Orthopaedics Flashcards

1
Q

What is osteoarthritis?

A

Wear and tear in synovial joints
Imbalance between cartilage damage and chondrocyte response

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2
Q

What are the risk factors for osteoarthritis?

A

Obesity
Age
Occupation
Trauma
Female
FHx

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3
Q

Which joints are commonly affected in OA?

A

Hips
Knees
DIP hands
CMC thumb
Lumbar spine
Cervical spondylosis

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4
Q

What xray changes are seen in OA?

A

L- Loss of joint space
O- Osteophytes
S- Subarticular sclerosis (increased density bone along joint line)
S- Subchondral cysts (fluid filled holes in bone)

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5
Q

Outline presentation of OA

A

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

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6
Q

What are the hand signs in OA?

A

Heberden’s nodes (DIP)
Bouchard’s nodes (PIP)
Squaring at base of thumb
Weak grip
Reduced ROM

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7
Q

Outline diagnosis of OA

A

Clinical diagnosis if >45y, has typical pain associated with activity and no morning stiffness

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8
Q

Outline management of OA

A

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

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9
Q

What are the SEs of NSAIDs

A

GI- Gastritis and peptic ulcers
Renal- AKI and CKD
CV- HTN, HF, MI, stroke
Exacerbating asthma

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10
Q

What are the indications for joint replacement?

A

OA (most common)
Fractures
Septic arthritis
Osteonecrosis
Bone tumours
RA

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11
Q

What are the options for joint replacement?

A

Total- Replace both articular surfaces of joint
Hemiarthroplasty- Replace half joint
Partial joint resurfacing- Replace part of joint surface

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12
Q

Outline what occurs during joint replacement surgery in terms of anaesthetics and drugs

A

General anaesthetic
Prophylactic ABs
TXA

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13
Q

What guidance regarding VTE prophylaxis is given after joint replacement surgery?

A

LMWH:
28d hip
14d knee

Can also use aspirin, DOAC or anti-embolism stocking

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14
Q

What are the risk factors for prosthetic joint infection?

A

Prolonged operative time
Obesity
Diabetes

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15
Q

What are the symptoms of a prosthetic joint infection?

A

Fever
Pain
Swelling
Erythema
Increased warmth

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16
Q

Outline prosthetic joint infections

A

More likely to occur in revision surgery
Most common- Staph aureus

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17
Q

Outline diagnosis of prosthetic joint infection

A

Clinical findings
Xrays
Raised inflammatory markers
Cultures (blood or synovial fluid

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18
Q

Outline management of prosthetic joint infection

A

Repeat surgery- Joint irrigation/debridement/complete replacement
Prolonged ABs

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19
Q

What is a compound fracture?

A

Skin broken, broken bone exposed to air

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20
Q

What is a stable fracture?

A

Sections of bone remain in alignment

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21
Q

What is a pathological fracture?

A

Bone breaks due to abnormality within bone

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22
Q

What is a comminuted fracture?

A

Breaks into multiple fragments

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23
Q

What is a Salter-Harries fracture?

A

Growth plate fracture
Only occurs in children

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24
Q

What is a greenstick fracture?

A

Bone cracks on one side- Not all way through bone
More common in children

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25
What is a buckle fracture?
Most common fracture in young children Bone soft and flexible- Bends- Bulge in bone rather than break
26
What is a Colle's fracture?
Transverse fracture of distal radius Distal portion displaced posteriorly- Dinner fork deformity FOOSH
27
Outline scaphoid fracture
Caused by FOOSH Located at base of thumb Tenderness in anatomical snuffbox Has retrograde blood supply- Avascular necrosis and non-union
28
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
29
What are the main cancers that metastasise to bones?
Po- Prostate R- Renal Ta- Thyroid B- Breast Le- Lung
30
What are fragility fractures?
Occur due to weakness in bone Usually due to osteoporosis Risk defined by FRAX score
31
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
32
How is the risk of fragility fracture reduced?
1st line: Calcium and Vit D Bisphosphonates (eg: Alendronic acid) Denosumab- Blocks osteoclast activity
33
What is the MoA of bisphosphonates?
Interfere with osteoclasts and reduce their activity, preventing reabsorption of bone
34
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
35
What imaging is used in fractures?
Xrays- 2 views required CT scan- If xray inconclusive/further info required
36
How is mechanical alignment of a fracture achieved?
Closed reduction- Manipulation of limb Open reduction- Surgery
37
List the possible early complications of fractures
Damage to local structures Haemorrhage Compartment syndrome Fat embolism VTE (due to immobility)
38
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
39
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
40
Outline presentation of fat embolism
24-72h after fracture Gurd's criteria
41
List Gurd's major criteria for fat embolism
Respiratory distress Petechial rash Cerebral involvement
42
List Gurd's minor criteria for fat embolism
Jaundice Thrombocytopenia Fever Tachycardia
43
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%
44
List risk factors for hip fractures
Increasing age Osteoporosis Female
45
What is the timing for starting to operate on a hip fracture?
Within 48h
46
Where is the intertrochanteric line?
Between the greater and lesser trochanter
47
What is an intra-capsular hip fracture?
Break in femoral neck within capsule of hip joint Affects area proximal to intertrochanteric line
48
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)
49
Outline non-displaced intra-capsular fracture
Internal fixation (screws) Intact blood supply
50
Outline displaced intra-capsular fractures
Replace head of femur Disrupted blood supply
51
When is a total hip replacement offered?
Patients who can walk independently and fit for surgery
51
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
52
What is an extra-capsular fracture?
Blood supply to head of femur intact- Head of femur doesn't need replacing Intertrochanteric and subtrochanteric fractures
53
Outline intertrochanteric fractures
Between lesser and greater trochanter Dynamic hip screw
54
Outline subtrochanteric fractures
Distal to lesser trochanter, occurs to proximal shaft of femur Intramedullary nail
55
Outline presentation of hip fracture
Pain in groin/hip, may radiate to knee Unable to weight bear Shortened, abducted and externally rotated
56
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
57
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
58
What is compartment syndrome?
Abnormally increased pressure within fascial compartment- Cuts off blood flow Can be acute/chronic
59
What is acute compartment syndrome?
Associated with acute injury- Bleeding/tissue swelling increases pressure
60
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)
61
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
62
Outline chronic compartment syndrome
Usually associated with exertion Pain, numbness or paraesthesia NOT AN EMERGENCY Diagnosis- Needle manometry Treat- Fasciotomy
63
What is osteomyelitis?
Inflammation in bone and bone marrow Usually caused by bacterial infection Most common cause- Staph aureus
64
List the risk factors for osteomyelitis
Open fractures Ortho operations Diabetes (foot ulcers) Peripheral artery disease IV drug use Immunosuppression
65
Outline presentation of osteomyelitis
Fever Pain and tenderness Erythema Swelling Lethargy, nausea and muscle aches
66
Outline investigations of osteomyelitis
Xray MRI- Best for establishing diagnosis Raised inflammatory markers Blood cultures Bone cultures
67
Outline xray findings of osteomyelitis
Periosteal reaction (changes to surface of bone) Localised osteopenia (thinning of bone) Destruction of areas of bone
68
Outline management of osteomyelitis
Surgical debridement Antibiotic- 6wks flucloxacillin (can add rifampicin or fusidic acid for 1st 2wks)- Clindamycin in penicillin allergy
69
Which antibiotics are used to treat MRSA?
Vancomycin Teicoplanin
70
List different types of bone sarcoma
Osteosarcoma- Most common Chondrosarcoma- From cartilage Ewing sarcoma- Bone and soft tissue cancer affecting children
71
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
72
Outline presentation of sarcoma
Soft tissue lump Bone swelling Persistent bone pain
73
Outline investigations of sarcoma
1st line for bony lumps/persistent pain)- Xray 1st line for soft tissue lumps- US CT or MRI Biopsy
74
Where is the most common site for sarcoma to metastasise to?
Lungs
75
Outline management of sarcoma
Surgery Radio/chemotherapy Palliative care
76
What are ganglion cysts?
Sacs of synovial fluid from tendon sheaths/joints
77
Outline presentation of ganglion cysts
Can appear rapidly (days) or gradually Visible, palpable lump Not painful Firm and non-tender Well-circumscribed Transilluminates
78
Outline diagnosis of ganglion cysts
Clinical US can help confirm
79
Outline management of ganglion cyst
Conservative Needle aspiration Surgical excision
80
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
81
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
82
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
83
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
84
List sensory symptoms of carpal tunnel syndrome
Numbness Paraesthesia Burning sensation Pain
85
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
86
Which condition is bilateral carpal tunnel syndrome associated with?
Acromegaly
87
List risk factors for carpal tunnel syndrome
Repetitive strain Obesity Perimenopause RA Diabetes Acromegaly Hypothyroidism
88
What is carpal tunnel syndrome?
Compression of median nerve as travels through carpal tunnel in wrist
89
What is Dupuytren's contracture?
Fascia of hand thickens and tightens leading to finger contractures Finger tightened into flexed position and cannot fully extend
90
List risk factors for Dupuytren's contracture
Age FHx- Autosomal dominant Male Manual labour (vibrating tools) Diabetes Epilepsy Smoking and alcohol
91
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
92
Outline diagnosis of Dupuytren's contracture
Table-top test- Place hand flat
93
Outline management of Dupuytren's contracture
Conservative Surgery- Needle fasciotomy/limited fasciectomy/dermofasciectomy
94
Outline management of trigger finger
Rest and analgesia Splinting Steroid injections Surgery to release A1 pulley
95
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
96
List RFs for trigger finger
40-60y Women Diabetes
96
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
97
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
98
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
99
What is Finkelstein's test?
Used to diagnose De Quervain's tenosynovitis Make fist with thumb inside fingers- Pain radial aspect of wrist
100
What is torticollis?
Waking up with unilaterally stiff and painful neck due to muscle spasm
101
What are the red flags indicating cauda equina?
Saddle anaesthesia Urinary retention Incontinence Bilateral neuro signs
102
What are the red flag indications of spinal stenosis?
Intermittent neuro claudication
103
What are the red flag symptoms of ankylosing spondylitis?
<40y Gradual onset Morning stiffness Night time pain
104
What are the red flags for spinal infection?
Fever History of IV drug use
105
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
106
What is the role of the sciatic nerve?
Sensation to lateral lower leg and foot Motor function to posterior thigh/lower leg/foot
107
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
108
What are the main causes of sciatica?
Lumbosacral nerve root compression: Herniated disc Spondylolisthesis Spinal stenosis
109
What is bilateral sciatica a red flag for?
Cauda equina syndrome
110
What does localised tenderness to spine suggest?
Spinal fracture Cancer
111
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
112
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
113
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
114
Outline pain management advice for back pain
1st line- NSAIDs (ibuprofen/naproxen) Codeine Benzos (diazepam)- For muscle spasms (only use up to 5d)
115
Outline management of sciatica
Amitriptyline Duloxetine (NO gabapentin/pregabalin/diazepam/oral corticosteroids) Epidural corticosteroid injections Local anaesthetic injections Radiofrequency denervation Spinal decompression
116
What level does the spinal cord terminate?
L2/L3 Tapers into conus medullaris
117
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
118
Outline management of cauda equina syndrome
Immediate hospital admission Emergency MRI Lumbar decompression surgery
119
Outline metastatic spinal cord compression
Compresses any part of spinal cord (not just isolated to cauda equina) Presents similarly to cauda equina syndrome
120
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
121
What is spinal stenosis?
Narrowing of part of spinal canal, resulting in compression of spinal cord or nerve roots
122
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
123
Outline investigations of spinal stenosis
MRI Exclude peripheral artery disease (ankle-brachial pressure index and CT angiogram)
124
Outline management of spinal stenosis
Exercise and weight loss Analgesia Physio Decompression surgery- Laminectomy
125
What is meralgia paraesthetica?
Local sensory symptoms of outer thigh caused by compression of lateral femoral cutaneous nerve
126
Outline function of lateral femoral cutaneous nerve
Carries only sensory signals Innervation to upper outer thigh
127
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
128
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
129
What is trochanteric bursitis?
Inflammation of bursa over greater trochanter
130
Outline presentation of trochanteric bursitis
Pain localised to outer hip Gradual onset Worse with activity, may disrupt sleep Pain on resisted movement Trendelenburg- Positive
131
Outline management of trochanteric bursitis
Rest and ice NSAIDs- Ibuprofen or naproxen Physio Steroid injections
132
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
133
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
134
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
135
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
136
Outline investigations of meniscal tears
1st line- MRI Arthroscopy
137
Outline management of meniscal tears
RICE NSAIDs Arthroscopy
138
What is the role of the ACL?
Stops tibia sliding forwards in relation to femur
139
What is the role of the PCL?
Stops tibia sliding backwards in relation to femur
140
Outline presentation of ACL injury
Twisting injury to knee Pain Swelling Pop sound/sensation Instability of knee joint- Tibia can move anteriorly
141
Outline diagnosis of ACL tear
Anterior drawer test 1st line- MRI Arthroscopy
142
Outline management of ACL tear
RICE 1st line- NSAIDs Arthroscopic surgery- New ligament formed with tendon graft
143
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
144
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
145
Outline management of Osgood-Schlatter disease
Reduce physical activity Ice NSAIDs
146
What is a rare complication of Osgood-Schlatter disease?
Complete avulsion fracture- Tibial tuberosity separated from rest of tibia- Requires surgery
147
What are the 4 boundaries of popliteal fossa?
Semimembranosus and semitendinosus Biceps femoris Medial head of gastrocnemius Lateral head of gastrocnemius
148
Outline presentation of Baker's cyst
Symptoms localised in popliteal fossa Pain/discomfort Fullness Pressure Palpable lump/swelling Restricted ROM in knee
149
What sign is associated with BAker's cyst?
Foucher's sign- Lump gets smaller/disappears when knee flexed 45 degrees
150
Outline presentation of ruptured Baker's cyst
Pain Swelling Erythema
151
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)
152
Outline management of Baker's cyst
No treatment if asymptomatic Modified activity NSAIDs Physio US-guided aspiration Steroid injections
153
What is Achilles tendinopathy?
Damage, swelling, inflammation and reduced function in Achilles tendon
154
What are the RFs for Achilles tendinopathy?
Sports that stress Achilles Inflammatory conditions (RA and ank spond) Diabetes Raised cholesterol Fluoroquinolone ABs (ciprofloxacin)
155
Outline presentation of Achilles tendinitis
Gradual onset Pain/aching in Achilles tendon on heel with activity Stiffness Tenderness Swelling Nodularity on palpation of tendon
156
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
157
Outline Achilles Tendon rupture
Sudden onset injury Loss of connection between calf muscles and heel
158
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
159
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
160
Outline diagnosis of Achilles tendon rupture
US
161
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
162
Outline plantar fasciitis
Inflammation of plantar fascia (attaches at calcaneus and travels along sole of foot)
163
Outline presentation of plantar fasciitis
Gradual onset of pain on plantar aspect of heel Worse with pressure, walking/standing Tenderness to palpation
164
Outline management of plantar fasciits
Rest, ice, NSAIDs Steroid injections- Can be painful
165
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
166
Outline presentation of fat pad atrophy
Pain and tenderness on plantar aspect of heel Worse with activity and walking barefoot on hard surfaces
167
Outline management of fat pad atrophy
Diagnosis- US thickness of fat pad Comfortable shoes, custom insoles Adapt activity Weight loss if appropriate
168
Outline Morton's Neuroma
Dysfunction of nerve in intermetatarsal space towards top of foot
169
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
170
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
171
Outline management of Morton's neuroma
Adapting activities NSAIDs Insoles Weight loss if appropriate Steroid injections Radiofrequency ablation Surgery- Excision of neuroma
172
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
173
Outline management of bunions
Diagnosis- Weight bearing xrays Wide, comfortable shoes and analgesia Surgery definitive
174
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
175
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
176
Outline supraspinatus tendinopathy
Inflammation and irritation of supraspinatus tendon Impingement at point it passes between humeral head and acromion Test- Empty can test
177
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
178
Outline management of frozen shoulder
NSAIDs Intra-articular steroid injections Hydrodilation (injecting fluid to stretch capsule) Manipulation under anaesthesia Arthroscopy
179
Outline rotator cuff tears
Occur due to acute injury (eg: FOOSH) or degenerative changes with age
180
What is the function of the supraspinatus?
Abducts arm
181
What is the function of the infraspinatus?
Externally rotates arm
182
What is the function of the teres minor?
Externally rotates arm
183
What is the function of the subscapularis?
Internally rotates arm
184
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
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Outline investigations of rotator cuff tears
Xrays- Rule out other pathologies US or MRI scans
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Outline management of rotator cuff tears
Degenerative- Conservative management Non-surgical- Res and adapted activities, NSAIDs, physio Surgical- Arthroscopic rotator cuff repair
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What is subluxation?
Partial dislocation
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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
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Outline posterior shoulder dislocations
Associated with electric shocks and seizures
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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
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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
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Outline investigations of shoulder dislocation
Xray- Not always required before reduction- Performed after to confirm placement and assess for fractures MRI with contrast Arthroscopy
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What is olecranon bursitis?
Inflammation and swelling of bursa over elbow (ulna) Student's elbow
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Outline presentation of olecranon bursitis
Young/middle aged men Swollen, warm, tender, fluctuant
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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
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Outline aspiration of bursa
Pus- Infection Straw-coloured- Infection less likely Blood stained- Trauma/infection/inflammatory causes Milky- Gout/pseudogout
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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
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Outline repetitive strain injury
Umbrella term for soft tissue irritation, microtrauma, strain from repeated activities
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Outline presentation of repetitive strain injuries
History of repetitive activities Pain, exacerbated by using associated joints/muscles/tendons Aching Weakness Cramping Numbness
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Outline management of repetitive strain injuries
RICE NSAIDs Steroid injections (in specific scenarios)
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What is epicondylitis?
Inflammation at point where tendons of forearm insert into epicondyles at elbow Repetitive strain injury
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What is the function of the tendons that insert into the medial epicondyle?
Flex wrist
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What is the function of tendons that insert into lateral epicondyle?
Extend wrist
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Outline lateral epicondylitis
Tennis elbow Pain and tenderness at lateral epicondyle Weakness in grip strength
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Outline medial epicondylitis
Golfer's elbow Pain and tenderness at medial epicondyle
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Outline management of epicondylitis
Clinical diagnosis Rest NSAIDs Orthotics Steroid injections Platelet-rich plasma (PRP) injections Extracorporeal shockwave therapy
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