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Yr3 - General Surgery > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

Principles of fracture management

A

Reduce
Hold
Rehabilitate

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2
Q

Pathophysiology of osteoarthritis

A

Degradation of cartilage and remodelling bone due to active chondrocytes
Release of enzymes break down collagen and proteoglycans destroying articular cartilage
Exposure of underlying subchondral bone -> sclerosis
Reactive remodelling -> formation of osteophytes and subchondral bone cysts
Loss of joint space

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3
Q

Risk factors for OA

A 
Primary
Secondary
- trauma
- infiltrative disease
- connective tissue disease
Obesity 
Advancing age
Female gender
Manual labour occupations
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4
Q

Clinical features of OA

A

Small joints of hands and feet, hip joint and knee joint
Insidious, chronic and gradually worsening
Pain and stiffness - worsened with activity
Deformity and reduced range of movement
Bouchard nodes - swelling of PIPJs
Heberden nodes - swelling of DIPJs

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5
Q

X-ray features of OA

A

Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis

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6
Q

Management of OA

A 
Conservative
- education
- weight loss
- physiotherapy
Medical
- simple anagesics
- topical NSAIDs
- intra-articular steriod injections
Surgical
- osteotomy
- arthrodesis
- arthroplasty
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7
Q

Outcomes of open fractions

A

Skin
Soft tissues
Neurovascular injury
Infection

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8
Q

Management of open fractures

A 
Urgent realignment and splinting of limb
Broad spectrum antibiotic cover
Tetanus vaccination
Photograph wound
Remove gross debris
Dress in saline-soaked gauze
Debridement of wound and fracture site
Skeletal stabilisation
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9
Q

Define compartment syndrome

A

Critical pressure increase within a confined compartmental space

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10
Q

Pathophysiology of compartment syndrome

A

Fluid deposition in compartment -> intra-compartmental pressure
Increase in hydrostatic pressure
Compression of traversing nerves - paraesthesia
Arterial inflow compromised

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11
Q

Clinical features of compartment syndrome

A 
Usually present within hours
Severe pain
- disproportionate to injury
- worse by passively stretching muscle bellies of muscles
- not improved by analgesia
Parasthesia
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12
Q

Investigations for compartment syndrome

A

Diagnosis is clinical
Intra-compartmental pressure monitor
Creatine kinase

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13
Q

Management of compartment syndrome

A

Keep limb at neutral level
Improve oxygen delivery with high flow oxygen
Augment blood pressure with bolus of IV crystalloid fluids
Remove all dressings/splints/casts
Treat symptomatically
Surgical fasciotomy
Monitor renal function - rhabdomyolysis or reperfusion injury

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14
Q

Main causative organisms of septic arthritis

A

S.aureus
Streptococcus spp
Gonorrhoea
Salmonella

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15
Q

Risk factors for septic arthritis

A 
Age > 80yrs
Pre-exisiting joint disease
DM 
Immunosuppression
Chronic renal failure
Hip or knee joint prosthesis
IV drug use
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16
Q

Clinical features of septic arthritis

A

Single swollen joint causing severe pain
Pyrexia
Red, swollen warm joint that’s painful on active and passive movements

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17
Q

Investigations for septic arthritis

A

Routine bloods - FBC, CRP, ESR
Blood cultures
Joint aspiration
Plain radiograph

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18
Q

Management of septic arthritis

A

Empirical antibiotic treatment

Surgical irrigation and debridement

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19
Q

Complications of septic arthritis

A

Osteoarthritis

Osteomyelitis

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20
Q

Define osteomyelitis

A

Infection of bone

- caused by haematogenous spread, direct inoculation or direct spread from nearby infection

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21
Q

Common causative organisms of osteomyelitis

A 
S. aureus
Streptococci
Enterobacteur spp
H.influnzae
P.aeruginosa
Salmonella spp.
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22
Q

Risk factors for osteomyelitis

A

Diabetes mellitus
Immunosuppression
Alcohol excess
IV drug use

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23
Q

Clinical features of osteomyelitis

A

Severe pain
- constant
- worse at night
Low grade pyrexia

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24
Q

Investigations for osteomyelitis

A 
Routine bloods
Blood cultures
Plain film radiographs
- osteopaenia
- periosteal thickening
- endosteal scalloping
- focal cortical bone loss
Culture from bone biopsy at debridement
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25
Management of osteomyelitis
``` Long-term IV antibiotic therapy >4 weeks Surgical management - pt deteriorates - evidence of deterioration - progressive bone destruction ```
26
Complications of osteomyelitis
Overwhelming sepsis Mortality Growth disturbance in children Chronic osteomyelitis
27
Name bone forming tumours
``` Benign - osteoma - osteoid osteoma - osteoblastoma Malignant - osteosarcoma ```
28
Name cartilage forming tumours
``` Benign - condroma - osteochondroma - chondroblastoma Malignant - chondrosarcoma ```
29
Name fibrous tissue tumours
``` Benign - fibroma - fibromatosis Malignant - fibrosarcoma ```
30
Name giant-cell tumours
Benign - benign osteoclastoma Malignant - malignant osteoclastoma
31
Name marrow tumours
Malignant - Ewing's tumour - myeloma
32
Common primary sites for metastatic bone cancers
``` Renal Thyroid Lung Prostate Breast ```
33
Common site of metastatic bone cancers
Spine
34
Management of metastatic bone cancer
Rarely surgical Systemic therapies - often palliative Prophylactic nailing of long bones - high risk of pathological fractures
35
Risk factors for primary bone cancer
``` Genetic association - RB1 and p53 - osteosarcomas - TSC1 and TSC2 mutation - chondroma Previous exposure to radiation of alkylating agents in chemotherapy Benign bone condition ```
36
Clinical features of bone tumours
Pain - not associated with movement - worse at night
37
What is achilles tendonitis
Inflammation of calcaneal tendon Repetative action -> microtears leading to localised inflammation Can lead to tendon rupture
38
Risk factors for achilles tendonitis
``` Unfit individual who has sudden increase in exercise frequency Poor footwear choice Male gender Obesity Recent fluoroquinoline use ```
39
What is an achilles tendon ruputure
Complete loss of function of ipsilateral calf muscle | - commonly occurs during athletic activity
40
Clinical features of achilles tendonitis
Gradual onset of pain and stiffness - worse with movement - improved with mild exercise of heat application
41
Clinical features of achilles tendon rupture
Sudden-onset severe pain in posterior calf Audible popping sound Loss of power of ankle plantarflexion
42
Describe Simmond's Test
For Achilles tendon rupture | Squeeze affected calf - if rupture present foot won't plantar flex
43
Management of achilles tendonitis
``` Supportive measures - stop precipitating exercise - ice - anti-inflammatory medication regularly Chronic cases - rehabilitation - physiotherapy ```
44
Management of achilles tendon rupture
Analgesia and immobilisation - ankle splinted in plaster in full equinus or moon boot with large heal raise insert - after 2 weeks bring to semi-equinus - after 4 weeks brought to neutral position and held for another 4 weeks Delayed presentation or re-rupture requires surgical fixation - end to end tendon repair
45
Classification of ankle fractures
Type A = below syndesmosis Type B = at syndesmosis Type C = above syndesmosis
46
Ottawa Ankle Rules
Used when diagnostic uncertainty where patient is able to mobilise and no deformity - bone tenderness at posterior edge/tip of lateral/medial malleolus - inability to bear weight both immediately and in A&E for 4 steps If any then plain radiograph taken
47
Immediate management of ankle fractures
Immediate fracture reduction - below knee back slab - plain film radiograph - neurovascular examination
48
When is conservative management of an ankle fracture suitable
Non-displaced medial malleolus fractures Weber A or Weber B without talar shift Those unfit for surgical intervention
49
When in surgical management of an ankle fracture suitable
Displaced bimalleolar or trimalleolar fractures Weber C fractures Weber B with talar shift Open fractures
50
Describe ankle sprain
``` Ligamentous injury High ankle sprain - injury to syndesmosis Low ankle sprain - injury to ATFL or CFL ```
51
Presentation of ankle fracture
Inversion injury on plantarflexed ankle Significant swelling and pain Fingertip tenderness to distal malleoli
52
Management of ankle sprain
Conservative - ice - analgesia - elevation - early mobilisation
53
Define hallux valgus
Medial deviation of first metatarsal and lateral deviation/rotation of hallus with associated joint subluxation
54
Risk factors for hallux valgus
Female Connective tissue disorders Hypermobility syndromes
55
Clinical features of hallux valgus
Painful medial prominence - aggrevated by - walking - weight-bearing - narrow toed shoes
56
Management of hallux valgus
Conservative - analgeisa - adjust footwear - physiotherapy Surgical - chevron - remove V shape and shift laterally to normal alignment and pin - common for mild deformities - scarf - longitudinal osteotomy made within shaft for distal portion to be moved laterally and fixed - lapidus - base of 1st metatarsal and medial cuneiform fused - keller - open joint capsule, remove diseased joint surfaces, joint stabilised by suturing of surrounding tissue and scar tissue - common when arthritis severe
57
Describe plantar fasciitis
Inflammation of plantar fascia | - micro-tears
58
Risk factors for planatar fasciitis
``` Anatomical features - excessive pronation - pes cavus (high arches) Weak plantar flexors or tights gastrocnemius or soleus Prolonged standing or excessive running Leg length discrepancy Obesity Unsupportive footwear ```
59
Clinical features of plantar fasciitis
Sharp pain across plantar aspect of foot - worse at heel - radiate down arch - worse in first few steps
60
Management of plantar fasciitis
Activity moderation and regular analgesics Physiotherapy Corticosteriod injections Plantar fasciotomy
61
Causes of talar fracture
``` High-energy trauma - fall from height - RTC Ankle forced in dorsiflexion Commonly talar neck ```
62
Clinical features of talar fracture
Immediate pain and swelling Clear deformity Unable to dorsiflex or plantarflex ankle
63
Management of talar fracture
Undisplaced - conservative in weight-bearing orthosis | Displaced - immediate reduction and surgical repair
64
Complications of talar fracture
Avascular necrosis | Osteoarthritis
65
Stabilisers of the elbow joint
``` Static - humeroulnar joint - medial ligaments - collateral ligaments - radiocapetellar joint - joint capsule - extensor origin tendons Dynamic - surrounding musculature - anconeus, brachialis and triceps brachii ```
66
Clinical features of elbow dislocation
High energy fall Painful and deformed joint Swelling and decreased function Sensory deficit in ulnar nerve
67
Management of elbow dislocation
``` Closed reduction - sufficient analgesia/sedation - above elbow backslab to keep elbow at 90 degrees Simple dislocation - 5-14 days immobilisation - early rehabilitation Complicated dislocation - operative fixation - open reduction and internal fixation (ORIF) ```
68
Criteria for complicated elbow dislocation
Fracture present Open injury Neurovascular compromise
69
Complications of elbow dislocation
Early stiffness - loss of terminal extension Stretching of ulnar nerve Recurrent instability
70
Features of terrible triad
Elbow dislocation with - lateral collateral ligament injury - radial head fracture - coronoid fracture
71
Define epicondylitis
Chronic symptomatic inflammation of the forearm tendons at the elbow
72
Another term for lateral epicondylitis
Tennis elbow
73
Another term for medial epicondylitis
Golfer's elbow
74
What attaches to lateral epicondyle
Common extensor tendon
75
What attaches to medial epicondyle
Pronator teres tendon | Flexor carpi radialis tendon
76
Risk factors for lateral epidcondylitis
Occupations and hobbies that are a/w excessive use of extensive forearm muscles
77
Clinical features of lateral epicondylitis
Pain - affects elbow - radiates down forearm - worsens over weeks-months - most often affects dominant arm
78
Management of lateral epicondylitis
Modify activities - reduce repetitive actions causing condition Simple analgesics and topical NSAIDs Corticosteriod injections Physiotherapy Refer to surgery if symptoms not controlled
79
Causes of olecranon bursitis
Repetitive flexion-extension movements -> irritation of bursa Gout RA Infection through skin abrasion or puncture
80
Clinical features of olecranon bursitis
Pain and swelling over olecranon | ROM preserved
81
Investigations of olecranon bursitis
``` Routine bloods - FBC and CRP Serum urate levels X-ray Aspiration of fluid - symptomatic - microscopy and culture ```
82
Clinical features of olecranon fracture
``` FOOSH Elbow pain, swelling and lack of mobility Bi-modal age distribution - young = high energy injury - old = low energy direct injury ```
83
Management of olecranon fracture
``` Adequate analgesia Non-operative - immobilisation in 60-90 degrees - early introduction of ROM at 1-2 weeks Operative - tension band wiring - olecranon plating ```
84
Criteria for operative management of olecranon fracture
Displacement > 2mm
85
Complications of olecranon fracture
Loss of ROM - elderly often non-operative management as loss no functional loss High rate of removal of metalwork
86
Clinical features of radial fracture
FOOSH Elbow pain - on supination/pronation Swelling and bruising at elbow
87
Management of radial head fracture
``` Adequate analgesia Non-operatively - immobilisation with sling for less than 1 week - early mobilisation Surgery - ORIF ```
88
Peak incidence of supracondylar humeral fractures
5-7 years
89
Clinical features of supracondylar humeral fractures
``` Recent fall or trauma - FOOSH Sudden onset severe pain Reluctance to move arm Gross deformity and swelling Reduced ROM Ecchymosis of anterior cubital fossa ```
90
Management of supracondylar fracutres
Conservative - above elbow cast in 90 degrees flexion Surgical - closed reduction and percutaneous K-wire fixation - open reduction with percuatneous pinning if open fracture
91
Complications of supracondylar fractures
``` Nerve palsies - anterior interosseous nerve Malunion - cubitus varus deformity - extended forearm deviates towards midline Volkmann's contracture - wrist/hand held in permanent flexion ```
92
Common causes of femoral shaft fracturs
High-energy trauma Fragility fractures in elderly - low-energy Pathological fractures Bisphosphonate-related fractures
93
Clinical features of femoral shaft fractures
Pain in thigh, hip or knee Unable to bear weight Obvious deformity
94
Management of femoral shaft fractures
``` Stabilise patient Adequate analgesia Immediate reduction and immobilisation In-line traction Surgically fixed if complicated - antegrade intramedullary nail - external fixation ```
95
Complications of a femoral shaft fracture
``` Nerve or vascular injury - pudendal or femoral nerve Mal-union, delayed union or non-union - risk increased with smoking and post op NSAIDs Infection Fat embolism ```
96
Clinical features of neck of femur fracture
Trauma - often low energy in elderly Pain - groin, thigh or referred to knee Inability to bear weight
97
Investigations for neck of femur fracture
``` X-ray Routine bloods - FBC - U&Es - Group and save - creatinine kinase - rhabdomyolysis Urine dip Chest x-ray ECG ```
98
Management of neck of femur fracture
``` Displaced subcapital - hip hemiarthroplasty Inter-trochanteric and basocervical - dynamic hip screw Non-displaced intra-capsular - cannulated hip screws Sub-trochanteric - intramedullary femoral nail ```
99
Post operative complications of NOF patients
``` Immediate - pain - bleeding - leg-length discrepancies - neurovascular damage Long-term - joint dislocation - aseptic loosening - peri-prosthetic fracture - deep infection/prosthetic joint infection ```
100
Define osteoarthritis
Degenerative joint disease | Characterised by loss of articular cartilage
101
Risk factors for OA of the hip
``` Systemic - increasing age - > 45 years - obestiy - female gender - genetic factors - vitamin D deficiency Local - history of trauma - anatomic abnormalities - muscle weakness - joint laxity - participation in high impact sports ```
102
Clinical features of OA of the hip
``` Pain - felt in groin - aggrevated by weight-bearing - improved on rest Stiffness - improves with mobility - associated grinding or crunching Antalgic gait Pain on passive movement Reduced ROM Flexed flexion deformity and Trendelenburg gait ```
103
Signs of OA on x-ray
Loss of joint space Subchondral sclerosis Bony cysts Osteophytes
104
Management of OA of the hip
``` Pain control - WHO analgesic ladder Lifestyle modification - weight loss - regular exercise - smoking cessation Physiotherapy - slows disease progression and improves joint mechanics Total hip replacement ```
105
Complications of hip replacement
``` Revision hip arthroplasty - prosthesis designed for 15-20 years Thromboembolic disease Bleeding Dislocation Infection Loosening of prosthesis Leg length discrepancy ```
106
Aetiology of ACL tear
History of twisting knee whilst weight bearing - usually athletes - without contact - landing from jumpt
107
Clinical features of an ACL tear
Rapid joint swelling and significant pain | Lachman's and anterior drawer test
108
Investigations for ACL tear
X-ray | MRI scan of knee
109
Managment of ACL tear
``` RICE Conservative - rehabilitation - strengthen quadriceps to stabilise knee Surgical - tendon or artificial graft ```
110
Complications of an ACL tear
Post-traumatic osteoarthritis
111
Clinical features of PCL tear
High-energy trauma Posterior knee pain Instability of the joint Positive posterior drawer test
112
Management of PCL
Conservatively - knee brace - physiotherapy Surgery
113
Define iliotibial band syndrome
Inflammation of iliotibial band - longitudinal fibres form shared aponeurosis of tensor fasicae latae and gluteus maximus
114
Risk factyors of ITBS
``` Regular exercise - repetitive flexion and extension of the knee - weightlifters, runners, cyclists Anatomical - genu varum - excessive internal tibial torsion - foot pronation - hip abductor weakness ```
115
Clinical features of ITBS syndrome
Lateral knee pain | - exacerbated by exercise
116
Management of ITBS syndrome
``` Modify activity Regular simple analgesics Local steriod injections Physiotherapy Surgical release of iliotibial band ```
117
Grades of MCL tear
``` 1 - mild injury - minimally torn fibres - no loss of MCL integrity 2 - moderate injury - incomplete tear - increased laxity of MCL 3 - severe injury - complete tear - gross laxity of MCL ```
118
Clinical features of MCL tear
Trauma to lateral aspect of knee Immediate medial joint pain Swelling Increased laxity of MCL - valgus stress test
119
Investigations of MCL tear
X-ray | MRI
120
Management of MCL tear
``` Grade I - RICE - analgesia - strength training - full exercise in 6 weeks Grade II - analgesia - knee brace - weight-bearing/strength training - full exercise in 10 weeks Grade III - analgesia - knee brace and crutches - surgery if distal avulsion - full exercise in 12 weeks ```
121
Complications of MCL tear
Instability of joint | Damage to saphenous nerve
122
PAthophysiology of meniscal tears
``` Trauma or degernerative disease - twisted knee Different types of tear - longitudinal - most common - degenerative - vertical - transverse ```
123
Clinical features of meniscal tears
``` Tearing sensation Intense sudden onset pain Swellig Locked in flexion Tenderness Significant joint effusion Limited knee flexion ```
124
Investigations of meniscal tears
X-ray | MRI
125
Management of meniscal tears
RICE Arthroscopic surgery for large tears - surture - trimmed
126
Complications of meniscal tears
OA Knee arthroscopy risks - DVT - damage to local structures
127
Clinical features of tibial plateau fractures
``` History of trauma - axial loading - high-impact injury Sudden onset pain Unable to weight-bear Swelling of knee Ligament instability ```
128
Investigations of tibial plateau fractures
``` X-ray - lipohaemarthrosis CT - assess severity - surgical planning ```
129
Management of tibial plateau fractures
``` Non-operative - hinged knee brace - non/partial weight-bearing for 8-12 weeks - physiotherapy - suitable analgesia Operative - ORIF - hinged knee brace - non/partial weight-bearing for 8-12 weeks - physiotherapy ```
130
Causes of adhesive capsulitis
``` Primary - idoipathic Secondary - rotator cuff tendinopathy - subacromial imingement syndrome - biceps tendinopathy - previous surgical intervention or trauma - inflammatory conditions - diabetes mellitus ```
131
Stages of adhesive capsulitis
Initial painful stage Freezing stage Thawing stage
132
Clinical features of adhesive capsulitis
Generalised deep and constant pain of shoulder - often disturbs sleep Stiffness Reduced function
133
Investigations for adhesive capsulitis
Usually clinical diagnosis X-ray unremarkable MRI imaging - thickening of glenohumeral joint capsule
134
Management of adhesive capsulitis
``` Self-limiting condition Education and reassurance - physiotherapy - shoulder exercises Management of pain - paracetamol and NSAIDs - steriod injections and oral corticosteriods Surgical intervention - if no improvement after 3 months - joint manipulation under GA to remove capsular adhesions to humerus - arthographic distension - surgical release of glenohumeral joint capsule ```
135
Complications of adhesive capsulitis
Proportion of patients will never regain full ROM - regain movement beyond that required to perform activities of daily living Symptoms persist beyond 2 years Recur in contralateral shoulder
136
Define biceps tendinopathy
Pathological change - typically due to overuse | - painful, swollen and structurally weaker tendon that is at risk of rupture
137
Aetiology of biceps tendinopathy
Occurs in both proximal and distal biceps tendon Younger individuals - sports with repetitive flexion movements - tennis, cricket Older individuals - degenerative
138
Clinical features of biceps tendinopathy
``` Pain - worsened by stressing tendon - weakness - flexion and supination - stiffness Disuse atrophy ```
139
Investigations for biceps tendinopathy
Clinical Blood tests and X-ray to rule out other differentials USS - thickened tendons MRI
140
Management of biceps tendinopathy
``` Conservative - analgesia - ice therapy - physiotherapy - USS steriod injections Surgical - arthroscopic tenodesis - tenotomy ```
141
Describe biceps tendon rupture
Complete or partial | Sudden forced extension of flexed elbow
142
Risk factors for biceps tendon rupture
``` Biceps tendinopathy Steriod use Smoking Chronic kidney disease Fluoroquinolone antibiotics ```
143
Clinical features of biceps tendon rupture
Sudden onset pain and weakness - pop feeling Marked swelling and bruising in antecubital fossa Reverse Popeye sign - buldge in arm as proximal belly retracts
144
Management of biceps tendon rupture
``` Conservative - lower demand patients - analgesia - physiotherapy Surgical - occur within a few weeks ```
145
Classification of clavicle fractures
``` Type 1 - most common - middle third Type 2 - lateral third Type 3 - medial third ```
146
Pathophysiology of a clavicle fracture
``` Direct or indirect trauma Medial fragment -> superiorly - pull of SCM Lateral fragment -> inferiorly - weight of arm ```
147
Managment of clavicle fracture
Conservatively - sling - support elbow and improve deformity - early movement of shoulder - prevent frozen shoulder Surgical - open fractures - comminuted fractures or shortened - ORIF 2-3 months post injury if fail to unite
148
Clinical features of humeral shaft fractures
Pain and deformity Falling onto outstreached limb or laterally onto adducted limb If radial nerve involved - reduced sensation of dorsal 1st webspace - weakness in wrist extension
149
Management of humeral shaft fractures
``` Re-alignment of the limb Conservative - humeral brace Surgical - ORIF - intramedullary nails if pathological fractures, polytrauma or severely osteoporotic bones ```
150
Complications of humeral shaft fractures
Non-union Mal-union Varus angulation - transverse fractures Radial nerve injury
151
Classification of rotator cuff tears
Acute - < 3 months Chronic - > 3 months Partial or full thickness
152
Name the rotator cuff muscles and their function
Supraspinatus - abduction Infraspinatus - external rotation Subscapularis - internal rotation Teres minor - external rotation
153
Risk factors for rotator cuff tears
``` Age Trauma Overuse Repetitive overhead shoulder movements Overweight Smoking Diabetes mellitus ```
154
Clinical features of rotator cuff tears
Pail over lateral aspect of shoulder Inability to abduct arm above 90 degrees Tenderness over greater tuberosity and subacromial bursa region Supra and infraspinatus atrophy
155
Investigations for rotator cuff tears
``` X-ray - unremarkable - exclude fracture USS - presence and size MRI - size, characteristics and location ```
156
Managment of rotator cuff tears
``` Conservative - present within 2 weeks injury - analgesia - physiotherapy - corticosteriod injections Surgical - present after 2 weeks post injury or remain symptomatic - large tears - arthroscopically or open approach ```
157
Complications of a rotator cuff tear
Adhesive capsulitis | Enlargement of tear
158
Types of shoulder dislocation
Anterior - force applied to extended, abducted externally rotated humerus Posterior - seizures or electrocution - direct blow to anterior shoulder or force through flexed adducted arm
159
Clinical features of shoulder dislocation
Painful shoulder Reduced mobility Feeling instable Loss of shoulder contours and anterior buldge
160
Associated injuries of a shoulder dislocation
Bony Bankart lesion - fracture of anterior inferior glenoid bone - common in recurrent dislocations Hill-Sachs defects - impaction injuries on the chondral surface of posterior and superior portions of the humeral head Fractures of greater tuberosity and surgical neck of humerus Soft Bankart lesion - avulsions of anterior labrum and inferior glenohumeral ligament Glenohumeral ligament avulsion Rotator cuff injuries
161
Investigations for shoulder dislocation
``` X-ray - anterior-posterior, Y-scapular and axial views Anterior dislocations - AP view - head out of glenoid fossa Posterior dislocation - light bulb sign ```
162
Management of shoulder dislocation
Appropriate analgesia Reduction, immobilisation and rehabilitation Broad-arm sling - typically 2 weeks Physiotherapy
163
Complications of shoulder dislocation
``` Chronic pain Limited mobility Stiffness Recurrence Adhesive capsulitis Nerve damage Rotator cuff injury Degenerative joint disease ```
164
Define subacromial impingement syndrome
Inflammation and irritation of the rotator cuff tendons as they pass through the subacromial space
165
Pathophysiology of impingement syndrome
``` Intrinic mechanisms - rotator cuff muscle weakness - humerus shifts proximally towards body - overuse of shoulder - repetitive microtrauma - degenerative tendinopathy Extrinsic mechanisms - anatomic features - scapular musculature - glenohumeral instability ```
166
Clinical features of SAIS
Progressive pain in anterior superior shoulder - exacerbated by abduction Elicited by Neers Impingement or Hawkins test
167
Differential diagnosis of SAIS
Muscular tear Neurological pain Frozen shoulder syndrome Acromioclavicular pathology
168
Management of SAIS
``` Conservative - analgesia - NSAIDs - regular physiotherapy - corticosteriod injecitons Surgical - 3 months without response ```
169
Complications of SIAS
Rotator cuff degeneration or tear Adhesive capsulitis Cuff tear arthropathy Complex regional pain syndrome
170
Differential diagnosis of rotator cuff tear
Fracture Persistent glenohumeral subluxation Brachial plexus injury Radiculopathy
171
Differential diagnosis of clavicle fracture
Sternoclavicular dislocation | ACJ seperation
172
Differential diagnosis of biceps tendinopathy
Inflammatory arthropathy Radiculopathy OA Rotator cuff disease
173
Differential diagnosis of adhesive capsulitis
``` Acromioclavicular pathology - injury - arthritis Subacromial impingement syndrome Muscular tear Autoimmune disease ```
174
Differential diagnosis of achilles tendonitis
Ankle sprain Stress fracture OA
175
Differential diagnosis of hallux valgus
``` Gout Septic arthritis Hallux rigidus OA RA ```
176
Differential diagnosis of plantar fasciitis
Achilles tendonitis Morton neuroma Calcaneal stress fracture Inflammatory artropathy
177
Differential diagnosis of lateral epicondylitis
Cervical radiculopathy Elbow osteoarthrits Radial carpal tunnel syndrome
178
Differential diagnosis of olecranon bursitis
Inflammatory arthropathies Gout Cellulitis Septic arthritis
179
Differential diagnosis of OA of the hip
Trochanteric bursitis Gluteus medius tendinopathy Sciatica Femoral neck fracture
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Differential diagnosis of ACL tear
Fracture Meniscal tear Collateral ligament tear Quadriceps or patellar ligament tear
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Differential diagnosis for swollen knee following trauma
Fracture Cruciate ligament tear Collateral ligament tear Osteochondritis dissecans
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Describe cauda equina syndrome
Surgical emergency | Caused by compression of the cauda equina
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Causes of cauda equina syndrome
Disc herniation - L5/S1 and L4/L5 Trauma - vertebra fracture and subluxation Neoplasm Infection Chronic spinal inflammation - ankylosing spondylitis Iatrogenic
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Clinical features of cauda equina
``` Saddle anaesthesia Bilateral sciatica Painless urinary retention Urinary and faecal incontinence Erectile dysfunction ```
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Consequences of untreated cauda equina syndrome
Chronic neuropathic pain Impotence Perform intermittent self-catheterisation Faecal incontinence requiring manual evacuation Loss of sensation Lower limb weakness -> wheelchair
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Differential diagnosis of cauda equina syndrome
Radiculopathy - radiating back pain - no faecal, urinary or sexual dysfunction Cord compression - characterised by upper motor neurone signs
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Investigations for cauda equina syndrome
Whole spine MRI
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Management of cauda equina syndrome
Early neurosurgical review for urgent decompression High dose steriods - dexamethasone Surgical decompression
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Define radiculopathy
Conduction block in the axons of a spinal nerve or its roots | - causing weakness and paresthesia/anaesthesia
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Define radicular pain
Pain deriving from damage or irritation of the spinal nerve tissue - particularly dorsal root ganglion
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Causes of radiculopathy
``` Intervertbral disc prolapse - repeated minor stresses Degenerative diseases - neuroforaminal or spina canal stenosis Fracture Malignancy Infection ```
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Clinical features of radiculopathy
Pareasthesia and numbess Weakness Radicular pain - burning, deep, strap-like pain
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Red flag symptoms to identify causes of radiculopathy
``` Cauda equina syndrome - faecal incontinence - painless urinary retention - saddle anaesthesia Infection - immunosuppression - IV drug user - unexplained fever Fracture - chronic steriod use - significant trauma - osteoporosis Malignancy - new onset after Metastatic disease - history of malignancy ```
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Differential diagnosis of radiculopathy
``` Referred pain Myofascial pain Thoracic outlet syndrome Greater trochanteric bursitis Iliotibial band syndrome Meralgia paraesthetica Piriformis syndrome ```
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Management of radiculopathy
``` Depends on underlying cause Symptomatic management - analgesia - WHO ladder - neuropathic pain medications - Amitriptyline - physiotherapy ```
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Causes of spinal cord compression
``` Neoplastic - metastatic from thyroid, lung, breast, renal, prostate - primary bone tumours - haematological - myeloma Traumatic - vertebral fracture - facet joint dislocation Infective Disc prolapse ```
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Clinical features of spinal cord compression
``` Sensation and proprioception impaired Pain Weakness Presence of upper motor neurone signs - hypertonia - hyperreflexia - clonus ```
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Differential diagnosis of spinal nerve compression
``` Lumbago - pain in lumbar region with no radiation Sciatica - radiates to buttocks/lower limb Cauda equina - lower motor neurone signs ```
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Investigations for spinal cord compression
MRI of whole spine
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Management of spinal cord compression
High dose corticosteriods - PPI for gastric protection Surgical decompression
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What is carpal tunnel sydrome
Compression of median nerve within the carpal tunnel of the wrist
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Risk factors for carpal tunnel syndrome
``` Female gender Age Pregnancy Obesity Previous injury Repetitive hand or wrist movements ```
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Clinical features of carpal tunnel syndrome
``` Throughout distribution of median nerve - thumb and radial 2.5 fingers - Pain - Numbness -Paraesthesia - palm usually spared due to palmar cutaneous branch Worse at night Later stages - weakness of thumb abduction - wasting of thenar eminence ```
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Differential diagnosis for carpal tunnel syndrome
Cervical radiculopathy Pronator teres syndrome Flexor carpi radialis tenosynovitis
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Investigations for carpal tunnel syndrome
Clinical diagnosis - Tinel's test - Phalen's test
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Management of carpal tunnel syndrome
``` Conservatively - wrist splint Medically - corticosteriod injections Surgical - carpal tunnel release surgery - cut through flexor retinaculum ```
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Complications of carpal tunnel surgery
``` Persistent CTS symptoms - incomplete ligament release Infection Scar formation Nerve damage Trigger thumb ```
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Complications of carpal tunnel syndrome
Permanent neurological impairment
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What is De Quervain's tenosynovitis
Inflammation of the tendons within the first extensor compartment of the wrist -> pain and swelling
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Risk factors forDe Quervain's tenosynovitis
Age - 30-50 Female Pregnancy
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Clinical features of De Quervain's tenosynovitis
Pain near base of thumb | Associated swelling
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Differential diagnosis for De Quervain's tenosynovitis
Arthritis of carpometacarpal joint Intersection syndrome Wartenber's syndrome
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Management of De Quervain's tenosynovitis
``` Conservative - lifestyle modification - avoid repetitive actions - wrist splint Medically - steriod injections Surgically - surgical decompression ```
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Pathophysiology of distal radius fracture
FOOSH | Increase with age - osteoporosis
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Classification of distal radius fractures
``` Colles' - dorsal displacement of distal fragment Smiths' - volar displacement of distal fragment Barton's - intra-articular fracture ```
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Risk factors for distal radius fractures
``` Increasing age Female Early menopause Smoking Alcohol excess Prolonged steroid use ```
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Clinical features of distal radial fractures
Episode of trauma Immediate pain +/- deformity Swelling
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Differential diagnosis of distal radial fractures
Forearm fracture Carpal bone fractures Tendonitis or tenosynovitis Wrist dislocation
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Investigations for distal radial fractures
Wrist plain radiograph - radial height < 11mm - radial inclination < 22 degrees - radial volar tilt > 11 degrees
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Management of distal radial fracture
Closed reduction Below elbow backslab - repeat radiographs after 1 week Surgical intervention in significantly displaces or unstable - ORIF - K-wire fixation - external fixation
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Complications of distal radial fracture
Malunion Median nerve compression OA
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Define Dupuytren's contracture
Contraction of longitudinal palmar fascia Painless nodule -> fibrous cords -> flexion contractures - limits digital movement
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Risk factors for Dupuytren's contracture
``` Smoking Alcoholic liver disease Cirrhosis Diabetes mellitus Occupational exposures - vibration tools or heavy manual work ```
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Clinical features of Dupuytren's contracture
Reduced ROM Nodular deformity Complete loss of movement
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Management of Dupuytren's contracture
``` Conservative - hand therapy Medical - injectable collagenase clostridum histolyticum Surgical - excision of disease fascia ```
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Define ganglionic cysts
Non-cancerous soft tissue lumps that occur along any joint or tendon Arise from degeneration within joint capsule/tendon sheath Filled with synovial fluid
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Risk factors for ganglionic cysts
Female OA Previous joint or tendon injury
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Clinical features of ganglionic cysts
Smooth spherical painless lump adjacent to affected joint | Soft and able to transilluminate
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Differential diagnosis for ganglionic cysts
``` Tenosynovitis Giant cell tumour of tendon sheath Lipoma OA Sarcoma ```
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Management of ganglionic cysts
Monitor - most disappear spontaneously If causes pain or reduced ROM - aspiration - cyst excision
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Clinical features of scaphoid fracture
Following trauma - high energy Sudden onset pain and bruising Tenderness on floor of anatomic snuffbox
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Investigations for scaphoid fracture
Plain radiograph - scaphoid series Wrist immobilisation and repeat radiographs MRI scan of wrist
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Management of scaphoid fracture
``` Undisplaced - strict immobilisation Displaced - surgical - percutaneous variable pitched screw ```
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Complications of scaphoid fractures
``` Avascular necrosis - risk increases the more proximal the fracture Non-union - most commonly due to poor blood supply - internal fixation and bone grafts ```
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Define trigger finger
Finger or thumb click or lock when in flexion - preventing return to extension
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Pathophysiology of trigger finger
Flexor tenosynovitis - repetitive movements leading to inflammation of tendon and sheath Nodal formation
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Risk factors for trigger finger
``` Prolonged gripping or use of hand RA DM Female Age ```
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Clinical features of trigger finger
Painless clicking/snapping/catching when trying to extend finger May become painful over time
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Differential diagnosis of trigger finger
Dupuytren's contracture Acromegaly Infection Ganglion
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Management of trigger finger
``` Conservative - avoid painful activities - small splint at night Medical - steroid injections Surgical - percutaneous trigger finger release ```

Yr3 - General Surgery (17 decks)

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