Orthopaedics

Question 1

Achilles tendon disorders

Answer 1

Achilles tendon disorders are the most common cause of posterior heel pain. Possible presentations include tendinopathy (tendinitis), partial tear and complete rupture of the Achilles tendon.

Risk factors

quinolone use (e.g. ciprofloxacin) is associated with tendon disorders

hypercholesterolaemia (predisposes to tendon xanthomata)

Achilles tendinopathy (tendinitis)

Features

gradual onset of posterior heel pain that is worse following activity

morning pain and stiffness are common

calf muscle eccentric exercises - this may be self-directed or under the guidance of physiotherapy

The management is typically supportive including simple analgesia and reduction in precipitating activities.

Achilles tendon rupture

Achilles tendon rupture should be suspected if the person describes the following whilst playing a sport or running; an audible ‘pop’ in the ankle, sudden onset significant pain in the calf or ankle or the inability to walk or continue the sport.

An examination should be conducted using Simmond’s triad, to help exclude Achilles tendon rupture. This can be performed by asking the patient to lie prone with their feet over the edge of the bed. The examiner should look for an abnormal angle of declination; Achilles tendon rupture may lead to greater dorsiflexion of the injured foot compared to the uninjured limb. They should also feel for a gap in the tendon and gently squeeze the calf muscles if there is an acute rupture of the Achilles tendon the injured foot will stay in the neutral position when the calf is squeezed.

An acute referral should be made to an orthopaedic specialist following a suspected rupture.

Question 2

Adhesive capsulitis

Answer 2

Adhesive capsulitis (frozen shoulder) is a common cause of shoulder pain. It is most common in middle-aged females. The aetiology of frozen shoulder is not fully understood.

Associations

diabetes mellitus: up to 20% of diabetics may have an episode of frozen shoulder

Features typically develop over days

external rotation is affected more than internal rotation or abduction

both active and passive movement are affected

patients typically have a painful freezing phase, an adhesive phase and a recovery phase

bilateral in up to 20% of patients

the episode typically lasts between 6 months and 2 years

Management

no single intervention has been shown to improve outcome in the long-term

treatment options include NSAIDs, physiotherapy, oral corticosteroids and intra-articular corticosteroids

Question 3

Shoulder Pain

Answer 3

Adhesive capsulitis presents as a painful stiff shoulder with restriction of active and passive range of motion in abduction, internal and external rotation. However external rotation often shows the most marked restriction and is the first movement to show impairment. The stem describes difficulty dressing and doing up her bra as well as weakness of external rotation suggesting a globally impaired range of motion. Patients often report difficulty sleeping on the affected side. Other indications that the answer is adhesive capsulitis, include coexisting diabetes, female gender and symptoms in the non-dominant hand, all of which are common findings in this condition

Acromioclavicular degeneration is often associated with popping, swelling, clicking or grindings and a positive scarf test not reported in the stem

Subacromial impingement patients often complain of pain on overhead activities and demonstrate a painful arc of abduction on examination - worse between 90 and 120 degrees. There may also be popping, snapping or grinding.

Rotator cuff tears can occur either due to specific trauma or chronic impingement. Patients will normally describe weakness as well as pain and there may be muscle wasting and tenderness on palpation. There may be a painful arc of movement and weakness of the affected muscle.

Patients with calcific tendinopathy would normally have tenderness on palpation of the affected area and be reluctant to move the arm. There may be overlap with symptoms of impingement syndrome making this a less likely answer.

Question 4

Ankle injury Ottawa rules

Answer 4

The Ottawa Rules with for ankle x-rays have a sensitivity approaching 100%

An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:

bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)

bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)

inability to walk four weight bearing steps immediately after the injury and in the emergency department

There are also Ottawa rules available for both foot and knee injuries

Question 5

Ankle Sprain

Answer 5

The anterior talofibular ligament extends from the talus to the fibula and functions to restrict inversion in plantar flexion. It is the weakest of the lateral ligaments and is thus the most commonly sprained ligament during over-inversion injuries.

The deltoid ligament lies on the medial aspect of the ankle and resists eversion. It is therefore unlikely to be injured in this inversion injury.

The interosseous ligament lies between the tibia and fibula superior to the ankle joint and would be unaffected unless accompanied by trauma to lower leg.

The Lisfranc ligament connects the second metatarsal to the medial cuneiform. Disruption to this ligament is more commonly seen with direct blows, such as dropping a heavy object on the foot, or indirectly, by placing an axial load on a plantarflexed foot, with some degree of rotation. In this scenario, a simple sprain to the anterior talofibular ligament would be much more common.

Ankle sprain

The bony components of the ankle joint include the distal tibia and fibula and the superior aspect of the talus. Their configuration is such that they form a mortise, with the body of the talus acting as the tenon. This arrangement is secured by a number of ligamentous structures:

The syndesmosis binds the distal tibia and fibula together (another example of a syndesmosis is the distal radio-ulnar joint). It is composed of the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), interosseous ligament (IOL) and the interosseous membrane.

The distal fibular is secured to the to the talus by the anterior and posterior talofibular ligaments (ATFL and PTFL) and to the calcaneus by the calcaneofibular ligament. These ligaments are sometimes referred to collectively as the lateral collateral ligaments.

The distal tibia is secured to the talus by the deltoid ligament, in view of its triangular shape.

A sprain is a stretching, partial or complete tear of a ligament. In the ankle, this can be divided into high ankle sprains involving the syndesmosis and low ankle sprains involving the lateral collateral ligaments.


Low ankle sprains

Presentation:

most common (>90%) with injury to the ATFL the most common offender

inversion injury most common mechanism

pain, swelling, tenderness over affected ligaments and sometimes bruising

patients usually able to weight bear unless severe

Investigation:

Radiographs should be done according to the Ottawa ankle rules as 15% of sprains are associated with a fracture.

MRI if persistent pain and useful for evaluating perineal tendons.


Treatment:

Non-operative with rest, ice, compression and elevation (the so-called RICE protocol).

Occasionally a removable orthosis, cast and/or crutches may be required for short-term symptom relief.

If symptoms fail to settle or there is significant joint instability then an MRI and surgical intervention may be contemplated, but this is rare.

High ankle sprains

Presentation:

Injuries to the syndesmosis are rare (about 0.5%) and severe.

The mechanism of injury is usually external rotation of the foot causing the talus to push the fibula laterally.

Patients frequently find weight-bearing painful in comparison to low ankle sprains.

Pain when the tibia and fibula are squeezed together at the level of the mid-calf (Hopkin’s squeeze test).


Investigations:

Radiographs may show widening of the tibiofibular joint (diastasis) or ankle mortise.

MRI if high suspicion of syndesmotic injury, but normal plain films.


Treatment:

If no diastasis then non-weight-bearing orthosis or cast until pain subsides.

If diastasis or failed non-operative management then operative fixation is usually warranted.

Isolated injuries to the deltoid ligament are rare as they are frequently associated with a fracture and one should always be on the lookout for Maisonneuve fracture of the proximal fibula. Provided the ankle mortise is anatomically reduced then treatment can be as per a low ankle sprain, if not then reduction and fixation may be warranted.


Question 6

Carpal tunnel syndrome

Answer 6

Carpal tunnel syndrome is 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 his hand to obtain relief, classically at night

Examination

weakness of thumb abduction (abductor pollicis brevis)

wasting of thenar eminence (NOT hypothenar)

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

Electrophysiology

motor + sensory: prolongation of the action potential

Treatment

corticosteroid injection

wrist splints at night

surgical decompression (flexor retinaculum division)

Question 7

De Quervain’s tenosynovitis

Answer 7

De Quervain’s tenosynovitis

De Quervain’s tenosynovitis is a common condition in which the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed. It typically affects females aged 30 - 50 years old.

Features

pain on the radial side of the wrist

tenderness over the radial styloid process

abduction of the thumb against resistance is painful

Finkelstein’s test: the examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction. In a patient with tenosynovitis this action causes pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus

Management

analgesia

steroid injection

immobilisation with a thumb splint (spica) may be effective

surgical treatment is sometimes requiredA 34-year-old medical secretary reports pain on the thumb side of her right wrist, ongoing for the past week. She also reports that right wrist appears more swollen than her left. On examination, she has pain over her radial styloid on forced flexion of the thumb

Finkelstein’s test: the examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction. In a patient with tenosynovitis this action causes pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus

Important for meLess important

This patient likely has De Quervain’s tenosynovitis therefore Finkelstein’s test would be appropriate. It can be falsely positive in osteoarthritis however this is unlikely in a young patient.

Both Phalen’s (pushing the dorsal sides of the hands together) and Tinel’s (percussion over the median nerve) test are seen in carpel tunnel.

Carpel tunnel is common in office workers causing pain, numbness and tingling. This patient is more likely to have De Quervain’s tenosynovitis because the pain is associated with movement of the thumb with minimal involvement of the fingers.

Mill’s test identifies lateral epicondylitis or tennis elbow. It is performed by flexing the patients wrist whilst the arm is pronated and elbow extended. If positive, the test reproduces pain over the lateral epicondyle.

Forced extension of the wrist with a supinated and extended forearm is the test for medial epicondylitis or golfers elbow. There is no eponymous name. If positive, the test reproduces pain over the medial epicondyle.

Question 8

Discitis

Answer 8

Discitis

Discitis is an infection in the intervertebral disc space. It can lead to serious complications such as sepsis or an epidural abscess.

Features

Back pain

General features

pyrexia,

rigors

sepsis

Neurological features

e.g. changing lower limb neurology

if epidural abscess develops

Causes

Bacterial

Staphylococcus aureus is the most common cause of discitis

Viral

TB

Aseptic

Diagnosis

Imaging: MRI has the highest sensitivity

CT guided biopsy may be required to guide antimicrobial treatment

Treatment

The standard therapy requires six to eight weeks of intravenous antibiotic therapy

Choice of antibiotic is dependent on a variety of factors. The most important factor is to identify the organism with a positive culture (e.g. blood culture, or CT guided biopsy)

Complications

sepsis

epidural abscess

Further investigation:

Assess the patient for endocarditis e.g. with transthoracic echo or transesophageal echo. Discitis is usually due to haematogenous seeding of the vertebrae implying that the patient has had a bacteraemia and seeding could have occurred elsewhere

Duke’s Criteria for Endocarditis
Given the positive blood culture for a ‘typical’ organism, this patient would score one major criterion at present. Any endocardial involvement demonstrated on an echocardiogram (valvular lesions) would be a second and give a firm diagnosis of bacterial endocarditis. The treatment of complicated discitis usually lasts for 6-12 weeks with only the first two needed as intravenous treatment. If endocarditis is diagnosed this will also change the length of time intravenous therapy is offered and may also alter the total length of time treatment is required although practice does vary from unit to unit.

Question 9

Dupuytren’s contracture

Answer 9

Dupuytren’s contracture has a prevalence of about 5%. It is more common in older male patients and around 60-70% have a positive family history

Specific causes include:

manual labour

phenytoin treatment

alcoholic liver disease

diabetes mellitus

trauma to the hand

Features

the ring finger and little finger are the fingers most commonly affected

Management

consider surgical treatment of Dupuytren’s contracture when the metacarpophalangeal joints cannot be straightened and thus the hand cannot be placed flat on the table.

In Dupuytren’s contracture there is a thickening of the palmar aponeurosis, which tends to draw the medial digits inwards, and in severe cases can interfere with the functioning of the hand. There is no sensory element to this condition, making a median/ulnar nerve palsy unlikely. Ganglions tend to present as palpable cystic swellings, usually on the dorsum of the hand and trigger finger is associated with snapping/catching of a digit on flexion.

Question 10

Elbow pain

Answer 10

Elbow pain

The table below details some of the characteristic features of conditions causing elbow pain:

Condition

Notes

Lateral epicondylitis (tennis elbow)

Features

pain and tenderness localised to the lateral epicondyle

pain worse on resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended

episodes typically last between 6 months and 2 years. Patients tend to have acute pain for 6-12 weeks

Medial epicondylitis (golfer’s elbow)

Features

pain and tenderness localised to the medial epicondyle

pain is aggravated by wrist flexion and pronation

symptoms may be accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement

Radial tunnel syndrome

Most commonly due to compression of the posterior interosseous branch of the radial nerve. It is thought to be a result of overuse.

Features

symptoms are similar to lateral epicondylitis making it difficult to diagnose

however, the pain tends to be around 4-5 cm distal to the lateral epicondyle

symptoms may be worsened by extending the elbow and pronating the forearm

Cubital tunnel syndrome

Due to the compression of the ulnar nerve.

Features

initially intermittent tingling in the 4th and 5th finger

may be worse when the elbow is resting on a firm surface or flexed for extended periods

later numbness in the 4th and 5th finger with associated weakness

Olecranon bursitis

Swelling over the posterior aspect of the elbow. There may be associated pain, warmth and erythema. It typically affects middle-aged male patients.

Question 11

Greater trochanteric pain syndrome

Answer 11

Greater trochanteric pain syndrome is also referred to as trochanteric bursitis.

It is due to repeated movement of the fibroelastic iliotibial band and is most common in women aged 50-70 years.

Features

pain and tenderness over the lateral side of thigh

Trochanteric bursitis presents with lateral hip pain with tenderness over the greater trochanter on palpation, hence why the patient can not lie on the affected side. It is most commonly seen in middle-aged women particularly after an increase in training or activity, as in this case. On examination, there is point tenderness over the greater trochanter as well as at pain on extremes of rotation, abduction or adduction.

In iliotibial pain syndrome pain is felt on the lateral portion of the knee where the band becomes irritated and inflamed on passing over the lateral femoral epicondyle.

Early osteoarthritis is a possibility in this patient given her age, however, there would be other features present such as stiffness and loss of mobility. It would also have a more insidious onset. In patients who do not respond to treatment for trochanteric bursitis, hip X-ray is indicated to rule out osteoarthritic changes.

Femoroacetabular impingement (FAI) causes anterior hip pain as opposed to lateral pain and as such is not the correct answer.

In a stress fracture, the pain would improve with rest and be worse during exercise. Pain is usually described as a deep aching pain in the groin. You would expect some clue in the question as to a history of steroid use or excessive training.

Question 12

Transient synovitis (irritable hip)

Answer 12

Hip problems in children

The table below provides a brief summary of the potential causes of hip problems in children

Condition

Notes

Development dysplasia of the hip

Often picked up on newborn examination
Barlow’s test, Ortolani’s test are positive
Unequal skin folds/leg length

Typical age group = 2-10 years
Acute hip pain associated with viral infection
Commonest cause of hip pain in children

Perthes disease

Perthes disease is a degenerative condition affecting the hip joints of children, typically between the ages of 4-8 years. It is due to avascular necrosis of the femoral head

Perthes disease is 5 times more common in boys. Around 10% of cases are bilateral

Features

hip pain: develops progressively over a few weeks

limp

stiffness and reduced range of hip movement

x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening

Slipped upper femoral epiphysis

Typical age group = 10-15 years
More common in obese children and boys
Displacement of the femoral head epiphysis postero-inferiorly
Bilateral slip in 20% of cases
May present acutely following trauma or more commonly with chronic, persistent symptoms

Features

knee or distal thigh pain is common

loss of internal rotation of the leg in flexion

Juvenile idiopathic arthritis (JIA)

Preferred to the older term juvenile chronic arthritis, describes arthritis occurring in someone who is less than 16 years old that lasts for more than three months. Pauciarticular JIA refers to cases where 4 or less joints are affected. It accounts for around 60% of cases of JIA

Features of pauciarticular JIA

joint pain and swelling: usually medium sized joints e.g. knees, ankles, elbows

limp

ANA may be positive in JIA - associated with anterior uveitis

Septic arthritis

Acute hip pain associated with systemic upset e.g. pyrexia. Inability/severe limitation of affected joint

Question 13

Hip problems in children

Answer 13

The table below provides a brief summary of the potential causes of hip problems in children

Condition

Notes

Development dysplasia of the hip

Often picked up on newborn examination
Barlow’s test, Ortolani’s test are positive
Unequal skin folds/leg length

Transient synovitis (irritable hip)

Typical age group = 2-10 years
Acute hip pain associated with viral infection
Commonest cause of hip pain in children

Perthes disease

Perthes disease is a degenerative condition affecting the hip joints of children, typically between the ages of 4-8 years. It is due to avascular necrosis of the femoral head

Perthes disease is 5 times more common in boys. Around 10% of cases are bilateral

Features

hip pain: develops progressively over a few weeks

limp

stiffness and reduced range of hip movement

x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening

Slipped upper femoral epiphysis

Typical age group = 10-15 years
More common in obese children and boys
Displacement of the femoral head epiphysis postero-inferiorly
Bilateral slip in 20% of cases
May present acutely following trauma or more commonly with chronic, persistent symptoms

Features

knee or distal thigh pain is common

loss of internal rotation of the leg in flexion

Juvenile idiopathic arthritis (JIA)

Preferred to the older term juvenile chronic arthritis, describes arthritis occurring in someone who is less than 16 years old that lasts for more than three months. Pauciarticular JIA refers to cases where 4 or less joints are affected. It accounts for around 60% of cases of JIA

Features of pauciarticular JIA

joint pain and swelling: usually medium sized joints e.g. knees, ankles, elbows

limp

ANA may be positive in JIA - associated with anterior uveitis

Septic arthritis

Acute hip pain associated with systemic upset e.g. pyrexia. Inability/severe limitation of affected joint

Question 14

Iliotibial band syndrome

Answer 14

Iliotibial band syndrome is a common cause of lateral knee pain in runners, occurring in around 1 in 10 people who run regularly.

Features

tenderness 2-3cm above the lateral joint line

Management

activity modification and iliotibial band stretches

if not improving then physiotherapy referral

Question 15

Knee pain meniscal tear

Answer 15

Typically result from twisting injuries.

Features

pain worse on straightening the knee

knee may ‘give way’

displaced meniscal tears may cause knee locking

tenderness along the joint line

Thessaly’s test - weight bearing at 20 degrees of knee flexion, patient supported by doctor, postive if pain on twisting knee

Knee locking and giving-way are common features of the meniscal lesions. A positive Thessaly’s test confirms the diagnosis.

ACL injury typically presents more acutely with a history of popping, immediate pain and swelling and instability of the knee.

LCL injury typically occurs from direct impact on the LCL e.g. contact sport. There is usually pain and swelling particularly at the lateral side of the knee joint.

Fat pad impingement typically has a history of knee hyperextension.

Osteochondritis dissecans is typically a condition in adolescents.

Question 16

Knee problems older adults

Answer 16

The table below summarises the key features of common knee problems:

Condition

Key features

Osteoarthritis of the knee

Patient is typically > 50 years, often overweight
Pain may be severe
Intermittent swelling, crepitus and limitation of movement may occur

Infrapatellar bursitis
(Clergyman’s knee)

Associated with kneeling

Prepatellar bursitis
(Housemaid’s knee)

Associated with more upright kneeling

Anterior cruciate ligament

May be caused by twisting of the knee - ‘popping’ noise may have been noted
Rapid onset of knee effusion
Positive draw test

Posterior cruciate ligament

May be caused by anterior force applied to the proximal tibia (e.g. knee hitting dashboard during car accident)

Collateral ligament

Tenderness over the affected ligament
Knee effusion may be seen

Meniscal lesion

May be caused by twisting of the knee
Locking and giving-way are common feature
Tender joint line

Question 17

Lower back pain

Answer 17

Lower back pain: prolapsed disc

A prolapsed lumbar disc usually produces clear dermatomal leg pain associated with neurological deficits.

Features

leg pain usually worse than back

pain often worse when sitting

The table below demonstrates the expected features according to the level of compression:

Site of compression

Features

L3 nerve root compression

Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test

L4 nerve root compression

Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test

L5 nerve root compression

Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test

S1 nerve root compression

Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test

Management

similar to that of other musculoskeletal lower back pain: analgesia, physiotherapy, exercises

if symptoms persist 9e.g. after 4-6 weeks) then referral for consideration of MRI is appropriate

NSAIDs are now first-line management of lower back pain following updated NICE guidelines in 2016. Recommended NSAIDs include ibuprofen or naproxen and consideration should be given to co-administration of PPI.

Paracetamol alone is not recommended for lower back pain and for patients unable to tolerate NSAIDs co-codamol should be considered.

A short course of benzodiazepines can be considered in patients who reports spasms as a feature of their pain. Since this is not mentioned in the stem answer 2 would be incorrect.

Answer 5 is incorrect as NICE currently recommends only referring patients to physiotherapy who are at higher risk of back pain disability or whose symptoms have not improved at follow-up. In addition, there is likely to be some delay in attending physiotherapy and NSAIDs can be started immediately.

Question 18

Lumbar spinal stenosis

Answer 18

Lumbar spinal stenosis

Lumbar spinal stenosis is a condition in which the central canal is narrowed by tumour, disk prolapse or other similar degenerative changes.

Patients may present with a combination of back pain, neuropathic pain and symptoms mimicking claudication. One of the main features that may help to differentiate it from true claudication in the history is the positional element to the pain. Sitting is better than standing and patients may find it easier to walk uphill rather than downhill. The neurogenic claudication type history makes lumbar spinal stenosis a likely underlying diagnosis, the absence of such symptoms makes it far less likely.

Pathology

Degenerative disease is the commonest underlying cause. Degeneration is believed to begin in the intervertebral disk where biochemical changes such as cell death and loss of proteoglycan and water content lead to progressive disk bulging and collapse. This process leads to an increased stress transfer to the posterior facet joints, which accelerates cartilaginous degeneration, hypertrophy, and osteophyte formation; this is associated with thickening and distortion of the ligamentum flavum. The combination of the ventral disk bulging, osteophyte formation at the dorsal facet, and ligamentum flavum hyptertrophy combine to circumferentially narrow the spinal canal and the space available for the neural elements. The compression of the nerve roots of the cauda equina leads to the characteristic clinical signs and symptoms of lumbar spinal stenosis.

Diagnosis

MRI scanning is the best modality for demonstrating the canal narrowing. Historically a bicycle test was used as true vascular claudicants could not complete the test.

Treatment
Laminectomy

Question 19

Meralgia paraesthetica

Answer 19

Meralgia paraesthetica

Meralgia paraesthetica comes from the Greek words meros for thigh and algos for pain and is often described as a syndrome of paraesthesia or anaesthesia in the distribution of the lateral femoral cutaneous nerve (LFCN). It is an entrapment mononeuropathy of the LFCN, but can also be iatrogenic after a surgical procedure, or result from a neuroma. Although uncommon, meralgia paraesthetica is not rare and is hence probably underdiagnosed.

Anatomy

The LFCN is primarily a sensory nerve, carrying no motor fibres.

It most commonly originates from the L2/3 segments.

After passing behind the psoas muscle, it runs beneath the iliac fascia as it crosses the surface of the iliac muscle and eventually exits through or under the lateral aspect of the inguinal ligament.

As the nerve curves medially and inferiorly around the anterior superior iliac spine (ASIS), it may be subject to repetitive trauma or pressure.

Compression of this nerve anywhere along its course can lead to the development of meralgia paraesthetica.

Epidemiology

The majority of cases occur in people aged between 30 and 40.

In some, both legs may be affected.

It is more common in men than women.

Occurs more commonly in those with diabetes than in the general population.

Risk factors 3

Obesity

Pregnancy

Tense ascites

Trauma

Iatrogenic, such as pelvic osteotomy, spinal surgeries, laparoscopic hernia repair and bariatric surgery. In some cases, may result from abduction splints used in the management of Perthe’s disease.

Various sports have been implicated, including gymnastics, football, bodybuilding and strenuous exercise.

Some cases are idiopathic.

Patients typically present with the following symptoms in the upper lateral aspect of the thigh:

Burning, tingling, coldness, or shooting pain

Numbness

Deep muscle ache

Symptoms are usually aggravated by standing, and relieved by sitting

They can be mild and resolve spontaneously or may severely restrict the patient for many years.

Signs:

Symptoms may be reproduced by deep palpation just below the ASIS (pelvic compression) and also by extension of the hip.

There is altered sensation over the upper lateral aspect of the thigh.

There is no motor weakness.

Investigations:

The pelvic compression test is highly sensitive, and often, meralgia paraesthetica can be diagnosed based on this test alone

Injection of the nerve with local anaesthetic will abolish the pain. Using ultrasound is effective both for diagnosis and guiding injection therapy in meralgia paraesthetica

Nerve conduction studies may be useful.

Question 20

Olecranon bursitis

Answer 20

Olecranon bursitis

Olecranon bursitis describes inflammation of the olecranon bursa, the fluid-filled sac overlying the olecranon process at the proximal end of the ulna. This bursa exists to reduce friction between the posterior aspect of the elbow joint and the overlying soft tissues. Inflammation may result from trauma, infection, or systemic conditions such as rheumatoid arthritis or gout. Olecranon bursitis is also known as ‘student’s elbow’ because the repetitive mild trauma of leaning on a desk using the elbows is a common cause. It is categorised as septic or non-septic depending on whether an infection is present.

Epidemiology

More common in men

Typically presents between age 30 and 60

Causes

Repetitive trauma (29%) - writers and students leaning on elbows, plumbers, miners

Direct trauma (17%)

Infection (33%) - 50% of cases occur in immunosuppressed patients (alcohol abuse, diabetes, taking steroids, renal failure, malignancy). 90% of cases due to Staphylococcus aureus.

Gout (7%)

Rheumatoid arthritis (5%)

Idiopathic (5%)

Patients with non-septic olecranon bursitis typically present with a subacute onset of:

swelling over the olecranon process (100%)

For many patients, this will be the only symptom. Some patients with non-septic olecranon bursitis also complain of:

tenderness over the bursa (45%)

erythema over the bursa (25%)

Patients with septic bursitis are more likely to have pain and fever:

• tenderness over the bursa (92-100%)
• fever (40%)

Signs:

Swelling over the posterior aspect of the elbow, usually fluctuant and well-circumscribed, appearing over hours to days4

Tenderness on palpation of the swollen area

Redness and warmth of the overlying skin

Fever

Skin abrasion overlying the bursa

Effusions in other joints if associated with rheumatoid arthritis

Tophi if associated with gout

Movement at the elbow joint should be painless until the swollen bursa is compressed in full flexion.

Investigations:

Not always needed if a clinical diagnosis can be made and there is no concern about septic arthritis, e.g. a well patient without pain, fever or erythema of the bursa.

Aspiration of bursal fluid for microscopy (Gram stain and crystals) and culture is essential if septic bursitis is considered. Purulent fluid suggests infection whereas straw-coloured bursal fluid favours a non-infective cause.

Question 21

Osteoarthritis joint replacement

Answer 21

Osteoarthritis joint replacement

Joint replacement (arthroplasty) remains the most effective treatment for osteoarthritis patients who experience significant pain.

Selection criteria

around 25% of patients are now younger than 60-years-old

whilst obesity is often thought to be a barrier to joint replacement there is only a slight increase in short-term complications. There is no difference in long-term joint replacement survival

Surgical techniques

for hips the most common type of operation is a cemented hip replacement. A metal femoral component is cemented into the femoral shaft. This is accompanied by a cemented acetabular polyethylene cup uncemented hip replacements are becoming increasingly popular, particularly in younger more active patients. They are more expensive than conventional cemented hip replacements hip resurfacing is also sometimes used where a metal cap is attached over the femoral head. This is often used in younger patients and has the advantage that the femoral neck is preserved which may be useful if conventional arthroplasty is needed later in life

Post-operative recovery

patients receive both physiotherapy and a course of home-exercises

walking sticks or crutches are usually used for up to 6 weeks after hip or knee replacement surgery

Patients who have had a hip replacement operation should receive basic advice to minimise the risk of dislocation:

avoiding flexing the hip > 90 degrees

avoid low chairs

do not cross your legs

sleep on your back for the first 6 weeks

Complications

wound and joint infection

thromboembolism: NICE recommend patients receive low-molecular weight heparin for 4 weeks following a hip replacement

dislocation

Question 22

Osteoarthritis of the hip

Answer 22

Osteoarthritis of the hip

Osteoarthritis (OA) of the hip is the second most common presentation of OA after the knee. It accounts for significant morbidity and total hip replacement is now one of the most common operations performed in the developed world.

Risk factors

increasing age

female gender (twice as common)

obesity

developmental dysplasia of the hip

Features

chronic history of groin ache following exercise and relieved by rest

red flag features suggesting an alternative cause include rest pain, night pain and morning stiffness > 2 hours

the Oxford Hip Score is widely used to assess severity

Investigations

NICE recommends that if the features are typical then a clinical diagnosis can be made

otherwise plain x-rays are the first-line investigation

Management

oral analgesia

intra-articular injections: provide short-term benefit

total hip replacement remains the definitive treatment

Complications of total hip replacement

venous thromboembolism

intraoperative fracture

nerve injury

Reasons for revision of total hip replacement

aseptic loosening (most common reason)

pain

dislocation

infection

Question 23

Osteomyelitis

Answer 23

Osteomyelitis describes an infection of the bone.

Staph. aureus is the most common cause except in patients with sickle-cell anaemia where Salmonella species predominate.

Predisposing conditions

diabetes mellitus

sickle cell anaemia

intravenous drug user

immunosuppression due to either medication or HIV

alcohol excess

Investigations

MRI is the imaging modality of choice, with a sensitivity of 90-100%

Management

flucloxacillin for 6 weeks

clindamycin if penicillin-allergic

Question 24

Osteoporosis assessing risk

Answer 24

We worry about osteoporosis because of the increased risk of fragility fractures. So how do we assess which patients are at risk and need further investigation?

NICE produced guidelines in 2012: Osteoporosis: assessing the risk of fragility fracture. The following is based on those guidelines.

They advise that all women aged >= 65 years and all men aged >= 75 years should be assessed. Younger patients should be assessed in the presence of risk factors, such as:

previous fragility fracture

current use or frequent recent use of oral or systemic glucocorticoid

history of falls

family history of hip fracture

other causes of secondary osteoporosis

low body mass index (BMI) (less than 18.5 kg/m²)

smoking

alcohol intake of more than 14 units per week for women and more than 14 units per week for men.

Methods of risk assessment

NICE recommend using a clinical prediction tool such as FRAX or QFracture to assess a patients 10 year risk of developing a fracture. This is analogous to the cardiovascular risk tools such as QRISK.

FRAX

estimates the 10-year risk of fragility fracture

valid for patients aged 40-90 years

based on international data so use not limited to UK patients

assesses the following factors: age, sex, weight, height, previous fracture, parental fracture, current smoking, glucocorticoids, rheumatoid arthritis, secondary osteoporosis, alcohol intake

bone mineral density (BMD) is optional, but clearly improves the accuracy of the results. NICE recommend arranging a DEXA scan if FRAX (without BMD) shows an intermediate result

QFracture

estimates the 10-year risk of fragility fracture

developed in 2009 based on UK primary care dataset

can be used for patients aged 30-99 years (this is stated on the QFracture website, but other sources give a figure of 30-85 years)

includes a larger group of risk factors e.g. cardiovascular disease, history of falls, chronic liver disease, rheumatoid arthritis, type 2 diabetes and tricyclic antidepressants

There are some situations where NICE recommend arranging BMD assessment (i.e. a DEXA scan) rather than using one of the clinical prediction tools:

before starting treatments that may have a rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer).

in people aged under 40 years who have a major risk factor, such as history of multiple fragility fracture, major osteoporotic fracture, or current or recent use of high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone or equivalent per day for 3 months or longer).

Interpreting the results of FRAX

Once we’ve decided that we need to do a risk assessment using FRAX and have entered all the data we are left with results to interpret.

If the FRAX assessment was done without a bone mineral density (BMD) measurement the results (10-year risk of a fragility fracture) will be given and categorised automatically into one of the following:

low risk: reassure and give lifestyle advice

intermediate risk: offer BMD test

high risk: offer bone protection treatment

Therefore, with intermediate risk results FRAX will recommend that you arrange a BMD test to enable you to more accurately determine whether the patient needs treatment

If the FRAX assessment was done witha bone mineral density (BMD) measurement the results (10-year risk of a fragility fracture) will be given and categorised automatically into one of the following:

reassure

consider treatment

strongly recommend treatment

If you use QFracture instead patients are not automatically categorised into low, intermediate or high risk. Instead the ‘raw data’ relating to the 10-year risk of any sustaining an osteoporotic fracture. This data then needs to be interpreted alongside either local or national guidelines, taking into account certain factors such as the patient’s age.

When should we reassess a patient’s risk?

NICE recommend that we recalculate a patient’s risk (i.e. repeat the FRAX/QFracture):

if the original calculated risk was in the region of the intervention threshold for a proposed treatment and only after a minimum of 2 years, or

when there has been a change in the person’s risk factors

Question 25

Patellofemoral pain syndrome

Answer 25

Patellofemoral pain syndrome is now the preferred term for chondromalacia patellae

Softening of the cartilage of the patella.

Common in teenage girls.

Characteristically anterior knee pain on walking up and down stairs and rising from prolonged sitting.

Usually responds to physiotherapy.

Question 26

Rotator cuff injury

Answer 26

Rotator cuff injuries are the most common cause of shoulder problems. A spectrum of disease is recognised:

1. Subacromial impingement (also known as impingement syndrome, painful arc syndrome)
2. Calcific tendonitis
3. Rotator cuff tears
4. Rotator cuff arthropathy

Symptoms

shoulder pain worse on abduction

Signs
-painful arc of abduction. With subacromial impingement, this is typically between 60 and 120 degrees. With rotator cuff tears the pain may be in the first 60 degrees.

tenderness over anterior acromion

Question 27

Scaphoid bone

Answer 27

The scaphoid has a concave articular surface for the head of the capitate and at the edge of this is a crescentic surface for the corresponding area on the lunate.

Proximally, it has a wide convex articular surface with the radius. It has a distally sited tubercle that can be palpated. The remaining articular surface is to the lateral side of the tubercle. It faces laterally and is associated with the trapezium and trapezoid bones.

The narrow strip between the radial and trapezial surfaces and the tubercle gives rise to the radial collateral carpal ligament. The tubercle receives part of the flexor retinaculum. This area is the only part of the scaphoid that is available for the entry of blood vessels. It is commonly fractured and avascular necrosis may result.

Question 28

Talipes equinovarus

Answer 28

Talipes equinovarus, or club foot, describes an inverted (inward turning) and plantar flexed foot. It is usually diagnosed on the newborn exam.

Talipes equinovarus is twice as common in males than females and has an incidence of 1 per 1,000 births. Around 50% of cases are bilateral.

Most commonly idiopathic. Associations include:

spina bifida

cerebral palsy

Edward’s syndrome (trisomy 18)

oligohydramnios

arthrogryposis

The diagnosis is clinical (the deformity is not passively correctable) and imaging is not normally needed.

Management*

in recent years there has been a move away from surgical intervention to more conservative methods such as the Ponseti method

the Ponseti method consists of manipulation and progressive casting which starts soon after birth. The deformity is usually corrected after 6-10 weeks. An Achilles tenotomy is required in around 85% of cases but this can usually be done under local anaesthetic

night-time braces should be applied until the child is aged 4 years. The relapse rate is 15%

*reference: BMJ 2010; 340:c355: Current management of clubfoot. Bridgens J, Kiely N

Question 29

Trigger finger

Answer 29

Trigger finger is a common condition associated with abnormal flexion of the digits. It is thought to be caused by a disparity between the size of the tendon and pulleys through which they pass. In simple terms the tendon becomes ‘stuck’ and cannot pass smoothly through the pulley.

Associations* (idiopathic in the majority)

more common in women than men

rheumatoid arthritis

diabetes mellitus

Features

more common in the thumb, middle, or ring finger

initially stiffness and snapping (‘trigger’) when extending a flexed digit

a nodule may be felt at the base of the affected finger

Management

steroid injection is successful in the majority of patients. A finger splint may be applied afterwards

surgery should be reserved for patients who have not responded to steroid injections

*there is scanty evidence to support a link with repetitive use

Answer 30

Diagram of the brachial plexus

Erb-Duchenne palsy (‘waiter’s tip’)

due to damage of the upper trunk of the brachial plexus (C5,C6)

may be secondary to shoulder dystocia during birth

the arm hangs by the side and is internally rotated, elbow extended

Klumpke injury

due to damage of the lower trunk of the brachial plexus (C8, T1)

as above, may be secondary to shoulder dystocia during birth. Also may be caused by a sudden upward jerk of the hand

associated with Horner’s syndrome

*LOAF muscles

Lateral two lumbricals

Opponens pollis

Abductor pollis brevis

Flexor pollis brevis

Question 31

Upper limb fractures

Answer 31

Colles’ fracture

Fall onto extended outstretched hands

Described as a dinner fork type deformity

Classical Colles’ fractures have the following 3 features:

Features of the injury

1. Transverse fracture of the radius
2. 1 inch proximal to the radio-carpal joint
3. Dorsal displacement and angulation

Smith’s fracture (reverse Colles’ fracture)

Volar angulation of distal radius fragment (Garden spade deformity)

Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed

Bennett’s fracture

Intra-articular fracture of the first carpometacarpal joint

Impact on flexed metacarpal, caused by fist fights

X-ray: triangular fragment at ulnar base of metacarpal

Monteggia’s fracture

Dislocation of the proximal radioulnar joint in association with an ulna fracture

Fall on outstretched hand with forced pronation

Needs prompt diagnosis to avoid disability

Galeazzi fracture

Radial shaft fracture with associated dislocation of the distal radioulnar joint

Occur after a fall on the hand with a rotational force superimposed on it.

On examination, there is bruising, swelling and tenderness over the lower end of the forearm.

X Rays reveal the displaced fracture of the radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint.

Barton’s fracture

Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation

Fall onto extended and pronated wrist

Scaphoid fractures

Scaphoid fractures are the commonest carpal fractures.

Surface of scaphoid is covered by articular cartilage with small area available for blood vessels (fracture risks blood supply)

Forms floor of anatomical snuffbox

Risk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal 1/3)

The main physical signs are swelling and tenderness in the anatomical snuff box, and pain on wrist movements and on longitudinal compression of the thumb.

Ulnar deviation AP needed for visualization of scaphoid

Immobilization of scaphoid fractures difficult

Radial head fracture

Fracture of the radial head is common in young adults.

It is usually caused by a fall on the outstretched hand.

On examination, there is marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination).