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Flashcards in Orthopedics Deck (105)

What is non specific low back pain?

Tension, soreness and/or stiffness in the lower back region for which it isn’t possible to identify a specific cause of the pain
Diagnosis is dependent on the clinician being satisfied that there is not a specific cause for their patient’s pain
May include referred pain in the upper leg


What is radicular pain?

Pain caused by irritation or compression of nerve roots
Typically pain/numbness in a dermatomal distribution


Describe the epidemiology of low back pain

Annual incidence of first episode: 6%-15%
Annual incidence of any episode: 1% - 36%
Lifetime prevalence: Estimates up to 84%


Name some specific causes of low back pain

Inflammatory disorders: ankylosing spondylitis
Cauda equina compression
Non-spinal causes of back pain


How common is infection as a cause of low back pain? And how would you go about diagnosing it?

Account for


Where is the lower back?

Area bounded by the bottom of the 12th ribs, the buttock creases and the mid-axillary line


What investigations would you do in a patient that you suspected had an infective cause for their lower back pain?

Imaging, blood count, inflammatory markers


In whom are osteoporotic fractures a more likely cause of their lower back pain?

Older people, female, low body mass, taking glucocorticoids, past history of fragility fracture, Cushing's syndrome, alcohol intake, smoking, regular falls


How do you diagnose osteoporosis?

Measure bone mineral density using a DEXA scan
Normal: t score >-1
Osteopenia: >-2.5


What is the specific treatment for osteoporosis? What is the mechanism of action?

Bisphosphonates: encourage osteoclasts to undergo apoptosis so reducing bone resorption
Examples: alendronate, risendronate, zoledronic acid


What are the most common malignancies which may present as lower back pain?

Primary: Myeloma, Intra-abdominal disease
Metastatic disease: Breast, Prostate, Lung


What malignant cause of back pain do you suspect in a patient who presents with >60, back pain, weight loss + other abdominal symptom or new onset diabetes?

Pancreatic cancer


What malignancy might you suspect in a patient who presents as >60 with persistent back pain?

Multiple myeloma


What investigations would you do for a patient who you suspect has multiple myeloma?

Bloods; FBC, Calcium, Plasma viscosity/ESR


What investigation would you do for a patient with suspected pancreatic cancer as a cause of their back pain?

Urgent direct access CT


What are the nice guidelines on patients with cancer with back pain in whom you should act urgently (

Pain in the thoracic or cervical spine
Progressive lumbar spinal pain
Severe unremitting lower spinal pain
Spinal pain aggravated by straining (for example, at stool, or when coughing or sneezing)
Localised spinal tenderness
Nocturnal spinal pain preventing sleep


How does Ankylosing spondylitis typically present?

Young men
Gradual onset
Relieved by exercise
Morning stiffness


What are extra articular symptoms of Ankylosing spondylitis?

Uveitis: inflammation of uvea, pigmented layer between inner retina and outer fibrous layer of sclera and cornea
Enthesitis: inflammation of the entheses, sites where tendons or ligaments insert into bone


What might you see on an X-ray of an Ankylosing spondylitis spine?

Bamboo spine: vertebral body fusion by marginal syndesmophytes
Typically involves thoracolumbar and/or lumbosacral junctions and predisposes to unstable vertebral fractures
Outer fibres of annulus fibrosis of IV discs ossify which results in the formation of the syndesmophytes between adjoining vertebral bodies


What is inflammatory back pain?

Chronic back pain >3 months
Onset of symptoms before age 45 yrs
Back pain at night
Morning stiffness (>30 mins)
Improvement with exercise


When should you consider Ankylosing spondylitis as opposed to inflammatory back pain?

If several factors present together:
Inflammatory back pain
Alternating buttock pain
Response to NSAIDs
Onset of symptoms before age 45
Peripheral disease manifestations (arthritis, dactylitis, enthesitis)
Confirmed acute anterior uveitis
Positive family history
HLA-B27 positive
Sacroiliitis/spondylitis by imaging


What is cauda equina syndrome and what key symptoms would you ask a patient about?

Compression of nerve roots below level of spinal cord termination: caused by central disc prolapse, tumour
Weakness / numbness in legs
Bowel or bladder dysfunction
Saddle / perineal anaesthesia


What is the nice guidance on suspected cauda equina
compression in people with cancer?

Immediate referral metastatic spinal cord compression co-ordinator if: neurological symptoms including radicular pain,
any limb weakness, difficulty in walking, sensory loss or bladder or bowel dysfunction


Name some non spinal causes of low back pain

Abdominal aortic aneurysm
Pancreatitis / pancreatic cancer
Renal pain (stone/infection)
Peptic ulcer
Gynaecological disorders: fibroids


List some red flags which you want to ask about in a patient presenting with lower back pain

Age >50
Bladder dysfunction
Cancer history
Immune suppression
Rest/night pain
Saddle anaesthesia
Lower extremity neurological deficit
Weight loss
Recent infection


What is Lasègue's sign?

Straight leg raise: determine whether patient with low back pain has a herniated disk, often at L5
Patient experiences sciatic pain when straight leg raised between 30 and 70 degrees


What is Kernig test?

Thigh flexed at the hip, knee at 90 degrees
Subsequent extension in knee is painful and often resisted
May indicate sub arachnoid haemorrhage or meningitis


What is bragards test?

Used to determine whether a source of lower back pain is nervous or muscular
Straight leg raise is done, if positive, leg lowered just below point of pain and then ankle is dorsiflexed
If pain increases, pain is likely nervous in origin
If no increase in pain, source is likely muscular


When is imaging of spine needed for low back pain?

Investigation for specific cause of back pain: Metastatic Disease, Bloods may be more appropriate and easier to organise
When surgery is being considered: Suspected cauda equina compression - Immediate, Radicular pain that is not resolving, To identify those with operable lesions congruent with symptoms, Selected patients who might be considered for spinal fusion


What is non specific low back pain?

Tension, soreness and/or stiffness in lower back region for which it isn’t possible to identify a specific cause of the pain
Diagnosis is dependent on the clinician being satisfied that there is not a specific cause for their patient’s pain
May include referred pain in the upper leg


What different durations of back pain might present?

Acute: 3 months: Prevalent cases, Major health burden


Describe the management of acute low back pain

Exclude serious causes of back pain: Ask about micturition
Avoid bed rest
Encourage activity
Adequate analgesia: Paracetamol, NSAIDs, mild opioids, Muscle relaxants if indicated
Specific treatment not required: No evidence of effectiveness


What do you do to manage sub acute Radicular pain?

Consider imaging or surgical opinion: Test clinically for nerve root compression, Sensitive but not specific
Delayed surgery less likely to reduce any neurological deficit: Many still improve without surgery, Remember risks of surgery


Describe the care pathway for persistent low back pain which goes on for more than 12 months

GP advice and analgesia, if no improvement then choice of acupuncture, exercise or manual therapy
If continuing problems, try one or more further course of treatment
If continuing pain and disability, then combined physical and psychological therapy of 100 contact hours
If continuing pain and disability, consider surgical referral


What choice of physical therapies are available to treat back pain?

Acupuncture: up to a maximum of 10 sessions over a period of up to 12 weeks
Exercise: up to a maximum of eight sessions over a period of up to 12 weeks, aerobic activity, movement instruction, muscle strengthening, postural control, stretching
Manual Therapy: up to a maximum of nine sessions over a period of up to 12 weeks


What are problems with chronic non-specific low back pain?

90% of costs, Vast majority of health care usage
Unlikely to ever get better
Major impact on quality of life (DALYs)
Variable course
Treatment only modest benefit


What factors indicate a poor prognosis in a patient with chronic low back pain?

Widespread pain, severity, duration, previous episodes, anxiety and/or depression, higher somatic perceptions and/or distress, adverse coping strategies, low social support, older age, higher baseline disability, and greater movement restriction


What are Patient expectations for treatment of back pain?

Clear diagnosis
Pain relief
Physical examination
Confirmation that pain is real
Confidence based association: understanding, listening, respect, and shared decision making


What factors concern patients most at a pain clinic?

Spoiled identity: more important than pain or disability
Unmet expectations: GP don't take their pain seriously, appear not to care
Making sense of pain: doctors don't help them make sense of pain; just provide a medical interpretation
The future: acceptance / accommodation


Describe the fear avoidance model in regards to pain

Pain experience leads to fear of pain, which leads to avoidance of the activity, which then leads to disuse, disability and depression, this then exacerbates the pain experience
The way for patients to avoid this cycle is that they don't experience fear about their pain, so they confront it and therefore more likely to recover


What acute treatments are available for back pain?

Pain killers: Paracetamol, NSAIDs (Oral, Topical), Opioids (Weak, Strong)
Muscle relaxants (acute pain only): Benzodiazepines (diazepam)


What opioids can be used to treat back pain?

Weak opioids: Codeine, Dihydrocodeine
Strong opioids: Morphine, Buprenorphine, Tramadol (some consider to be weak), Oxycodone, Fentanyl (patches)


What are some problems with using strong opioids to treat back pain?

Addiction, sedation, depression, black market


Describe the use of antidepressants to treat back pain

Specific effect on chronic pain
Tricyclics – amitriptyline, nortriptyline
Best evidence for higher doses
Side effects: Sedation, constipation, dry mouth, blurred vision Duloxetine – pain specific evidence
Not Other SSRIs or SNRIs
May help depression – if present
Night time sedation may be helpful
Allow 4-6 weeks for effect
Back pain specific evidence base weak


What anti epileptic drugs can be used for back pain?

Gabapentin / pregabalin
Used widely for chronic pain
Back pain specific evidence very limited


What is osteopetrosis?

Congenital condition: failure of bone reabsorption
No differentiation between cortex and medulla, multiple cortical layers
Bones are brittle and prone to fracture
No room for marrow to grow so marrow failure, peripheral cytopenias
Bones expand and cause neural compression symptoms


What is osteogenesis imperfecta?

Congenital condition of brittle bones, susceptible to fractures due to mutation in type 1 collagen
Autosomal dominant
Blue sclera and neural deafness from bone overgrowth
X-rays show reduced bone density and cortical disorganisation


What are 4 common differentials for shoulder problems?

Frozen shoulder: Global restriction of all shoulder movements
Glenohumeral OA: Global restriction of all shoulder movements
Impingement syndrome+/- rotator cuff tear: Pain on overhead activities; weakness and inability to actively abduct shoulder
Instability: patients in teens or twenties with a hx shoulder dislocation


How can the location of shoulder pain help you to decide what the problem is?

Frozen shoulder and OA painis mainly anterior: over glenohumeral joint
Impingement and cuff tear pain usually laterally in subacromial region or on lateral aspect of the arm


What are the components of a shoulder examination?

Look: Swelling/wasting/scars/sinuses
Feel: mass/crepitus/Temperature/ Tenderness over the SC joint, clavicle, AC joint, spine of scapula, subacromial space, glenohumeral joint
Move: Active then passive
Special Tests: specific to the findings from the history, neers test for shoulder impingement (passively forward flex shoulder, pain in anterior shoulder), Hawkins Kennedy test


What is the lightbulb sign on an AP radiograph of a shoulder?

Posterior glenohumeral joint dislocation


What is the mechanism for a posterior glenohumeral joint dislocation?

Axial loading of the adducted internally rotated arm
Forward fall on the point of the elbow
Seizure could cause sudden contraction of the internal rotators of the shoulder which can cause a posterior dislocation


What injuries are associated with posterior glenohumeral joint dislocation?

Glenoid rim fracture
Labral tear
Compression fracture of humeral head


What is perthes disease?

Childhood hip disorder initiated by a disruption of blood flow to the femoral head
Osteonecrosis or avascular necrosis occurs and the bone stops growing


What is slipped capital femoral epiphysis?

Fracture through growth plate which results in slippage of the overlying end of the femur
The epiphysis remains in the acetabulum while the metaphysis moves in an anterior direction with external rotation
Usually causes groin pain and a painful limp
Occurs in obese adolescent males


Which muscles form the rotator cuff?

Teres minor


What is a drop arm test?

Abduct patients arm to 90 degrees then ask them to lower it slowly. Positive test- arm will drop
Test for supraspinatus damage


Which muscles form the rotator cuff?

Teres minor


What is a drop arm test?

Abduct patients arm to 90 degrees then ask them to lower it slowly. Positive test- arm will drop
Test for supraspinatus damage


What are nice guidelines on arthroplasty in patients with NOF fractures?

Total hip replacements should be given to patients who are:
able to walk independently out doors with no more than the use of a stick
Not cognitively impaired
Fit for anaesthesia
If they are less fit a hemiarthroplasty is performed


How are extracapsular hip fractures managed?

Internal fixation, usually with a dynamic hip screw


How do you test supraspinatus?

Ask patient to elevate the arm at 30 deg of abduction, while the
examiner resists it by downward pressure
If there is a tear in the supraspinatus, the patient will not be able to elevate the arm


How do you test infraspinatus?

Ask patient to externally rotate the shoulder with elbows at 90 deg. The examiner resists it
If there is a tear, the patient will be weak compared to the opposite side


How do you test subscapularis?

Ask the patient to push backwards against resistance with arm behind back
If there is a tear this would be weak compared to the other side


What clinical features and examination finding differences would there be between OA and frozen shoulder?

Frozen shoulder and OA both have global restriction of all
Crepitus may be present in OA but not in frozen shoulder
Radiographs are normal in frozen shoulder not in OA


What examination findings might make you suspect impingement syndrome / rotator cuff tear?

Pain on overhead activities; sometimes weakness and
inability to actively abduct the shoulder


In an elbow examination, what are you feeling for?

Tenderness over lateral,medial epicondyles
Relation between the 2 epicondyles and olecranon tip
Soft spot over radial head: Palpate radial head by rotating forearm


What findings on elbow examination would you expect in a patient with olecranon bursitis?

Swelling and inflammation superficial to the elbow joint
Usually full range of movement


What findings would you expect on elbow examination of a patient with tennis elbow?

Degenerate tear in the origin of extensor carpi radialis brevis
Tenderness just anterior to lateral epicondyle
Pain on resisted extension


What findings would you expect to find on elbow examination of a patient with golfers elbow?

Medial epicondylitis: Degenerate tear over the common flexor origin
Pain on resisted wrist flexion


What would you expect to find on elbow examination of a patient with OA?



What findings would you expect on elbow examination of a patient with cubital tunnel syndrome? How would you diagnose this condition?

Compression of ulnar nerve behind the medial epicondyle
Pain worse on elbow flexion
Diagnosis based on ulnar nerve examination (neurological) and nerve conduction studies


What characteristics would make you suspect articular vs periarticular joint problems?

Articular: joint line tenderness, Pain at the end of range of movement in all planes, Crepitus, Active and passive movement equal
Periarticular: point tenderness over involved structure, pain exacerbated by movement or stress, active movement more than passive


What characteristics make you think of inflammatory vs non inflammatory joint problems?

Inflammatory: morning stiffness >15 mins, relieved by activity, warmth, redness, swelling/bogginess
Non inflammatory: worse at end of day, relieved by rest, crepitus, restricted movement


Give an example of an asymmetrical polyarthritis

Psoriatic arthritis


What aspects of a history would you want to know to look at joint problems?

Previous episodes
Locking or giving way
Systemic features: fever, night sweats, lymphadenopathy, weight loss, anorexia, malaise
Extra articular features: skin, nails, mucous membranes, eyes, heart, lungs, abdo organs
Medication: steroids, diuretics, COCP/HRT
Psychosocial: stress, disability


What are some reg flags to look out for with joint problems?

One hot, red, intensely painful joint, limitation of movement, systemic illness: septic arthritis
Rapid onset swelling after trauma: haemarthrosis, fracture
Sever pain at rest/night: malignancy
Systemic symptoms, fever, weight loss: inflammatory arthritis, malignancy
Children with a limp: fracture, septic arthritis, SUFE, perthes


What is SUFE?

Slipped upper femoral epiphysis


What is perthes disease?

AVN of femoral head in childhood


What are some differentials for an acute mono arthritis?

Septic arthritis
Inflammatory arthritis


What are some differentials for polyarthritis?

Viral arthritis
Psoriatic arthritis
Seronegative spondyloarthritis
Chronic gout
Polymyalgia rheumatica
Systemic sclerosis


What crystals are present in gout and pseudogout?

Gout: urate
Pseudogout: calcium pyrophosphate


How does gout present?

1st MTP, feet or ankles
Obese patients
On diuretics
More in males


Which joints are usually affected by pseudogout?



What investigations would you do for gout?

U and Es
Serum urate
Microscopy of synovial fluid: pseudo gout - positively birefringent rhomboid crystals, gout - negative needle shaped


What is management for gout?

Analgesia - NSAIDs, colchicine
Weight loss
Avoid alcohol and purine rich foods (red meat, marmite, mussels)
Avoid thiazide diuretics
Consider prophylaxis - allopurinol (not in acute attack)


What are risk factors for OA?

Abnormal joint loading - previous fracture or instability
Poor muscle function


Describe the pathophysiology of OA

Surface cracks in cartilage, bone exposed
Becomes burnished - eburnation
Bone and cartilage fragments in joint cavity
Osteophytes form
Alteration in composition of cartilage: reduce proteoglycans and collagen, increase water, chondrocyte hypertrophy
Alteration of mechanical properties
Reduced shock absorption


Describe the clinical presentation of OA

Joint pain, stiffness
Muscle weakness and wasting
Reduced function
Hips, knees, base of thumb, DIPs (heberdens nodes)


What investigations would you do for OA?

Consider bloods to exclude inflammatory causes: FBC, ESR
X-ray: loss of joint space, osteophytes, subchondral cysts, subchondral sclerosis


What is the management for OA?

Education and advice
Weight reduction
Exercise and muscle strengthening
Aspiration of effusion and joint injections
Joint replacement


What is the pathophysiology of RA?

Genetic predisposition and immunological trigger
T cell mediated immune response
RF antigen/IgG interaction
Compliment fixation
Inflammatory response
Recruitment of inflammatory cells with release of enzymes and prostaglandins
Angiogenesis in synovium and proliferation, pannus invasion
Destruction of articular cartilage and underlying bone


What is the clinical presentation of RA?

Symmetrical peripheral polyarthritis
Joint pain
Early morning stiffness
Joint destruction and deformity: ulnar deviation, z deformity, swan neck, boutonnière, subluxation, claw toes, cervical spine pain
Extra articular features: episcleritis, scleritis, effusions, fibrosis, nodules, vasculitis, rashes, weight loss, fever, fatigue


What investigations might be done for RA?

Anti CCP antibodies
X-ray: soft tissue swelling, loss of joint space, erosions, joint destruction


What is management for RA?

Refer to rheumatology
Urgent referral if: small joints, >1 joint, delay of >3 months between onset and presentation
Physical exercise/OT/physio
Monoclonal antibodies/ anti TNFa
Surgery: nerve decompression, tendon repair, joint replacement
Spinal fusion


What is the embryological origin of the appendicular skeleton?

Neural crest mesenchyme


What are the components of the thenar compartment of the hand?

Abductor Pollicis brevis
Flexor Pollicis brevis
Opponens Pollicis


What is a compound fracture?

Wound through adjacent or overlying soft tissues communicates with site of break


What factors may influence haemarthrosis development?

Bleeding disorders
Neurological deficits: charcots joint
Intra articular neoplasms
Vascular abnormality: haemangioma, AV malformation, aneurysm, synovial vascular structural abnormality


What are risk factors for spinal stenosis?

Age >40
Previous back surgery
Previous injury


What are risk factors for osteoporotic spinal compression fracture?

Older age (>50 women, >65 men)
Previous vertebral compression fracture
Low body weight
Recent weight loss
Fhx osteoporosis
White or Asian
Post menopausal
Secondary amenorrhoea
Corticosteroid use
Glucocorticoid excess
Vit d deficiency
Low calcium


What are the 5 causes of spondylolisthesis?

Dysplastic: birth defect
Isthmic: Repetitive spine trauma, gymnasts and weight lifters
Degenerative: joints become arthritic
Traumatic: Sudden injury or trauma
Pathologic: tumour or other abnormality


What are possible complications of a scaphoid fracture?

Avascular necrosis
Non Union


What are risk factors for hip fracture?

Age over 65
Female sex
High energy trauma


What are the Ottawa knee rules?

Decide if patient needs X-ray if any of following are present
Age over 55
Tenderness over fibular head
Discomfort confined to patella on palpation
Inability to flex knee to 90 degrees
Inability to bear weight for at least 4 steps