Surgery (6) Flashcards
What differential diagnosis to always consider in hip pain?
ALWAYS CONSIDER:
- Inflammatory arthritis
- Fracture
- Infection or Infiltration
- Cancer
- local joints
Characteristic features of osteoarthritic pain
Osteoarthritis
- joint pain
- stiffness worse on activity
- swelling
Characteristic features found on examination of trochanteric bursitis
- Lateral hip pain aggravated by direct pressure
- Tenderness over trochanteric bursa
Characteristics of hip pain in meralgia paraesthetica
- localised area of pain/paraesthesia over lateral thigh
- it is not affected by hip movement
Characteristics of pain in iliotibial band syndrome
- Lateral hip pain that radiates down leg side
- exacerbated by running/walking
- Tenderness over IT band
Management: activity modification and iliotibial band stretches; if not improving then physiotherapy referral
Characteristics of pain in lumbar radiculopathy
- Pain + paraesthesia + reduced sensation + weakness + back pain
- Straight leg raise elicits pain
Characteristics of pain in lumbar spinal stenosis
- pain that radiates to leg/groin
- exacerbated by walking
- relieved by sitting or leaning forwards
- numbness/weakness
Treatment: laminectomy
When to suspect osteonecrosis?
Suspect when there is:
- anterior groin pain
- hx of corticosteroids
Components of MSK examination
LOOK, FEEL, MOVE
- Check for pain/tenderness beforehand
- Offer to examine the joint above and below
- Complete examination with a neurological and vascular examination
Components of ‘LOOK’ part of MSK examinaion
- Ask patient to stand
- Look for bony abnormalities
- Look for soft tissue abnormalities
- Look for scars
- Observe gait
- Trendelenburg test
How to perform the Trendelenburg test?
Trendelenburg test
(assesses abductor muscle function)
- Ask patient to place their hands on your outstretched hands (for stability) and ask them to stand on the leg that you are examining, lifting the contralateral leg off the ground (for 30 seconds)
- Feel for a drop in the pelvis on the contralateral side. If there is abductor pathology (gluteus medius and minimus) on the side you are examining then the contralateral side (the normal side) will sag down (“Sound Side Sags”)
‘FEEL’ component of hip examination
- Temperature of joint
- Palpation of bony landmarks – greater trochanter, mid-inguinal point
- Measure leg-length to look for discrepancy
MOVE component of hip examination
- Flexion (130 degrees)
- Thomas’ test
- flex opposite side to eliminate lumbar lordosis
- affected side lifts up to reveal fixed flexion deformity
- Abduction (normal to 45)
- Adduction (30 degrees)
- Rotation – 45 each way – NB: this is often affected earliest in OA
Characteristics of osteoarthritis
Chronic disease characterised by:
- joint pain
- limited movement
- inflammation localised to the joint
- without systemic effects
Primary and secondary causes of osteoarthritis
Primary
age, obesity, occupation
Secondary
Paget’s disease, Acromegaly,
haemochromatosis, Wilson’s disease
Characteristic hand changes of osteoarthritis
Characteristic X-ray changes in OA
Management of osteoarthritis
Conservative:
- help with weight loss
- local muscle strengthening exercises and general aerobic fitness
Medical:
- paracetamol and topical NSAIDs are first-line analgesics. Topical NSAIDs are indicated only for OA of the knee or hand
- second-line treatment is oral NSAIDs/COX-2 inhibitors, opioids, capsaicin cream and intra-articular corticosteroids
* PPI should be co-prescribed with NSAIDs and COX-2 inhibitors. These drugs should be avoided if the patient takes aspirin
Non-pharmacological
- supports and braces
- TENS
- shock absorbing insoles or shoes
- if conservative methods fail then refer for consideration of joint replacement
OA vs RA
What can be seen OE of hip fracture and why
- Leg lying externally rotated and shortened
Iliopsoas muscle attaches to the lesser trochanter
→ if fracture is proximal to the attachment →pull of muscle → causes the affected limb to lie shortened and externally rotated
General rules of fracture management
Fracture Management (General) – 4 R’s
- Resuscitation
- Reduction (if required)
- Restriction
- Rehabilitation
General complications of fractures
- Tissue damage → haemorrhage and shock/muscle damage
- Prolonged bed rest → chest infection, UTI, pressure sores, DVT
- Anaesthesia → anaphylaxis, aspiration
- Compartment syndrome
- Neurological
- Delayed union/malunion
- Avascular necrosis
