Orthopaedics (Unit 4: Minor Adult Disorders) Flashcards
What is an enthesis?
Short fibrous origin of a muscle
What is Golfer’s elbow?
Inflammation of the common origin of the flexor muscles of the forearm
What is tennis elbow?
Inflammation of the common origin of the extensor muscles of the forearm
How can recovery from common enthesopathies be sped up?
Course of anti-inflammatory agents
Steroid injections
What is the surgical management of enthesopathies if required?
Scraping the origin of the muscle from the bone and permitting it to slide distally (“decompressing”)
What is neuropraxia?
Stretching and compression of nerves
Why is early diagnosis essential in nerve entrapments?
Continued pressure will lead to atrophy of the nerve which at best takes a very long time to recover and is usually permanent
What are common sites of intrinsic nerve entrapment?
Median nerve at the wrist
Ulnar nerve at the elbow
Ulnar nerve at the wrist
Posterior tibial nerve at the ankle
What are extrinsic causes of nerve entrapments?
Accidents with loss of consciousness
Patients in bed or plaster casts
Which nerve is the most common site at risk of extrinsic pressure?
Common peroneal nerve as it winds around the head of the fibula
How is nerve entrapment diagnosed?
Numbness or tingling in the area should be taken seriously
Weakness and real sensory loss ar diagnostic
(If in doubt do nerve conduction studies)
How is nerve entrapment managed?
Remove cause if obvious
If symptoms persist surgical relief of pressure
What is tenosynovitis?
Inflammation of tendons and their associated synovial sheaths
What is tenosynovitis often associated with?
Rheumatoid Arthritis
What normally precipitates tenosynovitis?
Unusual levels of activity or overuse
What is a bursa?
Small sac of fibrous tissue lined with synovial membrane anf filled with fluid
What is the purpose of bursae?
“Bearing” aimed at improving muscle and joint function by reducing friction (usually where tendons and ligamens pass over bones)
However may also form in response to pressure
What are the most common sites of bursitis?
Shoulder
Knee
Elbow
Greater trochanter at the hip
What is pre-patellar bursitis also called?
Housemaid’s knee
What would make you suspicious that there was an infection of the bursa?
Tense swelling associated with cellulitis and general ill health
What is the treatment of chronic bursae?
If tender may be excised although patient should be encouraged to remove the underlying cause
What is the treatment for infected bursae?
Incised and drained (leads to spontaneous recovery through scarring and fibrosis)
When might a painful spasmodic flat foot warrant early intervention and what would be found on examination?
Occurs acutely in middle age
Painful tender swelling over insertion of tibialis posterior
Indicates acute or impending degenerative rupture
If a flat foot is associated with pain what conservative intervention may help and why?
Medial heel lift will correct the deformity of the hind part of the foot and stabilize the medial arch
If pain is a persistent problem in flat feet what intervention is required?
Fusion of the subtalar joint (no to be undertaken lightly as profoundly disturbs function)
What are bunions?
Fluid filled bursae found around bony prominences
Where are bunions usually found?
Distal part of first metatarsal and occasionally ove rthe fifth
What do bunions indicate?
Form as a natural response to pressure and indicate an underlying abnormality which should be treated
What are corns?
Painful excessive corny skin formed in response to pressure
What is Hallux valgus?
Turning away of the phalanges of the big toe from the midline (usually because of a deformity at the joint line)
What is Hallux rigidus?
Osteoarthritis of the first MTP
What is the likely cause of Hallux rigidus in adolescents?
Osteochondral fracture (not always easy to prove)
What are the treatment options for adolescent with Hallux rigidus alone?
Metatarsal bar (so toe doesn't bend when walking) Surgery if bar not cosmetically accepted
In the elderly is Hallux rigidus more likely to occur with or without Hallux valgus?
With Hallux valgus
What does the surgical management of minor Hallux rigidus involve?
Surgical removal of the osteophytes with an osteotomy of the proximal phalanx
What is the most reliable treatment of Hallux rigidus?
Surgical fusion in a neutral position
What is the cause of Hallux valgus?
Unknown (but gives more problem in women and many sufferers have a short first metatarsal often in varus)
What management of Hallux valgus is suitable at almost 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
When is it appropriate the use Keller’s procedure when treating Hallux valgus?
To be avoided in the young
Probably unnecessary if the joint is not painful
When is Hallux valgus with rigidus seen?
In older people where joint degeneration is usually secondary to the valgus deformity
What is “claw foot”?
Condition of the foot where wasted muscles make the bones and the toe nails appear more prominent (like a dog’s foot)
What us the cause of claw foot?
Muscle weakness of deficiency
What is claw foot often associated with?
Minor spinal abnormalities such as spina bifida occulta
What are hammer toes secondary to?
Disruption of the MTP joints
How might patients with hammer toe present?
Generally sore forefeet (metatarsalgia)
What is the management of hammer toes?
Fusion of the interphalangeal joints in a straight position (so they don’t rub)
Good pair of soft comfortable shoes
What gives rise to a neuroma?
Cutaneous nerves to the toes become trapped or irritated between the metatarsal heads
What is the characteristic presentation of a neuroma?
Dull throbbing pain with sharp exacerbations
Tingling of the toes
How can the symptoms of a neuroma be confirmed?
Sideways compression of the foot produces a palpable click, reprodcing the symptoms
What are the outcomes of neuromas?
Excision may leave sensory disturbance to affected toes
Recurrence is common
What are the risks of an ingrown toenail?
Infection (becomes self-perpetuating and long term)
Secondary blood borne infections
What are the treatment options for ingrown toenails?
Careful nail care
Removal of nail
Wedge resection
(Comestic may be necessary after)
What is the plantar fascia?
Tough layer of fibrous tissue which runs from the os calcis to each toe base
What are the symptoms of plantar fascitis?
Sore instep (often wore first thing or after long sitting) Minimally relieved by walking Then a persistent ache exacerbated by change of direction or walking on rough ground
What is the course of plantar fascitis?
Most cases are self limiting and settle spontaneously
What are the management options for plantar fascitis?
Insoles (hollowed out under tender area)
Soft shoes
Local injection of steroids
Surgical stripping of fascia (unpredictable)
What is the most common cause of neuropathy in the western world?
Diabetes
Which 2 groups of people are likely to suffer from achilles tendinitis and rupture?
Young athletes
Middle aged men
How is achilles tendinitis in young athletes treated?
Rest is usually adequate
Surgical decompression of tissue surrounding the tendon will often relieve symptoms
What should be avoided when treating achilles tendon problems?
Steroid injection (penetration of the tendon may lead to rupture)
How might achilles tendinitis present in middle aged men?
phase of discomfort may precede rupture indicating degeneration within the tendon tissue
What is a potential cause of achilles problems in middle aged men?
Lower a=part of tendo achilles has a poor blood supply and is a point of weakness in some people who keep particularly active into middle age
How is an achilles tendon rupture treated?
Equinis plaster for min 8 weeks
Can be sutured by open or closed technique
What is the prognosis of a tendo achilles rupture?
Significant risk of re-rupture but decreases with time (wearing felt raise in heel will help)
What structures are commonly involved in pathological conditions causing shoulder discomfort?
Subacromial bursa Supraspinatus tendon AC joint Biceps tendon Rotator cuff
What is a painful arc suggestive of?
Supraspinatus tendon inflammation or a subacromial bursitis
What is an effective management for supraspinatus tendon inflammation or subacromial bursitis?
Steroid injection into the bursa or around the tendon (should not be done repetitively)
What would be seen on radiograph if a patient is suffering severe pain alongside painful arc?
Calcified material within the supraspinatus tendon
After temporary response to injection what will be seen on investigation?
Degenerative changes and osteophytes in the AC joint
Persistent supraspinatus tendon inflammation will lead to…
Rupture of the supraspinatus muscle
What is frozen shoulder?
Condition in which there is little or no glenohumeral movement
What causes frozen shoulder?
Trauma (epileptic fit or electric shock)
Often cause is obscure
What is the management of frozen shoulder?
Usually recover in 18-24 months
Psychological support
Manipulation under anaesthetic (maybe)
