Orthopaedics Flashcards
summarise the entire process of describing a fracture radiogarph
Describing a fracture: PAID • Radiographs must be orthogonal: request AP and lat. films. • Need images of joint above and joint below #. • 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
fracture healing process
Reactive Phase (injury – 48hrs) Reparative Phase (2 days – 2 wks) • Consolidation (endochondral ossification) of woven bone → lamellar bone Remodelling Phase (1wk – 7yrs) • Remodelling of lamellar bone to cope ¯c mechanical forces applied to it (Wolff’s Law: “form follows function”)
classifying cause of fracture
Classification • Traumatic # § Direct: e.g. assault ¯c metal bar § Indirect: e.g. FOOSH → clavicle # § Avulsion • Stress # § Bone fatigue due to repetitive strain § E.g. foot #s in marathon runners • Pathological # § Normal forces but diseased bone - Local: tumours - General: osteoporosis, Cushing’s, Paget’
open fracture managemetn
Open fractures require 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
open # classify and complications
Gustillo Classification of Open #s
• Wound <1cm in length
• Wound ≥1cm ¯c minimal soft tissue damage
• Extensive soft tissue damage
Clostridium perfringes • Most dangerous complication of open # • Wound infections and gas gangrene • ± shock and renal failure • Rx: debride, benpen + clindamycin
4 steps in fracture management
resus
reduce
restrict
rehab
open reduction and internal fixation indications
Open reduction (and internal fixation) § Accurate reduction vs. risks of surgery § Intra-articular #s § Open #s § 2 #s in 1 limb § Failed conservative Rx § Bilat identical #s
rehab after fracture key points
Principles
• 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
general fracture compolications
General Complications Tissue Damage • Haemorrhage and shock • Infection • Muscle damage → rhabdomyolysis Anaesthesia • Anaphylaxis • Damage to teeth • Aspiration Prolonged Bed Rest • Chest infection, UTI • Pressure sores and muscle wasting • DVT, PE • ↓ BMD
specific fracture complications`
Immediate • Neurovascular damage • Visceral damage Early • Compartment syn. • Infection (worse if assoc. ¯c metalwork) • Fat embolism → ARDS Late • Problems ¯c union • AVN • Growth disturbance • Post-traumatic osteoarthritis • Complex regional pain syndromes
common nerve palsies assoc with #
rarely get nerve damage with # but if they do…
Ant. shoulder dislocation
Humeral surgical neck
Axillary N. Numb chevron
Weak abduction
humeral shaft Radial N. Waiter’s tip
Elbow dislocation Ulnar N. Claw hand#
Hip dislocation Sciatic N. Foot drop
neck of fibula /
Knee dislocation
Fibular N.
Foot drop
compartment syndrome presentation and mx
Pain > clinical findings • Pain on passive muscle stretching • Warm, erythematous, swollen limb • ↑ CRT and weak/absent peripheral pulses Rx • Elevate limb • Remove all bandages and split/remove cast • Fasciotomy
problems with bone union and reasons
Delayed Union: union takes longer than expected
Non-union: # fails to unite
Causative Factors: 5 Is
• Ischaemia: poor blood supply or AVN
• Infection
• ↑ interfragmentary strain
• Interposition of tissue between fragments
• Intercurrent disease: e.g. malignancy or malnutrition
non bone union classify
Non-union Classification • Hypertrophic § Bone end is rounded, dense and sclerotic • Atrophic § Bone looks osteopenic
management non union
Management
• Optimise biology: infection, blood supply, bone
graft, BMPs
• Optimise mechanics: ORIF
define malunion
Malunion: # healed in an imperfect position
• Poor appearance and/or function
avascular necrosis where etc
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 just FYI
Myositis Ossificans • Heterotopic ossification of muscle @ sites of
haematoma formation
• → restricted, painful movement
• Commonly affects the elbow and quadriceps
• Can be excised surgically
complex regional pain syndrome
Definition
• Complex disorder of pain, sensory abnormalities,
abnormal blood flow, sweating and trophic changes in
superficial or deep tissues.
• No evidence of nerve injury.
Causes
• Injury: #s, carpal tunnel release, ops for Dupuytren’s
• Zoster, MI, Idiopathic
Presentation
• Wks – months after injury
• NOT traumatised area that is affected: affects a
NEIGHBOURING area.
• Lancing pain, hyperalgesia or allodynia
• Vasomotor: hot and sweaty or cold and cyanosed
• Skin: swollen or atrophic and shiny.
• NM: weakness, hyper-reflexia, dystonia, contractures
salter harris fractures
5 types Straight across • Above • Lower • Through • CRUSH
look up pics
risk of arrested growth increases with the numbers
risk factors for osteoporosis
Steroids • Hyper- para/thyroidism • Alcohol and Cigarettes • Thin (BMI<22) • Testosterone low • Early Menopause • Renal / liver failure • Erosive / inflame bone disease (e.g. RA, myeloma) • Dietary Ca low / malabsorption, DM
presentation of NOF and key Qs to ask
• O/E: shortened and externally rotated • Key Qs: § Mechanism § RFs for osteoporosis / pathological # § Premorbid mobility § Premorbid independence § Comorbidities § MMSE
initial management of NOF#
Resuscitate: dehydration, hypothermia • Analgesia: morphine, fascia iliaca block • 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
NOF# imaging
- Ask for AP and lateral film
- Look @ Shenton’s lines
- Intra- or extra-capsular?
- Displaced or non-displaced
- Osteopaenic?
avn of femoral head
If retinacular vessels damaged there is risk of
AVN of the femoral head → pain, stiffness and OA
classify NOF’
Intracapsular: subcapital, transcervical, basicervical
• Extracapsular: Intertrochanteric, subtrochanteric
classify intracapsular #
Garden Classification of Intracapsular Fractures • Incomplete #, undisplaced • Complete #, undisplaced • Complete #, partially displaced • Complete #, completely displaced
summarise surgical management of neck of femur facture
Intracapsular • 1,2: ORIF ¯c 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
complications and prognosis NOF#
Specific Complications
• AVN of fem head in displaced #s (30%)
• Non / mal-union (10-30%)
• Infection
• Osteoarthritis
Prognosis
• 30% mortality @ 1yr
• 50% never regain pre-morbid functioning
• >10% unable to return to premorbid residence
• Majority will have some residual pain or disability
Colle’s fracture
Clinical Features • Fall onto an outstretched hand • Most common in elderly females ¯c osteoporosis • Dinner fork deformity Radiographic Features • Extra-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 =22O) • ± avulsion of ulna styloid • ± impaction
managemnet Colle’s
Examine for neurovascular injuries as median nerve and radial artery lie close. • If much displacement → reduction § 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 X-Ray – satisfactory position? § No: ortho review and consider MUA ± K wires § Yes: home ¯c # clinic f/up w/i 48hrs for completion of POP • 6 wks in POP + physio • If comminuted, intra-articular or re-displaces: § Surgical fixation
complication of Colle’s fractur
Median N. injury • Frozen shoulder / adhesive capsulitis • Tendon rupture: esp. EPL • Carpal tunnel syn. • Mal- /non-union • Sudek’s atrophy / CRPS
scaphoid #
Clinical Features
• FOOSH
• Pain in anatomical snuffbox
• Pain on telescoping the thumb
management scaphoid fracture
Request scaphoid x-ray view
• If clinical hx and exam suggest a scaphoid #, it should
initially be treated even if the x-ray is normal.
§ # may become apparent after 10 days due to
localised decalcification.
• Place wrist in scaphoid plaster (beer glass position)
• If initial x-ray is negative, pt. returns to # clinic after 10
days for re-xray.
§ # visible → plaster for 6 wks
§ No visible # but clinically tender → plaster for 2
wks
§ # not visible and not clinically tender → no plaster
Specific Complications
• Main risk is AVN of the scaphoid as blood supply runs
distal to proximal.
§ → stiffness and pain at the wrist
classify radial and ulnar #
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
manage radial and ulnar #
• 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
classify shoulder disloc
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).
presntation shoulder disloc
Presentation • Shoulder contour lost: appears square • Bulge in infraclavicular fossa: humeral head • Arm supported in opposite hand • Severe pain
disloc shouldr manage
Specific Management
• Assess for neurovascular deficit: esp. axillary N.
§ Sensation over “chevron” area before and
after reduction.
§ Occurs in 5%
• X-ray: AP and transcapular view
• Reduction under sedation (e.g. 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 a sling for 3-4wks
• Physio
complications shoulder disloc
Recurrent dislocation
§ 90% of pts. <20yrs with traumatic dislocation
• Axillary N. injury
impingement syndrome/painful arc
Pathology
• Entrapment of supraspinatus tendon and subacromial
bursa between acromion and grater tuberosity of
humerus.
• → subacromial bursitis and/or supraspinatous tendonitis
Presentation
• Painful arc: 60-120O
• Weakness and ↓ ROM
• +ve Hawkin’s test
inv management impngement syndromfe
Ix • Plain radiographs: may see bony spurs • US • MRI arthrogram Rx • Conservative § Rest § Physiotherapy • Medical § NSAIDs § Subacromial bursa steroid ± LA injection • Surgical § Arthroscopic acromioplasty
ddx painful shouldre arc
Impingement
• Supraspinatous tear or partial tear
• AC joint OA
frozen shoulder presentation
Frozen Shoulder: Adhesive Capsulitis Presentation • Progressive ↓ active and passive ROM § ↓ ext. rotation <30O § ↓ abduction <90O • Shoulder pain, esp. @ night (can’t lie on affected side) Cause • Unknown, may follow trauma in elderly • Commonly assoc. ¯c DM
frozen shoulder manage
Rx • Conservative: rest, physio • Medical § NSAIDs § Subacromial bursa steroid ± LA injection
rotator cuff tear
• 2O to degeneration or a sudden jolt or fall
• Partial tears → painful arc
• Complete tear
§ Shoulder tip pain
§ Full range of passive movement
§ Inability to abduct the arm
§ Active abduction possible following passive
abduction to 90O
§ Lowering the arm beneath this → sudden drop
- “drop arm” sign
Rx: open or arthroscopic repair
supercondylar fracture of the humeurs
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.
risk of neurovasc probs, compartment syndrome, gunstock deformity
femoral and tibfib fractures specific management
Specific Management • Resus and Mx life-threatening injuries first. • X-Match § Tibial #: 2 units § Femoral #: 4 units • Assess neurovascular status: esp. distal pulses • If open § Abx and ATT § Take to theatre urgently for debridement, washout and stabilisation • Fixation methods § Intramedullary nail § Ex-fix § Plates and screws § MUA ¯c fixed traction for 3-4mo
complications femoral or tibfib fracture
Specific Complications • Hypovolaemic shock • Neurovascular § SFA: swelling and check pulses § Sciatic nerve • Compartment syndrome • Respiratory complications § Fat embolism § ARDS § Pneumonia
ankle ligament strain
Ligament Strains
• Typically twisting inversion injury
§ Strains anterior talofibular part of lateral
collateral ligament
• Medial deltoid ligament strains are rare.
• May be assoc. ¯c malleolar avulsion #s
ankle fractures classify andn treat
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 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 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 classic histories
History
• 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
Knee Haemarthrosis • 1O: spontaneous bleeding § Coagulopathy: warfarin, haemophilia • 2O: trauma § ACL injury: 80% § Patella dislocation: 10% § Meniscal injury: 10% - Outer third where its vascularised § Osteophyte #
manage acutely-injured knee
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
manage ruptured ACL
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.
define osteoarthritis
Degenerative joint disorder in which there is
progressive loss of hyaline cartilage and new bone
formation at the joint surface and its margin.
RFs, classify, symptoms OA
Aetiology / Risk Factors • Age (80% > 75yrs)
• Obesity
• Joint abnormality
Classification
• Primary: no underlying cause
• Secondary: obesity, joint abnormality
Symptoms • 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 of OA
Bouchards and Heberdens nodes
§ ‘Pouchards’ (prox), ‘Heberdips’ (dist.)
• Thumb CMC squaring
• Fixed flexion deformity
Qs to ask in OA hx
History • Pain severity, night pain • Walking distance • Analgesic requirements • ADLs and social circumstances • Co-morbidities • Underlying causes: trauma, infection, congenital
x ray changes OA
X-ray Changes • Loss of joint space • Osteophytes • Subchondral cysts • Subchondral sclerosis • Deformity
management options OA
MDT: GP, physio, OT, dietician, orthopod Conservative • Lifestyle: ↓ wt., ↑ exercise • Physio: muscle strengthening • OT: walking aids, supportive footwear, home mods Medical • Analgesia § Paracetamol § NSAIDs: e.g. arthrotec (diclofenac + misoprostol) § Tramadol • Joint injection: local anaesthetic and steroids Surgical • Arthroscopic Washout § Mainly knees § Trim cartilage § Remove loose bodies. • Realignment Osteotomy § Small area of bone cut out § Useful in younger (<50yrs) pts. ¯c medial knee OA § High tibial valgus osteotomy redistributes wt. to lateral part of joint. • Arthroplasty: replacement (or excision)
manage standard mechanicalback pain
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 and presnet
Disc Prolapse
• Herniation of nucleus pulposus through annulus fibrosus
Presentation
• 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 sigsn
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 herniation compressing L5 root
L4/5 → 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 herniation compressing s1 roote
L5/S1 → S1 Root Compression • Weak foot plantarflexion and eversion • Loss of ankle-jerk • Calf pain • ↓ sensation over sole of foot and back of calf
manage disc herniation
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.
spondylolisthesis
Spondylolisthesis • Displacement of one lumbar vertebra on another § Usually forward § Usually L5 on S1 • May be palpable Causes • Congenital malformation • Spondylosis • Osteoarthriti
manage spondylolisthesis
Presentation • Onset of pain usually in adolescence or early adulthood § Worse on standing • ± sciatica, hamstring tightness, abnormal gait Dx: Plain radiography Rx • Corset • Nerve release • Spinal fusion
spinal stenosis summary
Spinal Stenosis • Developmental predisposition ± facet joint osteoarthritis → generalized narrowing of lumbar spinal canal. Presentation • Spinal claudication § Aching or heavy buttock and lower limb pain on walking § Rapid onset § May c/o paraesthesiae/numbness § Pain eased by leaning forward (e.g. on bike) • Pain on spine extension Ix: MRI Rx • Corsets • NSAIDs • Epidural steroid injection • Canal decompression surgery
acute cord compression presentation
Acute Cord Compression • Bilateral pain: back and radicular • LMN signs at compression level • UMN signs and sensory level below compression • Sphincter disturbance
acute cauda equina compression
Acute Cauda Equina Compression • Alternating or bilateral radicular pain in the legs • Saddle anaesthesia • Loss of anal tone • Bladder ± bowel incontinence
management of acute cord / c equina compresion
Rx
• Large prolapse: laminectomy / discectomy
• Tumours: radiotherapy and steroids
• Abscesses: decompression
emergency!!!
Perthe’s of the hip pathogeneiss
Osteochondritis • Idiopathic condition in which bony centres of
children/adolescents become temporarily softened due
to osteonecrosis.
• Pressure → deformation
• Bone hardens in new, deformed position
Radiography
• Initially: ↑ density / sclerosis
osgood schlatter’s
Osgood-Shlatter’s
• Tibial tuberosity apophysitis + patellar tendonitis
• Children 10-14yrs, M>F=3:1
• Assoc. ¯c physical activity
• Symptoms: pain below knee, esp ¯c quads contraction
• X-ray: tuberosity enlargement ± fragmentation
• Rx: rest, consider POP
causes of avascular necrosis of a bone
Causes • # or dislocation • SCD, thalassaemia • SLE • Drugs: steroids, NSAIDs
ddx of a limping child
DDH • Transient synovitis • Septic arthritis • Perthes’ • Slipped Capital Femoral Epiphyses • JIA / Still’s Disease
developmental dysplasia of the hip
DDH • Congenital hip joint deformity in which the femoral head is or can be completely / partially displaced. Epidemiology • Incidence: 1/1000 • Sex: F>M Predisposing Factors • FH • Breech presentation • Oligohydramnios Presentation • Screening • Asymmetric skin folds • Limp / abnormal gait Ix • US is v. specific Mx: maintain abduction • Double nappies • Pavlik harness • Plaster hip spica • Open reduction: derotation varus osteotomy
transient synovitis in a child
Transient Synovitis: Irritable Hip • Commonest cause of acute hip pain in children Presentation • 2-12yrs • Sudden onset hip pain / limp • Often following or with viral infection • Not systemically unwell Ix • PMN and ESR/CRP are normal • -ve blood cultures • May need joint aspiration and culture Mx • Rest and analgesia • Settles over 2-3d
Perthe’s disease child
Perthes’ Disease • Osteochondritis of the femoral head 2O to AVN. Epidemiology • 4-10yrs • M>F=5:1 Presentation • Insidious onset • Hip pain initially, then painless • 10-20% bilateral Ix • X-rays normal initially • ↑ density of femoral head § Becomes fragmented and irregular § Flattening and sclerosis • Bone scan is useful Mx • Detected early and < half femoral head affected § Bed rest and traction • More severe § Maintain hip in abduction ¯c plas
slipped capital femoral epiphysis / SUFE
Slipped Capital Femoral Epiphysis • Postero-inferior displacement of femoral head epiphysis • 10-15yrs • Two main groups § Fat and sexually underdeveloped § Tall and thin Presentation • Slip may be acute, chronic or acute-on-chronic • Acute § Groin pain § Shortened, externally rotated leg § All movements painful • 20% bilateral Ix • Confirm Dx by x-ray Mx • Acute: reduce and pin epiphysis • Chronic: in situ pinning § Epiphyseal reduction risks AVN Complications • Chondrolysis: breakdown of articular cartilage § ↑ risk ¯c surgery
osteomyelitis risk factors and causes
Pathophysiology • Source: local or haematogenous. • Organisms § Staph § Strep § E. coli § Pseudomonas § Salmonella (in SCD) • RFs § Vascular disease § Trauma § SCD § Immunosuppression (e.g. DM) § Children - Rich blood supply to growth plate - \ usually affects metaphysis
osteomyelitis symptoms, inv and managemnt
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 RFs, cause, signs
Pathophysiology • Source: local or haematogenous. • Organisms § Staph: 60% § Streps § Gonococcus § Gm-ve bacilli • RFs § Joint disease (e.g. RA) § CRF § Immunosuppression (e.g. DM) § Prosthetic joints Symptoms • Acutely inflamed tender, swollen joint. • ↓ROM • Systemically unwell
septic arthritis inv and management and complic
nvestigations • Joint aspiration for MCS § ↑↑ WCC (e.g. >50,000/mm3 ) : mostly PMN • ↑ESR/CRP, ↑WCC, Blood cultures • X-ray Management • IV Abx: vanc + cefotaxime • Consider joint washout under GA • Splint joint • Physiotherapy after infection resolved Complications • Osteomyelitis • Arthritis • Ankylosis: fusion Differential • Crystal arthropathy • Reactive arthritis
summarise key info about bone metastasis of other cancers
Commonest bone tumours
• Bronchus, thyroid, breast, kidney and prostate
• Usually radiolucent (except prostate which is sclerotic)
• Usually axial skeleton (contains red marrow)
• Present with pain or pathological #
§ Path # → internal fixation
§ Pain → radiotherapy
fibrous dysplasia
“Ground Glass” lytic lesion
Shepherds crook deformity of
prox. femur
Osteochondroma
10-20 M>F = 3:1 Commonest benign bone tumour May be related to previous trauma Knee Cartilage-capped bony outgrowth
encochondroma just fyi
O sign - Oval lucencies ¯c radiodense rim Endosteal scalloping 10-40 M=F
Chondroblastoma
knee epiphysis 10-20 yrs old
chondrosarcoma
>40 Pain + lump Arise de novo or from chondromas 70% 5ys Pelvis Axial skeleton Lytic lesion Fluffy “popcorn calcification”
malignant cartilagenous
osteoid osteoma
M>F = 2:1 Teens and 20s Severe nocturnal pain relieved by aspirin Hot on bone scan Lower limb Diaphyseal cortex Lytic lesion ¯c central nidus and sclerotic rim
osteoblastoma
Osteoblastoma Pain unresponsive to aspirin Spine
giant cell tumour
Giant Cell Tumour / Osteoclastoma 20-40 (After fusion of growth plate) F>M Knee Abut joint surface Soap bubble appearance Solitary, expansile, lytic lesion
osteosarcoma
Adolescents M>F = 2:1 Commonest 1O bone tumour Pain, warm, bruit May arise 2o to Paget’s or irradiation Knee Metaphysis Periosteal Elevation: - Sunburst appearance - Codman’s triangle
malignant bone cancer
Ewing’s sarcoma
malignant bone ca Ewing’s Sarcoma <20 Painful, warm, enlarging mass Systemic: fever, ↑ESR, anaemia, ↑WCC Long bone diaphysis Lytic tumour Onion-skin periosteal reactio
brachial plexus basic anatomy
Anatomy
• C5-T1
• Roots leave vertebral column between scalenus
anterior and medius.
• Divisions occur under the clavicle, medial to coracoid
process.
• Plexus has intimate relationship ¯c subclavian and
brachial arteries. Median N. is formed anterior to
brachial artery
Erb’s palsy
High (C5/6): Erb’s Palsy
• Abductors and external rotators paralysed
• Waiter’s tip position
• Loss of sensation in C5/6 dermatomes
Klumpke’s palsy
Low (C8/T1): Klumpke’s Paralysis
• Paralysis of small hand muscles
• Claw hand
• Loss of sensation in C8/T1 dermatomes
radial nerve lesions
Radial Nerve (C5-T1)
Low Lesions: posterior interosseous nerve
• Site: # around elbow or forearm
§ E.g. # 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 lesions
Ulnar Nerve (C8-T1)
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 lesions
Median Nerve (C5-T1)
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 anatomy
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.
carpal tunnel causes and symptoms
Causes • F>M • Primary / idiopathic • Secondary • Water: pregnancy, hypothyroidism • Radial # • Inflammation: RA, gout • Soft tissue swelling: lipomas, acromegaly, amyloidosis • Toxic: DM, EtOH 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
management carpal tunnel syndrome
Ix • Not usually performed • Nerve conduction studies • US Non-surgical Mx • Mx of underlying cause • Wrist splints § Neutral position § Esp. @ night • Local steroid injections Surgical Mx • 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
summary of Dupytren’s contarcture
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 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 § Retroperitoneal fibrosis • Smoking Management • 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 • Tendon fibrosis, trigger finger • Ulnar N. palsy
trigger finger
Trigger Finger
• Tendon nodule which catches on proximal side of
tendon sheath → triggering on forced extension.
• → Fixed flexion deformity
• Usually ring and middle fingers
• Assoc. ¯c RA
• Rx: steroid injection (high recurrence) or surgery
ganglion
Ganglion • Smooth, multilocular cystic swellings • Mucoid degeneration of joint capsule or tendon sheath • May be in communication ¯c 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 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
§ Between ASIS and inguinal ligament
• Pain ± paraesthesia on the lateral thigh
• No motor deficit
• ↑ risk ¯c 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
Baker’s Cyst • Popliteal swelling arising between the medial head of gastrocnemius and semimembranosus muscle • Herniation from joint synovium • Usually 2O to OA • Rupture: acute calf pain and swelling § DVT differentia
hallux valgus
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 heels Mx • Conservative: bunion pads, plastic wedge between great and second toes. • Surgical: metatarsal osteotomy
hammer toe, mallet toe, claw toe
check know what they look like
