Orthopaedics Flashcards
Describe lateral epicondylitis
Lateral epicondylitis: worse on resisted wrist extension/supination whilst elbow extended
also pain and tenderness localised to the lateral epicondyle
Typically house painting or playing tennis (‘tennis elbow’)
Describe causes of hip pain
- osteoarthritis
- inflammatory arthritis
- referred lumbar spine pain (positive femoral nerve stretch test)
- greater trochanteric pain (trochanteric bursitis)
- avascular necrosis
- pubic symphysis dysfunction (common in pregnancy)
- transient idiopathic osteoporosis (uncommon, pregnancy)
Describe osteomyelitis and its management
Osteomyelitis describes an infection of the bone
Classification
- haematogenous osteomyelitis
> vertebral osteomyelitis is the most common form of haematogenous osteomyelitis in adults
> risk factors: sickle cell anaemia, IVDU, immunosuppression, infective endocarditis - non-haematogenous osteomyelitis:
> contiguous spread of infection from adjacent soft tissues to the bone or from direct injury/trauma to bone
> risk factors: diabetic foot ulcers/pressure sores, diabetes mellitus, peripheral arterial disease
Microbiology
- Staph. aureus is the most common cause except in sickle-cell anaemia where Salmonella species are most common
Investigations: MRI
Management
> flucloxacillin for 6 weeks
> clindamycin if penicillin-allergic
Describe the pathophysiology and clinical features of compartment syndrome
can occur following fractures (or following ischaemia reperfusion injury in vascular patients)
characterised by raised pressure within a closed anatomical space
> raised pressure will eventually compromise tissue perfusion resulting in necrosis
> 2 main fractures carrying this complication: supracondylar fractures and tibial shaft injuries.
Features
> Pain, especially on movement (even passive)
> excessive use of breakthrough analgesia
> Paraesthesia
> Pallor
> Arterial pulsation may still be felt as the necrosis occurs as a result of microvascular compromise
> Paralysis of the muscle group may occur
describe the diagnosis and management of compartment syndrome
Diagnosis
> measurement of intracompartmental pressure via needle manometry
> Pressures >20mmHg are abnormal and >40mmHg is diagnostic
> no pathology on x-ray
Treatment: cut dressings down to skin
> prompt and extensive fasciotomies releasing all compartments
> Myoglobinuria may occur following fasciotomy leading to renal failure - aggressive IV fluids
> Where muscle groups are necrotic at fasciotomy - debridement +/- amputation
Death of muscle groups may occur within 4-6 hours
Describe the following knee problems:
- Infrapatellar bursitis
- Prepatellar bursitis
Infrapatellar bursitis- Clergyman’s knee
> Associated with kneeling
Prepatellar bursitis - housemaid’s knee
> Associated with more upright kneeling
Describe features and causes of cauda equina syndrome
Clinical features
> Urinary retention, bladder distension
> Reduced/absent anal tone, faecal incontinence
> Bilateral sciatica
> bilateral motor weakness in legs
> Saddle anaesthesia
> loss of perianal sensation (S2-S4)
causes
- disc prolapse in lumbosacral canal
investigations
- pre and post-voiding bladder scan (retention/incomplete bladder emptying)
- emergency MRI whole spine (within 4 hours)
Management
> Neurosurgery referral - decompression laminectomy within 24h
> Metastatic cancer: IV dexamethasone, radiotherapy
Complications
- urinary dysfunction requiring catheterisation
- sexual dysfunction
- chronic pain
- leg weakness
Describe the clinical features and causes carpal tunnel syndrome
caused by compression of median nerve in the carpal tunnel
History
> pain/pins and needles in thumb, index, middle finger
> unusually the symptoms may ‘ascend’ proximally
> patient shakes hand to obtain relief, classically at night
Examination
> weakness of thumb abduction (abductor pollicis brevis)
> wasting of thenar eminence
> Tinel’s sign: tapping causes paraesthesia
> Phalen’s sign: flexion of wrist causes symptoms
Causes
- idiopathic
- pregnancy
- oedema e.g. heart failure
- lunate fracture
- rheumatoid arthritis
- acromegaly
- hypothyroidism
- diabetes
- chronic renal failure
describe the diagnosis and management of carpal tunnel syndrome
Electrophysiology: motor + sensory: prolongation of the action potential
Treatment
- 6-week trial of conservative treatments mild-moderate
> wrist splints at night: particularly useful if transient factors present e.g. pregnancy
+/- corticosteroid injection
if severe symptoms or persistent:
> surgical decompression (flexor retinaculum division)
Describe sciatica
Causes
> Prolapsed lumbar disc
Clinical features
> Clear dermatomal leg pain associated with neurological deficits
> Leg pain worse than back pain
> Pain worse when sitting
Management
> analgesia, physiotherapy, exercises
> if symptoms persist >4-6 weeks, refer for MRI
Describe the presentation of scaphoid fractures
wrist fracture, typically due to fall onto an outstretched hand (FOOSH).
Presentation
> Pain along radial aspect of wrist at the base of the thumb
> Loss of grip / pinch strength
Signs:
- maximal tenderness over anatomical snuffbox
- pain elicited by telescoping of the thumb (pain on longitudinal compression)
- tenderness of the scaphoid tubercle (volar aspect of the wrist)
- pain on ulnar deviation of the wrist
Investigations
- Plain film radiographs
- CT scan if ongoing clinical suspicion
- MRI is definite investigation
describe complications and management of scaphoid fractures
Management
- Immobilisation with a Futuro splint or standard below-elbow backslab
- referral to orthopaedics
> undisplaced fractures of the scaphoid waist - cast for 6-8 weeks
> displaced scaphoid waist fractures
- surgical fixation
proximal scaphoid pole fractures
- surgical fixation
Complications
non-union → pain and early osteoarthritis
avascular necrosis
> most of the blood supply is derived from the dorsal carpal branch (branch of the radial artery), in a retrograde manner. Interruption of the blood supply risks avascular necrosis
What’s the normal position of the wrist joint?
10 degrees of volar angulation
describe open fracture management
ATLS approach
- inspect and photograph wound
- cover wound with saline soaked swab
- early antibiotics - IV cefuroxime, consider tetanus
Investigations - X-ray for diagnosis
management
- temporary stabilisation
> thomas splint - femur
> backslab - tibia
- definitive debridement and stabilisation in theatre
describe the classification of open fractures
Gustilo Anderson Classification
Type I
- skin wound <1cm
- clean
- simple fracture pattern
Type II
- laceration >1cm but <10cm
- moderate soft tissue damage
- adequate bone coverage
Type III
- laceration >10cm with extensive soft tissue damage
> IIIA: adequate soft tissue cover of bone but segmental / severely comminuted wounds
IIIB: extensive soft tissue injury with periosteal stripping and bone exposure; major wound contamination
IIIC: open fracture with arterial injury requiring repair
describe causes and features of septic arthritis
most common organism overall is Staphylococcus aureus
young adults who are sexually active - Neisseria gonorrhoeae is the most common organism (disseminated gonococcal infection)
causes
- bacteraemia - haematogenous spread
- direct innoculation (trauma / surgery)
- contiguous spread (adjacent osteomyelitis)
Features
> acute, swollen joint
> restricted movement
> examination findings: warm to touch/fluctuant
> fever
describe investigations and management of septic arthritis
Investigations
- synovial fluid sampling: joint aspiration
> before Abx unless extreme
fluid often cloudy if septic
send fluid for gram stain, culture and crystal analysis
aspirate prosthetic joints in theatre
- blood cultures + bloods
- joint imaging (X-ray)
Management
- intravenous antibiotics: flucloxacillin or clindamycin if penicillin allergic for 4-6 weeks
- needle aspiration should be used to decompress the joint
- arthroscopic lavage may be required
can get irreversible joint damage due to release of proteolytic enzymes within 8 hours
describe investigations, management and complications of cauda equina syndrome
investigations
- pre and post-voiding bladder scan (retention/incomplete bladder emptying)
- emergency MRI whole spine (within 4 hours)
Management
> Neurosurgery referral - decompression laminectomy within 24h
> Metastatic cancer: IV dexamethasone, radiotherapy
Complications
- urinary dysfunction requiring catheterisation
- sexual dysfunction
- chronic pain
- persistent leg weakness / altered sensation
describe the contents of the carpal tunnel
tendons:
- flexor digitorum profundus (4)
- flexor digitorum superficialis (4)
- flexor pollicis longus (1)
nerve:
- median nerve
Describe the following eponymous fractures
- Colles’
- Bennett’s
- Pott’s
- Smith’s
- Monteggia’s
- Galeazzi
- Barton’s
- Colles’ - dinner fork deformity
FOOSH resulting in transverse fracture of radius 1 inch proximal to radiocarpal joint with dorsal displacement and angulation - Bennett’s - intra-articular fracture of first CMC joint from fist fight, triangular fragment at ulnar base of metacarpal on X-ray
- Pott’s - bimalleolar ankle fracture on forced foot eversion
- Smith’s: (reverse Colles’) volar angulation of distal radius fragment, caused by falling backwards onto palm of outstretched hand
- Monteggia’s: dislocation of proximal radioulnar joint due to ulna fracture due to FOOSH with forced pronation
- Galeazzi: radial shaft fracture with dislocation of distal radioulnar joint (direct blow)
- Barton’s - distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation (fall onto extended and pronated wrist)
Describe the classification of ankle injuries and their management
Weber classification of ankle fractures
- type A: below level of ankle joint
> syndesmosis intact
> usually stable
> remain weight-bearing as tolerated in CAM boot for 6 weeks - type B: at the level of ankle joint
> syndesmosis intact or torn
> medial malleolus may be fractured
> deltoid ligament may be torn
> variable stability - type C: above ankle joint
> syndesmosis disrupted
> medial malleolus fracture and deltoid ligament rupture
> open reduction and external fixation (ORIF)
Maisonneuve fracture: spiral fibular fracture that leads to disruption of the syndesmosis with widening of the ankle joint
> surgery is required
Management
> prompt reduction of ankle fractures (before X-ray if neurovascular compromise)
> young patients with unstable/high velocity/proximal injuries - surgical repair with compression plate
> elderly patients - conservative management
List the Ottawa ankle rules
Ottawa ankle rules (to determine need for X-rays): if pain in malleolar zone and
> inability to weight bear for 4 steps
> tenderness over distal tibia
> bone tenderness over distal fibula
describe scheuermann’s disease
epiphysitis of the vertebral joints
predominantly affects adolescents
symptoms: back pain, stiffness
X-ray changes
- epiphyseal plate disturbance
- anterior wedging
clinical features
- progressive kyphosis
management
- physiotherapy
- analgesia
- severe cases may require bracing, surgical stabilisation
describe a ganglion cyst
cyst arising from a joint or tendon sheath
most commonly seen on dorsal aspect of wrist
features
- firm and well-circumscribed mass that transilluminates
management
- often disappear spontaneously within months
- surgical excision is indicated if severe symptoms or neurovascular manifestations
list late radiological features of avascular necrosis
- crescent sign: subchondral collapse
- osteochondral fracture
- flattening of femoral head
- joint space narrowing
describe the following tumours
- osteoma
- giant cell tumour
- chondrosarcoma
osteoma
- benign overgrowth of bone, typically on the skull
- associated with Gardner’s syndrome (variant of familial adenomatous polyposis)
giant cell tumour
- tumour of multinucleated giant cells within fibrous stroma
- peak incidence: 20-40 years
- usually in epiphyses of long bones
- X-ray: double bubble or soap bubble appearance
chondrosarcoma
- malignant tumour of cartilage
- most commonly affects axial skeleton
- more common in middle age
Describe hip fractures and their management
Features
> pain
> shortened and externally rotated leg
Classification
> intracapsular (subcapital)
> extracapsular: these can either be trochanteric or subtrochanteric
Garden classification system also used to classify NOF fractures
Management
- Intracapsular hip fracture
> Undisplaced: internal fixation, or hemiarthroplasty if unfit.
> displaced: replacement arthroplasty (total hip replacement or hemiarthroplasty)
» sciatic nerve damage associated with THR
- Extracapsular hip fracture
> stable intertrochanteric fractures: dynamic hip screw
> reverse oblique, transverse or subtrochanteric fractures: intramedullary device
List red flags in back pain
Age <18 or >50
Immunosuppression
Waking from pain
night sweats, fever, weight loss
recent trauma
progressive neurological deficit
worst at night or at rest
thoracic back pain
bladder or bowel dysfunction
history of malignancy
Describe cubital tunnel syndrome
due to compression of the ulnar nerve as it passes through the cubital tunnel
> ulnar nerve travels between two heads of FCU in cubital tunnel retinaculum
clinical features
- tingling and numbness of the 4th and 5th fingers
- weakness of finger abduction
- hypothenar wasting
- pain worse on leaning on the affected elbow
- +ve Tinel’s at elbow
- history of OA / prior trauma
investigations: clinical diagnosis but nerve conduction studies may be used
management
- avoid aggravating factors
- physio
- soft elbow splints
- surgery in resistant cases
Describe necrotising fasciitis and its management
classification:
- type 1: mixed anaerobes and aerobes (often occurs post-surgery in diabetics) - most common
- type 2: Streptococcus pyogenes
Risk factors
> skin factors: recent trauma, burns or soft tissue infections
> diabetes mellitus
> intravenous drug use
> immunosuppression
The most commonly affected site is the perineum (Fournier’s gangrene).
Features
> acute onset
> pain, swelling, erythema at the affected site
> rapidly worsening cellulitis with pain out of keeping with physical features
> extremely tender over infected tissue with hypoaesthesia to light touch
> skin necrosis and crepitus/gas gangrene are late signs
> fever and tachycardia may be absent or occur late in the presentation
Management
> urgent surgical referral debridement
> intravenous antibiotics
Prognosis - average mortality of 20%
describe shoulder dislocation
humeral head dislodges from glenoid cavity of scapula
anterior dislocation: FOOSH
posterior dislocation: seizures, electric shock
inferior dislocation
management: reduction
- if recent reduction e.g. Kocher reduction may be attempted without analgesia/sedation
- some patients may require analgesia or sedation to relax rotator cuff muscles
describe achilles tendinopathy
risk factors
> quinolone use e.g. ciprofloxacin
> hypercholesterolaemia (xanthomata)
achilles tendinitis
- gradual onset of posterior heel pain that is worse following activity
- morning pain and stiffness
management
- rest, ice, analgesia
- reduction in precipitating activities
- calf muscle eccentric exercises
achilles tendon rupture
- audible pop in the ankle while playing a sport or running
- sudden onset significant pain in the calf or ankle
- inability to walk or continue the sport
simmond’s
- abnormal angle of declination
- greater dorsiflexion than uninjured side
- palpate for gap in tendon
- squeeze muscles to check integrity of tendon
imaging: US first-line
acute referral to orthopaedics if rupture
management:
> RICE immediately
> non-surgical: immobilisation
> surgical: reattachment
describe achondroplasia
AD disorder caused by mutation in FGFR-3
this results in abnormal cartilage
- short limbs (rhizomelia) with shortened fingers (brachydactyly)
- large head with frontal bossing and narrow foramen magnum
- midface hypoplasia with flattened nasal bridge
- trident hand deformity
- lumbar lordosis
mostly a sporadic mutation, risk factor is increasing parental age
describe subacromial impingement
first stage of rotator cuff disease, most common cause of shoulder pain
clinical features
- pain exacerbated by overhead activities and lifting objects away from body
- night pain
- painful arc of abduction between 60-120 degrees
- tenderness over anterior acromion
- X-ray may show calcification of supraspinatus tendon
management
- physiotherapy
- NSAIDs
- subacromial injections
- surgery
describe spondylolysis and spondylolisthesis
spondylolysis
- congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affects L4/5
- commonest cause of spondylolisthesis in children
spondylolisthesis
- one vertebra is displaced relative to its immediate inferior vertebral body
- may occur as a result of stress fracture or spondylolysis
- treatment
> active monitoring
> individuals with radicular symptoms or signs will require spinal decompression and stabilisation
describe metatarsal fractures
the 5th metatarsal is the most commonly fractured metatarsal and is the most common site of midfoot
> proximal avulsion fractures (pseudo-Jones fractures): most common type
> associated with lateral ankle sprain and often follows inversion injuries of the ankle
> jones fractures
> transverse fracture at the metaphyseal-diaphyseal junction
metatarsal stress fractures
- occurs in otherwise healthy athletes
- most common site is 2nd metatarsal shaft
> features: pain and bony tenderness, swelling, antalgic gait
investigations: stress fractures may appear normal on X-ray but sometimes there is a periosteal reaction 2-3 weeks later
> isotope scan or MRI if inconclusive
describe Sweet’s syndrome
aka acute febrile neutrophilic dermatosis
features
- fever
- painful inflamed or blistered skin rash
- mucosal lesions
- joint pain
- headache
associations: HLA B54
- IBD
- RA / lupus
- URTI
- immunodeficiency
treatment
- systemic steroids
describe acetabular labral tear and femoroacetabular impingement (FAI)
labral tears may occur as a result of trauma or degenerative change
features
- acute history / contact sport
- hip/groin pain
- snapping sensation
- patient able to weight bear with pain on external rotation
- locking sensation
FAI
- chronic condition predisposing to acetabular tear
describe de Quervain’s tenosynovitis
common condition in which sheath containing extensor pollicis brevis and abductor pollicis longus tendons is inflamed
typically affects females 30-50 years old
features
- pain on radial side of wrist
- tenderness over radial styloid process
- abduction of thumb against resistance is painful
- Finkelstein’s test: examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction
> if positive will cause pain over radial styloid process and along tendons
management
- analgesia
- steroid injection
- immobilisation with a thumb splint (spica)
- surgery
describe plantar fasciitis
inflammation of plantar fascia
most common cause of heel pain in adults
clinical features
- gradual onset heel pain
- pain is worse around medial calcaneal tuberosity
- exacerbated by walking on tip toes
management
- rest, ice, analgesia
- wear shoes with good arch support and cushioned heels
- insoles / heel pads
- physio
- steroid injections
describe superficial radial neuritis (Wartenberg’s syndrome)
entrapment of the superficial branch of the radial nerve
features
- pain over distal radial forearm
- paraesthesia over dorsal radial aspect of hand
- symptoms at rest regardless of thumb and wrist position (as opposed to De Quervain’s tenosynovitis)
list causes of a dupuytren’s contracture
- alcoholic liver disease
- phenytoin treatment
> also causes peripheral neuropathy - diabetes
- manual labour
- trauma to the hand
describe hip dislocation
mostly caused by trauma or falls from height
Posterior hip dislocation
- most common
- associated with internally rotated, adducted and shortened limb
- can result in sciatic nerve injury
> reduced sensation in posterior leg and foot
> impaired ability to dorsiflex foot
Anterior hip dislocation
- rare
- associated with externally rotated and abducted limb with no leg shortening
Management
- analgesia
- reduction under GA within 4h
complications
- sciatic or femoral nerve injury
- avascular necrosis
- osteoarthritis
- recurrent dislocation
describe the management of suspected scaphoid fracture with unconclusive imaging
wrist splint
further imaging + clinical review in 7-10 days
describe an osteochondroma
benign tumour, aka exostosis
- most common benign bone tumour
- more in males, usually <20 years
- cartilage-capped bony projection on the external surface of a bone
describe multiple myeloma
most common primary bone malignancy
pathophysiology:
> neoplastic proliferation of plasma cells which manifest as skeletal lesions
> neoplastic plasma cells produce immunoglobulins
commonly age >40
clinical features
- back pain
- bone pain
- pathological fracture
- systemic features
myeloma screen
- IgG, IgA, IgM - heavy chains
- urine sample for Bence Jones protein (light chain)
solitary lesion - plasmacytoma
treatment
- radiotherapy / chemotherapy
- stem cell transplantation
- bisphosphonates
- prophylatic fixation
list primary tumours that metastasise to bones
- lung - lytic
- breast - sclerotic
- thyroid - lytic
- renal - lytic
- prostate - sclerotic / lytic
describe the clinical features of bone tumours
- pain (night pain)
- swelling
- systemic features: unexplained weight loss, night sweats, fatigue
- pathological fracture
- nerve compression
- history of malignancy
describe a unicameral bone cyst
aka simple cyst
benign non-neoplastic, most common in young adults
commonly in metaphysis of long bones (60% humerus)
often present with pathological fracture
treatment
- nil if asymptomatic
- fractures - usually heal normally
- bone curettage and graft sometimes required
describe osteosarcoma
most common primary malignant bone tumour
bimodal distribution
- children and young adults
- older adults (malignant conversion of Paget’s disease)
X-ray: Codman triangle (from periosteal elevation) and sunburst pattern
metaphyseal region of long bones affected - distal femur, proximal tibia most common
symptoms
- pain
- fever
- mass
- pathological fracture
management
- chemotherapy
- surgical resection
describe Ewing’s sarcoma
small round blue cell tumour
commonly affects pelvis and long bones
- most common in males 10-20 years
- associated with t(11;22)
X-ray features:
> lytic lesion with lamellated / onion type periosteal reaction
> affects diaphysis of long bones
treatment
- chemotherapy (risk of developing AML/myelodysplasia later)
- radiotherapy
- curative resection
list Kanavel’s signs
signs of pyogenic flexor tenosynovitis
- pain to palpation of flexor tendon sheath
- uniform swelling along entire finger
- held in passive flexion
- pain with passive extension
describe quadriceps tendon rupture
can occur with foot planted and knee bent or direct trauma
clinical features
- pain
- tenderness at site of rupture
- palpable defect in quad tendon
Knee X-ray: patella baja
treatment
- knee immobilisation in brace
- surgical repair
describe proximal humerus fracture
due to fall onto outstretched hand in elderly or high energy trauma in young patients
clinical features
- pain and swelling
- decreased motion
complications: axillary nerve or artery injury
management
- sling immobilisation
- surgical repair
describe a Lisfranc injury
tarsometatarsal fracture dislocation
traumatic disruption between the articulation of the medial cuneiform and base of the 2nd metatarsal
management
- surgery: ORIF. arthrodesis
describe a fat embolism
can occur following fracture of long bones e.g. femur
fat globules released into circulation and can lodge in pulmonary arteries
diagnosed with Gurd’s criteria
- respiratory distress
- petechial rash
- cerebral involvement
- jaundice
- thrombocytopaenia
- fever
- tachycardia
operate early to reduce risk of fat embolism syndrome
describe spinal stenosis
3 types
- central stenosis
- lateral stenosis
- foramina stenosis
causes
- congenital
- degenerative
- herniated disc
- malignancy
- fracture
clinical features
- gradual onset
- symptoms absent at rest but appear when standing/walking
- lower back pain
- buttock and leg pain (intermittent neurogenic claudication)
- leg weakness
- improvement walking uphill or bending forwards
investigations - MRI scanning
management
- exercise and weight loss
- analgesia
- physiotherapy
- decompression surgery: laminectomy
describe meralgia paraesthetica
burning sensation over anterolateral thigh due to compression of lateral femoral cutaneous nerve of thigh
clinical features
- burning
- numbness
- pins and needles
- cold sensation
- localised hair loss
aggravated by walking / standing up and improved sitting down
can be caused by sudden weight gain
extension of hip worsens symptoms
management
- conservative: rest, looser clothing
- medical: paracetamol, NSAIDs, neuropathic medications e.g. amitriptyline
- surgical: decompression
describe trochanteric bursitis
clinical features
- aching/burning pain over outer hip (greater trochanteric pain syndrome)
- pain worse with activity, after sitting for a prolonged period of time and trying to sit cross-legged
- tenderness over greater trochanter but no swelling
positive Trendelenburg
management
- rest, ice, analgesia
- steroid injections
describe a meniscal tear
May be caused by twisting of the knee
> Locking and giving-way are common feature
> rotational sporting injury accompanied by pop sound or sensation
clinical features
- pain, swelling, stiffness
- reduced ROM
- tender joint line
management
- RICE
- analgesia
- surgery: arthroscopy
describe an ACL tear
Anterior cruciate ligament tear
> May be caused by twisting of the knee - pivot shift mechanism
clinical features
- popping noise
- rapid onset of knee effusion with pain and swelling (haemarthrosis)
- instability or giving way
- positive anterior draw test / Lachman test
investigations: MRI, arthroscopy
management
- NSAIDs
- physiotherapy
- arthroscopic reconstruction
describe Osgood-Schlatter disease
inflammation at tibial tuberosity at insertion of patellar ligament
commonly ages 10-15, males
usually unilateral but can be bilateral
clinical features
- visible or palpable hard and tender lump
- pain anterior knee
- pain exacerbated by physical activity, kneeling and extension of knee
management
- rest, ice
- NSAIDs
- hard non-tender lump present permanently after
complication - complete avulsion fracture
describe a Baker’s cyst
non-tender lump in popliteal fossa
causes
- meniscal tear
- knee injuries
- OA, inflammatory arthritis
clinical features
- pain, swelling, fullness/pressure
- Foucher’s sign: increase in tension of the Baker’s cyst on extension of the knee
investigations: USS, MRI
management
- no treatment if asymptomatic
- physiotherapy, analgesia
- US-guided aspiration
- steroid injections
- surgery
describe fat pad atrophy
atrophy of fat pad protecting calcaneus
atrophy can occur from age, repetitive strain from running, jumping or steroid injections for plantar fasciitis
clinical features
- similar to plantar fasciitis
- pain and tenderness over plantar aspect of heel
- symptoms worse with activities, especially barefoot
investigations - ultrasound
management
- comfortable shoes, custom insoles
- weight loss if appropriate
describe Morton’s neuroma
dysfunction of nerve usually between 3rd and 4th metatarsals
clinical features
- pain at front of foot at location of lesion
- sensation of lump in shoe
- burning, numbness or pins and needles in distal toes
- exacerbated by high heels/narrow shoes
investigations
- deep pressure applied to intermetatarsal space causes pain
- metatarsal squeeze
- Mulder’s sign: painful click when manipulating metatarsal heads
- US/MRI
management
- adapting activities, insoles, weight loss
- analgesia, steroid injections
- radiofrequency ablation, surgery
describe paediatric fracture classification for fractures affecting the epiphyseal plate
Salter-Harris classification (SALTR)
Grade I - straight across epiphyseal plate
> X-ray often normal
Grade II - above the physis
> fracture through physis and metaphysis
Grade III - lower than the physis
> fracture through physis and epiphysis
Grade IV - through the physis
> fracture through metaphysis, physis and epiphysis
Grade V - rammed (crushed)
> crush injury involving the physis, X-ray may appear normal
> growth disruption
describe types of paediatric fractures
- Complete fracture
> both sides of the cortex are breached - Salter Harris fracture
> fracture affecting epiphyseal plate - Toddler’s fracture
> oblique tibial fracture in infants - plastic deformity
> stress on bone resulting in deformity without cortical disruption - greenstick fracture
> unilateral cortical breach only - buckle “torus” fracture
> incomplete cortical disruption resulting in periosteal haematoma only
list causes of pathological fracture in children
osteogenesis imperfecta
- radiology shows translucent bones, multiple fractures (especially long bones), wormian bones (irregular patches of ossification), trefoil pelvis
osteopetrosis
- bones become harder and more dense
- AR condition
- radiology: lack of differentiation between cortex and medulla described as marble bone
describe Simmonds triad
- calf squeeze test
- observation of the angle of declination
- palpation of the tendon
describe acromioclavicular joint dislocation
normally occurs secondary to direct injury to superior aspect of acromion
clinical features
- loss of shoulder contour
- prominent clavicle
Rockwood classification
management
- physio
- reconstruction or ORIF with hook plate
describe glenohumeral dislocation
types
- anterior dislocation
> associated with axillary nerve injury
> flattened deltoid, head of humerus palpable at front of shoulder
- posterior dislocation
> uncommon
> usually due to seizures or electric shock
> lightbulb sign on X-ray
X-ray features
- Hill Sachs lesion
management
- shoulder reduction +/- analgesia/sedation
describe iliotibial band syndrome
non-traumatic overuse injury often seen in runners, cyclists
clinical features
- pain/tenderness on palpation of lateral knee
- pain elicited when heel strikes floor
- pain may radiate to outer thigh/calf
- swelling outer knee
management
- rest, ice, analgesia, physio
describe bunions
aka hallux valgus
bony lump created by deformity at MTP joint at base of hallux
investigations
- weight bearing X-ray
management
- conservative: wide, comfortable shoes and analgesia, bunion pads
- surgery
describe the clinical features of a dupuytren contracture
palmar fascia becomes thickened and tight and develops nodules
clinical features
- hard nodules on palm
- skin thickening and pitting
- finger pulled into flexion
- impossible to fully extend finger
- ring finger most likely to be affected
investigations
- table top test: hand cannot rest completely flat on a table
management
- conservative
- surgical: needle fasciotomy, limited fasciectomy, dermofasciectomy
describe trigger finger
aka stenosing tenosynovitis
most commonly affects first annular (A1) pulley at the MCP joint
clinical features
> painful tender finger around MCP joint on the palm side of the hand
> finger does not move smoothly
> gets stuck in flexed position
> popping/clicking sound upon extension
symptoms are worse in the morning and improve during the day
management
- rest and analgesia
- splinting
- steroid injections
- surgery
describe olecranon bursitis
aka student’s elbow
usually young/middle-aged man with an elbow that is swollen, warm, tender and fluctuant
management
- rest, ice, compression, analgesia
- aspiration of fluid
- steroid injections
describe Marfan’s syndrome
AD connective tissue disorder
caused by defect in fibrillin-1 (FBN1 gene)
Features
- tall stature with long arms
- high-arched palate
- arachnodactyly
- pectus excavatum
- pes planus
- scoliosis of > 20 degrees
heart:
- dilation of the aortic sinuses
> aortic aneurysm, aortic dissection, aortic regurgitation
- mitral valve prolapse
lungs: repeated pneumothoraces
eyes:
- upwards lens dislocation (superotemporal ectopia lentis)
- blue sclera
- myopia
- dural ectasia
life expectancy: 40-50 years
describe the clinical features of damage to the following nerves:
- femoral nerve
- obturator nerve
- lumbosacral trunk
- sciatic nerve
- femoral nerve
> Weakness in knee extension, loss of the patella reflex, numbness of the thigh - obturator nerve
> Weakness in hip adduction, numbness over the medial thigh - lumbosacral trunk
> Weakness in ankle dorsiflexion, numbness of the calf and foot - sciatic nerve
> Weakness in knee flexion and foot movements, pain and numbness from gluteal region to ankle
Most nerve injuries recover within six to eight weeks, but occasionally nerve damage can be permanent.
describe a PCL tear
Mechanism
- anterior force applied to the proximal tibia (e.g. knee hitting dashboard during car accident)
- hyperextension injury
examination
- posterior sag sign - tibia lies back on femur
- paradoxical anterior drawer test
describe collateral ligament tears
medial collateral ligament
- mechanism: leg forced into valgus via force outside the leg
>Tenderness over the affected ligament
> Knee effusion may be seen
describe patellar dislocation
mechanism
- traumatic primary event: direct trauma or severe contraction of quadriceps with knee stretched in valgus and external rotation
risk factors: genu valgum, tibial torsion and high riding patella
Skyline x-ray views of patella
> osteochondral fracture may be present
associated injuries
- popliteal artery
- common peroneal nerve injury: foot drop gait (loss of dorsiflexion)
20% recurrence rate
describe a patellar fracture
2 types:
i. Direct blow to patella causing undisplaced fragments
ii. Avulsion fracture
features
- swelling, bruising
- palpable gap
- if straight leg raise possible, extensor mechanism is intact
investigations: knee X-ray AP & lateral
management
- undisplaced with intact extensor mechanism: non-operative in hinged knee brace for 6 weeks
- displaced/loss of extensor mechanism: surgical management with screws/wires
describe rib fractures
clinical features
- severe sharp chest wall pain
- pain more severe with deep breaths/coughing
- crackles on auscultation if underlying lung injury / hypoventilation pneumonia long-term
investigations - CT chest
complication - pneumothorax, flail chest
management
> analgesia: morphine, nerve blocks
> surgical fixation if >12 weeks with failed healing
describe a tibial plateau fracture
Occur in the elderly (or following significant trauma in young)
Mechanism: knee forced into valgus or varus, but the knee fractures before the ligaments rupture
Varus injury affects medial plateau and if valgus injury, lateral plateau depressed fracture occurs
Classified using the Schatzker system
describe chondromalacia patellae
Teenage girls, following an injury to knee e.g. Dislocation patella
featurs
- pain on going downstairs or at rest
- grinding sensation / clicking
- quadriceps wasting/ weakness
describe flail chest
multiple rib fractures with 2 or more rib fractures along 3 or more consecutive ribs
flail segment moves paradoxically during respiration and impairs ventilation
associated with pulmonary contusion
treatment - invasive ventilation, surgical fixation
describe Salter Harris fracture classification
SALTR
S - straight across physis
A - above the physis
> growth plate and metaphysis
L - lower than the physis
> growth plate and epiphysis
T - through the physis
> through all 3 layeres
R - right through
> crush injury of growth plate
describe osteogenesis imperfecta
defective osteoid formation
associated features
- hypermobility
- blue/grey sclera
- triangular face, short stature, dental problems
- deafness
- bone deformities: bowed legs, scoliosis
- joint and bone pain
management - bisphosphonates, vitamin D
describe osteopetrosis
bones become harder and more dense
AR condition
radiology - marble bone
> lack of differentiation between cortex and medulla
describe biceps tendon rupture
mechanism - sudden excessive eccentric contraction of biceps brachii
clinical features
- sudden pop or tear at shoulder (proximal tendon) or at antecubital fossa (distal tendon)
- pain, bruising, swelling
- popeye deformity in the middle of the upper arm
- hook test
biceps squeeze test: causes forearm supination if intact
investigations - ultrasound, MRI
treatment
- conservative: physio
- surgical repair
describe
- Hill Sachs lesions
- Bankart lesions
Hill Sachs defect
> posterolateral humeral head depression fracture due to anterior dislocation
Bankart lesion
> injuries of anteroinferior glenoid labral complex
> common complication of anterior shoulder dislocation
describe a perilunate dislocation
mechanism: wrist extended with ulnar deviation
Mayfield classification
treatment - urgent reduction + fixation with K wires + ligament reconstruction +/- carpal tunnel release
describe extensor tendon subluxation
weakness of sagittal bands that hold extensor tendon centrally over MCP joint
causes
- traumatic
- chronic
- commoner in RA
clinical features
- tendon subluxes on flexion
- flicks back in extension or finger has to be straightened manually
management
- acute: splint with MCPJ extended for 6 weeks
- surgical repair/reconstruction if failed conservative or chronic
describe a radial / posterior interosseous nerve palsy
causes
- trauma
- RA of elbow
- compression neuropathy
clinical presentation
- weakness of active extension of wrist/fingers and thumb
- wrist drop
- normal passive movement
management
- if laceration - repair nerve
- synovitis - treat inflammation
- compression neuropathy - surgical decompression
describe thumb CMC OA and STT OA
thumb carpometacarpal osteoarthritis
> pain and stiffness
> pain on wringing/removing stiff lids
> +ve Grind test
scapho-trapezio-trapezoid OA also causes radial pain
management
- non-operative: analgesia, splintage, steroid injection
- surgical: excise (trapeziectomy), fuse, replace
describe hallux rigidus
1st MTPJ osteoarthritis
clinical features
- pain, stiffness
- prominent bump
management
- non-operative: accommodative footwear, rocker sole, orthotics
- operative: cheilectomy, fusion
describe adhesive capsulitis (frozen shoulder)
- common in middle age and diabetics
clinical features (typically develop over days)
- painful, stiff movement
- limited active and passive movement in all directions
- loss of external rotation and abduction
phases: painful freezing phase, adhesive phase, thawing phase
clinical diagnosis
management
- NSAIDs
- physiotherapy
- oral or intra-articular corticosteroids
what is the most common reason total hip replacements need to be replaced?
aseptic loosening of the hip replacement
describe calcific tendonitis
calcification and tendon degeneration near the rotator cuff insertion
diagnosis - X-ray
> calcium deposits overlying the rotator cuff insertion
treatment
- NSAIDs
- physiotherapy
- steroid injections
- US-guided needle lavage
describe rotator cuff tears
causes: traumatic injuries in young patients as well as degenerative disease in the elderly patient
clinical features
- pain of insidious onset with pain worse on overhead activities
- pain in deltoid region
- night pain
- acute pain and weakness with with traumatic tear
- loss of active ROM with normal passive ROM
gold standard investigation - MRI
management
- NSAIDs
- physiotherapy
- subacromial corticosteroid injections
- surgery
describe rotator cuff arthropathy
rotator cuff tear leading to abnormal glenohumeral wear and subsequent superior migration of the humeral head
clinical features
diagnosis
- shoulder X-ray showing glenohumeral arthritis with a decreased acromiohumeral interval
treatment
- minimally symptomatic:
> activity modification
> subacromial steroid injections
> physical therapy
shoulder arthroplasty if progressive pain and deterioration of shoulder function
list complications of distal radius fracture
- median nerve injury
- compartment syndrome
- vascular compromise
- malunion
- rupture of extensor pollicis longus tendon
late: OA, complex regional pain syndrome
describe osteochondritis dissecans
fragment of bone in the knee becomes detached due to a lack of blood supply
most common in young adults who are active / participate in sports
features
- knee pain
- intermittent swelling
- locking of joint
describe Sever’s disease
aka calcaneal apophysitis
type of growing pain
Calcaneus grows
faster than leg muscles / tendons - leads to tight Achilles tendon and calf
> in active children, calcaneus is pulled hard by the Achilles tendon,
leading to tiny cracks
-> pain, swelling and tenderness
of heel
Usually age 8-14, settles by age 15
Management: analgesia, keep as
active as pain allows, ice, stretching exercises
describe superior gluteal nerve damage
clinical features
- lateral pelvic tilt
- trendelenburg gait
- reduced hip abduction
- positive Trendelenburg’s test
investigations: MRI
complication of hemiarthroplasty
management
- supportive: walking stick on contralateral side
- if associated with arthroplasty, usually recovery within 2y
describe radial tunnel syndrome
due to compression of the radial nerve within radial tunnel near elbow
presents similarly to lateral epicondylitis but pain is typically distal to epicondyle
pain worse on elbow extension / forearm pronation
may also have numbness/tingling in dorsum of hand or fingers due to compression of radial nerve
describe ankle sprains
inversion injury: anterior talofibular ligament
eversion injury: deltoid ligament
