Ortho Flashcards
1
Q
What is osteoporosis?
A
Reduced bone mineral density
2
Q
What medications increase the risk of osteoporosis?
A
- Corticosteriods
- SSRIs
- PPIs
- Anti-epileptics
- Anti-oestrogens
3
Q
How can bone mineral density be measured?
A
DEXA scan
4
Q
How can bone density be represented? Which of these is key?
A
- Z/T scores
- Z scores represent the number of standard deviations that patients bone density falls bellow the mean for their age
- T scores represent the number of standard deviations below the mean for a healthy young adult
- T score at the hip is key for assessing someones level of osteoporosis
5
Q
What T scores would indicate normal bone mineral density, osteopenia and osteoporosis?
A
More than -1 = normal
- 1 to -2.5 = osteopenia
Less than -2.5 = osteoporosis
6
Q
What is the first line treatment for osteoporosis? What are key side effects to remember?
A
- Bisphophonates e.g. alendronate
- Reflux - take on empty stomach 30 mins before food
- Atypical fractures (femoral)
- Osteonecrosis of the jaw
- Osteonecrosis of the external auditory canal
7
Q
What is the follow up for started on bisphosphonates?
A
- Repeat FRAX and DEXA 3-5 yrs after starting
- If BMD improves consider withholding treatment for at least 18 months then repeat Ix
8
Q
What investigations are important for ?septic arthritis?
A
- Bloods - WCC, CRP
- XR
9
Q
What are important to mention if referring to ortho for ? septic arthritis?
A
- ROM - minimal ROM
- Weight bearing - NWB
- Systemic features - systemically unwell
- WCC/CRP
10
Q
What are ddx for septic arthritis?
A
- OA
- Fracture
- Gout
- Cellulitis
- Haemarthrosis
11
Q
What is the most common causative organism of septic arthritis? What is an important cause to consider in sexually active individuals?
A
- Staph aureus
- Neisseria gonorrhoea
12
Q
When aspirating a joint for septic arthritis what should you send the sample for?
A
- Gram staining
- Crystal microscopy
- Culture
- Antibiotic sensitivities
13
Q
What is often first line treatment of septic arthritis?
A
- Flucloxacillin plus rifampicin
- Continued for 3-6 wks
14
Q
Give 3 types of fracture
A
- Compound fracture
- Stable fracture
- Pathological fracture
15
Q
What is a compound fracture?
A
When the skin is broken and the broken bone is exposed to air
16
Q
What is a stable fracture?
A
When the sections of bone remain in alignment at the fracture
17
Q
What is a pathological fracture?
A
When a bone breaks due to an abnormality within the bone
18
Q
How can you describe/present fractures?
A
- Describe the radiograph
- What type of fracture?
- Where is the fracture?
- Is it displaced?
- Is there anything else going on?
- Joint involvement?
- Another fracture?
- Underlying bone lesion?
19
Q
How can you classify different types of fractures?
A
- Complete (all the way through bone)
- Transverse
- Oblique
- Spiral
- Comminuted - Incomplete (whole cortex is not broken)
- Bowing
- Buckle
- Greenstick - Salter-Harris (growth plate fracture)
20
Q
What are the types of paediatric fractures?
A
- Complete - both sides of cortex breached
- Toddlers fracture - oblique tibial fracture in infants
- Plastic deformity - stress on bone -> deformity without cortical disruption
- Greenstick fracture - unilateral cortical breach only
- Buckle (‘torus’) fracture - incomplete cortical disruption -> periostea haematoma only
21
Q
In children, fractures may also involve the growth plate. How are these classified?Which require surgery?
A
Salter-Harris system
Remember SALTER:
- I (S) - straight through (physis only)
- II (A) - above (physis and metaphysis)
- III (L) - beLow (physis and epiphysis to include joint)
- IV (T) - through (fracture involving all 3)
- V (ER) - everything ruined (crush injury)
Type II is most common and is relatively stable
Types III, IV, V will usually require surgery
Type V is associated with disruption to growth
22
Q
What do you need to mention when describing where a fracture is?
A
- Bone involved
- What part of the bone is affected:
- Diaphysis
- Metaphysis
- Epiphysis
23
Q
How do you investigate fractures?
A
- XR - two views are always required
- CT - if XR is inconclusive or further information needed
24
Q
What are the principles of fracture management?
A
- Pain relief
- Mechanical alignment
- Closed reduction (manipulation of the limb)
- Open reduction (surgery) - Provide relative stability for healing
- External casts
- K wires
- Intramedullary wires
- Intramedullary nails
- Screws
- Plate and screws
25
What are potential early complications of fractures?
- Damage to local structures
- Haemorrhage
- Compartment syndrome
- Fat embolism
- VTE
26
What are potential late complications of fractures?
- Delayed union
- Malunion
- Non-union
- Avascular necrosis
- Osteomyelitis
- Joint instability
- Joint stiffness
- Contractures
- Arthritis
- Chronic pain
27
What happens in fat embolism? When does in occur?
- Fat globules are released into circulation following a fracture (of a long bone)
- These may become lodged in blood vessels and cause obstruction
28
What can fat embolism lead to? What is used for diagnosis?
- Fat embolisation can cause a systemic inflammatory response leading to fat embolism syndorme
- Occurs 24-72 hrs after the fracture
Gurd's criteria is used for diagnosis:
- Major criteria - resp distress, petechial rash, cerebral involvement
- There is a long list for the minor criteria
29
What is the management of fat embolism? How can it be avoided?
- Management = supportive
- Operating early to fix the fracture
30
What are causes of pathological fractures?
- Tumours (prostate, renal, thyroid, breast, lung)
- Osteoporosis
- Paget's disease of the bone
31
Where are common sites for pathological fractures?
- Femur
- Vertebral bodies
32
What is a Colle's fracture?
Transverse fracture of the distal radius
33
How can Colle's fracture be described?
- Dinner fork deformity
- Distal radius is dorsally displaced (posterior when think of anatomical position)
34
What are early complications of a Colle's fracture?
- Median nerve injury - acute carpal tunnel syndrome presenting with weakness/loss of thumb/index finger flexion
- Compartment syndrome
- Vascular compromise
35
What is a Smith's fracture?
Volar displacement of the distal radius (opposite of Colle's)
36
What typically causes a Smith's fracture?
Falling backwards onto the palm of an outstretched hand or falling with wrists flexed
37
How can Smith's fracture be described?
Garden spade deformity
38
What is a FOOSH?
A fall onto an outstretched hand
39
What fractures are commonly caused by a FOOSH?
- Colle's fracture
- Scaphoid fracture
40
What is the scaphoid?
One of the carpal bones at the base of the thumb
41
What is a key sign of scaphoid fractures?
Tenderness in the anatomical snuffbox
42
How do scaphoid fractures present?
- Pain along radial aspect of wrist and at base of thumb
- Loss of grip/pinch strength
43
What is important to know about scaphoid fractures?
- They have a retrograde blood supply
- The blood vessels supply the bone from only one direction
- This means a fracture can cut off the blood supply -> avascular necrosis and non-union
44
How do you investigate a scaphoid fracture?
- Plain film radiographs - AP and lateral view
- MRI is definite investigation but is normally used second line where XR is inconclusive
45
What is the initial management of scaphoid fractures?
- Immobilisation with a Futuro splint/below-elbow backslab
- Referral to orthopaedics
46
Which bones have vulnerable blood supplies in which a fracture could lead to avascular necrosis?
- Scaphoid bone
- Femoral head
- Humeral head
- Talus, navicular and fifth metatarsal in the foot
47
What do ankle fractures involve?
- The lateral malleolus - distal fibula
- The medial malleolus - distal tibia
48
What can be used to classify fractures of the lateral malleolus?
- Weber classification
- Describes the fracture in relation to the distal syndesmosis
- The tibiofibular syndesmosis is important for the stability/function of the ankle joint
- If disrupted, surgery is more likely to me be required
Weber classification:
- Type A: below ankle joint (syndesmosis intact)
- Type B: at level of ankle joint (syndesmosis intact/partially torn)
- Type C: above ankle joint (syndesmosis disrupted)
49
What are the Ottawa rules for ankle injury?
Used to decide wether an ankle XR is required. Have a sensitivity approaching 100%
They state an XR is required ONLY if there is pain in the malleolar zone and any one of:
- Bony tenderness at the lateral malleolar zone
- Bony tenderness at the medial malleolar zone
- Inability to walk 4 weight bearing steps immediately after the injury and in the ED
50
What is the rule with pelvic fractures?
The pelvis is a ring therefore if one part of the ring is fractured, another part will also fracture
51
What are risk factors for hip fractures?
- Increasing age
- Osteoporosis
- Female sex
52
How can hip fractures be categorised?
- Intra-capsular fractures
- Extra-capsular fractures
53
What are key structures of the hip?
- Head
- Neck
- Greater trochanter (lateral)
- Lesser trochanter (medial)
- Intertrochanteric line
- Shaft (body)
54
Describe the blood supply of the head of the femur
- The head of the femur has a retrograde blood supply
- The medial and lateral circumflex femoral arteries join the femoral neck proximal to the intertrochanteric line
- Braches run along the femoral neck to the head
- They supply to only blood supply to the femoral head
- A fracture of the intra-capsular neck of the femur can damage these vessel -> avascular necrosis of the femoral head
55
What do intra-capsular fractures involve?
- A break in the femoral neck
- They affect the area proximal to the intertrochanteric line therefore can disrupt the blood supply to the femoral head
56
What is used to classify intra-capsular fractures?
Garden classification:
- Grade I - incomplete and non-displaced
- Grade II - complete and non-displaced
- Grade III - partial displacement
- Grade IV - full displacement
57
What is the management of grade I/II intra-capsular fractures?
- Internal fixation (with screws) to hold the femoral head in place as the fracture heals
- These fractures are non-displaced -> may have an intact blood supply -> able to heal without avascular necrosis occurring
58
What is the management of grade II/IV intra-capsular fractures?
- Hemiarthroplasty/total hip replacement
- These fractures are displaced -> blood supply to the femur is disrupted -> avascular necrosis of the femoral head
59
When is a total hip replacement vs a hemiarthroplasty offered?
Total is offered to pts who can walk independently and are fit for surgery
60
Does the head of the femur need to be replaced in extra-capsular hip fractures?
- No
- They do not disrupt the blood supply to the head of the femur
61
What are the two types of extra-capsular hip fractures? Include management
1. Intertrochanteric fractures
- Rx - dynamic hip screw (aka sliding hip screw)
2. Subtrochanteric fractures
- Distal to the lesser trochanter (but within 5cm)
- Rx - intramedullary nail
62
How do hip fractures present?
- Pain in the groin/hip - can radiate to the knee
- Not able to wt bear
- Shortened, abducted and externally rotated leg
63
What is the initial investigation of choice for hip fractures? What sign indicates a fractured NOF?
- XR - two views (AP and lateral)
- Disruption of Shenton's line
64
What is the principles of hip fracture management?
- Appropriate analgesia
- Ix to establish diagnosis (XR0
- VTE risk assessment and prophylaxis (LMWH)
- Pre-op assessment (bloods + ECG)
- Surgery (within 48 hrs due to risk of mobility/mortality)
- Post-operative physiotherapy (the operation should allow the pt to weight bear straight away)
65
What is compartment syndrome?
Where the pressure within a fascial compartment is abnormally elevated, cutting off the blood flow to the contents in that compartment
66
What is fascia? What do fascial compartments contain?
- Strong fibrous connect tissue, not able to stretch of expand
- Muscles, nerves and blood vessels
67
What type of compartment syndrome is an orthopaedic emergency? What is the risk?
- Acute compartment synbdrome
- Tissue necrosis
68
What causes acute compartment syndrome?
- Acute injuries associated with bleeding/tissue swelling which increases pressure within the fascial compartment
- Examples - bone fractures, crush injuries
69
How does acute compartment syndrome present?
5 P's
- Pain (disproportionate to injury)
- Paraesthesia
- Pale
- Pressure (high)
- Paralysis (late + worrying feature)
70
What is the management of acute compartment syndrome?
- Needle manometry to measure compartment pressure
- Escalate to orthopaedic reg/consultant
- Elevate leg (if affected) to heart level
- Maintain good BP (avoid hypotension)
- Emergency fasciotomy is the definitive management (within 6 hrs) - wound is left open and covered with a dressing
- Repeated trips to theatre to explore the compartment for necrotic tissue and to gradual close the compartment
71
Why do patients with acute compartment syndrome often require aggressive IV fluids?
Myoglobinuria may occur following fasciotomy -> renal failure
72
What is another name for chronic compartment syndrome?
Chronic Exertional compartment syndrome
73
What happens in chronic compartment syndrome?
- During exertion the pressure within a fascial compartment rises and blood blood is restricted -> symptoms
- During rest the pressure falls and the symptoms begin to resolve
- It is not an emergency
74
What are the symptoms of chronic compartment syndrome?
- Pain
- Numbness
- Paraesthesia
75
What is spinal stenosis?
Narrowing of part of the spinal canal -> compression of the spinal cord/nerve roots
76
What is the most common type of spinal stenosis in terms of location?
Lumbar spinal stenosis
77
What are the 3 types of spinal stenosis?
- Central stenosis - narrowing of central spinal canal
- Lateral stenosis - narrowing of the nerve root canals
- Foramina stenosis - narrowing of the intervertebral foramina
78
What is a key presenting feature of lumbar spinal stenosis with central stenosis?
- Intermittent neurogenic claudication
- Aka pseudoclaudication
- Typical symptoms are lower back pain, buttock and leg pain, leg weakness
79
How does lateral/foramina stenosis present?
Symptoms of sciatica
80
What exacerbates/improves the symptoms of spinal stenosis?
- The symptoms are absent at rest
- Bending forward expands the spinal canal and improves symptoms
- Standing straight extends the spine, narrowing the canal and worsening symptoms
81
What can the symptoms of intermittent neurogenic claudication mimic?
- Peripheral arterial disease
- Normal peripheral pulses/the ankle-brachial pressure index (ABPI)
82
What imaging is used to diagnose spinal stenosis?
MRI
83
What is the management of spinal stenosis?
- Wt loss
- Analgesia
- Physio
- Decompression surgery where conservative tx fails - laminectomy
84
What is another term for lower back pain?
Lumbago
85
What is a way for grouping together the causes of lower back pain?
1. Causes of mechanical lower back pain
- muscle strain
- herniated disc
- scoliosis
- degenerative changes
2. Red flag causes of lower back pain
- spinal fracture
- caudal equina
- spinal stenosis
- ank spon.
- spinal infection
3. Other causes
- ruptured AA
- kidney stones
- pancreatitis
- prostatitis
86
What spinal nerves for the sciatic nerve?
L4-S3
87
What does the sciatic nerve divide into?
Divides are knee into:
- Tibial nerve
- Common peroneal nerve
88
What are the main causes of sciatic?
Lumbosacral nerve root compression by:
- Herniated disc
- Spondylolisthesis
- Spinal stenosis
89
What does the sciatic nerve supply sensation and motor function to?
- Sensation - lateral lower leg and foot
- Motor - posterior thigh, lower leg, foot
90
What is the management of sciatica?
- Physio
- Analgesia:
- NSAIDs (first line)
- Codeine (as alternative)
- Benzodiazepines >5 days (for muscle spasm)
- Neuropathic med (amitriptyline/duloxetine only)
- Specialist management:
- Epidural corticosteroid injections
- LA injections
- Radiofrequency denervation
- Spinal decompression
91
What can be used to stratify the risk of a pt presenting with acute back pain, developing chronic back pain?
STarT Back screening tool
92
What is the caudal equina?
A collection of nerve roots that travel through the spinal canal after the spinal cord terminates (around L2/L3)
93
What do the nerves of the caudal equina supply?
- Sensation to the lower limbs, perineum, bladder, rectum
- Motor innervation to the lower limbs, anal and urethral sphincters
- Parasympathetic innervation of the bladder and rectum
94
What are potential causes of caudal equina syndrome?
- Herniated disc
- Tumours
- Spondylolisthesis
- Abscess
- Trauma
95
What are caudal equina red flags?
- Saddle anaesthesia
- Urinary incontinence/retention
- Faecal incontinence
- Loss of sensation in the bladder and rectum (not knowing when they are full)
- Bilateral sciatica
- Bilateral motor weakness in the legs
- Reduced anal tone on PR examination
96
What is the management of caudal equina?
- Immediate admission
- Emergency MRI scan
- Neurosurgical input - lumbar decompression surgery
97
How does metastatic spinal cord compression (MSCC) differ from caudal equina syndrome?
- In MSCC the spinal cord is compressed so it presents with upper motor neurone signs e.g. increased tone, brisk reflexes, upping plantar response
- In cauda equina the nerves compressed have exited the spinal cord -> they are lower motor neurones. It presents with LMM signs e.g. reduced tone and reflexes
A key feature of MSCC is back pain that is worse on coughing/straining
98
What may the management of MSCC involve?
- High dose dexamethasone (to reduce swelling and relieve compression)
- Analgesia
- Surgery
- Chemo/radio
99
What is trochanteric bursitis?
Inflammation of a bursa over the greater trochanter on the outer hip
100
How does trochanteric bursitis present? What are typical examination findings?
- Women aged 50-70
- Gradual onset lateral hip pian
- May radiate down outer thigh
- Aching/burning pain
- Worse with activity/sitting or sitting for long periods/trying to sit cross legged
- Ex - tenderness over greater trochanter, resisted abduction of hip/external and internal rotation
101
What is the management of trochanteric bursitis? How long can recover take?
- Rest
- Ice
- Analgesia (NSAIDs)
- Physio
- Steroid injections
Can take 6-9 months to recover
102
What is the function of the anterior cruciate ligament? Where does it originate from and attach too?
- Stops the tibia sliding forward in relation to the femur
- Originates from the lateral aspect of the intercondylar notch of the femur and attaches to the anterior intercondylar area of the tibia
103
How does an ACL tear present?
- A 'pop'
- Rapid onset swelling
- Instability or giving way
Occurs following a twisting injury
104
What are the special tests for ACL injury?
Anterior drawer of Lachman tests
105
What are the first line and gold standard investigations for ACL injury?
- First line - MRI
- Gold standerd - arthroscopy
106
What is the management of ACL injury?
- RICE
- NSAIDs
- Crutches and knee braces
- Physio
- Arthroscopic surgery to reconstruct the ligament (use a graft of tendon from another location)
107
What is the purpose of the medial and lateral meniscus of the knee?
- Help the femur and tibia fit together and move smoothly across each other
- Act as shock absorbers
- Help stabilise the joint
108
How does meniscal tear present?
- A 'pop'
- Rapid onset swelling
- Instability or giving way
- Locking
Occur during twisting movements in the knee - sports in young people, standing from seated with an awkward twist in older people
109
What are the special tests for meniscal tears?
- McMurray's test
- Alley grind test
Not recommended in clinical practice as can worse tear
110
What are the first line and gold standard investigations for meniscal tear?
- First line - MRI
- Gold standerd - arthroscopy
111
What is the management of meniscal tear?
- RICE
- NSAIDs
- Physio
- Arthroscopic surgery to repair/resect the affected meniscus
112
What happens in Achilles tendon rupture?
A sudden onset injury results in rupture of the Achilles and loss of connection between the calf muscles and the heel
113
What are RF for Achilles tendon rupture?
- Sports that stress the Achilles
- Increasing age
- Existing Achilles tendinopathy
- FHx
- Fluoroquinolone abx
- Systemic steroids
114
What antibiotic should you look out for in someone presenting with Achilles tendinopathy or rupture?
- Fluoroquinolones (ciprofloxacin, levofloxacin)
- Rupture can occur spontaneously within 48hrs of starting them
115
What are examination signs of Achilles tendon rupture? What is the special test?
- Tenderness to the area
- Palpable gap in the Achilles tendon
Normally flexion of the calf pulls on the Achilles -> plantar flexion. This is lost meaning:
- When relaxed and dangling the ankle will rest in a dorsiflexed position
- Weakness of plantar flexion
- Unable to stand on tiptoes
Simmond's calf squeeze test:
- Pt is prone with feet hanging freely off the bed
- When squeezing calf muscle of leg with intact Achilles there will be plantar flexion
- When ruptured there is no connection -> a lack of plantar flexion
116
How do you diagnose Achilles tendon rupture?
USS
117
What is the management of Achilles tendon rupture?
- Same day ortho r/v
- Rest and immobilsation
- Ice
- Elevation
- Analgesia
Debate between non-surgical vs surgical management:
- Non-surgical management - specialist boot to immobile ankle, higher risk of re-rupture
- Surgical - surgical fixation
118
What is the rotator cuff made up of? What are the actions of each muscle?
SITS
- Supraspinatus - abducts arm
- Infraspinatus - externally rotates arm
- Teres minor - externally rotates arm
- Subscapularis - internally rotates arm
119
What can cause rotator cuff tear?
- Acute injury e.g. FOOSH
- Degenerative changes related to age/overhead activities (e.g. tennis, construction work)
120
How do rotator cuff tears present?
- Shoulder pain - difficulty getting comfortable at night
- Weakness and pain with movements relating to site of tear
121
What investigations can diagnose rotator cuff tear?
USS/MRI
122
What is the management of rotator cuff tear?
- Rest
- Analgesia
- Physio
- Surgery
- Where physio fails
- Arthroscopic rotator cuff repair
123
What is another name for frozen shoulder?
Adhesive capsulitis
124
What are the two types of frozen shoulder?
- Primary - occurring spontaneously without any trigger
- Secondary - occurring in response to trauma, surgery, immobilisation
125
What is the basic anatomy of the shoulder?
- The glenohumeral joint is a ball and socket joint
- It is surrounded by connective tissue which forms the joint capsule
126
What happens in frozen shoulder?
Inflammation and fibrosis in the joint capsule -> adhesions -> capsule tightens around the joint -> restricts movement
127
What are the 3 phases of frozen shoulder? How long do these typically last?
1. Painful phase - shoulder pain, worse at night
2. Stiff phase - affects active and passive movement (external rotation most), pain settles during this phase
3. Thawing phase - gradual improvement and return to normal
The entire illness lasts 1-3 yrs - normally 6 months in each phase
128
How do you diagnose frozen shoulder?
- Clinical diagnosis - hx + ex, exclude other causes of shoulder pain and stiffness
- Imaging is not normally required
- USS/CT/MRI can show thickened joint capsule
129
What is the management of frozen shoulder?
- Continue to use arm but don't exacerbate pain
- Analgesia
- Physio
- Steroid joint injections
- Hydrodilation
- Surgery (particularly resistant/severe cases)
- Manipulation under anaesthesia (forcefully stretching capsule)
- Arthroscopy to cut adhesions
130
What is the glenoid cavity?
Socket aspect of the shoulder joint
131
What are the 2 types of shoulder dislocation? Which is more common?
- Anterior dislocation (90% of shoulder dislocations)
- Posterior dislocation (associated with electric shocks and seizures)
132
What's a key complication of shoulder dislocation? How does it present?
- Axillary nerve damage
- Loss of sensation in 'regimental badge' area over lateral deltoid
- Motor weakness in the deltoid and teres minor muscles
133
What is olecranon bursitis? What is it sometimes called?
- Inflammation and swelling of the bursa over the elbow
- Olecranon is part of the ulnar bone
- 'Students elbow'
134
What are causes of olecranon bursitis?
- Friction from repetitive movements
- Trauma
- Inflammatory conditions (e.g. RA/gout)
- Infection (septic bursitis)
135
How does olecranon bursitis present?
Young/middle aged man with an elbow that is:
- Swollen
- Warm
- Tender
- Fluctuant (fluid filled)
136
When would you aspirate fluid in olecranon bursitis?
- When an infection is suspected
- To relieve pressure
- Pus - infection
- Straw-coloured - infection less likely
- Milky - gout/pseudogout
137
What is the management of olecranon bursitis?
- Rest
- Ice
- Analgesia (paracetamol/NSAIDs)
- Protect elbow from pressure/trauma
- Manage infection with abx
- Steriods in problematic cases where infection is excluded
138
What is epicondylitis?
Inflammation at the point where to tendons of the forearm insert into the epicondyles of the humerus
139
What are the 2 types of epicondylitis?
- Medial epicondylitis
- Lateral epicondylitis
140
What is lateral epicondylitis aka?
Tennis elbow
141
How do you test for lateral epicondylitis?
- The muscles that insert into the lateral epicondyle act the extend the wrist
- Mill's test involves stretching these extensor muscles whilst palpating the lateral epicondyle
Mill's test:
- The elbow is extended
- The forearm pronated
- The wrist is flexed
- Pressure on the lateral epicondyle -> pain
142
What is medical epicondylitis aka?
Golfer's elbow
143
How do you test for medical epicondylitis?
- The muscles that insert into the medial epicondyle act to flex the wrist
- A golfer's elbow test involves stretching these flexor muscles whilst palpating the medial epicondyle
Golfer's elbow test:
- The elbow is extended
- The forearm is supinated
- Wrist and fingers are extended
- Pressure on medial epicondyle -> pain
144
What's the management of epicondylitis?
- Self-limiting and resolves with time (can be years)
- Rest
- Analgesia
- Physio
- Orthotics (elbow braces/straps)
- Steroid injections
145
What is De Quervain's tenosynovitis?
- A condition where there is swelling and inflammation of the tendon sheaths in the wrist
- Primarily affects 2 tendons; abductor pollicis longus, extensor pollicis brevis
146
What is De Quervain's tenosynovitis aka? Why?
- 'Mummy thumb'
- Bilateral De Quervain's tenosynovitis can because by new parents repetitively lifting babies in a way that stresses the tendons of the thumb
147
How does De Quervain's tenosynovitis present?
Pain on radial aspect of the wrist
148
What is another name for trigger finger?
Stenosing tenosynovitis
149
What happens in trigger finger?
- The flexor tendons of the fingers pass through tunnels (sheaths) along the length of the fingers
- In trigger finger there is thickening of the tendon or tightening of the sheath
- This prevents the tendon moving smoothly through the sheath
- Most commonly affects part of the sheath = A1 at the metacarpophalangeal joint
150
What are RF for trigger finger?
- 40/50s
- F>M
- DM (T1>T2)
151
How does trigger finger present?
- Tender around MCP joint
- Does not move smoothly
- Makes popping/clicking sound
- Gets stuck in flexed position
Symptoms worse in morning
152
What is the management of trigger finger?
- Analgesia
- Splinting
- Steroid injections
- Surgery to release A1
153
What happens in Dupuytren's contracture? What causes it?
- Fascia of the hand becomes thickened and tight -> finger contractures
- It's unclear why this happens but is thought to be due to micro trauma
154
How does Dupuytren's contracture present? Which finger is most often affected?
- Finger flexion
- A thick nodular cord can be palpated from the palm into the affected finger
- Ring finger
155
How can you test for Dupuytren's contracture?
Table top test:
- Get the pt to position their hands flat on a table
- If the hand cannot rest completely flat, the test is positive
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What is the management of Dupuytren's contracture?
- Conservative (do nothing)
- Surgical - fasciotomy/fasciectomy
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What happens in carpal tunnel syndrome?
Compression of the median nerve as it passes through the carpal tunnel
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What is the carpal tunnel? What does it contain?
- Passage way between the forearm and the hand
- Formed by the flexor retinaculum
- The median nerve and the flexor tendons of the forearm
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What causes carpal tunnel syndrome?
- Idiopathic
- Swelling of the contents (swelling of tendon sheaths due to repetitive strain)
- Narrowing of the tunnel
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What are RF for carpal tunnel syndrome?
- Repetitive strain
- Obesity
- RA
- Diabetes
- Acromegaly
- Hypothyroidism
Exams may want you to pick up on features indicating underlying cause e.g. bilateral carpal tunnel and acromegaly
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How does carpal tunnel syndrome present?
- Gradual onset symptoms
- Symptoms worse at night (may wake from sleep)
- Sensory symptoms in median nerve distribution:
- Numbness
- Paraesthesia
- Burning
- Pain
- Motor symptoms:
- Weakness of thumb movements
- Weakness of grip strength
- Thenar muscle atrophy
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What are special tests for carpal tunnel syndrome?
- Phalen's test
- Tinel's test
Both will induce sensory symptoms
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How do you investigate carpal tunnel syndrome?
Nerve conduction studies
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What is the management of carpal tunnel syndrome?
- Rest
- Wrist splints at night (minimum 4 wks)
- Steroid injections
- Surgery - flexor retinaculum is cut to release pressure on the median nerve
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What are ganglion cysts?
Sacs of synovial fluid that originate from tendon sheaths/joints
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Where do ganglion cysts commonly occur?
- Wrist
- Fingers
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How do ganglion cysts present?
- Visible lump
- Non tender
- Firm
- Transilluminates
- Can appear rapidly (over days) or gradually
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What is the management of ganglion cysts?
- Conservative - 40-50% will resolve spontaneously
- Needle aspiration
- Surgical excision
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What is osteomyelitis?
Inflammation in a bone and bone marrow - usually due to a bacterial infections
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What is haematogenous osteomyelitis?
When a pathogen is carried through the blood and seeded in the bone (most common mode of infection)
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What are sarcomas?
Cancers originating in the muscles, bones or other types of connective tissue
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What are the types of bone sarcoma?
- Osteosarcoma
- Chrondrosarcoma - originating from cartilage
- Ewing sarcoma - bone and soft tissue cancer, most often affects children and young adults
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How does sarcoma present?
- Soft tissue lump
- Bone swelling
- Persistent bone pain
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How do you investigate sarcoma?
- XR - initial Ix for bony lumps/persistent pain
- USS - initial Ix for soft tissue lumps
- CT/MRI to visualise in more detail + for metastatic spread (CT thorax as commonly spreads to lungs)
- Biopsy for histology of cancer
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What is the management of sarcomas?
- Surgery - aim for complete resection
- Radiation - often used in conjunction with surgery. Pre-op (neoadjuvant) to shrink the tumour or post-op (adjuvant) to minimise the risk of local reoccurrence
- Chemo - typically used neo-adjuvant/adjuvant to minimise the risk of recurrence
