ortho unit 4

Question 1

Enthesis

Answer 1

short fibrous origin of a muscle

Question 2

enthesopathy

Answer 2

inflammation of a muscle origin

Question 3

golfers elbow

Answer 3

enthesopathy of common origin of the flexor muscles of the forearm- medial

Question 4

tennis elbow

Answer 4

enthesopathy of the common origin of the extensor muscles of the forearm- lateral

Question 5

Prognosis of enthesopathy

Answer 5

may arise spontaneously but generally due to repetitive movements or overuse. Prognosis good, esp if clear cause, will resolve spontaneously

Question 6

Severe enthesopathy

Answer 6

occasionally condition may become chronic or severe enough to warrant intervention. Recovery can be sped up by a course of anti inflammatory agents. Local steroid injections to the point of inflammation can also be useful

Question 7

Why, when giving steroid injections for enthesopathy, must care be taken to ensure that there is no leakage into the subcutaneous fat or skin

Answer 7

results in pain being exacerbated and the patient is left with a dimple

Question 8

Surgery for enthesopathy

Answer 8

v small no of patients require surgery. Scraping of the muscle from the bone and permitting it to slide distally, thus decompressing the area

Question 9

Neuropraxia

Answer 9

compressing and stretching

Question 10

what will continued pressure on nerve result in

Answer 10

atrophy of the nerve- at best takes a long time to recover and is usually permanent

Question 11

extrinsic nerve entrapments

Answer 11

victim inadvertently presses on a nerve e.g. when unconscious or in plaster cast

Question 12

common site of risk of extrinsic entrapment

Answer 12

common perineal nerve as it winds around the head of the fibula

Question 13

intrinsic nerve entrapments

Answer 13

most cases, structural or anatomical variations or inflammatory swelling

Question 14

common sites of intrinsic nerve entrapment

Answer 14

median nerve at wrist
ulnar nerve at elbow
ulnar nerve at wrist
posterior tibial nerve at ankle

Question 15

diagnosis or nerve entrapment

Answer 15

numbness or tingling should be taken seriously. Weakness and real sensory loss are diagnostic. If in doubt- nerve conduction studies

Question 16

management of nerve entrapment

Answer 16

Obvious causes e.g. cast must be removed. If symptoms persist- surgical relief of pressure may be required- cutting the skin and fascia

Question 17

Tenosynovitis

Answer 17

inflammation of tendons and their associated sheaths- often associated with rheumatoid arthritis. May arise spontaneously often with no known cause- usually precipitated by unusual levels of activity or overuse.

Question 18

Bursae

Answer 18

small sac of fibrous tissue lined with synovial membrane and filled with fluid- acts as a natural form of bearing- improves muscle function by reducing friction- usually where tendons and ligaments pass over bone

Question 19

Bursitis

Answer 19

Bursar are prone to disorders resulting from repetitive movement or strain, or from being subjected the abnormal loads. Chronic discomfort over the bursa, swelling of the bursa

Question 20

Most common sites of bursitis

Answer 20

Knee elbow and greater trochanter of hip. Also shoulder

Question 21

Infection of the bursa

Answer 21

Happens occasionally- results in a tense swelling of the bursaassociated with cellulitis and malaise

Question 22

treatment

Answer 22

generally nothing less patient demands it, if tender they may be excised. Patient should be encouraged to remove the underlying cause. Infected bursa should be incised and drained- this often leads to a spontaneous recovery through scarring and fibrosis

Question 23

Flat feet

Answer 23

normal variation unless painful. Painful flat foot is rare. Occasionally v painful spasmodic flat foot can be associated with infection or chronic inflammatory disease. Occasionally occurs in middle age- examination reveals a painful and tender swelling over the insertion of tibias posterior- may indicate acute or impending degenerative rupture and warrants early intervention

Question 24

Painful flat foot

Answer 24

medial heel lift. If pain is a persistent problem- subtler joint can be fused- disturbs foot and ankle function profoundly

Question 25

Bunions

Answer 25

fluid filled bursae- sound around bony prominences- commonly over distal part of first MCP, occasionally over the 5th. Form as a natural response to pressure and indicated an underlying abnormality. Occasionally become infected and need drained followed by treatment

Question 26

corn

Answer 26

another way in which the body responds to pressure- painful excessive corny skin may be superficially removed but in the long term it will recur unless the underling cause of high pressure is removed

Question 27

Hallux valgus

Answer 27

turning away of the phalanges of the big toe from the mid line, usually because of deformity at the joint line

Question 28

hallux rigidus

Answer 28

OA or 1st MTP joint

Question 29

Hallux rigidus alone treatment

Answer 29

can occur in adolescents and adults. Adolescents- said to be as a result of osteochondral fracture. Conservative treatment- metatarsal bar- usually fails as people don’t accept cosmetic consequences. Adults- can present at any age- surgery usually required.

Question 30

Surgery for hallux rigidus alone

Answer 30

Removal of osteophytes with osteotomy of proximal phalanx. Surgical fusion in a neutral position is most reliable. Interposition arthroplasty with silastic spacer- mixed results

Question 31

Hallux valgus alone

Answer 31

More problems in women. Many have a short first metatarsal, often in varus

Question 32

Management of hallux values alone

Answer 32

Depends on age-
Realignment of 1st MCP to a more lateral position and excision of any bony prominence (exostosis) over the first metatarsal head- satisfactory results at almost any age
Kellers procedure- excision of MCP joint- avoided in young and probs not necessary if joint isn’t painful

Question 33

Hallux values with rigidus

Answer 33

Older people, joint degradation usually secondary to the values deformity.
Older patients may be satisfied by well fitting extra depth shoes to relieve pain. If this fails- kellers arthroplasty- reserved for older less active patient as severely disrupts normal foot mechanics

Question 34

Claw foot

Answer 34

wasted muscles make the bones and nails look more prominent. Implies muscle weakness or deficiency. Often associated with minor spinal abnormalities e.g. spina bifida occulta- therefore, should be approached with caution as far as surgery is concerned

Question 35

Hammer toe

Answer 35

Top of toe looks like end of hammer, Secondary to the disruption of the MCP joints. Patient may present with generally sore forefeet- metatarsalgia. Cause of primary lesion is unknown and treatment often unsatisfactory.

Question 36

Surgery to hammer toes

Answer 36

fusion of interphalangeal joints in a straight position so they don’t rub on shoes. Often a good pair of soft and comfortable shoes is all thats needed

Question 37

Neuromas

Answer 37

Cutaneous nerves to toes trapped or irritated in between metatarsal heads (mortons neuroma). Cause is uncertain, due to secondary repetitive trauma and may be associated with metatarsal head prolapse. Difficult to diagnose. Pain dull and throbbing often with sharp exacerbations which are accompanied by tingling of the toes. Sideways compression of the foot produced a palpable click, reproducing symptoms. Treatment by excision may be accompanied by subsequent sensory disturbance to the affected toes. Recurrence is common

Question 38

Ingrowing toenails

Answer 38

Uncomfortable and painful. Cause- associated with poor nail care- curved nail grows into nail fold and digs in- may lead to secondary infection. Can also lead to secondary blood borne infections. Careful nail care and straight cutting will usually control the condition. However, it may be necessary to remove the nail to clear up chronic infection. Wedge resection of nail bed may retain toe nail and remove problem.. Definitive treatment- remove nail bed using phenol after nail has been removed.

Question 39

Plantar fascia

Answer 39

tough layer of fibrous tissue which runs from the os calais to each toe base

Question 40

plantar fascitis

Answer 40

painful disorders of the foot- soreness of instep of foot, often worse after sitting for a while. Symptoms minimally relieved by sitting but then persist as a debilitating ache, often exacerbated by change of direction or walking on rough ground. Most cases are self limiting although symptoms may last several months or years.

Question 41

Plantar fasciitis on examination

Answer 41

tenderness at a point on the hind foot- at origin of plantar fascia medially, Discomfort is often more diffuse.

Question 42

Treatment of plantar fasciitis

Answer 42

No specific cure, usually gets better by itself. Insoles hollowed out under tender area may help, soft shoes, insoles, modern sports trainers. Local injection of steroids and long acting anaesthetic can be v effective if there is a marked tender point. Some patients demand surgery- stripping of fascia from the os calcis- results are unpredictable

Question 43

Sensory neuropathy

Answer 43

feet without sensation- tend to develop sores- inability to perceive minor trauma.

Question 44

Commonest cause of neuropathy in western world

Answer 44

diabetes- diabetics should regularly inspect their feet and be sure the nails are tidy. Footwear must be chosen with care. Once established ulcers are difficult to heal and secondary infection may lead to amputation

Question 45

Achilles tendinitis

Answer 45

Young adults- signify overuse- area tender or swollen. Rest usually adequate. If recurrent- surgical decompression of tissue surrounding joint.
Middle aged men- phase of discomfort may precede rupture of achilles tendon- indicated degeneration within tendon tissue, Achilles tendon has poor blood supply and is often a point of weakness in people who keep particularly active into middle age

Question 46

Why should steroid injection be avoided in achilles tendinitis

Answer 46

penetration of tendon may lead to rupture

Question 47

Achilles tendon rupture

Answer 47

Will heal if ankle is kept in equines plaster for minimum of 8 weeks. Tendon can be sutured by open or closed technique. High risk of complication with open suture. High risk of re rupture with any method although this decreases with time

Question 48

Shoulder discomfort

Answer 48

Pain, particularly on movement. Pain may be limited to a particular range of movement. Symptoms quite freq are associated with a recent incident such as a pull, or period of unusual activity e.g. DIY

Question 49

Structures commonly involved in pathological conditions causing shoulder discomfort

Answer 49

subacromial bursa 
supraspinatus tendon
AC joint
biceps tendon
rotator cuff as a while
May be difficult or impossible to localise which one of these structures gives rise to symptoms

Question 50

Management of shoulder discomfort

Answer 50

Most settle with rest, gentle exercise, anti inflammatory drugs and time. If these do not help, a careful examination may reveal a point of tenderness. Tenderness under active movement with a painful arc is suggestive of a supraspinatus tendon inflammation or a subacromial bursitis. Steroid injection into bursa or around the tendon but not into it, can be very effective- should only be done with care. Occasionally sufferer may have very severe pain and a radiograph will show calcified material within supraspinatus tendon- injection or surgery to removed calcified material is well justified- many people only respond temporarily to the injection and further investigation shows degenerative change and osteophytes in the AC joint. This can lead to rupture of the supraspinatus muscle. Surgery to relieve cause and repair the rotator cuff will bring effective pain relief and return of function.

Question 51

Frozen shoulder

Answer 51

Little or no glenohumeral movement. Occurs rarely in those who have had a specific trauma incident e.g. epileptic fit or electric shock. People eventually recover after 18months to 2 yrs- they require a lot of psychological support and physio. Condition may be helped by manipulation under anaesthetic.