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Finals > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

Describe the pathophysiology of osteoarthritis

A

Synovial joints
Combination of genetics and overuse and injury
Imbalance between cartilage wearing down and chondrocytes repairing it, leading to strucural issues

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2
Q

List some risk factors of osteoarthritis

A 
Age
Obesity
Occupation
Trauma
Female
FH
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3
Q

List the joints commonly affected by osteoarthritis

A 
Hips
Knees
Sacroiliac joints
DIPs 
CMC of the thumb
Wrist
Cervical spine - spondylosis
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4
Q

List the 4 key X-ray changes of osteoarthritis

A

Loss of joint space
Osteophyte formation
Subchondral cysts
Subchondral sclerosis

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5
Q

How does osteoarthritis present

A

Joint pain
Stiffness - worsens with activity
Deformity - bulky, bony enlargement of the joint
Crepitus on movement
Effusions around the joint
Instability
Reduced function/range of movement of the joint

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6
Q

Describe the signs of osteoarthritis in the hands

A 
Heberden's nodes - DIP
Bouchards nodes - PIP 
Squaring at the base of thumb - CMC 
Weak grip 
Reduced ROM
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7
Q

When can OA be diagnosed

A

Patient >45
Typical symptoms with activity
No morning stiffness

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8
Q

How is osteoarthritis managed

A

Patient education
Lifestyle change - weight loss, physiotherapy, OT, orthotics
Analgesia - oral paracetamol and topical NSAIDs, oral NSAIDs (PPI), opiates (codeine), topical capsaicin, intra-articular injection, joint replacement

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9
Q

What is a hemiarthroplasty

A

Replacing one half of the joint

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10
Q

What is a total joint replacement

A

Replacing both articular surfaces of the joint

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11
Q

Which organism is most common in prosthetic joint infections

A

Staphylococcus aureus

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12
Q

List some risk factors for prosthetic joint infection

A

Prolonged op time
Obesity
Diabetes

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13
Q

What are some symptoms of prosthetic joint infection

A 
Fever
Pain
Swelling
Erythema 
Warm
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14
Q

How is a prosthetic joint infection diagnosed

A

Clinical finding
X-ray
Blood tests - Inflammatory markers and cultures

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15
Q

How is prosthetic joint infection managed

A

Antibiotics and surgery - Joint irrigation, debridement complete replacement

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16
Q

What is a compound fracture

A

Skin is broken and broken bone is exposed to air

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17
Q

What is a stable fracture

A

Sections of bone remain in alignment at the fracture

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18
Q

What is a pathological fracture

A

Bone breaks due to an abnormality within the bone

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19
Q

What is a salter-harris fracture

A

Growth plate fracture - occurs only in children

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20
Q

What is a Comminuted fracture

A

Breaking into multiple fragments

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21
Q

What is a compression fracture

A

Affects the vertebrae in the spine

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22
Q

Describe a Colle’s fracture

A

Transverse fracture of the distal radius
Causes the distal portion to displace posteriorly (upwards)
Causes a dinner fork deformity
Commonly a result of a fall onto outstretched hand

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23
Q

Describe a scaphoid fracture

A

Fall onto outstretched hand
Scaphoid is a carpal bone at the base of the thumb
Key sign - tenderness in the anatomical snuffbox (groove between tendons when you extend thumb)

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24
Q

Why is it important to spot scaphoid fractures

A

Scaphoid bone has retrograde blood supply with blood vessels supplying the bone from only one direction

Avascular necrosis and non-union if blood supply cut off

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25
Q

List some bones which if fractured may result in avascular necrosis, impaired healing and non union due to vulnerable blood supplies

A 
Scaphoid
Femoral head
Humeral head 
Talus
Navicular and 5th metatarsal in foot
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26
Q

What is the name of the fibrous join between the tibia and fibula

A

Tibiofibular syndesmosis

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27
Q

What is the function of the tibiofibular syndesmosis

A

Stability and function of the ankle joint

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28
Q

What is the Weber classification

A

Used to describe fractures of the lateral malleolus - fracture is described in relation to the distal syndesmosis

Type A - below the ankle joint - syndesmosis in tact
Type B - at the level of the ankle joint - syndesmosis intact or partially torn
Type C - above the ankle joint - syndesmosis disrupted

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29
Q

Why is the weber classification of lateral malleolus fractures important

A

Decide management - surgery more likely if syndesmosis disrupted

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30
Q

What must you look for with pelvic ring fracture

A

Another fracture in the pelvic ring

Bleeding - shock

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31
Q

List some causes of pathological fractures

A

Pagets disease of bone
Osteoporosis
Cancer mets

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32
Q

List the cancers which commonly metastasise to bone

A 
Prostate
Renal 
Thyroid
Breast 
Lung
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33
Q

What are fragility fractures

A

Fractures occuring due to weakness of the bone - usually due to osteoporosis

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34
Q

What tool is used to calculate a patients risk of fragility fracture over the next 10yrs

A

FRAX tool

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35
Q

What scan is done to measure bone mineral density

A

DEXA scan

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36
Q

Give the WHO criteria for osteoporosis and osteopenia

A

T score at hip
>-1 - normal
-1 to -2.5 osteopenia

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37
Q

What is the first line treatment for reducing the risk of fragility fractures

A

Calcium
Vit D
Bisphosphonates /denosumab

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38
Q

How do bisphosphonates work?

A

Interfere with osteoclasts, reducing their activity and preventing the reabsorption of bone

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39
Q

List some important side effects and patient info for bisphosphonates

A

Reflux and oesophageal erosison - taken on empty stomach, stand up for 30 mins after

Osteonecrosis of jaw an external auditory canal

Atypical fractures - femoral

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40
Q

Describe the action of denosumab

A

Monoclonal antibody that works by blocking the activity of osteoclasts

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41
Q

What is the investigation of choice for fractures

A

X-ray - 2 views - AP and lateral

CT if X-ray inconclusive and more info required

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42
Q

What are the principles of fracture management

A

Mechanical alignment

Relative stability

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43
Q

How is mechanical alignment achieved

A

Closed reduction via manipulation of the limb

Open reduction via surgery

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44
Q

How is relative stability of a fracture achieved

A 
External casts 
K wires
IM nails 
IM wires
Screws
Plates and screws
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45
Q

Describe the management of fractures

A

Pain management
Closed reduction and plaster cast with FU in fracture clinic
Refer to on call trauma and ortho team, admit, NBM, trauma meeting

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46
Q

List some early complications of a fracture

A 
Damage to local structures
Haemorrhage - shock and death
Compartment syndrome
Fat embolism 
DVT
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47
Q

List some longer term complications fo fractures

A 
Delayed union - slow  
Malunion - misaligned 
Non-union - failure to heal 
Avascular necrosis 
Infection - osteomyelitis
Joint instability 
Joint stiffness 
Contractures
Arthritis
Chronic pain
Complex regional pain syndrome
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48
Q

What is a fat embolism

A

Fat globule from long bone fracture travels through systemic circulation and causes blood flow obstruction

Causes systemic inflammatory response

Presents 24-72hrs after fracture

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49
Q

Which criteria is used for Fat embolism syndrome

A 
Gurd's criteria
Major criteria 
- Resp distress
- Petechial rash 
- Cerebral involvement
Minor criteria  
- Jaundice 
- Thrombocytopenia
- Fever
- Tachycardia
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50
Q

How is fat embolism syndrome treated

A

Supportive

Operate early to prevent this occurring

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51
Q

Give some risk factors for hip fractures

A

Osteoporosis
Female
Age

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52
Q

What are the two classes of hip fracture

A

Intracapsular

Extracapsular

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53
Q

What is the capsule of the hip joint

A

Strong fibrous structure
Attaches to the rim of the acetabulum on the pelvis and the intertrochanteric line on the femur
Surrounds the head and neck of the femur

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54
Q

Describe the blood supply of the femoral head

A

Retrograde supply
Medial and lateral circumflex femoral arteries join the femoral neck just proximal to the intertrochanteric line and branches run up toward the femoral head

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55
Q

What is the intertrochanteric line

A

Line between greater and lesser trochanter of femur

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56
Q

Which classification is used for intra-capsular neck of femur fractures

A 
Garden classification 
Grade 1-4
1 - partial # and no displacement
2 - complete # and no displacement
3 - partial displacement
4 - full displacement
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57
Q

How are non-displaced intracapsular femur fractures managed

A

Blood supply still intact - Internal fixation (screws)

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58
Q

How are displaced intracapsular femur fractures managed

A

Risk of avascular necrosis
Head of femur needs to be replaced
Hemiarthroplasty - co-morbidity or limited mobility
Total hip replacement for those mobile and fit for surgery

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59
Q

What are the two types of extra-capsular hip fractures

A

Intertrochanteric - occurs between greater and lesser trochanters
Sub trochanteric - distal to lesser trochanter

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60
Q

How are extra-capsular fractures treated

A

Intertrochanteric - Dynamic hip screw

Sub trochanteric - IM nail (through greater trochanter)

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61
Q

Describe the presentation of a hip fracture

A

Pain in groin or hip
Not being able to weight bear
Shortened, abducted and externally rotated leg
Cause of fall - anaemia, electrolytes, arrhythmia, HF, MI, Stroke, infection

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62
Q

What is shentons line and how is it used

A

Shentons line seen on AP hip X-ray
One continuous line formed by medial border of femoral neck to inferior border of superior pubic ramus

Disruption to shentons lone indicates fractured neck of femur

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63
Q

When should hip fracture surgery be carried out

A

<48hrs of # occurring

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64
Q

When should patients weight bear after surgery

A

Right away

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65
Q

How does trochanteric bursitis present

A

Lateral hip/thigh pain with tenderness over the greater trochanter

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66
Q

Describe compartment syndrome

A

Abnormally elevated pressure in a fascial compartment cuts off blood flow to the contents of that compartment

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67
Q

What is fascia

A

Strong fibrous connective tissue

Not able to stretch or expand

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68
Q

What do fascial compartments contain

A

Muscle
Nerve
Blood vessels

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69
Q

What causes acute compartment syndrome

A

Injury - oedema and bleeding
Bone fracture
Crush injuries

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70
Q

How does compartment syndrome present

A 
5Ps 
Pain disproportionate to underlying injury - worsened by passive stretching of muscle
Paraesthesia
Pale
Pressure - high 
Paralysis is a late sign
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71
Q

How is compartment syndrome managed

A

Needle manometry - measure the compartment pressure
Escalate to ortho reg or consultant
Remove bandages and dressings
Elevate leg to heart level
Maintain good BP
Definitive treatment - emergency fasciotomy - operation to cut through fascia down entire length of compartment to release pressure then debride necrotic tissue - wound left open and covered with dressing. May require skin graft later

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72
Q

Describe chronic compartment syndrome

A

Increased pressure with exertion
Pain, numbness and paraesthesia stops with rest

Needle manometry for diagnosis
Fasciotomy for treatment

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73
Q

What is osteomyelitis and how is it caused

A

Inflammation of bone/bone marrow
Usually caused by bacterial infection
Acute/chronic
Haematogenous osteomyelitis - pathogen carried through blood and seeded in bone or direct contamination

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74
Q

Which bacteria commonly causes osteomyelitis

A

Staphylococcus aureus

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75
Q

List some risk factors for osteomyelitis

A 
Open #
Ortho op 
DM
PAD
IVDU
Immunosuppression
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76
Q

How does osteomyelitis present

A 
Fever
Pain and tenderness
Erythema
Swelling 
Non-specific  - fatigue, nausea, fever, muscle ache
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77
Q

How is osteomyelitis investigated

A

X-ray - not too helpful but some changes are periosteal reaction, localised osteopenia and destruction

MRI is best imaging modality

Bloods - WCC, Inflammatory marker, blood cultures

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78
Q

How is osteomyelitis managed

A

Surgical debridement
Antibiotics therapy - prolonged course, 6 weeks flucloxacillin with rifampicin or fusidic acid in first 2 weeks or clindamycin in pen allergic or vancomycin/teicoplanin in MRSA

Chronic osteomyelitis - 3 months antibioitcs

If due to prosthesis - complete revision surgery

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79
Q

What is a charcot joint

A

One which has become disrupted and damaged secondary to a loss of sensation - seen in diabetes

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80
Q

What are sarcomas

A

Cancers of muscle, bone and other connective tissue

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81
Q

How do sarcomas present

A

Soft tissue lump - growing, painful or large
Bone swelling
Persistent bone pain

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82
Q

How should you investigate sarcomas

A

Xray - bone lump/persistent pain
Ultrasound - soft tissue lump
CT/MRI - lesion in more detail and look for metastatic spread
Biopsy for histology

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83
Q

Where does sarcoma commonly spread to

A

Lungs

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84
Q

What causes Kaposi’s sarcoma (red/purple skin lesions)

A

HSV8

HIV

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85
Q

How does Osteomalacia present

A

Bone pain
Tenderness
Proximal myopathy
Waddling gait

86
Q

What is osteomalacia

A

Lack of bone mineralisation

Vit D deficiency

87
Q

What is the prognosis for acute low back pain

A

Should improve within 2 weeks

May become chronic

88
Q

What is the prognosis for sciatica

A

Most recover by 4-6weeks

89
Q

List some causes of mechanical back pain

A 
Muscle or ligament sprain
Facet joint dysfunction
Sacroiliac joint dysfunction
Herniated disc
Spondylolisthesis 
Scoliosis
Degenerative changes
90
Q

Give some causes of neck pain

A

Muscle or ligament strain
Torticollis
Whiplash
Cervical spondylosis

91
Q

List some red flag causes of back pain

A

Spinal fracture - major trauma

Cauda equina - saddle anaesthesia, urinary retention, incontinence, bilateral neurological symptoms

Spinal stenosis - intermittent neurogenic claudication

Ankylosing spondylitis - <40yo, gradual onset, morning stiffness or night time pain

Cancer - previous or current, weight loss, night pain, age >50

Infection - fever, IVDU

92
Q

What are sine abdominal/thoracic causes of back pain

A 
Pneumonia
Ruptured AAA
Kidney stones
Pyelonephritis 
Pancreatitis
Prostatitis 
PID
Endometriosis
93
Q

Which spinal nerves form the sciatic nerve

A

L4-S3

94
Q

Describe the path the sciatic nerve takes

A

Sciatic nerve through the greater sciatic foramen, in the buttock area on either side. It travels down the back of the leg. At the knee, it divides into the tibial nerve and common peroneal nerve

95
Q

What is the function of the sciatic nerve

A

Provide sensation to the lateral lower leg and foot

Motor function to posterior thigh, lower leg and foot

96
Q

What symptoms does sciatica cause

A 
Unilateral pain from the buttock down the back of the thigh to below the knee or foot 
Electric or shooting 
Paraesthesia 
Numbness
Motor weakness
Reflexes may be affected
97
Q

What are the main causes of sciatica

A

Herniated disc
Spondylolisthesis
Spinal stenosis
Cauda equina if bilateral

98
Q

What is a test which can help diagnose sciatica

A

Sciatic stretch test
Patient lies on back with leg straight
Examiner lifts one leg from the ankle with the knee extended until the limit of hip flexion is reached
Dorsiflex foot and this recreates sciatic pain in the buttock/posterior thigh - sciatic nerve root irritation. Symptoms then improve on flexing the knee

99
Q

Describe the STarT back screening tool

A

Stratify the risk of a patient with acute back pain developing chronic back pain

Helps guide initial management

/9

100
Q

How are patients at low risk of developing chronic back pain managed

A

Self management
Education
Reassurance
Analgesia - NSAIDs, codeine, benzodiazepines
Staying active and continuing to mobilise as usual
Safety net

101
Q

How are patients at medium/high risk of developing chronic back pain managed

A 
As for low risk with:
Physiotherapy
CBT
Group exercise 
Radiofrequency denervation 
Safety net
102
Q

How is sciatica managed

A

Amitryptiline
Duloxetine fi symptoms persisting or worsening

Chronic management - epidural corticosteroid injections, LA injections, radiofrequency denervation, spinal compression

103
Q

What is the cauda equina

A

Collection of nerve roots that travel through the spinal canal after the spinal cord terminates around L2/3

104
Q

What do the nerves of the cauda equina do

A

Sensation to perineum, bladder and rectum
Motor to lower limbs, anal and urethral sphincters
Parasympathetic to bladder and rectum

105
Q

List some causes of cauda equina

A 
Herniated disc
Tumours - mets
Spondylolisthesis 
Abscess
Trauma
106
Q

What are some red flag symptoms of cauda equina

A 
Saddle anaesthesia
Loss of sensation in bladder/rectum
Urinary retention or incontinence
Faecal incontinence 
Bilateral sciatica 
Bilateral or severe motor weakness
Reduced anal tone
107
Q

Describe the management of cauda equina

A

Immediate hospital admission
Emergency MRI
Neurosurgical review - lumbar decompression surgery

108
Q

Describe the presentation of metastatic spinal cord compression

A

Back pain worse on coughing or straining

Motor and sensory symptoms

109
Q

Describe the treatment of Metastatic spinal cord compression

A 
High dose dexamethasone 
Analgesia
Surgery 
Radiotherapy
Chemotherapy
110
Q

What may a patient with intermittent claudication but normal ABPI have

A

Spinal stenosis - pseudo claudication

111
Q

Describe the symptoms of a lumber spinal stenosis

A

Psuedoclaudication

Symptoms better when lean forward and at rest

112
Q

Define radiculopathy

A

Compression of the nerve roots as they exit the cord and column leading to motor and sensory symptoms

113
Q

How is spinal stenosis diagnosed

A

MRI

Exclude PAD - ABPI and CT angiogram

114
Q

How is spinal stenosis managed

A 
Exercise
Weight loss
Analgesia 
Physiotherapy 
Decompression surgery 
Laminectomy
115
Q

What is meralgia paraesthetica

A

Mononeuropathy

Compression of the lateral femoral cutaneous nerve (L1,2,3 - carries only sensory signals)

Burning, pins and needles, cold sensation, numbness over the upper outer thigh

Symptoms aggravated by walking or standing and extending the hip

116
Q

Describe the management of meralgia Paraesthetica

A

Rest
Loose clothing
Weight loss
Physiotherapy

Medical - paracetamol, NSAIDs, neuropathic (amitriptyline, duloxetine, gabapentin and pregabalin), local injections of steroids or anaesthetic

Surgical - decompression, transection, resection

117
Q

What is trochanteric bursitis

A

Inflammation of the bursa at the greater trochanter

Tickening of the synovial membrane and increased fluid production - swelling

118
Q

What are bursa

A

Synovial membrane filled sacs with synovial fluid found at bony prominences to reduce friction between bone and soft tissue during movement

119
Q

What causes trochanteric bursitis

A

Friction from repetitive movement
Trauma
Inflammatory condition - RA
Infection - septic bursitis

120
Q

Describe the presentation of trochanteric bursitis

A

Lateral hip pain - aching or burning
May worsen after activity, standing after sitting prolonged time or trying to sit cross legged, disrupts sleep
Gradual onset
May radiate down thigh

121
Q

What may be found on examination in trochanteric bursitis

A

Trendelenburg test - ask patient to stand one legged on affected leg. Normally the other side of pelvis remains level or goes up slightly. Positive Trendelenburg is when other side drops down suggesting weakness in that hip

Resisted abduction, internal and external rotation of hip

122
Q

Describe the treatment of trochanteric bursitis

A 
Rest
NSAIDs
ICE
Steroid injections
Physiotherapy

If caused by infection give antibiotics

123
Q

Describe the anatomy of the knee

A

2 menisci (medial and lateral) between condyles of femur and tibia

Patella - patella tendon inserts into tibial tuberosity

Quadriceps tendon - when contracts causes knee extension

Between condyles of the femur is an intercondylar notch
Between the condyles of the tibia is an intercondylar area

Anterior and posterior cruciate ligaments - both originate from the intercondylar notch (ACL- lateral aspect and PCL - medial aspect) of the femur, ACL attaches anterior intercondylar area of tibia and PCL attaches to the posterior intercondylar area of the tibia

Medial and lateral collateral ligaments

124
Q

How do meniscal tears occur

A

Twisting of the knee

125
Q

What symptoms may a person with meniscal tear have

A 
Pain - may be referred to hip 
Swelling
Stiffness
Restricted ROM
Locking of the knee
Instability or the knee giving way
126
Q

What may be found on examination in a person with a meniscal tear

A

Localised tenderness on the joint line
Swelling
Restricted ROM

127
Q

List some Ottawa knee rules

A

A patient requires a knee X-ray after acute knee injury if any of the following present

  • > 55yo
  • Patella tenderness
  • Fibular head tenderness
  • Cannot flex the knee to 90 degrees
  • Cannot weight bear
128
Q

What investigations do you do for diagnosing meniscal tear

A

MRI - 1st line

Arthroscopy

129
Q

Describe the management of meniscal tears

A 
Refer to A&E/# clinic 
RICE 
NSAIDS
Physio 
Surgery - arthroscopy - repair or resection (results in OA)
130
Q

What is the function of the ACL

A

Prevents the tibia sliding forward in relation to the femur

131
Q

What is the function of the PCL

A

Prevents the tibia sliding backwards in relation to the femur

132
Q

How is the ACL typically damaged

A

Twisting injury to the knee

133
Q

Describe the presentation of an ACL injury

A

Pain
Swelling
Pop sound or sensation
Instability of the knee joint - tibia can move anteriorly below the femur - knee can buckle

134
Q

List some test on examination which can help assess for ACL damaged

A

Anterior drawer test - patient is supine with hip flexed to 45 degrees and knee flexed to 90 degrees with foot flat on the couch. Examiner sits on patients toes to stabilise the foot. Examiner holds the leg just below the knee and pulls the proximal tibia anteriorly, sliding it forward from the femur - no clear end point and tibia moves excessive distance anteriorly

Lachman test - knee is tested while flexed at 20-30 degrees

135
Q

How is ACL damage investigated

A

MRI

Arthroscopy

136
Q

How is ACL damage treated

A

Refer to A&E or # clinic if symptoms suggest

RICE
Crutches and knee braces
Physiotherapy
Arthroscopic surgery - new ligament formed using a graft of tendon from another location (hamstrings, quadriceps, bone-patellar tendon bone)

137
Q

Describe Osgood-Schlatter disease

A

Inflammation at the tibial tuberosity where the patella ligament inserts
Lump in this location - tender at first due to active inflammation
Avulsion fractures at the tibial tuberosity
Unilateral
Males aged 10-15

138
Q

Describe the borders of the popliteal fossa

A

Semimembranosus and semitendinosus tendons - superior and medial

Biceps femoris tendon - superior and lateral

Medial head of
gastrocnemius - inferior and medial

Lateral head of gastrocnemius - inferior and lateral

139
Q

What are Baker’s cysts

A

Fluid filled sacs in the popliteal fossa

Synovial fluid squeezed out of the knee joint and collects in the popliteal fossa. A connection between the synovial fluid in the joint and the cyst can remain so the cyst will continue to enlarge. They do not have their own epithelial lining so difficult to remove as contained in soft tissue

140
Q

What causes a Bakers cyst

A

Secondary to degenerative changes in the knee joint

Can occur with other knee pathology - meniscal tears, OA, Knee injuries, inflammatory arthritis

141
Q

Describe the presentation of a Baker’s cyst

A

Symptoms in back of knee
Pain or discomfort
Fullness or pressure
Palpable lump/swelling
Restricted range of movement - large cysts
Oedema if cyst compresses venous drainage of the leg

142
Q

What is a sign of a bakers cyst

A

Foucher’s sign - lump gets smaller when knee is flexed to 45 degrees

143
Q

When sis a bakers cyst most apparent?

A

When the patient stands and the knees are fully extended

144
Q

Describe a ruptured Baker’s cyst

A

Pain
Swelling
Erythema

145
Q

What are some differentials of a Baker’s cyst

A 
DVT
Popliteal artery aneurysm 
Abscess
Ganglion cyst
Lipoma 
Varicose veins 
Tumour
146
Q

Describe the investigations for a Baker’s cyst

A

USS

MRI - assess for other pathology such as meniscal tears

147
Q

How are Baker’s cysts managed

A

Modified activity - avoid exacerbating symptoms
Analgesia - NSIADs
Physio
Ultrasound guided aspiration
Steroid injection
Surgery - arthroscopic procedures to treat underlying knee pathology - resection is difficult and is likely to recur

148
Q

Which nerve injury causes a foot drop

A

Peronal nerve

149
Q

Which drugs can precipitate an Achilles tendinopathy and rupture

A

Fluoroquinolone antibiotics (ciprofloxacin)

150
Q

Describe Simmonds calf squeeze test

A

Normally when calf is squeezed, this results in plantar flexion of the foot. No plantar flexion occurs if the Achilles tendon is ruptured

151
Q

What is the plantar fascia

A

Thick connective tissue that attaches the calcaneus at the heel and travels along the sole of the foot and branches out to connect to the flexor tendons of the toes

152
Q

Describe plantar fascitis

A

Inflammation of the plantar fascia

Gradual onset pain on the plantar aspect of the heel
Worse with pressure, particularly when walking or standing for long periods of time. Tenderness to palpation of this area

153
Q

Describe the management of plantar fascitis

A 
Rest
Ice
Analgesia
Physiotherapy 
Steroid injections
Extracorporeal shockwave therapy 
Surgery
154
Q

Describe the pathophysiology of frozen shoulder (adhesive capsulitis)

A

Inflammation and fibrosis in the joint capsule causes adhesions which bind the capsule and cause it to tighten around the joint and restrict movement

155
Q

Describe the typical course of symptoms in adhesive capsulitis

A

Painful phase - shoulder pain, worse at night

Stiff phase - shoulder stiffness develops and affects both active and passive movement (external rotation)

Thawing phase - gradual improvement in stiffness and return to normal

156
Q

Describe the test for supraspinatus tendinopathy

A 
Jobe test (empty can test) 
Patient abducts their shoulder to 90 degrees and fully internally rotates the arm as if they are emptying a can of water. The examiner pushes down on the arm as the patient resists. The test is positive if there is pain or if the arm gives way
157
Q

What are the signs on examination of acromioclavicular joint arthritis

A

Tenderness to palpation

Pain is worse at the extremes of shoulder abduction, from 170 degrees onwards when arm is overhead

Positive scarf test - pain caused by wrapping the arm over the chest and opposite shoulder

158
Q

How is adhesive capsulitis diagnosed

A

History and examination - exclude other causes of shoulder pain and stiffness

CT/MRI may show thickened joint capsule but not required for diagnosis

159
Q

Describe the management of adhesive capsulitis

A 
Continue to use the arm but do not exacerbate the pain 
Analgesia - NSAIDs
Physiotherapy 
Intra-articular steroid injections
Hydro dilation

Surgery - resistant and severe cases - manipulation under anaesthesia (forcefully stretching the capsule to improve ROM) and arthroscopy (cut the adhesions and rerelease the shoulder)

160
Q

Which disease is adhesive capsulitis associated with?

A

Diabetes

161
Q

Which range of movement is most affected in adhesive capsulitis

A

External rotation

162
Q

List the muscles of the rotator cuff and their actions

A

Supraspinatus - abducts the arm
Infraspinatus - externally rotates the arm
Teres minor - externally rotates the arm
Subscapularis - internally rotates arm

163
Q

Which activities are more likely to cause rotator cuff injury

A

Acute injury - fall onto outstretched hand
Overhead activities
Degenerative change with age

164
Q

How do rotator cuff injuries present

A

Shoulder pain
Weakness and pain with specific movements relating to the site of the tear
Pain in first 60 degrees of abduction

165
Q

How are rotator cuff tears diagnosed

A

CT/MRI

X-ray - exclude bony pathology

166
Q

How are rotator cuff tears managed

A

Degenerative - conservative management - rest, adapted activity, analgesia, physiotherapy

Surgery - arthroscopic rotator cuff repair

167
Q

How does subacromial impingement present

A

Painful arc of abduction 60-120 degrees

168
Q

Describe shoulder subluxation

A

Partial shoulder dislocation - head pops back in

169
Q

Name and describe the two types of shoulder dislocation

A

Anterior dislocation - >90% cases, head of Humerus moves forward in relation to glenoid cavity, Occurs when the arm is forced backward whilst abducted and extended at the shoulder

Posterior dislocation - associated with electric shock and seizure

170
Q

List some associated damage with shoulder dislocation

A

Axillary nerve damage - C5 and C6 nerve roots, damage causes loss of sensation in regimental badge area over lateral deltoid and motor weakness in teres minor and deltoid muscles

Fractures
Hil-sachs lesions - compression fractures on the posterolateral part of head of humerus
Bankart lesion - tear in anterior portion of the glenoid labrum

171
Q

Describe the apprehension test in shoulder dislocation

A

Patient lies on back
Shoulder abducted and elbow flexed
Shoulder externally rotated
As arm approaches 90 degrees of external rotation patient will be worried and anxious and want you to stop - previous dislocation or subluxation

172
Q

What investigations are done in shoulder dislocations

A

Xray - before and after reduction
MRI - shoulder damage and plan for surgery
Arthroscopy

173
Q

Describe the acute management in shoulder dislocation

A

Analgesia, muscle relaxants and sedation
Gas and air (entonox) - 50% nitrous oxide and 50% O2
Broad arm sling
Close reduction of shoulder
Dislocation associated with fracture requires surgery
Post reduction Xray
Immobilise shoulder

174
Q

Describe the ongoing management of shoulder dislocation

A

High risk of recurrence
Physiotherapy
Shoulder stabilisation surgery

175
Q

How do patients with shoulder dislocation present

A

Arm held to their side
Buldge and palpable at front of shoulder
Assess for fracture, nerve and vascular samage

176
Q

What is epicondylitis

A

Type of repetitive sprain injury

Inflammation at the point where the tendons of the forearm insert into the epicondyles on the distal end of the humerus

177
Q

What is the function of the tendons inserting into the medial epicondyle?

A

Flex the wrist

178
Q

What is the function of the tendons inserting into the lateral epicondyle

A

Extend the wrist

179
Q

Describe lateral epicondylitis

A

Tennis elbow
Pain and tenderness at the lateral epicondyle
Pain radiates down the forearm
Weak grip strength

180
Q

Describe Mills test

A

Stretching the extensor muscles of the forearm while palpating the lateral epicondyle
Elbow is extended., forearm supinated and the wrist and fingers are extended. Examiner holds the patients elbow with pressure on the lateral epicondyle - if this causes pain then is positive indicating lateral epicondylitis

181
Q

Describe Cozen’s test

A

Elbow extended, forearm pronated, wrist deviated in the direction of the radius and a hand in a fist. Examiner holds the patients elbow with pressure on lateral epicondyle. The examiner applies resistance to the back of the hand while the patient extends the wrist. If it causes pain, it is positive indicating lateral epicondylitis

182
Q

Describe medial epicondylitis

A

Golfers elbow
Pain and tenderness on the medial epicondyle
Pain may radiate down the arm and there may be weak grip strength

183
Q

How do you test for medial epicondylitis

A

Golfers elbow test
Elbow extended, forearm supinated, wrist and fingers extended
Examiner puts pressure on the medial epicondyle and is positive if pain

184
Q

Describe the management of epicondylitis

A 
Rest
Adapting activity 
Analgesia
Physiotherapy 
Orthotics - elbow straps/braces
Steroid injections
Platelet rich plasma injections
Extracorporeal shockwave therapy
185
Q

What is De Quervain’s tenosynovitis

A

Type of repetitive strain injury

Inflammation and swelling of the tendon sheaths in the wrist under the extensor retinaculum

186
Q

Which two tendons are most affected in De Quervain’s tenosynovitis

A

Abductor pollicis longus

Extensor pollicis brevis

187
Q

How does De Quervain’s tenosynovitis present

A 
Radial side of hand 
Pain radiating to forearm 
Ache 
Burn 
Weakness
Numbness
Tenderness
188
Q

Describe Finkelsteins test for De Quervain’s tenosynovitis

A

Make a fist with thumb inside
Adduct the wrist (ulnar deviation)
Movement causes pain on radial aspect as strain on APL and EPB - positive for De Quervain’s tenosynovitis

189
Q

How is De Quervain’s tenosynovitis managed

A 
Rest 
Adapting activity 
Splints 
Analgesia - NSAIDs
Physiotherapy
Steroid injections 
Surgery - rare - cut the extensor retinaculum releasing the pressure and creating more space for tendons
190
Q

Describe Dupuytren’s contracture

A

Palmar fascia becomes thickened and tight leading to finger contractures (fingers pulled into flexion and restricting ability to extend)

191
Q

List some risk factors for Dupuytren’s contracture

A 
Age
FH - autosomal dominant
Male
Manual labour - vibrating tools
DM
Epilepsy 
Smoking and alcohol
192
Q

Describe a test for Dupuytren’s contracture

A

Table top test - patient can not position hands completely flat on a table

193
Q

Which finger is most affected by Dupuytren’s contracture

A

Ring finger

194
Q

How is Dupuytren’s contracture managed

A

Conservative or surgical

Needle fasciotomy - insert needle through skin to divide and loosen the cord causing the contracture

Limited fasciotomy - removal of abnormal fascia and cord to release contracture

Dermofasciectomy - remove abnormal cord, fascia and skin, replace removed skin with skin graft

195
Q

Describe carpal tunnel syndrome

A

Compression of the median nerve as it travels through the carpal tunnel in the wrist, causing pain and numbness in the median nerve distribution of the hand

196
Q

Describe the carpal tunnel

A

Between the carpal bones and the flexor retinaculum (fibrous band that wraps across the palmar side of the wrist)

The median nerve and flexor tendons of the forearm travel through the carpal tunnel

197
Q

What does the palmar cutaenous branch of the median nerve supply and is it affected in carpal tunnel syndrome

A

Palm sensation

Not affected in carpal tunnel syndrome - does not pass through carpal tunnel

198
Q

List some risk factors for carpal tunnel

A 
Repetitive strain
Obesity
Perimenopause
RA
DM
Acromegaly - bilateral 
Hypothyroidism
199
Q

What does the median nerve supply

A

Motor - abductor pollicis brevis, opponens pollicis, flexor pollicis brevis

Sensory - thumb, up to lateral half of ring finger

200
Q

List some symptoms of carpal tunnel syndrome

A

Sensory symptoms of thumb to lateral aspect of ring finger - pain, burning, numbness and pins and needles

Motor symptoms of thenar muscles - weak thumb movement, weak grip strength, difficulty with fine thumb movements, thenar atrophy

201
Q

Name and describe two special tests for carpal tunnel syndrome

A

Tinnel’s - tapping on wrist at location median nerve passes through tunnel (middle at point where wrist meets the hand), test is positive when sensory symptoms are triggered

Phalen’s test - fully flexing the wrist and holding it in this position, often done by asking the patient to put backs of hand together and bend wrists at 90 degrees. Positive when symptoms of carpal tunnel resent

202
Q

Describe the Kamath and Slothard carpal tunnel questionaire

A

High score replaces need for nerve conduction studies
Predicts likelihood of CTS based on questionaire

  • Do the symptoms wake you at night?
  • Do you have trick movements to make the symptoms go?
  • Is your little finger affected?
203
Q

How is carpal tunnel syndrome diagnosed

A

Nerve conduction studies - how well the signals pass through the carpal tunnel along the median nerve

204
Q

Describe the management of carpal tunnel

A

Rest and altered activity
Wrist splints that maintain a neutral position of the wrist worn at night - minimum 4 weeks
Steroid injections
Surgery - flexor retinaculum transverse carpal ligament is cut to release pressure on median nerve

205
Q

What is a ganglion cyst and how does it present

A

Sac of synovial fluid originating from tendon sheath or joint capsule
Synovial membrane herniates forming a pouch
Appear suddenly/gradually
Non-tender - although may compress nerves to give sensory and motor symptoms
Well circumscribe
Transilluminates
Hard

206
Q

Describe the management of ganglion cysts

A

Conservative - 50% resolve spontaneously
Needle aspiration - may recur
Surgery - remove affected part of tendon sheath/ joint capsule - infection and scarring

207
Q

List the carpal bones

A 
Scaphoid
Lunate
Triquetrum
Pisiform
Trapezium
Trapezoid
Capitate
Hamate
208
Q

How is Achille’s tendon rupture managed

A

Equinus cast - foot held in plantar flexion

209
Q

What is Froments sign

A

Inability to pinch normally between the first and second digits
Ulnar nerve pathology

210
Q

Which nerve roots form the ulnar nerve

A

C8-T1

211
Q

Which nerve roots form the radial nerce

A

C5-T1

Finals (18 decks)

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