Ortho unit 4 Flashcards
define enthesis
short fibrous origin of a muscle
define enthesopathy
common sites for it to occur
symptoms
causes
management
inflam of the enthesis (short fibrous origin of a muscle)
common origin of the flexor muscles of the forearm (golfers elbow)
common origin of the extensor muscles of the forearm (Tennis elbow)
severe discomfort on using the affected muscle
many ethesis can be inflamed at a given time- causes are obscure
common ones around elbow may occur spontaneously but are ass. with repetitive movement/overuse
rest results in spontaneous recovery
if it becomes chronic and severe anti-inflams speed up recovery, steroid injections (into the enthesis with no leakage into fat or skin as this results in increased pain and patient is left with a dimple)
small no. need surgery - scrape the origin of the muscle from the bone and permit it to slide distally ‘decompressing’ the area. but encourage patients to wait for spontaneous recovery
signs and management of 4 common nerve entrapments
nerves are sensitive to compression/stretching. this injury = neuropraxia
continued pressure = atrophy of the nerve and is usually permanent so need early diagnosis.
can be intrinsic or extrinsic.
extrinsic - unconscious pressing on nerve. patients in bed or in plaster cast are at risk of pressure on nerves at exposed sites.
most common site = common peroneal nerve as it winds round head of fibular
most cases are intrinsic caused by anatomical variations or inflam swelling - common site = median nerve at write, ulnar at elbow, ulnar at wrist, posterior tibial nerve at ankle.
symptoms - numbness, tingling, weakness. weakness and real sensory loss are diagnostic. if doubt do nerve conduction studies. obvious causes eg cast must be removed. if symptoms persist - surgery - cut skin and fascia
define bursitis and tenosynovitis
bursitis = bursae (small sac of fibrous tissue lined with synovial membrane and filled with fluid. natural form of bearing wt aimed at improving muscle and joint function by decreasing friction, usually where tendons/ligs pass over bone. can also form in response to pressure) prone to disorders resulting from repetitive movement/strain/subject to abnormal loads.
bursae around the shoulder are commonly affected. most common sites = knee, elbow and greater trochanter of hip.
chronic discomfort over bursae ass. with pressure or movement. may be swelling of the bursa. may be infection resulting in a tense swelling ass. with infection of the skin (cellulitis) and general ill health (malaise)
chronic bursae with no symptoms need no treatment unless affects life eg swelling interferes with dressing. if tender can be excised but patient should be encouraged to remove the underlying cause eg using a kneeling mat. infected bursae should be incised and drained which leads to spontaneous recovery through scarring and fibrosis.
tenosynovitis = inflam of tendons and their ass. synovial sheaths. often ass. with RA, but can also occur spontaneously but is usually precipitated by unusual levels of activity/overuse. often ass. with worker compensation + litigation
common adult foot disorders
flat feet bunions and corns hallux valgus and hallux rigidus claw foot and hammer toes neuromas ingrown toenails plantar fascitis neuropathic feet achilies tendonitis and rupture
flat feet
painful flat foot is rare. if symptom free = normal variation
painful spasmodic foot may be ass. with infection/chronic inflam disease. occasionally it occurs acutely in middle age
examination shows painful and swollen area over insertion of tibialis posterior - may indicate acute/impending degenerative rupture and needs early intervention.
if no pain - no treatment
if pain - a medial heel lift will correct the deformity of the hind part of the foot and stabilise the arch.
if pain is persistent - fusion of subtalar joint but this can disturb foot and ankle function
bunions and corns
bunions - fluid filled bursae which are found at bony prominences (common over distal part of 1st metatarsal and occasionally over 5th). Natural response to pressure and indicate underlying abnormality which should be treated rather than bunion. occasionally they get infected and need drainage followed by treatment of the cause/review of footwear
corns - reaction to pressure. painful excessive corny skin. may be removed but will return if underlying cause is not removed
hallux valgus and hallux rigidus
hallux = big toe
both conditions of 1st metatarsal joint
conditions can occur together or separate
HV - turning away of phalanges of the big toe from the midline, usually due to deformity at the joint line
HR - OA of metatarsophalangeal joint
HR alone - can occur in teens and adults. in teens it is due to osteochondral fracture. conservative treatment = use of metatarsal bar to provide a rocker at the front of the foot so the toe doesn’t need to bend when walking - but usually fails as youngsters dont accept the cosmetic consequences on their shoes so get surgery. in adults conservative management isnt enough so surgery is required - remove osteophytes and osteotomy of prox phalynx is enough in minor cases, fusion in a neutral position is the most reliable. interposition arthroplasty is an alternative with a silicone spacer but gives mixed results
HV alone - more problems in women. no evidence it is due to shoes. many have short first metatarsal, often in varus. cause unknown. realignment to a more lateral position and excision of bony prominence (exostosis) over 1st met gives satisfactory results. excision of the metatarsophalangeal joint - the kellers procedure is to be avoided in young people and is unnecessary if the joint isnt painful.
HR and HV - older people where joint degeneration is secondary to the valgus deformity. old people usually satisfied with having pain relieved by well fitting, extra depth shoes. if it fails - kellers arthroplasty. this operation disrupts normal foot mechanics so reserve for the older, less active patient.
claw foot and hammer toes
claw - wasted muscles make the bones and toes nails appear more prominent like a dogs foot. implies muscle weakness/deficiency. often ass. with minor spinal abnormalities eg spinal bifida occulta so approach surgery wth caution
hammer - top of toe looks like hammer. they are secondary to the disruption of the metatarsophalangeal joints. abnormalities leading to prolapse of met heads and joint disruption isnt understood. present with sore forefeet (metatarsalgia). cause of primary lesion is unknown and treatment is unsatisfactory. surgery includes fusion of interphalangeal joints in a straight position so they dont rub on shoes. often a good pair of soft comfortable shoes is all that is needed.
neuromas
cutaneous nerves of toes trapped/irritated between met heads (mortons neuroma). cause unknown but prob due to repetitive trauma and therefore ass. with met head prolapse as described in hammer toes. difficult to diagnose, pain is dull and throbbing with sharp exacerbation, accompanied wth tingling of toes. difficult to localise. sideways compression of foot produces a palpable click reproducing symptoms. treatment by excision may cause more sensory disturbance to the toes. recurrence is common.
ingrown toenails
v uncomfortable and apinful
cause is unclear - maybe poor nail care
nail grows into nail fold - can cause secondary imfection. this then becomes long term nagging infection with acute and painful flare ups. could lead to secondary blood borne infections - serious consequences if have prostetic joints or heart valves
careful nail care and straight cutting controls it. may need to remove nail to clear up chronic infection. tends to recur - wedge resection of nail bed - retains toe nail and removes the issue. surest way to resolve it is to remove the nail bed using phenol after removing the nail, but some cosmetic surgery may also be necessary.
plantar fascitis
tough layer of fibrous tissue runs from the calcis to each toe base. cause obscure and is spontaneous in onset. soreness of the instep, often worse first thing in morn/after sitting for hours - minimally relieved by walking but then persist as ache. exacerbated by rough ground/change in direction. most settle but symptoms can last months/years. many tender points on the hindfood at the origin of plantar fascia medially on examination. discomfort is diffuse
no cure. insoles hollowed out under the tender area may help but can cause discomfort around edges of the hollow. soft shoes and insoles can relieve symptoms. if there is a marked tender point - steroid inj and log acting anaesthetic. some demand surgery - strip the fascia from the os calcis - results unpredictable
neuropathic feet
if have sensory neuropathy youre at risk of sores. most common in areas where leprosy is seen partic the far east. in west - usually due to diabetes - need to regularly inspect feet and ensure nails are tidy. choose suitable footwear and maybe get extra depth which are soft on the uppers (can be prescribed). ulcers are difficult to treat and secondary infection can lead to amputation.
achilles tendonitis and rupture
pain around the achilles where it inserts into the os calcis. seen in young athletes and middle aged men.
young athletes - over use. area may be tender/swollen. rest to recover, if recurrent - surgical decompression of tissue surrounding the tendon can eradicate symptoms. avoid steroid inj as can rupture if tendon is penetrated.
middle ages men - period of discomfort before rupture - indicated degeneration within tendon tissue. not understood but do know that the lower part of tendon has poor blood supply and is a point of weakness in people who stay active in middle age. if the tendon ruptures it will heal if ankle is kept in equinus plaster for min 8 weeks. tendon can be sutured (open or closed) - open has high risk of comps, but risk of re rupture. wearing a felt raise in heel of shoe for as long as poss will help
list common shoulder disorders
what part of shulder is commonly involved
management - specifically focusing on painful arc
One symptom of shoulder discomfort is pain, particularly on movement. The pain may be limited to a particular range of movement. Symptoms quite frequently are associated with a recent incident such as a pull, or a period of unusual activity such as DIY
subacromial bursa, supraspinatous tendon, AC joint, biceps tendon, rotator cuff as a whole
can be difficult to localise and must settle with rest and time
may need arthrography/arthroscopy to resolve diff diagnosis
if rest, gentle exercise, anti-inflams dont help - careful examination may reveal point of tenderness. Tenderness under active movement with a painful arc = supraspinatous tendon inflam or a subacromial bursitis. A steroid inj into bursa/around tendon (but not into) can be effective - but remains controversial.
if severe pain and radiograph reveals calcification in supraspinatous tendon - inj/surgery to remove calcified material is justified for the pain relief achieved. many only respond to steroid inj temporarily. further investigation often shows degenerative changes and osteophytes in AC joint. This can cause rupture of supraspinatous muscle which is part of rotator cuff. RC tears can be large, even small ones cause a lot of pain. Surgery to relieve cause and repair RC will bring effective pain relief and restore some function. Repetitive injections can result in further degeneration of RC and should not be practiced.
