Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
1587 Cards in this Set
- Front
- Back
|
Joint arthrosis, causes, demographics, diagnostic modalities (symptoms, signs, tests).
|
Cause
- Idiopathic for most people. - Secondary causes include trauma, metabolic and congenital disorders. Demographics - Generally appears in middle age. - Often asymptomatic process between 30-40. - Almost everyone above 70 has some degree of osteoarthrosis. Diagnostic modalities: History (pain worse after exercise, relieved by rest, morning stiffness) Physical exam (pain, swelling, limitation of movement) Xray is the first diagnostic tool. |
|
|
Extra question: What are physical changes in a joint which is osteoarthritic?
|
Bone spurs (osteophytes), Narrowed joint space and changed alignment (axis). Cyst formation. Subluxation may result.
|
|
|
Extra question: What are the most common locations of osteoarthrosis in descending order?
|
1. Spine - spondyloarthrosis
2. Knee - gonarthrosis 3. Hip - coxarthrosis |
|
|
Joint arthrosis: Conservative treatment
|
Conservative treatment of osteoarthrosis includes:
- Medications - Physical therapy Lifestyle changes to increase exercise and reduce weight are additionally important. Medications: - NSAIDS! - COX-2 inhibitors - Artificial joint fluids (Synvisc, hyalgan), relief up to 6 mnths. - Glucosamine and chondroitin sulfate may reduce pain. - Steroid injections into joints reduces inflammation. Physical therapy Improves muscle strength and joint stability and mobility. Divided into: Kinesiotherapy and Physiotherapy. |
|
|
Joint arthrosis: Surgical treatment
|
Surgery is indicated only in severe osteoarthrosis.
Surgical options: - Arthroscopic surgery, to trim torn and damaged cartilage and wash out joint. - Osteotomy, change alignment of bone to relieve stress or load. - Arthrodesis, fusion of bones. - Arthroplasty, total or partial. |
|
|
Pathogenesis, clinical appearance and diagnostic modalities of Talipes equinovarus.
|
Talipes equinovarus (clubfoot) is a congenital deformity of the foot involving one or both feet (50%).
The foot appears to be rotated internally at the ankle. Occurs in 1 in every 1000 newborns. M:F 2:1 Pathogenesis: Causes can be: -Genetical (Edward's syndrome) -Compartment syndrome -Previously it was believed that uterine factors could cause it but no longer. -Breech presentation. -Inversion at the subtalar joint. -Adduction at the talonavicular joint. -Equinus (plantarflexion of ankle, so like standing on toe) Diagnosis is mainly clinical but Xray may help. |
|
|
Describe treatment methods of congenital Talipes equinovarus.
|
Clubfoot can be treated either non-surgically or surgically.
Should start immediately to improve outcome. First part of the treatment is to CORRECT the deformity. This is done by different braces, serial casting, or splints called knee-ankle foot orthoses (KAFO). Other orthotic options include Dennis-Brown bars, ankle-foot orthoses or custom foot orthoses (CFO). A new modern method is the Ponseti method which is successful in 95% of cases. It involves serial casting with gradual reduction. After reduction is successful a tenotomy of the calcaneal tendon is required in 80% of cases to reduce flexion of the foot. Botox has been tested as a new method to relax the calf muscles instead of tenotomy, with good success. To avoid relapse night-time braces are worn until 4 years of age. If splints and casts are not enough to reduce the deformity then surgery may be required to correct tendons, ligaments and bones and this is then done between 9 and 12 months of age. |
|
|
Denote and discuss congenital foot deformities, except for talipes equinovarus.
|
Pes planus (flat foot), pes cavus, congenital toe deformities, etc.
In pes planus the arch of one or both feet collapsed. Pes planus cannot be diagnosed on a newborn because it is normal especially with the extra fatpad to have a flat-appearing foot. The arch is usually fully developed at 4 to 6 years old. Persisting flat feet also usually become arched in adolesence and adulthood. It seems from trials that walking alot barefoot as a child prevents the condition. Treatment of pes planus is walking barefoot, arch supports in shoes. Pes cavus is less common than pes planus. It commonly features a varus (inverted) hindfoot, a plantarflexed position of the first metatarsal, an adducted forefoot and dorsal contracture of the toes. Pes cavus can accompany neuromuscular disorders such as Charcot-Marie-Tooth syndrome or be idiopathic. Pes cavus is estimated to exist in 10% of people. Pes cavus, just like pes planus may cause foot pain, plantar fasciitis and arthritis. Pes cavus is also treated with shoe implants. If pain is severe surgery is performed. |
|
|
Another name for Genu valgum.
|
Knock-knees.
|
|
|
What type of genu valgum is normal?
|
Mild genu valgum is normal in children between 2 to 5 years old and is naturally corrected.
|
|
|
What diseases often accompany genu valgum?
|
Rickets, obesity.
|
|
|
Can adult genu valgum be treated with orthotic treatment?
|
No
|
|
|
So how is Genu valgum treated?
|
Lifestyle restrictions, NSAIDs, Braces, exercise programs and physiotherapy. Surgery in recalcitrant cases.
Normally if genu valgum persists into adolescence then a surgical OSTEOTOMY is performed to straighten then legs. Total knee replacement surgery may be required later in life to relieve pain and complications. If treatment is initiated in early childhood, then braces may be an option. |
|
|
What is the goal of osteotomy in genu valgum?
|
To correct the anatomic axis between the femur and tibia to 0-2 degrees of valgus.
|
|
|
What is the typical gait pattern of genu valgum. Explain it.
|
Circumduction, meaning that the individual legs swing outward while walking.
|
|
|
What is the most important clinical characteristic of genu valgum?
|
Knee pain!
|
|
|
Why should not young people with genu valgus receive total knee replacement instead of osteotomy?
|
Because knee replacements wear out over time and thus would not last so long.
|
|
|
How is genu valgum assessed?
|
Assessment is performed with Xray. Knees should be in full extension. Mechanical axis is drawn from the center of the femoral head to the midpoint of the ankle joint. Normally this mechanical axis passes 6mm medially to 14mm medially to the medial tibial spine. In genu valgum the mechanical axis passes laterally to the midpoint of the knee joint. Another method if quantification is to be done is to use the angle between the axis of the femur and tibia.
|
|
|
Who is typically affected by Legg-Calvé-Perthes syndrome?
|
Young children
|
|
|
What is the cause of Legg-Calvé-Perthes syndrome?
|
No identified cause but there is a reduction of blood flow to the hip joint.
|
|
|
What is the pathogenesis of Legg-Calvé-Perthes syndrome?
|
Since the blood flow to the region is reduced, there is loss of bone mass which leads to some degree of collapse and deformity of the femoral head and acetabulum.
|
|
|
What are the symptoms of Legg-Calvé-Perthes syndrome?
|
Hip, knee or groin pain which is exacerbated by movement. The pain somehow resembles that of toothache and is rather severe.
Reduced range of motion at the hip joint. Painful or antalgic gait. Athrophy of thigh muscles from disuse may occur in severe cases. Inequality of leg length. |
|
|
Why may there be pain in the knee in Legg-Calvé-Perthes syndrome?
|
The pain from the hip may be referred to the knee.
|
|
|
Demographics of Legg-Calvé-Perthes syndrome?
|
Boys:Girls 4:1
Usually diagnosed 5-12 years old. |
|
|
How to diagnose Legg-Calvé-Perthes syndrome? What are the signs?
|
X-ray. Flattened and later fragmented head of femur.
If X-ray inconclusive then bone scan or MRI may be needed. |
|
|
What is the goal of treatment of Legg-Calvé-Perthes syndrome?
|
To avoid severe degenerative arthritis.
|
|
|
What is the traditional treatment of Legg-Calvé-Perthes syndrome centered on?
|
It is centered on removing pressure from the joint until the disease has run its course (until the medial circumflex femoral artery has developed and the head of femur is intact).
|
|
|
Different treatments of Legg-Calvé-Perthes syndrome?
|
Traction (removing fem.head from acetabulum and reducing wear)
Braces, orthotics (for avarage 18 months) Physiotherapy Surgery |
|
|
What does modern treatment of Legg-Calvé-Perthes syndrome focus on?
|
Removing pressure from the hip joint to increase blood flow, in concert with physiotherapy.
|
|
|
How is pressure reduction achieved in treatment of Legg-Calvé-Perthes syndrome?
|
By using crutches or canes and the avoidance of running-based sports.
|
|
|
What type of exercise is recommended for Legg-Calvé-Perthes syndrome?
|
Swimming is highly recommended.
Cycling. |
|
|
Why is it so important with physiotherapy and exercise in Legg-Calvé-Perthes syndrome?
|
Because even though orthotics and other measures may stabilize the joint until the disease passes for the femoral head and acetabulum to be smooth and allow for full range of motion exercise is needed.
|
|
|
Incidence of Legg-Calvé-Perthes syndrome?
|
1/1000 lifetime risk.
Caucasians more affected. |
|
|
Prognosis of Legg-Calvé-Perthes syndrome?
|
Children under the age of 6 have the best progrnosis because the femoral head can heal and remodel. If developed or diagnosed late the prognosis is worse with high risk of early osteoarthritis.
|
|
|
Where does the word scoliosis come from and what does it mean?
|
Scoliosis comes from the greek word skolios, meaning "crooked".
|
|
|
The three general causes of scoliosis?
|
1. Congenital, for example due to fused ribs or problematic vertebral formation.
2. Neuromuscular scoliosis, due to poor muscle control or weakness, or paralysis due to disease such as muscluar dystrophy. 3. Idiopathic scoliosis has no known cause. |
|
|
Which type of scoliosis is most common?
|
Idiopathic scoliosis.
|
|
|
Which gender has highest incidence of scoliosis?
|
Females.
|
|
|
What is the definition of scoliosis?
|
Abnormal curvature of the spine.
|
|
|
What may hint that scoliosis can worsen?
|
If growth is not finished scoliosis often worsens as growth progresses.
|
|
|
Causes of scoliosis?
|
Adolescent idiopathic scoliosis has no clear causal agent and is generally believed to be multifactorial and genetics are believed to play a role.
In the neuromuscular type there are known causal agents such as muscular weakness etc. |
|
|
What is the name of the test of scoliosis when the patient bends forward and how is it performed?
|
Adams Forward Bend Test.
Patient bends forward and any prominence or abnormal angle is noted. A scoliometer may be used. |
|
|
What is the standard diagnostic modality used for scoliosis?
|
Xray. AP and lateral.
|
|
|
Using which angle is scoliosis assessed?
|
The Cobb angle.
Perpendicular lines drawn from the upper endplate of the uppermost involved vertebrae and crossed with the lower endplate of the lowest vertebrae involved. The angle between these perpendicular lines is the Cobbs angle. |
|
|
What is the main determinant of treatment of scoliosis?
|
Severity of curvature and skeletal maturity.
|
|
|
What are the conventional options for treatment of scoliosis?
|
1. Observation
2. Physical therapy 3. Occupational therapy 4. Chiropractic or osteopathic therapy 5. Casting (EDF) 6. Bracing 7. Sugery |
|
|
Which physiotherapeutic method is often used in scoliosis and what is it?
|
The Schroth method.
The Schroth method i based on the assumption that scoliosis results from complex muscular assymetries and it then targets specific muscles in its exercises strengthening to cause symmetry in back musculature. |
|
|
Under what circumstances are braces (orthotics) implemented in the therapy of scoliosis?
|
When skeletal development is not yet complete and there is a risk of progression of curvature.
Another indication is in an adult, to relieve scoliosis-related pain. A condition to use braces is that the curve is not grave enough to warrant surgery. |
|
|
What is the most commonly used brace in scoliosis?
|
TLSO, Thoracolumbosacral orthosis.
|
|
|
What in another commonly used bra in scoliosis?
|
The Milwaukee brace.
|
|
|
How much time during the day is the TLSO usually worn?
|
22-23 h.
|
|
|
What is the reasoning behind using braces in scoliosis?
|
Either to prevent progression in a growing child or to delay the need for surgery.
|
|
|
What is the main different between the TLSO and the Milwaukee brace?
|
The Milwaukee brace also includes a neck ring which is attached to two vertical rods which themselves are attached to the brace.
|
|
|
The TLSO is used for curvatures of what part of the spine?
|
In the thoracolumbar region.
|
|
|
The Milwaukee brace is used for curvatures of what part of the spine?
|
The thoracic region.
|
|
|
Name the third important type of brace for scoliosis, and what is special about it?
|
Charleston Bending Brace.
It is only worn nighttime. It is molded when the patient is bending to the opposite side of the curve and thus it improves the corrective action of the brace. |
|
|
What are the circumstances under which a Charleston Bending Brace may be used to treat scoliosis?
|
That the curvature should be in the 20-40 degree range and apex of the curve needs to be below the level of the shoulder blade.
|
|
|
When is surgery for scoliosis recommended?
|
Generally surgery is recommended when scoliosis has a high likelihood for progression. (45-60 degree magnitude).
Curves that would be cosmetically unacceptable as an adult. Curves in patients with spina bifida and cerebral palsy that interfere with sitting and care. Curves that interfere with physiological functions, such as breathing. |
|
|
What are the two main types of surgery for scoliosis?
|
Anterior fusion (through the side) OR
Posterior fusion (through the back) One or both types may be needed. |
|
|
What is the most widely performed surgery for scoliosis? Explain it.
|
Spinal fusion.
The vertebraes of the curvature are fused by implanting grafts (auto or allo), so that the spine becomes straight and rigid. |
|
|
What is the "compromise" of spinal fusion?
|
That movement of the spine is lost.
|
|
|
What needs to be done in spinal fusion besides fusing the vertebrae?
|
Metal implants.
|
|
|
Why do we need metal implants after spinal fusion surgery?
|
Because otherwise pseudoarthrosis (false joints) may occur at sites where vertebrae failed to join.
|
|
|
What are the different parts of the metal impants used after spinal fusion surgery?
|
Rods, screws, hooks and wires.
|
|
|
What is the name of the metal implants technique after spinal fusion surgery?
|
Cotrel-Dubousset instrumentation
|
|
|
What is the outcome of most spinal surgeries for scoliosis?
|
In general, modern spinal fusion have good outcomes with high degree of correction and low rates of failure and infection. Patients tend to have normal lives with unrestricted activities.
|
|
|
Where are autografts for spinal fusion taken from?
|
Usually the hips, sometimes the ribs.
|
|
|
What is thoracoplasty for, and another name for it?
|
Thoracoplasty, or costoplasty, is a surgery sometimes performed together with spinal fusion or as a standalone and is done to correct the "rib hump" which occurs due to rotational curvature of the spine, or to retrieve bone grafts for the spinal fusion.
It involves the removal of typically 4-6 segments of adjacent ribs that protrude from the chest wall. |
|
|
How many segments of ribs are removed in thoracoplasty and how long is each segment?
|
Usually 4-6 adjacent segments of ribs are removed, and they are usually one or two inches long. 2.5-5cm.
|
|
|
What are the main risks of thoracoplasty?
|
1. Increased pain in the rib area.
2. Reduced pulmonary function. |
|
|
What are common complications of scoliosis surgery? And what is the rate of complications?
|
5%
Inflammation of the soft tissue or deep inflammatory process. Breathing impairments. Bleeding. Nerve injuries. Reoperation is required by an additional 5%. |
|
|
What are the three major forms of congenital spina deformities?
|
Hyperlordosis, kyphosis and scoliosis.
|
|
|
What is the general theory behind the formation of congenital spine deformities?
|
Alteration in the molecular and macromolecular process of embryogenesis may lead to structural defects involving the spine and spinal cord.
|
|
|
What is the main difference in diagnosing idiopathic or congential infantile scoliosis?
|
In the idiopathic form there are no visible vertebral defects on Xray whilst on the congenital one we can see vertebral deformities that were formed prenatally.
|
|
|
Give examples of the deformities seen in vertebraes of children with congenital scoliosis.
|
Failure of formation, with only parts of vertebraes:
- Anterior central defects. - Incarcerated hemiverebraes. - Hemivertebraes (piece of pie) - Wedge vertebrae - or multiple hemivertebrae. Failure of segmentation: - block vertebrae (fused) - Unilateral unsegmented bar. Or it can be mixed. |
|
|
Posterior congenital spinal segmentation defects would result in what kind of spinal curve?
|
Lordosis.
|
|
|
Anterior congenital spinal segmentation defects would result in what kind of spinal curve?
|
Kyphosis
|
|
|
Lateral congenital spinal segmentation defects would result in what kind of spinal curve?
|
Very bad scoliotic curves.
|
|
|
Total congenital spinal segmentation defects would result in what kind of spinal deformity?
|
Short spine.
|
|
|
Anterior formation failure would result in what kind of spinal deformity?
|
Kyphosis
|
|
|
Posterior formation failure would result in what kind of spinal deformity?
|
Lordosis
|
|
|
Lateral formation failure would result in what kind of spinal deformity?
|
Classic hemivertebrae with scoliosis.
|
|
|
What is the prognosis for congenital scoliosis?
|
11% are nonprogressive
14% are mildly progressive 75% are severely progressive!!! |
|
|
Why is evaluation and general examination of a patient with idiopathic or known congenital scoliosis different?
|
Because the congenital variant is associated with many other deformities of other organ systems.
|
|
|
How many % of patients with congenital scoliosis have defects in 4 other organ systems?
|
82%!!!!
|
|
|
How many % of patients with congenital scoliosis have defects in 7 other organ systems?
|
61%!!!
|
|
|
Which is the organ system which is mostly associated with spinal deformities?
|
The genitourinary tract.
|
|
|
What type of genitourinary abnormalities are often seen in conjunction with congenital scoliosis?
|
Ectopic kidneys, single kidney, duplicate ureters, obstructive uropathy.
|
|
|
What other organ system is often associated with congenital scoliosis and how often?
|
The cardiovascular system 10-15%.
|
|
|
What is the prevalence of spinal dysraphic lesions in patients with congenital scoliosis?
|
40%.
|
|
|
Give examples of dysraphic lesions.
|
Fibrous dural band, tethered spinal cord, diastematomyelia, syringmyelia, intradural lipoma.
|
|
|
Which kind of surgeries additionally to spinal fusion surgery are available for congenital type scoliosis?
|
Hemiepiphysiodesis and hemivertebrae excision, vertebrectomy.
|
|
|
What is more common, congeital scoliosis or congenital kyphosis?
|
Congenital scoliosis
|
|
|
What may untreated congenital kyphosis lead to?
|
Paraplegia.
|
|
|
What are the two types (causes) of congenital kyphosis?
|
Defects of segementation (posterior) or defects of formation (anterior).
|
|
|
What is the compensation of the lumbar spine to thoracic kyphosis?
|
Hyperlordosis, which leads to lower back pain.
|
|
|
If a formation failure of a vertebrae is both anterior and lateral, what will result?
|
Kyphoscoliosis.
|
|
|
Why can paraplegia develop in patients with congenital kyphosis?
|
Because the blood supply, especially to the upper thoracic level, is reduced in kyphosis.
|
|
|
What is the only treatment option for congenital kyphosis?
|
Surgery. Bracing has proven useless.
|
|
|
What is the main goal of surgical treatment of congenital kyphosis?
|
Prevention of paraplegia.
|
|
|
What is the common type of surgery for congenital kyphosis caused by anterior formation failure?
|
Posterior fusion.
|
|
|
What type of surgery is performed for a patient with congenital kyphosis greater than 50 degrees?
|
A combined anterior and posterior arthrodesis (fusion).
|
|
|
What is another name for fusion of joints?
|
Arthrodesis
|
|
|
Which is the least common of the 3 major patterns of congenital spinal deformities?
|
Congenital lordosis
|
|
|
What is the cause of congeital lordosis?
|
A failure of posterior segmentation.
|
|
|
Is congenital lordosis progressive?
|
Yes.
|
|
|
What is the only treatment modality for congenital lordosis?
|
Surgery.
|
|
|
What are the indications for corrective surgery in congenital lordosis?
|
Either when there is major deformity or when pulmonary function is lost.
|
|
|
Mention other types of congenital spine malformations besides scoliosis, lordosis and kyphosis.
|
Sacral and lumbosacral agenesis.
Congenital cervical spine anomalies. -Synostosis -Basilar impression -Odontoid anomalies -Kippel-Feil syndrome |
|
|
What is the clinical significance of sacral and lumbosacral agenesis?
|
The patient lacks motor/sensory function below the normal portion of the spine.
|
|
|
What is the name of classification of sacral and lumbosacral agenesis?
|
Renshaw.
|
|
|
What are the different levels of classification of sacral and lumbosacral agenesis?
|
Type I - Partial or total UNILATERAL sacral agenesis.
Type II - Partial sacral agenesis with a bilaterally symmetrical defect. Type III - Variable lumbar and total sacral agenesis, with the ilia articulating with the sides of the lowest present vertebrae. Type IV - Variable lumbar and total sacral agenesis, with the caudal endplate of the lowest vertebra resting above either fused ilia or an iliav amphiarthrosis. |
|
|
What is the etiology of sacral agenesis?
|
The exact mechanism is unknown but it is believed to be caused by disturbances in differentiation of the embryo in the fourth and seventh postovulatory weeks.
|
|
|
What is the range of severity of congenital cervical spine deformities?
|
Congenital anomalies range in severity from those that are benign and asymptomatic to anomalies that can potentially cause fatal instability.
|
|
|
How common are congenital cervical spine deformities?
|
Rare!
|
|
|
What is typical of the time of presentation of cervical spine deformities?
|
They usually are asymptomatic well into adulthood.
|
|
|
Explain basilar impression.
|
Basilar impression (invagination) is a deformity of the bones of the base of the skull at the margin of the foramen magnum.
|
|
|
What are the risks with basilar impression?
|
Higher risk of neurologic damage from injury, circulatory compression and impairment of CSF flow.
|
|
|
What are the presenting symptoms of a person with basilar impression?
|
Neck ache, headache, neurologic compromise.
|
|
|
How is basilar impression assessed?
|
By the lateral radiograph using lines in the anteroposterior direction.
|
|
|
What is occipitocervical synostosis?
|
Occipitocervical synostosis is characterized by a partial or complete congeital union between the atlas and the base of the occiput.
|
|
|
What is torticollis?
|
Torticollis is a condition in which the neck is twisted and tilted in one direction due to MUSCLE CONTRACTION/SPASM.
|
|
|
Tortus means what in latin?
|
Twisted
|
|
|
Collum means what in latin?
|
Neck
|
|
|
What are the most common general causes of torticollis?
|
Congenital causes, trauma and infections.
|
|
|
How frequent is congenital torticollis?
|
0,4% of newborns
|
|
|
Avarage age of onset of noncongenital torticollis?
|
40
|
|
|
Female:male ratio of torticollis?
|
M:F 1:2
|
|
|
What are local etiologies of torticollis in adults?
|
Acute wryneck, occurs overnight, resolves in 1-2 weeks.
Cervical spina torticollis, due to fracture, dislocation, subluxation, infection, spondylosis, tumor etc. Inflammatory torticollis, such as myositis, lymphadenitis or TB Infectious torticollis, due to infection of surrounding soft tissue, such as nasopharyngeal abscess, retropharyngeal abscess, cervical adenitis, tonsillitis, mastoiditis, and sinusitis. |
|
|
What are compensatory etiologies of torticollis in adults?
|
Tilting of the head to suppress an essential head tremor.
Tilting of the head to compensate for double vision secondary to ocular muscle palsy. |
|
|
What are central etiologies of torticollis in adults?
|
Idiopathic spasmodic torticollis occurs more frequently in females, and onset occurs in those ages 30-60.
Dystonias such as torsion dystonia, generalized tardive dyskinesia, Wilsons disease, L-dopa therapy, and neuroleptic drug-related dystonia. |
|
|
What are pediatric local etiologies of torticollis?
|
Congenital causes, such as pseudotumor of infancy, hypertrophy or abscnece of cervical musculature, spina bifida, hemivertebrae, and Arnold-Chiari syndrome.
Otolaryngologic causes, such as vestibular dysfunction, ototis media, cervical adenitis, pharyngitis, retropharyngeal abscess, and mastoiditis. Esophageal reflux Syrinx with spinal cord tumor Traumatic causes, such as birth trauma, cervical fractures or dislocation, and clavicular fractures Juvenile rheumatoid arthritis |
|
|
What are pediatric compensatory causes of torticollis?
|
Strabismus with fourth cranial nerve palsy
Congeital nystagmus Posterior fossa tumor |
|
|
What are central causes of pediatric torticollis?
|
Dystonias including torsion dystonia, drug-induced dystonia and cerebral palsy!
|
|
|
What is the pathophysiology of congenital muscular torticollis?
|
It is believed to be caused by trauma to the soft tissues of the neck just before or during delivery. So it is more commonly seen in breech and forceps deliveries.
|
|
|
What is the presentation of a patient with torticollis?
|
The head is rotated and twisted to one direction, and the chin in pointed toward the opposite shoulder.
Intermittent painful spasms of the sternocleidomastoid, trapezius and other neck muscles may occur. |
|
|
How does congenital torticollis usually present?
|
By a nontender enlargement of the sternocleidomastoideus muscle, at around 4-6 weeks postnatally. By 4-6 months the mass is absent but there is consistent contraction.
|
|
|
What are treatment options for torticollis?
|
Conservative therapy includes physical therapy and medications, and if it fails, surgery:
Sternocleidomastoid release Selective denervation Dorsal cord stimulation |
|
|
What is the treatment schedule for congenital torticollis?
|
Conservative therapy for the first 12-24 months is allowed before surgery is pursued because 90% of patients respond to passive stretching in the first year of life.
|
|
|
Another name of bone infection
|
Osteomyelitis
|
|
|
Another name for low back pain
|
Lumbago
|
|
|
How many people are affected by lumbago at some point in life?
|
80%
|
|
|
Which is the most common job-related disability in the USA?
|
Lumbago (low back pain)
|
|
|
How can we classify lumbago in terms of duration?
|
Acute, subacute or chronic.
|
|
|
How does lumbago usually respond to conservative treatment?
|
Usually we see significant improvemtn within a few weeks from onset.
|
|
|
How long does acute lumbago last?
|
less than 4 weeks
|
|
|
How long does subacute lumbago last?
|
4-12 weeks
|
|
|
How long does chronic lumbago last?
|
more than 12 weeks
|
|
|
What is the cause of majority of lumbago?
|
Musculoskeletal problems.
|
|
|
How many % of low back pain fall into the category of benign musculoskeletal problems (non specific low back pain)?
|
Over 99%
|
|
|
Give some examples of mechanical causes of low back pain.
|
Degenerative discs
Disc herniation Fractures Leg length difference Restricted hip motion |
|
|
Give some causes of inflammatory low back pain
|
RA
Infection, osteomyelitis Seronegative spondyloarthritides (ankylosing spondylitis) |
|
|
What may be metabolic causes of low back pain?
|
Osteoporosis with fractures
Osteomalacia Ochronosis Chondrocalcinosis |
|
|
Other causes of low back pain?
|
Neoplasia
Psychosomatic Pagetäs disease Referred pain Depression Oxygen deprivation |
|
|
What are the usual causes of the injury to the muscles around the lower back?
|
Sprain or strain.
|
|
|
What does strain refer to?
|
Overstreching and tear of muscle.
|
|
|
What does sprain refer to?
|
An overstretching and tear of a ligament.
|
|
|
What causes the sprain or strain in the lower back?
|
Overactivity or sudden activity of the muscles.
|
|
|
What does coccydynia mean?
|
Coccyx pain.
|
|
|
What is the commonest cause of coccydynia?
|
Sitting to abruptly. Falling on the coccyx.
|
|
|
What may be joint problems causing pain in the lower back?
|
Osteoarthritis, rheumatoid arthritis, degeneration of discs or a spinal disc herniation.
|
|
|
So when is testing for low back pain indicated?
|
Only when the low back pain persists for more than a few weeks (acute is 4).
|
|
|
What is the diagnostic approach to low back pain?
|
Determination of underlying cause is made through a combination of history, physical examination and when necessary, diagnostic imaging with Xray, MRI or CT scans.
|
|
|
When are CT and MRI scans indicated in low back pain?
|
If pain is persistent.
Or if pain is accompanied by: Recent significant trauma, Mild trauma if age above 50, Unexplained weight loss, Unexplained fever, Immunosuppression, Previous or current cancer, Intravenous drug use, Osteoporosis, Chronic steroid use, Age greater than 70 years, Focal neurological deficits, Duration greater than 6 weeks. |
|
|
What are the main categories of management of acute low back pain?
|
Self care
Activity Physical therapy Medications Spinal manipulation |
|
|
What are the conservative treatment modalities of chronic back pain?
|
Exercise
Tricyclic antidepressants (since 2007) Antibiotics (if osteomyelitis) Acupuncture (not proven) Behavioral therapy Alexander technique Spinal manipulation Therapeutic massage is a proven method. |
|
|
When is surgery indicated for low back pain?
|
If conservative treatment does not relieve pain or when the patient develops neurological deficits beyond the point of pain, such as leg weakness, bladder or bowel incontinence, which can be seen with severe lumbar disc herniation, causing cauda equina syndrome or spinal abscess.
|
|
|
What are common types of surgeries for low back pain?
|
Microdiscectomy
Discectomy Laminectomy Foraminotomy Spinal fusion (however has not proven efficacy) Lumbar artificial disc replacement. Also implantation of a spinal cord stimulator which is normally used in sciatica. |
|
|
What are the different aspects of self-care of low back pain?
|
Application of heat or cold, and continued activity within the limits of pain. Medium-firm mattresses have shown to be the superior choice.
|
|
|
Is activity recommended in acute low back pain?
|
Yes, physical activity aids in recovery from back pain. Prolonged rest is contraindicated.
|
|
|
What are methods of physical therapy of low back pain?
|
Heat, ice, massage, ultrasound and electrical stimulation. Active therapies can consist of stretching, strengthening and aerobic exercises.
|
|
|
What medications are used in acute low back pain?
|
Short term NSAIDs or acetaminophen.
Muscle relaxants have some benefit. |
|
|
What is spondylolisthesis?
|
Anterior displacement of a vertebra or the vertebral column in relation to the vertebra below.
|
|
|
Where in the spine is spondylolisthesis most common?
|
At L4-L5 or L5-S1
|
|
|
How is spondylolisthesis classified?
|
Spondylolisthesis is classified into 5 categories based on the ETIOLOGY.
1) Congenital or dysplastic 2) Isthmic 3) Degenerative 4) Traumatic 5) Pathologic |
|
|
How are most patients with spondylolisthesis managed, conservatively or surgically?
|
Conservatively
|
|
|
What are the indications for surgery of spondylolisthesis?
|
In patients with incapacitating symptoms, radiculopathy, neurogenic claudication, postural or gait abnormality resistant to nonoperative measures, and significant slip progression.
|
|
|
What is the goal of surgery in spondylolisthesis?
|
To stabilize the spinal segment and decompress the neural elements if needed.
|
|
|
How is spondylolisthesis graded?
|
Spondylolisthesis is graded by taking two measurments. The width of the lower involved vertebra, and the length of slippage of the above one. A percentage of slippage is calculated.
Grade I: 0-25% Grade II: 25-50% Grade III: 50-75% Grade IV: 75-100% |
|
|
Which is the most common etiology of spondylisthesis?
|
The isthmic (spondylolytic) one.
|
|
|
What region is affected in the isthmic (spondylolytic) type of spondylolisthesis?
|
The pars interarticularis, at the region of the junction of the pedicle and lamina.
|
|
|
What happens in spondylolysis (isthmic defect)?
|
The part with the inferior articulating processes are separated from the rest of the vertebra and it is allowed to slip leading to spondylolisthesis.
|
|
|
What may be complications of spondylolisthesis?
|
Decrease in the AP diameter of the pelvic inlet and problems at delivery.
Compression of the spinal cord and all its associated problems. |
|
|
What is the preferred diagnostic modality of spondylolisthesis?
|
Lateral and anteroposterior plain radiographs.
The pars defect may be visualized with a bilateral oblique radiograph. |
|
|
What is the radiographic sign of pars defect in a oblique radiograph of the lumbar spine?
|
Like a Scottie dog with a collar.
|
|
|
Transverse fractures are caused by?
|
Direct high energy force.
|
|
|
Oblique fractures are caused by...
|
angular or rotational force.
|
|
|
segmental type fractures are caused by...
|
high energy force
|
|
|
spiral type fractures are caused by...
|
rotational low energy force.
|
|
|
comminuted fractures means what? and what causes it?
|
that there are more than two fracture fragments, its caused by high energy force.
|
|
|
impacted fracture is caused by...
|
compression
|
|
|
green-stick fractures refers to...
|
an incomplete fracture of one cortex, often occuring in children.
|
|
|
what is the rule of 2s in Xray?
|
2 sides = bilateral
2 views = AP + lateral 2 joints = above and below fracture 2 times = before and after reduction |
|
|
what does a pathologic fracture mean?
|
that it was caused by an underlying bone weakness due to for example osteoporosis/tumour.
|
|
|
what does it mean that a fracture is nondisplaced?
|
fracture fragments are in anatomic alignment
|
|
|
what does it mean that a fracture is displaced?
|
fracture fragments are not in anatomic alignment
|
|
|
what does it mean that a fracture is distracted?
|
that fracture fragments are separated by a gap
|
|
|
what does it mean that a fracture is angulated?
|
that the direction of the fracture apex is in either varus or valgus orientation.
|
|
|
what does it mean that a fracture is translated?
|
that there is a percentage of overlapping bone at fracture site.
|
|
|
what does it mean that a fracture is rotated?
|
that the fragments are rotated about the long axis of the bone
|
|
|
What is the mnemonic for indications of OPEN reduction?
|
NO CAST
N= Non-union O= Open fracture C= neurovascular Compromise A= intra-Articular fracture S= Salter-Harris 3,4,5 T= polyTrauma |
|
|
What are additional indications for open reduction?
|
Failed closed reduction.
Cannot cast or apply traction due to site. Pathologic fractures Potential for improved function with open reduction. |
|
|
How are reductions of fractures maintained?
|
External stabilization: splints, casts, traction, external fixator
Internal fixation: percutaneous pinning, extramedullary fixation (screws, plates, wires), intramedullary fixation rods. |
|
|
What are early local complications of fracture?
|
Compartment syndrome
Neurological injury Vscular injury Infection Implant failure Fracture blisters |
|
|
What are late local complications of fractures?
|
Mal or nonunion
Avascular necrosis Osteomyelitis Heterotopic ossification Posttraumatic arthritis Reflex sympathetic dystrophy |
|
|
What are systemic complications of fractures?
|
Sepsis
Deep vein thrombosis Pulmonary embolus Acute respiratory distress syndrome Hemorrhagic shock |
|
|
What is the definition of avascular necrosis?
|
Disruption of blood supply to bone leads to ischemia and necrosis.
|
|
|
What are the sites which are usually involved with avascular necrosis?
|
Head of femur because it is extensively covered with cartilage and relies on intraosseus supply.
Proximal pole of scaphoid, body of talus. |
|
|
What are risk factors for AVN?
|
steroid use
chronic alcohol abuse post-traumatic fracture/dislocation septic arthritis sick cell-disease storage disease (e.g. Gauchers) dysbarism (Caissons disease "the bends") idiopathic (Chandlers disease) |
|
|
What is the clinical presentation of long bone or unstable pelvic fractures?
|
Local swelling, tenderness, deformity of the limbs and instability of the pelvis
|
|
|
Which investigations should be performed in a patient with recent trauma and a suspiscion of long bone or pelvic fracture?
|
Xrays of lateral cervical spine, AP chest, abdominal xray, pelic AP, AP and lateral of ALL long bones suspected to be injured.
|
|
|
What is the treatment of recent trauma patients with suspected fractures?
|
ABCs
assess genitourinary injury with rectal and vaginal exam. external or internal fixation of all fractures DVT prophylaxis |
|
|
What are the complications of long bone and unstable pelvis fractures?
|
HEMORRHAGE - life threatening
ARDS fat embolism venous thrombosis bladder/bowel injury neurological damage possible future obstetrical problems persistent sacro-iliac joint pain posttraumatic arthritis |
|
|
What is the mnemonic and the meanings of Orthopedic emergencies?
|
VON CHOP
Vascular compromise Open fracture Neurological compromise Compartment syndrome Hip dislocation Osteomyelitis/Septic arthritis Pelvic fracture (unstable) |
|
|
Definition of open fracture.
|
Fractured bone in communication with the external environment.
|
|
|
What is the name of the classification system of open fractures?
|
Gustilo
|
|
|
Classify open fractures:
|
Type I: Wound less than 1cm.
Type II: Wound between 1-10cm Type III: Wound above 10cm |
|
|
What is the most common causative organism of septic arthritis in adults?
|
S. aureus
|
|
|
What is the most common route of infection of the joints?
|
Hematogenous spread
|
|
|
What is the clinical presentation of a patient with septic arthritis?
|
An inability to bear weight, localized joint pain, erythema, warmth, swelling with pain on active or passive ROM +-fever.
|
|
|
How do we treat septic arthritis?
|
With antibiotics, empiric treatment, later adjusting to aspirate.
|
|
|
How do we monitor treatment of septic arthritis?
|
CRP
|
|
|
What is the most common organism in osteomyelitis?
|
S. aureus just like in septic arthritis
|
|
|
What is the causative agent of osteomyelitis in patients with sickle cell disease?
|
Salmonella typhi.
|
|
|
What are the mechanisms of spread to the bone in osteomyelitis?
|
Hematogenous or through exogenous spread via open fractures, or local tissue infection.
|
|
|
What is the typical clinical picture of osteomyelitis?
|
Localized extremity PAIN +-fever or swelling 1 to 2 weeks after respiratory infection or at another nonbony site.
|
|
|
What are the investigations we perform when we suspect osteomyelitis?
|
Blood culture, aspirate cultures, ESR, CRP, CBC for leukocytosis
Xray, bone scan (nuclear med.) and MRI is most sensitive |
|
|
What is the treatment modality for osteomyelitis?
|
IV antibiotics, empiric treatment, adjustment after aspirate has been analyzed.
Surgical decortication and drainage +- local antibiotics (antibiotic beads) if MRI suggest an abscess |
|
|
What is the definition of the compartment syndrome?
|
Increased interstitial pressure in an anatomical "compartment" (calf, forearm) where muscle and tissue are bounded by fascia and bone with little room for expansion.
When interstitial pressure in such a compartment exceeds the capillary perfusion pressure it will inevitably lead to muscle necrosis due to ischemia. This will also eventualy cause nerve necrosis. |
|
|
What is the commonest causes of compartment syndrome?
|
1. FRACTURE, particularly of tibia, crush injury etc...
2. Extracompartmental causes such as constrictive dressings, or circumferential burns |
|
|
What are the 5 Ps or the comPartments syndrome?
|
Pain
(out of proportion for type of injury, not relieved by analgesics, increased with stretch of compartment muscles is specific Pallor Paresthesia Paralysis Pulselessness |
|
|
What are the investigations we perform in compartment syndrome?
|
Usually no investigations are necessary as it is based on clinical findings (stretch of compartment incr. already severe pain).
Catheter can be used to measure compartment pressure in unconscious patients. |
|
|
Treatment for compartment syndrome
|
Nonoperative
Removal of constricting dressings, elevate limb to level of the heart. Operative urgent fasciectomy 48-72h postop: wound closure +-debridement |
|
|
What are complications of the compartment syndrome?
|
rhabdomyolysis, with renal failure due to myoglobinuria, Volkmanns ischemic contracture, calcifications etc.
|
|
|
Is cauda equina a surgical emergency?
|
YES
|
|
|
How many patients with a dislocated hip suffer fractures elsewhere at the time of injury?
|
50%
|
|
|
What should be performed if there is suspiscion hip dislocation?
|
Full trauma surgery
examination for neurovascular injury prior to reduction Reduction Hip precautions later |
|
|
Why do we need to reduce hip dislocations rapidly and not wait?
|
To reduce the risk of AVN.
|
|
|
Which is most common, anterior or posterior hip dislocation due to trauma?
|
Posterior.
|
|
|
In a anteroir hip dislocation how would the involved leg present?
|
Abducted, externally rotated and shortened.
|
|
|
In posterior hip dislocation how would the involved leg present?
|
Adducted and internally rotated.
|
|
|
What is the mechanism of injury of a posterior dislocation of the hip?
|
Severe force to the knee with hip flexed and adducted such as when the knee hits the dashboard in a car accident.
|
|
|
What is the normal treatment schedule for a posteroir dislocation of the hip?
|
Closed reduction under GA
Open reduction, internal fixation (ORIF) if the dislocation is unstable, if there are intraarticular fragments or posterior wall fracture. Postreuction CT to assess joint congruity and fractures If reduction is unstable, the hip needs to be put in traction for 4-6 weeks. |
|
|
What are the complications of all types of hip fractures?
|
post-traumatic arthritis
AVN fracture of femoral head, neck or shaft sciatic nerve palsy hetertopic ossification thromboembolism (PE!!!!) |
|
|
Which method is used in closed reduction of a dislocated hip?
|
The rochester method.
|
|
|
How many joints are there in the shoulder?
|
4
|
|
|
Which are the 4 joints in the shoulder?
|
Glenohumeral, Acromioclavicular, Sternoclavicular and scapulothoracic.
|
|
|
What are the factors causing shoulder instability (3)?
|
Shallow glenoid
Loose capsule Large mobility |
|
|
Which is the most commonly dislocated joint in the body?
|
The glenohumeral joint
|
|
|
Why is the glenohumeral joint the most commonly dislocated joint in the body?
|
Because its stability is sacrificed for motion.
|
|
|
What does recurrence rate of shoulder dislocation depend on?
|
Age of first dislocation. If first dislocation occured under the age of 20 the risk is between 65 and 95% of redislocation. Later it decreases.
|
|
|
What are complications of dislocation of the shoulder?
|
Tuberosity fracture, glenoid rim fracture
Rotator cuff or capsular tear, shoulder stiffness Injury to axillary nerve/artery, brachial plexus Recurrent or unreduced dislocations which is the most common complication |
|
|
What is the absolutely most common type of shoulder dislocation?
|
Anterior
|
|
|
What is the mechanism of dislocating the shoulder anteriorly?
|
Abducted and externally rotated arm or blow to posterior shoulder.
|
|
|
Clinical features of anterior shoulder dislocation?
|
Pain
Arm held in slight abduction, external rotation, because internal rotation is blocked. "squared off" shoulder +apprehension test +relocation test +sulcus sign |
|
|
What are investigations performed in suspiscion of a anteroir dislocation of the shoulder?
|
Xrays, AP, transscapular, axillary
|
|
|
What is a Hill Sachs lesion?
|
divot in posterior humeral head due to forceful impaction of an anteriorly dislocated humeral head against the glenoid rim.
|
|
|
what is a bony Bankarts lesion?
|
avulsion of the anterior glenoid labrum (with attached bone fragments) from the glenoid rim.
|
|
|
What is the treatment of anterior shoulder dislocation?
|
Closed reduction with IV sedation and muscle relaxation
obtain postreduction xrays check post-reduction neurovascular status sling for 3 weeks followed by shoulder rehabilitation. |
|
|
What are the two techinques of closed reduction of a anterior shoulder dislocation?
|
Traction-countertraction: assistant stabilizes torso with a folded sheet wrapped across the chest while the MD applies gentle steady traction.
Stimson: while patient lies prone with arm hanging over table edge, hang a 5lb weight on wrist for 15-20 minutes. |
|
|
What is typical about the diagnosis of posterior shoulder dislocations?
|
That they are missed on initial presentation due to poor physical exam and radiographs. 60-80% actually.
|
|
|
What is the mechanism of posterior shoulder dislocations?
|
Adducted, internally rotated, flexed arm.
Usually occurs during electrocution, epileiptic shock or ethanol ingestion but may sometimes occur during a fall on an outstretched hand. |
|
|
What are the clinical features of a posteriorly dislocated shoulder?
|
Arm is held in adduction and internal rotation and external rotation is blocked.
anterior shoulder flattening, prominent coracoid, palpable mass posterior to shoulder posterior apprehension "jerk" test.... |
|
|
How do we reduce a posteriorly dislocated shoulder?
|
By inferior traction on a flexed elbow with pressure on the back of the humeral head.
|
|
|
What are clinical characteristics of rotator cuff disease?
|
Night pain with difficulty sleeping no affected side.
Pain worse with active motion Weakness and loss of range of motion. Tenderness to palpation over greater tuberosity. |
|
|
Mechanism of injury to the acromioclavicular joint?
|
fall onto shoulder with adducted arm (fall onto tip of shoulder).
|
|
|
What types of Xrays should be taken in suspected acromioclavicular joint pathology?
|
AP, Zanca view (10-15 degrees cephalic tilt), axillary +- stress views
|
|
|
Treatment of acromioclavicular joint pathology?
|
Nonoperative treatment is most common with a sling for 1-3 weeks, ice and analgesia.
If both AC and CC ligaments are torn and or the clavicle is displaced posteriorly then surgery is indicated. The surgical procedure involves excision of lateral clavicle with AC/CC ligament reconstruction. |
|
|
What part of the clavicle is most often fractures?
|
The middle segment.
|
|
|
In which subset of patients are clavicular fractures common?
|
In children.
|
|
|
What are the mechanisms of fracture of the clavicle?
|
Fall on the shoulder 87%
Direct trauma to clavicle 7% FOOSH 6% |
|
|
What are the clinical features of a fractured clavicle?
|
Pain and tentin of skin
Arm is clasped to chest to splint shoulder and prevent movement. |
|
|
What is the treatment of a clavicular fracture?
|
Evaluation of status of entire upper limb.
In proximal and middle third clavicular fractures we put a sling for 1-2 weeks with early ROM and strenthening exercises once the pain subsides. If the end are more than 2 cm apart we should consider an open reduction internal fixation. |
|
|
What is the definition of frozen shoulder? And an alternative name?
|
Adhesive capsulitis is characterized by progressive pain and stiffness of the shoulder usually resolving spontaneously after 18 months.
|
|
|
What is the mechanisms by which frozen shoulder occurs?
|
If frozen shoulder is primary it is caused by diabetes mellitus.
In secondary adhesive capsulitis it is usually due to prolonged immobilization. |
|
|
What are the typical clinical features of frozen shoulder?
|
Gradual onset of shoulder pain with a progressive decrease in the ROM. The pain subsides usually after 6 months but the stiffness and decr in ROM usually progresses and lasts for up to 18 months.
|
|
|
What is the typical progrnosis for frozen shoulder?
|
It usually resolves spontaneously after about a year and a half.
|
|
|
What is the treatment of fronzen shoulder?
|
Active and passive ROM
NSAIDs and steroid injections if there is pain Manipulation under anesthesia Arthroscopy for debridement/decompression |
|
|
What may happen to the head of the humerus in a proximal humeral fracture?
|
AVN
|
|
|
How and who gets proximal humeral fractures?
|
The elderly with osteoporosis and FOOSH.
Young in a high energy trauma such as MVA. |
|
|
What are the clinical features of a proximal humeral fracture?
|
Pain, swelling, tenderness and painful ROM.
|
|
|
What are investigations to be performed in suspicion of a proximal humeral fracture?
|
test axillary nerve function
xrays AP, transscapular, axillary CT scan to evaluate for articular involvement and fracture displacement. |
|
|
What is the common classification system of proximal humeral fractures?
|
Neer classifcation.
|
|
|
What is the Neer classification based on?
|
The displacement of 4 fracture segments, the head, the greater and smaller tuberosities and the shaft.
|
|
|
What are the levels of the Neer classification?
|
nondisplaced: displacement less than 1cm or angulation <45 degrees
displaced: displacement > 1cm or angulation > 45 degrees dislocated/subluxed; humeral head dislocated from glenoid |
|
|
What is the treatment options of proximal humeral fractures?
|
Nonoperative measures are sling immobilization for nondisplaced fractures or closed reduction followed by sling for a minimally displaced fracture.
Operative options are ORIF. |
|
|
When is hemiarthroplasty neccessary in a proximal humeral fracture?
|
If shoulder joint function is threatened. Especially in elderly.
|
|
|
What are the complications of proximal humeral fractures?
|
AVN, axillary nerve palsy, non or malunion, shoulder stiffness, posttraumatic arthritis.
|
|
|
What are the causes of humeral shaft fractures?
|
Direct blows or MVA which are the most common. FOOSH, twisting injuries, metastases in elderly.
|
|
|
Which nerve must be tested before and after treatment ofa humeral shaft fracture?
|
The radial nerve
|
|
|
How are humeral shaft fractures generally treated?
|
Conservatively with a sling and cast. This cast should produce downward traction. After 10 days this hanging cast should be changed for a Sarmiento functional brace.
If there are any indications for open suergery such as open fractures ro neurovascular compromise then operation is performed which involves compression plating or intramedullary rod insertion or possibly external fixation. |
|
|
What are complications of humeral shaft fractures?
|
Radial nerve palsy, however spontaneous recovery is to be expected after 4 months.
Non or malunion Decreased ROM Compartment syndrome. |
|
|
What is the peak age for supracondylar elbow fractures?
|
7 years of age.
|
|
|
What is the mechanism of injury of almost all supracondylar fractures?
|
Hyperextension during FOOSH.
|
|
|
What are the clinical features of a supracondylar fracture?
|
Pain, swelling, point tenderness
Neurovascular injury, assessment of median and radial nerve and radial artery. |
|
|
What are investigations for suspected supracondylarf racture?
|
AP and lateral elbow Xrays
|
|
|
What are the treatment options for supracondylar fractures?
|
If the fracture is nondisplaced, it should be casted in 90 degree flexion for 3 weeks.
If it is displaced or there is vascular injury or an open fracture then it required percutaneous pinning followed by limb cast with elbow flexion of 90 degrees. In adults, ORIF is always required. |
|
|
What are complications of supracondylar fracture?
|
Joint stiffness, brachial artery injury, median or ulnar nerve injury, heteropotic ossification, malunion, compartment syndrome which leads to Volkmanns ischemic contracure and malalignment cubitus varus.
|
|
|
What subset of the population usuallly acquires radial head fractures?
|
Young adults.
|
|
|
Is radial head fractures common?
|
Yes
|
|
|
what is the mechanism of injury in a radial head fracture?
|
FOOSH with elbow extended and forearm pronated.
|
|
|
What are the clinical features of a radial head fracture?
|
Marked local tenderness on palpation over radial head (lateral elbow)
Decreased ROM at elbow Pain on pronation/supination |
|
|
Which fractures are involved in the "Terrible Triad"???
|
Radial head fracture
Coronoid fracture Elbow dislocation |
|
|
What are Xray findings on radial head fractures?
|
Anterior fat pad ("sail sign") or the prescence of a posterior fat pad indicated occult radial head fractures.
|
|
|
What is the name of the classification of radial head fractures?
|
Mason classification
|
|
|
How is an undisplaced radial head fracture treated?
|
By elbow slab or sling for up to 5 days with early ROM
|
|
|
How is an displaced radial head fracture treated?
|
Open reduction, internal fixation if angulation exceeds 30 degrees
|
|
|
How is an comminuted radial head fracture treated?
|
Radial head excision +- prosthesis
|
|
|
How is an Comminuted fracture with posterior elbow dislocation of radial head fracture treated?
|
Radial head excision +- prosthesis.
|
|
|
What are the complications of radil head fractures?
|
joint stiffness, myositis ossificans, recurrent instability
|
|
|
Why shouldnt the elbow be immobilized for more than 2 to 3 weeks?
|
Because loss of ROM will be great.
|
|
|
What causes a fracture of the olecranon?
|
A direct trauma to the posterior aspect of the elbow (fall on the point of the elbow)
|
|
|
What are the clinical features of a olecranon fracture?
|
+-loss of active extension due to avulsion of triceps tendon.
|
|
|
In the treatment of sponydolytic spondylolisthesis, which two groups are patients divided into?
|
Low grade (<50% slippage)
High grade (>50%) |
|
|
Who are the patients with low grade spondylisthesis and what are their symptoms?
|
They are usually young patients with low back pain and radiculopathy.
|
|
|
What are additional factors in the clinical presentation of high-grade spondylolisthesis?
|
Besides back pain there may also be cosmetic deformity, hamstring tightness, radiculopathy, abnormal gait or it may actually be asymptomatic.
|
|
|
What are initial conservative treatment options for patients with symptomatic isthmic spondylolisthesis?
|
Activity modification, pharmacological intervention, and a physical therapy consultation.
|
|
|
What are the pharmacological agents which may be used initially in spondylolisthesis?
|
NSAIDs combined with acetaminophen.
|
|
|
If radicular pain is severe in spondylolisthesis, which is an conservative way of treating it?
|
By a short course of oral steroids. (Prednisone and methylprednisolone)
|
|
|
When may surgery be considered for a patient with low-grade isthmic spondylolisthesis?
|
Only when symptoms have persisted more than 6 weeks and only after 6-12 MONTHS of non-operative therapy (activity modification, pharmacology and physiotherapy)
|
|
|
What are the surgical options for low-grade isthmic spondylolisthesis?
|
Posterolateral fusion
Posterolateral fusion with decompression |
|
|
What is the outcome of posterolateral fusion of low grade isthmic spondylolisthesis?
|
significant improvements in 2 year outcomes.
|
|
|
Does the fusion with decompression of isthmic spondylolisthesis show an improvement in outcomes?
|
No, not according to several randomized studies.
|
|
|
What are the surgical options of HIGH-grade isthmic spondylolisthesis?
|
-Posterior interlaminar fusion
-In situ posterolateral fusion -In situ anterior fusion (ALIF) -In situ circumferential fusion -Instrumented posterolateral fusion -Surgical reduction with instrumented posterior lumbar interbody fusion. |
|
|
What is the reason for age related aging of the intervertebral discs?
|
The nucleus polposus dehydrates and loses elastin while gaining collagen, so it can be compared to a chronic fibrotic process.
|
|
|
What causes the local back pain from a ruptured and herniated intervertebral disc?
|
Compression of the posterior longitudinal ligament and adjacent structures and by a local inflammatory process initiated by the contents of the nucleus polposus.
|
|
|
Which direction is most common for herniation of the intervertebral disc?
|
Posterolaterally (on the side of the posterior longitudinal ligament)
|
|
|
Where will chronic pain be felt in a herniated disc?
|
In the area (dermatome) supplied by the compressed nerve root.
|
|
|
Where do 95% of disc herniations occur?
|
In the lower lumbar region, between L4-L5 or L5-S1.
|
|
|
What causes sciatica? And explain the pain of sciatica.
|
Sciatica is pain in the lower back, side of the hip and thigh and extending to the leg.
It is usually caused by disc herniation in the L5 S1 region compressing the sciatic nerve roots. |
|
|
Why is sciatica so common?
|
Because the IV formaina in the lumbar region decrease in size and the lumbar nerves increase in size with age.
|
|
|
Where do symptom-producing disc herniations occur almost as often as in the lumbar region?
|
Cervical region.
|
|
|
What causes a herniation of a cervical disc?
|
A sudden forcible flexion of the neck, such as in a car accident.
|
|
|
What is the anatomical difference between a herniation in the cervical area and the lumbar area?
|
In the cervical area the disc will compress the nerve root of the same level whilst in the lumbar region the compression will be on the nerve root one level below.
|
|
|
What are the symptoms of disc herniation in the cervical area?
|
Pain in the neck, shoulder, arm and hand, so a kind of radiculopathy but in this region.
|
|
|
What is the meaning of the term "chemical radiculitis"?
|
It is derived from the inflammatory reaction which occurs to the components of the herniated nucleus pulposus. It is characterized by severe local pain.
|
|
|
Why can NSAIDs or corticosteroids be so effective in treatment of radicular pain due to herniation, protrusion or tear?
|
Because of the inflammatory reaction which occurs to the contents of the nucleus pulposus.
|
|
|
Why is disc herniation often delayed as a diagnosis?
|
Because the patient often presents with undefined pains in the thighs, knees or feet.
|
|
|
How are traumatic lumbar disc herniations often caused?
|
By lifting heavy objects whilst bening in the waist instead of the knees.
|
|
|
Why is keeping the back straight while for example lifting so important?
|
Because when the back is straight the pressure is distributed over the whole disc but may increase locally 20-fold with bent back.
|
|
|
Are genes involved in disc herniation?
|
Yes, there is a strong genetic predisposition.
|
|
|
Which is the inflammatory mediator that is released from a herniated disc?
|
TNF-alpha
|
|
|
How is diagnosis generally made of disc herniation?
|
By the history, symptoms, and physical examination. Followed by radiographic tests to rule out other causes such as spondylolisthesis, degeneration, tumours, metastases and space-occupying lesions, as well as to evaluate the efficacy of potential treatment options.
|
|
|
What is the sign used to test for lumbar disc herniation in physical examination?
|
The Laségue's sign
|
|
|
How is the Laségue's sign performed?
|
By lifting the leg up with straight knee whilst the patient is lying.
If pain increases it is positive. If pain does not increase it is negative and compression of the nerve root can almost be excluded. |
|
|
What is the sensitivity and specificity of Laségues sign and what is its significance?
|
The specificity of Laségues sign is rather low meaning that even though it is positive it can be due to other causes. However the Laségues sign is very sensitive meaning that if it does indeed NOT increase pain then the problem must be caused by something else.
|
|
|
What are two techniques of conservative treatment of disc herniation which has shown either inconvlusive or contraindicated results?
|
Spinal manipulation (chriopractor)
Non-surgical spinal decompression |
|
|
When should surgery be considered for disc herniation?
|
Only as a last resort after all conservative treatments have been tried.
Another indication is if the patient has significant neurological deficit. |
|
|
Which are the surgical options in the treatment of disc herniation?
|
Chemonucleolysis (dissolving disc)
IDET (minimally invasive), annuloplasty Discectomy/microdiscectomy Tessys method (endoscopic approach) Laminectomy Hemilaminectomy Lumbar fusion (if recurrencies occur) Anterior cervical discectomy and fusion. Disc arthroplasty Dynamic stabilization Artificial disc replacement Nucleoplasty |
|
|
What are the surgical goals in surgery of disc herniations?
|
To relieve nerve compression, as well as the relief of associated back pain and restoration of normal function.
|
|
|
What are the imaging modalities used in suspiscion of disc herniation?
|
X-ray may not always conclude a disc herniation because of its inability to show soft tissues but it may exlude other causes as well as cause suspiscion of disc herniation.
CT can show the shape and size of the spinal canal, its contents and the structures around it, including soft tissues. MRI is the best way to see a disc herniation. Myelogram is done with xray plus contrast in CSF. Electromyograms and Nerve conduction studies measure the electrical impulse along nerve roots, peripheral nerves and muscle tissue. |
|
|
What is WHO's definition of osteoporosis?
|
Bone mineral density 2.5 standard deviations or more below the mean peak bone density as measured by bone densitometry.
|
|
|
What is the name of the technique for measuring bone density?
|
Dual-energy X-ray absorptiometry.
|
|
|
Normal bone has a T-score greater than...
|
-1 (one standard deviation lower than mean peak)
In white women!! |
|
|
Osteopenia has a T-score between...
|
-1 and -2.5
In white women!! |
|
|
Osteoporosis has a T-score lower than...
|
-2.5
In white women!! |
|
|
Why does the T-score only reflect the bone density in white women?
|
Because the WHO doesnt have enough data to create scores for other ppl of the population.
|
|
|
What is the most common type of osteoporosis?
|
Postmenopausal osteoporosis. (Primary type 1)
|
|
|
What is the name of age-related osteoporosis and which gender is most affected by it? What is the age after which it occurs?
|
Senile-osteoporosis, occurs after age 75 and both genders are affected equally.
(Primary type 2) |
|
|
What is secondary type osteoporosis caused by?
|
Due to chronic predisposing problems or disease, or medications such as glucocorticoids.
|
|
|
What is the main consequence of osteoporosis?
|
Incresed risk of fractures.
|
|
|
What are the typical osteoporotic fractures?
|
Proximal femur, vertebral compression fractures, rib fractures, proximal humeral fractures and distal radial fractures.
|
|
|
What are the typical symptoms for vertebral crush fractures?
|
Sudden back pain, often with radiculopathic pain, and rarely with spinal cord compression or cauda equina syndrome.
|
|
|
Why do hip fractures so often require urgent surgery?
|
Because they are related to a high mortality (20% at 1 year). Hip fractures significantly increase the risk of DVT and PE.
|
|
|
Name the calculator used to calculate the risk of future fractures:
|
FRAX.
|
|
|
What are the important criteria of the FRAX calculator?
|
Gender, age, previous fractures, BMD, smoking, alcohol, weight etc.
|
|
|
What are the nonmodifiable risk-factors for osteoporosis?
|
Age (incr with age)
Gender (female) European and Asian ancestry Family history of osteoporosis |
|
|
What are the potentially modifiable risk factors for osteoporosis?
|
Excess alcohol (small amounts are beneficial)
Vitamin D deficiency Tobacco smoking Malnutrition Inactivity Heavy metals (cadmium, lead) |
|
|
Which diseases and disorders are related to osteoporosis?
|
Immobilization causes bone loss
Hypogonadal states (Turners, Klinefelter, Kallman, anorexia nervosa, andropause, hypothalamic amenorrhea or hyperprolactinemia) Endocrine disorders (Cushings, hyperparathryoidism, thyrotoxicosis, hypothyroidism, diabetes mellitus, acromegaly, adrenal insufficiency) Malnutrition, parenteral nutrition, malabsorption Rheumatologic disorders (RA, AS, SLE) Renal insufficiency can lead to osteodystrophy Hematologic disorders (MM, monoclonal gammopathies, lymphoma, leukemia, mastocytosis, hemophilia, sickle-cell, thalassemia) Several inherited disorders Scoliosis of unknown cause also have a higher risk of osteoporosis. Parkinssons, COPD |
|
|
What are drugs which are directly linked to osteoporosis?
|
Glucocorticosteroids
Anticonvulsants (barbiturates, phenytoin) Less evidence: L-Thyroxine Aromatase inhibitors used in BC... Anticoagulants (heparin warfarin) PPIs interfere with calcium absorption Thiazolidinediaones Lithium |
|
|
What is the underlying pathogenesis in all types of osteoporosis?
|
An imbalance between bone resorption and bone formation.
|
|
|
How does a decrease of estrogen influence the bone remodelling process?
|
Estrogen normally inhibits the action of osteoclasts, so its abscence causes increased bone resorption.
|
|
|
What are the main radiological findings of osteoporosis?
|
Cortical thinning and increased radiolucency of bones.
Fractures are obviously also visible. |
|
|
What happends if there is multiple fractures of the spine in osteoporosis?
|
Kyphosis of the thoracic spine apparent as a "Dowager's hump".
|
|
|
What are the different preventive methods of osteoporotic fractures?
|
Lifestyle modifications (smoking, alcohol, exercise, nutrition sufficient in vit. D and calcium)
Medication Bisphosphonates (alendronate, pamidronate) Raloxifene (selective estrogen receptor modulator) Estrogen-replacement Testosterone in hypogonadal men. Calcitonin |
|
|
Which are new medications which may replace bisphosphonates?
|
Teriparatide and strontium ranelate.
|
|
|
What does "established" osteoporosis signify?
|
That fracture has already occured.
|
|
|
What is the mechanism of action of the antiosteoporotic drug Denosumab?
|
Denosumab is a human monoclonal antibody which binds to RANKL and prevents it from exerting its action of the RANK thereby reducing bone resorption.
|
|
|
What is the typical change in the bones in Paget's disease?
|
Enlarged and deformed bones.
|
|
|
Which gender is more affected by Paget's disease?
|
Women
|
|
|
What is the prevalence of Paget's disease?
|
1,5-8% depending on region.
|
|
|
Is there any genetical component of Paget's disease?
|
Yes, there are strong familiar inheritance patterns.
|
|
|
What test should children of parents with Paget's disease take and when?
|
After age 40, children to parents with diagnosed Paget's should get blood alkaline phosphatase tests every two or three years.
If alkaline phosphatase tests are positive, then more extensive testing should be performed. |
|
|
What are the possible etiologies of Paget's disease of bone?
|
Viral (paramyxoviruses, such as measles)
Genetic |
|
|
What is the pathogenesis of Paget's disease?
|
Initially, an increased number of hyperactive osteoclasts cause bone resorption.
This initial process is followed by recruit of osteoblasts to involved area and increased bone formation. However the bone formation is disorganized. |
|
|
What are the symptoms of Paget's disease?
|
Usually it is mild and asymptomatic.
Bone pain most common. Headaches and hearing loss if skull is affected. Pressure on nerves. Somnolence may be due to vascular steal syndrome. Paralysis. Increased head size, bowing of limb, curvature of spine. Hip pain. Arthritic pain if cartilage is damaged. Teeth may spread intraorally. Chalkstick fractures can occur. Mosaic bone pattern is symptomatic. Hypercementosis of teeth. |
|
|
How is diagnosis of Paget's disease made?
|
Characteristic appearance on Xray.
Elevation of alkaline phosphatase. Bone scans (nuclear medicine) |
|
|
What does the term "nonunion" signify?
|
A PERMANENT failure of healing following a fracture.
|
|
|
What may be the causes of nonunions?
|
-If there is movement in the fracture.
-If there is a poor blood supply to the area. -If there is an infection. |
|
|
Which patient group has a higher incidence of nonunions?
|
Smokers.
|
|
|
What is the most common tissue between the ununited fragments of a nonunion?
|
Scar tissue
|
|
|
If the tissue between the nonunion contains cartilage and joint cavity it is a called a...
|
Pseudoarthrosis
|
|
|
What is the typical clinical presentation of a nonunion?
|
A history of a fracture. The patient complains of persistent pain at the site and may also notice abnormal movement or clicking at the level of the fracture.
|
|
|
What is a bone callus?
|
A bone callus is a temporary formation of fibroblasts and chondroblasts which forms at the area of a bone fracture as the bone attempts to heal itself.
|
|
|
When can usually callus formation be visualized on an Xray?
|
3 weeks post fracture.
|
|
|
What are the two main physiological types of nonunions?
|
Hypertrophic nonunion
Atrophic nonunion |
|
|
What is the underlying problem in the hypertrophic nonunion?
|
Callus is formed, BUT there was a problem with initial reduction, meaning that the two fragments are not aligned to each other.
|
|
|
What is the underlying problem in the atrophic nonunion?
|
No callus is formed. This is due to impaired bone healing, for example due to vascular causes, or metabolic causes such as diabetes mellitus.
|
|
|
What is the prognosis for an untreated nonunion?
|
By definition a nonunion will not heal without treatment.
|
|
|
What is the surgical treatment of nonunions?
|
-Removal of scar tissue between fracture fragments.
-Reduction -Fixation with metal plates, rods and pins -Bone grafts |
|
|
What is the definition of a malunion?
|
A faulty (causing incorrect alignment) or incomplete union after a fracture.
|
|
|
So has the fracture of a malunion healed?
|
Yes, but in an incorrect manner.
|
|
|
What are the physical deformations of a malunion?
|
The bone can be shorter than normal, twisted or bent in a bad position. Often they all occur together.
|
|
|
What are symptoms of malunions?
|
Deformities
Swelling Pain Difficulty bearing weight. |
|
|
What is the treatment options for malunions?
|
Osteotomy (cutting the bone) at or near the original fracture.
Realignment and fixation. |
|
|
How are bones lengthened to its correct length?
|
Using the Ilizarov method.
|
|
|
What are the causes of malunions?
|
More or less the same as those for nounion such as initial malalignment, inadequate immobilization or infectious process.
|
|
|
What is the definition of a stress fracture?
|
The failure of the skeleton to withstand submaximal forces over time causes incomplete fractures called stress fractures.
|
|
|
What distinguishes stress fractures from common fractures causatively?
|
Stress fractures are caused by "unusual or repeated stress" rather than a solitary, severe impact which causes the common fractures.
|
|
|
How could the appearance of stress fractures be described?
|
A very small sliver (flisa) or crack in the bone. Sometimes dubbed "hairline fracture".
|
|
|
Where do stress-fractures commonly occur?
|
In the weight bearing parts of the skeleton such as the tibia and metatarsals.
|
|
|
What subgroup of the population commonly present with stress fractures?
|
Athletics.
|
|
|
What is special about the pain related to stress fractures?
|
The pain is usually low at the beginning of exercising, then gradually increasing to maximum at the end.
|
|
|
What is the common presentation of a stress fracture?
|
It could present as a generalized area of pain and tenderness associated with weight bearing.
|
|
|
How are stress fractures diagnosed?
|
Usually by history and clinical examination. Investigations can be performed but are not necessary for diagnosis.
|
|
|
What are the imaging modalities of choice for stress fractures?
|
Xray, but often inconclusive in the case of stress fractures.
CT, MRI or 3-phase bone scan. |
|
|
What is the only option for complete healing of a stress fracture?
|
Rest.
|
|
|
What are the factors influencing the time needed for healing of a stress fracture?
|
Location, severity and the efficiency of the body in healing, and nutritional intake.
|
|
|
How is proper rest assured and for how long?
|
Cast of walking boot are usually used for a period of 4-8 weeks. More severe injuries may require rest for up to 16 weeks.
|
|
|
What is a significant risk after initiating physical activity after the period of rest in a stress-fracture?
|
Refracturing because the bone might require several months to fully heal.
|
|
|
What is a general rule in the initial phases of resumed activity after a stress fracture?
|
That exercise volume should not increase by more than 10% per week.
|
|
|
How can stress on the area of a previous fracture be reduced during initiation of physical activity?
|
Bracing or casting the limb with different supportive devices may reduce the stress to the particular area.
|
|
|
Is surgery required in the treatment of stress fractures?
|
Only in the very severe cases.
|
|
|
What is the pathophysiology of stress fractures?
|
The stress applied repeatedly to an area of bone, even though not severe enough to cause a frank fracture, overwhelms the capacity of the osteoblasts to remodel.
|
|
|
Besides athletes, who may acquire stress fractures?
|
Sedentary people (has slow bone remodelling) who suddenly undertake a burst of exercise.
Soldiers who march long distances. |
|
|
What are the preventive methods for stress fractures?
|
Adding moderate stress to the bones (in such a manner that it increases the efficiency of bone remodelling)
Strengthening exercises which builds muscle to support weight. |
|
|
Another name of dislocation.
|
Luxation
|
|
|
Partial dislocation
|
Subluxation
|
|
|
What is the definition of dislocation?
|
The bones in a joint become displaced or misaligned.
|
|
|
What always happens in a dislocation?
|
Ligament damage
|
|
|
Swedish for sprain.
|
Stukning
|
|
|
Swedish for strain.
|
Muskelsträckning.
|
|
|
What are typical symptoms of a strain?
|
Localized pain
Stiffness Discoloration and brusing |
|
|
Who are at highest risk of developing muscle strains?
|
People who play sports.
|
|
|
What is the mnemonic for remembering the first-line treatment for muscle strains?
|
R.I.C.E
Rest Ice Compression Elevation |
|
|
Why is rest important in a muscle strain?
|
To prevent further progression of the strain.
|
|
|
Why is ice applied to a strain?
|
To reduce edema and hematoma by reducing blood flow to the area.
|
|
|
How long should ice be applied to the area?
|
Never longer than 15 minutes.
A layer of fabric should be placed between the ice and skin to avoid skin damage. |
|
|
Why is elevation of the limb performed in a muscle strain?
|
Elevation to the level of the heart prevents excessive pooling of blood around the injury.
|
|
|
Compression of a strained muscle is performed to...
|
reduce the accumulation of blood.
|
|
|
What are the three clinical tests performed to test for union in fractures?
|
Abscence of movement between fragments.
Abscence of tenderness on firm palpation. Abscence of pain during angulating forces over the site of fracture. |
|
|
What must be performed to confirm union?
|
Radiography
|
|
|
What are the two radiological findings which confirms union?
|
Callus bridging the fracture.
Continuity of the trabeculae across the fracture. |
|
|
What are the three fundamental principles of fracture treatment?
|
Reduction
Immobilization Preservation of function |
|
|
When is reduction of a fracture usually necessary?
|
When there is MALALIGNMENT of more than a few degrees.
|
|
|
When is reduction of a fracture usually not necessary?
|
When there is imperfect apposition, but the alignment is correct.
|
|
|
What are the three ways of reduction?
|
Closed manipulation.
Mechanical traction. Open operation. |
|
|
Closed manipulation is usually performed with or without general anesthesia?
|
With GA. Sometimes local or regional anesthesia.
|
|
|
What is the reasoning behind mechanical traction when reducing a fracture?
|
Due to muscles which may shorten the limb and displace the bone fragments we might need to add traction..
|
|
|
How is traction applied when reducing a fracture?
|
Either with the use of weights of by a screw device.
|
|
|
Give two examples of fractures which commonly do not require immobilization?
|
Fractures of the clavicle, or of phalanges which are covered by periosteum.
|
|
|
What are the three indications for immobilization of a fracture?
|
1. to prevent displacement due to angulation force.
2. to prevent movement which may interfere with union. 3. to relieve pain |
|
|
What are the 4 methods of immobilization of a fracture?
|
1. A plaster of Paris cast or other external splint.
2. Continous traction 3. External fixation 4. Internal fixation. |
|
|
What is the main reason for use of external fixators?
|
When internal fixation cannot be performed in open or infected fractures due to the risk of biofilm.
|
|
|
What are the different methods for internal fixation?
|
1. Metal plate with screws
2. Intramedullary nail. 3. Dynamic compression screw-plate 4. Condylar screw-plate 5. Tension band wires 6. Transfixion screws or Kirschner wires |
|
|
Under what circumstances are the conventional metal screw-plates used?
|
Long bone fractures.
|
|
|
In whom are scaphoid fractures common?
|
In young adults.
|
|
|
What is the usual mechanism of injury of the scaphoid bone?
|
Fall on an outstretched hand.
|
|
|
Describe the most common fracture of the scaphoid.
|
A transverse fracture through the middle of the bone.
|
|
|
Is there any displacement between fragments of a scaphoid fracture?
|
No usually not.
|
|
|
What may occur if there is displacement between the fragments of the scaphoid bone?
|
Degenerative arthritis.
|
|
|
Why are fractures of the scaphoid bone often missed?
|
Because the pain is usually slight, and it can also be missed on radiographs.
|
|
|
What are the clinical signs of a scaphoid fracture?
|
Tenderness on palpation over the scaphoid, especially in the anatomical snuffbox.
Impairment of wrist movement. |
|
|
What projections of radiographs should be requested for a suspected scaphoid fracture?
|
AP, lateral and two oblique.
|
|
|
What should be done if a patient has signs of a scaphoid fracture but the radiograph is inconclusive?
|
The radiograph should be repeated in 2 weeks.
|
|
|
If xray cannot visualize a scaphoid fracture but there is still strong clinical suggestions for it, what should be done?
|
Either an MRI or a bone scan.
|
|
|
What is the standard method of treatment of a scaphoid fracture?
|
Immobilization of the wrist is a plaster until the fracture is shown radiologically to be united, usually after 2-3 months.
|
|
|
How big a plaster should be used in the case of a scaphoid fracture?
|
It should extend from the metacarpophalangeal joints of the fingers and the interphalangeal joint of the thumb down to halflength of the forearm. It should be designed in such a way that the fingers are free to move.
|
|
|
Is the incidence of complications in scaphoid fractures high?
|
Yes
|
|
|
What are the 4 most important complications of scaphoid fractures?
|
Delayed union
Nonunion Avascular necrosis Osteoartritis |
|
|
What is done if there is no union after 4 months?
|
The plaster is removed, and after 3-4 weeks we judge if there is any disability in the joint. If there isn't, we deliberately ignore the fracture but if there is wrist limitations we will suggest surgery.
|
|
|
What are the features of a nonunion of a scaphoid bone?
|
Well-defined fracture margins due to sclerosis and pseudoarthrosis.
|
|
|
What determines the treatment of a nonunion of a scaphoid bone?
|
The degree of wrist impairment and osteoarthritic changes.
|
|
|
What must inevitably follow in a nonunion of the scaphoid bone?
|
Osteoarthtritic changes of the radiocarpal joint.
|
|
|
What is the recommended treatment of a symptomatic scaphoid nonunion?
|
Internal fixation with a compression screw.
|
|
|
Which part of the scaphoid is sensitive to avascular necrosis? And what are the main risks?
|
The proximal fragment of a fracture. Osteoarthritic changes and wrist impairment.
|
|
|
What are the clinical features of osteoarthritis of the wrist?
|
Pain, especially in use.
Restriction of ROM. |
|
|
What is the mechanism of injury in a 1st metacarpal fracture?
|
A forced abduction of the thumb. Or a longitudinal blow.
|
|
|
Where is pain/deformity evident in a 1st metacarpal fracture?
|
Distal to the anatomical snuffbox.
|
|
|
What are the two distinct types of fractures of the 1st meatcarpal bone?
|
A transverse fracture close to the base which does not go into the joint.
An oblique fracture which joins the carpometacarpal joint. |
|
|
Which type of fracture of the first metacarpal bone is the more serious and why?
|
The oblique one which joins the joint because it usually leads to osteoarthritic changes. Also the segment is often displaced and disturbs the abductor pollicis longus tendon.
|
|
|
What is the name of the oblique type of 1st metacarpal fracture?
|
Bennets fracture
|
|
|
What is very important in the treatment of the fracture of the 1st metacarpal bone?
|
Proper reduction and immobilization if there is displacement (in oblique fractures) because otherwise there will be osteoarthritis.
|
|
|
What is the treatment of the majority of displaced 1st metacarpal fractures?
|
Internal fixation with screw, or alternatively with Kirschner wires because in the majority of cases the fragments cannot be held immobilized by plaster.
|
|
|
Why is it not recommended to imobilize fingers for more than 2-3 weeks?
|
Because they will rapidly loose ROM.
|
|
|
How may undisplaced fractures of the shafts of the phalanges be treated?
|
"Buddy splintage" meaning that binding the fractures finger to the same segment of the next finger.
|
|
|
How are more complicated displaced fractures of the bases and apexes of phalanges treated?
|
By reduction and fixation with for example Kirschner wires.
|
|
|
What is the mchanism of damage in the mallet finger?
|
A sudden passive flexion of the distal phalanx such as a ball hitting the tip of the finger.
|
|
|
How is the mallet finger treated?
|
Uninterrupted splintage in the fully straight position for 6 weeks. The proximal interphalangeal joint is left free.
|
|
|
What if there is a lagre peice of bone which occured as an avulsion fracture in the mallet finger?
|
Then it can be fixed with a Kirschner wire.
|
|
|
What is a "Boxer's fracture"?
|
An isolated displaced fracture of the neck of the 5th metacarpal.
|
|
|
What is special about the reduction of a Boxers fracture?
|
That reduction is easy to achive by dorsal displacement but is hard to maintain.
|
|
|
When will surgical fixation with a Kirschner wire be necessary for a Boxers fracture?
|
Only if displacement angulation is over 40 degrees.
|
|
|
Which is the most common of all fractures?
|
Colles fracture.
|
|
|
Above what age does Colles fractures usually occur?
|
40+
|
|
|
What gender is especially affected and why?
|
Women, osteoporisis.
|
|
|
What is the mechanism of injury in the Colles fracture?
|
Fall onto an outstreched arm.
|
|
|
Is there displacement in the majority of Colles fracture?
|
Yes
|
|
|
Where is the location of the Colles fracture?
|
2cm proximally to the distal end of the radius.
|
|
|
What kind of displacement typically occurs in the Colles fracture and what is its pseudonym?
|
"Dinner-fork" due to upward and backward displacement of the distal fracture segment.
|
|
|
What is it called if the distal segment displaces downwards instead?
|
Smiths fracture. (reverse Colles)
|
|
|
What is the standard method of treatment of a displaced Colles fracture?
|
Reduction under local or general anesthesia with immobilization with a below elbow plaster cast.
|
|
|
What are the two types of plasters used to immobilize a Colles fracture?
|
The dorsal plaster slab (covers 2/3rds of the circumference of the forearm)
The complete encircling plaster. |
|
|
What can be an advantage of the dorsal plaster slab?
|
It can much more easily be removed if swelling should occur soon after injury.
|
|
|
What is important in the management of Colles fractures?
|
That radiographs be taken immediately after reduction to check for displacement and also at the first checkup, because redisplacement is common even if there is immobilizatin.
|
|
|
Why is it important that redisplacement of a Colles fracture be found early?
|
Because if redisplacement did occur and it is found 2 weeks later, there is little chance of success of reduction.
|
|
|
How long should there be plaster immobilization in a Colles fracture?
|
5-6 weeks if displaced, 2-3 if undisplaced.
|
|
|
What alternative method of immobilization may be used in younger patients with a colles fracture?
|
An external fixator.
|
|
|
Why is an external fixator commonly used in young patients with Colles fractures?
|
Because reduction is hard to maintain in young patients.
|
|
|
What will happen if redisplacement is not discovered and reduced?
|
Union will occur in this deranged alignment with ugly deformity.
|
|
|
What can be done if the bones healed in an incorrect alignment?
|
Osteotomy and bone transplant and stabilization with internal fixation.
|
|
|
What are the general complications of a Colles fracture?
|
Malunion
Subluxation of the distal radio-ulnar joint. Rupture of extensor pollicis longus. Compression of median nerve. Stiffness of fingers or shoulder. Reflex sympathetic dystrophy. |
|
|
What is another name for the reverse colles or smiths fracture?
|
Bartons fracture
|
|
|
How is the Smiths fracture with joint involvement immobilized?
|
With the use of an internal fixation device called the Butress plate which is screwed to the proxmial fragment and prevents anterior slide of the distal segment.
|
|
|
Butress in swedish means...
|
stöd, stävpelare (ungefär som man använder med växter)
|
|
|
How is the Smiths fracture without joint involvement managed?
|
With a plaster cast which includes the elbow which keeps the hand in dorsiflexion and full supination.
|
|
|
In what kind of fracture is the distal radioulnar joint dislocated?
|
In the galeazzi fracture.
|
|
|
Where is the fracture in the galeazzi fracture?
|
In the distal shaft of the radius.
|
|
|
What is the mechanism of injury in the Galeazzi fracture?
|
A fall onto the arm.
|
|
|
What must usually be done in the Galeazzi fracture to prevent redisplacement?
|
Its hard to maintain reduction in the galeazzi fracture so it must usually be fixated internally with a metal plate and screws. Once the fracture is reduced the distal radioulnar joint is usually reduced without difficulty.
|
|
|
What kind of plaster is used in the galeazzi fracture?
|
A full length plaster cast with the elbow flexed and the forearm in supination until union occurs.
|
|
|
What is the opposite to the galeazzi fracture?
|
The Monteggia fracture.
|
|
|
Describe the Monteggia fracture.
|
In the Monteggia fracture there is a fracture of the proximal shaft of the ulna with a dislocation of the head of the radius (compared to a distal radial fracture with ulnar head deviation in the galeazzi)
|
|
|
Is the Monteggia fracture common?
|
No
|
|
|
What is the mechanism of injury of the Monteggia fracture?
|
A fall associated with forced pronation of the forearm or a direct blow to the back of the upper forearm.
|
|
|
How is the Monteggia fracture reduced and immobilized?
|
It usually requires ORIF for the fracture, but the proximal radioulnar joint can be reduced with forced supination.
|
|
|
What is a nightstick fracture?
|
An isolated ulnar shaft fracture.
|
|
|
What is special with fractures to the shafts of the forearm?
|
They are significantly prone to severe displacement.
|
|
|
So the fact that the forearm shaft fractures are prone to displacement leads to the conclusion that reduction and fixation often have to be performed...
|
internally.
|
|
|
What is the difference between children and adults concerning fractures of the shafts of the forearm?
|
Children have more resilient bones and thus often the result is greenstick fractures. In that respect treatment can be more conservative in children with closed reduction and immobilization with a full-length plaster cast.
|
|
|
Describe a greenstick fracture.
|
The best way to decribe a greenstick fracture is that it is An incomplete fracture.
|
|
|
What is the typical time period before union in a forearm shaft fracture?
|
10-12 weeks
|
|
|
What is the most common type of internal fixation used for fractures of the shafts of the forearm?
|
Metal plate with 6 screws, 3 in each segment.
|
|
|
What is a severe complication of a forearm shaft fracture?
|
Compartment syndrome.
|
|
|
What is the treatment of compartment syndrome?
|
Fasciotomy
|
|
|
In whom are humeral neck fractures more common and why?
|
In elderly women due to osteoporsis.
|
|
|
What is the common mechanism of injury in a humeral neck fracture?
|
A fall onto the arm.
|
|
|
What is the typical displacement of a humeral neck fracture?
|
There may be no displacement or there may be such displacement that the shaft appears to be abducted or adducted in realtion to the head.
|
|
|
What is a favourable feature of the humeral head fractures?
|
That the bone fragments are usually firmly impacted to one another which favours recovery.
|
|
|
What are clinical signs of a humeral head fracture?
|
Pain and extensive bruising in the upper and middle part of the upper arm.
|
|
|
How can the presence of impaction be evaluated clinically?
|
If the slighest passive movement of the arm causes severe pain there is no impaction (meaning that the fragments do not move together) but if there is not so much pain then there is impaction.
|
|
|
What are three extremely important points to bear in mind concerning the treatment of a humeral head fracture?
|
1. Even severe displacements are compatible with restoration of adequate function.
2. Fragments cannot be immobilized without extensive plaster or internal fixation. 3. The shoulder will become stiff if immobilized for long. |
|
|
So what is the standard conservative method of treatment of impacted humeral head fractures?
|
Immobilization is unnecessary.
Active and assisted shoulder movements should be begun immediately and continued daily, the arm being carried in a sling in the intervals between treatment. |
|
|
what is the standard conservative method of treatment of UNimpacted humeral head fractures?
|
Support the arm in a sling, supplemented with a body bandage to hold the arm close to the body the first week.
Shoulder movements should be deferred the first 2-3 weeks and then initiated to allow the shoulder a full mobility. |
|
|
In what patients are the conservative treatment methods for humeral head fractures not satisfactory?
|
In younger patients.
|
|
|
What is the treatment for younger patients with humeral head fractures?
|
ORIF. Closed reduction is too hard.
|
|
|
What are the two choices in internal fixation of the humeral head?
|
Metal plate fixed with screws or tension band wiring.
|
|
|
When may a replacement arthroplasty be required for a humeral head fracture?
|
If there is severe comminuted three- or fourpart fracture.
|
|
|
What are the common complications of a humeral head fracture?
|
Joint stiffness.
Arterial injury (brachial artery). Nerve injury (axillary nerve) Dislocation of the shoulder |
|
|
How is injury to the axillary nerve evidenced?
|
Patient not able to contract the deltoid muscle (abduction of arm) or anesthesia of the lateral arm.
|
|
|
How is axillary nerve damage treated?
|
Expectant.
|
|
|
What other nerve structures may be damaged in humeral head fractures?
|
The brachial plexus
|
|
|
What governs the treatment of a fracture of the greater tuberosity of the humerus?
|
If there is displacement.
If none, treatment consists of exercises. If there is severe displacement, proper reduction should be attempted with ORIF. |
|
|
What is an important complication of a fracture of the greater tuberosity of the humerus?
|
Painful arc syndrome.
|
|
|
Mechanism of injury of a fracture of the shaft of the humeruss.
|
An indirect twisting force or a direct blow to the shaft.
|
|
|
What part of the humeral shaft is usually involved in a fracture?
|
The middle third.
|
|
|
Which age group usually sustains a humeral fracture?
|
All adult age groups but not children.
|
|
|
Twisting cause of the humeral shaft fracture will give rise to what kind of fracture?
|
A spiral fracture.
|
|
|
A direct blow to the humerus will cause what kind f shaft fracture?
|
A transverse, short oblique or comminuted fracture.
|
|
|
Which part of the humerus is a common site for pathological fractures in metastatic carcinoma?
|
The proximal shaft.
|
|
|
Under what circumstances is reduction and strict fixation carried out in a humeral shaft fracture?
|
Only if alignment is severely disturbed is reduction neccessary, otherwise the shaft fragments are expected to heal ok.
|
|
|
What is the standard method of treatment of a humeral shaft fracture which is inacceptably displaced?
|
Closed reduction under anesthesia with plastering which needs not give perfect immmobilization.
The plaster needs only run from the axilla to the elbow. |
|
|
When may internal reduction and fixation be attempted in a humeral shaft fracture?
|
If alignment is severely disturbed.
|
|
|
What are the methods of internal fixation in a humeral shaft fracture?
|
Metal plate with screws of preferably an intramedullary nail.
|
|
|
What method of fixation should be used in an open fracture?
|
An external fixator.
|
|
|
What nerve is injured in humeral shaft fractures and how common is its injury?
|
In 10-15% the radial nerve is injured.
|
|
|
What is the typical outcome of radial nerve damage?
|
Forearm extensor paralysis with wrist drop.
|
|
|
What is the treatment of radial nerve damage?
|
If it was a closed fracture the treatment is expectant and intervention only done if reinnervation does not occur within expected time frame.
|
|
|
What is the mechanism of injury of the supracondylar humeral fracture?
|
A fall onto an outstretched hand.
|
|
|
What age group normally acquires a supracondylar fracture?
|
Children, it is uncommon in adults.
|
|
|
Why is this type of fracture potentially serious?
|
Because of the risk of brachial artery damage.
|
|
|
If there is displacement in a supracondylar fracture of the humerus, what is the characcteristic feature?
|
The distal segment is displaced posteriorly.
|
|
|
What is the treatment of an undisplaced supracondylar fracture in children?
|
Plaster for three weeks.
|
|
|
What is the treatment of a displaced supracondylar fracture in children?
|
Manipulative reduction under anaesthesia, followed by immobilization in plaster.
|
|
|
How is a displaced supracondylar fracture of the humerus reducted?
|
By applying longitudinal traction and forward pull to realign the fragments.
|
|
|
What if even after reduction the fragments are unstable and prone to redisplacement?
|
Then internal fixation with two fixation pins is undertaken.
|
|
|
Which is the nerve which may be injured in a supracondylar fracture of the humerus?
|
The median nerve.
|
|
|
How is a brachial artery damage dealt with?
|
1. First bandage or splint is removed.
2. Any displacement is reduced. 3. Heat is applied to the whole body to cause general vasodilation. If the above fails, proceed: 4. Brachial artery exploration surgery. 5. Anterier fasciotomy to prevent compartment syndrome after resolving the brachial artery flow. |
|
|
What is the anatomical difference between a supracondylar fracture in a child and adult?
|
In the adults the supracondylar fractures usually involves the joint and have a T or Y appearance.
|
|
|
So how are supracondylar fractures of the humerus often treated in adults?
|
By ORIF.
|
|
|
What is a common late outcome of a supracondylar humeral fractures in adults?
|
Osteoarthritis
|
|
|
What age group sometimes acquire condylar fractures of the humerus?
|
Children.
|
|
|
Are condylar fractures of the humerus common?
|
No, but troublesome.
|
|
|
Which condyle is more commonly involved?
|
The lateral one. (Capitulum)
|
|
|
Why is a condylar fracture of the humerus often troublesome?
|
Because it is often displaced.
|
|
|
How is an undisplaced condylar fracture of the humerus treated?
|
By plaster for a few weeks, followed by a course of mobilizing exercises.
|
|
|
How is an displaced condylar fracture of the humerus treated?
|
First manipulation under anesthesia followed by plastering is tried.
If reduction fails this way operation with internal fixation is initiated with a small screw keeping the condyle attached. |
|
|
What are late complications of a condylar fracture of the humerus?
|
Osteoarthritis and nonunion.
|
|
|
Humeral epicondylar fractures usually affects which side?
|
Medial, compared to condylar fractures which normally are lateral.
|
|
|
What is the mechanism of injury of the medial epicondylar fracture?
|
Either direct violence or more commonly due to avulsion fracture
|
|
|
Is there severe displacement in a medial epicondylar fracture?
|
Usually no, it needs only be treated with a plaster for 3 weeks.
|
|
|
What are the important complications of an epicondylar fracture?
|
1. Inclusion of the medial epicondylar fragment in the elbow joint.
2. Injury to the ulnar nerve. |
|
|
What should be performed if the epicondyle enters the joint cavity?
|
Attempt to reduce the condyle under anesthesia, and if closed approach fails then operation should be attempted.
|
|
|
What is the mechanism of injury in the elbow dislocation?
|
Fall onto an outstretched arm.
|
|
|
Is an elbow dislocation a common injury and in what age group?
|
It is failry common both in adults and children.
|
|
|
What is the most common morphology of the dislocation of the elbow?
|
The ulna and radius are displaced posteriorly from the humerus.
|
|
|
What are the fractures which are associated with a posterior dislocation of the shoulder?
|
The coronoid process of the ulna.
Radial head. Capitulum or medial epicondyle. |
|
|
What is the standard method of treatment of a dislocated elbow?
|
The joint should be reduced under GA as fast as possible. (usually easy). Reduction should be confirmed by radiography.
Thereafter the elbow should be rested in a plaster backslab for 2 weeks. Then exercises. |
|
|
What may be complications of an elbow dislocation?
|
Brachial artery or nerve injury.
JOINT STIFFNESS |
|
|
What is the most efficient way to prevent or treat elbow joint stiffness?
|
With persevered joint exercising!!!
|
|
|
Should manipulation or passive stretching be performed in the elbow?
|
No, the elbow doesnt like it :) and it may worsen the stiffness.
|
|
|
What may happen if a child is being pulled by the arm?
|
The radial head may be subluxated from the annular ligament.
|
|
|
How is a "pulled elbow" corrected?
|
Easily by applying upward pressure on the forearm and alternating between supination and pronation.
|
|
|
How is the olecranon of the ulna fractured and in what age group?
|
By a fall onto the tip of the elbow, and it usually occurs in adults.
|
|
|
Is the joint commonly involved in a fracture of the olecranon?
|
Nearly always the fracture communicates with the joint.
|
|
|
What are the three different types of fractures of the olecranon?
|
Either a crack without dislocation or a clean break with separation or a comminuted fracture.
|
|
|
What is the treatment of a "crack only" type of olecranon fracture?
|
Protection of the elbow with a light plaster cast for 2-3 weeks.
|
|
|
Why cannot displaced fractures of the olecranon be reduced without operation?
|
Because the triceps will pull the olecranon to redislocate it, so internal manipulation is essential.
|
|
|
What is the method of internal fixation of a displaced olecranon?
|
1. By a long coarse-threaded cancellous screw passed down the bone from the upper surface of the olecranon.
2. Tension band wiring. |
|
|
What is the common method of treatment of a comminuted fracture of the olecranon?
|
Removal of pieces of olecranon.
Drilling small holes in the proximal ulna. Attaching the triceps tendon to these small holes. |
|
|
What are the main complications of an olecranon fracture?
|
Nonunion, malunion and osteoarthritis.
|
|
|
In whom is the radial head fracture common?
|
In young adults it is one of the most common occuring fractures.
|
|
|
What is the mechanism of injury in the radial head fracture?
|
A fall onto a pronated outstretched arm.
|
|
|
What is the most usual configuration of the fracture of the head of the radius?
|
A vertical crack through the cone-shaped head.
|
|
|
What is the treatment for a vertical fracture of the head of the radius?
|
Only rest in plaster for 2-3 weeks until the pain settles, after which exercises are initiated.
|
|
|
What is the second more severe type of radial head fracture?
|
If there is displacement or comminution.
|
|
|
What is the treatment for a comminuted radial head fracture?
|
If it is not possible to fix the small fragments the radial head should be excised.
|
|
|
Why is a radial head fracture commonly overlooked?
|
Because the fracture line is usually hard to see in the beginning.
|
|
|
What is an alternative to excision of the radial head in modern practise?
|
Replacement of the radial head with a prosthesis.
|
|
|
What is the difference of the radial head fractures in young adults compared to children?
|
In children the fracture more commonly goes through the neck with a tilting of the head and thus requires some mode of reduction and fixation. The head should never be excised in children.
|
|
|
Are there any complications after a radial head fracture?
|
Usually it is without complications but sometimes osteoarthritis will follow.
|
|
|
In what age group might we expect shoulder dislocations?
|
In adults.
|
|
|
Which types of dislocation of the shoulder is by far the most common?
|
Anterior shoulder dislocation.
|
|
|
What is the mechanism by which anterior shoulder dislocation occurs?
|
By a fall on an outstretched arm or by a direct blow.
|
|
|
Where does the humeral head usually come to lie in an anterior shoulder dislocation?
|
In the infraclavicular fossa just below the coracoid process.
|
|
|
What is the usual mechanism of injury of a posteriorly dislocated shoulder?
|
Mostly due to epileptic seizures or electric shock which can cause violent medial rotation.
|
|
|
What are the clinical signs of anterior shoulder dislocations?
|
The pain is severe and the patient is unwilling to attempt any movement of the shoulder.
A prominence can be felt in the infraclavicular fossa. The most lateral part of the shoulder is now the acromion so the shoulder is less convex and more "spiky". |
|
|
What are the radiographic findings in an anterior shoulder dislocation?
|
That the humeral head does not rest in the glenoid fossa.
|
|
|
Why is a posterior shoulder dislocation often overlooked?
|
Because its features are not very striking.
|
|
|
What is the most important sign of posterior shoulder dislocation?
|
A fixed medial rotation of the arm which cannot be laterally rotated.
|
|
|
Which radiological projection is most important in a suspected posterior shoulder dislocation?
|
The lateral view.
|
|
|
What are the different reduction methods of an anteriorly dislocated shoulder?
|
1. The Kocher maneuver.
2. Sime-abducted traction with foot in axilla of patient. |
|
|
Describe the Kocher maneuver for anteriorly dislocated shoulders.
|
1. Apply downward traction on the humerus with the elbow flexed 90 degrees.
2. Rotate the arm laterally. 3. Adduct the arm by carrying the elbow accross the body toward the midline. 4. Rotate the arm medially so that the hand falls on the opposite side of the chest. |
|
|
How is a posteriorly dislocated shoulder reduced?
|
By applying longitudinal traction on the arm while laterally rotating it.
|
|
|
What must be done after reduction of a dislocated shoulder?
|
First reduction must be confirmed by radiographs and clinical testing.
Then the arm should be in sling for a few days but as soon as the pain subsides active movements should be encouraged. |
|
|
What are the important complications of a dislocated shoulder?
|
Injury to the axillary nerve (anterior).
Other nerve injuries Vascular injury Associated fractures. Recurrent dislocations (anterior) |
|
|
Which are the fractures which are commonly associated with dislocations of the shoulder?
|
The greater tuberosity.
Neck of humerus. |
|
|
Which muscle is paralyzed in damage of the axillary nerve?
|
The deltoid.
|
|
|
Which is the artery which may be damaged in disocations of the shoulder?
|
The axillary artery.
|
|
|
What are the factors which cause an increase likelihood of recurrent anterior dislocations of the shoulder?
|
Young age at first dislocation.
Inadequate immobilization in the first few days. |
|
|
What are the characterstic lesions which are visible under the circumstances of recurrent anterior shoulder dislocations?
|
1. The Bankart lesion
2. Hill-Sachs lesion. |
|
|
Describe the Bankart lesion.
|
The inferior labrum and capsule are stripped from the anterior margin of the glenoid rim.
|
|
|
Describe the Hill-Sachs lesion
|
There is a "dent" on the posterolateral aspect of the articular surface of the head of humerus.
|
|
|
In what shoulder configuration is the humeral head easily redislocated?
|
In the abducted, extended and externally rotated
|
|
|
What does the Hill-Sachs lesion look like on a radiograph?
|
Like a dense edged area.
|
|
|
What are the methods of choice of repair of a recurrent dislocation of the shoulder?
|
Some kind of intervention which aims to repair the anterior missing parts of the capsule.
1. Putti-Platt operation, which shortens the subscapularis tendon to disallow lateral rotation. 2. The Bankart technique involves repair of the anterior glenoid labrum. |
|
|
What are future methods of repair of recurrent anterior shoulder dislocations?
|
Arthroscopic repair through suture anchors.
|
|
|
Which are the bony parts of the shoulder girdle?
|
The clavicle and the scapulae.
|
|
|
Describe the mechanisms of injury and commoness of clavicular and scapular fractures.
|
Clavicular fractures are common and are caused by indirect injury such as fall on the shoulder. Scapular fractures are uncommon and occur through direct violence.
|
|
|
What is the most common site of fracture of the clavicle?
|
The junction between the middle third and the lateral third.
|
|
|
Are clavicular fractures usually displaced or undisplaced?
|
Displaced, with the lateral fragment pointing medially and inferiorly.
|
|
|
What is the normal method of treatment of a fractured displaced clavicle?
|
It was customary to bandage the arm in a figure-eight-bandage but its no longer used.
Nowadays most surgeons will advice no more than an a simple sling, for the relief of pain. (2 weeks) Active shoulder movements should be started as soon as the initial sharp pain subsides (after 1 week) |
|
|
What is the only common residual disability of a fractured clavicle?
|
A deformity.
|
|
|
Which injuries are more common, the ones to the sternoclavicular joint or the ones to the acromioclavicular joint?
|
The acromioclaviclar joint
|
|
|
What is the mechanism of injury in a dislocation or subluxation of the acromioclavicular joint?
|
A fall onto the shoulder.
|
|
|
Which are the two ligaments which supports the acromioclavicular joint?
|
The conoid and trapezoid ligaments.
|
|
|
Among which people are the injuries involving the acromioclavicular joint common?
|
Among rugby players.
|
|
|
What is the main difference between a subluxation and dislocation of the acromioclavicular joint?
|
In the subluxation only the joint capsule is torn while in the dislocation both accessory ligaments, namely the conoid and trapezoid ligaments are torn.
|
|
|
What is the radiographic sign of acromioclavicular dislocation?
|
A big bag between the acromion and lateral end of clavicle.
|
|
|
What is the treatment of a subluxation of the acromioclavicular joint?
|
Rest of the arm in a sling for 2 weeks with early exercises.
|
|
|
What is the treatment of a dislocation of the acromioclavicular joint?
|
ORIF. Closed methods are usually insufficient.
|
|
|
What is the common internal method of fixation in acromioclavicular dislocation?
|
A screw passing through the clavicle into the coracoid process which keeps the acromion and clavicle closesly opposed.
|
|
|
Most metacarpals fractures are caused by what mechanism of injury?
|
By direct injury such as a object falling on the foot.
|
|
|
What are other mechanisms of injury in the metatarsals?
|
Avulsion fractures (base of 5th)
2nd & 3rd fatigue fractures. |
|
|
What nearly always causes a fracture of the base of the fifth metatarsal?
|
A twisting injury in which the foot is forced into inversion and equinus.
|
|
|
What are the clinical signs of fifith metatarsal avulsion fracture?
|
Pain in the outer border of the foot, with difficulty in walking. There is marked local tenderness over the base of the metatarsal.
|
|
|
How is fracture of the fifth metatarsal bone confirmed clinically?
|
By radiography.
|
|
|
Which is the structure of the fifth metatarsus which is fractured and whihc muscle is attached to it?
|
The styloid process, which provides attachment for the peroneus brevis muscle.
|
|
|
Which is a less common but more serious fracture of the fifth metatarsal and what is its mechanism of injury?
|
The Jones fracture, which is caused from local trauma to the lateral side of the foot. (Common in footballers etc.)
|
|
|
Why is a plaster used in the fifth metatarsal fracture? Is it needed for union?
|
No, union would occur also without a plaster but it is solely used for the relief of pain.
|
|
|
Which kind of plaster is used in fracture of the 5th metatarsal?
|
A below knee walking plaster.
|
|
|
In whom may internal fixation be an alternative?
|
In young athletes who need rapid recovery or in patients who demonstrate nonunion.
|
|
|
What is Os vesalianum?
|
An accessory ossicle (small bone) of the fifth metatarsal in young children during bone development, which sometimes is mistaken for a fracture. Fracture is ruled out if the structure appears on bilateral radiographs.
|
|
|
Which configuration of fracture of a metatarsal is likely to occur from a falling object on the foot?
|
An transverse or short oblique type.
|
|
|
What is the mode of treatment of a metatarsal shaft fracture?
|
Immobilization 3-4 weeks, but just for pain. Then walking exercises should be initiated.
|
|
|
What is the name of the commonly occuring stress fractures of the 2nd and 3rd metatarsals?
|
The March fracture
|
|
|
In what bones are the stress fractures most common?
|
In the metatarsals, especially the 2nd and 3rd.
|
|
|
What is the main difference between the stress fractures and normal fractures in terms of clinical presentation?
|
There is no history of direct violence which may lead to a missed diagnosis.
|
|
|
Which part of the metatarsal is usually affected by a stress fracture?
|
The neck of shaft.
|
|
|
What is the name sometimes used to describe the radiological appearance of a stress fracture?
|
A hairline crack.
|
|
|
What are the clinical symptoms and signs of a stress fracture of the metatarsal?
|
Severe pain in the forefoot on walking. The onset of pain IS rapid but without obvious cause.
Swelling of the foot, with well marked local tenderness over the affected metatarsal. |
|
|
Why should radiographs be repeated after say 1-2 weeks post first-visit?
|
Because the first radiograph is usually inconclusive until the borders of the fracture are more clearly visible.
|
|
|
What is the treatment of a stress fracture of the metatarsal bone?
|
Purely symptomatic. If only light pain then no treatment is required but if pain is severe then a below knee walking plaster is used for 4 weeks.
|
|
|
Describe the Lisfranc fracture-dislocation.
|
An uncommon condition in which suluxation of the tarsometatarsal joints is combined with a fracture.
|
|
|
What usually causes the Lisfranc fracture-subluxation?
|
Forced inversion or eversion of the forefoot when the hindfoot is fixed, and only occasionally by a crushing injury of the foot.
|
|
|
Why is clinical diagnosis of the Lisfranc subluxation-fracture difficult?
|
Because soft tissue swelling often masks the bony deformity.
|
|
|
What are the principles of treatment of the Lisfranc fracture-subluxation?
|
Reduce the dislocation and thereafter to immobilize the foot in a belowknee walking plaster for 6-8 weeks.
|
|
|
When may operative reduction be required in a Lisfran fracture-dislocation?
|
If closed reductive techniques fail.
|
|
|
What if there is a severely comminuted Lisfranc fracture-dislocation?
|
Well then Arthrodesis might have to be considered.
|
|
|
Which are most common, fractures to the ankles or fractures to the foot?
|
By far fractures to the ankles.
|
|
|
Which tarsal bone is most commonly fractured?
|
Calcaneus.
|
|
|
The second most commonly fractured tarsal bone?
|
Talus
|
|
|
What is the mechanism of injury in the talus fracture?
|
A fall on the heel from a height. Or the foot pedals of the vehicle causes this type of injury in a car crash. However the calcaneus is much more commonly fractured,
|
|
|
What is the most serious type of talus fracture?
|
A fracture through the neck of talus.
|
|
|
What is the old name for talus neck fracture?
|
Aviator's astragalus (ankle bone)
|
|
|
Why was the talus neck fracture termed the aviators astralagus?
|
Because of the high incidence among pilots of crashed aircrafts.
|
|
|
If there is displacement what happens to the fragments in the talus neck fracture?
|
The body of the talus (the part below the tibia), is displaced posteriorly out of the ankle joint.
|
|
|
What is the biggest problem with displaced talar neck fractures?
|
When the body of talus is displaced posteriorly out of the joint the major blood supply to it inevitably becomes injured and the incidence of avascular necrosis is high.
|
|
|
What is the mode of treatment of an undisplaced talus neck fracture?
|
Immobilisation in a below knee plaster for 10-12 weeks. Mind the blood supply to the talus!
|
|
|
What is the mode of treatment of a displaced talus neck fracture?
|
ORIF with cannulated cancellous screws.
Then belowknee plaster for 10-12 weeks. |
|
|
Synonyms for cancellous...
|
porous, perforated.
|
|
|
synonym for cannulated...
|
tubed...
|
|
|
Is walking with crutches allowed in a talus neck fracture?
|
Yes, but weight bearing on the affected foot should be avoided the first 6 weeks.
|
|
|
What are the main complications of talus neck fracture?
|
Non-union
Avascular necrosis Osteoarthritis |
|
|
Why is nonunion prone to happen in the talus neck fracture?
|
Because as we discussed blood supply is an important factor in fracture healing and it is often impaired to the body of talus.
|
|
|
How is avascular necrosis recognised?
|
A marked difference of radiolucency 1-2 months after the injury, because the body of the talus does not join in the osteoporotic process going on around it.
In later stages the diagnosis is obvious because the bone collapses into an amorphous (without shape) mass. |
|
|
What is the treatment of an established avascular necrosis of the body of the talus?
|
Arthrodesis, meaning the fusion of the ankle, subtalar and talo-navicular joints.
|
|
|
What is the treatment for disbling osteoarthritis of the ankle and subtalar joints post-talus neck fracture?
|
Arthrodesis.
|
|
|
What are the more common types of talus fractures?
|
The minor chip or flake fracture in which small pieces of bone are pulled off.
|
|
|
What is the mechanism of injury of the minor chip or flake fractures of the talus?
|
They often accompany severe strains of the ankle and occur at the site of ligamentous insertions.
|
|
|
What is the spectrum of fractures of the calcaneus?
|
The fractures of the calcaneus may be just small cracks or isolated fractures without displacement but there may also be severe communited compression fractures whihc crushes the bone from above downwards.
|
|
|
Which fractures of the calcaneus are the more common?
|
Unfortunately the serious compression fractures.
|
|
|
What is the mechanism of injury of calcaneal fractures?
|
Allmost all calcaneal fractures are caused by a fall from a height.
|
|
|
What does the type of calcaneal fracture mainly depend on?
|
The force of impact... thus the height of the fall.
|
|
|
Describe the force transmittance of the minor calcaneal fractures.
|
The weight thrust is transmitted through the talus to the upper articular surfaces of the calcaneus, which HOLDS, and then transmits the force to the calcaneal tuberosity, which may crack.
|
|
|
Describe the force transmittance of the compression calcaneal fractures.
|
The calcaneal articulating surfaces fails to hold the force from above, and is shattered and driven downward into the body and tuberosity of the bone.
|
|
|
What are the clinical features of a minor calcaneal fracture?
|
History of fall (few feet)
Severe local pain Patient unable to put weight on affected heel. Little softtissue swelling Marked local tenderness over the tuberosity. No palpable deformity Late ecchymosis on the sole Movements in the joints are not restricted. |
|
|
How is diagnosis of a minor calcaneal fracture made?
|
With radiographs, lateral and especially axial! because may be missed on lateral.
|
|
|
What is the mode of treatment of a minor calcaneal fracture?
|
Unlike compression fractures, the minor ones are easy to treat.
All thats needed is a 4 week below knee plaster. Walking is allowed from the very beginning. |
|
|
What are the complications of minor calcaneal fractures?
|
None
|
|
|
What is inevitably true about the outcome of a calcaneal fracture?
|
Some residual disability.
|
|
|
What are the clinical features of a calcaneal compression fracture?
|
History of a fall onto the heels from a considerable height.
Severe pain, unable to bear weight on heel. Deformity of the tuberosity, such as flattened, broadened and shortened. Visible ecchymosis after 1-2 days on the plantar aponeurosis. Marked restriction of eversion and inversion at the midtarsal and subtalar joints. |
|
|
What must be checked regarding physical examination if there is a suspected calcaneal compression fracture?
|
Vertbreal body crush fractures of the lumbar and lower thoracic spine.
|
|
|
How is a calcaneal compression fracture diagnosed?
|
Easily on Lateral radiographs.
|
|
|
What are the characteristic features of a calcaneal compression fracture on lateral radiographs?
|
The upper surface of the calcaneus is distinctly flattended so that the line of the subtalar joint forms a straight line with the upper surface of the tuberosity.
Today CT can show exactly the extent of damage and subtalar joint involvement. |
|
|
What is the main reason why so few calcaneal compression fracture patients may reaquire a near normal foot?
|
Due to the involvement and destruciton of the subtalar joint.
|
|
|
What has been the change in recent years in the treatment of calcaneal compression fractures?
|
Going from more conservative methods to more aggressive treatments.
|
|
|
What are the methods of reduction of a calcaneal compression fracture in todays practice?
|
Open reduction with internal fixation.
Reduction by closed leverage. |
|
|
How is ORIF of a calcaneal compresion fracture performed today?
|
First CT to accurately visualize the area.
Exposure of the calcaneus from the lateral side. Reducting and packing the calcaneus with bone graft and application of screws and plates. |
|
|
Which method of treatment should be regarded as the preferred one?
|
ORIF
|
|
|
How is reduction by closed leverage performed?
|
A Steinmann pin is driven into the back of the calcaneus and levered downwards.
|
|
|
What are the conservative methods of treating a calcaneal compression fracture?
|
Foot elevation to reduce edema.
Early mobilizing exercises. |
|
|
What are the complications of a calcaneal compression fracture?
|
Stiffness in subtalar and midtarsal joints.
Osteoarthritis. Limp. Associated fractures of the spine. |
|
|
What may prevent a little of the stiffness in the subtalar and midtarsal joints?
|
Proper elevation for several weeks in and active exercise in the early phase.
|
|
|
What is the main problem of the osteoarthritis which develops after a compression fracture of the calcaneus.
|
Pain
|
|
|
What is the mode of treatment of severe disabling osteoarthritis after a calcaneal compression fracture?
|
Arthrodesis.
|
|
|
Why is a limp common after a calcaneal compression fracture?
|
Because the subtalar joint normally acts like a spring which tenses the calcaneal tendon, so after it has been damaged the calf muscles are slack and there may be a problem in plantar flexion of the foot.
|
|
|
Another name for the ankle.
|
The talocrural joint.
|
|
|
Which is the only fracture which is more common than fractures to the bones involved in the ankle?
|
The distal radial ones (Colles).
|
|
|
What is a general title of ankle fractures?
|
Pott's fractures.
|
|
|
Are there many types of fractures of the ankle?
|
Yes, many types of fractures and fracture-dislocations.
|
|
|
Which structures of the ankle are most commmonly fractured?
|
The medial, or lateral malleolus or both.
|
|
|
Which are the most severe types of fractures of the ankle?
|
The ones in which the inferior articular surface of the tibia is shattered.
|
|
|
What are the three main mechanisms of injury to the ankle?
|
1. An abduction or lateral rotation force, or both.
2. Adduction force. 3. Vertical compression force. |
|
|
Where is the fracture if there is a lateral rotation or abduction force?
|
In the lateral malleolus (fibula)
Or avulsion fracture of medial malleolus. |
|
|
Where is the fracture if there is a adduction force?
|
In the medial malleoulus or lateral malleolus from avulsion.
|
|
|
Where is the fracture if there is a vertical compression force?
|
Anterior marginal fracture of the tibia + anterior displacement of talus.
|
|
|
What is the result of a severe lateral rotation or abduction force?
|
Fracture of both malleoli and lateral displacement of the talus.
|
|
|
What is the result of a severe adduction force?
|
Fracture of both malleoli and medial displacement of the talus.
|
|
|
What is the result of a severe vertical compression force?
|
Comminuted fracture of the tibial articulating surface + fracture of the fibula + upward displacement of the talus.
|
|
|
In the point of view of treatment, what are the 7 distinct patterns of fracture of the ankle?
|
1. Isolated lateral malleolar frac.
2. Isolated medial malleolar frac. 3. Fracture of lat. mal. with lat. talus shift. 4. Fracture of both malleoli with talus shift. 5. Tibio-fibular diastasis (separation) 6. Posterior marginal fracture of the tibia with posterior displacement of talus. 7. Vertical compression fracture of the lower articular surface of the tibia. |
|
|
What is the mode of treatment of undisplaced ankle fractures of the different kinds?
|
Generally, there is no need for more treatment than immobilization in a plaster cast for 3-6 weeks with a below knee plaster.
|
|
|
What are the most important points when it comes to treatment of displaced ankle fractures?
|
To restore the tibiofibular relationship to form the ankle mortise, and to restore the talus relationship with the tibiofibularmortise.
|
|
|
How is reduction generally performed in a displaced ankle fracture?
|
With closed manipulation under general anesthesia.
|
|
|
How is immobilization normally ensured in a displaced ankle fracture?
|
A plaster cast is usually sufficient for 8-10 weeks. However recheck radiographs often to ensure no redisplacement occured.
|
|
|
When may operative reduction and fixation be performed in a displaced ankle fracture?
|
When closed techniques are not suffieicnt either to reduce or to keep it reduced.
|
|
|
What are the usual methods of internal fixation in a displaced ankle fracture?
|
With the use of plates and screws.
|
|
|
What is surprisibg about the diagnosis of à ruptured calcaneal te don?
|
That it is often misdiagnosed or missed.
|
|
|
What are the nisdiagnoses of calcaneal tendon rupture?
|
Strained musxle or a ruptured plantaris tendon.
|
|
|
Is the rupture usually partial or complete?
|
Complete.
|
|
|
What happens if the tendon is left untreated?
|
It will heal spontaneously but it will be lengthened.
|
|
|
What are the clinical features of a Ruptured calcaneal tendon?
|
While running or jumping there is a sudden severe pain at the bck of the ankle. It feels as if something struck him.
Tenderness as site. Edema and ecchymosis may diminish the gap between the tendon fragments. |
|
|
What is the crucial test in the diagnosis of a calcaneal tendon rupture?
|
That the patient should lift the heel when standing on the affected foot. This is impossible due to diminished plantar flexion.
|
|
|
What is the nonoperative mode of treatment of calcaneal tendon rupture?
|
Below-knee plaster for 6 weeks with foot in moderate equinus to relax the tendon and prevent stretching.
Crutches to decrease weightbearing for thr first two weeks. |
|
|
For whom is operative treatment of calcaneal tendon rupture done?
|
For younger patients.
|
|
|
How is it done?
|
The fragments of the tendon are sutured together using either absorbable or nonabsorbable sutures.
Atter that the foot is rested in a plaster in plantarflexion for 2 weeks. |
|
|
What is important for both operative and consvative treatment following removal of plaster?
|
That vigorous exercises are initiated with the goal to restore the calf muscle strength.
|
|
|
What are the two mechanisms of injury of the patella?
|
Either through a sudden forceful contraction of the quadriceps or from a direct blow.
|
|
|
What type of fracture of the patella is caused by a muscular violence?
|
A clean break with separation.
|
|
|
What kind of fractures normally are caused by direct violence to the patella?
|
Cracks or comminutions.
|
|
|
Which diagnosis is commonly confused with a patellar frcture?
|
Bipartite patella ichildren in which two ossification centers of the patells exist.
|
|
|
How can a bipartite patella be distinguished from a fracture?
|
Abscnece of tenderness
Rouned edges around the separation point of the fragments. |
|
|
Which are the radiographs needed to diagnose a patellar fracture
|
Normally only AP and lateral but sometimes oblique or skyline views are need for smaller fragments.
|
|
|
What is the mode of treatment of a cracked patella without separation?
|
Below knee plaster.
|
|
|
What is the mode of treatment of a clean fracture with separation in the patella?
|
Fixation of fragments with a screw.
|
|
|
What is the mode of treatment of a comminuted fracture of the patella?
|
Excision of the patella.
|
|
|
Why are we not afraid of a separation of a patellar crack fracture?
|
Because its aponeurosis is intact.
|
|
|
What is the other method of fixating a separated patellar fracture besides a screw?
|
Tension band wiring.
|
|
|
Why must the patella be excised if perfect restoration of articular surfaces of the l
Patella is impossible? |
Because of later disabling osteoarthritis.
|
|
|
What are the results of excising the patella?
|
Excellent, as long as operation and aftertreatment are good.
|
|
|
What is the loss when there is no patella?
|
Decreased power of extension which can translate to difficulty climbing stairs.
|
|
|
Is knee dislocation common?
|
No
|
|
|
Why is it fortunate that the knee is rarely Dislocated?
|
Because injuries to the popliteal artery or nerve trunks are common in knee dislocations.
|
|
|
Which are the ligaments that hold the knee together?
|
The anterior and posterior cruciate ligaments and the medial and laterla ligaments. And ofcourse the joint capsule.
|
|
|
What must happen to some or all of the ligaments when there is knee dislocation?
|
Rupture.
|
|
|
How many types of lateral patellar dislocations arer recognized?
|
Three
|
|
|
What are the three types of lateral patellar disloctions?
|
Acute
Recurrent Habitual |
|
|
What does habitual patellar dislocation signify?
|
Dislocation every time the knee is flexed.
|
|
|
What is normally the cause of habitual or recurrent dislocztions of the patella?
|
Develoopmental abnormalities in the knee.
|
|
|
What is the mechanism of injury of an acute lateral displacement of the patella?
|
An injury to the knee when the knee is flexed.
|
|
|
What is the clinical manifeststion of acute lateral displacement of the patella?
|
The patient is unable to extend the leg unless spontaneous reduction occured.
Later the knee will swell fromm effusion which may be bloodstained if the capsule was torned. |
|
|
Which commonly associated injury requires radiological examination in the acute lateral dislocation of patella?
|
Osteochondral fracture.
|
|
|
How is an acute dislocation of the patella treated?
|
Easily by applying medialward pressure on the patells while the knee is gradually extended.
A few days rest with firm bandaging followed by a course of quadriceps exercises. |
|
|
What not to forget in the aftercare of an acute patellar disloction.
|
To take xrays for osteochondral fractures.
|
|
|
What is the reason why it is so important to ddetect osteochondral fractures?
|
Because if they are not treated they will invariably lead to severe osteoarthritis.
|
|
|
How are osteochondral fractures of the knee treated?
|
By arthrosccopic techniques either to fix or to remove the frsgments.
|
|
|
Which gender is prone to recurrent patellar dislocstions?
|
Girls
|
|
|
When does normally the first dislocation occur in recurrent osteochondral dislocations?
|
In adolescnence
|
|
|
What hapens after the first dislocation in recurrent patellar dislocrions?
|
The dislocations occur with increasing ease and more frequently.
|
|
|
What is the movement which usually causes dislocation in recurrent dislocations of the patella?
|
Extending the leg from a flexed or semiflexed posititon.
|
|
|
In whom are injuries to the ligaments of the knees common?
|
In athletes and sportsmen.
|
|
|
Are injuries to the knee lgaments a serioous problem?
|
Yes, they usually cause lasting problems with the knee.
|
|
|
What is the change seen in medicine concerning the trestment of injured knee ligsments?
|
A more aggressive approach is advocated nowadays.
|
|
|
What is the main future probldm when a ligament of the knee is injured?
|
Laxity and instability of the knee.
|
|
|
What are the four main categories of injuries to the ligaments of the knee?
|
1. Tear of the medial ligament.
2. Tear of the lateral ligament. 3. Tear of the cruciate ligaments. 4. Strains or inncomplete tears. |
|
|
Mechanism of injury of the medial ligaments.
|
Abduction of the tibia upon the femur.
|
|
|
How can we know if it is only the medial ligament which is torn or also the cruciate or capsule?
|
Wide abduction cannot be performed if only the medial ligsment has been torn.
|
|
|
Clinica, features of medial ligament rupture of the knee.
|
Tenderness along the medial ligament.
Blood stained effusion. |
|
|
How is a medial ligament rupture diagnosed?
|
A radiograph is taken while abducting the knee and the gap is measured to determine if only the medial or also the crusciate or capsule has been torn.
Arthrodcopy may precisely determine the state of ligaments. |
|
|
Is the treatment for medial ligament rupture surgical or nonsurgical?
|
Some surgeons recommend surgery ehile others like conservative.
|
|
|
Describe the conseevstive treatment of medial knee ligament tear?
|
Aspiration of knee effusion.
Long leg plaster 6 weeks. Patient is allowed to walk. Ater removsl, intensivd exercises. |
|
|
Describe the operative technique for torn medial ligsment of the knee.
|
Medial or anteromedial incision.
Rent in capsule and medial ligsment is sutured. 6 weeks plaster. |
|
|
What if during operation for medial ligsment tear we see that the meniscus is damaged?
|
Then the meniscus is removed, or if the damage is only a small peripheral tear it can be sutured.
|
|
|
What is during operstion for medial ligsment of the knee tear we see that the cruciate ligaments are torn?
|
The cruciate ligaments are best left alone in the acute stages.
|
|
|
Which is more common, medial or lateral ligament of the knee tear?
|
Medial by far.
|
|
|
If the force doesnt tear the lateral ligament of the knee, what other injury may occur?
|
An avulsion ffracture of the fibula at the point of insertion of the lateral ligment.
|
|
|
What kind of force can cause a tear of the latereal ligament of the knee?
|
An adduction force upon the tibia.
|
|
|
What is a common complication of the injury which causes a tear of the lateeral ligmanet of the knee?
|
If the tibia is adducted forcibly on thd femur it id common that the common peroneal nerve is injured fromm stretching.
|
|
|
Why is injury to the common peroneal nerve so bad?
|
Because stretch injury to this nerve is usually irrecoverable.
|
|
|
How is the anterior cruciate ligament torn?
|
By a force driving the tibia anteriorly over the femur.
|
|
|
How is the posterior cruciate ligsment torn?
|
By a force driving the tibia postriorly overe the femur.
|
|
|
What is the name of the test to test for anterior cruciate ligament rupture and how is it performed?
|
The anterior draw test.
The knee is flexed 90degrees and the tibia can be drawn anteriorly on the femur too much. |
|
|
What is the other test for anterior cruciiate rupture and how is it performed.
|
The lachman test.
The knee is flexed only 10 or 20 degrees. Otherwise the test is the same as the anterior draw test. |
|
|
How is posterior cruciate ligsment rupture tested?
|
Backward force is put under the patella on the tibia and it moves backwards.
|
|
|
What is the current mode of treatment of antereior cruciate ligsment tear?
|
Wait and see.
First notng is done and then if disability persists reconsstruction of the anterior cruciate is attempted. |
|
|
What is the common result of anterior cruciate ligsment reconstruction?
|
Seldom restores full stability. Also it deteriorates with time.
|
|
|
What is the material preferred for reconstruction of the anterior cruciate ligsment?
|
A strip of aponeurosis or tendon, usually the patellar tendon.
|
|
|
Which avulsion fracture may accompany the posterior tibial fracture.
|
The posterior tibial spine.
|
|
|
What is the mode of treatment of a rupture of the posterior cruciate ligsment?
|
Same as sith anterior, wait and see if diability persisist.
|
|
|
What should be done if there is avulsion fracture of the posterior tibial spine?
|
It should be reduced and fixed operatively.
|
|
|
What type of injuries causes strains of the ligaments of the knee?
|
The same injuries which causes tears but with less force.
|
|
|
Which is the most common of all knee injuries?
|
Strain if the medial ligament.
|
|
|
What is the main difference in the clinical picture of a simple strain or complete tear of a ligament of the knee?
|
Even though there will be pain and swelling the knee will be STABLE.
|
|
|
Which is the diagnosis which is difficult to distinguish in the early stages from a strain of the medial ligament?
|
A medial meniscus tear.
|
|
|
What can be done to accurately differentiate between a ligament strain and medial meniscus ruoture?
|
Arthroscopy
|
|
|
What if arthroscopy is not available?
|
With time it will be evident. A medial meniscus tear will cause swelling and limitation of movement of the knee for more than 2-3 weeks.
|
|
|
Shat is the course of a strain of the medial or lateral ligaments of the knee?
|
Normally lthere is pain of decreasing intensity for 2 months but eventually full recovery is to be expected.
|
|
|
What is the mode of trestment of a strain if the ligaments of the knee?
|
None, but if there is severe pain it can be rested for 2 weeks in a groin to malleoli plaster.
|
|
|
Another name for menisci.
|
Semilunar cartilages
|
|
|
In whom are tears of the menisci common?
|
In men under 45.
|
|
|
Which meniscus is most commonly injured?
|
The medial.
|
|
|
To shat kind of activity is a meniscus tear related?
|
To sporting or squatting activities.
|
|
|
What is the mechanism of injury of a meniscus tear?
|
A twisting injury while thie knee is flexed or semiflexed.
|
|
|
What are the three types of tears of the menisci?
|
1. Buckethandle tear
2. Posterior horn tear 3. Anerior horn tearq |
|
|
Which type of tear of the menisci is the most common?
|
Bucket-handle
|
|
|
How do all three types of meniscus tears begin?
|
As a longitudinal split.
|
|
|
What is the chief effect of a buckethandle type tear?
|
It will block full extension of the knee!!!
|
|
|
What is it called the fact that s buckethsndle tear causes blocked extension of the knee.
|
Locking
|
|
|
Why is there no effusion of blood in the knee after a tear of the menisci?
|
Because the menisci have no blood supply.
|
|
|
Why do major tears of the menisci not heal?
|
Beacause the menisci have no blood supply.
|
|
|
Is there any effusion after a mesniscal tear?
|
Yes but only of synovial fluid.
|
|
|
Describe the typical history of a patient with meniscal tear.
|
Age 18-50. Twisting injury caused fall and pain in the anteromedial aspect. Unable to fully extend knee. Next day he notices big swelling. After 2 weeks he can resume activity but soon another twisting injury occurs with recurrent swelling. It recurs repeatedly.
|
|
|
What are the signs during examination of thd recent stages after meniscal tear?
|
Effusion, wasting of quadriceps, local tenderness anteriomedially and characteristic bucket handle locking. Sharp pain if extension is forced passively.
|
|
|
Can anything be seen on plain radiographs of torn menisci?
|
No
|
|
|
How is diagnosis of meniscal tear made?
|
Through a period of observation. The surgeon should be cautious with the diagnosis unless there is recurrent typical incidents, with effusion following each time.
Arthroscopy and MRI may confirm diagnosis. |
|
|
What is the main late complication of a torn meniscus?
|
Osteoarthritis
|
|
|
What is the modde of treatment of a meniscal tear once diagnosis is estsblished?
|
Excision of the meniscus or displaced fragment either surgically or arthroscopically.
|
|
|
What type of meniscal injury is more common in the eldderly?
|
The horizontal degenrative meniscal tear.
|
|
|
What is the clinical manifestation of a degenerative horizontal meniscal tear?
|
Persistent pain at the medial aspect of the knee.
|
|
|
What is the usual course of a horizontal degenerativ tear of the meniscus?
|
Resolved symptoms within a few months.
|
|
|
What should be dine if symptomms of a horizontal degenerative tear persist for long?
|
Arthroscopy for trimming or removal of the meniscus.
|
|
|
What js the main clinical difference between a haemarthrosis and serous effusion?
|
That the haemarthrosis develops rapidly in a few hours whilst a seerous effusion takes a day to develop.
|
|
|
Which tibial condyle is fractured most commonly?
|
The lateral condyle.
|
|
|
What is the fracture of the lateral condyle of the tibia called and why?
|
Bumper fracture because it occurs when the bumper of the car hits the outer side of the knee.
|
|
|
Which are the most common patients of a bumper fracture?
|
Women above middle age. So osteoporosis is cntributory.
|
|
|
What are the three types of lateral condyle fractures of the tibia?
|
Comminuted compression fracture.
Depressed plateau type. Oblique shearing fracture. |
|
|
Which is the most common type of lateral tibisl condyle fracture?
|
Comminuted compression fracture.
|
|
|
Which investigations are recommendeded in tibial laeral condyle fractures?
|
Plain radiographs may fail to show the extent but CT provides a detailede view.
|
|
|
What is the widdely accepted method of trestment of comminuted compression fractures of the lateral condyle of the tibia?
|
Aspirate any hemarthrosis
To accept the displacement, avoid rigid immobilization and to encourage active movements of the knee fromm the beginning! A plaster splint is usedd during the night for the first 2-4 weeks but is removed during the day to allow exercises. |
|
|
How should a depressed plateaue fracture of the lateral tibisl condyle be treated?
|
By surgical elevation of the plateau to normal level with the use of plates and screws.
|
|
|
How are oblique shearing fracture of the latersl condyle of the tibia treated?
|
By ORIF by a cancellous screw. It is essentisl that the reduction is perfect so that the articular surface is smooth.
|
|
|
What are the complications of fractures of the lateral tibisl condyle.
|
Genu valgum
Joint stiffness Late osteoarthritis |
|
|
What are the different types of supracondylar fractures of the femur?
|
Either the more common transverse fracture in or a vertical one which may give a T appearance.
|
|
|
What is the tendency regarding treatment of a suprscondylar fracture of the femur?
|
ORIF by a nail plate or screw plate.
|
|
|
What is a conservstive method of treating supracondylar fracture?
|
As for femoral shaft fractures, with a thomas splint with a knee flexion attachment with continous weight traction.
|
|
|
What differs the condervstive trestment of a femoral shaft fracture and supracondylar fracture?
|
That knee flexion is not important in a shaft fracture but very important to provide reduction in a supracondylar fracture.
|
|
|
Are femoral condylar fractures common? What causes them?
|
No they are uncommon. They are caused by direct violence to the region of the knee.
|
|
|
What are the two types of femoral condyle fractures?
|
Oblique shearing fracture separating the lateral condyle OR T shaped fracture separating both condyles.
|
|
|
What does the treatment of femoral condyle fractures depend on?
|
The degree of displscement.
|
|
|
How are undisplaced fractures of the ffemoral condyles treated?
|
Immobilization in a long leg plaster for 6-8 weeks walking being allowed from an early stage.
|
|
|
How are displaced fractures of the femoral condyles treated?
|
First closed reduction is tried. If it is successful the leg is immobilized either in a thomas splint or long leg plaster.
|
|
|
What if closed reduction techniques fail?
|
Then ORiF with multiple cancellous screws holding the separated condyle.
|
|
|
What are complications of femoral condylar fractures?
|
Stiffness in the knee.
Osteoarthritis. Arterial or nerve injury. |
|
|
What treatment may prevent stiffness in the knee?
|
Active exercises.
|
|
|
What treatment may prevent osteoarthritis from developping?
|
Accurate reduction.
|
|
|
Which artery may be injured in a fracture of the femoral condyle?
|
The pooplitesl artery.
|
|
|
In what age group do femoral shaft fracutures occur and what causes them?
|
In all age groups and they are normally caused by severe violence such as car or aeroplane crash.
|
|
|
Which part opf the shaftt is most commonly fractured?
|
Upper middle and lower occur ss frewuently.
|
|
|
What types of fractures are observed of the femoral shaft?
|
Transverse, oblique, spiral, comminuted or of the greenstick type.
|
|
|
Is displacement common in femoral shaft fractures?
|
Yes, more often than not there is overlap or angulation due to the pulling action of the quadriceps.
|
|
|
What is an important emergency issue with the femoral shaft fracutres?
|
That it usually causes bleeding of about 0,5 to 1,5 litres into the thigh, which may predispose to hypovolemic shock.
|
|
|
A special type of fracture for which the upper part of the shaft of femur normally shows...
|
Pathological fractures from metastatic carcinoma.
|
|
|
What is a must when considerring the radiographic examination of a femoral shaft fracture?
|
That the hip and knee be included.
|
|
|
What was previously the mainstay of treatment of femoral shaft fractures?
|
Conservative treatment with thomas splint.
|
|
|
Nowadays what kind of treatment predominates femoral shaft fractures?
|
Orif
|
|
|
Is conservative treatment not as effective as aggressive treatment?
|
It is, but the period of disability is much longer. So the siof surgeery is to restore normal function much more rapidly.
|
|
|
What is the preferred method of internal fixation of a femoral shaft fracture?
|
A long intramedullary nail.
|
|
|
Which fractures are not suitable for correction with intramedullary nail?
|
Comminuted fractures or fractures close to the upper or lower end of the shaft.
|
|
|
What are the principles of conservative treatment of femoral shaft fractures?
|
Reduction by manipulation and continous traction by a weight and by immobilizaation with a thomas splint.
|
|
|
How is traction applied to the leg in coservstive treaatment of femoral shaft fractures?
|
Either by adhesive skin strappings or by a steinmann pin though the upper tibia.
|
|
|
When are activd exercises begun after a femoral shaft fracture?
|
When the acute pain subsides usually after 1 week.
|
|
|
Wh at are the main goals of exercises in a femoral shaft fracture?
|
To prevent foot equinus and to strengthethe quadriceps.
|
|
|
How long should femoral shaft fractures be splinted?
|
Usually around 16 weeks.
|
|
|
When may a functional brace be used in femoral shaft fractures?
|
The splinting may sometimes be substituted for by a functional walking brace sbout 6-8 weeks after the injury which allows the patient less bedridden time.
|
|
|
When is external fixation of a femoral shaft fracture normally used?
|
When therer is a open or contamintaed wound.
|
|
|
How is intramedullary nailing preferrably performedd?
|
By the closed techniwue meaning that the fracture itself is not exposed. Guided by radiography.
|
|
|
How is the nail secured in its place?
|
By locking screws which prevent rotation and increase stability.
|
|
|
Is there sny need for plaster after intramedullary nail operation?
|
No.
|
|
|
When may the patient start walking after intramedulkary nail operation?
|
2-3 weeks. With crutches initially.
|
|
|
What is the method of treatment of femoral shaft fractures for children younger than 3?
|
Gallows or Bryants traction.
|
|
|
Explain the bryants or gallows method.
|
The childs lower limbs are suspended in an overhead beam which lifts the lower trunk and pelvis of the child from the mattress as provide constant traction.
|
|
|
How long must the children be suspended in this gallows or bryants traction?
|
3-4 weeks since the healing of the childs bones is more rapid than that of adults.
|
|
|
Which is a disastrous complication of the gsllows traction and how is it avoided?
|
Spasm of the major artery or the limb with ischemia. It is prevented by keeping the leg flexed by simple back-splints.
|
|
|
What are the most important complications of femoral shaft fractures?
|
Dislocation of the hip (not a complication but an association)
Injury to a maj. Artery Injury to a nerve Infection Delayed union Nonunion Malunion Stiffness of the knee |
|
|
Which is the artery which is most dangerous to damage during a femoral shaft fracutre?
|
The femoral artery.
|
|
|
Which is the nerve which is most significant in femoral shaft injuries?
|
The sciatic nerve.
|
|
|
After how long must additional treatment methods be considered if weidtbearinng allowing union has not occured?
|
5 months
|
|
|
What are the radiographic signs of nonunion of femoral shaft fractures?
|
Fracture surfaces become rounded and sclerotic.
|
|
|
How is nonunion of the femoral shaft treated?
|
By freshening the fracture and inserting a conductivd or inductive bone graft followed by fixation usually with an intramedullary nail.
|
|
|
What are the two main types of pelvic fractures?
|
The stable (intact pelvic ring) or unstable ones.
|
|
|
Are fractures of the pelvis common?
|
No
|
|
|
When do pelvis fractures pose problems?
|
Only when they are unstable or ehen they damage some intrapelvic organ.
|
|
|
Which are te most commonn fractures of the hip?
|
Trough the inferioor or superior ischipubic ramus.
|
|
|
How do fractures of the pubic rami occur?
|
In elderly as a result of a minor fall to the side.
|
|
|
Is fracture of the ischioubic rami considered a fragility fracture?
|
Yes
|
|
|
What are the sites of avulsion fractures of the hip and whichi muscles cause them and in what patient group may we expect them?
|
Athletes or young sportsmen. Inferior anterior iliac spine with the rectus femoris muscle, or the superior anterior iliac spine sith the sartorius or the ischial ramus sith the hamstrings.
|
|
|
What is the treatment for isolated fractures of the pelvis?
|
None, besides pain.
|
|
|
What must happen for a unstable pelvic ring to occur?
|
Fracture of both an anterior part and an posterior part.
|
|
|
Which are the areas which are normally fractured anteriorly?
|
The ischial rami or the pubic symphysis.
|
|
|
Wich is normally the posterior fracture?
|
Either a disloction through the sacroiliac joint or a fracture through the ilium.
|
|
|
How are the bone fragments of the unstable pelvic ring fracture displaced?
|
Normally displacement is mild but it can be severe with the innominate bone displaced markedly superior in relation to the sacrum.
|
|
|
What are the mechanisms of injury of unstable pelvic ring fractures?
|
AP crushing
Side crushing Vertical shearing force trsnsmitted through the femur with upward displacement of half the hip. |
|
|
What factors make unstable pelvic ring fractures even more difficult to treat?
|
If the fracture goes through the acetabulum or when the sacroiliac joint is disrupted.
|
|
|
What should be the goal if the patients who are otherwise fit?
|
To restore normal anatomy vigourously.
|
|
|
What emergency usually accompanies hip fractures?
|
Severe shock.
|
|
|
What is the method of treatment if displacement of the hip is only slight.
|
Then bed rest is enough for 4-6 weeks.
|
|
|
How is a dislocated pubis symphysis reduced?
|
Sometimes manual pressure is enough but more efficient is an external fixator frame with pins inserted at two sites in the anterior aspect of the wings.
|
|
|
What is the adult counterpart of rickets?
|
Osteomalacia
|
|
|
Where might we find patients with osteomalacia?
|
In asia.
|
|
|
What is the cause of nutritional osteomalacia?
|
Deficiencyp of vit.d in the diet or lack of sunlight.
|
|
|
What is the characteristics of the bone trabeculae in osteomalacia?
|
Then are not thin but they contain a poorly calcfied osteoid substance.
|
|
|
What are the two main features of osteomalacia clinically?
|
Bone pain and deformity.
|
|
|
What are the radiographic features of osteomalacia?
|
Decresed density of the whole skeleton.
Abnormally thin cortices. Long bones may be curved and multiple small fractures called loosers zones. |
|
|
What is differentiating a radiograoh of osteomalacia from osteoporosis?
|
The multiple smll fractures called loosers zones.
|
|
|
What are the lab values in osteomalacis?
|
Calcium normal or low.
Phosphate is low. Alkaline phosphatase increased! Vit. D levels are low. |
|
|
What is the treatment of osteomalacia?
|
Administration of vit.d and calcium.
|
|
|
What is the pediatric form of osteomalacia and what is its most important difference?
|
Rickets, and it occurs in dveloping bones and thus shows different pathology.
|
|
|
What are the other csuses of rickets and osteomalacia besides hypovitamonosis d?
|
Familial hypophosphatemia
Cystinosis Uraemic osteodystrophy Coeliac disease |
|
|
What is the mechanism of rickets in familial hpophosphatemia?
|
Impaired absorption of phosphstes by renal tubules and increased excretion in bowels.
|
|
|
What is the mechanism of osteomalacia in coeliac disease?
|
The doigestive system looses its ability to absorb calcium and vit.d.
|
|
|
Another name for osteogenesis imperfecta?
|
Fragilitas ossium
|
|
|
Previous question....
|
Collagen
|
|
|
How is osteogenesis imperfecta acquired?
|
It is not, it is inherited as a congenital disorder.
|
|
|
What is the result of defective collagen formation in osteogenesis imperfecta?
|
Soft and brittle bones.
|
|
|
What are other tissues which are affect by osteogenesis imperfecta?
|
Teeth, tendons, skin and ligaments.
|
|
|
The worst form of osteogensis imperfecta is not inhertied from the parents but probably form from....
|
A mutation.
|
|
|
What is the outcome of the worst form of osteogenesis imperfecta?
|
The child is born with multiple fractures and does not survive.
|
|
|
How many fractures are commonly sustained in the first few years of life of a child with inherited osteogenesis imperfecta?
|
A many as 50 or more.
|
|
|
What are additional features of individuals with osteogenesis imperfecta?
|
Deep blue discoloration of the sclers.
Deafness from otosclerosis. Ligamentous laxity. |
|
|
What is the treatment of osteogenesis imperfecta?
|
Fractures are treated in the ordinary way.
|
|
|
What is the main clinnical manifestation of achondroplasia?
|
A marked shortness of the limbs, with cnsequent dwarfing.
|
|
|
Is achondroplasia acwuired or inherited?
|
Inherited
|
|
|
What is the pathology behind the shortening of the limbs?
|
There is a failure of ossification of the long bones which then may be only half their normal length.
|
|
|
Is growth of the trunk impaired?
|
Not nearly as much as that of the limbs.
|
|
|
When during a childs life is achondroplasia seen?
|
Immediately after birth with visibly shortened limbs.
|
|
|
What height may a patient with achondroplasia normally not reach?
|
130 cm
|
|
|
What is a special feature of the hand of an achondroplast?
|
Trident hand.
Short and broad hands with three central digits which are almost equal in length. |
|
|
What are the characterstics of the head of a patient with achondroplasia?
|
It is a little bigger than normal and has a bulging forehead and a depressed nasal bridge.
|
|
|
What are spinal signs of achondroplasia?
|
Marked lumbar lordosis with thoracic kyphosis.
|
|
|
Is there any mental impairment and what is the life expectancy?
|
No mental impairment. Life expectancy is about normal.
|
|
|
What are radiographic changes in a patient with achondroplasia
|
Besides striking limb shortness there sre characteristic pelvic changes with a broadened pelvic inlet buti decreased ap diameter.
|
|
|
What are the hopes for future treatment of achondroplasia?
|
With techniques such as the ilizarovs method we could possibly give achondroplasts normal limb lengths.
|
|
|
Another name for DeQuervains disease.
|
DeQuervains stenosing tenovaginitis.
|
|
|
Is DeQuervains disease common?
|
Yes it is common and well known.
|
|
|
What is the cause of DeQuervains tenovaginitis?
|
Unknown but probably related to friction from overuse.
|
|
|
What are the clinical characteristics of DeQuervains disease?
|
Pain over the styloid process of the radius with a palpable thickening of the extenser pollicis brevis and abductor pollicis longud tendons.
|
|
|
In which gender is DeQuervains disease more common?
|
Women. 5 times.
|
|
|
What are the symptoms of DeQuervains stenosing tenovaginitis?
|
Pain on using the hand, especially wh en movement tenses the abductor pollicis longus and extensor pollicis brevis tendons.
|
|
|
How do we treat DeQuervains disease?
|
By conservative treatment with rest by splintage.
Injection of hydrocortisone and local anesthetic into the tendon sheath produces recovery in 80%. |
|
|
What if conservative methods of treatment for dequervains fail?
|
Then an operation which divides the thickened tendons will provide cure.
|
|
|
Describe what happens in osteochondritis dissecans.
|
Osteochondritis dissecans is a localsed disease of convex joint surfaces in which a small segment of bone becomes AVASCULAR and may then slowly separate together with the cartilage attached to it.
|
|
|
Which are the joints which are affected by osteochondritis dissicans?
|
Knee and elbow.
|
|
|
Which is the form of osteochondritis dissecans which occurs in children?
|
Osteochondritis juvenilis.
|
|
|
What is the disease which resembles osteochondritis dissecans inn the metatarsal heads?
|
Freibergs disease.
|
|
|
What are postulated causes of osteochondritis dissecans?
|
Impairment of blood supplypossibly due to thrombosis of an end artery.
|
|
|
What is the late consequence of osteochondritis dissecans?
|
Osteoarthritis due to irregular joint surface.
|
|
|
Which age group is mainly affected by osteochondritis dissecans?
|
Adolescent or young adult.
|
|
|
What are the early symptoms of osteochondritis dissecans?
|
Mild mechanical irritation of the joint... Namely a tendency to psin after use with recurrent effusion of clear fluid.
|
|
|
What are the symptoms when the fragment is loose in the joint cavity?
|
Recurrent locking of the joint with sudden pain and effusion.
|
|
|
What are the radiographic signs of osteochondritis dissecans?
|
There is a clear excavation in the adticular surface of the bone with a discrete bone fragment lying either within the cavity or elsewhere in the joint.
|
|
|
What is the treatment of osteochondritis dissecans?
|
Until the fragments has loosened it is expectsnt. In cases of small lesions in adolescence redt in plaste for 2 months may facilitate reattachment.
A detached fragment dho uld usually be removed. If it is very big it csn be reattached. |
|
|
What are ganglion cysts?
|
They are cystic swellings located around joints and contain mucoid tissue.
|
|
|
What are the postulated mechanisms by which ganglion cysts appear?
|
They might be formed during trauma or due to synovial herniation.
|
|
|
Which are the joints most affected by ganglion cysts?
|
The ankle and wrist.
|
|
|
What is the difference between the gznglion cysts and the synovial cysts?
|
That we know that the synovial cysts are communicating with the synovial cavity.
|
|
|
So where do the synovial cysts mainly occur?
|
Around the joints especially the knees.
|
|
|
Should a ganglion cyst be treated?
|
Only if it causes problems. Then it is removed.
|
|
|
Which is the most common cystic swelling around the hand?
|
Gangln cyst
|
|
|
What is the ganglion cyst wall composed of?
|
Fibrous tissue
|
|
|
Is the ganglion cyst a true cyst?
|
No because it does not contain an endothelial lining.
|
|
|
What is the gangln cyst of the wridt often confused with?
|
A bony prominence.
|
|
|
What may be complications of a gsngln cyst of the wrist?
|
Compression of the ulnar or median nerve or their branches.
|
|
|
Describe the typicsl patient age and gender and symptoms of a patient with chondromalacia or the patella.
|
A girl 15-18 years old with aching pain behind the patella.
|
|
|
What exacerbates the pain in chondromalacia of the patella?
|
Climbing or decending stairs.
|
|
|
Is there any effusion of fluid in chondromalacia of the patella?
|
Yes
|
|
|
How can pain be elicited clinically in chondromalacia of the patella?
|
By applying pressure to the side of the patella and siplacing it a little.
|
|
|
Which other structure may be tender during chondromalacia of the patella?
|
The medial femoral condyle may be sensitive to touch.
|
|
|
Another feature of chondromalacia of the patella which can be examined...
|
Crepitation when the patient is doing knee bening exercises that can be felt by the examiners hand over the knee.
|
|
|
What is the cause of chondromalacia of the patella?
|
Unknown
|
|
|
What is the pathology of chondromalacia of the patella?
|
The articular cartilage of the patella, especially the medial faucet is roughened and fibrillated which leads to friction and damage and pain.
|
|
|
What is the treatment of chondromalacia?
|
Nonoperative. An elastic bandage is applied and exercise should be reduced. This will normally reduce symptoms to an acceptsble level.
|
|
|
Why should operative repair of the chondromalacia of the patella not bd unddertaken?
|
Because results are dissapointing.
|
|
|
The medical name for tennis elbow.
|
Lateral epicondylitis.
|
|
|
Which muscles attach to the lateral epicndyle?
|
The extensor muscles of the forearm.
|
|
|
What is the main clinical symptom of lateral epicondylits, also known as tennis elbow?
|
Pain at the site of origin of the extensor tendons in the lateral epicondyle of the humerus.
|
|
|
What is the golfers elbow?
|
Medial epicondylitis, similar to tennis elbow but the origin are the muscles arising from the medial epicondyle.
|
|
|
What is the cause of the tennis and golfers elbow?
|
A strain of the muscles attached.
Particularly the extensor carpi radialis brevis. |
|
|
What are the histologicsl signs of the tendons of the muscles in epicondylitis?
|
There is no inflammation but angiofibroblastic tendinosis suggests repetitive microinjury with attempted healing.
|
|
|
Shich patients are typical for getting the tennis or golfers elbrow.
|
30-50 years presenting with pain over the epicondyle typically radiating down the forearm.
|
|
|
Where is the point of maximum tenderness in the tennis elbow?
|
Precisely anterior to the lateral epicondyle.
|
|
|
How can pain be aggravated in lateral epicondylitis?
|
By flexing the wrist to stretch the extensor tendons.
|
|
|
Can radiographs show any abnormalities in lateral epicondylitis?
|
Sometimes MRI can show sift tissue edema and thickening of tendon origins,
|
|
|
What is the typical progression of tennis elbow?
|
Typically the pain subsides after 1 to 2 years.
|
|
|
What are conservative treatment methods for tennis elbow in decreasing order?
|
Rest
NSaIDs Injection of LA and GCS locally Orthotic devices such as band splints are popular if patient wishes to continue sporting activities. Sonic shock wave. Eccentric strenthening exercises. |
|
|
When should surgery be considere for tennis elbow?
|
If persistent severe pain fails to respond to conservstiv methods.
|
|
|
How is surgery performed?
|
Trough an incision through the tendon origins thereby detaching the pain-sensitive fibres from the bone while allowing natural healing to occur.
This can all be done arthroscopically. 80% of patients report pain relief. |
|
|
Which is the structure contracted in the Dupuytrens contracture?
|
The palmar apopneurosis.
|
|
|
What is an aponeurosis?
|
A sheath formeed by tendinous structures.
|
|
|
What is dupuytrens contracture charscterised by in the established phase?
|
By flexion contracture of one or more of the fingers due to thickening and shortening of the palmar aponeurosis.
|
|
|
What is the cause of dupuytrens contracure
|
It is unknown.
|
|
|
Is there an inheritance pattern of dupuytrens contracture?
|
Yes
|
|
|
Patients eith which disease have an increased incidence of dupuytrens.
|
Epileptics, which is thought to be either due to genetical factors or dome relationdhip with anticonvulsants.
|
|
|
Which is the muscle from which the plantar aponeurosis radiates?
|
The palmaris longus.
|
|
|
Wherre is the insertion of the plantar aponeurosis?
|
In the proximal and middle phalanges of the fingers.
|
|
|
How thick can the apooneurosis get in dupuytrens?
|
Up to half a centimeter or more.
|
|
|
Which part of the hand is affect most by dupuytrens?
|
The medial half (ulnar).
|
|
|
So which fingers are moost seriously flexed in dupuytrens?
|
The little and ring fingers.
|
|
|
What then, is dupuytrens disease?
|
When dupuytrens contracture occurs in multiple sites, such as the soles of the feet or the penis.
|
|
|
Which gender has a higher incidence of dupuytrens?
|
Men have a much higher incidence.
|
|
|
What are the eary signs of dupuytrens contracture?
|
Nodule below the ring finger in the palm, but no flexion contracture.
|
|
|
What happens to this nodule later.
|
The thickening spreads from the initial nodule and eventually full extension of the affected fingers is prevented.
|
|
|
What is the time frame of the ddevelopment of dupuytrens contracture?
|
Months or years.
|
|
|
How are dupuytren bands distinguished from thicken muscle tendons?
|
By the fact that they dont move during flexion or extension of the fingerrs which the muscles tendons do.
|
|
|
Which is the only effective mode of treatment of dupuytrens?
|
Operation.
|
|
|
What are possible undrway medicaitons for dupuytrens?
|
Proteolytic drugs.
|
|
|
At what degrees is surgery required for dupuytrens contracture?
|
If cntracutre flexion exceeds 30 degrees at the metacarpophalangeal joint or 15 degrees at the proximal interphalangeal joint.
|
|
|
How is operation for dupuytrens done and why is not simple division of the aponeurosis recommended?
|
Total excision of the thickend part is recommended because simple division will tend to recur.
|
|
|
Why is sometimes skin grafting necessary for dupuytrens contracture?
|
Because sometimes the aponeurosis involves the palmar skin which then has to be removed and replaced with graft.
|
|
|
What is the main clinical difference between a complete and incomplete tear of the rotator cuff of the shoulder?
|
A complete tear seriously impairs the ability to abduct the shoulder.
|
|
|
Synonymous to a complete tear of the rotator cuff is...
|
Supraspinatus tear...
|
|
|
Cause of rotator cuff tear?
|
A sudden strain of the suoraspinatus tendon, usually due to a fall. Usually the injury is rather mild.
|
|
|
What is a predisposing factor to rotator cuff tear?
|
Age relatedmdegeneration of the tendon.
|
|
|
Which muscles other than the supraspinatus may be involved if the injury is severe?
|
The subscapularis, infraspinatus... Im not sure whether the teres minor...
|
|
|
Which is the typical patient with a torn rotator cuff?
|
A man over 60.
|
|
|
What is his complaints?
|
After a fall he complains of pain on the tip of the shoulder and down the upper arm and an inability to raise the arm.
|
|
|
Can the patient with a rotator cuff tear abduct the arm?
|
The but only with rotation of the scapula, and maximum 45-60 degrees.
|
|
|
Is there a full range of passive abduction of the shoulder in rotator cufff tear?
|
Yes
|
|
|
If passive abduction of more thsn sixty degrees is done, can the patient thehold the arm abducted if oassive help is removed?
|
Yes
|
|
|
So the characteristic of shouldere movement in torn supraspinatus can be summarized as...
|
Inability to initiate glenohumeral abduction with sustsined ability to keep abduction after passive abductioon.
|
|
|
What is the main difference here from the painful arc syndrome?
|
I the painful arc syndrome glenohumeral abduction CaN be performed but it is PAInFuL.
|
|
|
What are the neccesaary radiological examinations of a rotator cuff tear and what can be seen?
|
Ultrasound and MRI.
Ultrasound can detect a complete tear of the suoraspinatus tendon but MrI will provie details of all structures. |
|
|
Why should operation be svoided in older patients eith a rotator cuff tear?
|
Because degenerative state makes it impracticable.
|
|
|
So what is the mode of treatment for old people with rotator cuff tear?
|
Expectant. The disability generally becomes less noticable.
|
|
|
In which patient group should operation be undertaken for ruptured rotator cuff?
|
For younger patients.
|
|
|
How is the operation performed to repair a torn rotstor cuff?
|
Either through open surgery or arthroscopic techniques depending on the surgeon.
The tear is sutured. Sometimes acromioplasty is necessaary to prevent later problems in the area. |
|
|
How long should the arm be rested after repair of a ruotured supraspinatus tendon.
|
Passive movements can be initiated after a few days but active abduction of the arm should be delayed 4 weeks.
|
|
|
What is characteristic of thd pain in the painful arc syndrome?
|
The pain is present only in the midrange of shoulder abduction, but there is no pain in the extremes.
|
|
|
How many different shoulder lesions are the different causes of the painful arc syndrome.
|
5
|
|
|
Name the five causes of painful arc syndrome...
|
1. Minor tear of supraspinatus tendon
2. Supraspinatus tendonitis 3. Calcium deposits in supraspinatus tendon. 4. Subacromial bursitis 5. Crack fracture of the greater tuberosity. |
|
|
What is the reason that pain occurs only ithe middle of abduction movement in painful arc syndrome?
|
Because the distance between the upper end of humerus and the acromion process is short, and thhus if there is any tender or swollen part of the supraspinatus tendon, it will be compressed, since abducting the shoulder further diminishes the space between the humerus and acromion.
|
|
|
In which type of lesioif the pain of the painful arc syndrome worst and how bad is the pain?
|
In thef calcified deposit type. The pain may be so severe tht the patient cnnot move the arm or sleeo and may seek emergency care.
|
|
|
What may radiology help with in the oainful arc syndrome?
|
Xray may see a calcified deposit. MRI can show more detailedd pathology.
|
|
|
Which is another condition which is sometimes confused with the painful arc syndrome?
|
Osteoarthritis of the acromioclavicular joint because also here the pain exists during a certsin ohsse of abduction.
|
|
|
What is the difference of the pain in the painful arc syndrome and in acromioclavicular arthrtitis?
|
In the painful arc syndrome there is onset of pain earlier in abduction and it stops at full abduction. In acromioclavicular osteoarthritid the pain increases all the way and starts at 90 degrees.
|
|
|
What is the treatment of the painful arc syndrome?
|
In mild cases no treatment is required. If more severe theeach type of pathology determines the treatment.
|
|
|
What is the treatment of calcified depositis in the suorasoinstud tendon?
|
Injection of hydrocortisone into the calcium deposit. If it fails the crystals may be dispered with an aspiration needle followed by lavage of the subacromial space.
|
|
|
What is the mode of treatment of cntusion or crack fracture of the greater tuberosity of the hunerus?
|
Exercises!
|
|
|
What is the mode of therapy of an incompete tear of the supraspinatus or supraspinatus tendinitis or bursitis?
|
Physiotheraoy with ultrasound and inrferential therapy.
|
|
|
What if the painful arc syndrome is chronic and unresponsive to conventional therapy?
|
Then operation with acromioplasty and coracoplasty is initiated. This can be done either openly or arthoscopically.
|
|
|
Which is the nerve that is compressed in the carpal tunnel syndrome?
|
The median nerve.
|
|
|
Which is the structure which compresses the median nerve in the carpal tunnel syndrome?
|
The flexor retinaculum.
|
|
|
Which patient group are most prone to carpal tunnel syndrome?
|
Middle aged and elderly women.
|
|
|
What is the cause of carpal tunnel syndrome?
|
Usually unknown but any spaceoccypying lesion in the carpal tunnel may be the cause.
|
|
|
Give examples of recognized causes of carpal tunnel syndrome?
|
Chronic inflammatory thickening of tendon sheaths.
Osteoarthritid of the wrist. Deformity or malunion after fractutr of lower end of radius. Myxedema (hypothyroidism) |
|
|
What are he clinicsl manifestations of carpal tunnel syndrome?
|
Both motor and sensory.
Tingling, numbness or discomfort in thd radial three and a half digits. Feeling of clumsiness in carrying out find motor coordination. Tingling is worst during night. |
|
|
What are the clinical signs in a moderate degree of carpal tunnel syndrome?
|
Decresed sensation in the medisn nerve distribution of the hand.
|
|
|
What are the clinical signs in a severe case of carpal tunnel syndrome?
|
Wasting and weakness of muscles of the hand, particularly the abductor pollicis brevis.
|
|
|
What is the name of the test peformed to test for carpal tunnel syndrome?
|
Durkan test.
|
|
|
How is the durkan test performed?
|
By compression of the carpal tunnel for 30 seconds. If there is increase in symtpoms such as tingling it is positive.
|
|
|
What are investigstions for carpal tunnel syndrome?
|
Electrophysiological nerve conduction tests may show decreased conduction.
|
|
|
What must be ruled out before diagnosing carpal tunnel syndrome.
|
Exclude other neurolohical causes especially those that arise in the brachial plExus or lesions of the median nerve elsewhere along its path.
|
|
|
What is the conservative method of treatment of carpal tunnel syndrome?
|
Resting the wrist in a simplpe splint for 3 weeks.
|
|
|
What can be injected at the site of the carpal tunnel for relief?
|
Hydrocortisone
|
|
|
How often is injection of hydrocortisone curative?
|
50% of the time.
|
|
|
How is full relief secured?
|
By division of the flexor retinaculum.
|
|
|
Medical name of trigger finger?
|
Digital tenovaginitis stenosans.
|
|
|
What is the cause of trigger finger? Also known as digital tenovaginitis stenosans?
|
A thickening and constriction of the MOUTH of a fibrous digitsl sheat interfere with the free gliding of the contained flexor tendons.
|
|
|
So to describe trigger finger in four words...
|
Thickened flexor tendon sheath.
|
|
|
What happens to the flexor tendon within the thickened sheath in digital tenovaginitis stenosans?
|
It is slimmed within the sheath but swollen just outside, making it hard to enter the sheath at that point.
|
|
|
So can the finger affected be extendedd?
|
Yes but first it gets stuck snd when sufficient force is added it open with a snap... Thereby the name trigger finger or snapping finger.
|
|
|
In whom does trigger finger occur?
|
In middle aged people especially women.
I children it occurs in the thumb. |
|
|
What is the complaint in the adult type of digital tenovaginitis stenosans?
|
Cmplaint of tenderness at the base of the tendon sheath and of locking in full extension.
|
|
|
What are clinical signs of trigger finger?
|
A palpable nodule at the base of the affected finger. A little tender. Snapping cannot be reproduced by passive movements.
|
|
|
What is the main difference between the adult and the pediatric or infantile type of trigger finger?
|
The innfant cannot extend the affected thumb.
|
|
|
What are the methods of treatment of trigger finger?
|
Hydrocortisone injected into the nodule can achieve relief.
If not an incision through the mouth of the tendon sheath relieves both the adult and infantile types. |
|
|
What are the causes of bursitis?
|
Either infection or machanical irritative inflammation.
|
|
|
What is the cause of irritative bursitis?
|
Excessive pressure or friction and occasionally by a gouty deposit.
|
|
|
What is the morhohology of the bursa n irritativd bursitis?
|
There is inflammation of the bursal wall and serous effusion inside the cavity.
|
|
|
Give a very common example and its name of an irritative bursitis.
|
The "bunion" which forms at the medial aspect of the head of the first metatarsal in hallux valgus.
|
|
|
What are other common sites of irritative bursitis?
|
Prepatellar bursitis or "housemaid knee"
Olecranon bursitis Subacromial bursitis (which can cause painful arc syndrome) |
|
|
What is the treatment of irritative bursitis?
|
In many cases inflammation subsides if the pressure or friction is prevented.
If the sac is distended it can be aspirated and then hydrocortisone can be injected to prevent recurrence. If all above fails bursectomy is performed. |
|
|
Give examples of acute infective bursitis and how do they occur?
|
If a bursa is infected, such as infected bunion, infected olecranon bursa or infected patellar bursa.
Tuberculous bursitis can occur and is often involving the trochatereic bursa. |
|
|
What is the treatment of acute infectious bursitis?
|
Surgical drainage and antibacterial drugs.
|
|
|
What is the treatment of chronic bursitis?
|
Excision of thd bursa.
|
|
|
What is the postulated underlying pathology in plantar fscitis?
|
Inflammation
|
|
|
What is the main clinical symptom of plantar fasciitis?
|
Pain anteriorly to the calcaneus.
|
|
|
In what systemic disorders may plantar saciitis be a part?
|
In widespread inflammatory conditions such as Reiters disease.
|
|
|
What is the site of inflsmmation more specifically in plantar fascitis?
|
In the soft tissues at the site of attachment of the aponeurosis or the plantar fascia on the inferior asapect of the tuberosity of the calcaneus.
|
|
|
What is the clinical complaint in plantar fasciitis?
|
Pain when standing or walking undeer the heel. The pain extens medially and into the sole.
|
|
|
What is the range of severity of plantar fascitis?
|
It ranges from mild pain to very severe disability.
|
|
|
What are the signs during examination that lead to suspicion of plantar. Fasxiitis?
|
There is marked tenderness over the site of attachment of the plantar aponeurosis.
|
|
|
What is the difference betwen the pain ithe tender heel pad compared to plantar fssciiitis?
|
The maximum point of tendrness is more anteeriorly located in plantar fascitis.
|
|
|
What can be seen on radiography in plantar fascitis?
|
Usually nothing. There might be bone spurs projecting from the calcaneus but its signifance is unknown.
|
|
|
What is the mode of treatment of plantar fascitis?
|
A course of NsAIDs is usually prescribed. The heel should be protected by a resilient cushion on an insole.
These measures are usually sufficient but may take a long time. |
|
|
What if conservative measures of plantar fascitis fail?
|
Then an injection of hydrocortisone is performed.
If plantar fascitis is part of a widespread inflammatory disorder the whooe disorder is attacked. |
|
|
What is a common cause of achilles tendinopathy in young patients?
|
Calcaneal paratendinitis.
|
|
|
What is the pathology in calcaneal paratenditinis?
|
The soft tissue around the calcaneal tendon (paratendon) is inflamed from excessive friction.
|
|
|
What does this imflammation of the paratendon cause?
|
Decreases the gliding movements of the tendon.
|
|
|
Who are the typical pstients for calcaneal paratendinitis?
|
Active atheletic youngsteer.
|
|
|
What are the typical clinical symotoms of calcaneal paratendinitis?
|
Pain in the calcaneal region which is made worse by running or dancing.
|
|
|
What are the clinical signs of calcaneal paratendinitis?
|
Tenderness when palpating with index finger and thumb deep to the tendon and there is a slight local thickening in this region. The tendon itself is normal.
|
|
|
What is the treatment of calcaneal paratendinitis?
|
Local physiotherapy may be helpful, particularly by the application of ultrasound therapy or from eccentric calf muscle training.
In other cases an injection of hydrocortisone is necessary to relieve pain. If this too fails, removal of the contents of the paratendon must be removed surgically. |
|
|
Which is the commonest cause opf pain behind the heel?
|
Post-calcaneal bursitis.
|
|
|
Which are the mos commmon paients with postcalcaneal bursitis?
|
Young women.
|
|
|
Where is the postcalcaneal bursa located?
|
Between the tuberosity of the calcaneus and the skin.
|
|
|
What is the cause of postcalcaneal bursitis?
|
Repetitive friction on the bursa due to tightly fitting shoe. The friction causes irritative bursitis with thickening of the wall of the bursa and possibly distension with fluid.
|
|
|
What is the clinical problems of postcalcaneal burisitis?
|
Troublesome tenderness where the swelling is in contact with the shoe.
|
|
|
What aggravates the symptoms of postcalcaneal bursitis?
|
Walking, and they end to be worse in winter.
|
|
|
What is another name for postcalcaneal bursitis?
|
Winter heel
|
|
|
What is the clinical sign of postcalcaneal bursitis?
|
There is an obvious porminence of td back of the heel which mich be thickened and red.
|
|
|
What is the treatment of postcalcaneal bursitis?
|
The back of the heel can be protected with doule lsyer of elastic adhesive strapping and by wearing shoes with soft backs.
If these measures fail the bursa should be excised. |
|
|
Which is the more common bones to be involved in tuberculosis?
|
The vertebrak bodies and the bones whihc are associated with tuberculous infection of joints.
|
|
|
Can tubereculosis occur isolated in a long bone?
|
Yes occasionally.
|
|
|
What is the route of entrance to the bone for the mycobacteria?
|
Through the bloodstream or through direct invasion ffrom adjacent tissues.
|
|
|
What is the typical histological pattern of tuberculous bone infection?
|
Typical.
Bone is destroyd and resplaced by caseating granulomatous tissue with lymphocytic infiltrates and gisnt cells. |
|
|
What happens to vertbral bodies which are infected with uberculosis?
|
They are collapsed anteriorly, which gives thea wedge shape.
|
|
|
Is bone or joint tuberculosis more common?
|
Joint
|
|
|
Which after the vertebrak bodies are the bones most commonly affected by tuberculosis?
|
The metscarpals and phalanges of the hand.
|
|
|
What is the name of this type of tuberculosis?
|
Tuberculous dactylitis.
|
|
|
What is the charcteristics seen in tuberculous dactylitis?
|
A fusiform swelling which at first represents thickened inflamed periosteum.
|
|
|
What are the clinical features of tuberculous bone infection?
|
Normally there is evidence of ill constitutional health.
Others symptoms deoend on the locus of infection. Pain is usually the first symptom in bone and joint tuberculosis. |
|
|
What are the radiographic signs of bone tuberculosis?
|
Diffuse rarefaction of around site of infection.
Erosioon or eating away of bone, with fluffy ill defines nonsclerotic line. Sometimes a shadow in soft tissues representing abscess. |
|
|
What are the clinical features of tuberculous bone infection?
|
Normally there is evidence of ill constitutional health.
Others symptoms deoend on the locus of infection. Pain is usually the first symptom in bone and joint tuberculosis. |
|
|
What are the radiographic signs of bone tuberculosis?
|
Diffuse rarefaction of around site of infection.
Erosioon or eating away of bone, with fluffy ill defines nonsclerotic line. Sometimes a shadow in soft tissues representing abscess. |
|
|
What are the clinical features of tuberculous bone infection?
|
Normally there is evidence of ill constitutional health.
Others symptoms deoend on the locus of infection. Pain is usually the first symptom in bone and joint tuberculosis. |
|
|
What are the radiographic signs of bone tuberculosis?
|
Diffuse rarefaction of around site of infection.
Erosioon or eating away of bone, with fluffy ill defines nonsclerotic line. Sometimes a shadow in soft tissues representing abscess. |
|
|
What are the main clinical features of all types of arthritis?
|
Pain and decreased range of movements.
|
|
|
What are factors which makes arthritis strongly unlikely?
|
If there is no swelling or if the joint moves freely and painlessly through its nromal range.
|
|
|
What factors strongly influences the incidence of the different types of arthritis?
|
Racial influences are the most important.
|
|
|
In which race is osteoarthritis the most common?
|
In the white race.
|
|
|
Which are the commonly occuring types of arthritis?
|
Rheumatoid arthritis
Osteoarthritis Gouty arthritis Ankylosing spondylitis Psoriatic arthritis Arthritis of rheumatic fever. Hemophilic arthritis Neuropathic arthritis |
|
|
If rheumatoid arthritis had to be described in only a few words, what would be the most accurate description?
|
A chronic inflammation of multiple joints.
|
|
|
Are there any constitutional symptoms in theumatoid arthritis.
|
Yes, there are usuallly mild constitutional symptoms.
|
|
|
Which conditions mimic the joint changes seen in rheumatoid arthritis?
|
Juvenile chronic arthritis
Reiters syndrome Psoriatic arthritis SLE Other connective tissue or collagen diseases |
|
|
What is the cause of rheumatoid arthritis?
|
The cause is unknown.
|
|
|
What are the two postulations about the cause of rheumatoid arthritis?
|
1. Autoimmunity
2. Caused by infection. |
|
|
Why do we believe that there is an autoimmune variant of rheumatoid arthritis?
|
Because we found that the serum of many patients contains the anticollagen 2 antibody Rheumatoid factor.
|
|
|
What is the presence of rheumatoid factor in a patient called?
|
Seropositive rheumatoid arthritis.
|
|
|
Which are the two pathogens which are thought to invoke an anticollagen ii antibody?
|
Viruses or mycoplasma or diphteroid bacteria.
|
|
|
Describe the pathological findings of a joint which is involved in the rheumatoid process.
|
Synovium is thickened.
Articular cartilage softens and erodes. Subchondral bone may be eroded. The eroded surface becomes covered by a pannus. |
|
|
What do we believe is the cause of the erosion of cartilage and bone seen in theumatoid arthritis?
|
Inflammatory molecules and lytic enzymes involved in inflammation of the synovial membrane.
|
|
|
What happens with the disease after several months or years
|
It often gradually becomes quiescent, but leaving permanently damaged and deformed joints.
|
|
|
Which is the typical patient with rheumatoid arthritis?
|
Young or middle-aged female. It does also affect men though.
|
|
|
Which joints are most likely to be affected in rheumatoid arthritis?
|
The peripheral joints rather than the central joints.
Hand, wrists, feet, knees and elbows. |
|
|
Describe the onset of rheumatoid arthritis.
|
The onset is gradual, with increasing pain and swelling of a joint. Soon a number of joints are similarly affected.
|
|
|
Is pain worst during rest or during activity?
|
Pain is worse during rest, or to be exact, pain is worst when RESUMING activity after a period of rest. So the morning are the worst periods for a rheumatoid patient. After having used the joint the whole day the pain is less in the evening.
|
|
|
What are the constitutional symptoms commonly observed in a patient with rheumatoid arthritis?
|
Tiredness, anemia and sometimes a little fever.
|
|
|
What can be noticed during examination of a patient with rheumatoid arthritis?
|
Swollen joints from synovial thickening.
Warmth around the joint. Restricted ROM. Movement is painful. |
|
|
Which is worse, seropostitive or seronegative in regard to symptoms?
|
Serpositive.
|
|
|
Which part of the spine must be exmined thorougly because it is commonly affected in rheumatoid arthritis?
|
The cervical spine.
|
|
|
Why is it so important to check the involvement of the cervical spine?
|
Because intervertebral disc degradation in this area could possible lead to subluxation which could impinge and threaten the spinal cord.
|
|
|
What are other extraarticular features of rheumatoid arthritis?
|
Swollen lymph nodes.
Muscle wasting Subcutaneous theumatoid NODULES. Anemia |
|
|
What are the radiographic features of rheumatoid arthritis?
|
In early disease there are no radiographical changes.
Later there is diffuse rarefaction of the surrounding bone. Eventually narrowing of the joint space (from joint cartilage destruction) In severe cases there may be seen erosion of the bone. |
|
|
Is radioisotope bone scanning of any use in rheumatoid arthritis?
|
Yes, it shows increased uptake in area of affected joint.
|
|
|
How many criteria of how many needs to be filled to diagnose rheumatoid arhtiritis?
|
4 out of 7.
|
|
|
Name the seven criteria for RA.
|
1. Morning stiffness in and around joints lasting more than 1 hour.
2. Arthritis of three or more joints simultaneously. 3. Arthritis in at least one area in a wrist, metacarpal or proximal interphalangeal joint. 4. Symmetrical arthritis 5.Rheumatoid nodules. 6. Positive rheumatoid factor 7. Radiological changes typical of RA on hand and wrist Xray. |
|
|
What is the clue to searching for other critera for rheumatoid arthritis?
|
Simultaneous arthritis of several joints with a raised ESR. (Tells is there is an inflammatory arthritis of multiple joints)
|
|
|
Which are the conditions which should be rules out before diagnosis of RA should be done?
|
Psoriatic arthritis.
Reiters syndrome SLE Scleroderma |
|
|
Even though RA usually subsides after a few months or years, what progression might be expected in the joints?
|
Because RA often leaves the joints damaged, there will be superimposed osteoarthritis. Especially if the knees are involved.
|
|
|
Is there any cure for rheumatoid arthritis?
|
No.
|
|
|
Outline the six categories of treatment in their order in which they should be executed.
|
1. Rest and constitutional treatment
2. Drugs 3. Intraarticular GCS injection 4. Physiotherapy 5. Occupational therapy 6. Operation |
|
|
When is rest believed to be extra beneficial in RA?
|
In the early stages of disease and during exacerbations.
|
|
|
Which are the drugs commonly used in RA?
|
First line: NSAIDS
Second line: Gold salts, sulfasalazine Third line: GCS |
|
|
Name a few NSAIDs commonly used in RA...
|
ipuprofen, indomethacin, naproxen, phenoprofen and piroxicam (COX2 inhibitor)
|
|
|
Give more examples of second line drugs beside gold salts and sulfasalazine...
|
Penicillamine (nephrotoxic), Azathiprine and Methotrexate (immunosuppressive)
|
|
|
Which is the molecule which is attacked by a rather new and promising agent in immunotherapy of RA?
|
TNF.
|
|
|
What is the name of this anti-TNF drug?
|
Infliximab, adalimumab etc.
|
|
|
Why are GCS avoided in almost all patients with rheumatoid arthritis but the most severe ones?
|
Because of their serious side efefcts such as diabetes, osteoporosis, depression, purple stria, hair loss, hypertension, central obesity, easy brusing etc.
|
|
|
Why has the use of intraarticular corticosteroids been decreased lately?
|
1. Risk of infection, especially with repeated injections.
2. Risk of accellerating a degenerative reaction, of unknown cause. 3. Gives short duration of relief 4. Repeated injections at severeal sites. |
|
|
What are different modalities of physiotherapy undertaken in rheumatoid arthritis?
|
Hydrotherapy (water exercises)
Infrared heating |
|
|
What is meant by occupational therapy?
|
It means to help the patients to develop less painproducing ways of dealing with daily activites such as bathing, toilet cokking, feeding, boarding public transport, and many others.
|
|
|
When may operation have a place in rheumatoid arthritis?
|
When joints have been permanently damaged operation might be neccessary to relieve disability.
|
|
|
But doesnt operation have any place in the early stages RA?
|
Yes, actually it does.
|
|
|
So what is the operation which is carried out in the early stages of RA?
|
Synovectomy. Removal of thickened and inflamed synovial membrane.
|
|
|
What are the benefits of synovectomy?
|
Besides from reducing inflammation it may slow the inflammatory process and thus the degeneration of the joint.
|
|
|
What are synonyms of chronic juvenile arthritis?
|
Juvenila rheumatoid arhtritis or Still's disease.
|
|
|
Is chronic juvenile arthritis common?
|
No it is uncommon.
|
|
|
Is chronic juvenile arthritis a single disease entity?
|
No, it consists of many distinct conditions.
|
|
|
Name the different conditions compromising the chronic juvenile arthritis.
|
1. sero-positive polyarthritis
2. Classical Stilläs disease a) with systemic manifestations b) with polyarthritis, and c) with pauciarticular arthritis (minimal joint involvement) 3. sero-negative polyarthritis with sacro-ilitis. 4. arthritis associated with psoriasis, UC or Crohns disease. |
|
|
Does the seropositive chronic juvenile arthritis differ from the adult variant of theumatoid arhritis in any way?
|
No.
|
|
|
Does seropositive chronic juvenile arthritis occur more often in girls than boys?
|
Yes.
|
|
|
What is usually the age of onset of seropositive chronic juvenile artheritis?
|
Late childhood.
|
|
|
What is usually the age of onset of classical Stilläs disease type of chronic juvenile arthritis?
|
In EARLY childhood.
|
|
|
What are the systemic involvements in the first typ e of Stilläs disease?
|
Lymphadenopathy, splenomegaly.
|
|
|
What is the late outcome of all types of Stills disease?
|
Rather good.
|
|
|
What is the age of onset of seronegative chronic juvenile arthritis with sacro-iliitis?
|
Late childhood
|
|
|
Which gender is most affected by the seronegative arthritis with sacroilitis?
|
Boys.
|
|
|
What may seronegative arthritis with sacroilitis lead to in early adult life?
|
Ankylosing spondylitis.
|
|
|
For which antigen are patients with seronegative arthritis with sacroilitis usually positive?
|
HLA-B27.
|
|
|
What are the similartities in the treatment of chronic juvenile arthritis to that of adult rheumatoid arthritis.
|
Almost everything in regard to therapy is similar.
|
|
|
What are the differences in the treatment of chronic juvenila arthritis in comparison to adult RA?
|
Reliance on aspirin before NSAIDs because of less risk of GI problems.
|
|
|
What are other names for Gouty arthritis?
|
Podagra, urate crystal synovitis.
|
|
|
Metabolism of which molecules lead to gouty arthritis?
|
Purines.
|
|
|
What are the molecules which are deposited in gouty arthritis?
|
Uric acid salts.
|
|
|
Which is the most commonly deposited uric acid salt?
|
Sodium biurate.
|
|
|
Where in the body are these uric acid crystals deposited?
|
In connective tissues especially in the cartilages, the walls of bursae and in ligaments.
|
|
|
Who will get gouty arthritis?
|
Individuals who have a genetical predisposition.
|
|
|
Why do we think about "attacks" when we are talking about gouty arthritis?
|
Because it is so that patients with gouty arthritis experience attacks of arthritis for example after ingestion of foods rich in purines or after an operation or recent injury.
|
|
|
What kinds of foods are rich in purines?
|
Liver, kidney, sweetbreads, beer and heavy wines.
|
|
|
What is the reason to why uric acid crystals are favourably deposited in cartilages or ligaments or any connective tissue for that matter?
|
Because, these tissues have a SLUGGISH BLOOD SUPPLY which gives these molecules time to precipitate in this location.
|
|
|
What happens just after the crystals have deposited in the cartilage?
|
There is an inflammatory response to these crystals.
|
|
|
What happens in an acute attack of gouty arthritis?
|
There is rapid inflammatory response with subsequent removal of the crystals and resoration of the tissue to normal.
|
|
|
So when do the gout depositis become more problematic?
|
It is when the uric acid levels in the blood are elevated chronically. This allows for a chronic inflammatory reation in the affected joints and thus thereis time for serious joint damage to occur.
|
|
|
What are the gouty depositis sometimes called?
|
Tophi
|
|
|
What are other commmon sites for tophi besides intraarticular and what may they form there?
|
They may form nodules in for example the olecranon bursa or in the cartilages of the ear.
|
|
|
Which gender and what age doe gouty arthritis mainly affect?
|
There is a male to female ratio of 10:1 which means that 9 out of 10 patients are male. The age is almost always above 40.
|
|
|
Which are the joints most commonly affected by gouty arthritis?
|
The peripheral joints, as in rheumatoid arthritis which is also not the central joints.
|
|
|
What is special about gouty arthritis?
|
It occurs in recurrent attacks.
|
|
|
What is usually the location of the first attack of gouty arthritis?
|
The great toe.
|
|
|
Explain the onset of an attack of gouty arthritis. When during the day does it occur?
|
An attack of gouty arthritis is usually RAPID in onset and occurs more commonly during the NIGHT.
|
|
|
What is the appearance of the afected joint in gouty arthritis?
|
It is swollen, red and glossy.
|
|
|
What is the severity of pain in gouty arthritis?
|
It is VERY severe. Movements are greatly restricted because of the pain.
|
|
|
How long does an attack of gouty arthritis last.
|
It lasts a few days, and it is as if theere was never anything wrong, because the joint is normal between attacks.
|
|
|
How can we know if there is a chronic gouty arthritic process going on?
|
If there are several joints involved and they are thickened and nodular, and painful on movements.
|
|
|
If gouty arthritis is suspected, where should we look for nodules?
|
Around the olecranon bursa and in the cartilagesof the ears.
|
|
|
What are the radiograhic features of gouty arthritis?
|
In acute attacks there are NO radiographic changes.
In chronic gout the deposisits shows as clearcut erosions adjacent to the articular surfaces. |
|
|
So just to repeat, what, with one word can be seen on radiographs of chronic gouty arthritis?
|
Eroisions!
|
|
|
How do we diagnose gouty arthritis?
|
By first exluding other arthritides with an acute onset, such as pyogenic arthritis, pseudogout, hemophilic arthritis and rheumatic fever.
|
|
|
What are the features which are suggestive of gouty arthritis?
|
History of previous attacks.
Symptom free intervals. A raised plasma urate. Prescence of tophi in ears or elsewhere. Crystal detection in synovium. Favourable response to treatment. |
|
|
What is the common course of gouty arthritis?
|
It usually recurs in acute attacks.Early attacks subside in a few days but if the gout is chronic then the affected joints are gradually disorganised, and permanent disability is inevitable.
|
|
|
Which drugs are used in acute attacks of gouty arthritis?
|
An NSAID such as indomethacin or naproxen. Colchicine is also effective.
|
|
|
What is also important in an acute attack of gouty arthritis?
|
That the joint be rested until the attack has subsided.
|
|
|
What if there is a large effusion in a joint?
|
Then it should be aspirated and replaced by hydrocortisone.
|
|
|
For whom should be used the long term plasma uric acid reducing drugs?
|
For patients with frequent attacks or chronic gouty arthritis.
|
|
|
Which two types of drugs are used in the treatment of chornic gout?
|
Probenecid and Allopurinol.
|
|
|
How does probenecid work?
|
Probenecid reduces the reabsorbtion of uric acid in the tubules of the kidneys.
|
|
|
How does allopurinol work?
|
Allopurinol inhibits the enzyme xanthine oxidase and thus reduces the formation of uric acid.
|
|
|
What is a hazard with the use of probenecid?
|
Formation of kidney stones.
|
|
|
What is pseudogout?
|
Similar condition to gout caused by depositition of calcium pyrophosphate.
|
|
|
Which part of the body is mostly involved in ankylosing spondylitis?
|
As the name implies, the spine.
|
|
|
Which are the joints involved in a few cases of AS?
|
The proximal joints of the limbs, especially the hips.
|
|
|
How could ankylosing spondylitis be described briefly?
|
Chronic inflammation of the joints of the spine.
|
|
|
Where does AS begin?
|
In the sacroiliac joints.
|
|
|
What does "ankylose" mean?
|
To grow together and merge.
|
|
|
What does spondylitis mean?
|
Inflammation of the vertebrae.
|
|
|
What is the speed of progression of AS?
|
It progresses SLOWLY, gradually creeping up to the spinal column from below.
|
|
|
What does simply "ankylosis" mean?
|
Hardening of the joints.
|
|
|
Does AS always progress to ankylosis (hardening) of the affected joints?
|
No, disease progression can be arrested at any stage.
|
|
|
What is the typical radiographic appearance of the sacroiliac joints in advances AS?
|
Complete fusion of the joints.
|
|
|
Which patient group typically are affected with AS?
|
Young males.
|
|
|
Is there any hereditary factor for AS?
|
Yes there is a strong link between the HLA-27 antigen and AS.
|
|
|
Which was the chronic juvenile arthritis connected with AS?
|
The seronegative chronic arthritis with sacroilitis.
|
|
|
What is the cause of AS?
|
It is unknown but believed to be an autoimmune reaction to an infective organism.
|
|
|
In howmany percent of patients is the HLA-B27 antigen present?
|
80-90%
|
|
|
What strucutres of the joints are affected in As?
|
The articular cartilages, synovium and ligaments show chronic inflammatory changes and eventually they ossify.
|
|
|
So ankylosing spondylitis could be compared to what kind of treatment?
|
Arthrodesis
|
|
|
What are the ages in which AS almost always begins?
|
Between 16-25 years of age.
|
|
|
What are the early symptoms fof AS?
|
Aching PAIN in the lower back and increasing STIFFNESS.
|
|
|
What are later symptoms of akylosing spondylitis?
|
The pain migrating upwards.
Diffuse radiating pain down one or both limbs is also common. |
|
|
What are the signs of AS on physical examination?
|
Marked DECREASE OF MOVEMENT of all involved segments.
If the thoracic spine is involved the chest expansion during inspiration is reduced to as low as 2.5 cm from the normal of 7.5 cm due to ankylosis of the costovertebral joint. There might be involvement of hip or shoulder joints. |
|
|
So what actually is the main difference between RA and AS?
|
That AS attacks the central joints while RA affects the peripheral ones.
|
|
|
What are the signs of AS on EARLY radiographs?
|
Fuzziness and widening of the sacroiliac joints.
|
|
|
Which is the far more sensitive method to detect early changes in AS?
|
MRI of the sacroiliac joint.
|
|
|
What is the typical radiographic finding of the spine in advanced As and what is it called?
|
Bony ankylosis of the spine, called BAMBOO SPINE.
|
|
|
So bamboo spine is a radiological finding?
|
Yes
|
|
|
What bloog investigations are performed in AS?
|
ESR is elevated (in active disease)
CRP is elevated (in active disease) HLA-B27 |
|
|
What must the early stages of AS be distinguished from?
|
Other causes of low back pain and sciatica.
|
|
|
What features are diagnostic of AS?
|
Decreased movements in the spine.
Reduced chest expansion. Typical radiographic findings. Raised ESR. |
|
|
After how long does AS usuallly cease to progress?
|
After 10-15 years.
|
|
|
What is the range of stiffness left after cessation of active disease?
|
It varies widely among individuals but it always leaves some residual stiffness.
|
|
|
What are complications of AS?
|
Fixed flexion deformity, intercurrent respiratory infections, and iridocyclitis, which in severe cases may lead to blindness. There is also a relationship with Chron's disease.
|
|
|
Is treatment of AS usually efficient?
|
No, it is rather unsatisfactory.
|
|
|
What is the first line agent of AS?
|
A NSAID.
|
|
|
What is the only indication for steroids in the treatment of AS?
|
Iridocyclitis.
|
|
|
Which are the new agents which show rather promising results in AS?
|
The anti-TNF-alpha drugs such as infliximab and adalimumab.
|
|
|
What is more important in AS, rest or activity?
|
Activity! To preserve the ROM of the spine.
|
|
|
How should a patient with AS sleep?
|
On a firm matress, ideally in the supine positiion with a single pillow, to maintain normal spinal alignment.
|
|
|
What can be done if flexion deformity has already eveolved?
|
Then hip arthroplasty can be tried to maintain an upright stance.
|
|
|
Which types of cancer are commonly metastasizing to bones?
|
Breast, prostrate, lung and kidney and thyroid cancer.
|
|
|
What is the difference in age in patients with secondary metastatic bone tumours or primary bone tummours?
|
Metastatic tumours, even though much more common, occur later in life while the primary bone tumours occur in younger patients.
|
|
|
Which are the bones which commonly host metastases and why?
|
The bones which contain vascular marrow.
1. Vertebral bodies 2. Pelvis 3. Ribs 4. Superior femur and humerus. |
|
|
What happens at a location of metastatic cancer in bone?
|
The bone is syimply destroyed and replaced with tumour.
|
|
|
What can occur at this site?
|
Pathological fracture.
|
|
|
What are the symptoms of metastatic bone tumours?
|
Pain in the region, but sometimes it is asymptomatic until a pathological fracture occurs.
|
|
|
What are common symptoms if the spine is involved?
|
Progressive neurological symptoms and back pain.
|
|
|
What are symptoms of advanced metastatic disease?
|
Hypercalcemia, nausea, dehydration adn even coma.
|
|
|
What are the radiographic findings of a metastatic bone tumour?
|
The bone appears to have been eaten away so that there is a clear area of circumscribed lysis without any reaction in the surrounding bone.
|
|
|
Which are the two best radiographic investigations of bone metastases?
|
Bone radioisotope scanning and MRI.
|
|
|
How are the primary bone tumours classified?
|
Into four groups depending if they origniate from bone, cartilage, fibrous tissue or of uncertain origin. They are further subdivided inot bening and malignant lesions.
|
|
|
Which area the benign bone tumours arising from bone?
|
Osteoma
Osteoid osteoma Osteoblastoma Giant-cell tumour |
|
|
Which are the malignant bone tumours arising from bone?
|
Osteosarcoma
|
|
|
Which are the benign bone tumours arising from cartilage?
|
Enchondroma
Osteochondroma Chondromyxoid fibroma Chorndoblastoma |
|
|
Which are the malignant bone tumours arising for catilage?
|
Chondrosarcoma
|
|
|
Which are the benign bone tumours arising from fibrous tissue?
|
Fibrous cortical defect.
Non-ossifying fibroma Fibrous dysplasia. |
|
|
Which are the malignant bone tumours arising from fibrous tissue?
|
Malignant fibrous histiocytoma.
|
|
|
What are the benign bone tumours of uncertain origin?
|
Simple bone cysts.
Aneurysmal bone cysts. |
|
|
Which are the malignant bone tumours of unknown origin?
|
Ewing's sarcoma
Adamantinoma |
|
|
In which gender is osteoid osteoma more common?
|
In males, 3x
|
|
|
In what age is osteoid osteoma commonly occuring?
|
Between 10 and 25.
|
|
|
What bones are mostly involved in osteoid osteoma?
|
Most often the cortex of the long bones but sometimes the cancellous bone of the vertebrae.
|
|
|
What does "nidus" mean in swedish?
|
Näste, bo.
|
|
|
What is the characteristic pathomorphology of an osteoid osteoma?
|
Formation of a small nidus of osteoid tissue, surrounded by a sclerotic zone of newly formed bone.
|
|
|
How does this lok on a radiograph?
|
Like a dense cortical thickening on a long bone with a central lucency (nidus).
|
|
|
What are the clinical features of an osteoid osteoma?
|
There is well localized pain of increasing intesity.
There might be local tenderness. |
|
|
During what time of day is the pain worse?
|
During night.
|
|
|
What are diagnostic features of osteoid osteomas?
|
Pain is worse during night and is relieved by NSAIDs.
|
|
|
Which is the radiographic method which can best show the nidus?
|
CT scan.
|
|
|
What is the common mode of treatment of osteoid osteoma?
|
In younger patient it may resolve spontaneously after several months, but most require surgical removal.
|
|
|
What is the surgery performed in osteoid osteoma?
|
The nidus needs to be removed. It can be done in an open approach but recently it is more common to insert a needle with the CT as a guide and the lesion is ablated (skära bort) with radiofrequency coagulation.
|
|
|
What is another name or description of osteochondroma?
|
Cartilaginous exostosis.
|
|
|
What does exostosis translate to in swedish?
|
Godartad bentumör.
|
|
|
Which is the commonest benign tumour of bone?
|
Osteochondroma, AKA cartilaginous exostosis.
|
|
|
What is the age of occurence for osteochondroma, AKA cartilaginous exostosis?
|
10-20.
|
|
|
From where does the tumour originate?
|
From the growing cartilaginous epiphyseal plate.
|
|
|
What is the appreance of an osteochondroma, AKA cartilaginous exostosis?
|
It is like an outgrowth like a mushroom with a bony stalk.
|
|
|
Is there always a stalk in the osteochondroma?
|
No, rarely it is sessile with a broad base, so not resembling a mushroom.
|
|
|
What is capping the bony stalk of the osteochondroma?
|
A cartilaginous cap.
|
|
|
For how long does this cartilaginous cap of the osteochondroma continue to gro?
|
As long as bone development and groth occurs, so it stops together with bone development. Basically it acts like an accessory epiphysis.
|
|
|
Is there any condition with multiple osteochondroma?
|
Yes, in multiple exostoses, AKA diaphjyseal aclasis.
|
|
|
What should be suspected if there is continued growth of the osteochondroma after puberty?
|
Change to malignancy.
|
|
|
How does the patient with osteochondroma present?
|
The tumour may be seen as a circumscribed hard swelling near a joint.
|
|
|
Is there any pain?
|
Usually not.
|
|
|
What can plain radiographs visualize?
|
The bony mushroom-like stalk but not the larger cartilaginous cap until it calcifies when skeletal maturity occurs.
|
|
|
What must be told to patients with an osteochondroma?
|
To seek prompt radiography if there is a sudden increase in size or pain.
|
|
|
How is osteochondroma, AKA cartilaginous exostosis treated?
|
Excision if it causes pain or if it enlarges after puberty.
Biopsy must be sent for routine histoligcal examination to exclude malignancy. |
|
|
Where is an enchondroma likely to occur?
|
In the metacarpals and phalanges of the hand.
|
|
|
What is the likely prsentation of an enchondroma?
|
Deformity or pathological fractures.
|
|
|
What is the names of the disease in which there are multiple enchondromas?a
|
Multiple endocndromatosis, or Olliers disease.
|
|
|
Does an enchondroma sometimes become malignant?
|
Not the solitary ones but if there are multiple they might end up as chondrosarcomas.
|
|
|
When is operation required for encondromas?
|
Only if the tumor starts enlarging.
|
|
|
How should small enchondromaas be treated?
|
Expectantly.
|
|
|
How can pathological fractures of the metacarpals or phalanges of an enchondroma be treated?
|
Normally by simple splintage.
|
|
|
What is more common, single enchondromas or multiple?
|
Multiple.
|
|
|
What is the significance of enchondromas if they sometimes occur in the forearm?
|
Enchondromsa of the forearm many times limit growth and cause shortening of the affected limb.
|
|
|
What patient group gets osteosarcomas?
|
Young patient between 10-25.
|
|
|
Can osqteosarcomma occur later in life and with which disease is it then associated?
|
Pagets disease.
|
|
|
Which are the cells from which osteosarcomas arise?
|
Primitive bone forming cells.
|
|
|
Name the commonest sites of osteosarcoma.
|
Lower end of femur.
Upper end of tibia. So around the knee. Upper end of humerus, so shoulder. With other words it is in those areas where active growth is at its peak. |
|
|
In which regioof the bnes does the osteosarcoma start?
|
In the metaphysis.
|
|
|
What happens with the tumour when its developing?
|
The osteosarcoma grows and destroys the bone in the metaohysis and finally bursts into the soft tissues, but it seldom crosses the epiphyseal plate into the epiohysis.
|
|
|
What is the histological appearanc of the tumor?
|
It varies widely because any type of connective tissue may be represented.
|
|
|
S what are the substances of which the tumour may consist?
|
Cartilage, fibrous tissue, myxomatous tissue, but BONE is most common.
|
|
|
Does the osteosarcoma metastasize?
|
Yes it does bsy definition since it is malignant. It metastasiEs early primarily to lungs and sometimes to other bones.
|
|
|
What is normally the presentation of osteosarcoma?
|
Gradually increasing bone pain with a growing swelling.
|
|
|
What does examination of a patient with osteosarcoma reveal?
|
A hard mass around a joint, normally the knee or shoulder. The overlying skin is warm because of vascularity. The skin may appear stretched and shiny.
|
|
|
What do plain radigraphs show in a osteosarcoma?
|
Medullary and cortical destruction of the metaphysis. Later the cortex appears to have been burst open at one or more places by soft tissue extensions.
|
|
|
What can MRI of a osteosarcoma show?
|
Accurate details and elineation of the tumour and invasion of soft tissues.
|
|
|
What does Codmans triangle refer to?
|
The codmans triangle is form by new bone being laid down under the distended periosteum.
|
|
|
What are the 'spicules' of new bosne in the tumour called radiographically?
|
Suns rays.
|
|
|
What will radioisotope scanning of the tumour show?
|
Increased uptake.
|
|
|
What other radiograohs should be taken?
|
Chest radiographs to look for metastases but now is mandatory CT lung fields.
|
|
|
How should specimens for pathology be collected?
|
By closed needle or open biopsy.
|
|
|
How much specimen should be collected?
|
Alot, because othereise it may be confused for ewings tumour, chondrosarcoma or even metastatic tumour.
|
|
|
What was the mortiality of osteosarcoma previous to introductn of chemotherapy?
|
80%
|
|
|
What is the modern prognosis of osteosarcoma?
|
Much much better.
|
|
|
What is the mode of treatment of osteosarcoma?
|
Powerful cytotoxic drugs and surgery.
|
|
|
Give examples of the drugs used in osteosarcoma
|
High dose methotrexate, doxorubicin, cisplatin, ifosfamide in combinations.
|
|
|
For how long is chemotherapy done?
|
For 6 months to 12 months after ablation of the tumour surgically.
|
|
|
Why are the drugs started before surgical ablation of the tumour?
|
To allow pathologists to study the tumours response to the drug to aid in prognosis.
|
|
|
What is performed surgically in the case of osteosarcoma?
|
Previoousdly amputation was the mode of chce but nowadays radical resection with replacement witha metallic prosthesis or massive bone grafts is commonly done.
|
|
|
Another name for osteoclastoma.
|
Giant cell tumour.
|
|
|
Is the osteoclastoma benigor malignant?
|
Benign.
|
|
|
But what is different from it from other benign bone tumours?
|
Osteoclastomas tend to recur after local removal or curettage.
|
|
|
In which age group do the osteoclastomas mainly occur?
|
Between 20 and 40.
|
|
|
In how many percents of cases do the osteoclStomas behave as malignant tumour?
|
In 10%
|
|
|
What do we mean wihen we say that an osteoclastoma behaves as a malignant tumour?
|
That is metastasizes, commonly to the lungs.
|
|
|
What are the commonest sites of an osteoclastoma?
|
LOwer femur, uppere tibia, so knee.
Lower radius. Upper humerus. So much like the osteosarcoma. |
|
|
We said that osteosarcomas grow in tqhe metaphysis, how is osteoclastoma different?
|
It usually grown in the epiphysis, in other words distal to the epiphyseal plate.
|
|
|
What occurs at the site of the tumour?
|
It destroys the bone but new bone is formed under the raised periosteumos that the ends become EXPANDED.
|
|
|
What may happen at these distal parts of the bone in case of small injury?
|
Pathological fracture.
|
|
|
What are the symotoms of an osteoclastoma?
|
Pain at the site and gradually increasing swelling.
Sometimes pathological fracture is the only telltale sign. |
|
|
What is seen on eximation of a patient with osteoclastoma?
|
Tender and firm swelling around the ends of bones.
|
|
|
So what is so different about the clinical findings and radiography of an osteoclastoma and osteosarcoma?
|
Mainly thst they occur in different age groups. If it is after fusion of the epiphyseal plate then it is most probably a osteoclastoma.
|
|
|
What is seen on a radiograph of osteoclastoma?
|
Lytic destruction of bone substance, but no periosteal reaction. The tumour often extends as far as the articular surface of a joint.
|
|
|
Which type of radiograph will help determine the amount of soft tissue extension of the tumour?
|
MRI
|
|
|
What is the most common method of removal of a osteoclastoma?
|
High speed burr curettage.
|
|
|
What is the rate of recurrence when using this method?
|
20-25%
|
|
|
How can the recurrence rate be reduced further after curettage?
|
By adjuvant therapy applied to the loning of the cavity after curretage.
|
|
|
What are methods of adjuvant therapy?
|
Chemical phenol.
Freezing with liquid nitrogen. |
|
|
Qhat kind of therapy is sometimes used and is capable of bringing permanent cure?
|
Radiotherapy
|
|
|
Another name or description for Ewings tumour.
|
Endothelial sarcoma of bone.
|
|
|
In what bone stubstance does the ewings tumour arise?
|
In the bone marrow.
|
|
|
In which bones are the ewings tumours normally occurinng?
|
In the shaft of femur, tibia or humerus.
|
|
|
So the bone structure in which it arises is the ... Instead of the metaphysis like in osteosarcoma.
|
Diaphysis
|
|
|
From which cells is the ewings tumour believed to develop?
|
From endothelial cells in the bone marrow.
|
|
|
Describe the tumour consistency of the ewings.
|
It is soft and vascular.
|
|
|
What is so bad about ewings tumour?
|
It is highhly malignant.
|
|
|
What happens with the periosteum in ewings sarcoma?
|
There is a STrIKiNG periosteal reacton with subsequent layers of new bone laid under it.
|
|
|
Where do the cells of the ewings sarcoma metastasize?
|
To the lungs or other bones.
|
|
|
What is the age in which ewings sarcoma is the commonest?
|
Between 5 and 20.
|
|
|
What are typical features of ewings sarcoma?
|
Pain and a rapidly growing swelling close to the middle of the shafts of one of the long bones.
|
|
|
What are the general symptomms in ewings sarcoma?
|
Fever, malaise and weight loss.
|
|
|
What is felt on examination?
|
The swelling is firm, diffuse or fusiform and of firm consistency. The overelying skin in stretched and warm.
|
|
|
What can radiograohs of a ewings sarcoma show?
|
Destruction of bone with CONCENTRIC layers of subperiosteal new bone.
|
|
|
What are the concentric layers of subperiosteal bone appearance called on radiography?
|
Onion peel appearance.
|
|
|
What will MRI scanning reveal in ewings sarcoma?
|
A large soft tissue mass.
|
|
|
Why is an isotope scanning necessary in ewings sarcoma?
|
To detect any multifocal lesions. So metastases basically. For staging.
|
|
|
What other radiograph is necessary to get in ewings sarcoma?
|
Of the chest for metastases.
|
|
|
what may be confused with early ewings tumour?
|
Osteomyelitis. Because of increased ESR and fever.
|
|
|
What was the prognosis of ewings sarcoma until recently?
|
Invariably fatal.
|
|
|
What are the survival rates with modern chemotherapy?
|
5 year survival of 50-60%.
|
|
|
Wich are the agents used to treat ewings tumour?
|
Vincristine, cyclophosphamide, dactinomycin and doxorubicin.
|
|
|
How may the tumour be treated surgically?
|
By radical excision with prosthesis or by amputation.
|
|
|
From ehich bne substance does the plasmacytoma arise?
|
Bone marrow
|
|
|
In which age group does plasmacytoma occur?
|
50-70
|
|
|
Another name for plasmacytoma...
|
Myeloma.
|
|
|
What is the prognosis of myelomas?
|
It is usually fatal but moedn therapy gives survival rates of 10 years or longer.
|
|
|
How are myelomas disseminated and where?
|
The metastatic plassma cells are released to the blood stream and travel to the bone marrow of many bones.
|
|
|
When the patient seeks medical attentn the lesions are usually already...
|
Multiple.
|
|
|
Which bones are chiefly affected by myeloma?.
|
The ones containing abundant red bone marrow.
|
|
|
Where is pathological fracture especially common with myeloma?
|
In the spine.
|
|
|
What are the systemic symptoms of mltiple myeloma?
|
General ill health with local bone pain at one or more sites, sometimes with a pathologicsl fracture.
|
|
|
Why is a patient with multiple myeloma normally pale?
|
Because of associated anemia due to supression of the bone marrow.
|
|
|
Why do patients often acquire multiple infections if they have multiple myeloma?
|
Because of suppression of formation of immune cells in the bone marrow.
|
|
|
What are the typical radiographical findings in multiple myeloma?
|
Typical punched out multiple lesions. Especially in skulls pelvic bones, vertebral bodies etc.
|
|
|
Which is the superior imaging method for multiple myeloma?
|
MRI
|
|
|
What kind of anemia occurs in multiple myeloma?
|
Microcytic
|
|
|
What are other laboratory tests useful in multiple myeloma?
|
ESR is increased
Bence jones proteins, meaning monoclonal antibodies. Are present in the urine. Serum globulins are increased. |
|
|
What kind of biopsy is performed and what does it show?
|
Bone marrow biopsy shows profusion of plasma cells.
|
|
|
How is definitve diagnosis of multiple myeloma performed?
|
Iliac or sternal marrow biopsy will confirm diagnosis when the clinical pictuire is equivocal.
|
|
|
What is the prognosis of multiple myeloma?
|
It is usally fatal but its progression can be checked with an improved treatment regiment.
|
|
|
How are the tumour foci treated in MM?
|
By radiotherapy.
|
|
|
Which are the chemotherapeutic agents used for MM?
|
Thalidomide, bortezomib.
|
|
|
What is another method of treatment under way?
|
Bone marrow transplants.
|
|
|
What are the two types of fibrous dysplasia which can occur in bone?
|
Monostotic fibrous dysplasia or polystotic fibrous dysplasia.
|
|
|
What is the pathology of monostotic fibrous dysplasia of bone?
|
A solitary area of bone is partly replaced by fibrous tissue.
|
|
|
What is the czuse of fibrous dysplasia?
|
Unknown.
|
|
|
What is the relationship between monostotic and polystotic fibrous dysplasia?
|
Unknown.
|
|
|
Which is the site normally affected by fibrous dysplasia?
|
One of thd limb bones.
|
|
|
What happens to the medullary cavity at a site of monostotic fibrous dysplasia?
|
It expands at the cost of bone.
|
|
|
What may occur at a site of fibrous dysplasia due to minor injury?
|
Pathological fracture.
|
|
|
In what age grous do the monostotic fibrous dysplasia occur?
|
In children and young adults.
|
|
|
What are the symptoms of fibrous dyspllasia?
|
Local pain in the affected bone but often it is asymptomatic and is an incidental xray finding.
|
|
|
What are the signs of monostotic fibrous dysplasia on xray?
|
A zone of lucency often with a homogenous appearance of ground glass and a thick sclerotic rim.
|
|
|
So summarize the xray findings of monostotic fibrous dysplasia again.
|
A lucency with thick sclerosis around and iside this kucency theree is ground glass appearance.
|
|
|
What is the mode of tretment of monostotic fibrous dysplasia?
|
Depends on the size of the lesion.
Simple curettage and autogenous bone grafting is ineffective, but for larger lesions cortical bone grafts with internal fixation may sometimes control deformity. |
|
|
What is the characteristic features of polyostotic fibrous dysplasia?
|
There is a generalized replacement of bone by fibrous tissue.
|
|
|
Is there any evidence of hyperparathyroidism in polyostotic fibrous dysplasia?
|
No
|
|
|
Is polyostotic fibrous dysplasia rare and what is its cause?
|
Yes it is rare and its cause is unknown unlike the conditions in which hyperparathyroidism causes fibrous replacement of bone.
|
|
|
How many bones are usually involved in polyostotic bone dysplasia?
|
Between two to more than twelve.
|
|
|
Which are the bones most commonly affected by polyostotic fibrous dysplasia?
|
The long bones. Especially the femur.
|
|
|
What happens to. Affected bonees?
|
They are liable to bending or breaks.
|
|
|
Ate what age is the onset of polyostotic fibrous dysplasia?
|
Childhood.
|
|
|
When is the condition usually recognized?
|
In early adult life.
|
|
|
What are the main features of polyostotic fibrous dysplasia?
|
Mainly deformity. And pathological fractures.
|
|
|
What is the usual prognosis of polyostotic fibrous dysplasia?
|
It oftn progresses to seve crippling.
|
|
|
What are radiographic features of polyostotic fibrous dysplasia?
|
Welldefined transradiant areas with homogenous ground glass apearrance just like in monostotic fibrous dysplasia.
|
|
|
Another name for neurofibromatosis.
|
Von recklinghausens disease.
|
|
|
How is von recklingshausens disease aquired?
|
It is inherited.
|
|
|
What are the characteristics of von recklinghausen disease?
|
Pigmented areas on the skin, cutaneous fibromata, multiple neurofibromata in the course of cranial or perioheral nerves.
|
|
|
What are the neurofibromata?
|
Connective tissue arranged in whorls with a few nerve fibers.
|
|
|
Are the skin fibromata present at birth?
|
No
|
|
|
Whedo the skin lesions of neurofibromatosis dedvelop?
|
In early childhood life.
|
|
|
What do the skin kesions of neurofibromatosis consist of?
|
Multiple cafe aulait spots and neurofibromata which may be flat or raised.
|
|
|
What are the main orthopedic difficulties in neurofibromatosis?
|
In the libility to scoliosis and neurological disturbances to the limbs. There may also be pathological fractures especially of the tibia in children due to invasioof neurofibromata in thef bone.
|
|
|
Why does scoliosis occur in neurofibromatosis?
|
It is unknown.
|
|
|
What conditins does ddevelopmental dysplasia of the hip joint include?
|
Congenital hip dislocaiton
And Adult dysplasia of the hip. |
|
|
What is developmental dysplasia of the hip characterised by in terms of changes in the hip?
|
Shallow acetabulum!
Defective harmony between the head of femur and acetabular socket. Predisposition to osteoarthritis in adult life. |
|
|
What is a better name for congenital dislocation of the hip?
|
Congenital dedvelopmental dysplasia of the hip.
|
|
|
Why isnt the name changed from congenital hip dislocation to ddh?
|
Because of its wide use it would be useless.
|
|
|
When does congenital dislocation of the hip occur?
|
Either before, during or just after birth.
|
|
|
Is congenital dislocation of the hip common?
|
Yes, it is one of the most common congenital skeletal deformitiesaffecting 1 in 1000 neonates.
|
|
|
What will be the outcome if ddh is missed in a child?
|
Lifelong crippling.
|
|
|
What are the groups of causes leading to cngential dislocation of the hip?
|
Genetical and environmental.
|
|
|
What are the genetical factors which can predispose to ddh?
|
Genetically deteermined JOINT LAXITY.
|
|
|
What does genetical joint laxity lead to?
|
A general instability of the joint.
|
|
|
What may the uterus of female fetuses produce which also produces joint laxity?
|
In response to maternal estrogens and progesterone the fetal uterus may produce relaxin, which can produce joint laxity.
|
|
|
What is the reason why females are more prone to ddh than males?
|
The previous question. The femal fetal uterus may oroduce relaxin.
|
|
|
What is another genetically determinator of ddh?
|
Genetically determined dysplasia of the hip.
|
|
|
What are the features of the genetically determined dysplasia of the hip?
|
Defective ddevelopment of the acetabulum.
Defective development of the head of femur. |
|
|
What are intrauterine factors which oredisposes to cngenital dislocation of the hip?
|
Breech position. Due to mechanical factors.
|
|
|
A postnatal factor of ddh?
|
Postnatal positioning.
|
|
|
How was postnatal positioning evidenced to cause greater incidence of ddh?
|
It was seen among eskomios who rapped their babies to a board with the hips adducted.
|
|
|
Which position of the hip is the good one for acetabular development?
|
Abduction.
|
|
|
What is the big difference between dysplasia that occur mainly due to genetically edtermined hip laxity or to those that occur due to mechanical factors such as breech delivery?
|
That if there is joint laxity the dislocations may often be bilateral.
|
|
|
Where is the femoral head in a diclocated hip?
|
It is dislocated upwards and laterally.
|
|
|
What is the position of the femoral neck in a congenital hip dislocatiob?
|
It is usually anteverted more than the 25 degrees accepted.
|
|
|
What is late in dvelopment in the femur when it is dislocated?
|
The nuckeus of the femoral head is late in its development when its not lying in the acetabular fossa.
|
|
|
What is late in dedvelopment of the acetabulum in hip dislocation
. |
The roof of the acetabular fossa.
|
|
|
What happens to the labrum of the acetabulum if there is oersistent dislocation?
|
The labrum usually folds into the acetabulum.
|
|
|
What may this labrum also known as limbus cause?
|
Difficulty in reducing the moral head back into the acetabular socket.
|
|
|
What happens to the joint capsule if dislocAtion is allowed to persist?
|
It is gradually elongated.
|
|
|
How much more common is hip dilocation in girls?
|
6 times.
|
|
|
How often is there bilateral involvement?
|
In a third of cases.
|
|
|
If it is not looked for at birth, when is the abnormality normally found?
|
When the child begins walking,
|
|
|
What happens with walking in a chikd with oersistent hip dislocation?
|
There is normally a dedlayed walking and when it does occur there is a limp or waddling gait.
|
|
|
What are signs of congenital hip dysplasia in a child which oresents late?
|
Shortening of the affected limb.
Assymetry if unilateral. Restricted abduction in flexion. The affected limb is excessivly mobile in its long axis. Telescopic movement. |
|
|
What are the three most important features of radiography of congenital hip dysplasia?
|
1. Small ossific centree in the head of femur.
2. Upslope of the bony acetabular roof. 3. Femoral head displaced upwards and laterally. |
|
|
When are these changes best seen?
|
After 4 months of life.
|
|
|
What are other methids besides xray which may show ddh?
|
Arthrography.
Ultrasound scanning. |
|
|
How is diagnosis made in the newborn?
|
By the screening tests of Barlow or Ortolani.
|
|
|
Explain how the Barlows and Ortolanis tests are performed.
|
The doctor faces the childs perineum, grips the thighs suoeriorly and flexes the hip.
Then the hips are steadily abducted while the middle finger apllies pressure to the greater trochanter (ortolani) or the thumb gives anteriior pressure (barlows). |
|
|
What can be detected with the ortolanis test?
|
A dislocated femoral head snaps back into the acetabulm with an audible and palpable jerk or jolt.
|
|
|
What can be detect with the barlows test?
|
An unstable joint dislocates posteriorly when pressure is applied anteriorly.
|
|
|
So the ortolani tests trues to...
|
Reduce a dislocated joint.
|
|
|
And the barlows test tries to...
|
Dislocate an unstable joint.
|
|
|
What are other thing noted when performing the barlows and ortolani tests?
|
The range of abduction in flexion of the hip.
|
|
|
What may indicate a dislocation in regard to the amount of abduction in a hip?
|
If there is restriction to abduction in fkexion it may signify a persistent dislocstion snd prompt radiograohy shoukd be performed.
|
|
|
Why is radiograohy often inconvlusive in newborns?
|
Because of thee high proportion of radiolucent cartilage.
|
|
|
So what should be performed in a child with restricted abduction?
|
If initial radiograohy is inconclusive it should be repeated. It is usually diagnostic at 4 months of age.
|
|
|
Which is the techniwue which is more and more used in screening of newborns?
|
Ultrasound.
|
|
|
What is the presentation of ddh in older children if missed at birth?
|
Delayed and abnormal walking.
|
|
|
What is the most important examinatory sign in cldren between 1-2 years?
|
As eith newborns it is restriction to abduction in flexion.
|
|
|
What is the course znd prognosis of ddh?
|
The earlier it is detected and treated the better the prognosis.
|
|
|
How many patients with detection after 1 year of age can be expected to live symptomfree lives?
|
Only slightly more than half.
|
|
|
What are late problems with ddh?
|
Gradual redislocation or subluxation as well as degenerative changes.
|
|
|
What is the complication rate if the problem is found early?
|
Simple treatment assures a normal dedvelopment of the hip.
|
|
|
What does the treatment of ddh depend on?
|
The age of the patient.
|
|
|
Which are the four patient groups of ddh?
|
Neonates
6 months to 6 years 7-10 years Adolescents and adults |
|
|
What happens in most cases of congenital hip dislocation which is oresent at birth?
|
It spontaneously reduces within 3 weeks.
|
|
|
So decisions for definitve treatment shouldent be made until...
|
Three weeks after birth.
|
|
|
If the hip has spontaneously reduced, what should be the next step?
|
Reassessment at 6 months of age and again at 1 year.
|
|
|
What is recommended generally if the dislocation is persistent after three weeks?
|
Splinting of the hip in the abducted position for 3 months.
|
|
|
What are the methods of splinting in early treatment of ddh?
|
Simple plaster of paris or better is the Pavlic harness.
|
|
|
Which were the formerly used splints and why has the pavlic splint replaced them?
|
The denis-brown and van rosen splints. They were replaced because the pavlic splint allows more movements.
|
|
|
What are the three principles of teratmentde in the age group 6 months to6 years?
|
1. To secure concentric reduction
2. To provide conditions favourable to continued stability and normal development. 3. To observe the hips regularly. |
|
|
Up to what age is closed reduction of the hip joint clinically practisable?
|
Up to the age of 18 months.
|
|
|
For what age groups is operative reduction almost invariably neccessary?
|
After 3 years.
|
|
|
What is the standard method of closed reduction?
|
To apply weight traction with the child either on a frame or Bryants gallows suspension, and while traction is maintained, gradually abduct the hips, a little more each day, until 80 degrees of abduction is reached after 3-4 weeks.
|
|
|
What if reduction has not taken place after 4 weeks?
|
An attempt of manual reduction is done under general anesthesia.
|
|
|
What if full reduction is secured after 4 weeks?
|
The limbs are immobiliZed for a period in. A plaster of paris in a medially rotated and abducted positioon.
|
|
|
What is frequently complicating open reduction of the hip?
|
The limbus having inverted over the acetabulum.
|
|
|
What is done to this labrum, limbus?
|
It is removed.
|
|
|
What is done after open reduction of the hip?
|
It is immobilized in the same way as in the closed method, with a plaster of paris.
|
|
|
What if during open reduction the surgeon sees that the neck of the femur is anteverted more than 25 degrees?
|
Then this excessive anteversion needs correction.
|
|
|
How can excessive anteversion of the femoral neck be corrected.
|
Either surgically or closed.
|
|
|
What is the closed method of correcting an excessive anteversion?
|
By fixing the limb in flexion and moderate abduction, with a limited amount of walking allowed normally spontaneously corrects the anteversion. It takes a year or more.
|
|
|
What is the mthod of correcting anteversion surgically?
|
Rotation osteotomy.
|
|
|
How is rotation osteotomy performed?
|
Osteotomy below the trochanteric level and rotating the femoral shaft laterally. Then the fragments are fixed with plate and screw.
|
|
|
What is done if acetabular dysplasia persists? Such as shallow acetabulm or lack of roof?
|
Operative correction of the acetabulum.
|
|
|
What are the four different ways of correcting the acetabulum?
|
1. Osteotomy of the innominate bone.
2. Pericapsular osteotomy of ilium. 3. Shelf acetabuloplasty. 4. Chiaris displacement osteotomy of the ilium. |
|
|
What is the first thing to determine inn children with ddh if it is found at 7-10 years.
|
If treatment should be undertaken at all.
|
|
|
What dtermines if it should be treated or not?
|
The level of disability.
|
|
|
If the disability is so great as to opt for treatment, what are the lines of treatment?
|
Open reduction in which the femur may have to be shortened in the subtrochanetric region.
|
|
|
What should also be performed at the same time or later?
|
Corrective deepening of the acetabular fossa by any of the prreviously mentioned techniques.
|
|
|
What are the lines of treatment in children aged 11 and above for ddh?
|
For a freshly diagnosed ddh the method is not to treat at all unless secondary degenerative changes has occured.
|
|
|
What if secondary degenerative changes have occured and disability therefore is severe?
|
Then arthroplasty or arthrodesis can be attempted.
|
|
|
Additional names for juvenile slipped capital femoral epiphysis.
|
Slipped upper femoral epiphysis. Adolescent coxa vara, epiphyseal coxa vara.
|
|
|
So the names to remember for slipped capital epiohysis of femur are....
|
Coxa vara.
|
|
|
Describe juvenile slipped capital epiphysis of femur.
|
The upper femoral epiphysis has displaced from its natural position on the femoral neck.
|
|
|
Wen does juvenile slipped capital femoral epiphysis occur?
|
I late childhood.
|
|
|
Where exactly does the displacement occur?
|
In the growth plate, the epiphyseal plate.
|
|
|
Is epiphyseal coxa vara usually bilateral?
|
Yes but not simultaneously.
|
|
|
What is the cause of epiphyseal coxa vara.
|
Unknown but associated with overweight from endocrine dysfunction or from other causes.
|
|
|
What is the pathology behind coxa vara?
|
The junction between the capital epiphysis and neck of the femur loosens. With weightbearing the downward force the epiphysis is displaced.
|
|
|
What does wikipedia call this loosening of the epiphysis?
|
Fracture.
|
|
|
Where is the epiphysis always displaced?
|
Posteriorly and inferiorly!!!
|
|
|
So where does the slipped epiphysis come to lie in relation to femur?
|
Posteriorly to the femoral neck.
|
|
|
Does the displacement occur rapidly or slowly?
|
Usually gradually but sometimes rapidly due to injury or so.
|
|
|
What happens in the new displaced location?
|
The epiphysis will fuse with the neck in this abdnormal position.
|
|
|
What is the late complication of a slipped capital femoral head?
|
Developpment of osteoarthritis.
Hip dislocation? |
|
|
I what age does the slipped capital epiphysis occur?
|
Between 10 and 20.
|
|
|
What can be found in about half the cases of slippe dcapital epiphysis?
|
Evidednce of endocrine dysfunction and overweight.
|
|
|
What are the typical symptoms of a slipped capital epiphysis?
|
Gradual onset of pain in the hip with a limp. Rarely they occur affter an injury such as a fall.
|
|
|
What are the characteristic signs on physical examination of a patient with a slipped capital femoral head?
|
Selective restrictiion of. Movement ithe hip.
Flexion, abduction and medial rotation are limited. |
|
|
What happens if movement is forced behind restriction?
|
Pain.
|
|
|
Which is the most important radiograph to obtain in slipped capital epiphysis of the femur.
|
The lateral radigraph can detect even slight slippage.
|
|
|
In which patient should slipped capital femoral epiphysis be suspected?
|
In all patients betwen 10-20 years of age who complain of pain in the hip or knee.
|
|
|
Where is pain often refferred to in slipped capital femoral epiphysis?
|
To the knee.
|
|
|
What are the complications of slipped capital femoral epiphysis.
|
Avascular necrosis of the epiohysis.
Cartilage necrosis. Late osteoarthritis. |
|
|
What is the treatment of slight slippage of the epiphysis? And what does slight slippage refer to?
|
Slight displacement is if its less than 40 degrees as shown by lateral radiographs.
The only treatment is to prevent further slippage by driving threaded wires or slender screws along the neck of the femur into the epiohysis. |
|
|
What can be done if displacement is severe?
|
Manipulation, operative replacement and compensatory osteotomy.
|
|
|
Which is the method oreferred by most surgeons in the treatment of severe slipp capital epiphysis?
|
Compensatory osteotomy.
|
|
|
How is compensatory osteotomy performed?
|
Osteotomy at subtrochanteric level where an anteriorly wedge-shaped piece of bone is removed so that the angle is corrected.
|
|
|
What is arthrogryposis multiplex congenita?
|
Stiff joints due to defective musculsr development.
|
|
|
What is usually the cause of muscular defection in arthrogryposis?
|
Nerve conduction failures.
|
|
|
What are common coexisting malformations with arthrogryposis multipex cogenita?
|
Clubfeet and hip dislocation.
|
