movement term 2 Flashcards
what 2 parts of the spine are most mobile?
cervical and lumbar
what is excessive kyphosis
‘hunchback’
what is excessive lordosis? who does it often occur in?
excessive arching of back
heavily pregnant women, due to the weight distribution of baby
describe the curvature of a normal vertebral column
Thoracic and sacral kyphosis – primary curvatures – present in the foetus
Cervical and lumbar lordosis – secondary curvatures – develop later
what is scoliosis?
you see like a S shape when look at spine from back (should be straight, when viewed from back)
learn general plan of vertebrae and how it differs in each part of spine
see movement lecture on 4th jan 2017
what foramina do spinal nerves pass?
intervertebral foramina
which vertebrae contain transverse foramina? what is the function of transverse foramina?
C1-C6
passage of vertebral artery and vein to/from brain
which vertebrae are most prone to dislocation? is this likely to harm spinal cord?
cervical
less likely as vertebral foramen is very large in cervical part of spine
what is another name for the C1 vertebrae? and what is special about it?
atlas (C1)
- “circular like a globe, which shows the world like an atlas does”
- no spinous process or body
Consists of anterior and posterior arches, each of which has a tubercle and a lateral mass.
There is a tubercle each on the medial surface of the lateral mass for the transverse ligament, which holds in place the dens of the C2 vertebrae.
what is another name for the C2 vertebrae? and what is atypical about it?
axis (C2)
- “the axis on which the globe (atlas) spins on”
C2 has two large flat surfaces, the superior articular facets, upon which the atlas rotates.
It’s distinguishing feature is the dens (G. tooth), also known as the odontoid process (or peg)
This held in position by the transverse ligament of the atlas - prevents horizontal displacement of the atlas.
nb together the atlas and the axis allow for rotation of neck
what type of joint is the one between the atlas and the dens (of the axis)? why is this clinically relevant?
synovial
it can be affected by rheumatoid arthritis
what part of the axis is most vulnerable to fracture, why?
the dens
- as this part is less dense
what shape is the vertebral body of thoracic vertebrae?
heart shaped
“the heart is in the thorax”
what part of thoracic vertebrae do the tubercles of the ribs articulate with?
tubercle articulate with costal facets on transverse process of vertebrae (SAME number as rib)
what part of thoracic vertebrae do the heads of the ribs articulate with?
Head of rib articulates with the superior demifacet of the corresponding (same number) vertebra and the inferior demifacet of the vertebra above
what is spondylolisthesis?
Spondylolisthesis is where a bone in the spine (vertebra) slips out of position, either forwards or backwards.
what is the name of the joints between vertebrae? (not the ones seperates by discs)
zygapophysial (facet) joints
Facet (zygapophysial) joints occur between superior and inferior articular processes of adjacent vertebrae
Orientation of articular facets determines types of movements that are possible
what are the 2 parts of intervertebral discs?
Annulus fibrosis – peripheral fibrocartilage ring attached to the rim of vertebral body
Nucleus pulposus – central gelatinous substance that acts as a ‘shock absorber’
- and distribution of weight
what happens to your vertebral discs as you get older? and what affects does this have?
water content of discs decreases
- reduced flexibility of spine
- reduced shock-absorber capability
what are the 5 main ligaments of the vertebral column?
- ligamentum flavum
- posterior longitudinal ligament
- anterior longitudinal ligament
- interspinous/supraspinous ligament
- intertransverse ligament (between transverse processes)
what is the function of ligamentum flavum?
binds lamina of adjacent vertebrae (paired)
- ie around zygapophysial joints
holds vertebrae together
what is the function of the posterior longitudinal ligament?
prevents posterior herniation of articular discs (ie slipped disc) onto spinal cord
what is the function of the anterior longitudinal ligament?
prevents hyperEXTENSION of vertebral column
what is the function of the interspinous/supraspinous ligaments?
prevents hyperFLEXION of vertebral column (along with the posterior longitudinal ligament)
what is ‘whip lash’? what is it caused by?
hyperEXTENSION of cervical spine
- anterior ligament is torn
- (in severe cases, get ‘tear drop’ fracture of vertebrae and dislocation of one above)
Commonly caused by rear-end shunts (RTAs), especially if head rest too low
what are the 3 places in the body where osteoporosis is most common?
- distal radius (colles fracture)
- shaft of femur
- vertebrae (especially thoracic)
what type of fractures occur in the vertebraeof people with osteoporosis?
compression (‘wedge’) fracture
what happens to vertebral bodies as you get older?
loss of bone density with age –> CONCAVE vertebral bodies
this puts increased force of rims of vertebrae, and OSTEOPHYTES develop in response
what is a ‘slipped disc’? where is it most likely to occur?
herniation(/prolapse) of nucleus pulposus (of intervertebral disc) into vertebral canal
normally L4/L5 or L5/S1
what can severe cases of slipped disc cause? what are the red flags for this?
cauda equina syndrome (compresses most of cauda equina)
- incontinence (loss of bladder function)
- inability to squeeze external anal sphincter (when do PR)
- can’t feel around anus
- loose function of bladder, bowel and legs if not treated!!!
“unable to ride a horse if you have cauda EQUINA syndrome”
what does a normal intervertebral disc look like on MRI? and an abnormal one?
normal = whiteish (shows high water content!)
dehydrated = black and thinner than normal
what part of the normal curvature of the spine do people tend to loose as they get older? (which can cause back pain)
lumbar lordosis
what happens to the vertebrae and intervertebral discs as you age?
Discs lose water and lose strength and become thinner
Vertebral endplates and underlying bone structure loses strength
Repetitive loading/trauma can result in annular tears in the discs
Dryer, weaker discs result in slacker ligaments
Spine is less stable
New bone grows to try to stabilise the spine
Increased load over the facet joints
what is an osteophyte?
a bony projection associated with the degeneration of cartilage at joints
(in spine, means that patients cannot extend their spine)
what does the growth of osteophytes result in?
osteoarthritis
what two things should patients with lower back pain do?
keep flexible
keep strong
(even if it hurts!)
what are 7 risk factors for back pain?
- genetics
- high BMI
- low muscle strength
- not using spine enough (mechanical loading strengthens vertebral bodies + increases water content in discs)
- heavy physical jobs (/not lifting things correctly)
- poor mental health
- poor posture (incl sitting at comp descs)
what is a typical presenting history of someone with mechanical (‘simple’) back pain?
- 1st episode: sudden onset while lifting/twisting/turning
- recurrent episodes with decreasing inter-episode frequency
- variable pain related to posture/position
- better lying flat
- may radiate to but or leg
- often worse at end of day
- does NOT wake them up at night
what is the recommended management of mechanical back pain?
- light exercise
- no imaging (100% of people over 65 have changes on x-ray)
- keep active (not bed rest)
- return to work with light duty option
- analgesics as needed
how long does lower back pain have to be going on for before you consider secondary care referral?
longer than 6 weeks
if lower back pain is not responsive to normal analgesics (paracetamol, NSAIDs, opiods) - which it often isn’t!, what drugs should be used?
low dose antidepressants
(amitriptyline, duloxetine)
nerve modulators/anti-epileptic drugs
(pregabalin, gabapentin)
what are the spinal roots of the sciatic nerve?
L4-S3
what are the symptoms of sciatica? 3
pain: radiating from back down leg to BELOW knee
may be associated with pins + needles in leg
may be associated with numbness and weakness (most commonly foot drop and loss of ankle jerk reflex)
what is the most common cause of weight loss in the elderly?
depression
what are ‘red flag’ symptoms of back pain? 9
- age at FIRST onset very young (20s) or very old (70+)
- history of cancer
- weight loss
- constant (24hr) pain >1 month
- no response to treatment
- pain worse at rest
- history of immunosuppresion, positive HIV or IV drug abuse
- UTI or other infection
- pain wakes patient up at night
what infection in the back do immunosuppressed patients sometimes get?
discitis
what cancers commonly metastasise to bone? 6
Breast. Prostate. Lung. Kidney. Thyroid. liver.
what is a typical presentation of inflammatory back pain?
- insidious onset (can’t remember/pinpoint when it started - as came on so gradually)
- nocturnal pain with marked early morning stiffness (stiff back >30mins after waking)
- better with exercise, worse with rest
- family history
- buttock pain (normally unilateral, and swaps sides, comes + goes)
why do patients with inflammatory back pain get pain in their buttocks?
inflammation in sacroilliac joints
what is ankylosing spondylitis?
a type of RA which involves long term inflammation of the spine
pain and stiffness in spine
affects young people
(men more than women)
FH of associated diseases (IBD, psoriasis, RA, type 1 diabetes etc)
what is ‘bamboo spine’?
Bamboo spine is a radiographic feature seen in untreated ankylosing spondylitis that occurs as a result of vertebral body fusion by marginal syndesmophytes. It is often accompanied by fusion of the posterior vertebral elements as well.
what are the risk factors for osteoporosis? 7
- age
- female (esp LACK of oestrogen post menopause)
- smoking
- steroids
- alcohol
- family history (important)
- inflammatory conditions (incl autoimmune stuff)
what are the symptoms of osteoporosis?
NO symptoms
until you get a fracture
(eg hip fractures or wedge fractures in spine)
‘the silent disease’
what are the risk factors for osteomalacia?
- low calcium/vit D diet
- darker skin
- low sunlight exposure
what is paget’s disease?
thickening/increased turnover of bones (esp pelvis, spine and/or thigh)
often asymptomatic
have very high alkaline phosphatase (ALP)
prevelence increases with age
what is a typical presentation of back pain caused by a neoplasm or infection
- insidious onset (sometime subacute)
- slow deterioration
- 24hr pain
- weight loss
- associated symptoms
- sometimes fever
what are the ‘red flag’ symptoms of cauda equina syndrome? 5
lower back (and/or leg) pain
numbness around the anal and genital region
(ask! - patients won’t volunteer this!)
paralysis of one or both legs
loss of bowel control (bowel incontinence)
loss of bladder control (urinary incontinence)
what is spinal stenosis?
Spinal stenosis is an abnormal narrowing (stenosis) of the spinal canal that may occur in any of the regions of the spine. This narrowing causes a restriction to the spinal canal, resulting in a neurological deficit.
The main symptoms of spinal stenosis are pain, numbness, weakness and a tingling sensation in one or both legs. This can make walking difficult and painful.
Most cases occur in people aged over 60
requires surgery
what are the three joints of the pelvic girdle?
2x sacroilliac joint
1x pubic symphysis
what is another name for the hip bone?
what three bones make up the hip bone?
where do they fuse?
innominate bone
- illium
- ischium
- pubis
fuse at the acetabulum
what three structures stabilise the hip joint?
- acetabular anatomy (natural deep, made deeper by acetabular labrum - a rim of cartilage)
- fibrous capsule
- ligaments
what are the three ligaments that stabilise the hip joint?
- ILEOfemoral
- PUBOfemoral
- ISCHIOfemoral
each originate from bone that’s in their name
the articular surface is crescent shaped and is deficient inferiorly.
what is this gap called?
what bridges this gap?
acetabular notch
bridged by: transverse acetabular ligament
what is the proximal and distal attachements of the fibrous capsule surrounding the hip joint?
proximal: encircles rim of acetabulum
distal: intertrochanteric line and greater trochanter (of the femoral neck)
describe the position + function of the iliofemoral ligament
covers hip joint SUPERIORLY + ANTERIORLY
“makes sense since illium is most superior + anterior of the parts of the hip bone”
- strongest ligament
prevents hyperEXTENSION of hip (during standing)
- ‘screws in’ femoral head
describe the position + function of the pubofemoral ligament
covers hip joint INFERIORLY + ANTERIORLY
- “pubic bone is anterior + inferior”
- prevents excessive ABDUCTION
- – “ie pulls leg towards PUBic bone”
describe the position + function of the ischiofemoral ligament
covers hip joint POSTERIORLY
- weakest ligament
“the ISCHiofemoral ligament wISHes it could domore but it is pushed to the BACK by the other stronger ligaments!”
what is shenton’s line?
imaginary line drawn along the inferior border of the superior pubic ramus (superior border of the obturator foramen) and along the inferomedial border of the neck of femur. This line should be continuous and smooth.
Interruption of the Shenton line can indicate:
- developmental dysplasia of the hip (DDH)
- fractured neck of femur
what is the most commonly fractured part of the hip bone?
superior or inferior pubic rami
what is a ‘hip fracture’ normally referring to?
a fracture to the neck of the femur
what is an open book fracture?
where the pubic symphasis is completely broken and the two hip bones are pushed apart
what is the commonest cause of posterior hip dislocation?
RTAs (leg is driven back)
impact to knee when hip is: - flexed - internally rotated - adducted ie seated position
what other 2 injuries might occur with a posterior hip dislocation?
- sciatic nerve injury
- acetabular fracture
when do anterior hip dislocations occur?
when hip is:
- flexed
- (leg) abducted
- (leg) externally rotated
The thigh and leg act as a lever, with the fulcrum being the posterior edge of acetabular socket, popping the femoral head out of the socket anteriorly.
on presentation: limb is externally (laterally) rotated, abducted and flexed!
what is a central dislocation of the hip?
what other injuries occur alongside it? 2
aka medial dislocation
head of femur is pushed hard into pelvis
- large haemorrhage
- acetabulum fracture (as head of femur effectively breaks through acetabulum to get into pelvis)
what are the three blood vessels which supply the femoral head?
what occurs if these are blocked by dislocation/fracture?
- branch of the obturator artery (at ‘top’ of head)
- lateral femoral circumflex artery
- medial femoral circumflex artery
avascular necrosis of femoral head
what does subluxation mean?
just a little slipping of joint (it’s not fully in place but is also not completely dislocated!)
what is the treatment for congenital dysplasia of the hip?
kids have to be in casts/braces to hold their hip jointss in place for first few weeks (or months, depending on severity) of life
what are the 3 main flexors of the hip?
and the 6 weak flexors?
- illiosoas
- rectus femoris (one of the quads)
- sartorius
weak flexors:
- pectineus
- tensor fasciae latae
- adductor longus
- adductor brevis
- adductor magnus (anterior part)
- gracilis
what are the main extensors of the hip?
- gluteus maximus
- the hamstrings
- adductor magnus (posterior/hamstring part)
which muscle in the posterior thigh is NOT considered to be a hamstring?
why?
short head of biceps femoris
- doesn’t span the hip joint so only flexes the knee, doesn’t also extend the hip, like the true hamstrings
what are the 4 true hamstrings?
- LONG head of biceps femoris
- semitendinous
- semimembranous
- posterior (hamstring) part of adductor magnus
what are the abductors of the hip? 3
what is their main function?
gluteus medius + minimus
also tensor fascia latae
keeping the pelvis level when you lift one foot off the ground
what are the main adductors of the hip? 6
- adductor brevis
- adductor longus
- adductor magnus (anterior (adductor) part!)
- pectineus
- obturator externus
- gracilis
what are the lateral rotators of the hip? 7
- gluteus maximus
- piriformis
- superior gemellus
- obturator internus
- inferior gemellus
- quadratus femoris
- obturator externus
what are the 3 medial rotators of the hip?
- ANTERIOR fibres of gluteus medius
- ANTERIOR fibres of gluteus minimus
- tensor fasciae latae
what is the blood supply to the hip joint?
medial and lateral circumflex femoral arteries
- branches of deep artery of the thigh (profunda femoris)
- – which is a branch of femoral artery
a branch of the obturator artery
what 4 nerves could be damaged during a hip fracture?
- femoral nerve
- obturator nerve
- superior gluteal nerve
- nerve to quadratus femoris
what are the different types of hip fracture?
classified based on where in the bone they occur
intracapsular (in neck of femur)
extracapsular (distal to greater trochanter)
- intertrochanteric (proximal to lesser trochanter)
- subtrochanteric (the 5cm distal to the lesser trochanter)
when examining a patient with a suspected hip fracture, what should you ‘look’ for during an ‘end of bed’ expection?
- symmetry of hips
- length length (of legs) discrepancy
- muscle wasting
- scars
- around the bedside
what is the management/treatment for hip fractures?
- pain management
- hydration
- treat medical problems
- medically optimise for surgery
surgery (put in a metal hip)
- early mobilisation after surgery
what are 3 possible causes of atraumatic acute swelling in the knee?
- acute gout
- flare of OA
- flare of RA
(nb always be looking out for septic joints)
what are two possible causes of chronic knee pain/swelling?
- OA
- bursitis
what are the 2 main types of hip fracture?
if broken, what treatment do they normally get, especially in the elderly?
intracapsular (proximal to superior + inferior trochanters)
- partial hip replacement (replace head of femur, leave native acetabulum)
- – due to risk of avascular necrosis (AVN)
extracapsular (distal to trochanters)
- plate and rod or two rods in femur + neck of femur
what type of hip replacement is given to people with severe arthritis?
total hip replacement
replace neck/head of femur AND acetabulum
what 3 bones articulate with each other to form the knee joint?
- femur
- tibia
- patella
(NOT the fibula!)
what are the 3 articulation points at the knee joint?
2 x femorotibial (medial + lateral) (lateral femoral condyle articulates with lateral tibial condyle + same with medial)
1 x femoropatellar
is the knee more stable in flexion or extension?
extension
what structures act to deepen (+ so stabilise) the knee joint?
the menisci
- made of fibrocartilage
- thicker at external margins (form a wedge shape)
(nb the don’t connect in the middle!)
meniscal tears:
- why do they occur?
- symptoms?
- treatment?
- possible complications?
- sports injury
- degenerative changes
- pain of knee
- locking of knee
- repair
- resection
- associated with development of OA
what 3 sets of things provide stability of the knee joint?
- ligaments INSIDE the joints (intra-articular)
- ligaments OUTSIDE the joint (extra-articular)
- surrounding muscles
name the two intra-articular ligaments of the knee?
what are there attachments + directions?
which is stronger?
anterior cruciate ligament
- anterior intercondylar region (of the tibia) -> supero-posteriorly -> lateral femoral condyle
posterior
- posterior intercondylar region (of the tibia) -> supero-anteriorly -> medial femoral condyle
the PCL is stronger than the ACL
nb called cruciate as they cross over and form a cross
“if it starts anterior (and so is named anterior) then it must travel posteriorly to cross the joint”
what is the function of the:
- PCL?
- ACL?
PCL:
- prevents hyperFLEXION
- prevents posterior displacement of the tibia on the femur (eg walking down hill/stairs)
- main stabiliser of flexed knee when weight bearing
ACL:
- prevents hyperEXTENSION
- prevents anterior displacement of the tibia on the femur
what sort of action can cause injury to:
- the PCL?
- the ACL?
PCL:
- landing on the tibial tuberosity with the knee flexed
ACL:
- hyperextension
- force applied anteriorly
name the two extra-articular ligments
what is their structure?
what are their functions?
which are attached to the meniscus?
tibial (aka medial) collateral ligament
- flat band
- prevents aBduction at the knee
- ATTACHED to meniscus
fibular (aka lateral) collateral ligament
- cord-like band
- prevents aDduction at the knee
- NOT attached to meniscus
nb if attached to meniscus then means injury of one is likely to injure the other too
what is the ‘unhappy triad’ of knee injuries?
what normally causes it?
cause:
- excessive lateral twisting of the flexed knee
- blow to lateral side of extended knee
- torn tibial (medial) collateral ligament
- torn medial meniscus
- torn ACL (as it’s taut during flexion)
nb these injuries may occur in isolation but often see them together
which three tendons make up the ‘goose foot’?
what is the latin name for this?
where is this?
- semitendonosus
- gracilis
- sartorius
pes anserinus (pes = foot)
proximal part of tibia (medial knee)
what groups of muscles stabilise the knee joint?
- quads (anteriorly)
- hamstrings (posteriorly)
- sartorius
- gracilis
- illiotibial tract
what is the iliotibial tract
a thickening of the fascia lata on the lateral side of the thigh
it is tightened by the small muscle: tensor fasciae lata
what is the function of the sartorius muscle?
- flexes at the hip
- abducts the hip
- laterally rotates the hip
- flexes the knee
“Turning the foot to look at the sole demonstrates all four actions”
nb although sartorius is in anterior compartment, it flexes (NOT extends) at the knee!
how does locking of the knee occur?
what ‘unlocks’ the knee?
as joint approaches full extension, femur undergoes a few degrees of MEDIAL ROTATION on the tibia = locking!
(very stable position, therefore thigh muscles can relax)
‘unlocked’ by the POPLITEUS muscle
- this LATERALLY ROTATES the femur
“POPliteus POPs the knee out, unlocking it!”
how does inflammation of the bursae around the knee joint present?
aka bursitis
- non-red swellings around knees (not normally painful)
- very fluidy effussion
basically oedema around the knee
which way does the patella normally dislocate?
why?
what part of the knee joint tries to prevent this?
how do you get patella ‘back in’?
almost always dislocates LATERALLY
because
- rectus femoris, vastus intermedius + vastus lateralis all pulling superoLATERALLY
- ONLY vastus medialis is pulling superoMEDIALLY (though tries to counteract as fibres are more horizontal than other quads
lateral femoral condyle is larger and so sticks out more than medial one to try to prevent lateral dislocation
extend knee very slowly (with lots of analgesia) and, as you approach full extension, pop patella back in! - very painful!!
are men or women more likely to get dislocation of the patella? why?
women are much more likely
as pelvis is wider and shallower
-> so femur comes towards knee at more oblique/diagonal angle
aka Q angle is larger in females (angle between femur on the tibia)
so lateral pull on the knee is stronger
what is it called when:
- tibia is ADDUCTED with respect to femur?
- tibia is ABDUCTED with respect to femur?
what can both of these things lead to? why?
tibia is ADDUCTED with respect to femur:
- genu varum
- ‘bow-leggedness’
tibia is ABDUCTED with respect to femur:
- genu valgum
- ‘knocked-knees’
“valGUM knees are stuck together with GUM”
OA, as weight of body is not evenly distributed across knee joint -> strain on one side
osteoarthritis:
- what does it look like on x-rays?
- when is it most painful?
on x-rays:
- unclear edges of bone
- osteophytes
- uneven joint spaces
nb appearance of OA on x-ray is poorly correlated to people’s perception of symptoms so joint replacement is decided more on symptoms + QOL than x-ray findings
most painful when active, improves on rest
what 3 bones make up the ankle joint?
what movements are possible at the ankle?
tibia (forms medial malleolus)
fibula (forms lateral malleolus)
talus
- dorsiflexion + plantar flexion ONLY!
is the ankle most stable (best congruity) in dorsiflexion or plantar flexion?
why?
dorsiflexion
talus is wider anteriorly than posteriorly
- during dorsiflexio, anterior part of the trochlea moves between the malieoli
- spreading the tibia + fibula slightly, increasing their grip on the talus
what are the 4 main ligaments of the ankle joint?
lateral:
- anterior talofibular ligament
- posterior talofibular ligament
- calcaneofibular ligament
medial:
- deltoid ligament (medial malleolus -> talus, navicular + calcaneus)
which nerve + artery supplies these compartments of the leg + what movements do the muscles in these compartments produce:
- anterior?
- posterior?
- lateral?
anterior:
- deep fibular (peroneal) nerve
- anterior tibial artery
- dorsiflexion
posterior:
- tibial nerve
- posterior tibial artery
- plantar flexion
lateral:
- superficial fibular (peroneal) nerve
- fibular artery
- eversion
at what joint does inversion + eversion primarily occur?
subtalar joint (between talus + underlying calcaneus)
with some movement at the transverse tarsal joint
what are most ankle sprains caused by?
which is the weakest ligament of the ankle? + so the most commonly injured
inversion of a plantar-flexed foot
- though can get eversion injuries but less common (as deltoid ligament is strong)
anterior talofibular ligament
what are the 3 arches of the foot?
what are the functions of these arches? 4
- medial longitudinal (MLA)
- lateral longitudinal (LLA)
- transverse (TA)
- distribute weight
- act as shock absorbers
- increase flexibility of foot
- springboards for propulsion during walking, running + jumping
what 2 mechanisms support the arches of the foot?
passive support:
- ligaments
- shape of the bones
active support
- intrinsic muscles of foot
- extrinsic muscles of foot
what is it called when someone has no foot arches (‘flat foot’)?
- 2 types?
- normal cause?
- exacerbated by? 2
- problems caused? 2
- treatment?
pes planus
flexible
- most common
- arch is present when non-weight bearing but absent when standing
rigid
- arch never present
- eg due to fusion of tarsal bones
normal cause: loose or degenerating ligaments
- gaining weight
- long time standing
- may be asymptomatic
- can result in displacement of talus infero-medially
- > misalignment of ankle + knee -> pain
- can also decrease shock absorption -> lower back pain
treatment: orthotics (specialised insoles)
what movements are possible at the toes?
- flexion/extension
- limited abduction/adduction
what is the commonest cause of calcaneal fractures?
jumping off something + landing on heel
how do you tell if a patella is from the right or left leg?
the ‘point’ of the patella points inferiorly and the lateral articular surface is larger than the medial surface, you can work this out from knowing this
where is the tibial plafond?
the horizontal bit of the tibia which is directly above the talus
what are 5 tips for effectively examining an orthopaedic x-ray?
- 2 views are better than 1 (always do lateral + AP views)
- Compare with other side
- Compare current with previous images (of same patient)
- Keep your eye on the ball (eg ignore constipation if person w hip pain)
- Look for the unexpected (eg apical lung mass pushing on brachial plexus in xray of shoulder coukld cause shoulder pain where no shoulder injury)
what sort of pelvic injury could you expect to see in a patient with a high force/crash injury?
Pubic symphysis and sacroiliac joint diastasis
fractures of the tibial plateau are often subtle on x-ray, what 2 signs can you look for?
Lipohaemarthrosis (blood etc in bursae above patella + around joint)
Depressed tibial plateau
nb see these in lateral x-ray
what are avulsion fractures?
what do they look like on x-ray?
the tendon or ligament pulls off a piece of the bone
- see a ‘floating’ bit of bone - as ligaments/tendons don’t show on xray
what do GALS and REMS stand for?
what are they used for?
GALS
- gait
- arms
- legs
- spine
- – a screening exam
REMS
- Regional Exam of the Msk System
- – more detailed exam
rheumatoid vs osteo arthritis:
- age of onset?
- speed of onset?
- joint symptoms?
- symmetric?
- duration of morning stiffness?
- systemic symptoms?
rhematoid
- any age
- relatively rapid (weeks/months)
- joints are painful, swollen, stiff
- symmetric joints affected
- norm over an hour
- fatigue + generally feeling unwell
osteoarthritis
- late in life
- slow (over years)
- joints ache + may be tender but no swelling
- often start asymmetric then go to both sides
- norm less than an hour
- no systemic symptoms
joints normally affected in:
- RA?
- OA?
rheumatoid:
- shoulders
- elbows
- wrists
- MCP joints
- thumbs
- knees
- ankles
- — get ‘swan neck deformity’ in hands
osteo:
- neck
- base of thumb
- PIP + DIP joints
- lower back
- hips
- knees
- base of big toe
what is it called when OA affects:
- proximal IP joints?
- distal IP joints?
proximal IP joints:
- Bouchard’s nodes
distal IP joints:
- Heberden’s nodes
- “hebrides islands are far out into see, so most distal!”
what can cause secondary OA?
- following injury
- congenital abnormal joint
- abnormal stresses on joint (eg obesity)
- previous inflammation (so can get secondary to RA or inflammatory arthritis)
- neuropathic joints (eg due to diabetes mellitus)
psoriatic arthritis:
- risk of getting if you have psoriasis?
- joints affected?
- symetric?
- other signs? 2
30% of people witrh psoriasis will get
- elbows
- knees
- ALL joints in hands
often asymmetric
- dactylitis (inflammation of whole digits) - ‘sausage fingers’
- enthesitis (inflammation where tendons insert)
nb psoriasis norm affects the OUTSIDE of joints (opposite to ezcema)
what is the ‘prayer sign’ a sign of?
flexion contractures secondary to diabetes (after long time of having it)
positive prayer sign is when fingers don’t touch all the way down when you do a ‘prayer sign’
what can affect gait in ‘normal’ people? 9
- height
- weight
- build
- age
- clothing
- shoes
- pain
- mental state/mood
- intoxication
what brain structure does alcohol affect which has a knock effect on a person’s coordination?
what is the name of this gait?
which direction does an intoxicated person normally fall?
cerebellum
ataxic gait
- not symmetrical, flailing arms + legs around
on their back (injure back of head)
what gait changes are typically seen in the elderly?
how do elderly people tend to increase their walking speed?
- reduction in overall velocity
- reduction in step/stride length
- decreased arm swing
- decreased rotation of pelvis
- more flat footed approach to both heel strike + push off
to increase speed
- elderly taake more steps
- normally people just increase stride length
gait cycle:
- two main phases?
- start of cycle?
- stance phase (60%)
- swing phase (40%)
start = ‘heel strike’
nb when one leg is in stance other is in swing and vice versa, 10% of time they are both in stance = double support
what action occurs at the hip to keep the hips level when one foot is off the ground?
what muscles provide this movement? 3
what gait is present when these muscles are damaged?
abduction at hip
- gluteus medius
- gluteus minimus
- tensor fascia lata
trendelenburg gait
what structure is essential for the final stage of the stance phase?
what is this stage called?
if this structure was damaged, what bsort of abnormal gait would be present?
- what are the main features of this gait? 2
hallux (big toe)
‘toe-off’
- (aka pre-swing)
apropulsive gait
(weak push off)
- shorter stride length
- decreased gait velocity
during the swing stage, what are the three mechanisms by which the swinging leg is shortened?
- hip flexion
- knee flexion
- ankle dorsiflexion
what muscle contracts to prevent you falling forwards?
soleus
an ‘anti-gravity’/posture muscle
what muscles contract to maintain a relatively stable centre of gravity?
aDductor muscles
they pull the knees into the midline to limit lateral shift in gravity
how should you, generally, assess gait?
top down approach
- look at arms and trunk before legs
- symmetry
- orientation of parts
- timing of motions
assess specific tasks
- stairs, running etc
what are the 5 broad groups of pathology which can affect gait?
- motor impairment
- sensory impairment
- pain
- physical restriction (eg in gait)
- lack of normal restriction (ie hypermobility)
what is the type of gait commonly caused by a major stroke?
describe it
what compensatory mechanisms are often employed?
hemiplegic gait
on affected side:
- arm in flexion all the time, reduced swing
- leg is in extension (poor ability to flex)
- foot unable to dorsi flex -> drop foot
lift hip up and swing leg around = circumduction
- as can’t shorten limb during swing phase
what is the name of the gait seen in patients with parkinson?
describe it
festinating gait
(shuffling)
slow small shuffling steps
difficulty starting, stopping and turning corners
what is the technical for ‘limping’? seen when someone has acute or chronic pain in a part of one leg
antalgic gait
what sort of gait is seen in patients who have reduced sensation in their feet and legs?
describe it
who is this most commonly seen in?
insensate gait
hard to see without instrumented gait analysis, only very subtle changes:
- walk a bit slower
- slightly wider gait
normally secondary to diabetes
‘foot drop’:
- cause?
- gait? (w description)
- treatment?
damage to common fibular/peroneal nerve (normally at the head of the fibula)
-> loss of motor innervation to anterior compartment -> inability to dorsiflex foot
high steppage gait
- patients flex their knee + hip more than normal to shorten limb, to compensate for lack of dorsiflexion
- often walk with a ‘thud’
treat with a splint or electrically stimulating of muscles
what is the name of the gait often seen in patients with cerebal palsy?
describe it
why does it occur?
Equinus gait ('toe walking')
- "horses walk on their toes"
- walk on their toes (plantar flexion)
- move their arms and trunk around a lot to balance
- knees slightly flexed all the time
due to contractures of the plantar flexor muscles, tendons become permanentely shorter
- us arms and trunk more for balance as walking on toes is much less stable
what gait changes can be seen in people with hypermobility?
- can become flat footed (pes planus)
- foot often pronates a lot during walking
