Orthopaedics and Traumatology Flashcards
Osteoarthritis
• Most common type of Arthritis; Characterised by Cartilage loss with Periarticular Bone
Response; Multifactoral process with Mechanical factors
o Significant inflammation of Articular and Periarticular structures
o Most common cause of Disability in the Western world in older adults
• Increasing prevalence with age; Uncommon <50yrs; Most >60yrs have radiological evidence
but only 1/4 symptomatic; Geographical Variation (e.g. Hip OA more common in Eurasians,
Knee OA more common in Asians)
• Joint Pain, Morning Joint Stiffness, Functional Limitation, Crepitus, Restricted Movement,
Bony Enlargement, Joint Effusion and Inflammation, Bone Instability and Muscle Wasting
Pathophysiology of Osteoarthritis
• OA is a result of active, sometimes inflammatory, potentially reparative
processes rather than inevitable result of trauma and ageing
• Predisposing Factors – Obesity, Hereditary, Gender, Hypermobility, Trauma, Congenital Joint Dysplasia or Dislocations, Occupation, Sport
• Abnormal local mechanical factors that
affect loading and wear
• Inflammation starting at Periarticular Entheses in inflammatory phase; Focal Destruction of
Articular Cartilage commonly seen
o Spectrum between Atrophic disease (Cartilage destruction without Subchondral bone
response) to Hypertrophic disease (Massive new bone formation on joint margins)
o Focal Synovitis due to fragments of shed bone or cartilage
• Under normal circumstances, Cartilage degradation by wear and
production by Chondrocytes is balanced; In OA, balance is lost and focal erosion develops
o Disordered repair from adjacent cartilage, failure of ECM
synthesis and Fibrillation and Fissuring of joint surface
o Cartilage ulceration lead to exposure of bone to
increased stress, leading to Microfractures and Cysts;
Attempted repair leads to Abnormal Sclerotic
Subchondral bone formation and Osteophytes
Nodal OA
DIPs more often affected than PIPs; Often start
around female menopause; Can co-exist with Thumb-base OA
o Painful, associated with Tenderness, Swelling,
Inflammation and Impairment
o Inflammatory phase can settle over time, leaving painless
bony swellings posterolaterally (Heberden’s Nodes on
DIPs, Bouchard’s nodes on PIPs)
o XR: Marginal Osteophytes and Joint space loss
Hip OA
7-25% of Adult Caucasians; Less common in African and Asians
o Superior-pole Hip OA – Joint space narrowing and Sclerosis
affecting weight-bearing upper surface of Femoral Head and
Acetabulum; More common in men
▪ Early onset assoc Acetabular Dysplasia or Labral tears
o Medial Cartilage Loss – More common in women and associated
with hand involvement (=Nodal Generalised OA); Bilateral and
rapidly disabling
Knee OA
40% >75yrs; More common in women
o Strongly linked to Obesity; Typically, bilateral
o Medial compartment most commonly affected leading to Varus
deformity; Retropatellar OA may co-exist; Marrow involvement
predicts progression and eventual joint replacement
o RF: Previous Trauma, Meniscal and Crucial Ligamental tears
Crystal Associated OA
CPPD in Cartilage (= Chondrocalcinosis); Knees
and Wrist TFCC most commonly affected; Patchy, linear Calcification on XR
o Chronic Arthropathy (Pseudo-OA) especially in Elderly women with severe CPPD
o Marked Osteophyte and Cyst formation
o Associated with Pseudogout (Acute Crystal Arthritis)
o Presence of Calcium Apatite in Bloody Joint Effusion has poor outlook, joints require
early surgical replacement
Rarer Forms of OA
Primary Generalised OA (NGOA = Nodal OA typically with either Knees, first MTP, Hip or Intervertebral; Sudden and severe onset; Female with familial tendency) and Erosive OA (DIPs, PIPs equally affected; Poor functional outcomes, marked radiological Osteolysis; Destructive phases followed by remodelling
Management of Osteoarthritis: Investigations
Investigations – ESR might be normal, CRP mildly raised; RF
and ANA negative
o XR changes usually only when damage is advanced;
Useful for preop planning
o MR – Meniscal tears, Early Cartilage Injury and
Osteochondral changes
o Arthroscopy – Identify Early Fissuring and Surface
Erosion; Aspiration of Synovial Fluid during painful effusion shows viscous fluids with
few Leukocytes
Management of Osteoarthritis: Treatment
• Guiding principle to treat Symptoms and Disability ≠ Radiological appearance
o Education about disease reduces Pain, Distress and Disability, and improves
Compliance with treatment; Psychosocial factors to be considered
• Physical Therapy – Weight Loss, Strength and Stability-building Exercises, Hydrotherapy
o Local Heat and Ice packs, Massages, Local NSAID gels
o Insoles for flat feet, Contralateral walking sticks
• Analgesia and Anti-inflammatories – Paracetamol before NSAIDs; NSAIDs and COX-2 Inhibitors
used intermittently when possible; Cautious use of Opioids in elderly
• Intraarticular Corticosteroids – Short term improvement during Painful Effusions
o Frequent injections to same joint should be avoided
• No clinical benefit from Glucosamine and Chondroitin; Unclear benefit of Intraarticular
Hyaluronan; No proven DMARDs for OA
Surgical Management of Osteoarthritis
o Replacement Arthroplasty (E.g. THR, TKR); 1% Complication rate; Prosthesis Loosening and Late Infection most serious o Novel Arthroplasty Techniques – Hip Resurfacing, Unicompartmental Knee Replacement (less major) o Other Surgical techniques include Realignment Osteotomy, Excision MTP Arthroplasty, MTP Joint Fusion
Perthe’s Disease
Idiopathic (possibly Avascular)
Necrosis of Proximal Femoral Epiphysis
o Presents as a painless limp usually in boys 3
– 12yrs; Occasionally Bilateral
o If Severe, might require Surgical correction
Transient Synovitis of the Hip (Irritable Hip)
Painful
limitation of movement typically Unilateral; After
URTI usually in boys
o Usually resolves after few weeks; 2 – 3% develop Perthe’s disease
o Treatment with Rest and NSAIDs until pain resolves, typically 7 – 10/7
Trochanteric Bursitis
Trauma or Unaccustomed exercise, also in Inflammatory Arthritis
o Worse on walking up the stairs; Tender to lie on
o Exercise, Steroid Injection although poor evidence base; Surgery often necessary
o Gluteus Medius Tendonopathy at Insertion into trochanter can cause similar
syndrome, but does not respond to injection; Demonstrated on MRI
Sacroiliac Joint Dysfunction
Caused by abnormal motion of SIJ; Presents with LBP, Buttock,
Sciatic Leg, Groin and Hip pain; Bending, Stairs and Rising from seat can provoke
o Hypermobility – Typically, Extra-articular due to weakened, injured or sprained
ligaments; Joint degeneration occurs over time
o Post-pregnancy Pelvic Joint pain believed to be due to stretched out ligaments (due
to Relaxin) failing to return to normal tautness
o Hypomobility – Locks due to wearing down with age or OA; Also, can occur with
Ankylosing Spondylitis or RA
o Treatment with Rest, Ice/Head, NSAIDs, Corticosteroid Injections (If benefit reported,
confirms the diagnosis); Surgical fixation of SIJ
Meniscal Injury
• Menisci are partially attached Fibrocartilages that stabilise the Femoral Condyles on the flat
Tibial Plateaux; Resilient to injury but more vulnerable with age
o Torn by injury, commonly in sports which involve twisting and bending
o Immediate Medial or Lateral Knee Pain and Swelling within hours; Affected side is
tender; The Knee might lock flexed if large tear
• Immediate treatment to apply Ice Compress; MRI will demonstrate the tear
• Early Arthroscopic repair or Trimming of torn meniscus is essentially, especially in active
sportspeople; Reduces Recurrent pain, Swelling and Locking but not risk of Secondary OA
• Post-op Quadriceps exercises aid return to sport and activity
• Clinically examined with Apley’s Grind Test
Cruciate Ligament Injury
• ACL resists Anterior Translation and Medial Rotation of Tibia
on Femur, while PCL resists Posterior Translation and Lateral
Rotation of Tibia on Femur
• Torn Cruciate accounts for around 70% of Haemarthrosis in
young people; Often co-exists with Meniscal tears; Clinically
examined with Anterior Draw Test, Posterior Sag
• MRI is investigation of choice; Requires urgent Orthopaedic
referral, with reconstructive surgery necessary; Significant
incidence of Secondary OA
Collateral Ligament Injury
• Medial Ligament more commonly affected than Lateral; Pain typically at insertion into Upper
Medial Tibia, worsened by standing or stressing (Varus and Valgus stress at 0 and 30deg)
• Physiotherapy and Local Corticosteroid Injection
OSTEOCHONDROSIS
• Focal disturbance of the Ossification Centre of the ends of bones
• Osgood-Schlatter Disease – Localised pain and Swelling, over Tibial
Tubercle or Patella Tendon Insertion; Usually athletic teens;
Responds to local treatment and changes in sports
• Sever’s Disease – Osteochondritis of Achilles insertion into Calcaneus
PATELLOFEMORAL PAIN SYNDROME
• Knee pain ranging from Mild to Severe Discomfort, seeming originating from Posterior surface
of Patella and Femur; Excluding Intra-articular and Peri-Patellar Pathology
• Runners, Cyclists, Basketball players; Thought to be due to increased pressure on joint
• Discomfort worsened by sitting with bent knees or descending stairs
• Managed with Exercise therapy, NSAIDs, Rest; Surgery only in extreme cases
Chondromalacia Patellae
Patellar Articular Cartilage Softening; Fibrillated Retropatellar Cartilage seen on Arthroscopy
o Patellar Misalignment, or Recurrent Dislocation (Typically, Adolescent girls) = Surgery
ILIOTIBIAL BAND SYNDROME
• Common injury to knee associated with Running, Cycling, Hiking and Weight-
lifting; Range from stinging sensation superolateral to knee joint, to Swelling
and Thickening of IT band
o Most commonly pain felt during foot strike, and might persist
• Can result from Abnormal leg or feet anatomy, Unaccustomed exercise, or
abnormal loading, for example, “toeing in” while cycling
• Manage with RICE followed by stretching; Muscle strengthening of Gluteus and Medial Quadriceps by Exercise therapy
CONDITIONS OF THE SHOULDER
Shoulder is a shallow joint with large ROM; Humeral head held by Rotator cuff (Supraspinatus, Infraspinatus, Teres Minor, Subscapularis) which is part of the joint capsule
o Rotator cuff, especially Supraspinatus, prevents Humeral head blocking against the Acromion during Abduction; Deltoid pulls up, Supraspinatus pulls in, allowing for turning movement; Greater Tuberosity glides under Acromion without impingement
Rotator Cuff (Supraspinatus) Tendonosis (=Impingement Syndrome)
• Common cause of shoulder pain in all ages; Follows trauma in 30%, Bilateral in <5%
• Pain radiates to Upper arm, made worse by Arm Abduction and Elevation; Worst during
middle of Abduction range (‘Painful arc’)
• Painful spasm of Trapezius can occur; Passive elevation reduces impingement
• Might have associated Subacromial Bursitis; Isolated Bursitis can occur in direct trauma, such
as Falling-on-outstretched Arm or Elbow; Acromioclavicular Osteophytes increase the risk of
impingement, might require surgical removal
• Treatment with Analgesia, NSAIDs and PT; Severe pain response to US-guided Injection of
Corticosteroids into Subacromial Bursa; 10% with develop worse pain 24-48hrs after injection
o 70% will improve and self-mobilise; PT reduces Persistent Stiffness
Rotator Cuff Tear
• Caused by trauma but also spontaneously in Elderly and Rheumatoid Arthritis
• Prevents Active Abduction of arm; Initiation of elevation assisted by other arm; Deltoid
muscle can hold in place once elevated
• Surgical tear repair in younger people; Not always possible in Elderly or RA
ADHESIVE CAPSULITIS (=FROZEN SHOULDER)
• Inflammation and Stiffness of the capsule around the
Glenohumeral joint
• Uncommon; Can develop with Rotator Cuff lesions or
following Hemiplegia, Chest or Breast Surgery, or MI;
Severe Shoulder pain and Complete loss of all shoulder
movements, including Shoulder rotation; Constant pain,
Worse at night and in the cold
• High dose NSAIDs, Intra-articular Local Anaesthetics and
Corticosteroids might be helpful
• Arthroscopic release speeds functional recovery
BICEPS TENDINOPATHY
• Inflammation of tendon around Long Head of Biceps muscle; May occur due to sudden
overuse, especially in older patients; Repeated trauma of overuse which might be
accompanied by impingement beneath Coracoacromial arch by Osteophyte
o Primary Biceps Tendinopathy if Inflammation within Bicipital groove of Humerus
• May be associated with Rotator Cuff tears, especially is Subscapularis tendon is involved
• Typically present with Insidious onset of discomfort around tendon in the anterior shoulder
• RICE, NSAIDs, PT, Injection of Local Anaesthetic and Steroids; Surgery if partial rupture;
Alternatively, Arthroscopic decompression
EPICONDYLITIS
• Inflammation of the tendon insertion (Enthesitis) of extensors (Lateral Epicondylitis =Tennis
Elbow) or Flexors (Medial Epicondylitis =Golfer’s Elbow); Local tenderness, pain radiating onto
affected muscles; Pain at rest might also be present
o LE – Gripping or holding a heavy bag; Most painful with Wrist Flexion of Pronated arm
ME – Carrying a tray
• Rest and PT; Local Corticosteroid Injection into point of maximum tenderness when pain is
severe, requires PT F/U to prevent recurrence; Brace might help
o Avoid Ulnar nerve when injecting for Medial Epicondylitis
o Might require surgical release if persistent and resistant to treatment
OLECRANON BURSITIS
• =Student’s Elbow; Bursitis following pressure, pain and swelling behind Olecranon; Rule out
Septic and Gouty Bursitis; Bursa should be aspirated for Gram stain and Microscopy for
crystals; If Infective cause ruled out, injection of Hydrocortisone can be performed
• Septic Bursitis requires formal drainage and course of Antibiotics
ULNAR NEURITIS (CUBITAL TUNNEL SYNDROME)
• Narrowing of the Ulnar groove (secondary to OA or RA), or due to frictional damage from
Cubitus Valgus deformity (possibly complication from childhood fractures)
• Initially sensory symptoms (E.g. Reduced sensation over little finger and medial half of ring
finger; Clumsiness and weakness of small muscles of hand innervated by Ulnar nerve
(Adductor Pollicis, Interossei, Abductor Digiti Minimi, Opponens Digiti Minimi)
• Nerve conduction studies to identify site of lesion; Surgical decompression ± Transposition of
nerve in front of elbow (if Subluxation occurs)
CARPAL TUNNEL SYNDROME
• Median Nerve Compression within limited space of Carpal Tunnel; Thickened ligaments,
Tendon sheaths or Bony Enlargement, but typically unknown aetiology
• Early morning Numbness, Tingling and Pain in Median nerve distribution; Radiates to forearm
• Fingers feel swollen; Wasting in later disease of Abductor Pollicis Brevis, and sensory loss of
radial three and a half fingers
• Pain elicited by Tinel’s sign (tapping nerve) or Phalen’s Test (Holding wrist in flexion)
• Treatment – Splint wrist in Dorsiflexion overnight (relieves symptoms and is diagnostic), used
nightly for several weeks often leads to full recovery
o Otherwise Corticosteroid injection into Carpal Tunnel (avoiding the nerve) helps in
70%, although pain can recur
o Persistent symptoms or nerve damage (resulting in prolonged latency across Carpal
Tunnel evidenced by Nerve Conduction studies) require Surgical Decompression
TENOSYNOVITIS
• Finger flexor tendons run through synovial sheaths and loops;
Inflammation occurs with repeated or unaccustomed use or in
Inflammatory Arthritis, leading to sheath thickening which are
often palpable
• Trigger Finger – Finger remained in flexed position in the
morning, or after gripping, and needs to be manually reduced;
Tender tendon nodule palpable, usually in distal palm
o More common in Diabetic patients
• Dorsal Tenosynovitis – Hourglass distribution of swelling from
the back of the hand and under the Extensor Retinaculum; Less common, except in RA
• De Quervain’s Tenosynovitis – Pain and swelling around Radial Styloid where Abductor
Pollicus Longus is held in place of retaining band
o Local Tenderness and Pain of styloid worsened by Thumb Flexion into palm
• Treatment of Tenosynovitis – Resting, Splinting and NSAIDs might help; Local Corticosteroid
injections alongside the Tendon under low pressure (Not into tendon itself)
o Surgical release might be needed if symptoms persist
WRIST GANGLIONS
Jelly filled, often painless swelling caused by Partial Tear of joint capsule or tendon sheath;
Treatment is not essential as they resolve or cause little trouble; Surgical excision otherwise
DUPUYTRENS CONTRACTURE
• Painless, Palpable Fibrosis of Palmar Aponeurosis; Fibroblasts invading Dermis due to Abnormal Signalling of Wnt pathway; Males, Caucasians, Diabetes and ETOH XS o Associated with Peyronie’s Disease (Inflammatory Disorder of Corpora Cavernosa)
• Puckering of Skin and Gradual flexion, usually in Ring and Little Fingers; Can also occur in the
feet, where it is more aggressive
• Intralesional Steroid Injections may help in early disease; Surgical release only for severe
deformity; Transcutaneous Needle Aponeurotomy, Collagenase Injections under investigation
HEEL PAIN
• Plantar Fasciitis – Enthesitis at insertion of
Tendon into Calcaneus; Local pain under the heel
when standing and walking with local Tenderness
• Plantar Spurs – Traction Lesions at insertion of
Plantar Fascia; Usually asymptomatic; Painful
after traumatic injury
• Calcaneal Bursitis – Pressure-induced Bursa that
produces Diffuse Pain and Tenderness under the
heel; Compression of heel pad from sides is
painful (C/f Plantar Fascia Pain)
• Treated with Heel Pads and Reduced Walking; Often Self-limiting; Dorsiflexion splint at night
to stretch the Fascia might be helpful
o Medial approach Ultrasound-guided Corticosteroid Injection if required
ARCHILLES TENDONOSIS
• Painful, Tender swelling a few cm above Tendon insertion (C/f Sever’s Disease); Tendon
damage or rupture more likely if on Quinolones; Therapeutic ultrasound is helpful; Avoid
walking barefoot and jumping
o Local Injections might cause tendon rupture
o Autologous Platelet Concentrate Injection may be used but poor evidence
Achilles Bursitis
Clearly anterior to Tendon; Can be safely injected with Steroids
MORTON’S METATARSALGIA
• Typically, due to Neuroma between Third and Fourth Metatarsal
heads; Pain, Burning and Numbness in adjacent surfaces of
affected toes when walking
• Wider, Cushion-soled shoes can help; Steroid Injections or
Excision might be necessary
HALLUX VALGUS (BUNIONS)
• Lateral migration of the big toe; Commonly a complication of
Rheumatoid Arthritis; Modern shoe shapes delay onset
• Either due to Bursitis or Bony lesion of MTP Joint; Majority of the
deformity contributed by the head of the first Metatarsal bone; OA,
Reduced ROM or Discomfort with
• Treatment with Footwear, Orthotics, RICE, NSAIDs, Paracetamol; If
severe deformity or for Cosmesis, Surgical correction possible
(Bunionectomy)
LOWER BACK PAIN
• Often Traumatic and work-related; Episodes generally short-lived and self-limiting; Chronic
Back Pain responsible for 14% of Long-term disability in the UK
• Reg Flags – Age (<20 or >50yrs), Persistent,
Severe Traumatic Mechanisms, Worst at
night or in the morning (Inflammatory
Arthritis, Infection or Spinal Tumours),
Associated with Systemic Signs, Associated
with Neurological Signs
o Spinal XR only for red flags; MRI
preferable to CT if Neurological
Signs; CT for bony pathology;
Specialist interpretation
o Bone Scans (Infective or Malignant
lesions suspected)
o FBC, ESR (Useful for identifying PMR,
especially in Elderly), Ca, Myeloma Screen (Serum Protein
Electrophoresis, Free Light Chain Assay, Beta-2 Microglobulin, etc)
• If between 20-50yrs likely Mechanical Back Pain – Early Analgesia and Rest, Activity within
limits of pain, Advice and Exercise Programmes to prevent Chronic Pain Syndromes
o Physical Manipulation of uncomplicated back pain produces short-term relief
