Orthopaedics - Clinical conditions Flashcards
Osteoarthritis
- What is it?
- Risk factors?
- Pathology?
- Presentation in patient? (vs RA) (history)
- Examination & results?
- Investigations & results?
- Management?
- Inflammation of the bone joint -> wear and tear
- Old age, injury, obesity, inflammation
- Chondrocyte due to inflammation makes type 1 collagen (no longer T2)
- Image
OA: crepitus
- Small joint effusions
Patella tap
- X-ray: osteophytes (response to loss of hyaline cartilage), subchondral cysts, sclerosis, narrowing of joint space
- NP: losing weight, exercise,
P: NSAIDs + PPI
glucocorticoid injections -> only for exacerbations
knee replacement -> 2 weeks need for recovery 4-6 weeks ok
dextamethasone also antiemetic
Flucloxacilin during surgery
propofol (milky white) -> anaesthesia (pain) sedation (sleep),
fentanyl (opiod) peak 7 mins (20 min half life) analgesia/respiratory depression/ anaesthesia/ interferes with pupillary response,
s/e opiods: dependance, hypogonadism and adrenal insufficiency
s/e: GORD, abdominal pain, diarrhoea
morphine 20 mins to work,
What is ESR?
What elevates ESR?
erythrocyte sedimentation rate is the rate at which red blood cells sediment in a period of one hour. It is a common hematology test, and is a non-specific measure of Inflammation
Osteoporosis
- What is it/pathology?
- Risk factors?
- Presentation in patient? (vs RA) (history)
- Examination & results?
- Investigations & results?
- Management?
- Primary osteoporosis (type 1 and 2) is by far the most common form of osteoporosis.
Type 1: postmenopausal women
Type 1: increase in osteoclast no, a result of oestrogen withdrawal
Type 2: elderly persons of both sexes (senile osteoporosis)
Type 2: generally occurs after age 70 and reflects attenuated osteoblast function
- Women
Long term corticosteroids
low BMI/ malabsorption
previous fracture
RA
(image)
- online programme, such as FRAX or Q-Fracture
DEXA measures bone mineral density (compared to the bone mineral density of a healthy young adult and someone who’s the same age and sex as you)
- physical activity, stop smoking, maintain a normal BMI level (between 20–25 kg/m²), dec alcohol intake to improve their bone health and reduce the risk of fragility fractures
Osteoporosis
- Other groups who are at risk of developing osteoporosis include:
- people who…
steroid medication > three months
women who have had their ovaries removed
FH of osteoporosis eating disorder, such as anorexia or bulimia (Vit D & callium)
don’t exercise regularly
smoke or drink heavily
Wrist and hand
Scaphoid fracture
- Epidemiology
- Blood supply
- Clinical features
- Differential diagnosis
- Ix
- Management
- Complications
- Men 20-30
10% associsated fracture
trauma high energy
- Branches of the radial artery.
The dorsal branch supplies 80% of the blood, enters in the distal pole and travels in a retrograde fashion towards the proximal pole.
Consequently, fractures can compromise the blood supply, leading to avascular necrosis (AVN) and subsequent degenerative wrist disease.
- sudden onset wrist pain
tenderness in the anatomical snuffbox (medially abductor pollicis longus & extensor pollicis brevis tendons, extensor pollicis longus tendon). Radial artery, superficial radial nerve, cephalic vein)
pain on palpating the scaphoid tubercle
pain on telescoping of the ipsilateral thumb.
4.
- Distal radial fracture,
- an alternative carpal bone fracture,
- fracture of the base of the 1st metacarpal,
- or a ulnar collateral ligament injury.
- scaphoid series: anteroposterior, lateral, oblique views.
sometimes not detected (undisplaced) fracture: wrist immobilised in a thumb splint and repeat plain radiographsin 10-14 days for further evaluation
6.
- Undisplaced fractures: strict immobilitasion in a plaster with a thumb spica splint. However, undisplaced fractures of the proximal pole have a high risk of AVN and surgical treatment may be advocated.
- Displaced fractures should be fixed operatively -> percutaneous variable-pitched screw, which can be placed across the fracture site to compress it.
Fractures of the distal radius
- Occur at which site of the bone?
- What are the three most common eponymous distal radius fracture types:
- Aeitiology
- Describe a colles fracture
- Smiths fracture
- Describe Bartons fracture
- Risk factors
- Clinical features
- Neurological examination of the distal
- DD
- Investigations
- Management
- Following reduction, the arm should be restricted to allow for bone healing:
- The main complications following distal radius fractures are:
- distal metaphysis
- Colles’ , Smith’s, and the Barton’s fracture.
- FOOSH
5-15yo
elderly osteoporosis -> fragility fractures
- Extra-articular fracture,
dorsal angulation,
dorsal displacement within 2cm of the articular surface
sometimes avulsion fracture of the ulnar styloid
- volar angulation
+/- volar displacement
extra articular
- Intra articular fracture of the distil radius with associated dislocation of the radio-carpal joint
can be described as volar (more common) or dorsal (less common), depending on whether the volar or dorsal rim of the radius is involved.
- Osteoporosis, Increasing age, Female, Early menopause, Smoking or alcohol excess, Prolonged steroid use
- trauma,
immediate pain +/- deformity,
+/- neurological involvement paraesthesia or weakness
o/e: neurovascular compromise; check nerve function (see below) and limb perfusion (capillary refill time and pulses). Additionally, remember to examine the joints above and below to identify occult injuries.
- image
10.
- Forearm fracture (e.g. Galeazzi or Monteggia fractures)
- Carpal bone fractures
- Tendonitis or tenosynovitis
- Wrist dislocation
- X-ray distal radius fracture if:
- Radial height <11cm
- Radial inclination <22 degrees
- Radial (volar) tilt >11 degrees
- A-E (Stabalise and resus)
Displaced fractures: closed reduction in the ED.
Various techniques can be employed, however all involve ensuring sufficient traction and manipulation under anaesthetic.
This can be performed under conscious sedation with a haematoma block or Bier’s block.
13.
Stable and successfully reduced fractures can typically be placed in a below-elbow backslab case, then radiographs repeated after 1 week to check for displacement
Significantly displaced or unstable fractures can require surgical intervention, as they have a risk of otherwise displacing over time
Options of surgical management include open reduction and internal fixation (ORIF), K- wire fixation, or external fixation
Once sufficient bone healing has occurred, patients should be rehabilitated via physiotherapy to ensure the regaining of full function.
14.
- Malunion: poor realignment leads to a shortened radius compared to the ulnar, leading to reduced wrist motion, wrist pain, and reduced forearm rotation. Can be treated with corrective osteotomy of the malunion
- Median nerve compression, ~ in patients who heal in a significant degree of malunion
- OA, especially with intra-articular involvement from the original fracture
- Any intra-articular step of the radiocarpal joint >2mm is advised to be surgically corrected
Carpal tunnel syndrome (compression of the median nerve)
- Epidemiology
- Causes
- Clinical features
- Differential diagnosis
- Managment
- Complications of surgery
- W>M
~ 45-60
median nerve: lateral 3.5 digits
2.
- Myxodema (hypothyroidism)
- Edema
- DM
- Idiopathic
- Amyloidosis
- Neoplasms (ganglion, lipoma)
- Trauma
- Rheumatoid arthritis
- Acromegaly
- Pregnancy
- Pain/paraesthesia in lateral 3.5 digits
Palm is often spared -> palmar cutaneous branch of the median nerve branching proximal to the flexor retinaculum and passing over the carpal tunnel.
worse at night -> wrist flexed, leaned
Percussing over the median nerve (Tinel’s Test)
Holding the wrist in full flexion for one minute (Phalen’s Test).
Wasting of LOAF:
- Lateral two lumbricals
- opponens pollicis
- abductor pollicis brevis
- flexor pollicis brevis
4.
- Cervical Radiculopathy
C6 nerve root involvement may produce pain or paraesthesia in a similar distribution however will likely have an element of neck pain or symptoms involving the entire arm length
- Pronator teres syndrome (median nerve compression by pronator teres)
Symptoms will also extend to the proximal forearm and sensation of the palm will also be reduced
- Flexor carpi radialis tenosynovitis
This can be distinguished by tenderness at the base of the thumb
- Wrist splint
PT
corticosteroid injections
NSAIDs
Carpal tunnel release surgery - day case - local anaesthesia
- persistent CTS symptoms (from incomplete release of ligament), infection, scar formation, nerve damage, or trigger thumb
Dupuytrens Contracture
- What is it?
- Epidiemiology
- Give examples of thickening of fascia in other areas
- RF:
- Clinical features
- Differential diagnosis
- Ix
- Management
- Prognosis
- contraction of the longitudinal palmar fascia
starting as painless nodules
bilateral in 45%
- 6xM
40-60
ulnar digits
3.
- Leddarhose disease (Plantar fibromatosis),
- Peyronie disease (Penile fibramotosis),
- Garrod nodes (Fibramotosis of dorsal proximal interphalangeal joints)
- smoking*, alcoholic liver cirrhosis, diabetes mellitus, and certain occupational exposures, idiopathic
- O/E: thickened band, nodules, blanching on extension of effected digit
Huestons test: unable to lay their palm flat on a tabletop, this is a positive test
- stenosing tenosynovitis, ulnar nerve palsy, trigger finger
- Clinical diagnosis
Routine bloods: LFTs, random glucose / HbA1C, to assess for potential associated RF
- Conservative:
- Hand therapy* (stretching exercising)
- Injectable collagenase clostridum histolyticum (CCM) early stages
Surgical:
- Excision of diseased fascia: indicated in those with functional impairment, MCP joint contracture >30 degrees, any PIP contracture, or rapidly progressive disease.
- A fasciectomy, performed under local/general, anaesthetic more common. Various approaches to this are present:
+ Regional fasciectomy, whereby the entire cord is removed (the most common approach)
+ Segmental fasciectomy, whereby only short segments of the cord are removed
+ Dermofasciectomy, whereby the cord and overlying skin are removed, to be followed by a skin graft
- Closed fasciotomy (also termed percutaneous needle fasciotomy) is a less commonly performed procedure. It has the benefit of being performed in the outpatient setting under local anaesthetic and hence is more suitable for co-morbid patients who are unsuitable for major surgery.
- Finger amputation is very rarely for Dupuytren’s contracture, only ever considered in very severe cases where there has been a delay in presentation and failure of initial management.
- Recurrence 66%
De Quervain’s tenosynovitis
- What is it? click on the image on this page
- What are the main RFs for developing De Quervain’s tenosynovitis include:
- Clinical features
4.
- Investigation
- Conservative management
- Complications of surgical decompression
- Inflammation of the tendons within the first extensor compartment of the wrist, resulting in wrist pain and swelling.
2.
- Age – most common between 30-50 years
- Female gender
- Pregnancy
- Certain occupations or hobbies, especially those that involve repetitive movements
- Pain near the base of the thumb
Associated swelling (secondary to thickening of the tendon sheath). Movements involving grasping or pinching are particularly painful and difficult
O/e: there will be swelling and palpable thickening over the tendon group fibrous sheath.
Finkelstein’s test is often positive.
- image
5.
- Arthritis of Carpometacarpal (CMC) joint – more gradual in onset, usually with a negative Finkelstein’s Test and positive Grind test. The Grind test involves forcefully pushing thumb against CMC joint whilst also rotating it slightly, with a positive result producing pain felt on the volar side of the wrist.
- Intersection syndrome – tendons of the first compartment cross over with those of the second compartment, resulting in pain felt over the second compartment.
- Wartenberg’s syndrome – neuritis of the superficial radial nerve, often seen in those wearing tight jewellery.
6.
- Lifestyle advice (avoiding repetitive actions) and a wrist splint.
- Steroid injections
- Surgical decompression of the extensor compartment can be performed under local or general anaesthetic. This involves a transverse or longitudinal incision made and the tendon sheath split in the central aspect in a longitudinal direction, thus allowing the tunnel roof to form again as it heals but wider and with more space for the tendons to move.
- Failure to resolve,
reduce ROM in wrist or hand,
neuroma formation
nerve impingement
Ganglionic cysts
- What are they
- RF
- Clinical features
- Differential diagnosis
- Management
- Non-cancerous tissue lumps
occur along any degenerated joint or tendon
filled with synovial fluid
~ hands & feet
60-70% dorsal aspect of the wrist
F>M
peak age 20-40
2.
- Female
- OA
- previous joint or tendon injury
3.
- smooth spherical painless lump
- appeared suddenly or grown over time
o/e:
- soft and will transilluminate
- bone -> ROM nerve-> compression, pain, paraesthesia
4.
- Tenosynovitis – no discrete mass, with the swelling tracking along the tendon.
- Giant cell tumour of tendon sheath – the mass is solid, does not translumuniate, and is fixed to the underlying sheath (therefore less mobile than a cyst).
- Lipoma – not be entirely spherical and does not trans-illuminate.
- OA – scaphotrapeziotrapezoid joint, palpable, hard, non-cystic, and immobile mass that does not trans-illuminate.
- Sarcoma – not well circumscribed or mobile lesions.
5.
Monitor - spontaneously disappear
If it causes pain or effects ROM:
- aspiration +/- steroid injection
- Cyst excision removing the cyst capsule along with a portion of the associated tendon sheath (recurrence is less than with aspiration, but still possible)
Trigger finger
- What is it?
- Pathophysiology
- Clinical features
- DD
- Management
- finger or thumb click or lock when in flexion, preventing a return to extension, affect one or more tendons
occuring spontaneously, associated with RA, amyloidosis & DM, female, ageing
- flexor tenosynovitis (repetitive movements), localised nodal formation, nodes get stuck in the pulley
- Painless clicking/snapping/catching when trying to extend their finger
4.
- Dupuytren’s contracture – flexion is painless, fixed and cannot be passively corrected.
- Acromegaly – excessive growth hormone results in swelling of flexor synovium within tendon sheath due to increased extracellular volume, limiting both flexion and extension in the affected digit.
- Infection (within tendon sheath) – usually preceded with trauma and the finger becomes swollen, erythematous, and tender, with passive movement of the digit causes marked pain.
- Ganglion – involving a tendon sheath.
5.
- Advice regarding activities that cause pain should be given and a small splint can also be used to hold the finger in the extension position at night (this keeps the roughened portion of the tendon in the tunnel which makes it smoother)
- steroid injections
Trigger finger secondary to multiple nodular thickenings along the course of the ring finger’s deep (black arrows) and superficial flexor tendons (white arrow) in the left hand.
Spine - radiculopathy
- What is it?
- Caused by
- Clinical features
- Red flags for cauda equina
- DD for radicular pain should include pseudoradicular pain syndromes: these are conditions that do not arise directly from nerve root dysfunction, but cause radiating limb pain in an approximate radicular pattern.
- Management
- What is myelopathy
- nerve roots become pinched or damaged
2.
- Intervertebral disc prolapse
Repeated minor stresses that predispose to rupture of the annulus fibrosus and sequestration of disc material (the nucleus pulposus)
- Degenerative diseases of the spine – leading to neuroforaminal or spinal canal stenosis
The cervical spine is the most mobile segment of the spine and degenerative change is a normal part of ageing process; 80% of the population over 55 years old have degenerative changes between C5/6 and C6/7
- Fracture – either trauma or pathological
- Malignancy – ~ metastatic
- Infection – such as extradural abscesses, osteomyelitis (most commonly tuberculosis (‘Pott’s disease’)), or Herpes Zoster
- Sensory (paraesthesia and numbness)
Motor (weakness)
Radicular pain is often also present, typically described as a burning, deep, strap-like, or narrow pain. It is not uncommon for radicular pain to be intermittent.
- saddle anaesthesia, loss of anal tone, urinary retension -> overflow incontinence, feacal incontinence,
- image
- Only Cauda equina requires surgery
Surgery if unremitting pain despite comprehensive non-surgical management, progressive weakness, and new or progressive myelopathy
Symptomatic management:
- Analgesia: neuropathic medication -> Amitriptyline is usually first line, which may then be added to GABA antagonists (such as pregabalin or gabapentin). The patients may also suffer from muscle spasms and these can be managed with benzodiazepines (often diazepam) and/or baclofen.
- Physiotherapy
- A disorder that results from severe compression of the spinal cord -> decompression surgery.
Causes: spinal stenosis, spinal trauma and spinal infections, as well as autoimmune, oncological, neurological and congenital disorders.
Myelopathy can be cervical and thoracic; cervical myelopathy is the most prevalent.
Cauda equina syndrome
- Where does the conus medularis taper. The cauda equina is formed of?
- Cauda equina syndrome is caused by compression of the cauda equina:
- Clinical features
- Classification into 3 groups:
- Differential Diagnosis
- Investigations
- Management
Peak onset 40-50
- L1, LMN
- Muscle paresis or paralysis
- Fibrillations
- Fasciculations – caused by increased receptor concentration on muscles to compensate for lack of innervation.
- Hypotonia or atonia – Tone is not velocity dependent.
- Hyporeflexia – Along with deep reflexes even cutaneous reflexes are also decreased or absent
- Strength – weakness is limited to segmental or focal pattern, Root innervated pattern
- The extensor Babinski reflex is usually absent. Muscle paresis/paralysis, hypotonia/atonia, and hyporeflexia/areflexia are usually seen immediately following an insult. Muscle wasting, fasciculations and fibrillations are typically signs of end-stage muscle denervation and are seen over a longer time period. Another feature is the segmentation of symptoms – only muscles innervated by the damaged nerves will be symptomatic.
2.
- Disc herniation – most common at L5/S1 and L4/L5 level
- Trauma – including vertebral fracture and subluxation
- Neoplasm – either primary or metastatic
- The most common cancers that spread to spinal vertebrae are thyroid, breast, lung, renal and prostate
- Infection – e.g. discitis or Potts disease
- Chronic spinal inflammation – e.g. ankylosing spondylitis
- Iatrogenic – e.g. haematoma secondary to spinal anaesthesia
3.
- Reduced lower limb sensation (often bilateral), bladder or bowel dysfunction, lower limb motor weakness, severe back pain, and impotence.
- assess is bladder dysfunction, specifically the presence of retention. Confirmed retention or reduced ability to void (loss of desire, reduced urinary sensation) suggests complete or incomplete CES respectively.
- perianal (the lower sacral dermatomes, termed “saddle” anaesthesia) or lower limb anaesthesia, loss of anal tone, urinary retention, and lower limb weakness and hypoflexia.
- PR examination and a post-void bladder scan.
4.
- Cauda Equina Syndrome with retention (CESR) – Presents as back pain with unilateral or bilateral sciatica, lower limb motor weakness, sensory disturbance in the saddle region, loss of anal tone, and loss of urinary control
- Incomplete Cauda Equina Syndrome (CESI) – As above, however only altered urinary sensation (e.g. loss of desire to void, diminished sensation, poor stream, and need to strain); painful retention may precede painless retention in some cases
- Suspected Cauda Equina Syndrome (CESS) – Cases of severe back and leg pains with variable neurological symptoms and signs, and a suggestion of sphincter disturbance
Most cases will be progressive in nature and will not immediately cause complete compression on the cauda equina. This is important for the management, as incomplete cauda equina syndrome has a greater potential for neurological recovery.
5.
- Radiculopathy – presents with radiating back pain, however there will be no faecal, urinary, or sexual dysfunction in these patients
- Cord compression – a surgical emergency with a similar pathophysiology to CES, however is characterised by upper motor neurone signs
- whole spine MRI gold standard
- Early neurological review
High dose steroids
surgical decompression (within 24hrs -> save bladder function)
Acute spinal cord compression
- Aetiology
- Clinical features
- DD
- Investigations
- Management
- Neoplastic:
Most commonly metastatic (MSCC) from the primary malignancies of thyroid, lung, breast, renal, and prostate; primary bone tumours, as well as haematological malignancies (e.g. myeloma) can also cause ASCC
- Traumatic:
Typically via vertebral fracture or facet joint dislocation (although complete severance of the cord is possible)
- Infective:
Infections resulting in abscess formation can cause compression on the spinal cord; chronic infections are typically seen with tuberculosis and fungal infections
- Disc prolapses:
This is a rare cause of spinal cord compression, as lumbar disc herniation typically causes compression of the cauda equina inferior to the spinal cord
- Narrowed cord canal inc risk of cord compression
e. g. RA, ankylosing spondylitis, ligamentum flavum hypertrophy, osteophyte formation
2.
- UMN signs: hypertonia, hyperreflexia*, Babinski’s sign, and clonus (present below the level of the lesion)
- *Reflexes tend to be absent at the level of the lesion, as the lower motor neurone within the ventral horn is compressed, so producing a lower motor neurone deficit
- Any autonomic involvement is a late stage and therefore carries a worse prognosis. Clinical features include bowel incontinence or constipation or urinary retention
- Lumbago, cauda equina syndrome
- MRI of the whole spine
routine blood tests
- corticosteroids + PPI
surgical decompression
surgical and oncological review
Neck of femur
- Mortality
- Aetiology
- The neck of the femur is around ? degrees to the shaft (also anteverted by roughly ? degrees), with the femoral head sitting within the acetabulum. Blood supply from?
- Classification
NOF fractures can be classified by the fracture line in relation to the joint capsule:
- What is the garden classification?
- clinical features
- The lateral rotator group is a group of six small muscles of the hip which all externally (laterally) rotate the femur in the hip joint. It consists of the following muscles:
- DD
- Ix
- Management
- Complications
- 30% at one year
2.
- Low energy injuries – such as a fall in frail older patient; or
- High energy injuries – such as a RTA, affecting the ipsilateral side.
- 130, 10, medial circumflex artery
4.
- Intracapsular – either subcapital (through the junction of the head and neck) or basocervical fracture (through the base of femoral neck)
- Extracapsular – either intertrochanteric (between the two trochanters) or subtrochanteric (<5cm distal to the lesser trochanter)
- Image -> further classifiy intracapsular fractures
- Hx or trauma, osteoporosis or renal failure
o/e shortened and externally rotated
with pain on pin-rolling the leg and axial loading. The patient will be unable to straight leg raise.
- Piriformis, gemellus superior, obturator internus, gemellus inferior, quadratus femoris and the obturator externus.
Innervated by the sacral plexus (L4-S2), obturator exterunus lumbar plexus .
8.
- Fractures of the pelvis (especially pubic ramus fractures), acetabulum, femoral head and femoral diaphysis all need to be considered.
- Pathological fractures should be considered if there is not a significant history of trauma.
9.
Imaging AP & lateral views of the affected hip
Routine blood tests: FBC, U&Es, coagulation screen, G&S
Urine dip, CXR, ECG
- A-E
Analgesia + anti-emetic (ondansetron?),
Dalteparin?
Surgical:
- Subcapital* -> Hip hemiarthroplasty -> Replacement of the femoral head and neck via a femoral component fixed in the proximal femur
- Intertrochanteric and Basocervical* -> Dynamic hip screw -> Consists of a lag screw into the neck, a sideplate, and cortical screws. The lag screw is able to slide through the sideplate, allowing for compression and primary healing of the bone.
- Non-displaced intra-capsular -> Cannulated hip screws -> Three non-parallel screws in an inverted triangle formation. Are also used in valgus-impacted fractures
- Subtrochanteric -> Intramedullary Femoral Nail (medullary cavity of the femur for stabilisation)
Displaced intra-capsular fractures in normally well and active elderly patients with high performance status can be treated with Total Hip Replacement, replacing both the femoral head and neck (via a femoral component) and the acetabulum (via an acetabular cup).
- Immediate post-op complications: pain, bleeding, leg-length discrepancies, and potential neurovascular damage, all of which should be consented for pre-operarively.
Long term complications following repair: joint dislocation, aseptic loosening, and peri-prosthetic fracture.
The mortality following a femoral neck fracture is up to 30% at one year.
- Intracapsular fracture management?
- Following your surgery, we encourage you to be up and out of bed as quickly as you can manage, and the physiotherapists will help you with this. This is so that you do not risk complications related to reduced mobility. These include:
- The artificial ball and stem are known as the prosthesis, which can be cemented or uncemented. What is the difference
- Hemi arthroplasty
- image
- Cemented parts are attached to healthy bone using bone cement.
Uncemented parts are made from a material with a coating that the bone grows onto to keep it in place.
Osteoarthritis (loss of articular cartilage)
- RF
- Clinical features
- DD
- Ix
- Management
- There are a number of different approaches to hip replacement surgery that can be taken, defined by their relation to gluteus medius:
- Increasing age (>45 yrs), Gender (women > men), Genetics*, Vitamin D deficiency
Obesity, Hx of trauma to the hip, Anatomic abnormalities, Muscle weakness/myopathy, Joint laxity, Participation in high impact sports
- Dull aching pain (aggravated by activity & relieved by rest)
o/e: muscle wasting, leg length discrepency, fixed flexion deformity, patients can walk with antalgic or trendelenberg patterns, crepitus & often reduced ROM
3.
- Trochanteric bursitis – presents with lateral hip pain radiating down the lateral leg, with associated point tenderness over the greater trochanter
- Gluteus medius tendinopathy – lateral hip pain with point tenderness over the muscle insertion at the greater trochanter
- Sciatica – low back pain and buttock pain, but often radiates down the posterior leg to below the knee. Diagnosis is made with the straight leg raise to produce Lasègue’s sign
- AVN of the femoral head – there are likely to be risk factors involved in the history (e.g. excessive steroid use, arterial disease etc) and radiographic changes will also differ compared to that of OA
- Femoral neck fracture – ~ Hx of trauma or known severe osteoporosis. The patient will be unable to weight bear due to pain and the limb will appear shortened and externally rotated
4.
- Narrowing of the joint space
- Osteophyte formation
- Sclerosis of the subchondral bone
- Presence of cysts
- Initial: analegesia, lifestyle mod, PT to slow disease progression
Long term: surgery -> THR or hemiarthroplasty
6.
ACL tear
- Aetiology
- Clinical features
- DD
- Ix
- Managment
- Complications
6a. how long does recovery take? - What is a PCL tear?
- Clinical features & Ix
- Management
- What is valgus and varus
- twisting the knee, landing from a jump
2.
- rapid joint swelling* and significant pain
- if delayed presentation patient may state leg gives way
- Lachman Test and Anterior Draw Test
Lachman (supposedly better): The knee is flexed at 20–30 degrees, one hand behind the tibia and the other grasping the patient’s thigh. It is important that the examiner’s thumb be on the tibial tuberosity. The tibia is pulled forward to assess the amount of anterior motion of the tibia in comparison to the femur. An intact ACL should prevent forward translational movement (“firm endpoint”) while an ACL-deficient knee will demonstrate increased forward translation without a decisive ‘end-point’ - a soft or mushy endpoint indicative of a positive test. More than about 2 mm of anterior translation compared to the uninvolved knee suggests a torn ACL (“soft endpoint”), as does 10 mm of total anterior translation.
Anterior draw: Flexing the knee at 90 degrees, placing the thumbs on the joint line, index fingers on the hamstring tendons posteriorly, force is then applied anterior to demonstrate tibial excursion
- Fracture, meniscal tear, collateral ligament tear, quadriceps or patellar ligament tear
4.
- Plain knee Xray (anterior & lateral) exclude bony injuries, any joint effusion, or a lipohaemarthrosis present.
- MRI scan of the knee gold standard
- *50% of ACL tears will also have a meniscal tear, with the lateral meniscus being the more commonly affected
- RICE
Conservative: rehabilitation, patient can usually wieght bear, canvas knee splint for comfort
If you do not have the full ROM in your knee before having surgery, your recovery will be more difficult.
It’s likely to take at least 3 weeks after the injury occurred for the full range of movement to return.
surgical: hamstring or patella tendon
6. Post traumatic OA
6a. Recovering from surgery usually takes around 6 months, but it could be up to a year before you’re able to return to full training for your sport.
7. less common, prevent hyperflexion of the knee joint, high energy trauma,
8. immediate posterior knee pain
o/e: positive posterior drawer test + posterior sag
MRI of knee -> gold standard
- Conservatively: knee brace + physio
Surgery: insertion of a graft
- image
MCL tear
- Function
- MCL injuries can be graded from one to three:
- Clinical features
- Ix
- Management
- Complications
- Valgus stabiliser, most often injured when external rotational forces are applied to the lateral knee, such as a impact to the outside of the knee.
- Grade I – mild injury, with minimally torn fibres and no loss of MCL integrity
Grade II – moderate injury, with an incomplete tear and increased laxity of the MCL
Grade III – severe injury, with a complete tear and gross laxity of the MCL
- Trauma to the lateral aspect of the knee
report hearing a POP with immediate medial joint line pain
associated haemarthrosis
increased laxity when performing the valgus stress test
extremely tender along the medial joint line, but may be able to weight bear.
*A Grade II and III tear can be distinguished clinically on medial stress testing; Grade II is lax in 30 degrees of knee flexion but solid in full extension, whereas Grade III is lax in both these positions.
- Knee Xray (exclude fracture)
MRI (extent and grade)
5.
Grade I Injury: RICE with analgesia (typically NSAIDs) as the mainstay. Strength training as tolerated should be incorporated, with an aim to return to full exercise within around 6 weeks.
Grade II Injury: Analgesia with a knee brace and weight-bearing/strength training as tolerated. Patients should aim to be able to return to full exercise within around 10 weeks
Grade III Injury: Analgesia with a knee brace and crutches, however any associated distal avulsion then surgery is considered. Patients should aim to be able to return to full exercise within around 12 weeks.
- Instability in the joint and damage to the saphenous nerve
Meniscal tears
- Function
- Pathophysiology
- Clinical features
- Ix
- Management
- Complications
- (1) shock-absorbers of the knee joint
(2) increase articulating SA - attached to the medial collateral ligament
Trauma injury & degenerative
Young patient who has twisted their knee whilst it is flexed and weight-bearing, with the onset of symptoms following soon after.
The most common type of tear is a longitudinal/ ‘bucket-handle’ tear – whereby the central tear becomes separated from the lateral fragment.
- Vertical
- Longitudinal (Bucket-Handle)
- Transverse (Parrot-beak)
- Degenerative
3.
- Tearing sensation in the knee
- intense onset of pain
- Swells slowly subsequently over a period of 6-12 hours
- free body -> locked in flexion and unable to extend
- o/e: Joint line tenderness, significant joint effusion, and limited knee flexion. Specific tests to identify a meniscal tear include McMurray’s Test* and Apley’s Grind Test* (although in the acutely swollen knee, they can often prove difficult)
- MRI gold standard
- RICE. Most small (<1cm) meniscal tears will initially swell however the pain will subside over the next few days as the tear heals.
For larger tears or those remaining symptomatic, arthroscopic surgery is indicated:
- If the tear is in the outer third of the meniscus (where it has a rich vascular supply), then the tear can often sutured back together
- If the tear is in the inner third, then the tear is often trimmed (and middle third tears may either be repaired or trimmed)
6.
- A meniscal tear is a risk factor for developing OA
- Knee arthroscopy carries a risk of deep vein thrombosis and damage to local structures, such as the saphenous nerve and vein, the peroneal nerve, and the popliteal vessels.
Tibial plateau fracture
- A
- Clinical features
- DD
- Ix
- Classification
- Management
- Complications
- Hx of trauma, axial loading, high-impact injuries
- sudden onset pain, unable to weight bear, swelling of the knee
o/e: ?neurovascular damage e.g. popliteal vessel dissection or common fibular nerve damage
- knee dislocation, knee fracture, meniscal injuries, ligamentous injuries,
- Plain AP and lateral x ray (lipohaemarthrosis will be present)
CT needed apart from undisplaced (Assess severity and surgical planning)
*presence of fat in the joint indicates that there is an intra-articular fracture present (e.g. tibial plateau, patella, distal femur)
- image
6.
- Non-op in uncomplicated (including no evidence of ligamentous damage, tibial subluxation, or articular step <2mm):
Hinged knee brace ~8-12wks
PT + anaesthesia
- Surgery in complicated (open fractures, or compartment syndrome)
ORIF -> restore the joint surface congruence. Any metaphyseal gaps can be filled with bone graft or bone substitute.
Post-op, a hinged knee brace is fitted with early passive ROM but limited or non-weight bearing for around 8-12 wks months is typically required.
- External fixation may also be warranted, with delay to any ORIF, especially in cases of significant soft tissue injury or in polytrauma / highly comminuted fractures where an ORIF may not be suitable.
*Complicated fractures: articular step ≥2mm, angular deformity ≥10 degrees, any metaphyseal-diaphyseal translation, ligamentous injury requiring repair, or those with associated tibial fractures.
- post traumatic OA
Iliotibial band syndrome (inlfammation of the aponeurosis)
Most common cause of lateral knee pain in athletes caused by impingement of the band against the lateral femoral condyle
- Clinical features
- Special tests
- DD
- Management
- Lateral knee pain exacerbated by exercise
- image
- degenerative joint disease, fractures, and ligamentous injury
4.
- modify their activity
- analgesics during periods of acute pain
- Longer-term management:
Local steroid injections
Physiotherapy
- Surgical Management (symptomatic or functionally limited after 6 months)
Release of the iliotibial band from its attachments from the patella, allowing for a greater ROM. This can be done either percutaneously or via an open approach.
Olecranon fractures
- Pathophysiology, draw the elbow joint
- Clinical history
- Ix
- Management
- Intra-articular fracture
FOOSH (sudden pull of the triceps and brachialis)
In younger patients usually direct trauma
- tenderness palpating the olecranon
disruption to the triceps mechanism means often there is an inability to extend the elbow against gravity
Mayo classification and the Schatzker classification
- Bloods: clotting, G&S
Plain AP & L xray
- A-E
analgesia
Management decided by degree of displacement:
- Non-op management (displacement <2mm), with immobilisation in 60-90 degrees elbow flexion and early introduction of range of motion at 1-2 weeks
There is increasing use of non-operative management for all patients over 75, irrespective of displacement, as whilst the degree of extension may be lost, the functional outcome is often appropriate
- Operative management (displacement >2mm), requiring (depending on fracture configuration) techniques such as tension band wiring (if fracture proximal to the coranoid process) or olecranon plating (if at level of, or distal to, the coranoid process) may be used
There is a very high rate of removal of metalwork, as due to the very superficial nature of the injury, it often impacts the patient significantly
Radial head fracture (most common fracture of the elbow, 20-60yo)
- Pathophysiology
- Clinical features
- Ix
- How are radial head fractures classified?
- Management
6.
- ~ indirect trauma; with axial loading of the forearm causing the radial head to be pushed against the capitulum of the humerus. This most commonly occurs with the arm in extension and pronation.
- Hx of FOOSH
o/e: may be tenderness on palpation over the lateral aspect of elbow and radial head, with pain and crepitation on supination and pronation. Elbow effusion or limited supination and pronation movements.
*An Essex-Lopresti fracture describes a fracture of the radial head with disruption of the distal radio-ulnar joint, and will always require surgical intervention.
- Clotting screen and G&S
Plain AP & Lateral Xrays
Elbow effusions on a lateral projection is termed a “Sail sign”, shown as an elevation of the anterior fat pad, in keeping with an occult fracture.
CT imaging
- Masons classification
- A-E, analgesia, check for neurovascular comprimise
- Mason type 1 injuries – non-op, short period of immobilization with sling (<1 week) followed by early mobilisation
Mason Type 2 injuries – no mechanical block -> treated as per a T1 injury, mechanical block -> surgery (typically an open reduction internal fixation (ORIF))
Mason Type 3 injuries – surgical intervention, either via ORIF or radial head excision or replacement (especially in highly comminuted fractures)
What is ORIF- this is a 2-part surgery:
- Broken bone is reduced/ back into place.
- Internal fixation device is placed on the bone -> screws, plates, rods, or pins that are used to hold the broken bone together.
Lateral epicondylitis
- What is it?
- Clinical features
- DD
- Ix
- Management
- Complications/prognosis
- What is medial epicondylitis
- Chronic inflammation
35-54
repetitive injury -> microtears in the tendon -> granulation tissue formation
Lateral epicondylitis -> tennis elbow
Medial epicondylitis -> golfers elbow
the common extensor tendon attached to the lateral epicondyle (superficial extensors of the forearm)
- Pain extending down the forearm (worsens over wks to mnths)
o/e: tenderness over the lateral epicondyle on palpation
due to pain reduced grip strength but still full ROM
- Cervical radiculopathy – often associated with neck pain and stiffness, as well as a sensorimotor deficit in the affected dermatome/myotome
Elbow OA – joint stiffness, worse towards the end of the day, associated with reduced ROM and end-range pain
Radial carpal tunnel syndrome – maximal tenderness is localised to area distal to radial head (rather than the lateral epicondyle), with pain on thumb and index finger extension
- US & MRI
5.
- Modify activities
- analgesics + topical NSAIDs
- corticosteroid injections every 3-6months
- PT + orthoses (wrist or elbow brace)
Surgical Treatment -> refer to orthopaedics
Open or arthroscopic debridement of tendinosis and release or repair of any damaged tendon insertions
> 50% damage tendon transfer
- Lateral epicondylitis is self-limiting and spontaneously improves in 80-90% of people in 1-2 years.
- damage to the tendons that attach to the medial epicondyle
pronator teres
flexor carpi radialis
o/e: tenderness over the tendons
treatment the same as above
Shoulder dislocation
- Types
- Clinical features
- Ix
- How can you tell the difference between an anterior and posterior dislocation on a plain xray
- Management
- Prognosis
- Complications
- anteroinferior (95%) -> direct impaction or FOOSH extended, abducted, externally rotated (Think trying to hold ur childs hand)
posterior -> seizures, electrocution
inferior -> hyper abduction of the arm
- Painful, acute loss of ROM, feeling of instability, assymetry of the shoulders,
loss of contour -> deltoid flattened
but buldge of the head of the humerus may be seen
assess axillary and suprascapular nerves
Associated injuries:
Bony:
- Bony Bankart lesions are fractures of the anterior inferior glenoid bone, ~ present in those with recurrent dislocations
- Hill-Sachs defects are impaction injuries to the chondral surface of the posterior and superior portions of the humeral head, present in approximately 80% of traumatic dislocations
- Fractures of the greater tuberosity and the surgical neck of humerus can also occur
Labral, ligamentous, and rotator cuff:
- (Soft) Bankart lesions are avulsions of the anterior labrum and inferior glenohumeral ligament
- Glenohumeral ligament avulsion
- Rotator cuff injuries occur frequently in anterior dislocations; in younger patients, around a third have at least one tear
- Trauma series -> Xrays of anteriorposterior, Y-scapular & axial views
- Posterior -> light bulb sign symmetrical
- A-E, analgesia, neurovascular status
reduction, immobalisation and rehabilitation
shoulder dislocations -> closed reduction using the hippocratic method -> broad arm sling
~ 2wks for immobilisation for anterior dislocation
PT
Future surgical treatment may be warranted for recurrent pain, instability, large Hill-Sachs defects, or large (bony) Bankart lesions.
Future surgical treatment may be warranted for recurrent pain, instability, large Hill-Sachs defects, or large (bony) Bankart lesions.
- chronic pain, limited mobility, stiffness, and recurrence
adhesive capsulitis, nerve damage, and rotator cuff injury
Adhesive capsulitis/ frozen shoulder (glenohumeral joint capsule becomes more contracted on the humeral head)
- W>M
40-70yo
- Pathophysiology
- Clinical featureas
- Differential Diagnosis
- Ix
- Management
- 40-60, No trauma Hx, F>M
2.
- Primary adhesive capsulitis (idiopathic)
- Secondary adhesive capsulitis
Commonly associated with rotator cuff tendinopathy, subacromial impingement syndrome, biceps tendinopathy, previous surgical intervention or trauma, inflammatory conditions, and diabetes mellitus
- Adhesive capsulitis progresses in three stages:
freezing, frozen, thawing
3.
Generalised deep and constant pain of the shoulder (which may radiate to the bicep), that often disturbs sleep.
Associated symptoms include stiffness and a reduction in function.
O/e: may be loss of arm swing, atrophy of the deltoid muscle.
Limited ROM, principally affecting external rotation and flexion of the shoulder (a full ROM should prompt consideration of alternative DD).
4.
- Acromioclavicular pathology (e.g. acriomioclavicular joint injury, acromioclavicular arthritis, glenohumeral arthritis) – a more generalised pain may be present with weakness and stiffness related to pain
- Subacromial impingement syndrome (rotator cuff tendinopathy, subacromial bursitis) – may present with preserved passive movement and history of repetitive overuse/ external compression of subacromial space risk factors
- Muscular tear (rotator cuff tear, long head of biceps tear) – the weakness often persists when the shoulder pain is relieved
- Autoimmune disease (PMR, RA, SLE) – may present with a polyarthropathy and systematic symptoms
- Xrays
MRI (thickening of the glenohumeral joint capsule, rule out subacromial impingement syndrome)
HbA1c
- Dull ache, end ROM sharp pain
External rotation first movement that goes (in OA and frozen shoulder)
3 Stages:
Freezing: PAIN is high ~3months
Frozen: pain still present now STIFFNESS 3-9months
Thawing: both pain and stiffness start to reduce 8-19months
6.
Analgesia: glenohumeral analgesia (freezing pain)
PT (frozen +/- analgesia)
Thawing no treatment
More likely in: diabetics, Hx or trauma, hypothyroidism, cholesterol of cardiovascular problems
Can start doing exercises at home: 3 sets of 10, 3 times a day, for three months
If no imporvemnet then manipulation under anaesthertic, or capsular release - to remove capsular adhesions to the humerus, arthrogaphic distension or surgical release of the glenohumeral joint capsule.
Tibia and fibula fractures
- Most common fracture site?
- Pathophysiology: The tibia is prone to trauma due to its…
- Ix
- Management
- tibial shaft
- Superficial position in the leg (open fractures are common)
The mechanism of injury dictates the type of fracture with a relatively high degree of predictability:
- Low-energy fractures are invariable twisting, inversion or eversion injuries, and often occur following a fall from standing height
- High-energy fractures are caused typically by a direct blow to the tibia and fibula, resulting in fracture comminution and soiling of the wound
- A plain radiograph should be obtained in all suspected cases, ensuring the entire tibia and fibula with the knee and ankle joints are included.
In tibial plateau fractures and Pilon fractures, a CT scan is typically required to aid in operative planning.
4.
- fracture reduction (typically performed under sedation)
- back-slab initially
above-knee: tibial plateau and diaphyseal fractures
below-knee: Pilon and ankle fractures
- repeat plain film radiograph.
- If the reduction is not adequate, repeat reduction
- check nuerovasculature
- Any signs of compartment syndrome should be recognised and managed early. In many centres, a compartment monitor is inserted for all high-energy injuries and diaphyseal fractures (irrespective of the energy involved).
Definitive management thereafter is to achieve skeletal stability. Almost all of these injuries require surgical fixation, specifically:
- Tibial plateau will nearly all require fixation (Schatzker 1 injuries in elderly patients with low functional demand may be treated conservatively)
- Tibial diaphysis and Pilon fractures (unless undisplaced) will all require fixation
- Ankle fractures will predominantly require surgical fixation, however if deemed intrinsically stable may be treated conservatively
Achilles tendonitis
- What is it?
- RF
- Clinical features
- DD
- Management
- Inflammation of the calcaneal tendon, more prevelent in high intensity activities -> achiles tendon rupture
- Unfit individual who has a sudden increase in exercise frequency, poor footwear choice, male, obesity, or recent fluoroquinolone use (for tendon rupture).
3.
- Gradual onset of pain and stiffness
- Worse with movement (~ improved with mild exercise or heat application)
- O/e: tenderness over the tendon on palpation (usually worse 2-6cm above its insertion site), with pressure over the tendon with your fingers reproducing this pain.
Tendon rupture:
- sudden-onset severe pain in the posterior calf,
- audible popping sound and a feeling that something ‘went’
- O/e: marked loss of power of ankle plantarflexion (the peroneal tendons contribute to plantarflexion so this movement remains, but significantly weakened).
- Indicators of a clinical tendon rupture are Simmonds test(below) and a palpable ‘step’ in the Achilles tendon.
- Achilles tendonitis is ankle sprain, stress fractures (tibial or calcaneal), or osteoarthritis. For tendon rupture, the main differential diagnoses are an ankle fracture or ankle sprain.
- Tendonitis
- Acute -> Supportive measures: stop precipitating exercise, ice the area, and use anti-inflammatory medication regularly
- Chronic -> rehabilitation and PT; slow controlled movement against resistance
Rupture
<2 wks:
- Analgesia, immobilisation, with the ankle splinted in a plaster in full equinus*
- Provided with crutches and not allowed to weight bear.
- Position is held for 2 weeks
- Next, ‘semi-equinus’ for 4 wks
- Next, neutral position for 4 wks
Delayed presentations (>2 wks) or cases of re-rupture requires surgical fixation with an end-to-end tendon repair.
*It is worth noting that more units are now switching from plaster immobilisation to using a weight-bearing orthosis (a ‘moonboot’), with a large heel raise insert; this achieves the same position as described above (equinus), but the patient can fully weight bear immediately.
Talar fracture
- What is the mechanism of fracture?
- Clinical features
- DD
- Ix
- How do you classify talar fractures
- Management
1.
- High-energy trauma, e.g. fall from height/ RTA, ankle is forced in to dorsiflexion
- talar neck (~50%)
- high risk of AVN
- Immediate pain and swelling
If the talus is dislocated -> clear deformity -> overlying skin may be ‘threatened’ (i.e. white, non-blanching, and tethered), heralding an impending conversion to an open injury. Assessing distal neurovascular status is also vital.
O/e: unable to dorsiflex or plantarflex their ankle
check if this injury is open or closed
- ankle fractures and Pilon fractures
- AP & Lateral (dorsiflexion & plantarflexion) Xrays
differentiate between type I and II injuries (see below), as plantar flexion will reduce any subluxation present.
- Hawkins Classification (determines management and risk of AVN)
- Undisplaced -> non weight bearing orthosis
Displaced fractures -> immediate reduction & subsequent surgical repair
Type I Fractures: Plaster with non-weight bearing crutches for approx 3 months. Following this, the region should be assessed for evidence of union and AVN in fracture clinic.
Type II to IV Fractures: attempted closed reduction in the ED. Then, a cast should be placed and repeat radiographs obtained to ensure it remains in position. If reduction is not possible, open reduction out-of-hours is needed.
Definitive surgical fixation is required on the next available list with the correct expertise, with referral onward to a tertiary centre if needed. Post-operatively, patients will require an extended period of non-weight bearing.
Hallux valgus
- What is it
- Pathophysiology
- RF
- Clinical features
- DD
- Ix
- Management
- complications
- Deformity at the MTPJ
Medial deviation of the first metatarsal
Lateral deviation +/- rotation of the hallux, with associated joint subluxation.
~>65
~W
- First metatarsal inherently unstable relies on intrinsic static stabilisers (bones and ligaments) and dynamic stabilisers (muscles and tendons)
Extrinsic tendons become a deforming force -> drift medially
- F, CT disorders, hypermobility syndrome
- painful medial prominence
o/e: assess position and lateral deviation
assess ROM and crepitus
- Gout, Septic arthritis, Hallux rigidus, OA, RA
- Xray: 15 degrees (mild 15-20°, moderate 21–39°, and severe >40°)
7.
- Analgesia
- Adequate footwear
- Orthosis
- PT
Surgical
- Chevron procedure – a ‘V shaped’ osteotomy of the distal first metatarsal, allowing the first metatarsal to be shifted laterally back into a normal alignment, then fixed by pins and screws -> Commonly used for mild deformities image
- Scarf procedure – a longitudinal osteotomy is made within the shaft of the first metatarsal, for the distal portion to be moved laterally and fixed with two screws -> Useful for when the deformity is moderate to severe
- Lapidus procedure – the base of the first metatarsal and medial cuneiform are fused -> Often used when the underlying cause is tarsometatarsal joint hypermobility
- Keller procedure – incision is made over the first MTPJ and the joint capsule is opened to expose the joint, with the diseased joint surfaces removed for a space to be left that is stabilised by suturing of surrounding tissues and subsequent scar tissue -> commonly chosen when the first MTPJ arthritis is severe
complications for all: wound infection, delayed healing, nerve injury, and osteomyelitis. Recurrence is not uncommon.
- avascular necrosis, non-union, displacement and reduced ROM.
THR vs hemiarthroplasty
A total hip replacement (total hip arthroplasty or THA) consists of replacing both the acetabulum and the femoral head
hemiarthroplasty generally only replaces the femoral head
DE QUERVAIN’S TENOSYNOVITIS
- E
- What are the extensor compartments of the wrist
- CF
- DD
- Rx
- W>M, 30-50, pregnancy
- image
- pain near the base of the thumb
Finkelstein’s test
- Arthritis of Carpometacarpal (CMC) joint
Intersection syndrome
Wartenberg’s syndrome
- Conservative:
lifestyle advice (avoiding repetitive actions)
wrist splint
Steroid injections
Surgery:
surgical decompression of the extensor compartment (local or general anaesthetic) This involves a transverse or longitudinal incision made and the tendon sheath split in the central aspect in a longitudinal direction, thus allowing the tunnel roof to form again as it heals but wider and with more space for the tendons to move.
Complications: failure to resolve, reduce ROM in wrist or hand, neuroma formation, and nerve impingement
what is this procedure?
scarf
What is this procedure
Keller - severe
How does bone heal after a fracture?
proximal olecranon fracture Rx surgically?
In this tension band wiring one K-wire extends radially outwards and erodes the neck
Distal olecranon fracture Rx surgically?
olecranon plate
describe salter harris classification
