Orthopaedics and Trauma Flashcards
1
Q
Where do Bone cells originate from?
A
Mesenchymal Stemm Cells → Osteoblasts & Osteocytes
Haematopeitics stem cells → Osteoblast
2
Q
What is the role of Osteoblasts?
A
- produces osteoid (bone matrix)
- has a massive synthetic capacity
- has a high alkaline phosphate activity
- eventually dies and becomes a bone lining cell
3
Q
What is the role of Osteoclasts?
A
- they are on the bone ‘surface’
- Cancellous bone (Howships lacunae)
- Cortical bone (lead cutting cones)
- multi-nucleate (derived from macrophage cell line)
- they have a brush border
- increases surface area and where acid phosphatase and collagenase act to break bone down
- Integrins ‘attach’ osteoclast to bone ‘surface’
- Mechano-transducers
- the connection between the force through the bone and cell biology
4
Q
What is the acronym used for an Acute handover?
A
ATMIST
- Age
- Time
- Mechanism
- Injuries (top to toe, know so far)
- Signs (vitals)
- Treatment
5
Q
What is used to guide advanced life support?
A
A to E-assessment
- Airway
- Breathing
- Circulation + abdomen
- Disability
- External factors
6
Q
What are the most immediate life-threatening Airway and Breathing problems?
A
ATOM FC
- Airway obstruction
- Tension Pneumothorax
- Open Pneumothorax
- Massive Haemothorax
- Flail chest
- Cardiac Tamponade
7
Q
What is the definition of a flail segment?
A
Two or more adjacent ribs broken in two or more places
causes paradoxical movement of the chest when breathing
8
Q
What is the pathology seen in this radiograph?
A
9
Q
Explain the signs seen in the four classes of blood loss.
A
Class I: up to 750mL
Class II: 750-1500 mL
Class III: 1500-2000 mL
Class IV: > 2000mL
10
Q
What Vascular problems may arise in Circulation?
A
- Direct arterial injury
- Occlusion of venous outflow
- i.e Compartment syndrome
11
Q
What is compartment syndrome? Txt?
A
When veins within a fascial space occlude → increase in venous pressure and pressure within the fascial compartment
This results in the arterial supply being occluded → necrosis as tissue within the compartment are not adequately perfused
If the pressure in the compartment approaches 20-30 mmol of mercury below the diastolic it paramount to identify it as compartment syndrome
There is usually associated severe pain
Txt with a fasciotomy
12
Q
What happens if there is a missed compartment syndrome?
A
The tissues wihtin the compartment will die → in a fixed ocontractorf the muscle which can be difficult to treat
i.e forearm
Volkman’s Ischaemic contracture
13
Q
What investigations are done for a fracture?
A
X-ray the whole bone
above and below the break
in two views
14
Q
How to describe the radiograph of a fracture
A
- Identify which bone
- Where in the bone is the fracture
- Intra-articular
- Epiphysis
- Physis
- Metaphysis
- Diaphysis
- What sort of bone is it
- normal (for age), pathological
15
Q
How would you present a fracture?
A
This is a
- Displaced
- Intra-articular (where in the bone)
- Fracture (broken or not)
- Of the distal (which end is it)
- Tibia (the bone)
most important part
16
Q
What are the different fracture patterns, what do they mean?
A
- Simple
- transvers, oblique, spiral
- Communited
- how many parts
- Displaced
- angulated, translated, burst
- length, alighnment and rotation
- Special Types
- Greenstick, avulsions
17
Q
Explain the biomechanics of Bone
A
Anisotropic
- Strength is non-uniform
- i.e Strength in compression, Weak in bend/ torsion
- to facilitate healing bones shoude be under compression
Dynamic
- Self-repair
- Changes with age/ prolonged immobilisation
18
Q
Why are long bones hollow?
A
- Bending strength
- proportional to the radius power force
- increase in diameter → higher relative bending strength
- “Optimise” Tissue available
- Physiological
- Bone marrow reservoir
- Medullary blood supply
19
Q
What would a fracture of the femur in two places suggest about the condition of the patient and their outcome?
A
- lots of energy put into cause the break therefore lots of soft tissue injury/ sweeling
- higher rate of slow healing or poor healing due to the internal soft tissue damage
- higher rate of infection
20
Q
What are the three basic principles of fracture management?
A
-
Reduce the fracture if it’s been displaced
- length, alignment and rotation
- closed vs open
-
Stabilise
- external: sling, POP, external fixator
- internal: wires, intramedullary (nails), intramedullary (plates),
- Rehabilitate
- Nothing
- Replacment
21
Q
Wha are the two main ways of bone healing?
A
- Primary bone healing
- bone heals as if it is routine bone turnover
- when the bone fragments are perfectly aligned
- have to be completely reduced and compression is solid
- Secondary bone healing
- when there doesn’t need to be absolute alignment or bone healing
- good compression, with a little bit of movement
- this stimulates hematoma → callus → more calcium put down → forms primary then secondary bones
- process of 6-8 weeks and remodelling after is 28months up to 2 years
22
Q
What is the gross anatomy of the hip joint?
A
23
Q
What is the blood supply to the femoral head and why is this significant in hip fractuers?
A
The Ligamentum teres artery forsm part of the supply to the femroal head however isn’t a major supply in adults as it is in children
if there is significant soft tissue damage, reducing and fixing the hip joint but it may not be successful
30-40% chance the patient may need a replacement due to poor supply (Hemi-Arthroplasty), full arthroplasty if fit and helathy
24
Q
What complications may be seen in a traumatic communited knee fracture?
A
- slow bone healing, due to damged soft tissue
- mal-alignment of the knee
- infection
- post traumatic artheritis
25
What are the principles of Polytrauma care?
* Damage control vs Early Total care
* Maintaining physiological parameters (poor output of outcomes, wait until they are stable before surgery if possible)
* Acidosis
* Hypothermia
* Coagulopathy
26
What is Paget's disease of the bone?
When osteoclast and osteoblast activity is dysregulated usually affects the pelvis, skull spine and legs
* more osteoclast activity than osteoblast and dysregulated bone remodelling
this can cause an atypical fracture
27
What are examples of elective surgery?
* Dupuytren's disease
* Rheumatoid hand
* Cuff Arthropathy
* Hip replacement (non-traumatic)
* Knee replacement (non-traumatic)
* Spinal fusion
28
What are the general complications of orthopaedic surgery?
* Poor wound healing infection
* infection in a hip replacement may require, complete replacement of the implant
* Dislocation
* Component disassembly
* DVT/PE
* Chest infection
* Urinary retention
* Sepsis\*
* Medical complications, MI/CVA/renal failure
29
What are the late complications of orthopaedic surgery?
* Infection
* Osteoarthritis
* weakening of surrounding tissue
* Loosening of the components
* Recurrence/ functional deterioration
30
What is the Palmar Fascia?
- associated muscles
- clinical significance?
* Tough layer anchoring skin to skeleton
* longitudinal and transverse fascia
* Extension of forearm fascia
* Tightened by palmaris longus (apes)
* Dupuytren’s disease: thickening of the fracture
31
What is Dupuytren's disease?
- causes?
- treated?
* Thickening of the palmar fascia
* starts of as nodules then the line develops into a thickened band that stands out on the palm on the front of the arm
* Contracture
* Causes
* Genetic: more common in males
* Smoking
* Alcohol
* Diabetes/epilepsy treatment
* surgical removal
32
What problems can occur with the flexor tendons?
* traumatic rupture (cuts)
* Trigger fingers: catching of tendons at the A1 fully
* Rugby jersey finger (closed, finger hood and forcefully pulled)
33
What is Trigger Fingers?
- cause?
- treatment?
* Catching of tendons at A1 pulley: the finger remains in a bent position
* Degenerate nodule (usually in older people)
* collagen fibres get stiffer and more brittle
* tendon kinks under load as it comes out of the sheath at that point
* causing the collagen to break
* thickening of sheath
* diffused swelling around the tendon
* a stiff finger that can't be easily straightened
* due to overuse, and degeneration
* Treatment:
* steroid injection,
* cut the A1 pulley so it's bigger so the tendon doesn't catch as much
34
What are the sensory dermatomes for the nerves in the hand?
(look at your hand and trace it, palm and dorsum)
- clinical tests for loss of sensation? (3)
* dryer airer compared to another
* dry rubber, different sens of friction
* two-point discrimination with paper clip
35
What is carpal tunnel syndrome?
- structures it effects?
- presentation/ aetiology?
* Median nerve compression at wrist
* Tendons/ Nerves
* Nerve function. lost in 3 thenar muscles in severe cases
* Experience sensory symptoms in the radial half of the hand.
* occurs spontaneously in _35-45 y/o_ - usually in females (can get it in the 3rd trimester of pregnancy)
* lots of tingling
* occurs in _75 y/o_
* thenar wasting - may
* numbness
* not as much tingling
36
What are the Thenar muscles?
- innervation
- action
* Abductor pollicis brevis *(median nerve)*
* Opponens pollicis *(median nerve)*
* Flexor pollicis brevis *(superficial=median, deep= ulnar)*
* Adductor (ulnar)
* gives fine control of thumb and the ability to oppose the thumb
37
What are carpal tunnel signs?
| (3)
* Thenar wasting
* Loss of abduction
* Loss of opposition
38
What is cubital tunnel syndrome?
- what causes it (3)
- what structures does it effect
* Ulnar nerve compression at the elbow
* Medial epicondyle fascial compression
* Arcade of Struthers: thin fibrous aponeurotic band extending from medial head of triceps to medial intermuscular septum
* Between the ulnar and humeral heads of the flexor carpi ulnaris
* Nerve supplies the Forearm & hand muscles therefore it results in
* Sensory symptoms ulnar half of hand.
* lack of flexion in the forearm and the hand --\> muscle wasting
39
Which muscles are impacted in Cubital Tunnel syndrome?
- how and why?
- symptoms/ presentation
Hypothenar waisting - mainly seen in the medial side of the hand overall reduced grip strength, as the little finger gives the most grip strength
* Flexor digiti minimi
* Abductor digiti minimi
* Opponens digiti minimi
- struggle with gripping things, shoelaces buttons,
- experience tingling
* Interossei
* FCU, FDP (m/r/l)
40
Give an overview of the Interosseous Muscles
- structure
- action
- innervation
* Palmar/dorsal muscles
* Insertion to proximal phalanx
* Adduction/abduction
* Insertion to extensor hood
* Interphalangeal extension
* Ulnar nerve
41
What are signs of Ulnar nerve damage?
* Wasted hypothenar web spaces
* Paradoxical wasting thenar
* the muscles underneath (the interossei) it are wasted so it looks as if the abductor pollicis and opponents pollicis are wasted
* Proximal forearm wasting
* Clawing of digits
* because of intrinsic muscle wasting of the flexor
42
What are the extensor tendons?
* Extend MCP joints of fingers
* Thumb tendons
* Wrist tendons
* Extensor Retinaculum
* 12 in all
* Some multistranded (APL/EDC/EDQ)
43
What is Quervain's disease?
- causes
* caused by Thickening of the extensor retinaculum
* can also be caused by degeneration
* similar to trigger fingers
* Triggering and pain of thumb extensors as the tendons kink as they pass through that point
* Due to
* overuse (hammer)
* Ciprofloxacin (antibiotic)
* Anastrazole (hormonal manipulation for breast cancer)
44
Label this diagram?
-
45
What are ruptures that can occur in the dorsal extensor?
* Lacerations
* Fracture
* Synovitis
* Arthritis
* No triggering
46
Give an overview of the Digital extensor hood
- clinical significance
* Long extensors
* Interossei
* Lumbrical
* Finely balanced
* Complex multibundle flat tendon
- Mallet finger in the elderly: rupture of the tendon after minor activity --\> dropped tip of the fingers
47
Give an overview of the Osteology of the hand
* 3 phalanges in fingers
* 2 phalanges in thumb
* 5 metacarpals
* 2 sesamoids in thumb
* 8 carpal bones
48
What are the carpal bones?
49
What are bone problems of the hand?
* Radial fracture - most common wrist injury
* Scaphoid fracture - second most common
* falling on an outstretched hand
* 1st CMC osteoarthritis
* Rheumatoid arthritis
50
What is this an image of?
* Thumb base osteoarthritis
* lots of joint spaces
* the majority aren't painful
51
What pathology does this X-ray show?
Rheumatoid arthritis
52
Between which points in the nerve tract would cause LMN condition?
* anywhere between the Motor cortex in the brain to the lower motor neuron in the anterior horn of the spinal cord
53
What are the different signs seen in UMN and LMN lesions?
_Upper Motor Neuron_
* Held in flexed posture if chronic.
* Increased tone
* Pyramidal weakness (Flexor muscles stronger than extensors)
* Brisk reflexes.
* a clear demarcation of sensory changes
_Lower Motor Neuron_
* Wasting/Fasciculations
* Flaccid tone
* Weakness in either a myotomal distribution or a peripheral nerve distribution
* Reduced reflexes.
* Dermatomal or peripheral nerve distribution of sensory loss.
54
What are Myotomes and Dermatomes
* Myotomes - Relationship between the spinal nerve & muscle
* Dermatomes - Relationship between the spinal nerve & skin
55
What is this an image of?
- which dermatomes are affected?
* Herpes Zoster
* Goes to the V1 branch of the Trigeminal Nerve (CN V)
* T4 and T5 in the rips
56
What are the myotomes of C5-T1
- what are their respective muscle actions?
57
What reflexes are associated with spinal roots C5-C8?
- what is the clinical significance?
* **Biceps reflex** – C5 reflex conveyed through the musculocutaneous nerve.
* **Supinator jerk** – C6 reflex conveyed through the radial nerve.
* **Triceps jerk** – C7 reflex conveyed through the radial nerve.
* **Finger jerk** – C8 reflex conveyed through the median and ulnar nerve.
_In low motor lesions the reflex is depressed_
58
What is a nerve Impingement and what are the causes?
- what does the result of the impingement?
* when a nerve is trapped/ compressed
_Causes_
* slipped disk/ herniation - causes nucleus pulposus to herniate into the spinal canal compression the nerves
_Results in_
* pain on the neck - which radiates/ aggravated by neck movement
* sensory loss
* weakness
* loss of reflexes
59
What type of imaging is this and what does it show?
- what is the weighting/ plane
- what is the effect of the pathology shown?
* T2 weighted MRI, coronal view
* shows _herniated disk_ C6 disk causing _root nerve impingement_
can cause a Cervicoradicular Myelopathy (root= radiculopathy, spinal cord=mylopathy)
* there may be no motor neuron signs at the level the root is pressing on as it exits the spinal cord
* but it's also pressing the spinal cord so you get upper motor neuron signs below that
60
What are different types of Nerve plexus injuries?
- what are their corresponding repairs?
* **Avulsion:** Tearing of the nerves from its attachment at the spinal cord. – Require surgical repair
* **Rupture:** Tearing of the nerves but _not from its attachment to the spinal cord_ – Require surgical repair
* **Neuroma:** tumour or growth of the nerve tissue. Can arise from the axon or myeloma – Require surgical repair
* **Neurapraxia:** Axons remain intact, but myelin damage causes an interruption of the impulse down the nerve fibre – _Good prognosis._
* it is intact so better recovery
61
What pathology is seen in this image?
- what are the consequences of this pathology to other structures?
* C5-T1 lesions causing flail arm
* **cervical root avulsion**
* Left shoulder subluxation
* Atrophy of the left deltoid, supraspinatus and infraspinatus
62
What are the causes of Brachial plexus Injury?
(4 main groups)
* Trauma
* Erb-Duchenne type paralysis: Avulsion of C5,C6 roots.
* Klumpke paralysis: Avulsion of C8, T1 roots.
* Cancer
* Lung cancer: Pancoast's tumour
* Radiotherapy
* Inflammatory
* Brachial neuritis
* Structural
* Thoracic outlet syndrome
63
What is Erbs palsy (Erb-Duchennetype paralysis)?
- What is the cause
- what is the effect on other structures?
* Avulsion of C5, C6 roots
* Usually caused during parturition or as a blow to the shoulder in adults
causes weak muscles in the following
* Biceps (flexes the arm)
* Brachioradialis (flexes the arm in semi-prone position)
* Deltoid (abducts the arm)
* Supraspinatus (abducts the arm)
* Supinator (externally rotates the arm)
_the arm doesn't work but the hand does_
64
What is Klumpke’s Palsy?
- What is the cause
- What is the effect on other structures?
* Inferior trunk plexus injury involving **Avulsion of C8/T1**
* Clutching for an object when falling from a height, at birth when pulled with the arm in a breach delivery
* Involves trunk that supplies median and ulnar nerves
* Unable to flex wrist or fingers
* Weakness of all small muscles of the hand
* Sensory loss hand and inner border of the forearm
* May lead to a claw hand
* Arm works but hand does not!
65
What is Pancoast Tumour?
- What is the neurological effect of this tumour
- What are further implications of treating the tumour?
* An apical lung cancer close to the inferior brachial plexus
* the tumour can infiltrate into the lower brachial flexus
* effects the arm but the hand works
* Pain in the shoulder girdle and inner arm
* Ipsilateral horners syndrome
Can also experience radiation-induced brachial plexopathy
* experienced 6 yrs post radiation
* associated with treatment for breast, lung cancer and lymphoma
* pain is not a consistent feature
66
What is radiation-induced Brachial plexopathy
* experienced 6 yrs post-radiation treatment
* associated with treatment for breast, lung cancer and lymphoma
* pain is not a consistent feature
67
What is Ipsilateral horners syndrome?
- cause
- symptoms
* An interruption of nerve supply from the brain to the face and eye, on one side of the body.
* Usually caused due to injury to the spinal cord, stroke, tumour or underlying conditions.
* **Symptoms:** small pupils (miosis), little or no sweating on the affected side, drooping of the eyelids and unequal pupils.
68
What is Idiopathic Brachial Neuritis
- cause?
- symptoms/presentation?
- investigation/ treatment?
* Aetiology not clear, infectious, post-infectious
* Severe pain over days; as the pain diminishes, it is followed by weakness and wasting (motor impact is \>sensory)
* Typically monophasic (rarely happens again)
* Rarely bilateral
* MRI shows thickening and enhancement.
* NCS/EMG is useful for prognostication.
* Treatment:
* Analgesia, physiotherapy
* Limited evidence for the use of steroids
69
What are the two presentations of Thoracic Outlet Syndrome?
- what do they result in?
**Neurogenic:** predominantly affects the _median-innervated abductor pollicis brevis muscle_
* results in _thenar wasting_
**Vascular:** High rib causes area of stenosis with a post stenotic dilatation.
* Clots may form in the dilated vessel with small fragments that then become detached and pass down the brachial artery into the hand. Acute ischaemic changes lead to _Raynaud’s phenomenon_.
70
What are the anatomical variations that cause compression sites in Thoracic Outlet Syndrome?
(2)
* Between anterior and middle scalene muscles
* Beneath clavicle in the costoclarvicular space
* Beneath tendon of Pectorlis minor
71
What is the Neurogenic presentation of Thoracic Outlet Syndrome?
(3)
* Paresthesia, numbness, weakness
* Not localised to specific nerve distribution
* Reproducibly aggravated by elevation or sustained use of arms or hands.
72
What is the Vascular presentation of Thoracic Outlet Syndrome?
(5)
* Forearm fatigue within minutes of use.
* Swelling and cynaosis
* Collateral venous patterning over the ipsilateral shoulder, chest wall and neck.
* Rarely pain, pallor and coldness (arterial involvement).
* Lower BP on affected arm, diminished distal pulses.
73
# what is the supply of the long thoracic nerve?
How can the Long Thoracic Nerve be damaged?
- what pathology does this result in? and why?
- how can damage be tested
* blows or pressure to the posterior triangle of the neck
* damaged during a radical mastectomy
* leads to a **winged scapula******
* Long thoracic nerve supplies the serratus anterior muscle.
* The serratus anterior muscle pulls the _medial border of the scapula_ to _the posterior thoracic wall and stabilises it there_
* Impairment of the long thoracic nerve leads to “winging” of the scapula
* pushing against a wall causes the scapula to wing out
74
What are the common sites of compression in the Median nerve?
* Wrist --\> (carpel tunnel syndrome)
* Elbow
75
# LOAF
What does the Median nerve innervate in the hand?
* **_L_**ateral 2 lumbricals
* **_O_**pponens pollicis
* **_A_**bductor pollicis brevis
* **_F_**lexor pollicis brevis
76
What is Carpal Tunnel Syndrome?
- causes (5)
- symptoms/presentation (3)
- diagnostic tests (2)
* Median Nerve entrapment at the carpal tunnel
* can also be damaged in wrist fractures
Caused by
* Diabetes
* Pregnancy
* Hypothyroidism
* Rheumatoid arthritis
* Repetitive strain
Symptoms/ presentation
* can cause thenar waisting
* tingling in three and a half fingers,
* wake up at night to shake their hand
Diagnostic tests
* Tinel's sign - tap to reproduce symptoms
* Phalen's sign - fold-down wrist to reproduce symptoms
77
What is the common site of compression of the Interosseous Nerve?
- how else might it be damaged
(where does the nerve arise from)
arises from the median nerve just above the elbow
* Prone to compression between 2 heads of pronator teres muscle
* Gripping tightly with forced pronation
* Prolonged use of a screwdriver!
* May also be damaged in careless blood taking
78
What is seen in Inrersosseous nerve syndrome?
- why are these signs seen?
* weakness in flexors of DIP (end joints of the) joint of the thumb (flexor policis longus supplied by the n.)
* weakness in _dip joints of index and middle fingers_ – (flexor digitorum profundus supplied by the n.)
* weakness of pronation
* results in a flat pinch
79
How is sensory innervation of the median nerve impacted depending on where the lesion is?
* if the lesion is more distal there is greater sensory and motor disfunction
* one of the sensory branches of the median nerve decussates earlier on
80
What are the two different motor pathologies associated with the ulnar nerve?
* Ulnar palsy at the elbow
* Higher lesion in the upper limb: Paralysis of the ulnar half of the flexor digitorum profundus (FDP), interossei and lumbricals. The ring and little fingers are not flexed and there is no claw.
* Ulnar palsy at the wrist - Claw hand
* Flexion at the DIP (FDP is intact)
* Flexion at the PIP (interossei are paralysed)
* hyperextension at the MCP (lubricals are paralysed).
81
What are two key branches of the ulnar nerve and how are they clinically significant?
82
How could the Ulnar nerve be damaged?
* fractures
* compression at the Guyon's canal (at the pisiform bone)
* occupationally, cycling, rheumatoid arthritis can cause this as the nerve is so superficial
83
What sign indicates Ulnar n. palsy?
- what is the biomechanics behind this?
* Froment's sign
* Ulnar nerve supplies the Ulnar nerve abductor pollicis causes this
84
How do you distinguish between Ulnar lesion vs a C8 lesion?
motor examination exam
* C8 supplies
* all finger extensors - radial nerve so a finger extension would be effected
* Flexor Digitorum Profundus of index/ middle finger- median nerve
* Radial nerve palsy (extenders effected) - flappy wrist
* Numbness in the region of the anatomical snuffbox indicates radial nerve damage
85
What Radial Nerve pathologies are there?
- causes
* Radial nerve palsy (extenders effected) - flappy wrist
* Numbness in the region of the anatomical snuffbox indicates radial nerve damage
86
What does a nerve conduction study do?
- what two conditions can it identify
* determines the amplitude and velocity along peripheral nerve
* Demyelinating conditions- slower velocity
* Axonal loss - decrease in amplitude
87
What does a Needle EMG measure?
- what two pathologies can it distinguish between?
* measures the electrical activity of the muscle during voluntary contraction.
* The pattern of the electrical activity can help distinguish a lesion arising from the _nerve (neurogenic) vs muscle (myopathic)_
88
What are common shoulder symptoms?
* Pain
* Stiffness
* Weakness
* Instbaility
can be a combination of all
89
What are the rotator cuff muscles?
* Subscapularis
* Infraspinatus
* Teres minor
* Supraspinatus\*
\*anterior shoulder
90
Give an overview of the biomechanics of the rotator cuff muscles
* they work in _force couples_ to force the humeral head against the glenoid
* when they are not working properly the deltoid and the pec major can exert a force that causes instability of the humeral head
* they provide a **Fulcrum** for power muscle to move the arm
* Deltoid, Pec major, Trapezius, Lat dorsi, Teres major
* if the rotator cuff muscles aren't working when the power muscles are activated it could cause the humeral head to slide out of its glenoid joint
91
What are risk factors for shoulder pain?
* Sports related injuries
* Traumatic injuries
* Degenerative conditions
* Work related conditions (scaffolding)
92
What subacromial problems are there?
* AC joint Arthritis
* Rotator Cuff tears
* results in bursitis and pain
* Calcific Tendonitis
93
What is Subacromial Impingement?
* It's a common symptom of another shoulder joint condition
* Pain on abduction & rotation of arm, Felt over deltoid
* Extrinsic cause
* Bony spurs grow over time that dig into the tendon
* Intrinsic cause: (more common)
* Tendinopathy: microstructure is effected
* results in cuff weakness
* allows the head of the humerus to migrate up slightly --\> tendon impingement, bursitis and pain
94
How is Subacromial Impingement treated?
_Non-surgical:_ aims to strengthen the muscles coordinate the rotator cuff and centre the humeral head against the glenoid
* Activity modification
* Physiotherapy
_Surgical:_ Arthroscopic (keyhole) surgery
* Subacromial decompression: physiotherapy is still important after surgery
* Debridement of bony and soft tissue impinging areas
95
Give an overview of Rotator Cuff tears
-cause, symptoms, aetiology
* Most common - supraspinatus/infraspinatus
* Weakness & Pain
* Tendon degeneration is normal and eventually can lead to a tear
* 15% in 60s have a full-thickness tear
* Repair if symptomatic
* acute tears (falls, full-thickness tears) usually do surgery
* and tendon degeneration tear try and use non-operative treatment
96
What Glenohumeral joint problems are there?
* Osteoarthritis
* Frozen shoulder
* Instability
97
What types of Gelno humeral Arthritis are there?
* Osteoarthritis
* Rheumatoid Arthritis
* Post-traumatic arthritis
* Rotator cuff tear arthritis
* badly and chronically torn
* translation of the head away from the glenoid
* results in secondary arthritis requires a shoulder replacement
98
What are the symptoms of Arthritis?
* Stiffness
* Crepitus & grinding
* Pain at rest and at night
* Pain with activity
99
What types of shoulder replacements are there?
* Anatomic
* resurfacing the arthritic parts of the socket with plastic and the head with metal
* fulcrum for power muscles still provided by rotator cuffs
* can't be done if there is a failure in the rotator cuff muscles
* contraindicated in rotator cuff tear arthritis
* Reversed
* creates a mechanical fulcrum for power muscles
100
What is Frozen Shoulder?
- symptoms
- pathological cause
- aetiology/ risk factors
* Pathology: _Inflamed thickened capsule_
* __idiopathic, posttraumatic, stroke
* Symptoms: Stiffness and Pain
* and loss of PASSIVE motion (EXTERNAL ROTATION) - examiner can't move the arm either
* X-ray normal
* 40-60 years old
* most commonly occurs in Females, Diabetics (difficult to treat)
101
What is the treatment for Frozen Shoulder (Adhesive capsulitis)
_Non-surgical_
* Natural history is to resolve over 2 years - can be painful for patients
* Steroid Injections
* Hydrodilatation - trying to rupture the tight capsule
_Surgical_
* Capsular release and manipulation
* _arthroscopic capsular release_ - keyhole surgery to remove release the fibrous capsule and form a ring around the shoulder until muscle or bone can be seen
102
What is Shoulder Instability
- aetiology/ risk factors
* in 95% of cases this is anterior dislocation of the join
* the Anterior labral ligament is torn (a _Bankart lesion_)
* the Younger age of first dislocation= higher chance of recurrence
* Risk factors
* Collision sports
* Hyperlaxity (younger patients)
103
What is the treatment for Shoulder Instability?
Usually Surgical treatment
* Arthroscopic stabilisation - labral repair
* Open stabilisation - capsule tightening
* Bony procedures - augmenting glenoid
104
What types of traumatic conditions are there?
_Bony Trauma_
* Fractures
* Dislocations
_Soft Tissue Trauma_
* Biceps Problems
* Pec Major Rupture
105
What is the pathology in this individual?
- how can you tell?
Right shoulder Pec Major rupture
when they stand with hands-on-hips and squeeze
* the nipple drops lower
* and there is loss of contour of the axilla
* with bruising down the arm
106
What pathology is seen in this image?
- how is it treated?
Proximal Humeral Fracture
* nails/ plates that go down the centre of the bone
* or other operative routes
107
What pathology is seen in this image?
- How is it treated?
Acromioclavicular Joint Dislocation
* fix it down with sutures and anchors
108
Where does the Lower motor neuron begin?
* at the Conus medularis
* L2
* at the Cauda aquina
109
What is the difference between Conus medullaris and Cauda aquina syndromes?
* **cauda aquina** pain radiates and is more severe
* it's unilateral/ asymmetric pain of the perineum, thighs and legs
* asymmetrical motor loss
* ankle and knee reflexes reduced **conus medullaris** is only the ankle reflexes
* bowel symptoms are a later presentation
110
What causes Cauda equina syndrome?
* Disc herniation,
* spinal fracture,
* tumours
111
What causes Conus medullaris syndrome?
* Disc herniation, tumour,
* Inflammatory conditions
* Infection
112
Review the lower limb dermatomes and myotomes
L1-S5
113
What action do lesions of the following roots affect?
L1-S1
* **L1/2:** Hip flexion
* **L3/4:** Knee extension
* **L4:** Foot inversion
* **L5:**
* **** Knee flexion,
* Ankle dorsiflexion,
* Toe extension,
* Foot inversion and eversion
* **S1:**
* **** Knee flexion
* Ankle plantarflexion
* Toe flexion
* Foot eversion
114
Where does the Femoral nerve originate from?
- what does it innervate
* originates from L2,L3,L4
* sensory and motor innervation to the leg
115
Where does the Obturator nerve originate from?
- what does it innervate
* originates from L3,L4
* innervates
* the medial compartment of the thigh
* the obturator muscle
* adducts the hips
116
Where does the lateral cutaneous nerve originate from?
- what does it innervate
* originates from L2, L3
* innervates
* the sensation on the outer aspect of the thigh
117
Where does the Sciatic nerve originate from?
- branches?
* originates from L4,5,S1,2,3
* it has a fibular and tibial portion
118
What are causes of Lumbosacral plexus lesions?
* Childbirth (large head, prolonged labour)- esp obturator n., numbness inner thigh, pudendal n.
_Structural_
* Haematoma (on Warfarin)
* Abscess
* Malignancy
* Infiltration
* Trauma
_Non-structural_
* Inflammatory,
* Diabetes
* Vasculitis
* Radiotherap
119
What are causes of femoral nerve damage?
* pelvic fracture
* pregnancy
* gynae surgeries
* hysterectomy
* femoral bypass
120
What is the effect of femoral nerve lesions?
* Hip flexors, Iliopsoas affected if proximal damage (above inguinal Ligament)
* Only knee extension is effected if lesion is below inguinal ligament
* Distal lesion may produce a pure motor or pure sensory syndrome
121
How would Femoral/Lateral cutaneous nerve lesions present?
* difficulty doing stairs, or standing from a sitting position
* knee-buckling
* sensory loss or tingling on the lateral thigh (lat cut. n.)
* sensory loss or tingling on the medial thigh (Fem N.)
122
What is Sciatica?
- causes
- differentials
* Pain in sciatic n. distrib
* Nerve root entrapment (usually L5 / S1)
* _Causes_: Trauma, Haematoma Rarely sciatic nerve compression per se (Piriformis synd) Or misplaced IM injection
* _Differential diagnosis_: Hip – pain may radiate not below knee Sacroiliac joints
123
What is Piriformis syndrome?
* compression of the sciatic nerve by the piriformis muscle
124
What are causes of sciatic nerve injury?
* Isolated hip fracture
* Pelvic/sacral fracture - sacral plexus
125
What is important to remember about the anatomy of the sciatic nerve in terms of injury?
Partial sciatic n. damage can look like Common peroneal or Tibial n. damage, as the sciatic nerve has two branches. The issue might still be more proximal
126
What is the effect of a Tibial nerve lesion
- causes?
- presentation
* Can’t stand on tiptoes Weak foot inversion Painful numb sole
* _Causes:_
* Trauma: Haemorrhage
* Bakers cyst
* Nerve tumour
* Entrapment by the tendinous arch at the soleus muscle
* _Presentation_
* sole pain, worse when standing/ walking (no heel pain )
127
What is the presentation of Common peroneal (fibular) nerve lesion?
- cause
* Sensory loss -dorsum of foot and outer aspect lower leg
* Weakness of -dorsiflexion and eversion of foot
* causing foot drop
_Cause_
* Broken fibula
* tight plaster casts, leg crossing, Weight loss- slimmers palsy
128
What are causes of Neurogenic Foot drop?
* Upper motor neuron (brain/ spinal cord)
* Conus
* L4/L5
* Cauda equina
* Sacral plexus
* Sciatic n.
* Common peroneal n
129
What is Polyneuropathy and Peripheral neuropathy?
* **Polyneuropathy** – generalised relatively homogeneous process affecting many peripheral nerves with the distal nerves affected most prominently.
* **Peripheral neuropathy** – refers to any disorder of the peripheral nervous system including radiculopathies and mononeuropathies
130
What are common causes of Length dependent polyneuropathy
- clinical symptoms
* Common causes (Toxic/metabolic causes)
* Diabetes
* Alcohol
* B12 def
* Chemotherapy
* Idiopathic
* Clinical symptoms
* Numbness, paraesthesia, weakness
* Pain (small fibres)
131
What is non-length dependent polyneuropathy?
* referes to a demyelinating syndrome
* Guillian-Barré sundrome
132
What is Guillain Barre syndrome?
* Acute inflammatory demyelinating polyneuropathy
* Immune response to a preceding infection that effects the myelin sheath
* Rapidly progressive (days to weeks) weakness including limbs, facial, respiratory and bulbar muscles
* Absent reflexes
133
What is Neuronpathy?
- types (2)
* Form of polyneuropathy
* Disorders that affect specifically the population of neurons.
* Motor neuronopathy –
* Site of damage: _Anterior horn cell_
* Causes: ALS, Polio
* Sensory neuronopathy –
* Site of damage: _Doral root ganglion_
* Causes: Sjogrens syndrome, Paraneoplastic
134
What is Polyradiculopathy?
- causes
* syndrome that affects multiple nerve roots.
* Caused by:
* Spinal stenosis: Cervical, lumbar
* Cancer: Leptomeningeal metastases
* Infection: Lyme, HIV,
135
What are "Shin splints"
- causes
- presentation
- management
* Pain in the anterior or lateral part of the leg caused by:
* Muscle bulk increases 20% during exercise and contributes to the transient increase in intracompartmental pressure
* Anterior and lateral compartments of the lower leg are commonly affected
* Generally causes pain on and post exercise- AKA Shin Splints
* Manage with RICE (rest / cooling – ice
136
What is compartment syndrome?
* Increase in pressure within a myofascial compartment which has limited ability to expand
* May be acute or chronic
* Acute compartment syndrome is a surgical emergency
137
What are the causes of compartment syndrome
(4 main groups) (TEDD)
_Trauma_
* Fractures (1-6% Tibial Fractures)
* Crush Injuries
* Burns
* Electric Shock
* Fluid Injection
_Drugs_
* Warfarin/other anticoagulants • Anabolic Steroid use • Iv drug use
_Disease_
* Haemophilia
_External Causes_
* Tight splints/casts • Tourniquet
138
What are the consequences of compartment syndrome?
* Tissue perfusion is proportional to the difference between the capillary perfusion pressure and the interstitial fluid pressure therefore _elevated compartment pressure causes muscle and nerve ischemia_
* Untreated, within 6-10 hours, the final result is _muscle infarction, tissue necrosis, and nerve injury_
* Certain tissues are more sensitive than others and this can be a clue to diagnosis
* Sensory nerves- numbness
139
Go through Acute posterior compartment syndrome in the legs
- muscles affected
- other structures affected?
* Superficial posterior Plantar flexors of foot
* Gastrocnemius, Plantaris, Soleus
* Sural nerve
* Sensation to the lateral aspect of the foot and distal calf
- if the foot is plantiflexed it causes pain
140
Go through Acute anterior compartment syndrome in the legs
- muscles affected
- other structures affected?
* Dorsiflexion muscles of ankle and foot
* Tibialis anterior, Extensor digitorum longus Extensor hallucis longus, Peroneus tertius
* _dorsiflexion causes pain_
* Anterior tibial artery
* Commonly injured in lateral tibial plateau fractures
* Deep peroneal nerve
* Sensation to the first dorsal web space may be lost
141
What are the signs of compartment syndrome?
(6)
* Pain! (out of proportion to the original injury)
* Pain +++ on passive stretching
* Tense limb
* Decreased function of the compartment muscles
* Distal neurologic compromise
* Reduced distal pulses
142
What investigations can be done in suspected compartment syndrome?
* Clinical suspicion is all important
* Measuring of intra-compartmental pressures can be useful
* Creatine kinase (CK) of 1000-5000 U/mL Myoglobinuria
143
What is the treatment/management of compartment syndrome
- complications?
* Often surgery is required
* Aim is to lay open the myofascial compartment and diminish intra-compartmental pressure
* don’t forget to look for external causes Tight casts/ splints Dressing
* If fasciotomy is performed within 25-30 hours following onset of acute CS, the prognosis is good
* Little or no return of function can be expected when diagnosis and treatment are delayed
* can lead to Rhabdomyolysis --\> renal failure
* Limb lose
