Block 12 Week 2 Flashcards
Fractures and Soft Tissue Injuries
A careful history and physical examination predict radiographic findings with a high degree of accuracy.
Before Discharge:
- check pt for safe mobility
- pt should receive explicit aftercare instructions
Multiple trauma:
- non critical orthopaedic injuries should be diagnosed and treated only after other more threatening injuries have been addressed
Terms used to describe fracture
Clinically how fracture presents:
- history of loss of function
- pain tenderness
- swelling
- abnormal motion
- deformity
We confirm a fracture with a radiograph study
At times we use CT (computed tomography), MRI (magnetic resonance imaging)
Open vs closed fracture
- We can use the terms open or closed. Less desirable terms are simple or compound
- Open fracture: fracture is exposed to the outside environment in any manner
- This exposure may be as obscure as a puncture wound or as gross as splintered bone protruding through the skin.
- It is sometimes difficult to determine whether a small wound in proximity to a fracture actually communicates with that fracture
Anatomical Location
Anatomical Location:
- name of bone
- left or right
-standard reference notes along the bone eg. surgical neck of the humerus
- direction of the fracture line
- Position and Alignment of fracture:
Any deviation from normal is termed displacement.
Displacement may be described in a quantitive measurement in mm or as a percentage of the bone width. - By convention, the position of the distal fragment is described relative to the proximal
Angulation - deviation from normal alignment
Avulsion - fracture refers to a bone fragment that is pulled away from its normal position by either the forceful contraction of a muscle or the resistance of a ligament to a force in the opposite direction
Impaction: refers to forceful collapse of one fragment of bone into or onto another.
Pathological trauma
- fracture which occurs through abnormal bone
- when the fracture occurs through trivial trauma.
Diseases which cause structural weakness predisposing to injury:
- primary or metastatic malignancies
- cysts
- osteomalacia
- osteogenesis imperfecta
- scurvy
- rickets
- pagets disease of the bone
Fractures through osteoporotic bone of the elderly usually are not described as pathologic.
When fractures occur in normal bones and history of trivial trauma is elicited, violence or battering should be suspected
Stress / Fatigue fracture
Repeated low intensity forces may lead to resorption of normal bone resulting in a stress fracture. Other names for this condition are fatigue fracture and March fracture.
Stress fractures are usually very difficult to visualise on plain X-rays.
These fractures are usually picked upon X-rays taken a week or two later or when CT scan or MRI are used to investigate the injuries
FATIGUE FRACTURE: Fatigue fractures (also known as overuse fractures) are a type of stress fracture due to abnormal stresses on normal bone.
INSUFFICIENCY FRACTURE: which occurs due to normal stresses on abnormal bone.
Pathalogy: Accumulation of micro-injuries/microfractures (plastic irreversible deformations) of the normal bone reaching the failing point in which their accumulation exceeds the repair pace/capacity of the bone, hence the gross failure and traumatic fracture ensue. In other words, injury happens faster than healing.
pelvis and lower limb (most common)
Eponym fracture names
Boxer’s
Chauffeur’s
Dashboard
Colles’
Hangman’s
Jones’
Le Fort
Pott’s
Salter-Harris,
Smith’s
BOXERS
A boxer’s fracture is a break in the neck of the 5th metacarpal bone in the hand
CHAUFFERS FRACTURE
A chauffeur fracture occurs when the pointed tip at the end of your radius (radial styloid process) breaks. A chauffeur fracture is a type of distal radius fracture, which means the break is at the end of the radius bone.
DASHBOARD FRACTURE
The name dashboard fracture refers to a fracture which typically occurs in automobile accidents with impaction of the knee upon the dashboard. This results in fracture of the posterior rim of the acetabulum by the femoral head.
COLLES FRACTURE
A Colles fracture is a break in the radius close to the wrist. It was named for the surgeon who first described it. Typically, the break is located about an inch (2.5 centimeters) below where the bone joins the wrist.
A Colles fracture is a common fracture that happens more often in women than men.
HANGMANS FRACTURE
- A hangman’s fracture is the result of hyperextension of the upper cervical spine. In typical hangman’s fracture the pedicles of the axis (C2) break symmetrically.
JONES FRACTURE
A Jones fracture is a fracture of the bone on the pinky toe side of your foot, the fifth metatarsal bone. This fracture can happen when you increase your training, increase pressure on your feet from gaining weight, or run on uneven surfaces.
LE FORTS FRACTURE
The term LeFort fractures is applied to transverse fractures of the midface
POTTS FRACTURE
A Pott’s fracture is a type of ankle fracture, characterized by a break in the lateral or medial malleolus, one of the bony protrusions on the sides of the ankle. Sometimes both of these bones can break at the same time, usually as the result of a severe ankle sprain.
SALTER HARRIS FRACTURE
What is a Salter-Harris fracture?
A Salter-Harris fracture is a fracture in the growth plate of a child’s bone. A growth plate is a layer of growing tissue close to the ends of a child’s bone. It’s very important to get this condition diagnosed since it can affect a child’s growth.
SMITHS FRACTURE
A Smith fracture is a fracture of the distal radius featuring volar displacement or angulation. It typically results from a fall on the dorsum of the hand with a flexed wrist
Fracture healing
- The process of fracture to union begins with a hematoma - caused by rupture of vessels crossing the fracture line
- The hematoma bridges the fragments and is followed by an inflammatory phase when granulation tissue forms on the fracture surfaces.
- Resorption of the hematoma provides the first continuity between the fragments; however, this procallus provides no structural rigidity for bearing stress
- With remodelling, callus subsequently is formed on the periosteal and endosteal surfaces of the bone acting as a biologic splint. This area first becomes mineralised by deposition of calcium phosphate and then under goes osseous metaplasia.
- Callus is resorbed as the original fracture surfaces develop firm bony union. In some bones such as the skull and the neck of the femur where periosteum is deficient, there maybe virtually no callus formation.
Abnormal Union
Delayed Union - is a union that takes longer than usual for a particular fracture location
Malunion - occurs when a residual deformity exists.
A malunion occurs when a fractured bone heals in an abnormal position, which can lead to impaired function of the bone or limb and make it look like it is ‘bent’ (pic malunion).
Nonunion - is a failure of a fracture to unite. The most agreed-upon standard definition of nonunion made by the FDA is a fracture that persists for a minimum of nine months without signs of healing for three months.
Pseudarthrosis - when nonunion results in a false joint it is termed pseudarthrosis
Causes of Pseudoarthrosis
- Moving too soon after surgery before bones have fused
- Medical Conditions
- Congenital conditions
- Surgical technique
Fractures in Children
- Bones of children are soft and resilient and sustain numerous incomplete fractures
- GREENSTICK fractures: incomplete angulated fractures of long bones
- TORUS fracture: incomplete fracture characterized by wrinkling or buckling of the cortex
Torus Fracture (Distal radius buckle fracture)
This fracture is a common injury in children.
It is often caused from falling on the hand.
This fracture causes one side of the bone to bend, but does not actually break through the entire bone.
is an incomplete fracture that normally heals within one month.
SALTER HARRIS CLASSIFICATION
- Used to describe physeal (epiphyseal) fractures
Greenstick Fratcures
Greenstick fracture is a mild bone fracture commonly seen in young children.
This kind of fracture is characterized by a crack or break on one side of a long bone in the arm or leg that does not extend all the way through the bone. The bone fracture occurs the same way you would bend a green branch of tree.
Fractures in children
TYPE 1: injuries involve only a slip of the zone of provisional classification
TYPE 2: injuries are similar to type one injuries with a fracture extending into the metaphysis
TYPE 3: are composed of a slip of a growth plate plus a fracture through the epiphyses involving the articular surface
TYPE 4: are similar to type 3 fractures with additional involvement of a metaphysical fracture
TYPE 5: fractures are crushing injuries of the epiphyseal plate usually produced by a compressive force
Diagnostic Modalities - Plain X-rays
- The most common way to diagnose (confirm or exclude) fractures is to use X-rays. Other pathological conditions can be identified e.g. penetrating trauma, foreign bodies, air and gas may also be detected.
- Atleast two views perpendicular to each other are mandatory in examining long bones and an oblique view is also usually obtained. If doubt still exists the clinician should ask for more views in various degrees of obliquity to the other films
- A fracture line is most visible when it is parallel to the X Ray beam, and is invisible when it is exactly 90o to the beam. The clinician should never accept a study that examines the bone in only one plane
- When a long bone is found to be fractured, it is imperative that the bone be viewed radiographically in its entire length.
- In unstable patients in whom the risk of moving the patient does not outweigh the benefit of the more detailed study, a portable film is acceptable.
-Even with good techniques some fractures are not visible initially and do not appear until the margins of the fracture absorb. Absorption widens the radiolucent line and a defect appears in 7 to 10 days . If a fracture is suggested but not visible at the initial visit, the injury should be treated as a fracture and re-examined clinically and radiographically in 7 to 10 days
DIAGNOSTIC M: RADIONUCLEOTIDE BONE SCANNING
- Radionucleotide bone scanning is helpful to detect stress fractures, occult fractures and certain other bone lesions
- A radionuclide scan is an imaging technique that uses a small dose of a radioactive chemical (isotope) called a tracer that can detect cancer, trauma, infection or other disorders.
DIAGNOSTIC M: COMPUTED TOMOGRAPHY
- CT is used to confirm possible fractures or to define better displacements, alignment, fragmentation or fracture
Diagnostic M: Magnetic Resonance Imaging (MRI)
- MRI is the most advanced non-invasive examination of orthopedic structures
Complication of fractures
- Infection such as OSTEOMYELITIS (inflammation of bone marrow), SEPTIC ARTHRITIS. The risk is associated more with open fractures. You can reduce the risk of infection using vigorous irrigation and debridement of the wound and the use of antibiotics if needed.
What causes osteomyelitis?
Osteomyelitis occurs when bacteria from nearby infected tissue or an open wound circulate in your blood and settle in bone, where they multiply. Staphylococcus aureus bacteria (staph infection) typically cause osteomyelitis.
- Hemorrhage: the skeleton has a rich blood supply so you can lose a large amount of blood, shock, and death from exsanguination. The risk is greater in certain pelvic fractures or fractures of the shaft of the femur.
- Vascular Injuries: for example popliteal artery injury in knee injuries.
- Nerve Injuries: nerves can be injured by blunt or penetrating trauma
SEPTIC ARTHRITIS
Septic arthritis is an infection in the joint (synovial) fluid and joint tissues. It occurs more often in children than in adults. The infection usually reaches the joints through the bloodstream
SYMPOTMS:
-Fever
-Joint pain
-Joint swelling
Nerve Injuries
Neuropraxia (bruised nerve): is a contusion of a nerve with disruption of the ability to transmit impulses; normal function usually returns in weeks to months. The most mild injury to a peripheral nerve
Axonotmesis: is a more severe crush injury to a nerve. The injury to nerve fibres occurs within their sheets. Spontaneous healing is possible but slow. Anatomical interruption of the axon with no or only partial interruption of the connective tissue framework. T
Neurotmesis: is the severing of a nerve usually requiring a surgical repair. When the nerve is completely severed, all functions are absent including superficial sensation to touch, pain, and temperature; deep sensation to muscle and joint movements, position, deep pressure ,and vibration; motor supply and deep tendon reflexes ;and response to electrical stimulation
- For less severe injuries any subjective changes in sensation should be noted. Light touch is a good screening test. Two point discrimination is a more sensitive examinations and should be used routinely in evaluating digital nerves.
Compartment Syndrome
- Compartment syndrome is a serious acute emergency complication that should be considered whenever pain and paraesthesia occur in an extremity after a fracture within an enclosed osseofascial space.
- The immediate threat is to the viability of nerve and muscle tissue within the involved compartment but infection, gangrene, myoglobinuria and renal failure also may ensue.
- Compartment syndrome can occur with soft tissue trauma alone and even with open fractures.
Presentation:
- In a conscious patients, pain that is disproportionate to the injury or physical findings is a hallmark finding in the compartment syndrome.
- Pain often is characterised as deep burning and unrelenting and is difficult to localise.
-Pain on passive stretching of the muscle groups in their suggestive compartment is an important finding.
-Pallor and loss of pulses are late and ominous signs.
Complete fasciotomy is the only treatment that can reliably normalise elevated compartment pressure and this should be carried out as quickly as possible
Compartment Syndrome
- You can get compartment syndrome in any muscle, but it most often affects the muscles in the lower legs and forearms.
Symptoms:
- pain in a muscle – this may feel like a burning pain or a deep ache (moving the body part can make the pain even worse)
- swelling or bulging of the muscle
-numbness, weakness or pins and needles
- tightness or difficulty moving the affected body part
Two types:
- Sudden (acute) compartment syndrome.
This is when compartment syndrome happens suddenly you’ll need surgery as soon as possible to relieve the pressure in the muscle.
This type of surgery is called FASCIOTOMY. During a fasciotomy, the surgeon makes cuts around the muscle to relieve the pressure.
Gradual (chronic) compartment syndrome:
- develops gradually, surgery is not required. You can avoid the activity that causes the symptoms to reduce symptoms eg switch from running to low impact exercises.
COMPARTMENT SYNDROME
- Compartment refers to separate sections of the body that contain muscles, nerves, and blood vessels surrounded by a layer of fibrous connective tissue, called fascia.
- When the pressure within these compartments rises, normal blood flow can be cut off, leading to tissue damage due to hypoxia, or the lack of oxygen.
- The first ones to feel the effect of compression are the veins, because the pressure inside their lumen is normally low.
- As the pressure increases, the arteries will become compressed next and this obstructs the normal blood flow.
-This cuts off the oxygen supply and hypoxia develops, which causes cells to start releasing substances like histamine and nitric oxide.
- These substances cause capillaries to become leaky so fluid leaks out, causing extracellular edema that further increase intra-compartment pressure
Muscles:
- Hypoxia prevent their mitochondria from producing adenosine triphosphate, or ATP, which is the cell’s main source of energy.
- So without ATP, there’s an increase of intracellular sodium levels which cause water to move into the cells causing intracellular edema.
CAUSES
- most common cause is bleeding after injury
-This typically occurs with long bone fracture, like the tibia or the forearm bones, and penetrating wounds or surgical procedures that injure blood vessels.
- Other causes are swelling of the tissue after severe burns, intravenous drug injection, repetitive use of the injured muscles, or a vigorous muscle contractions like in a tetany or seizures.
- Any limb compression, like from a crush injury or from an inappropriately placed cast can also lead to compartment syndrome.
6 P’s for the signs of compartment syndrome
- pain
- paresthesia - which is an abnormal sensation like feeling of pins and needles or numbness that can even progress to anesthesia, or loss of sensation.
- pulselessness
- pallor
- poikilothermia - which is the inability to regulate body temperature and usually presents as cold extremities.
- paralysis
Avascular Necrosis
Avascular Necrosis - disease that results from the temporary or permanent loss of blood supply to the bone
- When blood supply is cut off, the bone tissue dies and the bone collapses.
- Often happens at the end of long bones.
Causes: fracture, injury, damage to blood vessels, long term use of corticosteroids
Symptoms:
- minimal early joint pain
- Increased joint pain as bone and joint begin to collapse
- Limited range of motion due to pain
talus (in pic)
Complex Regional Pain Syndrome:
- symptoms normally start a few weeks after fracture, surgery and injury but can also develop without known cause.
- The most common and prominent symptoms is Dissproportionate PAIN ( constant or intermittent, burning, stinging sensation)
- Tends to afect your lower extremities more:
legs, feet, arms and hands. Most common cause is bone fracture - wrist fracture.
Fat Embolism Syndrome:
- Most common cause orthopedic trauma, which somehow opens venuous sinusiods which fat gets through.
- The embolized fat obstructs capillary beds. Often the embolisms form within pulmonary capillaries.
- Embolized fat droplets can travel to microvasculature throughout the body. FES is, therefore, a multiorgan disease and can damage any microcirculatory system within the body.
Common symptom’s of FES:
- respiratory distress
-altered mental status
- rash
Subluxation: Subluxation occurs when a bone is partially pulled or pushed out of place (out of its normal relationship to the other bones that make up a joint). This can happen in joints such as the kneecap, hip, finger, elbow, or shoulder.
A subluxation may be caused by a direct blow to the joint, a fall, or a sudden twisting movement. Everyday activities may cause this injury if a person has unstable joints.
The treatment for subluxations may include resetting the joint, pain relief, rehabilitation therapy, and, in severe cases, surgery.
FRACTURE DISLOCATION
- Fracture and dislocation occur at the same time.
SPRAIN
- Ligamentous injury resulting from abnormal motion of a joint
- Pts may say they hear a ‘snap’ or ‘pop’ at the time of injury
MANAGAMENT:
- Intially apply ice, elevation and analgesia (NSAIDs)
- Immobilisation is used to provide protection and comfort in the intial management of most injuries using splints, braces and casts
- Ultrasound is a reliable and readily available imaging modality for sprains.
TENDINITIS
Common sites:
- rotator cuff of the shoulder
- Achilles tendon
- Radial aspect of the wrist and elbow joint
Management:
- Ice
- rest
- NSAIDs
- rehabilitation and training and control of force loads to prevent reoccurence
BURSITIS
Common sites of bursitis:
- Olecranon
- Subacromial
- Greater trochanter of the femur
- Prepatellar bursa
MANAGEMENT OF ORTHAPEDIC INJURIES
MANAGEMENT OF ORTHAPEDIC INJURIES:
- Primary: ABCDE assessment
- SECONDARY: Assessment of orthapedic injuries is part of the secondary survey unless there is profuse bleeding or ischaemia of the limb
- FOCUSED ASSESSMENT: Inspection, Palpatation, Neurovascular status, range of movements
- PAIN CONTROL
- IMAGING
What is ABCDE in primary assessment?
- Airway
- Breathing
- Circulation
- Disability
- Exposure
MANAGEMENT OF ORTHAPEDIC INJURIES
MANAGEMENT OF ORTHAPEDIC INJURIES:
- Reduction of fracture or dislocation
- Wound management in open fractures
- Splinting and Bandaging
- Casts
- Surgery
- Rehabilitation
Cuboital Fossa
Is the area of transition between the anatomical arm and forearm.
Triangular space:
Superior border: transverse line between the medial and lateral epicondyles of the humerus.
Medial border: Pronator Teres
Lateral border:
Brachioradialis
The contents which pass through the cubital fossa
- Radial nerve
- Median nerve
- Brachial artery
- Biceps Tendon
- The roof of the cubital fossa contains several superficial veins. Notably the MEDIAN CUBITAL VEIN, which connect the basilic and cephalic vein and can be accessed easily - common site for venepuncture
Carpal Tunnel Syndrome
- Carpal tunnel syndrome is caused by compression of the medial nerve as it travels through the carpal tunnel in the wrist, causing pain and numbness in the median nerve distribution on the hand.
zero to finals
https://www.youtube.com/shorts/61fE1TV_-Qk?feature=share
FDP tendon - bend the fingertip joint of index, middle, ringer and small finger (for cadaver this is the bottom tendon)
FDS tendon- bends the middle finger joint of index, middle, ring and small finger (cadaver this is the top tendon)
Posterior Compartment of Arm Muscles
Radial Nerve
Radial Nerve innervates all of the posterior compartment muscles
Anatomical Snuff Box (Radial Fossa)
- Triangular depression on lateral aspect of hand.
- It is located at the level of the carpal bones and is best seen when the thumb is extended.
Borders:
-Ulnar (medial) border: Tendon of the extensor pollicis longus.
-Radial (lateral) border: Tendons of the extensor pollicis brevis and abductor pollicis longus.
-Proximal border: Styloid process of the radius.
-Floor: Carpal bones; scaphoid and trapezium.
-Roof: Skin
Note: The terms medial and lateral are used in the context of the anatomical position, where the forearm is supinated. Take care when describing these borders, as when observing a patient’s anatomical snuffbox, the forearm is usually pronated).
Contents of Anatomical Snuffbox
- Radial Artery -
- Superficial Branch of the Radial nerve
- Cephalic vein
Movements of the hand
Intrinsic muscles of the hand: THENAR MUSCLEs
The thenar muscles are three short muscles located at the base of the thumb:
- Opponens Pollicis
- Abductor Pollicis brevis
- Flexor Pollicis Brevis
The muscle bellies produce a bulge, known as the thenar eminence.
They are responsible for the fine movements of the thumb.
The median nerve innervates all the thenar muscles.
Opponens Pollicis:
Attachments: Originates from the tubercle of the trapezium and the associated flexor retinaculum. It inserts onto the lateral margin of the first metacarpal.
Action: opposition of the thumb, by medially rotating and flexing the metacarpal on the trapezium.
ABDUCTOR POLLICIS BREVIS:
Attachments: Originates from the tubercles of the scaphoid and trapezium, and from the associated flexor retinaculum. Attaches to lateral side of proximal phalanx of the thumb.
Actions: Abducts the thumb.
FLEXOR POLLICS BREVIS:
Attachments: Originates from the tubercle of the trapezium and from the associated flexor retinaculum. Attaches to the base of the proximal phalanx of the thumb.
Actions: Flexes the metacarpophalangeal joint of the thumb.
Innervation: Median nerve (recurrent branch). The deep head is innervated by the d branch of the ulnar nerve.
HYPOTHENAR MUSCLES
The hypothenar muscles form the hypothenar eminence – a muscular protrusion on the medial side of the palm, at the base of the little finger:
- Opponens Digiti Minimi
-Abductor Digiti Minimi
-Flexor Digiti Minimi Brevis
The ulnar nerve innervates the muscles of the hypothenar eminence.
OPPONENS DIGIT MINIMI:
Attachments: Originates from the hook of hamate and associated flexor retinaculum, inserts into the medial margin of metacarpal V.
Actions: It rotates the metacarpal of the little finger towards the palm, producing opposition.
ABDUCTOR DIGIT MINIMI:
Attachments: Originates from the pisiform and the tendon of the flexor carpi ulnaris. It attaches to the base of the proximal phalanx of the little finger.
Actions: Abducts the little finger.
FLEXOR DIGIT MINIMI BREVIS:
Attachments: Originates from the hook of hamate and adjacent flexor retinaculum, and inserts into the base of the proximal phalanx of the little finger.
Actions: Flexes the metacarpophalangeal joint of the little finger.
Lumbrical Muscles
There are four lumbricals in the hand, each associated with a finger. They are very crucial to finger movement, linking the extensor tendons to the flexor tendons.
Denervation of these muscles is the basis for the ulnar claw and hand of benediction.
Attachments: Each lumbrical originates from a tendon of the flexor digitorum profundus. They pass dorsally and laterally around each finger, and inserts into the extensor hood.
Actions: Flexion at the MCP joint and extension at the interphalangeal (IP) joints of each digit.
Innervation: The lateral two lumbricals (of the index and middle fingers) are innervated by the median nerve. The medial two lumbricals (of the little and ring fingers) are innervated by the ulnar nerve.
HAND OF BENEDICTION (preachers hand)
- When making a fist patient is unable to flex there thumb, index or middle finger
- Flexor Digitorium Profundus and FLexor Digitorium Superficialis allows you to flex the fingers. They are all supplied by the median nerve aswell as the thenar muscles
- The Flexor Digitorium profundus is supplied by the median and ulnar nerve. So when the median is nerve is damaged you cant flex the other three fingers but you can flex the last 2 because there supplied by the ulnar nerve.
LUMBRICALS INNERVATION
Ulnar Claw
- Ulnar claw is present all the time when the hand is rest, whereas the hand of benediction only happens when you ask the patient to flex the fingers
- How it looks: Distal and proximal interphalangeal joints are flexed but the MCP joint is extended
- Cause: damage to the ulnar nerve which supplies the last two lumbricals
INTEROSSEI
The interossei muscles are located between the metacarpal bones of the hand. They can be divided into two groups – dorsal and palmar.
In addition to their actions of abduction (dorsal interossei) and adduction (palmar interossei) of the fingers, the interossei also assist the lumbricals in flexion at the MCP joints and extension at the IP joints.
Dorsal Interossei:
Attachments: Each interossei originates from the lateral and medial surfaces of the metacarpals. They attach into the extensor hood and proximal phalanx of each finger.
Actions: Abduction of the digits. Assists in flexion at the metacarpophalangeal joints and extension at the interphalangeal joints.
Innervation: Ulnar nerve.
Palmar Interossei
These are located anteriorly on the hand. There are three palmar interossei muscles (although some texts describe a fourth muscle at the base of the proximal phalanx of the thumb).
Attachments: Each interossei originates from a medial or lateral surface of a metacarpal, and attaches into the extensor hood and proximal phalanx of same finger.
Actions: Adduction of the digits. Assists in flexion at the metacarpophalangeal joints and extension at the interphalangeal joints.
Innervation: Ulnar nerve.
There are two other muscles in the palm that are not lumbricals or interossei and do not fit in the hypothenar or thenar compartments:
- PALMARIS BREVIS
- ADDUCTOR POLLICIS
PALMARIS BREVIS:
Attachments: Originates from the palmar aponeurosis and flexor retinaculum, attaches to the dermis of the skin on the medial margin of the hand.
Actions: Wrinkles the skin of the hypothenar eminence and deepens the curvature of the hand, improving grip.
Innervation: Ulnar nerve.
ADDUCTOR POLLICIS:
Attachments: One head originates from metacarpal III. The other head originates from the capitate and adjacent areas of metacarpals II and III. Both attach into the base of the proximal phalanx of the thumb.
Actions: Adductor of the thumb.
Palmaris Brevis Muscle
Adductor Pollicis
What causes Osteoarthritis
Osteoarthritis is thought to result from an imbalance between cartilage damage and the chondrocyte response, leading to structural issues in the joint
LOSS
The changes in osteoarthritis can be seen on a x-ray.
The memonic for what to look out for is ‘LOSS’
L: Loss of joint space (bones comes closer to each other’
O: Osteophytes (little bits of bone which come out of either end of the bone)
S: Subarticular Sclerosis (increased density of the bone, along the joint line where the bones come in contact with each other)
S: Subchondral Cysts (small fluid filled holes in the bone along the joint line )
- X ray may not necessarily correlate with symptoms. So you may have someone with significant bone changes and no symptoms
- Equally someone with severe symptoms of osteoarthritis may only have mild x-ray changes
Joints commonly affected by osteoarthritis
- knees
- hips
- sacroiliac joints
- distal interphalangeal joints of the hand (DIP)
- carpometacarpal joint at the base of the thumb (CMC)
- wrist
- cervical spine - ( osteoarthritis of cervical spine is called cervical spondylosis)
Signs:
- HABERDENS NODES ( occur in the DIP joint)
- BOUCHARDS NODES (occur in the PIP)
- Squaring of the base of the thumb (CMC joint)
- Weak/ reduced grip
- Reduced range of motion
What is the carpometacarpal joint?
- Saddle joint
- CMC joint key joint where osteoarthritis occurs in people who use there hands a lot
Hand sign in advanced RA
-Z-shaped deformity to the thumb
-Swan neck deformity (hyperextended PIP and flexed DIP)(flat pip)
-Boutonniere deformity (hyperextended DIP and flexed PIP) (first pic) (bumpy pip)
-Ulnar deviation of the fingers at the MCP joints
Boutonniere deformity is caused by a tear in the central slip of the extensor components at the proximal interphalangeal (PIP) joint. The central slip connects to the middle phalanx at the PIP, and the lateral bands go around the PIP and connect to the distal phalanx. When the patient tries to straighten their finger, the lateral bands pull on the distal phalanx, causing the distal interphalangeal (DIP) joint to hyperextend and the PIP joint to flex.
Swan neck deformity is the opposite of Boutonnieres deformity. It is caused by an extensor mechanism imbalance, causing flexion of the DIP joint and extension of the PIP joint.
Atlantoaxial Subluxation
Atlantoaxial subluxation occurs in the cervical spine. Synovitis and damage to the ligaments around the odontoid peg of the axis (C2) allow it to shift within the atlas (C1).
Subluxation can cause spinal cord compression and is an emergency. This needs to be considered when a patient is having a general anaesthetic and requires intubation. MRI can be used to visualise changes in these areas as part of a pre-operative assessment.
Crystal Arthritis (gout)
-excessive uric acid levels, which causes crystallized uric acid (monosodium urate crystals ) to be deposited into tissues
-Gout is caused by the precipitation and deposition of monosodium urate crystals into the joint spaces and tissues, resulting in inflammatory arthritis.
-Precipitation of monosodium urate is due to increased uric acid production or decreased uric acid excretion.
Purine-rich foods include red meats, liver, shellfish, and alcohol increase risk of gout
Gout Presentation
- Single (unilateral)
- Acute
- Hot
- Swollen
- Painful
The number one differential diagnosis is Septic Arthritis
Which joint is most likely to be implicated in a gout attack ?
- The first metatarsophalangeal (MTP) joint is most commonly implicated in a gout attack - the base of toe
- Also the carpometacarpal joint (CMC joint) - the base of the thumb
- Wrist
What is Pseudogout ? (acute gout)
When we have too much calcium pyrophosphate dihydrtae crystals, which deposit into tissues and cause inflammation.
often idiopathic
Gouty Tophi
Gouty tophi are subcutaneous uric acid deposits typically seen on the hands, elbows and ears.
The crystals are not deposited into the joint but instead are deposited under the skin.
- The most common place to see this is in the DIP in the hands
Diagnosis
- Diagnosis can be made clinically or by aspirating fluid from the joint. It’s usually done clinically.
- It is important to exclude septic arthritis (because it is a potentially joint and life threatening diagnosis)
- When you aspirate fluid from the joint in gout you’ll see no bacterial growth. In gout you’ll also see needle shaped crystals which are ‘negatively birefringent of polarized light’. And on further investigation you find monosodium urate crystals.
- If there is bacterial growth this is septic arthritis rather than gout.
Typical gout x-ray changes
-Maintained joint space (no loss of joint space)
-Lytic lesions in the bone
-Punched out erosions
-Erosions can have sclerotic borders with overhanding edges
Management of Gout
Firstly managing a acute flare, this is when patient is in pain with red, hot joint:
-1st line: NSAIDs - Naproxen, Ibuprofen
- 2nd line: COLCHICINE. This is used in situations where using NSAIDs would be inappropriate such as renal impairment and heart disease. Common side effect of this drug is diarrhoea
- 3rd line: Steroids ( predinosolone)
Secondly providing prophylaxis to reduce the risk of a flare:
- ALLOPURINOL - Xanthane oxidase inhibitor. Works by reducing the uric acid level.
- Lifestyle changes: Losing weight, stay hydrated and reducing the consumption of alcohol and purine rich food.
Symptoms of Septic Arthritis
- SA is a infection within a joint
- Pain
- Swelling: is due to joint effusion, which is where the fluids in the tissues around your joint increase
- fever
- sweats
- rigors
- confusion
- Its musculoskeletal emergency, as it causes rapid destruction of cartilage and bone, and can become
life-threatening - Symptoms often last for around 2 weeks
RISK FACORS FOR SA:
- trauma
- local infection
- IV drug users
- recent invasive procedures
- medications: corticosteroids, immunosuppressants and antibiotics
TREATMENT:
- antibiotics (long course): 2 weeks of IV antibiotics,
followed by 4 weeks of oral antibiotics may be needed to clear them
Describe the functions of synovium and cartilage
Anatomical Snuffbox
DELTOID AND TERES MINOR
Proximal humeral fractures can lead to injury to the axillary nerve, as it travels medially to the surgical neck of the humerus.
The nerve damage affects the deltoid and teres minor muscles.
Injury to the axillary nerve results in:
- Weakness of the deltoid and teres minor muscles - paralysis of the deltoid and teres minor muscles resulting in weakness in shoulder abduction and external rotation.
- Loss of sensation of the area of the skin over the lateral shoulder (regimental badge area) as the upper lateral cutaneous nerve of the arm will be affected.
- Wasting of the deltoid muscle can occur over time and results in a loss of the rounded appearance of the shoulder giving the shoulder a flattened appearance.
