MSK Cortex Regional Adult Orthopaedics - Spine & Upper Limb Flashcards
What is the treatment for “mechanical” back pain?
Analgesia and physiotherapy. Bed rest is not advised as this will lead to stiffness and spasm of the back
And acute disc tear can occur where?
In the outer annulus fibrosis of an intervertebral disc (which classically happens after lifting a heavy object)
When is pain characteristically worse in an acute disc tear?
On coughing (this increases disc pressure)
What is the treatment for an acute disc tear?
Analgesia and physiotherapy are the mainstay of treatment
Where is the commonest site of of a disc prolapse where a nerve root is impinged?
Lower lumbar spine with L4, L5 and S1 nerve roots causing sciatica
In the lumbar spine, when there is a disc prolapse and a nerve is impinged which of the higher or lower of the two vertebra in the effected segment is usually compressed?
Lower
Describe a L3/4 prolapse?
L4 root entrapment > pain down to medial ankle (L4), loss of quadriceps power, reduced knee jerk
Describe a L4/5 prolapse?
L5 root entrapment > pain down dorsum of foot, reduced power Extensor Hallucis Longus and tibialis anterior
Describe a L5/S1 prolapse?
S1 root entrapment > pain to sole of foot, reduced power planarflexion, reduced ankle jerks
What is the 1st line treatment for a nerve root compression?
Analgesia, maintaining mobility and physiotherapy (occasionally drugs for neuropathic pain can be used - gabapentin)
What is a bony nerve root entrapment?
OA of the facet joints resulting in osteophytes impinging on exit nerve roots
What is the treatment for bony nerve root entrapment in suitable candidates?
Surgical decompression, with trimming of the impinging osteophytes
How do the signs and symptoms of spinal stenosis differ from vascular claudication?
- Claudication distance is inconsistent
- Pain is boring (rather than cramping)
- Pain is less walking uphill (spine flexion creates more space for the caudal equina)
- Pedal pulses are preserved
What surgery may be performed for spinal stenosis if symptoms fail to improve with conservative management?
Decompression surgery to increase space for the caudal equina to help alleviate symptoms
What is cauda equina syndrome?
A very large central disc prolapse compressing all the nerve roots of the cauda equina
Prolonged cauda equina syndrome can cause what?
Permanent nerve damage requiring colostomy and urinary diversion
What are the symptoms of cauda equina syndrome?
- Bilateral leg pain, parasthesiae or numbness in a saddle pattern (saddle anaesthesia)
- Altered urinary function
- Altered bowel function
What is the management of caudal equina syndrome?
Urgent MRI to determine the level of prolapse and urgent discesctomy once the diagnosis is confirmed
What are the “red flags” in back pain?
- Back pain in the younger patient (<20 years)
- New back pain in the older patient (>60 years)
- Nature of pain - constant, severe, worse at night
- Systemic upset
What is an osteoporotic crush fracture?
In severe osteoporosis, spontaneous crush fractures of the vertebral body can occur leading to acute pain and kyphosis
What is the treatment for osteoporotic crush fractures?
Usually conservative, however, some clinicians have tried balloon vertebroplasty
What is cervical spondylosis?
Disc degeneration leading to increased loading and accelerated OA of the facet joints
What are the symptoms of cervical spondylosis?
Slow onset stiffness and pain in the neck which can radiate locally to shoulders and the occiput
Children with Down syndrome are at risk of developing an instability where in the vertebrae?
Atlanto-axial (C1/C2) with subluxation potentially causing spinal cord compression
What makes up the shoulder girdle?
Scapula
Clavicle
Proximal humerous
Supporting muscles including the deltoid and rotator cuff
Which muscles make up the rotator cuff?
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
Where do the supraspinatus, infraspinatus and teres minor attach?
Greater tuberosity
Where does the subscapularis attach?
Lesser tuberosity
What does the supraspinatus do?
Responsible for initiating abduction
What does the infrapinatus and teres minor do?
External rotation
What does the subscapularis do?
Is the principle internal rotator
Impingement syndrome causes a painful arc between which angles of abduction?
60 - 120 degrees
What are some causes of impingement syndrome?
- Tendonitis subacromical bursitis
- Acromioclavicular OA with inferior osteophyte
- A hooked acromion rotator cuff tear
What is the treatment of impingement syndrome?
Conservative in the first instance with NSAIDs, analgesics, physiology and subacromial injection of steroid (up to 3 may be required). Subacromial decompression surgery may be performed if conservative treatment isn’t successful
A rotator cuff tear usually affects which tendon?
Supraspinatus
What is adhesive capsulitis (frozen shoulder)?
Progressive pain and stiffness of the shoulder in patients between 40 and 60, resolving after around 18‐24 months
What is the principle clinical sign in frozen shoulder?
Loss of external rotation?
How does acute calcific tendonitis present and what causes it?
Acute onset of severe shoulder pain and is characterised by calcium deposition in the supraspinatus tendon
What is the treatment for acute calcific tendonitis?
Subacromial steroid and local anaesthetic injection. It is self-limiting with pain easing as the calcification reabsorbs
What treatment can be given to patients with recurrent dislocations?
Bankart repair - stabilises the shoulder by reattaching the labrum and capsule to the anterior glenoid which was torn off in the first dislocation
Carpal tunnel syndrome is due to the compression of which nerve?
Median
What are the causes of carpal tunnel syndrome?
- Idiopathic (most cases)
- Rheumatoid arthritis
- Fluid retention (pregnancy, diabetes, chronic renal failure, hypothyroidism
- Fractures around the wrist (esp. collet fracture)
Does carpal tunnel syndrome mostly affect men or women?
Women (8:1 ratio)
Chronic carpal tunnel syndrome may have what on examination?
Muscle wasting of the thenar eminence
What tests can be done to reproduce the symptoms in carpal tunnel syndrome?
Tinel’s test (percussing over the median nerve OR Phalen’s test (holding the wrists hyper-flexed which decreases space in the carpal tunnel)
What investigation can be performed to confirm carpal tunnel syndrome?
Nerve conduction studies - slowing of conduction across the wrist
Carpal tunnel decompression involves doing what?
Division of the transfer carpal ligament
Cubital tunnel syndrome is due to the compression of which nerve?
Ulnar
Ulnar compression can be due to what?
- Tight band of fascia forming the roof of the tunnel (Osborne’s fascia)
- Tightness at the intermuscular septum
- Compression between two heads at the origin of flexor carpi ulnaris
Which joints make up the elbow and what are the responsible for?
Humero-ulnar joint - flexion/extension
Radio-capitallar joint - supination/pronation
Where does the triceps muscle insert?
Coronoid process
Where does the biceps muscle insert?
Bicipital tuberosity of the radius
Forearm supination is performed using which muscles?
Biceps and supinator muscles
Forearm pronation is performed using which muscles?
Pronator teres muscle proximally and the pronator quadrates distally
The common extensor origin of the wrist arises from where?
Lateral epicondyle
The common flexor origin of the wrist arises from where?
Medial epicondyle
What is the proper name for Tennis elbow?
Lateral epicondylitis
What causes tennis elbow?
Repetitive strain injury in those who regularly perform resisted extension at the wrist OR due to degenerative enthesopathy
What is the proper name for Golfer’s elbow?
Medial epicondylitis
Why is a steroid injection less commonly used for Golfer’s elbow than Tennis elbow?
Risk of injury to ulnar nerve
An elbow severely affected by RA or OA at the humero‐ulnar joint which isn’t satisfactorily treated with conservative management can be treated surgically with which operation?
Total elbow replacement
Describe dupuytren’s contracture?
Hyperplasia of palmar fascia with normal fascial bands forming nodules and cords progressing to contractures at the MCP and PIP joints
What is the pathology involved in dupuytren’s contracture?
Proliferation of myofibroblast cells and the production of abnormal collagen (type 3 rather than type 1)
Duputren’s contracture can be a feature of what disease?
Alcoholic cirrhosis (also more common in diabetics)
What is the name for the connective tissue disorder involving the growth of fibrous plaques in the soft tissue of the penis?
Peyronie’s disease
What is the name of the fibromatosis which causes thickening of the feet’s fascia?
Ledderhose disease (plantar fibromatosis)
What degree of contracture at the MCP joint may be tolerated in duputren’s contracture?
30 degrees
What degree of contracture at the PIP joint may be tolerated in duputren’s contracture?
None (PIPJ readily stiffens and any contracture here is usually an indication for surgery)
What is trigger finger?
Nodular enlargement of the affected tendon, usually distal to a fascial pulley over the metacarpal neck (the A1 pulley). The finger may lock in a flexed position as the nodule passes under the pulley
Which fingers does trigger finger most commonly affect?
Middle and ring finger
What is the first line treatment for trigger finger?
Steroid injection around the tendon sheath
What are Heberden’s nodes?
Stiffness and bony thickening of the DIP joints - sign of OA
What is the name for tiffness and bony thickening of the PIP joints?
Bouchard’s nodes
In severe OA what surgery on the index finger may be performed to preserve pinch-grip?
Arthrodesis (fusion)
Does RA tend to spare the PIP or DIP joints?
DIP
What are the 3 stages of RA in the hands?
- Synovitis and tenosynovitis
- Erosions of the joints
- Joint instability and tendon rupture
What type of drugs are mainly used for RA?
Disease modifying anti-rheumatic drugs (DMARDs)
What hand deformities may be present in patients with RA?
- Volar MCPJ subluxation
- Ulnar deviation
- Swan neck deformity (hyperextension at PIPJ with flesion DIPJ)
- Boutonniere deformity (flexion at PIPJ with hyperextension at DIPJ)
- Z-shaped thumb
What is a ganglion cyst?
A common mutinous filled cyst found adjacent to a tendon or synovial joint
What is a ganglion cyst on the posterior knee called?
Baker’s cyst
