Orthopaedics Unit 4 Flashcards
what is an enthesopathy
inflammation of a muscle origin
possible to have multiple inflammations at one point causing many aches and pains
what is golfer’s elbow
inflammation of origin of the flexor muscles of the forearm at the medial epicondyle
what is tennis elbow
inflammation of origin of the extensor muscles of the forearm at the lateral epicondyle
what are features of enthesopathies
may arise spontaneously but mostly commonly associated with repetitive movements or overuse
most recover spontaneously with rest
Tx for an enthesopathy that becomes chronic or severe
NSAID
local steroid injections [have to ensure steroid is injected into the enthesis with no leaked into subcut fat or skin, as this would exacerbate pain]
what is the surgery for enthesopathies in severe cases
scraping the origin of the muscle from the bone and permitting it to slide distally thus “decompressing” the area
[although patients should be encourage to wait as, spontaneous recovery is likely]
what is neuropraxia
continued pressure that has lead to atrophy of the nerve
takes a long time to recover and can be permanent
what are the 2 types of nerve entrapments
1) extrinsic
- i.e. LOC and patient presses on a nerve or patients in bed or plaster casts
- most common site is common peroneal nerve as it winds around the head of the fibula
2) intrinsic
- causes by structural local anatomical variations or inflammatory swelling
where are common sites of intrinsic nerve entrapments
median nerve at the wrist
ulnar nerve at the elbow
ulnar nerve at the wrist
posterior tibial nerve at the ankle
Sx for nerve entrapments
numbness
tingling
weakness
sensory loss
Ix = nerve conduction study
Mx for nerve entrapments
need to reduce pressure
surgical relief of pressure may be required
- cutting skin and fascia
what is tenosynovitis and what is it associated with
Inflammation of tendons and their associated synovial sheaths
associated with RA
when does tenosynovitis occur spontaneously
usually it is precipitated by unusual levels of activity, or overuse
what is a bursa
small sac of fibrous tissue lined with synovial membrane and filled with fluid
what is the function of a bursa
natural form of “bearing” aimed at improving muscle and joint function
reduces friction, usually where tendons and ligaments pass over bones
new ones can form in response to pressure
what causes inflammation of a bursa
repetitive movement or strain, or from being subject to abnormal loads
where are the most common sites of bursitis
knee
elbow
shoulder
greater trochanter at the hip
Sx of bursitis
chronic discomfort over the bursa, associated with causative elements such as movement or pressure
swelling of the bursa
what is housemaid’s knee
swelling of pre-patellar bursa
what are Sx of an infection of the bursa
tense swelling associated with infection of the skin (cellulitis) and general ill health (malaise).
Tx for chronic bursae
need no Tx unless patient demands so
if tender, may be excised
Tx for infected bursae
incised and drained
- leads to spontaneous recovery through scarring and fibrosis
features of a painful spasmodic flat foot
associated with infection or chronic inflammatory disease
can occur acutely in middle age
- o/e painful and tender swelling over tibialis posterior insertion
- may indicate acute or impending degenerative rupture
- warrants early intervention
if a flat foot in an adult is associated with pain, what is a possible Tx
a medial heel lift
- will correct the deformity of the hind part of the foot and stabilise the medial arch.
if a flat foot in an adult is associated with PERSISTENT pain, what is a possible Tx
fusion of subtalar joint
- will disturb foot and ankle profoundly
what are bunions
fluid filled bursae found around bone prominences
commonly over the distal part of the 1st metatarsal and occasionally over the 5th
Tx of bunions
form as a natural response to pressure from underling abnormality
- Tx this
if bunion becomes infected
- drainage
what are corns and what is the Tx
painful corny skin formed in response to high pressure
Tx
- can be removed
- need to Tx underling cause and remove cause of high pressure
what is hallux valgus
turning away of the phalanges of the big toe from the mid-line
what is hallux rigidus
OA of the metatarsophalangeal joint
what is the relationship between hallux valgus and hallux rigidus
can occur separately or together
who gets hallux rigidus alone
can occur in adolescents and adults
who gets hallux valgus alone
may occur at any age.
in cases of hallux rigidus in adolescents, what is the cause thought to be
osteochondral fracture [not easy to prove]
Tx of hallux rigidus in adolescents
conservative Tx
- use of a metatarsal bar to provide a rocker at the front of the foot so that the toe need not bend in normal walking
surgical Tx
- same as adults
why does conservative Tx of hallux rigidus in adolescents normally fail
do not accept the cosmetic consequences on their shoes
Tx of hallux rigidus in adults
in minor cases
- surgical removal of the osteophytes with an osteotomy of the proximal phalanx
- surgical fusion in a neutral position
alternative option
- Inter- position arthroplasty with a silicone plastic (silastic) spacer [mixed results]
in cases of hallux valgus alone, what are the features of the condition
F > M
Many, but not all, sufferers have a short first metatarsal, often in varus.
Mx of hallux valgus
can depend on age
any age
- Realignment of the first metatarsal to a more lateral position and excision of any bony prominence (an exostosis) over the first metatarsal head
elderly
- Keller’s procedure = Excision of the metatarsophalangeal joint
- avoid in the young
- unnecessary if joint is not painful
who gets Hallux valgus with also Hallux rigidus
older people where joint degeneration is usually secondary to the valgus deformity
Mx of Hallux valgus with also Hallux rigidus
in older patients
- may be satisfied by having their pain relieved by well fitting shoes
if this fails
- Keller’s arthroplasty = excision of metatarsophalangeal joint then put in an artificial joint
why should you try to avoid Keller’s arthroplasty
severely disrupts normal foot mechanics
should be reserved for the older, less active patient.
what is claw foot
wasted muscles of the foot make the bones and the toe nails appear more prominent
implies muscle weakness or deficiency
what is claw foot associated with
weak or denervated small muscles of the feet
minor spinal abnormalities such as spina bifida occulta
what is hammer toe
top of the toe looks like the end of a hammer
secondary to the disruption of the metatarsophalangeal joints
Sx of hammer toe
metatarsalgia
- generally sore forefoot
Tx of hammer toes
good pair of soft, comfortable shoes
Surgery
- fusion of the interphalangeal joints in a straight position, so that they do not rub on the shoes
what is a neuroma
when the cutaneous nerves to the toes become trapped or irritated between the metatarsal heads there is a benign growth of nervous tissue
a.k.a Morton’s neuroma when in the foot
secondary to repetitive trauma
Sx of neuroma
dull and throbbing pain
sharp exacerbations
accompanied by tingling of the toes
difficult to localise
what is the classic clinical sign of Morton’s neuroma
sideways compression of the foot produces a palpable click, reproducing the symptoms.
Tx of Morton’s neuroma
excision
- s.e. = sensory disturbance to affect toes
recurrence is common
what causes ingrowing toenails
curved nail grows into the nail fold and digs in
trauma to skin can lead to secondary skin infection
can lead on to secondary blood bourne infections
[big issue it patient has prosthetic joints or heart values]
Tx of ingrowing toenails
remove the nail to clear up chronic infection
Wedge resection of the nail bed may retain the toe nail and remove the problem.
if keeps recurring
- remove the nail bed using phenol after removing the nail
what is plantar fascia
a tough later of fibrous tissue which runs from the os calcis to each toe base
Sx of plantar fascia
soreness of the instep, often worse first thing on rising, or after sitting for a few hours
minimally relieve by walking, but then persist as a debilitating ache
exacerbated by change of direction, or walking on rough ground
o/e
- tenderness at the origin of the plantar fascia medially
Tx for plantar fascia
self-limiting
- but may last few months to years
Sx relief
- Soft shoes and insoles, particularly modern sports trainers
if marked tender spot
- local injection of steroids and long acting local anaesthetic
surgery
- stripping of the fascia from the os calcis
- results unpredictable
what are neuropathic feet
feet without sensation (sensory neuropathy)
most common cause is diabetes [in western world] and leprosy [in developing world]
what are the issues that can develop because of sensory neuropathy
developing sores
- due to inability to perceive minor trauma
ulcers and secondary infection
- can lead to amputation
who gets achilles tendinitis
2 groups
1) Young athletes
- from over use
- area may be tender or swollen
2) Middle aged men
- phase of discomfort may precede rupture of the tendon achilles
- due to degeneration within the tendon tissue
Tx for achilles tendinitis in young athletes
rest
if recurrent however,
- surgical decompression of the tissue surrounding the tendon
why is steroid injections avoided in achilles tendinitis
injection into the tendon will lead it to rupture
why is it thought that the achilles tendon tissue degenerates
has a poor blood supply
Tx for tendon rupture
1) ankle is kept in an equinus plaster for a minimum of eight weeks
OR
2) tendon can be sutured either by a closed technique or by open suture
- has high risk complication
both methods have a significant risk of re-rupture, although this decreases with time
what does arcomioclavicular joint consist of
joint between the acromion process of the scapula and the clavicle
what are Sx of shoulder pathology
pain, particularly on movement
limited ROM
Sx associated with recent incident
what are the structures involved in shoulder discomfort
the subacromial bursa, the supraspinatus tendon, the acromioclavicular joint, the biceps tendon, and the rotator cuff as a whole.
Mx of shoulder discomfort
1st line
- rest, gentle exercise, anti-inflammatory drugs
what does tenderness under active movement of the shoulder suggest
painful arc
= supraspinatus tendon inflammation or a subacromial bursitis
Tx of supraspinatus tendon inflammation or a subacromial bursitis
steroid injection into the bursa or around the tendon
what happens in Calcific tendinitis of the shoulder
get calcified material within the SUPRASPINATUS tendon that can be seen on imaging
causes very severe pain
Tx = removal of material
what is frozen shoulder
condition in which there is little or no glenohumeral movement
cause often obscure
can be caused by specific trauma incident, such as a fit
Mx of frozen shoulder
people eventually recover
- 18months to 2 years
Tx of supraspinatous tendon inflammation
steroid injection into the bursa
who gets frozen shoulder and what is the Sx
[what is the principal sign]
characterised by progressive pain and stiffness of shoulder in patients aged 40-60 y/o over 18-24 months
[loss of external rotation]
what age group gets what pathology of shoulder discomfort
young - instability, dislocation
middle age - rotator cuff tear, frozen shoulder
elderly - glenohumeral OA
