Orthopaedics Flashcards
What Classification Is Used for Open Fractures?
Gustilo Anderson classification
Classification of Open Fractures
Type 1: <1cm would and clean
Type 2: 1-10cm clean wound
Type 3a: >10cm and high energy but with adequete soft tissue coverage
Type 3b: >10cm and high energy but with inadequete soft tissue coverage
Type 3c: All injuries with vascular injury
How do you manage an open fracture?
Resuscitation and stabilisation of the patient
Urgent realignment and splinting of the fracture
Broad spectrum antibiotic cover and tetnus vaccination
Wound and fracture site debridement
Removal of devitalised tissue
Reasses and document neurovascular status
Vascular team surgical exploration of any vascular compromise
What problems can an open fracture cause?
Skin - significant tissue loss
Soft tiasue devitalisation/muscle, tendon, or ligament loss
Neurovascular injury - nerves and vessels may be compressred
Infection - direct contamination reduced blood supply insertion of metalwork for fracture stablisation
Principals of fracture management?
Reduce
Hold
Rehabillitate
Why is fracture reduction important?
Tamponade of bleeding
Reduction in the traction on surrounding soft tissues (excessively swollen tissues have higher rates of wound complications)
Reduction in tracture on the ransversing nerves to reduce the risk of neuropraxia
Reduction of pressure on transversing blood vessels restoring any affected blood supply
What does the defeinitive manouvere in fracture reduction entail?
Correction of the deforming forces that resulted in the injury
(Sometimes exaggerating fracture first to uncouple the proximal and distal fracture fragments)
What should be considered when immobilising a fracture
Whether traction is needed
Which method will be used (splint, plaster cast)
How long ‘hold’ has been in place - in first two weeks there should be space allowed for swelling
If their is axial stability (plaster should cross joint above and below)
Can the patient weight bare?
Will the patient need thromboprohylaxis?
Safteynetting on compartment syndrome
What is compartment syndrome?
Critical pressure increase within a compartmental space, can affect any fascial compartment
What are the causes of compartment syndrome?
High-energy trauma, crush injuries, or fractures that cause vascular injury Burns Iatrogenic vascular injury Tight casts or splints DVT Post perfusion swelling
What is the pathophysiology of compartment syndrome?
Fascial compartments are closed and cannot be descended, so any fluide will cause intra-compartmental pressure increase, compressing the veins. This increases the hydrostatic oressure within them causing fluid to move out of the veins into the compartment causing further presure increase.
The transversing nerves are compressed.
Arterial inflow is compromised leading to ischemia
Signs and symptoms of compartment syndrome
Cold pale limb Parathesisa Paralysis Severe pain disproportionate to the injury worsened by passive stretching the muscle bellies of the muscles traversing the affected fascial compartment Tension of the compartment
What is the normal pressure within a fascial compartment?
0 to 8 mmHg
What organ needs to be monitored in particular in compartment syndrome?
Kidneys, potential effects of rhabdomyolysis or reperfusion injury
What is the initial management of compartment syndrome?
Keep limb at neutral level with the patient
High flow oxygen
Augment blood pressure
Removal all splints casts and dressings
Treat symptomatically with opiod analgesia
Treat symptomatically with opiod analagesia
What is the defenitive treatment of compartment syndrome?
Fasciotomoy
What blood test can be useful in diagnosing compartments syndrome?
Creatine kinase
Elevated/trending upwards
What are the common caustive organisms in septic artheritis?
Staph aureus (adults)
Streptococcus spp.
Gonorrhoea (sexualy active patients)
Salmonella (sickle cell)
What is the pathophysiology of septic artheritis?
Bacteraemia seeds to joint/Direct innoculation/Spreading from adjacent osteomyelitis
What are the risk factors for septic artheritis?
Age > 80 Any pre-existing joint disease DM or immunosuppresion Chronic renal failure Hip or knee joint prosthesis IVDU
How does septic artheritis present?
Single swollen joint
Severe pain
Pyrexia (60%)
Red swollen joint
Joint is rigid patient cannot tolerate passive or active movement
Note that in prosthetic joint infections symptoms and signs can be more subtle
Differential diagnosis for Septic Artheritis?
Flare of osteoartheritis Haemarthrosis Crystal arthropathies RA Reactive artheritis Lyme disease
Investigations for septic artheritis?
Routine bloods including FBC and CRP
Blood ESR and urate levels
A joint aspritation (in theatre if prosthetic joint) and analysis for gram stain, leucocyte count, polarisinf microscopy , fluid culture BEFORE ANTOBITOICS STARTED UNLESS PATIENT OVERLY SEPTIC
Plain radiograph (normal/soft tissue swelling/fat pad shift/ joint space widening)
What are the complications of septic artheritis?
Osteoartheritis
Osteomyelitis
Spesis
What is the management of septic artheritis
If septic sepsis 6
Empirical antibiotics after any planned cultures of aspirates (4-6 weeks, 2 of which are IV)
Irrigation and debrident
Revision surgery of prosthetic joint
What are the causes of frozen shoulder?
Primary adhesive capsulitis (idopathic capsulitis)
Secondary adhesive capsulitis - rotator cuff tendinopathy, subacromial impingement syndrome, bisceps tendinopathy, previous surgery or trauma, or known joint arthopathy
Association with inflamatory diseases - ?autoimmune element
What are the stages of frozen shoulder?
Painful
Freezing
Thawing
Pain associated with limitation in shoulder movement present throughout
Clinical features of a frozen shoulder
Generalised deep contsant oain radiating to the bicep
Often distrubs sleep
Loss of join function, stiffness
Loss of arm swinf
Atrophy of the deltoid muscle
Generalised tenderness on palpation
Limited ROM - external rotation and flexion of the shoulder
Which sex is frozen shoulder more comman in?
Females
What is the peak onset of frozen shoulder?
40 to 70 years old
What investigations would you undertake in a patient with frozen shoulder?
Can be a clinical diagnosis
Plain film radiographs can rule out acriomioclavicular pathology or atypical fracture presentation
MRI imaging can reveal a thickening of the glenohumeral joint capsule
HbA1c may be useful as may patients with adhesive capsulitis have diabetes
What is tha management of adhesive capsulitis?
Self limiting
Recovery months-years
Education reassurance
Physiotherapy
If fails to improve with above and simple analgesia corticosteroid injections can be considered
Potentially surgical interventions: joint manipulation under general anaesthetic to remove capsular adhesions to the humerus, arthogaphic distension, surgical release of the glenohumeral joint capsule
Complications of frozen shoulder?
Small proportion of patients will never regain full motion
Perisistence beyond two years
Recurrence in contralateral shoulder
What is adhesive capulitis/frozen shoulder?
Glenohumeral joint capsule becomes contracted and adherent to the humeral head
Results in shoulder pain and reduced ROM
What is subacrominal impingement syndrome?
Inflamation and irritation of the rotator cuff tendons as they pass through the subacromial space
Attrition between the coracoaceomial arch and the supraspinatus tendon or subacromial bursa
What pathology is encompassed by SAIS
Rotator cuff tendionsis
Subacromial bursitis
Calcific tendinitis
Typically what age are oatients presenting with shoulder impingement?
Under 25
Active or in manual professions
Clincal features of SAIS
Progressive pain in the anterior super shoulder
Exacerbated by aduction, relieved by rest
Associated with weakness and stiffness secondary to the pain
Positive Neers impingement test
Positive Hawkins test
What is Neers impingement test
The arm is placed fully internally rotated by the patients side and passively flexed
Positive if pain is oresent in anterolateral aspect of the shoulder
What is Hawkins test?
Shoulder and elbow flexed to 90*, examiner stablises the humerus and oassively internally rotates the arm.
Positive if pain in anterolateral aspect of the shoulder.
Intrinsic mechanisms of SAIS
Muscular weakness
Overuse of the shoulder
Degenerative tendinooathy
Extrinsic mechanisms of SAIS
Anatomical facotrs
Scapular musculature
Glenohumeral instability
Differential diagnosies for shoulder impingement?
Muscular tear (rotator cuff tear, long head bisceps tear)
Neurological oain
Frozen shoulder syndrome
Acromioclavicular pathology
How woudl you investigate shoulder impingement?
Clinical diagnosis
Confirm via MRI (formation of subacromial osteophytes and sclerosis subacrimial bursitis, humeraly cystic changes, narrowing of the subacromial space)
Management of shoulder impingemeny
NSAIDs
Physio
Corticosteroid injections can be trialled
Surgical repair of muscular tears
Surgical removal of the subacromial bursa
Surgical removal of a section of the acromion
Complications of SAIS
Rotator cuff degeneration and tear Adhesive capulitis Cuff tear arthropathy Complex regional pain syndrome Usually resoleves with conservative management
Where is the subacromial space and what runs in it?
Below the coracoacromial arch and above the humeral head
Rotator chff tendons long head of the biceps tendon and the coraco-acromial soace run through it, all surrounded by the subacromial bursa
What muscles does the rotator cuff include and what do they do?
Supraspinatus - abduction
Infraspinatus - external rotation
Teres minor - external rotation
Subscapularis - internal rotation
What does the rotator cuff do?
Supports and rotates the glenohumeral joint
Classication of rotator cuff tears
Acute (<3 months)
Chronic (>3 months)
Partial thickness
Full thickness (small/medium/large)
Pathophysiology of rotator cuff tears?
Acute: occur within tendons with pre-exisiting degeneration, alone with minimal force (or larger forces in younger individuals)
Chronic: individuals with degenerative microtears to the tendons, most commmonly from overuse, seen more in older patients
Risk factors for a rotator cuff tear
Age Trauma Overuse Reoeititve overhead shoulder motions BMI>25 Smoking Diabetes mellitus
Investigating a rotator cuff tear?
Urgent plain film radiograph to exclude a fracture
Most likely unremarkable but may be reduced acromiohumeral distance pr sclerosis cyst formation on the greater tuberosity of the humerus
USS to establish size and presence of tear
MRI to dectect size charecteristics and location of the tear
Clinical features of rotator cuff tear
Pain over lateral aspect of the shoulder
Inability to abduct the arm above 90 degrees
Tenderness of greater tuberosity and subacrimal bursa regions
Supraspinatus and infraspinatus atrophy can maybe be seen in a massive teR
Positive Jobe’s test
Positive Gerber’s lid off test
Positive posterior cuff test
Differentials for a rotator cuff tear
Fracture
Persistent gelnohumeral subluxation
Brachial plexus injury
Radiculopathy
Management of a rotator cuff tear
Within 2 weeks of injury - conservative: analgesia, physio, trial of corticosteroid injection
Surgical management after two weeks or if remaining symptomatic despite conservative management - or large and massife tears
Repair - arthroscopically or open
Main complications of rotator cuff tear
Adhesive capsulitis
Enlargement of tear
Which patients most commonly present with clavicle fractures?
- Adolescents and young adults
2. Over the age of 60 - association with osteoperosis
What classification is used for clavicle fractures?
The Allman classification system
What are the fracture types of the Allman classification system?
Type 1 - middle third of clavicle - most common as this is the weakest segment. Usually stable but significant deformity present.
Type 2 - lateral third of the clavicle. When displaced often unstable
Type 3 - least common, medial third - associated with multi-system polytrauma.
As the mediastinum sits directly behind the medial aspect of the clavicle they can be associated with neurovascular compromise, pneumothorax or haemothorax
How do clavicle fractures occur and where do the fragments typically displace?
Direct or indirect trauma
Medial - superior
Lateral - inferior
Clinical features of a clavicle fracture
Sudden onset localise severe pain, worsened on active movement of the arm, following trauma
?Open injury - subcut location of clavicle
Threatened skin - tented tethered white non blanching (subcut location of clavicle)
Brachial plexus injury
What differentials should you consider in a broken clavicle?
Sternoclavicular dislocation
ACJ seperation
How would you investigate a clavicular fracture?
Plain film AP and modified-axial radiograph to assess displacement
(CT imaging to assess medial clavicle injury)
Management of a clavicle fracture
Usually conservative even if significant deformity
Sling until pain free movement of the shoulder
Early movement of the shoulder joint
Surgical intervention if open fracture or very communited/very shortened/bilateral fractures
ORIF at 2-3 months if failure to reunite
What are the complications of a clavicle fracture?
Neurovascular injury
Puncture injury
Non-union
How long does a clavicular fracture take to heal?
4-6 weeks
What are the risk factors of a humeral shaft fracture?
Increasing age
Osteoperosis
Previous fractures
Which patients most commonly present with a humeral shaft fracture?
Younger pts - high energy trauma
Older patients - low impact
What are the clinical features of a humeral shaft fracture?
Pain
Deformity
Reduced sensation over the first dorsal webspace if radial nerve involvement
Weakness in wrist extension if radial nerve involvement
What causes a humeral shaft fracture?
FOOSH
Lateral fall onto an adducted limb
What is a Holstein-Lewis Fracture?
Distal third of the humerus, entrapment of radial nerve
Wrist drop
Loss of sensation in radial distribution
Surgical management indicated
How would you investigate a humeral shaft fracture?
AP plain film radiograph of the humerus
CT for pre op planning in sever comminuted cases
What is the management of a humeral shaft fracture?
Realingment of the limb - usually conservative in a funcitional humeral brace
Surgical fixation in few patients involving an open reduction and internal fixation with a plate,
Intramedullary nailing may be indicated in the presence of pathological fractures, polytrauma or severly osteoporotic bones
What is the most common site of shoulder fracture?
Proximal humerus
How do proximal humeral fractures usually happen?
FOOSH
Often in the contect of osteoporosis
Low energy in elderly or high energy in younger patients
How does a proximal humeral fracture present?
Pain around the upper arm Pain around the shoulder Restriction of arm movement Inability to abduct their arm Potentially loss of senstation in the lateral shoulder (regemental badge area) and loss of power of the deltoid muscle if damage to axillary nerve
Which vessels can be compromised by a proximal humerus fracture
Circumflex vessels
What investigations should be ordered for a proximal humerus fracture?
Urget bloods including a coagulation and Group and Save
Serum calcium and myeloma screen if pathological cause suspected
Plain film radiograph - lateral scapular, AP, axillary views
Potentially at CT scan for pre op planning
How do you classify proximal humeral fractures?
Neer classification system
How are proximal humeral fractures managed?
Immobilisation initially with early mobilisation including pendular exercises at weeks 2-4
Correctly applied polysling allowing arm to hang so that gravity can aid the reduction of fragments
Surgical fixation if displaced open or neuro vascular compromise
ORIF, intermedullaey nailing, hemiarthoplasty, reverse shoulder arthroplasty
What are the conplications of a humeral shaft fracture
Avascular necrosis of the humeral head
Axillary nerve injury
Reduced ROM
What are the potential complications of a dislocated shoulder?
Chronic pain Limited mobility Stiffness Recurrence Adhesive capulitis Nerve damage Rotator cuff injury Degerative joint disease Chronic joint instability
What is the most common type of shoulder dislocation and how does it occur
Anteroinferior
Clasically caused by a force being applied to an extended, abducted, externally rotated humerus
How might a posterior shoulder dislocation be caused
Seizure
Electorcution
(A direct vlow to the anterior shoulder or force through a flexed adducted arm)
How does a dislocated shoulder present
Pain
Reduced mobility
Instability
Asymmetry with the contralateral shoulder
Loss of shoulder contours (flattened deltoid)
Anterior bulge from head of the humerus
Axillary or suprascapular nerve damage
Associated bony injury
Associated labral ligamentous or rotator cuff injury
How should you invesitgate a shoulder dislocation
Plain radiograph
AP
Y-scapular (usefull for diff between anterior and posterior) and or axial views
MRI If suspected labral or rotator cuff injuries
What does the lightbulb sign on an xray of the shoulder mean
Anterior dislocation
How to manage shlulder dislocation
Assess neurovascular status before and after reduction
Manipulation under anaesthesia if failed closed reduction
Once reduced place arm in broad arm sling for aprox two weeks
What is the olcecranon
Region of the proximal ulna from its tip to the coronoid process. It articulates with the trochlea of the distal humerus.
How do olecranon fractures typically occur?
FOOSH
Sudden pull of the triceps and brachiallis.
Triceos further distract the fracture
How do olecranon fractures present?
Elbow swelling
Elbow pain
Lack of mobility and inability to extend elbow against gravity
Posterior aspect of the elbow is tender
Which imaging should be performed when an olecranon fracture is suspected?
Plain AP and lateral radiographs
Affected joint and those above and below
Management of an olecranon fracture
Establish the degreee of of the fracture on imaging
Minimal displacement or pt very elderly - imobilise in a 60-90 degree flexion, early introduction of ROM
Displacement >2mm
- proxmial to coranoid process: tension band wiring
- at level of or distal to coranoid process: olecranon plating
What areas, relative to the joint capsule, can a neck of femur fracture occur in?
- Intra-capsular – from the subcapital region of the femoral head to basocervical region of the femoral neck, immediately proximal to the trochanters
- Extra-capsular – outside the capsule, subdivided into:
1. Inter-trochanteric, which are between the greater trochanter and the lesser trochanter
2. Sub-tronchanteric, which are from the lesser trochanter to 5cm distal to this point
Describe the blood supply to the neck of femur
Retrograde
Passes from distal to proxmial along the femoral neck to the femoral head
Predominantly through the medial circumflex femoralartery
The medial circumflex femoral artery lies directly on the intra-capsular femoral neck
What are the risks of a displaced intra-capsular neck of femur?
If displaced, blood supply to the femoral head may be disrupted
Avascular necrosis of the femoral head
Will require athroplasty
How are intracapsular neck of femur fractures classified?
Garden Classification
Describe the Garden CLassification
I: non displaced, incomplete
II: non displaced, complete
III: partial displacement
IV: full displacement
How will a fractured neck of femur classically present?
Limb is shortened, externally rotated
Hx of trauma, pain in groin/thigh/ref to knee (elderly)
Inability to weight bear
What are the definitive surgical options for a fractured NOF
Hip hemiarthroplasty (displaced sub-capital) DHS (inter-trochanteric/basocervical) Cannulated hip screws (non-displaced intra-capsular) Anterogreade intramedullary femoral nail (sub trochanteric)
What is the one year mortality of a femoral neck fracture?
30%
What is osteoarthritis?
Degenerative joint disease
Loss of articular cartilage
Risk factors for OA
Age >45 years Female Family history Low bone density Vit D deficiency History of joint trauma Anatomic abnormalities Muscle weakness Joint laxity Participation in high impact sports
Where do patients with hip OA report pain?
Groin most commonly Lateral hip Deep buttock Aggravated by weight bearing, improved with rest Dull, aching pain
What gait will a patient with hip OA have?
Antalgic
Late stage: fixed flexion deformity causing Trendelenburg gait
Differential Diagnoses for Hip OA?
Trochanteric bursitis
Gluteus medius tendinopathy
Sciatica
FNOF
What features will be seen in joints affected by OA on a radiograph?
Joint space narrowing
Osteophyte formation
Sclerosis of the subchondral bone
Subchondral bone cysts
What tool can be used for a quantitative evaluation of disease progression in OA?
WOMAC
What is the management of OA?
Analgesia
Lifestyle modifications: weight loss, regular exercise, smoking cessation
Physiotherapy - improve joint mechanics, strengthens muscles, slows disease progression
Surgical intervention may be warrented if conservative efforts do not work - eg. hip OA hemiarthroplasty
What surgical approaches can be taken to a hip replacement?
Posterior (most common, risk of sciatic nerve damage)
Anterolateral
Anterior
How long does a modern hip prostheisis typically last?
15-20 years
Which joints are most commonly affected by OA?
- Knee
- Hip
- Hand
What clinical sign may you be able to feel when examining a patient with severe knee OA?
Crepitus
What differentials should be considered in patients with OA of the knee?
Meniscal or ligament injury
Referred pain from another joint (e.g. hip) or the back
Crystal arthropathies
Patellofemoral arthritis
What views of the knee should be obtained on X-ray?
AP to assess for OA (LOSS)
Skyline view to see patellar well
What classification system is used to classify OA of the knee?
Kellgren and Lawrence
Describe the Kellgren and Larwence system
Grade 0- no radiographic features of OA
Grade 1 - unclear joint space narrowing and possible osteophytic lipping
Grade 2 - definite osteophytes and possible joint space narrowing on AP weigh-bearing views
Grade 3 - Multiple osteophytes, definite joint space narrowing, evidence of sclerois and possible bony deformity
Grade 4 - large osteophytes, marked joint spaced narrowing, severe sclerois, definite bony deformity
Total knee replacement is the standard treatment for OA of the knee. How long do these tend to function for?
10 years
What is Patellofemoral Osteoarthritis?
Degeneration of articular cartilage along the trochlear groove and on the underside of the patella
Specifically worse with activty putting pressure on the patella such as
What is the role of the anterior cruciate ligament?
Stabiliser of the knee joint
Limits anterior translation of the tibia relative to the femur
Contributes to internal rotational stability
Typically, what kind of history will a patient with an ACL tear present with?
Twisting knee whilst wait bearing - often occuring in athletes
Unable to weight bear
Rapid joint swelling (very vascular so clinically apparent in 15-30 mins)
Significant pain
Joint instability if delayed presentation
What specific tests can identify potential ACL damage on examination?
Lachman Test
Anterior Draw Test
How do you conduct the Lachman’s test?
- Place knee in 30 deg of flexion, with one hand stablising the femur
- Pull the tibia forward to asses the amount of anterior movement of the tibia compared to the femur
- Compare to the contralateral knee
How do you perform the anterior draw test?
- Flex knee to 9o degrees
- Place thumbs on the joint line and index fingers on the hamstring tendons posteriorly
- Apply force anteriorly to demonstrate any tibial excurison
What is a positive Lachmans test?
Soft/mushy feel
Translation of tibia in affected leg is more than 3mm greater than that of the other leg
What is a positive anterior draw test?
Tibia has more movement/ligament is loose compared to contralateral side
What is the most specific test for ACL tear?
Lachman’s test
What differentials may you consider when suspecting a patient has an ACL tear?
Proximal tibial fracture Distal femur fracture Meniscal tear Collateral ligament tear Quadriceps tendon tear Patellar ligament tear
What imaging would you perform on a patient with a suspected ACL tear?
- Plain film radiograph of the knee - AP and lateral views
Segond fracture is pathognomic of ACL injury (bony avulsion of the lateral proximal tibia)
Will rule out any other bony injuries, joint effusion or lipohaemarthosis present - MRI - gold standard for diagnosis, will also pick up any associated meniscal tears
Management of an ACL tear?
Rest, Ice, Compression, Elevation
Conservative - rehabilitation to strengthen quadriceps to stabilise the knee, COuld put a cricket pad knee splint for comfort if non-weight bearing.
Surgical - performed after prehabilitation period, surgical reconstruction involving use of a tendon or artificial graft OR in some cases an acute repair if MRI imagin favourable
Main complication of an ACL tear?
Post-traumatic osteoarthritis
What are the menisci of the knee?
C-shaped fibrocartillage found in the knee joint
What is the function of the menisci of the knee?
Shock-absorber of the knee
Increase articulating surface area
What does the medial meniscus of the knee attach to?
Medial collateral ligament
Is the lateral meniscus attached to the lateral collateral ligament?
No
And it is more circular than the medial
What are the two most common causes for meniscal tears?
Trauma-related injury
Degenerative disease
What is the typical mechanism of a meniscal tear due to trauma>
Twisted knee, flexed while weight bearing
What are the four types of meniscal tears of the knee?
Vertical
Longitudinal (Bucket-Handle)
Transverse (Parrot-Beak)
Degenerative
What is the most common type of meniscal tear in the knee?
Longitudinal (Bucket-Handle)
What history to patients with a meniscal tear present with?
Tearing sensation
Intense sudden-onset pain
Invariably slow swelling subsequently over a period of 6-12 hours
If a meniscal tear which results in a free body within the knee, in which position will the knee be locked?
Flexion
Unable to extend
How would a meniscal tear of the knee appear on examination?
Tenderness Joint effusion Limited knee flexion McMurray's Test Positive Apley's Grind Test
How do you perform McMurray’s Test and what makes it positive?
Hold knee and foot, flex knee whilst externally rotating, Then extend.
Positive in the presence of pain and/or click/snap/clunk/thud
Differential Diagnosis for a meniscal tear?
Fracture
Cruciate ligament tear
Collateral ligament tear
Osteochondritis dissecans
How do you investigate a meniscal tear?
Plain film radiograph of knee to exclude a fracture?
An MRI is gold standard investigation to confirm a meniscal tear and to indentify the type of tear.
Management of a meniscal tear?
Rest, elevation, compression and ice for the acutely swollen knee
Larger tears (>1cm) arthroscopic surgery is indicated
- Outer third (very vascular) suture repair
- Inner third trimmed to reduce locking symptoms
- Middle could be either of the above
Complications of knee arthoscopy
DVT
Damage to local structures such as the saphenous nerve and vein, peroneal nerve, popliteal vessels
What does the extensor mechanism of the knee consist of?
Quadriceps muscle group Quadriceps tendon Patella Patellar retinaculum Patellar ligament Adjacent soft tissues
What can cause injuries to the extensor mechanism?
Chronic degenerative disease (weakening of the collagen) Overuse injuries (weakening of the collagen) Acute trauma (contraction against a flexed knee)
Where does quadraceps tendon rupture occur?
Unilaterally
Site of insertion with the superior pole of the patella
Risk factors for extensor mechanism injury?
Increasing age (rare in under 40s) CKD DM RA Medications (corticosteroids, fluoroquinolones)
How do patients with a quadriceps tendon rupture typically present?
Report hearing a pop
Tearing sensation followed immediately by pain in the anterior knee or thigh
Difficulty weight bearing
History of sudden and excessive loading of the quadriceps muscles (landing from a jump)
How would a quadriceps tear appear on examination?
Localised swelling
Tender palpable defect above the superior pole of the patella
(Complete tear: inability to straight leg raise, and loss of the ability to extend the knee. These will be inhibited in a partial tear)
Differentials for acute knee pain after intense loading on the quadriceps tendon muscle
Patella tendon rupture
Patella fracture
Femoral shaft fracture
Quadriceps tendon rupture
How would you investigate a quadriceps tendon rupture?
Clinical diagnosis, especially in complete tears (absent SLR, loss of knee extension)
A plain film radiograph will show a caudally displaced patella, useful to r/o fracture
USS for definitive diagnosis and measuring the degree of rupture
MRI if still uncertain
How do you manage a quadriceps tendon rupture?
Where extensor mechanism is still intact, immobilisation of knee in a brace and rehab
Otherwise, surgical intervention (longitudinal drill holes, suture anchors, end to end sutures) and then brace immobilisation and rehab at 6 weeks
How may a patella fracture occur?
Direct trauma
Eccentric contraction of the quadriceps muscle
How would the examination of a fractured patella present?
The pain will be made worse with movement and the patient will be unable to straight leg raise (due to damage to the extensor mechanism). They may not be able to weight bear.
Patellar defect palpable
Bruising and swelling
How does the AO FOundation Classification classify patella fractures?
(1) extra-articular or avulsion fractures
(2) partial articular
(3) complete articuar
Imaging for a patella fracture?
Plain film radiograph (skyline, anterior-posterior, lateral)
CT if comminuted fracture
How do you manage a patella fracture?
Conservative management: non-displaced, minimally displaced, vertical fractures where extensor mechanism remains functional. Brace or cylinder cast.
Surgical otherwise, ORIF with tension band wiring is the most widely accepted method.
How does patellar dislocation occur?
Lateral shift of the patella, leaving the trochlea groove of the femoral condyle.
Usually due to disruption of the medial patellofemoral ligament.
Usually a result of non-contact injury to the knee
What patellofemoral disorders can predispose a patient to a patella dislocation?
Ligament laxity
Reduced osseous constraint form the the lateral femoral condyle
Imbalance between stronger lateral tissues which are able to overcome weaker medial structures
What kind of stress may cause a patellar dislocation?
Valgus stress (strong lateral force)
Clinical Presentation of a Patellar DIslocation?
Hemarthorois of the knee (rupture of the medial restraints of the patella) Medial swelling Reduction when knee extended Pain Instability Locking of the knee after trauma
Imaging for a suspected dislocated patella?
X-rays; To exclude associated fractures (osteochondral, avulsion); subluxation will be seen on a lateral view
CT: To measure tuberosity tibia-trochlea groove distance
MRI: To differentiate degree of tear; to rule out osteochondral fractures
Indicated in young patients with primary dislocation
How do you manage a patellar dislocation?
Conservative: immobilistaion for 6 weeks + analgesia
Surgery (if recurrent/chronic, patellofemoral symptoms, failed conservative management), arthoscopically +/- surgical repair od retinaculum or immediate patellar realignment
What is trigger finger?
Finger or thumb locks in flexion, preventing a return to extension
What usually preceeds trigger finger?
Flexor tenosnovitis (from repeatative movement) leading to inflammmation of the tendon and sheath Superfical and deep flexor tendons with local tenosynovitis at the metacarpal head subsequently develop localised nodal formation on the tendon, distal to the pulley This node can pass move proximal to the pullex in flexion but can not pass back under during flexion
What pulleys are involved in The Flexor Sheath and Pulley System?
Palmar aponeurosis
Annular ligaments
Cruciate ligaments
Is trigger finger painful?
Patients usually report painless clicking/snapping/catching when trying to extend their finger
Can become painful over time, over the volar aspect of the metacarpophalangeal joint
Differentials for trigger finger?
Dupuytrens contracture
INfection
Ganglion (involving tendon sheath)
Acromegaly (resulting in flexor synovium swelling)
How do you diagnose trigger finger?
Clinical diagnosis
Bloods if suspicious of another cause
How can trigger finger be managed?
Conservative if mild: exercises, splint to maintain extension at night ( keeps roughened end of the tendon in the tunnnel, making it smoother). Steroid injections.
Surgical: Usually a percutaneous trigger finger release with a needle under local can be used. If sever may warrent surgical decompression
In carpal tunnel syndrome, which nerve is compressed due to raised pressure within the carpal tunnel?
Median nerve
What are the risk factors for carpal tunnel syndrome?
Female Increasing age Pregnancy Obesity DM RA Hypothyroidism Occupations using repeatitive hand movements (vibrating tools)
What are the clinical features of carpal tunnel syndrome?
Pain, numbness, paraesthesia throughout the median nerve sensory distribution
Palm sparing (palmar cutaneous branch of the median nerve branches proximal to the flexor teinaculum and passing ove the carpal tunnel)
Symptoms are worse at night
Weakness of thumb abduction (later finding)
Wasting of the thenar eminence (later finding)
Which tests can be used on examination to help diagnose carpal tunnel syndrome?
Tinels Test
Phalen’s Test
What is Tinel’s Test?
Percussion over the median nerve can reproduce sensory symptoms of carpal tunnel
What is Phalen’s test?
Sensory symptoms of carpal tunnel reproduced by holding wrist in flexion for a full minute.
Differential Diagnosis for Carpal Tunnel syndrome?
Cervical radiculopathy, C6 - will be an element of neck pain or symptoms involving the entire arm
Pronator teres syndrome: Palm not spared, symptoms will extend to proximal forearm
Flexor Carpi Radialis tenosynovitis: Can be distinguished by tenderness at the base of the thumb
How might carpal tunnel syndrome be managed?
- Conservative: hand therapy, wrist splint at night to prevent flexion
- Surgical: carpal tunnel release surgery, involving cutting through the flexor retinaculum to reduce pressure on the median nerve
What can long term untreated CTS lead to?
Permanent neurological impairment
What is a Colles’ Fracture
Most common wrist fracture
Extra-articular fracture of the distal radius
Dorsal angulation and dorsal displacement within 2cm of the articular surface
FOOSH - wrist forced into supination
Avulsion fracture of the ulnar styloid
Colles’ fracture - Dorsally Displaced Distal radius → Dinner fork Deformity
What is a Smith’s fracture?
Volar angulation of the distal fragment of an extra-artiuclar fractue of the distal radius +/- volar displacement
Forced pronation type injury (falling backwards)
Which wrist fracture is an intra-articular fracture of the distal radius?
Barton’s fracture
Associated dislocation of radio-carpal joint
What are the main risk factors for osteoporosis?
Increasing age Female gender Early menopause Smoking or alcohol excess Prolonged steroid use
How should you assess a fracture for neruovascular compromise?
- Check nerve function
- Check limb perfusion (cap refil + pulses)
- Remember to examine joints above and below for occult injuries
How would you check the motor function of the median nerve?
Abduction of the thumb
How would you check the motor function of the ulnar nerve?
Adduction of the thumb
How would you check the motor function of the radial nerve?
Extension of the IPJ of the thumb
How would you check the sensory function of the median nerve?
Radial surface of distal 2nd digit
How would you check the sensory function of the ulnar nerve?
Ulnar surface of 5th digit
How would you check the sensory function of the radial nerve?
Dorsal surface of 1st webspace
How would you check the motor function of the anterior interosseous nerve?
Make and OK sign (opposition of thumb and index finger)
Which three measurements on a plain radiograph would help diagnose a distal radial fracture?
Radial height <11cm
Radial inclincation <22 degrees
Radial volar tilt > 11 degrees
When reducing a distal radius fracture, ensuring sufficient traction and manipulation, which blocks may be used?
Haematoma block
Bier’s block
What should happen after an open reduction of a distal radial fracture?
Below-elbow backslab cast
Radiograph after 1 week to check for displacement
When might a distal radial fracture require surgery and what options are there?
Significant displacement
UNstable
Intra-articular step of radiocarpal joint >2mm
ORIF with plating or K wire fixation
Main complications of any fracture?
Neurovascular compromise (ie. median nerve compression in a wrist fracture) Malunion OA
Which structure is contracted in Dupuytren’s contracture?
Longitudinal palmar fascia
Which digits are usually affected by Dupuytren’s contracture?
Ulnar digits (ring finger and little finger)
Where to fiborous cords and flexion contractures develop as painless nodules in Dupuytren’s contracture?
MCP and interphalangeal joints
What demographic typically present with Dupuytren’s contracture?
Men
40-60 years
What is the basic pathophysiology of Dupuytren’s contracture?
Fibroplastic hyperplasisa
Altered collagen matrix of palmar fascia
Compositional changes lead to the thickening and contraction of the palmar fascia
Risk factors for Dupuytren’s contracture?
SMoking
Alcoholic liver cirrhosis
DM
Occupational exposures (heavy manual work, vibrating tools)
Clinical features of Dupuytren’s contracture?
Reduced ROM
Nodular deformity
May be complete loss of movement
Bilateral in half of patients
How with Dupuytren’s contracture appear on examination?
Thickened band
Palpable firm nodule adherent to the skin
Skin blanching on active extension of the affected digits
MCP PIP joints in affected digit contracted in advanced disease
Positive Huestons test
What is Hueston’s test?
Ask patient to lay their palm flat on a tabletop
Positive if they cannot
Specific for Dupuytren’s contracture
What differentials should be considered in suspected Dupuytren’s contracture?
Stenosing tenosynovittis
Ulnar nerve palsy
Trigger finger (nodule present associated with finger motion)
Conservative management of Dupuytren’s contracture?
Suitable at early presentation without functional disability or rapid progression
Hang therapy, stretching exercises
Injecyable collagenase clostridum histolyticum (CCM), guided sometimes by USS
Surgical management of Dupuytren’s contracture?
Progressive disease, functional disability, MCP joint contracture >30 degrees, PIP contracture Excision of diseased fascia: -Regional fasciectomy -Segmental fasciectomy -Dermofasciectomy
Post surgical prognosis for Dupuytren’s contracture?
Excellent functional outcomes
But recurrence up to 66 percent
What is the most common cause of cauda equina?
Lumbar disc herniation
How will osteomyelitis present on an x-ray?
Regional osteopenia
Focal cortical loss
Periosteal changes
What are the criteria that must be fufilled in order for patients to recieve a total hip replacement over a hemiarthoplasty?
- Able to mobilise independently with no more than a walking stick
- Are not cognitatively impaired
3, Are medically fit for anaesthesia and the procedure
What T score on DEXA scan confirms the diagnosis of osteoperosis?
Less than -2.5
Use of which antibiotics are a known risk factor for developing Achilles tendon rupture?
Fluoroquinolones such as ciprofloxacin
How does pagets disease present on blood tests?
Normal electrolytes
Markedly raised ALP
What may be seen on X Ray in Pagets disease?
Mixed osteolytic, osteoblastic and sclerotic appearance
Which ATT can cause gout?
Pyrazinamide and ethambutol
Due to reduced renal urate excretion
What is a boxers fracture?
Fracture of the hand caused by a direct blow to the hand or high energy
Fifth metacarpal fracture (usually)
Patterns of radial never injury
Very high lesions - impingement: wrist drop and triceps weakness
High lesions - humeral shaft fracture: reduced sensation in the anatomical snuffbox but no triceps weakness
Low lesions - fracture of foreham (e.g. radial head): finger drop and no sensory loss
How are scaphoid fractures managed?
Not always detected by initial radiographs, especially if undisplaced
If clinical suspicion, patient hsould have wrist immobilised in a thumb splint and repeat plain radiograph in 10-14 days for further evaluation
Why is propanolol useful in portal HTN as prophylaxis against variceal bleeds and therefore the long term intervention of choice?
Non-selective beta blockers reduce portal blood pressure
How would you test for axillary nerve damage?
Test sensation over the lower half of the right deltoid muscle
How does axillary nerve damage most commonly occur?
Shoulder injuries such as dislocation or fracture of the surgical neck of the humerus
The terminal branch of this nerve supplies the upper lateral cutaneous nerve of the arm which innervated the skin over the inferioir portion of the deltoid (regimental badge area)
Frozen shoulder features
Absense of symptoms outside of the shoulder region is consistent with frozen shoulder
Pain at night
Pain on both passive and active movement
Features of impingement syndrome?
Pain on shoulder abduction
Which is worse at night
Painful arc between 70-120 degrees of abduction
How does patellar tendinitis present?
Anterior knee pain at inferior pole of the patella
Chronic course
Often occurs in people who run of perform repetative jumping movements (also known as jumpers knee) - pressure on extensor mechanisms and consequently the patella tendon
Pain initially only present on exercise but progresses to all the time, exacerbated by exercise
Negative hence the cruciate ligaments are intact
What will worsen pain in lateral epicondylitis?
pain worse on wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended
An allergy to which drug would contraindicate use of sulfasalazine?
Aspirin
What other common rheumatology drug does azathiprine have a severe interaction with?
Azathioprine and allopurinol have a severe interaction causing bone marrow suppression
What is osteosarcoma?
Osteosarcoma - malignant tumour that occurs most frequently in the metaphyseal region of long bones prior to epiphyseal closure
What type of soft tissue injury is most commonly associated with fracture of the medial part of the tibial plateau?
ACL
What type of fractures are inter and sub-trochanteric fractures of the femoral neck classed as?
Extracapsuler
What is the supraspinatous muscle responsible for?
first 15 degrees of abduction
What nerve innervates the supraspinatous muscle?
Suprascapular nerve
How is the common peroneal nerve commonly damaged?
Fibula fracture
Use of tight plaster cast
Where does the sensory function of the common peroneal nerve cover?
ANterolateral aspect of leg and dorsum of the foot
Boarders of the femoral triangle?
SAIL
S – Sartorius – lateral border
A – Adductor longus – medial border
IL – Inguinal Ligament – superior border
Contents of the femoral triangle from lateral to medial across the top of the thigh?
N – Femoral Nerve A – Femoral Artery V – Femoral Vein Y – Y-fronts C – Femoral Canal (containing lymphatic vessels and nodes)
Risk factors for malunion and nonunion?
Smoking
Cardiac disease
Diabetes
Infection
What kind of nerve damage causes a winged scapula?
Long thoracic nerve
What injury is acute rotator cuff tear associated with?
Shoulder dislocation
Which muscle is responsible for shoulder abducation beyond 15 degrees?
Deltoid muscle
Which muscles might be torn during a shoulder dislocation?
Supraspinatous
Infraspinatous
Teres minor
What does the infraspintus muscle do?
Laterally rotates the arm at the shoulder (glenohumeral) joint
Which nerve innervates the infraspinatous?
The suprascapular nerve is a nerve, same as supraspinatus
Which nerve innervates the deltoid muscle?
Axillary nerve
What does the deltoid muscle do?
Stabalises the glenohumeral joint
Anteior head: f;exes and internally rotates arm
Middle head: abducts arm
Posterior head: Extends and laterally rotates arm
Which imaging is best to visualize the rotator cuff?
MRI (mostly formed of ligaments and muscles)
Action of teres minor?
Laterally rotate arm
Helps to hold humeral head in glenoid cavity of scapula
What is the nerve supplying teres minor?
Axilary nerve (C5, C6) - same as deltoid
What muscles make up the rotator cuff?
Supraspinatous
Infraspinatus
Teres minor
Subscapularis
What does the lateral cutaneous nerve supply?
The lateral cutaneous nerve supplies sensation to the anterior and lateral aspect of the thigh.
Entrapment of the lateral cutaenous nerve is commonly due to intra and extra pelvic causes, what presenting complaint will it cause?
burning pain of anterior thigh which worsens on walking.
There is a positive tinel sign over the inguinal ligament.
Symptoms of illeoingual nerve compression?
Pain over the inguinal ligament which radiates to the lower abdomen.
There is tenderness when the inguinal canal is compressed.
How might a femoral nerve injury present?
On examination pt has weak hip flexion, weak knee extension, and impaired quadriceps tendon reflex, as well as sensory deficit in the anteromedial aspect of the thigh.
Where does the femoral nerve supply sensation to?
the anteromedial aspect of the thigh
What nerve is at risk during a total hip replacement?
Sciatic nerve is at risk during a total hip replacement
Being unable to dosiflex or plantar flex the foot suggest damage to which nerve?
Sciatic nerve
What is Lamber Eatonsyndrome
Lambert Eaton syndrome involves weakness in the muscles of the proximal arms and legs, and one of the ways it can be differentiated from myasthenia gravis is that the legs are normally worse affected
autoimmune response to sclc
Lumbar spinal stenosis may mimic IC, how can it be differentiated?
Lumbar spinal stenosis is a condition in which the central canal is narrowed by tumour, disk prolapse or other similar degenerative changes.
Patients may present with a combination of back pain, neuropathic pain and symptoms mimicking claudication. One of the main features that may help to differentiate it from true claudication in the history is the positional element to the pain. Sitting is better than standing and patients may find it easier to walk uphill rather than downhill. The neurogenic claudication type history makes lumbar spinal stenosis a likely underlying diagnosis, the absence of such symptoms makes it far less likely.
What common analgesia might delay bone healing?
Use of NSAIDS will slow bone healing
What is tennis elbow and where is the pain?
Tennis Elbow = LaTeral Epicondyle = wrist exTension
What suggests a femoral shaft fracture as opposed to a hip fracture?
In femoral shaft fractures, the area over the fracture site (the thigh) is often visibly deformed. Additionally, you would expect the pain to be located primarily at this site rather than in the hip.
How will x ray appear in frozen shoulder
Normal
What causes wrist drop on pronating the wrist
Radial never damage often secondary to mid shaft fracture of humerus
an inability to extend his right wrist and fingers and when he pronates his right arm his wrist drops
What is spinal stenosis and where does it most commonly affect?
Narrowing of spinal canal which results in compression of the spinal cord or nerve roots
Usually affects the lumbar or cervical spine
What are the three types of spinal stenosis?
Central stenosis - narrowing of central spinal cord
Lateral stenosis - narrowing of the nerve root canals
Foramina stenosis - narrowing of the intravertabral foramina
Causes of spinal stenosis?
Congenital
Degenrative - facet joint changes, disc disease, bone spurs
Herniated discs
Thickening of the ligamenta flava or posterior longitudinal ligament
Spinal fracture
Spondylothesis
Tumours
What is spondylolisthesis
Anterior displacement of a vertebra out of line with the one below
Can cause spinal stenosis
How might spinal stenosis present?
Gradual onset
Severity varies as per degree of narrowing
Lower back pain, Buttock leg pain, leg weakness - central lumbar - worse with standing straight better with bending
Sciatica - lateral stenosis and foramina stenosis
Radiculopathy
Severe compression - cauda equina syndrome
What is radiculopathy?
Compression of the nerve roots as they exit the spinal collum leading to motor and sensory symptoms
Investigating spinal stenosis?
MRI primary imaging investigation
Exclude PAD - ABPI Ct angio may be appropriate in central lumbar stenosis as mimics IC - pseudoclaudication
Management options in spinal stenosis?
Exercise and weight loss if appropriate
Analgesia
Physiotherapy
Decompression surgery where conservative treatment fails (with variable results)
What is laminectomy?
Removal of part of or all of the lamina (bony part forming the posterior part of vertebral foramen, attaching to spinous process) from the affect vertebra
Can be used in management of spinal stenosis
What is lumbago?
Lower back pain
Usually non-specific/mechanical
How long does it take for acute lower back pain to improve?
1-2 weeks
How long does it take for sciatica to recover?
4-6 weeks
What is sciatica and the sciatic nerve?
Symptoms associated with irritation of the sciatic nerve, formed by L4-S3
It exits the posterior part of the pelvis through the great sciatic foramen, in the buttock area on either side and travels down the back of the leg.
At the knee it divides into the tibial nerve and common peroneal nerve
Supplies sensation to the lateral lower leg and the foot
Supplies motor function to the posterior thigh, lower leg and foot
Symptoms of sciatica?
Unilateral pain from the buttock radiating down the back of the thigh to below the knee or feet 'Electric' 'shooting' pain Paraesthesia Numbeness Motor weakness Reflexs may be affected
When is sciatica a red flag symptom?
Bilateral - cauda equina
Main causes of sciatica?
Lumbosacral nevre root compression:
Herniated disc
Spondylolithesis
Spinal stenosis
Challenges with lower back pain?
Identifying serious pathology
Speeding up recovery
Reducing risk of chronic lower back pain
Managing symptoms
Causes of mechanical back pain?
Muscle or ligament sprain Facet joint dysfunction Sacroilliac joint dysfunction Herniated disc Spondylosithesis Scoliosis Arthritis affecting discs and facet joints
Causes of neck pain?
Muscle or ligament strain
Torticollis (waking up with unilaterally stiff and painful neck due to muscle spasam)
Whiplash (RTA)
Cervical spondylitis (degenrative changes to the vertebrae)
Red flag causes of back pain?
Spinal fracture
Cauda equina
Spinal stenosis (itermittent neurogenic claudication)
Ankylosing spondylitis (under 40, gradual onset, morning stiffness, nighttime pain)
Spinal infection (fever of hx of IVDU)
What are some non MSK causes of back pain?
Pneumonia Ruptured AAA Kidney stones Pyelonephritis Pancreatitits Prostaitis PID Endometirosis
Key aspects of back pain hx?
Major trauma (spinal fracture)
Stiffness in the morning or with rest (ankylosing spondylitis)
Age under 40 (ankylosing spondylitis)
Gradual onset of progressive pain (ankylosing spondylitis or cancer)
Night pain (ankylosing spondylitis or cancer)
Age over 50 (cancer)
Weight loss (cancer)
Bilateral neurological motor or sensory symptoms (cauda equina)
Saddle anaesthesia (cauda equina)
Urinary retention or incontinence (cauda equina)
Faecal incontinence (cauda equina)
History of cancer with potential metastasis (cauda equina or spinal metastases)
Fever (spinal infection)
IV drug use (spinal infection)
Key examination findings on spinal examination?
Localised tenderness (fracture, cancer)
Bilateral neurological motor or sensory signs (cauda equina)
Bladder distension (urinary retention - cauda equina)
Reduced anal tone on PR examination (cauda equina)
What cancers commonly metastisise to the spine?
PoRTaBLe
Po – Prostate R – Renal Ta – Thyroid B – Breast Le – Lung
Investigation of chronic back pain?
Clinical diagnosis: mechanical/non-specific back pain
X-ray CT for fracture
Emergency MRI if ?cauada equina
AS: CRP and ESR, X ray spinal and sacrum (bamboo spine- fusion - late disease), MRI (bone marrow odema in early disease)
What tool can be used to stratify the risk of a patient with acute back pain?
STarT Back tool
Low risk: total score 3 or less subscore 3 or less
Med risk: Total score over 3 subscore 3 or less
High risk: Total score over 3 subscore over 3
Management of acute lower back pain secondary to a serious underlying condition?
Same-day ref to on-call orthopedic team for urgent MRI in ?cauda equina
Inflammatory markers and urgent rhuematology review if ?AS
Full in-line spinal immobilisation, admission to a trauma unti and x-rays/CT scans for spinal injury after major trauma
How would you manage patients presenting with acute lower back pain (with serious underlying causes ruled out) with low risk of chronic back pain?
Self management Education Reassurance Anlagesia Staying active and continuing to mobolise as tolerated
How would you manage patients presenting with acute lower back pain (with serious underlying causes ruled out) with moderate-high risk of chronic back pain?
Self management Education Reassurance Anlagesia Staying active and continuing to mobolise as tolerated Physiotherapy Group exercise CBT
When might patients presenting with acute lower back pain require ref to orthopedics or neurosurgery?
Neurological signs or symptoms particullarly if progressive or severe
Pain relief for chronic low back pain?
- NSAIDs (ibuprofen or naproxen)
- Codeine as an alternative
- Benzodiazepines (e.g. diazepam) for muscle spasam (up to 5 days max)
If pain originates in facet joints radiofrequency denervation may be an option (raidofrequency targets medial branch nerves that supply sensation to the facet joints associated with back pain under local)
DO NOT USE: TCAs, opioids gabapentin or pregabalin
Management of sciatica
- NSAIDs (ibuprofen or naproxen)
- Codeine as an alternative
- Amitriptyline
- Duloxetine
Specialist managementL Epidural corticosteroid injections Local anaesthetic injections Radiofrequency denervation Spinal decompression
DO NOT USE: Benzodiazapines, oral corticosteroids, gabapentin or pregabalin
What is osteomylitis and how does it occur?
Osteomyelitis refers to inflammation in a bone and bone marrow, usually caused by bacterial infection.
Haematogenous osteomyelitis refers to when a pathogen is carried through the blood and seeded in the bone. This is the most common mode of infection.
Alternatively, osteomyelitis can occur due to direct contamination of the bone, for example, at a fracture site or during an orthopaedic operation.
May be acute or chronic
Most common causative organism for osteomyelitis?
Staphylococcus aureus
Risk factors for osteomyelitis?
Open fractures
Orthopaedic operations, particularly with prosthetic joints
Diabetes, particularly with diabetic foot ulcers
Peripheral arterial disease
IV drug use
Immunosuppression
How does osteomyelitis present?
Fever
Pain and tenderness
Erythema
Swelling
The presentation of osteomyelitis can be quite non-specific, with generalised symptoms of infection such as fever, lethargy, nausea and muscle aches.
X rays cannot exclude osteomyelitis and are often normal, what changes might they show, usually in later disease?
Periosteal reaction (changes to the surface of the bone) Localised osteopenia (thinning of the bone) Destruction of areas of the bone
What are the best imaging investigation for establishing a diagnosis of osteomyelitis?
MRI scans
How might you investigate osteomyelitis?
MRI scans are the best imaging investigation for establishing a diagnosis.
Blood tests will show raised inflammatory markers (e.g., WBC, CRP and ESR).
Blood cultures may be positive for the causative organism.
Bone cultures can be performed to establish the causative organism and the antibiotic sensitivities.
X-rays
How is osteomyelitis treated?
Surgical debridement of the infected bone and tissues Antibiotic therapy (6 weeks acute, 3 months chronic)
Osteomyelitis associated with prosthetic joints (e.g., a hip replacement) may require complete revision surgery to replace the prosthesis.
Antibiotic management of osteomyelitis?
Prolonged courses of antibiotics are required to treat osteomyelitis. The BNF page on osteomyelitis recommends for acute osteomyelitis:
6 weeks of flucloxacillin, possibly with rifampicin or fusidic acid added for the first 2 weeks
Alternatives to flucloxacillin are:
Clindamycin in penicillin allergy
Vancomycin or teicoplanin when treating MRSA
Chronic osteomyelitis usually requires 3 months or more of antibiotics.
What is sarcoma and what are the different types?
Sarcomas are cancers originating in the muscles, bones or other types of connective tissue. There are many subtypes of sarcoma, which vary in their histology, location and degree of malignancy.
Types of bone sarcoma include:
Osteosarcoma – the most common form of bone cancer
Chondrosarcoma – cancer originating from the cartilage
Ewing sarcoma – a form of bone and soft tissue cancer most often affecting children and young adults
Types of soft tissue sarcoma?
Rhabdomyosarcoma – originating from skeletal muscle
Leiomyosarcoma – originating from smooth muscle cancer
Liposarcoma – originating from adipose (fat) tissue
Synovial sarcoma – originating from soft tissues around the joints
Angiosarcoma – originating from the blood and lymph vessels
Kaposi’s sarcoma – cancer caused by human herpesvirus 8, most often seen in patients with end-stage HIV, causing typical red/purple raised skin lesions but also affecting other parts of the body
How does sarcoma present?
A soft tissue lump, particularly if growing, painful or large
Bone swelling
Persistent bone pain
How might you investigate sarcoma?
X-ray is the initial investigation for bony lumps or persistent pain.
Ultrasound is the initial investigation for soft tissue lumps.
CT or MRI scans may be used to visualise the lesion in more detail and look for metastatic spread (particularly a CT thorax, as sarcoma most often spreads to the lungs).
Biopsy is required to look at the histology of the cancer.
What system is used to stage sarcoma?
TNM staging system or a number system
How is sarcoma managed?
Surgery (surgical resection is the preferred treatment)
Radiotherapy
Chemotherapy
Palliative care
Where does sarcoma most commonly metastise to?
Lung
Degenerative disc disease is often related to ageing. What factors may precipitate it?
Progressive dehydration of the nucleus pulposus
Daily activities causing tears in the annulus fibrosis
Injuries or pathology resulting in instability
Including mechanical insults (such as spinal fractures), iatrogenic injuries (such as spinal surgery), or systemic metabolic processes (such as osteoporosis)
Stages of changes in degenerative disc disease?
- Dysfunction – outer annular tears and separation of the endplate, cartilage destruction, and facet synovial reaction
- Instability – disc resorption and loss of disc space height, along with facet capsular laxity, can lead to subluxation and spondylolisthesis
- Restabilisation – degenerative changes lead to osteophyte formation and canal stenosis
What is Lasègue test?
Lasègue test, also known as the straight leg raise, is used to assess for disc herniation in patients presenting with lumbago.
With the patient lying down on their back, the examiner lifts the patient’s leg while the knee is straight. The ankle can be dorsiflexed and / or the cervical spine flexed for further assessment.
A positive sign is when pain is elicited during the leg raising +/- ankle dorsiflexion or cervical spine flexion. Sensitivity and specificity have been reported at 91% and 26% respectively.
What test can be used to support the diagnosis of OA over De Quervain’s tenosynovitis in a pt with a painful wrist?
The key differentiator is the grind test. This is performed by holding the 1st proximal phalanx and metacarpophalangeal joint in examiner’s hands and forcefully pushing against trapeziometacarpal joint, while also rotating it slightly, to cause grinding motion. A positive test is one that induces pain, suggestive of osteoarthritis of the trapeziometacarpal joint.
Features of ulnar nerve injury?
Pt unable to fully extend or flex 4th and 5th fingers
Numbness in the hand which is particularly pronounced over the 4th and 5th fingers.
When the radial nerve is injured in elbow fracture what features might be present?
Pt is unable to flex or extend the elbow.
Extension of the wrist and fingers in the arm is weak.
Sensory loss over the dorsum of the hand.
Positive test in tennis elbow (epicondylitis)
Cozen’s test positive
What X ray sign is pathognomonic for a posterior shoulder dislocation?
lightbulb sign on AP view.
What type of shoulder dislocation is most common?
Anterior
Female atheletic triad?
Amennorhea
Osteoperosis
Anorexia
What is a Colles fracture?
This describes a fracture of the distal radius along the metaphysis with no articular involvement. They are the most common type of distal radius fractures.
Lateral cutaneous nerve of thigh compression
Burning thigh pain - ? meralgia paraesthetica - lateral cutaneous nerve of thigh compression
