Orthopaedics unit 4 Minor adult disorders - deck 1

Question 1

Why are all the disorders describe in this unit termed ‘minor’ disorders and what is it important to remember about these conditions ?

Answer 1

• They are “minor” in the sense that many are self-limiting in their natural history, and many have nonsurgical solutions.
• It is important to appreciate that, although these conditions are common, they are often of sufficient severity to cause considerable inconvenience and discomfort to the sufferer

Question 2

Define what is meant by the term ‘enthesis’

Answer 2

The enthesis is the term given to the short fibrous origin of a muscle

Question 3

Define what is meant by the term ‘enthesopathy’

Answer 3

Refers to an inflammation of a muscle origin

Question 4

What are the 2 most common sites for an enthesopathy to develop and what is the name given when it develops at each of these sites?

Answer 4

1. The common origin of the flexor muscles of the forearm - Golfer’s elbow
2. The common origin of the extensor muscles of the forearm - Tennis elbow.

Question 5

What is the main presenting feature of tennis and golfers elbow ?

Answer 5

Tennis elbow - a painful and tender lateral epicondyle and pain on resisted middle finger and wrist extension, discomfort on using the affected muscle

Golfers elbow - painful and tender medial epicondyle, discomfort on using the affected muscle

Question 6

Can more than one enthesopathy occur at a time and if so who usually deals with these cases ?

Answer 6

• Yes they can giving rise to many aches and pains
• These cases are usually dealt with by a rheumatologist

Question 7

How do the common enthesopathies around the elbow (tennis and golfers) arise?

Answer 7

• They are commonly associated with repetitive movements or overuse
• But may arise spontaneously

Question 8

What is the general prognosis of an enthesopathy ?

Answer 8

Generally good, esp if there is a clear cause, rest usually results in spontaneous recovery

Question 9

If rest does not result in spontaneous recovery of an enthesopathy what can be done to speed up the recovery process?

Answer 9

• Recovery may be speeded up with a course of anti-inflammatory agents.
• Local steroid injections into the point of maximum tenderness also can be of value.

Question 10

Why must care be taken to ensure a steroid injection is ejected directly into the enthesis with no leakage into the subcutaneous fat or skin to help treat an enthesopathy?

Answer 10

As if there is leakage into the S/C fat and skin, this results in the pain being exacerbated and the patient is left with an unsightly dimple.

Question 11

Even after tehniques used to speed up the recovery process in patients with enthesopathies a very small number will still have a chronic enthesopathy - what can be done in these patients ?

Answer 11

Surgery - This consists of scraping the origin of the muscle from the bone and permitting it to slide distally thus “decompressing” the area

Question 12

Why should patients be encouraged to wait before considering surgery to treat an enthesopathy ?

Answer 12

Because spontaneous recovery is highly likely.

Question 13

What is meant by the term neuropraxia ?

Answer 13

This is compression or stretch of a nerve resulting in nerve injury

Question 14

What does continued pressure damaging a nerve lead to?

Answer 14

Atrophy of the nerve which, at best, takes a very long time to recover

Question 15

Once atropy of a nerve has occurred what is the prognosis?

Answer 15

• It usually results in permanent nerve damage (at least in part)
• Hence why early diagnosis and management of neuropraxa is important

Question 16

What are the two main mechanisms by which nerve entrapments can occur ?

Answer 16

Due to extrinsic or intrinsic causes

Question 17

Give some examples of extrinsic causes of nerve entrapments

Answer 17

• Accidents where consciousness is lost and the victim inadvertently presses on a nerve.
• Patients in bed or in plaster casts are at risk from pressure on nerves in exposed sites.

Question 18

What is the most common nerve site at risk of nerve entrapment from Patients in bed or in plaster casts and why

Answer 18

The common peroneal nerve as it winds around the head of the fibula

Question 19

What are the main causes of intrinsic nerve entrapment ?

Answer 19

Structural local anatomical variations or inflammatory swelling

Question 20

What are the common sites for intrinsic nerve entrapment and name the affected nerve?

Answer 20

1. The median nerve at the wrist
2. The ulnar nerve at the elbow
3. The ulnar nerve at the wrist
4. The posterior tibial nerve at the ankle.

Question 21

What is the most common type of nerve entrapment - intrinsic or extrinsic ?

Answer 21

Intrinsic

Question 22

What are the presenting features for the diagnosis of nerve entrapment?

Answer 22

• You should be suspicious when there is any numbness or tingling in the area supplied by the nerve should be taken seriously
• Weakness and real sensory loss are diagnostic in the the area supplied by a nerve.

Question 23

What test can be used to aid diagnosis of nerve entrapment if you are unsure?

Answer 23

Nerve conduction studies

Question 24

What is the treatment of nerve entrapment ?

Answer 24

• Obvious causes such as bandage or cast must be removed.
• If symptoms persist then surgical relief of pressure may be required. This involves cutting the skin and fascia.

Question 25

Define what tenosynovitis is

Answer 25

This is inflammation of tendons and their associated synovial sheaths

Question 26

What are the causes of tenosynovitis ?

Answer 26

• It is often associated with RA
• In other situations it may arise spontaneously, often with no known cause but usually it is precipitated by unusual levels of activity, or overuse.

Question 27

Why is it important to be aware of tenosynovitis ?

Answer 27

It is often associated with worker compensation and litigation.

Question 28

Define what a bursa is

Answer 28

A bursa is a small sac of fibrous tissue lined with synovial membrane and filled with fluid.

Question 29

What is the function of a bursa?

Answer 29

It acts as a natural form of “bearing” aimed at improving muscle and joint function by reducing friction, usually where tendons and ligaments pass over bones.

Question 30

Bursa are naturally occurring in joints but what may bursae form in response to ?

Answer 30

Pressure

Question 31

What is the underlying causes of bursae disorders ?

Answer 31

Repetitive movement or strain, or from being subject to abnormal loads

Question 32

What are the most common sites of bursitis ?

Answer 32

Around the knee and the elbow, and the greater trochanter at the hip may also be affected.

Note the shoulder is commonly affected but discussed later on in this unit.

Question 33

How does bursitis usually present ?

Answer 33

Chronic discomfort over the bursa, usually associated with the causative element, such as movement or pressure.

May also have swelling of the bursa e.g. in housemaid’s knee when the pre-patellar bursa swells

Question 34

What complication can develop when someone has bursitis and how does this present ?

Answer 34

Occasionally there may be an infection of the bursa. This results in a tense swelling associated with infection of the skin (cellulitis) and general ill health (malaise).

Question 35

What are the symptoms and treatment of chronic bursae?

Answer 35

• They have no symptoms (trick question)
• They require no treatment unless demanded for convenience e.g. it interfers with dressing themselves or appearance

Question 36

If a bursae is tender what can be done to treat it ? but what is encouraged before this

Answer 36

They can be excised but the patient should be encouraged to remove the underlying cause e.g. by using kneeling mat

Question 37

What is the treatmeant of infected bursae?

Answer 37

They should be incised (cut open) and drained as this often leads to a spontaneous recovery through scarring and fibrosis.

Question 38

What are the only foot abnormalities which matter ?

Answer 38

Those which cause symptoms - usually pain

Question 39

Is the treatment of a foot abnormality which does not result in a functional abnormality justified ?

Answer 39

No it is seldom justified

Question 40

Are painful flat feet common ?

Answer 40

• No it is rare that you will get painful flat feet
• Symptom free flat feet are a normal variation and are very common in certain races and should be ingored

Question 41

In adults what is done to correct a painful flat foot and how does it correct the flat foot?

Answer 41

A medial heel lift will correct the deformity of the hind part of the foot and stabilise the medial arch

Question 42

If an adult has a persistently painful flat foot despite correction with orthotics what can be done to treat it ?

Answer 42

Fusion of the subtalar joint

Question 43

What may a painful, spasmodic flat foot be indicative of ?

Answer 43

Infection or chronic inflammatory disease.

Or Occasionally it occurs acutely in middle age and examination reveals a painful and tender swelling over the insertion of tibialis posterior.

Question 44

If a patient presents with a painful spasmodic flat foot with a painful and tender swelling over the insertion of the tibialis posterior, what may this indicate ?

Answer 44

Impending degenerative rupture warranting early intervention.

Question 45

Define what a bunion is

Answer 45

This is a fluid filled bursae, which are found around bony prominences

Question 46

Where are bunions commonly found ?

Answer 46

Over the distal part of the first metatarsal and occasionally over the fifth

Question 47

Why do bunions form and what do they indicate ?

Answer 47

They form as a natural response to pressure and indicate an underlying abnormality which should be treated rather than the bunion

Question 48

What is the treatment for bunions ?

Answer 48

Treatment of the underlying bony abnormality and a review of footwear

Question 49

What is the treatment if a bunion becomes infected ?

Answer 49

Drainage, followed a few weeks later by treatment of the cause or a review of the footwear.

Question 50

Define what a corn is

Answer 50

This is thick, hard, painful dead areas of skin

Question 51

Why do corns form ?

Answer 51

They are another way in which the body reacts to areas of high pressure (they therefore often form over a bunion)

Question 52

What is the treatment of a corn ?

Answer 52

They can be superficially removed

Question 53

Corns will reoccur unless what is done ?

Answer 53

Unless the underlying cause of the high pressure is removed.