Orthopaedics Part 3 Flashcards
What is Leriche syndrome?
- atheromatous disease involving iliac vessels
- blood flow to pelvic viscera compromised
- buttock claudication and impotence
Diagnosis Leriche syndrome:
- angiography
- iliac occlusions usually treated with endovascular angioplasty and stent insertion
Red flags for lower back pain:
- <20yo or >50yo
- history previous malignancy
- night pain
- history trauma
- systemic symptoms
Spinal stenosis onset, symptoms, examination and diagnosis:
- gradual
- unilateral or bilateral leg pain (with or without back pain)
- numbness, weakness worse on walking and resolves when sitting
- relieved by sitting, leaning forwards and crouching
- examination normal
- MRI diagnosis
Presentation of ankylosing spondylitis:
- young man with LBP and stiffness
- worse in morning and improves with activity
- peripheral arthritis
Peripheral arterial disease lower back pain presentation:
- pain on walking, relieved by rest
- absent or weak foot pulses
- limb ischaemia
- past history: smoking and other vascular disease
Back pain management:
- NSAIDs
- co-prescribe PPI for >45yo
- exercise and manual therapy
- epidural injections of local anaesthetic and steroid for acute and severe sciatica
Investigation lower back pain:
- lumbar spine x-ray
- MRI if non-specific back pain and malignancy, infection, fracture, cauda equina or ankylosing spondylitis suspected
- no other imaging can see neurological/soft tissue structures
L3 nerve root compression features:
- sensory loss anterior thigh
- weak quadriceps
- reduced knee reflex
- positive femoral stretch test
L4 nerve root compression features:
- sensory loss anterior knee
- weak quadriceps
- reduced knee reflex
- positive femoral stretch test
L5 nerve root compression features:
- sensory loss dorsal of foot
- weakness in foot and big toe dorsiflexion
- reflexes intact
- positive sciatic nerve stretch test
S1 nerve root compression features:
- sensory loss posterolateral leg and lateral foot
- weakness plantar flexion of foot
- reduced ankle reflex
- positive sciatic nerve stretch test
Management prolapsed disc:
- analgesia, physio, exercises
- if symptoms persists, referral for consideration MRI
Motor and sensory supply of femoral nerve:
motor: knee extension, thigh flexion
sensory: anterior and medial aspect of thigh and lower leg
Typical mechanism of injury femoral nerve:
- hip and pelvic fractures
- stab/gunshot wounds
Motor and sensory supply of obturator nerve:
motor: thigh adduction
sensory: medial thigh
Typical mechanism of injury of obturator nerve:
anterior hip dislocation
Motor and sensory supply of lateral cutaneous nerve of thigh:
no motor
sensory: lateral and posterior surfaces of thigh
Typical mechanism of injury of lateral cutaneous nerve of thigh:
compression of nerve near the ASIS - meralgia paraesthetica, condition characterised by pain, tingling and numbness in distribution of lateral cutaneous nerve
Motor and sensory supply tibial nerve:
motor: foot plantar flexion and inversion
sensory: sole of foot
Typical mechanism of injury of tibial nerve:
not commonly injured as deep
popliteal lacerations, posterior knee dislocation
Motor and sensory supply common peroneal nerve:
motor: foot dorsiflexion and eversion, extensors hallucinate longus
sensory: dorsal of foot and lower lateral part of leg
Typical mechanism of injury common peroneal nerve:
- injury at neck of fibula
- tightly applied lower limb plaster cast
- foot drop
Motor and sensory supply superior gluteal nerve:
motor: hip abduction
sensory: none
Typical mechanism injury superior gluteal nerve:
- misplaced IM injection
- hip surgery
- pelvic fracture
- posterior hip dislocation
- positive Trendelenburg sign
Motor and sensory supply inferior gluteal nerve:
motor: hip extension and lateral roatation
sensory: none
Typical mechanism of injury inferior gluteal nerve:
- association with sciatic injury
- difficulty rising from seated position
- can’t jump, can’t climb stairs
Muscles of anterior compartment and innervation:
-tibialis anterior
-extensor digitorum longus
-peroneus tertius
-extensor hallucis longus
all supplied by deep peroneal nerve
Action of tibias anterior:
- dorsiflexion ankle
- inversion
Action of extensor digitorum longus:
- extends lateral four toes
- dorsiflexes ankle joint
Action of peroneus tertius:
- dorsiflexes ankle
- eversion
Action of extensor hallucinate longus:
- dorsiflexion ankle
- extends big toe
Muscles of peroneal compartment and innervation:
-peroneus longus
-peroneus brevis
supplied by superficial peroneal nerve
Action of peroneus longus:
- eversion
- assists in plantar flexion
Action of peroneus brevis:
plantar flexion ankle
Muscles of superficial posterior compartment and innervation:
-gastrocnemius
-soleus
innervated by tibial nerve
Action of gastrocnemius:
plantar flexion foot (may also flex knee)
Action of soleus:
plantar flexor
Muscles of deer posterior compartment and innervation:
-flexor digitorum longus
-flexor hallucis longus
-tibialis posterior
tibial nerve
Action of flexor digitorum longus:
flexes lateral four toes
Action of flexor hallucis longus:
flexes great toe
Action of tibialis posterior:
- plantar flexor
- inversion
Presentation lumbar spinal stenosis:
- back pain
- neuropathic pain
- symptoms mimicking claudication
- sitting better than standing and may find it easier to walk uphill rather than downhill
Most common underlying cause of lumbar spinal stenosis:
- degenerative disease
- begins in intervertebral disc where cell death and loss of proteoglycan and water content leads to progressive disc bulging and collapse
- increased stress transfer to posterior face joints - cartilaginous degeneration, hypertrophy, osteophyte formation
- thickening and distortion of ligaments flavum
Diagnosis and treatment lumbar spinal stenosis:
- MRI scanning
- laminectomy
What is meralgia paraesthetica:
- entrapment mononeuropathy of lateral femoral cutaneous nerve
- can also be iatrogenic post surgery or neuroma
What nerve is affected in meralgia paraesthetica and how?
- lateral femoral cutaneous nerve
- originates from L2/3
- runs beneath iliac fascia as it crosses surface of iliac muscle and exits through or under lateral inguinal ligament
- as it passes inferiorly to anterior superior iliac since, repetitive trauma or pressure
Risk factors meralgia paraesthetica:
- obesity
- pregnancy
- tense ascites
- trauma
- iatrogenic
- sports
- idiopathic
Symptoms meralgia paraesthetica:
- burning, tingling, coldness, shooting pain
- numbness
- deep muscle ache
- aggravated by standing and relieved by sitting
- can be mild and resolve spontaneously
Signs of meralgia paraesthetica:
- may be reproduced by deep palpation below ASIS and extension of hip
- altered sensation upper lateral thigh
- no motor weakness
Investigations meralgia paraesthetica:
- pelvic compression test highly sensitive
- injection with local aesthetic abolishes pain
- US
- nerve conduction studies
Which metatarsal is most and least commonly fractured?
- 5th most common
- 1st least common
5th metatarsal fractures:
- proximal avulsion fractures (Pseudo-Jones) - proximal tuberosity, associated with lateral ankle sprain often follow inversion injuries of anlke
- Jones fractures - less common, transverse fracture at metaphysical-diaphyseal junction
Metatarsal stress fractures:
- healthy athletes
- most common site of metatarsal stress fractures is 2nd metatarsal shaft
Features and investigations of metatarsal fractures:
- pain and bony tenderness, swelling, antalgic gait
- x-rays to distinguish between displaced and non-displaced fractures (periosteal reaction seen 2-3weeks later)
- isotope scan or MRI
What is Morton’s neuroma?
- benign neuroma affecting inter metatarsal plantar nerve
- most commonly 3rd metatarsophalangeal space
- more common female
Features Morton’s neuroma:
- forefoot pain
- worse on walking
- Mulder’s click
- loss of sensation distally in toes
Diagnosis and management of Morton’s neuroma:
- clinical diagnosis but US helpful
- metatarsal pad
- referral if persistent for >3 months
- corticosteroid injection and neurectomy of involved interdigital nerve and neuroma
What is Froment’s sign?
- asses for ulnar nerve palsy
- adductor pollicis muscle function
- hold piece of paper between thumb and index finger - object then pulled away
- if palsy, unable to hold paper and will flex flexor pollicis longus to compensate
What is Phalen’s test?
- assess carpal tunnel syndrome
- more sensitive than Tinel’s
- hold wrist in maximum flexion and test positive if numbness in median nerve distribution
What is Tinel’s sign?
- assess for carpal tunnel syndrome
- tap median nerve at wrist and test positive if tingling over distribution of median nerve
What is an open fracture defined as?
- disruption of bony cortex
- associated with breach in overlying skin
Features osteoarthritis of the hand:
- bilateral
- carpometacarpal joints, distal interphalangeal joints affected more than proximal interphalangeal joints
- episodic joint pain
- stiffness worse after inactivity, only few minutes in morning compared to RA
- painless nodes: Heberden’s at DIPJ and Bouchard’s at PIPJ
- squaring of thumbs - fixed adduction
X-ray findings of osteoarthritis in hands:
osteophytes and joint space narrowing
Most common location of OA:
knee
Second most common location OA:
hip
Features osteoarthritis of hip:
- chronic history groin ache relieved by rest
- red flag: rest pain, night pain, morning stiffness >2 hours
What scoring system is used for OA of hip?
Oxford hip score
Management OA of hip:
- oral analgesia
- intra articular injections
- total hip replacement definitive treatment
Complications OA of hip and reasons for total hip:
- VTE, intraoperative fracture, nerve injury
- total hip: aseptic loosening, pain, dislocation, infection
Patients who have had a hip replacement operation should receive basic advice to minimise the risk of dislocation:
- avoid flexing hip >90 degrees
- avoid low chairs
- no leg crossing
- sleep on back for 6 weeks
Complications joint replacement:
- wound and joint infection
- thromboembolism (LMWH for 4 weeks)
- dislocation
What is osteochondritis dissecans?
- pathological disease affecting subchondral bone
- most often knee
- also effects on joint cartilage, pain, oedema, free bodies and mechanical function
- affects children and adolescents with open growth plates (juvenile OCD) and adults with closed (adult OCD)
Risk factors OCD:
- trauma
- male
- genetic
Features OCD:
- knee pain and swelling, typically after exercise
- knee catching, locking and/or giving way
- feeling a painful clunk when flexing or extending knee - involvement of lateral femoral condyle
Signs OCD:
- joint effusion
- full range movement without signs of ligamentous instability
- external tibial rotation when walking
- tenderness on palpation of cartilage of medial femoral condyle when knee flexed
- Wilson’s sign
What is Wilson’s sign?
- for detecting medial condyle lesion
- with knee at 90 degrees and tibia internally rotated, gradual extension leads to pain at 30 degrees (external rotation of tibia relieves)
Investigations OCD:
- x-ray: subchondral crescent sign or loose bodies
- MRI: to evaluate cartilage, loose bodies, stage and assess stability of lesion
- CT: preoperative planning
- scintigraphy: sign of osteoblastic activity
2 types osteomyelitis:
- haematogenous
- non-haematogenous
What is haematogenous osteomyelitis?
- from bacteraemia
- monomicrobial
- most common in children
- vertebral most common from in adults
- risk factors: sickle cell, IV drugs, immunosuppression due to meds or HIV, infective endocarditis
What is non-haematogenous osteomyelitis:
- contiguous spread of infection or from direct injury
- polymicrobial
- most common in adults
- risk factors: diabetic foot ulcers/pressure sores, diabetes, peripheral arterial disease
Most common organism in osteomyelitis:
- staph aureus
- sickle cell: salmonella
Investigation and management of osteomyelitis:
- MRI
- flucloxacillin for 6 weeks
- or clindamycin
Typical presentation osteoporotic vertebral fractures:
- asymptomatic
- acute back pain
- breathing difficulties
- gastrointestinal problems due to compression of organs
- minority have history of trauma
Signs and investigation of osteoporotic vertebral fracture:
- loss of height
- kyphosis
- localised tenderness on palpation of spinous processes at fracture site
- x-ray of spine first line - wedging of vertebra due to compression (old fractures have sclerotic appearance)
How to calculate 10-year risk of osteoporotic fracture:
QFRacture tool or FRAX
