MSK Flashcards
What is the diagnostic test for fractures?
Xray
What imaging modality is best for soft tissue and liagments?
MRI
what can treatment of an open fracture involve?
ORIF = open reduction, internal fixation
surgical debridement
IV abx
tetanus vaccine
What can treatment of a closed fracture involve?
treated non-surgically with immobilisation
What is the most common fracture in children?
Greenstick
what is a subluxation? How does it present?
Partial dislocation
often after injury
often obvious deformity or typical posturing
Ix and Mx for a subluxation?
XR to confirm diagnosis and rule out any concurrent fractures
Mx - reduction & stabilisation
check neurovascular status before and after
What does presentation of compartment syndrome involve?
Pain out of proprotion - excessive need for breakthrough pain relief pallor parathesia pulselessness polkilothermia paralysis
Investigations for compartment syndrome
intracompartmental pressure measurements
>20mmHg - abnormal
>40mmHg - diagnostic
XR usually normal
CK and urine myoglobulin elevated
What does management of Compartment syndrome involve?
Immediate fasciotomy
aggressive IV fluids -
fasciotomy often results in renal failure
if tissue necrotic - consider debridement and amputation
Patient presenting with a couple days history of pain moving shoulder
middle aged
diabetic
hx of shoulder injury/surgery
Adhesive capsulitis
what conditions is adhesive capsulitis associated with?
diabetes
thyroid disease
what clinical signs O/E are indicative of adhesive capsulitis?
external rotation more affected
Coracoid pain test positive
What investigations are done for adhesive capsulitis?
none - usually clinical
XR only done if symptoms persistent or is presentation atypical - r/o any fractures of posterior dislocation
How is adhesive capsulitis managed?
first line - NSAIDs and physio
second line - intra-articular steroids (can give PO)
Pain on abduction and positive empty can test
which muscle is affected?
Supraspinatus
Pain on external rotation
which tendon is affected?
Infraspinatus
adhesive cap is a ddx - with hx of DM
Pain on internal rotation
which tendon is affected?
Subscapularis
Painful abduction
recent over the head activity
painful arc 60-120°
anterior acromion tenderness
Subacromial impingement
Management approach for rotator cuff injuries?
NSAIDs
physio
IA steroids - if symptoms persistent or unresponsive to NSAIDs
FOOSH followed by externally rotated arm at side of body
greater fullness of the shoulder
may be visibly deformed
Anterior shoulder dislocation
Ix and management for Anterior shoulder dislocation?
XR
reduction and appropriate pain relief
Which nerve should be tested on shoulder dislocations? How is it tested?
axillary nerve
- check sensation in the deltoid
Causes of posterior shoulder dislocation?
seizures
electrocution
medially rotated arm - very locked in position
front of shoulder appears flat
prominent coracoid process
posterior dislocation
Ix and Mx of posterior dislocation
XR - axillary view
mx - posterior reduction (closed)
if missed/ no detected - open reduction up to 8/52 after injury
Lower back pain red flags
aged under 20 or over 50 hx of previous malignancy night pain/ pain wakes them up hx of trauma systemically unwell/constitutional symptoms saddle anaesthesia loss of anal sphincter tone loss of bowel/bladder continence
Diagnosis of lower back pain
clinical - no lab or imaging needed
Management of lower back pain
Patient education
Analgesia - NSAIDs/Paracetamol
muscle relaxants
! avoid bed rest !
morning stiffness <15mins worse with certain activities onset often post injury fluctuating symptoms overuse also RF
mechanical back pain
morning stiffnedd >1hr better with movement insidious onset progressive typically younger patients
Inflammatory back pain
male in 20s lower back pain of insidious onset morning stiffness (longer duration) improves on exercise pain at night - imporved on getting up sacroiliac pain
Ankylosing spondylitis
signs of ankylosing spondylitis on examination
reduced lateral flexion
reduced forward flexion
positive schobers test (>5cm)
Other features of Ankylosing spondylitis?
6As apical fibrosis (lung disease) anterior uveitis aortic regurg achilles tendonitis AV node block amyloidosis
Investigations for ankylosing spondylitis
raised inflammatory markers - ESR/CRP
XR - ‘bamboo spine’
sclerosis, subchondral erosions and syndesmophytes and squaring of lumbar vertebrae
if XR normal but clinical suspicion remains - MRI
genetic tests for HLA-B27
CXR - apical fibrosis
spirometry - restrictive picture
Management of ankylosing spondylitis
first line = NSAIDs
If peripheral joint involvement = DMARD (sulphasalazine)
Encourage regular exercise and physio
What nerves are compressed in cauda Equina?
L1-S5
What are the causes of Cauda Equina?
central disc prolapse - L4/5 or L5/S1
others include - trauma, haematoma, infection, tumours
Presentation of Cauda Equina?
Lower back pain bilateral sciatica or progressive neuro deficit in limbs Decreased anal tone bowel/bladder incontinence saddle anathesia
Ix for Cauda Equina?
urgent MRI
Management for Cauda Equina?
surgical decompression
under neurosurgery
What are the complications of cauda equina?
bladder/bowel/sexual dysfunction
leg weakness
sensory impairment
What is herniated disc pulposus?
A condition characterised by lower limb pain resulting from spinal nerve compression
Causes of herniated disc pulposus?
herniated disc
vertebral body mets
back pain
unilateral leg pain - worse than back
worse on sitting, radiates to foot/toes
associated numbness and paresthesia
herniated disc pulposus
presentation of L1-L3 nerve roots affected in herniated disc pulposus involves…
pain from lower back radiating to hip or anterior thigh
reduced knee reflex
+ve femoral stretch - thigh pain
presentation of L4-S1 nerve roots affected in herniated disc pulposus involves….
pain radiates below the knee
Investigation for herniated disc pulposus
MRI diagnostic
Management for herniated disc pulposus?
analgesia - NSAIDs
physio
exercising
persistent symptoms - 4-6wks can refer for an MRI
What is spinal stenosis?
The narrowing of part of the spinal canal resulting in compression of the spinal cord and nerve roots
commonly lumbar spine affects, in 50-60s
Causes of spinal stenosis include?
congenital stenosis, degenerative changes, herniated discs, spinal fractures and tumours
insidious back pain,
paresthesia on ambulation and relieved when supine
Bilateral leg pain - often worse on standing and walking or leaning forward
normal pulse
lower extremity pain and numbness
spinal stenosis
spinal stenosis presenting with unilateral leg pain suggests?
unilateral foraminal stenosis
spinal stenosis presenting with bilateral leg pain suggests?
central or bilateral foraminal stenosis
Ix for spinal stenosis?
MRI
to r/o PAD - ABPI & angio
Management approach to spinal stenosis?
spinal specialist to recommend exercise, analgesia and physio
DDX for spinal stenosis
peripheral arterial disease
neuropathy
What is kyphosis?
‘hunchback’ - a curvature of the spine measuring 50 degrees or greater on an X-ray
often seen in those with osteoporosis and in the elderly
What is lordosis?
the inward curve of the lumbar spine
often seen in pregnancy
What is scoliosis?
a sideways curvature of the spine
treated dependent on the degree of scoliosis
<20° = exercise and monitor
21-45° = bracing
>45° = surgery
loss of cartilage under the patella
chondromalacia patella
chondromalacia patella presentation
pain in the knee - dull ache
aggravated by deep bending
hypermobile patella with significant crepitus = grinding sensation
Investigations
XR = bone to bone (patella and femur)
what is patellofemoral pain syndrome?
broad term for pain in and around the patella - chondromalacia patella is one of the causes
knee pain - worse on straightening the knee
associated swelling, stiffness
restricted ROM and locking
instability
hx of injury
Mechanism of injury = twisting leg
Meniscal tear/injury
What special tests can be done to test for meniscal injury?
Mc Murray’s
Apley grind tests
not in clinical practice due to causing pain and worsening the injury
What are Ottawa Knee rules?
used to determine if imaging warranted
- aged 55+
- isolated patella tenderness
- fibular head tenderness
- cannot flex knee to 90°
- cannot wait bear <4 steps
scoring any 1 of criterion warrants imaging
Ixs for meniscal injury
XR - if ottawa rules warrant
MRI scan - first line
arthroscopy - GOLD STANDARD (diagnosis and allows for therapeutic intervention)
management for meniscal injury?
Conservative - RICE protocol
NSAIDs - first line analgesia
Physio for rehab
Surgery - arthroscopy
loss of anterior/posterior stability
knee painful, swollen
Weight bearing can be difficult
‘pop’ heard during injury
+drawer tests
Cruciate ligament injury
What does mechanism of injury for ACT involve?
blow to the back of knee combined with rotation - often in sports
What does mechanism of injury for PCT involve?
anterior force - dashboard collision in RTA
How are cruciate ligament injuries investigated?
Conservative management - RICE
NSAIDs first line
physio - pre and post surgery
arthroscopic surgery
- if reconstruction required
- young, active patients
Pain, swelling and redness in knee - swelling prominent
difficult to kneel or walk
history of trauma
occupation or recreational activities involving repetitive or prolonged kneeling
pre-patellar bursitis
Causes of Pre-patella bursitis?
acute trauma
chronic trauma - repetitive pressure/overuse
gout or RA/SLE
Ix for pre-patellar bursitis?
bursal aspiration - rule out septic knee or crystal-induced bursitis
bloods - CRP, ESR, WCC, uric acid, blood glucose, ANA and RF
XR - if bony abnormality suspected
management of pre-patellar bursitis?
if confidently ruled out septic joint
- ICE, activity modification and simple analgesia
if not responsive to conservative measures - aspirate or steroid injection
Septic joint suspected = empirically treat with antibiotics (flucloxacillin 500mg QDS)
Single joint
hot painful erythematous swollen joint
restricted ROM
tender on palpation
may have hx of trauma, recent illness, IV drug user, STI
Septic joint
What are common organisms associated with septic joint
children - staph or strep
sexually active adults - Neisseria gonorrhoeae
Ix for septic joint
aspirate - gram stain and culture
contraindicated if prosthetic joint
Management of septic joint
IV Abx - vancomycin
what is acute osteomyelitis? what is the most common causative organism
infection of bone commonly caused by staph aureus
non-specific pain
fever
malaise
swelling around affected bone
acute osteomyelitis
Ix for acute osteomyelitis?
Bloods - raised WCC, CRP, ESR
XR = osteopenia and bone destrctiion
- MRI better
Blood culture and bone cultures
Management of acute osteomyelitis?
High dose flucloxacillin (6/52)
- if pen allergy = offer clindamycin
some may need surgical debridement
What is chronic osteomyelitis associated with?
Prosthetic joints
Management of chronic osteomyelitis?
3/12 of antibiotics (perhaps longer)
some may require complete revision/replacement surgery of prosthetic limb
osteoma info?
benign tumour - overgrowth of bone often in skull
association gardener’s syndrome (polyps/FAP)
osteochrondroma info?
most common benign bone tumour
more common in males, under 20s
‘cartilage capped bony protrusion’
giant cell tumour?
benign tumour
multinucleated giant cells
affects 20-40s
epiphyses of long bones predominantly affected
XR = double bubble or soap bubble - described as radiolucent lesion
Osteosarcoma info
malignant bone tumour
mainly children and adolescents
metaphyseal region
may have pagets, Rb gene and radiotherapy hx
younger age (child-teenager) Bone pain intially localised then persistent ache in the area - pain at night B symptoms
osteosarcoma
Ix and management for osetosarcoma
XR - codman triangle or sunburst patten
mx - chemotherapy and radiation therapy
Other malignancy bone tumours
erwing’s sarcoma - children/adolescents in the pelvic and long bones
- severe pain and Onion skin appearance on XR
Chondrosarcoma - affects axial skeleton and middle aged men
aged 10-17, mainly males high BMI Limping pain in knee pain in hip (&groin) affected leg externally rotated reduced ROM and loss of internal rotation
slipped capital femoral epiphysis (SCFE)
How is SCFE investigated?
XR
- bilateral hips
- lateral views
- frog shaped position
Management of SCFE?
internal surgical fixation (1-2 screws)
often bilateral procedure as prophylactic measure
What is Legg Calve Perthes disease?
self-limiting disease affecting children in the growing phase and is essentially AVN of femoral head
RFs for Legg Calve Perthes?
boys
aged 4-8yrs
hypercoagulability
painless limp + hip pain
- worse on activity
- gradual onset over a few weeks
shortening of limb
O/E: reduced ROM
Legg Calve Perthes
Investigations for Legg Calve Perthes?
AP XR - lateral views in frog leg position
= widening joint space in earlier stages
= decreased/flattened femoral head size in later stages
if XR normal but pt symptomatic - MRI
Management of Legg Calve Perthes?
earlier stage + younger age (<6yrs) = Conservative
- immobilise, cast/braces
- appropriate physio and monitoring with XR
if later stage, more sever case or older age (>6yrs) of presentation = surgical intervention
What is developmental hip dysplasia?
A spectrum of conditions affecting the proximal femur and acetabulum
RFs for developmental hip dysplasia?
first born girls breech baby left hip usually affected more birth weight >5kg oligohydramnios
restricted abduction of hip in flexion
+ve barlow or ortalani tests
legs may be not symmetrical when flexed bilaterally
developmental hip dysplasia
Outline the tests involved in developmental hip dysplasia
barlow = attempts to dislocate femoral head
ortolani = attempts to relocate the femoral head
Ix for developmental hip dysplasia?
US - confirms diagnosis
if abover age of 4.5/12 - can do XR
Management of developmental hip dysplasia
observe and consider splinting
- 3-6weeks needed for hip to stabilise
- Pavlik harness - <4-5/12
dislocated hip = reduce, splint
Screening measures for developmental hip dysplasia?
routine US in infants
- hip problem in first degree family member
- breech presentation at 36weeks+
- multiple pregnancy
Newborn checks - barlow and ortolani done in examination
Localised point tenderness on the outside of hip
- on lateral aspect on hip + thigh
- can radiate down thigh
O/E = pain on flexion+ extension, abduction and rotation
+ve trendelenburg test
trochanteric bursitis
Diagnosis and management of trochanteric bursitis?
clinical diagnosis - no Ix needed
mx - exercise, RICE and analgesia
= steroid injection into bursa
recovery time = 6-9 months, sometimes longer
Pain in hip
uanble to mobilise + unable to bear weight
shortened and internally roatated
- may be flexed and adducted
Hip dislocation
Ix for dislocated hip?
XR - confirm dx + rule out concurrent fractures also
Management of dislocated hip?
ABCDE approach
analgesia
reduce hip under GA within 4hrs - reduce risk of AVN
long-term mx = physiotherapy
which type of hip dislocation is the most common? mechanism of injury?
posterior
major/high imapct trauma
dashboard due to RTA
complications from hip dislocation?
sciatic/femoral nerve injury
AVN
OA - more in older pts
recurrent dislocation - if there is damage to supporting ligaments
RFs for AVN?
alcoholism
steroids use
chemotherapy/immunosupressant
sickle cell anaemia
groin pain - radiates to leg
pain resistant to analgesia
presence of RFs - etoh, steroid use, chemo/immunosuppressed. SCA
AVN of hip
Investigations for AVN of hip?
XR
- initially normal, some signs of osteopenia/microfractures may be present
- later = collapse of articular surface, crescent sign
> 6wks symptomatic + normalXR = consider MRI
Management of AVN of hip?
ortho referral and MRI if not previously been done
early tx - total hip replacement = increase chances of hip survival
pain in groin
unable to bear weight
leg shorterned, externall rotated and adducted
older pt, female, minor injury
NOF/hip fracture
Ix and dx of NOF/hip#?
XR - AP and lateral view needed
- disrupted Shenton’s line seen on AP
MRI/CT done if XR normal but clinical suspicion remians
classfication system of hip fractures? In which is blood supply affected?
Garden System - 4 types
Types 3&4 = disrupted blood supply
Management of Hip fractures
Intracapsular - internal fixation or hemiarthroplasty (unfit pt)
Extracapsular - dynamic hip screw or intramedullary device if oblique, transverse or subtrochanteric
otho input & surgery needed on same day or within 48hrs
encourage weight bearing and mobilisation soon after surgery = faster recover
if hip pain
leg abducted and externally rotated
normal length of affected leg
anterior dislocation
joint pain and stiffness little or no effusion no erythema reduced ROM joint crepitus
older pt
if in hands - heberden’s nodes or bouchard’s nodes
Osteoarthritis
RFs for osteoarthritis?
obesity increasing age occupation trauma female FHx
Ix and classical findings in OA?
XR
- loss of joint space
- subchondral sclerosis
- osteophytes
Management of OA?
educate + advise weight loss if appropriate
exercises + improve muscle strength
pain control - analgesia, joint aspiration/injections
surgery - knee replacement
What is metabolic bone disease?
refers to conditions/problems in bones resulting from abnormalities in minerals - calcium & phosphate vitamins - vit D deficiency bone mass bone structure
what is osteoporosis?
Osteoporosis is the loss of bone mass
weakening of bone - poses risk of fractures
RFs for osteoporosis?
post-menopausal women increasing age smoker steroid use (long-term) low BMI
Presentation of osteoporosis?
often asymptomatic and diagnosed when a pt has a fracture
not associated with pain
Ix & Dx of osteoporosis?
DEXA scan - look at T score
-2.5 to 0 = osteopenia (mild thinning/weakening of bone)
< -2.5 = osteoporosis
Management of osteoporosis?
- bisposphonates
- drug holiday every 3-5yrs - calcium + vitD supplements
Side effects of bisphosphonates?
oesophagitis - take while sitting up straight
osteonecrosis of jaw
Screening tools for osteoporosis?
FRAX
QFracture
what is Osteomalacia? What is the term for it in children?
softening of bones secondary to low vitD levels which in turn leads to decreased bone mineral density
referred to as rickets in children
Causes of osteomalacia?
bone pain
bone and muscle tenderness
proximal myopathy (arms and legs)
- waddling gait (difficulty getting around)
common seen fracture - NOF
Ixs in osteomalacia?
bloods - low vitD/calcium/phosphate and raised ALP
XR = translucent bands (looser zones and pseudofractures
Management of Osteomalacia?
vitD supplementation
calcium supplementation is dietary intake inadequate
What is Paget’s disease?
increased and uncontrolled turnover of bone
which bones are affected in Paget’s disease?
skull, spine/pelvis, long bones of lower extremities
RFs fro paget’s disease
male
increasing age
FHx
northern latitude
usually asymtpomatic
bone pain + isolated raised ALP
bowing of tibia
bossing of skull
Paget’s disease
Ix for Paget’s disease?
blood - raised ALP, normal calcium/phosphate
other markers - PINP, CTx,
urinary NTx and hydroxyproline
XR
- early disease = osteolysis
- later disease = mixed lytic/sclerotic lesions
- skull = thickened vault & osteoporosis circumscripta
Bone scintigraphy - increased uptake = focally active bone lesions
Management of Paget’s disease?
bisphosphonates - oral or IV
Complication of paget’s disease?
deafness (CN involvement)
bone sarcoma
bone disorder (CKD-MBD)
What is renal bone disease?
low vitD means that there is high serum phosphate
this in turn means high calcium
calcium stimulates osteoclast activity
dysregulating bone turnover
3 main features of bone disease?
osteomalacia - increased bone turnover without adequate calcium
osteoporosis
osteosclerosis = compensatory increased osteoblastic activity without adequate calcium - cannot mineralise properly
How is CKD-MBD investigated?
XR of spine
- sclerosis at the ends of vertebrae
- osteomalacia in the centre of vertebra
Management of CKD-MBD?
active forms of vit D
low phosphate diet
osteoporosis tx with bisphosphonates
insidious onset of pain in the lateral aspect of elbow, can radiate down forearm feels like a burning sensation pain on wrist extension difficulty lifting/raising objects
localised point tenderness
+ve maudsley test
reduced ROM - passive & active
lateral Epicondylitis
aka ‘tennis elbow’
Mx of lateral epicondylitis?
conservatively manage - rest, physio and NSAIDs
point tenderness of the medial aspect of the elbow
insidious onset of pain
hx of repetitive movements - occupational or sports
Medial epicondylitis
Which muscles are affected in medial epicondylitis?
flexors and pronators
Management of epicondylitis?
conservatively manage
- rest, physio and NSAIDs
mechanism of injury FOOSH
pain and tenderness
dinner forks - prominent back and depressed front
colle’s fracture
what are key features of a colles?
- transverse fracture
- 1inch proximal to radio-carpal joint
- dorsal displacement and angulation
Management of a colles fracture?
straighten deformity and immbolise for ~6wks
distal fracture
displaced ventrally
mechanism of injury - falling on flexed wrists
Smith’s wrists
Ix and Mx for smith’s fracture
XR & straighten/immbolise
hard nodules turn into thicker, nodular cord
can be palpated on affected palm
ring/small fingers commonly affected
+ve table top test
Dupuytren’s contracture
RFs for Dupuytren’s contracture
manual labour/trauma to hand
phenytoin treatment
alcoholic liver disease
DM
Ix and Mx of Dupuytren’s contracture
clinical diagnosis - no Ix needed
early cases = monitor
step 2 = steroid injection
surgery
- removal of abnormal fascia
not using affected arm extended forearm in pronation distressed only on moving elbow no swelling, bruising around the elbow or wrist tenderness absent in most supination of forearm - resistance+pain
Pulled elbow
Ix for pulled elbow
XR - subluxation of radial head
Management of pulled elbow?
reduction and immobilisation - flexed at 90°
analgesia for pain management
FOOSH
Pain along radial aspect of wrist
loss of grip/pinch strength
wrist effusion
anatomical snuffbox tenderness
pain on telescoping thumb and ulnar deviation
Scaphoid fracture
Investigations for a scaphoid fracture?
XR wrist - AP and lateral views
CT = XR normal but clinical suspicion
MRI - definitive when other imaging has been inconclusive
Management of scaphoid fractures?
immobilise with futuro splint/backslab
refer to orthopaedics
if imaging inconclusive - see ortho within 7-10days
6-8wks cast = undisplaced #
surgical fixation = displaced #
or proximal scaphoid pole #
complications of scaphoid #?
AVN
non-union = pain and early onset arthritis
aching tingling and paresthesia in the hand
hand feels swollen, numb and can have burning sensations
lateral aspect of palm , thumb, index, middle and half ring finger
symptoms nocturnal - temporary relief on shaking/hanging on bedside
worsened by strenuous movement
+ve phalen’s and tinel’s test
Carpel tunnel syndrome
which nerve is affected in carpal tunnel?
median nerve
Ix for Carpel Tunnel syndrome?
nerve conduction studies/electrophysiological studies
Management of carpel tunnel syndrome?
conservative = NSAIDs & nocturnal splints and steroid injections for 6wks
if severe/very symptomatic = surgical decompression
pain on radial aspect of wrist
tender on radial styloid process
abduction of the thumb against resistance painful
+ve finkelstein’s test = ulnar deviation and longitudinal traction
De Quervain’s tenosynovitis
management of De Quervain’s tenosynovitis ?
analgesia, steroid injection, splinting of thumb
surgical tx sometimes required
Boxer’s fracture
punching resulting in fracture of the 5th metatarsal
Management of boxer’s fracture?
immobilise with splint
analgesia
hx of recent trauma
ankle pain and swelling
unable to weight bear
medial/lateral malleolus tenderness and swelling
Ankle fracture
What are the Ottawa ankle rules?
bony tenderness on either
- lateral malleolar zone
- medial malleolar zone
bony/point tenderness on 5th metatarsal or navicular pain
inability to weight bear (<4steps)
Ixs for ankle fracture?
XR
Management for ankle fracture?
open fracture = surgical fixation
closed fracture = reduce and splint
mechanism of action = inversion of foot
pain. , swelling, tenderness over the affected ligaments
- sometimes bruising
reduced ability to weight bear
ankle sprain
Which ligament is commonly sprained in the ankle
anterior-inferior tibio-fibula ligament
Ix for ankle sprain?
if Ottowa ankle criterion met = XR
MRI if persistent pain (evaluate perineal tendons)
Management of ankle sprain?
non operative - RICE protocol
occasionally given cast/splint for short-term relief
persistent symptoms or significant joint instability = consider MRI & surgery
high ankle sprains mechanism of injury and key feature?
usually occurs following external rotation of foot - talus and fibular pushed laterally
more severe pain on weight bearing
hopkin’s squeeze test elicits pain
What is achilles tendinopathy?
involves damage, swelling, inflammation and reduced function of achilles tendon
RFs for achilles tendinopathy?
sports, inflammatory conditions, diabetes, raised cholesterol and flouroquinolone use
gradual onset pain on arching achilles tend or heel with activity
stiffness
tenderness & swelling
nodularity on palpation of tendon
achilles tendonopathy
management for achilles tendinopathy?
rest, altered activities and analgesia
using insoles
extracorporeal shock-wave therapy, or surgery
sudden onset pain in the achilles or calf snapping sensation or sound palpable gap, tender around achilles more dorsiflexed foot weak plantar flexion unable to stand on tiptoes \+ve simmonds/thompsons test
Achilles tendon rupture
Investigation and diagnosis of achilles rupture?
US
management of achilles rupture?
admit to hospital - ortho referral
immediate mx = rest, immobilise, RICE
non-surgical = boot in full plantar flexion for 6-12weeks + long period of rehab
surgical = reattachment of tendon, immobilise in boot and slowly adjust to neutral position + long period of rehab
development of bony lump over the MTP of base of big toe
develops over time
first metatarsal becomes angulated medially
pain particularly on walking or wearing tight socks
bunion/hallux valgus
Ix for bunion/hallux valgus ?
weight bearing XR
- assess extent of deformity
management of bunion/hallux valgus ?
conservatively manage through advising using wide, comfortable socks
analgesia
definitive tx = surgery - realign bone and correct deformity
toes middle joint is bent
deformity often of 2nd, 3rd and fourth middle toe
hammer toes
how are hammer toes managed?
definitive = surgical fixation
gradual onset pain on plantar aspect of heel
- worse with pressure, standing or walking for prolonged periods
- pain described as stabbing
- most painful are first few steps
- relieved on rest
plantar aspect of heel is tender to palpate
plantar fasciitis
plantar fasciitis diagnosis and management?
clinical diagnosis - no Ix needed
management - rest and advise insole use
exercise and physio
NSAIDs
RFs of plantar fasciitis?
aged 40-60
runners
obesity
pain between the 3rd, 4th toes - marble sensation
- pain can be described as a burning, numbness or parasthesia
pain eliciited on deep palpation
+ve metatarsal squeeze test
mulder’s sign +ve
morton’s neuroma
How to investigate morton’;s neuroma?
US or MRI - confirms diagnosis
Management of morton’s neuroma?
Adapting activities, better footwear/insoles
analgesia
if appropriate advise weight loss
steroid injections, radiofrequency ablation and surgery
commonly in diabetics with peripheral neuropathy
swelling, pain and redness
altered shape of foot
hx of injury/fractures of bones in foot
charcot’s joint
