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
MECHANICAL BACK PAIN
• Stiff back, Scoliosis might be present; Muscle spasm visible and palpable, causing Local Pain
and Tenderness; Lessens on sitting or lying
• RF for recurrent episodes – Female, Elderly, Pre-existing Chronic Pain Syndrome, Psychosocial
Factors; Chronic LBP is a major cause of Disability and Time off work
• Lower Back Pain is common in pregnancy – Altered Spinal Posture and Increased Ligamental
Laxity; Usually Hyperlordosis on standing
o Weight control, Pre- and Post-Natal Exercise; Analgesia and NSAIDs best avoided in
Pregnancy and Breastfeeding; Not associated with Epidural injections
Lumbar Spondylosis
• Intervertebral discs are fibrous joints comprising a
tough capsule that inserts into rim of adjacent
vertebrae; Joint allows twisting and bending
• Changes in the disc occasionally start in teenage years,
and increase with age; Changing disc composition,
breakage, shrinkage and loss of compliance occurs
o Surrounding fibrous zones develop
Circumferential or Radial Fissures
o Visible on MRI as decreased disc hydration, but
typically asymptomatic
o Thinning and loss of compliance leads to
Bulging of Disc
• Reactive changes in Adjacent Vertebrae – Sclerotic
bone, Osteophyte formation along rim; Most commonly at L5/S1 and L4/L5
o Schmorl’s node – Disc prolapse through adjacent vertebral endplate; Painless, but
may accelerate disc degeneration
• Spondylosis leads to Episodic Mechanical Back Pain, Progressive Spinal Stiffening, Facet Joint
Pain, Acute Disc Prolapse, Nerve Root Irritation, Spinal Stenosis and Spondylolisthesis
Facet Joint Syndrome
• Secondary OA of the misaligned Facet Joints, which can be secondary to Spondylosis; Pain
typically worse on Back Extension, which may radiate to buttocks
o OA, Effusion or Ganglion Cyst on MRI
• Direct Steroid injections under imaging may help but unknown long-term benefit; PT can help
reduce Hyperlordosis; Weight loss is helpful in the obese population
ACUTE DISC PROLAPSE
• Central Disc Gel may extrude into fissure in surrounding fibrous zone, causing Acute Pain and
Muscle Spasm; Often Self-limiting; Extrusion beyond limits of fibrous zone =Disc Prolapse
• Weakest Posterolaterally, where the Disc may impinge onto Nerve Roots; Pain often starts
dramatically during lifting, twisting or bending; Associated with Paraesthesia, Numbness,
Neurological signs typically in one leg
o Back pain typically Diffuse, Unilateral and Radiates to Buttock; Muscle Spasm leads to
Scoliosis that reduces when lying down
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• Central, High Lumbar Disc Prolapse may cause Spinal Cord Compression and Pyramidal Tract
signs (UMN Signs – Spasticity, Hyperreflexia, etc); Below L2/L3 produces LMN lesions
• Straight-Leg-Raise test is positive in Lower Lumbar Disc Prolapse (Raising above 30deg); Pain
in affected leg produced by raise of contralateral leg associated with large or central prolapse
• Upper Lumbar Disc prolapse produces positive Femoral-Stretch-Test (Pain on Anterior Thigh
when Knee flexed in Prone Position)
Sciatica (Pain radiating from Back to Buttock and Leg)
• L5 and S1 Nerve Root compressed by Lateral Prolapse of L4/L5 and L5/S1 Disc; Acute onset of
pain that may follow physical activity or minor injury, although unlikely causative
• Most resolves with initial rest and analgesia following early mobilisation
Treatment of Disc Prolapse
• Short period of Bed Rest, lying flat (Lower disc injury) or Semi-recline (High lumbar disc);
Analgesia and Muscle Relaxants
• Once pain tolerable, encourage Mobilisation and PT; Guided Epidural or Nerve Root Canal
Injection reduces pain rapidly but unknown place in therapy
• Referral for Microdiscectomy/Hemilaminectomy if Severe Neurological signs, Pain >6-10/52,
or if Disc is central; Neurosurgical Emergency if Bladder or Anal Tone Affected
SPONDYLOLISTHESIS
• Adolescents and Young Adults with Bilateral Congenital Pars Interarticularis Defects which
cause Instability and lead to Vertebral Slip, with or without preceding injury
o Rarely can lead to Cauda Equina Syndrome
o Requires careful monitoring during growth spurt
• Degenerative Spondylolisthesis – May occur in Older People with Lumbar Spondylosis and OA
of the Facet Joints
SCOLIOSIS
• Lateral Spinal Curvature; 3% of people, more common
and typically more severe in girls;
• Might be stable or progressive over time; Mild Scoliosis
mostly asymptomatic, but severe cases can interfere
with breathing
• Unknown aetiology; Associated with Muscle Spasms,
Cerebral Palsy, Marfan Syndrome, Neurofibromatosis
• Minor curves may just involve observation; Treatment
can involve bracing (worn until end of growth) or
Surgical Fusion; Lack of evidence for Chiropractors,
Dietary supplements
BACK PAIN IN THE CHILD
• Back Pain is a symptom of concern in young and pre-adolescent children, as causes are more
likely to be identified; The younger the child, the more significant the pathology
o Red Flags – Young Age, Febrile (Infection), Persistent Pain or Pain causing Waking at
Night (Malignancy), Painful Scoliosis, Focal Neurological Signs, Systemic Signs
• Mechanical Causes – May have Muscle Spasm or Soft Tissue Pain from Injury
• Tumour – Spine is common site for Osteoid Osteoma, or other primary tumours and mets
• Osteomyelitis or Discitis – Localised Tenderness, Reluctance to Walk or Weight-bear along
with Fever and Systemic Upset; XR might suggest abnormalities but MRI required; IV Abx
• Cord or Nerve Root Entrapment – Tumour or Disc Prolapse
• Spondylolysis and Spondylolisthesis – Stress Fracture of Pars Interarticularis; Increased risk in
certain sporting activities (Cricket Bowling, Gymnastics); If Bilateral, Forward Slip of Vertebral
Disc can occur, potentially leading to Cord or Nerve Root Compression
o Pain on Spinal Extension and Localised Tenderness; Changes on XR but CT required
• Scheuermann Disease – Osteochondrosis of Vertebral Body leading to Fixed Thoracic Kyphosis
± Pain; XR for Diagnosis; Often Incidental Finding
• Complex Regional Pain Syndrome – Diagnosed if no physical cause found; May be
exacerbated by Psychological stress
LIMP IN THE CHILD
Age: 1-3
Acute Painful Limp: Infection: septic arthritis, osteomyelitis of hip or spine Transient synovitis Trauma-accidental/non accidental Malignant disease Chronic/Intermittent DDH, talipes Neuromusuclar JIA
Limp in the Child
Age: 3-10 years
Acute painful limp: Transient synovitis Septic arthritis Trauma and overuse injuries Perthes JIA Malignant disease Chronic Intermittent Limp: Perthes disease NMD: DMD Tarsal coalition
Limp in the Child
Age: 11-16years
Acute Painful Limp: Mechanical Slipped capital femoral epiphysis Avascular necrosis of the femoral head Reactive arthritis JIA Septic arthritis/osteomyelitis Bone tumours and malignancy Chronic/ intermittent: Slipped capital femoral epiphysis (chronic) JIA Tarsal coalition
Compartment Syndrome
• Increased pressure within fascial compartment resulting in vascular insufficiency of tissues
within; Leg or Arms more commonly involved; Presents as Severe Pain (Classically
Disproportionate), Poor Pulses, Mobility, Numbness or Pallor of affected compartment
o Commonly due to Physical trauma, such as Fracture or Crush Injury
o Acute Compartment Syndrome requires Urgent Fasciotomy to relieve pressure
▪ Typically, all compartments of limb are released regardless of involvement
o Anterior Tibial Syndrome – Severe Pain occasionally with Foot Drop
o Untreated Acute Compartment Syndrome can lead to limb loss or disability (E.g.
Supracondylar Fractures leading to Volkmann’s Ischaemic Contracture)
• Complications include Ischaemia and Necrosis, Rhabdomyolysis and Renal Failure
Chronic Compartment Syndrome
Pain with exercise; Symptoms typically resolve with rest;
Neurapraxia
Temporary loss of Nerve Conduction often due to Ischaemia following
pressure; Axonotmesis – Damage to Nerve Fibre (Axon) with the Epineural tube still intact;
Good recovery as nerve regrowth is guided; Neurotmesis – Division of the whole nerve
o Regrowth fibrils can cause a Traumatic Neuroma if unable to bridge
o Epineural repair with nylon sutures; if gaps cannot be repaired without excessive
tension, Nerve-cable Interfascicular Autografts used; 50% regain function
Median Nerve
Injury above Antecubital Fossa; Ochsner’s Test (Clasping test for FDS), FPL
test, Loss of Sensation over Thenar palm; APB test most reliable
Ulnar Nerve
Instability to cross fingers (Adduction); Froment’s Paper Test, Ulnar half sensory
Radial Nerve
Wrist Drop (When Elbow Flexed, Forearm Pronated); Snuffbox Sensory loss
Sciatic Nerve
All muscles below the knee, and sensation below Lateral Knee
Common Fibular Nerve
Commonest LL Nerve Injury; Inability to Dorsiflex Foot and Toes,
Sensory loss of Dorsum of foot
Tibial nerve
Calcaneovalgus, Inability to stand on tiptoe or Invert Foot; Sensory loss of Sole
Arterial Injury
Pressure and Elevation; Examination of distal pulses; Exploration and Vascular
Repair may be needed; Complications include Gangrene, Contractures, False Aneurysms
(Dissections) and AV Fistulae
Septic Arthritis
• Consider for any Acutely Inflamed Joint; Rapid destruction under 24hr; Mostly in Knee; Less
overt inflammation if immunocompromised, or underlying Joint Disease
• RF: Pre-existing Joint Disease, DM, Immunosuppression, CKD, Recent Joint Surgery,
Arthroplasty complication, IVDU, >80yrs age
• Urgent joint aspiration for Synovial Fluid MC+S (NB: If Joint implant, needs to be done in
theatre); Blood cultures might be useful
• IV Abx (After aspiration) empirical therapy until sensitivities known; Most commonly due to S
aureus, Strep, N gonorrhoea and Gram-Negative Bacilli (E.g. Coliforms)
o Flucoxacillin 1g/6h IV, or Clindamycin if Pen-Allergic; Vancomycin if MRSA suspected,
Cefotaxime if Gonococcal or Gram-Negative suspected
• Orthopaedic advice regarding Arthrocentesis, Lavage, Debridement; Splint for <48h, Provide
Analgesia and consider early mobilisation with PT
Osteomyelitis
• Infection of Bone; Acute Haematogenous, Contiguous Local
Infection, or Vertebral;
• All forms can progress to Chronic Osteomyelitis – Pain, Fever and
Suppuration with long remissions; Thick Irregular Bone on
Radiographs; Radical Excision, Skeletal Stabilisation and Plastics
input for Dead-space management, plus Antibiotics for >12/52
• Raised ESR, CRP, WCC; Positive BC in 60%; Bone Biopsy and Culture
is gold standard but rarely required in Acute Osteomyelitis; MRI is
sensitive and specific
• Drain abscesses, Removal of Dead Bone (Sequestra) by Open Surgery
o Vancomycin 1g/12h and Cefotaxime 1g/12h IVI until sensitivities; Continue 6/52
Tuberculosis of the Bone (Vertebral Body =Pott’s Disease)
1-3% of all TB; Haematogenous or
Local Lymphatic spread; Local Pain, Swelling and ‘Cold Abscess’ Formation with Joint Effusion;
Systemic symptoms of Weight Loss, Malaise, Fever, Lethargy
o DDx – Malignancy, Other Infections, Gout, RA
o Loss of Bone Density, Periosteal Changes and Cyst Formation; May have associated
Soft Tissue Inflammation (E.g. Tenosynovitis, Bursitis), especially on MRI
o PET is superior for imaging; Bone scans useful for diagnosing Dactylitis, which is more
common in Childhood TB of the Bone
o Abscess Drainage, Immobilisation of Joints, RIPE; Joint Repair or Replacement might
be needed for if Joint Destruction
SPINAL TRAUMA
• Assume spinal injury in any serious accident and in all where MOI unknown, or if patient is
unconscious; C-collar, Head blocks and Spinal board
o Suspect if – Dermatomal Sensory Loss, Strenuous Diaphragmatic Breathing,
Hypotonia, Hyporeflexia, Paralysis, Bradycardia and Hypotension in Normovolaemia,
Priapism, Urinary Retention, Unexplained Ileus, Poikilothermia
o Graded by ASIA scale (based on Motor and Sensory function)
• Initial Resuscitation and treatment of Shock; Serial Neurological observations
• If clear Cord injury and patient stable – CT first line
• Early Treatment of Spinal Cord Injury – Controversial use of Steroids; Early Surgical
Decompression, Skeletal Traction
o Anticoagulation – Acute Cord injury patients at right of developing VTE
Complications of Cord Injury
• Respiratory Insufficiency (Might require Ventilation), Hypotension (Likely below level of
Lesion due to Sympathetic Interruption and Neurogenic Shock; Avoid overload), Skin ulcers
from immobility, Bladder overstretching
• Spinal Shock (≠Neurogenic) – Anaesthesia and Flaccid Paralysis with Urinary Retention
followed by Reflex Emptying; Riddoch’s Mass Reflexia in response to stimuli (e.g.
Temperature); Legs may become permanently flexed, with dorsiflexion (Spastic Paraplegia in
Flexion); Unpredictable duration for recovery
• GU Complications – UTI, Detrusor-Sphincter Dyssynergia, Autonomic Dysreflexia
Spinal Cord Injury Patterns
• Narrowest diameter is within Thoracic spine, where injury more likely to be complete;
Ischaemic injury often spreads below level of mechanical injury
• Root pain and LMN at level of lesion, and UMN and Sensory Changes below (Spastic
Weakness, Hyperreflexia, Upgoing Plantars, Loss of Coordination, Proprioception, Vibration,
Temperature and Nociception)
Brown-Séquard Syndrome
Ipsilateral loss of Dorsal Column modalities and Motor loss below
level of lesion plus Contralateral loss of Spinothalamic sensation from a few levels below
Anterior Cord Syndrome
Infarction of Cord supplied by ASA, leading to Complete Loss of
Motor Function, Pain and Temperature sensation below lesion; Dorsal Column modalities
(Soft touch, Vibration, Proprioception) intact
Central Cord Syndrome
Hyperextension Injury with Pre-existing Spinal Stenosis; Greater Loss of Motor Power in Upper Extremities compared to Lower Extremities, combined with
varying patterns of Sensory loss and Sphincter Dysfunction
Cauda Equina Syndrome
• Saddle-area Anaesthesia, Incontinence/Retention of Faeces and Urine, Poor Anal Tone,
Paralysis ± Sensory Loss
• Requires MRI within 4hrs and Urgent Neurosurgical Referral
• Compression can be due to Extrinsic tumours, Primary Cord tumours, Spondylosis, Spinal
Stenosis, Achondroplasia, Fluorosis, Central Disc Herniation, Trauma, Spinal SAH, Abscess, TB
or Pathological Fracture due to Malignancy
CHEST TRAUMA
• ABCDE Approach; Senior Traumatology if major trauma
• Oxygen for all via NRB Mask 15L/min; Stridor indicates possible upper airway compromise,
requiring urgent Definitive Airway
• Assume Spinal Instability – C-spine Precautions required
o Tension Pneumothorax – Breath sounds, Respiratory Distress, Tracheal Deviation
(away from Tension), Cyanosis, Distended Neck Veins, Asymmetry
o Large cannula decompression in second Intercostal Space in the Mid-Clavicular line
o Haemopneumothorax – Large (adult 32G) Chest Drain; If >1500ml =Massive, or
>300/hr requires Thoracotomy
o Sucking Chest Wounds – Three-sided dressing
o Respiratory Embarrassment due to Pain, Flail Chest or Diaphragmatic Injury require
Intubation and Ventilation; Chest Drain if chance of Bronchial, Lung and Chest tear
• Control Haemorrhage – Pressure and Elevation; Crossmatch; 2 Wide-bore cannula IVI; 2L
Crystalloid fluid challenge if <90mmHg and likely Hypovolaemic
o Cardiac Tamponade – Beck’s Triad of JVP, Hypotension, Quiet Heart Sounds ± Pulsus
Paradoxus (abnormally large drop in SV/BP/Pulse Waveform in Inspiration
o Pericardial Aspiration by Needle left of Xiphoid; Aim for Left shoulder with needle
angled 45deg to Horizontal
o XM >6u, 2 large bore IVI, Monitoring, ITU care and facilitates for Thoracotomy
• Neurological - GCS, AVPU, Pupillary Light Reflex
• Regular Observations, ECG, CXR, Secondary Survey, Tetanus ± Anti-Tetanus Ig
ABDOMINAL TRAUMA
• ABCDE, XM ±Theatre for Exploratory Laparotomy if not responding quickly
• Penetrating Injury mostly require Laparotomy/Laparoscopy; Laparotomy if Posterior Rectus
has been breached – Assess degree under LA, Wound Extension if necessary with expert
o Liver most commonly involved; Also, Small Bowel, Diaphragm and Colon
• Blunt Trauma – Splenic Injury and Rupture (Shock, Abdominal Tenderness, Distention, Left
Shoulder-tip Pain, Overlying Rib Fracture), Mesenteric tear, Liver, Bladder and Aorta
Fractures
• Described based on Site (Bone and part of Bone fractured), Obliquity (Transverse, Oblique,
Spiral or Multi-fragmentary), Displacement and Soft Tissue Involvement (Open/closed,
Neurovascular Status, Compartment Syndrome)
• Healing Time – ‘Rule of 3’ – Closed, Paediatric, Metaphyseal, UL fracture will heal in 3 weeks;
Complicating factors (Adult, Diaphyseal, LL, Open) will double healing times
• Pathological Fracture =Occurs in Diseased or Abnormal Bone; Suspect if energy for trauma is
abnormally low; Commonest causes Osteoporosis, Bony Mets (E.g. Breast, Bone); Also,
Osteomalacia, Osteomyelitis, Bone Tumours and Osteogenesis Imperfecta)
o Search for Primary Cancer is unclear cause; Osteoporosis Prevention; Prevention of
met deposits with EBRT and Prophylactic IM Nails
Emergency Management of Open Fractures
• ATLS Management (ABCDE)
• Assessment – Neurovascular Status, Soft Tissues, Photograph Wound
• Antisepsis – Wound swab, Copious Irrigation and Antiseptic Dressing
• Alignment – Reduction plus Splint
• Anti-Tetanus – Check status and Immunise appropriately
• Antibiotics – Third Generation Cephalosporin ± Metronidazole if
Grossly contaminated
• Analgesia – IV Opiates titrated to effect
Complications of Fractures
• Bleeding, Organ Injury, Neurovascular Injury, Skin issues, Infection,
Malunion/Non-Union/Contractures, Embolism, Stone disease
• Fat Embolism (Days 3 – 10) – Confusion, Dyspnoea, Tachycardia, Hypoxaemia, Seizures,
Febrile, Petechial Rash; ITU, Expert help, Shock Management, Monitor CVP and UO; Treat
Respiratory Failure
• Crush/Compartment Syndromes – Renal failure due to Fluid Loss, DIC, Myoglobin release
General Management of Fractures
• Displaced Fractures require Reduction unless function and appearance satisfactory
o MUA under Radiographic Screening; Traction may be used (e.g. Femoral Shaft
Fractures, Spinal Injury); Open Reduction (± Internal Fixation)
o ORIF especially if fractures involve Joint Articulations, due to
high risk of Osteoarthritis
o Prompt Internal Fixation of all fractures in Polytrauma leads
to large reductions in serious complications (Fat Embolism,
ARDS), and reducing mechanical ventilation time
▪ K-wire or Bone clamp; ±Plates, Pilot hole drilled and Screws Inserted
▪ Lag screw technique most appropriate for Oblique fractures
• Immobilisation – E.g. using Plaster of Paris
o Immobilisation can lead to Muscle Atrophy, Stiff Joints and Osteoporosis; Return to
normal function as soon as possible
• External Fixation useful if Burns, loss of Skin and Bone, or Open Fracture as part of DCS
FEMORAL FRACTURES
• 75,000 Patients with Hip Fractures annually in the UK; 10% die within 1/12 of #, >30% 1yr
• Intracapsular Fractures occur just below Femoral head, causing External Rotation, Adduction
and Shortening due to action of Iliopsoas
o Disruption of Medial Femoral Circumflex can lead to Ischaemic Necrosis of Femoral
Head, especially if there is excessive displacement
Management of Neck of Femur Fractures
• ABCDE, Treat Shock with Crystalloids
• Analgesia – E.g. Morphine IVI, Femoral Nerve Block, Antiemetic
• Imaging – XR Hip or CT
• Preparation for Theatre – Blood (FBC, U/Es), CXR, ECG, NBM, XM, Consent
• Orthogeriatric opinion for concurrent Medical issues
• Surgery – Intracapsular requires Hemiarthroplasty (with native acetabulum, unless fractured)
due to risk of Avascular Necrosis if native femoral head is retained; If previously good mobility
and high chance of recovery of mobility, consider Total Hip Replacement (esp if younger)
o Intertrochanteric/Extracapsular – Dynamic Hip Screw; Allows for stability of fracture
but allows compression during load; Reduced hospital stay and improved rehab
Femoral Shaft Fracture
• Requires considerable force; Look for other fractures
• Check Distal Pulses and look for swelling – Risk of Compartment Syndrome, Sciatic Nerve
Injury and Femoral Artery Injuries
• Definitive Treatment with locked Intramedullary Nail across fracture
PELVIC FRACTURES
• Single Fractures are often stable and require just a few weeks rest; ≥2 Fractures leads to
Pelvic Ring instability, 25% of which associated with internal injuries
o Leg Length Discrepancy, Abdominal Distention, Bruising, Perineal or Scrotal
Haematoma or Urethral Trauma
o Tenderness of Iliac Crests, Pubic
Symphysis, Sacrum and SI Joints
o Diagnosis by Pelvic Radiograph/CT
• ABCDE, Analgesia; Cystogram before Cath if
Urethral Trauma suspected alt: Suprapubic
• Complications include – Haemorrhage,
Genitourinary Tract Trauma, Paralytic Ileus,
Sciatic Nerve Entrapment
• Malgaigne’s Fracture – Disruption Anteriorly and
Posteriorly with Displacement of a fragment
containing the Acetabulum
• Acetabular Fractures – Posterior Lip or Transverse; ORIF and Reconstruction of Articular
Surface required to delay onset of Secondary Osteoarthritis
Clavicular Fracture
• Most seem to occur after direct blow to shoulder (prev
thought FOOSH); Most common in Middle third;
• Broad arm sling, Follow-up XR at 6/52 to ensure union
• Internal Fixation is non-union of Lateral #
• Complications include Brachial Plexus injury, Subclavian
Vascular injury and PTX
AC Joint Dislocation
• Tender prominence over AC joint; Adduction across body cause increased pain; XR might
appear normal and require weight-carrying views
• Sling support and Mobilisation; Surgery if persistent symptoms
Shoulder Dislocation
• Anterior Shoulder Dislocation – Following fall on Arm
or Shoulder; Loss of Shoulder contour, Anterior Bulge
due to Humoral head
o Check Neurovascular status (Axillary Nerve to
Deltoid); Radiograph prior to reduction to
ensure no associated fracture
o Analgesia and Simple Reduction (Longitudinal
Traction in Abduction), or Kocher’s Method
o Radiograph post-reduction; Broad arm sling;
Surgery if Recurrent Dislocation or
Young/Athletic
• Posterior Shoulder Dislocation – Rare; Limitation of External Rotation; Lateral Radiographs
essential for diagnosis; Refer to Orthopaedics
Biceps Tendon Rupture
Discomfort midway while lifting or pulling; Mass appears on Elbow Flexion like ‘Popeye’;
Repair rarely indicated as function remains
Humeral Fracture
• Supracondylar Fracture =Most common in Childhood; Peaks 5-7yrs
• Compromise of Brachial Artery, Median, Radial or Ulnar Nerve
• Keeping Elbow in Extension prevents exacerbating damage; Avoid flexion, if non-displaced,
Back-slab and Sling, if angulated with intact Posterior Cortex, Reduction Under Anaesthetic,
and if Posteriorly Displaced, ORIF
Radial Head Fracture
• Elbow Swollen and Tender over Radial Head; Tender when Pronation and Supination;
Undisplaced fractures can be kept in Collar and Cuff Sling; Displacement requires ORIF
• 3-14% Associated with “Terrible Triad” – Radial Head Fracture, Elbow Dislocation and
Coronoid Process Fracture leading to Joint Instability
Elbow Dislocation
• FOPOSH with Elbow Flexed causes Posterior Ulnar displacement on Humerus; Reduction
under Anaesthetic/Analgesia
• Flex Elbow to relax Biceps Brachii; With fingers on Epicondyles and thumbs on Olecranon,
Push thumbs forward and down onto Forearm; Chunk should be heard
• Post-reduction Radiograph, Immobilise in Back slab
• If Olecranon Fracture – ORIF if displaced
Colle’s Distal Radial #
Common in Osteoporotic, Post-menopausal women with FOOSH;
Dorsal Angulation and Displacement (=Dinner-Fork deformity); Avulsion of Ulna might occur
o Reduction under Anaesthesia and Tourniquet (=Bier’s Block Method)
o Median nerve injury will resolve over time; Other complications include Tendon injury
(especially EPL), Malunion and Non-union
Smith’s Distal Radial # Fracture
Distal Radial Fragment Anteriorly Angulated and Displaced
o More commonly requires fixation due to migration of fracture fragments
Bennett’s Fracture
CMC Fracture/Thumb Dislocation; Managed with Percutaneous Wire
Fixation to reduce risk of secondary OA
Scaphoid Fracture
Common, easily missed on Radiography; Results from FOOSH
o Tender in Anatomical Snuffbox and Scaphoid Tubercle; Pain on Axial Thumb
Compression and Ulnar Deviation of Pronated Wrist
o Scaphoid Series imaging; If negative but clinical suspicion, MRI may be used, or if
unavailable Cast and Re-XR in 2/52
o Avascular Necrosis of the proximal pole can occur, as it relies on Interosseous supply
from Distal portion
Hand Fractures
• Base of Second and Third Metacarpals, where movement is centred; Less tolerant of
Malalignment and Imperfect reduction; Fifth most commonly involved, especially in Punching
• Stable closed fractures splint/cast for 2/52, Unstable require K-wire or ORIF
• Longer periods of splinting can lead to Stiffness – Adhesions, Contracture, Fibrosis and
Ligament Shortening
• Refer for any with Rotational Deformity (Clinically), as well as multiple fractures
• Proximal Phalanx – Likely associated with Rotational Deformity, requiring surgery
• Middle Phalanx – Control rotation by Malleable Metal Splint and Neighbour-Strapping
• Distal Phalanx – Often open; If closed, Trephining the nail reduces swelling; Partial Fingertip
amputations might require Split Grafts from Thenar Eminence
• Gamekeeper’s Thumb – Laxity of Ulnar Collateral Ligament of the Thumb; Leads to weakness
of Pincer Grip, crucial to ensure complete tears are managed surgically
o Might require Examination under Anaesthetic; XR might show Bone Avulsion
Tendon Injury
• Failure to extend MCP = Extension Tendon division; 75% are closed injury
• Failure to flex DIP against resistance = FDP division; Failure to flex PIP against resistance =
FDS; Flexor Tendon injuries by Primary Repair; Staged repair with plus graft if Loss of Tendon
Substance or Delayed presentation
Patella Injury
• Patella Dislocation – Typically Lateral due to Twisting Motion of LL combined with Quadriceps
Contraction; Reduction with gentle medial pressure and Extension
o Radiographs post-reduction to ensure no fractures
o Immobilisation in Cast/Brace to allow recovery
• Recurrent Dislocation – Associate Developmental Abnormalities; Might require Surgery to
strengthen Medial Expansion
• Patella Fracture – Fall on Flexed Knee or due to Dashboard Injury; Non-displaced Fractures
can be splinted; Displacement warrants ORIF
Ankle Fractures
• Rotation causes Oblique Lateral Malleolar
Fractures, or proximal fracture of Fifth
Metatarsal due to Fibularis Brevis Avulsion
• If Stable Fracture involving one side of ankle,
Cast; Unstable or Displaced require surgery
• Maisonneuve’s Fracture – Proximal Fibular plus
Syndesmosis Rupture, and Medial Malleolus
Fracture or Deltoid Ligament Rupture; Surgery
Lisfranc Fracture Dislocation
• One or more Metatarsals displaced by Tarsals
• Commonly missed in Polytrauma, but can also be caused by
mis-stepping off kerb; May cause Compartment Syndrome,
Secondary OA and Persistent pain
• ORIF may be required to achieve precise anatomic reduction
Metatarsal Stress Fracture
• =March Fracture; Distal third of Metatarsal due to recurrent
stress; Most commonly second or third Metatarsal
• Common cause of foot pain, especially if new activity
• Reduce movement 6-12/52; Cast or special shoes;
Achilles Tendon Rupture
• Sudden pain at back of Ankle during Running or Jumping as injury occurs; Might be perceived
like a kick; Possible to walk with limp
• Unable to Plantarflex against stress; Gap may be palpated in tendon course, esp after 24h
• Simmonds Squeeze Test – Pain and Less Plantarflexion on affected side
• Percutaneous or Open Tendon Repair; Later onset rupture might require reconstruction
• Conservative treatment more suitable for Smokers, Diabetics and >50yrs due to infection and
recurrence risk
