MSK Flashcards
What is a garden class I fracture?
Incomplete/impacted, valgus angulation of distal component
What is a garden class II fracture?
Complete fracture, undisplaced
What is a garden class III fracture?
Complete, partially displaced fracture
What is a garden class IV fracture?
Complete, totally displaced
What is the Weber classification used for?
Fibula fractures
What is a Weber class A fracture?
Distal to the ankle syndesmosis
What is a weber class B fracture?
At the level of the ankle syndesmosis
What is a weber class C fracture?
Proximal to the ankle syndesmosis
What is the Gustilo classification used for?
Open fractures
What is a Gustilo I fracture?
Low energy fracture
Small clean wound
What is a Gustilo II fracture?
Moderate energy, clean wound >1cm
Mild-moderate comminution
What is a Gustilo III fracture?
High energy
Extensive skin damage
Neurovascular damage and wound contamination
What is the Salter-Harris classification?
Physeal (growth plate) fractures
What is a Salter-Harris class I fracture?
Complete physeal fracture
What is a salter-Harris class II fracture?
Complete physeal fracture + chip of metaphysis
What is a salter-Harris III fracture?
Physeal fracture extending through epiphysis
What is a salter-Harris class IV fracture?
Physeal and epiphyseal and metaphyseal fractures
What is a salter-Harris class V fracture?
Compression fracture of growth plate
What do the increasing numbers in salter-Harris classification mean?
Increasing risk of growth arrest
What is the most common type of salter-Harris fracture?
II
What is the garden classification used for?
Intracapsular hip fractures
What is the common order for all MSK examinations?
Look
Feel
Move
Special tests
What do you look for from behind in a spinal examination?
Asymmetry - head, shoulders, pelvis
Scoliosis
Muscle wasting
Scars
What do you look for from the side in a spinal examination?
Kyphosis
Lordosis
What does asking a patient to walk on tip toes test?
S1
What does asking a patient to walk on their heels test?
L5
What do you feel for when palpating the spine?
Spinous processes
Paraspinal muscles
Start at occipital protuberance and move down to SI joints
What level is the iliac crest at?
L4
What level is the PSIS at?
S2
What movements of the cervical spine should you test?
Flexion/extension
Rotation
Lateral flexion
What movement of the thoracic spine should you test?
Rotation - hold pelvis still from behind and ask patient to turn to face you
What movements of the lumbar spine should you test?
Flexion/extension
Lateral flexion
What is the Schrober test?
Testing lumbar flexion
What are the 4 special tests for sciatica?
Straight leg raise
Save’s test - dorsiflex ankle, produces pain below knee (at full SLR)
Relax knee - pain goes away
Borg’s test - push in upper popliteal fossa
What is Spurling’s sign?
Laterally flex neck to side of pain
+ve = pain down arm
How do patients with spinal stenosis walk?
Flex forward
Widens gaps in spine to reduce pain
What are the components of a peripheral nerve examination?
Inspection Tone Power Reflexes Sensation Coordination
What does 0 on the ASIA chart mean?
Total paralysis
What does 1 on the ASIA chart mean?
Palpable or visible contraction
What does 2 on the ASIA chart mean?
Active movement, full ROM when gravity is eliminated
What does 3 on the ASIA chart mean?
Full ROM against gravity
What does 4 on the ASIA chart mean?
Full ROM against moderate resistance in a specific muscle position
What does 5 on the ASIA chart mean?
Full ROM against full resistance expected from an otherwise unimpaired person
How do you test the C5 myotome?
Elbow flexion
How do you test the C6 myotome?
Wrist extension
How do you test the C7 myotome?
Elbow extension
How do you test the C8 myotome?
Finger flexion
How do you test the T1 myotome?
Finger abduction
How do you test the L2 myotome?
Hip flexion
L3 myotome?
Knee extension
L4 myotome?
Ankle dorsiflexion
L5 myotome?
Extensor hallucis longus (big toe extension)
S1 myotome?
Ankle plantarflexion
What is the supply to the Biceps reflex?
C5
What is the supply to the brachioradialis/supinator reflex?
C6
What is the supply to the triceps reflex?
C7
What if Hoffman’s sign?
UMN sign
Click your finger with theirs in-between
Positive if the clasp their fingers
Analogous to clonus in lower limb
What is the nerve supply to the patella reflex?
L4
What is the nerve supply to the ankle reflex?
S1
What is babinski’s sign?
Stroke along metatarsal V then across to the big toe
First movement of big toe must be extension, followed by fanning of the other toes = UMN sign
How do you test for clonus?
Relax ankle by rolling it then sudden and sustained dorsiflexion
3-4 beats is normal, more than 5 is not - UMN sign
What dermatome do you test in the middle finger?
C7
Where is the L1 dermatome?
Groins
Where is the L2 dermatome?
Hands in pockets
Where is the L3 dermatome?
Knee
Where is the L4 dermatome?
Inside calf
Where is the L5 dermatome?
Outside calf
Where is the S1 dermatome?
Lateral foot and sole
What are the red flag symptoms for back pain?
Age outside 18-55 Non-mechanical pain Night pain Thoracic pain Systemic features: weight loss, night sweats History of malignancy, infection or trauma Steroid/drug abuse Widespread neurology
Define widespread neurology
Neurological symptoms that can’t be explained by a single nerve root defect
What is cauda equina syndrome?
Compression, trauma, spinal stenosis or other damage to the cauda equina
I.e. The spinal cord after its termination at L2
What are the features of cauda equina syndrome?
Bilateral sciatica + perianal numbness (saddle anaesthesia)
Complete cauda equina = detrusor involvement - painless retention leading to incontinence
What is the treatment for cauda equina syndrome?
Surgical decompression within 48 hrs of sphincter dysfunction for good prognosis
What part of the vertebral body is commonly affected by tumours?
Pedicle
What colour is water on T2-weighted MRI?
White
What are the most common cancers found in the spine?
Mets
Lung, breast, kidney, prostate, thyroid
What primary tumour may appear in the spine?
Myeloma
What infections may be present in the spine?
Spondylo-discitis
Epidural abscess
Paravertebral abscess
TB
What are the features of neurological claudication?
Proximal to distal Variable distance Sit to relieve (jelly legs) Relieved in minutes Associated pins and needles, numbness and weakness
What are the features of vascular claudication?
Distal to proximal
Fixed distance
Stand to relieve
Relieved in seconds
What is the management for spinal stenosis?
Physio
Pain relief
Injections
Surgical decompression
What is the conservative/medical management of sciatica?
Short period of bed-rest Analgesics Muscle relaxant eg diazepam Neuromodulating agents eg gabapentin Physio once pain is under control
What surgery may be offered for sciatica?
Mini discectomy
Micro discectomy
What are the features of mechanical pain?
Varies with activity and time
Relieved by rest
What is the management of mechanical back pain?
Conservative with core stabilisation
Bed rest is bad
Aim for return to function ASAP
Simple analgesics and physio
What is referred pain?
Irritation of end place supplies felt in the whole area that the nerve supplies
What is the distinguishing feature of sciatica?
Must go below the knees
If it doesn’t, it is referred pain not sciatica
In the shoulder, if passive movement is greater than active, what does this suggest?
Nerve or tendon injury
What are the common shoulder problems in the 10-30 age group?
Instability
Muscle packing problem
What are the common shoulder problems in the 40-60 age group?
Impingement
Adhesive capsulitis (frozen shoulder)
Inflammatory Arthropathy
What are the common shoulder problems in 60-80 year olds?
Degenerative cuff tear
Osteoarthritis
Cuff arthropathy
What are the 4 articulations at the shoulder?
Glenohumeral
Sternoclavicular
Acromioclavicular
Scapulothoracic
What is the function of the glenoid labrum?
Increases depth of joint
Increases stability
What is the conjoined tendon?
Coracobrachialis + short head of biceps
What is the main surgical approach to the shoulder?
Deltopectoral
What are the stabilising factors of the shoulder joint?
Labrum Ligaments Capsule Muscles Negative pressure Contact
What is true singing of the scapula?
Long thoracic nerve damage
What is the most common cause of winged scapula?
Muscle imbalance
What is Popeye’s sign?
Rupture or adhesionary tear of biceps tendon
What nerve may be damaged in a posterior shoulder dislocation?
Axillary
How do you palpate the shoulder?
Use 2 fingers
One side at a time
Only palpate the affected shoulder but still look and move both
How do you feel the head of humerus?
Rotate shoulder internally and externally to feel the head moving in the sulcus
What movements do you test at the shoulder?
Forward elevation
Rotation: external and internal
Abduction: with palms facing up
How do you test internal rotation at the shoulder?
Put hands behind back, how high can their thumb reach? Should be mid-thoracic spine for full ROM
How do you test external rotation of the shoulder?
Lock elbows at side
What condition is suggested if both active and passive movements are restricted at the shoulder?
Frozen shoulder
Arthritis
Through what degrees of shoulder abduction is painful arc syndrome?
40-120
How do you test rotator cuff function?
Supraspinatous: abduction
Infraspinatous & teres minor: resist pressure when in full external rotation
Subscapularis: empty beer can
What is the Scarff test?
Put arm across neck
Pain = acromioclavicular joint pain
What are the causes of impingement at the shoulder?
Bursitis
Tendonitis (eg calcific)
Inflammation
Tear
What scoring system is used for hypermobility?
Beighton score
Ligamentous laxity
How do you finish a shoulder examination?
Neurological examination
Examination of cervical spine
What is the main clinical feature of a frozen shoulder?
How is a frozen shoulder managed?
1- NSAIDs, steroid injections
2- MUA, distension, arthrogram
3- leave it alone
Physio may make it worse
How do you manage shoulder impingement?
Physio
Steroid injections
USS/MRI to check for cuff tear
Su acromegaly decompression
How are steroid injections used in impingement syndrome?
Maximum 3
Each 6 weeks apart
Only give 2nd if the first gives sustained benefit
What is a Bankart lesion?
Shoulder dislocation causing tear of the glenoid labrum in the anteroinferior portion
Provides an area for the humeral head to dislocate into
What is a Hill-Sack’s lesion?
Impaction causes fracture of posterior humeral head
What are the common conditions of the elbow in children?
Pulled elbow
Fractures: supracondylar, epicondyles, radial neck
Infection
What are the common elbow conditions in older people?
Lateral epicondylitis
Medial epicondylitis
Osteoarthritis
Fractures: radial head, Olecranon, distal humerus
Nerve entrapment: ulnar, palmar interosseous, median
What do you look for in all MSK examinations?
MRS SAD Muscle wasting Rash Scars Swelling Asymmetry Deformity
Which deformity of elbow alignment is a functional problem?
Valgus - can stretch the ulnar nerve, causing palsy
What is 3-point relation at the elbow?
Olecranon, medial and lateral epicondyles make an isosceles triangle when bent, and a straight line when extended
What movements do you test at the elbow?
Flexion/extension
Supination/pronation, with elbows bent at side
What are the special tests at the elbow?
Golfer’s elbow: flex wrist against resistance, palpate for tenderness
Tennis elbow: extend wrist against resistance, palpate lateral epicondyle for tenderness
Instability: test collateral ligaments
What is the most common elbow dislocation?
Posterolateral
What are the causes of a stiff elbow?
OA
RA
What is the volar surface of the hand?
Palmar surface
What is the relation of the MCPJ of the thumb and those of the other fingers?
Thumb MCPJ is at 90degrees to others
What is the normal resting posture of the hand?
Cascade: little finger is the most flexed at rest
What does a single palmar crease signify?
Simian crease
Seen in down’s and other congenital syndromes
What are Heberden’s nodes?
Swelling and deformity of distal IPJs
Classic of OA
What are the signs of RA in the hands?
Symmetrical swelling
Ulnar deviation of proximal finger joints
What are Dupuytren’s?
Contracture of fibrous bands in palmar fascia
What are the borders of the anatomical snuffbox?
Radial side: extensor pollicis brevis
Ulnar side: extensor pollicis longus + extensor digitorum
What does tenderness in the anatomical snuffbox suggest?
Scaphoid injury
What does tenderness at the tip of the radial styled process suggest?
deQuervain’s disease
= tenovaginitis of combined sheath of EPB and AbPL
What movements do you test in the hand?
Wrist flexion/extension
Ulnar/radial deviation
Pronation/supination
How do you test thumb movements?
Hold patient’s hand flat on the table dorsal surface down
- Stretch to the side (extension)
- Point to the ceiling (abduction)
- Pinch my finger (adduction)
- Touch your little finger (opposition)
How do you test flexor digitorum profundus?
Hold proximal IPJ extended and ask patient to bend finger
How do you test flexor digitorum superficialis?
Inactivate profundus by holding other fingers in extension and ask patient to flex finger to be tested
What are the differences in the tendons of FDS and FDP?
FDS has 4 separate muscle bellies
FDP has 1 belly then splits into 4 tendons
What is the Tonodesis test?
Flex wrist - fingers extend
Extend wrist - fingers flex
How do you test extensor digitorum/indicis?
Make fist and stretch out relevant finger
What is Allen’s test?
Compress both ulnar and radial arteries, get patient to make fist and clench
Open hand out and release first radial artery: how quickly does it go from white to red? Then repeat releasing ulnar first
How do you test interosseous muscle function?
Spread fingers and push little fingers against each other
If one is weaker, that hand’s fingers will collapse
What is Froment’s sign?
Grip card between thumb and index finger
If adductor pollicis is weak, the affected thumb will be flexed to bring FPL into action
Also tests ulnar nerve function
What is Tennell’s test?
Tap halfway between borders of wrist to stimulate median nerve
Causes tingling/shooting in median distribution
What are nerve symptoms?
Tingling Weakness Numbness Pain Muscle wasting Loss of dexterity
How do you test nerve function in children following fracture?
Thumbs up = radial
Make O = anterior interosseous
Cross fingers = ulnar
What is Phalen’s test?
Flex wrist
Causing pain within 1 min = carpal tunnel
What are the causes of carpal tunnel syndrome?
Idiopathic Hypothyroidism Pregnancy Wrist fracture Work-related
What is the first part of the nerve affected when it is compressed?
Myelin, leading to decreased conduction velocity
Where are the majority of ulnar nerve compressions?
Cubical tunnel (elbow)
What digits are affected by ulnar nerve compression?
Ulnar 1.5 fingers
What muscles are affected by ulnar nerve compression?
Intrinsic muscles of hand
Adductor pollicis
FDP
What fracture can cause radial nerve damage?
Humeral shaft
Most commonly lower third of humerus
Where do you check sensory supply of the radial nerve?
1st dorsal webspace
What is the motor supply of the radial nerve?
Wrist extensors
Finger extensors
Extensor pollicis longus
What are the risk factors for Dupuytren’s contractures?
Family history
Alcoholism
Diabetes
Hand trauma
What is the threshold for intervention in Dupuytren’s?
When they can’t get their hand flat on the table
What is trigger finger?
Pulley that holds tendon against bone becomes thickened
Means the tendon gets stuck and doesn’t move smoothly
What is DeQuervain’s tenosynovitis?
Radial sided wrist pain
Swelling and tenderness over styloid
How do you test for flexor tendon injury?
Cascade
Tenodesis test
Squeeze test
FDS and FDP tests
What is tenosynovitis?
Chronic inflammation of a tendinous sheath
How many extensor compartments are there in the wrist?
6
What is the contents of the 1st extensor compartment of the wrist?
Abductor pollicis longus
Extensor pollicis brevis
What joints in the hand are commonly affected by osteoarthritis?
DIPJ
MCPJ
What are Bouchard’s nodes?
Swelling over PIPJs
What are the differentials for a lump in the hand?
Endochondroma
Giant cell tumour
Malignant tumour
Cystic eg ganglion
What type of scaphoid fracture takes longest to heal and why?
Tail
It is furthest from he blood supply (which is distal to proximal)
What does an enlarged gap between carpal bones suggest?
Ligament rupture
What is SNAC?
Scaphoid non-Union advanced collapse
What is the main risk with scaphoid fractures?
Avacular necrosis due to disruption of the blood supply
How are finger fractures stabilised?
Buddy strapping
Splintage
Internal fixation
What are the risk factors for hand infections?
Peripheral vascular disease Diabetes Immunocompromised Innocuous injury eg gardening Smoking IVDU
What are the feature of a flexor sheath infection?
Confines to digit affected
Tender on volar aspect
EMERGENCY
What is pollicisation?
Turning a finger into thumb
May also use a big toe to make a thumb
What is excision arthroplasty?
Removal of arthritic parts of the joint
What is interposition?
Autograft
In the thumb, take part of flexor carpi radialis and use it as a sling to wrap around the joint
Why do patients with arthritis get stiffness when starting walking after rest?
Normally cartilage creates a fluid film when you get up from a period of inactivity
Bone on bone in arthritis initially, as fluid takes longer to build up due to less cartilage being there
What are the red flag symptoms for the hip?
Severe night pain
Inability to weight bear on limb
History of malignancy
Rapid deterioration of symptoms
How do you do Trendelenburg’s test?
You’re testing the leg they’re standing on
Sit down and hold their pelvis, tell them to hold your elbows
If positive, you feel the pelvis drop and they push on your elbow (when they are stood on the bad leg)
How do you position the patient to feel the hip joint?
Patient laid on side with knees to chest
What bony prominences should you feel for in a hip examination?
ASIS PSIS Greater Trochanter Pubic Tubercle Ischial Tuberosity
What area is commonly tender in an arthritic hip?
Anterior groin
Other than bony prominences, what else do you feel for in a hip examination?
Pulses
Leg length - thumbs behind each medial malleolus
What movements should you test at the hip?
Flexion then…External and internal rotation
Ab and adduction
External and internal rotation with leg in extension
What movement at the hip is most sensitive to arthritis?
Internal rotation
What special tests do you do at the hip?
Leg length - pulses at the same time
Thomas’ test (fixed flexion deformity)
Trendelenburg
What does the leg look like when the hip is fractured?
Externally rotated and shortened
What are the features in a history that suggest OA?
Other joint involvement
Gradual onset, progressing over a long time
Pain, stiffness, loss of function
Family history
What is GTPS?
Greater Trochanteric Pain Syndrome
Eg Trochanteric bursitis
Terrible pain there all the time, can’t sleep on affected side
What is FAI?
Femoroacetabular impingement
Pre-arthritic hip, due to tearing of labrum
Common in sportsmen
How do you test for FAI?
Flexion + adduction + internal rotation
What are the causes of avascular necrosis of the head of femur?
Alcohol Steroid Transplant Liver disease Trauma
What does the head of femur look like in avascular necrosis?
White and sclerotic
What are the signs of hip infection?
Severe pain and systemic sepsis
Common in children
Very stiff and unable to weight bear
How do you manage hip infection?
USS shows fluid in hip
Urgent referral - needs decompression and cleaning early
What is SUFE?
Slipped Upper Femoral Epiphysis
When a lytic lesion has no clear edges, what does this suggest?
Aggressive tumour
No osteoblast activity
What are the risk factors for #NOF?
Caucasian Female 70+ years Osteoporosis, osteomalacia Diabetes, stroke, alcoholism, chronic debilitating disease Muscle weakness, poor balance
What is the Garden classification of #NOF?
- Incomplete impacted fracture
- Complete undisplaced
- Complete with moderate displacement
- Severely displaced
What is the blood supply to the head of femur?
Intramedullary vessels in femoral neck
Ascending branches of medial and lateral circumflex femoral arteries
Vessels of ligamentum teres - insufficient in adults
What is the potential complication of displaced #NOF and why?
Avascular necrosis of femoral head
Tearing of ascending branches of medial and lateral circumflex arteries (found in capsule)
How are elderly patients managed post-op hip fractures?
Early mobilisation
To prevent pulmonary complications and bed sores
How are hip fractures managed in young people?
Reduce fracture and check with X-Ray
If satisfactory, fix with screws
Impacted fractures can be fixed as they lie
What is hemiarthroplasty?
Only femoral part of hip joint replaced
What are the indications for THR in hip fractures?
Acetabular damage
Metastatic or Paget’s disease
What are the advantages of hemiarthroplasty vs THR in hip fractures?
Shorter operating time
Less blood loss
Lower infection rate
What are the three types of proximal femur fracture?
Transcervical (neck of femur)
Intertrochanteric
Subtrochanteric
How are intertrochanteric fractures managed?
Internal fixation - dynamic hip screw
How do Subtrochanteric fractures compare to NOF fractures?
Blood loss greater in Subtrochanteric
How are Subtrochanteric fractures managed?
Open reduction + internal fixation with intramedullary nails and locking screws into femoral head
What is a common complication of Subtrochanteric fractures?
Malunion
What are the common presenting complaints with the knee?
Pain Stiffness Loss of function Locking Giving way Swelling Trauma
What is locking of the knee?
Can’t be flexed
What does the knee giving way going down stairs suggest?
PFJ problem
What does the knee giving way on twisting/locking suggest?
Meniscus problem
Osteoarthritis
What pain may be referred to the knee and why?
Hip
Femoral nerve innervation
What is an antacid gait?
Hopping onto the good leg as soon as possible
To avoid pain
What is a varus thrust?
Knee buckles to the side as it weight-bears
What bony landmarks should you feel for in the knee?
Femur Tibia Patella Joint line All done in 90degree flexion
What is the sweep test?
Testing for effusion in the knee
Sweep fluid from medial side, then push back
What special tests do you do for the knee?
Sweep test Collaterals Anterior/posterior drawer Lachman's Straight leg raise
How do you do anterior/posterior drawer tests?
Fix foot by sitting on it
Fingers either side of tibial tuberosity and rock back/forwards
What is Lachman’s test?
For ACL
Pull tibia back/forward on femur
One hand on each bone at 30degrees
What is the straight leg raise test for?
Shows extensor mechanism is intact
What knee conditions are common in adolescents?
Trauma/sporting injury eg meniscus, ACL, patella dislocation PFJ pain Osteochondritis dissecans Inflammatory arthritis Tumour Infection
What knee conditions are common in elderly patients?
Osteoarthritis Trauma Crystal deposition Infection Secondary tumour
What are the red flag symptoms for the knee?
Inability to weight bear Worsening pain Acutely very stiff knee Fever Night pain History of malignancy
What are the functions of the menisci?
Improve articulate congruency and stability
Control rolling and gliding of knee
Distribute load during weight bearing
Which meniscus is more liable to tearing and why?
Medial - less mobile than lateral meniscus
What types of meniscal tear are there?
Bucket-handle
Anterior horn
Posterior horn
Horizontal tear
What types of meniscal tear have worse healing?
Tears closer to the centre of the joint
This area is avascular
What is the common presenting complaint of a meniscal tear?
Severe pain
Knee locked in flexion
Young patient following twisting injury to the knee
What is the imaging of choice for meniscal tears?
MRI
White line through meniscus = tear
What is osteochondritis dissecans?
Small fragment of avascular bone and overlying cartilage separates from femoral condyle
Later appears as a loose body in the joint
Intermittent pain and swelling
What are the causes of loose bodies in the knee?
Injury - chip of bone or cartilage Osteochondritis dissecans Osteoarthritis Charcot's disease Synovial chondromatosis
What factors pre-dispose to OA of the knee?
Torn meniscus
Injury to articular surface
Ligament instability
Pre-existing deformity
Where does cartilage breakdown most commonly start in the knee?
Area of greatest weight-bearing…medial compartment
What may you observe in an osteoarthritic knee?
Swelling
Varus deformity
Quadriceps wasting
What are the signs of OA on X-ray?
Loss of joint space
Subchondral sclerosis
Osteophytes
Sunchondral cysts
What is the conservative management of osteoarthritis?
Analgesia
Apply warmth
Physio (quads)
Reduce joint load by sticks or weight loss
What are the indications for knee surgery in OA?
Persistent, unresponsive pain
Progressive deformity and instability
What happens in knee arthroscopy for OA?
Trim meniscal fragments/osteophytes and washout
Temporary relief, useful if reconstructive surgery is contraindicated
When is realignment osteotomy used for OA?
Medial compartment disease in young people
What are the sources of anterior knee pain?
Referred pain from the hip
Patellofemoral disorders
Knee joint disorders
Periarticular disorders
What is Osgood-Schlatter’s disease?
Tibial tubercle apophysitis
What patellofemoral disorders can cause anterior knee pain?
Patellar instability
Patellofemoral overload
Osteochondral injury
PFJ arthritis
What is suggested by the feeling of the knee wanting to give way, or actually doing so, during weight-bearing activity?
Chronic ligamentous instability
What are the types of tibiofemoral instability?
Sideways tilt (varus or valgus) Excessive glide (forwards or backwards) Unstable rotation
What are the indications for surgery in chronic ligamentous instability?
Intolerable giving way
Unacceptably reduced function
Associated internal injury eg torn meniscus
Symptomatic ligament injuries in adolescents
What is Sinding-Larsen-Johansson syndrome?
Patellar tendinitis due to patellar ligament strain or partial rupture
Common in adolescent athletes
Repeated episodes of pain and local tenderness
What is the function of the medial foot?
Stability and rigidity
What is the function of the lateral foot?
Flexibility
What is the function of the plantar fascia?
Helps support arch
Attaches skin to underlying tissue
What is suggested by acute pain around the 1st MTPJ?
Gout
What is metatarsalgia?
Diffuse ache across the forefoot
Where is the subtalar gap?
In front of the lateral malleolus
What is the nerve supply to the majority of the dorsum of the foot?
Superficial peroneal nerve
What is the sensory supply to the lateral foot?
Sural nerve
What should you look for when examining the foot?
Shoes
Whole leg: hip and knee
From front: alignment
Swelling, callosities, ulcers, vascularity
From behind: alignment, swelling, callosities, muscle bulk
Side: arches
Sole: plantar ulcer and callosities
How many toes should you see from behind the foot?
2
More indicates a flat foot - too many toes sign
What does walking on the outside of the feet test?
Tibialis posterior function
What does deep pain and tenderness under the medial arch suggest?
Plantar fasciitis
What movements should you test at the ankle?
Dorsiflexion Plantarflexion Inversion Eversion Flexion and extension of toes
What is the normal range of dorsiflexion at the ankle?
15 degrees
What is the normal range of plantarflexion at the ankle?
40 degrees
How do you test tibialis posterior function?
Point toes and push foot inwards while I resist
Tendon should stand out clearly behind medial malleolus
What is Thomson’s test?
Squeeze calf and foot automatically plantarflexes
Doesn’t happen if Achilles has ruptured
What happens to the heels when you stand on tiptoes?
Swing into valgus
Action of tibialis posterior
How do you complete a foot and ankle examination?
Vascularity - pulses
Neuro: sensation and proprioception
What is hallux valgus?
Bunion
What happens in bunion surgery?
Metatarsal osteotomy - break and move metatarsal and put in screws/staples
What is hallux rigidus?
Arthritis of 1st metatarsophalangeal joint
What are the surgical options for hallux rigidus?
Osteotomy
Arthrodesis
Arthroplasty: excision/interposition/replacement
What is planovalgus?
Flat foot
What is the treatment of planovalgus?
Medial arch support
Physio
Can reconstruct tib post tendon
What are the features of ankle arthritis?
Pain anteriorly over ankle
Stiffness
How do you treat ankle arthritis?
Limit movement eg braces
Total ankle replacement
Osteotomy, arthrodesis, arthroplasty
In what order are ankle ligaments commonly damaged?
Anterior talofibular
Calcaneofibular
Posterior talofibular
What proportion of ankle sprains are associated with a fracture?
15%
When is an X-ray indicated with ankle sprain?
Pain around the malleolus
Inability to weight bear/take 4 steps
Bone tenderness around base of metatarsal V
How do you remember the structures passing anterior to the medial malleolus?
All Hospitals Are Not Very Dirty Places
What else is commonly injured in ankle fractures?
Ligaments - invisible part of the injury
What ankle fractures require internal fixation?
Displaced fractures and fracture-dislocations
What are the complications of ankle fractures?
Joint stiffness
Complex regional pain syndrome
Osteoarthritis
What is a Pilon fracture?
Tibial plafond fracture
Severe axial compression of ankle joint eg fall from height
What is commonly associated with calcaneal fractures?
Spine, pelvis or hip injuries
What are the common causes of metatarsal fractures?
Direct blow
Severe twisting
Repetitive stress
What is the composition of bone extracellular matrix?
35% organic material: type I collagen, proteoglycans, glycosaminoglycans, lipids
65% inorganic material: hydroxyapatite
What are cutting cones?
In bone formation
Osteoclasts remove bone at the front of the cone, osteoblasts follow behind producing new bone
What is intramembranous ossification?
Preosteoblasts differentiate into osteoblasts which produce bone
This increases bone width
What is endochondral ossification?
Pre-existing cartilage template is replaced by bone to increase bone length
Due to osteoblast activity
Define fracture
Break in the structural continuity of bone
What are the local complications of fracture?
Local oedema
Inflammatory reactions
Neurovascular impairment
What is an open fracture?
Breach in skin or body cavity
What is primary bone healing?
Minimal granulation tissue and no callus
Cutting cones form and cross the fracture site
Osteoclasts clear damaged bone and osteoblasts produce new bone
Happens if defect/gap is small
What are the stages of secondary bone healing?
Haematoma formation
Fibrocartilaginous callus formation
Bony callus formation
Bone remodelling
How does a haematoma form over a fracture site?
Fracture causes rupture of vessels
Damaged tissue and platelets release cytokines, vasomodulatory substances and growth factors
Causes clot to form
What is Wolff’s law?
Bone can remodel and adapt to the loads placed on it
What are BMPs?
Bone Morphogenic Proteins
I.e. Cytokines, metabolites
Induce formation of bone and cartilage
How does PTH affect bones?
Stimulates osteoclasts
What factors interrupt bone healing?
Movement of bony fragments
Soft tissue lying in between bony fragments
Misalignment
Infection
Bone disease
Surrounding soft tissue injury - damages blood supply
What patient factors interrupt fracture healing?
Poor general health Malnutrition Drug therapy Age Smoking Diabetes
How does diabetes affect fracture healing?
Defective collagen production
How does smoking affect fracture healing?
Reduces osteoblast activity
Nicotine constricts vessels, reducing blood flow to fracture site
What local patient factors affect fracture healing?
Blood supply
Soft tissue damage
Bone loss - need bone contact for Union
What are the stages of fracture management?
Diagnosis
Reduction
Stabilisation
Rehabilitation
What forms the physical examination of a fracture?
Deformity - open or closed?
Neurovascular status distal to fracture
How do you describe displacement of a fracture?
Distal fragment relative to proximal fragment
What is fracture translation?
% displacement
What is anatomical reduction of a fracture?
To restore perfect bony anatomy and morphology
Required with joint fractures
What is functional reduction of a fracture?
To restore relationship between proximal and distal bone fragments
Length, alignment and rotation restored
Needed for metaphyseal and diaphyseal fractures
What is indirect reduction?
Closed reduction - lower infection risk
What are the indications for open reduction?
Failure of closed reduction
Large articular fragments
Avulsion fractures
Associated injuries eg arterial damage
What are the aims of fracture stabilisation?
Prevent fragment displacement
Alleviate pain
Allow soft tissue healing
Allow movement of unaffected joints
What are the different methods used for fracture stabilisation?
Sustained traction Cast splintage Functional bracing Internal fixation External fixation
What are the risks associated with cast splintage?
Cast too tight - constricts blood supply causing diffuse pain
Pressure sores
Stuff joints
Loose cast
What is functional bracing?
Segments of cast over bones, leaving joints exposed
Segments connected by hinges
How may ultrasound be used in fracture healing?
Exogen ultrasound bone healing system
Treat non-union fractures of long bones
Stimulates production of growth factors and proteins to increase removal of old bone and production of new bone
What are the indications for internal fixation?
Can't be reduced with other techniques Prone to displacement after reduction Poor or slow fracture Union suspected Pathological fractures Multiple fractures Patients with nursing difficulties
What are the potential complications of internal fixation?
Inaction
Non-Union
Implant failure eg metal fatigue
Re-fracture if implants removed too soon
What is external fixation?
Bone fixed above and below fracture site
Screws, pins and tension wires connected together by rigid bars or attached to a frame
What are the complications of external fixation?
Soft tissue damage
Over-distraction
Pin-track infection
What are the aims of early movement and weight-bearing following fracture?
Prevent oedema
Restore joint movement
Restore muscle power
Introduce patient back to normal activity
How does exercise help fracture healing?
Stimulates blood flow
Prevents soft tissue adhesions
Promotes fracture healing
What antibiotics do you give immediately once an open fracture has been diagnosed?
Co-amoxiclav or Cefuroxime
Clindamycin if penicillin allergic
How do you inspect an open fracture?
Clean or dirty Gross contamination Site and size Tidy or ragged damage Establish communication of wound with fracture Condition of soft tissues Neurovascular status
What are the steps in managing an open fracture in A&E?
ATLS assessment Tetanus prophylaxis + Antibiotics Inspect wound Photograph Revise splint from paramedics X-ray or CT Remove gross contamination and photograph again Refer to ortho, plastics or vascular and transfer
When is amputation indicated for open fractures?
Uncontrollable haemorrhage Incomplete traumatic amputation 4-6h of ischaemia Segmental muscle loss of 2 compartments Bone loss greater than 1/3 of the tibia
What are the causes of pathological fractures?
Tumour: primary or secondary
Infection
Metabolic disease: osteoporosis, osteogenesis imperfecta
What are the red flag symptoms for children?
Bone tenderness to palpation
Joint swelling
Muscle weakness
Fall in height or weight growth curve
What 5 cancers commonly metastasise to bone?
Kidney Prostate Thyroid Breast Lung
What are the red flag symptoms for soft tissue lumps?
> 5cm
Deep to deep fascia
Painful
Enlarging
What investigations should you do if pathological fracture is suspected?
X-ray whole bone CXR PSA Bence-Jones protein in urine (myeloma) Isotope bone scan CT chest MRI lesion
What are the treatment options for pathological fractures?
Intramedullary nail
Cement augmentation
Replacement
Consider excision if tumour is primary and prognosis good
What are the three most common types of primary bone tumour?
Osteosarcoma
Chondrosarcoma
Ewing’s sarcoma
Where do osteosarcomas commonly present?
Distal femur or proximal tibia
Young adult
How do malignant bone tumours present?
Mass - 80% Discomfort/pain - 40% Fracture Mets Systemic symptoms
How do soft tissue sarcomas present?
Large mass
Deep to deep fascia
Rapidly growing
Calcification within mass on radiograph
What are the urgent complications of a fracture?
Vascular injury Local visceral injury Compartment syndrome Haemarthrosis Nerve injury Infection Gas gangrene
What are the late complications of fracture?
Malunion Non-Union Avascular necrosis Muscle contracture Joint instability Regional pain syndrome Osteoarthritis
What vessel is commonly injured in 1st rib fracture?
Subclavian artery
What vessel is commonly affected in shoulder dislocation?
Axillary artery
What vessel is commonly damaged in humeral supracondylar fracture?
Brachial artery
What vessel is commonly affected in knee dislocation?
Popliteal artery
What nerve may be damaged in a humeral shaft fracture?
Radial
What nerves may be damaged in humeral supracondylar fracture?
Radial
Median
What nerve may be damaged in elbow dislocation?
Ulnar
What nerve may be damaged in a monteggia fracture?
Posterior interosseous
What nerve may be damaged in hip dislocation?
Sciatic
What nerve may be damaged in knee dislocation?
Peroneal
How may wrist fractures affect nerves?
Sometimes cause nerve compression
Median or ulnar nerve
Define compartment syndrome
Raised pressure within an enclosed fascial space
Leading to localised tissue ischaemia
What vessels are affected first in compartment syndrome?
Veins
What are the causes of acute compartment syndrome?
Fracture (70%) Crush syndrome Bleeding disorder / anticoagulants Soft tissue injury without fracture Reperfusion injury Infection Iatrogenic eg osteotomy, reduction
Where is compartment syndrome most common?
Lower limb
Mainly due to tibial fractures
What are the clinical features of compartment syndrome?
Pain: excessive or progressive, not relieved by analgesia
Tense, swollen compartment
Paraesthesiae
Pulses rarely absent
What test can tell you which compartment is involved in compartment syndrome?
Passive stretch test
Pain
How do you manage acute compartment syndrome?
Split circumferential dressings to skin
Single dose opiate
Reassessment
May need compartment pressure monitoring
Who should have compartment pressure monitoring?
Unconscious Difficult to assess Multiple injuries Associated nerve injury Young men
What are the compartments of the lower leg?
Anterior
Lateral
Deep posterior
Superficial posterior
How is fasciotomy of the lower leg performed?
2 incisions:
Medial and anterolateral
What are the three compartments of the thigh?
Anterior
Medial
Posterior
What are the three compartments of the forearm?
Palmar (flexor)
Dorsal (extensor)
Radial
How is compartment syndrome managed post-op fasciotomy?
Leave wounds open Loose absorbent dressings Gentle elevation Fluid balance and analgesia Re-inspection + debridement + delayed closure @ 2-5d
What are the complications of compartment syndrome?
Muscle necrosis Joint stiffness Nerve fibrosis Delayed fracture union Significant functional impairment
What type of deformity is common following tibial fracture?
Ischaemic contractures
How do microorganisms reach bones and joints?
Bloodstream
Direct invasion from skin puncture, operation or open fracture
What can microbial invasion in bones and joints lead to?
Pyogenic osteomyelitis
Arthritis
Granulomatous reaction (chronic)
Why does bone infection lead to necrosis more rapidly than soft tissue infection?
It is a rigid compartment so
More susceptible to cell death from pressure build-up in acute inflammation
What factors increase susceptibility to infection of bone?
Local factors: trauma, poor circulation, chronic bone or joint disease and presence of foreign bodies
Systemic factors: malnutrition, general illness, diabetes, RA, steroid treatment
Very young or very old age
What is the pathophysiology of acute pyogenic infection?
Pus formation = concentration of defunct leucocytes, dead bacteria and tissue debris
Often localised to form an abscess
What are the principles of treatment for pyogenic bone infection?
Analgesia and supportive measures Rest affected area Antibiotic or chemotherapy treatment Evacuate pus and necrotic tissue Stabilise bone if fractured Maintain soft tissue and skin cover
What organism is the most common cause of acute osteomyelitis?
Staph aureus
Why does acute osteomyelitis lead to bone necrosis?
Rising intraosseus pressure
Vascular stasis
Compromise of blood supply to bone
Where do children commonly get acute osteomyelitis?
Organisms settle in metaphysis of long bones
Commonly distal femur or proximal tibia
How does acute osteomyelitis present?
Most commonly children under 4
Severe pain, malaise and fever
May be history of preceding skin lesion, injury or sore throat
Holding limb still, acutely tender over nearby joint, pseudoparalysis
Where is the commonest site of acute osteomyelitis in adults?
Spine
What are the differential diagnoses for acute osteomyelitis?
Cellulitis
Sickle cell crisis
What are the complications of acute osteomyelitis?
Spread to joints or other bones
Pathological fracture
Growth disturbance
Persistent infection
What is subacute haematogenous osteomyelitis?
Osteomyelitis in a relatively mild form
Due to less virulent organisms or a more resistant patient
What is a Brodie’s abscess?
Small oval cavity surrounded by sclerotic bone
Classic of subacute haematogenous osteomyelitis
What is the commonest cause of osteomyelitis in adults?
Post-traumatic (open fractures)
How does chronic osteomyelitis present?
Following acute bone infection
Recurrent episodes of pain, redness, tenderness at affected site
What organism commonly causes septic arthritis?
Staph aureus
How do organisms get into a joint to cause septic arthritis?
Penetrating wound
Eruption of adjacent bone abscess
Blood spread from distant site
What joints are most commonly affected by septic arthritis?
Hip in children
Knee in adults
What does X-ray show in septic arthritis?
Soft tissue swelling
Widening of joint space due to effusion
Periarticular osteoporosis
How do you investigate septic arthritis?
Joint aspiration and send for microbiology
What are the differential diagnoses for an acute swollen joint?
Septic arthritis Osteomyelitis Acute haemarthrosis Transient synovitis Gout or pseudogout
What are the complications of septic arthritis?
Dislocation
Epiphyseal destruction
Growth disturbance
Ankylosis
What is the management of septic arthritis?
Antibiotics
Splintage
Drainage
What is NAI?
Non-accidental injury
What is the cause of 90% of fractures before age 1?
Non-accidental injury
What are Greenstick fractures?
One side of the periosteum stays intact when the bone is bent, so the fracture is not full thickness
Because periosteum is very thick in children
Give a cause of a physeal fracture
Knee hyper extension injury
What is the apophysis?
Centre of ossification where a tendon is inserting
In what order to the ossification centres develop at the elbow?
CRITOL Capitulum Radial head Internal (medial) condyle Trochlea Olecranon Lateral epicondyle
What are the differential diagnoses for a limping child?
Infection Developmental Dysplasia of the hip Perthes' disease SUFE (adolescent) Club foot
How does hip infection present in children?
Unable to weight bear
Raised WCC and CRP
Fever over 38.5
What are the risk factors for developmental dysplasia of the hip?
Female
Family history
Breach presentation at birth
How do you test for developmental dysplasia of the hip?
Ortolani test: reduces dislocation
Abduct and lift, feel it clunking back into place
How do you treat developmental dysplasia of the hip?
Frame to abduct and flex hip
What is Perthes’ disease?
Avascular necrosis of the hip
Cause of loss of blood supply unknown
Causes deformity of the head of femur and predisposes to OA
Commonly presents in 4-8y, but can be other ages
What is SUFE?
Slipped Upper Femoral Epiphysis
Neck of femur slipping and externally rotating can cause avascular necrosis, impingement or secondary OA
What is the incidence of club foot?
1 in 1000
How is club foot managed?
Slowly manipulating feet using plaster casts
Minor surgery may be required later on if the problem recurs
How does foot alignment change during development?
Infant: geno varum
2-3y: geno valgum
7y: adult alignment (coronal)
