Minor Adult Disorders

Question 1

What is an enthesis?

Answer 1

Short fibrous origin of a muscle

Question 2

2 common sites for enthesopathy in the arm?

Answer 2

Common FLEXOR origin of the forearm - GOLFER’s elbow

Common EXTENSOR origin of the forearm - TENNIS elbow

A person with either of these complains of quite severe discomfort on using the affected muscle

Question 3

Prognosis of enthesopathy?

Answer 3

Generally favourable, especially when there is a clear cause - rest usually results in spontaneous recovery

Question 4

Non-surgical intervention for enthesopathy?

Answer 4

May be required if it becomes severe or chronic

Recovery may be speeded up by NSAIDs.

Local steroid injections into the point of maximum tenderness can also be of value
(take care to ensure injecting into enthesis with no leakage into subcut fat or skin, as this results in pain being exacerbated and leaves an unsightly dimple)

Question 5

Surgical intervention for enthesopathy?

Answer 5

Very small no of pts - consists of scraping the origin of the muscle from the bone and permitting it to slide distally, thus ‘decompressing’ the area. If possible pts should be encouraged to wait as in the long term spontaneous recovery is highly likely

Question 6

What is neuropraxia?

Answer 6

Compression or stretching injury to a nerve

Question 7

What will continued pressure on a nerve lead to?

Answer 7

Atrophy - which at best takes a very long time to recover, but is usually permanent - therefore, early diagnosis and management is likely to give the best results

Question 8

Causes of nerve entrapment?

Answer 8

Extrinsic - accidents e.g. where consciousness is lost and the victim inadvertently presses on a nerve. Patients in bed or plaster are also at risk in exposed sites. The most common site is the common peroneal nerve which winds round the head of the fibula

Intrinsic - most cases - caused by structural and anatomical variations or inflammatory swellings

Question 9

4 common sites for intrinsic nerve entrapment?

Answer 9

Median nerve at the wrist
Ulnar nerve at the elbow
Ulnar nerve at the wrist
Posterior tibial nerve at the ankle

Question 10

Diagnosis of nerve entrapment?

Answer 10

Any numbness or tingling in the area supplied by the nerve. Weakness and sensory loss is diagnostic. If in doubt, perform nerve conduction studies.

Question 11

Management of nerve entrapment?

Answer 11

Obvious causes such as bandage or cast must be removed

If symptoms persist, then surgical relief of pressure may be required, which involves cutting the skin and fascia

Question 12

What is tenosynovitis?

Causes?

Answer 12

Inflammation of tendons and their associated tendon sheaths - it is a common problem and often assoc w RA

In other cases it may arise spontaneously with no obvious cause, but sometimes it is precipitated by unusual levels of activity or overuse. It is often assoc w worker compensation and litigation

Question 13

What are bursae?

Function?

Answer 13

A small sac of fibrous tissue lied with synovial membrane and filled with fluid.

It acts as a natural form of ‘bearing’ aimed at improving muscle and joint function by reducing friction, usually where tendons and ligaments pass over bone. They form in response to pressure.

Question 14

How can bursae become inflamed?

Where is commonly affected?

Answer 14

They are prone to irritation from repetitive movements or strain, or abnormal loads. The shoulder, knee, elbow and greater trochanter are the most commonly affected sites

Question 15

Clinical presentation of bursitis?

Management?

Answer 15

Chronic discomfort over the bursa, usually assoc with the causative element e.g. movement or pressure.

There may also be swelling, as seen in housemaid’s knee where there is swelling of the pre-patellar bursa

Usually rest, NSAIDs and remove causative factor (e.g. use kneeling mat) - if chronic bursitis interfering with ADLs it can occasionally be excised

Question 16

Signs of infection of a bursa?

Management?

Answer 16

Pain, tense swelling and assoc overlying cellulitis, general malaise

Incision and drainage leads to recovery, but leaves scarring and fibrosis.

Question 17

Causes of painful flat feet?

Answer 17

very rare - can be spasmodic, or assoc w infection or chronic inflammatory disease. Occasionally it occurs acutely in middle age and examination reveals tender swelling over tibialis posteior, which indicates acute/impending degenerative rupture and warrants early intervention

Question 18

Management of a painful flat foot which warrants intervention?

Answer 18

Medial heel lift will correct deformity of hind foot and stabilise medial arch

If pain persists, fusion of subtalar joints will help, although this profoundly affects foot and ankle function

Question 19

What are bunions?
Cause?
Complications?

Answer 19

Fluid filled bursae, found around bony prominences, commonly over distal 1st metatarsal (and occasionally 5th).

Form as a response to pressure and indicate underlying abnormality which should be treated, rather than the bunion itself

Occasionally they can become infected and need drainage, followed by treatment of the cause or review of footwear a few weeks later

Question 20

What are corns?

Management?

Answer 20

A painful excess of corny skin, another way in which the body reacts to high pressure.

May be removed superficially but will recur if the underlying cause is not resolved?

Question 21

What is hallux valgus?

What is hallux rigidus?

Answer 21

Hallux Valgus - deviation of the 1st toe laterally from the midline, usually because of a deformity at the joint line

Hallux Rigidus - OA of 1st MTP joint

They can occur separately or together. Rx depends on whether one or both are present.

Question 22

Hallux rigidus alone:

• in adolescents?
• in adults?
• Management of each?

Answer 22

Adolescents - usually as a result of osteochondral fractures

Conservative treatment includes metatarsal bar to provide a rocker at the front of foot so the toe doesn’t bend during walking. However this usually fails as young people don’t accept the cosmetic consequences, and so surgical intervention is usually required

Adults - may present at any age, although in the elderly it rarely occurs without hallux valgus. Conservative measures are rarely sufficient and surgery usually required

Surgery - removal of osteophytes with osteotomy of the proximal phalanx is often sufficient for minor cases. Surgical fusion in the neutral position is the most reliable and doesn’t give problems with high-heel shoes. Inter-position arthroplasty with silicone plastic spacer is an alternative which gives mixed results.

Question 23

Hallux valgus alone:

• aetiology?
• management?

Answer 23

Can occur at any age. More common in women, and no evidence that shoes cause it. Many, but not all, have a shortened 1st metatarsal, often in varus. Actual cause unknown.

Management depends on age - Realignment of 1st metatarsal to a more lateral position and excision of bony prominences (exostosis) over 1st metatarsal head gives satisfactory results at any age.
Keller’s procedure - excision of the 1st MTP joint (excision arthroplasty), should be avoided in the young and is probably unnecessary if the joint is not painful.

Question 24

Hallux valgus with rigidus:

• aetiology?
• Management?

Answer 24

Seen in older pts where joint degeneration is usually secondary to valgus deformity.

Older pts may be satisfied by having pain relieved by having well-fitting, extra-depth shoes. If this fails, Keller’s arthroplasty gives safe and rapid relief, however interrupts normal foot mechanics therefore should only be offered to older, less active pts

Question 25

What is claw foot?

Associations?

Answer 25

A condition where wasted muscles make the bones and toe-nails appear more prominent, like a dog’s foot.

Often assoc w minor spinal abnormalities e.g. spina bifida occulta. Many of the patients do indeed have weak or denervated small muscles of the feet.

Question 26

What is hammer toe?
Cause?
Presentation?
Management?

Answer 26

The toe, on top, looks like the end of a hammer

They are secondary to disruption of MTP joints. Abnormalities of the foot leading to metatarsal head prolapse and joint disruption are poorly understood

Pt may present with generally sore feet - metatarsalgia

Surgery includes fusion of the interphalangeal joints in a straight position so they do not rub on shoes, and often buying a pair of soft shoes. Treatment is often unsatisfactory

Question 27

What are neuromas?
Cause?
Symptoms and diagnosis?
Management?

Answer 27

Benign growths of cutaneous nerves which may have become trapped or irritated between the metatarsal heads.

Due to repetitive trauma and may be assoc w metatarsal head prolapse

Difficult to diagnose with certainty - characteristic dull pain and throbbing, accompanied by tingling of the toes. It is difficult to localise. Classically, Mulder’s click test produces a palpable click and reproduces symptoms.

Can be excised but often accompanied by sensory disturbance to the affected toes and recurrence is common

Question 28

Cause of ingrowing toenails?
Complications?
Management?

Answer 28

Poor nail care - curved nail grows into nail fold and digs in

Trauma to nail fold skin can lead to infection, which becomes self-perpetuating and can have long-term recurrences. This can occasionally lead to blood-borne infection, which can be especially problematic if the patient has a prosthetic joint or heart valve.

Careful nail care and straight cutting will control the condition. It may be necessary to remove the nail to clear up a chronic infection. Wedge resection of the nail bed may retain the toenail and remove the problem. The surest way to fix the problem is to remove the nail bed with phenol after removing the nail, but has cosmetic consequences.

Question 29

What is the plantar fascia?

What is plantar fasciitis?

Answer 29

Tough layer of fibrous tissue which runs from the os calais to the plantar aspect of the proximal phalanges

Plantar fasciitis includes a number of vague but painful disorders of the foot - the cause is obscure and it originates spontaneously with sudden onset.

Question 30

Symptoms of plantar fasciitis?
Examination?
Prognosis?

Answer 30

Painful instep, often worse after waking, or after sitting for a few hours. Minimally relieved by walking but then persist as a debilitating ache, often exacerbated by a change of direction.

On exam there may be tenderness at the point of the hind foot, at the medial origin of the plantar fascia. Discomfort is often more diffuse

Most are self-limiting although this may take several months

Question 31

Management of plantar fasciitis?

Answer 31

No specific cure

Hollow insoles may help but cause discomfort along the edge of the hollow. Soft shoes, esp modern trainers can relieve symptoms.

If there is marked tenderness at a specific point a local steroid injection and long-acting anaesthetic can be effective, although painful to administer. Surgical stripping of the fascia from the os calcis is very unpredictable.

Question 32

Causes of neuropathic feet?
Risk?
Management?

Answer 32

Far east - leprosy
West - diabetes

Inability to recognise trauma such as rubbing or stepping on objects

Regular foot care, inspecting to ensure nails are tidy and no cuts. Footwear with extra-depth and soft uppers.
This is essential as ulcers are difficult to heal and can also lead to infection and amputation

Question 33

Symptom of achilles tendinitis?
Who does it affect?
Causes of each?

Answer 33

Pain where the achilles inserts into the os calcis

Young Athletes - overuse. The area may be tender and swollen. Rest is usually adequate to recover, but if it is recurrent then surgical decompression of the surrounding tissue may be required. DO NOT INJECT STEROIDS AS IT MAY LEAD TO TENDON RUPTURE!

Middle-Aged Men - Period of discomfort may precede rupture of tendon, which indicates degeneration of tendon tissue. Cause is poorly understood, however inferior part of tendon has poor blood supply at its insertion into os calcis and is a point of weakness in some people who are particularly active in middle age

Also assoc w Ank Spond

Question 34

Management of achilles tendon rupture?

Answer 34

It will heal itself if the ankle is kept in an equinus plaster for a minimum of 8 weeks

Can be sutured either by a closed technique or open suture. Open has high complication rate.

No matter which method is chosen, there is a high risk of re-rupture, however this decreases with time.

Wearing a felt raise in the heel go the shoe for as long as possible will help

Question 35

5 shoulder structures often involved in shoulder pain/discomfort?
What groups are at particular risk of injury?

Answer 35

Subacromial bursa
Supraspinatus tendon
AC joint
Biceps tendon
Rotator cuff as a whole

High risk of injury if involved in heavy, repetitive work or contact sports

Question 36

How to localise cause of shoulder pain?

Answer 36

Can be difficult - specialist examination along with arthrography or arthroscopy may be required

Question 37

Management of shoulder pain?

Answer 37

First try rest, gentle exercise and anti-inflammatory drugs

If this doesn’t help, and there is tenderness under active movement within a painful arc, it may be supraspinatus tendinitis or subracromial bursitis - steroid injection into the bursa or around the tendon (but not into it) may help

Occasionally if severe pain, XR may reveal calcified material, in which case injections or even surgery may be justified for the relief of pain

Injections often only work temporarily

If degenerative change or osteophytes at AC joint, this may lead to rupture of supraspinatus tendon, which is very painful and problematic - surgery to remove the cause and repair the rotator cuff will be effective
(repetitive injections into the rotator cuff can result in further degeneration of the tendons and should not be performed)

Question 38

What is ‘frozen shoulder’?
Aetiology?
Management?
Prognosis?

Answer 38

Adhesive capsulitis - the joint capsule of the glenohumeral joint becomes inflamed and stiff, causing pain and severely restricting movement

Unaccustomed activity, or obscure injuries such as in an epileptic fit can or electric shock can precipitate it. Occurs mainly in 40-65y/o and more common in females

NSAIDs and analgesia can help the pain, and steroid injections can give short-term relief. Requires lots of physiotherapy.

Recovery generally takes 18-24 months