Clinical Anatomy + Pathology of Spine; Lower Limb ; Knee; Upper Limb [Instability, Impingement] Flashcards
How many vertebrae make up the spinal column?
How many sections?
How many vertebrae per section?
33 vertebrae
5 sections:
- 7 cervical
- 12 thoracic
- 5 lumbar
- 5 sacral (fused)
- 4 coccygeal (fused)
Curves of the healthy spine
4 curves of the healthy spine
Atlas (C1)
Does not have a vertebral body
Is fused with C2
C1 & C2 allow…
head rotation
C7 (Vertebra prominens)
- is spinous process bifid?
- does C7 transmit vertebral artery
No/very small foramina transverse process
Does not transmit the vertebral artery
Spinous process end is rounded and NOT bifid
Between which vertebrae is there no intervertebral disc?
c1 & c2
Intervertebral disc
- type of joint
- structure
Secondary cartilaginous joint
Outer annulous pulposus
Inner nucleus pulposus (squishy)
Facet joints (zygapophysial joints)
Flexion
extension
lateral flexion
at facet joints and intervertebral discs ==> cumulative effect.
Why is there less flexion/extension in thoracic spine?
Constraint of ribs.
Lumbar rotation is less than thoracic due to…
More vertically orientated facet joints.
Intervertebral disc loses water content with…leading to…
when is pain worse - on extension or flexion?
water content with ageing
Leads to overload facet joints & 2° OA
Pain worse with extension of spine
OA in one or two motion segments can be treated?
Yes
With localise fusion
Controversial as OA will affect adjacent level by 5 years and results inconsistent
Intervertebral Disc - what happens with age
Degeneration with age - loss H2O content
Most frequent in L4/5 & L5/S1
60% asymptomatic people over 45 have bulging discs on MRI
10% have disc extrusion
5% have asymptomatic nerve root compression
Therefore MRI not diagnostic
Where do most intervertebral disc prolapses occur?
Most at L4/5 or L5/S1
Lifting heavy object –> annulus tear –> twang
Rich innervation outer annulus
Pain on coughing
Most settle by 3 months
Where do motor neurons originate? (from spinal cord)
Anteriorly
Bodies in anterior grey horn.
Where do sensory neurons originate? (from spinal cord)
Originate dorsally.
Bodies in dorsal root ganglion.
Where do the anterior and posterior roots exit? (after forming mixed spinal nerve)
Intervertebral foramen
In the lumbar spine (cauda equine), sensory and motor nerves?
Run together with 2 pairs at each level susceptible to compression
Where does the spinal cord “end”?
At L1 –> Cauda equina
What is the structure at the end of the spinal cord? (where the cauda equina starts)
Conus medullaris
Upper motor neuron pathologies lead to…
Weakness
Spasticity
Increased tone
Hyperreflexia
Lower motor neuron pathologies lead to…
Weakness
Flaccidity
Loss of reflexes
Exiting nerve root (outside the thecal sac) passes…
Under the pedicle of the corresponding vertebra
L4 root passes under L4 pedicle.
Traversing nerve root pair…
whilst remaining in the thecal sac is positioned anteriorly (lateral recess)
In preparation to penetrate the thecal sac and become the next exiting nerve root more distally.
Which nerve root is commonly compressed in disc prolapse?
Traversing root
e.g. L5 root for L4/5 prolapse and S1 root for L5/S1 prolapse.
When can the exiting nerve root be compressed?
Far lateral disc prolapse can affect exiting nerve root.
What does nerve root compression cause?
Radiculopathy
Results in pain down the sensory distribution of the nerve root (dermatome)
Sciatica in the lower leg
Also weakness in any muscle supplied (myotome) and reduced or absent reflexes (LMN signs)
Radiculopathy
“pinched nerve”
Results in pain down the sensory distribution of the nerve root (dermatome)
Sciatica in the lower leg
Also weakness in any muscle supplied (myotome) and reduced or absent reflexes (LMN signs)
Which nerves contribute to the sciatic nerve?
L4, L5 and S1 nerve roots (along with s2 & s3)
Spinal stenosis
Where nerve roots have been compressed by osteophytes and/or hypertrophied ligaments in Osteoarthritis
Neurogenic claudication
walking downhill & uphill
Radiculopathy or burning pain on walking
Painful cramping or weakness.
Symptom of spinal stenosis
Difficult to walk downhill (painful)
Better walking uphill (less compression on the spinal nerve)
Babinski’s sign
Extensor plantar response (big toe is dorsiflexed and toes “fan” out)
Can indicate an upper neuronal lesion.
Abnormal plantar response
Cauda equina syndrome
Pressure (usually prolapsed disc) on all lumbosacral nerve roots at level of lesion including sacral nerve roots for bladder and bowel control.
BLADDER AND BOWEL CONTROL PROBLEMS
Loss of anal tone
Saddle anaesthesia
bowel dysfunction
If you suspect nerve root compression, what should you ask about?
Bladder and bowel control
Cauda equina syndrome
Loss of anal tone
Saddle anaesthesia
bowel dysfunction
Which muscles make up the erector spinae?
Iliocostalis
Longissimus thoracic
Spinalis thoracis
Source of sprains & strains
Ligaments of the spine
[Posterior Column]
Interspinous ligament
Supraspinous ligament
Ligamentum flavum
[Middle Column]
Posterior longitudinal ligament
Annulus fibrosis
[ Anterior column]
Anterior longitudinal ligament
Intervertebral disc
Chance Fracture
Unstable fracture
It consists of a compression injury to the anterior portion of the vertebral body and a transverse fracture through the posterior elements of the vertebra and the posterior portion of the vertebral body
Caused by violent forward flexion, causing distraction injury to the posterior elements.
“seatbelt injury”
T12-L2 common
Associated with intrabdominal injuries in 50% of cases
Causes of back pain
> Bones
- Fracture – trauma, osteoporosis, (spondylolisthesis)
- Tumour
- Infection
> Joints
- Spondylosis & OA
- Spinal stenosis
> Muscles & Ligaments
- Sprains & strains
> Disc
- Discogenic back pain
- Sciatica
- Cauda equina syndrome
Mechanical back pain
Related to joints, ligaments and muscles with no sinister “red flag” features
Worse with a ctiivty
Relieved by rest, worse with activity, tends to be long course or relapsing and remitting
May be related to obesity, poor posture, poor lifting technique
Nothing can be done surgically
- analgesia
- physio
- chiropractor
- pain clinic
When is surgery considered with sciatica?
Disc-ectomy or decompression for sciatica which hasn’t settled with 3 months’ conservative management
Pitfall - mechanical back pain can radiate to the buttock and thigh
Sciatica should go below the knee
Where should sciatica pain “go”
Below the knee at least.
False positive spine MRIs
Middle age (around 45yo)
Asymptomatic patients, but have:
- 40% disc bulge
- 30% have disc protrusion
- 10% have disc extrusion
- 5% have nerve root compression or deviation
The pelvis is made up of which bones?
Ilium (large, ear like one)
Ischium
Pubis
Sacrum
Ligaments of the pelvis
Sacrospinous ligament
Posterior sacroiliac ligament
Sacrotuberous ligament
VERY STRONG
Large force required to rupture them.
If veins/arteries in pelvis region are ruptured, what can occur? (general terms)
Pelvis has a large potential space for bleeding (esp. when fractured)
The blood can pool into the pelvic space.
so, close this pelvic space and allow blood to clot up - otherwise whole circulating volume can spread into the pelvic space.
Injury to pelvis
Sciatic nerve sensitive to injury at greater sciatic notch
Urethra, rectum and bladder can be injured with pelvic trauma
Surgery in Intra/extra capsular hip fractures
Intracapsular hip fractures
- vessels around head of femur are more likely to be damaged.
- Hip replacement
Extracapsular hip fracture
- vessels are less likely to be involved
- dynamic hip screw used
Which artery supplies the fovea capitis?
Artery of ligamentum teres (foveolar artery)
Avascular necrosis in the hip
Fracture, dislocation
Small end arteries are in the head of the femur (i.e. no anastomoses)
Tenuous blood supply to superior head of femur
Susceptible to blockage (fat, thrombus, nitrogen gas)
–> avascular necrosis
Abductors of the leg
What is the main one?
Gluteus minimus, medius and maximus
Gluteus medius is the primary abductor
When standing on one leg (as in walking), what do the abductor muscles do?
Tilt the pelvis towards then standing leg.
Trendelenburg gait - pelvis tilts away from standing leg
Main flexor of the hip joint?
Iliopsoas
The quads are innervated by which nerve?
The femoral nerve
Quadriceps muscle is made up of?
Rectus femoris
Vastus lateralis
Vastus medialis
Vastus intermedius (lies deep to rectus femoris)
Hamstring muscles innervated by?
Sciatic nerve
Serious muscle tear of the hamstring
Hamstring origin avulsion
Requires surgery to reattach
Which muscle tendon can be used for ACL reconstruction?
Semitendinosus can be used as a tendon graft.
Adductors of the thigh are supplied by which nerve?
Obturator (L2,3,4)
Can refer pain from hip to knee
Adductor hiatus
Gap between adductor magnus and the femur
Transmits femoral artery and vein from Subsartorial canal into popliteal fossa
Transmits saphenous nerve
What type of cartilage are menisci?
Fibrocartilage
Act as shock absorbers between convex femoral condyles and relatively flat plateau
Features of the menisci in the knee
C shaped
Triangular in cross section
Distribute load from convex femoral condyles to flat tibial articular surfaces.
Medial meniscus is fixed and thicker.
Lateral one is more mobile and thinner
We pivot through the medial compartment –> so MM tears are more common
Medial collateral ligament (MCL) resists…
Rupture leads to…
valgus stress
Rupture leads to valgus instability
ACL resists
Rupture leads to…
Internal rotation of tibia
Anterior translation/subluxation of the tibia in extension
Rupture sounds like a “Pop”
Haemarthrosis
Rupture leads to rotatory instability (subluxation)
1/3 compensate and are able to function well
1/3 can avoid instability by avoiding certain activities
1/3 do not compensate and have frequent instability or can’t get back to high impact sport
PCL resists…
Rupture leads to…
Posterior translation/subluxation of tibia
i.e. anterior subluxation of femur
Hyperextension of knee
Direct blow to anterior tibia or hyperextension injury
Popliteal knee pain and bruising
Isolated PCL rupture rare
Brusing in politeal fossa is classic sign
Pathognomonic
Lateral collateral ligament (LCL) resists…
Varus stress
Resists external rotation (with PCL and posterolateral corner)
What is the average tibiofemoral angle?
6° valgus (anatomical axis)
Results in centres of hip, knee and ankle (mechanical axis) aligning perfect
Symmetric distribution of load between medial and lateral compartments
Genu varum puts stress on…
Medial comportment leg
Medial osteoarthritis
Genu values puts stress on lateral compartment
Treatment for significant varies/valgus in adults?
Osteotomy
Involves breaking and resetting the bones.
Knee bursae
Prevent friction between bone and skin
Can become inflamed - common in those who kneel a lot.
Suprapatellar bursa
Infrapatellar bursa
Prepatellar bursa
Pes anserine bursa
Which nerve innervates the anterior compartment of the leg?
Deep fibular nerve
Which nerve innervates the lateral compartment of the leg?
Superficial fibular nerve
Which nerve innervates the superior and deep posterior compartments?
Tibial nerve
Compartment syndrome
Swelling in muscle compartments
Very painful
Bleeding and inflammation –> lots of fluid infiltrate
Blood dams up in the muscle.
Pressure increase –> occludes venous drainage
SECONDARY ischaemua
Fasciotomy to relieve pressure
Deltoid ligament is found where (foot)?
Medial aspect of the ankle
Which ligaments are you spraining in an ankle sprain?
Role your ankle
Lateral ligament sprain
2/3 ligaments sprained/incompetent for instability
Ligaments of the lateral aspect of the foot
anterior talofibular ligament
posterior talofibular ligament
calcaneofibular ligament
Talar shift is caused by
Occurs if either:
- the medial malleolus is fractured
- the deltoid ligament is ruptured
Lateralisation of talus under the tibia
Tarsal coalition
Abnormal connections between tarsal bones. Complete or partial union/
Worsening pain
Adolescents
Foot pronation
Eversion
Abduction
Dorsiflexion
Foot supination
Inversion
Adduction
Plantar flexion
Pes planus
Flat foot.
What happens if the tibias posterior tendon elongates?
Flat foot –> hind foot valgus.
Clawing of toes
Which toe does it NOT occur in?
Flexors stronger than extensors
Can happen in any toe except the big toe
Hammer toe
A hammer toe bends down toward the floor at the middle toe joint. This causes the middle toe joint to rise up. It usually affects the second toe.
The menisci act as?
Shock absorbers
Knee pivoting
Knee pivots on medial compartment through flexion and extension
Tibia internally rotates on flexion
Externally rotates one extension
Posterolateral corner
Rupture leads to…
PCL and LCL with polities and other smaller ligaments
Resists external rotation of the tibia in flexion.
Rupture leads to various and rotatory instability
MCL and LCL blood supply
MCL
- has very good blood supply and is more likely to heal
- is a lot thicker
LCL
- poor blood supply
- rope like
- less likely to heal
Types of meniscal tears
Longitudinal tear
Bucket handle tear
Radial tear
Parrot beak tear
Which meniscal tear is more likely to heal?
Longitudinal tear
Which meniscal tear is most commonly associated with knee locking?
Bucket handle tear
type of longitudinal, much wider lesion
displaced meniscal fragment frequently results in knee locking.
Meniscal tear - common patients
Sporting injury - younger patients
Getting up from squatting position (overload posterior horn of meniscus)
Can get spontaneous degenerate tears in older patients
50% of ACL ruptures have concomitant meniscal tear
Investigate with MRI
Best investigation for meniscal tear?
MRI
Accuracy decreases with age as there are false positive findings (degenerative)
Do radial meniscal tears heal?
No
Treatment of acute meniscal tear in younger patients
Arthroscopic repair in acute peripheral tears
Extensive rehab
6 weeks crutches
Cant play football/sport
Catching or locking (painful) - potential treatment
Consider arthroscopic meniscectomy for mechanical symptoms
For irreparable tears o failed meniscal repair
Bucket handle tear - presentation
Acute locked knee
Displaced bucket handle meniscal tear
Patietn will have 15° springy block to extension
Urgent surgery
If knee remains locked, may develop a FIXED FLEXION DEFORMITY (FFD)
If irreparable needs partial meniscectomy to unlock knee and prevent further damage
FFD
Fixed Flexion Disorder
Double PCL sign
Appears on sagittal MRI images of the knee when a bucket-handle meniscal tear (medial meniscus in 80% of cases) flips towards the centre of the joint so that it comes to lie anteroinferior to the posterior cruciate ligament (PCL) mimicking a second smaller PCL.
Knee ligament injury classification (grades 1-3)
Grade 1: Sprain, tear some fibres but macroscopically intact
Grade 2 - partial tear- some fascicles disrupted
Grade 3 - complete tear
MCL injury - healing
Usually heals well if complete tear
Unless combined with ACL or PCL rupture.
Brace, early motion and physio
Pain can take months to subside.
ACL rupture - treatment
Clinical tests?
When is surgery considered?
Rehab
Reconstruction (40% of ACL ruptures)
- autograft (patellar tendon or hamstrings)
- allograft: achilles, tibialis
- Synthetic graft
Clinical Tests
Lachman (done at 30°)
Anterior drawer Pivot shift
Role of Surgery
When there is rotatory instability not responding to physiological
Knee has to give way fro us to consider surgery
Protect meniscal repair
Rapid return to professional sport
Part of multilligament reconstruction.
Does NOT treat pain
Does NOT prevent arthritis
Rehab
3 months –> year rehab
Some never get back to full sport
20% failure rate
Graft donor site morbidity
Stiffness
LCL injury
Relatively uncommon
Varus and hyperextension
LCL doesn’t heal and can cause varus and rotatory instability
High incidence - common perineal nerve palsy
Often occurs in combination with PCL or ACL injury
Complete rupture needs urgent repair if early
Later –> reconstruction
Common fibular nerve palsy is commonly associated with..
LCL injury
Foot drop
PCL rupture - classic sign
Bruising in popliteal fossa.
Posterior sag of the tibia
Knee dislocation
> When bones that form the knee joint move out of place
> Serious high energy injury
- popliteal artery injury (tear, intimal tera and thrombosis)
- nerve injury - common fibular nerve
- at least 3/4 of the ligaments have gone
- compartment syndrome
> Emergency reduction
Any concerns with vascular status –> vascular surgery
> May need ex fix for temp stabilisation
Patellar Dislocation
> Rapid turn or direct blow
> Increased incidence in females, adolescents, ligamentous laxity, valgus knee, torsional abnormalities
> 10% –> recurrent dislocation
> Can cause chondral or osteochondral injury
Lower limb extensors mechanism rupture
Fall onto flexed knee with quads contraction
Previous tendonitis
Steroids
Chronic renal failure, ciprofloxacin (abc)
Unable to straight leg raise
Palpable gap
Requires surgical repair
Steroids and abs —> tendinitis
“Sound” of an ACL rupture
Pop
Soft tissue knee injuries associated with haemarthrosis
ACL rupture or fracture
Effusion
Meniscal or chondral injury (knee swells up after a day or so)
Pain all over the knee - due to?
Haemarthrosis
Blood is extremely irritant to synovium
Hyaline Cartilage
> Covers the surface of bone in synovial joints
> Decreases friction and distributes loads
> Comprised of water, collagen proteoglycans and chondrocytes
> Nutrition from synovial fluid and subchondral bone
> Proteoglycans highly hydrophilic –> act like balloons to give compressive strength.
> Collagen fibres give tensile strength
Cartilage Defects
> Traumatic > Atraumatic -- osteochondritis dissecans -- osteoarthritis -- inflammatory arthritis
> Only full thickness injuries can heal
> Healing is with fibrocartilage which has greater friction and is less wear resistant.
Osteochondritis dissecans
An area of the surface of the knee loses its blood supply and cartilage ± bone can fragment off.
Adolescents
Can heal or resolve spontaneously
If detaching on MRI can pin in place
If completely detached, can fix or remove.
Simply removing the fragment is the best treatment.
Cartilage Regeneration Techniques
- what kind of cartilage is used?
- when will NO techniques work?
ALL heal with fibrocartilage.
Fibrocartilage has higher friction and is less wear resistant
Better for small defects
~70% have improvement of symptoms
Drilling/microfracture - simplest and cheapest.
Osteochondral autograft or allograft
Mosaicplasty - take lots of little plugs and jam them in place
MACI - Membrane induced autologous chondrocyte implanatation
None of these work if you have arthritis
Knee replacement
Only for older patients with end stage arthritis
Total knee replacement preferred over partial.
TKR lasts 15-20 years in older patients
Risks - pain, stiffness, DVT/PE, medical complications, deep infection
Knee pain presentatin
Pain
- anterior
- often localised
Often subjective
Stiffness
Swelling/lump
Giving way
Deformity
Loss of sleep
Loss of function
- how far can they walk
- cannot kneel
How does the pain affect the individual?
Consider HIP pain
What should you consider in knee pain?
That it is referred hip pain.
Management of knee pain
Explanation - use a model
Keep mobile
Support
NSAID - short term
Analgesia
Physiotherapy
Referral – orthopaedics
Osgood schlatters
Common knee pain problem
Inflammation of the patellar ligament at tibial tuberosity/tubercle
Chondromalacia patellae
Inflammation of the underside of the patella and softening of the cartilage
Less common cause of knee pain.
Mechanism of ACL injury
Non-contact ACL injuries occur when rotation occurs in the knee joint with a fixed weight-bearing foot.
Anatomical parts of the ACL
Anteromedial portion
Posterolateral portion
When the knee is extended, the posterolateral bundle (PL) is tight and the anteromedial (AM) bundle is moderately lax. As the knee is flexed, the femoral attachment of the ACL becomes a more horizontal orientation; causing the AM bundle to tighten and the PL bundle to relax.
Hip pain - GP presentation
PAIN/ DISCOMFORT
REFERRED PAIN
NIGHT PAIN/INSOMNIA
EXERCISE RELATED PAIN
Have trouble with
WALK DISTANCES
PLAY SPORT
GO UP AND DOWN STAIRS
Pain and loss of function are subjective.
“LOSS” acronym
Loss of joint space
Osteophytes
Sclerosis
Subarticular cysts
Hip Pain - management
> Education > Weight reduction > Home adaptations > Walking stick > Analgesia > NSAIDs > Physio > Complementary medicines > Mobility allowance, disability badge for car.
SURGERY
- many cases referred to surgery
Hip pain - what to consider when referring.
Pain (worse at night)
Loss of function
Physical fitness
Mental fitness
Support at home
Age of patient
Uncertain about diagnosis
Common causes of Hip Pain
Rarer causes
Osteoarthritis Rheumatoid arthritis Other arthritis Fracture Referred from back Malignancy
Soft tissue - trochanteric bursitis, snapping olio-psoas tendon
Paget’s disease
Infection e.g. septic, TB
Avascular necrosis
Hip
? YOUNG FOR THR – BUT LIFE EXPECTANCY LIMITED ANYWAY?
HIS FEARS(REASONABLE) REGARDING OPERATION
HE SOLDIERED ON FOR YEARS – SHOULD HE PERSEVERE?
HIS HOUSING COULD BE ADAPTED
HE STILL GETS ABOUT WELL ENOUGH
BUT HIP PAIN IS LIMITING HIS SPORT – IS JOINT SURGERY JUSTIFIABLE?
HIP REPLACEMENT AT YOUNG AGE?
GOING FOR A CONTROVERSIAL TECHNIQUE
? MORE RISKY
? EXPENSIVE
? AVAILABL
TOO YOUNG FOR THR?
MORE STIFFNESS RATHER THAN PAIN; IS THAT ENOUGH REASON TO OPERATE?
OP NOW AS FITTER & MORE YEARS TO BENEFIT?
IF FOR SURGERY BEST PROSTHESIS IN TERMS OF LONGEVITY & RE-DOING?
Main indication of Hip replacement
Pain not controlled by painkillers.
Stabilisers of the shoulder joint
Static stabilisers
- shoulder capsule
- labrum
Dynamic stabilisers
- muscles surrounding the shoulder
Shoulder impingement - causes
- Tendonitis
- Cuff tear
- Subacromial bursitis
- Osteophytes from AC joint
General treatment for shoulder joint impingement
Injection into subacromial space
Painful arc in impingement
60-120° abduction is painful
What can help to prevent re-dislocation of the shoulder?
Cuff strengthening.
Bankart Lesion
Common complication of anterior shoulder dislocation
Detachment of the anterior inferior labrum from the underlying glenoid as a direct result of the anteriorly dislocated humeral head compressing against the labrum
Most commonly associated nerve injury of an anterior shoulder dislocation
Axillary nerve - stretched at quadrangular space.
Can press on brachial plexus and axillary artery
Regimental badge area pain
Adhesive Capsulitis
- pain?
- what is it?
- loss of movement
- phases
- History
- O/E
- Ix
- Treatment
Frozen shoulder. Capsule of joint becomes really tight.
40-50 y/o; females
Gradual severe, seething pain
Phases
Freezing - seething pain
Frozen - inflammation and pain settles, limitation of movement
Thawing - after 2-3 years
Residual stiffness after it has resolved.
History
- pain at rest
- pain at night
- anterior pain
- stiffness
O/E
global restriction n ROM
External rotation most affected.
Treatment
- gentle movements
- analgesia
- physio
- glenohumeral fluoroscopy
Operative
- manipulation under anaesthetic
- arthroscopic capsular release
- -> sling
- -> pain control
- -> physiotherapy
Nerve supplying anterior surface of the upper arm
Musculocutaneous nerve
Also supplies sensation to lateral forearm
Coracoclavicular ligament rupture
Due to AC joint dislocation or clavicle fracture
Displacement of joint/bones
Posterior compartment of upper arm - nerve supply
Radial nerve
Humeral shaft fracture - which nerve is susceptible to injury?
Radial nerve.
supplies all extensors upper limb –> wrist drop
Elbow joint - consists of
> Humero-ulnar joint
- trochlea and olecranon
- flexion/extension
> Radio-capitellar joint
- supination and pronation (+ radioulnar joints)
Common extensor origin of upper limb
Lateral epicondyle (associated with Tennis elbow)
Common flexor origin of upper limb
Medial epicondyle
Golfer’s elbow
Supracondylar fracture
Risk of:
Brachial artery occlusion
Median nerve injury (radial and ulnar can also be injured)
Monteggia fracture dislocation
Radius has dislocated
Ulna is fractured
Galeazzi fracture dislocation
Fracture of distal 1/3 of radius
Dislocation of distal radioulnar joint
Anterior compartment of the forearm - nerve supply
Median nerve
Except FCU (flexor carpi ulnari) and ulnar half of FDP (flexor digitalis profundus)
Extensors in the upper limb are innervated by?
Radial nerve
Scaphoid fracture - where is pain normally found?
Pain and swelling in the anatomic snuffbox
Infection of flexor tendon sheath
Fibrous tissue forms in tendon sheath
Can’t move the hand
Redness tracks down the finger and hand –> SURGICAL EMERGENCY
Thenar muscles and lateral 2 lubricals are supplied by the?
Median nerve.
Lumbricals 1 & 2, Opponens pollicis, Abductor pollicis brevis and Flexor pollicis brevis.
LOAF
(rest of hand muscles are supplied by ulnar)
Flexor Digitorum Superficialis
Flexion of PIPJ and MCPJ
Flexor Digitorum Profunuds
Flexion of DIPJ
Finger extension
Dorsal extensor tendon divides into a central slip that extends the PIP joint and then into two lateral bands /slips that extend to the DIP joint
Insertions of intrinsic muscles of hand
Insert into lateral bands and contribute to flexion MCPJ and extension at PIPJ
Boutonnière deformity
Central slip extensor tendon rupture or attrition
Testing the medial nerve, FDL and FDP
“Okay” sign
Ulnar nerve function
Testing dorsal interossei abduction against resistance
Froment’s test
Anterior and posterior dislocation of the shoulder
Anterior
- most common.
- Traumatic.
- Sports
- Hill-sachs lesion (recurrent)
Posterior
- infrequent
- epileptic fits
- electrocution
- “lightbulb sign” on X-ray: humeral head is internally rotated and pointing backwards
Instability presentation
Examination
Look
- abnormal shoulder contour
- muscle wasting
Feel
- tenderness, muscle spasm
Move
- good ROM
- Scapular winging
Tests
- rotator cuff strength
- apprehension
- relocation
- laxity
Ix
- radiographs (AP and oblique views)
- MRI (chronic cases)
Instability treatment and management
Treatment
- analgesia
- O2
- sedation
- reduction my manipulation
Post reduction treatment
- sling
- analgesia
- gradual mobilisation
- physio
Hill-Sachs lesion
Posterolateral humeral head compression fracture
typically secondary to recurrent anterior shoulder dislocations, as the humeral head comes to rest against the anteroinferior part of the glenoid.
Impingement syndrome
- age
- extrinsic and intrinsic causes
Pain originating from subacromial space.
Intrinsic causes
- tendon degeneration
- cuff dysfunction
Extrinsic
- clavicular spur/osteophyte
20s - RC tendinitis/subacromial bursitis
30s/40s - calcific tendonitis
50s/60s - cuff tear
70s - cuff arthropathy
Impingement -presentation / Exam / Treatment
> Age > Dominance > Pain --- regimental badge area of arm > Reach and stretch issues (picking up kettle) > Painful arc > Neurology > Neck pain
Examination
> Look
- contour, wasting, scapula position
> Feel
- tenderness bursa
> Move
- ROM active/passive, painful arc, RC strength
> Tests
- Hawkin’s, Jobe
—
Treatment
- rest
- pain relief
- physiotherapy
- up to 2 corticosteroid injections
- sling, physio and ROM exercises
- RC strengthening.
Surgery is last resort
- decompression
- removal of calcified deposits
Cuff Tear presentation
- O/E
- Treatment
Age 50-60s
Gray hair = cuff tear
Acute traumatic
Chronic attrition
Weakness (mostly)
Pain (less so)
O/E
> Look
– contour, wasting
> Feel
– tenderness sub deltoid region
> Move
– ROM active «_space;passive, RC weak
> Tests
Treatment
- analgesia
- rest
- sling
Chronic - physio, deltoid strengthening.
Acute - urgent Ix, early physio, early early early
Surgery
- arthroscopic / open
- sling
- no driving
- no heavy lifting
- physio
- chance of re tear
