Orthopaedics Flashcards
Classification of open #?
Gustilo - Anderson Grading system
Greenstick #?
A childhood fracture of young, soft bone in which the bone bends and bMixereaks
McMurray test?
Used to evaluate tears in the menisci of the knee joint.
Test by flexing knee with a values stress on the knee and ext rotating the foot. Lateral meniscus
Likewise, then flex knee with varrus stress and int rotate the foot. Medial meniscus.
Other examination pointers:
Test for collaterals without full extension.
Don’t look at examiner for reassurance.
Which nerve runs next to fibula? What can a # here causes?
Common perennial nerve. Damage can lead to foot drop
Radial nerve function?
Sensory and Motor.
Sensation thumb and first finger (back of hand)
Motor - wrist, finder extenstion (WRIST DROP)
Median Nerve function?
Mixed
Sens - thumb, index, middle and 1/2 ring finger
Motor - thenar eminence (BENEDICTION SIGN, APE HAND DEFORMITY)
Where can back pain come from?
Bones Discs Facet Joints Muscles and Ligaments Nerves Extra-spinal areas (Kidneys, pancrease, aorta)
Pathological Processes?
Degeneration Trauma Infection Malignancy Inflammation Metabolic Congenital Psychological
Cardinal Features of Acute/Chronic nerve root pain?
Leg pain worse than back pain
Pain to areas below knee
Paraesthesia, numbness, weakness (not always)
Nerve Root Tension Signs
Symptoms of acute lumbar nerve root pain
Severe predominant leg pain radiating below knee
Paraesthesia and numbness
Pain aggravated by coughing
Signs of acute lumbar nerve root pain
Loss of Lordosis (flat lower back)
Stiffness
Root tension signs
(Sometimes) abnormal neurology of single root - ir foot weakness, loss of ankle (S1) or knee (L3/4) reflex, numbness of single dermatome
What are the root tension signs?
Straight leg raise (SLR) - L5 and S1 compression results in pain (Secondary to disc protrusion at L4/5 or L4/S1 level)
Femoral stretch test - L3 and L4 compression gives pain (Secondary to L2/3 or L3/4 protrusion).
Differentials to consider in disc prolapse?
Peripheral Vascular Disease (therefore check pulses and circulation)
OA of hip/knees
Management of disc protrusion?
First 6 weeks: explanation/reasurance analgesia avoid lng bed rest mobilisation physio
After 6 weeks: Recheck red flags XRay/MRI Physio Patience Specialist Referal Epidural steroid and analgesia
After 2/3 months:
Discectomy (standard/micro)
Indications for a discectomy
Severe leg pain unresponsive to conservative measures (hx of sciatica, exam with nerve root tension, mri = disc prolapse)
Cauda Equina compression
Progressive neurological deficit
What is Cauda Equina Syndrome?
Massive central disc prolapse compressing nerves to bladder and bowel (S2,3,4) as well as L5 ad S1 roots
Symptoms and Signs of Cauda Equina Syndrome?
Acute bilateral leg pain
Bladder and bowel dysfunction
Saddle Anaesthesia
Weakness of foot, no ankle jerks
MRI shows massive L4/5 disc protrusion
Management?
urgent decompression
however this will still usually leave incomplete recovery from bladder and bowel symptoms
Which condition can cause neurological claudication?
Spinal Stenosis
Red flags for sinister back pain?
Extreme of age (under 20, over 55) Acute onset Nocturnal pain Fever, night sweats, weight loss Hx of malignancy Abdomincal mass Thoracic back pain Morning stiffness Bilateral or alternating pain Neurological disturbance Sphincter disturbance Current of recurrent infection Immunosuppresion Neuological Claudication (spinal stenosis)
Typical symptoms in spinal stenosis?
Over 50yrs
Previous hx of LBP
Bilateral leg pain on walking/standing with weakness and numbness
Improved with flexing (better walking uphill/rising a bike)
Examination findings?
Flat spine/Simian stance (leaning forward with hip and knees flexed - like a ape)
No stiffness
No significant neurology
Normal Pulses
SLR decreased or normal
Differentials in spinal stenosis?
PVD - intermitant claudicaiton
Peripheral neuropathy
Serious, sinister pathology in back pain?
Primary malignancy incl. myeloma
Secondary Malignancy (breast, prostate, lung, kidney, thyroid)
Infection
Inflammatory Disease (Ank. Spond.)
These all have RED FLAG symptoms
3 Joints of shoulder?
Gleno-humeral joint
Scapulo-thoracic joint
Acromio-clavicular joint
Ligaments of shoulder?
Coracoclavicular ligament (stabilizes A_C joint) Coracoacromial Joint
Muscles of Shoulder?
ROTATOR CUFF
Supraspinatus (abduction)
Infraspinatus and teres minor (ext. rotation)
Subscapularis (int. rotation)
Blood and Nerve Supply?
Axillary artery and nerve
Burse of shoulder?
Subacromial bursa, lies underneath acromium and above rotator cuff.
Can become inflammed after trauma and give rise to impingement pain.
Symptoms and signs of impinged rotator cuff?
Painful shoulder, esp in overhead movements
Tender greater tuberosity
Painful arc - rotator cuff rubbing against acromium
Positive impingement test (e.g Hawkin’s Test)
A completely torn rotator cuff results in complete loss of active abduction (passive fine) BUT if arm is passively listed to 30 degrees then deltoid take over and full abduction occurs
Hawkin’s test?
Hawkin’s Test assesses for possible rotator cuff impingement. Stabilize the scapula, passively abduct the shoulder to 90 degrees, flex the shoulder to 30 degrees, flex the elbow to 90 degrees, and internally rotate the shoulder. Pain is a positive test.
http://sitemaker.umich.edu/fm_musculoskeletal_shoulder/hawkin_s_test
Investigation of impinged rotator cuff?
X-ray Ultrasound Arthrogram Arthroscopy MRI
Treatment of impinged rotator cuff?
Explanation of symptoms Analgesia Physiotherapy Subacromial steroid injection Arthroscopic decompression subacromially
Frozen shoulder - what is it?
Painful and stiff shoulder with restricted movement in all directions
Associated with normal x-ray
Secondary to fibrosis and contractures of the gleno-humeral capsule
Clinical course?
Painful phase and beginning of stiff phase
Stiff phase, reducing pain
Recovery phase
Lasts for 2 years then improves, never to 100% however
