MSK Investigations and Management Flashcards
Disc prolapse causing sciatica management
Conservative treatment (NSAID) Consider surgery if not resolving after 3 months
When would you operate on a flat foot?
If rigid and painful with tarsal coalition (bony connection)
When would you do an MRI for back pain?
Only if red flags or considering surgery (non-resolving sciatica, spinal stenosis)
Tibialis posterior dysfunction management
Physiotherapy Insole NOT steroid injections Bespoke footwear Last line is surgery
Plantar fasciitis management
NSAIDs Night splints Taping Heel cups or medial arch supports Physio Steroid injection Can do surgery (but not usually)
Hallux valgus management
Shoe modifications, padding
Operative (only if pain, lesser toe deformities, functional limitation or other complications)
Management of mortons neuroma
Non operative (insoles, injections) Operative (excise)
Management of achilles tendonitis
Activity modification/analgesia NSAIDs Shockwave therapy Orthotics Physio Surgery
Management of achilles tendon rupture
Operative repair
Non-operative (casting)
Similar efficacy
Claw, hammer and mallet toe management
Surgery (tenotomies, tendon transfer, fusions or amputation)
Ankle fracture management
Stable - cast/moon boot
Unstable - ORIF
Lisfranc fracture management
ORIF
Femeroacetabular impingement syndrome (FAI) investigations
Radiographs
CT
MRI (labrum damage and bony oedema)
FAI CAM deformity management
Observation if asymptomatic
Arthroscopic/open surgery to remove CAM/debride labral tears
FAI pincer impingement management
Peri-acetabular osteotomy/debride labral tears in pincer impingement
FAI in older patients with secondary OA management
Arthroplasty
AVN investigations
Radiographs (normal in early disease)
MRI
Shows hanging rope sign (slcerotic line through femoral head/neck)
Management of AVN with no permanent changes to geography of femoral head
Bisphosphonates
Core decompression/bone grafting
Curretage and bone grafting
Vascularised fibular bone graft
Management of AVN with permanent changes to geography of femoral head
Rotational osteotomy (only good for small bits of bone) Total hip replacement
Investigations for idiopathic transient osteonecrosis of the hip (ITOH)
Raised ESR
X-ray (osteopaenia of head and neck, thinning of cortices, preserved joint space)
MRI (gold standard)
Bone scan
ITOH management
Self limiting (6-9 months) Analgesia Protected weight bearing to avoid stress fracture
Investigation for trochanteric bursitis
None, clinical diagnosis
Management of trochanteric bursitis
Analgesia
NSAIDs
Physio
Steroid injection
What hip replacement is used in younger patients?
Hybrid THA (uncemented cup, cemented stem)
What hip replacement is used in older patients?
Cemented THA (cemented cup and stem)
Should you x-ray in hip OA?
Only if it will affect management
DDH investigations
Clinical exam
US
Radiographs later on
Early picked up DDH management
Pavlik harness (23 hours a day for up to 12 weeks until US normal) Night time splinting for a few more weeks
Late picked up DDH management
Closed reduction (maybe tenotomies) with spica (hip plaster cast) Open reduction and osteotomies (pelvic or femoral) with spica
Both involve hip arthrograms to assess.
Reactive synovitis diagnosis and investigation
Kochers criteria
Ultrasound with maybe aspiration
Septic arthritis investigations
Blood tests/cultures
Kochers criteria
Radiographs to rule out other pathologies
Ultrasound and aspiration
Septic arthritis management
Open surgical washout
6 week antibiotics
Perthes disease investigations
Radiographs
MRI
Perthes disease management
Restrict weight bearing
Maintain ROM with physio
Surgery in young patients with severe disease and deformity (femoral and pelvic osteotomies)
SUFE investigations
Radiographs
MRI
SUFE management
Percutaneous pinning of the hip (with maybe pinning on the other side)
Open reduction if a very severe slip
Extensor mechanism rupture management
Surgical repair
Meniscal tear investigation
MRI
Meniscal tear management
Consider arthroscopic repair in acute peripheral years in younger patient
Arthroscopic menisectomy for mechanical symptoms or failed repair
URGENT surgery if acute locked knee to prevent fixed flexion deformity
Management of degenerative mensical tear
Injection may help
Menisectomy ONLY if mechanical symptoms, not pain
MCL rupture management
Brace, early motion physio
Rarely surgery
ACL rupture management
Around 40% require ACL reconstruction (not repair)
The rest get on
LCL rupture management
Complete rupture repair if within 2-3 weeks, reconstruction otherwise
Isolated PCL rupture management
Don’t require reconstruction (rare)
PCL tear as part of multiligament knee injury management
Needs reconstruction
Knee dislocation management
Check NV status Emergency reduction Recheck NV status May need external fixation for temporary stabilisation Multi ligament reconstruction
Any concerns with vascular status contact vascular surgery
Management of clubfoot
Ponseti method (serial casting with maybe achilles tenotomy)
Cerebral palsy management
Benzodiazepines
Baclofen
Botulinum toxin injections
Selective dorsal rhizotomy (surgery)
Duchenne muscular dystrophy investigation
CK
Muscle biopsy
Mucous cyst management
Leave alone
Excision
Trigger finger management
Conservative - often resolves spontaneously, splint to prevent flexion
Tendon sheath injection (steroid and LA, often curative, may be repeated 3 times)
Surgery (divide A1 pulley)
De quervains tenosynovitis clinical sign
Finklesteins test positive (thing where you try and dislocate your thumb)
De quervains tenosynovitis management
NSAIDs Splint Rest Steroid injection Surgical decompression
Dupuytrens management
Conservative - stretches, activity modification
Surgery - fasciectomy, amputation
Newer treatments - collagenase injection, percutaneous needle fasciotomy
Paronychia management
Elevate
Antibiotics
Incise and drain collection
Flexor tendon sheath infection management
Surgical emergency
Wash out tendon sheath
Nail/nailbed injury management
Keep nail if possible
Repair nail bed
Mallet finger management
Mallet splint for 6 weeks
PIPJ dislocation management
Vital to be treated acutely
Pull to reduce, buddy strap
PIPJ dislocation late presentation management
Impossible to reduce
May require fusion
PIPJ dislocation with fracture management
Needs fixation/stabilisation
Bennett’s fracture (fracture of 1st MC and CMC joint) management
Fixation
Hand burns management
Excise damaged skin and perform split skin grafts early
Aggressive mobilisation to prevent finger stiffness
Escharotomy
Rheumatoid nodule management
Excision if problematic
Recurrence high
Management of giant cell tumour of the tendon sheath
Leave if no functional issue
Marginal excision, incidence of recurrence
System used to grade the shape of the acromion
Bigliani acromial grading
Supraspinatus tendinopathy management
Active shoulder movement with physiotherapy
Steroid and local anaesthetic injection
If refractory try arthroscopic sub-acromial decompression
Management of calcifying teninopathy
Physiotherapy
NSAIDs
Steroid injection
Rarely excision of calcium
Management of ACJ OA
Rest
NSAID
Steroid injection
Refractory then removal of ACJ
Frozen shoulder management
Early physio and NSAIDs
Steroid injection
Surgical release with either manipulation under anaesthetic or arthroscopic arthrolysis
Management of tennis elbow
Steroid injections
Surgical release and debridement of ERCB origin (only for refractory cases)
Management of golfers elbow
Avoid injecting due to proximity to the ulnar nerve
Surgical debridement last resort
RA extensor tendon rupture management
Tendon transfer
Synovectomy can prevent
EPL rupture management
May require tendon transfer is affecting quality of life
Radiocapitellar OA management
Excise and maybe replace radial head
Management of tendon deformities in RA
Splintage Surgery (tendon reposition)
Management of shoulder dislocation
Closed reduction under sedation (first line)
Open reduction
Stabilisation and rehab
Management of elbow dislocation
Closed reduction under sedation
Open reduction rarely required
2 weeks in sling and rehab
Management of IPJ fracture
Closed reduction under digital or metacarpal block
Open reduction rarely required
2 weeks in neighbour strapping
If very unstable then volar slab in edinburgh position
Patellar dislocation management
Reduces with knee extension Radiographs Aspiration Brace Physio
Repeat patellar dislocation management
Lateral release/medial reefing
Patella tendon realignment
Knee urgent management
Reduction under sedation
May require theatre reduction
Splint/external fixation
Vascular and nerve repair
Knee dislocation imaging
X-ray (associated fractures)
MRI
Knee dislocation definitive management
Sequential ligamentous repair
Hip dislocation early management
Neurovascular assessment (esp sciatic) X-rays Urgent reduction Stabilise in tractions if required CT
Hip dislocation definitive management
Fixation of associated pelvic fractures
Management of undisplaced intracapsular femoral fracture
Hemi-arthroplasty
THR for young fit people
Management of extracapsular femoral fracture
Dynamic hip screw
Management of sub-trochanteric femoral fracture
Intramedullary device (also has screw portion that goes into femoral head)
