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
Charcot join
Definition
Definition
- Progressive destructive joint arthropathy
- 2ndary to disturbance of sensory innervation to the joint
- Painless deformed joint resulting from repetitive minor trauma.
Causes of charcot joints
peripheral vs central
Peripheral
- DM
- Peripheral N. injury
- Leprosy
Central
- Syringomyelia
- Tabes dorsalis
Gait
phases
Abnormalities table
Phases
- Initial contact / heel strike
- Stance
- Toe off
- Swing
Popliteal swelling
Examination
describe the lump and completeion
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
Popliteal swelling
differential
- 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
Baker cyst
What is is?
Dx
Mx
- Posterior herniation of knee joint capsule
- Assoc. c¯ degenerative knee joint disease
- Located below knee joint line
- *Dx**: US
- *Mx;** Aspiration possible: high recurrence
Shoulder examination
Look/feel/move/special/completion
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
Causes of ‘winged scapular’
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)
Shoulder Differential: Pain ± ↓ROM
- Rotator cuff: tear, tendonitis
- Subacromial bursitis
- Adhesive capsulitis (frozen shoulder)
- Joints: synovitis, OA, dislocation
- Humeral head: #, dislocation
- Referred pain from diaphragm
Hand examination
look/feel/move/function/special
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
- RA
- 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
Autonomous Sensory Areas
(median/ulnar/radial)
- Median: pulps of index and middle fingers
- Ulnar: pulp of little finger
- Radial: 1st dorsal web space
Autonomous Motor Supply
- 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
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
Differential of Dupuytren’s
- Skin contracture: look for scar from previous wound
- Congenital contracture of little finger
- Ulnar nerve palsy: ↓ sensation, +ve Froment’s sign
dupuytren’s contracture Important Hx
- Associations
- Function
- Previous therapy
- Other features of diffuse fibromatosis
Associations with dupuytren’s contracture
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
- Ledderhose disease
- Smoking
Pathophysiology of dupuytren’s contracture
Local microvessel ischaemia → ↑ xanthine oxidase activity → ROS production. → myofibroblast proliferation → collagen 3 formation-> Chronic inflammation → continued fibrosis
Management of dupuytren’s contracture
(non-surgical and surgical)
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
Capal Tunnel syndrome examination
look/feel/move/special/completion
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
Carpal tunnel syndrome differential (x2)
- More proximal median nerve lesion
- Cervical root lesion E.g. cervical disc herniation
Carpal tunnel sndrome Hx
- 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
Causes of carpal tunnel syndrome
Causes: I WRIST
- Idiopathic: commonest
- ?!Water: pregnancy, hypothyroidism
- Radial #
- Inflammation: RA, gout
- Soft tissue swelling: lipomas, acromegaly, amyloidosis
- Toxic: DM, EtOH
Carpal tunnel syndrome Ix
Not typically necessary
- Nerve conduction studies
- Determine lesion location
- Determine lesion severity
- US
Management of carpal tunnel syndrome
nonsurg/surg (and comps)
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
Other Locations (rather than flexor retinaulum) of Median Nerve Entrapment
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
RA hands examination findings
look/feel/move/completion
Look
- Hands
- Skin: joint erythema, palmar erythema
- Joint Swelling: MCPs and PIPs
- Muscle wasting: interossei, thenar eminence
- Deformity
- Ulnar deviation @ the MCPs
- Boutonniere deformity
- Swan neck deformity
- Z thumb
- 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
RA Viva
Hx
(and extra-articular features)
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
RA hands
Ix
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
RA hands Mx
MDT/Conservative/Medical/Surgical
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
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
OA Hands examination
look/move/function/completion
differential!
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
Hx Qs for OA
- Symptoms
- Pain
- Stiffness
- Affect on life
- Other joint disease
- Treatments so far
Mx of OA Hands
Non-Surgical
- Physiotherapy
- Analgesia
Surgical
- Joint arthrodesis
Ulnar nerve palsy Examination
look/feel/move/special/completion
Look
- Partial claw hand: little and ring fingers
- Wasting
- Hypothenar 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
Causes of Ulnar Nerve Palsy
Anatomical Compression
- Cubital tunnel syn.: elbow
- Guyon’s canal syn.: wrist
Trauma
- Supracondylar #s of humerus
- Elbow dislocation
Ulnar Paradox
Proximal lesions → paralysis of ulnar half of FDP
→ ↓ marked clawing of hand
Management of ulnar nerve palsy
non-surgical and surgical
Non-surgical
- Avoid repetitive flexion-extension of elbow
- Avoid prolonged elbow flexion
- Night splinting of elbow in extension
Surgical
- Ulnar nerve decompression
- Medial epicondylectomy
Radial nerve palsy
look/feel/move/completion
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
Causes of radial nerve palsy
v.high/high/low
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
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
Trigger finger
examination (look/feel/move)
pathology
causes
Mx
- *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
Back examination
Look/feel/move
supine (special; sacroiletis/straight leg raise)
neuro assessment
completion
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
Examination findings for Lumbar disc herniation
Look/feel/move/special/neuro
completion
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
Lumbar Disc Herniation
History
- 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
Lumbar Disc Herniation
pathophysiology
- Pre-existing lumbar spondylosis
- Rupture of annulus fibrosis c¯ herniation of nucleus pulposus into spinal canal
~Risk factors for lumbar disc herniation
(physiological, occupational, psychological)
Physiological
- ↑ age
- Poor posture
- Poor aerobic fitness
Occupational
- Heavy manual labour
- Frequent bending, lifting, twisting
- Repetitive or static work postures
Psychosocial
- Depression
Management of lumbar disc herniation
non-surgical (cons/med)
surgical (inidcations/procedures)
- *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
Quick neurological assessment of lower limb
Power/Reflexes/Sensation
- 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
