MSK Flashcards

1
Q

Epidemiology and risk factors for RA

A

Increased in women (2-4x)
Peak age is 40s

RFs
Smoking
Genetics - HLA DR4 and 1
Winter
Others - increased birth weight, silica exposure, alcohol abstention, obesity, diabetes,
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2
Q

Presentation of RA

A

ARTHRITIS
Insidious symmetrical polyarthritis
Small joints of hands or feet
Morning stiffness >30 minutes
PIP, MCP, wrist, MTP, ankle, knee, cervical spine (SPARES DIP)
Hand deformities - ulnar deviation, swan neck, Boutonnieres, Z deformity of thumb, piano key deformity of wrist

SYSTEMIC SIGNS
- Eyes: scleritis, episcleritis
- Skin: leg ulcers, rashes, raynauds
- Rheumatoid nodules
- Neuro: carpal tunnel, polyneuropathy
- Resp: pleuritic, pulmonary fibrosis
- CV: pericardial involvement, vasculitis, increased MI
- Kidneys: RARE
- Liver: mild hepatomegaly, raised transaminases
Thyroid disorders, osteoporosis, depression, splenomegaly, lymphadenopathy

Pain, fatigue, myalgia, weight loss

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3
Q

Investigations for RA

A
  • ESR, CRP, plasma viscosity - usually raised (can be normal)
  • FBC - normochromic normocytic anaemia, thrombocytosis, raised ferritin
  • LFTs - mildly raised ALP and GGT
  • Antinuclear antibody in 30% +

Rheumatoid factor - positive in 60-70% (and 10% normal population)

Anti-CCP

X-ray - soft tissue swelling, periarticular osteopaenia, decreased joint space, erosions, deformity

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4
Q

Management of RA

A

Start within 3 months
Simple analgesia + NSAIDs

DAS28 - number of joints and ESR. For active disease >5.1, remission <2.6

  1. Methotrexate + alt DMARD + short course steroid (min 6 months)
  2. different mono/combined DMARD therapy (min 6 month)
  3. TNF alpha inhibitors (adalimumab, etancercept, infliximab)
  4. Rituximab (anti CD20) + methotrexate
  5. Toclizumab (anti IL6)

Surgery if persistent pain, worsening joint function, progressive deformity, nerve entrapment, stress fracture

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5
Q

Complications of RA

A

Decrease mobility, restricted ADLs
Inability to work
Depression
Vasculitis
Systemic effects - pleuracy, heart complications, lymphadenopathy, neuropathy, anaemia, dry eye syndrome, anaemia, carpal tunnel, tendon rupture
Osteoporosis
Felty’s syndrome - enlarged spleen, decreased WCC + RA

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6
Q

Prognosis of RA

A

40% disabled in 10 years

Worse prognosis if: <30, male, insidious onset, persistent anaemia, increased number of joints, raised anti-CCP, early Xray changes

Pregnancy beneficial for RA

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7
Q

Criteria for RA

A

4 or more of:

  • morning stiffness >1 hour >6 weeks
  • at least 3 joints
  • hand joints
  • symmetrical
  • rheumatoid nodules
  • positive for rheumatoid factor
  • radiological changes
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8
Q

Epidemiology and risk factors for osteoarthritis

A

24% adults - knee, 11% hips

RFs
Genetic
Female
Obesity
High or low bone density
joint injury
decrease muscle strength
joint laxity or misalignment
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9
Q

Presentation of OA

A

Clinical without investigation if over 45, pain activity related and no morning stiffness

  • Pain exacerbated by exercise, relieved by rest
  • Stiffness after rest
  • Decreased function and range of movement
  • Swelling, tenderness
  • Crepitus
  • No systemic features
  • Heberdens DIP, Bouchards PIP
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10
Q

Investigations for OA

A

X-ray: osteophytes, decreased joint space, bone cysts, subarticular sclerosis

  • MRI for other causes of joint pain
  • Blood tests will be normal, should do baseline prior to starting NSAIDs
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11
Q

Management of OA

A
  • Promote function, physio, OT
  • Annual review if pain, multiple joints or regular meds
  • Encourage exercise
  • Encourage weight loss
  • Paracetamol +/- topical NSAIDs
  • Oral NSAIDs or COX2 inhibitors + PPI
  • Intra-articular corticosteroids

NO glucosamine, no arthroscopic lavage or debridement

  • Surgery if there is substantial limits on life
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12
Q

Xray changes in OA

A
Joint space narrowing
Subarticular sclerosis 
Subchondral cysts
Bone collapse
Osseous loose bodies
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13
Q

Epidemiology and RFs for septic arthritis

A

1-2% of prosthetic joint replacements
20% of joint surgery revisions
Most commonly staph aureus

RFs
Increasing age
Prior joint damage
Diabetes
Joint surgery - hip or knee
Immunodeficiency
Recent Steroid injection
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14
Q

Presentation of septic arthritis

A
Single/few joints - acute, very painful
Fever
Bacteraemia
Swollen, warm, tender
Effusion

TRIAD - fever, pain, impaired range of motion

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15
Q

Causes of septic arthritis

A

Staph aureus
Gonococcal
Group B Strep
Lyme disease

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16
Q

Investigations for septic arthritis

A

FBC - raised WCC, CRP

Synovial fluid examination - raised leukocytes, culture (also exclude crystal arthropathy)

Blood cultures

Imaging - US or MRI/CT

Have a higher index of suspicion if prosthetic joint

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17
Q

Treatment for septic arthritis

A

Surgical drainage + Lavage + High dose IV antibiotics

Antibiotics
- Start empirically before cultures, cover staph and strep as minimum, for minimum of 2-3 weeks

Flucloxacillin (if staph) - allergy to penicillin = clindamycin
Vancomycin = if MRSA
Cefotaxime - gonococcal

Corticosteroids may decrease extent of cartilage destruction

Splint in position of function

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18
Q

Prognosis of septic arthritis

A

10-20% mortality

Worse prognosis - over 65, shoulder, elbow or multiple sites

Staph - 50% get back to baseline

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19
Q

Referral for joint replacement

A

Should have tried all basic treatments (weight loss, pain relief)

If New Zealand score
<39 - primary care
40-69 - non-surgical
70+ then refer for surgery

Patient age, sex, smoking status or BMI should not be a barrier for referral

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20
Q

Complications for joint replacement

A
Joint infection
DVT/PE
Stiffness
Implant loosening/failure
Hip dislocation
Time span - need replacement after 10-15 years
Bleeding
Haemotoma
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21
Q

Classifications of gout

A

Deposition of monosodium urate monohydrate crystals

  • asymptomatic
  • hyperuricaemia
  • acute gout
  • chronic tophaceous gout

PRIMARY - in men 30-60 with acute attacks
SECONDARY - due to chronic diuretic therapy and associated with OA

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22
Q

Epidemiology and RF for gout

A

Increased in men 9:1
Increased in Asians and South Pacific

High meat diet
Diabetes
Seafood
Alcohol 
Chronic renal failure
Diuretic therapy
Obesity
High cholesterol
HTN
CHD
Psoriasis
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23
Q

Presentation of gout

A

First MTP joint (knee, tarsals, wrists, ankles, hands)
Acute pain in swollen joint that reaches crescendo in 6-12 hours

Florid synovitis
Will resolve in 5-15 days

If tophaceous gout - irregular firm nodules with chalky appearance beneath skin

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24
Q

Investigations for gout

A

Synovial fluid - MSU crystals
Gram staining and culture as infection and gout can co-exist

Serum uric acid - can be raised
Testing fasting lipids and glucose for hyperglycaemia

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25
Management of gout
ACUTE - NSAIDs and pain relief - Colchicine - Systemic corticosteroids - (continue allopurinol) ADVICE - stop alcohol, red meat, reduce protein - avoid purines - liver, kidney, seafood - avoid dehydration - increase exercise, stop smoking CHRONIC - Allopurinol - Canakinumab - if more than 3 attacks per year
26
Complications of gout
``` Renal disease from deposition of crystals Severe degenerative arthritis secondary infections carpal tunnel Nerve impingment ```
27
Prevention of gout
Manage RFs - HTN, diet, medications Start treatment if tophi, renal insufficiency, uric acid stones or diuretics. - Allopurinol - wait 1-2 weeks after attack to start - Febuxostat
28
Epidemiology of psoriatic arthritis
``` 5-25% of people with arthritis In 80% psoriasis precedes arthritis Increased in Caucasians 35-55 years old Autoimmune mediated - HLA B27 Women have more rheumatoid pattern, men with spondylitic subtype ```
29
Presentation of psoriatic arthritis
``` Joint stiffness, pain, swelling Relapsing and remitting Enthesopathy - Achilles tendon and plantar fascia common Tenosynovitis - affects flexors 20-30% conjunctivitis ``` Rheumatoid pattern - symmetrical polyarthritis. Hands, wrists, feet DIP not MCP. FEMALES Spondylytic pattern - morning stiffness, limitation of back movement, asymmetrical vertebral involvement Asymmetrical oligoarticular arthritis - dactylitis (sausage fingers) Lone DIP - hammer blow appearance Juvenile onset - 20% of childhood arthritis
30
Investigations for psoriatic arthritis
Raised ESR and CRP Raised IgA Raised neutrophils in synovial aspirate, no crystals X-ray changes - mild bony erosion, asymmetric erosive changes of small joints, DIP and PIP, erosion of distal tuft of distal phalanx Can do MRI or CT
31
Management of psoriatic arthritis
Refer to rheumatology - NSAIDs - Local corticosteroid injections (never oral due to rebound worsening of psoriasis) - DMARDs Methotrexate/sulfasalazine/leflunomide (not hydroxychloroquine) - TNF inhibitors (adalimumab/etanercept/golimumab/infliximab) if not responding to DMARD - Cytokine modulator (ustekinumab) if others failed
32
Complications of psoriatic arthritis
``` joint destruction Deformity Eye disease Aortitis (rare) Decreased QOL Increased risk of CVD ARTHRITIS MUTILANS - severe deformity (telescopic fingers) Radiological damage in 50% ```
33
Complementary therapies for MSK pains
Capsacin -5/5 Fishoil, evening primrose oild for RA Acupuncture for OA Glucosamine does not work or chondritin or chiropractors
34
Epidemiology of SLE
Increased in females 5:1 Peak age - 50-54 for women, 70-74 for adults Increased in Chinese, SE Asian and afro-Caribbean ``` RFs HLA DRB1 Defective complement C4 gene UV light EBV Drugs - chlorpromazine, hydralazine, methyldopa ```
35
Presentation of SLE
Relapsing remitting Fatigue and malaise Arthralgia - early morning stiffness, non-erosive, peripheral, symmetrical Photosensitive rash - malar rash Discoid (without systemic features) Pulmonary - pleurisy, fibrosing alveolitis APLS - PE CV - pericarditis, HTN, increased CV risk Renal - nephritis Anxiety and depression Any neurological presentation
36
Diagnostic criteria for SLE
4 or more from list (not at the same time) ``` Malar rash Discoid lupus Photosensitivity Oral ulcers Non-erosive arthritis in 2+ joints Pleuritis/pericarditis Renal involvement Seizures/psychosis Positive ANA Haematological disorder Immunological disorder ```
37
Investigations for SLE
FBC - Raised ESR, normocytic anaemia, normal CRP, leukopaenia, thrombocytopaenia Antibodies - ANA (95% sens) - Anti-dsDNA - 70% sens but more specific - levels reflect disease process - Anti-Sm - most specific but 30% sens - Anti0 SSA(Ro), Anti- SSB(La) in 15% and other connective tissue disease Check for antiphospholipid antibodies for APLS
38
Management of SLE
- Avoid sun exposure - Regular exercise - NSAIDs - Hydroxychloroquine for skin, arthralgia and myalgia - Cyclophosphomide - in life threatening disease - Mycophenolate mofetil - Azathioprine - Methotrexate or ciclosporin - IV gammaglobulin and granulocyte colony stimulating factor (if resistant) - BELIMUMAB as adjunct if active and antibody positive
39
Conditions associated with SLE
``` APLS scleroderma RA Sjorgen's thyroiditis Drug allergies ```
40
Epidemiology of ankylosing spondylitis
``` 0.1% of the population Increased in Northern European Peak onset 20-30 Increased in males (3:1) STRONG FHx - HLA B27 ```
41
Presentation of ankylosing spondylitis
Insidious onset under 30 years old Can be mild chronic or intermittent flares Systemic features - weight loss, fever, fatigue Morning stiffness Inflammatory back pain Pain improves with activity Early morning wakening Peripheral enthesis - 33% (Achilles tendonitis, plantar fasciitis) Peripheral arthritis - 33% - asymmetrical - hips, shoulders, chest wall, TMJ Tenderness of sacroiliac joints Limited range of spinal motion Lumbar lordosis, thoracic kyphosis, buttock atrophy
42
Extra-articular findings in ankylosing spondylitis
Acute anterior uveitis Aortitis Restrictive lung disease - pulmonary fibrosis in upper lobes Amyloidosis (rare) can cause renal dysfunction Neuro - C1/C2 subluxation leading to cervical myelopathy Osteoporosis or osteopaenia Cauda equina
43
Diagnostic criteria of ankylosing spondylitis
Radiological findings + 1 clinical finding Radiological - sacroilitis on X-ray Clinical - Lower back pain > 3 months, improves with exercise, not relieved by rest - Limitation of lumbar movement in both planes - Limit of chest expansion
44
Investigations for ankylosing spondylitis
FBC and CRP (can have normocytic anaemia) LFTs - ALP often raised Xray - may be normal in early disease, "bamboo spine", sacroilitis, enthesititis. Spinal osteopaenia common MRI SEXA scan US in enthesitis
45
Management of ankylosing spondylitis
- No DMARDs - NSAIDs + PPI - Local corticosteroid injections - Oral steroids - short term only - TNF alpha inhibitors e.g. etanercept or adalimumab] - Surgery: spinal fixation, vertebral osteotomy - Bisphosphonates for osteoporosis
46
Prognosis of ankylosing spondylitis
Increased risk of fractures Frozen thorax Blindness from recurrent uveitis 70-90% fully independent
47
Aetiology of lower back pain
Mechanical - hypermobility, arthritis, disc disease, scoliosis, spinal stenosis, sacroilitis - Bone disease, osteoporosis, osteomalacia, Paget's Non-mechanical: - Inflammation: Ankylosing spondylitis - Infection: osteomyelitis - Cancer: bony mets, myeloma Referred - Renal disease - Sickle cell crisis - Gynae - Fibromyalgia - Dissecting aortic aneurysm - Posterior duodenal ulcer
48
Epidemiology of back pain
60-80% have back pain at some point 1% have chronic back pain RFs - prolonged standing - awkward lifting - demanding jobs - obesity - stress - FHx
49
Red flags for back pain
Cauda equina syndrome - saddle anaesthesia, urinary/faecal symptoms Spinal fracture - sudden onset severe pain, relieved by lying down Cancer or infection - unrelenting pain, worse on lying Spondyloarthropathy
50
Investigations for back pain
Do not routinely offer imaging, imaging only if red flag symptoms - Lumbar X-ray if suspected fracture, mets, collapse from osteoporosis, Paget's CT or MRI FBC, ESR and CRP LFTs - ALP may be raised Urine - for infection
51
Appearance of cancer on X-ray
Prostate - sclerotic Lung, thyroid, kidney = osteolytic Breast -- either (most commonly osteolytic)
52
Management of back pain
- Information, reassurance, advice - Be active, no bed rest - Regular pain relief (NSAIDs, Paracetamol) - WHO pain ladder - Short course muscle relaxant if spams - Massage, MDT approach and exercise
53
Yellow flags for back pain
``` Belief that pain and activity are harmful Sickness behaviours - extended bed rest Social withdrawal Low mood, depression, anxiety, stress Problems at work Over protective family, no support Inappropriate expectations of treatment ```
54
When to refer for back pain
- Red flags, 2WW or urgent if CES - Progressive, persistant, or severe neurological deficit when neuro/ortho in 1 week - Pain/disability problematic >1-2 weeks - physio - > 6 weeks sciatica - see within 3 weeks
55
Red flag symptoms: cauda equina syndrome
Severe or progressive bilateral neurological deficit Recent onset urinary retention or incontinence Recent onset faecal incontinence Perianal or perineal sensory loss Laxity of anal sphincter
56
Red flag symptoms - spinal fracture
``` Sudden onset severe central pain Relieved by lying down History of major or minor trauma Strucutral deformity of spine Point tenderness over vertebral body ```
57
Red flag symptoms - cancer or infection
``` >50, <20 Pain remains when supine, aching night pain, disturbs sleep Hx of cancer Fever, chills and weight loss Recent infection IV drug user Immunocompromised ```
58
Red flag symptoms - spondyloarthropathy
Early morning stiffness > 45 minutes Night pain "gelling" Improves with movement, worse after rest
59
Most common location for sciatica due to disc prolapse
L5-S1
60
Presentation of prolapsed disc
``` Unilateral leg pain Radiates below the knee, into feet Leg pain > back pain Positive straight less raise Pain relieved by lying down Exacerbated by long walks and prolonged sitting Single dermatome ``` *cauda equina syndrome*
61
Investigation for prolapse disc
None if symptoms settle in < 6 weeks MRI is very sensitive X-ray and CT limited
62
Management of prolapsed disc
1. Analgesia - Paracetamol/NSAIDs - Add weak opiod/tramadol - Consider benzo, TCA or gabapentin - Pain clinic - Keep active, encourage swimming - Heat and massage - Avoid aggravating activities e.g. lifting 2. Physiotherapy 3. Surgery - Discectomy or spinal fusion - Prosthetic disc replacement
63
Measurement of bone density
Measured with DEXA scan It is expressed in relation to a reference population T-score - SD in relation to healthy population Z-score - comparison of density for normal age. <2 is below normal Normal T>1 Osteopaenia T between -1 and -2.5 Osteoporosis T < -2.5 Severe osteoporosis T
64
Epidemiology and RF for osteoporosis
Increase in women (post-menopause) Increased with age - 25% at 80 years 2 million women in the UK RFs - Parental history of RF - PMH of fragility fracture - Low BMI/anorexia - Corticosteroid > 3 months - Cushing's - Smoking - Alcohol - Falls = visual or hearing impairment, decreased strength, cognitive impairment, sedatives,
65
Secondary causes of osteoporosis
``` RA/inflammatory arthritis Prolonged immobilisation/sedentary lifestyle Primary hypogonadism Primary hyperparathyroidism Hyperthyroidism Post-transplantation CKD Crohn's, UC, Coeliac Untreated premature menopause Type 1 diabetes COPD Chronic liver disease ```
66
Drugs that can contribute to osteoporosis
``` PPIs Anticonvulsants Depot medroxyprogesterone Antidepressants Thiazolidinediones ```
67
Who should be assessed for osteoporosis?
``` Women > 65, Men > 75 Or under that age, if any RF - Previous fragility fracture - Frequent oral corticosteroids - Hx of falls - FHx of hip fracture - Causes of 2y osteoporosis - BMI <18.5 - Alcohol > 14 units per week ```
68
How is osteoporosis risk assessed?
FRAX or QFracture - gives 10 year fracture risk Green - no treatment or DEXA Amber - DEXA. Use result to determine if treatment required Red - treat, no necessity for DEXA
69
Primary prevention for osteoporosis
Bisphosphonates - ALENDRONATE - Must have adequate calcium and vitamin D - Do not take with food - Cause oesophageal ulcers - drink ++ water and sit up - 2nd line: risedronate, etidronate - Denosumab (monoclonal antibody that decreased osteoclasts) - Strontium ranelate - only to be prescribed by specialists
70
Secondary prevention for osteoporosis
Bisphosphonates +/- vitamin D/calcium supplements Raloxifene Denosumab/strontium
71
Describe osteomyelitis
Infection of the bone marrow which can spread to the bone cortex and periosteum - Dead bone can detach causing sequestrum - Most common distal femur, proximal tibia 2 types - Haematogenous from remote source - Direct (from contact with infected tissue)
72
Pathogens responsible for osteomyelitis
S. aureus (most common) Haemophilus influenza Streptococcus E.coli/Proteus/Pseudomonas/mycobacteria/fungi
73
Epidemiology and risk factors for osteomyelitis
``` Increasing incidence (due to increased diabetes and peripheral arterial disease) Bimodal age - children or adults ``` ``` RFs Trauma/open fracture Prosthetic joint Diabetes Peripheral arterial disease Chronic joint disease Alcoholism IV drug abuse Chronic steroid use Immunosuppression TB Sickle cell HIV/AIDS Catheter use ```
74
Presentation of osteomyelitis
``` Acutely febrile Bacteraemic Painful, immobile limb Swelling Extreme tenderness Exacerbated by movement ``` If vertebral - unremitting pain, worse at rest, night pain
75
What is Pott's disease
Osteomyelitis in the spine with TB
76
Investigations for osteomyelitis
``` FBC - raised WCC and CRP Blood cultures Expressed fluid should be cultured Urine dipstick Bone cultures - GOLD STANDARD MRI = imaging of choice ```
77
Management of osteomyelitis
4-6 weeks minimum antibiotics - Flucloxacillin, clindamycin if penicillin allergy MRSA - vancomycin If chronic infection - 12 weeks Surgical debridement
78
Spinal fracture - epidemiology and risk factors
50% of white females will have osteoporotic fracture Increased in females ``` RFs as osteoporosis Increased age Low BMI Parental history of fracture Corticosteroids > 3 months Cushing syndrome Smoking Alcohol Falls ```
79
Classification of spinal fractures
Wedge compression - isolated anterior column failure Stable burst - anterior and middle column compression failure, posterior intact Unstable burst - disruption of anterior, middle and posterior Flexion-distraction - wedge + tensile failure of posterior and centre of rotation is posterior and anterior Chance fracture = through spinous process, pedicles and vertebral bodies Translational fractures = disruption of canal alignment in transverse plane
80
Presentation of spinal fractures
``` Central spinal pain Non-radiating Disturbing sleep Can give weakness, numbness and tingling Kyphotic deformity Loss of balance Loss of standing height Usually T7-T8, T12-L2 ```
81
Investigations for spinal fractures
``` Lateral view, plain X-ray - wedging, spinal process misalignment FBC, CRP ALP, calcium Blood cultures DEXA scan CT/MRI ```
82
Management of spinal fractures
Anterior column only - 24-48 hours bed rest and analgesia - Pain will gradually improve over 6-12 weeks - Naproxen or diclofenac with Paracetamol - early mobilisation and orthosis - osteoporosis prophylaxis - Vertebroplasty/kyphoplasty/surgical stabilisation - if severe unrelenting pain, stabilising joint fracture by infecting cement - Pain clinic referral Multiple column involvement - STRICT bed rest - Analgesia - Open surgical reconstruction +/- decompression - osteoporosis prophy`laxis
83
Epidemiology and RFs for osteomalacia
50% adults have insufficient vitamin D Increased in non-Caucasians Increased in children and over 65s FHx has a component ``` RFs Pregnancy Obesity Housebound/institutionalised Routine covering of face and body Poverty Exclusive breast feeding >6 months Vegetarianism Living at high altitude Alcoholism ```
84
Aetiology of osteomalacia
GI malabsorption - surgery, short bowel, chronic pancreatitis, CF, Crohn's, coeliac, biliary disease Liver disease - cirrhosis Renal disease - defective 1,25-D3 Drugs - anticonvulsants, rifampicin, HAART, Severe calcium deficiency ``` RARE Hypophosphataemia Systemic acidosis Intoxication with fluoride or aluminium Hyperparathyroidism Mesenchymal tumour ``` Genetic rare causes - Fanconi's syndrome - Vitamin D dependent rickets (failure to convert 25 to 1,25)
85
Presentation of osteomalacia in children
``` Hypocalcaemic seizures or tetany Bone deformity - genu varum Anterior bowing of femur Internal rotation at ankle Irritable and reluctant to weight bear Impaired growth Increased susceptibility o infections ```
86
Presentation of osteomalacia in adults
``` Pain in hip, pelvis, thigh Proximal muscle weakness General lack of well being Diffuse muscle aches and weakness Diffuse muscle aches and weakness Lethargy Waddling gait Costochondral swelling Signs of hypocalcaemia ``` Bilateral symmetrical multiple fractures - femoral neck, scapula, pelvis
87
Investigations for osteomalacia
``` BCP - U&Es including calcium and phosphate LFTs - raised ALP PTH - raised FBC - anaemia if malabsorption Urine for CKD Vitamin D <25nmol/L ``` Radiograph of long bone - cupping, splaying, fraying metaphysis DEXA scan for decreased bone density
88
Management of osteomalacia
Calceferol 10,000IU for 8-12 weeks (use IM if problems with absorption) - Monitor calcium or a few weeks - Monitor VitD, PTH, calcium after 3-4 months and every 6-12 months
89
Mechanism of shoulder dislocation
95% are anterior - traumatic. Generally a fall with combination of abduction and extension - FOOSH Posterior - fall with arm in internal rotation and adduction e.g. epileptic fit or electricution
90
Epidemiology of shoulder dislocation
One of the most commonly dislocated joints Increased in males due to increased contact sports Peak at 20-30 and again at 60-80 If multiple dislocations - consider Ehlers-Danlos
91
Presentation of shoulder dislocation
ANTERIOR - Holds arm in external rotation - Humeral head palpable anteriorly - Abduction and internal rotation are resisted - CHECK RADIAL PULSE, DELTOID SENSATION (AXILLARY NERVE), RADIAL NERVE FUNCTION Posterior - Present with arm adducted and internally rotated - Abduction and external rotation painful- - May resemble frozen shoulder - Vascular and nerve problems not associated generally
92
Complications of shoulder dislocation
``` Axillary nerve or artery damage Brachial plexus damage Radial nerve damage Recurrent shoulder dislocation Rotator cuff injury ``` Bankart lesion - rupture of joint capsule and interior glenohumeral ligament HillSachs lesion - posterolateral head indentation fracture
93
Investigations for shoulder dislocation
Xray - AP + axillary Anterior - head under coracoid on AP, humeral head anterior to glenoid Posterior - may be normal on AP, may have lightbulb sign due to rotation . Head posterior to glenoid on rotation
94
Management of shoulder dislocation
Opioid Benzos for muscle spasms No fracture - closed reduction If fracture = surgery Multiple number of reduction methods Post reduction re-check neurovascular assessment Post-reduction xray Immobilise the shoulder for 3-6 weeks Analgesia and physiotherapy
95
Fracture healing stages
1. Fracture haematoma 2. Fibrovascular tissue replaces clot - collagen fibres laid 3. Subperiosteal bone formed at ends beneath periosteum 4. Primary callus response (few weeks) 5. Bridging external callus 6. Endosteoal new bone formation
96
Common wrist fractures
Colles- distal radius with dorsal displacement of fragments Smiths - distal radius with volar displacement of fragments Scaphoid Bartons - fracture dislocation of radiocarpal joint Chauffeur's - radial styloid fracture Greenstick - children
97
Colles fracture
Fracture through distal metaphysis of radius within 2-3cm of articular surface - dorsal displacement of fractures Common in elderly with osteoporosis From FOOSH - forced dorsiflexion of wrist Dinner fork deformity = backwards and laterally CHECK MEDIAN NERVE FOR DAMAGE Manage with anaesthesia, redaction and back slab. Surgical reduction only if intra-articular.
98
Complication of colles fracture
``` Median and ulnar nerve damage Compartment syndrome Deformity on healing Chronic pain Mal-union ```
99
Scaphoid fracture
Increased in males 20-30 years Vulnerable blood supply - high risk of avascular necrosis From FOOSH or RTA from steering wheel impact Tenderness in anatomical snuffbox 20% not seen on x-ray - need 4 views: PA, true lateral, semi-pronated oblique, PA and ulnar deviation Presumptive casting - 10 degrees of flexion with thumb and forefinger able to oppose. Repeat xray after 2 weeks
100
Smiths fracture
Reverse colles Fracture of distal radius with anterior displacement of fragments Caused by falling backwards Generally closed reduction
101
Bartons fracture
Distal radius fracture with additional dislocation at radiocarpal joint Colles or Smiths + dislocation May be entrapment of tendons of ulnar nerve or artery Operative reduction required
102
Nerve distribution in the hand
Ulnar - pinky side little and half of ring finger both sides Median - palm side of thumb, first, middle and half of ring finer Radial - back of hand, thumb, first, middle and half of ring finger. Not finger tips
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Most common sites for radial nerve damage
Proximal forearm Humeral fractures Radial aspects of wrist
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Causes of radial nerve damage
Axilla compression - shoulder dislocation OR Saturday night syndrome Upper arm - triceps and brachioradialis spared - usually due to fracture of humerous Elbow - tenderness over radial tunnel Wrist - radial fracture, elbow deformity, finger drop with intact sensation Superficial - pain and sensory loss, normal motor. Ruptured synovial effusion at elbow OR handcuffs, wristbands, plastercasts
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Muscles supplied by radial nerve that needs testing if suspecting damage
``` Triceps Brachioradialis Externsor carpi radialis longus Supinator Extensor digitorum ```
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Muscles supplied by ulnar nerve
Hypothenar muscles Adductor pollicis 3rd and 4th lumbricals Dorsal and palmar interorssei
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Causes of ulnar nerve damage
ELBOW Cubital tunnel syndrome, medical epicondylitis (golfer's elbow), supracondylar fracture, osteophytic encroachment in OA Claw hand deformity, unable to flex terminal phalanges or abduct little finger Wrist - cutaneous sensation usually spared Positive Tinel's and Phalen's sign
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RF for carpal tunnel syndrome
``` Late 50s Female Obesity FHx Post-colles fracture Short stature Injury Thyroid disorders Diabetes Acromegaly Inflammatory arthritis ```
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Presentation of carpal tunnel syndrome
``` Tingling, numbness, pain Worse at night Causes wakening Handing hand out of the bed Weakness in hand grip ``` Positive Phalen's Test Positive Tinel's Test
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Phalen's test
60s of flexion at the wrist causes pain or paraesthesia
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Tinel's test
Tapping over median nerve causes pain or paraesthesia
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Investigations and management of carpal tunnel
ENG - median nerve stimulation to detect muscle action potential over thenar eminence US MRI if ENG ambiguous Minimise aggravating factors Local steroid injections are diagnostic and therapeutic Surgical decompression - return to work in 12-19 days
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What runs through the carpal tunnel
Flexor digitorum superficialis and profundus Flexor pollicis longus Flexor carpi radialis Median nerve
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Attachment and function of FDP and FDS
FDS - attaches to middle phalanges. Flexes PIP, MCP and wrist FDP - attaches to distal phalanges Flexes DIP, MCP and wrist
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Presentation of extensor tendon damage
Mallet dinger - fixed flexion of DIP Boutonniere deformity - fixed flexion of PIP Inability to extend finger
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Epidemiology of polymyalgia rheumatica
84 per 100,000 Mean age 73. Exclusively over 50s Increase in females (3:1) Increased in North European
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Presentation of polymyalgia rheumatica
``` Morning stiffness > 45 minutes Bilateral shoulder or pelvic girdle aching For over 2 weeks in over 50s Symptoms worse on waking Flu like features at onset Sudden onset over 1-2 weeks ``` No lymphadenopathy No active infection No cancer No temporal arteritis
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Investigations for polymyalgia rheumatica
Raised inflammatory markers - CRP (more sensitive than ESR) ``` CHECK FBCs, U&Es, LFTs Protein electrophoresis Urinalysis Bence Jones protein, ``` Consider temporal arteritis in all with PMR
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Management for polymyalgia rheumatica
Glucocorticoids Referral to physio or OT 15mg prednisolone for weeks then drop very slowly Treatment for 1-2 years. Maintenance dose usually 2.5-5mg DEXA scan Calcium and vitamin D therapy +/- bisphosphonates Monitor - 15% get temporal arteritis
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Epidemiology of temporal arteritis
2.2 per 10,000 Increased in northern European increased in females (3:1) Common after 60
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Presentation of temporal artertitis
``` Recent onset temporal headache Worse at night Myalgia Malaise Fever Scalp tenderness Transient visual symptoms - diplopia, ischaemic optic neuritis, blurred vision, visual loss, amarousis fugax Jaw claudication Anoexia, weight loss, Thoracic aorta often involve ```
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Diagnostic criteria for temporal arteritis
3 out of 5 needs ``` Over 50 New headache Temporal artery abnormality - tenderness, pulsation Increased ESR Abnormal artery biopsy ```
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Investigations for temporal arteritis
Urgent referral for temporal artery biopsy Increased ESR or CRP FBC - normocytic normochromic anaemia, thrombocytosis LFTs - raised ALP Biopsy - 87% sensitivity Colour duplex ultrasonography
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Management of temporal arteritis
Urgent referral - should not delay treatment Steroids - 40g OD prednisolone, 60g if claudication If visual symptoms then IV prednisolone Lower once symptoms resolved or test results normal Start aspirin and PPI Osteoporosis prophylaxis
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Complications and prognosis of temporal arteritis
Permanent visual loss Aneurysms, dissections, stenotic lesions of aorta CNS disease - seizures, strokes Steroid related complications - osteoporosis, myopathy, bruising, diabetes, HTN Relief with treatment but relapses are common Often need steroids for 2 years
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Describe radial head and neck fractures
Radial head fractures are the most common elbow fractures in adults In children - radial neck Swelling over lateral elbow. Limited motion and point tenderness Neurovascular assessment Investigations - AP and lateral. Fat pad sign Urgent surgical treatment
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Describe olecranon fractures
Often low energy fractures causes by sudden pull of triceps or brachioradialis Swelling and tenderness over olecranon Inability to extend against gravity Should be seen clearly on lateral xray Immobilise in split at 60-90 degrees of flexion
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Elbow dislocation
2nd most common dislocation Terrible triad - - Elbow dislocation - Coronoid process fracture - Radial head fracture Associated with injury to brachial artery and nerve Prompt reduction essential
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Types of hip fracture / classification
Femoral neck # Femoral shaft # Femoral stress # Intracapsular - between edge of femoral head and insertion of joint capsule into the hip (intertrochanteric line) Assume vascular compromise Extracapsular - distal to intertrochanteric line Can be due to avulsion fractures from gluteus medius Assume vascular system spared Can use Garden's classification if intracapsular - Garden 1 - inferior cortex intact, no significant displacement 2 = trabeculae in line, fracture visible from superior to inferior cortex 3 = obvious complete #, slight displacement or rotation 4 = gross and often complete displacement
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Risk factors for hip fracture
Increased age Osteoporosis Family history of hip fracture (maternal) osteomalacia Falls = instability, decreased core strength, gait disturbance, sensory impairment
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Presentation of hip fracture
Pain in outer upper thigh or groin Pain may radiate to the knee Inability to weight bear Pain aggravated by flexion and rotation of the leg shortened, adducted and externally rotated leg
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Diagnosis of hip fracture
AP and lateral x-ray Disruption of trabecular, inferior or superior cortices and abnormality of pelvic contours Broken Shenton's line MRI should be performed if suspected but not seen on x-ray
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Shenton's line
Curved line formed by top of obturator foramen and inner side of neck of femur Line broken in hip #
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Management of hip #
Intracapsular - surgery within 24 hours - reduction and internal fixation - if young patient then dynamic hip screw where possible - if poor prognosis hemi-arthroplasty - if otherwise fit full hip-replacement Extra-capsular - Dynamic hip screw if trochanteric - Sub trochanteric = screws, nails and pins
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Complications of hip #
``` Mortality high - 10% at 1 month, 33% at 1 year Infection Haemorrhage Avascular necrosis Delayed union, malunion, non-union Pneumonia MI Stroke DVT/PE Pressure ulcers ```
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Femoral saft #
Severe pain, tense, swollen thigh Inability to weight bear X-ray AP and lateral - include bilateral hip and knee for comparison ``` Management - Cross match - Analgesia - Monitor pulses and sensation - Reduce and surgery - nails most common Early mobilisation ``` 4-6 months healing time Be aware: - Acute compartment damage - Vessel or nerve damage - Large potential blood loss
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Blood supply to femoral head
Most comes from upwards extending branch of profunda femoris which forms lateral and medial circumflex which then forms sub synovial ring Very small from ligamentum teres - branching from obturator artery
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Pelvic #
High energy trauma Tenderness, bruising, swelling, crepitus Haematuria and rectal bleeding Neuro and vascular abnormality in legs Can be due to lateral compression causing sacral # and sacroiliac disruption (side swipe car accidents) Can be due to AP compression - head on collisions = open book fracture, springs open hinging on sacroiliac joints ``` CT, PV and PR for bleeding ATLS! Leg length discrepancy Perineal bruising Pelvic binder at greater trochanter to tamponade bleeding ```
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Patella #
2 ways to fracture - Direct fall onto flexed knee - stellate shape - Sudden contraction of quadriceps to prevent fall = transverse # Check extensor mechanism = can patient lift heel from bed (if in tact then they can) Management - Undisplaced = conservative cylinder cast - Displaced or extensor mechanism affected = surgery - Tension batwing wiring - repair extensor retinaculum,
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Define compartment syndrome
Caused by increased pressure in a closed anatomical space Compromises circulation and function of tissues within the space. Can damage muscles and nerves Can be acute or chronic Acute is caused by trauma or intense exercise Chronic is caused by exercise
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Common sites for compartment syndrome | What can they damage
FOREARM - Ventral: median and ulnar nerves. Radial and ulnar artery - Dorsal: posterior interosseous nerve. No vessels LOWER LIMB - Anterior tibial: deep peroneal nerve. Anterior tibial artery. - Superficial posterior: none - Deep posterior: posterior tibial nerves and vessels. Peroneal artery - Peroneal: deep and superficial peroneal nerves GLUTEAL - uncommon. often have muscle necrosis and sciatic nerve palsy due to late diagnosis ABDOMINAL - in multiple trauma patient in profound shock - AKI, cardiac dysfunction, raised central venous pressure - Sudden release can cause ischaemia reperfusion injury, acidosis and cardiac arrest
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Aetiology of acute compartment syndrome
``` Fractures especially distal limbs Crush injury Burns Infection Prolonged limb compression Vascular - ischaemic, haemorrhage, phlegmasia caerulea dolens Iatrogenic - IM injections, vascular puncture (if anti-coagulated) Muscle hypertrophy in adults ```
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Presentation of acute compartment syndrome
Within 48 hours of injury Increase pain despite immobilisation of fracture Sensory deficit in nerves passing through compartment Muscle tenderness and swelling Excessive pain on movement May have peripheral pulses until late stages - pallor, pulselessness
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Investigations for acute compartment syndrome
CLINCIAL diagnosis Can measure pressure - Wick catheter, pressure transducer and site ported needles - MRI if ambiguous
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Management of acute compartment syndrome
Urgent decompression to reduce ischaemia Remove all dressings Urgent orthopaedic referral open FASCIOTOMY - skin and deep fascia divided along length of compartment, leave would open - debride any muscle necrosis Complication- tissue necrosis
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RF for chronic compartment syndrome
``` athletes under 40 repetitive motion exercise - tennis, running, gymnastics, cycling excessive training ```
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Presentation of chronic compartment syndrome
severe pain and tightness triggered by exercise Resolves with rest May have tinging and weakness May have abnormal gait
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Management of chronic compartment syndrome
Deep massage Limit offending activity Decompressive fasciotomy - used in athletes that refuse to modify activity
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Early complications of lower limb #
``` LOCAL vascular injury visceral injury e.g. bladder, bowel damage to nerves, tissue or skin haemoarthrosis compartment syndrome wound infection fracture blisters ``` ``` SYSTEMIC fat embolism shock vte, PE, DVT exacerbation of underlying disease e.g. COPD pneumonia ```
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Late complications of lower limb #
``` LOCAL delayed union malunion joint stiffness non-union contractures myositis ossificans avascular necrosis algodystrophy osteomyelitis growth disturbance/deformity ``` SYSTEMIC gangrene, tetanus, septicaemia fear of mobilising
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RF for delayed union
``` severe soft tissue damage inadequate blood supply infection insufficient splinting excessive traction increased age severe anaemia diabetes low vitamin D hypothyroid NSAIDs steroids complicated fracture osteoporosis ```
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presentation and management of non-union
``` pain at site, tenderness, swelling non-use of limb movement at the # site palpable gap absence of callus ``` ``` weight bearing and casting bone stimulation - teriparatide debridement bone grafting internal fixation ```
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Myositis ossificans
calcifications and bony formation in muscles increased risk after humeral supracondylar fracture
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Algodystrophy
``` "Sudeck's atrophy" Reflex sympathetic dystrophy Hand or foot Continuous burning pain Accompanied initially with swelling, warmth and redness Then pallor and atrophy ``` Manage with analgesia and physio
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Complications of casts
malunion if misplaced Cast disease - circulatory disturbance, inflammation, bone disease - Osteoporosis - Chronic oedema - Tissue atrophy - Joint stiffness ``` thermal ulcers during hardening pressure ulcers thrombophlebitis infection if wet skin decreased bone density ```
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Complciations of traction
``` pressure ulcers pneumonia/UTI permanent foot drop contractures peroneal nerve palsy pin tract infection Thromboembolism ```
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Complications of external fixation
``` Pin tract infection Pin loosening or breaking Interference with joint movement Neurovascular damage Misalignment if misplaced Psychological - visible deformity and disability ```
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Rehab post #
``` Prompt surgery MDT Physio OT Social workers Orthopaedics +/- geriatrics ``` EXERCISE ASAP Decreased motivation = decreased recovery Exercise is important
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Impact of amputation
``` PHYSICAL decreased mobility and dexterity stump or phantom limb pain infection increased care requirements muscle contractures therefore require regular stretching DVT/PE ``` ``` EMOTIONAL traumatic/PTSD depression adapting psychologically to the loss body image issues decreased social activities social isolation ``` Prosthetic limbs require skin desensitisation with compression bandaging
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Ankle joint
Involves tibia, fibular and talus Syndesmosis joint between tibia and fibular Tibiotalar joint allows dorsi and plantar flexion Subtalar joint between talus and calcaneous allows inversion and eversion
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Presentation of ankle #
``` immediate severe pain which can extend to foot and knee swelling bruising tenderness joint deformity inability to weight bear ```
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Ottawa rules for ankle #
X-ray is recommended if: - over 55 - unable to weight bear for 5 steps either at time of accident or evaluation - bone tenderness at posterior edge or tip of medial malleolus - bone tenderness at posterior edge or tip of lateral malleolus - tender 5th metatarsal, cuboid or navicular
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Investigations for ankle #
x-ray (Ottawa rules) AP, lateral and oblique views If one injury is seen, look for a second CT or MRI if soft tissue or intra articular joint
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Classification for ankle #
Danis-Weber classification A - fibular # below syndesmosis B - fibular # at the level syndesmosis C - fibular # above syndesmosis indicating rupture Operative if type C or some type B
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Pott's #
and # dislocation of distal tibia and fibular involving 2 elements of ankle ring, very unstable
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Pilon #
fracture of distal tibia and disruption of talar dome Due to falling from a height
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Management of ankle #
ABCDE If neurovascular compromise reduce immediately (before XR) Analgesia If not displaced or type A then conservative (or if not fit for surgery) 4-6 weeks in cast Repeat x-ray regularly to ensure reduction and healing if displaces then surgery If type C or some type B then operative Also if dislocation, bimalleolar #, joint incongruity Open reduction and internal fixation Early remobilisation and weight bearing
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Epidemiology of burns
0.3 per 1000 300 deaths per year Increased in under 5s or over 75 50% occur in kitchens
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What is the rule of 9s
Body split into different areas that either have 9% SA or 18%SA to estimate area of burns 9% for head and each upper limb 18% for torso front, torso back and each lower limb Use Lund and Bower chart for children as not equal
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Depth of burns
Epidermal/ Superficial partial thickness Superficial dermal Deep dermal Full thickness (3rd degree) 4th degree
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Describe an epidermal/ superficial partial dermal burn
``` Red Glistening Painful Brisk cap refill Heals in 1 week with no scarring ```
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Describe a superficial dermal burn
``` Pale pink/ mottled skin Swelling Small blisters Hypersensitive Wet/weeping Brisk cap refill Heals in 2-3 weeks Minimal scarring ```
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Describe a deep dermal burn
``` Blistering Dry Blotchy, cherry red Does not blanch No cap refill Decreased or absent sensation Heals in 3-8 weeks Scarring May require surgery ```
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Describe a full thickness burn
``` Old 3rd degree burn Dry White / Black No blisters No cap refill Absent sensation Requires surgical repair/grafting ```
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Describe 4th degree burn
Includes subcutaneous tissue, muscle or bone | Requires reconstruction and often amputation
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Initial baseline investigation in burns patient
Bloods - FBC, group and save, carboxyhaemoglobin, glucose, U&Es, pregnancy test ABG(s) CXR Cardiac monitoring Hourly urine outputs / catheter
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Management of minor burns
Stop burning - remove all clothing. any adherent clothing cool with water. remove all jewellery - rinse with tap water for at least 20 minutes - NOT ICED WATER as this causes vasoconstriction and can further tissue damage - brush off any dry chemicals first Minor - wash with soap and water - is blister >1cm then aspirate aseptically, if <1cm then leave - non-adhesive dressings with gauze padding, change after 3-5 days - if infection develops: flucloxacillin / erythromycin
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Management of major burns
ABCDE A - check for inhalation injury - endotracheal intubation if required B - ABGs and 100% O2, presume CO poisoning - elevate head and chest by 20-30 degrees to decrease neck and chest oedema - RARE: escharotomies to release chest tightness C - fluid replacement - IV line ASAP If burns >15% then start fluid replacement for minimum 24 hours 4ml Hartmann's per kg per % affected Strong opiate Sedation Prevent hypothermia Other - fasciotomy - gastric tube insertion - antibiotics if infection - grafts (must be within 3 weeks)
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When to refer to burns unit
Under 5, over 60 Burns to face, hands, neck, perineum or full thickness to large area Inhalation injury Chemical burn / ionising radiation / high pressure steam injury or electrical injury >10% SA in adults, >5% in child Pregnancy
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Complications of burns
``` Respiratory distress Fluid loss, hypovolaemia, shock infection raised metabolic rate increased plasma viscosity muscle damage (if electrical) - rhabdomylysis Poisoning Haemoglobinuria and renal damage Scarring ```
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Indications of inhalation injury
Can be subtle and present over 24 hours after incident - face/neck burns - singed eyebrows - carbon deposits in oropharynx/ sputum - acute inflammation of oropharynx - explosion in enclosed space - hoarseness - carboxyhaemoglobin >10% - history of impaired awareness Intubate and mechanical ventilation Transfer to burns unit
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Signs of non-accidental burns
``` Delayed or avoidance of treatment Incident not witnessed No explanation Implausible mechanism of injury Details change with time Lack of concern from accompanying adult Abnormal demeanour - withdrawn ``` Sharply demarcated Glove and stocking injury Uniform depth of burn Donut sparing of buttocks on bottom of tub
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Epidemiology of chronic pain
23% worldwide Increases with age, over 45s Increased in females Most common locations: back pain, headache, joint pain ``` Risk factors Pregnancy Hx of trauma or chronic pain Fhx smoking high risk occupation co-morbid personality ```
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Aetiology of chronic pain
MSK - OA, RA, osteomyelitis, osteoporosis, AS, myofascial disease, PMR, fractures, strains Neurological - diabetic neuropathy, spinal stenosis, brachial plexus traction injury, thoracic outlet syndrome, trigeminal neuralgia, alcoholism, thyroid disease, pernicious anaemia headache - migraine, temporal arteritis, glaucoma, Psychological - depression, anxiety, personality disorder, sleep disturbance Cancer = mets, myeloma, paraneoplastic syndrome Systemic diseases = SLE, Sjorgen's, diabetes, hypothyroid, hyperparathyroidism, HIV, Hep C
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Management of MSK chronic pain
Physiotherapy Paracetamol and/or NSAIDs OT Pain management psychology = relaxation techniques, stress management, coping skills, CBT
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Management of neuropathic pain
``` Gabapentin/pregabalin/amitryptiline/duloxetine Capsacin/topic lidocaine oxycodone physio/OT Pain management psychology TENS Pain clinic referral ```
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Alternative therapies used for pain management
Capsacin Acupuncture OA 5/5, LBP 5/5 GREEN Chiropractor 2/5 for OA and LBP AMBER Massage 5/5 LBP FM, 2/5 OA Relaxation therapy Tai chi Yoga
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Why would people use alternative therapies for pain relief?
``` Want more natural treatments Want to feel in control Persistent pain Pain not relieved by conventional treatment Concerns about medication side effects ```
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Benefits of CBT for pain
encourages problem solving attitude patients are pro=active involves homework provides coping mechanisms small improvement in pain and disability moderate increase on mood
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epidemiology of fibromyalgia
``` Increase in females (x10) 20-50 years most commonly low income being divorced failing to complete education 5% of population ```
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Presentation of fibromyalgia
``` chronic widespread pain unrefreshing sleep/tiredness fatigue sleep disturbance morning stiffness paraesthesia feeling of swollen joints problems with cognition headaches light headedness anxiety/depression ```
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Management of fibromyalgia
``` MDT approach EXERCISE - swimming, aerobic exercise, resistance training CBT Relaxation/physio Paracetamol/weak opioids/ tramadol Antidepressants Pregabalin/gabapentin ``` Take care not to over investigate
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What is O'Donohue's Triad
Knee injury triad ACL MCL Meniscus tear
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Most common to least common knee injury mechanisms
``` Valgus Twist Hyperextension Hyperflexion Varus ```
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Morton's neuroma
Interdigital neuritis in the feet Repeated trauma from walking causes irritation leading to neuroma Causes anaesthesia of interdigital sides of connecting toes Treated with surgical removal Pain on squeezing feet
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Jone's fracture
fracture at the base of the 5th metatarsal | avulsion fracture
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Achilles tendon rupture
Describe it as if kicked from behind and then fell Use Thompson's test Decrease recurrence with surgery for management Place wedges inside a boot for 2-4 weeks
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Plantar fascitiis
``` Heel pain worse on a morning Tenderness over calcaneus Gets better with walking Self-limiting Treat with stretching exercises ```
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Risk factors for congential dysplasia of hip
Female Oligohydramnios FHx Multiple pregnancies
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management of congenital dysplasia of the hip
Use US for diagnosis as the femur head is cartilage for 3 moinths Use calipers/splinting to keep hips externally rotated and abducted At 3months do x-ray. Hip spiker Muscle release Osteotomy if others fail = if need surgery then they will need a hip replacement in their 30s
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Perthe's disease
Increased in 6-9 year olds Males Pain, limping, no history of trauma Due to avascular necrosis of epiphyseal plates Head develops asymmetrically - mushroom shapes. Increased subluxation
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Slipped capital femoral epiphysis
``` Hypogonadism occurs in puberty Large hips Males passed off as "growing pains" 3 stages depending on angle of slip 1 = 10 degrees, 2 = 30, 3=45 1&2 fixed with pinning 3 = open fixation, but 20% risk of damaging blood supply Most around knees ```
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Osteogenesis imperfecta
``` Defect in gene for collagen Increased in females Most die in utero/labour If mild form then multiple breaks Blue sclera Heal very quickly Treat as you would normally treat the fracture Number of fractures decreases with age ```
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Congential talipes equinovarus
``` Club foot 1% Increased in males or FHx Increased in breech and oligohydramnios 5-10% bilateral ``` Treat with stretching and manipulation Serial splinting to minimise surgical intervention No limitations in life with treatment
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Epidemiology of DDH
``` Developmental dysplasia of the hip 1-3% of newborns Left hip more commonly affected Increased in female babies Increased in countries that swaddle babies ``` ``` RFs Sibling with DDH First born Vaginal delivery for breech (x17) C-section for breech (x7) Oligohydramnios Multiple pregnancy Prematurity Neuromuscular disorders - CP, meningocoele ``` 20% are bilateral
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Screening for DDH
``` Screened at birth and 6-8 week baby check US at 6 weeks ONLY if: - 1st degree FHx of DDH - Breech after 36 weeks - If breech < 36 weeks scan at birth ```
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Examination for DDH
At 3 months or under - Look for asymmetry of skin folds, leg length - Orlani and Barlow tests - Orlani - forward pressure on femoral head - Barlow - back pressure on femoral head. If movement then dislocating. Abduction < 60 degrees at 90 degrees of hip flexion Over 3 months - Unilateral limitation and symmetry of hip abduction - Galeazzi sign: unilateral femoral shortening when supine at hip flexed to 90 degrees
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Investigations for DDH
Dynamic US for hip stability and acetabular development US is better under 4 months After 4 months, pelvic X-ray better as the femoral ossification centre has developed Arthrography peri-operatively to determine if open or closed reduction
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Management of DDH
Early diagnosis gives better outcome Most self-stabilise by 2-6 weeks Non-surgical - Dynamic flexion-abduction orthosis (Pavlik harness) from the time of diagnosis - adjust as the child grows, remains in place at all times - Risk of avascular necrosis or temporary femoral nerve palsy - contraindicated once over 4.5 months Surgical - If don't respond or late diagnosis - Closed reduction with adductor or psoas tenotomy - THEN 3-4 months in abduction brace - If over 18 months then may need osteotomy
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Epidemiology of pes planus
``` 20% of adults 45% of children, but generally resolves before 10 years Common in young children Increased in Africans only pathological in 1% Increased in males Increased with obesity ```
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Foot findings in pes planus
Collapse of medial longitudinal arch Foot PRONATES VALGUS position of heel and forefoot
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Aetiology of pes planus
CHILDREN - Normal in 3-6 years - Neurological problems; CP or polio - Bony abnormalities: tarsal coalition, accessory navicular bone - Ligament laxity: Ehler's-Danlos, Marfan's ADULTS - Physiological in 20% - Decreased arch strength - dysfunction of tibilias posterior tendon, ligament tear, neuropathic foot (diabetes, polio), arthropathy, OA - Increased load - shoes limiting movement, tight Achilles tendon, obesity, pregnancy
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Symptoms of tibialis posterior dysfunction
Pain or swelling behind medial malleolus and along instep Change in foot shape (pes planus) Decreased walking ability and balance Ache on walking long distances
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Management of pes planus
CHILDREN - treatment often unnecessary - generic foot orthoses - surgery only if rigid ADULTS - exercise and barefoot walking - heel cord stretching to lengthen Achilles tendon - orthtics: heel wedge and arch support - Advice: shows with low heel and wide toes. weight reduction Surgical - if rigid, progressive or CP with equinovarus foot - Soft tissue reconstruction e.g. tibialis posterior or Achilles - Arthoeresis - Reconstructive osteotomy for realignment - Arthrodesis
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Complications of pes planus
``` Tibialis posterior dysfunction Hallux valgus Metatarsalgia Plantar fasciitis Knee pain ```
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Causes of in-toeing
Metatarsus varus - From birth, inward twisting of forefoot - Observe, 85% resolve - If persistent, splinting then surgery - Associated with DDH Tibial torsion - Presents at 1-3 years - Resolves spontaneously Internal femoral torsion - 3-10 years - Abnormal anteversion of femoral neck - At birth 40 degrees, 15 as adult, Slow transition causes intoeing - most have spontaneous resolution - Some require rotational osteotomy
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Genu Varum
Lateral bowing "bow legged) Normal in children under 2 Associated with out-toeing
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Causes of genu varum
``` Ricket's Scurvy Blout disease Paget's disease OA (in elderly) ```
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Pathological features of genu varum
Inter-malleolar distance >10cm FHx of skeletal abnormality Asymmetry of knees Abnormally short stature
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Genu valgum
``` Knock kneed Common between 2-4 years If symmetrical usually benign Measure intermalleolar gap Associated with intoeing ``` Causes: Rickets Scurvy RA/OA
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Epidemiology of scoliosis
Increased in FEMALES 2-3% More common to curve to right ``` RF Trauma Neuromuscular imbalance Congenital Most are idiopathic ```
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Types of scoliosis
Infantile - before 3 years. Increased in boys. Many resolve spontaneously. Some get severe deformity Juvenile - 3-10 years. increase in girls. high risk of progression. often require surgical intervention Adolescent idiopathic scoliosis (AIS) - 10 years to maturity. Occurs at onset or during puberty. Increase in females. Need surgery
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Presentation of scoliosis
Increasing pain with increasing deformity Unlevel shoulders Waistline asymmetry Rib prominence Scoliometer to measure Can place a wedge under one foot to see improvement, if improvement then may be due to a shorter leg.
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Aetiology of scoliosis
Idiopathic (80%) Congenital malformation of vertebrae (10%) - usually have GU deformity Neuromuscular - CP, spina bifida, polio Metabolic - Hunter's Crush # from trauma, osteoporosis, TB, malignancy Dysmorphic syndromes - neurofibromatosis, Marfan's, osteogenesis imperfect
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Causes of anterior bowing of legs
ALWAYS insignificant - Congenital absence of fibula - Neurfibromatosis type 1 - Osteogensis imperfecta
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Investigations for scoliosis
PA and lateral spine x-rays Cobb's angle is used to measure degree of scoliosis, needs to be >10 CT/MRI if required
227
Management of scoliosis
Infantile - generally no surgery Juvenile - generally require surgery AIS - surgery depends on size of curve Bracing - where still growing, trying to prevent worsening Exercises Surgery - in 25%, if Cobb's angle >45, solid fusion Magnetic expansion control growth rods
228
Complications of scoliosis
Decreased exercise capacity and weak respiratory muscles Compression of abdominal contents Severe = damage to spinal cord Psychological problems Cardiopulmonary problems at 60 degrees, myelopathy at 90 degrees
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Scheuermann's disease
thoracic kyphosis > 40 degrees Painless Surgery not required
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Define cerebral palsy
Group of permanent disorders of the development of movement and posture causing activity limitation that are attributed to disturbances in development of foetal or infant brain
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Classification of cerebral palsy
Spastic types = intermittent increase tone and pathological reflexes Athetoid - hyperkinesia Ataxic = loss of muscular co-ordination Mixed Other classficiations: - pre-natal, natal or post-natal - monoplegia, diplegia, hemiplegia - congenital or acquired
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TORCH infections
``` Toxoplasmosis Other Rubella Cytomegalovirus Herpes Simplex ```
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Epidemiology of cerebral palsy
``` 1 per 1000 live normal weight births 16 per 1000 underweight live births Increasing maternal age Increased in black population Increase in IUGR ``` In those severely injures, the lighter the birth the longer the life expectancy
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Presentation of cerebral palsy
Delayed developmental milestones Definitive diagnosis is hard under 18 months Abnormal posture and movement Most common = bilateral spastic cerebral palsy commonly associated symptoms: - Epilepsy - Failure to thrive - Bladder incontinence or increased infection - Constipation for decrerased mobility and intake - Drooling - Sleep disturbance - orthopaedics: joint contractures, hip/foot deformity, shortened muscles, scoliosis, #
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Investigations for cerebral palsy
Clinical examination and parental observation Exclude other causes: - Thyroid studies - Chromosomal analysis - Pyruvate and lactate levels - Amino acid levels for metabolism errors - CSF for hypoxia Imaging - US or MRI may be helpful Evoked potentials to check vision and hearing EEG - to detect damage post hypoxia
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Diseases associated with cerebral palsy
``` Intrauterine infections: TORCH, HIV Congenital malformation Toxic or teratogenic agents = alcohol, smoking, cocaine Maternal abdo trauma Maternal thyroid illness Intracranial haemorrhage Trauma Infection Hyperbilirubinaemia Seizures ```
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Management of CP
Physio, OT, speech therapy, recreational therapy, paediatrics, orthopaedics - Baclofen for muscle spasm - Alternatives: tizanidine, botulinum A - Diazepam or gabapentin - Surgery for fixed contractures - Mobility aids - Heat, cold, vibration to decrease spasticity - Splinting to increase range of movement at a joint
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Complications of CP
``` Moderate to severe learning difficulties Hearing loss Contractures Failure to thrive Osteoporosis Aspiration pneumonia Dental problems ``` Decreased life expectancy with severe forms
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Define Perthe's disease
Self-limiting hip disorder caused by ischaemia and subsequent necrosis of femoral head
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Epidemiology of Perthe's disease
4-8 years Increased in males (4:1) Increased in obesity Increased in Caucasians
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Pathogenesis of Perthe's disease
Avascular necrosis of femoral epiphysis Delayed ossific nucleus Articular cartilage is nourished by synovial fluid and continues to grow Cartilage columns distort Do not undergo normal ossification - excess calcified cartilage in bone Symptoms are due to # and subchondral collapse
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Presentation of Perthe's disease
``` Pain in hip or knee causing limp 4-8 years old Effusion due to synovitis 10-15% bilateral (but asymmetrical stages) All hip movements limited Antalgic gait Trendelenburg gait in late stages No history of trauma Roll test: roll leg in internal and external rotation when supine will produce guarding ```
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Investigations for Perthe's disease
FBC, ESR X-ray - Early: widening of joint space or normal - Later: decrease size of femoral head with patchy deformity - Later: collapse and deformity of femoral head (increased arthritis) Hip aspiration if ?septic Arthrogram or MRI
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Management of Perthe's disease
Under 6s respond better Over 6s tend to need surgery Physio to increase muscle strength and range of motion Surgery - proximal varus osteotomy
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Define slipped capital femoral epiphysis
Often atraumatic or associated with a minor injury. Most common adolescent hip disorders Instability of proximal femur growth plate - Preslip - Acute (10-15%) - Chronic (85%) Stable in 90%, unstable in 10%
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Epidemiology of slipped capital femoral epiphysis
``` I per 10,000 13 year old boys 11.5 year old girls Most common hip disorder Bilateral in 20% Left>right Increased in males Incidence rising ``` ``` RF Obesity Local trauma Neglected septic arthritis Short stature Hypothyroid Hypopituitarism Past radiation of pelvis ```
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Presentation of slipped capital femoral epiphysis
``` Discomfort in hip, groin, medial thigh during walking Pain worsens with running or jumping Acute <3 weeks, chronic > 3 weeks External rotation of leg on walking Hip motion is limited ``` Drehmann's sign - supine, passively flex the hip, leg falls into external rotation and abduction If chronic - atrophy of thigh and shortening of affected leg
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Investigations for Perthe's disease
AP and frog leg lateral x-ray | - widening of epiphyseal line or displacement of femoral head
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Management of Perthe's disease
Analgesia and immediate orthopaedic referral Avoid moving or rotating leg Surgery is mainstay of treatment - Prevents further slops - Prevent femeroactabular impingement - Centre to centre screw fixation across plate - OR open reduction and osteotomy of femoral neck
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Define transient synovitis
Irritable hip Common between 2 and 12 Acute onset of hip pain and a limp that gradually resolves Child otherwise well
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Clinical features of transient synovitis
``` Acute onset of hip pain or limp Between 2 and 12 Increased in boys (2:1) Inability to weight bear Leg held in flexion, adduction with slight external rotation Extension limited Child otherwise well persists for 1-2 weeks Resolves spontaneously ```
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Investigations for transient synovitis
``` Exclude other diagnoses FBC, CRP and ESR X-rays US - for effusion Aspirate fluid ``` ALL are normal
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Management for transient synovitis
Rest and analgesia
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Pathophysiology | Duchenne's muscular dystrophy
Most common muscular dystrophy X linked recessive Mutations in dystrophin gene - NO DYSTROPHIN PRODUCED Progressive muscle degeneration
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Presentation of Duchenne's
Progressive proximal muscular dystrophy Characteristic pseudohypertrophy of calves All have symptoms by 3 years Delayed motor milestones Waddling gait on running Gower's sign = climbing up with hands when getting off floor Failure to thrive Speech delay Raised LFTs Anaesthetic complications - rhabdomyolysis, malignant hyperthermia Fatigue ** Lose independent mobility by 8-11 years**
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Investigations for Duchenne's
Raised CK (x10-100x normal) from birth Normal CK rules out Duchenne's Muscle biopsy looking for dystrophin Genetic analysis
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Management of Duchenne's
Physio and orthoses may increase walking time Corticosteroids can increase walking by 6-24 months Bone protection After loss of mobility (8 to 11) then supportive and orthopaedic care Monitor cardiac and respiratory function
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Complications of Duchenne's
Joint contractures Resp failure (most common cause of death) Cardiomyopathy and cardiac failure learning difficulty (10-20%) Immobility - constipation, osteoporosis, obesity, HTN Weight loss
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Differences between Duchenne's and Becker's
Very similar Both x-linked recessive Dystrophin gene - fully gone in Duchenne's, partially functional in Becker's Walking ability lost at 40-60, in Duchennes 8-11 Presentation of Becker's is the same but slower - Difficultly climbing stairs and heavy lifting in teenage years
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Epidemiology of Osgood-Schlater's disease
``` Common cause of knee pain Boys between 12-15 Girls between 8 and 12 Common in athletes Increased in males ```
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Pathogenesis of Osgood-Schlater's
Possibly caused by small avulsion fractures from contraction of quadriceps muscles at insertion on proximal tibial apophysis Usually occurs during growth spurt before tibial tuberosity has finished ossification Strength of quadriceps exceeds force As avulsed # heal and grow the tibial tuberosity enlarges
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Presentation of Osgood-Schlater's
Gradual onset of pain and swelling below the knee Relieved by rest Made worse by extending the knee against resistance Tenderness and swelling at tibial tuberosity
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Management of Osgood-Schlater's
``` Rest from painful activities Ice Physio and stretching exercises Simple analgesia - Paracetamol and ibuprofen No corticosteroid injections Surgery rarely required ``` Most return to normal in 2-3 weeks
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Pathophysiology of Sever's disease
Line of ossification in calcaneal apophysis is thought to develop microfractures due to recurrent heel stresses combined with growth spurt of puberty
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Presentation of Sever's disease
``` 8 and 14 years old Heel pain in physically active individuals Gradual onset, worse on exercise Relieved by rest Often bilateral tenderness on palpation of heel at Achilles tendon insertion pain or dorsiflexion May have swelling at calcaneous ```
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Investigations and management of Sever's
X-ray to exclude tumour or fracture It is a clinical diagnosis Management with stretching, strengthening, heel lift Correct alignment with orthoses
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Antalgic gait
OA/Trauma - Avoids certain movements due to pain - limited joint range of motion - inability to fully weight bear - limp with slow and short steps
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Ataxic gait
Cerebellar disease - Arrhythmic steps - wide based - unsteady - highly impaired tandem gait - difficulty walking straight and turning
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Festinated gait
Parkinson's - Short steps (petit pas) - Decreased arm swinging - Stooped posture - Festination (hasty but short steps) - Centre of gravity behind or in front of feet
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Hemiparetic gait
Stroke - Limb extended and circumducted - Spastic quads and gluts - Extensors are stronger than flexors in legs - Foot plantar flexed causes dragging
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Scissor gait
Cerebral palsy - legs flexed slightly at hips and knees - Spastic gait, stiff, foot dragging - tiptoe walking - thighs and knees rub together
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Trendelenburg gait
Dropping of contralateral hip as ipsilateral adductors can't stabilise the pelvis. Body swings to other side to compensate
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Clavicle #
Most commonly middle 1/3 Then lateral 1/3 Then medial 1/3 Complications: - pneumothorax - brachial plexus damage - subclavian vessel damage Place in figure of 8 bandage and sling for 3 weeks
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Bankart lesion
Injury of the anterior glenoid labrum of the shoulder due to anterior shoulder dislocation
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Hill Sachs lesion
Damage to the posterior humeral head (reciprocal of Bankart lesion)
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How would a patient hold their arm in anterior dislocation?
Holds arm externally rotated and slightly abducted
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Damage that can occur in anterior dislocation?
Axillary artery Axillary nerve (37%) Suprascapular nerve Radial nerve
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Treatment of anterior shoulder dislocation
Disimpaction External rotation Abduction Internal rotation
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Salter Harris classification
Classification of fractures through the epiphyseal growth plate of the bone 1 - S Slip (separated or straight across) 2 - A Above fracture lies above the epiphysis or away from the joint 3 - L Lower - # below the physis in the epiphysis 4 - TE Through Everything - # through metaphysis, physis, epiphysis 5 - R Rammed - crushed physis 9rare) SALTER mneumonic
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Upper motor neuron signs
``` Upgoing plantar Increased tone Weakness Increased reflexes Sustained clonus ```
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Lower motor neuron signs
``` Decreased tone Weakness Wasting (atrophy) Arreflexia Muscle fasciculation's ```
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Spinal stenosis
Abnormal narrowing of the spinal canal that can occur in any of the regions of the spine Most commonly cervical spinal stenosis Lumbar spinal stenosis is next common Rare in thoracic Results in neurological deficit - Standing discomfort - Bilateral symptoms - Numbness - Weakness Intermittent neurogenic claudication - lower limb numbness, weakness, diffuse or radicular leg pain with paraesthesia Weakness of heaviness in buttocks radiating into lower extremities - Will resolve at rest, takes longer than vascular claudication
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Causes of spinal stenosis
``` Herniated intervertebral discs Compression # OA RA - less common Hereditary - too small at birth Spondylolisthesis - vertebra slips forward on one another Trauma Tumours of the spine ```
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Neurofibromatosis
Group of 3 conditions in which tumours grow in the nervous system NF1 - neurofibromas NF2 - schwann cells Schwannomatosis BENIGN
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Symptoms of neurofibromatosis 1
Light brown spots on skin - café au lait Freckles in arm pit and groin Small mumps within nerves and scoliosis
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Symptoms of neurofibromatosis 2
``` Hearing loss Cataracts Balance problems Flesh coloured skin flaps Muscle wasting Bilateral acoustic neuromas ```