Ortho/Msk Flashcards

Question

Knee locking differentials

Answer 1

* Meniscal tear * Cruciate ligament injury * Osteochondritis dissecans: adolescents * Loose body

Answer 2

* Assoc. c¯ deceleration and rotational movements * Hears a pop or feels something tear * Inability to continue sport or activity * Haemarthrosis w/i 4-6h * Instability / giving way following injury

Answer 3

* ACL * MCL * Medial Meniscus

Answer 4

**Mx of Meniscal Tear** Depends on * Age * Chronicity of injury * Location and type of tear **Non-Surgical** * Symptomatic Rx: e.g. analgesia **Surgical** * Arthroscopic or open * Partial meniscectomy * Meniscal repair

Answer 5

**Non-Surgical** * Rest and phyio to strengthen quads and hamstrings * Not enough stability for many sports **Surgical** * Gold-standard is _autograft_ repair * Usually semitendinosus ± gracilis (can use patella) * Tendon threaded through heads of tibia and femur and held using screws.

Answer 6

**Look** * Hallux * Unilateral or bilateral * Estimate degree of valgus * Rotation: nail faces medially * Bunion * Prominence of 1st metatarsal head ± bursa * Evidence of inflammation: bursitis * Extras * Hammer toes * Callosities on heel **Feel** * Inflammation of bunion * Localised tenderness e.g. OA of MTPJs **Move** * Assess ROM of toe joints **Completion** * Assess ROM of other toe joints * Assess gait * Examine shoes: abnormal weight-bearing

Answer 7

**Associations/RF** * Familial tendency * ↑ enclosed / pointed shoes * Assoc. c¯ RA **Ix** * Wt. bearing x-rays * Degree of valgus * _OA of MTPJ_ **Mx** Non-surgical * Appropriate footwear: wide, soft * Physio Surgical * Bunionectomy * 1st metatarsal realignment osteotomy * Excision arthroplasty

Answer 8

**Aetiology** * Imbalance between intrinsic and extrinsic toe muscles * Intrinsic: lumbricals * Extrinsic: long flexors and extensors * F\>M * Commoner in pts. c¯ RA * ↑ c¯ age * *Mx** * **Non-surgical:*** appropriate footwear * *Surgical** correction * Flexor-to-extensor tendon transfer * Arthrodesis * Resection of proximal phalangeal head

Answer 9

**Look** * Swelling * Deformity * Pressure necrosis **Feel** * Joint is not tender or warm * May feel crepitus * Subluxation or dislocation of the joint **Move** * Abnormal **Completion** * Neurological examination of the limb * Esp. pain and proprioception * Dip urine for glucose

Answer 10

Definition * Progressive destructive joint arthropathy * 2ndary to disturbance of sensory innervation to the joint * Painless deformed joint resulting from repetitive minor trauma.

Answer 11

**Peripheral** * DM * Peripheral N. injury * Leprosy **Central** * Syringomyelia * Tabes dorsalis

Answer 12

Phases 1. Initial contact / heel strike 2. Stance 3. Toe off 4. Swing

Answer 13

**Describe the Lump** * Visible popliteal swelling * Describe as for lump; * SSS CCC TTTT FPS * Pulsatile: swelling overlying popliteal A. * Expansile: popliteal aneurysm * Fluctuant and transilluminable: cystic **Completion** * Continue c¯ knee exam: signs of OA * Neurovascular assessment

Answer 14

* Skin + s/c tissue: lipoma * Artery: popliteal aneurysm * Vein: saphena varix @ SPJ * Nerve: tibial nerve neuroma * Enlarged bursae * Above knee joint line * Assoc. c semimembranosus * Baker cyst

Answer 15

* Posterior herniation of knee joint capsule * Assoc. c¯ degenerative knee joint disease * Located **_below_** knee joint line * *Dx**: US * *Mx;** Aspiration possible: high recurrence

Answer 16

Expose chest and shoulders **Look** * Inspect shoulder girdle and axilla * Skin: scars, bruising, erythema * Shape * Wasting: deltoid, supra- and infra-spinatous * Clavicular deformity * Joint swelling * Deformity * Joint dislocation * Scapula location * Winging of the scapula; _push against the wall_ **Feel** * Temperature and tenderness * Along clavicle from SCJ to ACJ * Acromion and coracoid (2cm inf. + med. to clavicle tip) * Biceps tendon in bicipital groove * Humoral head and greater and lesser tuberosities. * Scapular spine **Move**: functional + active + passive * **Abduction and adduction** *(First 25 of abduction is _supraspinatous_, rest is deltoid//Abduction at GHJ is ~80, rest is scapula rotation)* * Palpate acromion tip during abduction to determine GHJ movement * Pain: * 60-120O = _impingement_ or _rotator cuff tendonitis_ * 140-180 = _AC osteoarthritis_ * **Flexion and Extension** * **Internal and external rotation *(****External rotation most commonly ↓d in frozen shoulder)* * ***Functional screen*** * Ask pt. to put both hands behind the head * Ask pt. to reach behind back and touch shoulder blades * *Special Tests** * **Jobe’s Empty Can Test***: Supraspinatus * Shoulder flexed @ 90O, thumb pointing down, forced flexion of shoulder ***Infraspinatus + Teres Minor*** * Elbow flexed @ 90, forced external rotation of shoulder ***Gerber’s Lift Off:*** ***Subscapularis*** * Dorsum of hand placed against lumbar spine, pt. attempts to lift hand off against resistance ***Scarf Test:*** AC Joint Dysfunction * Place pt’s. hand on contralateral shoulder * Examiner pushes pt’s. flexed elbow posteriorly, eliciting discomfort ***Hawkin’s Test Shoulder***: Impingement Shoulder and elbow flexed @ 90O. Examiner pushes hand down ***Apprehension Test:*** GHJ Instability * Shoulder is abducted and externally rotated to 90O * Apprehension occurs as shoulder is slowly externally rotated Completion * Examine the cervical spine and elbow * Perform a neurovascular assessment

Answer 17

**_Winging_**: Seratus Anterior Weakness * Long-thoracic nerve damage: e.g. axillary surgery * Upper brachial plexus injury * Muscular dystrophy: e.g. FSH *(Facioscapulohumeral muscular dystrophy is a genetic muscle disorder in which the muscles of the face, shoulder blades and upper arms are among the most affected)*

Answer 18

* Rotator cuff: tear, tendonitis * Subacromial bursitis * Adhesive capsulitis (frozen shoulder) * Joints: synovitis, OA, dislocation * Humeral head: #, dislocation * Referred pain from diaphragm

Answer 19

Expose pts. arms up to elbow AND Lay hands on a **pillow** **Look** * Dorsum and palms * Skin * Scars: palm and carpal tunnel * Erythema * Calcinosis and tophi * Ulceration * Ganglia * Muscle Wasting * Median nerve: *thenar* eminence * Ulnar nerve: *1st dorsal interroseus* * Joints Swellings * Heberden’s: distal (DIP) * Bouchard’s: proximal (PIP) * Deformities * RA * Boutonniere’s * Swan neck * Z-thumb * Ulnar deviation @ the MCPs * MCP volar subluxation * Dupuytron’s * Trigger Finger * Mallet Finger * Claw Hand * Nails * Onycholysis * Pitting * Subungual hyperkeratosis * Extras * Elbows: _rheumatoid nodules, psoriatic plaques_ * Scalp and behind ears: psoriatic plaques **Feel** * Temperature * Joints: pain and swelling * Tendons: * palm for nodules or thickening. * Eblow nodules * Muscles * Median nerve: *thenar eminence* * Ulnar nerve: *1st dorsal interroseus* **Move** * Wrist * Prayer and reverse prayer positions (Check that fingers are opposed) * Thumb * Abduction * Fingers * Abduction and adduction (cross fingers for luck) * Opposition * Grip * *_Function_* * Fasten and unfasten button. * Pick up coin from flat surface * Write name * *Special Tests** * *_Median Nerve_** * Tinel’s * Phalen’s **_Ulnar Nerve_** * Froment’s: flexion of thumb @ IPJ = weak ADductor policis (pincer grip, abn -\> grip is provided by flexor pollicis longus ) **_de Quervain’s tenosynovitis_** (APL + EPB tendonitis) * Finkelstein’s; ulnar deviation at wrist stretches tendon **Completion** * Neurovascular status of the upper limb. * AP and lateral radiographs

Answer 20

* Median: pulps of index and middle fingers * Ulnar: pulp of little finger * Radial: 1st dorsal web space

Answer 21

* Median: abductor pollicis brevis 'okay sign' * Ulnar: abductor digity minimi 'push against little finger' (DAB/PAD) * Radial: MCP extension; wrist extension * median and ulnar little finger thumb oposition

Answer 22

**Look** * Often bilateral and symmetrical * Tethering or pitting of palmar skin * Visible tendon cords * Surgical scars: Z plasties * Fixed flexion of MCP and PIP joints * Usually little and ring fingers * Garrods Pads * Thickening of dorsal skin over PIPJ **Feel** * Palpate thickened tendons * Note fixation to skin **Move** * Assess ROM * Note fixed deformities by _loss of passive ROM_ * Ask pt. to lay hand flat on table **Function** * Ask pt. to pick up a coin and do up a button **Completion** * Abdominal exam for signs of CLD * Hx and Drug chart * Other features of diffuse fibromatosis

Answer 23

* Skin contracture: look for _scar_ from previous wound * _Congenital_ contracture of little finger * _Ulnar nerve palsy_: ↓ sensation, +ve Froment’s sign

Answer 24

* Associations * Function * Previous therapy * Other features of diffuse fibromatosis

Answer 25

Associations: **BAD FIBERS** * Bent penis: Peyronie’s (3%) * AIDS * DM * FH: AD * _Idiopathic : commonest_ * Booze: ALD * Epilepsy meds and epilepsy: phenytoin * Reidel’s thyroiditis and other fibromatoses * Ledderhose disease * Fibrosis of plantar aponeurosis * 5% c¯ dupuytren’s * Retroperitoneal fibrosis * Smoking

Answer 26

Local microvessel ischaemia → ↑ xanthine oxidase activity → ROS production. → myofibroblast proliferation → collagen 3 formation-\> Chronic inflammation → continued fibrosis

Answer 27

**Non-Surgical Mx** * Physiotherapy * Allopurinol may help **Surgical Mx** Indication; MCP or PIP contracture \>30 degrees Procedures * Fasciotomy * Partial fasciectomy * Z-plasty to lengthen wound * Post-op physio * Can damage ulnar nerve * Often recurs * Dermofasciectomy + full-thickness skin grafting * Lowest risk of recurrence * Arthrodesis and amputation

Answer 28

**Look** * Wasting of thenar eminence * Scars from previous surgery over flexor retinaculum **Feel** * Test light touch over _finger pulps_ * Test light touch over the t_henar eminence_ **Move** * Opponens pollicis * Abductor pollicis brevis **Special Tests** * Tinel’s * Phalen’s **Completion** * Hx * Look for underlying cause and associations

Answer 29

1. More proximal median nerve lesion 2. Cervical root lesion E.g. cervical disc herniation

Answer 30

* Symptoms * Tingling / pain in thumb, index and middle fingers * Pain worse @ night or after repetitive actions * Relieved by shaking / flicking hand * Causes * Hypothyroidism * Pregnancy * RA * Previous treatments

Answer 31

Causes: **I WRIST** * Idiopathic: commonest * ?!Water: pregnancy, hypothyroidism * Radial # * Inflammation: RA, gout * Soft tissue swelling: lipomas, acromegaly, amyloidosis * Toxic: DM, EtOH

Answer 32

Not typically necessary * Nerve conduction studies * Determine lesion location * Determine lesion severity * US

Answer 33

**Non-surgical Mx** * Mx of underlying cause * Wrist splints * Neutral position * Esp. @ night * Local steroid injections **Surgical Mx** Carpal tunnel decompression by division of the flexor retinaculum ***Complications*** * Scar formation: high risk for hypertrophic or keloid * Scar tenderness: up to 40% * Nerve injury * _Palmar cutaneous_ branch of the median nerve * Motor branch to the _thenar muscles_ * Failure to relieve symptoms

Answer 34

***Pronator syndrome*** * Entrapment between two heads of pronator teres ***Anterior interroseous syndrome*** * Compression of the anterior interosseous branch by the deep head of pronator teres * Muscle weakness only * Pronator quadratus * FPL * Radial half of FDP

Answer 35

**Look** * Hands * Skin: joint erythema, palmar erythema * Joint Swelling: MCPs and PIPs * Muscle wasting: interossei, thenar eminence * Deformity 1. Ulnar deviation @ the MCPs 2. Boutonniere deformity 3. Swan neck deformity 4. Z thumb 5. MCP volar subluxation * Surgical Scars * Wrist: carpal tunnel release * Thumb: joint replacement * Dorsum: tendon transfer * Ulna stylectomy * Wrist * Radial deviation * Volar subluxation of the ulnar styloid * Elbow * Rheumatoid nodules **Feel** * ↑ temperature of swollen joints = active synovitis * Joint tenderness * Median nerve sensation **Move** * Fixed flexion on prayer position * ↓ ROM **Special** * Finkelstein’s * Tinel’s and Phalen’s **Function** * Precision: unbutton shirt, pick up coin from table * Power: squeeze fingers * Writing * Walking aids, splints, wheelchair **Completion** * Hx * Examine for other features of RA

Answer 36

**Hx** * Symptoms * Early morning stiffness * Pain * Swelling * Affect on life * Extra-articular features: aNTI CCP Or RF * Treatments tried so far + any complications Extra-Articular Features: **aNTI CCP Or RF** * Nodules * Tenosynovitis: de Quervains and atlanto-axial subluxation * Immune: vasculitis, amyloidosis * Cardiac: pericarditis ± effusion * Carpal tunnel * Pulmonary: fibrosis, effusions * Ophthalmic: episcleritis, scleritis, Sjogren’s * Raynaud’s * Felty’s: RA + ↓PMN + splenomegaly

Answer 37

**Bloods** * FBC: ↓Hb, ↓PMN * ↑ESR and ↑CRP * Immune: RF, anti-CCP, ANA, HLA-DR3/4 **X-Ray** * Soft tissue swelling * Periarticular osteopenia * Loss of joint space * Periarticular erosions * Deformity

Answer 38

**MDT** * GP, physio, OT, rheumatologist, orthopod **Conservative** * Physio * OT: aids and splints **Medical** * Analgesia * Steroids: IM, PO or intra-articular * DMARDS * Biologicals * Other: CV risk, prevention of PUD and osteoporosis **Surgical** * Carpal tunnel decompression * Tendon repairs and transfers * Ulna stylectomy * Arthroplasty

Answer 39

Boutonierre’s: rupture of _central_ slip of extensor expansion → **PIPJ prolapse t**hrough “button-hole” created by the two lateral slips. Swan: rupture of _lateral slips_ → **PIPJ hyper-extension**

Answer 40

**Look** * Heberden’s nodes: swelling of DIPJs * Bouchard’s nodes: swelling of PIPJs * Squaring of the thumb CMC **Move** * ↓ ROM of passive and active motion **Function** * Unbutton shirt * Pick up coin from table * Writing **Completion** * Hx * Examine other joints for OA * Hips, lumbar spine, knees **_Differential_** * RA hands * Tophi

Answer 41

* Symptoms * Pain * Stiffness * Affect on life * Other joint disease * Treatments so far

Answer 42

Non-Surgical * Physiotherapy * Analgesia **Surgical** * Joint arthrodesis

Answer 43

**Look** * Partial claw hand: little and ring fingers * Wasting * Hy**po**thenar eminence * Dorsal interossei **Feel** * Loss of sensation in ulnar distribution **Move** * Weak abduction and adduction of fingers * Weak flexion of DIPJ in little and ring fingers Special * Froment’s; pincer grip * Weak adductor pollicis → flexion of thumb IPJ * Compensation by **FPL** * Elbow flex test * Full elbow flexion for 1min * → paraesthesia in little and ring fingers Completion * Examine neck: brachial plexus injury * Examine PNS of affected limb

Answer 44

**Anatomical Compression** * Cubital tunnel syn.: _elbow_ * Guyon’s canal syn.: _wrist_ **Trauma** * Supracondylar #s of _humerus_ * _Elbow dislocation_

Answer 45

Proximal lesions → paralysis of ulnar half of FDP → ↓ marked clawing of hand

Answer 46

**Non-surgical** * Avoid repetitive flexion-extension of elbow * Avoid prolonged elbow flexion * Night splinting of elbow in _extension_ **Surgical** * Ulnar nerve decompression * Medial epicondylectomy

Answer 47

**Look** * Wrist drop: holds hands out in front, palms down **Feel** * Loss of sensation over the first dorsal interosseous * May be sensory loss over dorsal forearm **Move** * Low * Loss of MCP extension * Preserved PIPJ extension: lumbricals * High: + wrist weakness * Very high: + triceps weakness **Completion** * Examine neck: brachial plexus injury * Examine PNS of affected limb

Answer 48

**Very High** → triceps paralysis + wrist drop + finger drop * Just below brachial plexus * Compression: crutches **High** → wrist drop + finger drop * Occur at spiral groove * Mid-shaft humerus #, Saturday night palsy **Low** → finger drop * Occur at elbow * Only involve posterior interosseous nerve therefore sensation preserved * Local wounds, # or dislocation

Answer 49

* *_Examination_** * *Look** * Flexion deformity of distal phalanx of one or more fingers **Move** * Terminal phalanx cannot be actively extended * _Can_ be passively extended **_Aetiology_** * Damage to extensor tendon of terminal phalanx. * e.g. avulsion # due to hyperflexion injury when catching a cricket ball **_Mx_** * X-ray: look for avulsion @ base of distal phalanx * Splint c¯ distal phalanx in extension for 6wks to allow tendon reattachment. * If avulsed bone is large may fix it c¯ a Kirschner wire

Answer 50

* *_Examination_** * *Look** * Flexion of middle or ring finger **Feel** * Palpate over palm proximally to digit for nodule. * ~ @ level of transverse palmar crease **Move** * Test active movement of finger * Snap on passive forced extension **_Pathology_** * Tendon nodule which catches on proximal side of tendon sheath → triggering on forced extension. * Often FDS tendon **_Causes_** * Idiopathic * Trauma * Activities requiring repetitive forceful flexion e.g. use of heavy shears * 2O to RA **_Mx_** * Steroid injection: often recurs * Tendon release by sheath incision

Answer 51

*Expose pt. to waist Begin c¯ pt. standing* * *Gait**?mobility aids * *Look** (360) * Deformities: * Abnormal posture * Spinal curvature: * kyphosis * lordosis * scoliosis * Wasting: Paraspinal and trapezius muscle bulk * Assymetry, Scars, Bruises/skin changes * **_MEASURE_** Wall-tragus test if neck hyperflexion **Feel** * Paraspinal muscle bulk and tenderness * Spine palpation: masses, steps * Spine percussion: tenderness **Move** * Cervical spine movement * Lateral fexion – “Try to touch your ear to your shoulder” * Flexion – “Put your chin down onto your chest” * Extension – “Put your head back as far as possible” * Rotation – “Look over your shoulder” * Lumbar spine: * Flexion – “Try to touch your toes” * Extension – “Lean back as far as possible” * Lateral flexion – “Lean to side, slide your hand down your leg” * **Special Tests**: Schober’s Test: Forward flexion * Mark 5cm below and 10cm above line between iliac crests (L3/4) * Maximum flexion should lengthen line by ≥5cm *Lie the patient supine* * Thoracic: * Rotation – “Twist your shoulders round” **Special Tests** * _Measure leg lengths_: apparent length discrepancy in scoliosis * ***_Straight Leg Raise_*** * Demonstrates lumbosacral nerve root irritation * Record angle @ pain onset * ***_Lesague’s Sign_*** * ↑ pain c¯ foot dorsiflexion * ?Femoral stretch test: * *Pt lying on front “Let me know if cause you any pain” Hold thigh and ankle, keep leg straight and extend hip Back pain radiating down anterior leg = positive test* * ***Sacroileitis Tests*** * Lateral compression * Stretch: FABER(/Patrick's) test: Flexion, abduction and external rotation of bent leg **Quick Neurological Assessment of Lower Limb** **Completion** * Complete neurological examination of lower limb * Especially perineal sensation * Consider a PR: exclude cauda equina compression

Answer 52

**Look** * Gait: half-flexed, painful back * Loss of normal lumbar lordosis * Posture: sciatic list * Attempt to ↓ nerve root compression by leaning to one side to open up the neural foramen **Feel** * Erector spinae spasm or tenderness **Move** * ↓ ROM: limited by pain **Special Tests** * Positive straight leg raise **Neurological** * Distal weakness and sensory loss * L4/5 disc L5 root sensory=Inner foot dorsum motor=Hallux exten * L5/S1 disc S1 root sensoru= Outer foot sole motor= Foot eversion + plantarflex reflect=Ankle **Completion** * Complete neurological examination of lower limb * Especially perineal sensation * Consider a PR: exclude cauda equina compression

Answer 53

* Occupation * Pain: site, radiation, associated injury, worse / better * Neurology: weakness, numbness and paraesthesia * Sphincter disturbance * Hx or features of malignancy * Effect on lifestyle * Previous Rx: analgesia, physio, surgery

Answer 54

* Pre-existing lumbar spondylosis * Rupture of annulus fibrosis c¯ herniation of nucleus pulposus into spinal canal

Answer 55

**Physiological** * ↑ age * Poor posture * Poor aerobic fitness **Occupational** * Heavy manual labour * Frequent bending, lifting, twisting * Repetitive or static work postures **Psychosocial** * Depression

Answer 56

* *_Non-Surgical Mx_** * **Conservative*** * Max 2d bed rest * Education: keep active, how to lift / stoop * Physiotherapy: “back school” * Psychosocial issues re. chronic pain and disability * Warmth ***Medical*** * Analgesia: paracetamol ± NSAIDs ± codeine * Muscle relaxant: low-dose diazepam (short-term) * Facet joint injections * *_Surgical Mx_** * **Indications*** * Progressive neurological deficit * Severe incapacitating pain * Failure of non-surgical options ***Procedures*** * Percutaneous microdiscectomy * Endoscopic discectomy * Hemilaminotomy + discectomy

Answer 57

* Power * L4: foot inversion and dorsiflexion * L5: great toe dorsiflexion * S1: foot eversion and plantar flexion * Reflexes * S1: Ankle * Sensation * L5: great toe and medial dorsum * S1: little toe and lateral sole