Orthopaedics Flashcards
Risk factors for Achilles’ tendon disorders
Cirpofloxacin
Hypercholesterolaemia
Features of tendinitis
Gradual onset of posterior heel pain following activity
Morning pain and stiffness
Management of tendinitis
Conservative- orthotics, rest, physiotherapy, ice
Medical- analgesia
Specialist- Extracorporeal shock-wave therapy (ESWT), possibly surgery, to remove nodules and adhesions or alter the tendon, may be used where other treatments fail
NB- not steroid injections
Investigate a suspected Achilles’ tendon rupture
Simmonds triad- palpation of snapped tendon, dorsiflexed angle of declination at rest, calf squeeze (no plantar flexion)
Other feratures;
Weakness of plantar flexion of the ankle (dorsiflexion is unaffected)
Unable to stand on tiptoes on the affected leg alone
USS
Referral to orthopaedics
Treatment
Conservative- Rest and immobilisation, Ice, Elevation, ankle boot
Medical- Analgesia
Surgical- repair
Features of adhesive capsulitis (frozen shoulder)
Shoulder pain
External rotation is more affected than internal rotation or abduction
Active and passive movements affected
Painful freezing phase, adhesive phase, recovery phase
Bilateral in 20%
Episode typically lasts between 6 months-2 years
Associations- middle aged females and DM
Management of adhesive capsulitis
May want an X ray to rule out pathology
Conservative- physiotherapy
Medical- NSAIDs, intra articular corticosteroids
Surgery- surgical release of the capsule
Webers classification of ankle fractures
Describe fractures of the lateral malleolus (distal fibula). The fracture is described in relation to the distal syndesmosis (fibrous join) between the tibia and fibula.
A- below syndesmosis
B- at level of syndesmosis
C- above syndesmosis which may be damaged
Management of an ankle fracture
Orthopaedic referral
Reduce
Surgical repair (older- conservative)
Ottawa rules for ankle x ray
Pain in malleolar zone and one of following;
- bony tenderness at medial malleolus
- bony tenderness at lateral malleolus
- inability to walk 4 weight bearing steps
What is a sprain
A stretching, partial, or complete tear of a ligament
Low ankle sprain
Most common- injury ATFL
Inversion injury
Usually able to weight bear unless severe of or high ankle sprain
RICE (rest, ice, compression, elevation)
Orthotics
Rarely surgery
High ankle sprain
External rotation of the foot
Weight bearing painful
Pain when fibula and tibia squeezed together
RICE (rest, ice, compression, elevation)
Orthotics
Rarely surgery (if diastisis eg. Tibia and fibula have separated)
Causes of a vascular necrosis of the hip
Long term steroids
Chemotherapy
Alcohol excess
Trauma
Features of AVN hip
Initially asymptomatic
Pain in affected joint
Investigations and management of AVN hip
X rays- may be normal (later- osteopenia and micro fractures, collapse of articular surface (crescent sign))
MRI- Gold standard
Refer to ortho- joint replacement
Bakers cyst
Can be primary or secondary to OA/ meniscal tears/ RA/ knee injuries or disease
Usually asymptomatic, if ruptured- DVT symptoms
Risk factors for biceps tendon rupture
Heavy overhead activities
Shoulder overuse/injury
Smoking
Corticosteroids (weaken tendons)
Features of biceps tendon rupture
Pop at distal or proximal tendon (with pain swelling and bruising)
Pop eye deformity if proximal/long tendon ruptures
Weakness on shoulder and elbow
Investigations and management of a biceps tendon rupture
Orthopaedic referral
Biceps squeeze (intact- forearm supination)
USS
Proximal- conservative
Distal- MRI, surgical
Buckle/torus fracture
Incomplete fracture of shaft of long bone with bulging of cortex (children)
Splinting and immobilisation
Carpal tunnel syndrome features
Compression of median nerve in carpal tunnel
Sensory- Pain/pins and needles in thumb, index, and middle fingers
Motor;
Weakness of thumb movements
Weakness of grip strength
Difficulty with fine movements involving the thumb
Wasting of the thenar muscles (muscle atrophy)
Symptoms ascend proximally
Patients shake hand to obtain relief typically at night
Causes of carpal tunnel
Idiopathic
Pregnancy
Oedema (heart failure)
Lunate fracture
Rheumatoid arthritis
Causes of bilateral carpal tunnel (look out for other features of the condition in exam)- rheumatoid arthritis, diabetes, acromegaly or hypothyroidism
Examination in carpal tunnel
Weakness of thumb abduction
Wasting of thenar eminence (not hypothenar)
Tinnels- tapping causes parasthesia
Phalens- flexion of wrist worsens symptoms
Investigations
Observations, hand and wrist exam
Bloods- DM, B12 deficiency, other routine bloods to exclude paraesthesia
Specialist- nerve conduction studies
Treatment
Conservative- wrist splints
Medical- corticosteroid injections,
Surgical- surgical decompression (cut flexor retinaculum)
Cauda equina syndrome
Lumbar sacral nerve roots that extend beyond the spinal cord are compressed
Causes of cauda equina
Disc prolapse (L4/5, L5/S1)
Tumours
Infection
Trauma
Haematoma
Features of cauda equina
Lower back pain
Bilateral sciatica
Reduced perianal sensation
Reduced anal tone (do a DRE)
Urinary incontinence (late stage sign- insensate)
Inability to maintain an erection/numb genitals
Investigation and management of CE syndrome
Urgent MRI
Surgical decompression
Colles fracture
Fall onto an outstretched hand
Distal radius fracture with dorsal displacement of fragments (and angulation)- think of the MOI (hit ground with outstretched hand, it will get bent back/dorsally)
Dinner fork type deformity
Compartment syndrome
2 main fractures causing this are supracondylar and tibial shaft injuries
Features of compartment syndrome
Pain on passive movement (excessive use of breakthrough analgesia is worrying, pain out of keeping with clinical signs)
6 P’s (presence of pulse doesn’t rule it out however)
Death of muscle group in 4-6 hours
Investigations and management of compartment syndrome
MSK exam, observations
Bloods- CK, FBC, UE (kidney involvement), CRP
Intracompartmental pressures (20+ bad, 40+ diagnostic), nothing on XRay
Prompt and extensive fasciotomy, IV fluids (kidneys), consider amputation
Features of cubical tunnel syndrome
Compression of ulnar nerve through the cubital tunnel
Tingling and numbness in 4/5th finger, intermittent, then constant
Weakness and muscle wasting
Pain worse on leaning on affected elbow
History of OA or trauma
Management of cubital tunnel syndrome
Avoid aggravating activity
Physiotherapy
Steroid injections
Surgery
Features of de Quervains tenosynvovitis
Pain on radial side of wrist
Tenderness over radial styloid
Abduction of thumb against resistance is painful
Finkelsteins test- examiner pulls thumb in ulnar deviation and causes pain
Management of DQ tenosynovitis
Conservative- Immobilisation with thumb splint, physiotherapy
Medical- analgesia, steroid injections
Surgery- cut the extensor retinaculum, releasing the pressure and creating more space for the tendons (Abductor pollicis longus (APL), Extensor pollicis brevis (EPB))
Features of discitis
Back pain
Systemic upset- pyrexia, rigors, sepsis
Neurological features- changing lower limb neurology if epidural abscess develops
Causes of discitis
Bacteria- staph aureus (endocarditis)
Viral
TB
Aseptic
Investigations
Bedside- MSK exam, observations, Mantoux test
Bloods- FBC, UE, LFT, CRP, ABG
Imaging- echocardiogram (endocarditis vegetation), MRI, CT guided biopsy (to determine effective treatment)
Management of discitis
6-8 weeks of IV ABX therapy
Complications- sepsis, epidural abscess
Causes of dupuytrens contracture
Manual labour
Phenytoin treatment
ALD
DM
Hand trauma
FH, male gender risks
Management of dupuytrens contracture
Surgical treatment when MCP’s cannot be straightened and hand cannot be placed flat on a table
ie. needle fasciotomy, Limited fasciectomy, Dermofasciectomy (remove skin as well as fascia)
Features of fat embolism
lungs- Tachycardia, tachypnoea, dyspnoea, hypoxia, pyrexia, 72 hours after injury
skin- Red brown impalpable petechiae rash, subconjunctival and oral haemorrhage or petechiae
brain/eyes- Confusion and agitation, retinal haemorrhages and intra arterial fat globules on fundoscopy
May see peripheral ground glass appearance on CTPA
NB- diagnosis of exclusion (eg. if D-dimer was negative, CTPA was clear, and symptoms depend on where the embolus travels)
Fracture management
Reduce, stabilise (surgery), preserve blood supply, rehabilitate
Immobilise including proximal and distal points
Monitor neuro vascular status
Manage infection esp. open fractures eg. IV broad spectrum ABX and tetanus prophylaxis
Closed- internal fixation device
Open- IV ABX, imaging, cover with wet dressing, debrided, lavaged and external fixation within 6 hours
Physio, occupational health, pathological- address underlying disease
Greater trochanteric pain syndrome (trochanteric bursitis)
Women 50-70
Pain over lateral side of hip/thigh
Tenderness on palpation of greater trochanter
Causes of an iliopsoas abscess
Haematogenous spread of bacteria eg. Staph aureus
Crohns (most common secondary cause)
Diverticulitis
CRC
UTI
Endocarditis
IVDU
Features of an iliopsoas abscess
Fever
Back/flank pain
Limp
Weight loss
Tests to diagnose iliopsoas inflammation
Supine- knee flexed and hip externally rotated. Place hand on affected side knee and get patient to push (pain)
Lie on unaffected side- hyperextend the affected hip (pain)
Investigations and management of an iliopsoas abscess
Usual tests (esp. blood cultures, septic screen)
CT abdomen is investigation of choice
ABX
Percutaneous drainage initial approach
Surgery if this fails or intra abdominal pathology
Iliotibial band syndrome
Cause of lateral knee pain in runners
Physio referral if activity modification doesn’t work
ACL injury features
Mechanism: high twisting force applied to a bent knee (PCL- hyperextension)
sudden ‘popping’ sound
knee swelling
instability, feeling that knee will give way
Anterior drawer test (90 degrees)
Lachmann test-30 degrees- better (3mm more than uninsured side)
Rapid swelling
Meniscal tear
Twisting injuries
Pain worse on straightening knee
Knee may give way
Knee locking
Delayed swelling
Tenderness along joint line (medial or lateral tenderness suggests M/L meniscus)
Thessalys test- weight bearing, 20 degrees knee flexion, positive if pain on twisting knee
May report popping sensation during injury
NB- MRI is initial imaging modality of choice, arthroscopy is gold standard
Red flags for lower back pain
Age <20 or 50+
Previous malignancy
Night pain
Pain at rest
Radicular, band like pain
History of trauma
Systemically unwell eg. Weight loss, fever
Thoracic pain
Cauda equina signs/symptoms
Investigations for lower back pain
Observations and MSK exam
No XRay (unless AS suspected), and only MRI if results may change management and where malignancy/infection/fracture/CES
Management of non specific lower back pain
NSAIDs first line (with PPI)
Exercise eg. Physiotherapy
Epidural injections of steroids if acute/severe sciatica
Features of lumbar spinal stenosis
Back pain , neuropathic pain, symptoms mimicking claudication
How to differentiate from vascular claudication- sitting better than standing, patients find it easier to walk uphill than downhill
Treat with laminectomy, always do ABPI to exclude vascular claudication
NB- due to degeneration, trauma, iatrogenic (ie. previous surgery), congenital
Meralgia paraesthetica risk factors
Lateral femoral cutaneous nerve (LCFN)
Obesity
Pregnancy
Ascites
Trauma
Iatrogenic (abdominal surgery)
Idiopathic
Features of meralgia parasthetica
Upper lateral thigh
Burning tingling, coldness, shooting pain
Numbness
Deep muscle ache
Aggregated by standing and extending hip, relieved by sitting
Mild, may resolve spontaneously, or may be severe
Hair loss
Signs;
Reproduce symptoms by deep palpation belie ASIS or extension of hip
Altered sensation over upper lateral aspect of thigh
No motor weakness
Investigations for MP
Nerve conduction studies
USS- possible cause
5th metatarsal fracture
Most commonly fractured and most common mid foot fracture
Often follows inversion injury of the ankle
Metatarsal stress fracture
Runners
2nd metatarsal shaft
Osteoarthritis hand features
Usually bilateral
CMC and DIP’s affected more than PIP’s
Episodic joint pain- worse with movement, relieved by rest
Stiffness esp. morning but not as long as RA
Swellings eg Heberdens (DIP), Bouchard (PIP)- bony osteophyte formation
Squaring if the thumb (fixed adduction)
Weak grip
Reduced range of motion
Features of OA of the hip
Chronic history of groin ache following exercise and relieved by rest
Complications of a total hip replacement
VTE (TED stockings, LMWH 4 weeks after hip replacement, started 6 hours post-op)
Intraoperative fracture
Nerve injury (sciatic)
Features of osteochondritis dissecans
Children and young adults
Knee pain and swelling typically after exercise
Knee catching, locking or giving away
Feeling a clunk when flexing or extending the knee
Joint effusion
Tenderness on palpation of the articular cartilage
Wilson’s sign- internal rotation causes pain
Osteomyelitis causes
Haematogenous- bacteraemia. Sickle cell, IVDU, immunosuppression eg. Steroids or HIV, infective endocarditis
Non Haematogenous- spread of infection from adjacent soft tissue or direct injury to bone. Diabetic foot ulcers, DM, PAD, pressure sores, open fractures, joint surgery etc.
Staph aureus most common, except in sickle cell where it’s salmonella
Investigations and management of osteomyelitis
MRI
Flucloxacillin for 6 weeks (clindamycin if allergic)
Management of patellar fractures
Undisplaced with intact extensor mechanisms can be managed non operatively with a hinged brace for 6 weeks
Displaced or loss of extensor mechanism- surgery and then knee brace
Flail chest
Caused by 2 or more rib fractures along 3 or more consecutive ribs (anteriorly)
Flail segment moves paradoxically during respiration and impairs ventilation of lung on side of injury
Surgery and invasive ventilation
NB- predisposes to a tension pneumothorax
Management of rib fractures
Conservative- analgesia to ensure breathing isn’t affected by pain, as inadequate ventilation may predispose to chest infection
Rotator cuff injury
Shoulder pain worse on abduction
Painful arc of abduction (subacromial impingement, between 60 and 120, with tear, may be in first 60)
Tenderness over anterior acromion
Acute rupture- acute severe pain and loss of strength ie. inability to abduct arm
Causes of a scaphoid fracture
FOOSH
Contact sport eg. Rugby
Scaphoid blood supply
Dorsal carpal branch (branch of radial artery) retrograde- liable to necrosis if this is damaged
Signs of scaphoid fracture
Maximal tenderness over anatomical snuffbox (sensitive but not specific)
Wrist joint effusion
Pain via telescoping of thumb
Tenderness of scaphoid tubercle
Pain on ulnar deviation of the wrist
Investigations for schaphpid fracture
Would do plain film radiographs, but MRI is actually what NICE recommend first line after clinical examination (but not common practice)
Management of a scaphoid fracture
Immobilise with futuro splint or standard below elbow backslab before X ray
Refer to orthopaedics (if inconclusive- further imaging 7-10 days later)
Undisplaced- cast for 6-8 weeks
Displaced of proximal scaphoid pole fractures- surgical fixation
Shoulder dislocations
Anterior- 95% of cases
arm is abducted and externally rotated
Posterior- seizure or electric shock
Recent dislocation- reduction can be attempted without analgesia/sedation (may require analgesia however)
MRI findings (damaged glenoid labrum)- Bankart and Hill-Sachs lesions
Subluxation of radial head (pulled elbow)
Most common upper limb injury in children under 6
Child often refuses examination due to the pain
Management- analgesia, passive supination of elbow whilst elbow is flexed at 90 degrees
Associations of talipes equinovarus (club foot)
Spina bifida
Cerebral palsy
Edwards syndrome (Trisomy 18)
Oligohydroamnios
Trigger finger
Abnormal flexion of the digits
Idiopathic, but associated with women, RA, DM
Stiffness and snapping when extending a flexed digit, a nodule may be present
Steroid injections, finger splints, surgery if no response
Risk factors for a fracture
Older age, long term bisphosphanate or corticosteroid use, bone tumour, osteoporosis, low BMI, prior fracture, trauma
Investigations for a fracture
A-E, physical exam (neuro vascular), observations
Booods
Imaging- XRay (2 planes 90 degrees to one another, pre reduction and post reduction)
Differentials for compartment syndrome
DVT
Acute limb ishcaemia
Rhabdomyolysis (crush injury, seizure- causes myalgia and generalised weakness)
Midshaft humerus fracture
Radial nerve
Fibula neck fracture
Common peroneal nerve
Supracondylar fracture
Median nerve
Shoulder dislocation
Axillary nerve
Hip dislocation
Sciatic nerve
Ways that a bone can be fixed
External casts
K wires
Intramedullary wires
Intramedullary nails
Screws
Plate and screws
Management of rotator cuff injury
X-Ray to rule out fracture
Physio, reduced overhead lifting, ICD packs
NSAIDs, intrarticular corticosteroid injection, nerve blocks
Surgical repair
What to remember with any joint pain
Think, could it be inflammatory ie. Do I need to check CRP and antibodies to rule out RA or another joint disease (rather than just thinking, okay, this is definitely adhesive capsulitis, think about what to say in OSCE- good to use them as differentials)
Features of transient synovitis
Inflammation of hip affecting young children
Occur within a week of viral illness, gradual onset of limp, refusal to weight bear, groin or hip pain, positive leg roll, abducted and externally rotated hip, low or mild fever, otherwise well
Management of transient synovitis
Ibuprofen and paracetamol
Rest
Follow up in a few days time with GP
NB- safety netting, if they develop fever and symptoms worsen, straight to AE (septic arthritis)
NB- child less than 3 with a new onset limp, urgent assessment
Investigations for osteomyelitis
Bedside- examination, observations
Bloods- FBC ESR CRP VBG UE LFT blood cultures and sensitivities
Imaging- X ray (nothing for 2 weeks, then sequestrum, destruction, periostea, reactions), MRI (most sensitive- 5 days)
Specialist- bone biopsy (culture and sensitivities)
Management of osteomyelitis
Local hospital guidelines for IV ABX (2 weeks IV, 4 weeks oral)- flucloxacillin, possibly with rifampicin or fuscidic acid added for the first 2 weeks
Consider surgical debridement
Perthes disease
Idiopathic a vascular necrosis of the femoral head (unilateral or bilateral, between ages of 4-10)
Features of Perthes disease
Slow onset of worsening symptoms (not acute or traumatic), with pain in hip or groin, limp (antalgic gait), restricted hip movements, referred pain to knee
Investigations for perthes disease
Same as osteomyelitis, but also do MRI if x ray is normal and symptoms persist
Management of Perthes disease
Analgesia
Mobilisation and physiotherapy
Non surgical containment (cast splint)
Surgical intervention
Regular X rays (assess healing)
Slipped upper (capital) femoral epiphysis
Where head of femur is displaced along the growth plate
Features of SUFE
Typically an obese, adolescent male undergoing a growth spurt (may also be history of minor trauma)
Hip, groin, thigh, or knee pain, restricted range of hip movement, antalgic gait, externally rotated hip, restricted movement in hip (internal rotation), trendelenburgs gait, obese
Management of SUFE
Analgesia
Physiotherapy
Treat endocrinopathy if relevant
Surgical repair
Developmental dysplasia of the hip (DDH)
Represents a spectrum of conditions affecting the proximal femur and acetabulum, ranging from acetabula immaturity to hip subluxation and frank hip dislocation
(The most common congenital abnormality of skeletal development)
Features of DDH
Picked up during newborn examinations or when child presents with hip asymmetry (length/shape), limp, reduced range of movement in hip, asymmetric skin folds, buttock flattening
Screening for DDH
Looked at during neonatal examination at birth and 6-8 weeks old
Findings that suggest it;
Different leg lengths
Restricted hip abduction on one side
Bilateral restriction in abduction
Difference in knee level when hips flexed
Clunking of hips on special tests (USS)
Management of DDH
Conservative- most will heal normally
Less than 6 months- Pavlik harness
More than 6 months- surgery with hip spica cast
Investigations for OA
MSK exam
Bloods- ESR CRP rheumatoid factor and anti CCP (all to exclude RA), FBC UE LFT (before giving diclofenac)
Imaging- XRay affected area
Cervical spondylosis
OA of the cervical vertebrae
Neck pain, complications- Radiculopathy and myelopathy (carpal tunnel, imbalance, limb stiffness)- refer to neurosurgery immediately
Think JW
What to do after hip replacement
Avoid flexing hip at 90 degrees
Avoid low chairs
Don’t cross legs
Sleep on back for 6 weeks
VTE prophylaxis
LMWH
28 days post elective hip replacement
14 days post elective knee replacement
Hand signs
Trousseaus- hypocalcaemia, carpal spasm when BP cuff inflated above systolic
Phalen- carpal tunnel syndrome
Chvostek- hypocalcaemia, tapping parotid causes facial muscles to twitch
Froments- ulnar nerve palsy
Finklesteins- de Quervains tenosynovitis
Tinnels- tapping wrist causes pain (carpal tunnel)
Most common reason for hip revisions
Aseptic loosening is the most common reason total hip replacements need to be revised
Management of carpal tunnel syndrome
Conservative- watch and wait, wrist splints
Medical- NSAIDs, corticosteroid injections
Surgery- surgical carpal tunnel release
Investigations for osteomalacia
Vitamin D is low (this causes osteomalacia)
Serum calcium is low
Serum phosphate is low
Serum alkaline phosphatase may be high
Parathyroid hormone may be high (secondary hyperparathyroidism)
Xrays may show osteopenia (more radiolucent bones)
DEXA scan shows low bone mineral density
Management of osteomalacia
Treatment is with supplementary vitamin D (colecalciferol). There are various regimes suggested by the NICE CKS on vitamin D deficiency. They involve correcting the initial vitamin D deficiency with one of the following:
50,000 IU once weekly for 6 weeks
20,000 IU twice weekly for 7 weeks
4000 IU daily for 10 weeks
A maintenance supplementary dose for of 800 IU or more per day should be continued for life after the initial treatment.
Patients with vitamin D insufficiency can be started on the maintenance dose without the initial treatment regime.
Management of meralgia parasthetica
Conservative- rest, weight loss, physiotherapy
Medical- paracetamol, NSAID, neuropathic painkillers, steroid injections
Surgical- decompression or transection of the nerve (lateral femoral cutaneous nerve)
What is trochanteric bursitis
Inflammation of a bursa over the greater trochanter on the outer hip.
Management of trochanteric bursitis
Conservative- Rest, Ice
Medical- Analgesia (e.g., ibuprofen or naproxen), Physiotherapy, Steroid injections
Ottawa rules for a knee Xray
Age 55 or above
Patella tenderness (with no tenderness elsewhere)
Fibular head tenderness
Cannot flex the knee to 90 degrees
Cannot weight bear (cannot take 4 steps – limping steps still count)
Management of a meniscal tear
Conservative- RICE, physiotherapy, knee brace
Medical- NSAIDs
Surgical- repair or reconstruction (arthroscopy) using quadriceps/hamstring tendon
Meniscal vs collateral ligament injuries
Meniscal- knee locking
Collateral ligament- knee instability
Management of a collateral ligament tear
Conservative- RICE, physiotherapy, knee brace
Medical- NSAIDs
Surgical- repair (arthroscopy)
Osgood-Schlatter disease
Inflammation at the tibial tuberosity where the patella ligament inserts. Visible or palpable hard and tender lump at the tibial tuberosity
Management of a Bakers cyst
Conservative- Modified activity to avoid exacerbating symptoms, Physiotherapy
Medical- Analgesia (e.g., NSAIDs), Steroid injections
Further- Ultrasound-guided aspiration
Olecranon bursitis
Students elbow
Swollen
Warm
Tender
Fluctuant (fluid-filled)
It is important to identify where bursitis is caused by infection. Features of infection are:
Hot to touch
More tender
Erythema spreading to the surrounding skin
Fever
Features of sepsis (e.g., tachycardia, hypotension and confusion)
NB- in septic arthritis, it is the elbow joint, not the bursae, that is swollen and erythematous (and reduced ROM)
Olecranon bursitis
Students elbow
Swollen
Warm
Tender
Fluctuant (fluid-filled)
It is important to identify where bursitis is caused by infection. Features of infection are:
Hot to touch
More tender
Erythema spreading to the surrounding skin
Fever
Features of sepsis (e.g., tachycardia, hypotension and confusion)
NB- in septic arthritis, it is the elbow joint, not the bursae, that is swollen and erythematous (and reduced ROM)
Management of olecranon bursitis
Conservative- Rest, Ice, Compression, Protecting the elbow from pressure or trauma
Medical- Analgesia (e.g., paracetamol or NSAIDs), Steroid injections may be used in problematic cases (where infection has been excluded)
Further- Aspiration of fluid may be used to relieve pressure
NB- where infected bursae is suspected, aspirate fluid for miscopy, culture, and sensitivities, and then give flucloxacillin
Management of epicondylitis
Conservative- rest, adapt activities, physiotherpay, orthotics
Medical- Analgesia (e.g., NSAIDs), Steroid injections
Surgical and specialist- Extracorporeal shockwave therapy or surgery to release tendons
Features of a hip fracture
Pain in the groin or hip, which may radiate to the knee
Not able to weight bear
Shortened, abducted, and externally rotated leg
What is the danger with intracapsular NOF fractures
Disruption of blood supply leading to avascular necrosis of the hip
Gardener classification for intracapsular NOF fractures
Grade I – incomplete fracture and non-displaced
Grade II – complete fracture and non-displaced
Grade III – partial displacement (trabeculae are at an angle)
Grade IV – full displacement (trabeculae are parallel)
III onwards is displaced
Management of a NOF fracture
Appropriate analgesia
Investigations to establish the diagnosis (e.g., x-rays)
Venous thromboembolism risk assessment and prophylaxis (e.g., low molecular weight heparin)
Pre-operative assessment (including bloods and an ECG)
Orthogeriatrics input
Morton’s neuroma
Injury of nerve between the 3rd-4th metatarsals
Burning, numbness or “pins and needles” felt in the distal toes
Ganglion Cyst
Ganglion cysts can appear rapidly (over days) or gradually. Patients present with a visible and palpable lump. It is not usually painful
Can disappear on their own, or be drained via needle aspiration
Spondylolisthesis
A condition in which the vertebral bodies slip forward in relation to the vertebrae beneath.
Features of a disc prolapse
Acute onset of severe back pain
Stabbing or resembling electric shock (most commonly of the lower back, called lumbago)
Radiates to the legs (sciatic pain) or the arms
Paraesthesia of affected dermatome
Muscle weakness and atrophy
Loss of deep tendon reflexes in the indicator muscles
Pain increases with pressure (e.g., from coughing or sneezing)
Short walks and changing position reduce the pain
Management of a disc prolapse
Conservative- physiotherapy, modification of activity, TENS device
Medical- analgesia, intraarticular steroids
Surgical- last resort (often a discectomy)
Mechanical back pain
Mechanical back pain is an umbrella term that covers a range of conditions. These include lumbar muscle sprain/strain, which typically cause spasms on movement, and sometimes stiffness lasting less than 30 minutes. Mechanical back pain is usually aggravated by movements, and certain postures.
You would expect it to last 2-4 weeks (longer- think of another diagnosis)
Red flag spinal fracture
Sudden onset of severe central spinal pain which is relieved by lying down.
There may be a history of major trauma (such as a road traffic collision or fall from a height), minor trauma, or even just strenuous lifting in people with osteoporosis or those who use corticosteroids (vertebral wedge fracture)
Structural deformity of the spine (such as a step from one vertebra to an adjacent vertebra) may be present.
There may be point tenderness over a vertebral body.
Red flag malignancy back pain
The person being 50 years of age or more.
Gradual onset of symptoms.
Severe unremitting pain that remains when the person is supine, aching night pain that prevents or disturbs sleep, pain aggravated by straining (for example, at stool, or when coughing or sneezing), and thoracic pain.
Localised spinal tenderness.
No symptomatic improvement after four to six weeks of conservative low back pain therapy.
Unexplained weight loss.
Past history of cancer — breast, lung, gastrointestinal, prostate, renal, and thyroid cancers are more likely to metastasize to the spine.
Imaging and spinal pathology
X ray not helpful, unless ankylosing spondylitis
MRI is imaging modality of choice
What you must always do with a patient when you believe that the diagnosis isn’t sinister
Safety net ie. what red flags to look out for, present to AE immediately
Management of sciatica
The initial management of sciatica is mostly the same as acute low back pain.
The NICE clinical knowledge summaries (updated 2020) state not to use medications such as gabapentin, pregabalin, diazepam or oral corticosteroids for sciatica. They state not to use opioids for chronic sciatica.
They suggest considering a neuropathic medication if symptoms are persisting or worsening at follow up, but not gabapentin or pregabalin, leaving at the main choices of:
Amitriptyline
Duloxetine
Also physio, intra articular steroids, decompression etc.
Management of sciatica
The initial management of sciatica is mostly the same as acute low back pain.
The NICE clinical knowledge summaries (updated 2020) state not to use medications such as gabapentin, pregabalin, diazepam or oral corticosteroids for sciatica. They state not to use opioids for chronic sciatica.
They suggest considering a neuropathic medication if symptoms are persisting or worsening at follow up, but not gabapentin or pregabalin, leaving at the main choices of:
Amitriptyline
Duloxetine
Features of osteomalacia
Young children- rickets
Adults- Bone pain, tenderness and proximal myopathy (waddling gait)
Features of talipes equinovarus (club foot)
Inverted + plantar flexed foot
Acromioclavicular joint injury
Injury to the AC joint is relatively common and typically occurs during collision sports such as rugby following a fall on to the shoulder or a FOOSH (falls on outstretched hand).
Grade I and II injuries are very common and are typically managed conservatively including resting the joint using a sling.
III- case-by-case assessment
Grade IV, V and VI are rare and require surgical intervention.
Investigations for supraspinatus tendinitis/subacromial impingement
USS or MRI
Management of supraspinatus tendonitis/ subacromial impingement
Conservative- activity modification, home exercises, referral to a physiotherapist
Medical- analgesia, intraarticular steroids
Smith fracture (reverse colles’)
Volar angulation of distal radius fragment (Garden spade deformity)
Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed
Bennets fracture
Intra-articular fracture of the first carpometacarpal joint
Impact on flexed metacarpal, caused by fist fights
X-ray: triangular fragment at ulnar base of metacarpal
Monteggias fracture
Dislocation of the proximal radioulnar joint in association with an ulna fracture
Fall on outstretched hand with forced pronation
Needs prompt diagnosis to avoid disability
Galeazzi fracture
Radial shaft fracture with associated dislocation of the distal radioulnar joint
Direct blow
Potts fracture
Bimalleolar ankle fracture
Forced foot eversion
Bartons fracture
Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation
Fall onto extended and pronated wrist
Chondromalacia Pataellae
Teenage girls, following an injury to knee e.g. Dislocation patella
Typical history of pain on going downstairs or at rest
Tenderness, quadriceps wasting
Patellar tendonitis
More common in athletic teenage boys
Chronic anterior knee pain that worsens after running
Tender below the patella on examination
Management of intracapsular hip fractures (Gardener)
Undisplaced- internal fixation, or hemiarthroplasty if unfit.
Displaced- arthroplasty (total hip replacement or hemiarthroplasty)
NB- total hip replacement is favoured to hemiarthroplasty if patients:
-were able to walk independently out of doors with no more than the use of a stick
-are not cognitively impaired
-are medically fit for anaesthesia and the procedure.
NB- #NOF is intracapsular (so internal fixation or arthroplasty)
NB- X-ray first line, MRI for occult fractures not seen on xray
Management of extracapsular hip fractures
Stable intertrochanteric fractures: dynamic hip screw
Reverse oblique, transverse or sub trochanteric fractures: intramedullary device
NB- mobility not a factor
Types of hip dislocation
Posterior dislocation: Accounts for 90% of hip dislocations. The affected leg is shortened, adducted, and internally rotated.
Anterior dislocation: The affected leg is usually abducted and externally rotated. No leg shortening.
Complications of a hip dislocation
Sciatic or femoral nerve injury
Avascular necrosis
Osteoarthritis: more common in older patients.
Recurrent dislocation: due to damage of supporting ligaments
Acromioclavicular dislocation
Prominent clavicle
Step deformity
Management of neck of femur fractures based on Gardener’s classification
1+2= dynamic hip screw
3+4= throw the joint on the floor ie. arthroplasty
What is an an effective and commonly used method of analgesia for elderly patients with a neck of femur fracture
An iliofascial nerve block
Normal lower limb variants in children
Flat feet (pes planus)- resolves 4-8 years
In toeing- resolves
Out toeing- resolves by 2 years
Bow legs (genu varum)- resolves by 4-5 years
Knock knees (genu valgum)- resolves
Imaging choice of osteoporotic vertebral fracture
X ray
ACL vs meniscal damage
While a meniscal tear can present similar to an ACL injury, you can differentiate the two by the timing of the swelling. ACL injuries swell immediately due to haemarthrosis, meniscal tears typically swell over time.
Knee injury comparisons
pass med page
Cauda equina vs sciatica
Sciatica;
Pain that radiates around the lower back, buttocks and/or leg(s)
A tingling sensation in the affected areas
Numbness in the affected areas
Generalised lower back pain
Muscle weakness in the legs
Cauda equina. Same Sx as sciatica but also;
Bladder/bowel disturbance
Numbness around the buttocks, perineum and genitals (saddle anaesthesia)
Reduced anal tone
Foot drop and poor reflexes in the lower limbs
Frozen shoulder on xray
no findings (OA- LOSS signs)
Intraoperative hypothermia
can cause excessive bleeding
Contaminated (farmyard) open wounds
Definitive surgical fixation can be done initially only if it can be followed by definitive soft tissue coverage. However more often than not an external fixation device is used as an interim measure while soft tissue coverage is achieved (which should be done within 72 hours).
