MSK Pathology Flashcards
What is cubital tunnel syndrome
Compression of the ulnar nerve as it passes around the medial epicondyle
What is the 2nd most common nerve entrapment
Cubital tunnel
Causes of cubital tunnel syndrome
Osteoarthritic or rheumatic narrowing of the ulnar groove
Can be without obvious cause
Fractures (injury)
Joint dislocation (injury)
Non-operative Rx for cubital tunnel
NSAIDs
Bracing/splinting
Surgical Rx for cubital tunnel
Nerve release
Clinical features of cubital tunnel syndrome
Hypothenar wasting Clas deformity Numbness Decreased sensation of little ad medial 1/2 of ring finger Tingling in hands and fingers Shooting pain when leaning on the elbow
What is a more common name for medial epicondylitis
Golfer’s elbow
What is more common golfers elbow or tennis
Tennis
What is the medial epicondyle the common origin for
Flexor tendons
Pathology of golfers elbow
Form repetitive strain injury
Microtears and degeneration in the tendons from overuse
Rx for golfers elbow
Activity modification
Rest
Physio.
Biological:
Platelet rich plasma injection
Which Rx should you never give in golfers elbow?
Nerve inject steroids
Clinical features of golfers elbow
Aching elbow pain (typically over medial elbow)
Worse with activity
Typically affects dominant arm
What is a more common name for lateral epicondylitis
Tennis Elbow
What is the most common elbow overuse injury
Tennis elbow
In shoulder dislocation what is stability sacrificed for
Mobility
What type of injury is tennis elbow
Repetitive strain injury
Ix for tennis elbow
Clinical Dx
Mill’s test
Cozen’s test
Clinical features of tennis elbow
Pain lateral elbow
Worsens with activity
Typically affects dominant arm
Point tenderness over lateral epicondyle
Rx for tennis elbow
Activity modification
NSAIDS
Physio.
Platelet rich plasma injections
What is Adhesive capsulitis also commonly known as
Frozen shoulder
What are the 3 stages of frozen shoulder
- PAIN with freezing (pain and decreased ROM)
- Stiffening or FREEZING(pain slightly resolves but stiffening worsens)
- Resolution/THAWING
How long can frozen shoulder take to resolve
up to 2yrs
Clinical features of frozen shoulder
Acute pain on movement and resting
Difficulty sleeping on affected side
Restricted ROM
Pain settles and stiffening begins
Stiffening persists more than the pain
Ix for frozen shoulder
Clinical Dx
Normal on x-ray
Rx for early presentation of frozen shoulder
Steroid injection
Physio
Analgesia (NSAIDs)
What is a shoulder dislocation
Loss of congruity between the head of the humerus and the glenoid fossa
What is the most common direction of dislocation
Anterior
What should potentially be considered in a posterior dislocation
Seizures
What type of joint is the shoulder joint
Synovial ball and socket
Clinical features of should dislocation
Extreme pain
Decreased ROM
Held in ABDUCTED and EXTERNALLY ROTATED position
Ix for shoulder dislocation
X-ray
AP and lateral
Rx for shoulder dislocation
Analgesia
Manipulation
Immobilisation
Physio.
Complications of shoulder dislocation
Labral tear
Axillary n. or a damage
Damage o brachial plexus
Increased risk of recurrence
When should you operate in shoulder dislocations
> 2 dislocations
How do ACL injuries typically occur
Through sporting
Common causes of ACL
Twisting injury to the knee with foot fixed to the ground Landing incorrectly Stopping sudden Changing direction suddenly Collision
Signs of ACL damage
Unstable knee
Effusion
+ve drawer test
Symptoms of ACL damage
Heard a pop
Pain
Quick swelling
Loss of full ROM
Ix for ACL damage
Often clinical
Rarely MRI
Rx for ACL injury
Rest
Physio
Swelling reduction
Analgesia
Surgery:
ACL reconstruction
Indications for surgical reconstruction in ACL injury
Prevention of further injury
Back to work
Back to sport
Prevention OA
Which is stronger the ACL or PCL of the knee
PCL
What is a common cause of PCL injury
Car crashes:
Bent knee hitting the dashboard
Signs of PCL injury
Posterior draw test
Posterior sag
Symptoms of PCL injury
Pain
Swelling
Difficult weight bearing
Unstable knee
Rx for PCL Injury
Analgesia
Physio.
Immobilisation
Swelling reduction
Why is PCL injury treated more conservatively
Surgical reconstruction is more difficult and more difficult to predict compared to ACL reconstruction
What is the most commonly fractures carpal bone
Scaphoid
What is a common complication of scaphoid fracture
AVN
What is AVN
Avascular necrosis
Death of the bone due to interrupted blood supply
Ix for suspected scaphoid fracture
Easily missed on x-ray
So dedicated scaphoid series
Clinical features of scaphoid fracture
Tender anatomical snuffbox Tender over scaphoid tubercle Pain on axial compression of thumb Pain on ulnar deviation of pronated wrist Pain on supination against pronation
Main cause of scaphoid fracture
Falling
On outstretched hand
Rx for scaphoid fracture
Cast
Rx for clinically suspected scaphoid fracture that is not detected x-ray
Cast
Re-xray in 2 weeks
Which of the collateral ligaments is more commonly injury
Medial
How is the medial collateral ligament injured
Due to lateral blow to the knee
Which ligament does a blow to the lateral knee injure
Medial collateral
Which ligament does a blow to the medial knee injure
Lateral collateral ligament
Describe injury to the lateral collateral ligament
Less common than medial injury
Tends to be more extensive and involve:
Cruciate
Common perineal nerve
Rx for collateral ligament injury
Rest
Firm support
Physio
When is surgery indicated for collateral ligament injury
Rarely
Unless complicated LCL injury
Clinical features of collateral ligament injury
No or minimal effusion Swelling Bruised one side Lateralised pain Feel of 'crack' sharp pain
What is an open fracture
Direct communication between a fracture and the external environment
What is the classification system used for open fractures
Gustilo Classification of Open Fractures
Complications of open fractures
Infection
Compartment syndrome
Non-union
Neurovascular injury
Describe Gustilo Classification System
Classifies open fractures
Based on:
Size of wound
Tissue damage
Classified into:
Stage 1
Stage 2
Stage 3 (3A,B,C)
Which open fractures require a vascular surgeon
Stage 3C (involvement of neuromuscular structures)
Ix for open fractures
Full ALTS assessment Repeated neurovascular examination Take photographs with ruler beside it X-rays Sometimes CT
Indications for emergency surgery
Polytraumatised
Gross contamination
Compartment syndrome
Neurovascular compromise
What are the BOAST guidelines for dealing with open fractures
Analgesia Take a photograph with a ruler next to it Splinting Neurovascular examination of patient Document it!!
What is the commonest reason for knee arthroscopy
Meniscal injury
What is the function of the menisci
Shock absorbers
What are the menisci of the knee
Medial
Lateral
Clinical features of meniscal injury
Slow swelling Painful to weight bear Sensation of knee giving way Locked knee (extension limited) Loss of full ROM
What does McMurrays test assess for
Knee meniscal injury
Surgery options for meniscal injury
Arthroscopy
Meniscal repair
Partial meniscectomy
Meniscal transplantation
Conservative Rx for meniscal injury
Physio
Analgesia
Swelling reduction
What causes Carpal Tunnel Syndrome
Compression of the median nerve as it passes through the carpal tunnel
Is carpal tunnel more common in F or M
F>M
Underlying causes of Carpal tunnel
Pregnancy Gout DM Idiopathic Acromegaly Local tumours RA Hypothyroidism Amyloidosis Sarcoidosis
What is the most common neuropathy
Carpal tunnel
Symptoms of carpal tunnel
Tingling in median nerve distribution
Numbness in medin nerve distribution
Pain
Can be worse at night
What is the median nerve distribution in the and
Lateral 3.5 digits
Ix for Carpal Tunnel
Usually clinical Dx (O/E)
Tinel’s Test
Phalens Test
Sometimes nerve conduction studies
Describe Tinel’s test
Tapping over the anterior wrist of the affected
+ve would elicit symptoms
Describe Phalen’s Test
Backwards paying
For 60 seconds
+ve if this elicits symptoms
Rx for Carpal Tunnel
Splintage
Rest
Weight reduction
Corticosteroid injection
Sometimes surgery if persistent
Surgery for carpal tunnel syndrome
Carpal tunnel release
Is Trigger finger more common in M or F
F>M
Associations with Trigger Finger
DM!
RA
Gout
Thyroid disease
Clinical features of trigger finger
Clicking sensation with movement of this digit
Lump in palmar aspect under pulley
May have to use the other hand to unlock the finer
Clicking may progress to locking (in flexed position)
Which level of pulley is commonly affected in trigger finger
Level of A1 pulley
Ix for trigger finger
Clinical Dx
Non-operative Rx trigger finger
Splintage
Rest
Steroid injection
Analgesia
Operative Rx trigger finger
Surgery:
Percutaneous release
Open surgery
Which finger is the most commonly affected in trigger finger
Ring finger
Who does Legg-Calve/Perthes disease affect
Children
What causes Legg-Calve
Idiopathic
Pathology of Legg-Calve disease
AVN of femoral head occurs
What are the phases of Legg-Calve disease
Avascular necrosis at femoral head (due to lack of blood supply)
Fragmentation (revascularisation) - painful phase
Reossification - bone healing
Clinical features of Perthes disease
Short stature Limping child Knee pain (referred from hip) Groin/hip pain Stiff hip joint Limited ROM of hip
Ix for Perthes/Legg -Calves disease
X-ray
MRI
Outcome of Perthes/Legg-Calves disease
Alot will resolve by itself
Is the prognosis better or worse for Perthes disease that occurs <6yrs
Better
As children bones recover well and model
Is the prognosis better or worse for Perthes disease that occurs in Adolescence
Worse
Poorer prognosis
More risk of developing OA
Ddx for unilateral Perthes/Legg-Calves disease
Septic hip
JIA
SCFE
Rx for Perthes/Legg-Calves
No definitive Rx
Maintain good hip motion.mobility
Analgesia
X-ray surveillance
What is the long term prognosis of Perthes/Legg-Calves disease determined by
The risk of developing OA in the deformed hip
Who is Legg-Calves/Perthes disease more common in M or F
Males
Is majority of Legg-Calves/Perthes disease unilateral or bilateral
Unilateral
only 15% is unilateral
What is the clinical term for irritable hip
Transient synovitis of the hip
What is the child cause of hip pain in children
Transient synovitis of the hip (irritable hip)
What type of Dx is hip transient synovitis
Dx of exclusion
What causes irritable hip
Inflammation of the synovium
Clinical features of irritable hip
Acute onset Acute hip pain Stiffness Limp Non-weight bearing
Ix for irritable hip
Dx of exclusion
Bloods normal
X-ray normal
Rx for irritable hip (transient synovitis)
Self limiting
Rest
Analgesia (NSAIDs)
What Dx do you need to exclude in order to Dx transient synovitis (irritable hip)
Septi arthritis
Osteomyelitis
Fractures
SUFE
What does SCFE stand for
Slipper Capital Femoral Epiphysis
What is the cause of SCFE
Unknown
Pathology of SCFE
Fracture through the growth plate which results in slippage of the overlying end of the femur
Displacement through the hypertrophic zone
What is the difference between stable and unstable SCFE
Stable - can weight bear
Unstable - cannot weight bear
What is a major risk factor for SCFE
obesity
What 2 signs can be seen on X-ray in SCFE
Trethowan Sign
Klein’s Line
Symptoms of SCFE
Pain in hip or knee
Groin pain
Some unable to weight bear
Limp
Signs of SCFE
Externally rotates posture and gait (waddling)
Reduced internal rotation (esp. in flexion)
Difference between chronic and acute SCFE
Chronic is >3 weeks
Which view of x-ray will you best see SCFE
Lateral
Describe the radiological classification of SCFE
Grade I/mild = <1/3 slippage
Grade II/moderate = 1/3 - 1/2 slippage
Grade III/severe = >1/2 slippage
Complications of SCFE
AVN (femoral head) Chorndrylosis Deformity Early OA Stable becoming unstable
What is a complication of stable SCFE
Stable becoming unstable
DD for SCFE
Transient synovitis Infection Missed DDH JIA Perthes
Operative Rx for SCFE
Pinning
Early internal fixation
Consultation orthopaedic surgeon
Where does the metaphysics move in SCFE
Anterior and proximal
Does stable or unstable SCFE have a higher risk for AVN
Unstable
What is acute osteomyelitis
Acute infection of the bone
Who does acute osteomyelitis normally affect
Children
What type of organism is the most common for acute osteomyelitis
Bacterial
Common Ddx for acute osteomyelitis
Acute septic arthritis
Acute inflammatory arthritis
Trauma (fracture, dislocation)
Transient synovitis
Rarer Ddx for acute osteomyelitis
Sickle cell crisis
Gaucher’s Disease
Rheumatic fever
Haemophilis
Skin Ddx for acute osteomyelitis
Cellulitis
Erisypelas
Necrotising fasciitis
Gas gangrene
Potential source of osteomyelitis in infants
Umbilical cord
Acute osteomyelitis organisms in infants <1yr
Staph Aureus
Group B strep
E.coli
Acute osteomyeltiis organisms in older children
Staph Aureus
Strep Pyogenes
Haemophilus influenza
Acute osteomyelitis organisms in adults
Staph Aureus
Coagulative -ve staphylococci
Pseudomonas aeroginosa
Acute osteomyelitis organisms in diabetic foot
Mixed infection
Including anaerobes
Acute osteomyelitis organisms in sickle cell disease
Salmonella
in which group would candida more commonly cause acute osteomyelitis
HIV/Aids
Debilitating illnesses
Complications of acute osteomyelitis
Septicaemia; death Metastatic infection Pathological fracture Chronic osteomyelitis Septic arthritis Altered bone growth
Clinical features acute osteomyelitis in infants
May be minimal signs Or may be very ill Failture to thrive Drowsy irritable Metatphyseal tenderness and swelling Decreased ROM Positional change
Clinical features acute osteomyelitis in children
Sever pain Reluctant to move Neighbouring joints held flexed Not weight bearing Fever Tachycardia Malaise (fatigue, nausea, vomiting)
Clinical features osteomyelitis in Adults
Primarily seen in thoracolumbar spine
Acute backache
Temperature/fever
History UTI, DM or immunocompromised
Basic Ix of acute osteomyelitis
Hx Examination FBC Diff WCC ESR CRP Blood cultures x3 at peak temperature U&E's - ill, dehydrated
Imaging Ix of acute osteomyelitis
Xray USS Aspiration Isotope bone scan Labelled white cell scan MRI
Gold standard for making a microbiological Dx in acute osteomyelitis
Bone biopsy and culture (though this is rarely required)
Supportive Rx for acute osteomyelitis
Fluids
Analgesia
Rest
Splintage
Abx Rx for acute osteomyelitis (including route and for how long)
Start on IV then switch to oral Duration 4-6weeks depending on response empirical choice (flucloxacillin + benzylpenicillin_
Indications for surgery in acute osteomyelitis
Aspiration of pus for Dx an culture
Abscess drainage
Debridement of dead/infected/contaminated tissue
Common sources of infection for osteomyelitis
Haemotogenous spread
Local spread from contiguous site fo infection - trauma (open fracture), surgery, joint replacement
Secondary to vascular insufficiency
Common source of acute osteomyelitis infection for osteomyelitis in adults
UTI
arterial line
Common sources of acute osteomyelitis infection in children
Boils
Tonsilitis
Skin abrasions
If there is no resolution of acute osteomyelitis what occurs
Chronic osteomyelitis
What is sequestrum
Necrosis of bone
What is Involucrum
Formation of new bone
Which three common conditions can cause intoeing
Tibial torsion
Metatarsus adducts
Femoral anteversion
What is intoeing
When a child walks or runs with their feet turned inwards
What is the main Rx for intoeing
In the vast majority it will correct itself
Rx for metatarsus adductus
95% will resolve on their own
Stretching/manipulation exercises can help
Some cases:
Casts/special shoes
Surgery
What is metatarsus adductus
Common foot deformity noted at birth
Which causes intoeing
when is flexible metatarsus adductus Dx
If the heel and forefoot can be aligned with each other on gentle pressure no forefoot while holding eel steady
Ix for metatarsus adductus
Physical examination
X-ray if non flexible/rigid
Signs of Metatarsus adductus
High arch
Wide separation of big and 2nd toe
What causes tibial torsion
Inwards rotation of the tibia
Prognosis for tibial torsion
Very good
Almost always corrects itself as the child grow
what common thing does tibial torsion cause
Intoeing
What is congenital dysplasia of the hip
Congenital hip dislocation
Who is DDH incidence higher in
First born girls>boys Left>right Olidohydramnios Breech position FH Other limb deformities
Which hip is more commonly affected in DDH
Left
Ix for DDH
All babies given full hip examination within 72hrs
Early Dx is crucial
Another hip examination at 68 weeks -
when is USS recommended for Dx DDH
If the hip feels unstable on routine examination FH of childhood hip problems Baby was breech Twins or multiple premature
Why are x-rays not used to diagnose DDH
Because most of babies bones are cartilaginous
Rx for DDH
Pavlik Harness
Describe Pavlik Harness
Where legs are held in flexed abducted position
Adjusted during growth
When is surgery indicated for DDH
If Dx>6 months
Or
Failure of Pavlik Harness
Why is the Left hip more affected in DDH
due to the way that babies present down the birth canal
What can excessive abduction in Pavlik harness (DDH) lead to
AVN
What are 2 clinical signs of DDH
Ortolani’s Sign
Barlows Sign
Red flags for Cauda Equine Syndrome
Saddle anaesthesia
Bilateral sciatic
Bowel/urinary dysfunction (incontinence/retention)
Rx for Cauda Equina
Urgent decompressive surgery
What is sciatica
Pain from lower back down the back of the thighs
What is saddle anaesthesia
Loss of sensation of buttocks, perineum ad inner thighs
What is caudal equine syndrome
Caused by the compression of the caudal equine (horses tail of the spinal cord)
Causes of caudal equine syndrome
Central lumbar disc props Tumours Trauma Infection Iatrogenic (spinal injection/surgery)
Where is the clavicle most commonly fractures
middle 1/3 (80%)
Rx for broke collarbone
Sling
Immobilisation
analgesia
Complications of clavicle fracture
Pneumothorax
Blood vessel injury
Nerve injury
What is the most common cause of compartment syndrome
Fractures
what is the pathology of compartment syndrome
Pressure within muscles build dangerous levels
Occluding vascular supply
Leading to hypoxia and eventually necrosis of the tissue
1st line/urgent Ix in compartment syndrome
Measuring intra-compartment pressure
>30mmHg defined as critical
What intra-compartment pressure is considered critical in compartment syndrome
> 30mmHg
Risk factors for compartment syndrome
Trauma
Bleeding Disorder
thermal injury
Intense muscular activity
Rx for compartment syndrome
Surgical review at Dx
Dressing release
Supportive
PROMPT fasciotomy
Worst case scenario:
Amputation
Clinical features of compartment syndrome
Pain Muscle tightness Paralysis Pallor Pulselessness Redness Oedema Mottling Firm wooden feeling on palpation
Which carpal fracture is easily missed on X-ray
Scaphoid
What is a common complication of scaphoid fracture
AVN
What is osteoporosis
Metabolic bone disease characterised by low/reduced bone mass and micro architectural deterioration of bone tissue
Fragile bones
What is there an increased risk of in osteoporosis
Increased fracture risk
Factors that the risk of fracture is related to
Increased age Females following menopause (due to decreased oestrogen) FH BMD Long term steroid use Smoking Alcohol
Endocrine causes of osteoporosis
Thyrotoxicosis hypoparathyroidism Cushing's Hyperprolactinaemia Hypopituitarism Low sex hormones (hypogonadism)
Rheumatic causes of osteoporosis
Rheumatoid arthritis
Ankylosing Spondylitis
Polymyalgia Rheumatica
SLE
GI causes of osteoporosis
IBD (UC or CD) Malabsorption syndromes (e.g coeliac) Chronic active hepatitis Alcoholic cirrhosis Cystic fibrosis Chronic pancreatitis Whipples disease
Medication Causes of Osteoporosis
Steroids!! PPI Aromatase inhibitors Heparin Warfarin Enzyme inducting anti epileptic medications
What is the main clinical relevance of Osteoporosis
Increased risk of fracture
Which assessment tool is used to assess the risk of fractures
FRAX assessment tool
Clinical features of osteoporosis
No specific symptoms
but fractures of bones occur n situations which would not normally cause a break in healthy bones
Ix for Osteoporosis
FRAX assessment tool (to determine risk of fracture)
X-ray
DEXA scan
Bloods (to rule out underlying causes)
Methods of preventing osteoporotic fractures
Minimise risk factors
Ensure good calcium and Vitamin D status
Falls prevention strategies
Medications
General Rx for osteoporosis
Quite smoking
Decreased alcohol
Weight bearing exercises
Calcium and Vitamin D rich diet
Medication Rx for Osteoporosis
Biphosphonates (1st line/main Rx) Denusomab Teriparatide (artificial PTH) Calcium supplements Vit. D supplements HRT
What is Denusomab
Monoclonal Antibody
What is the action of Denusomab
Reduces osteoclastic bone resorption
What is Teriparatide
Artificial parathyroid hormone
Who does HRT help in osteoporosis
Post-menopausal women
Side effects of HRT
Increased risk blood clots
Increased risk breast cancer
What is required for the use of bisphosphonates
Adequate renal function
Adequate vitamin D and Calcium required
Good dental health and hygiene also advised
Side effects of biphosphonatees
Oesophagitis
Uveitis
Not safe when eGFR<30mls/min
Atypical femoral fracture
Side effects of Denosumab
Allergy/rash
Symptomatic hypocalcaeimia when given to vit D deficient
Side effects of Teriparatide
Injection site allergy
Rarely hypercalcaemia
Allergy
what is the first line biphosphonate given
Alendronic acid
What is Paget’s Disease
Localised disease of bone turnover
Pathology of Paget’s Disease
Increased bone reabsorption followed by increased bone formation
Leads to disorganised/dysregulated bone remodelling
Aetiology of Paget’s Disease
Strong genetic component Environmental trigger (potentially viral infection?)
What is the commonest presentation of Paget’s Disease
Asymptomatic increase in serum alkaline phosphatase
What can develop rarely in Paget’s disease
Osteosarcoma
Symptoms of Paget’s Disease
Majority asymptomatic
Bone pain Bone deformity Bone fracture Excessive heat over Paget's bone Other neurological complications (e.g deafness if occurs at ossicles)
What complication can arise if Paget’s Disease affects the ossicles
Deafness
What are the 3 ossicle bones
Malleus
Incus
Stapes
Ix for Paget’s Disease
Serum Alkaline Phosphate
Xray
Pyridinoline (urine)
Bone scan
Should you treat asymptomatic Paget’s Disease
No
There is no evidence to treat asymptomatic Paget’s disease based on increased alkaline phosphatase alone
Keep an eye on it
Supportive Rx for Paget’s
NSAIDs
Paracetamol
Physio.
OT
Diet Rx for Paget’s
Calcium and Vitamin D rich
Medication Rx for Paget’s
Biphosphonates:
Zoledronic acid (one off injection)
Risedronate
Pamidnate
Who is surgery recommended for in Paget’s
Fractures
Deformities
Severe OA
What is osteogenesis imperfecta
Genetic disorder of connective tissue
What is osteogenesis imperfect characterised by
Fragile and fractured bones from mild trauma and even daily acts of life
Main clinical feature of osteogenesis imperfecta
Bones that break with little or no force
How many different types of osteogenesis imperfect are there?
8
Which is the most severe type of osteogenesis imperfecta
Type II
What is the cure for osteogenesis imperfecta
No cure
Rx for preventing fractures in OI
Prevent fractures:
IV Bisphosphonates
Immobilisation
Rx for managing fractures in OI
Rodding
Surgery
Rx for social aspects of OI
Education and social adaptations
Physio.
Rx for genetic aspect of OI
Genetic counselling for parents and next generation
Other features of Osteogenesis imperfecta apart from easily fractures bones
Growth deficiency
Defective tooth formation (dentigenesis imperfecta)
Hearing loss
Blue sclera
Scoliosis / Barrel Chest
Ligamentous laxity
Easy bruising
Ix for OI
X-ray
DNA collagen testing
Type II often Dx by USS at pregnancy
X-ray features of OI
Many fractures!!
Osteoporotic bones with thin cortex
Bowing deformities of long bones
What is an important Ddx in OI
Potential child abuse
What is Osteomalacia
Metabolic bone disease characterised by incomplete mineralistion of the underlying mature organic bone matrix (osteoid) following growth plate closure in adults
Difference between osteomalacia and Rickets
Underlying pathology is the same
Osteomalacia:
Occurs in adults when the epiphyseal plates have closed
Rickets:
Occurs in growing children when the epiphyseal plates are still open
Which deficiency causes rickets/osteomalacia
Vitamin D
Calcium
Ix for Osteomalacia
Serum calcium level Serum 25-hydroxyvitamin D levels Serum phosphate levels Serum urea and creatinine Intact PTH Serum alkaline phosphatase 24 hr urinary calcium
Ix for Rickets
Xray of a long bone Serum calcium Serum inorganic phosphorus Serum parathyroid hormone level Serum 25-hydroxyvitamin D levels Alkaline phosphatase and LFTs Serum createnine and urea Urinary calcium and phosphorus
Risk factors for Rickets
Age 6-18 month Inadequate sunlight exposure Breastfeeding Calcium defiency Phosphate deficiency FH Malabsorption disease Asian. African-Carribean
Risk factors for osteomalacia
Dietary Vitamin D and calcium deficiency
CKD
Limited sunlight exposure
Inherited disorder of Vit D and bone metabolism
FH
Clinical features of Rickets
Bone pain Muscle weakness Stunted growth Bone deformities: bowed legs Dental issues Fracture prone bones
Clinical features of osteomalacia
Vitamin D and Calcium deficient diets Lack of sunlight exposure Fractures Malabsorption syndrome Diffuse bone pain and tenderness Proximal muscle weakness Increased risk of falls
Rx for osteomalacia
Diet rich in calcium and Vitamin D
Vitamin D and calcium supplements
Vitamin D injection
Rx for Rickets
Diet rich in calcium and Vitamin D
Vitamin D and calcium supplements
Vitamin D injection
What is Femoral anteversion
When there is excessive femoral torsion and the femur turns inwards
What does femoral anteversion cause
Intoeing
Ix for femoral anteversion
Hx
O/E
Rx for femoral anteversion
Commonly corrects by itself as child grows
Very rare cases:
Surgery
Clinical features of anteversion
Intoeing
Sitting in W position
Is clubfoot a common or rare birth defect?
Common
Rx for Clubfoot
Ponseti method
Describe ponseti method
Gentle manipulation of the foot
Then putting into a cast
Repeated weekly for 5-8 weeks
Clinical appearance of clubfoot
foot turns medially and is inverted
Is clubfoot associated with limited space in the womb
Yes
Describe a negative trendelenburg test
Normal for pelvis to rise on the side of the lifted leg
Describe a positive trendelenburg test
Pelvis falls on the side of the affected leg
What is the cause of a positive trendelenburg test
Abductor muscle paralsysis
Meaning it cannot pull up the pelvis on the affected side
How to perform tredenelnburgs test
Place hands on either side of the patients pelvis
Use yourself to support the patient
Ask them to raise one leg
Assess to see if the pelvis dips on the side of the lifted leg
What is a chondrosarcoma
malignant tumour of cartilage
Symptoms of chondrosarcoma
Pain (particularly at night)
Mass or swelling
If on axial skeleton:
Sciatica
Bladder symptoms
Where does a chondrosarcoma typically affect
Most commonly axial skeleton compared to the appendicular skeleton
What is the issue with Rx for chondrosarcoma
Relatively insensitive to both chemotherapy and radiotherapy
Main Rx for chondrosarcoma
Surgery
What is the commonest joint disease in Europe
Knee OA
Risk factors for Knee OA
F>M
>55yrs (age)
Trauma to knee
FH
Strong associations for knee OA
obesity/increased BMI
Occupation
Age
Genetics
Symptoms of knee OA
Limited ROM Crepitus Joint deformity Bony overgrowths Swelling Pain on initiating movement Stiffness Morning stiffness often removes <30 mins
Rx for knee OA
NSAIDs Capsaicin Weight loss Exercise Local steroid injections Physio.
Surgery: knee replacement
Causes of rib fractures
CPR
Direct trauma
Coughing
Metastatic cancer
Clinical features of rib fracture
Pain worse on respiration
Sometime bruising on skin
Ix for rib fractures
x-ray
Complications of rib fractures
Pneumothorax
Pneumonia
Rx for rib fractures
No specific Rx
Analgesia
Rest
Ice pack
3-8 weeks to heal
What can chronic osteomyelitis follow
Acute osteomyelitis
Describe de novo chronic osteomyelitis
Never amounts to an acute infection
Moulders unnoticed then presents
Mild bone infection for yrs
Repeated breakdown of healed wounds
Pathology of chronic osteomyelitis
Cavities
Dead bone(retained sequestra)
Involucrum
Histological picture of chronic inflammation
Ix for chronic osteomyelitis
MRI (Dx) FBC WBC ESR CRP U&E's
x-ray CT USS Blood cultures Aspiration Isotope bone scan Labelled white cell scan Bone biopsy
De novo causes of chronic osteomyelitis
Following operation
Following open fractures
Organisms for chronic osteomyelitis
Staph. Aureus
E.Coli
Strep. Pyogenes
Proteus
However, commonly more than 1 organism
Rx for chronic osteomyelitis
Long term abx.
Surgery (surgical debridement)
Amputation not an unlikely scenario
Complications of chronic osteomyelitis
Chronically discharging since + flare ups Ongoing metastatic infection Pathological fracture Growth disturbances/deformities SCC at discharging site Recurrence Amputation
Who is chronic osteomyelitis commonly seen in
Adults
Who is acute osteomyelitis commonly seen in
Children
What is a rotator cuff tear
Tears in supraspinatus tendon
Or adjacent sub-scapularis and infraspinatus
Which is the most commonly affected muscle in rotator cuff tear
Supraspinatus
What are the 2 broad causes of rotator cuff tear
Chronic and cumulative
Acute tear
Describe acute rotator cuff tear
Trauma in younger patient
Describe chronic rotator cuff tear
Degeneration condition
Common elderly
Long term overhead activity
Which is more common acute or chronic rotator cuff tear
Chronic
Clinical features of potato cuff tear
Shoulder weakness
Shoulder pain
Night pain may affect sleep
Lying on affected shoulder
Acute:
Snapping sensation
Immediate arm weakness
Pain same
Ix for rotator cuff tear
O/E Clinical
X-ray
USS
MRI but USS is quicker and cheaper
non-operative Rx for rotator cuff tear
Analgesia: NSAIDs
Steroid injection
Physio.
Operative Rx for rotator cuff tear
Acute, young and active = early surgery
Chronic = surgery if symptomatic (try non-operative first)
What causes painful arc
Impingement syndrome
What is impingement syndrome
When the tendon catches under the acromion during abduction
When does impingement syndrome cause pain
On shoulder abduction
Pathology of impingement syndrome
Caused by a pathology which either:
the volume of the Subacromial space (e.g. OA)
Or
The size of the contents (e.g. Tendinopathy, Bursitis)
Clinical features of impingement syndrome
Pain Painful arch Pain during day to day activities Weakness Decreased ROM Pain at night Can affect sleep
Conservative Rx for impingement syndrome
Rest Avoid precipitating activities Physio. Analgesia Ice Steroid injections
What types of pathology can cause impingement syndrome
Rotator cuff tendinosis
Subacromial bursitis
Calcific tendinitis
OA shoulder
What 2 joints can shoulder osteoarthritis affect
Acromioclavicular
Glenohumeral
Risk factors for shoulder OA
Same as OA
age
Overuse
Shoulder trauma e.g dislocation
Clinical features of shoulder OA
Pain Crepitus Loss or ROM Morning stiffness <30 mins Worse with activity Better with rest Tenderness Joint swelling
Ix for shoulder OA
X-ray
Examination
FBC
Rx for shoulder OA
NSAIDs Physio Analgesia Heat treatment Joint replacement/surgery
Clinical features of olecranon bursitis
Swelling
Redness
Warmth skin
Pain/tenderness
What Ix should you carry out if concerned olecranon bursitis is infected
Joint aspirate
Send for culture an microscopy
Complications of olecranon bursitis
Septic bursitis
Abscess formation
Which 2 types of bursitis is it very important to differentiate between
Aseptic
and Septic
Aetiology of olecranon bursitis
Trauma
Infection
Gout
RA
Rx for septic bursitis
Urgent drainage
IV abx
Rx for aseptic bursitis
Avoid further trauma Rest ICE NSAIDs Corticosteroid injections
What is spinal stenosis
Narrowing of spinal canal which results in compression of the spinal cord and spinal nerves
What does spinal stenosis commonly result from
Degenerative changes in the lumbar spine
Clinical features of spinal stenosis
Unilateral or bilateral leg pain +/- back pain
Sciatica
Relieved by sitting forward
Worse on walking
Claudication type pain
Weakness at and below level affected
Numbness at and below level affected (paraesthesia)
Risk factors for spinal stenosis
OA/degenerative arthritis Age Manual labour FH Trauma Space occupying lesion Smoking
Ix for spinal stenosis
X-ray
MRI
Consider:
CT pyelogram
CT spine
EMG walking test
What will x-ray show in spinal stenosis
Degenerative changes Overgrowth of the facet joints
Narrowing of the disc spaces
Osteophyte formation.
Non-operative management of spinal stenosis
Education
Analgesia
Exercise
Physio.
Nerve root injection
Epidural injection
Why does leaning/sitting forwards relieve spinal stenosis
Increased intervertebral space
Other Rx for spinal stenosis
Nerve root injection
Epidural steroid injection
Red flags for spinal stenosis
Fever Nocturnal pain Weight loss Previous carcinoma Recent trauma Neurological deficit Bilateral sciatica + Saddle Anaesthesia _ urinary/bowel incontinence
What Rx is required in acute spinal stenosis with acute neurological deficit
Urgent surgical review and decompression
What is cervical spondylosis
Specific term for OA of the cervical spine
