Trauma and Orthopaedics Flashcards
What is cervical spondylosis, its presentation and management?
Degenerative changes of the cervical spine (degeneration of the annulus fibrosus)
Presentation: - Men > 60 yrs, women > 50 yes. Usually asymptomatic but can cause neck and arm pain + paraesthesia
5-10% develop cervical myelopathy
Management - Acute presentation = neurosurgical referral
Rotator cuff injury presentation, investigation and management
Shoulder pain and weakness, typically on abduction. Night pain. Typically >40 years old
US / MRI
Analgesia (maybe steroids but risks complete tear)
Surgery if complete, if incomplete then surgery if symptoms persist
Adhesive capsulitis presentation and management
No obvious trigger. Very unusual in a younger person. Severe shoulder pain, typically worse at night. Active and passive movement range is reduced.
Management - Analgesia, NSAIDs and physiotherapy earlier. Corticosteroids may help in early stages
Oral steroids for short term (<6 weeks) but no benefit after that.
Surgical release with either manipulation under anaesthesia or arthroscopic arthrolysis is most effective.
Pain in anterior shoulder on forced flexion of arm. Cause? Management?
Long head of biceps tendinopathy
Treatment - analgesia, corticosteroid injection (risks full rupture)
Rupture of long head of biceps, presentation and treatment.
Discomfort after something pops after lifting or pulling. Ball appears like a muscle on flexion of arm
Treatment - repair rarely needed as function remains.
Spinal stenosis cause and presentation
Generalised narrowing of the lumbar spinal canal
Causes - Facet joint OA and osteophytes that result in nerve compression
Presentation - Gradual onset unilateral or bilateral leg pain (with/out back pain). Resolves when sitting, crouching, leaning forward. Normal clinical examination, Pain on leg extension.
Spinal stenosis investigation and management
Investigations - MRI needed to confirm diagnosis and rule out malignancy
Treatment - decompressive laminectomy. If not help: - NSAIDs, epidural steroid injections, corsets
What is tennis elbow?
Lateral epicondylitis
Presentation, investigation and management of lateral epicondylitis.
Presentation - Most common aged 45-55. History of repetitive strain. Unaccustomed activity like house painting or playing tennis (tennis elbow). Pain worse during resisted wrist and digit extension. and passive wrist flexion with elbow extended.
Investigations - Clinical diagnosis (ask patient to extent wrist and resist extension of the middle finger). Consider Elbow X-ray (for complex presentation), MRI of C-spine to rule out other causes
Management - Simple analgesia (NSAID, rest, ice, brace) Most are “watch and wait” - most recover within 6-24 months. Physio. Local anaesthetic injection sometimes used (lidocaine). Severe cases not cured with conservative management = surgery, extracorporeal shock wave therapy
What is Golfer’s elbow?
Medial epicondylitis
Medial Epicondylitis presentation
Usually 4th - 5th decade of life. Pain and tenderness localised to the medial epicondyle
Worse with wrist flexion and pronation. Can also be tingling in 4th/5th digit due to ulnar nerve which runs behind it.
Treatment same as lateral epicondylitis
What is student’s elbow?
Olecranon Bursitis
What is a bursa?
Sac containing a small amount of synovial fluid that lies between a tendon and either skin or bone to act as a friction buffer. They can be deep (subacromial bursa) or superficial (olecranon bursa)
Bursitis - thickening and proliferation of the synovial lining, bursal adhesions, tags, chalky deposits. May result from repetitive stress, infection, autoimmune disease or trauma.
What is cubital tunnel syndrome?
Ulnar neuritis - Osteoarthritic or rheumatoid narrowing of ulnar groove and constriction of the ulnar nerve as it passes behind the medial epicondyle or friction of the ulnar nerve due to cubitus valgus can cause fibrosis (where arm is extended away from the body when elbow extended)
Cubital tunnel presentation, investigation and management
Presentation - intermittent sensory symptoms in the 4th / 5th finger. Worse when elbow resting on a firm surface or flexed/extended for long periods of time.
Clumsiness of the hand, weakness of the small muscles of the hand innervated by the ulnar nerve
Tests - could consider nerve conduction studies
Treatment - Analgesia, avoid aggravating activity, physiotherapy Surgical decompression for nerve compression syndromes (resistant cases).
What is pulled elbow, its presentation and treatment?
Sublaxation of the radial head
Typical patient - 1-4 year old who has been lifted by the arm during play causing the radial head to slip out of the annual ligament (arm is slightly flexed and twisted inwards)
Imaging not usually needed
Management - Reduction (cradling the elbow with thumb/forefingers over the radial head)
Dupuytren’s Contracture presentation and management
Usually men aged >40 of European descent. Presents with a small lump or multiple with pits in the palm, progressing to contractures of the fingers.
Management:
Early disease - monitor 6 months. Adjunct - Corticosteroid injection (triamcinolone acetonide( - those with evidence of diease but no contractures yet
Other injections - clostridium histolyticum
Late disease - surgery - Fasciectomy (removal of fascia)
L3 Nerve Compression Presentation
Sensory loss over anterior thigh.
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
L4 Nerve Compression Presentation
Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
L5 Nerve Compression Presentation
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve root
S1 Nerve Compression Presentation
Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
Management of a prolapsed disc
- Similar to that of other musculoskeletal lower back pain: analgesia (gabapentin, pregabalin or amitriptyline), physiotherapy, exercises
- If symptoms persist (e.g.. after 4-6 weeks) then referral for consideration if appropriate
- Urgent surgical referral - if bladder/bowel symptoms, weakness and cauda equina compression
What is Charcot’s foot, presentations and risk factors for it
Also called neuropathic foot. Joints become damaged due to loss of sensation.
Most common in diabetics, also alcoholic neuropathy is associated
Joint typically warm, red and swollen but not as painful as expected
Plantar Fasciitis, presentation and management
Common cause of heel pain in adults. Plantar fasciitis is what supports the arch of the foot. Arises due to microtrauma.
Pain usually worse around the medial calcaneal tuberosity. Risk factors - obesity, inactivity, excessive walking
Management - Mostly conservative - rest, appropriate footwear (shows with arch support) Analgesia, orthopaedics referral if conservative management fails
Compartment syndrome presentation and diagnosis
Complication that occurs following fractures. Characterised by raised pressure within a closed anatomical space
Pain, particularly on movement. Paraesthesia, pallor, PULSE DOES NOT RULE OUT. Paralysis of muscle group can occur
Diagnosis - measurement of intracompartmental pressure (>20 mmHg is suggestive, >40 mmHg is diagnostic)
Treatment of compartment syndrome
Prompt and extensive fasciotomies (deep muscles need deeper incisions)
Necrotic tissue = debrided
Myoglobinuria may occur following fasciotomy and can result in renal failure = may need aggressive IV fluids.
What are stress fractures?
Tiny hairline fractures in a bone. Caused by repetitive force, often from overuse (jumping, immobilisation)
What is tibial stress syndrome and what is an important differential?
Also called shin splints Overuse injury (or repetitive-load injury) of the shin area. Leads to persistent dull anterior leg pain
Important differential = Stress fracture = do an X-ray to rule out
Risk factors for Achilles disorders
Use of Quinolone (e.g. ciprofloxacin)
Hypercholesterolaemia (predisposes to tendon xanthomata)
Achilles tendon rupture diagnosis
Sudden pop whilst running or playing support. Sudden onset of pain in the calf or ankle and inability to walk
Examination - Simmond’s triad (lying prone, feet hanging over the bed) Rupture leads to greater dorsiflexion of injured foot. Squeeze calf - ruptured foot will stay in neutral position
US for diagnosis
Acute referral to orthopaedics
What is carpal tunnel syndrome?
Pressure on the median nerve, often cause to a tightening of the flexor retinaculum around the wrist
Presentation of carpal tunnel
Pins and needles in the thumb, index and middle finger. Symptoms often at night. Patients shake to obtain relief. Symptoms can ascend proximally
Examination - weakness of thumb abduction, wasting of the thenar eminence. Tinels and phalens sign (worse on flexion of the wrist)
Treatment of carpal tunnel syndrome
Corticosteroid injection Wrist splints at night Surgical decompression (flexor retinaculum division)
What is trigger finger?
o Common condition associated with abnormal flexion of the digits
Thought to be caused by a disparity between the size of the tendon and pulleys through which they pass (tendon becomes stuck and cannot pass through the pully smoothly)
Presentation of trigger finger
§ Swelling of the flexor tendon or tightening of the sheath
§ Ring and middle fingers commonly affected
§ Initially stiffness and snapping (trigger) when extending a flexed digit
§ A nodule at the base of the affected finger may be felt
Swelling of the tendon sheath along with nodule formation on the tendon proximal to A1 pulley prevents tendon sliding smoothly and instead ‘catches; causing the finger to lock in flexion
Treatment of trigger finger
Simple rest and sometimes splinting
Steroid injections if pain severe
Big risk factor for adhesive capsulitis?
Diabetes
