MSK wk 3 Flashcards
What are the consequences of childrens’ ligaments being stronger than the growth plates?
Easy to produce epihyseal separation
Difficult to dislocate or sprain
What are the consequences of young bones being more porous?
Tolerates for deformation
Fails in compression as well as tension
(Buckle + green stick fractures)
What are presenting parental concerns in children development?
In or Out-toeing Bow legs Kock knees Flat/curved feet Curly toes Tiptoe walking
What is the david jones system?
Symetrical Symtomatic Systemic illness Skeletal dysplasia Stiffness
What is a slipped upper/capital femoral epiphysis?
Posterior medial displacement of proximal femoral epiphysis in relation to neck
Normally in the widened zone of hypertophy in physis
Who is likely to get a slipped upper/capital femoral epiphysis?
Range 9-16 yrs
Boys more than girls
Girls often earlier peack age
What can cause a slipped upper/capital femoral epiphysis?
Idiopathic (adolescence, increased weight, delayed bone age) Secodnary to underlying disorder Ie hypothyroidism Hypogonadism Renal osteodystophy Growth hormone therapy
What is the presenting history of a slipped upper/capital femoral epiphysis?
Pain in groin/knee/thigh
Lip
Trauma
ER deformity
What is seen in the physical exam of a slipped upper/capital femoral epiphysis?
Look at body habitus (general physique)
Externally rotated extermity
Obligatory external rotation in flexion
ROM limited by pain
What is the radiological investigation into a slipped upper/capital femoral epiphysis?
X-ray in frog lateral position
If positive urgent review
What infections can cause limping in children?
Septic arthtis
Osteomyelitis
Transient synovitis
Muscle abscess
What is the history of an infection causing limp?
Pain (Limp) General maliase Increased temp Trauma? Psuedoparalysis Recent URTI Listen to parent - normally right
What is the examination process if infection is suscpeted in limping child?
Do they look sick
Is there a refusal to weight bear?
What movements hurt most on hip movement?
Upper limb dissuse?
What are the initial investigations into a limping child with suspected infection?
Temperature
X-ray?
Bloods - WCC, CRP, ESR, CK + cultures
What is the presentation of septic arthritis?
Limping Pseudoparalysis Swollen, red joint Refusal to move said joint Pain + temperature Most common in hip + knee
How should you investigate septic arthrtis?
FBC, ESR, CRP
blood cultures (usually staph A)
US!
Synovial fluid asporation - gramstain + culture
How do you treat septic arthrits?
Aspiration
Athroscopy
Arthrotomy
Antiobiotics IV
What are the risk factors for osteomyelitis?
blunt trauma
Recent infection
What is teh pathogenesis of acute haemotgenous osteomyelitis?
Vascular loops with terminal braches
Inhibited phagocytosis (due to low pO2)
Trauma
Rare in adults
What are the indicatins for surgery in osteomyelitis?
When any of the following need to be carried out Aspiration for culture Drainage of subperiosteal abscess Drainage of joint sepsis Debridement of dead tissue
What are the symptoms of transient synovitis?
Limping, often touch weight bearing Slightly unwell History of viral infection (URTI/ear) Apyrexial Allows joint to be examined Low CRP, normal WCC May have joint infusion Not that unwell
What are the most common shoulder or elbow injuries in teens/20s?
Fractures + instability
What are the most common injuries to shoulder and elbow in people in 30s-40s?
Rotator uff muscle injury
Capsulitis
What are teh most common injuries t the shoulder/elbow in the 50s/60s age group?
Impingement of AC joint
What is the most common injury of shoulder and elbow of 70s+?
Degnerative rotator cuff and joint
What is the epideimiology of UL fractures int eh varying age groups?
Young - high energy fracture
Elderly - osteoporotic
What is the likelyhood of an anterior shoulder dislocation?
90%
What is subacromial impingement?
Pain/dysfunction from any pathology which
Decreases volume of subacromial space
Increases size of contents
How do you treat subacromial impingenment?
Subacromial steroid injection
Physio
Arthroscopic subacromial decompression
How do you diagnose frozen shoulder (adhesive capsulitis)?
Clinical
X-ray
How do you treat a frozen shoulder?
If early - steroid injection
Iflater - surgery
What are the symtpoms of frozen shoulder?
First 0-9 months pain
Stiffness from about 4-5 months
And then thawing
Can last up to 18-24 months
What are the types of rotator cuff tears?
Traumatic
Degenerative
How do you treat rotator cuff tears?
Acute - early surgery
Chronic degnerative - surgery if symptomatic
Depends on size, time and age
What are the types of shoulder arthritis?
Osteoarthritis
Inflmammatory arthritis
Post traumatic arthritis
What are the common elbow pathologies?
Fractures/dislocations in young
Tendinopathies middle age
Degenerative disease in elderly
Cubital tunnel syndrome any age
What are the main nerves that get effected by ner palsies?
Ner roots
Brachial plexus
Sacral + lumbar plexus
Peripheral nerves
What is hilton’s law?
Nerves crossing a joint supply both the joint and the musles acting on it
What are the types of palsies that can affect the brachial plexus?
Erb’s palsy
Klumpke’s palsy
Total brachial plexus palsy
What are the roots of the main myotomes? (UL)
C5 - elbow flexors C6 - wrist extensors C7 - Elbow extensors C8 - Finger extensors T1 - Intrinsic hand muscles
What are the roots of the main myotomes of the LL?
L2 - hip flexors L3 - knee extensors L4 - Ankle dorsiflexors L5 - Long toes extensors S1 - Ankle plantar flexors
What can cause an axillary nerve palsy?
Shoulder dislocation
Fracture surgical neck of humerus
What are the symptoms of radial nerve palsy?
Dependant on site of lesion Wrist - loss of sensation Forearm - loss of finger extension arm - loss of wrist extension Axilla - kiss if elbow extension
What can cause carpal tunnel syndrome?
Trauma (distal radius fracture)
Swellings (ganglion, fibroma, lipoma)
Inflammatory (rhuem, gout, TB, amyloid)
Metabolic - pregnancy, hypothyroidism, mucopolysaccharidoses
What are the symptoms of carpal tunnel syndrome?
Nocturnal pain + parasethesia in median nerve
Wasting of thenar muscles
What is cubital tunnel syndrome?
Nerve entrapment (second most common)
Cubital tunnel between medial epicondyle and olecranon
Numbness on ulnar side of hand + difficulty with fine tasks
What are the symptoms of ulnar nerve palsy?
Wasting of muscles - 1st webspace
Guttering
Hypothenar wasting
Claw hand - Yperextenstion at MCP and flexion at ICJ
What is the ulnar paradox?
Distal lesion has a worse clawing than proximal lesion
Due to intact long flexors with distal lesion
What is forment’s test?
Get patient to hold sheet
If ulnar not working then thumb is bent
If negative thumb flat against 2ns digit
What is meralgia parasthetica?
Altered sensation + pain in lateral thigh
Compression of lateral femoral cutaneous nerve as travels under lateral border of inguinal ligament
What is the sign of common peroneal nerve palsy?
Foot drop
Slapping gait
What type of joint is the intervertebral disc?
Secondary cartiliginous
What makes up the intervertebral discs?
Annulus fibrous (outer layer - very tough) Nucleus pulpous - gelatinous core
When do discs fail?
Twisting movement
What direction do discs normally fil?
Posteriolateral
What are the degenerative pathological processes of the spine?
Tearing annulus fibrosis + protrusion of nucleus Nerve root compression by osteophytes Central spinal stenosis Abnormal movement (spondylosis + spondylodesis)
What are the presenting features of nerve root pain?
Limb pain worse than back pain Pain in a radicular distribution (like nerve root) Root tension signs Root compression signs Affected dermatomes/myotomes
How do you manage nerve root pain?
Physio
Strong analgesia
Most settle within 3 months
Refer for MRI after 12 weeks
What are the types of prolapse possible?
Bulge (common and mostly asymptomatic)
Protrusion (annulus intact but weakened
Extrusion (through annulus but intact
Sequestration (dessicated material inside spinal canal)
What is the most common cervical disc prolapse?
C5/6
What are the most common thoracic disc prolapse - how common are tehey overall?
Less than 1% of all prolapses
Most at T11-12
75% from T8-12
What are the most common lumbar prolapses (and direction)?
Normally L4/5 (45%)
L5/S1 - 40%
L3/4 - 10%
Most posteriolateral as posterior longitudinal ligamnet weakest
What is the loss at L5/S1 prolapse?
Little toe + sole of foot sensory loss
Motor weakness in plantar flexion foot
Ankle jerk reflex change
What is the loss at L4/L5 prolapse?
Great toe + 1st web space sensory loss
Extensor hallucis longus weakness
No reflex changes
What is the loss at L3/L4 prolapse?
Medial aspect of lower leg sensory loss
Quadriceps weakness
Knee jerk reflex change
What are the symptoms of cauda equina syndrome?
Bowel/bladder dysfunction
Saddle anaesthesia, loss of anal tone/reflex
Urinary retention
Leg weakness
What is spondylosis?
A coomon disease; effectively osteoarthritis
Degenerative changes at facet joints, discs + ligaments
Can sometimes cause myelopathy if severe
What are the ligaments of the spine?
Anterior longitudinal ligament Posterior longitudinal ligament Ligamentum flavum Interspinous and supraspinous ligaments Intertransverse ligament
Where do the longitudinal ligaments of the spine run?
Anterior - front of vertebral bodies (broad and strong)
Posterior - along back of vertebral bodies (narrower)
Where does the ligamentum flavum run?
Between laminae
Where do the inter/supraspinous ligaments run?
Between the spinous processes
Where do the intertransverse ligaments run?
Between transverse processes
How is spinal cluadication distinguished from vascular claudication?
Spinal claudication:
Usually bilateral Sensory dysaethesaie Poss weaknss (foot drop) Several minutes to ease after walking Worse walking down hills because spinal canal becomes smaller in extension Beter riding uphill/riding bicyles
What are the types of spinal stenosis?
Lateral recess stenosis
Central stenosis
Foraminal stenosis
How do you treat lateral recess stenosis/foraminal?
Non-operative measures
Nerve root injection
Epidural injection
Surgery
How do you treat central stenosis?
Non-op meausres
Epidural steroid injection
Surgery (80% improve)
What is an injury?
Physical damage or harm caused by accident or by an attack
Damage due to application of mechanical force
How are injuries classified?
By appearance/causation
Abraison, contusion, laceration, incised wounds
Gunshot wounds, burns etc
Manner of causation - suicidal, accidental etc
Nature - blunt force, sharp force explosive etc
What are blunt force injuries?
Caused by impact with blunt objects Can be: Contusions (bruises) - Abraisons (graze/scratch) Lacerations (cut/tear)
What affects the prominence of bruises?
Skin pigmentition Depth + location (mostly over loose skin) Fat - more subcut fat more bruses Age - children + elderly Coagulative areas
What are the resilient areas to brusing?
Buttocks
Abdomen
What is a sharp force injury + types?
Injury iwth any sharp cutting edge
Incision
Stab wound
What are passive defensive injuries?
Victum raises arms/legs for protection
Sliced, shelved often with skin flaps of hands and forearms (sharp weapon)
What are active defensive type injuries?
Victum trying to grab weapon or attackers hand
Sliced shelved incised wounds on palmar aspect of hand + web spaces
What is the pattern to self inflicted injuries?
Commonly sharp force
Site tends to be wrist/forearms, chest and abdomen
Often parallel with multiple and tentative incisions
What do the consequences of injury depend on?
Type of mechanical insult
Nature of targeted tissue
Forces involved
Number of impacts
What are the symptoms fo blood loss from brain?
35ml - symptomatic
40-50ml - clinical deterioation, life threatening
80-100ml - commonly fatal due to herniation and raised ICP
150ml - fatal
What causes a traumatic subarachnoid haemorrhange?
Rapid rotational movement of head - usually result of single punch to jaw/upper part of neck/side of head
Sudden unexpected twisting movement
Traumatic rupture of vessels at base of brain
Immediately unconious and in cardiac arest
What are the types of diffuse brain injury?
Diffuse axonal (clinical term) - immediate and prolonged coma with no mass lesion/metabolic abnormality
TIA
Traumatic axonal injury (pathological term) - damage due to trauma
What is a contusion?
Bruises
burst vessels in skin
What are teh types of skull fractures?
Linear (little force i.e falling)
Depressed (against protrusion i.e weapons hammer etc)
Ring fractures - higher force (high storey land on feet)
What is an abrasion?
Abraisons (graze/scratch) - scraping of skin surface
What is a laceration?
Lacerations (cut/tear) - tear/split due to CRUSHING
What is an incised wound (inscision)?
Incised - superficial, slashing - longer than deep
What is a stab wound?
Stab wound - penetrating from thrusting motion
Depth greater than length
What causes an extradural haemorrhage?
Rupture of meningeal artery
Bleeding in space outside dura
What causes a subdural haemorrhage?
Breaking of bridging veins
Lucid injuries - slow progression
