quick orthopaedics from ZTF Flashcards
four key x ray changes in osteoarthritis
- LOSS
- Loss of joint space
- Osteophytes (bone spurs)
- Subchondral cysts (fluid filled holes in the bone)
- Subarticular sclerosis (increased density of bone along the joint line)
osteoarthritis signs in hands
- Heberden’s nodes (in the DIP joints)
- Bouchard’s nodes (in the PIP joints)
- Squaring at the base of the thumb at the carpometacarpal joint
- Weak grip
- Reduced range of motion
diagnosis of osteoarthritis
- diagnosis can be made without any investigations if the patient is:
- over 45
- has typical pain associated with activity and
- no morning stiffness (or stiffness lasting under 30 minutes).
management of osteoarthritis
- lifestyle like lose weight
- paracetamol and topical NSAID
- NSAID and PPI
- opiate
- intra-articular steroid injection
- surgery
NSAID side effects
- Gastrointestinal side-effects, such as gastritis and peptic ulcers (leading to upper GI bleeding)
- Renal side-effects, such as acute kidney injury (e.g., acute tubular necrosis) or progressive kidney disease
- Cardiovascular side-effects, such as hypertension, heart failure, myocardial infarction and stroke
- Exacerbating asthma
what is a compound fracture
where the bone is exposed through the skin
what is a stable fracture
where the sections of bone remain in alignment at the site of the fracture
what is a transverse fracture
Transverse fractures are breaks that are in a straight line across the bone.
what are spiral fractures
As the name suggests, this is a kind of fracture that spirals around the bone. Spiral fractures occur in long bones in the body, usually in the femur, tibia, or fibula in the legs. However, they can occur in the long bones of the arms. Spiral fractures are caused by twisting injuries sustained during sports, during a physical attack, or in an accident.
what is a greenstick fracture
This is a partial fracture that occurs mostly in children. The bone bends and breaks but does not separate into two separate pieces. Children are most likely to experience this type of fracture because their bones are softer and more flexible.
what is a stress fracture
Stress fractures are also called hairline fractures. This type of fracture looks like a crack and can be difficult to diagnose with a regular X-rays. Stress fractures are often caused by repetitive motions such as running.
what are compression fractures
When bones are crushed it is called a compression fracture. The broken bone will be wider and flatter in appearance than it was before the injury. Compression fractures occur most often in the spine and can cause your vertebrae to collapse
what is an oblique fracture
An oblique fracture is when the break is diagonal across the bone. This kind of fracture occurs most often in long bones. Oblique fractures may be the result of a sharp blow that comes from an angle due to a fall or other trauma.
What is an impacted fracture?
An impacted fracture occurs when the broken ends of the bone are driven together. The pieces are jammed together by the force of the injury that caused the fracture.
what is a comminuted fracture
A comminuted fracture is one in which the bone is broken into 3 or more pieces. There are also bone fragments present at the fracture site. These types of bone fractures occur when there is a high-impact trauma, such as an automobile accident.
what is a colles fracture
A Colle’s fracture refers to a transverse fracture of the distal radius near the wrist, causing the distal portion to displace posteriorly (upwards), causing a “dinner fork deformity”. This is usually the result of a fall onto an outstretched hand (FOOSH).
which in the body have vulnerable blood supplies where fracture can commonly lead to avascular necrosis?
- scaphoid
- femoral head
- humeral head
- talus
- navicular
- 5th metatarsal
ankle fractures involve which bones
- lateral malleolus (distal fibula) or the
- medial malleolus (distal tibia).
what is the rationale of the weber classification of ankle fractures
- it classifies fractures of the distal fibula (lateral malleolus) in relation to the distal syndesmosis
- the syndesmosis is the join between the tibia and fibula
- the tibiofibula syndesmosis is v important for ankle function
- therefore if the syndesmosis is disrupted by the fracture then surgery is more likely to be required
describe the weber classificaton
The Weber classification defines fractures of the lateral malleolus as:
- Type A – below the ankle joint – will leave the syndesmosis intact
- Type B – at the level of the ankle joint – the syndesmosis will be intact or partially torn
- Type C – above the ankle joint – the syndesmosis will be disrupted
what are the main cancers that metastasize to bone
(mnemonic: PoRTaBLe):
- Po – Prostate
- R – Renal
- Ta – Thyroid
- B – Breast
- Le – Lung
difference between osteopenia and osteoporosis on dexa
side effects of bisphosphinates
- Reflux and oesophageal erosions
- Atypical fractures (e.g. atypical femoral fractures)
- Osteonecrosis of the jaw
- Osteonecrosis of the external auditory canal
instructions for taking bisphosphinates
take on an empty stomach with a full glass of water. Stand or sit upright for 30 minutes after taking them. You’ll also need to wait 30 minutes before eating food or drinking any other fluids.
alternative to bisphosphinates where they are not tolerated or contraindicated
Denosumab
how long after fracture does fat embolus typically present
24-72hrs later
causes of fat embolism syndrome
- fracture (typically long bones)
- orthopaedic procedures
- severe burns
- massive soft tissue injury
what happens in fat embolism
fat macroglobules pass into the small vessels of the lung and other sites, producing endothelial damage and resulting respiratory failure (acute respiratory distress syndrome (ARDS-like) picture), cerebral dysfunction and a petechial rash
presentation of fat embolism syndrome
- presents suddenly after 24-72hr latent period
- breathlessness ± vague pains in the chest.
- fever
- petechial rash
- CNS symptoms such as agitation, confusion, coma, seizures, drowsiness
- oliguria
presentation of acute compartment syndrome
- usually after injury such as bone fractures or crush injuries
- presents with the 5 Ps
- pain (disproportionate and not affected by analgesia)
- pressure (high)
- paraesthesia
- paralysis (a late and worrying sign)
- pallour
- importantly pulselessness is not a feature and this differentiates it from limb ischaemia
management of acute compartment syndrome
- Initial management involves:
- Escalating to the orthopaedic registrar or consultant
- Removing any external dressings or bandages
- Elevating the leg to heart level
- Maintaining good blood pressure (avoiding hypotension)
- Then emergency fasciotomy within 6 hours
- Wound left open and covered with a dressing
describe chronic compartment syndrome
- it’s also known as chronic exertional compartment syndrome
- presents with pain, paraesthesia and numbness made worse by exertion but which goes away with rest
diagnosis of chronic compartment syndrome
needle manometry is used to measure pressure in the compartment before during and after exertion
treatment for chronic compartment syndrome
fasciotomy
which bacteria causes most cases of osteomyelitis
staphylococcus aureus
risk factors for osteomyelitis
- Open fractures
- Orthopaedic operations, particularly with prosthetic joints
- Diabetes, particularly with diabetic foot ulcers
- Peripheral arterial disease
- IV drug use
- Immunosuppression
what signs of osteomyelitis might you see on x ray?
- Maybe no signs - you can’t exclude by X ray and need MRI
- Periosteal reaction (changes to the surface of the bone)
- Localised osteopenia (thinning of the bone)
- Destruction of areas of the bone
management of osteomyelitis
- surgical debridement
- antibiotic therapy
- flucloxacillin for 6 weeks with rifampicin and fusidic acid for the first 2 weeks
- clindamycin instead of fluclox in pen allegy
- vancomycin and teicoplanin in treating MRSA
what is osteosarcoma
cancer originating from the bone
what is chondrosarcoma
cancer originating from the cartilage
what is ewing sarcoma
- a form of bone and soft tissue cancer most often affecting children and young adults
what is rhabdomyosarcoma
originating from the skeletal muscle
what is leiomyosarcoma
smooth muscle sarcoma
where does leiosarcoma originate from
adipose tissue
where does synovial sarcoma originate from
from soft tissue around joints
where does angiosarcoma originate from
from the blood and lymph vessels
what is kaposi’s sarcoma
cancer caused by human herpesvirus 8, most often seen in patients with end-stage HIV, causing typical red/purple raised skin lesions but also affecting other parts of the body
where is the most common location for sarcoma to met to
lungs
red flag causes of back pain and the associated symptoms
- Spinal fracture (e.g., major trauma)
- Cauda equina (e.g., saddle anaesthesia, urinary retention, incontinence or bilateral neurological signs)
- Spinal stenosis (e.g., intermittent neurogenic claudication)
- Ankylosing spondylitis (e.g., age under 40, gradual onset, morning stiffness or night-time pain)
- Spinal infection (e.g., fever or a history of IV drug use)
non msk causes for back pain
- Pneumonia
- Ruptured aortic aneurysms
- Kidney stones
- Pyelonephritis
- Pancreatitis
- Prostatitis
- Pelvic inflammatory disease
- Endometriosis
the sciatic nerve is formed from which nerve roots?
L4-S3
describe the route of the sciatic nerve
- exits the posterior part of the pelvis through the greater sciatic foramen
- It travels down the back of the leg.
- At the knee, it divides into the:
- tibial nerve and the
- common peroneal nerve.
what does the sciatic nerve innervate
sensation to the lateral lower leg and the foot.
It supplies motor function to the posterior thigh, lower leg and foot.
what are the causes of sciatica
lumbosacral nerve root compression by:
- Herniated disc
- Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
- Spinal stenosis
bilateral sciatica should make you think____
it’s a RED FLAG for cauda equina
back stiffness in the morning or with rest should make you think:
ankylosing spondylitis
back pain red flags
- ankylosing spondylitis
- stiffness and pain in morning/with rest
- age <40
- gradual onset
- night pain
- spinal infection
- IV drug use
- fever
- cancer
- weightloss
- gradual onset
- night pain
- age over 50
- history of cancer (think mets)
- cauda equina
- urinary retention or incontinence
- faecal incontinence
- saddle anaesthesia
- bilateral neurological symptoms
what investigation for suspected cauda equina
MRI
investigations and findings in ank spon
- Inflammatory markers (CRP and ESR)
- X-ray of the spinal and sacrum (may show a fused “bamboo spine” in later-stage disease)
- MRI of the spine (may show bone marrow oedema early in the disease)
treatment of back pain
- NSAIDs (e.g., ibuprofen or naproxen) first-line
- Codeine as an alternative
- Benzodiazepines (e.g., diazepam) for muscle spasm (short-term only – up to 5 days)
management of sciatica
- NSAIDs (e.g., ibuprofen or naproxen) first-line
- Codeine as an alternative
- Benzodiazepines (e.g., diazepam) for muscle spasm (short-term only – up to 5 days)
- if symptoms persist or worsen at follow up
- neuropathic medication (NOT gabapentin or pregabalin
- so amitriptyline or duloxetine
- neuropathic medication (NOT gabapentin or pregabalin
red flags for cauda equina
- Saddle anaesthesia (loss of sensation in the perineum – around the genitals and anus)
- Loss of sensation in the bladder and rectum (not knowing when they are full)
- Urinary retention or incontinence
- Faecal incontinence
- Bilateral sciatica
- Bilateral or severe motor weakness in the legs
- Reduced anal tone on PR examination
where does spinal cord terminate
L2/L3
what do the nerves of the cauda equina supply
- Sensation to the perineum, bladder and rectum
- Motor innervation to the lower limbs and the anal and urethral sphincters
- Parasympathetic innervation of the bladder and rectum
causes of cauda equina
- Herniated disc (the most common cause)
- Tumours, particularly metastasis
- Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
- Abscess (infection)
- Trauma
management of suspected cauda equina
- Immediate hospital admission
- Emergency MRI scan to confirm or exclude cauda equina syndrome
- Neurosurgical input to consider lumbar decompression surgery
complications of cauda equina
Surgery should be performed as soon as possible to increase the chances of regaining function.
Even with early surgery, patients can be left with bladder, bowel or sexual dysfunction.
Leg weakness and sensory impairment can also persist.
what is MSCC
- When a metastatic lesion compresses the spinal cord (before the end of the spinal cord and the start of the cauda equina), this is called metastatic spinal cord compression (MSCC). This is different to cauda equina, which specifically refers to compression of the cauda equina.
how does metastatic spinal cord compression present
MSCC presents similarly to cauda equina, with back pain and motor and sensory signs and symptoms. A key feature is back pain that is worse on coughing or straining.
differentiate cauda equina and metastatic spinal cord compression
Cauda equina presents with lower motor neuron signs (reduced tone and reduced reflexes). The nerves being compressed are lower motor neurons that have already exited the spinal cord.
When the spinal cord is being compressed higher up by metastatic spinal cord compression, upper motor neuron signs (increased tone, brisk reflexes and upping plantar responses) will be seen.
what is Meralgia paraesthetica
localised sensory symptoms of the outer thigh caused by compression of the lateral femoral cutaneous nerve. It is a mononeuropathy, meaning it only affects a single nerve.
describe the origin of the lateral femoral cutaneous nerve
originates from varying combinations of L1, L2 and L3 nerve roots. It comes from behind the psoas muscle, around the surface of the iliacus muscle and under the inguinal ligament onto the thigh, just medial and inferior to the anterior superior iliac spine (ASIS).
are there motor or sensory symptoms with meralgia paraesthetica
lateral femoral cutaneous nerve only carries sensory signals. Therefore, there are no motor symptoms with meralgia paraesthetica.
presentation of meralgia paraesthetica
abnormal sensations (dysaesthesia) and loss of sensation (anaesthesia) in the lateral femoral cutaneous nerve distribution. The skin of the upper-outer thigh is affected. Patients may describe symptoms of:
- Burning
- Numbness
- Pins and needles
- Cold sensation
There may also be localised hair loss.
Symptoms are aggravated by walking or standing for a long duration and improve when sitting down.
Symptoms are often worse with extension of the hip on the affected side. This can be used to reproduce symptoms on examination.
management of maralgia paraesthetica
-
Conservative management involves:
- Rest
- Weight loss (if appropriate)
- Physiotherapy
-
Medical management is based around analgesia if pain is a feature, such as:
- Paracetamol
- NSAIDs
- Neuropathic analgesia (e.g., amitriptyline, gabapentin, pregabalin or duloxetine)
- Local injections of steroids or local anaesthetics
-
Surgical management may involve:
- Decompression – removing pressure on the nerve
- Transection – cutting the nerve
- Resection – removing the nerve
what is bursitis
inflammation of a bursa which causes thickening of the synovial membrane and increased fluid production, causing swelling.
bursitis can be caused by
- Friction from repetitive movements
- Trauma
- Inflammatory conditions (e.g., rheumatoid arthritis)
- Infection – referred to as septic bursitis
management of trochanteric bursitis
- Rest
- Ice
- Analgesia (e.g., ibuprofen or naproxen)
- Physiotherapy
- Steroid injections
can take 6-9 months to recover fully
presentation of trochanteric bursitis
- gradual-onset lateral hip pain (over the greater trochanter) that may radiate down the outer thigh.
- The pain is described as aching or burning.
- It is worse with activity, standing after sitting for a prolonged period and trying to sit cross-legged.
- It may disrupt sleep and be difficult to find a comfortable lying position.
- On examination, there is tenderness over the greater trochanter. There is not usually any swelling (unlikely bursitis in other areas).
- They may have positive trendellenburg’s
what are the ottowa knee rules
- they are used to determine if patients need an x ray after acute knee injury to look for a fracture
- a pt requires an x ray if any of the following are present
- Age 55 or above
- Patella tenderness (with no tenderness elsewhere)
- Fibular head tenderness
- Cannot flex the knee to 90 degrees
- Cannot weight bear (cannot take 4 steps – limping steps still count)
what are the two surgeries for a meniscal tear?
- both are arthroscopies
- Repair of the meniscus if possible
- Resection of the affected portion of the meniscus (this often results in osteoarthritis)
the cruciate ligaments are named after where they attach on the _____
tibia
- The ACL attaches at the anterior intercondylar area on the tibia
- The PCL attaches at the posterior intercondylar area on the tibia
in which direction do each of the cruciate ligaments stabilise?
The ACL stops the tibia from sliding forward in relation to the femur. The PCL tops the tibia sliding backwards in relation to the femur.
investigating knee ligament injuries
MRI scan is usually the first-line imaging investigation for establishing the diagnosis.
Arthroscopy can be used to visualise the cruciate ligament and is the gold-standard investigation for diagnosing a cruciate ligament tear.
management of cruciate ligament injury
- conservative managmenet with RICE
- NSAIDs
- Crutches
- physiotherapy
- arthroscopic surgery
what happens in ACL surgery
- Arthroscopy
- A new ligament is formed using a graft of tendon from another location. graft could be from:
- Hamstring tendon
- Quadriceps tendon
- Bone-patellar tendon-bone (taking part of the patella tendon as well as the bone it inserts into)
presentation of osgood-schlatter disease
- Gradual onset
- Common cause of anterior knee pain in adolescents
- Visible or palpable hard and tender lump at the tibial tuberosity
- Pain in the anterior aspect of the knee
- The pain is exacerbated by physical activity, kneeling and on extension of the knee
management of Osgood-Schlatter disease
rest
NSAIDs
Ice
complications of osgood-schlatter disease
The patient is usually left with a hard bony lump on their knee.
A rare complication is a complete avulsion fracture, where the tibial tuberosity is separated from the rest of the tibia. This requires surgical intervention.
what causes bakers cyst
- secondary to degenerative changes in the knee joint. They can be associated with:
- Meniscal tears (an important underlying cause)
- Osteoarthritis
- Knee injuries
- Inflammatory arthritis (e.g., rheumatoid arthritis)
Synovial fluid is squeezed out of the knee joint and collects in the popliteal fossa
complications of bakers cysts
- can rupture if pressure is high enough
- this causes pain, swelling and erythema in the surrounding tissue
- RARELY a ruptured bakers cyst can cause compartment syndrome
*
management of baker’s cyst
- no treatment required if asymptomatic
- non-surgical if symptomatic
- modified activity
- NSAIDs
- analgesia
- physio
- US guided aspiration
- surgical management would be to treat underlying knee pathology
what are the two types of achilles tendonopathy
- Insertion tendinopathy (within 2cm of the insertion point on the calcaneus)
- Mid-portion tendinopathy (2-6 cm above the insertion point)
risk factors for achilles tendonopathy
- Sports that stress the Achilles (e.g., basketball, tennis and track athletics)
- Inflammatory conditions (e.g., rheumatoid arthritis and ankylosing spondylitis)
- Diabetes
- Raised cholesterol
- Fluoroquinolone antibiotics (e.g., ciprofloxacin and levofloxacin)
investigations of achilles tendonopathy
clinical diagnosis
important to exclude achilles tendon rupture with a calf squeeze test
management of achilles tendonopathy
- Rest and altered activities
- Ice
- Analgesia
- Physiotherapy
- Orthotics (e.g., insoles)
- Extracorporeal shock-wave therapy (ESWT)
- Surgery, to remove nodules and adhesions or alter the tendon, may be used where other treatments fail
- REMEMBER THAT STEROID INJECTIONS ARE CONTRAINDICATED DUE TO RISK OF TENDON RUPTURE
Risk factors for achilles tendon rupture
- Sports that stress the Achilles (e.g., basketball, tennis and track athletics)
- Increasing age
- Existing Achilles tendinopathy
- Family history
- Fluoroquinolone antibiotics (e.g., ciprofloxacin and levofloxacin)
- Systemic steroids
presentation of achilles tendon rupture
- Sudden onset of pain in the Achilles or calf
- A snapping sound and sensation
- Feeling as though something has hit them in the back of the leg
signs of achilles tendon rupture on examination
- When relaxed in a dangled position, the affected ankle will rest in a more dorsiflexed position
- Tenderness to the area
- A palpable gap in the Achilles tendon (although swelling might hide this)
- Weakness of plantar flexion of the ankle (dorsiflexion is unaffected)
- Unable to stand on tiptoes on the affected leg alone
- Positive Simmonds’ calf squeeze test
describe simmonds calf squeeze test
- Simmonds’ calf squeeze test is the test for Achilles tendon rupture.
- The patient is positioned prone or kneeling with the feet hanging freely off the end of the bench or couch.
- When squeezing the calf muscle in a leg with an intact Achilles, there will be plantar flexion of the ankle.
- Squeezing the calf pulls on the Achilles. When the Achilles is ruptured, the connection between the calf and the ankle is lost.
- Squeezing the calf will not cause plantar flexion of the ankle in a leg with a ruptured Achilles. A lack of plantar flexion is a positive result.
how do you diagnose ruptured achilles tendon
Ultrasound to confirm following examination
management of ruptured achilles tendon
- debate between surgical and non-surgical methods
- surgery has lower rate of recurrance
- non-surgical avoids all surgical risks
- non-surgical
- special boot that’s initially in full plantarflexion
- gradually over 6-12 weeks the ankle is dorsiflexed
- surgical
- similar but tendon is reattached first
what is the plantar fascia?
plantar fascia is thick connective tissue. It attaches to the calcaneus at the heel, travels along the sole of the foot and branches out to connect to the flexor tendons of the toes.
what is the presentation of plantar fasciitis
Presentation is with a gradual onset of pain on the plantar aspect of the heel. This is worse with pressure, particularly when walking or standing for prolonged periods. There is tenderness to palpation of this area.
what is the management of plantar fasciitis
- Rest
- Ice
- Analgesia (e.g., NSAIDs)
- Physiotherapy
- Steroid injections (can be very painful and rarely cause rupture of the plantar fascia or fat pad atrophy)
what causes fat pad atrophy
age or inflammation from repetitive impacts, such as jumping activities, running, walking, and obesity. Local steroid injections (used to treat plantar fasciitis) can cause fat pad atrophy.
what is the presentation of fat pad atrophy
pain and tenderness over the plantar aspect of the heel.
Symptoms are worse with activities, particularly when barefoot on hard surfaces.
management of fat pad atrophy
comfortable shoes, custom insoles, adapting activities (e.g., avoiding high heels) and weight loss if appropriate.
what is the medical name for bunions
hallux valgus
what is actually happening in bunions
eformity at the metatarsophalangeal joint (MTP) at the base of the big toe. The first metatarsal becomes angled medially, the big toe (hallux) become angled laterally (towards the other toes), and the MTP joint becomes inflamed and enlarged. Over time, additional stress on the joint can result in osteoarthritis.
investigation of bunions
weight bearing x ray to check the extent of the deformity
managment of bunions
- comfortable shoes, bunion pads
- surgery is the definitive treatment
aspiration of fluid in gout will show
- No bacterial growth
- Needle shaped crystals
- Negatively birefringent of polarised light
- Monosodium urate crystals
management of an acute flair of gout is
- NSAIDs (e.g. ibuprofen) are first-line
- Colchicine second-line
- Steroids can be considered third-line
allopurinol rules in gout
Do not initiate allopurinol prophylaxis until after the acute attack has settled. Starting allopurinol can cause or worsen an attack of gout.
When a patient is already using allopurinol, they can continue taking it during further acute episodes.
what is frozen shoulder also called
adhesive capsulitis
what are the two types of adhesive capsulitis
primary: occurring spontaneously without any trigger
secondary: occurring in response to trauma, surgery or immobilisation
what is the pathophysiology of frozen shoulder
inflammation and fibrosis in the joint tissue lead to adhesions. adhesions bind the capsule and cause it to tighten around the joint, thus restricting movement
presentation and disease course in frozen shoulder
- painful phase
- may be worst at night
- stiff phase
- affects both passive and active movement
- external rotation is most affected
- pain settles during this phase
- thawing phase
- gradual reduction in stiffness and return to normal
each phase lasts around 6 months
up to 50% of patients will have persistent symptoms
most common differentials of shoulder pain and stiffness NOT preceded by trauma
- acromioclavicular joint arthritis
- supraspinatus tendonopathy
- glenohumoral joint arthritis
- adhesive capsulitis
rare but serious differentials for shoulder pain and stiffness not preceded by trauma
- septic arthritis
- inflammatory arthritis
- malignancy
describe supraspinatus tendinopathy and how you would examine for it
Supraspinatus tendinopathy involves inflammation of the supraspinatus tendon, particularly due to impingement at the point where it passes between the humeral head and the acromion.
The empty can test (AKA Jobe test) can be used to assess for supraspinatus tendinopathy. This involves the patient abducting the shoulder to 90 degrees and fully internally rotating the arm as though they are emptying a can of water. The examiner pushes down on the arm while the patient resists. The test is positive if there is pain or the arm gives way.
how would you examine for acromioclavicular joint arthritis?
- Tenderness to palpation o
- Pain is worse at the extremes of the shoulder abduction, from around 170 degrees onwards when the arm is overhead
- Positive scarf test – pain caused by wrapping the arm across the chest and opposite shoulder
diagnosis of adhesive capsulitis
clinical based on Hx and Examination
non-surgical management options for adhesive capsulitis
- Continue using the arm but don’t exacerbate the pain
- Analgesia (e.g., NSAIDs)
- Physiotherapy
- Intra-articular steroid injections
- Hydrodilation (injecting fluid into the joint to stretch the capsule)
surgical options for adhesive capsulitis
- Manipulation under anaesthesia – forcefully stretching the capsule to improve the range of motion
- Arthroscopy – keyhole surgery on the shoulder to cut the adhesions and release the shoulder
name the 4 rotator cuff muscles and what they do
- mnemonic SITS
- supraspinatus - abducts the arm
- infraspinatus - externally rotates the arm
- terres minor - externally rotates the arm
- subscapularis - internally rotates the arm
investigations in shoulder pain
X-rays will not show soft tissue injuries such as rotator cuff tears. They may be helpful for excluding bony pathology, such as osteoarthritis.
Ultrasound or MRI scans can diagnose a rotator cuff tear.
management of rotator cuff tears
- non-surgical options
- Rest and adapted activities
- Analgesia (e.g., NSAIDs)
- Physiotherapy
- younger and more active patients are more likely to have surgery to repair
- arthroscopic rotator cuff repair
what is the difference between subluxation and dislocation
- dislocation is where the ball comes completely out of the socket
- subluxation refers to partial dislocation and it easily pops back in
are shoulder dislocations likely to be anterior or posterior
90% are anterior
posterior shoulder dislocations are associated with:
electric shocks and seizures
what is the glenoid labrum
ring of cartilage around the glenoid cavity that creates a deeper socket - it can tear when shoulder dislocates
what are bankart lesions
tears to the anterior portion of the labrum.
These occur with repeated anterior subluxations or dislocations of the shoulder.
what are Hill-Sachs lesions
compression fractures of the posterolateral part of the head of the humerus. As the shoulder dislocates anteriorly, the posterolateral part of the humeral head impacts with the anterior rim of the glenoid cavity. Part of the humeral head is damaged, making the shoulder less stable and at risk of further dislocations.
what might cause axillary nerve damage and how does it present?
shoulder dislocation might damage axillary nerve
Damage to axillary nerve causes a loss of sensation in the “regimental badge” area over the lateral deltoid. It also leads to motor weakness in the deltoid and teres minor muscles.
which nerve roots does the axillary nerve come from?
C5 and C6
three important things to assess for in patients with shoulder dislocation
- Fractures
- Vascular damage (e.g., absent pulses, prolonged capillary refill time and pallor)
- Nerve damage (e.g., loss of sensation in the “regimental patch” area)
management of shoulder dislocation
- Analgesia, muscle relaxants and sedation as appropriate
- Entonox
- Closed reduction of shoulder (after excluding a fracture)
- Ideally this should happen as early as possible as muscles will spasm, making it harder to relocate the shoulder and increasing risk of neurovascular injury
- Dislocations with fracture may require surgery
- Post-reduction x-rays
- Immobilisation for a period after relocation of the shoulder
ongoing management of shoulder dislocation
- physiotherapy
- shoulder stabilisation surgery
- Repairing Bankart lesions
- Tightening the shoulder capsule
- Bone graft using bone from the coracoid process to correct a bony injury to the glenoid rim (Latarjet procedure)
- Correcting Hill-Sachs lesions (Remplissage procedure)
joint/bursae aspiration colours and what they may indicate
- pus - indicates infection
- straw coloured - infection less likely
- blood - indicates trauma, infection or inflammatory causes
- milky colour - indicates gout or pseudogout
management of olecranon bursitis
- Rest
- Ice
- Compression
- Analgesia (e.g., paracetamol or NSAIDs)
- Protecting the elbow from pressure or trauma
- Aspiration of fluid may be used to relieve pressure
- Steroid injections may be used in problematic cases where infection has been excluded
presentation of bursitis
- Swollen
- Warm
- Tender
- Fluctuant (fluid-filled)
when infection is a suspected cause of bursitis or if it cannot be excluded what is the treatment
- Aspiration of the fluid for microscopy and culture
- Antibiotics
- flucloxacillin first line
- clarithromycin as an alternative
managment of repetitive strain injury
they must stop doing the thing that made them get it
- R – Rest
- I – Ice
- C – Compression
- E – Elevation
epicondylitis is a specific type of:
repetitive strain injury
The tendons of the muscles that insert into the medial epicondyle act to
flex the wrist
The tendons of the muscles that insert into the lateral epicondyle act to
extend the wrist
lateral epicondylitis is also known as
tennis elbow
describe mills test and what is it for
lateral epicondyl is palpated with the elbow in an extended position and the forearm pronated
production of pain is a positive result for lateral epicondylitis
describe cozen test and what it’s for
elbow extended, forearm pronated, wrist deviated in the direction of the radius and hand in a fist. The examiner holds the patient’s elbow with pressure on the lateral epicondyle. The examiner applies resistance to the back of the hand while the patient extends the wrist.
If this causes pain, the test is positive, indicating lateral epicondylitis.
what is medial epicondylitis also known as
golfers elbow
how do you test for medial epicondylitis
stretching the flexor muscles of the forearm while palpating the medial epicondyle. The elbow is extended, forearm supinated and wrist and fingers are extended. The examiner holds the patient’s elbow with pressure on the medial epicondyle. If this causes pain, the test is positive, indicating medial epicondylitis.
management of medial epicondylitis
- counsel that it is normally self limiting and can take years to resolve
- Rest
- Adapting activities
- Analgesia (e.g., NSAIDs)
- Physiotherapy
- Orthotics, such as elbow braces or straps
what is trigger finger
condition causing pain and difficulty moving a finger. It is also known as stenosing tenosynovitis.
pathophysiology of tenosing tenosynovitis
sheaths that cover tendons at joints of fingers can thicken causing problems with tendon sliding through
there may be a nodule on the tendon that gets stuck causing stiffness and a pop as it moves through
risk factors for tenosing tenosynovitis
- in 40s
- female
- diabetes
- both types but mainly type 1
management of tenosing tenosynovitis
- rest
- splinting
- steroid injections
- surgery to release the sheath
which finger is most likely to be affected by dupuytren’s contracture
ring finger
management of dupuytren’s contracture
- do nothing
- surgery
- needle fasciotomy
- limited fasciectomy
- dermofasciectomy
- removal of skin too - skin graft is needed
risk factors for carpal tunnel
- Repetitive strain
- Obesity
- Perimenopause
- Rheumatoid arthritis
- Diabetes
- Acromegaly
- Hypothyroidism
so if you see it in an exam - consider whether there is an underlying cause
what is the distribution of sensory symptoms of carpal tunnel and which nerve is it
distribution of the palmar digital cutaneous branch of the median nerve, affecting the palmar aspects and full fingertips of the:
- Thumb
- Index and middle finger
- The lateral half of ring finger
motor symptoms of carpal tunnel
affect the thenar muscles, with:
- Weakness of thumb movements
- Weakness of grip strength
- Difficulty with fine movements involving the thumb
- Wasting of the thenar muscles (muscle atrophy)
describe phalen’s test for carpal tunnel
Phalen’s test involves fully flexing the wrist and holding it in this position. Often this is done by asking the patient to put the backs of their hands together in front of them with the wrists bent inwards at 90 degrees. The test is positive when this position triggers the sensory symptoms of carpal tunnel, with numbness and paraesthesia in the median nerve distribution.
describe tinnel’s test of carpal tunnel
Tinnel’s test involves tapping the wrist at the location where the median nerve travels through the carpal tunnel. This is in the middle, at the point where the wrist meets the hand. The test is positive when this position triggers the sensory symptoms of carpal tunnel, with numbness and paraesthesia in the median nerve distribution.
management of carpal tunnel
- Rest and altered activities
- Wrist splints that maintain a neutral position of the wrist can be worn at night (for a minimum of 4 weeks)
- Steroid injections
- Surgery
- flexor retinaculum (AKA transverse carpal ligament) is cut to release the pressure on the median nerve.
ganglion cyst diagnosis
- clinical diagnosis - could use US to exclude other causes
- examination findings
- Range in size from 0.5 to 5cm or more (most are 2cm or less)
- Firm and non-tender on palpation
- Well-circumscribed
- Transilluminates (shining a torch into the cyst causes the whole lump to light up)
management of ganglion cysts
managed conservatively, without any intervention. 40-50% of cysts will resolve spontaneously, but this can take several years.
Active management options for ganglion cysts are:
-
Needle aspiration
- high rate of recurrence
- Surgical excision
