Regional adult orthopaedics Flashcards
A man comes to see you saying he was lifting some logs when he got severe pain in his back. He says the pain is worse on coughing. What is this and do you do?
Acute dic tear. Analgesia and physiotherapy and advice that symptoms usually resolve in 2 - 3 months.
What is sciatica?
The nucleus polposis herniates/prolapses through a disc tea. Disc material then presses on an exiting nerve root resulting in pain and altered sensation in a dermatomal distribution
Damage to what disc and nerve causes a reduced knee jerk?
L3/L4 prolapse, L4 root entraptment
In a disc prolapse is it the nerve root of the lower of upper vertebrae that is damaged?
Lower
What nerve root is damaged if the patient complains of pain in the dorsum of the foot?
L5
How would you treat sciatica?
Analgesia
Maintain mobility
Physiotherapy
Gabapentin may help
What is spinal stenosis? why do you get it?
The cauda equina of the spinal cord has less space and so multiple nerve roots become compressed/irritated
A 70 year old man comes to you complaining of a burning pain in his back which is worse when walking downhill. He already suffers from intermittent claudication in his back.
Spinal stenosis
Why is the pain improved on walking uphill in people who suffer from spinal stenosis?
Spine flexion creates more space for the cauda equina
A patient comes in complaining on pain in both legs and a numbness in her bottom. She revels she had an episode of urinary incontinence yesterday. What do you do?
Cauda equina syndrome
Perform a rectal examination
Urgent MRI
Urgent discectomy
What changes might you seen on MRI in a patient with avascular necrosis of the femoral head?
Patchy sclerosis of the weight bearing area of the femoral head with a lytic zone underneath caused by granulation tissue. This lytic zone gives rise to the “hanging rope” sign.
What can you do surgically if you catch AVN early?
Drill holes in the femoral neck and into the abnormal are to relieve pressure, promote healing and prevent collapse.
What is the treatment for a collapsed femoral head due to AVN?
Total hip replacement
A patient presents to you with pain and tenderness in the region of the greater trochanter and, on examination has pain on resisted abduction.
Troachanteric bursitis
How is trochanteric bursitis treated?
Analgesia, NSAIDs, physiotherapy to strengthen other muscles
What does the anterior cruciate ligament do?
Prevent abnormal internal rotation of the tibia?
What does the PCL do?
Prevents hyperextension and anterior translation of the femur
What does the MCL do?
Resists valgus force
What does the LCL do?
Resists varus force and abnormal external roatation of the tibia.
A patient presents to you following a twisting injury yesterday at football.The have pain in the medial joint line, an effusion and complains of a locking of the knee meaning they cannot straighten it fully.
Meniscal tear
What is true knee locking?
A mechanical block to full extension caused by the torn meniscus flipping over and becoming stuck in the joint line.
A patient comes into A & E from a rugby match. He describes being tackled whilst standing and says he heard a pop. when the injury occured. The patient has a large effusion and when you drain this it is blood.
ACL rupture
What might an injury causing hyperextension of the knee cause?
PCL rupture
What will a valgus stress injury cause?
Rupture of the MCL
What will a varus stress injury cause?
Rupture of the LCL
What might a direct blow to the anterior tibia with the knee flexed cause?
PCL rupture
What clinical findings would you expect with a meniscal tear?
Effusion
Joint line tenderness
Pain of tibial rotation localising to the affected compartment.
What investigation would you order to confirm a meniscal injury?
MRI
What is the treatment for a meniscal tear in a young adult.
Arthroscopic repair or trimming of the meniscus.
Describe a meniscal tear that would be suitable for surgical repair.
Fresh tears involving the outer third of the meniscus.
What would you expect the clinical findings to be for a patient who presents with an ACL rupture?
Knee swelling
Positive lachman test
Describe the surgery for a torn ACL.
Tendon graft (usually patellar tendon) being passed through tibial and femoral tunnels at the usual location of the ACL.
How would you treat a MCL tear?
Hinged knee brace
A patient presents with laxity and pain of valgus stress with tenderness over the medial joint line?
MCL tear
If you have a complete knee disclocation, what ligaments have been ruptured and what are you at risk of?
All four ligaments
Risk of neurovascular injury
A patient, who is currently taking steroids for her crohn’s disease, presents to a & e after a fall complaining of knee pain. . On examination she has a positive straight leg raise test and a palpable gap below her patella.
Extensor mechanism rupture
What is the treatment of an extensor mechanism tear?
Surgical repair.
What test would you order to confirm an extensor mechanism rupture?
Ultrasound
A patient presents to the GP complaining of anterior knee pain which is worse on going downhill. They also complaining of a clicking sensation after prolonged sitting.
Patellofemoral dysfunction
What is the treatment for patellofemoral dysfunction?
Physiotherapy to rebalance the quadriceps muscle.
In what direction does the patella usually dislocate?
Laterally
A girl presents after being ran into at hockey. She sais she felt her knee cap move but it seemes to go back. Now it feels funny/
Patellar dislocation
A patient presents complaining that the appearance of her feet is horrible and she gets pain when walking. On examination there is later deviation of the great toe and a lump on the medial aspect of the foot.
Hallux valgus
What bony problem causes the appearance of hallux valgus?
Medial deviation of the first metatarsal and lateral deviation of the toe itself
What is hallux rigidis?
Osteoarthritis of the first MTP joint.
What is the gold standard treatment for hallux rigidus?
Arthodesis.
What conservative treatment would you try first in the treatment of hallux rigidus?
Still soled shoe to limit motion
Metal bar inserted into the sole of the shoe.
A 50 year old lady comes into your clinic complaining of a burnin,g tingling pain in her two middle toes. On examination there is a loss of sensation in the webbed space between these toes .
Mortons neuroma
What test would you order to confirm diagnosis of a mortons neuroma?
Ultrasound
What treatments would you recommend for a mortons neuroma?
Offloading insole, Steroid/local anaesthetic injections
Excision of the neuroma.
What is the treatment for a metatarsal stress fracture?
Rest for 6 - 12 weeks with a rigid soled boot.
A proffesional dancer presents with pain in her second and third toes.
Metarsal stress fracture
What is the treatment for achilles tendonitis?
Rest, physiotherapy, use of a heel raise
A patient presents saying they has a sudden pain in the back of their leg whilst playing squash. They described it saying it felt “as if they had been kicked”
Achilles tendon rupture
What movement can you not perform if you have ruptured your achilles tendon?
Plantarflexion of the foot.
If you decide to treat an achilles tendon rupture with a series of case, what position would you like to have the foot in?
The equinous position. The ankle plantarflexed with the toes pointing down.
A 50 year old man presents with pain on the instep of his foot when walking. He suffers from type 2 diabetes.
Plantar fasciitis
What is the treatment for plantar fasciatis?
Rest, achilles and plantar fascia stregthnening exercises.
When examining a patient at the diabetic review clinic you notice that his feet appear to have a rocker bottom appearance and are red and swollen. When you palpate this area it is red and tender.
Charcot foot
How do you treat charcot foot?
Immobilization and bracing.
Rupture of which tendon causes loss of the medial arch?
Tibialis posterior tendon
What is the problem in claw toes?
Hyperextension at the MTPJ with hyperflexion at the PIPJ and DIP.
What is the problem in hammer toes?
Hyperextension at the DIPJ
What are the treatment options for claw or hammer toe?
Tenotomy, tendon transfer, arthrodesis, amputation.
