Orthopaedics Flashcards
List the rotator cuff muscles and their actions?
- Supraspinatus – initiation of abduction
- Infraspinatus – external rotation
- Teres minor – external rotation
- Subscapularis – internal rotation
Shoulder red flag:
- Trauma, pain and weakness or sudden loss of ability to actively raise the arm (with or without trauma)
suspect rotator cuff tear
Shoulder red flag:
any shoulder mass or swelling?
suspect malignancy
Shoulder red flag:
red skin, painful joint, fever or person is systemically unwell?
suspect septic arthritis
Shoulder red flag:
trauma leading to loss of rotation and abnormal shape?
suspect dislocation
Shoulder red flag:
new symptoms of inflammation in several joints?
suspect inflammatory arthritis
What is impingement syndrome
This is a syndrome where the tendons of the rotator cuff (predominantly supraspinatus) are compressed in the tight subacromial space during movement producing pain
What are the main causes of impingement syndrome?
- Tendonitis (this will mainly be caused by overuse/ age – think wear and tear e.g. lots of sports and swimming)
- Subacromial bursitis (this will mainly be caused by overuse/ age – think wear and tear e.g. lots of sports and swimming)
- Acromioclavicular OA with inferior osteophyte
- A hooked acromion rotator cuff tear
Positive Hawkins kennedy test suggests?
impingement syndrome
this is pain on flexed and internally rotated shoulder
Presentation of impingement syndrome?
- Painful abduction arc
- Pain from impingement characteristically radiates to the deltoid and upper arm
- Tenderness may be felt below the lateral edge of the acromion
- Hawkins Kennedy test (IR flexed shoulder recreates pain)
- Generally, would not need any investigations
Management of impingement syndrome?
- Rest (in acute phase) and NSAIDs
- Exercise/ physio
- Subacromial injection of steroid
- Do not give more than 2 injections (only give a 2nd if actually had improvement) – risk of tendon damage
- Refer if not benefitting from treatment
- Orthopaedics can do subacromial decompression surgery
Explain what a rotator cuff tear is?
- Tendons (usually of supraspinatus) of the rotator cuff can tear with minimal or no trauma as a consequence of degenerative changes in the tendons
- e.g. a sudden jerk when on a bus holding a rail, then subsequent pain and weakness
- at least 20% of over 60 yo have asymptomatic cuff tears due to tendon degeneration
- in young people can get rotator cuff tendon tears due to significant injury .eg. shoulder dislocation but this is very uncommon
What tendon is usually involved in a rotator cuff tear?
supraspinatus
Presentation of a rotator cuff tear?
- Pain and weakness in shoulder
- May be sudden if associated with an event or gradual
- Weakness in rotator cuff muscles on examination
Rotator cuff tears can be seen on what type of imaging?
MRI or ultrasound but not XR
Management of rotator cuff tears?
- Acute rotator cuff tears by trauma should be referred to secondary care
- Optimal treatment is controversial
- Can have surgery however around a third of surgeries fail
- Many patients do well with physiotherapy to strengthen up the remaining cuff muscles which can compensate for the loss of supraspinatus
- Subacromial injection may help symptoms
What is adhesive capsulitis/ frozen shoulder?
- Disorder characterised by progressive pain and stiffness of the shoulder in patients between 40 and 60, resolving after around 18-24 months
- Aetiology is unclear – the capsule and glenohumeral ligaments become inflamed then thicken and contract
Presentation of frozen shoulder?
- Initially pain which will subside after 2-9 months
- Stiffness then follows for around 4-12 months
- The stiffness gradually thaws out over time with good recovery of shoulder motion
- The principle clinical sign is loss of external rotation (along with restriction of other movements) which can also occur in OA but this tends to affect older patients
Investigations for frozen shoulder?
- Diagnosis is clinical
- The main diagnostic test is the inability to do passive external rotation
- XR are usually only necessary if the presentation is atypical or the patient is not responding to treatment
- XR re commonly normal
- Blood tests and radiography only need to be performed if red flag shoulder symptoms are present
Management for frozen shoulder?
Consider referral to secondary care if pain and significant disability are present for more than six months despite appropriate conservative management
Best treatments are still quite unclear:
1. Analgesia – paracetamol and NSAIDs, use of transcutaneous electrical nerve stimulation machine may also be helpful
2. Encourage early activity
3. Physiotherapy with joint mobilisation combined with stretching exercises
4. Passive mobilisation and capsular stretching
5. Injection with corticosteroids can reduce pain and duration of symptoms in early stages
6. Surgical management can involve manipulation under anaesthesia and arthroscopic capsulotomy
Prognosis for frozen shoulder?
- The condition is generally self-limiting and over 90% of patients have returned to normal levels of functioning after 2 years without any treatment
- Relapses in the same shoulder are uncommon
- Some patients can have symptoms that last for several years of symptoms that never fully resolve
What are the 2 types of shoulder instability? explain?
traumatic - some shoulders after anterior dislocations do not stabilise and get recurrent subluxations and dislocations
atraumatic- idiopathic ligamentous laxity or Ehlers-Danlos or Marfans
What predicts the likelihood of further shoulder dislocations?
age at first dislocation
80% re dislocation rate in under 20s
20% re dislocation rate in over 30s
Treatment for recurrent shoulder dislocations caused by traumatic instability?
bankart repair (open or arthroscopic - reattachment of the labrum and capsule to the anterior glenoid which was torn off in first dislocation)
What is the carpal tunnel and what are its contents?
- The carpal tunnel of the wrist is formed by the carpal bones and the flexor retinaculum
- The median nerve passes through the carpal tunnel along with 9 flexor tendons (FDS and FDP to 4 digits plus FPL)
- Flexor digitorum superficialis action = flexion at the PIPs
- Flexor digitorum profundus action= flexion at the DIPs
What does the median nerve innervate?
FDP - digits index and middle
FDS all of it
FPL
Thenar muscles
all muscles of the anterior compartment of the forearm except flexor carpi ulnas and digits 4 and 5 of FDP
In terms of cutaneous innervation, it does the palmar aspect of the thumb to middle finger and all their tips on both sides
What does the median nerve innervate?
FDP - digits index and middle
FDS all of it
FPL
Thenar muscles
all muscles of the anterior compartment of the forearm except flexor carpi ulnas and digits 4 and 5 of FDP
In terms of cutaneous innervation, it does the palmar aspect of the thumb to middle finger and all their tips on both sides
What is carpal tunnel syndrome?
- Any swelling in the confines of the carpal tunnel can result in median nerve compression, the tendons are not particularly susceptible to compression, but the median nerve is
Causes/ who gets carpal tunnel syndrome?
- Most cases are idiopathic (risk factor is repetitive use e.g. typing) but can occur secondary to rheumatoid arthritis (synovitis means less space in tunnel), pregnancy, diabetes, chronic renal failure and hypothyroidism (all which cause fluid retention) and sometimes as a consequence of fractures around the wrist (esp Colles fracture)
- If occurs in pregnancy generally clears up after childbirth
- Women are up to 8 times more affected than men in general
Presentation of carpal tunnel syndrome?
- Paraesthesia in median nerve innervation (thumb, index and middle on palmar side and tips)
- Usually worse at night (because you may be flexing wrists in sleep which causes further compression)
- If more severe can get muscle wasting and weakness and patient may complain of clumsiness
- Examination may be loss of sensation or muscle wasting
- Symptoms can be reproduced by performing Tinel’s test (percussing over the median nerve) or Phalen’s test (holding the wrists hyperflexed) – note both need to be done for a while to work e.g. more than 30 secs
- Should also examine the neck to check this is not an alternative cause of symptoms (generally do different neck movements to see if reproduces pain and palpate along cervical spine)
What should you also examine apart from the hand in carpal tunnel syndrome?
cervical spine - check symptoms aren’t coming from something going on there - do movements and palpation to see if illicit symptoms
Two tests for carpal tunnel syndrome?
Tinel’s test (percussing over the median nerve) or Phalen’s test (holding the wrists hyperflexed) – note both need to be done for a while to work e.g. more than 30 secs
Investigations for carpal tunnel syndrome?
- In general you can make this is a clinical diagnosis
- May need to do additional investigations if you suspect an underlying cause
- Can consider the need for nerve conduction studies is the diagnosis is uncertain or referral for carpal tunnel surgery is planned
Management of carpal tunnel syndrome?
- Provide advice on sources of information and support
- Advice on lifestyle changes – e.. avoid repetitive hand wrist movement, arrange work place assessment if appropriate and driving safety
- Optimise management of any underlying conditions
- Trial nocturnal wrist splints e.g. spica splint
- Trial hand exercise/ mobilisation techniques
- Can also try and corticosteroid injection
- Surgical treatment involves carpal tunnel decompression, very successful surgery usually this is done if symptoms persist despite conservative treatment and/ or they are progressive and impacting on daily function
What is cubital tunnel syndrome and what can cause it?
- This involves compression of the ulnar nerve at the cubital tunnel (elbow behind the medial epicondyle) – funny bone area
- Can be caused by constricting fascial bands, sequelae to a childhood ulnar fracture, elbow dislocation, repetitive elbow flexion and extension e.g. in manual labourers can cause entrapment
Presentation of cubital tunnel syndrome?
- Paraesthesia in the ulnar 1.5 fingers
- Weakness of the ulnar nerve innervated muscles and clumsiness may be present
- e.g. interossei muscles (PAD and DAB – abduction and adduction), lumbricals (MCP flexion) and adductor pollicis
- Inspect for claw hand in extreme cases – hyperextension at MCPs and flexion of PIPs in last two fingers
- Can assess the strength of adductor pollicis with Froment’s test – get person to hold paper with thumbs – should be able to hold onto paper and keep thumb straight, if they have to bend thumb (engaging FPL) or lose paper – the test is positive and suggests weakness of adductor pollicis
- Can also do Tinnel’s test over the cubital tunnel
Claw hand is a deformity associated with what nerve being dysfunctional?
ulnar nerve at the wrist
What tests can you do for cubital tunnel syndrome?
- Can assess the strength of adductor pollicis with Froment’s test – get person to hold paper with thumbs – should be able to hold onto paper and keep thumb straight, if they have to bend thumb (engaging FPL) or lose paper – the test is positive and suggests weakness of adductor pollicis
- Can also do Tinnel’s test over the cubital tunnel
Investigations for cubital tunnel syndrome?
- Nerve conduction studies are usually performed to confirm a clinical diagnosis
- Ultrasound can be good for diagnosing the cause and site of ulnar neuropathy at the elbow
Management of cubital tunnel syndrome?
- Avoidance of aggravating factors e.g. prolonged full elbow flexion and pressure on the wrist may be sufficient in mild cases
- Nocturnal splinted at 45 degrees has been shown to be helpful
- Surgical decompression in those with persistent paraesthesia or objective weakness should be done to prevent muscle atrophy which is largely irreversible
Tennis elbow vs golfer elbow?
tennis = lateral epicondylitis = extension issue = bringing dorsal of hand towards face/ upwards
golfer = medial epicondylitis = flexion issue = bringing palm of hand down
What is tennis elbow?
lateral epicondylitis
* Repetitive strain injury in tennis players and others whom regularly perform resisted extension at the wrist
* Can occur in construction workers, using tools etc.
Presentation of tennis elbow?
- Insidious onset usually with no clear trigger
- Painful and tender lateral epicondyle
- Pain radiates down the extensor aspect of the forearm – the posterior forearm
- Exacerbation by activities that involves excessive and repetitive use of extensor muscles of the forearm – strong gripping and wrist movements
- Pain on resisted middle finger and wrist extension
- Reduced grip strength due to pain
- Preserved range of active and passive movements however
Management of tennis elbow?
- Generally self-limiting and spontaneously improves in 80-90% of people over 1-2 years
- Apply ice or heat to relieve pain
- Rest arm for 6 weeks
- Consider forearm strap/ wrist or elbow brace
- Corticosteroid injection can help in short term but not long term
- Refer to orthopaedics if uncertain diagnosis or pain persists despite 6-12 months primary care management
Explain pronation vs supination?
pronation is hand in anatomical position moved to palm facing downwards, supination is bringing hand back to anatomical position
What is golfers elbow?
- medial epicondylitis
- Repetitive strain injury in Golfers or people who regularly perform resisted flexion at wrist
- Less common than tennis elbow
What is more common tennis or golfer elbow?
tennis
What related condition can golfers elbow cause?
ulnar neuropathy
Presentation of golfers elbow?
- Pain and tenderness over medial epicondyle radiating into the forearm
- Aggravated by grasping objects and shaking hands
- Pain on resisted wrist flexion and pronation
Management of golfer elbow?
- Generally self-limiting and spontaneously improves in 80-90% of people over 1-2 years
- Apply ice or heat to relieve pain
- Rest arm for 6 weeks
- Consider forearm strap/ wrist or elbow brace
- Corticosteroid injections should not really be used as risk of hitting the ulnar nerve
- Refer to orthopaedics if uncertain diagnosis or pain persists despite 6-12 months primary care management
Steroid injection in golfer vs tennis elbow?
steroid injection generally only helps pain - not particularly helpful long term and kind of controversial over a good thing to do or not
shouldn’t do it in golfer elbow because risk of damaging the ulnar nerve
Steroid injection in golfer vs tennis elbow?
steroid injection generally only helps pain - not particularly helpful long term and kind of controversial over a good thing to do or not
shouldn’t do it in golfer elbow because risk of damaging the ulnar nerve
Bony tenderness over either malleolus and inability to weight bear
need ankle xr ?ankle fracture
What is dupuytrens contracture?
- Thickening and contracture of the subdermal fascia leading to fixed flexion deformity of the fingers
- The pathology is in the palmar fascia not the tendon
- There is the production of abnormal collagen, type 3 as opposed to type 1
In Dupuytrens contracture there is production of abnormal _____
collagen - type 3 as opposes to type 1
Pathology of dupuytrens contracture?
- It is a form of superficial fibromatoses
- Fibromatoses are basically fibrous overgrowth, kind of on the spectrum of benign and malignant because don’t really know what causes them and they are infiltrative but don’t metastasise
- You can get deep fibromatoses in the abdomen
What is Peyronies disease?
equivalent of dupuytrens contracture but on the penis
Aetiology/ risk factors for dupuytrens contracture?
- Not fully understood why this condition develops
- Tends to be more in males than females
- There is thought to be a genetic component and then a trigger e.g. alcohol, cirrhosis, smoking, epilepsy medication or trauma etc.
Presentation of dupuytrens contracture?
- Painless gradual progression where the fixed flexion deformity of the fingers increases
- The skin of the hand may be adherent to the diseased fascia and puckered, palpable nodules may be present
- Contractures most commonly affect the ring and little finger
- About half of people have bilateral involvement
Treatment of dupuytrens contracture?
- Mild contractures may be tolerated by patients but surgery is offered if the disease is interfering with function
- Surgical options include: fasciectomy (remove diseased tissue), fasciotomy (division of the cords) or amputation if severe
- Disease can recur post surgery
Explain what trigger finger is and how it presents?
- Tendonitis of a flexor tendon to a digit can result in nodular enlargement of the affected tendon, usually distal to a fascial pulley over the metacarpal neck
- Movement of the finger produces a clicking sensation as this nodule catches on and then passes underneath the pulley
- This sensation may be painful and the finger may lock in a flexed position as the nodule passes under the pulley but cannot go back through on extension
- The patient may have to forcibly manipulate the finger to regain extension, usually with pain
What are the most commonly affected fingers in trigger finger?
middle and ring
Management of trigger finger?
- In most cases injection of steroid around the tendon within the sheath will relieve symptoms
- Surgery can be offered in recurrent or persistent cases
Explain what tenosynovitis is?
- The finger flexor tendons run through synovial sheaths and under loops that hold them in place
- Tenosynovitis = inflammation of the synovial sheaths lining the tendons
Causes of tenosynovitis?
- Causes of tenosynovitis include repetitive strain sort injury or inflammation due to inflammatory arthritis e.g. rheumatoid arthritis
What is De Quervains tenosynovitis and how does it present?
- De Quervains tenosynovitis is a specific type involving the tendons used to straighten and extend the thumb
- There is local tenderness and pain at the styloid which is worsened by flexing the thumb into the palm
In tenosynovitis the tendon sheaths are often ____
palpable
In tenosynovitis the tendon sheaths are often ____
palpable
Management of tenosynovitis?
- Resting, splinting and NSAIDs may help
- Local corticosteroids injected alongside the tendon under low pressure may help
- Occasionally surgery may be needed if symptoms persist
What is a ganglion cyst?
- Common mucinous filled cysts found adjacent to a tendon or synovial fluid
- In some cases they occur after injury but in most there is no common cause
Presentation of a ganglion cyst?
- Most common in the hand (DIP joint) and wrist (dorsal or volar)
- They can also occur in the foot and ankle as well as the knee (Baker’s cyst)
- Can cause localised pain and irritation, however might not
- Main issue is cosmetic
- In some people they are intermittent and come or go or completely resolve with no treatment
- The cysts are firm, smooth and rubbery and should transilluminate
- Generally, don’t need any investigations and can be diagnosed from examination
Management of a ganglion cyst?
- Cosmetic surgery cannot be done on NHS- also swapping lump for a scar – so is patient better off? Scars can actually remain tender and cysts can also recur
- Needle aspiration may be attempted but recurrence is common after this treatment
- If swelling is causing localised discomfort surgical excision may be required
Humeral neck fracture: mechanism, fracture, management?
- Mechanism: low energy in osteoporosis FOOSH or fall onto shoulder
- Fracture: more commonly surgical neck vs anatomical neck, medial displacement of shaft due to pull of pectoralis major muscle
- Management: minimally displacement can be treated conservatively with a sling, most displacement will resolve when muscle spasm relaxes but in persistent displacement can do internal fixation
Anterior shoulder dislocation? mechanism, clinical presentation, complications, management?
- This is much more common than posterior shoulder dislocations
- Mechanism: excessive ER or fall onto back of shoulder
- Clinical presentation: loss of symmetry with loss of roundness of shoulder, arm adducted and supported by other arm
- Complications: recurrent dislocations, damage to axillary nerve (check the badge patch sensation), axillary artery and other nerves can be compressed/ stretched
- Management: closed reduction under sedation/ anaesthesia with neurovascular assessment before and after, sling for 2-3 weeks, then physio
Posterior shoulder dislocation, mechanism, clinical presentation, management?
- Mechanism: posterior force on adducted IR arm
- Clinical Presentation: can palpate humeral head posteriorly, less obvious on XR – looking for lightbulb sign
- Management: closed reduction under sedation/ anaesthesia with neurovascular assessment before and after, sling for 2-3 weeks, then physio
ACJ Injuries, mechanism, clinical presentation, management?
- Mechanism: fall onto point of shoulder, common sporting injury, may sprain, sublux or dislocate
- Clinical presentation: swelling, bruising, prominent clavicle
- Management: most managed conservatively with a sling followed by physio, surgery if chronic pain
Humeral shaft fracture, mechanism, complications, management?
- Mechanism: Direct trauma in RTA, or fall without twisting injury
- Complications: damage to radial nerve (presents with wrist drop and loss of sensation in 1st dorsal web space)
- Management: most treated non-operatively with functional humeral brace, in polytrauma might do internal fixations, non-unions require plating and bone grafting
Fracture of ulnar shaft/ nightstick mechanism, management?
- Mechanism: direct blow to ulnar (e.g. someone being hit with a nightstick!)
- Management: most cases are treated with conservative management
Oleocranon fracture, mechanism and management?
- Mechanism: fall onto point of elbow with contraction of triceps muscle
- Management: ORIF
Fracture of both radius and ulna, mechanism, management?
- Mechanism: Direct blow or FOOSH with forearm pronated (palm to ground)
- Management: these fractures are highly unstable, anatomical reduction is required to maximise function and prevent deformity
Monteggia fracture dislocation is_________
Fracture of the ulna with dislocation of the radial head at the elbow
Monteggia fracture dislocation, mechanism, what is it and management?
- Manchester United – at the elbow
- Mechanism: direct blow to posterior ulna, hyperpronated force on an outstretched arm
- What is it: Fracture of the ulna with dislocation of the radial head at the elbow
- Management: ORIF
Galeazzi fracture dislocation is ________
Fracture of the radius with dislocation of the ulna at the distal radioulnar joint
Galeazzi fracture dislocation mechanism, what is it, management?
- Glasgow Rangers – at the wrist
- Mechanism: FOOSH with pronation/ supination of the wrist
- What is it: Fracture of the radius with dislocation of the ulna at the distal radioulnar joint
- Management: ORIF
Dinner fork deformity?
colles fracture
Colles fracture, mechanism, what is it/ appearance, complications, management?
- Mechanism: FOOSH
- What is it/ appearance: extra-articular fracture of the distal radius within an inch of the articular surface with dorsal angulation/ displacement, dinner fork deformity
- Complications: median nerve compression from stretch of nerve or bleeding into a carpal tunnel
- Management: minimally displaced can be splinted, if more angulation correct by manipulation, if comminution or feels unstable may then need ORIF
Smith’s fracture, mechanism, what is it, management?
- Mechanism: fall onto back of flexed wrist
- What is it: extra-articular fracture of distal radius with volar angulation
- Management: all highly unstable and need ORIF
Barton’s fracture, mechanism, what is it, management?
- Mechanism: fall onto back of flexed wrist
- What is it: intra-articular fractures of the distal radius involving the dorsal or volar rim, can be classed as Barton’s with dorsal or volar angulation
- Management: ORIF
Scaphoid fracture, mechanism, clinical picture, difficulties, management and complications?
- Mechanism: FOOSH
- Clinical Picture: tenderness in the anatomical snuffbox and on compressing the thumb metacarpal
- Difficulties: it can be difficult to visualise these on CR and 4 views are taken if scaphoid fracture is suspected, around 5% of scaphoid fractures are not visible on initial XR but show up on radiographs 2 weeks later after resorption of the fracture ends as the first stage of fracture healing – IMPORTANT – if scaphoid fracture is suspected clinically but the XR fails to demonstrate a fracture, the wrist is still splinted and further assessment arranged for 2 weeks
- Management: undisplaced fractures are usually treated with plaster cast for 6-12 weeks
- Complications: scaphoid fractures are prone to non-union due to synovial fluid inhibiting fracture healing and AVN due to weak blood supply, AVN once established is difficult to treat and if patients are symptomatic, they may require partial or total wrist fusion, Non-unions, and displaced fractures may undergo surgery
Metacarpal and phalangeal fractures are mainly treated with?
neighbour strapping
What is bursitis and what bursa are most commonly affected?
- Inflammation of the bursa which are small sacs (that contain synovial fluid) located between muscles, tendons and bone structure
- Inflammation of bursa results in an increased production of synovial fluid, this causes enlargement of the bursa resulting in friction during movement which is what causes pain
- The most commonly affected bursas are: subacromial, oleocranon, trochanteric, prepatellar, infrapatellar
Causes of bursitis?
- Can be due to an autoimmune disorder which causes more of a chronic bursitis
- Can be due to overuse or trauma which causes a more acute course
- Can also get gout or septic bursitis – these again cause a more acute course
Presentation of bursitis?
- Joint pain, stiffness of joints, surrounding skin red
- In acute bursitis there is tenderness and pain on activation of the muscles adjacent to the inflamed bursa
- In chronic bursitis there is swelling with minimal pain
Investigations for bursitis?
- Can be diagnosed clinically
- But could do US or MRI to confirm
- And can do blood tests or analysis from fluid aspiration if worried about underlying cause
Management of bursitis?
- NSAIDs
- Can do steroid injection or local anaesthetics
- In septic bursitis give antibiotics
- In chronic/ recurrent can do surgical excision
Give brief overview of knee anatomy
extensor mechanism of the knee - quadriceps muscle, then quadriceps tendon which attaches to the patella, the patella which has the patella ligament/ tendon (called tendon but is bone to bone so really a ligament) that attaches the patella to the tibia
also have other supported structures: ACL and PCL which are crossing over ligaments in the middle, medial and lateral collaterals which sit either side, medial and lateral menisci
ACL Rupture, mechanism, clinical pictures, complications, management?
- Mechanism: high rotatory force on a planted foot e.g. skiing injury, feel a pop
- Clinical picture: pain, rotatory instability, knee gives way on turning, knee swelling, positive Lachmans and anterior drawer test
- Complications/ Prognosis: 1/3 will compensate well and be able to take part in all activity, 1/3 will manage by avoiding certain activities, 1/3 will do poorly
- Management: primary repair is not possible and have to do reconstruction using tendon graft with intensive rehab, can choose not to have surgery depending on level of function you want back
PCL rupture, mechanism, clinical picture, management?
- Mechanism: direct blow to anterior tibia with knee flexed e.g. RTA or hyperextension of tibia
- Clinical picture: pain, swelling from effusion, trouble going down stairs and instability in knee
- Management: only those with severe laxity and recurrent instability with frequent hyperextension or feeling unstable descending stairs are considered for surgical reconstruction
Meniscal tear, mechanism, clinical picture, management?
- Mechanism: twisting injury, often a sports injury, can also get degenerate tears with older age
- Clinical picture: localises pain to medial (majority) or lateral joint line and an effusion develops by the following day, complains of pain and has mechanical symptoms such as a catching sensation or locking where there is difficulty in straightening the knee, may feel knees about to give way if fragment caught in knee, bucket handle tears cause full mechanical block to knee extension, stein man test positive
- Management: meniscus only has blood supply to outer third so limited healing potential, surgery should only be attempted in young people with tears to this outer third, most meniscus tears are not suitable for repair, whilst they do not heal pain and inflammation do settle, steroid injections may help in short term, if pain does not settle then can do arthroscopic menisectomy
MCL rupture, mechanism, clinical picture, management?
- Mechanism: valgus stress e.g. rugby tackle from the side
- Clinical picture: laxity and pain on valgus stress with tenderness over the origin or insertion of the MCL
- Management: these are common but heal generally well, acute tears with a hinged knee brace, chronic MCL instability can be treated with MCL tightening (advancement) or reconstruction with a tendon graft
LCL rupture, mechanism, clinical picture, management?
- Mechanism: varus stress injury (may also damage PCL)
- Clinical picture: pain and laxity on varus stress, instability on rotational movement
- Management: surgical repair needed
knee dislocation, mechanism, clinical picture, complications, management?
- Mechanism: twisting injury (if lateral which is most common)
- Clinical picture: almost always dislocates laterally and then usually it has already relocated, medial pain and effusion, patella apprehension test positive
- Complications: high incidence of neurovascular injury, should be reduced as an emergency and may require external fixation for temporary stabalisation, need to watch for any issues with circulation to foot
- Management: usually require multiple ligament reconstruction
Difference between effusion in ACL vs meniscus injury?
ACL appears straight away and is a big effusion, meniscus is usually slow developing effusion over hours/ a day
What is the unhappy triad knee injury?
- Unhappy triad = rupture of ACL, medial meniscus and medial collateral ligament
Steroid injections into a tendon risk _____
tendon rupture
Extensor mechanism rupture of the knee, mechanism, clinical picture and management?
- Mechanism: the patellar tendon or quadriceps tendon can rupture with rapid contractile force which can occur after lifting a heavy weight, after a fall or spontaneously in a degenerate tendon, patellar tendon rupture tends to in < 40 and quadriceps tendon rupture in > 40
- Clinical picture: unable to do straight leg raise, usually have obvious palpable gap in extensor mechanism, can use US if need confirmation
- Management: treatment of complete and substantial partial tears is surgical with tendon to tendon repair or reattachment of the tendon to the patella
Describe patellar instability?
- Occurs after dislocation
- Risk of recurrent instability decreases with age and physiotherapy to strengthen the quadriceps may help
- Risk of recurrent dislocation after first time dislocation is around 10%
All ankle fractures need _______
prompts reduced to remove pressure on overlying skin and reduce risk of subsequent necrosis
Diabetes is a risk factor for _____
frozen shoulder
Describe pelvic lateral compression fracture
mechanism: force coming from the side
- Occurs with side impact where one half of the pelvis is displaced medially
- Fractures through the pubic rami or ischium are accompanied by a sacral compression fracture or SI joint disruption
Describe pelvic vertical shear fracture?
mechanism: force coming from below
- This occurs due to axial force on one hemipelvis e.g. a fall from height and the whole hemipelvis is displaced superiorly
- The sacral nerve roots and lumbosacral plexus are at high risk of injury and major haemorrhage may occur
- The leg on the affected side will appear shorter
Describe pelvic anteroposterior compression fracture?
mechanism: force coming from in front
- This occurs due to anterior to posterior force and can result in wide disruption to the pubic symphysis with the pelvis opening up (open book pelvic fracture)
- Substantial bleeding from torn vessels can occur and pelvic volume can increase substantially before tamponade and clotting will occur
Mechanism of most hip fractures?
Generally osteoporosis related in the elderly
Presentation of hip fracture?
unable to weight bear, minimum movement of hip, leg may be shortened and externally rotated (because iliopsoas is unopposed)
Investigations for a hip fracture?
x-ray initially, if XR doesn’t show fracture but clinically suspicious can do a CT or MRI
What is Shenton’s line?
can be used when looking to see if hip fracture on XR
medial edge of femoral neck to anterior edge of superior pubic ramus (loss of contour is sign of fractured neck of femur)
Why is it important to determine whether hip fracture is intra or extra capsular?
intracapsular fractures can disrupt blood supply to the femoral head which can cause AVN and non-union - so need to do a joint replacement - management different for extracapsular fractures
Hip fracture Management?
Intracapsular, high functioning, displaced fracture?
total hip replacement
Hip fracture management?
Intracapsular, high functioning, undisplaced fracture?
cannulated hip screws
Hip fracture management?
intracapsular, low functioning?
hemi-arthroplasty
Hip fracture management?
extra capsular, intertrochanteric?
dynamic hip screw
Hip fracture management?
extracapsular, subtrochanteric?
intramedullary nail
Mechanism of femoral shaft injuries?
These are usually high energy injuries (hence there is substantial risk of concomitant fracture elsewhere)
Complications/ risks in femoral shaft fracture
likely to bleed a lot (haemorrhage)
risk of fat embolism
Initial and definitive management of femoral shaft fracture?
- Initial management following ABCDE is femoral nerve block and Thomas splint to immobilise
- Definitive management is with surgery
Why are open fractures not uncommon with the tibia?
tibial shaft is subcutaneous
Commonest cause of compartment syndrome?
tibial fractures
Criteria for suspected ankle fracture?
ottawa - essentially bony tenderness and inability to weight bear
Management of ankle fractures?
- If there is only an isolated distal fibular fracture this is stable and can be managed with a cast or splint
- If deltoid ligament has ruptured or medial fracture this is unstable and needs surgery
- Ankle fractures can be associated with substantial soft tissue swelling and often need to delay the surgery to allow soft tissues to settle before operating (1-2 weeks)
What is common site for metatarsal stress fracture?
2nd metatarsal
Define osteomyelitis?
- Inflammation of the bone and medullary cavity, usually in long bones or vertebra, can be acute or chronic
Risk factors/ who tends to get osteomyelitis?
- Haematogenous spread in children, PWID or elderly with lines in
- diabetics may get osteomyelitis in their feet if have ulcers
- Staph A is most common cause
- Those with sickle cell disease may get salmonella
Presentation of osteomyelitis?
- Site is red, hot, swollen and painful
- May be loss of function
- May have a fever
Examination you can do for osteomyelitis?
- On examination can do probe to bone test – through ulcerated skin can you feel the bone with a blunt instrument
Investigations for osteomyelitis?
- XR to screen for acute and chronic osteomyelitis
- Then MRI and CT can help make diagnosis and decide treatment
- Usually confirm with a bone biopsy and should try take this before starting empirical antibiotics
Management for osteomyelitis?
- Often need surgery to remove infected tissue, drain and debride as antibiotics cant work on the walled off necrotic centres
- 6 weeks antibiotics – generally going to be flucloxacillin as Staph A most likely cause
Cause of septic arthritis and pathogens?
- Can be caused by direct invasion, blood stream infection or less commonly from an infectious focus from cellulitis or spread from osteomyelitis
Pathogens – usually bacterial
* Staph A
* Streptococci
* Only get staph epi if related to a prosthetic joint
* Neisseria gonorrhoea if sexually active
Presentation of septic arthritis?
- Septic arthritis is a medical emergency
- Joint is red, hot, painful and swollen, will be immobile
Investigations for septic arthritis?
- Aspirate joint and send fluid to micro, blood cultures, swabs, must check for crystals
Management for septic arthritis?
- Antibiotics – likely going to be flucloxacillin
What is important to protect the skin in an ankle fracture?
closed reduction
What is important in rib fractures?
adequate analgesia to ensure breathing is not affected by pain, inadequate ventilation could result in chest infections
Most common cause of heel pain in adults?
planter fasciitis
in a buckle fracture there is
bulging of the growth plate
what is plantar fasciitis?
- Self limiting repetitive stress/ overload or degenerative condition of the foot
Symptoms of plantar fasciitis?
- Pain walking at origin of plantar aponeurosis with localised tenderness on palpation of this site
- Common cause of heel pain
risk factors for plantar fasciitis?
- Diabetes, obesity and frequent walking on hard floors with no cushioning may be causative factors as well as degeneration with age
Management of plantar fasciitis?
- Rest, Achilles and plantar stretching may help
- Steroid injections can help
- Surgery is controversial
- Symptoms can take up to 2 years to resolve
Explain what developmental dysplasia of the hip is?
- Acetabulum (socket) and femoral head misaligned – typically present at birth
- Involves dislocation or subluxation of the femoral head during the perinatal period which affects subsequent development
- Because the femoral head and acetabulum aren’t in contact they grow out with proportion
Risk factors for DDH?
- More common in left hip but can be bilateral
- Breech position
- First borns
- Positive family history
- Down’s syndrome and other congenital conditions
Presentation of DDH?
- Dislocated hips tend to present early (2-3) but unstable present later
- In babies signs include shortening of one leg, asymmetric groin/ thigh skin creases and positive Ortolani or Barlow test
- If not picked up when a baby signs will be present when child starts to walk, may walk with a limp and waddling gait
- Initially it is not painful but will develop pain
- Those with DDH that go into adulthood will develop osteoarthritis of the hip
Describe the ortolani and barlow tests?
- Ortolani Test: reduction of a dislocated hip, as hip is abducted there is a clunk as it is pushed back into the socket, when adducted the hip dislocates again
- Barlow Test: dislocation of the hip, hip is adducted and backward pressure applied if positive the hip subluxates and glides off, if dislocating there is a sudden loss of resistance
Investigations for DDH?
- Positive Ortolani or Barlow in babies requires further evaluation with ultrasound where may see a dislocated hip, unstable hip or shallow acetabulum
- In children older than 4.5 months XRs are more useful
- CT and MRI may also be required
Management for DDH?
- Early diagnosis is key to success of treatment
- Mild cases can be closely observed
- Persistent dislocation or unstable hips in children under 1.5 years are reduced with a Pavlik harness which keeps hips flexed and abducted thus maintaining reduction
- In children with persistent dislocation over 1.5 years reduction is more likely to be required by surgery as acetabulum likely to be shallow, this has poorer prognosis
Transient synovitis vs septic arthritis?
- Transient synovitis = self limiting inflammation of the synovium of the joint commonly the hip
- Commonly occurs after URTI although sometimes no cause is found
- Very common cause of hip pain in children however need to exclude septic arthritis, perthes disease, arthritis and SUFE
- Presents with limp or reluctance to weight bear and may have restricted ROM but not as severe as septic arthritis
- Will not be systemically unwell
- Usually resolves in a few weeks with rest and NSAIDs
What is SUFE?
- Condition where the femoral head epiphysis (bit above the growth plate that grows) slips inferiorly in relation to the femoral neck
Who tends to get SUFE?
- It occurs because the growth plate is not strong enough to support body weight so the epiphysis slips due to strain
- Mainly affects overweight pre-pubertal adolescent boys whereas girls are less commonly affected
- Renal disease or hypothyroidism may predispose to SUFE
Presentation of SUFE?
- Pain and lump
- Pain can be felt in the groin or knee or thugh
- Loss of hip internal rotation is predominant sign followed by loss of abduction
Investigations for SUFE?
- XR is main investigation (frog leg lateral XR)
- Management
- Generally need urgent surgery to pin the femoral head and prevent further slip
- More the slip the worse the prognosis
What is Perthes disease?
- Idiopathic osteochondritis of the femoral head (AVN)
- The femoral head transiently loses blood supply resulting in necrosis and subsequent abnormal growth
Who tends to get perthes disease?
- Usually occurs between ages 4-9
- More common in very active boys of short stature
Presentation of perthes disease?
- Pain and limp
- Most cases unilateral
- Loss of internal rotation is usually first clinical sign followed by loss of abduction and later on positive Trendelenberg from gluteal weakness
Investigation for perthes disease?
xr
Management for perthes disease?
- Restriction of activities and weight bearing until ossification complete
- NSAIDs
- Can do operative management but can be controversial whether these are helpful
