Finals Revision > Ortho > Flashcards

Ortho Flashcards

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1
Q

Teen, dull ache on lower femur, XR shows “sunburst” pattern of subperiosteal bone?

A

Osteosarcoma

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2
Q

Compartment syndrome?

  • if not complaining of pain, what should raise suspicion?
  • why does presence of pulse not rule it out?
  • does XR show any pathology?
  • how long until muscle death?
  • why might aggressive IV fluids be needed?
  • what medications NOT to give as it makes it worse?
A
  • excessive use of breakthrough painkillers (plus pallor, paraesthesia, loss of pulse, paralysis)
  • pulse may still be felt as microvasculature compromise leads to muscle necrosis which can be compressed allowing pulse through
  • no
  • 4-6 hours
  • In case of myoglobinaemia causing acute tubular necrosis
  • DO NOT give anticoagulation, it makes it worse
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3
Q

Scaphoid fracture:

  • signs? (5)
  • Ix?
  • initial management?
  • orthopaedic management?
  • what is the vascular compromise?
A
  1. Maximal tenderness over anatomical snuffbox
  2. Wrist joint effusion (not if <4 hrs or >4 days old)
  3. Pain in telescoping of thumb
  4. Tenderness of scaphoid tubercle (volar wrist)
  5. Pain on ulnar deviation of wrist
  • XR: AP, lateral, oblique and Zilter view (ulnar deviation of wrist)
  • MRI should be 1st line imaging but usually 2nd line after XR
  • CT more sensitive than XR and may be used also if MRI not available
  • Futuro splint or elbow backslab
  • Referral to ortho for review and new imaging in 7-10 days

Undisplaced # of waist: cast for 6-8 weeks
All others: surgical fixation
(esp proximal pole, high risk of AVN)

Dorsal carpal arch of radial artery

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4
Q

Causes of gout?

XR features?

A

DARRT:

Diuretics
Alcohol
Renal disease
Red meat
Trauma

XR:

  • ‘punched out’ lesions with sclerotic margins
  • preservation of joint space (until late disease)
  • Soft tissue tophi may be seen
  • joint effusion
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5
Q

RF for AVF?

Imaging?

A

Long term steroids
Chemo
Alcohol abuse
Trauma

XR:
Early - may be normal or show osteopenia or micro fractures
Later - head collapse may show crescent sign

IX of choice - MRI

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6
Q

How to tell if hip pain in an adult is referred from lumbar spine?

A

Positive femoral nerve stretch test

Lie pt prone, extend hip with straight leg, then bend knee - elicits pain if referred from lumbar spine

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7
Q

Management of suspected osteoporosis in a patient with a suspected fragility fracture?

A

Age 75+ - start on oral bisphosphonate

<75 - perform a dexa scan, then enter the result into a FRAX calculator to determine risk

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8
Q

Imaging for spinal trauma?

A

XR first line if no neuro symptoms

CT if abnormal XR or if neuro signs present

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9
Q

Immediate management of open fracture?

A

IV Co-amoxiclav

Lavage and debridement within 6 hours in theatre

External fixation preferred due to infection risk - wait for soft tissue swelling to reduce before definitive management

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10
Q

Enchondroma?

A

Intramedullary metaphyseal cartilaginous tumour caused by failure of normal enchondral ossification at growth plate

Lucent with patchy sclerosis, risk pathological frac, asymptomatic

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11
Q

Osteoid osteoma

A

nidus of immature bone with sclerotic halo, intense pain esp at night, greatly relieved by NSAIDs

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12
Q

Simple vs aneurysmal bone cyst?

A

Simple:
Growth defect, asymptomatic, incidental finding, risk pathological frac

Aneurysmal:
AVM, locally aggressive, cortical expension and destruction (painful)
Curettage and bone graft

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13
Q

Osteosarcoma

A

Kids, usually around knee, peirosteal elevation and sunburst sign, assoc with retinoblastoma

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14
Q

Teenager with warm, boney swelling, fever and raised CRP - what tumour?

A

Ewing’s sarcoma

2nd most common, worse prognosis

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15
Q

Brodie’s abscess?

A

subacute osteomyelitis

Thin rim of sclerotic bone surrounding abscess

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16
Q

Brown’s tumour?

A

AKA osteitis fibrosis cystica/osteoclastoma

Due to untreated hyperparathyroidism
Histologically exactly same as Giant Cell tumour

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17
Q

Giant cell tumour

A

Multinucleated giant cells within a fibrous stroma

20-40 y/o, epiphysis of long bones

soap bubble/souble bubble appearance

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18
Q

Paget’s disease?

A

Uncontrolled osteoclast activity - increased bone turnover

Bone pain (skull, spine, pelvis, femur)
Isolated raised ALP

Deafness, fractures, skull thickening, high output cardiac failure

XR/isotope bone scan

Rx: bisphosphonates

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19
Q

Osteomyelitis pathophysiology?

Causative organisms?

A

Leucocyte enzymes -> local osteolysis/pus -> impaired blood flow -> difficult eradication -> sequestrum (dead bone) -> involucrum (new bone around)

Staph aureus most common
Salmonella in sickle cell

Ix: MRI

6 weeks fluclox/clinda

May need surgery and washout if not treating/if chronic (in chronic abx suppresses bacteria but not eradicate)

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20
Q

When each of the following cause septic arthritis:

  • staph aureus?
  • strep?
  • h influenzae?
  • neis gon?
  • e coli?
A

Staph - most common

Strep - second commonest

H influenzae - was commonest in kids before vaccine

Gon - consider in young adults

E coli - elderly, IVDU, seriously ill

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21
Q

Ix septic arthritis?

Rx?

A

Joint aspirate BEFORE Rx

Fluclox/clinda 6 weeks +/- arthoroscopic lavage

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22
Q

Osteoporosis:

  • what is it?
  • common causes?
  • what fractures are common?
A

quantitative defect of bone - low mineral density

Alcohol, steroids, smoking, menopause/low oestrogen, malabsorption, CKD, certain drugs, hyperthyroidism

NOF, vertebral crush, colles

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23
Q

Who should have osteoporosis risk assessed?
What scores are used?
When to reassess?

A

All women 65+ and men 75+
AND those younger but with risks e.g. steroid use, previous fragility fracture, low BMI

FRAX or QFracture - assess 10 year risk of fragility fracture
FRAX without DEXA gives low, med and high risk scores
With gives no rx, consider rx and recommend rx

Do not reassess again before 2 years unless significant change to circumstances

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24
Q

What to do if someone has a suspected fragility fracture?

A

If <75 - organise DEXA and put score into FRAX tool

If 75+ - treat regardless

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25
Osteoporosis prevention in long-term steroids?
Just 7.5mg Pred for 3 months massively increases risk If 65+ OR have previously had fragility fracture - treat If <65 - DEXA (if DEXA between 0 and -1.5, repeat scan in 1-3 years)
26
Ix of suspected spinal fragility fracture?
XR - may show wedge 2nd line - CT (shows bones) or MRI (shows if pathological frac e.g. from cancer) If fracture organise DEXA
27
Management osteoporosis?
Calcium and Vit D ``` Alendronate 1st line Zolendronic acid once yearly IV Strontium (increased osteoblasts) Raloxifene (SERM) Denusomab (monoclonal AB against RANK ligand reducing osteoclast activity) ```
28
SE bisphosphonates?
Oesophagitis/ulcers Osteonecrosis of jaw Atypical stress fractures (esp prox femoral shaft) Acute phase response may follow administration (fever, myalgia) Hypocalcaemia (reduced efflux from bone, usually subclinical)
29
Osteomalacia? | Causes?
Qualitative defect - abnormal softening. Defective mineralisation of osteoid (immature bone) due to inadequate calcium/vitD (Rickets in kids) VitD deficiency CKD Drugs e.g. anticonvulsants Liver disease Bone pain, bone/muscle tenderness, fractures (esp NOF), proximal myopathy (waddling gait) Bloods: - low vitD, Ca, Phos - Raised ALP, PTH XR: translucent bands (Looser's zones, or pseudofractures) Rx: VitD supplementation, Ca supplementation, possibly phosphate supplementation
30
What is renal dystrophy?
Bone changes due to CKD. Reduced phosphate excretion and VitD activation -> secondary hyperparathyroidism, sclerosis of bone, calcification of soft tissues
31
Mechanical back pain?
Recurrent, relapsing, reciting pain with NO neurological symptoms, worse with movement, relieved by rest Obesity, inactivity, poor lifting technique, facet joint OA, spondylosis (water loss from disks causing secondary OA) NSAIDs, continue normal activity, physio DO NOT offer spinal XR for low back pain without trauma
32
MRI for back pain?
Only id it is likely to change management and where malignancy, infection, fracture, caudal equine or ank spond is suspected
33
57 y/o man sudden onset severe lumbar back pain when lifting lawn mower out of shed, worse on coughing?
Acute disc tear Tear in annulus fibrosis which is richly innervated, MRI if suspect herniation, resolves in 2-3 months with analgesia/physio
34
Sciatic stretch test?
Straight leg raise causes pain in buttocks Also cross over sign - stretch on opposite side causes pain on affected side Due to impingement on nerve root (pain and weakness) from disc herniation or OA osteophytes Analgesia (+ amitriptyline/gabapentin) physio +/- discectomy if severe
35
Herniation relates to which nerve root in relation to it?
Usually one of the 2 lower vertebrae - lateral herniation or osteophyte will compress the upper one (e.g. in L4/5 herniation will affect L4 root) - more central ones will compress the lower one (in L4/5 herniation will affect L5) - If very central and large can compress cord/cauda equina
36
L3/4 prolapse, which nerve usually and symptoms?
L4 root entrapment : Pain to medial ankle, loss of quadriceps power, reduced knee jerk
37
L4/5 prolapse, which nerve usually and symptoms?
L5 entrapment: Reduced power extensor hallucis longs and tibialis anterior, pain to lateral leg/dorsal foot
38
L5/S1 entrapment which nerve usually and symptoms?
S1 entrapment: Pain to sole of foot, reduced power plantarflexion, reduced ankle jerk
39
Upper or lower motor neurone signs in cauda equine?
Lower
40
Ix for spinal stenosis? | Rx?
MRI Conservative or laminectomy
41
What does each rotator cuff muscle do?
Supraspinatus - initiate abduction Infraspinatus - ext rotation Teres minor - ext rotation Subscapularis - int rotation subscapularis odd one out - only one below scapula, only one to do internal rotation, only one to insert into lesser tuberosity (rest are in greater) Collectively - pull humeral head into glenoid to provide stability for deltoid to abduct arm
42
Causes of shoulder impingement? Rx? Tests for impingement?
Tendonitis, subacromial bursitis, ACJ osteophyte, hooked acromion Conservative Sub-acromial steroid injections x3 Subacromial decompression surgery Hawkins kennedy - internally rotate a flexed shoulder, recreates pain
43
Adhesive capsulitis classic history? First sign? Cause? Rx?
40+ y/o, progressive pain 2-9 moths, then progressive stiffness 4-12 months, eventually recovers well Loss of external rotation first sign Due to capsule + glenohumeral ligament becoming inflamed Rx: physio/analgesia IA injections Surgical release if loss of function
44
Acute calcific tendonitis? Ix? Rx?
Acute onset, severe shoulder pain with calcium deposit in supraspinatus tendon XR shows calcium Rx: subacromial steroid + local anaesthesia
45
Causes of shoulder instability?
Previous traumatic anterior dislocations (Bankart lesions) Atraumatic - idiopathic, Marfan's, Ehlers-Danlos If traumatic, bankers repair can stabilise
46
Tinel's test? Phalen's test? Ix for this? Rx?
Tapping = paraesthesia Wrist flexion = symptoms Ix - nerve conduction studies - slowed sensory and motor conduction Rx: wrist splint, steroid injections, splitting of flexor retinaculum
47
Signs of cubital tunnel syndrome?
Pain, paraesthesia, hypothenar wasting, weakness in index finger abduction Tinel's (behind medial epicondyle) Froment's sign - hold paper between thumb and index finger in fist - pull paper and weakness causes thumb flexion to compensate Nerve conduction studies, surgical release may be necessary
48
Rx trigger finger?
Steroid injection or division of A1 pulley
49
Dupuytren's cause? Where? Rx?
Abnormal hyperplasia of type 3 collagen in palmar fascia, skin becomes adherent causing pits/cords, and palpable nodules may be present Most commonly 4th finger, 50% bilateral Mild contractors up to 30 degrees at MCP, but >30 requires fasciotomy or fasciectomy Others = peyronie's disease of penis or Ledderhose disease (feet)
50
De quervain's tenosynovitis? Symptoms/signs/tests? Rx?
Inflammation of tendon sheath containing extensor pollicis brevis and aductor pollicis longus Pain on radial side of wrist, tenderness at radial styloid, pain on resisted thumb abduction Finkelstein's test - trip thumb and shortly ulnar deviate hand, recreating symptoms Analgesia, immobilisation with spica thumb splint Steroid injection Surgery
51
Why can hip pain be felt in the knee?
Obturator nerve supplies both joints Loss of internal rotation often first sign of hip pathology
52
Ix hip AVN? | Rx?
MRI in early stages - oedema etc XR later - head collapse, lytic lesions, sclerotic margin, hanging rope sign If detected early can drill holes in bone to relieve pressure If not THR needed
53
Function of the 4 knee ligaments?
ACL - resists internal rotation + anterior translation of tibia PCL - resists posterior + anterior translation of tibia MCL - resists valgus stress LCL - resists varus stress + external rotation of tibia
54
1st line Ix for knee soft tissue injuries?
MRI
55
Rule of 1/3 for ACL?
1/3 compensate and continue sports 1/3 manage by avoiding certain movements - no sports 1/3 struggle with daily activities Rx: physiotherapy to strengthen quads, ACL reconstruction with tendon graft from patellar tendon, semitendinosus or gracilis
56
What ligaments are commonly ruptured together in tibial plateau frackers?
MCL + ACL
57
Management of knee dislocation?
External fixation then multi-ligament reconstruction Popliteal injury common and reperfusion injures
58
Extensor mechanism rupture - which ligaments and predisposing factors? Rule for tendonitis? Ix? Rx?
Cause - rapid contractile force (high impact fall or spontaneous if degeneration) Patella tendon <40 y/o Quadriceps tendon >40 y/o ``` Predisposing: tendonitis Steroids Diabetes RA CKD Quinolones ``` DO NOT use steroid injection for extensor mechanism tendonitis XR or USS if obese Surgery
59
What does patellofemoral syndrome encompass? Who does it affect? Symptoms? Rx?
Encompasses chondromalacia patellae (softening of cartilage), lateral patellar compression syndrome and anterior adolescent knee pain Adolescent females - wider hips = more lateral pull on patella Anterior knee pain, worse downhill +/- clicking/grinding sensation +/- pseudo-locking (stiffness) Self-limiting (surgery last resort)
60
Predisposing factors for patellar instability? | What side is dislocation?
``` Female Laxity Shallow trochlear groove Genu valgum High riding patella ``` Usually lateral due to lateral pull of quads
61
Surgical Rx of hallux valgus? | Hallux rigidus?
Osteotomy - realignment Arthrodesis - surgery gold standard for hallux rigidus
62
Stress fray usually affects which bone? | When is callus seen on XR?
2nd metatarsal (or 3rd) After 3 weeks
63
Where does tibias posterior tendon insert?
Medial navicular - supports medial arch Tendonitis (repetitive strain) risks rupture Loss of medial arch will heal valgus Splintage avoids surgery,, predisposes to OA (arthrodesis)
64
Pes planus? | Pas cavus?
Flat foot - normal variant in 20% population High arched foot - often related to NMD
65
4 toe deformities? | Rx?
Claw toe - hyperextend MTP, flexed both IP Mallet - 90 degree bend DIP Hammer - Boutoinniere but of toe Curly - flat MTP, both IP curved so bottom of toe underneath Painful rubbing -> corns/skin breakdown Rx: - 'toe sleeves' - Surgery to relieve tight tendons/arthrodesis/amputaton if painful/rubbing on shoe
66
Is charcot joint inflamed?
Yes can be swollen/hot/red, but typically not sore
67
Spinal shock?
Spinal shock: - Physiological response to trauma - typically resolves in a day - Loss of motor + sensory + reflexes below injury - bulbocarvenous reflex absent until resolution Neurogenic shock: - temporary shutdown of sympathetic outflow (T1-L2) - Vasodilation (hypotension) and bradycardia (IV fluid) - High level injuries - typically resolves in 1-2 days - Priapsim due to unopposed parasympathetic
68
Primary vs secondary bone healing?
Primary - minimal fracture gap (<1mm) and bone bridges gap with osteoblasts - occurs in hairline fracs and when fixed with compression screws/plates Secondary - inflammatory response with pluripotent stem cell recruitment which differentiate into different cells. 4 stages: 1. inflammation 2. soft callus 3. hard callus 4. remodelling
69
Investigating a frac: - views on XR? - tomogram? - CT? - MRI? - Technetium bone scan?
AP and lateral + oblique for complex bones e.g. scaphoid, acetabulum, tibial plateau Mandibular frac CT - vertebrae, pelvis, calcaneus, scapular glenoid frac, ?articular damage MRI - occult frat where clinical suspicion but normal XR Technetium - stress frac (hip, femur, fibula, 2nd met)
70
Indications for ORIF?
``` Unstable Displaced Neurovascular compromise Irreducible Pathological Intra-articular ```
71
CRPS: - features? - Rx?
Constant burning/throbbing, allodynia, swelling, stiffness and skin colour changes Specialist pain team Drugs - amitriptyline, gabapentin, steroids TENS, physio, lodicaine, nerve block
72
Light bulb sign on shoulder XR?
Posterior dislocation Less common, 5% Due to posterior force on adducted and internally rotated arm
73
Management of ACJ dislocation?
Common in sports Grade 1 - sprain 2 - sublimed 3 - dislocated Conservative management (sling/physio) Reconstruction if chronic pain or early in young athletes
74
Elbow injuries: - management of olecranon frac? Anterior fat pad sign?
ORIF with tension band wiring radial head + neck frac ORIF
75
Combined ulnar + radial frac?
ORIF
76
Colles management? | What can be damaged?
Stable - splint Displaced simple - MUA + plaster Displaced unstable - MUE + k-wires or ORIF Median nerve damage Extensor pollicis longus rupture
77
Smiths management?
ORIF | These are unstable
78
What is a barton's?
intra-articular with dorsal/volar displacement if rim. Carpal bones sublet with displaced rim fragment ORIF
79
Management of scaphoid frac?
XR (4 views) - may not be visible for 2 weeks Futura splint 2 weeks then review Review by ortho for confirmation - CT if still clinical but no XR signs - If non-displaced - plaster cast 6-12 weeks - displaced - compression screw Non-union - screw fixation and bone graft
80
Mallet finger Rx?
Mallet splint 4 weeks minimum
81
Metacarpal frac rx?
Conservatively - strap to adjacent finger Unless severe rotational malalignment - then K wire fixation
82
What is mandatory in pelvic fracture?
PR exam to assess sacral nerve root function and look for presence of blood. General surgical review mandatory if blood - rectal tear
83
Acetabular frac rx?
Posterior frac associations w hip dislocation Oblique view radiograph required + CT may be required Conservative > reduction/fixation > THR (older patients)
84
Gout Rx in an old person taking warfarin?
Colchicine, because of risk of GI haemorrhage
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