MSK Flashcards
Epidemiology and risk factors for RA
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,
Presentation of RA
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
Investigations for RA
- 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
Management of RA
Start within 3 months
Simple analgesia + NSAIDs
DAS28 - number of joints and ESR. For active disease >5.1, remission <2.6
- Methotrexate + alt DMARD + short course steroid (min 6 months)
- different mono/combined DMARD therapy (min 6 month)
- TNF alpha inhibitors (adalimumab, etancercept, infliximab)
- Rituximab (anti CD20) + methotrexate
- Toclizumab (anti IL6)
Surgery if persistent pain, worsening joint function, progressive deformity, nerve entrapment, stress fracture
Complications of RA
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
Prognosis of RA
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
Criteria for RA
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
Epidemiology and risk factors for osteoarthritis
24% adults - knee, 11% hips
RFs Genetic Female Obesity High or low bone density joint injury decrease muscle strength joint laxity or misalignment
Presentation of OA
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
Investigations for OA
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
Management of OA
- 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
Xray changes in OA
Joint space narrowing Subarticular sclerosis Subchondral cysts Bone collapse Osseous loose bodies
Epidemiology and RFs for septic arthritis
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
Presentation of septic arthritis
Single/few joints - acute, very painful Fever Bacteraemia Swollen, warm, tender Effusion
TRIAD - fever, pain, impaired range of motion
Causes of septic arthritis
Staph aureus
Gonococcal
Group B Strep
Lyme disease
Investigations for septic arthritis
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
Treatment for septic arthritis
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
Prognosis of septic arthritis
10-20% mortality
Worse prognosis - over 65, shoulder, elbow or multiple sites
Staph - 50% get back to baseline
Referral for joint replacement
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
Complications for joint replacement
Joint infection DVT/PE Stiffness Implant loosening/failure Hip dislocation Time span - need replacement after 10-15 years Bleeding Haemotoma
Classifications of gout
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
Epidemiology and RF for gout
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
Presentation of gout
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
Investigations for gout
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
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
Complications of gout
Renal disease from deposition of crystals Severe degenerative arthritis secondary infections carpal tunnel Nerve impingment
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
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
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
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
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
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%
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
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
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
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
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
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
Conditions associated with SLE
APLS scleroderma RA Sjorgen's thyroiditis Drug allergies
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
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
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
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
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
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
Prognosis of ankylosing spondylitis
Increased risk of fractures
Frozen thorax
Blindness from recurrent uveitis
70-90% fully independent
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
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
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
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
Appearance of cancer on X-ray
Prostate - sclerotic
Lung, thyroid, kidney = osteolytic
Breast – either (most commonly osteolytic)
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
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
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
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
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
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
Red flag symptoms - spondyloarthropathy
Early morning stiffness > 45 minutes
Night pain
“gelling”
Improves with movement, worse after rest
Most common location for sciatica due to disc prolapse
L5-S1
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
Investigation for prolapse disc
None if symptoms settle in < 6 weeks
MRI is very sensitive
X-ray and CT limited
Management of prolapsed disc
- 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
- Physiotherapy
- Surgery
- Discectomy or spinal fusion
- Prosthetic disc replacement
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
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,
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
Drugs that can contribute to osteoporosis
PPIs Anticonvulsants Depot medroxyprogesterone Antidepressants Thiazolidinediones
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
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
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
Secondary prevention for osteoporosis
Bisphosphonates +/- vitamin D/calcium supplements
Raloxifene
Denosumab/strontium
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)
Pathogens responsible for osteomyelitis
S. aureus (most common)
Haemophilus influenza
Streptococcus
E.coli/Proteus/Pseudomonas/mycobacteria/fungi
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
Presentation of osteomyelitis
Acutely febrile Bacteraemic Painful, immobile limb Swelling Extreme tenderness Exacerbated by movement
If vertebral - unremitting pain, worse at rest, night pain
What is Pott’s disease
Osteomyelitis in the spine with TB
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
Management of osteomyelitis
4-6 weeks minimum antibiotics - Flucloxacillin, clindamycin if penicillin allergy
MRSA - vancomycin
If chronic infection - 12 weeks
Surgical debridement
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
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
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
Investigations for spinal fractures
Lateral view, plain X-ray - wedging, spinal process misalignment FBC, CRP ALP, calcium Blood cultures DEXA scan CT/MRI
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
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
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)
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
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
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
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
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
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
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
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
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
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
Fracture healing stages
- Fracture haematoma
- Fibrovascular tissue replaces clot - collagen fibres laid
- Subperiosteal bone formed at ends beneath periosteum
- Primary callus response (few weeks)
- Bridging external callus
- Endosteoal new bone formation
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
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.
Complication of colles fracture
Median and ulnar nerve damage Compartment syndrome Deformity on healing Chronic pain Mal-union
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
Smiths fracture
Reverse colles
Fracture of distal radius with anterior displacement of fragments
Caused by falling backwards
Generally closed reduction
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
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
Most common sites for radial nerve damage
Proximal forearm
Humeral fractures
Radial aspects of wrist
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
Muscles supplied by radial nerve that needs testing if suspecting damage
Triceps Brachioradialis Externsor carpi radialis longus Supinator Extensor digitorum
Muscles supplied by ulnar nerve
Hypothenar muscles
Adductor pollicis
3rd and 4th lumbricals
Dorsal and palmar interorssei
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
RF for carpal tunnel syndrome
Late 50s Female Obesity FHx Post-colles fracture Short stature Injury Thyroid disorders Diabetes Acromegaly Inflammatory arthritis
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
Phalen’s test
60s of flexion at the wrist causes pain or paraesthesia
Tinel’s test
Tapping over median nerve causes pain or paraesthesia
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
What runs through the carpal tunnel
Flexor digitorum superficialis and profundus
Flexor pollicis longus
Flexor carpi radialis
Median nerve
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
