Orthopaedics + spleen, pancreas and hernias cos you're an idiot Flashcards
What may cause adhesive capsulitis?
- idiopathic (primary)
- rotator cuff tendinopathy
- impingement
- biceps tendinopathy
- previous surgery or trauma
- diabetes
- inflammatory conditions
What are the 3 stages to adhesive capsulitis?
- painful stage
- freezing stage
- thawing stage
Describe the clinical features of adhesive capsulitis
- generalised deep and constant pain of shoulder which may radiate to bicep, disturbing sleep
- then STIFFNESS and reduced function/ ROM
- loss of arm swing, deltoid atrophy, generalised tenderness
- limited active and passive ROM, especially on external rotation and flexion of the shoulder
- affects 40-70 year olds
How would adhesive capsulitis be investigated?
- clinical diagnosis
- radiograph may be used to rule out OA
- MRI can reveal thickening of glenohumeral joint and rule out impingement but isnt routinely done
How is adhesive capsulitis managed?
- recovery over months to a year on its own however it often reoccurs and full ROM may not return
- paracetamol and NSAIDS
- physio
- Steroid injections
- if no improvement at all in 3 months of conservative management they can be considered for manipulation under anaesthetic
What shoulder problems most commonly affect 10-30 year olds?
- instability
Need to define if they have traumatic dislocations or if dislocations are atraumatic which may suggests hypermobility or capsule laxity
What shoulder problems most commonly affect 40-year olds?
- impingement
- frozen shoulder
- inflammatory arthropathy
What shoulder problems most commonly affect 60-80year olds?
- degenerative cuff tear
- osteoarthritis
- cuff arthropathy
Describe the allman classification of clavicle fractures?
- type 1: middle 1/3 of clavicle (75%)
- type 2: lateral 1/3 (20%)
- type 3: medial 1/3 (5%)
How are clavicle fractures managed?
- almost all are treated conservatively unless open fracture, failed unity or bilateral, as even when theyre very displaced the fragments unite well
- sling to support shoulder until they get pain free movement, should recover within 4-6 weeks
- encourage early mobilisation to prevent frozen shoulder
How are cuff tears classified?
- acute: <3 months, usually after trauma
- chronic >3 months: usually from degenerative microtears in older ppl
- partial or full thickness
- full thickeness can be small (<1cm), medium (1-3cm), large (3-5cm) or massive (>5cm or multiple tendons)
What action do each of the 4 rotator cuff muscles perform?
- teres minor and infraspinatus = external rotation
- supraspinatus= first 15 degree abduction
- subscapularis= internal rotation
Describe the clinical features of rotator cuff injuries?
- pain and weakness in the shoulder
- often hx trauma
- normal passive movement, often reduced active movement
- positive jobes, gerbers lift off or posterior cuff test
How are rotator cuff tears managed?
- conservative if presents within 2 weeks, small tear, not limited function or significant co- morbidities rule out surgery
- conservative management is physio, analgesia, steroid injections
- some medium, large and massive tears and persisting symptoms will be referred for arthroscopic or open (large complex tears) repairs and physio after- good outcomes
Describe 2 intrinsic mechanisms leading to subacromial impingement
Pathologies of rotator cuff tendons due to tension, this may be due to:
- muscular weakness leading to humerus shifting proximally towards body
- overuse of shoulder leading to microtrama and soft tissue inflammation
- degenerative tendinopathy
Describe 2 extrinsic mechanisms leading to impingement
Compression of rotator cuff tendons due to external compression:
- Congenital or aquired anatomical variations in shape and gradient of acromion
- reduction in function of scapular muscles which normally allow humerus to move under the acromion
- glenohumeral instability
What is subacromial impingement?
Inflammation and irritation of rotator cuff tendons are they pass through the subacromial space. It encompasses a range of pathologies along with it: subacromial bursitis, calcific tendinitis, rotator cuff tendinitis
Describe the clinical features of subacromial impingement syndrome
- presents age <25 or 40-70
- anterior superior shoulder pain
- pain exacerbated by abduction and relieved by rest
- NEERS TEST +ve: internally rotate then flex arm= pain
- HAWKINS TEST +ve: shoulder and elbow flexed in scapular plain, relax arm and internally rotate = pain
- if left untreated you get degeneration and tears in rotator cuff so may present with cuff tears
How is impingement investigated?
- clinical diagnosis
- Xray may should calcific tedonitis which may be cause, or OA (differential)
- MRI sometimes used as may show subacromial osteophytes, sclerosis, bursitis, humeral cystic changes or narrowing or subacromial joint space
How is impingement treated?
- analgesia, corticosteroid injections and physio is mainstay
- if symptoms persist for 6 months w/ no improvement, surgical intervention recommended
- surgical options inc arthroscopic rotator cuff repairs, bursectomy, acriomoplasty
- mixed results with surgery
Describe the clinical features of shoulder OA
- progressive pain and loss of active and passive ROM
- age >70 usually
How is shoulder OA investigated?
- ap and lateral plain radiograph
- CT to see if glenoid is degenerated
- MRI if weakness in any movement suggesting rotator cuff tear
What are the surgical options for should OA?
- if only humerus is affected-> shoulder hemi
- if glenoid surface is affected also-> total shoulder replacement
- if rotator cuff also affected so unstable-> reverse shoulder replacement (stops shoulder moving medially)
Give 5 risk factors for carpal tunnel syndrome?
- age 45-60
- female
- pregnancy
- obesity
- diabetes
- wrist injury
- hypothyroidism
- RA
- repetitive hand or wrist movements
Describe the clinical features of carpal tunnel syndrome
- pain, numbness, paraesthesia over the volar aspect of the thumb, index finer and middle finger
- palm spared (palmer cutaneous brance arises before flexor retinaculum and goes over the top)
- symptoms worse at night, relieved by hanging wrist out of bed or shaking it
- later you get weakness of thumb abduction and thenar eminence wasting
- percussing over median nerve (tinels) or holding wrist in full flexion for 1 minute (phalens test) may illicit symptoms
How will pronator teres syndrome be different from carpal tunnel?
pronator teres syndrome is median nerve compression at level of pronator teres so the symptoms will extend to the proximal forearm and include the palm
How is carpal tunnel managed?
1st= conservative- wrist splint worn at night, prevents wrist flexion + physio and various training exercises 2nd= corticosteroid injections 3rd= surgery: in severe cases, involved cutting flexor retinaculum to release pressure on the median nerve, 90% successful
What is dequervains tenosynovitis and how does it present
inflammation of tendons in first extensor compartment (EPB, APL) of wrist, resulting in pain and swelling near the base of the thumb, grasping and pinching are particularly difficult and there may be palpable thickening of the sheath. Finklestein test usually positive.
give 3 risk factors for dupuytrens contracture
- smoking
- alcoholic liver disease
- diabetes
- vibration tools and heavy manual work
Describe the clinical features of dupurytrens contracture
- reduced ROM of fingers
- reduced skin mobilituy
- nodular deformity
- ring and little finger most commonly involved
- cannot lay palm flat on table top (heustons test)
How is dupurytrens contracture managed?
- no functional loss-> hand therapy, keep active with stretched throughout the day
- injectable collagenase clostridium histolyticum used in some in early disease
- if functional impairmenent-> surgery: excision of diseased fascia, needle fascitomy may done under local if unfit for surgery, post op recurrence is 66%
Give 2 differentials for a ganglionic cyst and how you’d differentiate
- giant cell tumour of tendon sheath: mass is solid, fixed to sheath and doesnt transilluminate
- lipoma: doesnt transilluminate, less spherical
- OA: can cause hard non cystic immobile masses
- sarcoma: not well circumscribed or mobile
How are ganglionic cysts managed?
- most disappear spontaneously
- if causes pain of limits ROM you can aspirate +/- steroid injection although high rate of infection and recurrence
- cyst excision reserved for symptomatic cases recurring after aspiration
Describe the clinical features of scaphoid fractures
- high energy trauma (usually FOOSH)
- pain in wrist
- brusing
- tenderness in scuffbox or tubercle on volar or dorsal side of hand
How should suspected scaphoid fractures be investigated?
- ‘scaphoid series of radiographs’- ap lateral and oblique
- MRI is indicated if scaphoid fracture is clinically suspected even when xrays are normal
- while waiting for MRI, manage as fracture
How should scaphoid fractures be managed? (3)
- undisplaced fractures managed by strict immobilisation in plaster with a thumb spica splint
- undisplaced fractures of proximal pole have high risk of AVN so surgical treatment considered
- all displaced fractures need operation (usually percutaneous variable pitched screws)
give 2 complications of scaphoid fractures
- AVN most common in proximal fractures
- non union is also common in undiagnosed or inappropriately managed fractures due to its poor blood supply, internal fixation and bone grafts are often needd for these pts
How are trigger fingers managed?
- splints to hold it in extension overnight
- steroid injections
- surgery: percutaneous trigger finger release via needle under local. severe cases may need surgical decompression of tendon tunnel by splitting it surgically
give 4 risk factors for hip OA?
- age >45
- woman
- genetics
- vit d deficiency
- obesity
- Hx hip trauma
- participation in high impact sports
Describe the clinical features of hip OA
- dull ache pain around hip and groin extending down the thigh to the knee
- may present with knee pain- if they have trouble putting shoes and socks on the problem is really in the hip
- relieved by rest
- joint feels stiff after periods of immbolity
- quad and glut muscle wasting
- reduced power
- leg length discrepancy
- fixed flexion deformity
- antalgic or trendelenburg gait
- crepitus and reduced active and passive ROM- external rotation tends to go first
Give 3 differentials for hip OA and state how theyll be different
- Trochanteric bursitis: pain radiates down lateral leg and point tenderness over greater trochanter
- glut medius tendinopathy: lateral pain and point tenderness over muscle insertion at greater trochanter
- sciatica: lower back and buttock pain, radiates down back of leg and goes below the knee
- femoral neck fracture: hx trauma or known severe osteoporosis, unable to weightbear, acute onset, shortened and externally rotated
How is hip OA surgically managed?
- when conservative management not working
- total hip replacement usually
- hemi if less function needed and older
Give 3 complications of total hip replacments?
- thomboembolic disease
- bleeding
- dislocations
- infections
- loosening of prosthesis
- prosthesis fractures
- revisions (needed after around 20 yrs)
How will the clinical features of meniscal tears differ from ligamentous injury?
- ligamentous injuries tend to swell very quickly due to haemoarthorsis, meniscus is less vascular so swelling is over 6-12 hrs
- both are tearing sensations, ligaments may have popping sounds
- may carry on playing with meniscus tear, cant if ligament
- +ve lachmans, anterior draw or valgus/ varus stress tests with ligament injuries
How should suspected ligament/ meniscal injuries be investigated?
- MRI scan
- radiograph often also to exclude boney injuries
When is surgery done in ACL tears?
- active and younger pts, after a period of prehabilitation with physio
- usually use tendon or artificial grafts
How are MCL injuries managed?
- if there is a distal avulsion fracture-> surgery
- grade 1-> RICE, return to sport in 6 weeks
- grad 2-> RICE, knee brace, weight bear as tolerated, return in 10 weeks
- grade 3-> RICE, brace, crutches, return in 12 weeks
When in arthroscopic surgery indicated for meniscal tears?
when the tear is >1cm
if outer 1/3 of the meniscus is affected then tend to suture it together as good blood supply for regeneration
if inner 1/3 affected they tend to trim it
Describe the mechanism for tibial plateau fractures
- usually high energy trauma such as falls from heights or RTA
- often from falls onto feet with extended knee
- varus deforming forces applied in this injury mean the lateral plateau is most commonly injured
What other pathology are commonly associated with tibial plateau fractures?
- meniscal tears
- ligament injuries
- popliteal vessel dissection
- common fibular nerve damage
how should suspected tibial plateau fractures be investigated?
AP and lateral radiographs of the knee
CT scan usually needed also
How are tibial plateau fractures managed? (3)
- if no ligament damage, tibial sublaxation or articular step is <2mm, it is uncomplicated and can be managed with hinged knee brace and partial non weight bearing for 8-12 weeks + physio and analgesia
- if complicated, evidence of compartment syndrome, medial epicondyle fracture (even if undisplaced), they need surgery
- surgery is ORIF to restore joint surface congruence +/- bone graft to fill metaphyseal gaps
What is IT band syndrome?
Inflammation of the iliotibial band, it is the most common cause of lateral knee pain in athletes.
How is IT band syndrome tested for?
press on lateral epicondyle, extend the knee, pain will be felt at 30 degreess when the IT band passes over the lateral epicondyle
Who gets achilles tendonitis
classically it is unfit individuals who have sudden increase in excerise frequency
- poor footwear
- male
- obesity
How does achilles tendonitis and achilles rupture present
tendonitis: gradual onset pain and stiffness in posterior ankle which is worse with movement, tenderness over achilles tendon usually worse 2-6cm above insertion
rupture: sudden onset severe pain in posterior calf on forced planterflexion, popping sound, palpable step and positive simmonds test
