Ortho rest Flashcards
1
Q
what is subacromial impingement syndrome
A
irritation and inflammation of rotator cuff tendons (esp supraspitnatus) as they pass through the subacromal space
2
Q
what are causes of subacromial impingement syndrome
A
Intrinsic:
- muscle weakness (rotator cuff weakness > imbalanced forces > humerus rotates)
- hounder overuse (inflammation > reduced space)
- degenerative tendinopathy (acromium degeneration > cuff tear)
Extrinsic
- glenohumeral instabiklity
- anatomical variation
3
Q
what are signs and symptoms of subacromial impingement syndrome
A
painful arc (esp overhead activities)
decreased range of movement
weakness
hawkins +ve
4
Q
list differentials for a painful arc
A
- subacromial
- frozen shoulder
- rotator cuff tear
- OA
- septic arthritis
- gout/pseudogout
- RhA
5
Q
How do you investigate subacromial impingement
A
XR (true AP, caudal tilt, supraspinatus outlet)
CT arthrography /USS
MRI (RCM and tendons)
6
Q
How do you manage subacromial impingement
A
conservative: rest, physio
medcal: NSAID, steroid into subacromial bursa
Surgical: arthroscopic acromioplasty
7
Q
what is calcific tendonitis
A
calcification of tendons
unknown aetiology
8
Q
stages of calcific tendonitis
A
- pre-calcific (pain free)
- calcific (pain gradually increases)
- post calcific
9
Q
S/S calcific tendonitis
A
loss of ROM
Pain (catching / locking with crepitus)
supraspinatus atrophy
Hawkins positive
10
Q
Ix calcific tendonitis
A
XR (calcific deposiits)»_space; US
11
Q
Management of calcific tendonitis
A
non-operative: analgesia, phyiso, ECST, USS guided injection
Operative: surgical decompression
12
Q
what are the four muscles in the rotator cuff
A
supraspinatus
infraspinatus
subscapularis
teres minor
13
Q
what is the function of the rotator cuff muscles
A
to STABILISE the shoulder jount
14
Q
what are RF for rotator cuff tears
A
age, smoking, FH, hypercholesteraemia
15
Q
what are symotoms of rotator cuff tear
A
painful arc (if partial tear)
if complete tear:
- shouldertip pain, full range of passve movement
- inability to abduct arm
- lowering the arm beneath 90 degrees causes a SUDDEN DROP (as this is supraspinatus role, which is torn)
16
Q
management of rotator cuff tear
A
non-operatve: analgesia, physio, steroid injection
operative: shoulder arthroscopy, rotator cuff repair
17
Q
how does rotator cuff arthropathy occur
A
rotator cuff tear > loss of joint congruence > abnormal glenohumeral joint > degeneration
18
Q
What anatomical changes occur in rotator cuff arthropathy ?
A
rotator cuff insufficiency
glenohumeral joint dsestructon
subchondral osteoporosus
humeral head collapse
19
Q
What are S/S of rotator cuff arthropathy
A
Night pain with weakness / stiffness
Limited range of movement, crepitus, inability to abduct
20
Q
management of rotator cuff arthropathy
A
non-operative (analgesia, physio, subacromial steroid injection)
operative (arthroscopic debridement, hemiarthroèlasty ( reverse shoulder arthroplasty=
21
Q
what is the medical term for frozen shoulder
A
Adhesive capsulitis
22
Q
what is frozen shoulder – sx
A
FUNCTIONAL loss of ACTIVE and PASSIVE movement of shoulder with no clear cause (occasionally post-traumatic / post surgical)
external rotation most affected
23
Q
who does frozen shoulder typically occur in
A
F>M, middle ages
24
Q
pathophysiology of frozen shoulder
A
inflammatory process causing fibroblastic proliferation of the joint capsule
leads to mechanical block of motion
25
what are the three stages of FROZEN shoulder
1. Freezing (gradual onset of pain, lasts up to 6 months)
2. Frosen (stiff, decreased range of movement)
3. Thawing (gradual return of range of motion, may last 5 months to 2 years)
26
What is the shoulder pain like in froaen shoulder
worse at night
cannot lie on affected side
27
How do you manage frozen shoulder?
NONE
it is self limiting
28
what is the difference between a dislocation and a sublaxation
dislocation = TOTAL non-articulation of the bone head in the joint
sublaxation: PARTIAL non-articulation of the bone head in the joint
29
how does shoulder dislocation present
shoulder contour lost (square shoulder)
bulging infraclavicular fossa
arm supported by hand + severe pain
30
How do you investigate shoulder dislocation
Assess NV status (axillary nerve in Chevron area) before manipulating
also do XR before and after manipulation
31
how do you manage shoulder dislocation
1. Reduction (with sedation - traction method or stimson mthod)
2. Rest in sling for 3/4 weeks
3. Physio
32
complication of shoulder dislocation
- Axillary nerve palsy (at time of presentation due to trauma OR iatrogenic due to manipulation OR delayed onset due to hematoma)
- rotator cuff tear
- recurrent dislocation (<20yo)
33
where are bicep tendon ruptures most likely to occur
most in the LONG TENDON of the biceps
34
what are risk factors for bicep tendon ruptures
heavy overhead activities
shoulder overuse
smoking, steroids
35
what are S/S of biceps tendon rupture
POP sound
followed by pain, bruising, swe,ling
Popeye deformity (muscle bulk results in bulge in middle of upper arm)
Weakness in shoulder and elbow
36
what are ix for biceps tendon ruprure
biceps squeeze test
MSK USS
Urgent MRI if suspecged distal tendon rupture
37
what is the difference in presentation between lateral (tennis) epicondylitis and medial (golfer) epicondylitisa?
lateral (tennis) epicondylitis - pain is around LATERAL epicondyle, worse on wrist EXTENSION
medial (golfer) epicondylitis - pain is around medial epicondyle, worse on wrist FLEXION
38
How do you investgate epicondylitis
USS
39
How do you investgate epicondylitis
conservative (rest, NSAID gel, physio)
40
how does olecranon bursitis present
swelling over posterior elbow
associated pain, warmth, erythema
typically affects middle aged pts
41
what are conditions associated to carpal tunnel syndrome
Conditions causing tissue swelling:
- Pregnancy
- Acromwegaly
- AMyloidosis
Conditions causing tendon / nerve inflammation:
- DM (glycosilates the tendon=
- hypothyroidism=
- RA (esp bilateral)
42
what is carpal tunnel
compression of the median nerve within the carpal tunnel
43
how does CTS present
parasthesia in 3.5 fingers (palmar aspect)
shaking of hand relieves parasthesia
occasionally pain
weakness of hand when grasping objects
44
what does the median nerve innervate in the hand
sensory to 3.5 fingers (thumb, index, middle, 0.5 ring finger) palmar aspect
motor to flexors to hand
45
How do you assess for carpal tunnel syndrome
CLINICAL EXAM
EMG may be necessary
46
What does CTS clinical exam reveal
- weak thumb abduction
- wasting in theminar eminence
- Tinel's sign: pressing the carpal tunnel causes parasthesia
- Phalen's sign: flexion of wrist causes parasthesia
47
How do you manage CTS
conservative: rest the hand, wrist splints at night
surgical: corticosteroid injections > surgical decompression
48
what are EMG findings for CTS
AP prolongation in sensory and motor axons > allows to grade severity
49
what is de quervain's tenosynovitis
the sheath (proximal to thumb) contaning extensor pollicis brevis and abductor pollicis longus become infected
50
symptoms of de quervain's tenosynovitis
tenderness on radial side of wrist
Adbuction of thumb against resistance is painful
51
How does de quervain's tenosynovitis present on examination
Finkestein test: pull thumb in ulnar deviation and longitudinal tractrion > pain over radial styloid and radial side of wrist
52
how do you manage de quervain's tenosynovitis
activity modification
analgesia
steroid injection, thumb splint, surgery
53
what is a duptyren's contracture
progressive, painkless, fibrotic thickening of palmar fascia
fibroblasts are replaced by myofibroblasts which cause contraction
54
how do you manage duptyren's contracture
splinting
fasciotomy
collagenase injection
fasciecotomy
55
conditions associated with duptyren's contracture
AIDS
DM
FH
Booze
Epilepsy and epilepsy meds e.g. phenytoin
56
how can you split causes of EFFUSION in the kneee
BLOOD
- immediate: ACL, intra-articular fracture,
- delayed: menisceal tear (delayed)
- can also be spontaneous: coagulopathy
SYNOVIAL FLUID:
- synovitis
- gout, pseudogout
PUS
- septic arthritis
57
what causes joint tenderness along the joint line?
mensceal tear
58
What investigation myst you always do if suspecting cruciate ligament rupture
XR (exclude fracture) > MRI (visualise cruciates)
59
what is classical history of ACL injury
Rotational / deceleration injury (skiing, football)
heard a pop > knee gave way > unable to continue walking
HAEMARTHROSIS: massive swelling immedately, as ligament contains an artery (becomes clear within 4-6 hours)
60
how do you manage ACL injury
isolated: conservative mx (quads physio)
instability/ paediatric / young and sporty: reconstruction (autologous graft from hamstring or patellar tendon)
61
what is PCL history
tibia forced backwards with knee flexed
often multiligamented (rarely occurs in isolation)
62
how do you manage PCL injury
isolated: conservative:
instability/concurrent injury/paediatrc: reconstruction
63
MCL/LCL injury history
extreme valgus / varus injury
64
MCL/LCL management
usually conservative
65
what is the purpose of ACL
limit anterior translation of tiba relative to femur
provide stability in internal rotation
66
which two tests are positive for ACL injury
Lachman
Anterior draw
67
Explain Lachman test
knee at 30 degrees
pull knee forward to see how anterior tibia moves compared to femur
68
Explain Anterior Draw test
knee at 90 degrees
Thumbs along joint line, index along hamstrings posteriorly . Apply force to demonstrate tibial excursion
69
what is the function of menisci
joint surface contact and weightbearing
70
when is maximum loadbearing on the knee achieved
with a flexed knee at 90 degrees
71
what is hhyistory of menisci injury aand presentation
twisting injury (medial meniscus most common)
pain worse when loading knee in flexion (going downstairs)
pain across joint line, locking or catching of the knee
overnight effusion
72
how do you mange menisceal tear
arthroscopic debridement (risk of OA)
arthroscopic repair
73
how does osgood shattler present
knee pain after exercise (gradual onset), relieved by rest
localised tenderness and swelling over tibial tuberosity
74
osgood shattle management
analgesia, ice packs, protective knee pads, stretching
reassure
advise stopping / reducing all sporting acrivities
75
what is a baker's cyst
BAKERS CYST: popliteal extension of gastrocnemius-semimebranosus bursa (NOT a real cyst)
essentially there is knee effusion from intra-articular pathology > fluid escapes from the joint membrane into the popliteal fossa region (between head of gastrocnemius and semimembranosum)
76
how does a baker's cyst present
swelling in popliteal fossa
77
what are the three important joint parts holding the ankle togeter
syndesmosis
lateral collateral ligament
medial collateral ligament
78
how does an achilles rupture injury occur and present
S/S: pop in ankle, sudden onset pain in calf or ankle
inabability to walk or continue with ssport
79
How do you investigate achilles tendon rupture
SIMMONDS TRIAD:
put patient prone, feet over edge of bed:
1. Calf sqeeze (thomas' test: injury means you cannot elicit plantarflexion)
2. Angle of declination (injury means greater dorsiflexion in injured foot)
3. Gap (injury =gap in tendop path
80
what is diagnostic of achilles tendon rupture
USS
81
how do patients describe a morton's neuroms
like walking on a marble
shooting / stabbing / burning pain in ball of foot
numb toes
82
WHAT Is a morton's neuroma
NOT a true neuroma
is is a compression neuropathy of the common digital planntar nerve (aka benign fibrotic thickening of the nerve)
83
what does morton's neuroma commonly occur in response to
in responsse to irritation, trauma or pressure
84
how do you manage morton's neuroma
orthotics
change shoes (no tight / pointy shoes) > steroid injections > surgical resection
85
where doe morton's neuroma usually occur
3rd - 4th tarsal bone
86
what is plantar fascitiis
inflammation of plantar aponeurosis
87
S/S plantar fascitis
pain / tendernes of heel and sole of foot
worse after periods of inactivity, better with exercise
88
what is osteoporosis
reduced bone mineral density (T score -2.5; BMD more than 2.5 st devs lower than general population)
89
RF osteoporosis
Age
Female
Steroid use
Smoking, alcohol
low BMI
FH
premature menopause
caucasian, asian
sedentary
endocrine dosorders
CKD, MM
90
What scores can you do for osteoporosis
QFracture or. FRAX (assess 10 year risk of developing fracture)
91
what do you do wth Qfracture / FRAX results
if low risk: reassure
if medium risk: BMD test
high risk: offer bone protection
92
T score meaning
BMD compared to young reference pop
93
Z score meaning
BMD compared to age, gender and ethnic matched
94
How do you manage osteoporosis
Vitamin D
Calciun suppleents
PO biphosphonates (alendronate)
95
what do you give if biphosphonates are not tolerated (e.g. eGFR<30, severe GORD)
give SC biologics (denosumab)
96
what is most common cause of OA
wear and tear
97
what are S/S of OA
pain in large, weight bearing joints and hands
crepitus, joint locking, pain after exercise
better with rest
98
what signs do you see on the hands in OA
Herbenden's nodes (DIPJ)
Bouchard nodes (PIPJ)
99
investigtions for OA
XR (loss of joint space, osteophytes, subchondral cysts, subchondral sclerosis)
CT, MRI
100
conservative management of OA
CONSERVATIVE MX OF OA:
- WL
- Physio/occupational therapy
- TENS (transcutaneous electricaal stimulation)
101
medical management of OA
Medical mx of OA:
1. Paracetamol PO, topical NSAID
2. PO NSAID + PPO or weak opioid
3. intraarticular corticosteroid or
102
what is surgical management of OA
arthroscopy (trim the cartilage, remove ostephytes, lavage)
arthroplasty (joint replamenent)
103
what are red flag sx for back pain
age <20/ >50
malignancy hx
night pain
hx trauma
FLAWS
104
general mx of open fractures
they need URGENT washout (max 6h) and debridement in theatre
Use EXTERNAL FIXATION until soft tissues have healedd
105
what is CUBITAL TUNNEL SYNDROME
compression of the ulnar nerve
106
how does cubital tunnel syndrome present
parasthesia in 4th and 5th digit (worse on elbow flexion)
with weakness AND ulnar claw
107
what is RADIAL TUNNEL syndrome
compresson of posterior interosseus branch of radial Nerve
108
how does RADIAL TUNNEL SYNDROME present
similar to lateral epicondylitis
4-5cm distal to the lateral epicondyle
109
most common organism to cause osteomyelitis
S aureus
110
how do you treat osteomyelitis?
IMMEDIATE ABX (e.g. vanc + cef)
AND RADICAL DEBRIDEMENT INTO LIVING BONE
111
how do you treat septic arthritis
JOINT WASH OUT FIRST (COLLECT SAMPLE FOR MCS()
THEN ABX
112
when do you need to do a partial fasciectomy in duptyrens contractures
when the hand cannot be placed flat on the table
113
what is trigger finger
a tendon nodule which catches on the tendon sheath >> triggers on forced extension, leads to FIXED FLEXION deformity (uually of 3rd and fouth digits)
114
commonest method of analgesia for pts wth NOF fracture
iliofascial nerve block
this reduces opioid analgesia required
115
sx of lumbar spinal stenosis
back pain (standing > sitting, walking uphill > downhill=)
leaning forwards relieces pain
neuropathic pain
neurogenic claudication
preserved distal pulses
116
what shoud you change alendronate to in osteoporottic lady with UGI sx
change to risedribate, etudrinate first (before biologics)
117
first line OA analgesia
Oral Paracetamol + TOPICAL NSAID
(only after trying topical you can chhange to oral)
118
what test can you do to identify sciatic nerve pain
straight leg raise
119
which malignant neoplasm has onion skin appearance
EWING SARCOMA
120
who does Ewing occur in
in young people
121
what is a ganglion
'cyst' arising from a joint or tendon sheath
122
where and in whom are ganglions commonly seen
back of the wrist
3 times more common in women
123
how do you treat ganglion
reassure > will self resoslve
124
what is osteogenesis imperfects
a collagen disorder aka brittle bone disease
autosomal dominant
125
presenting sx of osteogenesis imperfecta
fractures following minor trauma
dental caries
blue tinge of sclera
deafness (otosclerosis)
126
how do you manage lateral malleolus fractures that are A, B or C
A: below syndesmosis > boot weight-bearingg as able for 6 weels
B: through syndesmosis > boot NON weightbearing 6w
C: above syndesmosis = ORIF + syndesmotic repair
127
how does ulnar nerve injury differ based on whether it is damaged at elbow or at wrist?
LESS SX if DAMAGED AT ELBOW
Damage at elbow: ulnar half of flexor digitorum profundus is also affected > less marked clawing due to reduced unopposed flexion at the IPJ. Sx will get worse as nerve regenerates, once FDB starts working
Damage at wrist: FDP not damaged >claw like appearancew
128
what bacterium causes osteomyelitiss in sickle cell disease
SALMONELLA
129
what is FIRST LINE MEDICATION for back pain
NSAID (+PPI if over 45)
(paracetamol was found to be ineffective)
130
how do you manage sciatica with no red flags
1. anto-neuropathic pain agent (gabapentin / pregab/ amyltriptiline) + physio
2. wait 4-6 weeks > if no response, routine referral to spinal surgery
131
what location of scaphoid fracture must you ALWAYS operate (ORIF) on
the proximal scaphoid pole
132
what does a CHARCOT JOINT look like
HOT and SWOLLEN
NOT or MILDLY TENDER (due to peripheral neuropathy)
bone remodelling with osteolysis
133
first line ix to rule out osteoporotic vertebral fracture
X ray spine
134
which rheymatoid condition is associated to carpal tunnel and why
rheumatoid arthritis
because it causes synovitis > joint swelling> bilat carpal tunnel
135
first line meds for back pain
NSAID
NOT paracetamol alone
136
which structure is most likely compromised in a scaphoid fracture
dorsal carpal arch of radial artery
137
what does a positive straight leg raise indicate
L5 root pain (herniated disc)
138
what is the key movement impaired in adhesive capsulitis
EXTERNAL ROTATION(both active and passovre)
