Orthopaedics II Flashcards
Which cancers that met to bone are sclerotic / lytic? [5]
PB KTL
Sclerotic —-> Lytic
NB: ProState = Sclerotic; Lung = Lytic
Describe what is meant by De Quervain’s tenosynovitis [1]
Which tendons does it most commonly affect? [2]
De Quervain’s tenosynovitis is a condition where there is swelling and inflammation of the tendon sheaths in the wrist. It is a type of repetitive strain injury
It primarily affects two tendons:
Abductor pollicis longus (APL) tendon
Extensor pollicis brevis (EPB) tendon
Describe the presentation of DQT [3]
Pain at the base of the thumb, which can extend to the forearm
Pain exacerbation during thumb abduction, gripping, or ulnar movement of the wrist
Tenderness of the anatomical snuffbox
Mangement for DQT? [3]
Non-operative:
First line:
- NSAIDS, rest and immobilisation with a splint
Second line:
- steroid injection
Operative:
- surgical release of 1st dorsal compartment (radial based incision proximal to the wrist)
Describe the pathophysiology of trigger finger [2]
Normal physiology:
- Flexor tendons of fingers pass through sheaths along the length of the fingers
Trigger finger:
- Get thickening of tendon or tightening of the sheath
- Means when flexed / extended it causes pain, stiffness or catching
- This spefically happens at the first annular pulley (A1) at the metacarpophalangeal (MCP) joint.
Clinical presentation of trigger finger? [3]
Presentation:
- Is painful and tender (usually around the MCP joint on the palm-side of the hand)
- swelling around MCP joint
* Does not move smoothly
* Makes a popping or clicking sound - hallmark feature
* Gets stuck in a flexed position
Non-operative [2] and operative treatment of trigger finger? [1]
Non-operative:
First line:
- splinting, activity modification, NSAIDs
Second line:
- Steroid injections
Operative:
- Surgery to release the A1 pulley - either percutaneous release or open release
Define Dupuytren’s contracture [1]
Describe the pathophysiology [2]
Dupuytren’s contracture is a condition where the fascia of the hand becomes thickened and tight, leading to finger contractures.
Pathophysiology:
* The palmar fascia of the hand forms a triangle of strong connective tissue on the palm.
- the fascia of the hands becomes thicker and tighter and develops nodules as a result of excessive collagen deposition
- Cords of dense connective tissue can extend into the fingers, pulling the fingers into flexion and restricting their ability to extend (contracture).
Describe the presentation of Dupuytren’s contracture [3]
- First sign: hard nodules on the palm.
- Skin thickening and pitting
- Finger pulled into flexion
- Most commonly the ring finger affected
Describe a test used to assess for DC [1]
Table-top test:
- The patient tries to position their hands flat on a table. If the hand cannot rest completely flat, the test is positive,
The median nerve supplies the motor function to the three thenar muscles. These muscles make up the muscular bulge at the base of the thumb that is responsible for thumb movements.
Which muscles are these? [3]
Which movements do they cause? [3]
Abductor pollicis brevis (thumb abduction)
Opponens pollicis (thumb opposition – reaching across the palm to touch the tips of the fingers)
Flexor pollicis brevis (thumb flexion)
NB: The other muscle that controls thumb movement is the adductor pollicis (thumb adduction). However, this is innervated by the ulnar nerve. Whether this is classed as one of the thenar muscles depends on where you look.
Describe the three tests can use to investigate carpal tunnel syndrome [3]
Tinel’s sign:
- Tapping over the volar aspect of the wrist at the carpal tunnel may elicit a tingling sensation or pain radiating into the median nerve distribution.
Phalen’s test
- Holding the wrists in full flexion for 60 seconds may reproduce or exacerbate symptoms in the median nerve distribution.
Durkan’s test (compression test):
- Applying direct pressure over the carpal tunnel for 30-60 seconds may provoke symptoms in the affected hand.
TOM TIP: I think of tapping a tin can (Tinel’s) to remember the difference between Phalen’s and Tinel’s test.
What are the primary investigation for establishing the diagnosis of carpal tunnel syndrome? [1]
Nerve conduction studies (EMG) are the primary investigation for establishing the diagnosis:
- A small electrical current is applied by an electrode (nerve stimulator) to the median nerve on one side of the carpal tunnel
- Recording electrodes over the median nerve on the other side of the carpal tunnel record the electrical current that reaches them.
Why do you need to check T4 in carpal tunnel syndrome? [1]
Can be caused by hypothyroidism
Management of carpal tunnel syndrome? [3]
Non-operative:
- NSAIDS, night splints, activity modifications
- Steroid injections
Operative:
- Carpal tunnel release - the flexor retinaculum (AKA transverse carpal ligament) is cut to release the pressure on the median nerve via open or endoscopic surgery
Firm and well-circumscribed mass that transilluminates on the dorsal aspect of the wrist → []
Firm and well-circumscribed mass that transilluminates on the dorsal aspect of the wrist → ganglion
NB: While fibromas are usually well-defined and firm, they do not transilluminate
*
What are the four rotator cuff muscles? [4]
What movements do they cause? [4]
S – Supraspinatus – abducts the arm (first 20/30 degrees)
I– Infraspinatus – externally rotates the arm
T – Teres minor – externally rotates the arm
S – Subscapularis – internally rotates the arm
Describe the difference between intrinsic tendon degeneration versus impingement syndrome in rotator cuff injuries
Intrinsic tendon degeneration
* Tendon hypo-perfusion of a watershed area
* Repetitive micro-trauma
Impingement syndrome can be classified as external, internal or secondary:
External
* Compression of rotator cuff tendons as they pass underneath the coracoacromial arch
* Narrowing of this space can occur due to osteophyte formation, bony spurs or malunion after fractures
Internal
* Associated with overhead and throwing sports activities causing small repetitive injuries
* Under surface fraying of infraspinatus tendon on the posterior glenoid
* Increased association with labral disorders
Secondary
* Glenohumeral instability leads to slight humeral head subluxation
* This narrows the acromiohumeral interval
The combination of extrinsic compression and intrinsic degeneration contributes to the spectrum of clinical findings associated with SIS (shoulder impingement syndrome)
As SIS represents a spectrum of pathology associated with damage to the rotator cuff tendons, it can progress with time. The progression of this spectrum can be thought of in 3 stages. Describe them [3]
Stage 1: haemorrhage and oedema surrounding the cuff tendons.
Stage 2: rotator cuff tendinopathy: fibrosis and inflammation of the tendons.
Stage 3: rotator cuff tears (varying degrees of severity). May have corresponding arthritic changes, or a coexistent long head of biceps tear.
In those with suspected SAIS, two common examination signs can be elicited
What are they? [2]
Neer’s impingement test
* Anterolateral shoulder pain reported during forward flexion with arm internally rotated
Hawkin’s test
Forced internal rotation of an arm held at shoulder height and elbow bent at 90º causes anterolateral shoulder pain
In those with suspected rotator cuff tendon tears, three common examination signs can be elicited
What are they? [3]
‘Empty can test’
* Evaluates supraspinatus
* Patient’s raise their arm to 90º in the scapular plane
* The arm is internally rotated (thumbs down)
* Downward pressure is applied to their arm
* Presence of weakness or pain indicates a tear
Posterior cuff test
* Evaluates infraspinatus
* Weakness or pain on resisted external rotation suggests a tear
Gerber’s lift-off test
* Evaluates subscapularis
* Patient attempts to lift a hand from small of the back, while resistance is applied
* Weakness or pain suggests a subscapularis tear
Describe the managment plan for rotator cuff injuries
Non-operative:
* Rest in the acute phase
* Offer paracetamol as 1st line analgesia. If no benefit consider oral NSAID
* Referral for a course (usually 6 weeks) of physiotherapy
* Consider subacromial corticosteroid injection
Operative:
Acromioplasty:
- Aims to increase the volume of the subacromial space, preventing mechanical irritation of the rotator cuff tendons
Rotator cuff repair:
- Aims to reattach the cuff tendons to the bone
Describe the pathophysiology of frozen shoulder [1]
The glenohumeral joint is the ball and socket joint in the shoulder. The glenohumeral joint is surrounded by connective tissue that forms the joint capsule.
In adhesive capsulitis, inflammation and fibrosis in the joint capsule lead to adhesions (scar tissue). The adhesions bind the capsule and cause it to tighten around the joint, restrict movement in the joint.
Get three stages (probs dont need to know)
1. Freezing Phase: synovitis leads to increased vascular permeability, resulting in capsular oedema, pain, and reduced range of motion (ROM). Progressive fibrosis and angiogenesis and nerve growth occur
2. Frozen Phase: Characterised by the progressive loss of glenohumeral movements due to a stiffened capsule.
3. Thawing Phase: This phase involves the gradual resolution of symptoms
Describe the clinical presentation of adhesive capsulitis [4]
Course of symptoms:
Painful phase
– shoulder pain is often the first symptom and often worse at night
Stiff phase
– shoulder stiffness develops and affects both active and passive movement (external rotation is the most affected) – the pain settles during this phase
Thawing phase
– there is a gradual improvement in stiffness and a return to normal
Symptoms
* external rotation is affected more than internal rotation or abduction
* both active and passive movement are affected
* the episode typically lasts between 6 months and 2 years
The main differentials in a patient presenting with shoulder pain not preceded by trauma or an acute injury are [3]
Shoulder pain preceded by trauma or an acute injury may be due to [3]
Pain with no trauma:
* Supraspinatus tendinopathy
* Acromioclavicular joint arthritis
* Glenohumeral joint arthritis
Pain preceded by trauma:
* Shoulder dislocation
* Fractures (e.g., proximal humerus, clavicle or rarely the scapula)
* Rotator cuff tear
Acromioclavicular (AC) joint arthritis can be demonstrated on examination by which positive test? [1]
Positive scarf test – pain caused by wrapping the arm across the chest and opposite shoulder
Tenderness to palpation of the AC joint
Investigations for frozen shoulder? [3]
Clinical diagnosis based on the patient’s history and physical examination
First-Line Investigations
- Xray - rule out other pathologies like OA
Further Investigations
- MRI
- US
- Contrast-enhanced MRI Arthrography
Describe the managment for frozen shoulder?
- Physiotherapy
- Analgesics
- Intra-articular corticosteroid injections
-
Surgical intervention:
- MUA (Manipulation under Anaesthesia): This procedure involves forcibly moving the shoulder joint under general anaesthesia.
- Capsular release surgery: This is a more invasive procedure where the tight portions of the joint capsule are cut to allow for greater movement.
Which nerves invervates the rotator cuff muscles and what are their nerve roots? [4]
Supraspinatous muscle:
- Suprascapular nerve
- C5-C6
Teres minor:
- axillary nerve
- C5-C6
Infraspinatous muscle:
- Suprascapular nerve
- C5-C6
Subscapularis muscle:
- Subscapularis nerve
- C5-7
Describe shoulder anatomy that prediposes impingement syndrome [3]
Impingement syndrome is caused by rotator cuff tendonitis as the tendons pass beneath the acromion. The supraspinatus muscle’s tendon is most commonly affected.
Patients with impingement syndrome often complain of pain when their arms are raised (this is particularly common in mechanics and manual labourers who work with their arms overhead).
When the arm is raised, the subacromial space narrows, which can result in impingement of the supraspinatus muscle tendon leading to an inflammatory response.
Typical findings on clinical examination in supraspinatus impingement syndrome include: [2]
- Pain experienced between 60-120° of shoulder abduction (known as a ‘painful arc’).
- Weakness and pain experienced when the supraspinatus muscle is isolated using the ‘Empty can/Jobe’s test
What is a way of remembering different radial / ulnar fracture names? [2]
GRUsome MURder
- Name of fracture, bone fractured, bone dislocated
- Galaezzi; Radial fracture; Ulnar dislocated
- Monteggia; Ulnar fracture; Radial dislocation
What is the difference in treatment plan for displaced and undisplaced Boxer’s fractures? [2]
Undisplaced, non-communicated:
- Ulnar gutter splint
Displaced:
- closed reduction, then plaster cast
