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MSK > Clinical Anatomy + Pathology of Spine; Lower Limb ; Knee; Upper Limb [Instability, Impingement] > Flashcards

Clinical Anatomy + Pathology of Spine; Lower Limb ; Knee; Upper Limb [Instability, Impingement] Flashcards

1
Q

How many vertebrae make up the spinal column?

How many sections?

How many vertebrae per section?

A

33 vertebrae

5 sections:

  • 7 cervical
  • 12 thoracic
  • 5 lumbar
  • 5 sacral (fused)
  • 4 coccygeal (fused)
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2
Q

Curves of the healthy spine

A

4 curves of the healthy spine

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3
Q

Atlas (C1)

A

Does not have a vertebral body

Is fused with C2

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4
Q

C1 & C2 allow…

A

head rotation

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5
Q

C7 (Vertebra prominens)

  • is spinous process bifid?
  • does C7 transmit vertebral artery
A

No/very small foramina transverse process

Does not transmit the vertebral artery

Spinous process end is rounded and NOT bifid

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6
Q

Between which vertebrae is there no intervertebral disc?

A

c1 & c2

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7
Q

Intervertebral disc

  • type of joint
  • structure
A

Secondary cartilaginous joint

Outer annulous pulposus

Inner nucleus pulposus (squishy)

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8
Q

Facet joints (zygapophysial joints)

A

Flexion
extension
lateral flexion

at facet joints and intervertebral discs ==> cumulative effect.

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9
Q

Why is there less flexion/extension in thoracic spine?

A

Constraint of ribs.

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10
Q

Lumbar rotation is less than thoracic due to…

A

More vertically orientated facet joints.

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11
Q

Intervertebral disc loses water content with…leading to…

when is pain worse - on extension or flexion?

A

water content with ageing

Leads to overload facet joints & 2° OA

Pain worse with extension of spine

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12
Q

OA in one or two motion segments can be treated?

A

Yes

With localise fusion

Controversial as OA will affect adjacent level by 5 years and results inconsistent

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13
Q

Intervertebral Disc - what happens with age

A

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

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14
Q

Where do most intervertebral disc prolapses occur?

A

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

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15
Q

Where do motor neurons originate? (from spinal cord)

A

Anteriorly

Bodies in anterior grey horn.

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16
Q

Where do sensory neurons originate? (from spinal cord)

A

Originate dorsally.

Bodies in dorsal root ganglion.

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17
Q

Where do the anterior and posterior roots exit? (after forming mixed spinal nerve)

A

Intervertebral foramen

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18
Q

In the lumbar spine (cauda equine), sensory and motor nerves?

A

Run together with 2 pairs at each level susceptible to compression

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19
Q

Where does the spinal cord “end”?

A

At L1 –> Cauda equina

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20
Q

What is the structure at the end of the spinal cord? (where the cauda equina starts)

A

Conus medullaris

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21
Q

Upper motor neuron pathologies lead to…

A

Weakness
Spasticity
Increased tone
Hyperreflexia

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22
Q

Lower motor neuron pathologies lead to…

A

Weakness
Flaccidity
Loss of reflexes

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23
Q

Exiting nerve root (outside the thecal sac) passes…

A

Under the pedicle of the corresponding vertebra

L4 root passes under L4 pedicle.

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24
Q

Traversing nerve root pair…

A

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.

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25
Q

Which nerve root is commonly compressed in disc prolapse?

A

Traversing root

e.g. L5 root for L4/5 prolapse and S1 root for L5/S1 prolapse.

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26
Q

When can the exiting nerve root be compressed?

A

Far lateral disc prolapse can affect exiting nerve root.

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27
Q

What does nerve root compression cause?

A

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)

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28
Q

Radiculopathy

A

“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)

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29
Q

Which nerves contribute to the sciatic nerve?

A

L4, L5 and S1 nerve roots (along with s2 & s3)

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30
Q

Spinal stenosis

A

Where nerve roots have been compressed by osteophytes and/or hypertrophied ligaments in Osteoarthritis

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31
Q

Neurogenic claudication

walking downhill & uphill

A

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)

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32
Q

Babinski’s sign

A

Extensor plantar response (big toe is dorsiflexed and toes “fan” out)

Can indicate an upper neuronal lesion.

Abnormal plantar response

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33
Q

Cauda equina syndrome

A

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

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34
Q

If you suspect nerve root compression, what should you ask about?

A

Bladder and bowel control

Cauda equina syndrome

Loss of anal tone
Saddle anaesthesia
bowel dysfunction

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35
Q

Which muscles make up the erector spinae?

A

Iliocostalis

Longissimus thoracic

Spinalis thoracis

Source of sprains & strains

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36
Q

Ligaments of the spine

A

[Posterior Column]

Interspinous ligament

Supraspinous ligament

Ligamentum flavum

[Middle Column]

Posterior longitudinal ligament

Annulus fibrosis

[ Anterior column]

Anterior longitudinal ligament

Intervertebral disc

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37
Q

Chance Fracture

A

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

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38
Q

Causes of back pain

A

> Bones

  • Fracture – trauma, osteoporosis, (spondylolisthesis)
  • Tumour
  • Infection

> Joints

  • Spondylosis & OA
  • Spinal stenosis

> Muscles & Ligaments

  • Sprains & strains

> Disc

  • Discogenic back pain
  • Sciatica
  • Cauda equina syndrome
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39
Q

Mechanical back pain

A

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
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40
Q

When is surgery considered with sciatica?

A

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

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41
Q

Where should sciatica pain “go”

A

Below the knee at least.

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42
Q

False positive spine MRIs

A

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
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43
Q

The pelvis is made up of which bones?

A

Ilium (large, ear like one)

Ischium

Pubis

Sacrum

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44
Q

Ligaments of the pelvis

A

Sacrospinous ligament

Posterior sacroiliac ligament

Sacrotuberous ligament

VERY STRONG

Large force required to rupture them.

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45
Q

If veins/arteries in pelvis region are ruptured, what can occur? (general terms)

A

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.

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46
Q

Injury to pelvis

A

Sciatic nerve sensitive to injury at greater sciatic notch

Urethra, rectum and bladder can be injured with pelvic trauma

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47
Q

Surgery in Intra/extra capsular hip fractures

A

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
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48
Q

Which artery supplies the fovea capitis?

A

Artery of ligamentum teres (foveolar artery)

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49
Q

Avascular necrosis in the hip

A

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

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50
Q

Abductors of the leg

What is the main one?

A

Gluteus minimus, medius and maximus

Gluteus medius is the primary abductor

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51
Q

When standing on one leg (as in walking), what do the abductor muscles do?

A

Tilt the pelvis towards then standing leg.

Trendelenburg gait - pelvis tilts away from standing leg

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52
Q

Main flexor of the hip joint?

A

Iliopsoas

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53
Q

The quads are innervated by which nerve?

A

The femoral nerve

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54
Q

Quadriceps muscle is made up of?

A

Rectus femoris

Vastus lateralis

Vastus medialis

Vastus intermedius (lies deep to rectus femoris)

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55
Q

Hamstring muscles innervated by?

A

Sciatic nerve

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56
Q

Serious muscle tear of the hamstring

A

Hamstring origin avulsion

Requires surgery to reattach

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57
Q

Which muscle tendon can be used for ACL reconstruction?

A

Semitendinosus can be used as a tendon graft.

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58
Q

Adductors of the thigh are supplied by which nerve?

A

Obturator (L2,3,4)

Can refer pain from hip to knee

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59
Q

Adductor hiatus

A

Gap between adductor magnus and the femur

Transmits femoral artery and vein from Subsartorial canal into popliteal fossa

Transmits saphenous nerve

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60
Q

What type of cartilage are menisci?

A

Fibrocartilage

Act as shock absorbers between convex femoral condyles and relatively flat plateau

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61
Q

Features of the menisci in the knee

A

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

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62
Q

Medial collateral ligament (MCL) resists…

Rupture leads to…

A

valgus stress

Rupture leads to valgus instability

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63
Q

ACL resists

Rupture leads to…

A

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

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64
Q

PCL resists…

Rupture leads to…

A

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

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65
Q

Lateral collateral ligament (LCL) resists…

A

Varus stress

Resists external rotation (with PCL and posterolateral corner)

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66
Q

What is the average tibiofemoral angle?

A

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

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67
Q

Genu varum puts stress on…

A

Medial comportment leg

Medial osteoarthritis

Genu values puts stress on lateral compartment

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68
Q

Treatment for significant varies/valgus in adults?

A

Osteotomy

Involves breaking and resetting the bones.

69
Q

Knee bursae

A

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

70
Q

Which nerve innervates the anterior compartment of the leg?

A

Deep fibular nerve

71
Q

Which nerve innervates the lateral compartment of the leg?

A

Superficial fibular nerve

72
Q

Which nerve innervates the superior and deep posterior compartments?

A

Tibial nerve

73
Q

Compartment syndrome

A

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

74
Q

Deltoid ligament is found where (foot)?

A

Medial aspect of the ankle

75
Q

Which ligaments are you spraining in an ankle sprain?

A

Role your ankle

Lateral ligament sprain

2/3 ligaments sprained/incompetent for instability

76
Q

Ligaments of the lateral aspect of the foot

A

anterior talofibular ligament

posterior talofibular ligament

calcaneofibular ligament

77
Q

Talar shift is caused by

A

Occurs if either:

  • the medial malleolus is fractured
  • the deltoid ligament is ruptured

Lateralisation of talus under the tibia

78
Q

Tarsal coalition

A

Abnormal connections between tarsal bones. Complete or partial union/

Worsening pain
Adolescents

79
Q

Foot pronation

A

Eversion
Abduction
Dorsiflexion

80
Q

Foot supination

A

Inversion
Adduction
Plantar flexion

81
Q

Pes planus

A

Flat foot.

82
Q

What happens if the tibias posterior tendon elongates?

A

Flat foot –> hind foot valgus.

83
Q

Clawing of toes

Which toe does it NOT occur in?

A

Flexors stronger than extensors

Can happen in any toe except the big toe

84
Q

Hammer toe

A

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.

85
Q

The menisci act as?

A

Shock absorbers

86
Q

Knee pivoting

A

Knee pivots on medial compartment through flexion and extension

Tibia internally rotates on flexion

Externally rotates one extension

87
Q

Posterolateral corner

Rupture leads to…

A

PCL and LCL with polities and other smaller ligaments

Resists external rotation of the tibia in flexion.

Rupture leads to various and rotatory instability

88
Q

MCL and LCL blood supply

A

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
89
Q

Types of meniscal tears

A

Longitudinal tear

Bucket handle tear

Radial tear

Parrot beak tear

90
Q

Which meniscal tear is more likely to heal?

A

Longitudinal tear

91
Q

Which meniscal tear is most commonly associated with knee locking?

A

Bucket handle tear

type of longitudinal, much wider lesion

displaced meniscal fragment frequently results in knee locking.

92
Q

Meniscal tear - common patients

A

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

93
Q

Best investigation for meniscal tear?

A

MRI

Accuracy decreases with age as there are false positive findings (degenerative)

94
Q

Do radial meniscal tears heal?

A

No

95
Q

Treatment of acute meniscal tear in younger patients

A

Arthroscopic repair in acute peripheral tears

Extensive rehab

6 weeks crutches

Cant play football/sport

96
Q

Catching or locking (painful) - potential treatment

A

Consider arthroscopic meniscectomy for mechanical symptoms

For irreparable tears o failed meniscal repair

97
Q

Bucket handle tear - presentation

A

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

98
Q

FFD

A

Fixed Flexion Disorder

99
Q

Double PCL sign

A

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.

100
Q

Knee ligament injury classification (grades 1-3)

A

Grade 1: Sprain, tear some fibres but macroscopically intact

Grade 2 - partial tear- some fascicles disrupted

Grade 3 - complete tear

101
Q

MCL injury - healing

A

Usually heals well if complete tear

Unless combined with ACL or PCL rupture.

Brace, early motion and physio

Pain can take months to subside.

102
Q

ACL rupture - treatment

Clinical tests?

When is surgery considered?

Rehab

A

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

103
Q

LCL injury

A

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

104
Q

Common fibular nerve palsy is commonly associated with..

A

LCL injury

Foot drop

105
Q

PCL rupture - classic sign

A

Bruising in popliteal fossa.

Posterior sag of the tibia

106
Q

Knee dislocation

A

> 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

107
Q

Patellar Dislocation

A

> 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

108
Q

Lower limb extensors mechanism rupture

A

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

109
Q

“Sound” of an ACL rupture

A

Pop

110
Q

Soft tissue knee injuries associated with haemarthrosis

A

ACL rupture or fracture

111
Q

Effusion

A

Meniscal or chondral injury (knee swells up after a day or so)

112
Q

Pain all over the knee - due to?

A

Haemarthrosis

Blood is extremely irritant to synovium

113
Q

Hyaline Cartilage

A

> 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

114
Q

Cartilage Defects

A 
> 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.

115
Q

Osteochondritis dissecans

A

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.

116
Q

Cartilage Regeneration Techniques

  • what kind of cartilage is used?
  • when will NO techniques work?
A

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

117
Q

Knee replacement

A

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

118
Q

Knee pain presentatin

A

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

119
Q

What should you consider in knee pain?

A

That it is referred hip pain.

120
Q

Management of knee pain

A

Explanation - use a model

Keep mobile

Support

NSAID - short term

Analgesia

Physiotherapy

Referral – orthopaedics

121
Q

Osgood schlatters

A

Common knee pain problem

Inflammation of the patellar ligament at tibial tuberosity/tubercle

122
Q

Chondromalacia patellae

A

Inflammation of the underside of the patella and softening of the cartilage

Less common cause of knee pain.

123
Q

Mechanism of ACL injury

A

Non-contact ACL injuries occur when rotation occurs in the knee joint with a fixed weight-bearing foot.

124
Q

Anatomical parts of the ACL

A

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.

125
Q

Hip pain - GP presentation

A

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.

126
Q

“LOSS” acronym

A

Loss of joint space

Osteophytes

Sclerosis

Subarticular cysts

127
Q

Hip Pain - management

A 
> Education
> Weight reduction
> Home adaptations 
> Walking stick
> Analgesia
> NSAIDs
> Physio
> Complementary medicines 
> Mobility allowance, disability badge for car.

SURGERY
- many cases referred to surgery

128
Q

Hip pain - what to consider when referring.

A

Pain (worse at night)

Loss of function

Physical fitness

Mental fitness

Support at home

Age of patient

Uncertain about diagnosis

129
Q

Common causes of Hip Pain

Rarer causes

A 
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

130
Q

Hip

A

? 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?

131
Q

Main indication of Hip replacement

A

Pain not controlled by painkillers.

132
Q

Stabilisers of the shoulder joint

A

Static stabilisers

  • shoulder capsule
  • labrum

Dynamic stabilisers

  • muscles surrounding the shoulder
133
Q

Shoulder impingement - causes

A
  • Tendonitis
  • Cuff tear
  • Subacromial bursitis
  • Osteophytes from AC joint
134
Q

General treatment for shoulder joint impingement

A

Injection into subacromial space

135
Q

Painful arc in impingement

A

60-120° abduction is painful

136
Q

What can help to prevent re-dislocation of the shoulder?

A

Cuff strengthening.

137
Q

Bankart Lesion

A

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

138
Q

Most commonly associated nerve injury of an anterior shoulder dislocation

A

Axillary nerve - stretched at quadrangular space.

Can press on brachial plexus and axillary artery

Regimental badge area pain

139
Q

Adhesive Capsulitis

  • pain?
  • what is it?
  • loss of movement
  • phases
  • History
  • O/E
  • Ix
  • Treatment
A

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
140
Q

Nerve supplying anterior surface of the upper arm

A

Musculocutaneous nerve

Also supplies sensation to lateral forearm

141
Q

Coracoclavicular ligament rupture

A

Due to AC joint dislocation or clavicle fracture

Displacement of joint/bones

142
Q

Posterior compartment of upper arm - nerve supply

A

Radial nerve

143
Q

Humeral shaft fracture - which nerve is susceptible to injury?

A

Radial nerve.

supplies all extensors upper limb –> wrist drop

144
Q

Elbow joint - consists of

A

> Humero-ulnar joint

  • trochlea and olecranon
  • flexion/extension

> Radio-capitellar joint
- supination and pronation (+ radioulnar joints)

145
Q

Common extensor origin of upper limb

A

Lateral epicondyle (associated with Tennis elbow)

146
Q

Common flexor origin of upper limb

A

Medial epicondyle

Golfer’s elbow

147
Q

Supracondylar fracture

A

Risk of:

Brachial artery occlusion

Median nerve injury (radial and ulnar can also be injured)

148
Q

Monteggia fracture dislocation

A

Radius has dislocated

Ulna is fractured

149
Q

Galeazzi fracture dislocation

A

Fracture of distal 1/3 of radius

Dislocation of distal radioulnar joint

150
Q

Anterior compartment of the forearm - nerve supply

A

Median nerve

Except FCU (flexor carpi ulnari) and ulnar half of FDP (flexor digitalis profundus)

151
Q

Extensors in the upper limb are innervated by?

A

Radial nerve

152
Q

Scaphoid fracture - where is pain normally found?

A

Pain and swelling in the anatomic snuffbox

153
Q

Infection of flexor tendon sheath

A

Fibrous tissue forms in tendon sheath

Can’t move the hand

Redness tracks down the finger and hand –> SURGICAL EMERGENCY

154
Q

Thenar muscles and lateral 2 lubricals are supplied by the?

A

Median nerve.

Lumbricals 1 & 2, Opponens pollicis, Abductor pollicis brevis and Flexor pollicis brevis.

LOAF

(rest of hand muscles are supplied by ulnar)

155
Q

Flexor Digitorum Superficialis

A

Flexion of PIPJ and MCPJ

156
Q

Flexor Digitorum Profunuds

A

Flexion of DIPJ

157
Q

Finger extension

A

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

158
Q

Insertions of intrinsic muscles of hand

A

Insert into lateral bands and contribute to flexion MCPJ and extension at PIPJ

159
Q

Boutonnière deformity

A

Central slip extensor tendon rupture or attrition

160
Q

Testing the medial nerve, FDL and FDP

A

“Okay” sign

161
Q

Ulnar nerve function

A

Testing dorsal interossei abduction against resistance

Froment’s test

162
Q

Anterior and posterior dislocation of the shoulder

A

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
163
Q

Instability presentation

A

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)
164
Q

Instability treatment and management

A

Treatment

  • analgesia
  • O2
  • sedation
  • reduction my manipulation

Post reduction treatment

  • sling
  • analgesia
  • gradual mobilisation
  • physio
165
Q

Hill-Sachs lesion

A

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.

166
Q

Impingement syndrome

  • age
  • extrinsic and intrinsic causes
A

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

167
Q

Impingement -presentation / Exam / Treatment

A 
> 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
168
Q

Cuff Tear presentation

  • O/E
  • Treatment
A

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 &laquo_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

MSK (11 decks)

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