Orthopaedics Flashcards
Bone Composition
Cells - osteoblasts, osteoclasts, osteocytes, OPCs
Matrix
Organic (osteoid 40%)
Collagen Type I
Resists tension, twisting and bending
Inorganic (60%)
Calcium hydroxyapatite
Resists compressive forces
Classification
Woven Bone - disorganised structure forms embryonic skeleton and fracture callus
Lamellar bone - mature bone (2 types)
- cortical/compact - dense outer layer
- Cancellous/trabecular - porous central layer
Intramembranous Ossification
Direct ossification of mesenchymal bone models - formed during embryonic development
skull bones, mandible + clavicle
Endochondral Ossification
Mesenchyme → cartilage → bone
Most bones ossify this way
Fracture Healing
Reactive Phase (injury - 48h)
- bleeding into # site - haematoma
- inflammation - granulation tissue by leukos + fibroblasts
Reparative phase (2 days- 2weeks)
- proliferation - osteoblasts + fibroblasts > cartilage + woven bone production > callus formation
- Consolidation (endochondral ossification) of woven bone > lamellar bone
Remodelling Phase (1wk - 7yrs) 5. Remodelling of lamellar bone to cope w mechanical forces applied to it
healing time
Closed, paediatric, metaphyseal, upper limb: 3wks
“Complicating factor” doubles healing time Adult Lower limb Diaphyseal Open
Fracture Classification
Traumatic #
- direct (eg assault w metal bar)
- indirect (FOOSH > clavicle #)
- avulsion
Stress #
- bone fatigue due to repetitive strain
- eg foot # in marathon runners
Pathological #
- normal force, diseased bone
Local: tumours
General: osteoporosis, Cushing’s, Paget’s
Describing Fractures
Radiographs must be orthogonal
Need Images below and above joint #
D PAID S S
Demographics
Pt. details
Date radiograph taken
Orientation and content of image
Pattern Transverse Oblique Spiral Multifragmentary Crush Greenstick Avulsion
Anatomical Location
Intra/extra-articular (dislocation or subluxation)
Deformity (distal relative to proximal) Translation Angulation or tilt Rotation Impaction (→shortening)
Soft tissues
Open or closed
Neurovascular status
Compartment syndrome
Specific # classification type
Salter-Harris
Garden
Colles’, Smith’s, Galeazzi, Monteggia
Management
4 Rs Resuscitation Reduction Restriction Rehabilitation
Mx 1. Resuscitation
ATSL guidelines
Trauma series in 1mary survey: C-spine, chest and pelvis
# usually assessed in 2ndary survey
Assess neurovascular status + look for dislocations
Consider reduction + splinting before imaging
↓ pain
↓ bleeding
↓ risk of neurovascular injury
X-ray once stable
Open frature requires urgent attention
Open fracture urgent attention
6As
Analgesia: M+M
Assess: NV status, soft tissues, photograph
Antisepsis: wound swab, copious irrigation, cover with
betadine-soaked dressing.
Alignment: align # and splint
Anti-tetanus: check status (booster lasts 10yrs)
Abx
Fluclox 500mg IV/IM + benpen 600mg IV/IM
Or, augmentin 1.2g IV
Mx: debridement and fixation in theatre
Gustillo Classification of Open #s
- Wound <1cm in length
- Wound ≥1cm c¯ minimal soft tissue damage
- Extensive soft tissue damage
Fracture Mx 2. Reduction
Displaced #s should be reduced (unless no effect on outcome - ribs)
Aim for anatomical reduciton (esp if articular surfaces)
Alignment more important than opposition
Methods - Manipulation/closed reduction Under local, regional or general anaesthetic Traction to disimpact Manipulation to align
-Traction Not typically used now. Employed to overcome contraction of large muscles: e.g. femoral #s Skeletal traction vs. skin traction
- Open reduction (+ internal fixation) Accurate reduction vs. risks of surgery Intra-articular #s Open #s 2 #s in 1 limb Failed conservative Rx Bilat identical #s
Fracture Management 3. Restriction
Interfragmentary strain hypothesis > tissue formed at # site depends on strain it experiences
Fixation → ↓ strain → bone formation
Fixation also → ↓ pain, ↑ stability, ↑ ability to function
Methods
Non-Rigid - slings, elastic supports
Plaster - POP
- in first 24-48h use back slab or split cast (risk of compartment syndrome)
Functional bracing - joints free to move but bone shafts support in cast segments
Continuous traction (collar + cuff)
Ex-fix
- Fragments held in position by pins/wires > connected to external frams
- intervention is away from field of injury
- useful in open #s, burns, tissue loss to allow wound access + ↓ infection risk.
- risks pin site infections
Internal fixation
- pins, plates, screws, IM nales
- usually perfect anatomical alignment
- increase stability
- aid early mobilisation
Mx 4. Rehabilitation
Immobility → ↓ muscle and bone mass, joint stiffness
Need to maximise mobility of uninjured limbs
Quick return to function ↓s later morbidity
Methods
Physiotherapy: exercises to improve mobility
OT: splints, mobility aids, home modification
Social services: meals on wheels, home help
Complications (General)
Tissue Damage
- haemorrhage + shick
- infection
- muscle damage - rhabdomyolysis
Anaesthesia
- anaphylaxis
- damage to teeth
- aspiration
Prolonged Bed rest
- chest infection, UTI
- Pressure sores + muscle wasting
- DVT, PE
- ↓ BMD
Complications (Specific)
Immediate
- neurovascular damage
- visceral damage
Early
- Compartment syndrome
- infection
- fat embolism - ARDS
Late
- problems w union
- AVN
- growth disturbance
- Post-traumatic osteoarthritis
- Complex regional pain syndromes
- Myositis ossificans
Neuro complications
severance is rare, stretching over bone edge more common
Seddon classification - 3 types
neuropraxia
axonotmesis
neurotmesis
Neuropraxia
temporary interruption of conduction w/o loss of axonal continuity
Axonotmesis
disruption of nerve axon > distal wallerian
neurotmesis
disruption of entire nerve fibre
surgery required and recovery usually incomplete
complications - Common Palsies
Ant shoulder dislocation, humeral surgical neck
> Axillary nerve Palsy
Test/result
Numb chevron - weak abduction
humeral shaft
complications - Common Palsies
Radial Nerve
Waiter’s tip
complications - Common Palsies
Elbow dislocation
Ulnar nerve
Claw hand
complications - Common Palsies
Hip dislocation
Sciatic nerve
foot drop
complications - Common Palsies
# neck of fibula knee dislocation
fibular nerve
foot drop
Compartment Syndrome
Osteofacial membranes divide limbs into separate
compartments of muscles.
Oedema following # → ↑ compartment pressure → ↓
venous drainage → ↑ compartment pressure
If compartment pressure > capillary pressure → ischaemia
Muscle infarction →
Rhabdomyolysis and ATN
Fibrosis → Volkman’s ischaemic contracture
Compartment syndrome Presentation + Rx
Pain > clinical findings
Pain on passive muscle stretching
Warm, erythematous, swollen limb
↑ CRT and weak/absent peripheral pulses
Rx
- elevate limb
- remove all bandages + split/remove cast
- fasciotomy
# complications Problems with union
Causative factors 5 Is
Delayed union/Non-union of fracture
Causative factors - 5 Is
- Ischaemia (poor blood supply or AVN)
- Infection
- ↑ interfragmentary strain
- Interposition of tissue between fragments
- intercurrent disease - eg malignancy or malnutrition
complications
Non-union classifcation
Mx
Malunion
Non-union classification
- hypertrophic - bone end rounded, dense and slerotic
- atophic - bone looks osteopenic
Management
Optimise biology: infection, blood supply, bone graft, BMPs
Optimise mechanics: ORIF
Malunion - #healed in imperfect position
Poor appearance and/or function
E.g. Gunstock deformity
Avascular necrosis
Death of bone due to deficient blood supply.
Sites: femoral head, scaphoid, talus
Consequence: bone becomes soft and deformed
→ pain, stiffness and OA.
X-ray: sclerosis and deformity.
Myositis Ossificans
Heterotopic ossification of muscle at sites of haematoma formation
> restricted painful movements
> commonly elbows + quadriceps
> can be excised surgically
Pellegrini-Stieda disease
- form of MO
- calcification of superior attachment of Medial Collateral Ligament at knee following trauma
Hip fracture RF
Osteoporosis w minor trauma
Major trauma
RF - Age + SHATTERED
Steroids Hyper-para/thyroidism Alcohol + Cigarrettes Thin (BMI <22) Testosterone low Early Menopause Renal/Liver Failure Erosive/inflamed bone disease (RA, myeloma) Dietary Ca Low/ Malabsorption, DM
Hip Fracture Presentation
O/E shortened and externally rotated
Qs Mechanism RFs for osteoporosis / pathological # Premorbid mobility Premorbid independence Comorbidities MMSE
Hip Fracture Initial Mx
Resuscitate: dehydration, hypothermia
Analgesia: M+M
Assess neurovascular status of limb
Imaging: AP and lateral films
Prep for theatre Inform Anaesthetist and book theatre Bloods: FBC, U+E, clotting, X-match (2u) CXR DVT prophylaxis: TEDS, LMWH ECG Films: orthogonal X-rays Get consent
Hip fracture Imaging
Ask for AP and lateral film Look @ Shenton’s lines Intra- or extra-capsular? Displaced or non-displaced Osteopaenic?
Hip fracture Key Anatomy
Capsule attaches proximally to acetabular margin and
distally to intertrochanteric line.
Blood supply to fem head:
- Retinacular vessels, in capsule, distal → prox
- Intramedullary vessels
- Artery of ligamentum teres.
If retinacular vessels damaged there is risk of AVN of the femoral head → pain, stiffness and OA
Hip Fracture Classification
(Garden classification
Intracapsular: subcapital, transcervical, basicervical
Extracapsular: Intertrochanteric, subtrochanteric
Garden Classification of Intracapsular Fractures
- Incomplete #, undisplaced
- Complete #, undisplaced
- Complete #, partially displaced
- Complete #, completely displaced
Hip Fracture Surgical Mx
Intracapsular
1,2: Open Reduction Internal Fixation w cancellous screws
3,4:
<55: ORIF c¯ screws.
f/up in OPD and do arthroplasty if AVN
develops (in 30%)
55-75: total hip replacement
> 75: hemiarthroplasty
Mobilises: cemented Thompson’s
Non-mobiliser: uncemented Austin Moore
Extracapsular
ORIF c¯ DHS
Hip # Surgical Discharge
complications
Prognosis
Involve OT + physio
Discharge when mobile + social circumstances permit
Spec complications
- AVN of femoral head if displaced #
- Non/malunion
- Infection
- Osteoarthritis
Prgn
- 30% mortality at 1 year
- 50% never regain premorbid function
10+% unable to return to premorbid residence
- majority will have residual pain/disability
Colle’s Fracture
Falling onto outstretched hands
elderly females w osteoporosis
dinner fork deformity
Radiology xtra-articular # of dist. radius (w/i 1.5” of joint) Dorsal displacement of distal fragment Dorsal angulation of distal fragment Normally 11 degrees volar tilt ↓ radial height (norm =11mm) ↓ radial inclination (norm=22degrees) ± avulsion of ulna styloid ± impaction
Colle’s# Mx
Examine neurovascular injuries - median nerve
and radial artery lie close.
If displaced a lot > reduce
Under haematoma block, IV regional anaesthesia
(Bier’s block) or GA.
Disimpact and correct angulation.
Position: ulnar deviation + some wrist flexion
Apply dorsal backslab: provide 3-point pressure
Re- XR - ortho review if not satisfactory position (MUA w K wires)
- if ok - home + #clinic w/i 48 hours for completion of POP (plaster)
If comminuted, intra-articular or re-displaces
- surgical fixation w ex-fix, kirschner wires or ORIF + plates
Colle’s # Spec Complications
Median N. injury Frozen shoulder / adhesive capsulitis Tendon rupture: esp. EPL Carpal tunnel syn. Mal- /non-union Sudek’s atrophy / CRPS
Smith’s / Reverse Colles’
Fall onto back of flexed wrist
Fracture of distal radius c¯ volar displacement and
angulation of distal fragment.
Reduce to restore anatomy and POP for 6wks
Barton’s Fracture
Oblique intra-articular # involving the dorsal aspect of distal radius and dislocation of radio-carpal joint
Reverse Barton’s involves the volar aspect of the radius
Scaphoid #s
Clinical features
FOOSH (fall onto outstretched hand)
Pain in anatomical snuffbox
pain on telescoping thumb
Mx
- Request scaphoid XR view
- If hx and exam > scaphoid #, initially treat even if XR normal
# may become apparent after 10d > localised decalcification.
- Place wrist in scaphoid blaster (beer glass position)
- if initial XR negative, pt returns to clinic after 10 days for re-XR
# visible → plaster for 6 wks
No visible # but clinically tender → plaster for 2
wks
# not visible and not clinically tender → no plaster
Scaphoid # complications
AVN of scaphoid - supply runs distal to proximal
> stiffness + pain at wrist
Radial + Ulna Shaft #
Classification
Monteggia
# of proximal 3rd of ulna shaft
Anterior dislocation of radial head at capitellum
May → palsy of deep branch of radial nerve →
weak finger extension but no sensory loss
Galleazzi
# of radial shaft between mid and distal 3rds
Dislocation of distal radio-ulna joint
Radial + Ulna Shaft #
Spec Mx
Unstable fractures
Adults: ORIF
Children: MUA + above elbow plaster
Fractures of forearm should be plastered in most stable position: Proximal #: supination Distal #: pronation Mid-shaft #: neutral
Shoulder Dislocation Classification
Anterior
95% of shoulder dislocations.
Direct trauma or falling on hand
Humeral head dislocates antero-inferiorly
Posterior
Caused by direct trauma or muscle contraction
(seen in epileptics).
Shoulder dislocation associated lesions
Bankhart Lesion - damage to anteroinferior glenoid labrum
Hill-Sachs Lesion
- cortical depression in posterolateral part of humeral head following impaction against glenoid rim during anterior dislocation
- 35-40% anterior dislocation
Shoulder dislocation presentation
Shoulder contour lost: appears square
Bulge in infraclavicular fossa: humeral head
Arm supported in opposite hand
Severe pain
Shoulder dislocation specific Mx
assess neurovasc deficit (esp axillary nerve)
Sensation over “chevron” area before and after
reduction.
Occurs in 5%
XR - AP and transcapular view
Reduction under sedation (propafol)
Hippocratic: Longitudinal traction c¯ arm in 30O
abduction and counter traction @ the axilla
Kocher’s: external rotation of adducted arm,
anterior movement, internal rotation
Rest Arm in sling 3-4 weeks
Physio
Shoulder Dislocation Complications
Recurrent dislocation
- 90% pt <20yr with traumatic dislocation
Axillary Nerve Injury
Recurrent Shoulder instability
TUBS - Traumatic Unilateral dislocations w Bankhart lesion oft require Surgery
AMBRI - Atraumatic Multidirectional Bilateral shoulder dislocation treated w Rehabilitation - may require inferior capsular shift
Impingement Syndrome/Painful arc
Entrapment of supraspinatus tendon + subacromial bursa betw acromnion + greater tuberosity of humerus
> subacromial bursitis +/or supraspinatous tendonitis
Impingement Syndrome/Painful arc
Presentation + Ix
Presents
Painful arc: 60-120 degrees
Weakness and ↓ ROM
+ve Hawkin’s test
Ix
Plain radiographs: may see bony spurs
US
MRI arthrogram
Impingement Syndrome/Painful arc
Rx
Conservative
Rest
Physiotherapy
Medical
NSAIDs
Subacromial bursa steroid ± LA injection
Surgical
Arthroscopic acromioplasty
Impingement Syndrome/Painful arc
DDx
Impingement
Supraspinatous tear or partial tear
AC joint OA
Frozen shoulder - Adhesive capsulitis
Progressive ↓ active and passive ROM
↓ ext. rotation <30O
↓ abduction <90O
Shoulder pain, esp night (can’t lie on affected side)
Cause - unknwon, may follow trauma in elderly (assw DM)
Rx - conservative - rest, physio
- Medical - NSAIDs, subacromial bursa steroid +/- LA injection
Rotator Cuff Tear
2ndary to degen or sudden jolt/fall
Partial Tears > painful arc
Complete tear > shoulder tip pain
- full range of passive movement
- inability to abduct arm
- active abduction possible following passive abduction to 90 degrees
- lowering arm beneath this > sudden drop (DROP ARM SIGN)
Supracondylar fractures of the humerus
Presentation
Common in children after FOOSH
Elbow very swollen and held semi-flexed.
Sharp edge of proximal humerus may injure brachial artery which lies anterior to it.
Supracondylar fractures of humerus
Classification
Extension
- Commonest type
- Distal fragment displaces posteriorly
- Gartland further classified extension type
Gartland further classified extension type:
Type 1: non-displaced
Type 2: angulated c¯ intact posterior cortex
Type 3: displaced c¯ no cortical contact
Flexion
- less common
- distal fragment displaces anteriorly
Supracondylar fractures of humerus
Spec Mx
Ensure no neurovascular damage
If radial pulse absent or damage to brachial
artery suspected, URGENT theatre for reduction ± on-table angiogram.
Median nerve is also vulnerable
Restore anatomy
No displacement → flex the arm as fully as
possible and apply a collar and cuff for 3wks –
triceps acts as sling to stabilise fragments.
Displacement → MUA + fixation with K-wires +
collar and cuff with arm flexed for 3wks.
Supracondylar fractures of humerus
Specific Complications
Neurovascular Injury
- Brachial artery
- Radial nerve
- Median nerve - esp anterior interosseus branch
>supplies deep forearm felxors (FPL, lateral half of FDP and pronator quadratur)
Compartment Syndrome
Monitor closely first 24h
Pain on passive extension of the fingers (stretches
flexor compartment) is early sign.
Mx: try extension of the elbow, surgical Rx may be
needed.
Volkmann’s ischaemic contracture can result → fibrosis of flexors → claw hand.
Gunstock Deformity
Valgus, varus and rotational deformities in the coronal plane do not remodel and → cubitus varus.
Cubitus varus deformity is referred to as a “gunstock”
deformity.
Femoral + Tibial Fractures
Spec Mx - Resus + Mx life-thretening - X-match Tibial #: 2 units Femoral #: 4 units
- Assess neurovascular status (esp distal pulses)
If Open
- abx + ATT (tetanus?)
- theatre for urgent debridement + washout + stabilisation
Fixation methods
- IM nail
- Ex- fix
- plates + screws
- MUA (manipulation under anaethesia) w fixed traction for 3-4m
Femoral + Tibial Fractures
Spec Complications
Hypovolaemic shock
Neurovascular
SFA: swelling and check pulses
Sciatic nerve
Compartment syndrome
Respiratory complications
Fat embolism
ARDS
Pneumonia
Ankle Injury
Ligament Strains
Typically twisting inversion injury
Strains anterior talofibular part of lateral collateral
ligament
Medial deltoid ligament strains are rare.
May be assw malleolar avulsion #s
Ankle Fracture
Ottowa ankle rules
X-ray ankle if pain in malleolar zone + in any of:
Tenderness along distal 6cm of posterior tib / fib
including posterior tip of the malleoli.
Inability to bear weight both immediately and in
ED
Ankle Fracture
Weber Classification
Relation of fibula # to joint line
A: below joint line
B: at joint line
C: above joint line
Weber’s B and C represent possible injury to the syndesmotic ligaments between tib and fib → instability
Ankle Fracture Mx
Weber A
Boot or below-knee POP
Non-displaced Weber B/C
Below-knee POP
Displaced Weber B/C
Closed reduction and POP if anatomical reduction achieved
ORIF if closed reduction fails
Knee Injury Hx
Mechanism
Swelling
Immediate = haemarthrosis = # or torn cruciates
Overnight = effusion = meniscus or other lgt
Pain / tenderness
Joint line = meniscal
Med/lateral margins = collateral lgts.
Locking: meniscal tear → mechanical obstruction
Giving way: instability following lgt. injury
Knee haemarthrosis
Primary Spont Bleeding
- coagulopathy, warfarin, haemophilia
Secondary trauma
- ACL injury 80%
- Patella Dislocation 10%
- Meniscal injury 10% - outer third where its vascularised
- osteophyte
Unhappy triad of O’Donoghue
ACL
MCL
Medial Meniscus
Mx of acutely injured knee
Full examination of acutely swollen knee after injury is
difficult.
Take x-ray to ensure no #s
Fluid level indicates a lipohaemarthrosis and
indicates either a # or torn cruciate.
If no # → RICE + later re-examination for pathology
If meniscal or cruciate injury suspected → MRI
Arthoroscopy
Direct vision of inside of knee joint by arthroscope
Can examine knee under anaesthesia (↓ muscle tone)
Meniscal tears can be trimmed or repaired.
Mx of Ruptured ACL
Conservative
Rest
Physio to strengthen quads and hamstrings
Not enough stability for many sports
Surgical
Gold-standard is autograft repair
Usually semitendinosus ± gracilis (can use patella
tendon)
Tendon threaded through heads of tibia and femur and
held using screws
Osteoarthritis
Degenerative Joint disorder - progressive loss of hyaline cartilage + new bone formation at joint surface and its margin
RF Age, obesity, joint abnormality
Classification
- Primary - no underlying cause
- Secondary - obesity, joint abnormality
Osteoarthritis Sx + Signs
Sx
Affects: knees, hips, DIPs, PIPs, thumb CMC
Pain: worse c¯ movement, background rest/night pain,
worse @ end of day.
Stiffness: especially after rest, lasts ~30min (e.g. AM)
Deformity
↓ ROM
Signs
Pouchards (prox), Heberdips (dist.)
Thumb CMC squaring
Fixed flexion deformity
Osteoarthritis Hx
Pain severity, night pain Walking distance Analgesic requirements ADLs and social circumstances Co-morbidities Underlying causes: trauma, infection, congenital
Osteoarthritis Path
Softening of articular cartilage → fraying and fissuring of smooth surface → underlying bone exposure.
Subchondral bone becomes sclerotic c¯ cysts.
Proliferation and ossification of cartilage in unstressed
areas → osteophytes.
Capsular fibrosis → stiff joints.
Osteoarthritis XR changes
Loss of joint space Osteophytes Subchondral cysts Subchondral sclerosis Deformity
Osteoarthritis Bloods
CRP may be mildly elevated
Ca, PO4 and ALP all normal
Osteoarthritis Rx
Conservative + Medical
MDT: GP, physio, OT, dietician, orthopod
Conservative
Lifestyle: ↓ wt., ↑ exercise
Physio: muscle strengthening
OT: walking aids, supportive footwear, home mods
Medical
Analgesia (paracetamol, NSAIDs, Tramol)
Joint injection - local anaesthetic + steroids
Osteoarthritis Surgical Rx
Arthroscopic Washout
>Mainly knees
>Trim cartilage
>Remove loose bodies.
Realignment Osteotomy
>Small area of bone cut out
>Useful in younger (<50yrs) pts. w medial knee OA
>High tibial valgus osteotomy redistributes wt. to lateral part of joint.
Arthroplasty: replacement (or excision)
Arthrodesis: last resort for pain management
Novel Techniques
Microfracture: stem cell release → fibro-cartilage
formation
Autologous chondrocyte implantation
Back pain (Mechanical Pain)
Soft tissue injury > dysfunction of whole spine > muscle spasm > pain
May have incited event (lifting)
Younger pt w no sinister features
Mx
- Conservative
Max 2d bed rest
Education: keep active, how to lift / stoop
Physiotherapy
Psychosocial issues re. chronic pain and disability
Warmth: e.g. swimming in a warm pool
Medical
Analgesia: paracetamol ± NSAIDs ± codeine
Muscle relaxant: low-dose diazepam (short-term)
Disc Prolapse definition + presentation
Herniation of nucleus pulposus through annulus fibrosus
Presents
L5 and S1 roots most commonly compressed by prolapse of L4/5 and L5/S1 discs.
May present as severe pain on sneezing, coughing or twisting a few days after low back strain
Lumbago: low back pain
Sciatica: shooting radicular pain down buttock and thigh
Disc Prolapse Signs
Limited spinal flexion and extension
Free lateral flexion
Pain on straight-leg raise: Lesague’s Sign
Lateral herniation → radiculopathy
Central herniation → corda equina syndrome
L4/5 disc prolapse > L5 root compression
Weak hallux extension ± foot drop
In foot drop due to L5 radiculopathy, weak
inversion (tib. post.) helps distinguish from
peroneal N. palsy.
↓ sensation on inner dorsum of foot
L5/S1 disc prolapse → S1 Root Compression
Weak foot plantarflexion and eversion
Loss of ankle-jerk
Calf pain
↓ sensation over sole of foot and back of calf
Disc Prolapse Ix + Rx
Ix: MRI (emergency if cauda equina)
Rx
Brief rest, analgesia and mobilisation effective in ≥90%
Conservative: brief rest, mobilisation/physio
Medical: analgesia, transforaminal steroid injection
Surgical: discectomy or laminectomy may be needed in cauda-equina syndrome, continuing pain or muscle
weakness.
Lumbar Microdisectomy
Commonest procedure for disc prolapse
Microscopic resection of the protruding nucleus pulposus
Posterior approach c¯ pt. in prone position.
May be performed endoscopically
Spondylolisthesis
Displacement of one lumbar vertebra on another
- usually forward
- usually L5 on S1
May be palpable
Causes - congen malf, spondylosis, OA
Presentation - onset of pain usually in adolescence or early adulthood > worse on standing
+/- sciatica, hamstring tightness, abn gait
Dx - Plain Radiography
Rx - Corset, nerve release, spinal fusion
Spinal Stenosis
Dev predisposition +/- facet joint OA > generalised narrowing of lumbar spinal canal
Presents Spinal Claudication - aching or heavy buttock and lower limb pain on walking - Rapid onset - May c/o paraesthesiae/numbness - Pain eased by leaning forward
Pain on spine extension
Ix - MRI
Rx - Corsets
NSAIDs
Epidural steroid injection
Canal decompression surgery
Neurosurgical Emergencies
Acute Cord Compression
Bilateral pain: back and radicular
LMN signs at compression level
UMN signs and sensory level below compression
Sphincter disturbance
Neurosurgical Emergencies
Acute Cauda Equina Compression
Alternate or bilateral radicular pain in legs
Saddle anaesthesia
Loss of anal tone
Bladder +/- bowel incontinence
Neurosurgical emergencies
Rx
Acute cord compression and Acute cauda equina compression
Large prolapse - laminectomy/disectomy
Tumours - radiotherapy and steroids
Abscesses - decompression
Osteochondritis
idiopathic condition > bony centres of children/adolescents become temporarily softened due to osteonecrosis
Pressure > deformation
Bone hardens in new deformed position
Radiography - intially ^density/sclerosis
- then patchy appearance
Osteochondritis
Scheuermann’s Disease
Vertebral ring epiphyses
AD
Vertebral Tenderness + kyphosis
XR - wedge-shaped thoracic vertebra
Osteochondritis
Kohler’s Disease
Navicular Bone
Children 3-5 years
Pain in mid-tarsal region > limp
Osteochondritis
Kienbochs Disease
Lunate bone
Adults
Pain over lunate, esp on active movement
impaired grip
Osteochondritis
Friedberg’s Disease
2nd/3rd metatarsal heads
around puberty
forefoot worse w pressure
Osteochondritis
Panner’s Disease
Perthe’s Disease
Panner’s - Capitulum of humerus
Perthe’s - hip
Traction Apophysitis
Osgood-Shlatter’s
Tibial tuberosity apophysitis + patellar tendonitis
Children 10-14 years M>F 3:1
Assw physical activity
Sx - pain below knee, esp w quads contraction
XR - tuberosity enlargement +/- fratmentation
Rx - rest, consider POP
Traction Apophysitis
Sinding Larsen’s Disease
Tranction tendinopathy with calcification of proximal
attachment of patellar tendon
Children 8-10yrs
Traction Apophysitis
Sever’s Disease
Calcaneal apophysitis
8-13 years
Sx - pain behind heal + limping
Rx - physio
Osteochondritis Dissecans
Piece of bone + overlying cartilage dissects off into joint space
Commonly knee (Med fem condyle), also elbow, hip , ankle
Young adult/adolescent
Sx - pain, swelling, locking, decreased ROM
XR - loose bodies, lucent crater
Mx arthroscopic removal
Avascular necrosis
# or dislocation SCD, thallassaemia SLE Gaucher's Drugs - steroids, NSAIDs
Acute Osteomyelitis
Pathophysiology
Source - local or haematogenous
RF Vascular disease Trauma SCD (sickle cell) Immunosuppression (e.g. DM) Children Rich blood supply to growth plate :. usually affects metaphysis
Organisms Staph Strep E. coli Pseudomonas Salmonella (in SCD)
Acute Osteomyelitis
Sx + Signs
Ix
Mx
Symptoms and Signs
Pain, tenderness, erythema, warmth, ↓ROM
Effusion in neighbouring joints
Signs of systemic infection
Investigations
↑ESR/CRP, ↑WCC
+ve blood cultures in 60%
X-ray: Changes take 10-14d Haziness + ↓ bone density Sub-periosteal reaction Sequestrum and involucrum
MRI is sensitive and specific
Management
IV Abx: Vanc + cefotaxime until MCS known
Drain abscess and remove sequestra
Analgesia
Septic Arthritis
Pathyphysiology
Source: local or haematogenous.
RFs Joint disease (e.g. RA) CRF Immunosuppression (e.g. DM) Prosthetic joints
Organisms Staph: 60% Streps Gonococcus Gm-ve bacilli
Septic Arthritis Sx + Ix
Symptoms
Acutely inflamed tender, swollen joint.
↓ROM
Systemically unwell
Investigations Joint aspiration for MCS ↑↑ WCC (e.g. >50,000/mm3) : mostly PMN ↑ESR/CRP, ↑WCC, Blood cultures X-ray
Septic Arthritis Mx + Complications
Management IV Abx: vanc + cefotaxime Consider joint washout under GA Splint joint Physiotherapy after infection resolved
Complications
Osteomyelitis
Arthritis
Ankylosis: fusion
High (C5/6): Erb’s Palsy
abductors + external rotators paralysed
waiter’s tip position
Loss of sensation in C5/6
Low C8/T1: Klumpke’s Paralysis
Paralysis of small hand muscles
Claw hand
Loss of senstaion in C8/T1 Dermatomes
Radial Nerve C5-T1 injury
Low lesions - posterior interosseous nerve
Site: # around elbow or forearm (eg #head of radius)
Loss of extension of CMC joints (finger drop)
No sensory loss
High Lesions
Site: # shaft of humerus where N. is in radial groove.
Wrist drop
Loss of sensation to dorsum of thumb root (snuff box)
Triceps functions normally
Very High Lesions
Site: axilla – e.g. crutches or Sat night palsy
Paralysis of triceps and wrist drop
Ulnar nerve C8-T1 injury
Site
Elbow: cubital tunnel
Wrist: in Guyon’s Canal
Effects
Intrinsic hand muscle paralysis → claw hand
Ulnar paradox: lesion at elbow has less clawing as
FDP is paralysed, decreasing flexion of 4th/5th digits.
Weakness of finger ad/abduction (interossei)
Sensory loss over little finger
Tests
Can’t cross fingers for luck
Froment’s Sign: flexion of thumb IPJ when trying to
hold onto paper held between thumb and finger.
Indicates weak adductor policis.
Median Nerve C5-T1 Damage
Injury Above the Antecubital Fossa
Can’t flex index finger IPJs (e.g. on clasping hands)
Can’t flex terminal thumb phalanx (FPL)
Loss of sensation in median distribution
Injury at the Wrist
Typically affects abductor pollicis brevis
Carpal Tunnel Syndrome
Carpal Tunnel Syndrome
Anatomy
Carpal tunnel formed by flexor retinaculum and carpal
bones.
Contains 4 tendons of FDS 4 tendons of FDP 1 tendon of FPL Median N.
Median N. supplies LLOAF (aBductor pollicis brevis)
Palmer cutaneous branch travels superficial to flexor
retinaculum → spares sensation over thenar area
Causes of carpal tunnel syndrome
F>M
Primary/idiopathic
Secondary Water: pregnancy, hypothyroidism Radial # Inflammation: RA, gout Soft tissue swelling: lipomas, acromegaly, amyloidosis Toxic: DM, EtOH
Carpal Tunnel Sx + Signs
Symptoms
Tingling / pain in thumb, index and middle fingers
Pain worse @ night or after repetitive actions
Relieved by shaking / flicking
Clumsiness
Signs ↓ sensation over lateral 3½ fingers ↓ 2-point touch discrimination Early sign of irreversible damage Wasting of thenar eminence > Late sign of irreversible damage Phalen’s flexing and Tinel’s tapping
Carpal Tunnel Syndrome Ix, Non-surgical Mx
Ix
Not usually performed
Nerve conduction studies
US
Non-surgical Mx Mx of underlying cause Wrist splints Neutral position Esp. @ night Local steroid injections
Carpal Tunnel Syndrome Surgical Mx + complications
Carpal tunnel decompression by division of the flexor retinaculum
Complications
Scar formation: high risk for hypertrophic or keloid
Scar tenderness: up to 40%
Nerve injury
Palmar cutaneous branch of the median nerve
Motor branch to the thenar muscles
Failure to relieve symptoms
Carpal Tunnel Syndrome
Other Locations of Median Nerve Entrapment
Pronator syndrome
Entrapment between two heads of pronator teres
Anterior interroseous syndrome
> Compression of the anterior interosseous
branch by the deep head of pronator teres
> Muscle weakness only
Pronator quadratus
FPL (flexor pollicis longus)
Radial half of FDP
Dupuytren’s Contracture
Progressive, painless fibrotic thickening of palmar
fascia.
The Patient M>F Middle age / elderly Skin puckering and tethering Fixed flexion contracture of ring and little fingers Often bilateral and symmetrical MCP and IP joint flexion
Dupuytren’s Contracture Associations
BAD FIBERS Bent penis: Peyronies (3%) AIDS DM FH: AD Idiopathic: commonest Booze: ALD Epilepsy and epilepsy meds (phenytoin)
Reidel’s thyroiditis and other fibromatoses
Ledderhose disease
>Fibrosis of plantar aponeurosis
>5% c¯ dupuytren’s
Retropitoneal fibrosis
Smoking
Dupuytren’s Contracture Mx
Conservative: e.g. physio / exercises
Fasciectomy
e.g. when hand can’t be placed flat on the table.
Z-shaped scars: prevent contracture
Can damage ulnar nerve
Usually recurs
Differential
Skin contracture: old laceration or burn
Differential
Skin contracture: old laceration or burn
Tendon fibrosis, trigger finger
Ulnar N. palsy
Trigger Finger
Tendon nodule which catches on proximal side of
tendon sheath → triggering on forced extension.
→ Fixed flexion deformity
Usually ring and middle fingers
assw RA
Rx: steroid injection (high recurrence) or surgery
Ganglion definition + presentation
Smooth, multilocular cystic swellings
Mucoid degeneration of joint capsule or tendon sheath
May be in communication w joint capsules / tendons
Presentation
90% located on dorsum of wrist.
Subdermal, fixed to deeper structures.
Limits planes of movement
May cause pain or nerve pressure symptoms
Ganglion Mx + differential
Management
50% disappear spontaneously
Aspiration ± steroid and hyaluronidase injection
Surgical excision
Differential
Lipoma
Fibroma
Sebaceous cyst
Meralgia paraesthetica
Entrapment of lat cutaneous nerve of thigh betw ASIS + inguinal ligament
Pain +/- paraesthesia on lateral thigh
No motor deficit
↑ risk w obesity: compression by belts, underwear
Relieved by sitting down
Can occasionally be damaged in lap hernia repair
Chondromalacia Patellae
Predominantly young women
Patellar aching after prolonged sitting or climbing stairs
Pain on patellofemoral compression: Clarke’s test
Ix: no abnormality on X-ray
Rx: vastus medialis strengthening
Baker’s Cyst
Popliteal swelling arising betw the medial head of
gastrocnemius and semimembranosus muscle
Herniation from joint synovium
Usually 2ndary to OA
Rupture: acute calf pain and swelling
DVT differential
Hallux Valgus
Great toe deviates laterally @ MTP joint
Pressure of MTP against shoe → bunion
↑ wt. bearing @ 2nd metatarsal head
→ pain: “Transfer metatarsalgia”
→ hammer toe
Aetiology
Pointed shoes
Wearing high heals
Mx
Conservative: bunion pads, plastic wedge between
great and second toes.
Surgical: metatarsal osteotomy
Morton’s Metatarsalgia/neuroma
Pain from pressure on an interdigital neuroma between the metatarsals.
Pain radiates to medial side of one toe and lateral side of another.
Rx: neuroma excision
