Ortho fifth yr Flashcards
What is iliotibial band syndrome?
common cause of lateral knee pain in runners
tenderness 2-3cm above the lateral joint line
also, ateral hip pain that radiates down the side of the leg and is exacerbated by walking or running
Tx:
activity modification and iliotibial band stretches
if not improving then physiotherapy referral
Summary of ACL rupture?
Sport injury. Most commonly injured knee ligament.
ACL attaches at the anterior intercondylar area on the tibia
Mechanism: high twisting force applied to a bent knee. Also blow to knee, skiing.
Typically presents with: loud crack, pain and RAPID joint swelling (haemoarthrosis). Instability - feeling like leg will give way.
Poor healing
Anterior drawer and Lachman’s test
MRI first line. Arthroscopy gold standard.
Management: send to A+E or fracture clinic. Conservative management (RICE). NSAIDs. Intense physiotherapy or surgery - A new ligament is formed using a graft of tendon from another location.
Summary of posterior cruciate ligament rupture?
Mechanism: hyperextension injuries - May be caused by anterior force applied to the proximal tibia (e.g. knee hitting dashboard during car accident
Tibia lies back on the femur
Paradoxical anterior draw test
Summary of medial collateral ligament tear?
Damage typically causes abnormal passive abduction of the knee
Mechanism: leg forced into valgus via force outside the leg
Knee unstable when put into valgus position
Summary of meniscal tear?
Rotational sporting injuries. Can occur with minor movement in elderly patients.
Sx: Pain (can be referred to hip or back), Stiffness, Restricted range of motion, Instability or the knee “giving way”, Delayed knee swelling, Joint locking (Patient may develop skills to ‘unlock’ the knee
O/E - Pain on straightening the knee. Localised tenderness on the joint line, Swelling, Restricted range of motion, McMurrays and Apley grind test,
Ix - MRI, arthroscopy
Tx - urgent referral, RICE, NSAIDs, PT, surgery (repair and resection)
Recurrent episodes of pain and effusions are common, often following minor trauma
Summary of Chondromalacia patellae?
Damage to the kneecap (patellar) cartilage - softening of cartilage
Teenage girls, following an injury to knee e.g. Dislocation patella, or overuse of joint
Typical history of anterior pain on going downstairs or at rest. Also crepitus and effusion.
Tenderness, quadriceps wasting
Responds to PT
Summary of patella dislocation?
Knee pain, usually with a large effusion (this may be haemarthrosis). There is tenderness around the medial retinaculum. The knee is held in flexion with lateral displacement of the patella
Most commonly occurs as a traumatic primary event, either through direct trauma or through severe contraction of quadriceps with knee stretched in valgus and external rotation
Genu valgum, tibial torsion and high riding patella are risk factors
Skyline x-ray views of patella are required, although displaced patella may be clinically obvious
An osteochondral fracture is present in 5%
The condition has a 20% recurrence rate
Summary of patella fracture?
pain and tenderness around the knee, well localised to the patella and a palpable gap may be appreciable
If the patient is able to straight let raise then the extensor mechanism is grossly intact.
2 types:
i. Direct blow to patella causing undisplaced fragments
ii. Avulsion fracture
X-ray
Undisplaced fractures, particularly vertical fractures with an intact extensor mechanism can be managed non-operatively in a hinged knee brace for 6 weeks and patients allowed to fully weight bear.
Surgery if displaced fracture
Summary of tibial plateau fracture?
Occur in the elderly (or following significant trauma in young)
Mechanism: knee forced into valgus or varus, but the knee fractures before the ligaments rupture
Varus injury affects medial plateau and if valgus injury, lateral plateau depressed fracture occurs
Classified using the Schatzker system - type 1-6
What are the Ottawa knee rules?
used to determine whether a patient requires an x-ray of the knee after an acute knee injury to look for a fracture
If following 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)
Summary of lateral epicondylitis?
Typically follows unaccustomed activity such as house painting or playing tennis (‘tennis elbow’)
Inflammation at the point where the tendons of the forearm insert into the epicondyles at the elbow. Lateral epicondyle act to extend the wrist
Most common in people aged 45-55 years and typically affects the dominant arm.
Pain and tenderness localised to the lateral epicondyle.
Pain worse on wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended. The pain often radiates down the forearm. It can lead to weakness in grip strength.
episodes typically last between 6 months and 2 years. Patients tend to have acute pain for 6-12 weeks
Tx - advice on avoiding muscle overload, simple analgesia, steroid injection, PT
Summary of medial epicondylitis?
“golfer’s elbow”
Sx:
pain and tenderness localised to the medial epicondyle
pain is aggravated by wrist flexion and pronation
symptoms may be accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement
can cause weakness in grip strength
Tx:
Rest, adapting activities, NSAIDs, PT, orthotics, steroid injections, PRP injections, Extracorporeal shockwave therapy
Summary of meralgia paraesthetica?
Refers to localised sensory symptoms of the outer thigh caused by compression of the lateral femoral cutaneous nerve. It is a mononeuropathy - a syndrome of paraesthesia or anaesthesia in the distribution of the lateral femoral cutaneous nerve (LFCN)
Following symptoms in the upper lateral aspect of the thigh:
Burning, tingling, coldness, or shooting pain
Numbness
Deep muscle ache
Symptoms are usually aggravated by standing, and relieved by sitting
They can be mild and resolve spontaneously or may severely restrict the patient for many years.
Symptoms may be reproduced by deep palpation just below the ASIS (pelvic compression) and also by extension of the hip.
There is altered sensation over the upper lateral aspect of the thigh.
There is no motor weakness.
Ix
Pelvic compression test
Injection with LA
Using ultrasound
Nerve conduction studies
Tx
Conservative - rest, looser clothing, WL, PT
Medical - paracetamol, NSAIDs, neuropathic analgesia, injections of steroids or LA
Surgery - decompression, transection, resection of nerve
Summary of osteochondritis dissecans?
Summary of osteochondritis dissecans?
A pathological process affecting the subchondral bone (most often in the knee joint) with secondary effects on the joint cartilage, including pain, oedema, free bodies and mechanical dysfunctions.
Affects children and young adults.
OCD may progress to degenerative changes if untreated.
Sx:
Knee pain and swelling, typically after exercise
Knee catching, locking and/or giving way: more constant and severe symptoms are associated with the presence of loose bodies
Feeling a painful ‘clunk’ when flexing or extending the knee - indicating the involvement of the lateral femoral condyle
O/E
Joint effusion
Tenderness on palpation of the articular cartilage of the medial femoral condyle, when the knee is flexed
Ix
X-ray (anteroposterior, lateral and tunnel views) - may show the subchondral crescent sign or loose bodies
MRI - used to evaluate cartilage, visualise loose bodies, stage and assess the stability of the lesion
What is adhesive capsulitis?
Frozen shoulder - shoulder pain and stiffness, loss of range of motion and function
Affects middle aged. DM risk factor
Primary - spontaneously w/o trigger, or secondary - response to trauma, surgery or immobilisation
The glenohumeral joint is the ball and socket joint in the shoulder. The glenohumeral joint is surrounded by connective tissue that forms the joint capsule. In adhesive capsulitis, inflammation and fibrosis in the joint capsule lead to adhesions (scar tissue). The adhesions bind the capsule and cause it to tighten around the joint, restrict movement in the joint.
Features of adhesive capsulitis?
Painful phase – shoulder pain is often the first symptom and may be worse at night
Stiff phase – shoulder stiffness develops and affects both active and passive movement (external rotation is the most affected) – the pain settles during this phase
Thawing phase – there is a gradual improvement in stiffness and a return to normal
The entire illness lasts 1 – 3 years before resolving (e.g., 6 months in each phase). However, a large number of patients (up to 50%) have persistent symptoms.
Differentials of adhesive capsulitis?
Shoulder pain not preceded by trauma:
Supraspinatus tendinopathy - inflammation and irritation of the supraspinatus tendon, particularly due to impingement at the point where it passes between the humeral head and the acromion. Empty can test!
Acromioclavicular joint arthritis - tenderness to palpation of AC joint, pain worse at extremes of shoulder abduction, positive scarf test
Glenohumeral joint arthritis
Other important differentials
Septic arthritis
Inflammatory arthritis
Malignancy (e.g., osteosarcoma or bony metastasis)
If preceding trauma or acute injury
Shoulder dislocation
Fractures (e.g., proximal humerus, clavicle or rarely the scapula)
Rotator cuff tear
Diagnosis and management of adhesive capsulitis?
Clinical diagnosis and excluding other causes of shoulder pain and stiffness
X-rays normal
US, CT, MRI would show a thickened joint capsule
Tx:
Continue using arm but don’t exacerbate pain
NSAIDs
PT
Inta-articular steroid injections
Hydrodilation
Manipulation under anaesthesia
Arthroscopy
Summary of avascular necrosis of the hip?
defined as death of bone tissue secondary to loss of the blood supply. This leads to bone destruction and loss of joint function. It most commonly affects the epiphysis of long bones such as the femur.
Causes - long term steroid use, chemotherapy, alcohol excess, trauma
Features - initially asymptomatic, pain in affected joint
Ix - X-ray normal initially, Osteopenia and microfractures may be seen early on. Collapse of the articular surface may result in the crescent sign
MRI - investigation of choice
Tx - joint replacement may be necessary
What is Cauda Equina syndrome?
a surgical emergency where the nerve roots of the cauda equina at the bottom of the spine are compressed.
It requires emergency decompression surgery to prevent permanent neurological dysfunction. However, even with immediate decompression, patients may still not regain full function.
Cauda equina is collection of nerve roots after spinal cord terminates around L2/3. Nerves of cauda equine (L3-S5 and Co) supply sensation to lower limbs, perineum, bladder and rectum, motor innervation to lower limbs and anal and urethral sphincters and parasympathetic innervation to bladder and rectum
Causes of CES?
Herniated disc (the most common cause)
Tumours, particularly metastasis
Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
Abscess (infection)
Trauma
Red flags of CES?
Saddle anaesthesia (loss of sensation in the perineum – around the genitals and anus)
Loss of sensation in the bladder and rectum (not knowing when they are full)
Urinary retention or incontinence
Faecal incontinence
Bilateral sciatica
Bilateral or severe motor weakness in the legs
Reduced anal tone on PR examination
Management of CES?
Immediate hospital admission
Emergency MRI scan to confirm or exclude cauda equina syndrome
Neurosurgical input to consider lumbar decompression surgery
Summary of metastatic spinal cord compression?
MSCC presents similarly to cauda equina, with back pain and motor and sensory signs and symptoms. A key feature is back pain that is worse on coughing or straining.
Requires rapid imaging and management. There are specialist MSCC coordinators who should be involved early to coordinate the imaging and treatment of patients with MSCC.
Tx - High dose dexamethasone (to reduce swelling in the tumour and relieve compression), Analgesia, Surgery, Radiotherapy, Chemotherapy
CES - LMNL, MSCC - UMNL
What is carpal tunnel syndrome?
caused by compression of median nerve in the carpal tunnel. Carpal tunnel formed between carpal bones and flexor retinaculum - contains median nerve and flexor tendons
median nerve supplies palmar digital cutaneous branch for sensory innervation, and motor function to thenar muscles (abductor pollicis breves, opponent pollicis, flexor pollicis brevis)
Sx:
pain/pins and needles in thumb, index, middle finger
unusually the symptoms may ‘ascend’ proximally
patient shakes his hand to obtain relief, classically at night
CTQ - high score may replace need for nerve conduction studies
O/E:
weakness of thumb abduction (abductor pollicis brevis)
wasting of thenar eminence (NOT hypothenar)
Tinel’s sign: tapping causes paraesthesia
Phalen’s sign: flexion of wrist causes symptoms
Electrophysiology
motor + sensory: prolongation of the action potential
Causes of carpal tunnel syndrome?
idiopathic
pregnancy
oedema e.g. heart failure
lunate fracture
rheumatoid arthritis
repetitive strain
obesity
perimenopause
DM
acromegaly
hypothyroidism
Tx of carpal tunnel syndrome?
6-week trial of conservative treatments if the symptoms are mild-moderate
corticosteroid injection
wrist splints at night
if there are severe symptoms or symptoms persist with conservative management:
surgical decompression (flexor retinaculum division)
Summary of cubital tunnel syndrome?
occurs due to compression of the ulnar nerve as it passes through the cubital tunnel.
Sx:
Tingling and numbness of the 4th and 5th finger which starts off intermittent and then becomes constant.
Over time patients may also develop weakness and muscle wasting
Pain worse on leaning on the affected elbow
Often a history of osteoarthritis or prior trauma to the area.
Ix - clinical diagnosis, nerve conduction studies can be used
Tx:
Avoid aggravating activity
Physiotherapy
Steroid injections
Surgery in resistant cases
Summary of cubital tunnel syndrome?
occurs due to compression of the ulnar nerve as it passes through the cubital tunnel.
Sx:
Tingling and numbness of the 4th and 5th finger which starts off intermittent and then becomes constant.
Over time patients may also develop weakness and muscle wasting
Pain worse on leaning on the affected elbow
Often a history of osteoarthritis or prior trauma to the area.
Ix - clinical diagnosis, nerve conduction studies can be used
Tx:
Avoid aggravating activity
Physiotherapy
Steroid injections
Surgery in resistant cases
