MSK Flashcards
What happens on clavicular fracture to the fragments?
Medial fragment moves superiorly due to unopposed scm action
Lateral fragment moves inferiorly due to limb weight and medially due to unopposed adductor pull
What is the first bone to start ossification? When?
Clavicle, 5/6th week
What is the last long bone to finish ossification? When?
Implication
How to overcome it?
Clavicle! 35-30 yrs
Potential to misinterpret epiphysis as a fracture
Image both clavicles, should be the same
Commonest site of humerus fracture?
What sort of fracture do they tend to be? Implication?
Surgical neck
Impacted - often stable and able to move arm passively
How would the arm be positioned if the greater tubercle was avulsed on the humerus? Why?
Medially rotated
Lack of attachment of lateral rotating muscles infraspinatous and teres minor leading to unopposed subscapularis medial rotation
How would a fractured shaft of humerus position post fracture? Why?
Proximal portion abducted by unopposed deltoid
How could a midshaft humerus fracture occur?
Direct blow
How could a surgical neck humerus fracture occur?
FOOSH in elderly with osteoporosis
How does a greater tubercle of humerus avulsion commonly occur?
Fall onto acrominion
How could an intercondylar fracture of the humerus occur?
Fall onto flexed elbow driving olecranon up
What is a colles fracture?
What position does it end up in? With what signs?
What other fracture commonly accompanies it?
Complete transverse fracture of distal 2cm of humerus
Distal fragment displaced dorsally and proximally
Radial styloid becomes proximal to ulna styloid
Dinner fork deformity
Avulsion of the ulna styloid
How does pain from a fractured scaphoid present?
Lateral wrist
Worse on dorsiflexion and abduction of hand
Telescoping thumb produces pain
What condition occurs if a scaphoid fracture undergoes avascular necrosis? What may have to occur then?
Degenerative joint disease of the wrist - may need fusing
What protective factors do the metacarpals have if fractured?
Closely bound so stable
Good blood supply
What is a boxers fracture?
Fracture of fifth metacarpal by hitting with the wrong knuckles
How do fractured phalanges usually occur? What type of fracture do they tend to be? Why is this important?
Crush injury
Comminuted
Close association with flexor tendons thus needs to be carefully realigned.
Where is the weakest point of the clavicle?
The join between the medial and lateral thirds
Define myotome
What does this imply for muscles?
What group of muscles of the upper limb are made from a single myotome?
The unilateral embryological muscle mass receiving innervation from a single spinal cord segment or spinal nerve
Most muscles consist of multiple myotomes
The intrinsic muscles of the hand (T1)
Sensation to the upper shoulder is provided by…
The supraclavicular nerves C3/C4
Sensation to the lateral arm is provided by?
Superior (c5/c6) and inferior (c5/c6) lateral cutaneous nerves of the arm
Nerves that supply sensation to the forearm and origin nerves
Lateral cutaneous nerve to the forearm - musculocutanious
Medial cutaneous nerve to the forearm - brachial plexus
Posterior cutaneous nerve to the forearm - radial
Sensation provided by ulnar nerve
Medial palm and dorsum with medial 1.5 digits
Sensation provided by median nerve directly
Lateral palm and lateral 3.5 digits palmer and tips of dorsal
Sensation provided by radial nerve directly
Lateral dorsum of hand and lateral 3.5 fingers except the tips.
How is pec major formed? What do the heads do? How can they be tested?
Big sternocostal head - adducts and extends the arm - abduct to 60degrees then adduct against resistance
Smaller clavicular head - flexes the arm - abduct to 90degrees then flex against resistance
Together adduction and medial rotation
Function of serratus anterior?
Test it?
Protracts the scapular when reaching anteriorly
Raises the gh joint to reach above 90degrees
Anchors the scapular so when pushing against resistance it doesn’t move backwards
Push against a wall and the stands should be visble/palpable
What is the classification method for growth plate fractures in children?
Salter harris
What is a salter harris 1
Fracture through the growth plate
What is a salter harris 2
Through growth plate and metaphysis
What is a salter harris 3
Through growth plate and epiphysis
What is a salter harris 4
Through growth plate, metaphysis and epiphysis
What is a salter harris 5
Impacted fracture of growth plate
What is the worst salter harris fracture prognostically ?
5
What is the commonest salter harris fracture?
2
What proportion of childhood fractures involve the growth plate?
What effect can this have?
One third
Stunted growth of that limb due to premature closure
Why are salter harris 3 and 4 worse than 1 and 2
Damages both zone of proliferation and zone of reserve cartilage
What are the phases of gait?
Stance - foot strike to toe off
Swing
What is a gibbous deformity of the spine?
One vertebra wedged causing increased forward flexion with sudden angulation and posterior ridge
Define kyphosis and lordosis
Curvature of spine in saggital plane with apex:
Kyphosis - posterior
Lordosis - anterior
What should be felt in a spinal exam?
Spinous processes
Paraspinal muscles
Sacroiliac joint
Consider feeling for AAA in lumbar pain
What are you feeling for on spinous process palpation?
In line
Tender
Prominent - ? Wedge fracture
What special tests can be done in a spine examination?
Spurlings sign
Schobers test
Straight leg raise
What is straight leg raise otherwise known as?
Interpret pain at 10degrees 50degrees and 90degrees
Lasegues test
10 - nerve root compression not herniated disc
50 - probable disc herniation
90 - normal
How can pain from a straight leg raise be worsened or relieved?
Worsen by dorsifexing foot
Relieve by flexing knee
What would ipsolateral (effected side) pain on a contralateral straight leg raise indicate?
Severe impingement
Possible high risk of cauda equina
What is spurlings sign?
Elicites nerve root irritation in neck
Extend and rotate neck to effected side
Apply downwards pressure
What is schobers test?
Assesses spinal flexion
Mark between dimples of venus, 10cm above and 5cm below
Flex and gap should increase from 15 to 20 cm
Red flags for lower back pain
55 Non mechanical Thoracic pain Night pain Systemic symptoms History of cancer Drug abuse or steroid use Widespread neurology Traumatic
What bladder problems are associated with cauda equina?
Urinary retention
Overflow incontinence
What features of back pain itself would raise concerns about cancer
Non mechanical
Worse at night
Progressive in spite of management
Xray features of vertebral cancer
Lucency or opacity
Winking owl sign (loss of pedicle)
Best imaging modality for suspected spinal infection
What may be seen?
MRI
Fluid in disc and vertebra
Epidural abcess
Xray changes in spinal infection
No change Disc narrowing Bony sclerosis Vertebral collapse Paraspinal mass
Which way do discs commonly herniate? Why?
Posteriolateral
Not straight posterior due to posterior longitudinal ligament, but backwards as patient flexes forwards pressure forces it back
What occurs as a result of dehydration of the nucleus pulposus?
Fibrosis
Narrowed disc space
Osteophyte formation
Why is an acute disc herniation more severe than an equivalent chronic herniation?
Inflammatory component in acute herniation with less time to react
What is the term for subluxation of the vertebra? Where dose it occur often?
Spondylolisthesis
L5 S1
What is spondylisis?
Inflammation of the vertebral joints
What is spondylosis?
General wear and tear / dysfunction of the vertebral joints generally related to disc degeneration and osteoarthritis
Management options for cervical radiculopathy
Conservative - collar, exercises, traction, rest
Surgical - disc removal and replacement or removal of some lamina
What are the characteristics of pain from spinal arthritis?
Worse on standing and following inactivity (eg. On getting up in the morning)
Eased by lying and stooping.
Conservative management options for osteoarthritis of the spine
Nsaids
Weight loss
Physical therapy
What is spondylolysis?
What can it cause?
Stress fracture of the vertebra arch between superior and inferior facets - risk of spondylolisthesis
Yellow flags in back pain
Belief pain is serious pathology or severely disabling
Belief that passive is better than active management
Avoidance of activities
Social or financial problems
Tendancy towards depression
Types of osteoporotic spine fractures
Wedge
Burst
Presentation of osteoporotic spine fractures
Central back pain Loss of height Kyphosis Paravertebral muscle spasm Neurological complications
What are the sorts of hypertonia?
General causes
Spasticity (inc clasp knife) - pyramidal
Rigidity (inc lead pipe and cogwheel) - extrapyramidal
What is the max number of clonus beats to be normal?
5
How can muscle power be measured?
MRC scale 0 - no 1 - twitch 2 - no gravity 3 - against gravity 4 - mild resistance 5 - strong resistance
Muscles to test myotomes
C5 - elbow flex C6 - wrist flex C7 - elbow extend C8 - finger flex T1 - finger abduct L2 - hip flex L3 - knee extend L4 - ankle dorsiflex L5 - big toe extend S1 - ankle plantarflex
What reflexs should be done onto the examiners fingers?
Biceps
Supinator
What are the neural levels of the core reflexs?
Biceps - c5 Brachialis - c6 Triceps c7 Knee l4 Ankle s1
Which way should babinskis reflex go in normal people?
Flex and adduct
How can reflexs be graded?
Increased +++ Normal ++ Reduced + Needs reinforcement +/- Absent -
What can be used to reinforce reflexes?
Clench teeth
Jendrassik’s manoeuvre
What can finger pointing test show you
Coordination
Past pointing
Intention tremor
What test should be preformed on the hands as a special reflex test?
Hoffmans
Isolate middle finger and flick distal segment, +ve if others flex
What should be felt on a shoulder exam?
Bones, joint and biceptial groove whilst arm is rotated
Basic movements in shoulder exam?
Flex
Abduct
Externally rotate with elbows at 90degrees
Internally rotate by dorsum of hand to small of back and raise up spine
How should supraspinatous power be assessed in a shoulder exam?
Internally rotate and abduct to 90degrees in plane of scapula
Elevate against resistance
OR
Drop arm test: Fully abduct then lower to 90 and hold
How should the external rotators be tested in a shoulder examination?
Elbows flexed from anatomic position and rotate against pressure
How can subscapularis be tested in a shoulder exam?
Put dorsum of hand over sacrum
Push posteriorly against resistance
What tests can be used to assess for impingement in the shoulder?
Hawkins test
Neers test
What is hawkins test?
Flex shoulder to 90, flex elbow to 90, internally rotate forearm across body. Depress hand and elevate elbow forcing internal rotation
What is neers test?
Internally rotate and fully flex shoulder
How can the AC joint be tested in a shoulder exam?
Cross arm test
Flex to 90 then adduct across body
How can the biceps be tested in a shoulder exam
Flex shoulder slightly from anatomical
Flex forearm against resistance
From flexed forearm supinate vs resistance
Test for anterior impingement in shoulder exam?
Apprehension test
Flex elbow
Abduct and externally rotate whilst stabilising scapula
Test for posterior instability on shoulder exam?
Pt supine
Hold arm at 30 degrees adduction with flexed elbow
Push back
Test for inferior instability on shoulder exam
Hold elbow and humeral head and apply downwards traction
What should be checked before assessing shoulders for instability?
Beighton score for hypermobility
Causes of shoulder instability?
Acute traumatic - dislocation causing weakening
Gradual stretch - repetitive overhead movements
Muscle pattern - unbalanced muscles pulling the head of humorous
What is the common mechanism behind traumatic anterior shoulder dislocation?
Excessive external rotation and extension
What effect do traumatic shoulder dislocations have on the physical surrounding structures?
Axillary nerve injury
Bankart lesion - glenoid labrum detachment
Hill-sachs lesion - compression fracture of posterior humoural head
What treatment options are available for shoulder instability?
Activity avoidance
Nsaids
Physiotherapy
Ligament repair surgery
How can the AC joint dislocate? What ligaments are involved in mild and severe dislocation?
Hard fall onto should
Mild results from AC ligament rupture
Severe results from AC and CC rupture
What is the technical name for frozen shoulder? What is it?
Adhesive capsulitis
Fibrosis and scarring between joint capsule and rotator cuff, subacromial bursa and deltoid
What causes adhesive capsulitis?
Injury (dislocation, rotator cuff tear, bicepital tendonitis) DM Heart disease Dupuytrons contracture Stroke
How is adhesive capsulitis subdivided?
Phases 1 2 and 3
1 - much pain progressive motion restriction
2 - reducing pain and very bad movement restriction
3 - resolving
What is the prognosis for adhesive capsulitis?
Will resolve itself in 2 to 3 years
Will not resolve in diabetic patients
What conservative treatment options exist for adhesive capsulitis?
Physiotherapy
NSAIDs
Corticosteroid injection
Surgical treatments for adhesive capsulitis
Arthroscopic capsular release
Manipulation under anaesthetic
Causes of rotator cuff tears
Acute trauma - FOOSH or lifting heavy weight
Chronic degeneration - repeated overhead motions, loss of blood supply with age
What is rotator cuff tear pain like? Associated with?
Worse at night
Weakness
Decreased range of motion
Treatment of rotator cuff injuries
Nsaids Physio Steroid injection Avoid exacerbating activities Surgical
Complication of rotator cuff injury?
Rotator cuff arthropathy due to superior displacement of humoural head rubbing against acromion
Which joint of the shoulder does OA most commonly effect?
AC
Where may pain from OA in the AC joint of the shoulder be?
Top of shoulder radiating to neck
Surgical options for GH and AC shoulder arthritis
Arthroscopy with debridement
GH replacement
AC joint resection (removal of part of the clavicle)
What do the short head of biceps and coracobrachialis form? Significance?
Conjoined tendon
Nearly all nerves and vessels medial to it so surgery lateral to it is safe
What should be conducted prior to assessing the shoulder for instability?
Examine for hypermobility using a beighton score
What is the term for an upper brachial plexus injury?
Presentation?
Erb duchenne palsy
Waiters tip
What is the term for a lower brachial plexus injury
Presentation
Klumpke paralysis
Claw hand
Causes of upper brachial plexus injuries?
Increased angle between neck and shoulder
Carry heavy backpack
Most common shoulder pathology in young people?
Instability
Most common age range for adhesive capsulitis
40-60
Most common age range for osteoarthritis of shoulder
> 60
What should be looked for on elbow examination?
Normal crap Bursa Rheumatoid nodules Carrying angle Hand for ulnar claw
What is carrying angle?
The normal valgus position of the forearm in relation to the arm
Up to15degrees in females
Up to10 degrees in males
What should be palpated in an elbow exam
Med lat epicondyles and olecranon - straight line in extension, triangle when flexed
Radial head
Biceps tendon
How should angle of pronation and supination be assessed?
From a starting point of palms medially
How to assess for tennis elbow?
Flex elbow to 90
Extend wrist against resistance
How to assess for golfers elbow
Flex elbow to 90 and supinate
Flex wrist against resistance
What neurological test may be performed at the elbow?
Tinnels test
What is tennis elbow?
What age range does it tend to present in?
Lateral epicondylitis
Inflammation of extensor tendons
40s-50
What is golfers elbow?
Medial epicondylitis
Treatment options for m and l epicondylitis
Limit activity Brace Nsaids Physiotherapy Corticosteroids Surgery to remove damaged tendon
What is the common mechanism of injury for s supracondyler humorous fracture?
FOOSH with hyperextended elbow pushes olecranon through weak area of bone remodelling in humorous
What is the grading system for supracondyler fractures of the humorous?
Gartland
1 - undisplaced
2 - angulated but in contact
3 - displaced
Complicaitons of supracondylar humorous fracture?
Varus deformity due to malunion
Brachial artery damage
Ulnar nerve damage
Why would an olecranon fracture usually require pinning?
Traction from triceps pulls fragment away
Why are children at greater risk of medial epicondyle fractures?
Weak as not fully ossified
What pneumonic can be used to determine the order of ossification around the elbow?
Capitulum Radial head Internal epicondyle Trochlea Olecranon External epicondyle
What is students elbow?
What is its counterpart?
Causes?
Students = subcutanious olecranon bursitis from repeated pressure and friction Other = subtendinous olecranon bursitis from repetitive movement
What are treatment options for elbow bursitis?
Aspiration
Corticosteriods
Nsaids
Xray views needed in suspected dislocated shoulder?
AP
Scapula Y
Axillary
What lumps in the hand occur with OA? Which joints?
Heberdens - DIP
Bouchards - PIP
What should be checked in suspected metatarsal fracture? How
Finger rotation
Check nail angle
Ask to make fist and look for crossing of fingers
Where can the scaphoid be palpated?
Palmer at base of thumb by tracing flexor carpi radialis
Waist in anatomical snuff box
Radial to listers tubercle on dorsum of hand
Where can the lunate be palpated?
Ulnar to listers tubercle on dorsum of hand
How to palpate triquestrum?
Radially deviate wrist and feel at top of ulnar
How to palpate pisiform
Within flexor carpi ulnaris
Where are the trapezium and trapezoid palpated?
Base of first and third metacarple
Where is the hamate palpated
Its hook beyond the triquestrum
How would you test the ulnar nerve in the hand?
Sensation on palmer little finger
Motor - abduct little fingers against resistance
Test interossei
Froments test - hold paper against resistance between thumb and index finger. If adductor pollicis deficient then thumb will bend
How would you test the median nerve in the hand?
Sensation on palmer middle finger
Motor - abduct thumb pressing on median eminance
OK sign against resistance
What branch of the median nerve is tested when making the ok sign? When is it commonly damaged?
Anterior interosseus nerve
Supracondylar fractures
Testing the radial nerve in the hand
Sensation - dorsal base of thumb
Motor - wrist extensors, finger extensors extensor pollicis all against resistance
What tendon is. Especially important to assess in distal radial fractures?
Extensor pollicis longus
Other than looking, feeling bones and testing nerves and tendons what other tests should be considered in a hand exam?
Functional tests
Vasculature (allens test, radial pulse)
What are spoon shaped nails called?
Causes?
Koilonychia
Iron deficiency anaemia
What is separation of the nail from the bed called? Appearence? Causes?
Onycholysis
White opacity
Trauma, infection, drugs
What deep horizontal grooves in the nail called? Causes?
Beau’s lines
Severe illness causing temporary cessation of cell division
What is overgrowth of the nail called? Causes?
Onychogryphosis
Trauma - acute or chronic (e.g. Shoe rubbing)
What are white lines on the nail called?.
Causes
Leukonychia
Injury to base of nail
Hypoalbuminaemia (liver disease)
What is a colles fracture?
What is often associated with it?
Extra articular transverse fracture of the distal 2cm of radius with dorsal displacement and impaction
Avulsed ulnar styloid
What occurs so commonly in patients with colles fractures it should be checked for?
Osteoporosis
What are the other fractures of the distal radius other than a colles?
Smiths
Bartons
What is a bartons fracture?
Which direction is usual?
Management?
An articular fracture of the distal radius
Usually involves volar deformity
Nearly always needs internal fixation
What hand positioning would make a scaphoid fracture worse?
Dorsiflexion and abduction
What treatment may be required in a scaphoid fracture with secondary avascular necrosis (common and medical term)
Fusion - arthrodesis
What is terry thomas sign?
Complication?
Scapholunate ligament injury causing gap to appear between bones
Arthritis
Causes of tenosynovitis?
Infection
Overuse
Rheumatoid arthritis
From which digits can tenosynovitis spread? Where too?
1 and 5
To the common flexor sheath, carpal tunnel and anterior forearmg
Term for tenosynovitis in APL and EPB tendon sheath?
Quervain tenovaginitis
How does Quervain tenovaginits present?
Pain on medial surface spreading up the forearm and down the thumb
Tenderness on anatomical snuff box
Sign that is positive in quervain tenovaginitis?
Finkelstein’s sign - grip thumb in closed fist and ulnar deviate to cause pain in snuffbox
Risk factors for dupuytrens contracture?
Family Male Northern european Liver disease Antiepileptic meds
Presentation of dupuytrens contracture?
Painless
Flexion of digits, usually 4 and 5
Ridged palmer skin
Dupuytrens is associated with?..
Planter fibromatosis (foot) Peyronie's disease (penis)
Treatment options for dupuytrens?
Surgical fasciotomy
Collagenase injection
Causes of carpal tunnel syndrome?
Idiopathic Pregnancy Hypothyroid Trauma Tenosynovitis Amyloidosis Infection Ganglion
Muscles effected in carpal tunnel syndrome?
Abductor pollicis brevis
Opponens pollicis
Flexor pollicis brevis
Treatment options for carpal tunnel syndrome?
Treat cause
Night splints
Steroid injection
Carpal tunnel release
What is mallet finger?
Forced flexion of extended finger avulses extensor tendon leaving dipj in fixed flexion
What is trigger finger?
Thickening of the a1 pully by the mcpj
Causes finger to lock and release with snapping noise
Treatments of trigger finger
Steroid injecition
Surgical pulley release
Where does osteoarthritis usually effect in the hand?
DIPJs Then 1st MCPJ Then PIPJs
What is a ganglion
Features
Leak of fluid from synovial capsule
Smooth mass which changes size
Where are ganglions usually found
Scapholunate joint
What is a ganglion on the dipj callled?
Complication?
Digital mucous cyst
Nail deformity
What is skiers thumb?
Tear to ulnar colateral ligament of 1st mcpj caused by fall onto outstreatched thumb
Types of gait to look out for on examination of the hip?
What are they?
Antalgic - limited weight baring on painful leg
Trendelenberg - contralateral hip drops on weight baring
Stiff hip gate - lack of full hip extension
Special tests to do on hip examination?
Trendelenbergs
Thomas test
What is thomas test?
Hand under lumber spine
Flex knee and hip until spine touches hand
Positive if contralateral leg raises
What does a positive thomas test mean?
Flexion deformity
If knee extends then rectus femoris tight
If knee flexes then iliopsoas tight
Position of leg in fractured neck of femur?
Shortened and externally rotated
How can neck of femur fractures be classified? What are the different classifications?
Garden
Stage 1 - incomplete fracture undisplaced
Stage 2 - complete fracture undisplaced
Stage 3 - complete fracture partially displaced
Stage 4 - complete fracture fully displaced
What can be used to assess 30 day mortality of fractured neck of femur?
Nottingham hip fracture score
What indicates a negative prognosis for mortality of a hip fracture?
Age Male Low hb Low mmts Institutionalised care Cormorbidities Malignancy Raised lactate
Types of neck of femur fracture?
Intracapular
Extracapsular
What is the condition called that results from a mismatch between head of the femur and the acetabulum?
Femoral acetabular impingement
What position worsens femoral acetabular impingement? Why is this an issue particularly in younger people?
Hip adduction, flexion and external rotation, a common position in sport
Treatment options for femoral acetabular impingement?
Activity avoidance
Nsaids
Physiotherapy
Arthrascopic repair and shaving
What sign has a high ppv for herniated disc?
Crossed straight leg raise
Raise contralateral leg and sciatica worsens ipsolaterally
What bedside test should be performed on all patients with acute back pain? Why?
Bladder scan
May be urinating but still retaining an amount of urine - retention
Condition associated with painful arc?
With high painful arc?
Shoulder impingement beneath ac joint
High - ac joint pathology
Another term for trochantic bursitis?
Greater trochantic pain syndrome
Cause of trochantic bursitis?
Overuse Inflammation Trauma Pressure Calcium deposition
Treatment of trochantic bursitis?
Rest
Ice
Nsaids
Causes of hip avascular necrosis?
Trauma - femoral neck fracture, dislocation, subluxation
Atraumatic - corticosteroids, alcohol abuse, intravascular coagulation, liver disease
Presentation of avascular necrosis of the femoral head
Groin pain radiating to buttocks and knee
Worse on weight bearing
Limited abduction
Painful passive movement
Xray features of femoral head avascular necrosis
Femoral head lucency Subchondral sclerosis Subchondral collapse Crecent sign, flattening of the head Joint space narrowing
Treatment of avascular necrosis of the femoral head?
Remove cause if able
Core decompression with graft insertion
Replacement
What tests should be run on a patient with a suspected septic hip?
WCC, CRP
USS
Aspiration
Presentation of a hip infection
Usually children
Severe pain and stiffness
Reluctance to bear weight and limp
Sepsis
Which gender is more likely to suffer congenital hip dysplasia?
Female
Test to identify congenital hip dysplasia? What are they? How to remember?
Barlow test (Barlows push Back) Adduct hip at 90 flexion whilst pushing posterior on knee feel for pop as hip dislocates Ortolani manoeuvre (Ortolani move Out) Abduct hip at 90 flexion whilst pressing on lesser trochanters and feel for a pop as hip relocates
Diagnosis of congenital hip dysplasia?
USS
Arthrography
Treatment options for congenital hip dysplasia?
Pavlik harness
Closed reduction and hip spica
Open reduction
Long term complications of congenital hip dysplasia
Adult arthritis
What age range is perthes most common
4-8 yrs but can be 2-15 yrs
Presentation of perthes
Mild groin pain refers to knee Reduced range of motion Inequality in leg length Thigh wasting Limp
Xray features of perthes?
Flattened femoral head progressing to fragmented femoral head
Natural history of perthes?
Avascular necrosis of head of femur due to insufficiency of artery oc ligamentum teres
Bone fragments
Bone replaced and reossifies
Bone heals
Treatment needed for most perthes patients?
Nothing! Watchful waiting
If needed treatment options for perthes?
Physiotherapy
Activity avoidance
Cast
Surgery
Classic age range for slipped femoral epiphysis? Most common gender?
Males 10-16
Females 12-14
Most common in males
Presentation of slipped femoral epiphysis
Gradual onset 20% bilateral Hip pain Limp Shortened leg
What xray view to see slipped femoral epiphysis?
Frog leg
Treatment of slipped femoral epiphysis?
Surgical pinning
What is an issue with using xrays to screen for sinister causes of lower back pain? What are they good for?
Xrays wont show malignancy until most of the vertebra is gone
Good for suspected fractures
Good for reassuring patients
What blood tests may be of use in a patient presenting with simple back pain?
Fbc
Esr
Treatment options for simple lower back pain?
Paracetamol / NSAIDs
Short course of diazapam
Early mobilisation and return to normal activities
Physiotherapy
Usual cause of sciatica
Pressure onto the nerve roots L5 to S1 NOT the sciatic nerve!
Which nerve root is most commonly effected by prolapsed disc?
L5
Causes of lumbar nerve root irritation?
Prolapsed disc
Venous congestion
Osteophytes
How long does sciatia usually take to resolve? Mechanism of healing if caused by disc prolapse?
6 weeks
Shrinkage and fibrosis of the disc
What presentation of long term herniated disc patient would benefit most from surgery?
Indication for rapid surgery in disc herniation?
Patients with long term leg symptoms
Cauda equina, rapidly evolving motor radiculopathy
Treatment options for herniated disc if watchful waiting fails?
Chemonucleoslysis - enzyme to dissolve disc
Discectomy - pop the disc out
How does sciatica present?
Pain radiating down back or side of thigh into calf and foot. Worse on movement. Worse on coughing or sneezing as CSF shockwave travels around the nerve.
Examination findings of sciatica?
Sciatic scoliosis - bending chest to side to reduce pressure on trapped nerve
Straight leg raises positive
Reduced forward flexion
Impaired reflexes and muscle weakness
What is spinal stenosis? Pathology? Causes?
Stenosis of spinal canal
Causes pressure, decreased blood flow and ischemia
Causes are congenital, idiopathic, spondylosis, spondylolisthesis, pagets disease
Signs and Symptoms of spinal stenosis
Rapid or insidious onset
Worse on mobilisation relieved by rest
Stooping to increase size of canal (eased on a bike or walking uphill!)
What is the term for the syndrome caused by spinal stenosis? What is similar? How can they be differentiated?
Neurogenic claudication
Similar to vascular claudication
N - starts proximal and spreads distal, C - opposite
N - worse on walking and standing, C - just walking
N - eases on several minutes sitting, C - eases with seconds of rest
N - stoops, C - normal posture
N - can cycle! C - limited whatever exercise
N - normal skin and pulses, C - pale, hairless and pulseless
How would spinal stenosis be diagnosed? Treatment?
MRI
Symtomatic treatment
Can consider epidural
Surgical decompression
What blood test is most sensitive for spinal infection?
Esr
If you suspect a spinal infection what needs to be done?
MRI
Biopsy!
Culture
Then antibiotics
Pathology of TB of the spine? (Potts)
Infection on the anterior margin of the body near the disc
Spread to, then destruction of, the disc
Anterior collapse causing angular kyphosis
Abscess formation
How can infectious narrowing of the disc space be differentiated from degenerative (spondylosis)
Lack of osteophytes
Presentation of potts disease?
Back pain Back stiffness Kyphosis Abscess Spinal cord compression
Treatment of mallet finger
Splint the finger for 6-8 weeks
Indications. For surgery in rheumatoid arthritis?
Tendon repair
Mcp joint arthroplasty (placing in rubber surfaces)
Arthrodesis
Removal of rheumatoid nodules
What is the term for the for the line drawn from the asis through the patella to the tibial tuberosity? What should the deviation from the asis patella to the patella tuberosity be?
The q angle
Roughly 9-18 degrees in valgus
Causes of increased q angle?
Genu valgum
External tibial torsion
Tests for knee effusion?
Patella tap
Medial sweep with lateral push
What is the normal range of knee flexion?
Young - ankle to bum
Elderly - roughly 110 degrees
Additional test for acl injury? How?
Lachmans test
Knee at 20 degree flexion
Push thigh down and pull tibia up
If acl rupture then end point will be boggy, if intact will be firm
Hand conditions associated with rheumatoid arthritis?
Carpal tunnel syndrome
Raynauds
Trigger finger
Tendon rupture
Complications of total hip replacement?
DVT, PE
Dislocation
Bleeding/nerve damage
Infectoin
What proportion of hip replacements will develop infection? What is the treatment? Risk factors?
1%
Revision and antibiotics
Diabetes, immunosuppression and immunocompromised state, smoking
In an patient with chronic hip pain where is the pain most likely to be located if the problem is with the joint itself? What about if it is a trochanteric bursitis or spinal pain?
Joint - groin
Trochantic bursa - greater trochanter
Spine - buttocks
If hip pain is generalised how may surgeons isolate the pain to a joint problem prior to committing to a replacement operation? How is this done?
Anaesthetic and steroid injection
Performed as a day case under local anaesthetic and xray visualisation
Risks of intra articular hip steroid injections?
Infections
Steroid induced necrosis
When performing a knee examination what other joint should be assessed, especially if no clear knee cause is elicited?
Hip
Risk factors for hip osteoarthritis
SUFE Perthes CHD Septic arthritis Trauma
In what direction valgus/varus does the knee classically point in osteo and rheumatoid arthritis?
OA - varus
RA - valgus
When performing a knee examination what is the benefit of doing a straight leg raise?
Check the spine
Confirm extensor mechanisms are intact
What is knee locking?
Inability to fully extend the knee. It can still be flexed!
What is the likely cause of a traumatic rapidly developing knee effusion?
Bleeding secondary to acl rupture
Absolute contraindication to aspiration of a knee effusion?
Overlying skin infection
What can cause patellofemoral joint problems? Who does it normally effect?
Pain in the anterior knee caused by patella malaligment, muscular imbalance or overuse. Degeneration of this joint can occur following fractures or dislocations. Tends to effect the young.
What is the pain of patello femoral joint pathology like?
Anterior
Worse up and down stairs
Worse on standing from chair
Treatment options for patellofemoral joint problems
Physiotherapy to strengthen vastus mediallis
Strapping/taping
Activity modification
Realignment surgery
What is the typical history of a ACL injury?
Twist on fixed foot with knee flexed
Sudden pain and rapid joint swelling
Treatment of acl injury?
Immidiate - aspiration of blood eases pain
Long term - activity avoidance or reconstruction
Prognosis of acl injury?
1/3 back to normal
1/3 suffer when playing sport
1/3 have constant pains and sensations of knee giving way
Presentation of a meniscal injury
Often follows sport or twisting action
Pain on joint line of knee
Rapid or slow swelling
Loss of extension
What surgery is performed now on meniscal tears? Why”
Repair
Not removal as weight distributes incorrectly and very high risk of arthritis
Which way does the patella usually dislocate?
Laterally
What mechanism may cause a pcl tear?
Fall onto tibial tuberoisty with flexed knee
Dashboard impact
Causes of knee locking?
Free body
Torn menisci
Osteophyte
Signs of RA on an xray?
Periarticular erosions Periarticular osteopneoa Soft tissue swelling Joint subluxation Joint malalignment
Four stages of Perthes
Bone dies
Bone fragments
Bone reossifies
Bone remodels
When would surgery be necessary in perthes?
When the head is no longer in the acetabulum
What should be looked for on an xray with a suspicion of slipped femoral epiphysis? Which view?
Klein’s line
Trace the lateral border of the femoral neck - should pass through the lateral 1/3rd of the head
Frog leg
What is a major differential for septic arthritis of the hip in a child?
Transient synovitis
What does transient synovitis tend to follow?
LRTI or gastroenteritis
What scoring system can be used to determine risk of septic arthritis vs transient synovitis? Componenets
Kocher criteria WCC >12 ESR >40 Unable to weightbare Fever >38.5
What is a scoliosis?
Deformity in spine rotation, lateral bending and lordosis
Causes of scoliosis?
Idiopathic
Congenital
Neuromuscular
Neuromuscular causes of scoliosis?
Polio
Muscular dystrophy
Cerebral palsy
What gait should be looked out for in knee exam? What does it mean?
Varus thrust
Lateral bowing of the knee on weightbearing
Knee OA in medial compartment with lax ligament or muscle weakness
Causes of sciatica
Herniated disc Spondylolythesis Spinal stenosis Piriformis syndrome Tumour
Antibiotic for use in mrsa patients?
Teicoplanin
Vancomycin
Open fracture classifcation?
Gustilo anderson
1- 10cm, high energy, gross contamination
A - can be closed
B - needs plastics, extensive periosteal stripping
C- neurovascular injury
Complications of open fractures
Infection
Compartment syndrome
NV injury
Periosteal stripping with non-union
Antibiotics for open fracture with allergic and mrsa alternatives
Coamoxiclav
Cefuroxime
Teicoplanin
What should be done to the wound before dressing an open fracture?
Remove gross contaminants
Photograph
When shoud an open fracture have surgery?
Within 24 hours in daytime!
Unless severe contamination or nv injury
Description of a fracture to a senior?
Pattern Angulation Rotation Translation Shortening
Risk factors for osteoporosis
Low peak bone mass Age Female Early menopause or late menarche Smoking Steroids Family history
Common fragility fractures in osteoporosis
NOF
Colles
Vertebral compression
Scoring system for osteoporosis?
FRAXS
Indications for fractured clavicle surgery
Open Tenting Nv compromise Involve AC joint Comminuted >2cm overlap
Grading for risk of septic arthritis?
Kocher criteria WBC >12 Inability to weightbare Fever >38.5 ESR >40 Score of 4 - 99% chance Score of 1 - 3% chance
When would you not asperate a joint in A+E?
Replacement! Do it in surgery
What is a two stage joint revision?
Remove infected prosthesis, wash out, add antibiotic cement
Add new joint 6 weeks later
Causes of posterior shoulder disolcation
Epilepsy
Electric shock
Complications of shoulder dislocation?
Hill sachs
Bankart
Axillary nerve
Rotator cuff tear
Significance of bankart or hillsachs?
Risk of recurrent dislocations
In case of a humeral shaft fracture with radial nerve injury when should surgery be considered?
> 2 months duration of palsy
If occured post manipulation
How should a humeral shaft fracture be treated normally?
Hanging cast
Types of forearm fractures?
Which typically need surgery?
Both bones
Isolated ulnar - fix
Galeazzi - distal radius with disruption of DRUJ - fix
Monteggia - prox ulnar with radial head dislocation - fix ulnar
What are the angles at the wrist with regards to the radius and ulnar. Significance?
Radial inclination - 22degrees - allows
Radial height - 2mm - allows ulnar deviation
Volar tilt - 11degrees - allows flexion
Causes of patellar fracture?
Direct blow - comminuted
Stopping a fall by tensing quads - transverse fracture
Treatment of a webber A fracture?
Boot or below knee cast
Types of webber b fracture and treatment
Without talar shift or med/pos malleolus fracture - below knee cast
With any of the above - surgery - orif
What fractures are associated with a fall onto the heels? Implication?
Calcaneum, impacted distal tibia, tibial plateau, pelvic, spine
If one is seen look for the others!
What is a common injury of the midfoot? What does it involve?
LisFranc injury
Injury to lisfrank ligament between metatarsal and cuneiform
Often associated with fractured metatarsal bases
How does a lizfrank injury present?
Swollen foot with bruising on the sole
Severe midfoot pain
How should a lizfrank injury be checked for if xrays are normal initially?
Weightbaring xrays
CT
Look at allignment
Problems with screw fixing intracapsular nof fractures.
Still risk of avascular necrosis
Needs to be non weightbearing after
Causes of compartment syndrome?
Fractures Crush injuries Burns Tight dressings/casts Bleeding/haemotomas Extravasation of iv fluid infusion
Complications of compartment syndrome
Infarction with muscle necrosis, rhabdomyolysis, contracture
What defines non union of a fracture?
Failure to heal within 9 months
What sorts of non-union are there? What causes each?
Hypertrophic - splayed ends - inadequate stability
Atrophic - tapered ends - inadequate biological mechanisms
How can you aid fracture healing if stability is the problem?
Non-weightbearing
More stable cast
Surgical stabilisation
Revision surgery
How can you aid fracture healing in a non union break if biological issues are the problem?
Stimulate bleeding
Apply bone graft
Ensure adequate nutrition
Stop smoking
What should be done before fixing a fracture associated with a tumour or prophylactically fixing a bone with a tumour? What is the big risk?
Embolise the tumour to reduce bleeding
Contaminates the entire bone
Which bone tumour is most likely to effect more elderly patients?
Chondrosarcoma
Which two bone tumours usually effect young adults
Osteosarcoma
Ewings sarcoma
Where does osterosarcoma usually occur?
Either side of the knee
Where does ewings sarcoma usually occur?
Pelvis or femur
Where does condrosarcoma usually occur?
Scapula
Pelvis
Femur
Treatment of a bite injury
Coamoxiclav
Clean pack and dress
Xray to exclude foreign body
What generic infections should be considered in a patient with a bite injury that act distant to the site of injury
Tetanus
Rabies
Commonest infection from a dog bite?
Pasteurella multocida
Msk complication of cushings?
Avascular necrosis of femoral head,
Osteoporosis
