Orthopaedics + Trauma + Surgery Flashcards
Describe Plantar Fasciitis, it’s signs and symptoms, and management
Between 4-7% of people have heel pain at any given time and around 80% are due to plantar fasciitis.
Signs and symptoms: Sharp, unilateral (70%) heel pain, worse on bearing weight on the heel after long period of rest, usually improved on walking. Dorsiflexion of foot may cause pain, and Achilles’ tendon and calves muscles may be tight.
Management:
- around 90% are self-limiting and recover with conservative management within 6months
- NSAIDs, heat and ice, calf exercise may help
- steroid injections if non-resolving or severe pain may help
- If injections fail refer, extracorporeal shockwave therapy is a reasonable alternative
What are some causes of heel pain?
- Diseases of the calcaneum
- Rupture of calcaneal tendon
- Postcalcaneal bursitis
- Plantar fasciitis
- lymphoma in children
- arthritis of the subtalar joint
- calcaneal paratendinopathy
- Tender heel pad
- infection
What is the straight leg raise test?
A test to determine whether low back pain has an underlying herniated disc. Patient lies down, or sits (less sensitive) and examiner raise leg with knee extended and ankle dorsiflexion. Sciatic pain at 30-70 degrees indicates +ve test and suggest herniated disc
Describe Benign Joint Hypermobility Syndrome, its symptoms, diagnostic criteria, and management.
Possible overlap with Ehlers-Danlos Type 3 (Hypermobility type), typically affects children and young adolescents.
Symptoms: Main features are joint Hypermobility, with exercise-related muscle and joint pain and some level of fatigue. Swelling, heat or redness are not present unless underlying injury. Extra-articulate symptoms include abdominal pain, headaches, and mood disturbance.
Diagnostic criteria: Beighton Hypermobility Score 1 point each for:
-left little finger passive dorsiflexion beyond 90degrees
-right little finger passive dorsiflexion beyond 90degrees
-left thumb passive dorsiflexion to flexor aspect of forearm
-right thumb passive dorsiflexion to flexor aspect of forearm
-left elbow hyperextends beyond 10degrees
-right elbow hyperextends beyond 10degrees
-left knee hyperextends beyond 10degrees
-right knee hyperextends beyond 10degrees
-trunk flexion with knees fully extended, palms and hands rest flat on floor.
4 or more entails a major criterion, arthralgia for more than 3 months in four or more joints also entails a major criterion.
Management:
- look for other hereditary connective tissue disorders or inflammatory joint conditions such as Ehlers-Danlos syndrome, Marfans, Juvenile idiopathic arthritis, RA, Ankylosing spondylitis, fibromyalgia.
- pain management and physiotherapy is needed
Describe low back pain, red flag symptoms, investigations.
Back pain is common. Most back pain is self-limiting. Pain brought on by activity and relieved by rest is rarely sinister.
Red flag symptoms:
- less than 20yrs or greater than 55yrs
- violent trauma
- alternating sciatica (both legs involved)
- bilateral sciatica
- weak legs
- weight loss
- fever or systemically unwell
- ESR greater than 25mm/hr
- oral steroids
- local bony tenderness
- previous neoplasia
- faecal/urinary incontinence
- perianal paraesthesia
Investigations:
- examine in underwear ideally, test forward flexion and extension, lateral flexion and rotation, straight leg test.
- if pain last more than 4 weeks do FBC, CRP(infection) ESR (if high think metastases or myeloma and do electrophoresis +/- bone aspirate), LFT (ALP is high in Paget’s disease and tumour), calcium. In absence of trauma MRI is gold standard investigation.
Describe Varicoceles, theirs features and management.
Varicosities of the pampiniform plexus. Most commonly occurs on left because testicular vein drains into renal vein. May be a presenting feature of renal cell carcinoma. Affected testis may be smaller and bilateral Varicoceles may affect fertility, repair has little effect on pregnancy rates.
Features: Distended scrotal vessels, feel like a bag of worms, patient may complain of dull ache. Associated with Subfertility.
Management:
- conservatively
- surgery or embolisation may be used if concerns about testicular function.
Describe Epidymitis, its symptoms, and management.
An infection of the epididymis can spread to testes (orchitis).
Symptoms: Unilateral tesitcular pain and swelling, urethral discharge may be present. If patient less than 20, severe pain and acute onset consider testicular torsion.
Management:
- if unknown organism, ceftriaxone IM once plus doxycycline PO BD for 10-14 days
- US to exclude underlying structural abnormalities.
Describe Testicular torsion, its symptoms, and management.
Twist of the spermatic cord resulting in testicular ischaemia and necrosis. Most common in males aged 10-30.
Symptoms: severe sudden onset unilateral pain. Cremaster if reflex is lost and elevation of testis does not ease pain.
Treatment:
Surgical exploration and fixing of testes.
Describe the management of Head injury.
Assess all patients within 15 minutes of arrival documenting GCS. If GCS less than 8 consider stabilising the airway, treat pain with low dose IV opiates.
-Full spinal immobilisation if
GCS less than 15, neck pain/ tenderness, paraesthesia extermities, focal neurological deficit, suspected c-spine injury
-If C-spine suspected 3 view C-spine X-ray is indicated, CT-spine is preferred if intubated, GCS less than 13
-Immediate CT head within 1 hr if
GCS less than 13 on admission, GCS less than 15 2hr after admission, suspected open or depressed skull fracture, suspected basal skull fracture, focal neurology, vomiting, post traumatic seizure, coagulopathy.
-contact neurosurgeon if
persistent GCS less than 8, unexplained confusion after 4h, reduced GCS post admission, progressive neurological signs, incomplete recovery post seizure, penetrating injury, cerebrospinal leak.
-CT head within 8 hours of injury
if 65 or older, history of bleeding or clotting disorders, dangerous mechanism of injury e.g. RTA, more than 30 minutes retrograde amnesia of events before had injury.
Describe Pilonidal sinus and its management.
Obstruction of natal cleft hair follicles around 6cm above the anus. In-growing of hair excites a foreign body reaction and may cause secondary tracks to open laterally +/- abscesses, with foul smelling discharge. (Barbers get them between infers). 10 times more common in men.
Management:
- excision of the sinus tract +/- primary closure.
- consider pre-op antibiotics
- offer hygiene and hair removal advice.
Describe Intraductal Papilloma, its symptoms, and management.
Growth of papilloma in a single duct. No increase risk of malignancy. Most common in women between 35-55.
Symptoms: Warty lump usually behind the nipple. Usually present with clear or blood stained discharge originating from a single duct. Ask the patient where and how many positions the discharge appears as if the nipple were a clock.
Management:
- history and examination
- reassure patient that most likely benign but all lumps should be referred urgently to breast one stop clinic.
Describe Duct Ectasia, its symptoms, and management.
Mammary duct ectasia may be seen in up to 25% of normal female breasts. It is a normal variant of breast involution and is not the same as Periductal mastitis.
Symptoms: Patients usually present with nipple discharge which may be from single or multiple ducts (usually present after age of 50), the discharge is often thick and green.
Management:
-should be referred to breast one stop clinic urgently.
Describe Ulnar Collateral Ligament Injury and its symptoms.
Can often occur due to falling onto an outstretched thumb. It of tens occurs due to falling while holding a skiing pole. It is therefore often referred to as skiers thumb.
Symptoms: the thumb will usually be painful, swollen, and bruised on the inside of the MCP joint. Movements that use the UCL (e.g. Pinching a key between the thumb and index finger) can induce pain.
Describe the symptoms associated with a fracture of the shaft of the humerus
Associated with radial nerve damage which is the most susceptible nerve here.
Describe the symptoms of a supracondylar fracture of the humerus.
Most commonly associated with ulnar nerve damage
