Back and Lower Extremity Flashcards
How does a fracture present?
After injury
Pain and swelling
Decreased range of motion
Deformity
What is the diagnostic test for fracture?
X ray
When is MRI vs x ray in musculoskeletal problems
MRI for ligaments and soft tissue
X ray for bones
Open fracture treatment
ORIF - open reduction internal fixation (with plates and pins)
Surgical debridement
Prophylactic IV antibiotics - cephalosporins such as cefazolin or cefuroxime
Tetanus vaccine
Closed fracture treatment
Non surgically with immobilisation (casts)
What is a green stick fracture and when does it happen ?
Common in children and infancy - soft bone bends without breaking fully
What is subluxation
Partial dislocation
How does pt present with subluxation
After injury with deformed joint and typical posturing
Investigations for dislocation / subluxation
X ray - confirm no concurrent fractures
Treatment for dislocation
Reduction and stabilisations
CHECK NEUROVASCULAR (pulses and sensation) STATUS BEFORE AND AFTER to see if symptoms are due to treatment or injury
What is a femoral neck fracture
Hip fracture
Typical presentation of femoral neck fracture
In elderly women with osteoporosis
Minimal injury
Pain in groin
Unable to bear weight
Shortened leg
Externally rotated and abducted
Investigation and treatment for femoral neck fracture
Ix - X ray
Tx - total hip replacement
Hip dislocation typical presentation
Usually posterior (dashboard injury)
MAJOR injury - high impact or trauma
Any age
Pain
Inability to bear weight
Deformity
Shorter leg
Ix and Tx for hip dislocation
Ix - x ray
Tx - reduction and stabilisation
Define bursitis
Acute of chronic inflammation of bursa (sac containing synovial fluid)
How does bursitis present
Localised tenderness in bursa
Decreased range of motion of joint due to swelling
SIGNIFICANT SWELLING
Diagnosis and treatment for bursitis
Diagnosis - clinical
Treatment - conservative management and analgesia is 1st line
Intra articulate steroid injection (only if 1st line doesn’t work
How do you determine if presentation is bursitis and not cellulitis or elbow fracture
Elbow fracture - history of injury
Cellulitis - infection of skin so should look red hot and inflamed
Bursitis is just swelling - no skin changes or injury
Typical presentation of osteoarthritis
Decreased ROM and function
joint crepitus (joint cracking on movement)
effusion
muscle weakness and wasting around joint due to less usage
JOINT PAIN WITHOUT STIFFNESS - pain increases with activity and stops with rest
No swelling or redness
Affects one or more weight bearing joints (hip, knee, wrist, spine)
Common osteoarthritis findings
NON inflammatory condition for ESR and CRP normal
Heberden’s nodes (DIP) - osteophytes on distal interphalangeal joints)
Bouchard’s nodes (PIP) - osteophytes on proximal interphalangeal joints
Diagnosed via X - Ray
- loss of joint space (due to cartilage loss)
- subchondral sclerosis (bright white showing bone damage)
- osteophytes (new bony formation)
Osteoarthritis management and treatment plan
Weight reduction (joints are weight bearing)
Low impact exercise and improve muscle strength
Analgesia - NSAIDs and PPI for gastric protection (long term omeprazole increases osteoporosis risk not osteoarthritis - bones not cartilage)
Tramadol if NSAIDs contraindication
Physiotherapist
Steroid (cortisone) joint injection in extreme cases
Orthopaedic surgery for joint replacement - last resort
List serious red flags for back pain
Significant trauma related to age or condition (e.g heavy lifting with osteoporosis)
Major or progressive motor/sensory deficit
Bowel or bladder incontinence
Urinary retention
Loss of anal sphincter tone
Saddle anaesthesia
History of cancer metastatic to bone
Suspected spinal infection (fever + any of above symptoms)
Treatment for mechanical back pain
Eliminate red flags
Pt education, NSAIDs, paracetamol, muscle relaxant
Avoid bed rest
How can you tell back pain is mechanical
Morning stiffness lasts less than 15 mins
Pain worsens with activities
Onset - injury
Fluctuating symptoms
Overuse is risk factor
How can you tell back pain is inflammatory
Morning stiffness lasts longer than an hour
Pain gets better with movement - throughout day
Onset - insidious lasting years
Progressive - symptoms don’t fluctuate
Usually young pts
What is ankylosing spondylitis
Chronic INFLAMMATORY joint disease of spine (causes vertebrae to fuse over time)
Who is ankylosing spondylitis more common in
Male Caucasians in mid twenties onwards
How does ankylosing spondylitis classically present + findings
Mid twenties Caucasian man
Insidious onset of back pain
Morning stiffness - inflammatory so over an hour
Family history (there is a genetic component)
Pain relieved by exercise
On X ray - bamboo spine
Cartilaginous joints so spine and sacroilium
Disease of synovial fluid similar to RA
Ankylosing spondylitis treatment
NSAIDs first line
Steroid injections
If other joint problems as well - DMARDs (disease modifying anti rheumatic drugs) - immunosuppressant - e.g. methotrexate
What is Cauda equina
Compression of spinal nerves L1 - S5
How does Cauda equina present
Saddle anaesthesia or paraesthesia
Recent onset of bladder dysfunction (retention)
Recent onset of faecal incontinence - laxity of anal sphincter
Severe or progressive neurological deficit in lower extremity
Cauda equina management
MRI and immediate decompression
What is herniated nucleus pulposus
Pain in leg due to compression of nerves in spine e.g. herniated disc
How does herniated nucleus pulposus present
Unilateral leg pain worse than low back pain - WORSENS WHEN SITTING DOWN
Pain radiation
Numbness and paraesthesia
Motor, sensory or reflex change
Limited to one nerve root
Symptoms vary depending on which disc is herniated (L1-L3 back pain radiates to hip or anterior thigh, L4-S1 pain radiates to below the knee to foot/toes)
What is spinal stenosis
Narrowing of spinal canal or neural foramina which can lead to root compression or ischaemia of spinal cord
How does spinal stenosis present
Insidious back pain
50-60 years old
Paraesthesia with ambulation but relieves when lying supine
Lower extremity numbness and pain
Leg pain - worse than back pain - RELIEVED BY LEANING FORWARDS AND WORSENS WITH STANDING OR WALKING
Pain will be unilateral is foraminal stenosis, bilateral is central or bilateral foraminal stenosis)
Normal pulse
Differential diagnoses for spinal stenosis prevention
Peripheral vascular disease
Neuropathy
What is the treatment for scoliosis
Depends on degree of scoliosis (lateral curvature)
<20 degrees - exercise and monitoring
21-45 - bracing
>45 - surgery
What is a vascular necrosis of hip (AVN)
Loss of blood supply to the femoral head causes death of bone (osteonecrosis)
Symptoms for AVN - avascular necrosis of hip
Groin pain with radiation into leg
Pain despite analgesia
Management and treatment for AVN - avascular necrosis of hips
MRI scan of hip then refer to orthopaedics is pain lasts longer than 6 weeks with normal radiographs
Total hip replacement
Risk factors of AVN - avascular necrosis
Alcoholism, use of steroids, chemotherapy and immunosuppressant medication, sickle cell anaemia
How to differentiate between SCFE (slipped capital femoral epiphysis) and LCP (legg calve perthes)
SCFE
adolescents (10-17)
Overweight children
Displacement of femoral neck
Operative treatment
LCP
Aged 4-8
Shorter children
Deformity of femoral head
Conservative treatment
What is SCFE - slipped capital femoral epiphysis
Hip disorder when upper femoral epiphysis is displaced - slipped through growth plate (epiphysis if between head and neck of bone) so the femoral epiphysis stays in hip socket whereas metal shy sis (end of femur) moves in anterior direction
Symptoms and presentation of SCFE - slipped capital femoral epiphysis
Adolescent boys (10-17) that are obese (may also have hypogonadism) presents with limp with leg externally rotated, knee pain, groin pain and ROM on exam
20-60% cases bilateral
How is SCFE - slipped capital femoral epiphysis diagnosed and treated
AP X-rays of bilateral hips and frog leg lateral
Treatment - surgical fixation with screws - bilateral side may be done prophylactically
What is legg calve perthes
Self limiting disease of femoral head comprising of necrosis, collapse, repairs and re-modelling
Why does LCP happen in young boys?
Disease affects bones in growing phase so only affects children
What is the typical presentation of legg calve perthes
Boys aged 4-8
Hypercoagulability
PAINLESS LIMP (gluteal medius lurch) - worsens with activity
Hip pain after activity
Pain relieved with rest
ROM
What is developmental hip dysplasia
Spectrum of conditions affecting proximal femur and acetabulum e.g acetabular immaturity, hip subluxation and frank hip dislocation
How is developmental hip dysplasia diagnosed and who is at higher risk
DIAGNOSED IN BABIES
- usually first born girls, breech babies, oligohydramnios (reduced amniotic fluid), family history
Ortolani and Barlow tests before 6 months age or ultrasound
Older than 6 months - X-ray
What is the treatment for developmental hip dysplasia and what happens if not diagnosed and treated
Treatment - observe and consider splinting , if hip dislocates then reduce and splint
If not diagnosed children may have delayed walking or crawling or can toe walk unilaterally
What is trochanteric bursitis
Localised pinpoint tenderness on outside of hip - not much in groin
What are the examination findings, how to diagnose and what is the treatment for trochanteric bursitis
Pain on flexion extension, rotation and abduction
Pain down thigh
No classical swelling like other bursitis
Localised pin point tenderness on outside of hip - not in groin
No investigations needed - clinical diagnosis
Treatment - exercises or steroid injection into bursa
What is chondromalacia patella
Runners knee - loss of cartilage under patella
What is patellofemoral pain syndrome
Broad term to describe pain in and around patella - can be caused by chondromalacia patella
How does chondromalacia patella present and investigation findings
Deep bending aggravates pain in knee
Hyper mobile patella with significant crepitus
X-rays of skyline view show bone on bone patella and femur
What is meniscus in knee
Medial and lateral menisci - cushions between femur and tibia on inside and outside of knee
How does meniscus tear present
Usually starts due to twisting injury whilst weight bearing
Torn fragment can trap in joint and cause TRANSIENT LOCKING AND CATCHING causing SEVERE knee pain
Above will cause effusion
What are the tests for meniscus injuries
MRI (views tissues better)
Special tests - McMurray (painful so less common) and Apley (also not used clinically as symptoms can be aggravated)
How does a cruciate tear present
Loss of anterior and posterior stability
Swollen knee (blood stained effusion within 30 mins of injury)
Painful
Weight bearing difficulty
Knee may give way
Usually on injury - may feel pop up during injury
Knee feels unstable
What are the special tests for cruciate ligament injuries
Positive anterior drawer test
Positive Lachman tests
Positive posterior draw
How do you differentiate between anterior and posterior cruciate tear
Anterior cruciate tear usually after blow to back of knee combined with rotation with foot fixed to ground
Use anterior drawer test when testing for ACL injury
Posterior cruciate tear follows anterior force such as dashboard of car after car accident
Use posterior drawer test when testing for PCL injury
Diagnosis and treatment for ACL/PCL injury
MRI
Treatment - conservative unless pt active e.g. athlete
Conservative management - PRICEM, bracing, physio
PRICEM - protect, rest, ice, compression, elevation, movement
What is osgood schlatter
One disease under umbrella term of osteochondritis
Tibial tuberosity apophysitis
Result of excessive muscle pull on growing bone
How does osgood schlatter present
Growing teenager especially 10-14 yrs
Active children e.g.footballer
Pain and swelling directly over tibial tuberculosis
Point tenderness on examination
Pain aggravated by loaded knee extension - increased symptoms with walking or using stairs
Osgood schlatter treatment
Modify exercises, physio and NSAIDs
Sx should resolve but may recur until skeletal maturity
Ankle fracture presentation, diagnosis and treatment
Presentation - Recent trauma with ankle pain and swelling
Can’t weight bear
Diagnosis - Ottawa ankle rules (no details needed) , x-ray
Treatment - if open - surgical fixation, if closed - reduce and splint
How does ankle sprain/strain present and how do you diagnose
Swelling and bruising
Pain after injury
Diagnosing - no fracture on X ray and Ottawa rules don’t apply, do MRI or US to see soft tissues
What is the difference between sprain and strain
Sprain - injury to ligament
Strain - injury to tendon
Achilles tendon injury presentation
Injury - a gap may be seen near to injury time
Feels like been struck above heel
Cannot tiptoe
Pt may be able to walk
Partial rupture more painful than complete
What is the Achilles tendon test
Simmons test aka Thomson’s test
Squeeze call - if ruptured, foot doesn’t move, if not, foot will flex
Typical presentation of plantar fasciitis
40-60 yrs
Runners
Obese
Heel pain and stabbing pain on bottom of foot especially first few steps in the morning, pain relieved by rest and worse when walking barefoot
Diagnosis and treatment of plantar fasciitis
Clinical diagnosis
Treatment - heel padding, insoles, exercises, physio therapy and NSAIDs
How does motor’s neuroma present
Pain between 3rd and 4th toe - feels like walking on a marble
More common in woman
Diagnosing Morton’s neuroma
Pain when squeezing toes from sides
Palpate web space - mulder sign - mulder click positive
What is charcot’s joint
Change in foot shape due to weakening / fracturing of the bones in the foot due to severe neuropathy (diabetes or peripheral vascular disease)
How does Charcot’s joint present
Rocker foot deformity
Swelling, pain, redness and altered shape
