . CLINICAL DIAGNOSIS
M: remove constricting cast/dressing, keep limb neutral level, high flow O2, augment BP with fluids, opioid analgesia + anti-emetics, don't give anti platelets, emergency open fasciotomy + leave skin incisions open, monitor U&E due to risks of rhabdomyolysis + reperfusion injury
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Open fractures
Direct communication w external - often through skin, pelvic may open to vagina/rectum
'In to out' where bone penetrates skin, or 'out to in' where high energy injury penetrates
May cause soft tissue loss, NV injury + infection (contamination, reduced vascularity, systemic compromise as often these happen in major trauma)
M: resus, realignment + splinting, broad spectrum AB, tetanus vaccination, remove gross debris, dress with saline-soaked gauze, photo of wound, surgery to deride, wash out, ensure skeletal stability, may need soft tissue coverage e.g. a skin graft
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Osteomyelitis
Infection of BONE
Often in metaphysics as lots of muscle attachments - route for bacteria in minor trauma. Can also be in small kids with no h/o trauma from haematogenous spread
Pyrexia, pain, spreads to erode bone + cortex - pus strips off periosteum - abscess - goes through skin leaving abscess draining into a sinus (rare now in UK-chronic). Can spread to joint-SA
Organisms: S aureus, group B strep (neonates), H influenza (less common cos of vaccine)
CF: warm tender swollen limb, limping, h/o infection, raised CRP ESR WCC, MRI
M: micro ABs, expose bone + release pus if not improving
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Pott's disease
Spinal TB, rare here obv
Tender vertebra, involves VB + crosses disc space causes abscess into psoas sheath
may lead to sinuses + paraplegia
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Radiological features of bone tumours
Creation/destruction of bone
Cortex-broken, eroded, thinner, indented
Medullar cavity wider than normal
Periosteum lifted off bone
Fusiform onion skin appearance - Ewing's sarcoma
Sunray radial calcification - osteogenic sarcoma
Invasion of soft tissues
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Primary malignant bone tumours
Disease of young people. Present with low grade persistent pain. E.g.:
Fibrogenic-moth eaten osteolytic lesion, bad prognosis
Osteogenic sarcoma-commonest primary, most in 10-25y, swelling, may be secondary to Paget's disease, lytic lesion + elevation of periosteum
Chondrosarcomas
Ewing's sarcoma: second commonest but still rare, in <20s most, grows in diaphysis of long bone, chemotherapy + resection can help. Onion skin-reaction of periosteum
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Bone marrow cancer
Myeloma - tumour of plasma cells. Pain + anaemia in older adults, XR-multiple punched-out lytic lesions, Bence-Jones proteins in urine
Lymphoma of bone - usually sign of disseminated disease, XR 'moth eaten' appearance
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Metastatic bone tumours
Commonest breast, bronchus, prostate and RCC
| Clear punched-out margins
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Osteoarthritis pathophysiology
More often cartilage than bone disease tbh. Due to insult to a joint-infection, trauma or joint disease, most in large weight - bearing joints.
1. Breakdown of articular surface: smooth surface breached, friction creates bits of articular cartilage shed into joint, inflammatory response after exercise
2. Synovial irritation
3. Remodelling: limited cartilage repair occurs, if lesions deep may get fibrocartilage formed (not as good), subchondral bone abnormally active so new bone forms as osteophytes which restrict joint movement
4. Eburnation: ivory-like reaction of bone like its been polished + subchondral cyst formation. Because of erosion of subchondral bone, raw bone rubbing together causing micro fractures in trabeculae - bone becomes more sclerotic. Synovial fluid enters the cancellous bone due to cracks in articular surface - cavities seen as cysts - fill with fibrous tissue
5. Disorganisation: joint progressively stiffer + more deformed due to osteophytes enlarging + bone wearing away, ligaments get looser as bone gets shorter
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OA radiological features
Loss of joint space
Osteophytes around joint margins
Sclerosis of weight-bearing surface
Subchondral bone cysts
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OA CF
CF: pain (worse weight bearing, synovitis after exercise stopped), loss of movement (osteophytes + reduced joint space, slow onset), altered function (often subconsciously restrict movement)
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OA management
LL aim to take a load w/o pain, UL aim to restore movement
Conservative: explanation (not RA, it is wear and tear), activity (keep active but stop if hurts), walking aids, physio for muscle bulk/joint movement, drugs (NSAIDs [intermittent as reduce chondrocyte activity so make it worse if always use] - co-codamol - steroid can help), v occasionally steroid injections
Surgery: debridement, arthrodesis (makes it painless and in good position e.g. small joins in hand), osteotomy (correct deformity so better load), arthroplasty
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LL nerve damage presentations
Femoral n - weak knee extension, loss of patella reflex, numb thigh
Lumbosacral trunk - weak ankle DF, numb calf + foot
Sciatic n - weak knee F + foot movements, pain + numbness from gluteal to ankle
Obturator n - weak hip adduction, numb over medial thigh
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Factors affecting bone growth
Growth hormone - until epiphyses close
Sex hormones - testosterone rapid increase in growth then epiphyseal closure
Thyroid hormones - permit normal growth, low slows growth, high osteoporosis
PTH - mobilises calcium from bone + increases tubular resorption
Vit C - collagen synthesis to made osteoid
VIt D - absorb calcium, affects muscle tone
Calcitonin -secreted if serum calcium is high
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Osteoporosis
Loss of bone from osteomalacia (less mineral), osteolysis (more osteoclast activity) + osteopenia (less osteoid)
Idiopathic-less oestrogen + collagen, thin cancellous bone, pain esp back, kyphosis, # like NoF, more in women. Give bisphosphonates
Disuse - e.g. bed bound patients, mobilise + weight bear
Steroids - large doses, pathological #
Normal calcium phosphate + ALP
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Osteomalacia
Softened bones in adults due to vit D deficiency
Long bones bow, small #, usually malnourished + have bone pain or crush # of vertebrae
Calcium + phosphate may be low, ALP high
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Hyperparathyroidism
Aka osteitis fibrosa cystica - excess resorption of calcium from skeleton, in severe get cysts of brown tissue in the bone
May be primary (excess PTH from PTH-secreting adenoma), secondary (excess PTH to mobilise calcium from bones because of low calcium from renal disease/malabsorption) or tertiary (gland secretes too much even tho reason is cured)
CF: moans, sore bones, abdominal groans, psychological moans
High calcium, low phosphate, high ALP
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Paget's disease
AKA osteitis deformans
Bone increases in width, lose normal architecture + get more blood supply - bone bigger
Bone warm to touch, can lead to high-output HF
Bone may bow, abnormally soft or excessively hard
Doesn't cross joint spaces -usually in individual bones
Painful
Leads to OA, pathological #, sarcoma in long standing
ALP is high
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Osteopetrosis
Marble bone disease
Bone looks solid but is v brittle
Autosomal recessive condition
Anaemia, thrombocytopenia from reduced marrow space
Lack of differentiation between cortex + medulla
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Achondroplasia
Long bones don't grow as much as normal so patients v short
Autosomal dominant
Normal strength bones, normal IQ, pedicles shorter so can get spinal stenosis as SC made narrower
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What are the physical signs of fractures?
Abnormal movement, crepitus between ends, visible/palpable deformity, bruising, tenderness, pain on stress by bending/compression, impaired function, swelling.
Sometimes hard to tell-undisplaced don’t cause deformities, unconscious patients can’t report pain. Particular fractures are often missed e.g. scaphoid, ribs
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Types of joint injury
Subluxation – partial contact between joint surfaces, normally just wait for periarticular tissues to heal but may need stabilisation if get instability symptoms
Dislocation – no contact between joint surfaces, need reduction and immobilisation until soft tissues healed, some joints like knee may need open repair. May lead to recurrent dislocation, avascular necrosis, chronic instability or OA
Fracture dislocation – often heal better as bone heals > ligaments, but early management harder as need to fixate the bony fragment
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Paediatric fractures difference to adults?
Most heal v well and faster.
Problematic ones:
* growth plate #
* lateral condyle # - tendency to displace
* supracondylar humerus # - stuff like Volkmann ischaemic contracture can be a complication
Specifically at risk of:
* greenstick #: cortex shows plastic deformity on side of impact but interrupted on opposite side because of the tension, often angulated may need reduction due to rotational component, not the same as complete fractures in adults which are more unstable
* plastic deformation
* torus/buckle #: from compression, quite stable, one cortex side broken, doesn’t need fixing
More force needed to disclose in children as the ligaments are stronger
Healing faster
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What is a Toddlers fracture?
oblique tibial # in infants
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Crystal arthropathies
Where crystals are deposited in joints/soft tissue, usually not apparent till 3rd/4th decade. Can lead to acute self-limiting attacks of inflammation or chronic destructive joint disease.
Gout: urate crystals deposited. Diet rarely involved. RF: dehydration (major operations, alcohol), soft tissue destruction e.g. chemo, diuretics in elderly. Present as a painful swollen joint. Treat w anti-inflammatories, if attacks recur long-term treatment w allopurinol (not acutely). Aspiration of knee helpful, under polarised light can see birefringent crystals
Pseudogout – pyrophosphate and hydroxyapatite deposition. Similar clinical picture, may be after local/systemic disorders + ass w acute inflammatory synovitis or chronic joint destruction. Treatment similar to gout but allopurinol not effective
