Trauma and Orthopaedics Flashcards
Outline the Salter-Harris Classification, who it’s used for and the rough classifications
A method used to grade fractures that occur in children and involve the growth plate
Type 1 – transverse fracture through the growth plate
Type 2 (most common) – fracture through the growth plate and the metaphysis
Type 3 – fracture through growth plate and epiphysis, sparing the metaphysis
Type IV – A fracture through all three elements of the bone, the growth plate, metaphysis, and epiphysis
Open fracture (any site including the hand) - answer the following:
- General pathology and mechanism of injury?
- Common presenting symptoms?
- Examination findings (signs)?
- Classification system used?
- Management?
- Complications?
General pathology and mechanism of injury:
- Fracture with break in the skin near the site of the broken bone
- Caused by a fragment of bone breaking through the skin at the moment of the injury
- Generally high energy trauma e.g. RTA or gunshot wound
- Need to ask about contamination
Common presenting symptoms:
- Pain
- Visible deformity
- Reduced use of limb/joint
Examination findings (signs):
- Open wound on exposure
- May have neurovascular compromise
Classification system:
- Gustilo-Anderson classification
Management:
- Early broad-spectrum antibiotics
- Surgical debridement within 24 hours (sooner if contaminated)
- Bone realignment and splinting (internal or external)
- Check tetanus vaccination status
Complications:
- Infection / sepsis
- Scarring
- Malunion
Outline the Gustilo-Anderson classification for open fractures
Suggest how it impacts management
Type 1: <1cm wound and clean
Type 2: 1-10cm wound and clean
Type 3A: >10cm wound and high-energy, but with adequate soft tissue coverage
Type 3B: >10cm wound and high-energy, but with inadequate soft tissue coverage
Type 3C: All injuries with vascular injury
Management:
3A managed by orthopaedics alone
3B requires plastics input
3C requires vascular input
Fractured neck of femur (intracapsular) - answer the following:
- General pathology and mechanism of injury?
- Risk factors?
- Common presenting symptoms?
- Examination findings (signs)?
- Classification system used?
- Differentials?
- Management?
- Complications?
- Expected outcomes?
General pathology and mechanism of injury:
- Fracture of the femoral neck proximal to the intertrochanteric line
- Low energy fall in the elderly
- High energy trauma in the young e.g. dashboard injury
Risk factors:
- Osteoporosis
- Any factors which increase falls risk e.g. poor eyesight, confusion
Common presenting symptoms:
- Pain
- Inability to weight bear
- Reduced ROM
Examination findings (signs):
- Shortened and externally rotated limb
- Reduced ROM
Classification system:
- Garden classification:
Differentials:
- Extracapsular neck of femur fracture
- Severe hip osteoarthritis
- Femoral shaft fractures
- Septic arthritis of the hip
Management:
Non-displaced (Grade 1 and 2) - urgent internal fixation with plates/screws
Displaced (Grade 3 and 4) - hemiarthroplasty
Also early mobilisation
Complications:
- Malunion
- DVT
- Avascular necrosis
- Hemiarthroplasty dislocation
Expected outcomes:
- High mortality rate (10% after 1 yr, 20% after 2 yrs)
Outline the classification used for intracapsular NOF fractures and how the results influence management
Grade 1 – incomplete and in-situ
Grade 2 – complete and in-situ
Grade 3 – incomplete and displaced
Grade 4 – complete and displaced
Grade 1 and 2 - blood supply likely to be intact, can use internal plates and screws
Grade 3 and 4 - blood supply unlikely to be intact, needs either a hemi-arthroplasty or THR
Fractured neck of femur (extracapsular) - answer the following:
- General pathology and mechanism of injury?
- Risk factors?
- Common presenting symptoms?
- Examination findings (signs)?
- Classification system?
- Differentials?
- Management?
- Complications?
- Expected outcomes?
General pathology and mechanism of injury:
- Occur between the greater and lesser trochanter, either on the intertrochanteric line or less than 5cm below it
- Low energy fall in the elderly
- High energy trauma in the young e.g. dashboard injury
- Twice as common as intracapsular fractures
Risk factors:
- Osteoporosis
- Any factors which increase falls risk e.g. poor eyesight, confusion
Common presenting symptoms:
- Pain
- Inability to weight bear
- Reduced ROM
Examination findings (signs):
- Shortened limb and less likely to be externally rotated
- Reduced ROM
Classification system:
- No classification system
Differentials:
- Intracapsular neck of femur fracture
- Severe hip osteoarthritis
- Femoral shaft fractures
- Septic arthritis of the hip
Management:
- Intertrochanteric fracture - Dynamic hip screw
- Subtrochanteric fracture - Intramedullary nail
Complications:
- Malunion
- DVT
- Fat emboli
Expected outcomes:
- Presence of a hip fracture increase mortality for the first year but after this period levels return back to near normal
Wrist fracture - answer the following:
- General pathology and mechanism of injury?
- Risk factors?
- Common presenting symptoms?
- Examination findings (signs)?
- Differentials?
- Management?
- Complications?
- Expected outcomes?
General pathology and mechanism of injury:
- Commonly refers to a distal radius fracture
- FOOSH is most common mechanism of injury
- High-energy trauma in young people e.g. fall from a ladder
- Low energy trauma in old people
Risk factors:
- Bimodal (extremes of young and old)
- Osteoporsis
Common presenting symptoms:
- Pain or tenderness
- Reduced ROM
Examination findings (signs):
- Bruising
- Swelling
- Joint deformity
Differentials:
- Scaphoid fracture - emergency
- Ligament damage / tendon rupture
Management:
- Stable and undisplaced = cast
- Stable and displaced = closed reduction then cast
- Unstable and displaced = closed reduction and K wire fixation or open reduction and plates
Complications:
- Post traumatic osteoarthritis
- Neurovascular complications e.g. medial nerve injury
- Malunion
- Compartment syndrome
Expected outcomes:
- 3 months to heal to return to all activities
- Full recovery can take up to 1 year
Ankle fracture - answer the following:
- General pathology and mechanism of injury?
- Risk factors?
- Common presenting symptoms?
- Examination findings (signs)?
- Classification system?
- Differentials?
- Management?
- Complications?
- Expected outcomes?
General pathology and mechanism of injury:
- Damage to either medial or lateral malleolus (tibia or fibula)
- Caused by a twisting mechanism
Risk factors:
- Bimodal distribution
- Obesity
- Smoking
- Alcohol consumption
Common presenting symptoms:
- Ankle pain
- Reduced ability to weight bear
Examination findings (signs):
- Swelling / redness
- Ankle deformity
- Reduced ROM
Classification system:
Danis-Weber (location of fibular fracture):
Differentials:
- Ankle sprain
- Subtalar dislocation
- Achilles tendon rupture
Management:
- Displaced fracture - reduce immediately and back slab
- Stable fracture (no talar shift) - immobilise with a cast/splint/boot below the knee for 6 weeks and x-ray after cast to check position
- Unstable fracture (talar shift) - fixation with a cast below the knee for 6 weeks
Complications:
- Malunion
- Post-traumatic arthritis
- Ankle stiffness
- DVT
- Neurovascular injury (if displaced)
- Infection (if open)
Expected outcomes:
- 90% mild/no ankle pain with minimal limitations and near full functional recovery at 1 year
Outline the classification used for ankle fractures, briefly describing each of the classifications and how it affects management
Danis-Weber classification
A - Below syndesmosis
B - At syndesmosis
C - Above syndesmosis (almost always need surgical fixation)
The more proximal the injury, the higher the likelihood of ankle instability
Therefore, Type C fractures almost always need surgical fixation
Tibial fracture - answer the following:
- General pathology and mechanism of injury?
- Common presenting symptoms?
- Examination findings (signs)?
- Differentials?
- Management?
- Complications?
- Expected outcomes?
General pathology and mechanism of injury:
- Either transverse/oblique or spiral fracture
- Transverse/oblique from direct blow, whereas spiral fracture from torsion/twisting
- Generally high energy trauma but can be low energy if elderly
Common presenting symptoms:
- Pain
- Inability to weight bear
Examination findings (signs):
- Deformity
- Swelling
- Bruising
- Look out specifically for compartment syndrome
Differentials:
- Soft tissue damage
- MSK injury e.g. muscle damage
- Nerve injury leading to pain
- DVT / underlying condition
Management:
- Reduction under analgesia and above knee backslab to control rotation
- Can consider non-surgical stabilisation with Sarmiento cast, but usually do surgery
- Generally requires surgery with intramedullary nail (or locking plates if quite proximal/distal)
Complications:
- Higher risk of compartment syndrome
- Anterior knee pain
- Malunion
- Malrotation
- Nerve injury
Expected outcomes:
- 4-6 months to heal completely
Osteoarthritis - answer the following:
- General pathology?
- Risk factors?
- Common presenting symptoms?
- Examination findings (signs)?
- Differentials?
- Management?
General pathology:
- Imbalance of the wearing down of cartilage and the repair of the cartilage by chondrocytes leading to cartilage destruction and imperfect cartilage regeneration
- General wear and tear over time
Risk factors:
- Obesity
- Age
- Previous trauma
- Overuse of joint / occupation
- Family history
Common presenting symptoms:
- Stiffness (worse at end of day)
- Pain (can be referred to adjacent joint!)
- Reduced range of movement
Examination findings (signs):
- Crepitus
- Reduced range of movement
- Effusions around the joint
- Bony enlargement of the joint
Differentials:
- Rheumatoid arthritis
- Fracture / ligament damage
- Septic joint
- Osteoarthritis of adjacent joint (not where complaint of pain is from)
Management:
Holistic approach!
- Weight loss if obese
- Physiotherapy / occupational therapy
- Analgesia (oral NSAIDs if knee OA, if any other joint then topical NSAIDs with Paracetamol as an adjunct if needed)
- Intra-articular corticosteroid joint injections
- Joint replacement / surgery
Fat Embolism - answer the following:
- Common cause and pathophysiology?
- Potential syndrome resulting from this including the triad of signs?
- What can be done to reduce risk of syndrome?
Common cause and pathophysiology:
- Fracture of long bones e.g. femur, causes release of fat into the circulation which can then become lodged in distal vessels and cause blood flow obstruction
Potential syndrome resulting from this and the triad of signs:
Fat embolism syndrome
1. Respiratory distress
2. Cerebral involvement
3. Petechial rash
What can be done to reduce risk of syndrome:
- Operate early to fix the fracture
State the management for the different types of hip fracture:
Intracapsular fracture (undisplaced)
Intracapsular fracture (displaced)
Extracapsular fracture (intertrochanteric)
Extracapsular fracture (subtrochanteric)
Describe the indications of use for hemiarthroplasty vs total hip replacement
Intracapsular fracture (undisplaced)
- Form of internal fixation to hold femoral head in place during healing (don’t need to replace femoral head)
Intracapsular fracture (displaced)
- Replacement of femoral head as high risk of avascular necrosis
Extracapsular fracture (intertrochanteric)
- Dynamic hip screw which both applies compression and ensures alignment during healing
Extracapsular fracture (subtrochanteric)
- Intramedullary nail
Hemiarthroplasty is performed if patient is not fully mobile or has significant co-morbidities. If the patient is fully mobile and fit for surgery, then a total hip replacement is generally used
Acute Compartment Syndrome - answer the following:
- Pathophysiology and common causes?
- Presentation?
- Management?
Pathophysiology and common causes:
- Where pressure within a fascial compartment is abnormally elevated which reduces blood flow to tissues within the compartment
- Commonly caused by fractures or crush injuries
Presentation:
5 Ps
- Pain (disproportionate to injury)
- Pale
- Paraesthesia
- Pressure (high)
- Paralysis (late and worrying sign)
Plus pulseless but does not help discriminate from acute limb ischaemia
Management:
- Emergency fasciotomy
Osteomyelitis - answer the following:
- Pathophysiology?
- Risk factors?
- Presentation?
- Investigations?
- Management?
Pathophysiology:
- Bacterial or fungal infection of the bone and bone marrow, which can be acute or chronic
- Can be from haematogenous spread in the blood or from direct contamination
Risk factors:
- Orthopaedic surgery
- Open fracture
- Peripheral arterial disease
- Diabetes
- Immunosuppressed
- IV drug use
Presentation:
- Severe pain / tenderness
- Fever
- Swelling
- Redness / erythema
- May be unable to weight bear
Investigations:
- Definitive diagnosis = MRI
- Gold standard = bone biopsy during debridement
- Plain x-ray (can’t exclude a diagnosis, but might see some changes on x-ray indicating osteomyelitis)
- Blood cultures
Management:
- Long-term antibiotics e.g. 6 weeks of Flucloxacillin
- May need surgical debridement of infection bone/tissue, if progressive or patient clinically unwell
List some complications of osteomyelitis
Acute:
- Sepsis / associated septic arthritis or soft tissue infections
- Necrosis of bone (osteonecrosis)
Ongoing:
- Chronic osteomyelitis
- Recurrence of infection
Children may develop growth disturbances
Outline common organisms causing osteomyelitis
S. aureus (most common)
Haemophilus influenzae
Streptococci
Pseudomonas aeruginosa
Salmonella
Cauda equina syndrome - answer the following:
- Pathophysiology?
- Causes?
- Red flag symptoms?
- Management?
Pathophysiology:
- Results from compression of the cauda equina (after the spinal cord terminates at L2/L3)
- Normally, nerve roots of the cauda equina supply:
1. Sensation to the perineum, bladder and rectum
2. Motor innervation to the lower limbs (past the knee) and the urethral/anal sphincters
3. Parasympathetics to the bladder and rectum
Causes:
- Herniated disc
- Cancer tumours (metastasis)
- Spondylolisthesis
- Abscess
- Spinal trauma
Red flag symptoms:
- Bilateral sciatica
- Perianal numbness
- Urinary retention or incontinence
- Faecal incontinence
- Loss of bladder or bowel sensation
- Erectile dysfunction
Management:
- Emergency MRI to confirm or exclude
- Emergency surgical decompression
Explain how Cauda equina syndrome is different from Metastatic spinal cord compression (MSCC) and how they present differently
Cauda equina syndrome is compression of the nerve roots at the cauda equina (for many different reasons)
Whereas Metastatic spinal cord compression is compression before the end of the spinal cord and the start of the cauda equina from a metastasis tumour of cancer
Presentation:
- Metastatic spinal cord compression has back pain that’s worse on coughing or straining
- MSCC tends to present with upper motor neurone symptoms, whereas cauda equina tends to present with lower motor neurone symptoms
Spinal stenosis - answer the following:
- Pathophysiology and 3 types?
- Causes?
- Presentation?
- Investigations?
- Management?
Pathophysiology:
- Refers to narrowing of the spinal canal leading to compression of the spinal cord at either the cervical or the lumbar level (lumbar is more common)
3 types:
1. Central stenosis
2. Lateral stenosis
3. Foramina stenosis
Causes:
- Congenital spinal stenosis
- Herniated disc
- Degenerative changes
- Thickening of ligamentum flavum or PLL
- Spondylolithesis
- Tumour
- Abscess
Presentation:
- Gradual onset
If central stenosis - then key presenting feature: intermittent neurogenic claudication:
- Lower back pain which improves on flexion of back but worsens on extension
- Buttock and leg pain
- Leg weakness (difficultly walking)
If lateral or foramina stenosis - sciatic is more commonly the presenting feature
Investigations:
- MRI
- May need investigations to exclude peripheral arterial disease
Management:
- Exercise / weight loss
- Physiotherapy
- Analgesia
- Decompression surgery if above does not work
Explain how you can differentiate between spinal stenosis and peripheral arterial disease?
Spinal stenosis:
- More likely to struggle with back pain
- Ankle-brachial pressure index is more likely to be normal
Peripheral arterial disease:
- Back pain is much less likely to be an issue
- Ankle-brachial pressure index is likely to be abnormal
Meralgia Paraesthetica - answer the following:
- Pathophysiology?
- Causes?
- Presentation?
- Investigations?
- Management?
Pathophysiology:
- Impingement of the lateral femoral cutaneous nerve leading to purely sensory symptoms in the nerve territory
Causes:
- Tight clothing
- Tool belts
- Obesity
- Pregnancy
Presentation:
- Patients can present with either abnormal sensations (dysaesthsia) or absent sensations (paraesthesia) of the lateral thigh on the affected nerve side
- Sensations can include: burning, tingling, cold sensation or numbness
Investigations:
- Generally diagnosis made on clinical picture
- May need to rule out more sinister causes with imaging
Management:
Varies based on suspected cause
Conservative:
- Exercise / weight loss
- Physiotherapy
- Rest
Medical:
- Analgesia
- NSAIDs
- Local steroid or analgesia injections
Surgery:
- Decompression surgery
- Transection or resection of nerve
Trochanteric bursitis - answer the following:
- Pathophysiology?
- Causes?
- Presentation?
- Which hip movements are restricted?
- Management?
- Recovery time?
Pathophysiology:
- Inflammation of the bursa over the greater trochanter of the femur, leading to thickening of the synovial membrane and increased fluid production
Causes:
- Repetitive use
- Trauma
- Infection (would be septic bursitis)
- Inflammatory conditions e.g. RA
Presentation:
- Gradual onset pain over the outer hip, can radiate down outer thigh
- Pain described as burning or aching
- Pain worse on exercise / on standing after sitting for a long time / on sitting cross legged / can’t lie on affected side
Which hip movements are restricted?
1. Trendelenburg test
2. Resisted abduction
3. Resisted internal rotation
4. Resisted external rotation
Management:
- Rest
- Analgesia
- Ice
- Physiotherapy
- Steroid injections
- If suspect infection, would need antibiotics
Recovery:
- Around 6-9 months to recover fully
Meniscal tears - answer the following:
- Pathophysiology?
- Mechanism of injury?
- Presentation?
- Special tests to confirm diagnosis?
- Investigations?
- Management?
Pathophysiology:
- Tearing of the cartilage within the knee joint (normally helps to increase articular surface and stability of the knee joint)
Mechanism of injury:
- In young people, generally a twisting motion of the knee e.g. during sports
- In older people, even a small twisting motion can cause a meniscal tear
Presentation:
- Heard a ‘pop’
- Locking of knee
- Knee pain (can be referred to the hip or back)
- Knee instability
- Swelling
- Reduced ROM and knee stiffness
Special tests to confirm diagnosis:
1. McMurray’s test (apply valgus and varus pressures on bent knee) - pain or restriction indicates tear
2. Apley grind test (on a bent knee facing supine, internally and externally rotate tibia) - pain indicates tear
Investigations:
- MRI is commonly used
- Arthroscopy is gold standard
Management:
- Conservative (rest, ice, compression, elevation)
- NSAIDs
- Physiotherapy after swelling settles
- Surgical repair or resection
ACL injury - answer the following:
- Pathophysiology?
- Mechanism of injury?
- Presentation?
- Special tests to confirm diagnosis?
- Investigations?
- Management?
Pathophysiology:
- Tearing of the anterior cruciate ligament within the knee joint (normally helps to prevent anterior movement of the tibia)
Mechanism of injury:
- More common than PCL injury
- Typically damaged during a twisting motion on a bent knee
Presentation:
- Heard a ‘pop’
- Knee pain (can be referred to the hip or back)
- Knee instability
- Swelling
Special tests to confirm diagnosis:
- Anterior draw test
Investigations:
- MRI is commonly used
- Arthroscopy is gold standard
Management:
- Conservative (rest, ice, compression, elevation)
- NSAIDs
- Crutches / knee brace
- Physiotherapy after swelling settles
- Surgical repair using donor from quadriceps or hamstring tendon
Osgood-Schlatter disease - answer the following:
- Pathophysiology?
- Presentation?
- Management?
- Prognosis
Pathophysiology:
- Repetitive use of the patella tendon causes series of micro-avulsion fractures
- Leads to inflammation and growth at the tibial tuberosity
Presentation:
- Typically occurs in young active males
- Gradual progression
- Visible/palpable mass on tibial tuberosity
- Generally unilateral, but can be bilateral
- Anterior knee pain, worsened by physical activity
Management:
- Conservative (rest, ice, compression, elevation)
- NSAIDs
- Activity modification (reduction)
Prognosis:
- Should resolve fully over time with the patient left with a bony lump on their knee
- Rare complication is an avulsion fracture (surgical intervention)
Baker’s cyst (popliteal cyst) - answer the following:
- Pathophysiology?
- Presentation?
- Investigation?
- Management?
Pathophysiology:
- Generally secondary to degenerative changes/injury
- Most commonly due to a meniscal tear, but can be OA/RA and other knee injuries
- Caused by squeezing of synovial fluid into the joint space which then accumulates (contained within the soft tissues)
Presentation:
- Visible swelling / fullness on full leg extension
- Pain or discomfort
- Pressure
- Restricted ROM (if large)
Also may rupture if pressure is great enough
Also may get leg oedema if vein compression occurs
Investigation:
- Ultrasound
- MRI if further evaluation is required e.g. prior to surgery
Management:
- No treatment if asymptomatic
- Modified activity to prevent exacerbation
- Analgesia
- Physiotherapy
- Aspiration
- Steroid injection
- Surgical intervention to treat underlying cause
Achilles tendon rupture - state the following:
- Pathophysiology?
- Risk factors?
- Symptoms and signs?
- Investigation?
- Management?
- Prognosis?
Pathophysiology:
- Sudden rupture of Achilles tendon and consequential loss of plantarflexion
Risk factors:
- Sports
- Age (old)
- Existing tendinopathy
- Family history
- Fluroquinolones (antibiotics)
- Steroids (systemic)
Symptoms and signs:
Symptoms: history of ‘pop’ sound, feeling of being kicked in the heel and pain
Signs: weakness of plantarflexion, palpable gap, positive Simmond’s test, tenderness
Investigation:
- Ultrasound
Management:
- Immediately: rest, immobilisation, elevation and analgesia
- VTE prophylaxis
- Non surgical e.g. boot or surgical e.g. reattachment management (debated)
Prognosis:
- Very long recovery process
- Should get back to pre-injury function
Achilles tendonitis - state the following:
- Pathophysiology
- Presentation
- Investigations
- Special test to exclude rupture
- Management
Pathophysiology:
- Inflammation of the Achilles tendon
Presentation:
- Aching posterior ankle pain, aggravated by activity or pressure
- Tenderness over the Achilles tendon
- Swelling and crepitus
Investigations:
- Mainly a clinical diagnosis
- May need an ultrasound if uncertainty (helps determine partial vs full tears)
Special test to exclude rupture:
- Simmonds’ test
Management:
- Same-day assessment by an orthopaedic specialist if rupture is suspected
Conversative: RICE
- Stop any precipitating activities e.g. rest
- NSAIDs in the short term, Paracetamol in the longer term
- Ice
If chronic
- Physiotherapy and rehabilitation
Plantar fasciitis - state the following:
- Pathophysiology
- Presentation
- Management
Pathophysiology:
- Inflammation of the plantar fascia of the base of the foot (attaches at calcaneus and flexor tendons of toes)
Presentation:
- Gradual onset of pain on sole of foot
- Pain is worse on pressure e.g. walking
- Tenderness on palpation of plantar aspect of foot
Management:
- Rest / activity modification
- Analgesia
- Ice
- Physiotherapy
- Steroid injections (risk of rupture of fascia and fat pad atrophy)
- Extracorporeal shockwave therapy
Fat pad atrophy - state the following:
- Pathophysiology
- Risk factors
- Presentation
- Investigation
- Management
Pathophysiology:
- Atrophy of the fat pad over the heel of the foot (normally helps to protect from impact)
Risk factors:
- Age
- Regular repetitive impacts e.g. walking
Presentation:
- Gradual onset of pain on sole of foot
- Pain is worse on pressure e.g. walking
- Tenderness on palpation of plantar aspect of foot
Investigation:
- Ultrasound of fat pad (ascertain thickness)
Management:
- Comfortable shoes / insoles
- Activity modification
- Weight loss
Morton’s neuroma - state the following:
- Pathophysiology
- Risk factors
- Presentation
- Special tests / investigations
- Management
Pathophysiology:
- Dysfunction of a nerve within the intermetatarsal space
- Most common between the 3rd and 4th toes
Risk factors (Victoria Beckham):
- High heels
- Narrow shoes
Presentation:
- Pain at the front of the foot
- Sensation of a lump
- Neuropathic pain (pins and needles, burning numbness)
Special tests / investigations:
- MTP squeeze
- Mulder’s sign (click on rubbing affected bones together)
- Ultrasound / MRI
Management:
- Activity modification
- Analgesia
- Insoles
- Weight loss
- Steroid infections
- Radiofrequency ablation
- Surgery
Hallux valgus - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Varus deviation of the metatarsal, leading to gradual valgus deviation of the phalanx
Presentation:
- Visible bony lump and deviation of the phalanx
- Pain/tenderness over first MTP
Investigations:
- Weight bearing x-ray
Management:
Conservative
- Comfortable shoes / bunion pads
- Analgesia
Surgical - many options
Gout - state the following:
- Pathophysiology
- Presentation
- Investigations
- Preventative treatment
- Management
Pathophysiology:
- Hyperuricemia, leading to deposition of monosodium urate crystals in synovium of joint
Presentation:
- Pain
- Swelling
Investigations:
- Joint fluid aspiration (showing no bacteria and monosodium urate crystals)
Preventative treatment:
- Allopurinol (xanthine oxidase inhibitor)
Management:
Conservative
- Weight loss
- Reduce alcohol intake
- Reduce purine-rich foods (meat and seafood)
Medical
- NSAIDs (first line)
- Colchicine
- Steroids
Adhesive capsulitis (frozen shoulder) - state the following:
- Pathophysiology
- Presentation (3 phases of condition)
- Diagnosis?
- Management
Pathophysiology:
- Inflammation and fibrosis of the joint capsule, leading to adhesions
- The adhesions bind the capsule, causing tightness and restricted movement
Presentation (3 phases of condition):
1. Painful phase - pain in shoulder joint, worse at night
2. Stiff phase - reduced range of movement (active and passive)
3. Thawing phase - gradual improvement in stiffness
Diagnosis:
- Mainly clinical
- May see joint capsule thickening on ultrasound/CT/MRI
Management:
- Analgesia (NSAIDs)
- Physiotherapy
- Intra-articular steroid injections
- Hydrodilation
- Manipulation under anaesthesia
- Arthroscopy
List some risk factors for developing adhesive capsulitis
- Diabetes
- Cardiovascular disease
- Prior surgery to affected shoulder
- Previous episodes of adhesive capsulitis
- Traumatic shoulder injury
- Thyroid disease
- Cancer
- Aged 40-60
List some differential diagnoses for adhesive capsulitis (frozen shoulder) -consider whether there is trauma or not
Trauma:
- Fracture
- Dislocation/subluxation
- Rotator cuff tear
No trauma:
- Supraspinatus tendinopathy
- AC joint OA
- Glenohumeral joint OA
(Rare)
- Septic arthritis
- Inflammatory arthritis
- Malignancy (osteosarcoma or bony mets)
Rotator cuff tears - state the following:
- Pathophysiology (including acute and chronic)
- Presentation
- Investigation
- Management
Pathophysiology:
- Injury to of one or more of the tendons of the rotator cuff muscles (SITS)
- Can be either a partial or full tear
- Can be acute (injury), or chronic (degenerative)
Presentation:
- Shoulder pain
- Weakness and pain (with specific movements relating to affected muscle)
- May have disrupted sleep from pain
Investigations:
- Ultrasound
- MRI
Management:
Conservative (if fragile or partial tear)
- Activity modification
- Analgesia
- Physiotherapy
Surgical
- Arthroscopic cuff repair (reattach tendon)
Shoulder dislocation - state the following:
- Pathophysiology
- Presentation
- Investigation
- Acute management
- Ongoing management
Pathophysiology:
- Humeral head entirely comes out of the glenoid cavity (if partial, then it’s subluxation)
- Majority of dislocations are anterior (90%)
Presentation:
- History of an acute injury
- Arm held against body
- Flattened deltoid and visible humeral head at anterior shoulder
Investigations:
- X-rays (may be required pre-reduction, definitely required post-reduction
- Contrast MRI for any suspected complications
- Arthroscopy if wish to visual joint internally
Acute management:
- Analgesia / gas and air
- Closed reduction method e.g. Hippocratic method (assess NV status, before and after)
- Broad arm sling / immobilisation
- Post-reduction x-ray
- May need manipulation under anaesthesia if closed reduction fails
Ongoing management:
- 2 weeks immobilisation with sling
- Physiotherapy
- Shoulder stabilisation surgery if instability
State the position that arm is commonly immediately before shoulder dislocation
Posterior force onto an abducted and extended arm
List the associated damage that can occur as a result of a shoulder dislocation
Bankart lesion
- Tear to the glenoid labrum (anterior portion)
Hill-Sachs lesions
- Compression fracture of humeral head (posterior-lateral portion)
Axillary nerve damage
- Weakness of deltoid muscles
- Absence of sensation in Regimental badge area
Associated bony fractures
- Clavicles
- Acromion
- Greater tuberosity of humerus
Rotator cuff tears
Outline the apprehension test (following shoulder dislocation), when it is done and what it shows
- Done after recovery from acute injury
- Tests for an shoulder instability post-subluxation or post-dislocation
Test:
- Shoulder is abducted to 90 degrees, elbow is flexed (arm is horizontal)
- Arm is then rotated externally (backwards)
Positive = patient is anxious and apprehensive (no pain)
Olecranon bursitis - state the following:
- Pathophysiology
- Causes
- Presentation
- Investigation
- Management
- First line antibiotic if infective cause
Pathophysiology:
- Inflammation of the bursa over the olecranon
- Thickening of the synovial membrane and increased fluid production causes swelling
Causes:
- Friction such as leaning on the elbow
- Infection (septic bursitis)
- Inflammatory conditions
- Trauma
Presentation:
- Swollen, warm, tender and fluctuant lump over the elbow
Investigation:
- Joint aspiration
Management:
- Rest / ice / compression
- Analgesia
- Aspiration to relieve pressure
- Steroid injection in problematic cases
First line antibiotic if infective cause:
- Flucloxacillin
What differentiates olecranon bursitis from infective bursitis (what additional features are seen in infective bursitis)?
- Hot
- Erythema spreading to surrounding skin
- Fever
- More tender
- Systemically unwell
What differentiates olecranon bursitis from septic arthritis (what additional features are seen in septic arthritis)?
- Swelling of the joint itself (rather than the bursa)
- Painful
- Associated reduced range of movement
Explain the following findings from aspiration of a bursa (suspected olecranon bursitis):
Pus
Straw coloured
Blood stained
Milky
Pus - infection likely
Straw coloured - normal / infection less likely
Blood stained - trauma, infection or inflammation
Milky - gout / pseudogout
Repetitive strain injury - state the following:
- Pathophysiology
- Causes
- Presentation
- Investigation
- Management
Pathophysiology:
- Umbrella term referring to soft tissue irritation and strain, resulting from repetitive activities
- Caused by microtrauma
Causes:
Any repetitive movements, done for a significant period of time
- Texting on phone
- Poor posture
- Computer mouse or keyboard
- Assembly line work
Increased risk from: small repetitive movements, vibration and awkward positions
Presentation:
- History of repetitive activity
- Pain
- Tender on palpation
- Aching
- Weakness
- Cramping
- Numbness
Investigations:
- Diagnosis usually made clinically, can rule other diagnoses out (x-ray, ultrasound, blood test)
Management:
- RICE (rest, ice, compression, elevation)
- Activity modification
- Analgesia
- Physiotherapy
- Steroid injections
Lateral epicondylitis - state the following:
- Pathophysiology
- Causes
- Presentation
- Investigation (including 2 special tests)
- Management
Pathophysiology:
- Inflammation at the point where the extensor muscle tendon inserts into the lateral epicondyle
Presentation:
- History of repetitive use of extensor muscles e.g. tennis
- Pain and tenderness over lateral epicondyle (often radiates down forearm)
- Weakness in grip
Investigation:
- Diagnosis made clinically
Special tests
1. Mills’s test
2. Cozen’s test
Management:
- Self limiting and resolves with time (may take years)
- Rest
- Analgesia
- Activity modification
- Physiotherapy / elbow brace
- Steroid injections
Medial epicondylitis - state the following:
- Pathophysiology
- Causes
- Presentation
- Management
Pathophysiology:
- Inflammation at the point where the flexor muscle tendon inserts into the medial epicondyle
- Aka golfers elbow
Presentation:
- History of repetitive use of flexors e.g. golf
- Pain and tenderness over medial epicondyle (often radiates down forearm)
- Weakness in grip
Management:
- Self limiting and resolves with time (may take years)
- Rest
- Analgesia
- Activity modification
- Physiotherapy / elbow brace
- Steroid injections
De Quervain’s tenosynovitis - state the following:
- Pathophysiology
- Presentation
- Special test
- Management
Pathophysiology:
- Swelling and inflammation of the tendon sheaths in the wrist
- Type of repetitive strain injury
- Particularly affects the abductor pollicis longus (APL) tendon and extensor pollicis brevis (EPB) tendon
- If bilateral, likely because lifting newborn babies (mummy thumb)
Presentation:
- Pain over the radial aspect of the wrist
- Weakness
- Neuropathic pain e.g. burning, pins and needles, numbness
Special test:
- Finkelstein’s test, tuck thumb into fist and ulnar deviation. Positive sign would be pain in radial aspect of wrist
Management:
- Rest
- Activity modification
- Splits (to restrict movement)
- Analgesia
- Physiotherapy
- Steroid injections
- Rare, surgery to release extensor retinaculum
Trigger finger - state the following:
- Pathophysiology
- Risk factors
- Presentation
- Diagnosis?
- Management
Pathophysiology:
- Either thickening of the flexor tendon e.g. a nodule, or tightening of the flexor sheath (of a particular finger)
- Most commonly affected is the A1 pulley at the MCP joint
Risk factors:
- 40’s or 50’s age
- Female
- Diabetes (T1>T2)
Presentation:
- Painful and tender finger (usually around MCP)
- Finger stuck in flexed position
- Lack of smooth movement
- Popping or clicking sound
- Worse in the morning, improves throughout the day
Diagnosis?
- Clinical
Management:
- Rest
- Analgesia
- Steroid injections
- Surgery to release flexor sheath (A1 pulley)
Dupuytren’s contracture - state the following:
- Pathophysiology
- Risk factors
- Presentation
- Special test
- Management
Pathophysiology:
- Thickening/tightening of the palmar fascia, leading to finger contractures (flexed position, unable to bend)
- Cords of dense connective tissue extend into the fingers, pulling fingers into flexion
- Unclear why it happens, ?inflammatory process in response to microtrauma
Risk factors:
- Male
- Older age
- Family history
- Diabetes
- Manual labour (vibrating tools)
- Smoking / alcohol
- Epilepsy
Presentation (first presentation and later):
- First presentation, hard nodules on the palm with thickened/pitted skin
- Progression causes fixed flexion of the finger (most commonly ring finger)
- Reduced function of the hand/finger
Special test:
- Table top (see if can get fingers flat on top of table)
Management:
- Leave alone
- Needle fasciotomy (divide/loosen cord)
- Limited fasciotomy (remove fascia and cord)
- Dermofasciotomy (remove fascia, cord AND overlying skin)
Carpal tunnel syndrome - state the following:
- Pathophysiology
- Risk factors
- Presentation
- Investigation and special tests
- Management
Pathophysiology:
- Compression of the median nerve at the carpal tunnel
- Compression comes from narrowing of the tunnel or swelling of the contents e.g. tendon sheaths
Risk factors:
- Most commonly idiopathic
- Repetitive activities
- Pregnancy
- Obesity
- Diabetes
- Acromegaly
- Hypothyroidism
- Rheumatoid arthritis
Presentations:
- Gradual onset of sensory and motor symptoms
Sensory symptoms:
- Neuropathic pain (burning, paresthesia, numbness) in palmar digital cutaneous branch distribution
- Palmar surface spared
Motor symptoms:
- Atrophied thenar muscles
- Weakness of thumb abduction and fine movements
- Reduced grip strength
Investigation and special tests:
- Nerve conduction studies
- Tinnel’s test
- Phalen’s test
Management:
- Rest
- Activity modification
- Splinting (holds in neutral position)
- Steroid injections
- Surgery to cut flexor retinaculum to release pressure
Ganglion cysts - state the following:
- Pathophysiology
- Presentation
- Investigation
- Management
Pathophysiology:
- Sacs of synovial fluid that originate from tendon sheaths or joints herniating, where fluids flows into the sac
- Commonly occur around the fingers/wrist but can occur anywhere
Presentation:
- Appear rapidly (over days)
- Visible, palpable, well-circumscribed, non-tender lump (0.5-5cm)
Investigations:
- Transilluminates
- Can use ultrasound to differentiate from other causes
Management:
- Conservatively (40-50% will resolve spontaneously, but can take years)
- Needle aspiration
- Surgical excision
What analgesia is provide in the emergency department for a closed fracture reduction?
First line: local/regional nerve block
- Can also use a short course of continuous sedation (realistically used more)
Outline some of the Ottawa criteria for x-ray in suspected ankle fractures
- Tenderness over the lateral malleolus
- Tenderness over the medial malleolus
- Inability to weight bear for 4 steps
Outline some of the Ottawa criteria for x-ray in suspected midfoot fractures
- Tenderness over the base of the 5th metatarsal
- Tenderness over the navicular bone
- Inability to weight bear for 4 steps
Give 3 reasons why the Ottawa criteria may not be accurate/relevant (when should they be discarded)
- Patient is intoxicated / reduced consciousness
- Other distracting painful injuries
- Evidence of reduced sensation in the lower limb (neurovascular injury will always need further interventions anyway)
On examination of a FOOSH patient, they have tenderness in the anatomical snuffbox however x-rays demonstrate no abnormalities. What is the next most appropriate management?
Repeat x-ray in 10-14 days
In the meantime, the patient should have a pre-emptive cast in the ‘beer glass position’
