MSK problems Flashcards
Possible causes of acute lower back pain?
Acute lower back pain • Mechanical, simple back pain • Nerve root pain • Possible serious spinal pathology • Suspected cord compression • Sciatica - lumbar disc prolapse
Pathophysiology of cauda equina?
What are the red flags for cauda equina syndrome?
CAUDA EQUINA (spinal cord ends at L1)f -Compression of nerves at bottom of spinal cord leads to damage
Symptoms
- Back pain
- Leg weakness
- Altered peri-anal or perineal sensation = saddle anaesthesia
- Loss of bladder/bowel control
What are the red flags for metastatic spinal cord compression?
Red flags of MSCC
• Back pain worse on coughing and lying flat
• Leg weakness
• Bowel/bladder dysfunction
•Reflexes - increased below compression, absent at level of compression, normal above level
(Cauda equina will normally have reduced reflexes)
What are the red flags for ruptured AAA?
Red flags for ruptured AAA
• Central umbilical pain radiating to the back
• Expansile and pulsatile central abdominal mass
• Hypotensive/collapse/shock
• Bruising
• Acute unwell
What must you include in your examination of someone presenting with acute back pain?
Acute back pain
- Gait assessment
- Spine examination
- Peripheral nerve examination
- Peripheral vascular examination
- Abdominal examination
- Rectal examination
How can you examine for nerve root pain?
Femoral stretch test for femoral nerve irritation (L2-L4)
Straight leg test for sciatica (L4 to S3)
What is the main cause of sciatica?
Lumbar disc prolapse
When is an X-Ray indicated for back pain?
Over 55 Systemically unwell History of trauma History of malignancy Infection HIV suspected
What is the management for suspected cord compression?
16mg dexamethasone + PPI
Urgent MRI
Urgent neuro/oncology referral
What are the most common distal radial fractures? What most commonly causes them?
Colles’ - falling on outstretched/extended hand (FOOSH)
Smiths’ - falling on flexed wrist
** check for ulnar styloid fracture in both
What is smiths fracture?
Radia fracture
-DISTAL part moves VOLAR (palmer)
How will Colles fracture present?
- Pain
- Dinner fork abnormality
- Tender and swollen (check pulses)
Investigations of Colles fracture and what is seen?
Wrist X-Ray
-EXTRA ARTICULAR fracture with DORSAL DISPLACEMENT (of the DISTAL radius- making dinner fork shape)
Acute managment of Colles fracture?
Longer term managment of Colles fracture?
Colles fracture
- Analgesia (heamatoma block +gasonair)
- Closed reduction (pull on it)
- Immobalise with Below elbow backslab or POP
- Elevate (sling)
- X ray to check position and check for ulnar styloid fracture
Longer term
- change to cast (6-8 weeks) once swelling reduces
- *Arrange fracture clinic follow up
- Advice patient to keep moving their thumb, elbow and shoulder
Complications of colles fracture?
Complications of colles fracture
- Median nerve injury (can abduct thumb)
- Carpal tunnel syndrome
- Osteoarthritis
- Reflex sympathetic dystrophy (Sudek’s atrophy) – refer to physio (long lasting pain disorder)
When is MUA urgent in a distal radius fracture?
Compound fracture
Nerve compression
On a lateral hip X-ray, what indicates a fractured neck of femur?
Interrupted Shenton’s line shows fractured NOF (imaginary curved line drawn along inferior border of superior pubic ramus to inferomedial border of neck of femur)
What is the most common type of shoulder dislocation?
What mechanism of injury causes this?
- Anterior dislocation is most common (95%)
- Blow to an abducted, externally rotated and extended extremity
- Can also be caused by force/trauma to posterior arm or FOOSH
Who does anterior dislocation most commonly affect?
What are complications of anterior dislocation in older patients (40 years)
Young males playing contact sports
Elderly patients falling on outstretched hand
Avulsion injruies/rotator cuff injuries common in older patients (MRI or USS)
What causes a posterior shoulder dislocation?
Posterior shoulder dislocation
- Trauma to anterior shoulder
- Fall onto stretched out internally rotated arm
What mechanism of injury is associated with posterior shoulder dislocation?
What does it look like on Xray?
Posterior shoulder dislocation
- Epileptic seizures
- Electrical shocks
- Direct blow during trauma
Light bulb sign on X ray
What is found on examination of anterior shoulder dislocation?
- Loss of shoulder contour - flattening of deltoid
- Anterior bulge from head of humerus- visable/palpable
- Step-off deformity at acromion with palpable gap below acromion
- their arm will probs be slightly abducted
- may also show damage to axillary nerve (sensation badge area and abduction arm)
How can you test for injury to the axillary nerve?
- Loss of sensation over lateral shoulder (badge area)
- Lack of contraction of deltoid during attempted abduction
How can you assess the radial nerve?
- Weakness of wrist extension
- Reduced sensation on dorsum of hand
- Abnormal triceps and brachioradialis reflexes
What might occur at the same time as an anterior shoulder dislocation?
Fracture of the humeral head, neck or greater tuberosity
What changes are seen on an X-Ray in anterior shoulder dislocation?
- Humeral head lies inferior to coracoid process on AP view
- Head of humerus anterior to glenoid on axillary view
What is the most common method to manipulate an anterior shoulder dislocation?
External rotation method
• Patient SUPINE on bed
• Affected arm is ADDUCTED and flexed to 90 degrees at the elbow
• Arm is slowly EXTERNALLY ROTATED
The shoulder should be reduced before reaching the coronal plane
What is the managment of anterior shoulder dislocation?
Anterior shoulder dislocation
- MUA to muscle relax (midazolam +/- propofol)
- Re Xray
- Physio
- Immoblisation (broad arm sling)
What are the two joints in the ankle and what movements do they facilitate?
True ankle joint
- Tibia, fibula, talus
- Facilitates dorsi/plantarflexion
Subtalar joint
- Calcaneus + talus
- Facilitates eversion/inversion
What is an ankle sprain?
What mechanism of injury usually occurs?
What ligament usually affected?
- Injury of ligaments
- Inversion injury (85%)
- most common injury site: lateral malleolus (Lateral joint capsule + anterior talofibular ligament)
How does an ankle sprain present?
If the patient had numbness/tingling after a sprain what would you think?
Ankle sprain
- tenderness and swelling
- bruising
- functional loss e.g. pain on weight bearing
- mechanical instability if SEVERE
*extensive bruising/swelling suggests ligament tear or fracture
Peroneal nerve injury (common) → ↓sensation over dorsum and lateral leg and ankle → ↓ proprioception at ankle joint
Investigations for ankle sprain?
- Bedside-examination – examine from knee down for tenderness over proximal fibula, lateral + medial malleolus and ligaments, Navicular, calcaneus, Achilles tendon, 5th metatarsal base
- Do Ottowa ankle rules to determine if X-ray is required
How can you manage a simple ankle sprain?
Managment if unable to weight bare?
POLICE -Protect from further injury -Optimal loading(gentle movements and weight bare when symptoms allow) -Iceand analgesia -Compression -Elevationabove hip level **Full recovery can take a month and advise to come back if not weight bearing after 4 days*
If unable to weight bare
- Crutches
- Below knee cast – 10 days for immobilisation
- OPD follow up
What are the 1st, 2nd, 3rd degree ankle sprains
Classified by severity of damage to ligaments
1st deg = damage to a few ligament fibres
2nd deg = significant damage to lig, but still intact
3rd deg = rupture of lig
Complications of ankle sprains?
Complications of ankle sprains
-Weakness and instability – related to↓ankle proprioception due prolonged immobilisation → recurrent sprains
Peroneal tendon subluxation – reflects torn peroneal retinaculum → perineal tendon to slip anteriorly
- Clicking or Slipping sensation
- Movement of ankle → subluxation
- Refer to orthopoedics
Differentials for ankle sprain
Ankle fracture or dislocation
What are the Ottawa ankle rules?
What do they indicate?
Ottawa ankle rules are used to determine if x-ray is required to exclude fracture:
ANKLE X-RAY indicated if any of the following
• Tenderness over posterior edge of lateral or medial malleolus
• Unable to weight bearimmediately after AND now
FOOT X-ray indicated if any of the following
• Tenderness in base of 5th metatarsal
• Tenderness at navicular bone
• Unable to weight bearimmediately after AND now
Initial managment of NOFF?
Managment of NOFF
ABCD(hypothermia) E assessment
IV access
- Bloods - FBC, U+Es (AKI), CK (could be lying for ages), glucose, crossmatch to prepare for surgery
- IV fluids if hypotension/dehydrated
- IV morphine (titrate up) + antiemetic
- ECG (look for arrhythmias/MI, may explain fall)
Additional
- Femoral nerve block (women in AndE)
- Lateral hip X-ray (repeats/MRI may be needed if cant see)
- Refer to orthopaedic surgery
- May need to realign or apply splint in the mean time
What is the surgical treatment for patients with OA and severe refractory pain?
Surgical (if significant impact on QofL and refractory to non surgical treatment)
Knee – Arthroscopic knee lavage ± debridement
Hip – total hip replacement (end stage OA). This can be cemented/non cemented/hybrid
What are the long term complications of this hip replacement?
Long term
- Aseptic loosening
- degeneration artificial socket
- hip dislocation
- revision (1 in 8 require revision in 10 years
Who are distal radial fractures most common in ?
Osteoporotic post-menopausal women get distal radial fractures
