Orthopaedics Flashcards
What is osteoarthritis?
Wear and tear in synovial joints
Imbalance between cartilage damage and chondrocyte response
What are the risk factors for osteoarthritis?
Obesity
Age
Occupation
Trauma
Female
FHx
Which joints are commonly affected in OA?
Hips
Knees
DIP hands
CMC thumb
Lumbar spine
Cervical spondylosis
What xray changes are seen in OA?
L- Loss of joint space
O- Osteophytes
S- Subarticular sclerosis (increased density bone along joint line)
S- Subchondral cysts (fluid filled holes in bone)
Outline presentation of OA
Joint pain and stiffness- Worse with activity and at end of day
Bulky, bony enlargement of joint
Restricted ROM
Crepitus on movement
Effusions (fluid) around joint
What are the hand signs in OA?
Heberden’s nodes (DIP)
Bouchard’s nodes (PIP)
Squaring at base of thumb
Weak grip
Reduced ROM
Outline diagnosis of OA
Clinical diagnosis if >45y, has typical pain associated with activity and no morning stiffness
Outline management of OA
Therapeutic exercise, weight loss, OT
1st line- Topical NSAIDs
Oral NSAIDs as required (with PPI)
Intra-articular steroid injections- Improve symptoms for up to 10wks
Joint replacement
What are the SEs of NSAIDs
GI- Gastritis and peptic ulcers
Renal- AKI and CKD
CV- HTN, HF, MI, stroke
Exacerbating asthma
What are the indications for joint replacement?
OA (most common)
Fractures
Septic arthritis
Osteonecrosis
Bone tumours
RA
What are the options for joint replacement?
Total- Replace both articular surfaces of joint
Hemiarthroplasty- Replace half joint
Partial joint resurfacing- Replace part of joint surface
Outline what occurs during joint replacement surgery in terms of anaesthetics and drugs
General anaesthetic
Prophylactic ABs
TXA
What guidance regarding VTE prophylaxis is given after joint replacement surgery?
LMWH:
28d hip
14d knee
Can also use aspirin, DOAC or anti-embolism stocking
What are the risk factors for prosthetic joint infection?
Prolonged operative time
Obesity
Diabetes
What are the symptoms of a prosthetic joint infection?
Fever
Pain
Swelling
Erythema
Increased warmth
Outline prosthetic joint infections
More likely to occur in revision surgery
Most common- Staph aureus
Outline diagnosis of prosthetic joint infection
Clinical findings
Xrays
Raised inflammatory markers
Cultures (blood or synovial fluid
Outline management of prosthetic joint infection
Repeat surgery- Joint irrigation/debridement/complete replacement
Prolonged ABs
What is a compound fracture?
Skin broken, broken bone exposed to air
What is a stable fracture?
Sections of bone remain in alignment
What is a pathological fracture?
Bone breaks due to abnormality within bone
What is a comminuted fracture?
Breaks into multiple fragments
What is a Salter-Harries fracture?
Growth plate fracture
Only occurs in children
What is a greenstick fracture?
Bone cracks on one side- Not all way through bone
More common in children
What is a buckle fracture?
Most common fracture in young children
Bone soft and flexible- Bends- Bulge in bone rather than break
What is a Colle’s fracture?
Transverse fracture of distal radius
Distal portion displaced posteriorly- Dinner fork deformity
FOOSH
Outline scaphoid fracture
Caused by FOOSH
Located at base of thumb
Tenderness in anatomical snuffbox
Has retrograde blood supply- Avascular necrosis and non-union
Outline Weber classification
Fractures of lateral malleolus
Type A- Below ankle joint- Leaves syndesmosis intact
Type B- Level of ankle joint- Syndesmosis intact/partially torn
Type C- Above ankle joint- Syndesmosis disrupted
What are the main cancers that metastasise to bones?
Po- Prostate
R- Renal
Ta- Thyroid
B- Breast
Le- Lung
What are fragility fractures?
Occur due to weakness in bone
Usually due to osteoporosis
Risk defined by FRAX score
Outline FRAX score
Risk of fragility fracture over next 10y
Uses bone mineral density- DEXA
Uses T score at hip
T >-1, BMD normal
T -1 to -2.5, BMD osteopenia
T <-2.5, BMD osteoporosis
T <-2.5 and fracture, BMD severe osteoporosis
How is the risk of fragility fracture reduced?
1st line:
Calcium and Vit D
Bisphosphonates (eg: Alendronic acid)
Denosumab- Blocks osteoclast activity
What is the MoA of bisphosphonates?
Interfere with osteoclasts and reduce their activity, preventing reabsorption of bone
What are the SEs of bisphosphonates?
Reflux and oesophageal erosions- Take on empty stomach, sit upright 30mins before eating
Atypical fractures
Osteonecrosis of jaw
Osteonecrosis external auditory canal
What imaging is used in fractures?
Xrays- 2 views required
CT scan- If xray inconclusive/further info required
How is mechanical alignment of a fracture achieved?
Closed reduction- Manipulation of limb
Open reduction- Surgery
List the possible early complications of fractures
Damage to local structures
Haemorrhage
Compartment syndrome
Fat embolism
VTE (due to immobility)
List possible long term complications of fractures
Delayed union
Malunion
Non-union
Avascular necrosis
Infection
Joint stability
Joint stiffness
Contractures
Arthritis
Chronic pain
Complex regional pain syndrome
What is a fat embolism?
Can occur following fracture of long bones
Fat globules released into circulation following fracture- Become lodged in blood vessels (eg: Pulmonary arteries)
Can cause systemic inflammatory response- Fat embolism syndrome
Outline presentation of fat embolism
24-72h after fracture
Gurd’s criteria
List Gurd’s major criteria for fat embolism
Respiratory distress
Petechial rash
Cerebral involvement
List Gurd’s minor criteria for fat embolism
Jaundice
Thrombocytopenia
Fever
Tachycardia
What is the prognosis of fat embolism?
Can lead to multiple organ failure
Supportive management and operate early to fix fracture
Mortality rate- Approx. 10%
List risk factors for hip fractures
Increasing age
Osteoporosis
Female
What is the timing for starting to operate on a hip fracture?
Within 48h
Where is the intertrochanteric line?
Between the greater and lesser trochanter
What is an intra-capsular hip fracture?
Break in femoral neck within capsule of hip joint
Affects area proximal to intertrochanteric line
Outline Garden classification
Used for intracapsular NOF fractures
Grade I- Incomplete fracture and non-displaced
Grade II- Complete fracture and non-displaced
Grade III- Partial displacement (trabeculae at angle)
Grade IV- Full displacement (trabeculae parallel)
Outline non-displaced intra-capsular fracture
Internal fixation (screws)
Intact blood supply
Outline displaced intra-capsular fractures
Replace head of femur
Disrupted blood supply
When is a total hip replacement offered?
Patients who can walk independently and fit for surgery
What is hemiarthroplasty and when is it offered?
Replace head of femur but leave acetabulum in place
Offered to patients with hip fractures who have limited mobility or sig. co-morbidities
What is an extra-capsular fracture?
Blood supply to head of femur intact- Head of femur doesn’t need replacing
Intertrochanteric and subtrochanteric fractures
Outline intertrochanteric fractures
Between lesser and greater trochanter
Dynamic hip screw
Outline subtrochanteric fractures
Distal to lesser trochanter, occurs to proximal shaft of femur
Intramedullary nail
Outline presentation of hip fracture
Pain in groin/hip, may radiate to knee
Unable to weight bear
Shortened, abducted and externally rotated
Outline imaging of hip fractures
1st line- Xray (2 views)
Disruption of Shenton’s line- NOF fracture
MRI/CT if xray negative but fracture still suspected
Outline management of hip fractures
Analgesia
Investigations
VTE prophylaxis (LMWH)
Pre-operative assessment- Bloods and ECG
Admit and surgery within 48h
Should be able to bear weight straight after surgery
What is compartment syndrome?
Abnormally increased pressure within fascial compartment- Cuts off blood flow
Can be acute/chronic
What is acute compartment syndrome?
Associated with acute injury- Bleeding/tissue swelling increases pressure
Outline presentation of compartment syndrome
Presents after acute injury
P- Pain disproportionate to injury
P- Paraesthesia
P- Pale
P- Pressure high
P- Paralysis (late and worrying feature)
Outline management of compartment syndrome
Clinical diagnosis based on signs and symptoms
Needle manometry- Measure compartment pressure
Elevate leg to heart level
Remove external dressings/bandages
Avoid hypotension
Emergency fasciotomy- Explore and debride
Outline chronic compartment syndrome
Usually associated with exertion
Pain, numbness or paraesthesia
NOT AN EMERGENCY
Diagnosis- Needle manometry
Treat- Fasciotomy
What is osteomyelitis?
Inflammation in bone and bone marrow
Usually caused by bacterial infection
Most common cause- Staph aureus
List the risk factors for osteomyelitis
Open fractures
Ortho operations
Diabetes (foot ulcers)
Peripheral artery disease
IV drug use
Immunosuppression
Outline presentation of osteomyelitis
Fever
Pain and tenderness
Erythema
Swelling
Lethargy, nausea and muscle aches
Outline investigations of osteomyelitis
Xray
MRI- Best for establishing diagnosis
Raised inflammatory markers
Blood cultures
Bone cultures
Outline xray findings of osteomyelitis
Periosteal reaction (changes to surface of bone)
Localised osteopenia (thinning of bone)
Destruction of areas of bone
Outline management of osteomyelitis
Surgical debridement
Antibiotic- 6wks flucloxacillin (can add rifampicin or fusidic acid for 1st 2wks)- Clindamycin in penicillin allergy
Which antibiotics are used to treat MRSA?
Vancomycin
Teicoplanin
List different types of bone sarcoma
Osteosarcoma- Most common
Chondrosarcoma- From cartilage
Ewing sarcoma- Bone and soft tissue cancer affecting children
List types of soft tissue sarcoma
Rhabdomyosarcoma- From skeletal muscle
Leiomyosarcoma- From smooth muscle
Liposarcoma- From adipose tissue
Synovial sarcoma- From soft tissue around joints
Angiosarcoma- From blood and lymph vessels
Kaposi’s sarcoma- Caused by HHV8- End-stage HIV- Red/purple raised skin lesions
Outline presentation of sarcoma
Soft tissue lump
Bone swelling
Persistent bone pain
Outline investigations of sarcoma
1st line for bony lumps/persistent pain)- Xray
1st line for soft tissue lumps- US
CT or MRI
Biopsy
Where is the most common site for sarcoma to metastasise to?
Lungs
Outline management of sarcoma
Surgery
Radio/chemotherapy
Palliative care
What are ganglion cysts?
Sacs of synovial fluid from tendon sheaths/joints
Outline presentation of ganglion cysts
Can appear rapidly (days) or gradually
Visible, palpable lump
Not painful
Firm and non-tender
Well-circumscribed
Transilluminates
Outline diagnosis of ganglion cysts
Clinical
US can help confirm
Outline management of ganglion cyst
Conservative
Needle aspiration
Surgical excision
Outline management of carpal tunnel syndrome
Rest and altered activities
Wrist splints to maintain normal position wrist at night (min 4wks)
Steroid injections
Surgery- Local anaesthetic- Cut flexor retinaculum
Outline nerve conduction studies used to diagnose carpal tunnel syndrome
Small electrical current applied by electrode to median nerve
Demonstrates how well signals passed through carpal tunnel along median nerve
Which special tests are used to test for carpal tunnel syndrome?
Tinel’s- Tap wrist- Numbness and paraesthesia
Phalen’s- Fully flex wrist- Numbness and paraesthesia
Outline presentation of carpal tunnel syndrome
Sensory symptoms in distribution of palmar digital cutaneous branch of median nerve affecting palmar aspects and full fingertips of:
Thumb
Index and middle finger
Lateral half of ring finger
Also motor symptoms
Symptoms worse at night- Can wake patient
List sensory symptoms of carpal tunnel syndrome
Numbness
Paraesthesia
Burning sensation
Pain
List motor symptoms of carpal tunnel syndrome
Affect thenar muscles:
Weakness of thumb movement
Weakness of grip strength
Difficulty fine movements involving thumb
Wasting of thenar muscle
Which condition is bilateral carpal tunnel syndrome associated with?
Acromegaly
List risk factors for carpal tunnel syndrome
Repetitive strain
Obesity
Perimenopause
RA
Diabetes
Acromegaly
Hypothyroidism
What is carpal tunnel syndrome?
Compression of median nerve as travels through carpal tunnel in wrist
What is Dupuytren’s contracture?
Fascia of hand thickens and tightens leading to finger contractures
Finger tightened into flexed position and cannot fully extend
List risk factors for Dupuytren’s contracture
Age
FHx- Autosomal dominant
Male
Manual labour (vibrating tools)
Diabetes
Epilepsy
Smoking and alcohol
Outline presentation of Dupuytren’s contracture
Hard nodules on palm
Skin thickening and pitting
Finger flexed, impossible to extend finger fully
Ring finger most commonly affected
Outline diagnosis of Dupuytren’s contracture
Table-top test- Place hand flat
Outline management of Dupuytren’s contracture
Conservative
Surgery- Needle fasciotomy/limited fasciectomy/dermofasciectomy
Outline management of trigger finger
Rest and analgesia
Splinting
Steroid injections
Surgery to release A1 pulley
Outline presentation of trigger finger
Painful and tender
Doesn’t move smoothly
Makes popping/clicking sound
Gets stuck in flexed position
Worse during morning and improves
List RFs for trigger finger
40-60y
Women
Diabetes
Outline management of De Quervain’s Tenosynovitis
Rest and adapting activities
Use splints to restrict movement
NSAIDs
Physio
Steroid injections
Rare- Surgery to cute extensor retinaculum
What is De Quervain’s tenosynovitis?
Swelling and inflammation of tendon sheaths in wrist
Affects:
APL tendon
EPB tendon
Type of repetitive strain injury
Pain on radial side of wrist
Mummy thumb- Pain from lifting babies in a way that stresses thumb tendons
Outline presentation of De Quervain’s tenosynovitis
Radial aspect of wrist near base of thumb
Pain, often radiating to forearm
Aching
Burning
Weakness
Numbness
Tenderness
What is Finkelstein’s test?
Used to diagnose De Quervain’s tenosynovitis
Make fist with thumb inside fingers- Pain radial aspect of wrist
What is torticollis?
Waking up with unilaterally stiff and painful neck due to muscle spasm
What are the red flags indicating cauda equina?
Saddle anaesthesia
Urinary retention
Incontinence
Bilateral neuro signs
What are the red flag indications of spinal stenosis?
Intermittent neuro claudication
What are the red flag symptoms of ankylosing spondylitis?
<40y
Gradual onset
Morning stiffness
Night time pain
What are the red flags for spinal infection?
Fever
History of IV drug use
What is the pathway of the sciatic nerve?
L4-S3 form sciatic nerve- Exits posterior pelvis through greater sciatic foramen- Down back of leg- Splits into tibial and common peroneal nerve
What is the role of the sciatic nerve?
Sensation to lateral lower leg and foot
Motor function to posterior thigh/lower leg/foot
Outline sciatica
Unilateral pain from buttock radiating down back of thigh to below knee/feet
Electric/shooting pain
Paraesthesia (pins and needles), numbness and motor weakness
What are the main causes of sciatica?
Lumbosacral nerve root compression:
Herniated disc
Spondylolisthesis
Spinal stenosis
What is bilateral sciatica a red flag for?
Cauda equina syndrome
What does localised tenderness to spine suggest?
Spinal fracture
Cancer
Outline sciatic stretch test
Diagnosis of sciatica
Lie on back with legs straight
Passive lift one leg from ankle with knee extended until limit of hip flexion reached- Dorsiflex ankle
Sciatica-type pain in buttocks/post. thigh
Symptoms improve flexing knee
Outline potential investigations of back pain
Xrays or CT scans- Fractures
Emergency MRI- Cauda equina
Ankylosing spondylitis:
CRP and ESR
Xray spine and sacrum- Bamboo
MRI spine- Bone marrow oedema
How is acute lower back pain managed?
Cauda equina- Same day referral
Ank spond- Inflammatory markers and urgent rheum
Trauma- Immobilisation, trauma unit, xrays/CT scans
Outline pain management advice for back pain
1st line- NSAIDs (ibuprofen/naproxen)
Codeine
Benzos (diazepam)- For muscle spasms (only use up to 5d)
Outline management of sciatica
Amitriptyline
Duloxetine
(NO gabapentin/pregabalin/diazepam/oral corticosteroids)
Epidural corticosteroid injections
Local anaesthetic injections
Radiofrequency denervation
Spinal decompression
What level does the spinal cord terminate?
L2/L3
Tapers into conus medullaris
What do the nerves of the cauda equina supply?
Sensation to lower limbs, perineum, bladder, rectum
Motor innervation lower limbs, anal and urethral sphincters
Parasympathetic innervation of bladder and rectum
Outline management of cauda equina syndrome
Immediate hospital admission
Emergency MRI
Lumbar decompression surgery
Outline metastatic spinal cord compression
Compresses any part of spinal cord (not just isolated to cauda equina)
Presents similarly to cauda equina syndrome
How can you tell the difference between cauda equina syndrome and metastatic spinal cord compression clinically?
CE- LMN- Reduced tone and reflexes
MSCC- UMN- Increased tone, brisk reflexes, upping plantar responses
What is spinal stenosis?
Narrowing of part of spinal canal, resulting in compression of spinal cord or nerve roots
Outline presentation of spinal stenosis
Intermittent claudication- Central spinal stenosis
Gradual onset
Lower back pain
Buttock and leg pain
Leg weakness
Symptoms absent at rest and seated, worsen with standing and walking
Outline investigations of spinal stenosis
MRI
Exclude peripheral artery disease (ankle-brachial pressure index and CT angiogram)
Outline management of spinal stenosis
Exercise and weight loss
Analgesia
Physio
Decompression surgery- Laminectomy
What is meralgia paraesthetica?
Local sensory symptoms of outer thigh caused by compression of lateral femoral cutaneous nerve
Outline function of lateral femoral cutaneous nerve
Carries only sensory signals
Innervation to upper outer thigh
Outline presentation of meralgia paraesthetica
Abnormal/loss of sensation in lateral femoral cutaneous nerve distribution
Skin of upper-outer thigh affected
Burning
Numbness
Pins and needles
Cold sensation
Hair loss
Symptoms often worse with extension of hip and improved by sitting down
Outline management of meralgia paraesthetica
Conservative:
Rest
Looser clothing
Weight loss
Physio
Medical:
Paracetamol
NSAIDs
Neuropathic analgesia (amitriptyline, gabapentin, pregabalin, duloxetine)
Surgical:
Decompression
Transection
Resection
What is trochanteric bursitis?
Inflammation of bursa over greater trochanter
Outline presentation of trochanteric bursitis
Pain localised to outer hip
Gradual onset
Worse with activity, may disrupt sleep
Pain on resisted movement
Trendelenburg- Positive
Outline management of trochanteric bursitis
Rest and ice
NSAIDs- Ibuprofen or naproxen
Physio
Steroid injections
Outline presentation of meniscal tears
Often occur during twisting movements in knee
Pop sound/sensation
Pain
Swelling
Stiffness
Restricted ROM
Locking of knee
Instability/knee giving way
Outline McMurray’s test
Used to diagnose meniscal tears
Lie supine- Passive flex knee- Internally rotate tibia and apply varus pressure- Carefully extend knee- Pain/restriction = Lateral meniscus
External rotation and valgus pressure = Medial meniscus
Outline Apley Grind test
Used to diagnose meniscal tears
Prone- Flex knee 90 degrees- Downward pressure through leg into knee- Internally/externally rotate- Pain localised to area of damage
Outline the Ottawa knee rules
Determines whether patient requires xray of knee after acute injury
> 55y
Patella tenderness
Fibular head tenderness
Cannot flex knee 90 degrees
Cannot weight bear
Outline investigations of meniscal tears
1st line- MRI
Arthroscopy
Outline management of meniscal tears
RICE
NSAIDs
Arthroscopy
What is the role of the ACL?
Stops tibia sliding forwards in relation to femur
What is the role of the PCL?
Stops tibia sliding backwards in relation to femur
Outline presentation of ACL injury
Twisting injury to knee
Pain
Swelling
Pop sound/sensation
Instability of knee joint- Tibia can move anteriorly
Outline diagnosis of ACL tear
Anterior drawer test
1st line- MRI
Arthroscopy
Outline management of ACL tear
RICE
1st line- NSAIDs
Arthroscopic surgery- New ligament formed with tendon graft
What is Osgood-Schlatter disease?
Inflammation at tibial tuberosity where patella ligament inserts
10-15y old males
Lots of minor avulsion fractures and healing causing anterior knee pain
Outline presentation of Osgood-Schlatter disease
Visible/palpable hard and tender lump at tibial tuberosity
Pain in anterior aspect of knee
Pain exacerbated by physical activity/kneeling/extension of knee
Outline management of Osgood-Schlatter disease
Reduce physical activity
Ice
NSAIDs
What is a rare complication of Osgood-Schlatter disease?
Complete avulsion fracture- Tibial tuberosity separated from rest of tibia- Requires surgery
What are the 4 boundaries of popliteal fossa?
Semimembranosus and semitendinosus
Biceps femoris
Medial head of gastrocnemius
Lateral head of gastrocnemius
Outline presentation of Baker’s cyst
Symptoms localised in popliteal fossa
Pain/discomfort
Fullness
Pressure
Palpable lump/swelling
Restricted ROM in knee
What sign is associated with BAker’s cyst?
Foucher’s sign- Lump gets smaller/disappears when knee flexed 45 degrees
Outline presentation of ruptured Baker’s cyst
Pain
Swelling
Erythema
Outline investigations of Baker’s cyst
1st line- US to rule out DVT
MRI if surgery required or to find underlying cause (eg: Meniscal tear)
Outline management of Baker’s cyst
No treatment if asymptomatic
Modified activity
NSAIDs
Physio
US-guided aspiration
Steroid injections
What is Achilles tendinopathy?
Damage, swelling, inflammation and reduced function in Achilles tendon
What are the RFs for Achilles tendinopathy?
Sports that stress Achilles
Inflammatory conditions (RA and ank spond)
Diabetes
Raised cholesterol
Fluoroquinolone ABs (ciprofloxacin)
Outline presentation of Achilles tendinitis
Gradual onset
Pain/aching in Achilles tendon on heel with activity
Stiffness
Tenderness
Swelling
Nodularity on palpation of tendon
Outline management of Achilles tendinopathy
Calf squeeze test- Tests for Achilles tendon rupture
Rest, ice and analgesia
Orthotics
Extracorporeal shock-wave therapy
Surgery to remove nodules and adhesions
AVOID steroid injections- Increase risk of rupture
Outline Achilles Tendon rupture
Sudden onset injury
Loss of connection between calf muscles and heel
List risk factors for Achilles Tendon Rupture
Sports increasing stress to Achilles (eg: Basketball, tennis, track athletes)
Increasing age
Existing Achilles tendinopathy
FHx
Fluoroquinolone ABs (Ciprofloxacin)
Systemic steroids
Outline presentation of Achilles tendon rupture
Sudden onset pain in Achilles/calf
Snapping sound/sensation
Feeling as though something has hit them in the back of the leg
In relaxed dangled position- Affected ankle dorsiflexed
Weakness of plantar flexion
Unable to stand on tiptoes on affected leg
+ve Simmonds’ calf test
Outline diagnosis of Achilles tendon rupture
US
Outline management of Achilles tendon rupture
Rest, immobilisation, ice, elevation, analgesia
VTE prophylaxis whilst leg immobilised
Non-surgical- Boot 6-12wks
Surgical- Reattach tendon, immobilise plantarflexed, slowly adjust to neutral
Outline plantar fasciitis
Inflammation of plantar fascia (attaches at calcaneus and travels along sole of foot)
Outline presentation of plantar fasciitis
Gradual onset of pain on plantar aspect of heel
Worse with pressure, walking/standing
Tenderness to palpation
Outline management of plantar fasciits
Rest, ice, NSAIDs
Steroid injections- Can be painful
Outline fat pad atrophy
Affects heel
Atrophy of fat pad can occur with age or inflammation from repetitive impacts
Local steroid injections can cause fat pad atrophy
Outline presentation of fat pad atrophy
Pain and tenderness on plantar aspect of heel
Worse with activity and walking barefoot on hard surfaces
Outline management of fat pad atrophy
Diagnosis- US thickness of fat pad
Comfortable shoes, custom insoles
Adapt activity
Weight loss if appropriate
Outline Morton’s Neuroma
Dysfunction of nerve in intermetatarsal space towards top of foot
Outline presentation of Morton’s neuroma
Exacerbated by high heels or narrow shoes
Pain at front of foot at location of lesion
Sensation of lump in shoe
Burning, numbness or ‘pins and needles’ felt in distal toes
How can you test for Morton’s neuroma?
Deep pressure causes pain
Metatarsal squeeze test causes pain
Mulder’s sign- Painful click felt when using 2 hands on either side of foot to manipulate metatarsal heads to rub neuroma
US or MRI
Outline management of Morton’s neuroma
Adapting activities
NSAIDs
Insoles
Weight loss if appropriate
Steroid injections
Radiofrequency ablation
Surgery- Excision of neuroma
Outline Halux valgus
Bunions
Bony lump created by deformity at MTP
1st metatarsal angles mdially, big toe angled laterally
MTP joint becomes inflamed and enlarged
Outline management of bunions
Diagnosis- Weight bearing xrays
Wide, comfortable shoes and analgesia
Surgery definitive
Outline frozen shoulder
Adhesive capsulitis
Middle aged diabetics
Inflammation and fibrosis in joint capsule leading to adhesions- Bind to capsule cause it to tighten and restrict movement
Outline presentation of frozen shoulder
Painful phase- Shoulder pain, worse at night
Stiff phase- Shoulder stiffness affecting active and passive movement- External rotation most affected
Thawing phase- Gradual improvement in stiffness abd return to normal
Outline supraspinatus tendinopathy
Inflammation and irritation of supraspinatus tendon
Impingement at point it passes between humeral head and acromion
Test- Empty can test
Outline acromioclavicular joint arthritis
Tenderness to palpation of AC joint
Pain worse at extremes of shoulder abduction- 170 degrees onwards when arm overhead
Positive scarf test
Outline management of frozen shoulder
NSAIDs
Intra-articular steroid injections
Hydrodilation (injecting fluid to stretch capsule)
Manipulation under anaesthesia
Arthroscopy
Outline rotator cuff tears
Occur due to acute injury (eg: FOOSH) or degenerative changes with age
What is the function of the supraspinatus?
Abducts arm
What is the function of the infraspinatus?
Externally rotates arm
What is the function of the teres minor?
Externally rotates arm
What is the function of the subscapularis?
Internally rotates arm
Outline presentation of rotator cuff tears
Shoulder pain
Weakness and pain with specific movements relating to site of tear
Difficult to get comfortable at night
Outline investigations of rotator cuff tears
Xrays- Rule out other pathologies
US or MRI scans
Outline management of rotator cuff tears
Degenerative- Conservative management
Non-surgical- Res and adapted activities, NSAIDs, physio
Surgical- Arthroscopic rotator cuff repair
What is subluxation?
Partial dislocation
What is the most common type of shoulder dislocation and how does this occur?
Anterior dislocation
Arm forced backwards whilst abducted and extended
Eg: Reaching up and trying to catch a heavy rockOutl
Outline posterior shoulder dislocations
Associated with electric shocks and seizures
Outline damage associated with shoulder dislocations
Glenoid labrum tear
Bankart lesions- Tear of anterior portion of labrum, occur with repeate dislocations
Hill-Sachs lesions- Compression fractures of posterolateral part of head of humerus- Increased risk future dislocations
Axillary nerve damage- Loss sensation of regimental patch and motor weakness deltoid and teres minor
Fractures
Rotator cuff tears
What is the apprehension test?
Assesses shoulder instability specifically in anterior direction
Positive after anterior dislocation or subluxation
Externally rotate arm- Dislocation- Patient becomes apprehensive that will dislocate
Outline investigations of shoulder dislocation
Xray- Not always required before reduction- Performed after to confirm placement and assess for fractures
MRI with contrast
Arthroscopy
What is olecranon bursitis?
Inflammation and swelling of bursa over elbow (ulna)
Student’s elbow
Outline presentation of olecranon bursitis
Young/middle aged men
Swollen, warm, tender, fluctuant
What are the features of an infected olecranon bursa?
Hot to touch
More tender
Erythema spreading to surrounding skin
Fever
Features of sepsis (tachycardia, hypotension, confusion
Outline aspiration of bursa
Pus- Infection
Straw-coloured- Infection less likely
Blood stained- Trauma/infection/inflammatory causes
Milky- Gout/pseudogout
Outline management of olecranon bursitis
Rest, ice, compression, paracetamol/NSAIDs
Protect elbow from pressure/trauma
Aspiration of fluid to relieve pressure
If infected:
Aspiration for MC&S
ABs- Flucloxacillin 1st line, clarithromycin (penicillin allergy)
Systemically unwell:
Septic 6
Outline repetitive strain injury
Umbrella term for soft tissue irritation, microtrauma, strain from repeated activities
Outline presentation of repetitive strain injuries
History of repetitive activities
Pain, exacerbated by using associated joints/muscles/tendons
Aching
Weakness
Cramping
Numbness
Outline management of repetitive strain injuries
RICE
NSAIDs
Steroid injections (in specific scenarios)
What is epicondylitis?
Inflammation at point where tendons of forearm insert into epicondyles at elbow
Repetitive strain injury
What is the function of the tendons that insert into the medial epicondyle?
Flex wrist
What is the function of tendons that insert into lateral epicondyle?
Extend wrist
Outline lateral epicondylitis
Tennis elbow
Pain and tenderness at lateral epicondyle
Weakness in grip strength
Outline medial epicondylitis
Golfer’s elbow
Pain and tenderness at medial epicondyle
Outline management of epicondylitis
Clinical diagnosis
Rest
NSAIDs
Orthotics
Steroid injections
Platelet-rich plasma (PRP) injections
Extracorporeal shockwave therapy
