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Musculoskeletal Mushkies Flashcards

1
Q

Hip examination?

A
  1. Look
  2. Feel
  3. Move
  4. Special Tests
  5. Completion
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2
Q

Hip exam look?

A
  1. Gait = antalgic, trendelenberg
  2. Standing = skin, shape, deformity
  3. Trendelenberg test
  4. Supine
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3
Q

Antalgic gait?

A

Reduced stance phase on affected side

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4
Q

Trendelenberg gait?

A

Sideways lurch of trunk to bring body weight over limb

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5
Q

Hip exam standing inspection?

A
  1. Skin = scars, bruising, erythema
  2. Shape = soft tissue/bony swelling, muscle wasting
  3. Deformity = coxa vara or valga
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6
Q

Trendelenberg test?

A

The sound side sags

  1. Negative = pelvis tilts up slightly on unsupported side
  2. Positive = pelvis drops on unsupported side (pathology of contralateral abductor mechanism)
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7
Q

Hip supine look?

A

Square the pelvis and measure leg length

  1. True length = ASIS to medial malleolus
  2. Apparent length = xiphisternum to medial malleolus
  3. Galeazzi test = tibial vs. femoral shortening
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8
Q

Hip examination feel?

A
  1. Palpate for tenderness
  2. ASIS, iliac crests and pubic rami
  3. Greater trochanter
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9
Q

Hip examination move?

A
  1. Abduction
  2. Adduction
  3. Flexion
  4. Internal rotation
  5. External rotation
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10
Q

Normal hip abduction?

A

45 degrees

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11
Q

Normal hip adduction?

A

30 degrees

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12
Q

Normal hip flexion?

A

130 degrees

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13
Q

Normal hip internal rotation?

A

20 degrees

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14
Q

Normal hip external rotation?

A

45 degrees

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15
Q

Hip examination special test?

A

Thomas’ test

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16
Q

Thomas’ test?

A
  1. Tests for fixed flexion deformity
  2. Masked by compensatory movement in pelvis or lumbar spine
  3. Obliterate lumbar lordosis
  4. Angle between thigh and bed = fixed flexion deformity
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17
Q

Completion of hip examination?

A
  1. Examine the knee and spine
  2. Perform a neurovascular assessment, esp. pulses
  3. AP and lateral radiographs of the pelvis
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18
Q

Causes of +ive trendelenberg test?

A

ASS

  1. Abductor wasting secondary to chronic pain
  2. Superior gluteal nerve injury = surgery
  3. Structural = DDH
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19
Q

True shortening of the leg causes?

A
  1. NOF
  2. Hip dislocation
  3. Growth disturbance of tibia/fibula e.g. fractures/osteomyelitis
  4. Surgery e.g. THR
  5. SUFE
  6. Perthes disease
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20
Q

Apparent shortening of the leg cause?

A

Scoliosis of the spine

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21
Q

Where is hip pain felt?

A
  1. Usually in groin or anterior thigh

2. Pain at back of hip is usually referred from lumbar spine

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22
Q

Causes of fixed flexion deformity?

A
  1. Osteoarthritis

2. NOF

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23
Q

Features of OA in the Hip?

A
  1. Trendelenberg gait
  2. Positive trendelenberg test
  3. Pain
  4. Stiffness
  5. Reduced ROM esp. internal rotation
  6. Fixed flexion deformity
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24
Q

Knee examination?

A
  1. Look
  2. Feel
  3. Move
  4. Special tests
  5. Completion
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25
Knee examination look?
1. Gait 2. Standing 3. Supine
26
Knee examination gaits?
1. Antalgic 2. Stiff = pelvis rises during swing phase 3. Varus thrust = medial collateral 4. Valgus thrust = lateral collateral
27
Knee examination standing examination?
1. Skin = scars, bruising erythema 2. Shape = swelling, muscle wasting (quads, hamstring) 3. Deformity = genu varus/valgus
28
Knee examination scars?
1. Arthroscopic ports 2. KR 3. Menisectomy
29
Popliteal fossa swelling?
Baker's cyst
30
Where to measure quadriceps circumference?
15cm from tibial tuberosity
31
Knee examination feel?
1. Temperature 2. Effusion = sweep test and ballot 3. Palpate
32
Knee examination palpation?
1. Position knees at 90 degrees 2. Joint line for tenderness = meniscal pathology 3. Patella, tendon, and tibial tuberosity 4. Popliteal fossa
33
Knee examination move?
1. Straight leg raise = extensor lag, hyperextension, fixed flexion deformity 2. Passive flexion of knee while palpating joint for crepitus 3. Normal range = 0-140
34
Knee examination special tests?
1. Cruciate ligaments = anterior + posterior drawer tests, Lachmann's 2. Collateral ligaments 3. Menisci tests = McMurray test, Apley grind test
35
Lachmann's?
ACL, more sensitive than anterior drawer test
36
Collateral ligament test?
1. In partial flexion (30) and full extension 2. Valgus stress = medial ligament 3. Varus stress = lateral ligament
37
Knee examination completion?
1. Examine hip and ankle 2. Perform neurovascular assessment 3. Standing AP and lateral and skyline radiographs of the knee
38
Causes of knee effusion?
1. Synovial fluid = synovitis 2. Blood 3. Pus = septic arthritis
39
Cause of bloody knee effusion?
1. 90% = ACL rupture 2. PCL rupture, intra-articular fracture, meniscal tear 3. Bleeding diatheses
40
Osteoarthritis defn?
Degenerative joint disorder in which there is progressive loss of hyaline cartilage, and new bone formation at the joint surface and its margin
41
Aetiology of osteoarthritis?
1. Age 2. Obesity 3. Joint abnormality
42
Classification of osteoarthritis?
1. Primary = no underlying abnormality | 2. Secondary = obesity, joint abnormality
43
Main osteoarthritis joints?
1. Knees 2. Hips 3. DIPs 4. PIPs 5. Thumb CMC
44
Osteoarthritis symptoms?
Pain, Stiffness, Deformity, Reduced ROM
45
Osteoarthritis pain?
1. Worse with movement 2. Background rest/night pain 3. Worse at end of the day
46
OA stiffness?
1. Esp. after rest (joint 'gelling') | 2. Lasts 30 mins (e.g. AM)
47
Deformity?
Genu varus
48
OA vs. RA --> valgus or varus?
1. OA = varus | 2. RA = valgus
49
Pathophysiology of osteoarthritis?
1. Softening of articular cartilage --> fraying and fissuring of smooth surface --> underlying bone exposure 2. Subchondral bone becomes sclerotic with cysts 3. Proliferation and ossification of cartilage in unstressed areas --> osteophytes 4. Capsular fibrosis --> stiff joints
50
OA Ix?
1. Bedside = examination 2. Bloods = exclude Rh (FBC, ESR, RF, ANA), check renal function (for NSAIDS) 3. Imaging XRAY --> LOSSD
51
OA Mx?
1. MDT = GP, physio, OT, dietician, orthopod 2. Conservative = lifestyle (weight, exercise), physio (muscle strengthening), OT (walking aids, footwear, home mods) 3. Medical 4. Surgical
52
OA Medical Mx?
1. Analgesia = paracetamol, NSAIDs, tramadol | 2. Joint injection = LA and steroids
53
OA Surgical Mx?
1. Arthroscopic washout = mainly knees, trim cartilage, remove loose bodies 2. Realignment osteotomy = small area of bone cut, useful in younger pts (<50) with medial knee OA, high tibial valgus osteotomy redistributes weight to lateral part of joint 3. Arthroplasty = replacement 4. Arthrodesis = last resort for pain Mx 5. Novel techniques = autologous chondrocyte implantation
54
Differences between OA and RA classification?
1. Pathology 2. Clinical 3. Radiology
55
OA vs. RA pathology?
1. OA = degenerative, negative serology | 2. RA = inflammatory, positive serology
56
OA vs. RA clinical differences?
1. OA = asymmetric, large joints, AM stiffness <30m, worse PM, hands = PIPJ and DIPJ, no extra-articular fx 2. RA = symmetric, small joints, AM stiffness >1hr, worse AM, hands = PIPJ and MCPJs, extra-araticular fx
57
OA vs. RA radiology differences?
1. OA = LOSS, mild deformity | 2. RA = Periarticular osteopenia and erosions, soft tissue swelling, severe deformity
58
Who pioneered hip arthroplasty?
Sit John Charnley in the 1960s
59
Types of hip arthroplasty?
1. THR 2. Hemiarthroplasty 3. Rsurfacing
60
THR fx?
1. Replace femoral head, neck and acetabulum | 2. Usually elective
61
Hemi-arthroplasty fx?
1. Replace femoral head and neck onlu | 2. May be uni or bipolar
62
Resurfacing fx?
Replacement of surface of femoral head
63
Types of hip arthroplasty prostheses?
1. Cemented = e.g. Thompson, recommended by NICE | 2. Uncemented = e.g. Austin-Moore, may be useful in younger pts, easier to revise
64
Hip arthroplasty techniques?
1. Posterior approach | 2. Anterolateral approach
65
Posterior approach for hip arthroplasty fx?
1. Access joint and capsule posteriorly, reflecting of the short external rotators 2. Gives good access 3. May have a higher dislocation rade 4. Sciatic nerve may be injured --> foot drop
66
Anterolateral approach for hip arthroplasty fx?
1. Incision over greater trochanter, dividing fascia lata 2. Abductors are reflected to access joint capsule 3. May have lower dislocation rate 4. Superior gluteal nerve may be injured --> trendelenberg gait
67
Complications of hip arthroplasty?
1. Immediate 2. Early 3. Late
68
Immediate complications of hip arthroplasty?
1. Nerve injury 2. Fracture 3. Cement reaction
69
Early complications of hip arthroplasty?
3Ds 1. DVT = up to 50^ w/o prophylaxis 2. Deep infection = must remove metalwork before revision 3. Dislocation (3%)
70
Late complications of hip arthroplasty?
1. Loosening = septic/aseptic 2. Leg length discrepancy 3. Metalosis 4. Revision = most replacements last 10-15 years
71
Metalosis?
Medical condition involving deposition and build-up of metal debris in the soft tissues of the body, hypothesized to occur when metallic components in medical implants, specifically joint replacements, abrade against one another.
72
Commonest complications of THR?
DVT
73
Peak incidence of DVT post THR?
5-10d post op
74
DVT prophylaxis for THR classification?
1. Pre-op 2. Intra-op 3. Post-op
75
Pre-op DVT prevention?
1. TED stocking 2. Aggressive optimisation e.g. hydration 3. Stop OCP
76
Intra-op DVT prevention?
1. Minimise length of surgery | 2. Use pneumatic compression boots
77
Post-op DVT prevention?
1. LMWH 2. Early mobilisation 3. Good analgesia 4. Physio 5. Adequate hydration
78
Hip resurfacing indications?
May be used in young (<65y/o), active people who are expected to outlive the replacement
79
Hip resurfacing advantages?
1. Metal on metal bearing weigh less 2. Larger head --> less dislocation and more stability 3. Preserve bone stock, making revision easier
80
Hip resurfacing disadvantages?
1. Cobalt and chromium metal ion release may cause pathology e.g. leukaemia 2. Risk of NOF if mal-positioned
81
Types of knee arthroplasty?
1. Cemented = UK 2. Uncemented = Europe 3. Can be uni/bicompartmental
82
Primary aim of knee arthroplasty?
Reduce pain
83
Knee arthroplasty procedure?
1. Performed under tourniquet 2. PCL is usually preserved 3. ACL is usually sacrificed (prosthesis is specifically designed to provide some compensation for this) 4. Metal prosthesis and an ethylene articular disc 5. Patellar surface can be re-surfaced 6. Knee bending after 2-3 days 7. 10 days hospital stay
84
Complications of knee arthroplasty?
1. Immediate 2. Early 3. Late
85
Immediate complications of knee arthroplasty?
1. Nerve injury = peroneal nerve (1%, foot drop) 2. Vascular injury = SFA, popliteal and genicular vessels 3. Fracture 4. Cement reaction
86
Early complications of knee arthroplasty?
3 Ds 1. DVT 2. Deep infection 3. Dislocation
87
Late complications of knee arthroplasty?
1. Loosening = septic or aseptic 2. Periprosthetic fractures 3. Reduced ROM and instability (loss of ACL)
88
Surgical Mx of RA in the knee?
1. Indicated in failed medical Mx 2. Synovectomy and debridement (can be done arthroscopically) 3. Removal of pannus and cartilage 4. Supracondylar osteotomy 5. TKR
89
DDx of haemarthrosis?
Primary or Secondary
90
Primary cause of haemarthrosis?
Without trauma --> bleeding diatheses
91
Secondary cause of haemarthrosis?
Secondary to trauma 1. ACL injury = 80% 2. Patellar dislocation = 10% 3. Meniscal tear, capsular tear, osteochondral facture = 10%
92
Ddx of knee locking?
1. Meniscal tear 2. Cruciate ligament injury 3. Osteochondritis dissecans = adolescents 4. Loose body
93
Presentation of ACL injury?
1. Associated with deceleration and rotational movements 2. Hears a pop or feels something tear 3. Inability to continue with sport or activity 4. Haemarthrosis w/in 4-6hrs 5. Instability/giving way following injury
94
Unhappy triad of O'Donoghue?
AKA 'Blown Knee', Injury is most often sustained when a lateral force impacts the knee while the foot is fixed on the ground 1. ACL 2. MCL 3. Medial meniscus
95
Mx of Meniscal tear?
1. Non-surgical = analgesia | 2. Surgical = arthroscopic/open --> partial meniscectomy/meniscal repair
96
Mx of ACL rupture?
1. Non-surgical = rest and physio to strengthen quads and hamstrings, not enough stability for many sports 2. Surgical = gold standard is autograft repair, usually semitendinosus +/- gracilis (can use patella), tendon threaded through the heads of tibia and femur and held using screws
97
Bunion aka?
Hallux Valgus
98
Hallux valgus examination?
1. Look = hallux, bunion, extras 2. Feel = inflammation of bunion, localised tenderness e.g. OA of MTPJs 3. Move = assess ROM of toe joints 4. Completion = assess ROM of other toe joints, assess gait, examine shoes
99
Hallux valgus look?
1. Hallux = unilateral/bilateral, estimate degree of valgus, rotation (nail faces medially) 2. Bunion = prominence of 1st metatarsal head +/- bursa, evidence of inflammation (bursitis) 3. Extra = hammer toes, callosities on heel
100
HVA?
Hallux Valgus Angle 1. Mild: 15–20° 2. Moderate: 21–39° 3. Severe: ≥ 40°
101
Aetiology of Hallux Valgus?
1. FHx 2. Enclosed/pointy shoes 3. RhA
102
Ix of hallux valgus?
Weight beating X rays = degree of valgus, OA of MTPJ
103
Mx of hallux valgus?
1. Non-surgical = wide + soft footwear, physio | 2. Surgical = bunionectomy, 1st metatarsal realignment osteotomy, excision arthroplasty
104
3 lesser toe deformities?
1. Hammer toe 2. Claw toe 3. Mallet toea
105
Aetiology of lesser toe deformities?
1. Imbalance between intrinsic and extrinsic toe muscles 2. F>M 3. RhA 4. Age
106
Intrinsic toe muscles?
Lumbricals
107
Extrinsic toe muscles?
Long flexors and extensors
108
Mx of lesser toe deformities?
1. Non-surgical = appropriate footwear | 2. Surgical = flexor-to-extensor tendon transfer. arthrodesis, resection of proximal phalangeal head
109
Charcot joint definition?
1. Progressive destructive joint arthropathy secondary to disturbance of sensory innervation to a joint 2. Results in a painless deformed joint resulting from repetitive minor trauma
110
Causes of charcot joint?
1. Peripheral = DM, peripheral nerve injury, leprosy | 2. Central = syringomyelia, tabes dorsalis
111
Charcot joint examination?
1. Look = swelling, deformity, pressure necrosis 2. Feel = tender, warmth, crepitus, subluxation or dislocation of joint 3. Move = abnormal 4. Completion = neurovascular status, dip urine for glucose
112
Gait phases?
1. Heel strike 2. Stance 3. Toe off 4. Swing
113
9 different Gaits?
AMPAH SHDC 1. Antalgic 2. Myopathic (Trendelenberg) 3. Parkinsonian 4. Ataxic (Cerebellar) 5. High stepping 6. Sensory/stomping gait 7. Hemiplegic 8. Diplegic 9. Choreiform
114
Description and cause of an antalgic gait?
1. Reduced stance phase and increased swing phase | 2. Cause = pain
115
Description and cause of a trendelenberg gait?
1. Hip dips, and shoulders lurch to contralateral side | 2. Cause = weak abductors
116
Description and cause of a Parkinsonian gait?
1. Slow initiation, shufflling steps, slow turn, poor arm swing, universal flexion 2. Cause = Parkinsonism
117
Description and cause of an Ataxic gait?
1. Wide based, clumsy, staggering, titubation, will lean towards side of lesion 2. Cerebellar, alcohol
118
Description and cause of a High stepping gait?
1. Foot strikes with ball and slaps the ground, due to weakness of dorsiflexion 2. Unilateral or bilateral
119
High stepping gait AKA?
1. Neuropathic gait 2. Steppage gait 3. Equine gait
120
Causes of unilateral steppage gait?
1. Peroneal nerve palsy | 2. L5 radiculopathy
121
Causes of bilateral steppage gait?
1. ALS 2. CMT 3. Peripheral neuropathies e.g. DM
122
Description and cause of a stomping/sensory gait?
1. Pt will slam foot hard onto floor ut sense it | 2. Cause = dorsal column (B12, tabes dorsalis), peripheral neuropathy e.g. DM
123
Description and cause of a hemiplegic gait?
1. Arm flexed, adducted, extended, internally rotated leg with circmuduction and foot drop 2. Cause = UMN
124
Description and cause of a diplegic gait?
1. Bilateral spasiticity worse in lower limbs, narrow base, dragging legs, scraping toes, tightness of adductors, scissoring if severe 2. Cause = Bilateral periventricular lesions e.g. CP
125
Description and cause of a choreiform gait?
1. Irregular, jerky, involuntary movements in all extremities, walking may accentuate their baseline movement disorder 2. Sydenham's chorea, Huntington's Disease and other forms of chorea, athetosis or dystonia
126
Different gaits mnemonic?
AMPAH SHDC 1. Antalgic 2. Myopathic (Trendelenberg) 3. Parkinsonian 4. Ataxic (Cerebellar) 5. High stepping 6. Sensory/stomping gait 7. Hemiplegic 8. Diplegic 9. Choreiform
127
Popliteal swelling Ddx?
1. Skin = lipoma 2. Artery = popliteal artery aneurysm/pseudo 3. Vein = saphena varix at SPJ 4. Nerve = tibial nerve neuroma 5. Baker's cyst 6. Enlarged bursa = above knee joint line, associated with semimembranosus
128
Baker cyst?
Posterior herniation of the knee joint capsule, associated with degenerative knee joint disease, located below the knee joint line
129
Dx of bakers cyst?
US
130
Bakers cyst mx?
Aspiration possible = high recurrence
131
Shoulder examination?
1. Look 2. Feel 3. Move = active then passive 4. Special tests 5. Completion
132
Shoulder examination look?
1. Skin = scars, bruising, erythema 2. Shape = wasting, clavicular deformity, joint swelling 3. Deformity = joint dislocation, scapula location, winging of scapula
133
Shoulder examination feel?
1. Temperature 2. Along clavicle from SCJ to ACJ 3. Acromion and coracoid (2cm inferior and medial to clavicle tip) 4. Biceps tendon is bicipital groove 5. Scapular spine 6. Humoral head, greater and lesser tuberosities
134
Shoulder examination move?
1. Functional screen 2. Abduction and adduction 3. Flexion and extension 4. Internal and external rotation
135
Functional shoulder screen move?
1. Ask pt to put both hands behind head | 2. Ash pt to reach behind back and touch shoulder blades
136
Shoulder examination abduction and adduction move?
1. First 25 degrees of abduction is supraspinatus, rest is deltoid 2. Palpate acromion tip during abduction to determine GHJ movement (abduction at GHJ is 80, rest is scapular rotation) 3. Pain = 60-120 (impingement or rotator cuff tendonitis), 140-180 (AC osteoarthritis)
137
What movement is most commonly reduced in frozen shoulder?
External rotation
138
6 special tests in the shoulder examination?
JIGSHA 1. Jobe's empty can test = supraspinatus 2. Infraspinatus + teres minor 3. Gerber's lift off = subscapularis 4. Scarf test = AC joint dysfunction 5. Hawkins-Kennedy test = shoulder impingement 6. Apprehension test = GHJ instability
139
Jobe's empty can test?
1. Supraspinatus | 2. Shoulder flexed at 90, thumb pointing down, forced flexion of shoulder
140
Infraspinatus and teres minor test?
Elbow flexed at 90, forced external rotation of shoulder
141
Gerber's lift off test?
1. Subscapularis | 2. Dorsum of hand placed against lumber spine, pt attempts to lift hand off against resistance
142
Scarf test?
1. AC joint dysfunction | 2. Place pts hand on contralateral shoulder, examiner pushes pts flexed elbow posteriorly, eliciting discomfort
143
Hawkins-Kennedy test?
1. Shoulder impingement | 2. Shoulder and elbow flexed at 90, examiner pushes hand down
144
Apprehension test?
1. GHJ instability 2. Shoulder is abducted and externally rotated to 90 degrees, apprehension occurs as shoulder is slowly externally rotated
145
Shoulder examination completion?
1. Examine cervical spine and elbow | 2. Neurovascular exam
146
Winging of scapula?
Serratus anterior weakness due to long thoracic nerve damage
147
Causes of winging of scapula (long thoracic nerve damage)?
1. Axillary surgery 2. Upper brachial plexus injury 3. Muscular dystrophy
148
Shoulder Ddx for pain +/- reduced ROM?
ASH RRJ 1. Adhesive capsulitis (frozen shoulder) 2. Subacromial bursitis 3. Humeral head = fracture, dislocation 4. Rotator cuff = tear, tendonitis 5. Referred pain from diaphragm 6. Joints = synovitis, OA, dislocation
149
Hand examination?
1. Look = dorsum and palms 2. Feel 3. Move 4. Function 5. Special tests 6. Completion
150
Hand examination look?
1. Skin = scars, erythema, calcinosis and tophi, ulceration, ganglia 2. Muscle wasting = median nerve (thenar eminence), ulnar nerve (1st dorsal interosseus) 3. Joint swellings = heberdens, bouchards
151
Hand examination feel?
1. Temperature 2. Joints = pain and swelling 3. Tendons = nodules or thickening 4. Muscles = median nerve (thenar eminence), ulnar nerve (1st dorsal interosseus)
152
Hand examination move?
1. Wrist = prayer and reverse prayer positions, check that fingers are opposed in prayer position 2. Thumb = abduction 3. Finger = abduction and adduction (cross fingers for good luck), opposition, grip
153
Hand examination function?
1. Fasten and unfasten button 2. Pick up coin from flat surface 3. Write name
154
Hand examination special tests?
1. Median nerve = Tinel's, Phalen's 2. Ulnar nerve = Froments 3. de Quervains tenosynovitis = Finkelsteins
155
Froment's sign?
1. Flexion of thumb at IPJ = weak ADductor pollicis (Ulnar nerve lesion) 2. Hold a piece of paper between their thumb and index finger. The object is then pulled away. If ulnar nerve palsy, unable to hold the paper and will flex the flexor pollicis longus to compensate (flexion of thumb at interphalangeal joint)
156
De Quervain's tenosynovitis?
Inflammation of the tendons on the lateral aspect of the wrist and thumb, in the first dorsal compartment i.e. abductor pollicis longus and extensor pollicis brevis tendons
157
Finkelstein's test?
Finkelstein's test = grab the thumb and ulnar deviate the hand sharply, leading to pain along the distal radius
158
Associations of Dupuytren's contracture?
BAD FIBERS 1. Bent penis = Peyronies 2. AIDS 3. DM 4. FHx: AD 5. Idiopathic = commonest 6. Booze = ALD 7. Epilepsy + meds = phenytoin 8. Reidel's thyroiditis + other fibromatoses 9. Smoking
159
Pathophysiology of Dupuytren's contracture?
1. Local microvessel ischaemia --> increased xanthine oxidase activity --> ROS production 2. ROS --> myofibroblast proliferation --> collagen 3 formation 3. Chronic inflammation --> continued fibrosis
160
Mx of Dupuytren's contracture?
1. Non-surgical = physio, allopurinol may help | 2. Surgical
161
Surgical indication for Dupuytren's?
MCP or PIP contracture >30 degrees
162
Dupuytrens contracture procedures?
1. Fasciotomy 2. Partial fasciectomy 3. Dermofasciectomy + full thickness skin grafting 4. Arthrodesis and amputation
163
Carpal tunnel syndrome examination?
1. Look = wasting of thenar eminence, scars from prev. surgery of flexor retinaculum 2. Feel = light touch over finger pulps, thenar eminence 3. Move = opponens pollicis, abductor pollicis brevis 4. Special tests = Tinel's, Phalen's 5. Completion = Hx, underlying cause
164
Carpal tunnel syndrome Ddx?
1. More proximal median nerve lesion | 2. Cervical root lesion = e.g. cervical disc herniation
165
3 causes of carpal tunnel syndrome?
I WRIST 1. Idiopathic 2. Water = pregnancy, hypothyroidism 3. Radial fracture 4. Inflammation = RA, gout 5. Soft tissue swelling = lipomas, acromegaly, amyloidosis 6. Toxic = DM, EtOH
166
Carpal tunnel syndrome Sx?
1. Tingling/pain in thumb, index and middle finger 2. Pain worse at night or after repetitive actions 3. Relieved by shaking/flicking hand
167
Carpal tunnel syndrome Ix?
1. Nerve conduction studies = Determine lesion location and severity 2. US 3. Further Ix not usually necessary
168
Carpal tunnel syndrome Mx?
1. Non-surgical = underlying cause, wrist splints (neutral positions, esp. at night), local steroid injections 2. Surgical = carpal tunnel decompression by division of the flexor retinaculum
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Complications of carpal tunnel syndrome surgery?
1. Scar formation = high risk for hypertrophic or keloid 2. Scar tenderness = up to 40% 3. Nerve injury 4. Failure to relieve symptoms
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Nerve injury in carpal tunnel syndrome?
1. Palmar cutaneous branch of the median nerve | 2. Motor branch to the thenar muscles
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Other locations of median nerve entrapment?
1. Pronator syndrome | 2. Anterior Interosseous syndrome
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Pronator syndrome?
Entrapment of median nerve between two heads of the pronator teres
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Anterior Interosseous syndrome?
Compression of the anterior interosseous branch of the median nerve by the deep head of the pronator teres, leading to muscle weakness only (pronator quadratus, FPL, radial half of FDP)
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Rheumatoid hand examination?
1. Look = hands, scars, wrist, elbow 2. Feel 3. Move 4. Function 5. Special 6. Completion
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Rheumatoid hand exam look?
1. Skin = joint and palmar erythema 2. Joint swelling = MCPs and PIPs 3. Muscle wasting = interossei, thenar eminence 4. Deformity
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RA hand deformities x 5?
1. Ulnar deviation at MCPs 2. Boutonnieres deformity 3. Swan neck deformity 4. Z thump 5. MCP volar subluxation
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RA wrist?
Radial deviation, volar subluxation of the ulnar styloid
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RA elbow?
Rheumatoid nodules
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RA hand exam feel?
1. Temperature 2. Joint tenderness 3. Median nerve sensation
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RA hand exam move?
1. Fixed flexion on prayer position | 2. Reduced ROM
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RA hand exam special?
1. Tinel's and Phalen's | 2. Finkelstein's
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RA hand exam function?
1. Precision = coin from table, button up shirt 2. Power = squeeze fingers 3. Writing 4. Walking aids, splints, wheelchair
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RA hand exam features?
Other features of Ra
184
RA in 3 words?
Symmetrical deforming polyarthropathy
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DDx for rheumatoid hands?
1. Psoriatic arthritis | 2. Jacoud's arthropathy
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Extra-articular fx of RA?
aNTI CCP Or RF 1. Nodules 2. Tenosynovitis = de Quervain's and AA subluxatoin 3. Immune = vasculitis, amyloidosis 4. Cardiac = pericarditis +/- effusion 5. Carpal tunnel syndrome 6. Pulmonary = fibrosis, effusions 7. Ophthalmic = episcleritis, scleritis, Sjogrens 8. Raynauds 9. Feltys
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X-ray features of RA?
1. Early = loss of joint space, periarticular ostoepenia | 2. Late = soft tissue swelling, periarticular erosions, defority
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Surgical Mx of RhA hands?
1. Carpal tunnel decompression 2. Tendon repairs and transfers 3. Ulna stylectomy 4. Arthroplasty
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OA hand examination?
1. Look = heberdens, bouchards, squaring of thumb CMC 2. Move = reduced ROM of passive and active motion 3. Function = unbutton shirt, pick up coin, writing 3. Completion = examine other joints
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OA hand Ddx?
1. RA hands | 2. Tophi
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What are bouchards nodes strongly associated with?
Polyarticular OA
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Mx of OA hands?
1. Non-surgical = physiotherapy, analgesia | 2. Surgical = joint arthrodesis
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Ulnar nerve exam?
1. Look = partial claw hand (little and ring fingers) with wasting of the hypothenar eminence and dorsal interossei 2. Feel = loss of sensation in the ulnar distribution 3. Move = weak abduction and adduction of little finger, weak flexion in DIPJ in little and ring fingers 4. Special = Froment's, Elbow flex test 5. Completion = neck (brachial plexus injury), examine PNS of affected limb
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Elbow flex test?
Full elbow flexion for 1 min --> paraesthesia in little and ring fingers
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Causes of ulnar nerve palsy?
1. Anatomical compression = cubital tunnel syndrome at elbow, guyon's canal syndrome at wrist 2. Trauma = supracondylar fractures of the humerus, elbow dislocation
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Ulnar paradox?
More proximal lesions have less clawing of the hand
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Ulnar nerve palsy Mx?
1. Non-surgical = avoid repetitive flexion-extension of elbow, avoid prolonged elbow flexion, night splinting of elbow in extension 2. Surgical = ulnar nerve decompression, medial epicondylectomy
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Radial nerve exam?
1. Look = wrist drop (hold hands out in front, palms down) 2. Feel = loss of sensation over the first dorsal interosseus, may be sensory loss over dorsal forearm 3. Move = low (loss of MCP extension, preserved PIPJ extension (Lumbricals)), high (+wrist weakness), very high (+triceps weakness) 4. Completion = examine neck (brachial plexus), examine PNS of affected limb
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Classification of causes of radial nerve palsy?
1. Very high 2. High 3. Low
200
Very high radial nerve palsy cause?
1. Triceps paralysis + wrist drop + finger drop 2. Just below brachial plexus 3. Compression: crutches
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High radial nerve palsy causes?
1. Wrist drop + finger drop 2. Occur at spiral groove 3. Mid shaft humerus fracture, saturday night palsy
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Low radial nerve palsy causes?
1. Finger drop 2. Occur at elbow 3. Only involve posterior interosseous nerve --> sensation preserved 4. Local wounds, fracture, or dislocation
203
Mallet finger definition?
Fixed flexion deformity of the distal phalanx of one or more fingers. Cannot be actively extended, but may be passively extended
204
Mallet finger cause?
1. Damage to extensor tendon of terminal phalanx | 2. e.g. avulsion fracture due to hyperflexion injury when catching a cricket ball
205
Mallet finger Mx?
1. Splint with distal phalanx in extension for 6 weeks to allow for tendon reattachment 2. If avulsed bone is large, may fix it with a Kirschner wire
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Trigger finger aka?
Stenosing tenosynovitis
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Trigger finger defn?
AKA stenosing tenosyonivits, a condition where a tendon nodule catches on the proximal side of the tendon sheath, leading to triggering on foxed extension (often the FDS tendon)
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Causes of trigger finger?
1. Idiopathic 2. Trauma 3. Activities requiring repetitive forceful flexion e.g. heavy shears 4. RA
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Mx of trigger finger?
1. Steroid injection = often recurs | 2. Tendon release by sheath incision
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Back Examination?
1. Look 2. Feel 3. Move 4. Special tests 5. Neuro assessment of lower limb 6. Completion
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Back exam look?
1. Gait 2. Spinal curvature 3. Paraspinal and trapezius muscle bulk 4. Wall-tragus test if neck hyperflexion
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Back exam feel?
1. Paraspinal muscle bulk and tenderness 2. Spine palpation = masses, steps 3. Spine percussion = tenderness
213
Back exam move?
1. Cervical spine movement 2. Lateral flexion = usually 30 degrees 3. Forward flexion = Schober's Test
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Schober's test?
1. Mark 5cm below and 10cm above levels of PSIS (sacral dimples, approx S2) 2. Maximum flexion should lengthen line by >=5cm
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Back exam special tests?
1. Measure true and apparent leg lengths (scoliosis --> discrepancy) 2. Sacroiliitis test = lateral compression, stretch (adduction of hip with hip and knee flexed) 3. Straight leg raise = demonstrates lumbosacral nerve root irritation, record angle at pain onset
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Straight leg raise aka?
Lasegue's sign
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Quick neuro assessment of lower limb?
1. Power = L4 (foot inversion and dorsiflexion), L5 (great toe dorsiflexion, S1 (foot eversion and plantarflexion) 2. Reflexes = S1 (Ankle) 3. Sensation = L5 (great toe and medial dorsum), S1 (little toe and lateral sole)
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Back exam completion?
1. Complete neuro examination of lower limb, esp. perineal sensation 2. Consider a PR = excludes a cauda equina compression
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Pathophysiology of lumbar disc herniation?
1. Pre-existing lumbar spondylosis | 2. Rupture of annulus fibrosus with herniation of nucleus pulposus into spinal canal
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Lumbar disc herniation risk factors?
1. Physiological = age, poor posture, poor aerobic fitness 2. Occupational = heavy manual labour, frequent bending/lifting/twisting, repetitive/static work postures 3. Psychosocial = depression
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Mx of lumbar disc herniation?
1. Conservative 2. Medical 3. Surgical
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Conservative mx of lumbar disc herniation?
1. Max 2d bed rest 2. Education = keep active, how to lift 3. Physio = back to school 4 .Psychosocial issues er: chronic pain and disability 5. Warmth
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Medical mx of lumbar disc herniation?
1. Analgesia = paracetamol +/- NSAIDs +/- codeine 2. Muscle relaxant = low dose diazepam (short term) 3. Facet joint injections
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Surgical mx of lumbar disc herniation?
1. Percutaneous microdiscectomy 2. Endoscopic discectomy 3. Hemilaminotomy + discectomy
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Indications for surgical mx of lumbar disc herniation?
1. Progressive neurological deficit 2. Severe incapacitating pain 3. Failure of non-surgical options

Medicine and Surgery Mushkies (52 decks)

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