Orthopaedics Flashcards
Risk factors for mechanical lower back pain
- Smoking
- Increasing age
- Pre-existing chronic widespread pain
- High levels of psychological distress
- poor self-related health
- dissatisfaction with work
Causes of mechanical lower back pain
- Lumbar disc prolapse
- Osteoarthritis
- Fractures
- Spondylolisthesis
- Heavy manual handling
- Stooping and twisting whilst lifting
- Exposure to whole body vibration
Presentation of mechanical lower back pain
- Sudden onset back pain and stiffness
o Pain worse in evening and during exercise
o Morning stiffness absent
o Relieved by rest - Scoliosis may be present when standing = spine twists and curves to side
- Muscular spasm visible and palpable
- Causes local unilateral pain and tenderness
- Episodes generally short-lived and self-limiting
- Once had one, increased risk of further back pain episodes
Red flags for mechanical lower back pain
- Starts before age of 20 or over 50
- Persistent and serious cause is suspected
- Worse at night/in morning, when inflammatory arthritis = e.g. ankylosing spondylitis, infection or spinal tumour
- Associated with systemic illness, fever or weight loss
- Associated with neurological symptoms/signs
- Hx of previous malignancy
- Hx of trauma
Investigations of mechanical lower back pain
- Spinal x-rays if red flags
- MRI more preferable than CT = Better for bone pathology
- Bone scans
Management of mechanical lower back pain
- Urgent neurosurgical referral if any neurological deficit
- Analgesia (paracetamol), NSAIDs (ibuprofen), codeine
- Combined with physiotherapy, back muscle training regimens and manipulation
- Acupuncture helps some
- Excessive rest avoided
- Re-education in lifting and exercises to prevent further attacks of pain
- Comfortable sleeping position using mattress of medium firmness
Presentation of S1 root lesion
o Pain = buttock down back of thigh to ankle/foot
o Sensory loss posterolateral aspect of leg and lateral aspect of foot
o Weakness in plantar flexion of foot
o Reduced ankle reflex
o Positive sciatic nerve stretch test
o Diminished straight leg raising
Presentation of L5 root lesion
o Pain = buttock to lateral aspect of leg and top of foot
o Sensory loss dorsum of foot
o Weakness in foot and big toe dorsiflexion
o Reflexes intact
o Positive sciatic nerve stretch test
o Diminished straight leg raising
Presentation of L4 root lesion
o Pain = lateral aspect of thigh to medial side of calf
o Sensory loss anterior aspect of knee and medial malleolus
o Weak knee extension and hip adduction
o Reduced knee reflex
o Positive femoral stretch test
Presentation of L3 root lesion
o Sensory loss over anterior thigh
o Weak hip flexion, knee extension and hip adduction
o Reduced knee reflex
o Positive femoral stretch test
Management of acute disc degeneration
- Acute stage
o Bed rest on firm mattress
o Analgesia NSAIDs
o Epidural corticosteroid injection - If Sx persisist after 4-6 weeks then referral for MRI if surgery considered
- Surgery
o Only for severe or increasing neurological impairment = foot drop or bladder symptoms
o Physio in recovery phase = help correct posture and restore movement
Types of hip dislocation
- Posterior dislocation (90%) = Affected leg is shortened, adducted and internally rotated
- Anterior dislocation = Affected leg abducted and externally rotated, no leg shortening
- Central dislocation
Management of hip dislocation
- ABCDE
- Analgesia
- Reduction under GA within 4 hrs
- Long-term Mx: physio to strengthen surrounding muscles
Complications of hip dislocation
- Sciatic or femoral nerve injury
- Avascular necrosis
- Osteoarthritis
- Recurrent dislocation
Presentation of hip fracture
- Pain
- Shortened and externally rotated leg
- May be able to weight bear (non-displaced or incomplete NOF fractures)
Location of hip fracture
- Intracapsular – from edge of femoral head to insertion of capsule of hip joint
- Extracapsular – trochanteric or subtrochanteric
Classification of hip fracture
Garden system
- Type I = stable fracture with impaction in valgus
- Type II = complete fracture but undisplaced
- Type III = displaced fracture, usually rotated and angulated but still has bony contact
- Type IV = complete bony disruption
Management of intracapsular hip fracture
o Undisplaced = internal fixation or hemiarthroplasty
o Displaced = arthroplasty or hemiarthroplasty
Total hip replacement if able to walk independently, not cognitively impaired and medically fit for anaesthesia and procedure
Management of extracapsular hip fracture
o Stable intertrochanteric = dynamic hip screw
o Reverse oblique, transverse or subtrochanteric = intramedullary device
Complication of hip fracture
Avascular necrosis
Causes of lateral epicondylitis
- House painting
- Tennis
Presentation of lateral epicondylitis
- Pain and tenderness localised to lateral epicondyle
- Pain worse on wrist extension against resistance with elbow extended or suprination of forearm with elbow extended
- Episodes last 6m-2y
- Acute pain for 6-12 wks
Management of lateral epicondylitis
- Advice on avoiding muscle overload
- Simple analgesia
- Steroid injection
- Physiotherapy
Features of ACL injury
o Sporting injury
o High twisting force applied to bent knee
o Sudden popping sound
o Knee swelling (haemoarthrosis)
o Poor healing
o Instability, feeling knee will give way
o Anterior draw test
o Lachman’s test
o Mx: intense physio or surgery
Features of PCL injury
o Hyperextension injuries
o Tibia lies back on femur
o Paradoxical anterior draw test
Features of MCL injury
o Leg forced into valgus via force outside leg
o Knee unstable when put into valgus position
Features of meniscal lesion
o Rotational sporting injuries
o Delayed knee swelling
o Joint locking
o Recurrent episodes of pain and effusions, often following minor trauma
Features of chondromalacia patellae
o Teenage girls, following injury to knee
o Pain on going down stairs or at rest
o Tenderness
o Quadriceps wasting
Features of patella dislocation
o Traumatic primary event
o RF: Genu valgum, tibial torsion, high riding patella
o Skyline XR of patella
Features of a tibial plateau fracture
o Elderly
o Knee forced into valgus or varus but knee fractures before ligaments rupture
o Schatzker system classification
Epidemiology of adhesive capsulitis (frozen shoulder)
Middle-aged females
Association of adhesive capsulitis
Diabetes
Presentation of adhesive capsulitis
- Shoulder pain and stiffness develops over days
- External rotation is affected more than internal rotation or abduction
- Both active and passive movement is affected
- Painful freezing phase, adhesive phase and recovery phase
- Bilateral in up to 20%
- Episode last 6m-2y
Management of adhesive capsulitis
- NSAIDs
- Physio
- Oral corticosteroids
- Intra-articular corticosteroids
Definition of ankle sprain
- Stretching, partial or complete tear of ligament
- High ankle sprains syndoesmosis
- Low ankle sprains lateral collateral ligaments
Presentation of ankle sprain
- Low ankle
o Most common with injury to ATFL
o Inversion injury most common mechanism
o Pain, swelling, tenderness over affected ligaments and sometimes bruising
o Patients usually able to weight bear unless severe - High ankle sprains
o Injuries t syndesmosis are rare and severe
o Mechanism usually external rotation of foot causing talus to push tibula laterally
o Weight-bearing painful
o Hopkin’s squeeze test Pain when tibia and fibula squeezed together at level of mid calf
Investigations of ankle sprain
- Low ankle
o Radiographs
o MRI if persistent pain and useful for evaluating perineal tendons - High ankle
o Radiographs widening of tibiofibular joint or ankle mortise
o MRI if high suspicion of syndesmotic injury but normal plain films
Management of ankle sprain
- Low ankle
o Non-operative with RICE
o Removal orthosis, cast and/or crutches for ST Sx relief - High ankle
o If no diastasis then non-weight bearing orthosis or cast until pain subsides
o If diastasis or failed non-operative MX then operative fixation
What is a colles fracture
Distal radius fracture with dorsal displacement of fragments
Presentation of colles fracture
- Fall onto outstretched hand (FOOSH)
- Dinner fork type deformity
XR findings of colles fracture
transverse fracture of radius, 1 inch proximal to radio-carpal joint, dorsal displacement and angulation
Early complications of colles fracture
o Median nerve injury carpal tunnel syndrome
o Compartment syndrome
o Vascular compromise
o Malunion
o Rupture of extensor pollicis longus tendon
Late complications of colles fracture
Osteoarthritis, Complex regional pain syndrome
Cause of scaphoid fracture
- FOOSH
- Contact sports
- Road traffic accident
Presentation of scaphoid fracture
- Pain along radial aspect of wrist, at base of thumb
- Loss of grip/pinch strength
- Point of maximal tenderness over anatomical snuffbox
- Wrist joint effusion
- Pain elicited by telescoping of thumb pain on longitudinal compression
- Tenderness of scaphoid tubercle
- Pain on ulnar deviation of wrist
Investigations of scaphoid fracture
- XR of wrist
- CT scan
- MRI definitive
Management of scaphoid fracture
- Immobilisation with Futuro splint or standard below-elbow backslab
- Referral to ortho
o Displaced fractures cast for 6-8 wks
o Displaced scaphoid wrist and proximal scaphoid pole fractures surgical fixation
Complications of scaphoid fracture
- Avascular necrosis of scaphoid
- Non-union pain and early osteoarthritis
What is compartment syndrome
Complication following fractures characterised by raised pressure within a closed anatomical space
Causes of compartment syndrome
- Supracondylar fractures
- Tibial shaft injuries
Presentation of compartment syndrome
- Pain, especially on movement, Excessive use of breakthrough analgesia
- Parasthesiae
- Pallor
- Arterial pulsation may still be felt
- Paralysis of muscle group
Investigations of compartment syndrome
Intracompartmental pressure measurements >40mmHg diagnostic
Management of compartment syndrome
- Prompt and extensive fasciotomies
- Aggressive IV fluids
Complications of compartment syndrome
- Death of muscle groups within 4-6 hrs
- Myoglobinuria
Causes of carpal tunnel syndrome
- Idiopathic
- Pregnancy
- Oedema (heart failure)
- Lunate fracture
- Rheumatoid arthritis
What is carpal tunnel syndrome
Compression by median nerve in carpal tunnel
Presentation of carpal tunnel syndrome
- Pain/pins and needles in thumb, index, middle finger
- Symptoms may ‘ascend’ proximally
- Shakes hand for relief, classically at night
- Weakness of thumb abduction (abductor pollicis brevis)
- Wasting of thena eminence
- Tinel’s sign tapping causes paraesthesia
- Phalen’s sign flexion of wrist causes symptoms
Investigations of carpal tunnel syndrome
Electrophysiology motor + sensory prolongation of action potential
Management of carpal tunnel syndrome
- 6 week trial of wrist splints ± corticosteroid injection
- Surgical decompression. flexor retinaculum division
Smith’s fracture
o Reverse of colles’ fracture
o Caused by falling backwards onto palm of outstretched hand or falling with wrists flexed
Barton’s fracture
o Distal radius fracture with associated radiocarpal dislocation
o Fall onto extended and pronated wrist
Bennett’s fracture
o Intra-articular fracture at base of thumb metacarpal
o Impact on flexed metacarpal, caused by fist fights
o XR triangular fragment at base of metacarpal
Monteggia’s. fracture
o Dislocation of proximal radioulnar joint in association with ulna fracture
o FOOSH with forced pronation
o Needs prompt diagnosis to avoid disability
Galeazzi fracture
o Radial shaft fracture with associated dislocation of distal radioulnar joint
o Occur after fall on hand with rotational force superimposed on it
o Bruising, swelling and tenderness over lower end of foreaem
o XR displaced fracture of radius and prominent ulnar head due to dislocation of inferior radio-ulnar joint
Radial head fracture
o Common in young adults
o Usually caused by FOOSH
o Marked local tenderness over head of radius, impaired movements at elbow and sharp pain at lateral side of elbow at extremes of rotation (pronation and supination)
Types of rotator cuff injury
- Subacromial impingement (painful arc syndrome)
- Calcific tendonitis
- Rotator cuff tears
- Rotator cuff arthropathy
Presentation of rotator cuff injuries
- Shoulder pain worse on abduction
o painful arc between 60 and 120 degrees)
o pain in first 60 degree in rotator cuff tears - Tenderness over anterior acromion
Primary causes of iliopsoas abscess
Staph aureus
Secondary causes of iliopsoas abscess
o Crohn’s
o Diverticulitis, colorectal cancer
o UTI, GU cancers
o Vertebral osteomyelitis
o Femoral catheter, lithotripsy
o Endocarditis
o IVDU
Presentation of iliopsoas abscess
- Fever, weight loss
- Back/flank pain
- Limp
- Hyperextension of hip elicits pain
Investigation of iliopsoas abscess
CT abdo
Management of iliopsoas abscess
- Abx
- Percutaneous drainage
- Surgery if failure of percutaneous drainage or prescence of antoher intra-abdominal pathology which requires surgery
What is a baker’s cyst
Not true cysts but distension of gastrocnemius-semimembranosus bursa
Causes of baker’s cyst
- Primary = no underlying pathology, typically seen in children
- Secondary = osteoarthritis, typically seen in adults
Presentation of baker’s cyst
- Swellings in popliteal fossa behind knee
- Rupture = pain, redness and swelling in calf
Management of baker’s cyst
- Children = normally resolve so no treatment
- Adults = treat underlying cause
What is osteochondritis dissecans
Pathological process affecting subchondral bone with secondary effects on joint cartilage
Presentation of osteochondritis dissecans
- Subacute onset of knee pain and swelling, typically after exercise
- Knee catching, locking and/or giving way
- Feeling a painful ‘clunk’ when flexing or extending knee
- Joint effusion
- Tenderness on palpation of articular cartilage of medial femoral condyle, when knee is flexed
- Wilson’s sign for detecting medial condyle lesion
Investigations of osteochondritis dissecans
- XR subchondral crescent sign or loose bodies
- MRI evaluate cartilage, visualise loose bodies, stage and assess stability of lesion
