Ortho/Msk Flashcards
Hip Examination
Setup/look/feel/move/TT/Completion
Set-Up
- Pt. should be in their underwear
- Note presence of walking aids
- Start c¯ pt. standing
Look
-
Gait
- Antalgic: ↓ stance-phase on affected side
- Trendelenberg: sideways lurch of trunk to bring body wt. over limb
-
Examine Pt. Standing (360)
- Skin
- Scars: esp. lateral and posterior
- Bruising, erythema
- Shape
- Soft tissue or bony swelling
- Muscle wasting: esp. gluteals
- Deformity: coxa vara or valga
- Skin
-
Trendelenberg Test
- Negative: pelvis tilts slightly up on unsupported side.
- Positive: pelvis drops on the unsupported side (strong side sags)
- Pathology of contralateral abductor mechanism
-
Examine Pt. Supine
- Square the pelvis and measure leg lengths
- True length: ASIS to medial malleolus
- Apparent length: xiphisternum to medial malleolus
- Galeazzi Test: tibial vs. femoral shortening.
- Square the pelvis and measure leg lengths
Feel
- Palpate for tenderness/wamth
- ASIS, iliac crests and pubic symphysis/tubercle
- Greater trochanter (trochanteric bursitis)
Move (passive and active)
- Abduction: 45
- Adduction: 30
- Flexion: 130
- (extension 10-15)
- Internal rotation: 20
- External rotation: 45
Special: Thomas’ Test *Caution if hip arthroplasty on non-test side* (forced flexion can → dislocation)
- Assesses for fixed flexion deformity with is otherwise masked by compensatory movement in pelvis or lumbar spine (excentuated lumbar lordosis required to maintain leg flat on bed)
- Place hand in hollow of pt lumbar spine
- Passively flex right hip with right hand up to limit of ROM
- With hand feel that lumbar lordosis has flattened
- positive test: left leg rises up (angle between thigh and bed = degree of fixed flexion deformity)
Completion
- Examine the knee and spine
- Perform a neurovascular assessment (esp. pulses).
- AP and lateral radiographs of the pelvis
+ve Trendelenberg test
- Abductor wasting (2O chronic pain)
- Sup. gluteal N. injury: surgery
- Structural: DDH
True and apparent Shortening
(discrepency >2)
- # : e.g. NOF
- Hip dislocation
- Growth disturbance of tibia/fibula
- Osteomyelitis
- # s
- Surgery: e.g. THR
- SUFE
- Perthes’ disease
Apparent Shortening
(discrepency>2, equal true length)
Scoliosis of the spine
Pelvic pathology e.g. hip ab/dduction contracture
Where is hip pain felt?
- -pain from the hip is felt…*
- -pain at the back of hip is usually…*
Pain from hip joint usually felt in groin or ant. thigh.
Pain @ back of hip is usually referred from lumbar spine
Causes of fixed flexion deformity in the hip
- *Osteoarthritis**; knee or hip
- *Other**
- Skin – burns and scar tissue cause contractures
- Muscles – hamstring contracture
- Joint – NOF# (intra-articular fractures), septic arthritis.
Features of OA of hip
x5
- ± Trendelenberg gait or +ve Test
- Pain
- Stiffness
- ↓ ROM: esp. internal rotation
- Fixed flexion deformity
Knee examination
set up/look/feel/move/special/complete
Set-Up
- Pt. should be in their underwear
- Note presence of walking aids
- Start c¯ pt. standing
Look
-
Gait
- Antalgic
- Stiff: pelvis rises during swing phase
- Varus thrust: medial collateral
- Valgus thrust: lateral collateral
-
Examine Pt. Standing (360)
- Skin
- Scars: arthroscopic ports, KR (midline longitudinal), menisectomy
- Bruising, erythema
- Shape
- Swelling: knee and popliteal fossa (Baker’s Cyst)
- Muscle wasting: quads, hamstrings
- Measure quads circumference @ 15cm from tib tuberosity
- Deformity
- Genu vara (bow legged): OA
- Genu valga (knock-knee): RA
- Examine Pt. Supine
Feel
- Temperature
-
Palpate Position knees @ 90
- Joint line for tenderness: meniscal pathology
- Patella, tendon and tibial tuberosity
- Popliteal fossa
- Effusion: ballot (and sweep test, inft->med->sup->lat, watch med bulge)
Move (active and passive, while palpating joint for crepitus)
- Straight leg raise; ?Extensor lag, ?Hyperextension, ?Fixed flexion deformity
- Flexion of knee
- Normal range = -10-140
- *Special Tests**
- Cruciate Ligaments*
- Ant + Post drawer tests: observe for posterior sag first = PCL tear
- Lachman’s: ACL, more sensitive cf. drawer test
- (Pivot shift test: only do in theatre under anaesthetic)
Collateral Ligaments
- In partial flexion ~30 (relax the joint capsule) and full extension
- Valgus stress (medial lig.) and varus stress (lateral lig.)
Menisci
- (McMurray test: Flex knee and hip to 90° Grasp sole of foot with one hand & knee with other hand, thumb feeling down one joint line and index finger feeling down the other, Straighten knee with foot held in external (medial meniscus) then internal (lateral) rotation Feel for ‘click’ and look for pt discomfort)
- (Apley grind test)
Completion
- Examine the hip and ankle.
- Perform a neurovascular assessment: esp. pulses
- Standing (weight bearing) AP and lateral and skyline radiographs of the knee
Differentials for knee effusions
- Synovial fluid: synovitis
- Blood
- 90% = ACL rupture
- PCL rupture, intra-articular #, meniscal tear
- Bleeding diathesis
- Pus: septic arthritis
McMurray test
With the patient supine the examiner holds the knee and palpates the joint line with one hand, thumb on one side and fingers on the other, whilst the other hand holds the sole of the foot and acts to support the limb and provide the required movement through range. The examiner then applies a valgus stress to the knee whilst the other hand rotates the leg externally and extends the knee. Pain and/or an audible click while performing this maneuver can indicate a torn medial meniscus. To examine the lateral meniscus the examiner repeats this process from full flexion but applies a varus stress to the knee and medial rotation to the tibia prior to extending the knee once again.
OA viva
Definition and pathophysiology
Define: Degenerative joint disorder in which there is progressive loss of hyaline cartilage and new bone formation at the joint surface and its margin.
Pathophysiology
- Softening of articular cartilage → fraying and fissuring of smooth surface → underlying bone exposure.
- Subchondral bone becomes sclerotic c¯ cysts.
- Proliferation and ossification of cartilage in unstressed areas → osteophytes.
- Capsular fibrosis → stiff joints.
OA
RF and Sx
Aetiology / Risk Factors
- Age (80% >75yrs)
- Obesity
- Joint abnormality
Symptoms
- Affects: knees, hips, DIPs, PIPs, thumb CMC
- Pain
- Worse c¯ movement
- Background rest/night pain
- Worse @ end of day
- Stiffness
- Especially after rest: joint “gelling”
- Lasts ~30min (e.g. AM)
- Deformity: e.g. genu varus
- ↓ ROM
OA classification
- Primary*: no underlying cause
- Secondary*: obesity, joint abnormality
OA Ix
- *Ix**
- Exclude Rheumatological Disease*
- FBC
- ESR
- RF, ANA
Check Renal Function
- Important before prescribing NSAIDs: esp. in elderly
- U+E
X-ray Changes
- Loss of joint space
- Osteophytes
- Subchondral cysts
- Subchondral sclerosis
Deformity
Management of OA
MDT/cons/Med/surg
- *MDT;** GP, physio, OT, dietician, orthopod
- *Conservative**
- Lifestyle: ↓ wt., ↑ exercise
- Physio: muscle strengthening
- OT: walking aids, supportive footwear, home mods
Medical
- Analgesia
- Paracetamol
- NSAIDs: e.g. arthrotec (diclofenac + misoprostol)
- Tramadol
- Joint injection: local anaesthetic and steroids
Surgical
- Arthroscopic Washout
- Mainly knees
- Trim cartilage
- Remove loose bodies.
- Realignment Osteotomy
- Small area of bone cut out
- Useful in younger (<50yrs) pts. c¯ medial knee OA
- High tibial valgus osteotomy redistributes wt. to lateral part of joint.
- Arthroplasty: replacement (or excision)
- Arthrodesis: last resort for pain management
- Novel Techniques
- Microfracture: stem cell release → fibro-cartilage formation
- Autologous chondrocyte implantation
OA vs RA
Hip Arthroplasty
(types/techniques)
Pioneered in 60s by Sir John Charnley
- *Types:**
- *THR**
- Replace femoral head, neck and acetabulum
- Usually elective joint arthroplasty
Hemi-arthroplasty
- Replace femoral head and neck only
- May be uni- or bi-polar
Resurfacing
- Replacement of surface of femoral head
Prostheses
- Cemented: e.g. Thompson (Recommended by NICE)
- Uncemented: e.g. Austin-Moore (Easier to revise (may be useful in younger pts.))
- *Techniques**
- *Posterior Approach**
- Access joint and capsule posteriorly, reflecting of the short external rotators.
- Gives good access
- May have higher dislocation rate
- Sciatic N. may be injured → foot drop
Anterolateral Approach
- Incision over greater trochanter, dividing fascia lata.
- Abductors are reflected to access joint capsule.
- May have lower dislocation risk
- Sup. Gluteal N. may be injured → Trendelenberg gait
Hip arthroplasty complications
(immediate,m early, late)
Immediate
- Nerve injury
- Fracture
- Cement reaction
Early
- DVT: up to 50% w/o prophylaxis
- Deep infection: 0.5-1.5% (Must remove metalwork before revision.)
- Dislocation (3%): squatting and adduction
Late
- Loosening: septic or aseptic
- Leg length discrepancy
- Metalosis: deposition and build-up of metal debris in the soft tissues of the body
- Revision: most replacements last 10-15yrs
Hip arthroplasty
DVT prophylaxis
pre/intra/post-op
Preventing DVT
- DVT is commonest complication of THR
- Peak incidence @ 5-10d post-op
Pre-Op
- TED stocking
- Aggressive optimisation: esp. hydration
- Stop OCP
Intra-Op
- Minimise length of surgery
- Using pneumatic compression boots
Post-Op
- LMWH: also rivaroxaban and dabigatran
- Early mobilisation
- Good analgesia
- Physio
- Adequate hydration
Hip resurfacing
advantage/disadvantages/indications
Advantages
- Metal-on-metal bearings wear less
- Larger head → ↓ dislocation / ↑ stability
- Preserve bone stock making revision easier
Disadvantages
- Cobalt and chromium metal ion release may cause pathology (e.g. leukaemia)
- Risk of NOF # if mal-positioned
Indications; May be used in young (<65), active people who are expected to outlive the replacement
Knee arthroplasty
Types/approach to surgery
Aim= Primary goal is to reduce pain
Types
- Can be uni- or bi-compartmental
- Cemented: UK
- Uncemented: Europe
The Surgery
- Performed under tourniquet
- PCL is usually preserved
- ACL is usually sacrificed (Prosthesis is specifically designed to provide some compensation for this)
- Metal prosthesis and an ethylene articular disc.
- Patella surface can be re-surfaced.
- Knee bending after 2-3 days.
- 10 days hospital stay
Knee arthroplasty complications
Immediate/early/late
Immediate
- Fracture
- Cement reaction
- Vascular injury
- SFA
- Popliteal and genicular vessels
- Nerve injury
- Peroneal nerve → foot drop (1%)
Early
- DVT
- Up to 50-70% w/o prophylaxis
- 25% c¯ prophylaxis
- Deep infection: 0.5-15% Must remove metalwork before revision.
Late
- Loosening: septic or aseptic
- Periprosthetic #s
- ↓ ROM and instability
- Loss of ACL
Surgical Mx of RA in the Knee
Indicated in failed medical Mx
- Synovectomy and debridement
- Can be done arthroscopically
- Removal of pannus and cartilage
- Supracondylar osteotomy
- Total knee arthroplasty
Haemarthrosis Differential
Primary/2nd to trauma
Primary Spontaneous
- w/o trauma
- May be 2O to coagulopathy
Secondary to Trauma (Immediate knee swelling)
- 80% ACL injury
- 10% 2ndary to patellar dislocation
- 10%
- Meniscal tear
- Capsular tear
- Osteochondral #
Knee locking differentials
- Meniscal tear
- Cruciate ligament injury
- Osteochondritis dissecans: adolescents
- Loose body
Presentation of ACL injury
- 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
What is the unhappy triad of O’Donoghue
- ACL
- MCL
- Medial Meniscus
Management of meniscal tear
Important factors, non-surg, surg
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
Management of ACL rupture
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.
Hallux Valgus Examination
Look/Feel/Move/Completion
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
Hallux Valgus
Associations(/RF), Ix, Mx
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
Aetiology and management
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
Charcot Joint Examination
Look/feel/move/completion
Neuropathic arthropathy, also known as Charcot joint, refers to progressive degeneration of a weight bearing joint, a process marked by bony destruction, bone resorption, and eventual deformity due to loss of sensation
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
Gait
phases
Abnormalities table
Phases
- Initial contact / heel strike
- Stance
- Toe off
- Swing
Dupuytren’s contracture
examination
look/feel/move/function/completion
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
Anatomy of Rheumatoid Hands
Boutonierre’s:
Swan:
Boutonierre’s: rupture of central slip of extensor expansion → PIPJ prolapse through “button-hole” created by the two lateral slips.
Swan: rupture of lateral slips → PIPJ hyper-extension
Mallet finger
examination (look/move)
Aeotiology
Management
- *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
