MSK Flashcards
most common cause of osteomyelitis
in normal
in px w sickle cell
normal - staph aureus
sickle cell - salmonella
imaging for osteomyelitis
MRI best for dx
mx osteomyelitis
surgical debridement of infected bone + tissues
acute =
flucloxacillin 6 wks
clindamycin if penicillin allergic
Vancomycin or teicoplanin when treating MRSA
chronic =
3 months+ abx
if assoc w prosthetics = complete revision surgery to replace
sx + s of ACL injury
Damaged during a twisting injury to knee
Sudden painful ‘popping’ sensation with rapid swelling
Inability to return to activity
Lateral knee and joint line tenderness
Lachman test often positive
Anterior drawer test may be positive
osteoporosis RFs
SHATTERED FAMILY
Steroid use >5mg/day prednisolone
Hyperthyroidism; hyperparathyroidism, hypercalciuria
Alcohol and tobacco use
Thin (BMI <22)
Testosterone low (e.g. anti androgen in cancer of prostate)
Early menopause (oestrogen is protective against it)
Renal or liver failure
Erosive/inflammatory bone disease (e.g. RA or myeloma)
Dietary Ca low/malabsorption or DMT1
Fhx
+ve simmonds sign
archilles tendon rupture
what maneuver is used for reduction of dislocated shoulders
Stimson
mx of diff grades of Acromioclavicular joint injury (shoulder hit in collision sports or FOOSH)
(rockwood classification used)
Grade I and II injuries are very common and are typically managed conservatively including resting the joint using a sling.
Grade IV, V and VI are rare and require surgical intervention.
III = either
when to do ankle x ray
if there is pain in the malleolar zone and:
1. Inability to weight bear for 4 steps
2. Tenderness over the distal tibia
3. Bone tenderness over the distal fibula
weber classification of ankle fractures
Related to the level of the fibular fracture.
Type A = below the syndesmosis - leaves it in tact
Type B = at the level of the ankle joint – the syndesmosis will be intact or partially torn
Type C = above the ankle joint – the syndesmosis will be disrupted
mx of ankle fractures
All ankle fractures should be promptly reduced to remove pressure on the overlying skin and subsequent necrosis
Weber A&B: cast/boot and weight bear as tolerated
Weber C (unstable): open reduction internal fixation
Follow-up in 6-8 weeks
what is a buckle fracture
incomplete fractures of the shaft of a long bone that is characterised by bulging of the cortex
head parts flattened out a bit due to pressure
typically occur in children aged 5-10 years
what is a greenstick fracture
occurs when a bone bends and cracks, instead of breaking completely into separate pieces. Most common in children under 10.
usually has a wedge + bit still hanging on
what is a salter harris fracture
A fracture that involves the epiphyseal plate or growth plate of a bone. Childhood fracture most common in the long bones.
what is spinal stenosis
refers to the narrowing of part of the spinal canal, resulting in compression of the spinal cord or nerve roots.
by tumour, disk prolapse or other similar degenerative changes.
presentation of spinal stenosis
gradual onset
Intermittent neurogenic claudication is a key presenting feature of lumbar spinal stenosis with central stenosis. It is sometimes referred to as pseudoclaudication. Typical symptoms are:
Lower back pain
Buttock and leg pain
Leg weakness
The symptoms are absent at rest and when seated but occur with standing and walking.
Bending forward (flexing the spine) expands the spinal canal and improves symptoms.
Standing straight (extending the spine) narrows the canal and worsens the symptoms.
Lateral stenosis and foramina stenosis in the lumbar spine tends to cause symptoms of sciatica.
always need MRI to confirm
how to mx suspected scaphoid fractures (maximal tenderness over anatomical snuff box)
immobilisation using a below-elbow back slab and repeat radiographs in 7-10 days/Futuro splint
subacromial impringement - where is the pain
a rotator cuff injury
= painful arc of abduction between 60 + 120 deg
where is the pain in rotator cuff tears
in the first 60 deg in arc of abduction
will also be weakness compared to opp arm, muscle wasting + tenderness
what is compartment syndrome
complication that may occur following fractures (or following ischaemia reperfusion injury in vascular patients)
- raised pressure within a closed anatomical space -> compromised tissue perfusion -> necrosis
most common fractures to result in compartment syndrome
supracondylar fractures and tibial shaft injuries.
features of compartment syndrome
Bone fracture or crush injury
Pain, especially on movement (even passive), disproportionate
- excessive use of breakthrough analgesia should raise suspicion for compartment syndrome
Parasthesiae
Pallor
Arterial pulsation may still be felt as the necrosis occurs as a result of microvascular compromise
Paralysis - worrying
limb swelling
dx compartment syndrome
usually clinical
measurement of intracompartmental pressure measurements using needle manometry
>20mmHg is abnormal and >40mmHg is diagnostic
tx compartment syndrome
essentially prompt and extensive fasciotomies
tx displaced intracapsular hip fracture
hemiarthroplasty (if not healthy/dementia) or total hip replacement (if healthy)
tx undisplaced intracapsular hip fracture
internal fixation (healthy)
tx extrascapular hip fracture
stable intertrochanteric fractures: dynamic hip screw
if reverse oblique, transverse or subtrochanteric fractures: intramedullary nail
features of hip fracture
pain
the classic signs are a shortened and externally rotated leg
patients with non-displaced or incomplete neck of femur fractures may be able to weight bear
red flags for lower back pain
age < 20 years or > 50 years
history of previous malignancy
night pain
history of trauma
systemically unwell e.g. weight loss, fever
thoracic/middle
sudden onset + progression
spinal stenosis back pain
gradual onset
unilateral/bilateral leg pain, numbness, weakness worse on walking
relieved by sitting down
, leaning forward + crouching down
clinical exam often normal
ank spon back pain
Typically a young man who presents with lower back pain and stiffness
Stiffness is usually worse in morning and improves with activity
Peripheral arthritis (25%, more common if female)
PAD back pain
Pain on walking, relieved by rest
Absent or weak foot pulses and other signs of limb ischaemia
Past history may include smoking and other vascular diseases
main cancers with mets to bones
PORTABLE
Po – Prostate
R – Renal
Ta – Thyroid
B – Breast
Le – Lung
what is polymyalgia rheumatica
inflam condition that causes pain + stiffness in shoulders, pelvic girdle + neck
strong assoc w GCA
older white px
presentation polymyalgia rheumatica
onset of sx over days to weeks, sx present for 2 wks b4 dx
pain + stiffness of: shoulders, pelvic girdle, neck
this is:
worse in morning
interferes w sleep
takes 45 mins to ease in the morn
improves w activity
NO TRUE WEAKNESS
assoc features:
systemic sx
muscle tenderness
carpel tunnel
peripheral oedema
dx polymyalgia rheumatica
Based on clinical presentation, response to steroids and excluding differentials.
Inflammatory markers usually raised
Ix b4 steroids:
FBC
U&Es
LFTs
Ca (abnormal in hyperparathyroidism, cancer + osteomalacia)
Serum protein electrophoresis for myeloma
TFTs
Creatine kinase for myositis
RF for RA
Urine dipstick
Consider:
Anti-nuclear antibodies (ANA) for SLE
Anti-cyclic citrullinated peptide (anti-CCP) for rheumatoid arthritis
Urine Bence Jones protein for myeloma
CXR for lung + mediastinal abnormalities (e.g., lung cancer or lymphoma)
tx polymyalgia rheumatica
15mg prednisolone daily then follow up after 1 week
If they have it there will be dramatic improvement in sx
Then follow reducing regime
additional mx for px on long term steroids
Don’t STOP
Don’t – steroid dependence occurs after 3 weeks of treatment, and abruptly stopping risks adrenal crisis
S – Sick day rules (steroid doses may need to be increased if the patient becomes unwell - double)
T – Treatment card – patients should carry a steroid treatment card to alert others that they are steroid-dependent
O – Osteoporosis prevention may be required (e.g., bisphosphonates and calcium and vitamin D)
P – Proton pump inhibitors are considered for gastro-protection (e.g., omeprazole)
what is Greater trochanteric pain syndrome (Trochanteric bursitis)
Due to repeated movement of the fibroelastic iliotibial band
Pain and tenderness over the lateral side of thigh
Most common in women aged 50-70 years
what is a t score and z score (+ what are they based on)
T score of -1.0 means bone mass of one standard deviation below that of young reference population
T score: based on bone mass of young reference population
Z score is adjusted for age, gender and ethnic factors
t score ranges
> -1.0 = normal
-1.0 to -2.5 = osteopaenia
< -2.5 = osteoporosis
< -2.5 + a fracture = severe osteoporosis
what is a compound fracture
when the skin is broken and the broken bone is exposed to the air. The broken bone can puncture through the skin.
what is a stable fracture
when the sections of bone remain in alignment at the fracture
what is a pathological fracture
when a bone breaks due to an abnormality within the bone
may occur with minor trauma or even spontaneously
Common sites are the femur and the vertebral bodies
what fractures typically occur in children
+ only occur in children
Greenstick and buckle fractures
Salter-Harris fractures only occur in children (adults do not have growth plates)
what is a colle’s fracture
a transverse fracture of the distal radius near the wrist, causing the distal portion to displace posteriorly (upwards), causing a “dinner fork deformity”.
what is a colle’s fracture the result of
fall on outstretched hand (FOOSH)
can also get scaphoid fracture
key sign of scaphoid fracture
tenderness in the anatomical snuffbox
problem w scaphoid fractures
scaphoid has a retrograde blood supply, with blood vessels supplying the bone from only one direction. This means a fracture can cut off the blood supply, resulting in avascular necrosis and non-union.
which bones have vulnerable BS
the scaphoid bone, the femoral head, the humeral head and the talus (bone at top of foot), navicular and fifth metatarsal in the foot
what bones do ankle fractures involve
lateral malleolus (distal fibula) or the medial malleolus (distal tibia)
what is the distal syndesmosis
fibrous join between the tibia and fibula
what happens in pelvic ring fractures
when one part fractures another part will also fracture
often lead to signif intra-abdominal bleeding, either due to vascular injury or from the cancellous bone of the pelvis -> shock and death -> emergency resuscitation + trauma management.
what is a fragility fracture
occur due to weakness in the bone, usually due to osteoporosis. They often occur without the appropriate trauma that is typically required to break a bone
FRAX tool
A patient’s risk of a fragility fracture over the next 10 years
DEXA scan
to measure bone mineral density
first-line mx to reduce risk of fragility fractures
Calcium and vitamin D
Bisphosphonates (e.g., alendronic acid) (start if >75 w/o waiting for a dexa scan)
how do bisphosphonates work
reduce osteoclast activity preventing resorption of bone
SEs of bisphosphonates
reflux + oesophageal erosions
atypical fractures
osteonecrosis of jaw
osteonecrosis of external auditory canal
how to take oral bisphosphonates
on an empty stomach sitting upright for 30 minutes before moving or eating
alt when bisphosphonates CI
Denosumab - a monoclonal antibody that works by blocking the activity of osteoclasts
what is a fat embolism
Can occur following the fracture of long bones (24-72 hrs after). Fat globules are released into the circulation following a fracture (poss from the bone marrow), they may become lodged in BVs and cause blood flow obstruction.
Can cause a systemic inflam response -> fat embolism syndrome
criteria for dx of a fat embolism
Gurd’s major criteria
- resp distress
- petechial rash
- cerebral involvement
Gurd’s minor criteria inc:
- Jaundice
- Thrombocytopenia
- Fever
- Tachycardia
what is osteomyelitis
inflammation in a bone and bone marrow, usually caused by bacterial infection
can be acute or chronic
ways infection can occur in osteomyelitis
Haematogenous osteomyelitis - when a pathogen is carried through the blood and seeded in the bone, most common
Can occur due to direct contamination of the bone from adjacent tissues / structures e.g. during op
osteomyelitis RFs
Open fractures
Orthopaedic operations, particularly with prosthetic joints
Diabetes, particularly with diabetic FOOT ULCERS
Peripheral arterial disease
IV drug use
Immunosuppression
osteomyelitis presentation
Fever
Pain and tenderness
Erythema
Swelling
Purulent discharge
quite non spec
initial signs of osteomyelitis on XR (not gd for dx)
Periosteal reaction (changes to the surface of the bone)
Localised osteopenia (thinning of the bone)
Destruction of areas of the bone
what is trochanteric bursitis
inflammation of a bursa over the greater trochanter on the outer hip
produces pain localised at the outer hip (greater trochanteric pain syndrome)
what are bursae
sacs created by synovial membrane filled with a small amount of synovial fluid.
-found at bony prominences (e.g., at the greater trochanter, knee, shoulder and elbow)
- reduce friction between the bones and soft tissues during movement.
what is bursitis
inflammation of a bursa -> thickening of the synovial membrane and increased fluid production -> causing swelling.
causes of bursitis
Friction from repetitive movements
Trauma
Inflammatory conditions (e.g., rheumatoid arthritis)
Infection – referred to as septic bursitis
trochanteric bursitis presentation
middle-aged patient with gradual-onset lateral hip pain (over the greater trochanter) that may radiate down the outer thigh
-pain is aching or burning
-worse with activity, standing after sitting for a prolonged period and trying to sit cross-legged
-may disrupt sleep, can’t get comfy
examination in trochanteric bursitis
tenderness over the greater trochanter (no swelling unlike bursitis in other areas)
special tests:
- Trendelenburg test
- Resisted abduction of the hip
- Resisted internal rotation of the hip
- Resisted external rotation of the hip
mx trochanteric bursitis
Rest
Ice
Analgesia (e.g., ibuprofen or naproxen)
Physiotherapy
Steroid injections
6-9 mths to recover fully
It can rarely be caused by infection but if so - abx
what does the ACL do
stops the tibia from sliding forward in relation to the femur
how is the ACL attached
The ACL attaches at the anterior intercondylar area on the tibia + originates from the lateral aspect of the intercondylar notch in the femur
first-line ix for dx ACL injury
MRI scan
gold standard for dx ACL injury
Arthroscopy
mx ACL injury
urgent referral in patients with an acute onset of knee pain associated with symptoms suggestive of an acute ACL tear
Conservative management RICE:
R – Rest
I – Ice
C – Compression
E – Elevation
NSAIDs for analgesia
Crutches and knee braces
Physiotherapy
Arthroscopic surgery
what is a baker’s cyst
a fluid-filled sac in the popliteal fossa (diamond in back of knee), causing a lump
causes of baker’s cysts
usually 2ndary to DEGENERATIVE changes in the knee joint. They can be associated with:
Meniscal tears (an important underlying cause)
Osteoarthritis
Knee injuries
Inflammatory arthritis
presentation baker’s cyst
Pain or discomfort
Fullness
Pressure
A palpable lump or swelling
Restricted range of motion in the knee (with larger cysts)
baker’s cyst examination
Most apparent when the patient stands with their knees fully extended. The lump will get smaller or disappear when the knee is flexed to 45 degrees (Foucher’s sign).
Oedema may occur if the cyst compresses the venous drainage of the leg.
presentation of ruptured baker’s cyst
causes inflammation in the surrounding tissues and calf muscle, presenting with:
Pain
Swelling
Erythema
DDx is DVT
first line ix bakers cyst
USS
mx baker’s cyst
none for asx
sx:
Modified activity to avoid exacerbating symptoms
Analgesia (e.g., NSAIDs)
Physiotherapy
Ultrasound-guided aspiration
Steroid injections
surgical mx if other knee path - arthroscopic procedures
what is subluxation
partial dislocation of shoulder
are most shoulder dislocations anterior or posterior
> 90% are anterior (head of humerus moves forward in relation to glenoid cavity)
occurs when arm is forced backwards whilst abducted + extended at the shoulder
what are posterior shoulder dislocations assoc w
electric shocks + seizures
key comp of shoulder dislocations
axillary nerve damage
where does the axillary nerve come from
C5 and C6 nerve roots (direct continuation of the posterior cord from the brachial plexus)
damage to axillary nerve
causes a loss of sensation in the “regimental badge” area over the lateral deltoid.
It also leads to motor weakness in the deltoid and teres minor muscles.
presentation shoulder dislocation
present after acute injury, px will know
muscles go into spasm + tighten around joint
arm held against side of body
deltoid flattened, head of humerus causing bulge + is palpable
what to assess px w shoulder dislocation for
Fractures
Vascular damage (e.g., absent pulses, prolonged capillary refill time and pallor)
Nerve damage (e.g., loss of sensation in the “regimental patch” area)
what is the apprehension test
assess for shoulder instability, specifically in the anterior direction
90 deg, external rotation - apprehension
what muscles make up the rotator cuff
S – Supraspinatus – abducts the arm (first 20 deg, deltoid does the rest)
I – Infraspinatus – externally rotates the arm
T – Teres minor – externally rotates the arm
S – Subscapularis – internally rotates the arm
ix to dx rotator cuff tear
Ultrasound or MRI scans
RFs frozen shoulder (/adhesive capsulitis)
diabetes
most commonly affects ppl of middle age
what happens in frozen shoulder (/adhesive capsulitis)
inflammation and fibrosis in the joint capsule (glenohumeral joint) -> adhesions -> bind capsule so it tightens around joint + restrict movement
what to do if little response to steroid tx for polymyalgia rheumatica
consider alt dx as sld have dramatic improv - refer to specialist
what is osteochondritis dissecans
pathological process affecting the subchondral bone causing knee pain after exercise, locking and ‘clunking’
usually children + young adults
ix osteochondritis dissecans
X-ray (AP, lateral, tunnel views) - subchondral crescent sign or loose bodies
MRI - used to evaluate cartilage, visualise loose bodies, stage and assess the stability of the lesion
what level does the spinal cord terminate
L2/L3
causes of cauda equina compression
Herniated disc (the most common cause)
Tumours, particularly metastasis
Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
Abscess (infection)
Trauma
red flags for cauda equina
Saddle anaesthesia (loss of sensation in the perineum – around the genitals and anus)
Loss of sensation in the bladder and rectum (not knowing when they are full)
Urinary retention or incontinence
Faecal incontinence
Bilateral sciatica
Bilateral or severe motor weakness in the legs
Reduced anal tone on PR examination
mx cauda equina
neurosurg emergency
- Immediate hospital admission
- Emergency MRI scan to confirm or exclude cauda equina syndrome
- Neurosurgical input to consider lumbar decompression surgery
features of metastatic spinal cord compression
Back pain - worse on coughing or straining
Motor and sensory signs and symptoms. (more UMN signs (if above L1) than cauda equina as nerves have not yet left the spinal cord)
tx metastatic spinal cord compression
High dose dexamethasone (to reduce swelling in the tumour and relieve compression)
Analgesia
Surgery
Radiotherapy
Chemotherapy
what does the achilles tendon do
connects the calf muscles (gastrocnemius and soleus) to the heel (the calcaneus bone)
flexion of the calf muscles pulls on the Achilles and causes plantar flexion of the ankle
RFs Achilles Tendinopathy
Sports that stress the Achilles (e.g., basketball, tennis and track athletics)
Inflammatory conditions (e.g., rheumatoid arthritis and ankylosing spondylitis)
Diabetes
Raised cholesterol
Fluoroquinolone antibiotics (e.g., ciprofloxacin and levofloxacin)
presentation Achilles Tendinopathy
gradual onset of:
Pain or aching in the Achilles tendon or heel, with activity
Stiffness
Tenderness
Swelling
Nodularity on palpation of the tendon
how to exclude achilles tendon rupture
Simmonds’ calf squeeze test
USS for dx of it
RFs achilles tendon rupture
Sports that stress the Achilles (e.g., basketball, tennis and track athletics)
Increasing age
Existing Achilles tendinopathy
Family history
Fluoroquinolone antibiotics (e.g., ciprofloxacin and levofloxacin) - can occur spontan within 48 hrs of tx
Systemic steroids
achilles tendon rupture presentation
Sudden onset of pain in the Achilles or calf
A snapping sound and sensation
Feeling as though something has hit them in the back of the leg
greater dorsifelxion (lie supine w feet hanging off bed)
examination signs for achilles tendon rupture
When relaxed in a dangled position, the affected ankle will rest in a more dorsiflexed position
Tenderness to the area
A palpable gap in the Achilles tendon (although swelling might hide this)
Weakness of plantar flexion of the ankle (dorsiflexion is unaffected)
Unable to stand on tiptoes on the affected leg alone
Positive Simmonds’ calf squeeze test (will not move the foot)
what is osteoporosis
signif reduction in bone density - weakening bones + making them more prone to fractures
when to assess someone for osteoporosis
Anyone on long-term oral corticosteroids or with a previous fragility fracture
Anyone >50 with RFs/fragility fracture (calc using FRAX + then NOGG guideline chart)
All women >65
All men >75
Treatment may be started without a DEXA in patients with a vertebral fracture
mx osteoporosis
Address reversible RFs
Address insuff intake of Ca + VD
Bisphosphonates
e.g. Alendronate 70 mg once weekly (oral)
Reassess bisphon tx after 3-5 yrs w repeat DEXA scan - stop if T-score>-2.5 apart from if high risk
what is osteomalacia
condition where defective bone mineralisation causes “soft” bones
due to insuff VD
rickets in adults
osteomalacia pres
asx
Fatigue
Bone pain
Muscle weakness
Muscle aches
Pathological or abnormal fractures
what are looser zones
fragility fractures that go partially through the bone
osteomalacia RFs
darker skin, low exposure to sunlight, living in colder climates and spending most of their time indoors
lab ix VD
Serum 25-hydroxyvitamin D
Less than 25 nmol/L – vitamin D deficiency
25 to 50 nmol/L – vitamin D insufficiency
other lab ix osteomalacia
Low serum calcium
Low serum phosphate
High serum alkaline phosphatase
High parathyroid hormone (secondary hyperparathyroidism)
imaging osteomalacia
X-rays may show osteopenia (more radiolucent bones)
DEXA scan shows low bone mineral density
tx osteomalacia
colecalciferol (vitamin D₃)
Loading dose then maintenance
check serum Ca within month of loading regime
presentation septic arthritis
single joint - often knee
rapid onset:
hot, red, swollen, painful joint
stiffness + reduced ROM
systemic sx = fever, lethargy
mx septic arthritis
local acute hot joint policy - to guide what team admits px (ortho, rheum, ID)
joint aspiration b4 abx
empirical IV abx
- Flucloxacillin (often first-line)
- Clindamycin (penicillin allergy)
- Vancomycin (if MRSA is suspected)
- Ceftriaxone (typically used for treating Neisseria gonorrhoea)
ctu 4-6 wks (IV then oral)
causes dupuytren’s contracture
manual labour
phenytoin treatment
alcoholic liver disease
diabetes mellitus
trauma to the hand
what is dupuytren’s contracture
thickening of the connective tissue in the palm. This results in the fingers taking on a ‘curled’ appearance, with an inability to extend the fingers.
what happens with a ruptured medial meniscus
Catching or locking of the knee with an inability to extend fully or bend the joint
what action might result in ruptured PCL
when a person jumps and lands on a bent knee or during impact with another person
RFs trigger finger (stenosing tenosynovitis)
- 40s/50s
- F>M
- DM
- RA
presentation trigger finger
-more common in the thumb, middle, or ring finger
- initially stiffness and snapping (‘trigger’) when extending a flexed digit
- a nodule may be felt at the base of the affected finger
worse in morn + improves through day
which spinal nerves form the sciatic nerve
L4-S3
route of sciatic nerve
exits the posterior part of the pelvis through the greater sciatic foramen, in the buttock area on either side.
It travels down the back of the leg.
At the knee, it divides into the tibial nerve and the common peroneal nerve.
what does the sciatic nerve do
supplies sensation to the lateral lower leg and the foot
supplies motor function to the posterior thigh, lower leg and foot.
sciatica presentation
unilateral pain from the buttock radiating down the back of the thigh to below the knee or feet. It might be described as an “electric” or “shooting” pain. Other symptoms are paraesthesia (pins and needles), numbness and motor weakness. Reflexes may be affected depending on the affected nerve root.
main causes of sciatica
lumbosacral nerve root compression by:
Herniated disc
Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
Spinal stenosis
why is bilateral sciatica a worry
a red flag for cauda equina syndrome
choices of neuropathic meds for sciatica
Amitriptyline
Duloxetine
what might indicate an epidural abscess
Signs of systemic sepsis with changing lower limb neurology
what is discitis
an infection in the intervertebral disc space
can lead to serious complications such as sepsis or an epidural abscess.
features of discitis
Back pain
General features
- pyrexia
- rigors
- sepsis
Neurological features
e.g. changing lower limb neurology
if an epidural abscess develops
causes of discitis
Bacterial - Staphylococcus aureus is the most common cause
Viral
TB
Aseptic
thumbs in OA
squaring
- Deformity of the carpometacarpal joint of the thumb resulting in fixed adduction of the thumb
Lateral subluxation of the base of the 1st metacarpal
painless nodes on the hand in OA
Heberden’s nodes at the DIP joints
Bouchard’s Nodes at the PIP joints
these nodes are the result of osteophyte formation.
presentation of carpal tunnel syndrome
pain/pins and needles in thumb, index, middle finger
unusually the symptoms may ‘ascend’ proximally
patient shakes his hand to obtain relief, classically at night
examination signs w carpal tunnel
weakness of thumb abduction (abductor pollicis brevis)
wasting of thenar eminence (NOT hypothenar)
Tinel’s sign: tapping causes paraesthesia
Phalen’s sign: flexion of wrist causes symptoms
causes of carpal tunnel
mainly idiopathic
There are a number of key risk factors:
Repetitive strain
Obesity
Hypothyroidism
MEDIAN TRAP
Myxoedma
Edema pre-menopause
Diabetes
Idiopathic
Acromegaly (bilateral carpal tunnel)
Neoplasm
Trauma
RA
Amyloidosis
Pregnancy
ix carpal tunnel
nerve conduction studies: motor + sensory: prolongation of the action potential
tx carpal tunnel
6-week trial of conservative treatments if the symptoms are mild-moderate
- corticosteroid injection
- wrist splints at night: particularly useful if transient factors present e.g. pregnancy
if there are severe symptoms or symptoms persist with conservative management:
- surgical decompression (flexor retinaculum division)
main neurovascular structure that is compromised in a scaphoid fracture
The dorsal carpal branch of the radial artery
what is flail chest
serious comp of multiple rib fractures following trauma
- caused by 2/+ fractures along 3/+ consecutive ribs (usually anterior)
-> chest wall becomes unstable: the flail segment moves paradoxically (opp way to normal) during respiration and impairs ventilation of the lung on the side of injury
best dx scan for rib fractures
CT chest
mx rib fractures
the majority of cases are managed conservatively with good analgesia to ensure breathing is not affected by pain
- inadequate ventilation may predispose to chest infections
- if the pain is not controlled by normal analgesia then nerve blocks can be considered
surgical fixation can be considered to manage pain if this is still an issue and the fractures have failed to heal following 12 weeks of conservative management
what is iliotibial band syndrome
a common cause of lateral knee pain in runners
- tenderness 2-3cm above the lateral joint line
hand deformities in RA
swan-neck deformity - hyperextension of the PIP joint and flexion of the DIP joint
Boutonniere deformity - flexion at the PIP joint and hyperextension at the DIP joint due to damage to central slip extensor tendon overlying PIP joint
Causes of avascular necrosis of the hip
long-term steroid use
chemotherapy
alcohol excess
trauma
where is the pain in avascular necrosis of the hip
anterior groin
where in long bones is the infection likely to occur in osteomyelitis
adults
children
Adults = E lders = E piphysis
Children = M inors = M etaphysis
most common site of metatarsal stress fractures
2nd metatarsal shaft
most commonly fractured metatarsal + how
proximal 5th metatarsal
Usually associated with a lateral ankle sprain and often follow inversion injuries of the ankle.
management for subluxation of the radial head (usually get from pulling injury)
Analgesia + Passive supination of the elbow joint whilst flexed to 90 degrees
how do meniscal tears typically result
twisting injuries
test used to assess for possible meniscal tears in the knee joint
McMurry’s
what is Cubital tunnel syndrome + presentation
compression of the ulnar nerve
presents w tingling/numbness in 4th/5th finger
Pain worse on leaning on the affected elbow
what is a charcot joint
neuropathic joint
a joint which has become badly disrupted and damaged secondary to a loss of sensation
a lot less painful than would be expected
swollen, red and warm
presentation of posterior hip dislocation
internally rotated and shortened limb
commonly get sciatic nerve injury
what is chronic compartment syndrome
During periods of exertion, pressure within the restricted compartment will rise and blood flow is restricted. This will cause the symptoms to begin. During rest, the pressure falls, and symptoms begin to resolve. It differs to acute compartment syndrome and is not a medical emergency.
differences:
Bilateral involvement
Happens on exertion
No neurovascular compromise
Relapsing and remitting pain
what is an avulsion fracture
where a small piece of bone attached to a tendon or ligament gets pulled away from the main part of the bone
usually in sports - changing direction
what is osgood-schlatter disease
type of osteochondrosis characterised by inflammation at the tibial tuberosity
indications for knee XR
ottowa knee rules
- age >/= 55
- isolated patella tenderness
- tenderness at the head of the fibula
- inability to flex the knee to 90deg
- inability to weight bare >4 steps immediately after injury and in the emergency department
