Musculoskeletal and Neurology Flashcards
1
Q
Key ortho history elements
A
- pain
- loss of function
- stiffness
- deformity
- swelling
2
Q
Muscle groups for hip movement
A
- Flexion: iliopsoas, rectus femoris, tensor fascia lata, quad
- Extention: Gluteus maximus and hamstrings
- Abduction: Gluteus medius and minimus
- Adduction: Adductors (longus, brevis, magnus)
- Internal rotation: Gluteus medius, minimus, iliopsoas
- External rotation: Gluteus maximus
3
Q
How should suspected hip OA be investigated?
A
- Bloods: FBC, U+Es, LFTs, ESR, RhF, ANA
- AP + Lateral X-rays of hip and pelvis
4
Q
X-ray features of hip OA
A
- Loss of joint space
- Osteophyte formation
- Subchondral sclerosis
- Subchondral cysts
5
Q
Hip OA treatment
A
- lifestyle mods: diet, exercise, weight loss
- physiotherapy
- OT: mobility aids and advice
- analgesia: WHO pain ladder
Surgical options - osteotomy
- arthroplasty
- arthrodesis
6
Q
Indications for total hip replacement
A
- instability
- severe pain or disability not relieved by non-surgical options
- rest pain or pain with movement
- loss of mobility
7
Q
Complications of total hip replacement
A
- Intraoperative: # of acetabulum or femur
- Immediate: dislocation (malalignment), damage to local structures
- Early: DVT, PE, sciatic nerve palsy, infection, fat embolism
- Late: infection, loosening, heterotopic ossification, leg-length discrepancy, periprosthetic #, thigh pain
8
Q
How to prevent total hip replacement postop DVT?
A
Prevention impossible
- pre-op: TEDs, optimise hydration
- peri-op: TEDs, compression boots, minimise length of surgery
- post-op: LMWH, early mobilisation with physio and maximise analgesia, optimise hydration
9
Q
Knee OA treatment
A
- lifestyle mods: diet, exercise, weight loss
- physio: strengthen quads
- OT: mobility aids, advice, elastic support
- Analgesia: WHO pain ladder
- Intra-articular steroid injections: temporary relief, if repeated causes cartilage and bone destruction
- Viscosupplementation: hyaluronic acid
Surgical - arthroscopic debridement + washout
- Patellectomy: PFOA
- Realignment osteotomy:
10
Q
Complications of total knee replacement
A
- Intraoperative: # tibia or femur
- Immediate: vascular injuries
- Early: DVT, PE, peroneal nerve palsy, infection, fat embolism
- Late: infection, loosening, patellar instability/#, periprosthetic #s
11
Q
Clinical features of knee RA
A
Stage 1 - proliferative: effusions, thicken synovium, stable joint
- Stage 2 - destructive: instability, muscle wasting, reduced movement range
- Stage 3 - reparative: severe pain + instability, fixed flexion + valgus
12
Q
Surgical options for knee RA
A
- Synovectomy + debridement: for failed medical treatment
- Supracondylar osteotomy: if knee stable + pain-free but valgus + flexion deformity
- Total knee replacement: for advanced joint destruction
13
Q
Dupuytren’s contracture differential
A
- skin/scar contracture
- tendon contracture: moves on passive flexion
- congential contracture: PIPJ little finger
- ulnar nerve palsy: ring and little fingers hyperextended MCPJ, flexed PIPJ
14
Q
Conditions associated with Dupuytren’s
A
POTFACED Peyronie's Occupation Trauma Familial Alcohol Cirrhosis Epilepsy meds Diabetes
15
Q
Surgical options for Dupuytren’s
A
When MCP joint bent forward at 30-45 and cannot be straighted; or PIPJ bent permanently at 10-20
- fasciotomy
- fasiectomy (zigzag incision to prevent volar contracture)
- dermatofasciectomy
- arthrodesis/amputation
16
Q
Causes of carpal tunnel syndrome
A
- idiopathic
- anatomical abnormalities: bone (wrist #s, acromegaly), soft tissues (lipoma, ganglia)
- physiological abnormalities: inflammatory (RA, gout), fluid balance (preg, meno, hypothyroid, obesity, amyloid, CRF), neuropathic (DM, alcoholism)
MEDIAN TRAPS Myxoedema Enforced flexion Diabetes neuropathy Idiopathic Acromegaly Neoplasms Tumours - lipoma, ganglion RA Amyloidosis Pregnancy/Premenstrual oedema Sarcoidosis
17
Q
Non-surgical option for Dupuytren’s
A
- If no contracture yet, watch and wait or corticosteroid injections (triamcinolone acetonide)
- radiotherapy
- injectable collagenous Clostridium histolyticum
18
Q
Carpal tunnel treatment
A
- remove underlying causes
- splint wrists as night
- proximal steroid injections
- carpal tunnel decompression (flexor retinaculum division)
19
Q
Complications of carpal tunnel decompression
A
- scar formation (keloid/hypertrophic)
- scar tenderness
- wound infection
- nerve injury: palmar cutaneous branch + motor branch to thenar muscles
- failure to relieve symptoms (incomplete division)
20
Q
Boundaries of carpal tunnel
A
- ulnar aspect: pisiform + hook hamate
- radial aspect: scaphoid + trapezium
- volar aspect: transverse carpal ligament
21
Q
Where else can median nerve be compressed?
A
- pronator syndrome: ligament of Struthers, pronator teres or flexor digitorum superficialis
- anterior interosseous syndrome: branch at deep head of pronator teres. Supplies flexor pollicis longus, pronator quadratus, radial FDP (weak OK sign) NO sensory signs
22
Q
Extra-articular manifestations of RA
A
- Opthalmic: episcleritis, scleritis, keratoconjuctivitis sicca
- Respiratory: effusions, fibrosis
- Cardiac: pericarditis
- Reticuloendothelial: lymphadenopathy, splenomegaly, felty’s
- Neurological: carpal tunnel, multifocal neuropathies
- Vascular: Vasculitis
23
Q
Investigations to confirm RA
A
- FBC: anaemia chronic disease
- ESR
- RhF + in 75%
- Anti CCP + 70%
- HLA-DR3/DR4 in 1/3
- ANA + in 30%
- X-rays
24
Q
Radiological stages of RA
A
Stage 1 - soft tissue swelling, periarticular osteoporosis
Stage 2 - joint space narrowing, small periarticular erosions
Stage 3 - marked articular destruction
25
Treatment of hand OA
- physio to maintain function
- analgesia: WHO ladder
- arthrodesis: trapeziectomy for thumb CMCJ OA
- arthroplasty: rare
- arthrodesis: if joint unstable or very painful
26
Which joints in hands often affected by OA?
- DIPJ: Heberden's nodes
- PIPJ: Bouchard's nodes
- CMCJ: 'square hand'
27
Ulnar nerve palsy causes
- Anatomical: cubital tunnel syndrome at elbow
- Trauma: anywhere along nerve, supracondylar #s, elbow dislocations
- Degenerative arthritis: compression from synovitis, osteophytes
- Rare: compression from fascia, ligaments, tumours, aneurysms, anatomical variants
28
How do you clinically differentiate between high and low ulnar nerve lesion?
- Low (below elbow): marked clawing as FDP to ring and little fingers still functioning
- High (above elbow): less marked clawing as paralysis of FDP (ulnar paradox). Also decreased sensation over ulnar border of hand
29
Ulnar nerve palsy treatment
Non-surgical
- for mild, intermittent symptoms, avoid prolonged and repetitive flexion, night splints in extension
Surgical
- for persistent, significant symptoms or neuro deficit
- ulnar nerve decompression (roof of cubital tunnel)
- ulnar nerve anterior transposition
- medial epicondylectomy
30
1 investigation for hallux valgus
Plain weight bearing x-rays to assess
- degree of valgus deformitiy
- 1st/2nd intermetatarsal angle and distal metatarsal angle
- presence of OA in 1st MTPJ
31
Aetiology of hallux valgus
- essentially unknown
- strong familial trait
- associated with enclosed footwear
- associated with RA
- can be secondary to prior deformity
32
Treatment options for hallus valgus
```
Non-surgical
- appropriate footwear (wide, soft)
- physiotherapy
Surgical
- Bunionectomy
- 1st metatarsal realignment osteotomy
- excision arthroplasty (Keller's procedure)
- Fusion: for degenerative joint disease
```
33
Aetiology of hammer toes?
- imbalance between intrinsic (lumbricals + interossei) and extrinsic (long flexors + extensors) muscles of lesser toes
- Commoner in females, elderly, RA
34
Hammer toes treatment
- appropriate footwear
Surgical
- Mobile deformity: flexor-to-extensor tendon transfer
- Fixed deformity: partial or total proximal phalangectomy +/- flexor extensor release, or PIPJ arthrodesis
- Painfull callosities: terminal phalangectomy
35
Aetiology of mallet toes?
- imbalance between intrinsic (lumbricals + interossei) and extrinsic (long flexors + extensors) muscles of lesser toes
- Commoner in females, elderly, RA and DM with peripheral neuropathy
36
Mallet toes treatment
- appropriate footwear
Surgical
- Mobile: flexor digitorum longus tenotomy
- Fixed: flexor tenotomy + middle phalangeal head + neck resection, or DIPJ fusion, or terminal phalanx amputation
37
Aetiology of claw toes?
- imbalance between intrinsic (lumbricals + interossei) and extrinsic (long flexors + extensors) muscles of lesser toes
- Commoner in females, elderly, RA
- May be secondary to peripheral neuropathy (DM, CMT), LMN (poliomyelitis), or UMN (cerebral palsy, MS, stroke)
38
Claw toes treatment
- appropriate footwear
Surgical
- Mobile: flexor-to-extensor transfer
- Fixed: partial proximal phalangectomy +/- flexor extensor release, or extensor tenotomy, or metatarsal head resection
39
Aetiology of mallet finger
- damage to extensor tendon to terminal phalanx +/- avulsed bone fragment
- from forced flexion, usually catching a ball
40
Acute management of mallet finger
- x-ray to exclude #
- mallet splint for 6 weeks with DIPJ in extension
- if avulsed bone >1/3 width joint, reposition with Kirschner wire
41
Aetiology of trigger finger
aka stenosing tenosynovitis: fibrosis + thickening of flexor tendon sheath as tendon enters digit
- idiopathic
- trauma
- congenital
- RA (similar)
42
Trigger finger treatment
- steroid injection of nodule
| - tendon release by incising sheath
43
Treatments for ingrowing toenails
- good nail care, chiropodist, transverse trimming, cotton wool to lift up nail, keep foot clean and dry
- simple nail avulsion: best for acute infection, reduces risk of osteomyelitis but likely recurrence
- wedge excision of nail and nail-bed down to periostum
- Zadek's procedure: total excision of nailbed including germinal matrix
44
Complications of ingrowing toenail surgery
- infection
- regrowth
- osteomyelitis
- septic arthritis
45
Causes of knee haemarthrosis
```
Primary spontaneous haemarthrosis
- without trauma
- may be secondary to coagulation disorder or vascular malformations
Secondary haemarthrosis
- secondary to trauma
- 80% ACL
- 10% patellar dislocation
- 10% tears in peripheral vascularised third of menisci, capsule, or osteochondral/osteophyte #s
```
46
History factors suggesting ACL injury
- valgus/external rotation, hyperextension, deceleration, rotational movements
- audible 'pop' or feels something tear
- inability to continue
- effusion within 4-6 hrs
47
Problems associated with ACL rupture
- meniscal tears
- collateral ligament injur
- progressive premature OA
48
How do you treat a meniscal tear?
```
Depends on age, chronicity, activity, location, type, length.
- symptomatic only
Arthroscopic or open:
- partial meniscectomy
- meniscal repair
- meniscal transplant
- meniscal replacement
```
49
Anatomy of medical meniscus
- semicircular
- anterior horn attaches to anterior intercondylar fascia of tibia
- posterior horn attaches posteriorly to intercondylar fascia
- bound to joint capsule peripherally
- bound to femur and tibia at midpoint by deep medial collateral ligament
50
Anatomy of lateral meniscus
- nearly circular
- covers greater area than medial menicus
- anterior horn attaches to tibial eminence
- posterior horn attaches behind tibial eminence
- loosely attached to tibial plateau by coronary ligament
- bound to medial meniscus via transverse ligament
51
Anatomy of ACL
- intracapsular
- originates from medial aspect of lateral femoral condyle
- inserts into anterolateral aspect of medial tibial plateau
- stops tibia moving forward in relation to femur
- consists of two bundles, anteromedial + posterolateral
52
Anatomy of PCL
- intraarticular but extrasynovial
- broad origin on lateral aspect of medial femoral condyle
- inserts inferior to articular surface between medial and lateral tibial plateaus
- stops tibia moving backwards in relation to femur
- two components, anterolateral group, anteromedial group
53
How to treat ACL ruptures?
Non-surgical
- intensive physiotherapy focusing on quads and hamstrings
Surgical
- intraarticular reconstruction: autologous hamstring tendon or bone-patellar tendon-bone graft
- extraarticular reconstruction: MacIntosh tenodesis
- combination of above
54
Causes of a locked knee
```
osteochondritis dissecans
meniscal tear
cruciate ligament injury
loose body
osteochondral #
intraarticular tumour (rare)
```
55
Causes of a radial nerve lesion
- High (brachial plexus): crutches, saturday night palsy
- Mid (radial groove): humerus #, tourniquet
- Low (elbow): wounds, surgery, #, dislocation. Only posterior interosseus branch involved = loss of MCPJ extension only
56
Causes of a painful shoulder
- Tendon (rotator cuff) disorders: tendinitis, rupture, frozen shoulder
- Joint disorders: glenohumeral arthritis, ACJ arthritis
- Referred pain: cervical spondylosis, cardiac ischaemia, mediastinal pathology
- Instability: dislocation, subluxation
- Bone lesions: infection, neoplasm
- Nerve lesions: suprascapular nerve entrapment
57
Aetiology of rotator cuff impingement
- repetitive rubbing of tendons under coracoacromial arch
- worse in 'impingement position' abduction, slight flexion, internal rotation
- critical area of poor vascularity in supraspinatus tendon
- contributing factors: ACJ osteophytes, rotator cuff swelling, subacromial bursitis
58
Impingement syndrome treatment
- avoid aggravating activity
- physiotherapy
- short course NSAIDs
- subacromial corticosteroid injections
- open or athrhoscopic subacromial decompression
59
Rotator cuff tear treatment
- physio to improve shoulder strength
- open or arthroscopic cuff repair and subacromial decompression
- open or arthroscopic cuff debridement (if unable to repair) and subacromial decompression
60
L3 nerve root compression
- Sensory loss over anterior thigh
- Weak quadriceps
- Reduced knee reflex
- Positive femoral stretch test
61
L4 nerve root compression
- Sensory loss anterior aspect of knee
- Weak quadriceps
- Reduced knee reflex
- Positive femoral stretch test
62
L5 nerve root compression
- Sensory loss dorsum of foot
- Weakness in foot and big toe dorsiflexion
- Reflexes intact
- Positive sciatic nerve stretch test
63
S1 nerve root compression
- Sensory loss posterolateral aspect of leg and lateral aspect of foot
- Weakness in plantar flexion of foot
- Reduced ankle reflex
- Positive sciatic nerve stretch test
64
Colles' Fracture features
1. Dorsal displacement of distal fragment
2. Radial displacement of hand
3. Radial shortening
4. Avulsion of ulnar styloid
