Ortho Flashcards
what is trochanteric bursitis?
inflammation of a bursa over the greater trochanter on the outer hip
what is greater trochanteric pain syndrome?
pain localised at the outer hip caused by trochanteric bursitis
what are bursae
sacs created by synovial membrane filled with a small amount of synovial fluid
found at bony prominences
act to reduce friction between bones and soft tissue during movement
what is bursitis
inflammation of a bursa. Causes thickening of the synovial membrane and increased fluid production, causing swelling
4 causes of bursitis
- friction from repetitive movements
- trauma
- inflammatory conditions e.g. RA
- infection (septic bursitis)
presentation of trochanteric bursitis
- middle aged patient with gradual onset lateral hip pain that may radiate down outer thigh
- aching or burning pain
- worse with activity,
standing after sitting for a prolonged period and trying to sit cross-legged - disrupted sleep. difficult to find a comfortable lying position
- tenderness over the greater trochanter. No swelling
name 4 special tests to establish a dx of trochanteric bursitis
1. +ve Trendelenburg test Pain on: 2. resisted abduction of the hip 3. resisted internal rotation of the hip 4. resisted external rotation of the hip
what does the Trendelenburg test involve?
establishes dx of trochanteric bursitis
stand one legged on the affected leg
normally the other other side of the pelvis should remain level or tilt upwards slightly
+ve Trendelenburg test: other side of pelvis drops down –> weakness in the affected hip
Management options for trochanteric bursitis
- rest
- ice
- analgesia NSAIDs
- Physiotherapy
- Steroid injections
- abx if caused by infection
septic bursitis presentation
- warmth, erythema, swelling and pain over the bursa
- may have fever
what is the recovery period for trochanteric bursitis
6-9m
what is trigger finger?
a condition causing pain and difficulty moving a finger
aka stenosing tenosynovitis
what is the pathophysiology of trigger finger?
- flexor tendons of finger pass through sheaths along length of finger
- thickening of tendon or tightening of sheath
- prevents tendon from smoothly moving through the sheath when finger is flexed and extended
- causing pain, stiffness or catching symptoms
what is the most commonly affected part of the sheath in trigger finger?
first annular pulley (A1)
at the MCP joint
what are the RFs for trigger finger?
- 40s or 50s
- women
- diabetics
what is the typical presentation of trigger finger?
troublesome finger that:
- is painful + tender (usually around the MCP joint on the palm-side of the hand
- does not move smoothly
- makes a popping or clicking sound
- gets stuck in a flexed position
Sx typically worse in morning and improve during the day
how to diagnose trigger finger
clinical diagnosis based on hx and examination
what are the management options for trigger finger
- rest and analgesia (some resolve spontaneously)
- splinting
- steroid injections
- surgery to release A1 pulley
what is a Baker’s cyst?
aka popliteal cysts
a fluid filled sac in the popliteal fossa, causing a lump
what are the borders of the popliteal fossa?
- superior + medial: Semimembranous and semitendinosus tendons
- superior + lateral: Biceps femoris tendon
- inferior + medial: medial head of the gastrocnemius
- inferior + lateral: lateral head of the gastrocnemius
what causes Baker’s cysts?
in adults, it’s usually secondary to degenerative changes in the knee joint
Synovial fluid squeezed out of knee joint
collects in popliteal fossa
a connection between the synovial fluid in the joint and Baker’s cyst can remain
allowing cyst to continue to enlarge as more fluid collects there
what are Baker’s cysts associated with?
- MENISCAL TEARS
- osteoarthritis
- knee injuries
- inflammatory arthritis e.g. RA
do Baker’s cysts have their own epithelial lining?
No but they are contained within the soft tissues
presentation of Baker’s cysts
Localised to popliteal fossa:
- pain or discomfort
- fullness
- pressure
- palpable lump or swelling
- restricted range of motion in the knee (with larger cysts)
- oedema if cyst compresses the venous drainage of the leg
What is Foucher’s sign
the Baker’s cyst lump will get smaller or disappear when the knee is flexed to 45 degrees
What does a ruptured Baker’s cyst present as?
inflammation in the surrounding tissues and calf muscles - pain - erythema - swelling rarely can cause compartment syndrome
name a critical differential diagnosis of a ruptured Baker’s cyst?
DVT
Name key differential diagnoses of a lump in the popliteal fossa
- DVT
- Abscess
- Popliteal artery aneurysm
- Ganglion cyst
- Lipoma
- Varicose veins
- Tumour
1st line Inx for a Baker’s cyst
US confirms dx and rules out DVT
2nd line inx for a Baker’s cyst
MRI can evaluate cyst further if required before surgery.
And demonstrate any underlying knee pathology e.g. meniscal tears
Management for asymptomatic Baker’s cysts
none
Management for symptomatic Baker’s cysts
- modified activity to avoid exacerbating sx
- NSAIDs
- Physiotherapy
- US-guided aspiration
- Steroid injections
Surgical: arthroscopic procedures to treat underlying knee pathology
What is compartment syndrome?
Pressure within a fascial compartment is abnormally elevated, cutting off the blood flow of the contents of that compartment
what do fascial compartments involve?
- muscles
- nerve
- blood vessels
surrounds by fascia
what is fascia?
a sheet of strong, fibrous connective tissue that encases the contents of the compartment
Not able to stretch or expand
what is required in acute compartment syndrome?
Ortho emergency:
Fasciotomy
what does a fasciotomy do?
relieve pressure within the compartment and restore blood flow by cutting through the fascia down the entire length of the compartment
compartment is explored to identify and debride any necrotic muscle tissue
wound is left open and covered with a dressing
what happens if acute compartment syndrome isn’t treated?
tissue necrosis and permanent damage
what is acute compartment syndrome usually associated with?
Acute injury where bleeding or oedema associated with the injury increases the pressure within the compartment
- bone fractures
- crush injuries
presentation of acute compartment syndrome
5 P’s
- Pain - disproportionate to the underlying injury, worsened by passive stretching of the muscle
- Paraesthesia
- Pale
- Pressure (high)
- Paralysis (a late worrying feature)
what is the difference between acute limb ischaemia and acute compartment syndrome
in acute compartment syndrome, the pulses may remain intact depending on which compartment is affected
how to diagnose acute compartment syndrome
primary a clinical diagnosis
needle manometry can be used to measure the compartment pressure. Manometer measures the resistance to injecting saline through a needle into the compartment
what is the initial mnx of acute compartment syndrome?
- escalate to ortho reg/consultant
- remove any external bandages
- elevate the leg to heart level
- maintaining good blood pressure (avoiding hypotension)
what is the definitive mnx for acute compartment syndrome?
emergency fasciotomy
Compartment syndrome
what happens after the fasciotomy
Pts require repeated trips every few days to theatre to explore the compartment for necrotic tissue which needs to be debrided
wound can take several weeks to close. May need skin graft
what is chronic compartment syndrome
aka chronic exertional compartment syndrome
exertion –> pressure within compartment rises –> blood flow to compartment is restricted –> symptoms
rest –> pressure falls –> symptoms resolve
not an emergency
Sx in chronic compartment syndrome
pain, numbness or paresthesia in affected compartment
made worse by increasing activity and resolve quickly with rest
how to confirm diagnosis of chronic compartment syndrome
needle manometry - measures pressure in compartment before, during and after exertion
treatment for chronic compartment syndrome
fasciotomy
Pathophysiology of Osgood-Schlatter Disease
caused by inflammation at the tibial tuberosity where the patella ligament inserts
multiple minor avulsion fractures occur where the patella ligament pulls away tiny pieces of the bone
leads to growth of the tibial tuberosity, causing a visible lump below the knee
initially this lump is tender due to inflammation. As the bone heals and inflammation settles, the lump becomes hard and non-tender
epidemiology of Osgood-Schlatter Disease
typically occurs in patients aged 10-15yrs
more common in males
presentation of Osgood-Schlatter Disease
gradual onset of symptoms:
- visible or palpable hard and tender lump at the tibial tuberosity
- pain in the anterior aspect of the knee
- pain is exacerbated by physical activity, kneeling and on extension of the knee
management of Osgood-Schlatter Disease
initially:
- reduce physical activity
- ice
- NSAIDs
once sx settle:
- stretching
- physio
prognosis of Osgood-Schlatter Disease
- sx will fully resolve over time
- left with a hard bony lump on knee
rare complication of Osgood-Schlatter Disease
a complete avulsion fracture: the tibial tuberosity is separated from the rest of the tibia. Requires surgical intervention
what is an Achilles Tendon Rupture?
a sudden onset injury resulting in rupture of the Achilles tendon and a loss of the connection between the calf muscles (gastrocnemius + soleus) to the heel (calcaneus bone)
what are the RFs for an Achilles Tendon Rupture
- sports that stress the Achilles e.g basketball, tennis, track
- increasing age
- existing Achilles tendinopathy
- family history
- Fluoroquinolone abx e.g. ciprofloxacin + levofloxacin)
- Systemic steroids
what is fluoroquinolone abx such as ciprofloxacin + levofloxacin associated with?
Achilles tendinopathy + rupture
rupture can occur spontaneously within 48 hrs of starting trx
stop trx if it occurs
presentation of an Achilles Tendon Rupture
- sudden onset of pain in the Achilles or calf
- a snapping sound and sensation
- feeling as though something has hit them in the back of the leg
signs on examination of an Achilles Tendon Rupture
- when relaxed in a dangled position, the affected ankle will rest in a more dorsiflexed position
- tenderness to the area
- a palpable gap in the Achilles tendon (swelling may hide this)
- weakness of plantar flexion of the ankle (dorsiflexion is unaffected)
- unable to stand on tip toes on the affected leg alone
- +ve Simmonds’ calf squeeze test
what is the Simmonds’ calf squeeze test
the special test for Achilles tendon rupture
squeeze calf hanging off bed
+ve if lack of plantar flexion
immediate mnx of Achilles Tendon Rupture
- reviewed by orthopaedics on same day
- rest + immobilisation
- Ice
- Elevation
- Analgesia
- VTE prophylaxis considered while ankle is immobilised
non-surgical mnx of an Achilles Tendon Rupture
- specialist boot to immobilise ankle
- 1st boot: full planter flexion of ankle
- over 6-12w boot gradually moves ankle to neutral position
- long rehab process required to get back to full pre-injury function
- higher risk of re-rupture compared to surgical mnx
surgical mnx of Achilles Tendon Rupture
reattaches the Achilles –> boots –> rehab
Where does the anterior cruciate ligament attaches to on the tibia?
anterior intercondylar area
Where does the posterior cruciate ligament attach to on the tibia?
posterior intercondylar area
function of the ACL
it stops the tibia from sliding forward in relation to the femur
function of the PCL
it stops the tibia sliding backwards in relation to the femur
How is the ACL damaged?
during a twisting injury to the knee
presentation of an anterior cruciate ligament injury
- pain
- swelling
- ‘pop’ sound or sensation
- instability of knee joint
- tibia can move anteriorly below the femur
- the knee can buckle
- increased risk of other knee injuries
name 2 special tests to assess for anterior cruciate ligament damage
- the anterior drawer test
- Lachman test
describe the anterior drawer test
- patient supine
- hip flexed to 45
- foot flat on couch
- Dr sits on toes
- Dr pulls proximal tibia anteriorly, sliding it forward from the femur at the knee
with ACL damage, the tibia can move an excessive distance anteriorly + no clear end-point to the movement
what’s the difference between the anterior drawer test and Lachman test
Lachman: knee is flexed at around 20-30 degrees
inx for ACL injury
1st line + diagnostic: MRI
gold standard to diagnose a cruciate ligament tear: Arthroscopy
symptoms suggestive of an acute ACL tear
- a ‘pop’
- rapid onset swelling
- instability or giving way
Mnx of ACL injury
- RICE
- NSAIDs
- crutches + knee braces: help protect knee while mobilising
- physio
- arthroscopic surgery
ACL injury
what happens in arthroscopic surgery
a new ligament is formed using a graft tendon from:
- hamstring tendon
- quadriceps tendon
- bone-patellar tendon-bone
What is DeQuervain’s Tenosynovitis?
swelling + inflammation of the tendon sheaths in the wrist
a type of repetitive strain injury
results in pain on the radial side of the wrist
what tendons are affected in DeQuervain’s Tenosynovitis
- Abductor pollicis longus (APL)
- Extensor pollicis brevis (EPB)
name a cause of bilateral DeQuervain’s Tenosynovitis
‘mummy thumb’ in new parents repetitively lifting newborn babies in a way that stresses the tendons of the thumb
what does the abductor pollicus longus do?
abduct the thumb and wrist
where does the abductor pollicus longus insert into
the base of the 1st metacarpal bone (at the base of the thumb)
what does the extensor pollicis brevis do?
also abducts the thumb and wrist
where does the extensor pollicis brevis insert into?
the base of the proximal phalanx of the thumb
what do tendon sheaths do?
surround tendons.
formed by connective tissue (synovial membrane) that covers the tendons + filled with synovial fluid
they help lubricate + protect the movement of tendons within them
what is the extensor retinaculum?
a fibrous band that wraps across the back (dorsal) side of the wrist
the APL + EPB pass underneath it
what is the pathophysiology of DeQuervain’s Tenosynovitis
repetitive movement of the APL + EPB under the extensor retinaculum result in inflammation + swelling of the tendon sheaths
presentation of DeQuervain’s Tenosynovitis
symptoms at radial aspect of wrist near base of thumb:
- pain, often radiating to forearm
- aching
- burning
- weakness
- numbness
- tenderness
what is the special test for DeQuervain’s Tenosynovitis
Finkelstein’s test (or maybe called Eichhoff’s test)
What is Finkelstein’s test?
pt makes fist with thumb inside fingers
adduct wrist
if this causes pain at the radial aspect of the wrist, the test is +ve —> De Quervain’s tenosynovitis
mnx of De Quervain’s tenosynovitis
- rest + adapting activities
- splints to restrict movements
- NSAIDs
- physio
- steroid injections
- Rare: surgery to release the extensor retinaculum to release pressure + create more space for tendons
FROZEN SHOULDER
Pathophysiology
aka adhesive capsulitis
inflammation + fibrosis in the joint capsule lead to adhesions
adhesions bind the capsule + cause it to tighten around the joint, restricting movement in the joint
what is primary adhesive capsulitis
(frozen shoulder)
occurring spontaneously without any trigger
what is secondary adhesive capsulitis
(frozen shoulder)
occurring in response to trauma, surgery or immobilisation
what is a key risk factor of frozen shoulder?
diabetes
describe the typical course of symptoms of frozen shoulder in 3 phases
Painful phase: shoulder pain is often the 1st symptom + may be worse at night
Stiff phase: shoulder stiffness develops + affects both active and passive movement (external rotation is the most affected). The pain settles during this phase
Thawing phase: gradual improvement in stiffness + a return to normal
how long does frozen shoulder last for?
1-3 years
but up to 50% have persistent symptoms
name 3 differential diagnoses in a patient presenting with shoulder pain not preceded by trauma or an acute injury
- Supraspinatus tendinopathy
- Acromioclavicular joint arthritis
- Glenohumeral joint arthritis
name 3 rare but important differentials of shoulder pain not preceded by trauma
- septic arthritis
- inflammatory arthritis
- malignancy e.g. osteosarccoma or bony metastasis)
name 3 differentials for shoulder pain
- shoulder dislocation
- fractures e.g. proximal humerus, clavicle or rarely the scapula)
- rotator cuff tear
what is supraspinatus tendinopathy?
inflammation + irritation of the supraspinatus tendon
particularly due to impingement at the point where it passes between the humeral head + the acromion
what test can be used to assess for supraspinatus tendinopathy?
the empty can test aka Jobe test
+ve if pain or arm gives way
Acromioclavicular joint arthritis signs on examination (3)
- tenderness to palpation of the AC joint
- Pain is worse at the extremes of the shoulder abduction, from around 170 degrees onwards when the arm is overhead
- +ve scarf test: pain caused by wrapping arm across chest + opposite shoulder
diagnosing adhesive capsulitis (frozen shoulder)
clinical, no imaging usually required
X-rays are normal but helpful in diagnosing osteoarthritis as a differential
US, CT or MRI can show a thickened joint capsule
non surgical mnx for adhesive capsulitis (frozen shoulder)
- continue using arm but don’t exacerbate pain
- NSAIDs
- physio
- intra-articular steroid injections
- hydrodilation (injecting fluid into the joint to stretch the capsule)
surgical mnx for adhesive capsulitis (frozen shoulder)
- manipulation under anaesthesia: forcefully stretching the capsule to improve the range of motion
- arthroscopy: keyhole surgery on the shoulder to cut the adhesions + release the shoulder
Dupuytren’s Contracture
Pathophysiology?
the palmar fascia of the hands becomes thicker + tighter + develops nodules
cords of dense connective tissue can extend into the fingers, pulling the fingers into flexion + restricting their ability to extend (contracture)
Dupuytren’s Contracture
why does the palmar fascia become thicker and tighter
unclear but thought to be an inflammatory process in response to microtrauma
Dupuytren’s Contracture
Risk factors?
- age
- FH (autosomal dominant)
- male
- manual labour, esp vibrating tools
- diabetes
- epilepsy
- smoking + alcohol
Dupuytren’s Contracture
Presentation?
- 1st sign: hard nodules on palm
- finger pulled into flexion
- can’t extend finger fully
- significantly affects function
Dupuytren’s Contracture
what finger is most and least likely to be affected
most: ring finger
least: index
Dupuytren’s Contracture
special test?
the table-top test
+ve if hand cannot rest completely flat on table
Dupuytren’s Contracture
Management?
- do nothing
- needle fasciotomy (aka needle aponeurotomy): insert needle to loosen cord causing contracture
- limited fasciectomy: remove abnormal fascia + cord to release contracture
- dermofasciectomy: remove abnormal fascia + cord + skin. Skin graft replaces removed skin
compound fracture?
when the skin is broken + the broken bone is exposed to the air.
the broken bone can puncture through the skin
stable fracture?
when the sections of bone remain in alignment at the fracture
pathological fracture?
when a bone breaks due to an abnormality within the bone
e.g. tumour, osteoporosis, Paget’s disease
terms used to describe what way a bone breaks
- transverse
- oblique
- spiral
- segmental
- comminuted
- compression fractures
- greenstick
- buckle (torus)
- Salter-Harris
Fractures
comminuted?
breaking into multiple fragments
Fractures
compression fractures?
affecting the vertebrae in the spine
Greenstick and buckle fractures typically occur in children or adults?
children
Fractures
Salter-Harris
growth plate fracture
only occur in children as adults don’t have growth plates
Colle’s fracture
- a transverse fracture of the distal radius near the wrist
- causing the distal portion to displace posteriorly (upwards)
- causing a ‘dinner fork deformity’
- usually the result of a fall onto an outstretched hand (FOOSH)
what causes a scaphoid fracture?
fall onto an outstretched hand (FOOSH)
scaphoid fracture sign
tenderness in the anatomical snuffbox
what is a complication of a scaphoid fracture and explain
avascular necrosis + non-union
because the scaphoid has a retrograde blood supply with blood vessels supplying the bone from only one direction
this means a fracture can cut off the blood supply
name some bones with a vulnerable blood supply where a fracture can lead to avascular necrosis , impaired healing + non-union
- scaphoid bone
- femoral head
- humeral head
- talus, navicular + 5th metatarsal in the foot
what do ankle fractures involve?
- lateral malleolus (distal fibula)
- medial malleolus (distal tibia)
what is the Weber classification?
used to describe fractures of the lateral malleolus (distal fibula)
the fracture is described in relation to the distal syndesmosis (fibrous joint) between the tibia and fibula
what is the tibiofibular syndesmosis
important for stability + function of the ankle joint
if a fracture disrupts it, surgery is more likely to be required
Weber classification
Type A
below the ankle joint - will leave the syndesmosis intact
Weber classification
Type B
at the level of the ankle joint - the syndesmosis will be intact or partially torn
Weber classification
Type C
above the ankle joint - the syndesmosis will be disrupted
Pelvic Ring fracture?
- the pelvis forms a ring
- when 1 part fractures, another part will also fracture (like a polo mint)
complications of a pelvic ring fracture
- intra-abdominal bleeding due to vascular injury or from the cancellous bone of the pelvis
- can lead to shock + death
what are common sites of pathological fractures?
femur and the vertebral bodies
what cancers metastasise to bone?
PoRTaBLe Po - prostate R - renal Ta - Thyroid B - breast Le - Lung
Ganglion Cysts
what are they?
sacs of synovial fluid that originate from the tendon sheaths or joints
Ganglion Cysts
where do they commonly occur?
wrist + fingers but can occur anywhere there is a joint or tendon sheath
Ganglion Cysts
pathophysiology
when the synovial membrane of the tendon sheath or joint herniates, forming a pouch
synovial fluid flows from the tendon sheath or joint into the pouch, forming a cyst
Ganglion Cysts
presentation
- visible and palpable lump
- not painful
- can appear rapidly or gradually
- rare: compresses nerves leading to sensory or motor symptoms
Ganglion Cysts
examination findings
- 0.5-5cm usually
- firm + non-tender on palpation
- well-circumscribed
- trans illuminates
Ganglion Cysts
diagnosis
- clinically !
- x-rays: normal bones + joints
- US: may help confirm dx + exclude other causes of lumps
Ganglion Cysts
mnx
- conservatively: 40-50% resolve spontaneously but can take several years
- needle aspiration
- surgical excision
Ganglion Cysts
disadvantage of needle aspiration for mnx
high rate of recurrence (50% or more)
Ganglion Cysts
pros and cons of surgical excision for mnx
+ recurrence rate is low
- infection, scarring
Fractures
cause of fragility fractures
weakness in the bone usually due to osteoporosis
Fractures
what is the FRAX tool
a patient’s risk of a fragility fracture over the next 10 years
Fractures
how can bone mineral density be measured?
with a DEXA scan
Fractures
T score of more than -1
normal
Fractures
T score of -1 to -2.5
osteopenia
Fractures
T score of less than -2.5
osteoporosis
Fractures
T score of less than -2.5 plus a fracture
severe osteoporosis
Fractures
1st line medical treatments for reducing the risk of fragility fractures
- Calcium + Vit D
- Bisphosphonates e.g. alendronic acid
Fractures
how do bisphosphonates work
they reduce osteoclast activity, preventing the reabsorption of bone
Fractures
side effects of bisphosphonates
- reflux and oesophageal erosions
- atypical fractures
- osteonecrosis of the jaw
- osteonecrosis of the external auditory canal
Fractures
instruction to patients taking biphosphonates
- take on an empty stomach
- sit upright for 30 min before moving or eating
Fractures
alternative to bisphosphonates where they are CI’d, not tolerated or not effective
Denosumab - a monoclonal antibody that blocks the activity of osteoclasts
Fractures
inx for suspected bone fracture
X-rays - 2 views are always required as a single view may miss a fracture
CT: more detailed view of bones when the x-rays are inconclusive or further info needed
Fractures
principles of fracture mnx
- achieve mechanical alignment
2. provide relative stability for some time to allow healing to occur
Fractures
how to achieve mechanical alignment of the fracture
- closed reduction via manipulation of the limb
- open reduction via surgery
Fractures
how to provided relative stability in a fracture
fix bone in correct position while it heals:
- external casts
- K wires
- Intramedullary wires
- intramedullary nails
- screws
- plates + screws
Fractures
what are complex fractures
those requiring surgery e.g. hip fractures
referred to the on-call trauma + orthopaedic team
Fractures
possible early complications
- damage to local structures
- haemorrhage leading to shock + potentially death
- compartment syndrome
- fat embolism
- VTE
Fractures
possible longer-term complications
- delayed union (slow healing)
- malunion (misaligned healing)
- non-union (failure to heal)
- avascular necrosis (death of bone)
- infection (osteomyelitis)
- joint instability
- joint stiffness
- contractures
- arthritis
- chronic pain
- complex regional pain syndrome
Fractures
how can a fracture of a long bone cause a fat embolism
fat globules are released into the circulation following a fracture (possibly from the bone marrow)
these globules may become lodged in blood vessels and cause blood flow obstruction
Fractures
what is fat embolism syndrome
fat embolisation can cause a systemic inflammatory response resulting in a fat embolism syndrome
Fractures
what is Gurd’s MAJOR criteria for the diagnosis of a fat embolism
- resp distress
- petechial rash
- cerebral involvement
Fractures
name some of Gurd’s MINOR criteria
- jaundice
- thrombocytopenia
- fever
- tachycardia
Fractures
mnx of fat embolism
supportive
operate early to fix the fracture reduces the risk of fat embolism syndrome
Osteomyelitis
what is it
inflammation in a bone and bone marrow, usually caused by bacterial infection
Osteomyelitis
what is haematogenous osteomyelitis
when a pathogen is carried through the blood and seeded in the bone
this is the most common mode of infection
Osteomyelitis
causes
- haematogenous osteomyelitis
- direct contamination of the bone: fracture site, ortho operation
Osteomyelitis
what organism causes most cases
Staphylococcus aureus
Osteomyelitis
types
acute or chronic
Osteomyelitis
RFs (6)
- open fractures
- orthopaedic operations. esp prosthetic joints
- diabetes, esp foot ulcers
- peripheral artery disease
- IV drug use
- immunosuppression
Osteomyelitis
what measures are taken to prevent infection in prosthetic joints
perioperative prophylactic abx
it’s more likely to occur in revision surgery rather than during initial joint replacement
Osteomyelitis
presentation (4)
- fever
- pain + tenderness
- erythema
- swelling
Osteomyelitis
potential signs on an x-ray
often no changes
- Periosteal reaction
- Localised osteopenia
- Destruction of areas of the bone
Osteomyelitis
x-ray: what is periosteal reaction
changes to the surface of the bone
Osteomyelitis
x-ray: what is localised osteopenia
thinning of the bone
Osteomyelitis
what is the best imaging inx for establishing dx
MRI
Osteomyelitis
what will blood tests show
raised inflammatory markers (WBC, ESR, CRP)
Osteomyelitis
what may blood cultures show
may be positive for causative organism (usually staph aureus)
Osteomyelitis
what can be performed to establish the causative organism and the abx sensitivities
bone cultures
Osteomyelitis
mnx
a combination of
-surgical debridement of the infected bone + tissues
- abx therapy
Osteomyelitis
abx dose and length of trx for acute osteomyelitis
6w of flucloxacillin
possible with rifampicin or fusidic acid added for the first 2w
Osteomyelitis
alternative to flucloxacillin if there is a penicillin allergy
clindamycin
Osteomyelitis
alternative to flucloxacillin when treating MRSA
vancomycin or teicoplanin
Osteomyelitis
how long is the course of abx required for chronic osteomyelitis
3m or more
Osteomyelitis
mnx of osteomyelitis associated with prosthetic joints
may require complete revision surgery to replace the prosthesis
which structures are joined by the ACL
lateral condyle of femur and tibia
Hip Fractures
major RFs (2)
- increasing age
- osteoporosis
Hip Fractures
what can they be categorised into?
Intra-capsular fractures
Extra-capsular fractures
Hip Fractures
why is the aim to perform surgery within 48h
Due to the morbidity and mortality
Hip Fractures
what is the capsule of the hip joint
a strong fibrous structure
Hip Fractures
where does the capsule attach
to the rim of the acetabulum on the pelvis and the intertrochanteric line
Hip Fractures
what kind of blood supply does the head of femur have
a retrograde blood supply
Hip Fractures
what is the only blood supply to the femoral head
the medial and lateral circumflex femoral arteries join the femoral neck just proximal to the intertrochanteric line
branches of this artery run along the surface of the femoral neck, within the capsule, towards the femoral head
Hip Fractures
how can it lead to avascular necrosis
A fracture of the intra-capsular neck of the femur can damage these blood vessels, removing the blood supply to the femoral head
Hip Fractures
mnx of pt with a displaced intra-capsular fracture
femoral head replaced with a hemiarthroplasty or total hip replacement
Hip Fractures
what do intra-capsular fractures involve
a break in the femoral neck, within the capsule of the hip joint
Hip Fractures
what area does a intra-capsular fracture affect
proximal to the intertrochanteric line
Hip Fractures
what classification is used for intra-capsular neck of femur fractures
the Garden classification
Hip Fractures
Intra-capsular: what does non displaced mean
may have an intact blood supply to the femoral head
it may be possible to preserve the femoral head without avascular necrosis occurring
Hip Fractures
what can a non displaced intra-capsular fracture be treated with
internal fixation (e.g. screws)
Hip Fractures
Intra-capsular: what does displaced mean
(grade III and IV) disrupt the blood supply to the head of the femur. Therefore, the head of the femur needs to be removed and replaced.
Hip Fractures
Garden classification: Grade I
incomplete fracture and non-displaced
Hip Fractures
Garden classification: Grade II
complete fracture and non-displaced
Hip Fractures
Garden classification: Grade III
partial displacement (trabeculae are at an angle)
Hip Fractures
Garden classification: Grade IV
full displacement (trabeculae are parallel)
Hip Fractures
intra capsular: what does a hemiarthroplasty involve
replacing the head of the femur but leaving the acetabulum (socket) in place
Cement is used to hold the stem of the prosthesis in the shaft of the femur.
Hip Fractures
intra capsular: hermiarthroplasties are often offered to which types of pts
limited mobility or significant co-morbidities.
Hip Fractures
intra capsular: what does a total hip replacement involve
replacing both the head of the femur and the socket
Hip Fractures
intra capsular: who is offered a total hip replacement
patients who can walk independently and are fit for surgery
Hip Fractures
what are extra-capsular fractures
Extra-capsular fractures leave the blood supply to the head of the femur intact.
Therefore, the head of the femur does not need to be replaced.
Hip Fractures
extra-capsular: where do intertrochanteric fractures occur
between the greater and lesser trochanter
Hip Fractures
extra-capsular: what are intertrochanteric fractures treated with
dynamic hip screw (aka sliding hip screw)
Hip Fractures
extra-capsular: what is a dynamic hip screw
screw goes through the neck and into the head of the femur.
A plate with a barrel that holds the screw is screwed to the outside of the femoral shaft.
The screw that goes through the femur to the head allows some controlled compression at the fracture site, whilst still holding it in the correct alignment.
Adding some controlled compression across the fracture improves healing.
Hip Fractures
extra-capsular: where do Subtrochanteric fractures occur
distal to the lesser trochanter (although within 5cm)
The fracture occurs to the proximal shaft of the femur
Hip Fractures
extra-capsular: what may a subtrochanteric fracture be treated with
an intramedullary nail
Hip Fractures
extra-capsular: what is an intramedullary nail
a metal pole inserted through the greater trochanter into the central cavity of the shaft of the femur
Hip Fractures
presentation
> 60 who has fallen with:
- shortened, abducted and externally rotated leg
- not able to weight bear
- pain in groin or hip which may radiate to knee
Hip Fractures
what may pts also be suffering from (determine cause of fall)
- Anaemia
- Electrolyte imbalances
- Arrhythmias
- Heart failure
- Myocardial infarction
- Stroke
- Urinary or chest infection
Hip Fractures
initial inx of choice
x-ray (2 views are essential)
- AP
- lateral
Hip Fractures
x-ray: what is a key sign of a fractured neck of femur
disruption of Shenton’s line
Hip Fractures
x-ray: what is Shenton’s line
AP view: one continuous curving line formed by the medial border of the femoral neck and continues to the inferior border of the superior pubic ramus.
Hip Fractures
what is used if x-ray is negative but fracture still suspected
MRI or CT
Hip Fractures
mnx on admission
- anlagesia
- x-ray
- VTE prophylaxis
- pre-op assessment: bloods, ECG
- Orthogeriatrics input
Hip Fractures
mnx: when should surgery be carried out
within 48hrs
Spinal Stenosis
what is it
narrowing of part of the spinal canal, resulting in compression of the spinal cord or nerve roots
Spinal Stenosis
what is the most common type
lumbar
Spinal Stenosis
whom is it more likely to occur in
> 60 yr patients
relating to degenerative changes in the spine
Spinal Stenosis
What are the 3 types
- central stenosis
- lateral stenosis
- foramina stenosis
Spinal Stenosis
what is central stenosis
narrowing of the central spinal canal
Spinal Stenosis
what is lateral stenosis
narrowing of the nerve root canals
Spinal Stenosis
what is foramina stenosis
narrowing of the intervertebral foramina
Spinal Stenosis
causes (7)
- congenital
- degenerative changes: facet joint changes, disc disease, bone spurs
- herniated discs
- thickening of the ligamenta flava or posterior longitudinal ligament
- spinal fractures
6, spondylolisthesis
- tumours
Spinal Stenosis
causes: what is Spondylolisthesis
anterior displacement of a vertebra out of line with the one below
Spinal Stenosis
what the difference between this and cauda equina/sudden disc herniation
sx tend to be gradual in spinal stenosis
Spinal Stenosis
what symptoms may severe compression show
features of cauda equina:
- saddle anaesthesia
- sexual dysfunction
- incontinence of bladder + bowel
Spinal Stenosis
what is a key presenting feature of lumbar spinal stenosis with central stenosis
Intermittent neurogenic claudication aka pseudoclaudication:
- lower back pain
- buttock and leg pain
- leg weakness
sx absent at rest and when seated but occur with standing and walking
Spinal Stenosis
why are sx absent at rest and when seated in Intermittent neurogenic claudication
Bending forward (flexing the spine) expands the spinal canal and improves symptoms.
Standing straight (extending the spine) narrows the canal and worsens the symptoms
Spinal Stenosis
symptoms in Lateral stenosis and foramina stenosis in the lumbar spine
symptoms of sciatica
Spinal Stenosis
definition of radiculopathy
compression of the nerve roots as they exit the spinal cord and spinal column, leading to motor and sensory symptoms.
Spinal Stenosis
what is the difference between peripheral arterial disease and symptoms of intermittent neurogenic claudication
peripheral pulses or the ankle-brachial pressure index (ABPI) are normal –>spinal stenosis.
back pain –> spinal stenosis
Spinal Stenosis
primary imaging inx for dx
MRI
Spinal Stenosis
conservative mnx
- Exercise and weight loss (if appropriate)
- Analgesia
- Physiotherapy
Spinal Stenosis
mnx where conservative trx fails
Decompression surgery
laminectomy: removal of part or all of the lamina from the affected vertebra
causative organism for gas gangrene
Clostridia perfringens
shoulder dislocation
what is it
head of humerus comes entirely out of glenoid cavity of the scapula
shoulder dislocation
what is subluxation
partial dislocation of the shoulder
the ball does not come fully out of socket and naturally pops back into place shortly afterwards
shoulder dislocation
what is an anterior dislocations
the head of the humerus moves anteriorly in relation to the glenoid cavity
can occur when the arm is forced backwards whilst abducted and extended at the shoulder
shoulder dislocation
what are posterior dislocations associated with
electric shocks and seizures
shoulder dislocation
what is the labrum
a rim of cartilage that creates a deeper socket for the head of the humerus to fit into
shoulder dislocation
associated damage: what are Bankart lesions
tears to the anterior portion of the labrum
occur with repeated anterior subluxations or dislocations of the shoulder
shoulder dislocation
associated damage: what are Hill-Sachs lesions
compression fractures of the posterolateral part of the head of the humerus
shoulder dislocation
associated damage: which nerve roots does the axillary nerve come from
C5 and C6
shoulder dislocation
associated damage: what can axillary nerve damage cause
loss of sensation in the ‘regimental badge’ area over the lateral deltoid
motor weakness in the deltoid and teres minor muscles
shoulder dislocation
presentation
- muscle will go into spasm and tighten around the joint
- deltoid appears flattened
- bulge at front of shoulder (head of humerus)
shoulder dislocation
what test is used to assess for shoulder instability
apprehension test
shoulder dislocation
what happens in the apprehension test
- patient lies supine
- shoulder abducted to 90 degrees. elbow flexed to 90 degrees
- slowly externally rotate shoulder
- pt becomes anxious and apprehensive
shoulder dislocation
inx
- xray excludes fracture
- MRI assesses shoulder for damage
- Arthroscopy
shoulder dislocation
acute mnx
- analgesia
- gas + air
- broad arm sling for support
- closed reduction of shoulder (after excluding fractures)
- post-reduction x-ray
- immobilisation for a period after relocation of the shoulder
shoulder dislocation
ongoing mnx
- physio to reduce risk of further dislocations
- shoulder stabilisation surgery
Meralgia Paraesthetica
what is it
localised sensory symptoms of the outer thigh caused by compression of the lateral femoral cutaneous nerve
a mononeuropathy
Meralgia Paraesthetica
where does the lateral cutaneous nerve originate from
- varying combinations of L1, L2 and L3 nerve roots
- behind psoas muscle
- around surface of iliacus muscle
- under the inguinal ligament onto the thigh
- just medial and inferior to the ASIS
Meralgia Paraesthetica
why are there no motor sx
the lateral femoral cutaneous nerve only carries sensory signals to the upper-outer thigh
Meralgia Paraesthetica
presentation
dysaesthesia (abnormal sensations) and anaesthesia to the upper-outer thigh
burning, numbing, pins + needles, cold
may have hair loss
Meralgia Paraesthetica
when are sx worse
walking or standing for a long duration
extension of hip
Meralgia Paraesthetica
dx
clinically
Meralgia Paraesthetica
conservative mnx
- Rest
- Looser clothing (tight clothes such as belts may add pressure to the nerve)
- Weight loss
- Physiotherapy
Meralgia Paraesthetica
medical mnx
- Paracetamol
- NSAIDs
- Neuropathic analgesia (e.g., amitriptyline, gabapentin, pregabalin or duloxetine)
- Local injections of steroids or local anaesthetics
Meralgia Paraesthetica
surgical mnx
Decompression – removing pressure on the nerve
Transection – cutting the nerve
Resection – removing the nerve
Plantar Fasciitis
what does the plantar fascia connect
thick connective tissue which attaches to the calcaneus at the heel
travels along the sole of the foot and branches out to connect to the flexor tendons of the toes.
Plantar Fasciitis
presentation
- gradual onset of pain on the plantar aspect of the heel
- worse with pressure (walking, standing)
- tenderness to palpation of area
Plantar Fasciitis
mnx
- rest
- ice
- analgesia
- physio
- steroid injections
- extracorporeal shockwave therapy
- surgery
Plantar Fasciitis
what could steroid injections potentially cause
- rupture of the plantar fascia
- fat pad atrophy
Fat Pad Atrophy
what can cause it
age or inflammation from repetitive impacts, such as jumping activities, running, walking, and obesity,steroid injections
Fat Pad Atrophy
sx
pain and tenderness over the plantar aspect of the heel
worse with activities, particularly when barefoot on hard surfaces.
Fat Pad Atrophy
how can thickness of the fat pad be measured
with an USS
Fat Pad Atrophy
mnx
- comfortable shoes
- custom insoles
- adapting activities (e.g. avoid high heels)
- weight loss
Morton’s Neuroma
what is it
dysfunction of a nerve in the intermetatarsal space (between the toes) towards the top of the foot
Morton’s Neuroma
where is the abnormal nerve usually located
between the third and fourth metatarsal
Morton’s Neuroma
cause
irritation of the nerve relating to the biomechanics of the foot.
High-heels or narrow shoes may exacerbate it.
Morton’s Neuroma
sx
- Pain at the front of the foot at the location of the lesion
- sensation of a lump in the shoe
- Burning, numbness or “pins and needles” felt in the distal toes
Morton’s Neuroma
3 ways to test for it
- deep pressure
- metatarsal squeeze test
- Mulder’s sign
Morton’s Neuroma
what happens when you apply deep pressure to the affected intermetatarsal space on the dorsal foot
causes pain
Morton’s Neuroma
what is a positive metatarsal squeeze test
pain
Morton’s Neuroma
what is Mulder’s sign
painful click is felt when using two hands on either side of the foot to manipulate the metatarsal heads to rub the neuroma
Morton’s Neuroma
how to confirm dx
US or MRI
Morton’s Neuroma
mnx options
- Adapting activities (e.g., avoiding high heels)
- Analgesia (NSAIDs if suitable)
- Insoles
- Weight loss if appropriate
- Steroid injections
- Radiofrequency ablation
- Surgery (e.g., excision of the neuroma)
Bunions (Hallux Valgus)
what is it
a bony lump created by a deformity at the metatarsophalangeal joint (MTP) at the base of the big toe.
The first metatarsal becomes angled medially,
the big toe (hallux) become angled laterally (towards the other toes),
the MTP joint becomes inflamed and enlarged.
Bunions (Hallux Valgus)
what can be used to asses the extent of the deformity
Weight-bearing x-rays
Bunions (Hallux Valgus)
conservative mnx
wide, comfortable shoes
analgesia.
bunion pads
Bunions (Hallux Valgus)
definitive trx
surgery: realign the bones and correct the deformity
Rotator Cuff Tears
name the 4 rotator cuff muscles
- supraspinatus
- infraspinatus
- teres minor
- subscapularis
Rotator Cuff Tears
what action does the supraspinatus do
abducts the arm
Rotator Cuff Tears
what action does the infraspinatus do
externally rotates the arm
Rotator Cuff Tears
what action does the teres minor do
externally rotates the arm
Rotator Cuff Tears
what action does the subscapularis do
internally rotates the arm
Rotator Cuff Tears
presentation
- Shoulder pain
- Weakness and pain with specific movements relating to the site of the tear (e.g., abduction with a supraspinatus tear)
Rotator Cuff Tears
diagnostic inx
US or MRI scans
Rotator Cuff Tears
non surgical mnx
- Rest and adapted activities
- Analgesia (e.g., NSAIDs)
- Physiotherapy
Rotator Cuff Tears
surgical mnx
arthroscopic rotator cuff repair, where the tendon is reattached to the bone during an arthroscopy
Carpal Tunnel Syndrome
cause
compression of the medial nerve as it travels through the carpel tunnel
due to swelling of the contents or narrowing of the tunnel
Carpal Tunnel Syndrome
what is the fibrous band that wraps across the front (palmar side) of the wrist
flexor retinaculum
aka
transverse carpal ligament
Carpal Tunnel Syndrome
where is the carpal tunnel situated
Between the carpal bones and the flexor retinaculum
Carpal Tunnel Syndrome
what travels through the carpel tunnel
The median nerve and the flexor tendons of the forearm
Carpal Tunnel Syndrome
which branch of the median nerve is responsible for sensory innervation of the palmar aspects and full fingertips of the thumb, index and middle finger
and the lateral half of ring finger
palmar digital cutaneous branch
Carpal Tunnel Syndrome
which parts of the hand are innervated by the palmar digital cutaneous branch
palmar aspects and full fingertips of the:
- Thumb
- Index and middle finger
- The lateral half of ring finger
Carpal Tunnel Syndrome
which branch of the median nerve is responsible for sensory innervation to the palm
palmar cutaneous branch
Carpal Tunnel Syndrome
why is the palmar cutaneous branch (+ therefore palm) not affected by carpal tunnel syndrome
this branch originates before the carpal tunnel and does not travel through the carpal tunnel.
Carpal Tunnel Syndrome
what muscles does the median nerve supply
- abductor pollicus brevis
- opponens pollicis
- flexor pollicis brevis
Carpal Tunnel Syndrome
which movement is Abductor pollicis brevis responsible for
thumb abduction
Carpal Tunnel Syndrome
which movement is Opponens pollicis responsible for
thumb opposition – reaching across the palm to touch the tips of the fingers
Carpal Tunnel Syndrome
which movement is Flexor pollicis brevis responsible for
thumb flexion
Carpal Tunnel Syndrome
key risk factors (7)
ROAR PHD
- repetitive strain
- obesity
- acromegaly
- RA
- perimenopause
- hypothyroidism
- diabetes
Carpal Tunnel Syndrome
possible causes of bilateral carpal tunnel syndrome
- RA
- diabetes
- acromegaly
- hypothyroidism
Carpal Tunnel Syndrome
presentation of onset
- gradual
- intermittent
- often worse at night
Carpal Tunnel Syndrome
sensory sx and where
numbness, paraesthesia, burning pain
palmar aspects and full fingertips of the:
- Thumb
- Index and middle finger
- lateral half of ring finger
Carpal Tunnel Syndrome
how may they try and relieve sensory sx
shaking their hand
Carpal Tunnel Syndrome
motor sx
affect the thenar muscles, with:
- Weakness of thumb movements
- Weakness of grip strength
- Difficulty with fine movements involving the thumb
- Wasting of the thenar muscles (muscle atrophy)
Carpal Tunnel Syndrome
what are the 2 special test for carpal tunnel syndrome
Phalen’s test
Tinnel’s test
Carpal Tunnel Syndrome
what can be used to predict the likelihood of a diagnosis of carpal tunnel syndrome
The Kamath and Stothard carpal tunnel questionnaire (CTQ)
Carpal Tunnel Syndrome
what is the primary inx for establishing the diagnosis
nerve conduction studies
Carpal Tunnel Syndrome
non surgical mnx
- Rest and altered activities
- Wrist splints that maintain a neutral position of the wrist can be worn at night (for a minimum of 4 weeks)
- Steroid injections
Carpal Tunnel Syndrome
surgical mnx
- day case under local
- endoscopic or open
- The flexor retinaculum (AKA transverse carpal ligament) is cut to release the pressure on the median nerve.
Sarcoma
what is it
cancer originating in the muscles, bones or other types of connective tissue
Sarcoma
name some bone sarcomas
- osteosarcoma
- Chondrosarcoma
- Ewing sarcoma
Sarcoma
what is the most common form of bone cancer
osteosarcoma
Sarcoma
key features that should raise suspicion
A soft tissue lump, particularly if growing, painful or large
Bone swelling
Persistent bone pain
Sarcoma
what is the initial inx for bony lumps or persistent pain
x-ray
Sarcoma
what is the initial inx for soft tissue lumps
US
Sarcoma
what may be used to visualise the lesion in more detail and look for metastatic spread
CT or MRI scans
esp CT thorax, as sarcoma most often spreads to the lungs
Sarcoma
what inx is required to look at the histology of cancer
biopsy
Sarcoma
staging
TNM or number system
Sarcoma
where is the most common location for sarcoma to metastasise to
lungs
Sarcoma
who guides trx
sarcoma multidisciplinary team (MDT)
specialist sarcoma centres
Sarcoma
mnx
Surgery (surgical resection is the preferred treatment)
Radiotherapy
Chemotherapy
Palliative care
Back Pain and Sciatica
what is another term for lower back pain
lumbago
Back Pain and Sciatica
what does non-specific or mechanical lower back pain refer to
patients who do not have a specific disease causing their lower back pain
Back Pain and Sciatica
what does sciatica refer to
symptoms associated with irritation of the sciatic nerve
Back Pain and Sciatica
causes of mechanical back pain
- Muscle or ligament sprain
- Facet joint dysfunction
- Sacroiliac joint dysfunction
- Herniated disc
- Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
- Scoliosis (curved spine)
- Degenerative changes (arthritis) affecting the discs and facet joints
Back Pain and Sciatica
causes of neck pain
- muscle or ligament strain
- torticollis
- whiplash
- cervical spondylosis
Back Pain and Sciatica
what is torticollis
waking up with a unilaterally stiff and painful neck due to muscle spasm
Back Pain and Sciatica
red flag causes of back pain
- spinal fracture
- cauda equina
- spinal stenosis
- ankylosing spondylitis
- spinal infection
Back Pain and Sciatica
abdo or thoracic conditions that can cause back pain
- Pneumonia
- Ruptured aortic aneurysms
- Kidney stones
- Pyelonephritis
- Pancreatitis
- Prostatitis
- Pelvic inflammatory disease
- Endometriosis
Back Pain and Sciatica
what forms the sciatic nerves
The spinal nerves L4 – S3 come together to form the sciatic nerve.
Back Pain and Sciatica
where does the sciatic nerve exit the pelvis
through the greater sciatic foramen, in the buttock area on either side
Back Pain and Sciatica
what does the sciatic nerve divide into and where
tibial nerve and the common peroneal nerve
at the knee
Back Pain and Sciatica
where does the sciatic nerve supply sensation to
lateral lower leg and the foot
Back Pain and Sciatica
where does the sciatic nerve supply motor function to
the posterior thigh, lower leg and foot
Back Pain and Sciatica
sx of sciatica
- unilateral pain from the buttock radiating down the back of the thigh to below the knee or feet
‘electric’ or ‘shooting’ pain - paraesthesia (pins + needles)
- numbness
- motor weakness
- reflexes may be affected
Back Pain and Sciatica
what are the main causes of sciatica
lumbosacral nerve root compression by:
- herniated disc
- spondylolisthesis
- spinal stenosis
Back Pain and Sciatica
what is bilateral sciatica a red flag for
cauda equina syndrome
Back Pain and Sciatica
what test can be used to help diagnose sciatica
The sciatic stretch test
Back Pain and Sciatica
what is involved in the sciatic stretch test
- pt lies on their back with their leg straight.
- examiner lifts one leg from the ankle with knee extended until limit of hip flexion is reached
- examiner dorsiflexes ankle.
Back Pain and Sciatica
what result in the sciatic stretch test indicates sciatic nerve root irritation
Sciatica-type pain in the buttock/posterior thigh
sx improve with flexing the knee
Back Pain and Sciatica
inx for suspected cauda equina
emergency MRI scan
Back Pain and Sciatica
inx for suspected ankylosing spondylitis
- CRP and ESR
- bamboo spin on x-ray
- MRI may show bone marrow oedema in early disease
Back Pain and Sciatica
what is used to stratify the risk of a patient presenting with acute back pain developing chronic back pain
STarT Back Screening Tool
Back Pain and Sciatica
what can pts at low risk for chronic back pain be managed with
- Self-management
- Education
- Reassurance
- Analgesia
- Staying active and continuing to mobilise as tolerated
Back Pain and Sciatica
additional mnx options for pts at medium or high risk of developing chronic back pain
- physio
- group exercise
- CBT
Back Pain and Sciatica
NICE advice on analgesia
1st line: NSAIDs
codeine as alternative
Back Pain and Sciatica
what med can be used for muscle spasm
benzodiazepine (diazepam) for up to 5d
Back Pain and Sciatica
what meds should you specifically not used for lower back pain
opioids, antidepressants, amitriptyline, gabapentin or pregabalin
Back Pain and Sciatica
mnx for pts with chronic lower back pain originating in the facet joints
radiofrequency denervation
- target and damage the medial branch nerves that supply sensation to the facet joints
- under local
Back Pain and Sciatica
initial mnx of sciatica
same as acute lower back pain
Back Pain and Sciatica
what meds should you not use in sciatica
gabapentin, pregabalin, diazepam or oral corticosteroids or opioids
Back Pain and Sciatica
what neuropathic meds would you consider if sx are persisting in sciatica
- amitriptyline
- duloxetine
Back Pain and Sciatica
specialist mnx options for chronic sciatica
- Epidural corticosteroid injections
- Local anaesthetic injections
- Radiofrequency denervation
- Spinal decompression
Cauda Equina Syndrome
what is it
a surgical emergency where the nerve roots of the cauda equina at the bottom of the spine are compressed
Cauda Equina Syndrome
at what level does the spinal cord termiante
around L2/L3
Cauda Equina Syndrome
what does the spinal cord taper down to
conus medullaris
Cauda Equina Syndrome
what is the cauda equina
‘horse’s tail’ - a collection of nerve roots that travel through the spinal canal after the spinal cord terminates
Cauda Equina Syndrome
what do the nerves of the cauda equina supply (sensation)
Sensation to the perineum, bladder and rectum
Cauda Equina Syndrome
what do the nerves of the cauda equina supply (motor)
Motor innervation to the lower limbs and the anal and urethral sphincters
Cauda Equina Syndrome
what do the nerves of the cauda equina supply (parasympathetic)
Parasympathetic innervation of the bladder and rectum
Cauda Equina Syndrome
what is it
the nerves of the cauda equina are compressed
Cauda Equina Syndrome
possible causes of compression
- Herniated disc (most common)
- Tumours, particularly metastasis
- Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
- Abscess (infection)
- Trauma
Cauda Equina Syndrome
key red flags
- saddle anaesthesia
- loss of sensation in the bladder + rectum
- urinary retention or incontinence
- faecal incontinence
- bilateral sciatica
- bilateral or severe motor weakness in the legs
- reduced anal tone on PR exam
Cauda Equina Syndrome
how to ask about saddle anaesthesia when taking a hx
“does it feel normal when you wipe after opening your bowels?”
Cauda Equina Syndrome
mnx
neurosurgical emergency:
- immediate hospital admission
- emergency MRI scan
- consider lumbar decompression surgery
Cauda Equina Syndrome
what is metastatic spinal cord compression (MSCC)
When a metastatic lesion compresses the spinal cord (before the end of the spinal cord and the start of the cauda equina)
Cauda Equina Syndrome
how does MSCC present
similarly to cauda equina, with back pain and motor and sensory signs and symptoms
Cauda Equina Syndrome
how to differentiate between MSCC and cauda equina on presentation
MSCC:
- back pain worse on coughing or straining
- UMN signs may be seen
Cauda Equina Syndrome
mnx of MSCC
oncological emergency
- rapid imaging
- high dose dexamethasone (to reduce swelling in tumour + relieve compression
- analgesia
- surgery
- radio + chemo
Meniscal Tears
what kind of joint is the knee
hinge joint
Meniscal Tears
function of the menisci
- help the femur and tibia fit together and move smoothly across each other
- shock absorber
- distribute weight throughout the joint
- help stabilise the joint
Meniscal Tears
what are the 4 ligaments of the knee
- Anterior cruciate ligament
- Posterior cruciate ligament
- Lateral collateral ligament
- Medial collateral ligament
Meniscal Tears
what movement of the knee does it oftenoccur in
twisting movements
Meniscal Tears
symptoms
- pop sound
- pain (may be referred to hip or lower back)
- swelling
- stiffness
- restricted RoM
- locking of the knee
- instability or giving way
Meniscal Tears
examination findings
- Localised tenderness on the joint line
- Swelling
- Restricted range of motion
Meniscal Tears
what are the traditional 2 key special tests for meniscal tears (but generally not used or recommended in clinical practice as they can cause pain and may worsen the meniscal injury)
McMurray’s test and Apley grind test
Meniscal Tears
what can be used to determine whether a patient requires an x-ray of the knee after an acute knee injury to look for a fracture
The Ottawa knee rules
Meniscal Tears
what are The Ottawa knee rules
a pt requires a knee x-ray if any are present:
- Age 55 or above
- Patella tenderness (with no tenderness elsewhere)
- Fibular head tenderness
- Cannot flex the knee to 90 degrees
- Cannot weight bear (cannot take 4 steps – limping steps still count)
Meniscal Tears
1st line imaging inx for establishing dx
MRI scan
Meniscal Tears
gold standard inx for diagnosing
arthroscopy
Meniscal Tears
mnx
- RICE
- NSAIDs
- physio
- arthroscopic surgery (repair or resection)
Olecranon Bursitis
what is it
inflammation and swelling of the bursa over the elbow
Olecranon Bursitis
what is the olecranon
the bony lump at the elbow, which is part of the ulna bone
Olecranon Bursitis
aka
“student’s elbow”, as students may lean on their elbow for prolonged periods while studying, resulting in friction and mild trauma leading to bursitis.
Olecranon Bursitis
presentation
a young/middle-aged man with an elbow that is:
Swollen
Warm
Tender
Fluctuant (fluid-filled)
Olecranon Bursitis
features that suggest the bursitis is caused by infection
- Hot to touch
- More tender
- Erythema spreading to the surrounding skin
- Fever
- Features of sepsis (e.g., tachycardia, hypotension and confusion)
Olecranon Bursitis
when to consider septic arthritis
- Swelling in the joint (rather than the bursa)
- Painful and reduced range of motion in the elbow
Olecranon Bursitis
inx if suspected infection
aspiration
Olecranon Bursitis
appearance of aspiration if suspected infection
pus
Straw-coloured fluid indicates infection is less likely
Olecranon Bursitis
if aspiration is blood stained what may this indicate
trauma, infection or inflammatory causes
Olecranon Bursitis
if aspiration is milky what may this indicate
gout or pseudogout
Olecranon Bursitis
what do you do with the aspiration
send to lab for MC&S:
- examine if crystals
- gram staining
Olecranon Bursitis
mnx
- Rice, ice, compress
- paracetamol/NSAIDs
- protect elbow from pressure or trauma
- aspiration to relieve pressure
- steroid injections
Olecranon Bursitis
mnx if infection suspected
- aspiration for MC&S
- 1st line: flucloxacillin (clarithromycin if allergic)
Achilles Tendinopathy
what is it
damage, swelling, inflammation and reduced function in the Achilles tendon.
Achilles Tendinopathy
what are the 2 types
- Insertion tendinopathy (within 2cm of the insertion point on the calcaneus)
- Mid-portion tendinopathy (2-6 cm above the insertion point)
Achilles Tendinopathy
presentation
gradual onset of:
- Pain or aching in the Achilles tendon or heel, with activity
- Stiffness
- Tenderness
- Swelling
- Nodularity on palpation of the tendon
Achilles Tendinopathy
RFs
- Sports that stress the Achilles (e.g., basketball, tennis and track athletics)
- Inflammatory conditions (RA, ankylosing spondylitis)
- Diabetes
- Raised cholesterol
- Fluoroquinolone antibiotics (e.g., ciprofloxacin and levofloxacin)
Achilles Tendinopathy
mnx
- exclude rupture
- rest, ice
- analgesia
- physio
- orthotics (insoles)
- extracorporeal shock-wave therapy
- surgery to remove nodules + adhesions or alter the tendon
Achilles Tendinopathy
what mnx is avoided
Steroid injections into the Achilles tendon
risk of tendon rupture.
Repetitive Strain Injury
what is it
an umbrella term that refers to soft tissue irritation, microtrauma and strain resulting from repetitive activities
Repetitive Strain Injury
name a specific example
Lateral epicondylitis (tennis elbow)
Repetitive Strain Injury
common examples of repetitive movements
- factory line worker
- computer mouse or keyboard
- poor posture
- texting/scrolling on smartphone
Repetitive Strain Injury
what certain characteristics of an activity increase the risk of repetitive strain injury
- Small repetitive activities (e.g., scrolling on a smartphone)
- Vibration (e.g., using power tools)
- Awkward positions (e.g., painting a ceiling)
Repetitive Strain Injury
presentation
- Pain, exacerbated by using the associated joints, muscles and tendons
- Aching
- Weakness
- Cramping
- Numbness
Repetitive Strain Injury
dx
clinically but may need to rule out others:
- x-ray
- US
- bloods
Repetitive Strain Injury
mnx
- RICE
- adapt activity
- discuss their duties w/ occupational health department at work
- NSAIDs
- physio
- steroids injections
Epicondylitis
what is it
inflammation at the point where the tendons of the forearm insert into the epicondyles at the elbow
it is a specific type of repetitive strain injury
Epicondylitis
what epicondyles are there
medial and lateral epicondyles on the distal end of the humerus
Epicondylitis
the tendons of the muscles that insert into the medial epicondyle act to ___
flex the wrist
Epicondylitis
the tendons of the muscles that insert into the lateral epicondyle act to ___
extend the wrist
Epicondylitis
what is lateral epicondylitis often called
tennis elbow
Epicondylitis
presentation of lateral epicondylitis
- pain + tenderness at the outer elbow
- radiate down forearm
- weakness in grip strength
Epicondylitis
what tests indicate lateral epicondylitis
Mill’s test
Cozen’s test
Epicondylitis
what is involved in Mill’s test
stretching the extensor muscles of the forearm while palpating the lateral epicondyle
Epicondylitis
what is involved in Cozen’s test
starts with elbow extended, forearm pronated, wrist deviated in the direction of the radius and hand in a fist.
The examiner holds the patient’s elbow with pressure on the lateral epicondyle.
The examiner applies resistance to the back of the hand while the patient extends the wrist
Epicondylitis
what indicates lateral epicondylitis on the Mill’s and Cozen’s test
if they cause pain, the test is positive
Epicondylitis
what is medial epicondylitis often called
golfer’s elbow
Epicondylitis
presentation of medial epicondylitis
- pain + tenderness at the inner elbow
- radiate down forearm
- weakness in grip strength
Epicondylitis
what does the golfer’s elbow test involve
stretching the flexor muscles of the forearm while palpating the medial epicondyle
Epicondylitis
diagnosis
clinical
Epicondylitis
mnx
- Rest
- Adapting activities
- Analgesia (e.g., NSAIDs)
- Physiotherapy
- Orthotics, such as elbow braces or straps
- Steroid injections
- Platelet-rich plasma (PRP) injections
- Extracorporeal shockwave therapy
Epicondylitis
surgery?
rare but may be required to debride, release or repair damaged tendons
what can scapular winging be caused by
a deficit in the serratus anterior muscle
or an injury to the long thoracic nerve (which innervates the serratus anterior muscle)
which metacarpal is most likely to be fractured after punching a wall
5th metacarpal
lady falls onto outstretched wrist. Has wrist drop, unable to extend wrist
fracture of the distal radius with volar displacement and angulation of the distal fragment
what is it
Smith’s/reverse Colles’ fracture
what nerve is vulnerable to injury with fractures of the humeral shaft
radial nerve
pt was sitting in the front passenger seat and his knee forcefully hit the dashboard. right leg internally rotated and slightly flexed.
what is it
Posterior hip dislocation
what does the saphenous nerve supply sensation to
over the medial aspect of the lower leg and foot
25yo visciously tackled in rugby. 3w later he noticed a tender, enlarging mass in the anterior aspect of his thigh. What is it
Myositis ossificans
supraspinatus muscle is innervated by which nerve
Suprascapular nerve
what sign on x-ray is pathognomonic for a posterior shoulder dislocation
lightbulb sign on AP view
sx of the female athletic triad
- osteoporosis
- eating disorders
- amenorrhoea
why are stress fractures more common in female athletes
Low oestrogen levels and poor nutrition in girls with eating disorders can lead to osteoporosis.
Osteoporosis is a RF for them to sustain stress fractures.
X-ray: Femoral head collapse and fragmentation suggestive of osteonecrosis
what is it
perthe’s disease
involvement of the distal third of the radial shaft and dislocation at the radio-ulnar joint
what fracture is this
Galeazzi Fracture
what is a recognised complication of total hip replacement
posterior hip dislocation
which nerve provides sensation over the posterolateral distal third of the leg and on the lateral aspect of the foot
sural nerve
how does Complex regional pain syndrome present
absence of nerve injury, characterised by pain, abnormal blood flow, trophic changes to the skin, sensory disturbance and autonomic features.
presenting weeks to months after an initial insult and in the neighbouring area
treatment of closed uncomplicated clavicle fracture
initial sling immobilisation for 2 weeks, following by range of motion exercises
indications for a box splint
Any patient suffering a limb fracture which is not grossly displaced
benefits of a box splint
- immobilisation
- limit bleeding
- reduce risk of NV compromise
- Reduce risk of soft tissue damage,
puts leg in cast. things that could have been done to prevent compartment syndrome
- elevate leg
- make sure cast not too tight
- use back slab to allow it to swell
3 ways you can injure your shoulder when you fall
- dislocation
- clavicle fracture
- ACJ separation
which inx is best for a cervical spine fracture
CT scan of the neck.
