Orthopaedic Medicine Flashcards
The literal translation of Orthopaedics?
“straight children”
Define “acute disease”?
strikes the patient suddenly
Immune response to an acute disease?
production of polymorphs (many nuclei)
Define “chronic disease”?
takes a long time to develop, and may last a long time
Immune response to a chronic disease?
production of lymphocytes in the bone marrow and spleen
Two principal symptoms in Orthopaedics?
Pain and stiffness
Overall treatment objectives in Orthopaedics?
Pain relief (in most cases cure cannot be achieved)
what is a “self-limiting” condition
a temporary condition that will get better
list the types of orthopaedic problems in terms of aetiology
Congenital abnormalities Inflammatory abnormalties Metabolic disorders Degenerative disorders Trauma
List the types of orthopaedic problems in terms of frequency
Arthritis + other joint conditions Back pain Conditions of Childhood Common adult disorders Common fractures
the definition for osteoarthritis
excessive wear of articular cartilage, resulting from a breakdown in the balance between wear and repair processes in the joint
classify the causes of osteoarthritis?
PRIMARY OA
- unknown cause (majority)
- problem with repair of cartilage
SECONDARY OA
- known cause
- problem with wear of cartilage
causes of secondary osteoarthritis?
1) Congenital (CDOH)
2) Childhood (Perthe’s disease, infection)
3) Trauma (fracture into a joint)
4) Metabolic (gout, crystal arthropathy)
5) Infection (TB)
6) Chronic inflammatory (rheumatoid)
symptoms of osteoarthritis
- pain during activity
- loss of function of affected joint and limb
- stiffness (secondary to the pain!!)
when is help usually sought by a patient from their GP when they have OA?
when simple pain relief doesn’t control the pain
when is help usually sought by a GP from specialist help when a patient has OA?
when the patient’s sleep is disturbed
usual examination findings of an OA patient?
- pain
- limitation of movement
what is the management of OA aimed at?
PAIN RELIEF, which then leads to return of function
list the conservative treatment options for OA
- Weight loss
- Use of a stick
- Physiotherapy
Analgesia can be used subsequently, or in parallel to these measures.
How does weight loss act as a conservative Tx for OA and explain
Reduces load on the joint
- loads of joints can be up to several times of body weight. modest weight reduction results in a significant difference to loads on joints. also helps with general well being.
How does the use of a walking stick act as a conservative Tx for OA and explain
Use in the opposite hand allows the shoulder girdle to tilt the pelvis.
- when we weight bear on a leg, the gluteal muscles are contracting on the same side in order to tilt the opposite side of the pelvis upwards to allow leg swing to take place. this action is essential for efficient walking. the use of a stick reduces the work required by the abductor muscles, so reduces the muscle induced load on the hip.
How does physiotherapy act as a conservative Tx for OA and explain
It is a controversial method, and balance is needed. Helps to maintain the natural tone of the muscles.
- exercises relieve stiffness and muscle spasm and therefore pain.
list the surgical treatment options for OA
- Nothing
- Arthrodesis
- Osteotomy
- Arthroplasty
Why is doing nothing considered a surgical treatment option for OA?
The patient has to be aware that the benefits of surgery must outweigh the risks. If the patient is very old and disabled, it surgery might not be the best option
What is arthrodesis?
Surgical stiffening of a joint in a position of function. Joint is cut out and bone ends are held together by external splint or screws until they heal with a bony bridge.
What type of patient is arthrodesis best used for?
Young person with a painful and limited range of movement in the affected joint
describe arthrodesis procedure in the hip joint
more acceptable in males as in females it will affect sexual activity.
fusion in 30 degrees of flexion and some abduction allows pain-free functional gait, whilst allowing sitting. prolonged recovery (6 months in plaster splint)
what type of joints is arthrodesis better for
smaller joints, like ankle and wrist
the long-term disadvantage of arthrodesis
puts stress on adjacent joints
What is osteotomy?
Surgical realignment of a joint. Redirects forces across a joint by removing a wedge of bone so that loads are more evenly distributed.
What type of patient is osteotomy best used for?
Young person who has maintained good range of movement despite the pain (typical in early stages).
If ROM is very limited, then realignment isn’t going to help because function can’t be restored.
what type of joints is osteotomy good for
hip and knee
the long-term disadvantage of an osteotomy
will only last 2-10 years. although correction can be achieved to a certain extent, the underlying abnormality hasn’t been dealt with.
What is arthroplasty?
Replacement of one or both surfaces of a joint.
What are the main limitations of arthroplasty?
1) Relieves pain and restriction of movement that pain brings, but does not help with the stiffness that is caused directly by the disease within the joint. This is because soft tissue distortion persists after replacement.
2) Joint replacement is not the same as a transplant. As soon as the joint is inserted, it begins to wear.
Ideal strategy of joint replacement?
the joint should outlive the patient
Why is joint replacement of the upper limbs not as common as the lower limb?
Arthroplasty does not really help with intrinsic stiffness, so is no use in the upper limb where a large range of motion is required.
list the main requirements of an artificial joint
- provide a functional and pain-free range of motion
- withstand the forces placed upon it
- doesn’t wear or come loose
- same stability as a natural joint
why is arthroplasty of the hip successful?
The hip joint is stable due to the deep ball and socket joint, as well as range of motion being fairly limited
What is involved in knee arthroplasty?
Balance of the collateral ligaments by cutting tight parts of the ligaments and then putting in artificial surface replacements to ensure the medial and lateral collateral ligaments are under equal tension.
List the general complications of joint arthroplasty
chest infection
UTI
pressure sores
DVT
List the specific early complications of joint arthroplasty?
dislocation
DVT
infection
why is dislocation a specific early complication of joint arthroplasty?
the prosthesis isn’t fully supported by surrounding tissues, scar tissue hasn’t formed yet, and muscles and their proprioceptors may be out of action due to the trauma of surgery.
why is deep vein thrombosis a specific early complication of joint arthroplasty and how is it prevented?
due to the inactivity after surgery etc. Prophylaxis should be given, but the best method is not agreed universally.
Why is infection an early complication of joint arthroplasty?
the presence of foreign material inhibits the body’s ability to kill bacteria
What bacteria commonly cause early infection in joint arthroplasty?
- recognised hospital bacteria (S. aureus)
- skin commensals (S. albus)
List the specific late complications of joint arthroplasty?
- late infection (blood borne - contamination of bloodstream - bacteraemia)
- loosening and wear (inevitable)
What is rheumatoid arthritis?
A chronic systemic inflammatory disease that is thought to be due to abnormal reactions to bacteria. It is characteries by symmetrical deformity.
Clinical presentation of rheumatoid arthritis?
Severe pain, swelling and deformity of the joints - especially the small joints of the hands and feet. (MCPs and PIPs, not DIPs)
Stiffness that is worse in the morning and improving throughout the day
what is the role of surgery in RA?
ensuring the patient is comfortable, whilst retaining as much function as possible. (mostly salvage - not correction of deformity!)
types of surgery carried out for RA?
1) Soft tissue surgery
- synovectomy
- limits damage to tendon sheaths and tendons themselves
- can be useful in early disease
2) Joint surgery
- excision arthroplasty
- usually done in combination with synovectomy
define avascular necrosis
bone tissue death through loss of blood supply
general causes of AVN
- spontaneoulsy/idiopathic
- trauma
what sites are most at risk of AVN after a trauma
- femoral head
- proximal scaphoid in the wrist
- proximal talus of the foot
what sites are prone to spontaneous AVN
- lunate bone in the wrist
- femoral head
list common situations when idiopathic AVN of the femoral head is seen
- chronic alcohol abuse
- high dose steroid therapy
- deep seas divers (Caisson’s disease)
X-ray appearance of AVN
Early - no changes
Later - dense bone, due to no blood vessels
When is it possible to reverse AVN?
If the blood supply can be re-established NATURALLY
Mx of AVN
Non-specific Tx. Often salvage with joint replacement needed.
define ‘crystal arthropathies’
deposition of crystals of the by-products of metabolism onto the surface of articular cartilage and within synovial fluid
how do crystal arthropathies arise?
- abnormality of metabolism resulting in excess production
- kidneys failing to eliminate them
the deposition of which crystal causes gout?
urate crystals
what is urate?
a waste product of cell metabolism
causes of gout?
- overuse of diuretics (most common)
- dehydration
- post chemotherapy
joints where gout is normally found
knee and first metatarsophalangeal joint
presentation of gout, and what condition must you rule out first
hot, swollen and tender joint.
must rule out infection, as this can cause a lot of damage to articular cartilage
Dx of gout
GS - fluid extraction of infected joint for presence of urate crystals
Also, high uric acid level in the blood
Mx of gout
NSAIDs
the deposition of which crystal causes pseudogout?
pyrophosphate crystals
the consequence of long-term pseudogout?
calcification of joint surfaces and menisci in the knee. long-term degeneration is likely, even with Tx
Mx of pseudogout
NSAIDs
define acute septic arthritis
an infection of the joint caused by bacteria that has spread through the bloodstream from a trivial site of infection
presentation of septic arthritis in children
the child is very unwell with an acute illness and high temp.
joint is very hot, tender and stiff
presentation of septic arthritis in adults
presents less acutely than children, and can be mistaken for just minor upset. then presents a few days later with blood poisoning, and may die as a result
most likely cause of a young adult presenting with septic arhtirtis
gonococcus, resulting from veneral disease
Mx of septic arthritis
- surgery - opening and washing of joint
2. IV ABx - first guess is anti-staph agent
what are the risks of inadequate Tx of septic arthritis
- risk of septicaemia
2. disintegration of articular cartilage, leading to bony fusion
what bacterial infection causes chronic septic arthritis
joint tuberculosis (TB) - spreads to the joints via the blood
presentation of chronic septic arthritis
- chronic ill health
- weight loss
- muscle wasting around infected joint
Mx of chronic septic arthritis
- TB drugs (RIPE)
- Surgery rarely necessary
presentation of meniscal tears
- pain
- fluid in the joint (effusion)
- locking
- giving way
examination findings of a meniscal tear
- poorly localised on examination
- discomfort is elicited by gently but forcibly extending the knee joint
most common mechanism of meniscal tear injury
- twisting injury
- foot gets stuck on the ground and the femur twists over the stationary tibia
which meniscus is more commonly torn and why?
medial more so than lateral
- medial meniscus is firmly attached to the medial collateral ligament
what type of meniscal lesion is very common in old age, and explain pathology
- cleavage lesion
- this is a horizontal split of the meniscus, which can act like a flap valve and allow build-up of synovial fluid within the meniscus forming a cyst
list the common types of meniscal tear patterns and give short explanation
- Bucket handle tear (vertical split, anchored at both ends)
- Parrot beak tear (a split off one end of the lateral meniscus)
why is extending the knee joint prevented in a meniscal tear?
the torn prt becomes jammed in the joint
Mx of meniscal lesions
Clinical suspicion - arthroscopy then Peripheral tears - suturing or Tear within substance - arthroscopic menisectomy
what are loose bodies in a joint also known as, and how do they arise?
- Osteochondral fragments
- fragments of cartilage and bone that are sheared off in injury
what is the consequence of the presence of loose bodies in a joint?
knee swells due to associated bleeding into the joint (haemarthrosis).
the loose body floats free in the synovial fluid
presentation of osteochondral fragments?
can present years later after the first incident with locking, pain, giving way, effusion
what is osteochondritis dissecans
osteochondral fragments that arise spontaneously
Mx osteochondral fragments
removal via arthroscope
compare the healing capacity of the collateral ligamentsand the cruciate ligaments
collateral ligament injuries can heal spontaneously because they have an excellent blood supply. cruciate ligaments do not heal spontaneously because once they are torn the blood supply is lost
mechanism of cruciate ligament lesions
hyperextension or twisting injuries
presentation of cruciate ligament injury
- “pop” sound
- swelling from haemarthrosis from bleeding of the artery in the cruciate ligament
- loss of anter-posterior stability
Mx of cruciate ligament injury
- leave ligament for a while and rehabilitate muscles
- synthetic ligament replacement
what causes dislocation of the patella
malformation of the patella or the femoral condyle, leading to the patella moving abrasively over the femur
presentation of dislocation of the patella
- spontaneous dislocation of the patella
- quadriceps extensor failure, therefore fall to the ground
Mx dislocation of the patella
Minor - surgical splitting of the vastus lateralis
Major - medial tightening (plication) of vastus medialis
why are prosthetic knee ligaments liable to fail?
there are no sensory receptors to let the brain know if the ligament is being over-stretched
most backache is self-limiting - T/F?
True!
A minor backache is easy to distinguish from a serious problem - T/F?
False! - difficult without extensive investigation
What is the collective name for non-nervous tissue in the spine?
spondylitides
What are the non-nervous tissues in the spine?
bones (vertebrae), muscles and ligaments
Abnormalities in spondylitides are known as?
Spondylitis
What is a possible consequence of a structural abnormality in the spondylitides?
Compression of the spinal cord, or nerve roots
What are the 3 types of pain experienced in spinal disorders?
- locally
- in another part of the body (referred pain)
- along the length of the nerve arising from an affected nerve root
How does ‘local pain’ in the back tend to present?
tends to be related to a whole region e.g. dorsal region. difficult to pinpoint the exact area
where can pain in the back be referred to?
from the back > buttock, thigh and leg (RARELY below the calf!)
from the neck > shoulder and upper arm
where do nerve roots emerge from the vertebrae?
intervertebral foramina
what are the intervertebral foramina surrounded by?
facet joints behind
IV discs in front
how does the brain interpret a pressure on a particular nerve root?
the brain interprets this as pain in the length of the spinal nerve which is originating from that particular nerve root
give the name of the disease where there is pressure on a nerve root in the lower lumbar region of the spine, and explain
Sciatica
the pressure on a nerve root in the lower lumbar region means pain is perceived in the sciatic nerve.
symptoms of sciatica?
pain in the leg, mainly the back of the leg. almost always down into the foot.
pain can be exacerbated by coughing
what are the ‘localising signs’ of nerve root pain?
loss of sensation or muscle weakness
how is referred pain distinguished from nerve root pain in the lower limb?
Referred pain involves the buttock, thigh, and leg, but generally never descends below the calf. This differs from nerve root pain, where the pain almost always extends down the back of the leg and into the foot.
what are the 2 general classifications of backache and neckache?
- Backache + Neckache related to the spondylitides
- Backache + Neckache related to the nervous tissue
3 backache conditions in the unit related to the spondylitides
- Aches and sprains
- Mechanical backache
- Spondylolisthesis
what is the cause of most back sprains
awkward twisting or poor lifting, cause muscle or ligament injuries
what is a good recommended lifting technique to minimise back sprains
reducing the distance between the back and the weight results in less leverage and reduced spinal loading
how are back sprains distinguished from neurological causes of backache?
the absence of signs of nerve compression (e.g. tingling, loss of sensation)
Mx of back sprains
a brief rest period
analgesia (if insufficient, give anti-inflammatories)
define ‘mechanical backache’?
it is an ill-defined condition, but can be thought of as recurrent back sprains
what are some possible causes of mechanical backache?
- spondylosis
- degeneration of the IV disc
- leads to increased loading on the facet joints, leading to the development of secondary OA
- primary OA
presentation and Mx of mechanical backache?
recurrent
no known cure - rest, analgesia and physio during a bad episode
define ‘spondylolisthesis’
slippage of one vertebrae relative to the one below
causes of spondylolisthesis?
- a bony abnormality which interferes with the stability of the facet joints
- can also occur due to either acute or fatigue fracture of the pars interarticularis
what is the pars interarticularis
joins the facet joints in the posterior spine
a fracture in the pars interarticularis with no forward slippage of vertebrae is known as?
spondylolysis
how can spondylolysis differ from spondylolisthesis?
doesn’t always cause pain!
presentation of spondylolisthesis
low back pain
very similar to mechanical backache presentation
Dx of spondylolisthesis
X-ray
Mx of spondylolisthesis?
spinal corset to relieve pain
similar Mx to mechanical backache
severe pain > surgical fusion
2 backache conditions in the unit related to nervous tissue
- prolapsed intervertebral disc
2. bony root entrapment
are “slipped disc” and “prolapsed disc” interchangeable terms?
No! the IV disc doesn’t “slip”, it is the disc contents which prolapse
the typical presentation of a prolapsed IV disc
men, < 40 years old
backache and legache passing down the back of thigh and leg into the foot
can arise after single episode of lifting, or can arise spontaneously
describe the pathology of a prolapsed disc
an abnormality in the IV disc leads to extrusion of the nucleus pulposus through the annulus fibrosis
if the prolapse extends backwards and laterally it impinges on a nerve root
if the prolapse extrudes posteriorly, it will impinge on the spinal cord, or more commonly the cauda equina
Mx of a prolapsed disc
- ensure nerves supplying bowel and bladder are not affected
- rest, and progressive gentle mobilisation
- analgesia and anti-inflammatories
if the pain of a prolapsed disc persists despite initial intervention, what is the Mx
do a myelogram to confirm location of prolapse (radio-opaque dye and x-ray)
removal of prolapsed material by surgery
what is the typical presentation of bony root entrapment?
- M or F
- > 40
- previous Hx of mechanical backache
- development of new leg pain radiating to the foot that is made worse by exercise
- episodes are acute and recurrent against chronic Hx of back pain
what is spinal claudication
the name given to leg pain radiating to the foot that is made worse by exercise
what is the cause of bony root entrapment
bony overgrowth around the intervertebral foramina where the nerve roots emerge
what is the bony overgrowth in bony root entrapment due to?
secondary to degenerative changes in the adjacent facet joints
Mx bony root entrapment
removal of bone overgrowth - can result in disturbance of spinal stability, so decision to operate is based on the severity
define cervical spondylosis
degeneration of the IV discs in the cervical spine
describe the appearance of a vertebrae with cervical spondylosis
- bony overgrowth causing narrowing of the disc space,
- narrow foramen
- presence of osteophytes
typical presentation of cervical spondylosis
- F > M
- > 40 years old
- dull neck ache, referred to shoulders and upper arms
- +/- entrapment of nerve roots, so tingling in the arms
Mx of cervical spondylosis
- no nerve root entrapment: analgesia, NSAIDs, soft collar, physio
- nerve root entrapment: surgical fusion of the vertebrae and decompression of the nerve root
what is the presentation of cervical disc disease
difficult to distinguish from cervical spondylosis, but sufferers tend to have no history of neck trouble
average age for a child to sit independently
9 months
average age for a child to stand
12 months
average age for a child to walk
20 months
what is the normal alignment of a child’s knees < 7 years old
slightly valgus, with the feet around 4cm apart
by what age is a child’s knees normally aligned?
7 years
what is genu valgum
knock knees
what is genu varum
bow legs
what is in-toeing
when a child’s feet point inwards and is exaggerated when they run
causes of in-toeing
femoral neck anteversion
tibial torsion
abnormal forefeet
describe the pathology of femoral neck anteversion
during development, the leg rotates on the pelvis so that the acetabulum points nearly backwards and the femoral head is pointing forwards.
if this rotatory process isn’t completed by birth then the femoral neck will be more anterior (anteverted) than normal.
what types of movements will a child with femoral neck anteversion be able to do?
internally rotate their femur a lot, but not externally rotate
Tx of femoral neck anteversion
no Tx! Will usually correct itself by age 10, but some are left with a little residual deformity
what is tibial torsion
the tibia is warped along its vertical axis
Tx of tibial torsion
No Tx! it is a normal variation and should be ignored
Tx of abnormal forefeet
no Tx - most cases correct themselves by age 7.
do not consider surgery before then
special shoes make a difference in abnormal forefeet - T/F?
False!
flat foot is a normal variation - T/F?
True!
what are the 2 types of flat feet and explain them
Mobile
- normal variation. the arch may not form until 7 years
Rigid
- implies underlying bony abnormality
rigid flat foot can be a sign of which disease?
rheumatoid arthritis
which toe is most likely to be curly?
5th toe
Tx of curly toes
Most resolve spontaneously so should be left alone
If fixed - requires surgical correction (only the 5th toe!)
what is Osgood Schlatter’s disease
inflammation of the attachment of the patellar tendon to the growing tibial epiphysis
cause of Osgood Schlatter’s disease
overuse injury, meaning excess traction by the quadriceps
Tx of Osgood Schlatter’s disease
Rest!
Symptoms will cease in mid-adolescence when the epiphysis fuses
who is more likely to experience adolescent knee pain - M/F?
Females
Tx of adolescent knee pain
just watch briefly - most girls grow out of the condition
?arthroscopy if symptoms persist
what is chondromalacia patellae
erosion of an area of the patella cartilage
what is the incidence of CDOH
1 or 2 live births per thousand
define CDOH
there is an underlying abnormality of the acetabulum, the femoral head or both, meaning that the hip joint is abnormal and likely to dislocate
CDOH is more common in boys than girls - T/F?
False! More common in girls
CDOH has a familial and racial tendency - T/F?
True
CDOH is more commonly unilateral - T/F?
False - more commonly bilateral
at what ages is a child screened for CDOH
birth, 3, 6 and 9 months
what are the tests for CDOH
Ortolani test - attempt to dislocate the hip by abduction of the thigh and external rotation
Barlow test - attempt to relocate the hip by adduction and depression of the femur
what results of the tests for CDOH would make you suspect something
a slight ‘click’ is a suspicious sign
a definite ‘clunk’ if diagnosis is positive
clinical signs of CDOH if the Dx was missed at birth
- shortening of the limb
- asymmetrical skin creases
- limited abduction
- limp
if the CDOH tests produce a ‘click’ what should be done
re-examine and radiograph in specialist clinic at 3 months
if the CDOH tests produce a ‘clunk’ what should be done
treat from birth
relocate femoral head in acetablum and maintain with splintage
Mx if CDOH is discovered late, but before weight bearing (ie sitting)
- period of gentle traction, then open or closed manipulation
- plaster splint for 3 months
Mx if CDOH is discovered late and weight bearing has commenced (ie walking)
surgery to deepen acetabulum and re-angulate the femoral neck
- results are only adequate and secondary arthritis is likely
what is club foot
deformity of the foot which makes it look like a gold club
what is club foot also known as
talipes equino varus
forms of club foot and explain them
- mild, postural form
- seen after breech birth due to position in the womb
- can be bilateral - fixed form
- due to developmental abnormalities of the leg nerves and muscles
- can be bilateral
Tx of club foot
Both forms:
- 2 phases of gentle stretching
- 1st phase corrects hindfoot
- 2nd phase corrects midfoot and forefoot
Mild form:
- the above for 6 weeks is all that’s needed
fixed form:
- surgery
for how long should a child with club foot be followed up?
until their feet stop growing (around 14 years)
late relapses not uncommon!
what is spina bifida occulta?
a neural tube defect, where one or more vertebrae don’t form properly and there is a small gap in the spine
what are the symptoms of spina bifida occulta?
- many have no symptoms
- mechanical backache
- tethering of the spinal cord to higher lumbar vertebrae during growth (diastamatomyelia)
what is spina bifida cystica?
a neural tube defect where the neural plate tissues are open with little or no bony cover
what is the difference between a menigocele and a myelomeningocele?
A meningocele is a cyst covering the open neural tissue in spina bifida cystica.
A myelomeningocele is a cyst where the open neural tissue is incorporated into the cyst wall
many children also have which severe symptom with spina bifida cystica
hydrocephalus -
increase in fluid in the brain, leading to mental retardation
what is the prognosis of spina bifida cystica
- many die at birth
- some have surgery but most are mentally retarded
- need early foot surgery to maintain shape
- try to keep the child mobile until adolescence to maintain a good height
what is cerebral palsy
a term given for delayed or arrested development of the nervous and musculoskeletal systems due to damage to the brain at birth
the spinal tissue develops abnormally in cerebral palsy - T/F?
False!
The spinal tissue develops normally
what is the consequence of the spinal tissue developing normally, but the brain being damaged in cerebral palsy?
a child will have uninhibited reflexes but will lack the coordination that is normally controlled by the brain.
results in spastic paralysis - some muscles contract strongly and others are flaccid
leads to abnormal muscle and bone growth, with secondary deformity of joints
define ‘hemiparesis’
when one arm and leg on the same side are affected
define ‘paraparesis’
when both legs are affected
define ‘quadraparesis’
when all limbs are affected
how do people with only minor degrees of spasticity in cerebral palsy present?
toe-walking in adolescence - calf muscle spasticity
General Tx of cerebral palsy
- wide support team
- physiotherapy
- splintage (caution - overuse can cause increased muscle spasm)
- surgery to lengthen tight muscles or denervate them
define scoliosis
deformity of the spine where there is an abnormal lordosis, leading to buckling and twisting of the vertebral column as a result of the action of muscles and gravity
causes of scoliosis
- most cases are idiopathic
- congenital abnormalities of the vertebrae
what is the principal effect that scoliosis has on an individual
mainly cosmetic, which causes a lot of distress
presentation of scoliosis
- twisting of the ribs
- hump on the shoulder
- girls - skirt hangs crooked
- pain - secondary to distress
do all curves in scoliosis progress?
- no
Mx of scoliosis
- early referral and Tx
- surgical correction
- correction of the rotatory element of the deformity, to remove the hump as this is the cause of most distress
what are the classic causes of a limp in children from birth?
- CDH
- infection of the hip
what are the classic causes of a limp in children between age 4-10 years?
- Perthe’s disease
what are the classic causes of a limp in children between 10-15 years?
- SUFE
what is Perthe’s disease?
osteochondritis (fragmentation of bone and overlying cartilage) of the femoral head epiphysis) - AVN of the growing femoral head
is Perthe’s disease more common in boys or girls?
Boys
is Perthe’s disease more commonly unilateral or bilateral?
Unilateral (20% are bilateral)
what is the incidence of Perthe’s disease?
up to 5 per 1000 children
classic presentation of Perthe’s disease
a painful limp followed by a slow recovery
Ix of perthe’s disease and what do they show
X-ray (may be normal at first presentation, but on repeat later will show changes)
Ultrasound - excess fluid at hip joint
Mx of Perthe’s disease
Minor (< half of femoral head involved) - no Tx needed
Major - maintain femoral head in acetabulum until disease runs natural course (can use splintage)
follow-up with periods of traction
What is Slipped Upper Femoral Epiphysis (SUFE)
slippage of the epiphysis of the femoral head on the femoral neck so that the head is abnormally tilted
what is the classic type of child who will present with SUFE
overweight sexually immature boy who has recently undergone a growth spurt
presentation of SUFE
limp, with pain radiating to the knee (due to sensory distribution of the obturator nerve)
Ix of SUFE
x-ray - must include a lateral view or slippage can be missed
Mx SUFE
Surgical
- Minor: pin hip in new deformed position
- Major: attempt to manipulate neck back onto head
Remove pins around 18 years old when epiphysis has fused
define ‘enthesis’
the short, fibrous origin of a muscle
define ‘enthesopathy’
inflammation of a muscle origin
give 2 examples of common enthesopathies
golfer’s elbow and tennis elbow
what is ‘golfer’s elbow’
inflammation of the common origin of the flexor muscles of the forearm (medial epicondyle of the humerus)
what is ‘tennis elbow’
inflammation of the common origin of the extensor muscles of the forearm (lateral epicondyle of the humerus)
causes of enthesopathies
- associated with repetitive movements
- can also arise spontaneously
Tx of enthesopathies
Encourage patients to wait because it is likely for spontaneous recovery in the long term
- anti-inflammatory agents
- local steroid injections into max tenderness site
- surgery (scrape origin of muscle from bone and permit it to slide distally)
why must care be taken when injecting steroid in enthesopathies
if there is leakage into the subcutaneous fat or skin, pain will be exacerbated and patient will be left with a dimple
define a ‘neuropraxia’
compression or stretching injury to a nerve (ie. nerve entrapment)
why is early diagnosis of neuropraxia important?
if there is continued pressure on the nerve, it will atrophy meaning recovery is long and the atrophy is usually permanent
what are the different types of causes of neuropraxia?
Extrinsic causes:
- accidents where consciousness is lost and the victim inadvertently presses on a nerve.
- patients in bed
- patients in a plaster cast
Intrinsic causes:
- structural local anatomical variations or inflammatory swelling
what is the most common site of an extrinsic cause of neuropraxia
the common peroneal nerve, where it winds around the head of the fibula
what are the most common sites of an intrinsic cause of neuropraxia
median nerve at the wrist
ulnar nerve at the wrist
ulnar nerve at the elbow
posterior tibial nerve at the ankle
Ix of neuropraxia
- clinical Dx of weakness and real sensory loss
- if doubtful, do nerve conduction studies
Mx of neuropraxia
remove obvious causes (bandage/cast)
surgical relief of pressure if symptoms persist. cutting of skin and fascia
define ‘tenosynovitis’
inflammation of a tendon and their associated synovial sheath
what condition is tenosynovitis often associated with
rheumatoid arthritis
causes of tenosynovitis
- idiopathic
- unusual high activity levels or overuse
what are bursae?
small sac of fibrous tissue lined by synovial membrane and filled with fluid
what is the role of bursae?
their role is ‘bearing’, for improving muscle and joint function by reducing friction where tendons and ligaments pass over bones
what type of activities make bursae likely to become inflamed?
- repetitive movement or strain
- being subject to abnormal loads
what are the most common sites for bursitis?
- shoulder
- knee
- elbow
- greater trochanter of the hip
what are the symptoms of bursitis
- chronic discomfort over the bursa
- +/- swelling
- +/- infection
what are the symptoms of an infected bursa?
- tense swelling
- infection of the skin (cellulitis)
- general malaise
Mx of a chronic bursa with no symptoms
No Tx unless patient demands it for convenience or appearance
Mx of a tender bursa
remove underlying cause
- excise if persistent
Mx of an infected bursa
incision and drainage
causes of a painful flat foot
- infection
- chronic inflammatory disease
- acute or impending rupture of the insertion of the tibialis posterior (seen in middle age, with a painful and tender swelling)
Tx of a pain-free flat foot
no Tx!
Tx of a painful flat foot
medial heel lift
Tx of a persistently painful flat foot
fusion of the subtalar joint
- disturbs foot and ankle function
what are bunions?
fluid filled bursae that are found around bony prominences which for in response to pressure and indicate underlying abnormality
what are corns?
another way (as well as bunions) that the body reacts to areas of high pressure
what does the term ‘hallux’ refer to?
the big toe
hallux valgus and hallux rigidus are conditions of which joint
the first MTP joint
define ‘hallux valgus’
the turning away of the phalanges of the big toe from the mid-line
define ‘hallux rigidus’
OA of the first MTP joint
hallux rigidus and hallux valgus always occur separately - T/F?
False - they can occur separately or together
Tx depends on whether one or both are present, and the age of the patient
what age group does hallux rigidus occur in
adolescents and adults (rarely seen without hallux valgus in the elderly)
what is the main probable cause of hallux rigidus in adolescents
osteochondral fracture (not always easy to prove)
Mx of hallux rigidus in adolescents
Metatarsal bar
- a rocker at the front of the foot so the toes don’t bend during walking
- usually fails due to cosmetic compliance issues
Surgery
- removal of osteophytes with osteotomy
- fusion in a neutral position
- interposition arthroplasty with a silastic spacer - alternative with mixed results
Mx of hallux rigidus in adults
Surgery
- removal of osteophytes with osteotomy
- fusion in a neutral position
- interposition arthroplasty with a silastic spacer - alternative with mixed results
what age group does hallux valgus occur in
it can occur at any age
what is the cause of hallux valgus
the cause is unknown!
Mx of hallux valgus
Dependent on age
Any age
- realignment of the 1st metatarsal to a more lateral position and excision of bony prominence
Only in adults, avoid in young
- Keller’s procedure: excision of the MTP joint
why is hallux valgus usually found with hallux rigidus in the elderly?
joint degeneration (rigidus) usually develops secondary to the valgus deformity
Mx of hallux valgus with rigidus
1) well-fitting extra depth shoes
2) Keller’s arthroplasty
define ‘claw foot’
wasting of small muscles of the feet make the bones and toenails more prominent - like a dogs foot
what condition is claw foot often associated with
spina bifida occulta
what is the cause of ‘hammer toes’
occur secondary to the disruption (prolapse) of the MTP joints - primary cause of this is unknown
how do people with hammer toes often present
generally sore forefeet - metatarsalgia
Tx of hammer toes
1) good pair of comfortable shoes is often all that’s required
2) fusion of the interphalangeal joints in a straight position
what are neuromas?
irritation of the cutaneous nerves to the toes between the metatarsal heads
causes of a neuroma
secondary to repetitive trauma
Presentation of a neuroma
- dull and throbbing pain with sharp exacerbations
- tingling of the toes
- poorly localising
- sideways compression of the foot produces a palpable click, reproducing the symptoms
Tx of a neuroma
excision
- may cause sensory disturbance of the toes
- recurrence is common
what are ingrowing toenails often associated with?
poor nail care
what are the consequences of ingrowing toenails?
- digging in of the curved nail into the nail fold
- secondary infection of the nail fold due to trauma
- secondary blood borne infections
Mx of ingrowing toenails
Control
- careful nail care and straight cutting
Definitive treatment
- nail removal, and nail bed removal using phenol
what is plantar fascia?
tough layer of fibrous tissue running from the os calcis to each toe base
define ‘plantar fasciitis’
a number of vague, but very painful and incapacitating disorders of the plantar fascia, with unknown cause and sudden onset
presentation of plantar fasciitis
- sore instep, worse in the morning
- relieved by walking, but persists as a dull ache
- pain is exacerbated by a change in direction, or walking on rough ground
how often do symptoms of plantar fasciitis usually last
a few months, or even years
- most cases settle spontaneously
Tx of plantar fasciitis
no specific cure - Tx relief
- insoles hollowed out under the tender area
- soft shoes
- local injection of steroids if marked tender point
- long acting local anaesthetic
define the term ‘‘neuropathic feet’
loss of sensation in the feet due to disease
what are neuropathic feet more prone to?
sores - due to inability to perceive trauma
what is the insertion point of the achilles tendon
the os calcis
what 2 groups of people is achilles tendinitis most commonly seen in
young athletes
middle aged men
cause of achilles tendinitis in young athletes
over-use
Tx of achilles tendinitis in young athletes
1) rest
2) surgical decompression of the tissue surrounding the tendon
cause of achilles tendinitis in middle aged men
the lower part of the achilles tendon has a poor bloody supply and is a point of weakness in some people who are active into middle age
Tx of achilles rupture in middle age
1) equinus plaster for 8 weeks minimum
2) suturing of tendon (high complication risk)
3) wear a felt raise inside shoe for as long as possible after treatment to decrease chance of re-rupture
what causes a ‘painful arc’ in shoulder movement
inflammation of the supraspinatus tendon
Tx of a painful arc
rest, gentle exercise and anti-inflammatories
what is ‘frozen shoulder’
a condition where there is little or no glenohumeral movement
frozen shoulder can occur rarely after which type of incident
specific trauma incident, e.g. epileptic fit or shock
outer membrane of bones
periosteum
main aims of early management of a fracture
- minimise effects of blood loss
2. reduce pain
2 main reasons for taking a history after trauma
clinical and medico-legal
what 5 main questions must be asked during a trauma history
- what happened
- how did it happen
- where and when
- what was the injured person like before it happened
- who is the person
what are the 7 main signs of a fracture
- pain
- deformity
- tenderness
- swelling
- bruising
- loss of function
- crepitus
what determines the positions of the proximal fragment and the distal fragment in a fracture?
proximal fragment - determined by the muscles
distal fragment - determined by gravity
what is the most important first aid Tx in fractures
elevation of the injured part to reduce the swelling by helping fluid to drain
injured arm - elevate above heart
injured leg - lying down with elevation above chest
explain the colouring of bruises as they age?
1) dark - deoxygenated blood loss into the soft tissues
2) green to yellow - the haemoglobin in the RBC is broken down and carried to the liver by scavanger cells
what tissues, other than bones, are often involved in injuries to the limbs
skin fat muscle blood vessels nerves
what 5 investigative techniques are commonly used to confirm fractures
1) x-ray
2) tomograms
3) Computerised axial tomography (CAT scan)
4) USS
5) radioisotope scanning
main Ix for fractures
x-ray (sagittal and coronal views)
what is a tomogram
an Ix technique that uses electronic detectors to view a “slice” through a body part
when are tomograms useful
when there are many overlapping structures and the area is difficult to see
what is a CAT scan
modern version of a tomogram, where tomograms are generated onto video screen
when is USS used in Ix fracture
to show the accumulation of fluid (especially blood)
when is radioisotope scanning used in Ix a fracture
where there is clinical doubt whether a bone is fractured or not, especially in injuries that are not acute
explain what is involved in radioisotope scanning
- radioactive substance injected
- attaches to phosphate molecules that are taken up by bone
- xray plate is placed under the affected part
- the more metabolically active the bone is, the faster it takes up the radioactive substance
- sites of high metabolic activity i.e. at the fracture will be seen on the radiograph
what 8 features are necessary to describe a fracture
- which bone is broken
- which side of the bone
- is it open or closed
- where on the bone is it broken
- what shape is the fracture
- how many fragments
- what is the position of the distal fragment
- could it be pathological
what 3 factors describe a distal fragment relative to the proximal one in a fracture?
- displacement (anterior, posterio, medial, lateral)
- angulation (anterior posterior, valgus, varus)
- Rotation (internal or external)
how is immediate pain relief in a fracture achieved?
- drugs - morphine or pethidine injections
2. splintage - a device which holds a fracture steady
what is the main requirement of a splint?
must encompass above and below the injured joint
what can be used as an alternative to splintage in immediate pain relief in fracture
traction
in what fractures sites is blood loss most significant
major long bones - particularly femur and tibia to a lesser extent
unstable pelvic fractures
how much blood can be lost in a femoral fracture
2-3 units
how much blood can be lost in a tibial fracture
1 unit
how much blood can be lost ina major pelvic fracture
6 units
what immediate management should be given in major long bone or pelvic fractures to help with blood loss
cross matching
venous line for transfusion should be established as soon as possible
pelvic fractures: 2 lines and a central venous line so that transfusion iskeeping up with loss
what is the immediate management of an open fracture
- surgery
- removal of debris and dead tissue to prevent the contamination of bone becoming an infection
- leave wound open for a few days so that closure can be achieved without any tension on the skin
- give broad spec ABx
what does the term ‘definitive Mx’ of a fracture mean
the technique used (after bleeding and pain have been controlled) to restore normal function to the injured part of the body
is a ‘perfect result’ always the aim in fixing fractures?
no -benefits must outweigh risks in Tx strategy
in an older person, perfect function may only be achieved at the expense of risk of complication
name for the process where a fracture is returned to normal position
reduction
name for the process where a fracture is held in its normal position whilst healing
holding
what are the two types of reduction and explain them
- closed reduction
- traction on the distal fragment then manipulation of the fragment back onto the proximal fragment - open reduction
- done if closed reduction is unsuccessful
- fracture site is opened and fragments are relocated under vision
list the 4 types of method for holding fractures in place
- casting
- external fixation
- internal fixation
- traction
what is the main requirement of a cast?
immobilise the joints above and below the fracture site
how does a cast work?
acts as a splint. controls joint movement therefore can control posture. exerts pressure at 3 points so holds the fractured bone in the correct position
disadvantages of casts
- heavy
- immobilise the joints
- can’t examine covered part or use x-ray
- costly and inconvenient
- result in muscle wasting and stiffness
what method is used to overcome the disadvantages of casting
Functional bracing - free the joints. permit motion in one direction
what is a disadvantage of functional bracing
very dependent on an extremely accurate fit - so can’t be used immediately after fracture when there is swelling
what are the properties of modern casting materials
- stronger and lighter than plaster of paris
- glass fibre and polyurethane resin combinations
- used as secondary casts 1 or 2 weeks after injury
what type of cast is modern casting materials ideal for?
cast bracing - a cast that is broken up with a hinge in the middle
when is external fixation appropriate as a holding technique in fracture healing
high energy fractures with soft tissue damage - provides stability of bones and allows access to soft tissues for dressings and grafts etc
can fractures be fixed definitively with external fixation?
potentially - if the fixator can be adjusted to permit movement in the later stages, although pin sites are an easy route for infection
what is internal fixation
the holding of a fractured bone using screws, nails or plates
when is internal fixation appropriate as a holding technique in fracture healing
- high level of accuracy required
- other methods have failed
list the possible ways which internal fixation may be used in fracture holding
- apposition
- interfragmentary compression
- interfragmentary compression with onlay device
- inlay device
describe the method of apposition in internal fixation
holds the fracture together in alignment using K-wires
still mobile, so fracture heals by natural callus formation
can be easily pulled out when union is established
describe the method of interfragmentary compression in internal fixation
holds two bone fragments firmly together by screws
describe the method of interfragmentary compression with onlay device in internal fixation
an onlay device (plate of metal) provides extra support to the screws in interfragmentary compression
what is a disadvantage of onlay devices
inhibit natural bone union and delay healing
what are inlay devices
intramedullary devices (normally screws) used in internally fixing fractures
advantage of using inlay devices as method of internal fixation
achieve correct alignment of bones without disturbing natural bone healing
high strength means they are ideal for long bone fractures
disadvantage of using inlay devices as method of internal fixation
relatively innacurate method of restoring anatomical position so can’t be used around joints
explain in general terms how traction functions as a method for holding a fracture in place
applying a relatively small weight to a limb exerts a pull along the axis of the broken limb which stimulates the muscles to contract and hold a broken bone in position
different types of traction as a fracture holding method
- static
- balanced
- dynamic
what is static traction
the pull is applied against another part of the body - used for short periods
example of static traction?
Thomas splint - the pull is applied against a ring which presses against the pelvis
what is balanced traction
the pull against the ring (and thus the pelvis) is balanced by a weight attached to the whole splint, which takes the pressure off the skin round the ring whilst maintaining traction of the leg
when is balanced traction used
when static traction is in danger of causing damage to the body by the pressure
what is dynamic traction
weights provide the pull and the counter force is achieved by tilting the bed
what is main purpose of traction
short-term pain relieving measure by changing muscle tone and relieving spasm
give the general timeline of a bone healing process
1-2 weeks : swelling
2-6 weeks : callus formation
6-12 weeks : bone forming
6-12 months : bone formed
1-2 years : bone returns to normal
movement in which direction stimulates healing in a broken bone?
micromovement directed along the long axis of the bone at right angles to the break
if bones are rigidly fixed, will they still heal?
yes, but will do so slowly
what is a ‘primary’ complication of a fracture
occurs as a consequence of injury
what is a ‘secondary’ complication of a fracture
occurs as a consequence of treatment
list the early primary complications of fracture
blood loss infection fat embolism renal failure soft tissue injury compartment syndrome
Mx of a stable fixed fracture with infection
will still heal despite infection, can be temporarily treated by drainage of pus and by antibiotics until union has occurred
Mx of an unstable open fracture, or an unstable fixed fracture with infection
stabilisation by external fixation and surgical wound cleansing with later bone grafting
what is the cause of fat embolism as an early primary consequence of fracture
unclear - thought to be a generalised abnormal response to injury
typical presentation of a fat embolism after fracture
- long bone fracture in male < 20 years old
- 2-5 days post inury j
- rapid and shallow breathing
- mild confusion
- rash on chest and back
what type of fracture injuries make people more prone to developing kidney failure
massive soft tissue injury and trapped for prolonged periods, where the trapped limbs are starved of oxygen
what is compatrtment syndrome
excessive localised soft tissue swelling
pathophysiology of compartment syndrome
- thick layers of fibrous sheath separate muscle groups creating compartments
- when fracture occurs there is bleeding into adjacent compartments and causes increased pressure and swelling
- there is decreased blood flow to the muscles as a result
- results in ischaemia
symptoms of compartment syndrome
- pain out of proportion to injury
- loss of muscle functioon
- altered sensation over compartment
- pulse distal to compartment is normal
how is diagnosis of compartment syndrome made
stretch the muscle to precipitate extreme pain
treatment of compartment syndrome
- remove dressings and plasters
- if persists, surgical decompression is required
list the early secondary complications of fracture
plaster disease renal stones immobility infection compartment syndrome
what is ‘fracture disease’
combination of musele wasting, stiffness and skin sores due to immobilsation of a fracture in a plaster
what are some consequences of immobilisation of a fracture
osteoporosis renal stones (caused by calcium from the thinning bone) stiffness muscle wasting skin sores
list the late primary complications of fracture
non-union delayed union mal-union growth arrest arthrits
list the late secondary complications of fracture
mal-union
infection
causes of fracture non-union
excess or too little movement soft tisse between bone ends poor bloody supply infection excessive traction
when is non-union said to have occured
20 weeks in lower limb (usually takes 12 weeks)
10 weeks tin he upper limb (usually takes 6 weeks)
what is delayed union
a period betwene expected union and accepted non-union when the decision to do something is contemplated
Tx of non-union
remove any underlying cause
stimulateunion by stabilisng the fracture and ading a bone graft
what is mal-union
the fracture has healend i a position that precludes normal function
causes ofal m-union
failure of treamtnet method
neglect of surgeon
failure to attend out-patient clinic
Tx of malunion
open reduction and internal fixation
what is growth arrest
whena fracture breaches the germinal layer of the epiphyiseal growth platre nd bone growth arrests, resulting in deformity
why can arthritis develop at a fracture site
if the joint is excessivley stressed
