Trauma And Orthopaedics Flashcards
What are the 2 types of neck of femur fractures ?
Intra-capsular - subcapital region of the femoral head to basocervical region of the femoral neck, immediately proximal to the trochanters
Extra-capsular - outside the capsule
Why are displaced intracapsular neck of femur fractures a major concern ?
The blood supply to the neck of the femur is retrograde passing from distal to proximal along the femoral neck to the femoral head. Predominantly through the medial circumflex femoral artery which lies directly on the intracapsular femoral neck. Therefore this fracture can disrupt the blood supply to the femoral head and avascular necrosis can occur.
What are the clinical features of a NOF fracture?
Pain - felt in groin, thigh or referred to the knee
Inability to weight bear
Shortened and externally rotated
Pain when pin rolling the leg
What are some differentials of a NOF fracture ?
Pubic ramus fracture
Acetabular fracture
Femoral head fracture
Femoral diaphysis fracture
Dislocated hip
Hip bursitis
Osteomyelitis
What investigations should be performed when suspecting a NOF fracture ?
Plain film radio graphic imaging - AP and lateral views of the affected hip
AP pelvis
Full length femoral radiographs
FBC, U&E’s, coag screen
CK if there is a long lie
In older patients - urine dip, CXR for cause of fall
What are the ligaments of the hip ?
Iliofemoral
Ischiofemoral
Pubofemoral
What some causes of a NOF fracture ?
-High energy trauma
-Pathological fracture - tumour or infection ( diseased bone )
-Reduced bone mineral density - osteopenia and osteoporosis ( long term steroids, alcohol consumption or malnutrition )
-Stress fracture
What is the garden classification of fractures ?
Classification of fractures according to the degree of displacement as seen on an AP radiograph.
what are the stages of the garden classification of fractures ?
Stage 1 - incomplete fracture line or impacted fracture
Stage 2 - complete fracture, non-displaced
Stage 3 - complete fracture line, partial displacement
Stage 4 - complete fracture line, complete displacment
What is Pauwels classifications of fractures ?
Classification of fractures according to the angle of the fracture line from horizontal.
What are the types of fractures in the Pauwels classification ?
Type 1 - 0 - 30 degrees
Type 2 - 30-50 degrees
Type 3 - more than 50 degrees
What are some risk factors for a NOF fracture ?
Age over 65
Risk factor for osteoporosis - menopause, smoking
Previous fragility fracture
History of falls
Poor nutrition
Low BMI
Dementia
Visual impairment
What is seen on examination of the hip in a NOF fracture ?
Affected leg is shortened, externally rotated and abducted
Palpation of the hip produces pain
Unable to perform a straight leg raise
Pain on gentle internal and external rotation
Soft tissue injury - bruising or swelling
What is the initial management for a NOF fracture ?
Analgesia - paracetamol, opioids and iliofascial or femoral nerve block
IV access for fluids, blood transfusion and the administration of meds
Assess and manage complications to prevent delays in surgical management
How quickly should you have surgery after a NOF fracture and what are the benefits of this ?
36 hours after admission
Higher rates of independent living,
Lower rates of non-union,
Shorter hospital admission
Reduced pain scores
Lower rates of complications and reduced 30 day and 1 year mortality rates
What does early mobilisation help after a NOF fracture ?
Prevent post-operative complications - VTE, pressure ulcers, bronchopneumonia
What is the management of an intra-capsular NOF fracture in a younger or fit patients and explain them ?
Cannulated screws - a set of screws being driven into the femoral head across the fracture which stabilises the fracture.
A dynamic hip screw - dynamic plate screwed across the fracture line into the femoral head
What is the management of an intra-capsular NOF fracture in older patients and explain them?
A total or hemi hip arthroplasty is recommended. This involves the removal of the femoral head and insertion of a prosthetic replacement. The acetabulum can also be reinforced with a socket in the context of osteoarthritic disease.
What is the management of extra-capsular NOF fractures ?
Internal fixation is favourable with dynamic hip screw or trochanteric femoral intramedullary nailing with screws entering the femoral head.
What are some indications for non-operative management of a NOF fracture ?
Patients that are too unwell for surgery
Short life expectancy
Delayed presentation or diagnosis of fracture with signs of healing
Immobile patients
Patients who decline surgery
How is a NOF fracture managed non-operatively ?
Casts, splints and traction
Periodic x rays of the affected hip are necessary to guide management
What are the aims of post-operative management ?
Enhance recovery
Promote early mobilisation
Prevent future fractures
What should be included in post-operative management of NOF fracture ?
Analgesia
Rehabilitation
Falls risk assessment
Diabetic assessment
Early mobilisation
Antibiotic prophylaxis
VTE prophylaxis
What are the complications of non-operative management of a NOF fracture ?
Fracture displacement
Non-union or mal union
Avascular necrosis of femoral head
VTE
Pressure sores
Infection
Death
What are the medical complications of surgical management of a NOF fracture ?
Surgical site infection
Anaemia
VTE
Bleeding
Fat embolism
What are the functional complications of surgical management of a NOF fracture ?
Nerve and vessel injury
Muscle and ligament damage
Leg length discrepancies
What are the complications related to dynamic hip screws and cannulated screws ?
Non - union and femoral head avascular necrosis
Soft tissue irritation caused by a lag screw pressing into soft tissue
Screw cut out
What are the complications related to total / hemiarthroplasty ?
Peri-prosthetic fracture, prosthetic loosening or dislocation of the prosthesis
Acetabular wear
Femoral shaft fracture
What are the causes of a distal radial fracture ?
FOOSH
- younger people in sport or involved in trauma
- elderly people with osteoporosis and low energy trauma
Pathological fracture if atraumatic ( investigate for malignancy )
What are the types of distal radial fracture and describe them ?
Colle’s fracture - extra-articular fracture with dorsal displacement
Smith’s fracture - extra-articular fracture with volar displacement
Barton’s fracture - intra-articular fracture with associated dislocation of the radiocarpal joint
What are some risk factors of distal radial fracture ?
Risk factors for osteoporosis :
- post menopause
- advanced age
- smoking
-low BMI
- inactivity
Risk factors for falling
- abnormal gait / balance
Muscle weakness
Poor visual acuity
What are some typical symptoms of a distal radial fracture ?
Pain
Swelling
Loss of function
What are some important areas to cover in taking a history of a suspected a distal radial fracture ?
Events around the fall - syncope, head injury
Clinical features of neurovascular compromise
PMH : osteoporosis, previous fragility fractures and co-morbidities
Family history : osteoporosis
Social history - smoking and alcohol, occupation
What clinical features suggest a neurovascular injury after a fracture ?
Paraesthesia - tingling, pins and needles or loss of sensation in hand
Pain - disproportionate to injury
Pallor
What may be seen on examination in a distal radial fracture ?
Deformity of the wrist
Swelling and / or bruising at the wrist
Tenderness on palpation of the distal radius
Less common :
Open wound or protruding bone through skin
Loss of sensation or movement distal to the fracture
Pulselessness or pallor of the hand
How do you assess the nerve supply is maintained in a distal radial fracture ?
Median :
- motor - grip strength and OK sign
- sensory - tip of second digit and thenar eminence
Ulnar :
- motor - finger abduction and adduction
- sensory - tip of little finger
Radial :
- motor - finger and wrist extension
- sensory - dorsal first webspace
What are some differentials for a suspected distal radial fracture ?
Scaphoid fracture
Ulnar styloid fracture
Radial shaft fracture
What are some bedside investigations that should be performed for a distal radial fracture ?
ECG - suspicion of cardiac reason for fall
Urine dipstick - UTI causing confusion for fall
Blood sugar monitoring - hypoglycaemic fall
What are some lab investigations that should be performed for a distal radial fracture ?
Baseline bloods - FBC, U&E, LFT
Bone profile
What relevant imaging should be performed when suspecting a distal radial fracture ?
X-ray : AP and lateral views of the wrist
CT : may be required if suspected intra-articular involvement or for pre-operative planning
MRI : may be required if suspected soft tissue injuries
What is used to assess if osteoporosis treatment should be started after a fragility fracture ?
FRAX risk assessment tool
What is the immediate management for a distal radial fracture ?
ABCDE assessment
Analgesia
Assessment of skin integrity and neurovascular status-capillary refill time and movement and ensation of the hand
Reduction of displaced fractures
Immediate immobilisation
What is the definitive management for a stable undisplaced radial fracture ?
Below elbow cast for 4-6 weeks
Repeat X ray at 1 week to ensure fracture remains undisplaced
What is the definitive management for a Colle’s fracture ?
Simple fracture : non-operative - manipulation under anaesthetic and below elbow cast for 4-6 weeks
Complex fracture : closed reduction and K wiring
( if can not be reduced, open reduction and internal fixation ( orif ) with plate and screws
What is the definitive management of a smith’s fracture ?
Requires surgical fixation and volar displacement is always unstable
ORIF with plate and screws
What is the definitive management of a barton’s fracture ?
Usually ORIF is required
What does the cast care advice include ?
Keep plaster dry
Do not scratch underneath plaster
Keep elevated for first week to reduce swelling
Keep fingers moving to improve circulation and reduce stiffness
When should a patient return to the emergency department after a distal radial fracture ?
If there is :
- Increasing pain in the area
- numbness in the fingers
- increasing swelling in the fingers
- Change of colour in the fingers
- the plaster becomes wet or damaged
What are some complications of a distal radial fracture ?
Infection
Bleeding
Neurovascular injury
Pain
Malunion
Stiffness or decreased range of motion
Median or ulnar damage
Osteoarthritis
Extensor pollicis longus rupture
Non-union
What are the 3 measurements taken from a plain radiograph that help in the diagnosis of a distal radial fracture and what are the ranges ?
Radial height < 11mm
Radial inclination < 22 degrees
Radial / volar tilt > 11 degrees
What is radial inclination ?
the angle between the articular surface of the radius and the radial styloid, measured on the posteroanterior (PA) view
What is radial height ?
the difference in length between the ulnar head and the tip of the radial styloid on the PA view
What is volar / radial tilt ?
an angle between a line drawn perpendicular to the long axis of the radius and a tangential line drawn along the radial articular surface
What is oestoarthritis ?
A progressive degenerative joint disorder often referred to as a dysfunctional wear and repair process within the joint where there is cartilage degradation and remodelling of bone and associated inflammation.
What is the pathological process of osteoarthritis ?
Over time continuous wear or trauma to the joint causes local inflammation and stimulation of chrondrocytes to release degradative enzymes. These enzymes break down collagen and release proteoglycan and ultimately destroy articular cartilage. This leads to exposure of underlying subchondral bone causing subchondral sclerosis and the continuous remodelling can from subchondral cysts and osteophytes.
What are the risk factors for osteoarthritis ?
Increasing age
Female
Obesity
Trauma to joint
What are the typical symptoms of osteoarthritis ?
Joint pain
Stiffness worse after activity and at the end of the day
Limitation in day to day activities
Aggravated by weight bearing
How to differentiate between inflammatory and non-inflammatory arthropathies ?
In inflammatory joint stiffness improves with activity and stiffness lasts loner than 30 minutes in the morning.
What are some findings seen in patients with osteoarthritis on examination ?
Reduced active and passive range of movement
Tenderness over the joint lines
Crepitus on movement
Antalgic gait or may have a mobility aid.
What are some differentials for osteoarthritis if it affects the knee ?
Meniscal or ligamentous tears
What are some differentials for osteoarthritis if it affects the hip ?
Trochanteric bursitis
Gluteus medius tendinopathy
Sciatica
Avascular necrosis
What are some differentials for osteoarthritis ( non specific to a joint ) ?
Fracture
Inflammatory arthropathies
Gout
Septic arthritis
Malignancy
What are some differentials for osteoarthritis if it affects the hand ?
De Quervain’s tenosynovitis
What are the relevant investigations for osteoarthritis ?
Bedside - BMI = obesity is a risk factor
Lab - serum CRP / ESR = if inflammatory arthropathies are suspected ( CRP/ESR usually normal in OA )
Imaging - x ray of joint
What are the x ray changes seen in osteoarthritis ?
Loss of joint space
Osteophytes
Subchrondral cysts
Subchondral sclerosis
What are the current NICE guidelines to diagnose someone with osteoarthritis ?
Over 45 years old
AND
Has activity related joint pain
AND
Has either no morning stiffness or stiffness that lasts no longer than 30 minutes
What is the conservative management of osteoarthritis ?
Education and advice about the condition
Exercise - strengthening and general aerobic fitness
Weight loss
Smoking cessation
What is the medical management of osteoarthritis ?
First line - topical NSAIDs
Second line - paracetamol and topical analgesia
Third line - NSAID, paracetamol and topical capsaicin
Fourth line - opioid, NSAID, paracetamol and topical capsaicin
Intra-articular corticosteroid injection can be offered
What is the surgical management of osteoarthritis ?
If pain persists past medical management or if severe disability is present consider surgery.
Joint replacement ( total arthroplasty or hemi-arthroplasty ) or fusion of the joint
Why is the femoral bone highly vascularised ?
Due to its role in haematopoesis
What artery supplies the femur ?
Penetrating branches of the profunda femoris artery
What are some causes of a femoral shaft fracture ?
High energy trauma
Fragility fractures in the elderly
Pathological fractures ( osteomalacia, metastatic deposits )
Bisphosphonate related fractures - transverse fracture
What are the clinical features of a femoral shaft fracture ?
Pain and swelling in the thigh, hip and / or knee pain
Inability to weight bear
Obvious deformity
Referred pain is common in elderly people
What are some investigations that need to be performed when suspecting a femoral shaft fracture ?
Routine urgent bloods - coag screen + group and save
If pathological cause serum calcium
Plain film radiograph AP + lateral of entire femur including hip and knee
Further imaging such as CT may be needed if there is poly injury
What immediate management is required for a femoral shift fracture ?
A - E assessment
Fluid resus
Analgesia - opioid
Iliofascial block
Potential antibiotic prophylaxis
Immediate reduction and immobilisation
What is the surgical management of a femoral shaft fracture ?
Surgically fixed within 24-48 hours ( sooner if open )
Antegrade intramedullary nail - more distal
External fixation ( delayed conversion to intramedullary nail )- used if unstable polytrauma or open fracture
What are som complications of a femoral shaft fracture ?
Nerve injury or vascular injury ( pudendal nerve - 10% and femoral nerve - rare )
Mal-union, delayed union or non-union
Infection especially in open fractures
Fat embolism
VTE
What are some clinical features of a distal femur fracture ?
Following a fall or traumatic injury
Severe pain in distal thigh
Inability to weight bear
What are some features that can be seen on examination in a distal femur fracture ?
Obvious deformity
Swelling
Ecchymosis of the distal thigh
Knee effusion ( if extend intra-articular )
What investigations should be performed for a distal femur fracture ?
Urgent bloods + coag screen and group + save
Serum calcium if pathological
AP + lateral plain film radiograph of knee and entire femur
If intra-articular involvement CT might be helpful
What is the immediate management of a distal femur fracture ?
If significant mal-alignment of the fracture requires initial realignment in A&E with analgesia and then immobilised using skin traction.
Immobilisation
What is the surgical management of a distal femur fracture ?
Retrograde nailing - Indicated in more proximal fractures
or ORIF - more distal or complex fractures
External fixation may be needed in severe comminuted or open fractures
What are some complications of distal femur fractures ?
Malunion
Non-union
Secondary osteoarthritis
What is usually the cause of a clavicle fracture ?
Trauma to the clavicle
Fall onto the shoulder
How are the clavicular fragments displaced in a clavicle fracture ?
Medial fragment will often be displaced superiorly due to the pull of the SCM
Lateral fragment will be displaced inferiorly from the weight of the arm.
What are the clinical features of a clavicular fracture ?
Sudden onset localised pain - worse on movement of the arm
Focal tenderness
Deformity
What is investigation is performed when suspecting a clavicular fracture ?
Palin film anteroposterior and modified - axial radiograph
What is the management of a clavicular fracture ?
Treated conservatively - sling ( elbow well supported )
Early mobilisation to prevent a frozen shoulder
Analgesia
All open fractures require surgery
ORIF may be necessary if non-union
What should be considered if the fracture is of the proximal clavicle ?
Pneumothorax
What is the healing time for clavicular fractures ?
4-6 weeks
What are some complications of clavicular fractures ?
Non-union
Neurovascular injury
Puncture injury - haemothorax or pneumothorax
What are the 4 rotator cuff muscles and what is their function ?
Supraspinatus - abduction
Infraspinatus - external rotation
Subscapularis - internal rotation
Teres minor - external rotation
What are some causes of rotator cuff tears ?
Pre-existing degeneration
Large force
Age - chronic
What are some risk factors for rotator cuff tears ?
Age
Trauma
Overuse
Repetitive overhead shoulder motions
Obesity
Smoking
DM
What are some clinical features seen in rotator cuff tears ?
Pain over lateral aspect of shoulder
Inability to abduct the arm above 90 degrees
Tenderness over greater tuberosity
Atrophy of muscles
What are some specific tests to perform to help assess the presence of a rotator cuff tear ?
Jobe’s test ( empty can test ) - place shoulder in 90 degrees abduction and 30 degrees flexion forwards and internally rotate. Gently push downwards
Gerber’s lift off test - internally rotate arm so the dorsal surface of the hands rest on the lower back. Ask patient to push against the examiner
What are the investigations to perform in a rotator cuff tear ?
Urgent plain film radiograph to exclude fracture
USS or MRI
What is the management of a rotator cuff tear ?
Analgesia
Physiotherapy
Large and massive tears can be considered for surgery
Repairs can be performed arthroscopically or via open approach
What is the main complication of a rotator cuff tear ?
Adhesive capsulitis
What is the most common site of a shoulder fracture ?
Proximal humerus
What are some causes of a shoulder fracture ?
Low energy injury - elderly person FOOSH
High energy trauma - younger
What are some risk factors for a shoulder fracture ?
Osteoporosis - female, menopause, prolonged steroid use,
Recurrent falls
Frailty
What are the clinical features of a shoulder fracture ?
Pain around upper arm and shoulder
Arm movement restriction
Inability to abduct the arm
Swelling and bruising
Loss of sensation in regimental badge area and loss of power of deltoid if axillary nerve is damaged.
What investigations should be performed after a shoulder fracture ?
Urgent bloods ( + coag screen and group and save )
Serum calcium if pathological fracture is suspected
Plain radiograph AP + lateral + axillary views
What is the management of a shoulder fracture ?
Immobilisation initially then early mobilisation
Correctly applied poly sling
Surgical if displaced, open or neurovascularly compromised - ORIF or intramedullary nailing
What are some complications of a shoulder fracture ?
Reduced range of motion
Avascular necrosis of humeral head
Neurovascular damage
What are the types of shoulder dislocation + causes ?
Anterior - most common ( force applied to an extended, abducted and externally rotated humerus )
Posterior - rare ( typically caused by seizures or electrocution )
What are some clinical features of a shoulder dislocation ?
Painful shoulder
Reduced mobility
Feeling of instability
Asymmetry
Loss of shoulder contours
Anterior bulge
What are some associated injuries in a shoulder dislocation ?
Bankart’s lesion
Hill-sach’s lesion
Humeral fractures
Rotator cuff injuries
What investigations should be performed for a shoulder dislocation ?
Plain radiograph ( AP, Y-scapular and / or axial view )
What is seen on x ray in a posterior dislocation ?
Light bulb sign
What should be performed if labral or rotator cuff injuries are suspected after a shoulder dislocation ?
MRI of the shoulder
What is the management of a shoulder dislocation ?
A-E assessment
Analgesia
Reduction, immobilisation and rehabilitation
Assess neurovascular status
Broad arm sling and physiotherapy
What are some complications of a shoulder dislocation ?
Recurrence
Adhesive capsulitis
Nerve damage
Rotator cuff injury
Labral and cartilaginous injuries
What are some risk factors for a humeral shaft fracture ?
Osteoporosis
Age
Previous fractures
What are some clinical features of s humeral shaft fracture ?
Pain
Deformity
Reduced sensation over 1st webspace & weakness in wrist extension ( radial nerve damage )
What are the causes of a humeral shaft fracture ?
FOOSH or falling laterally onto an adducted arm
High trauma in younger patients
What is a Holstein-Lewis fracture ?
A fracture of the distal third of the humerus resulting in the entrapment of the radial nerve. The resultant neuropraxia to the radial nerve will result in loss of sensation in the radial distribution and a wrist drop deformity.
What investigations should be performed when suspecting a humeral shaft fracture ?
AP and lateral plain film radiographs of the humerus ( the elbow and shoulder should be visible ).
In severely comminuted cases CT imaging may be requested for pre-operatively planning.
What is the management of a humeral shaft fracture ?
Realignment of the limb
Conservative - functional humeral brace and regular follow up with repeated plain film imaging
How long is the usual recovery of a humeral shaft fracture ?
Full union may take 8-12 weeks
What surgical options are there for a humeral shaft fracture ?
ORIF
Intramedullary nailing may be indicated in the presence of pathological fractures, polytrauma or severely osteoporotic bones.
What are some complications of a humeral shaft fracture ?
Non union or mal-union
Varus angulation ( more common in transverse fractures )
Radial nerve injuries ( usually improv after 3 months )
What is tendinopathy ?
A broad term used to encompass a variety of pathological changes that occur in tendons typically due to overuse. This results in a painful swollen and structurally weaker tendon.
What is a risk associated with tendinopathy ?
Rupture
What are some clinical features of biceps tendinopathy ?
Pain - made worse by stressing the tendon
Weakness
Stiffness
Tenderness over the tendon
Loss of muscle bulk due to disuse atrophy
What are some special tests performed to diagnose bicep tendinopathy ?
Speed test - patient stands with their elbows extended and their forearms supinated. They then forward flex their shoulders against the examiners resistance
Yergason’s test - patients stands with their elbows flexed to 90 degrees and their forearm pronated. They actively supinate against the examiners resistance
What are some differentials for bicep tendinopathy ?
Inflammatory arthropathy
Radiculopathy
Osteoarthritis
Rotator cuff pathology
What are some investigations for bicep tendinopathy ?
Largely clinical
FBC and CRP
Palin film radiographs - exclude other pathology
What is the management of bicep tendinopathy ?
Conservative - analgesia ( NSAIDs ) and ice therapy
Physiotherapy
USS guided steroid injections if unresponsive to conservative treatment
Surgical management rarely used
What usually caused a biceps tendon rupture ?
Sudden forced extension of a flexed elbow
What are some risk factors for a bicep tendon rupture ?
Previous ruptures
Steroid use
Smoking
CKD
Fluoroquinolones
What are some clinical features of a biceps tendon rupture ?
Sudden onset pain
Weakness
Feeling of a pop
Swelling and bruising
What is seen on examination of a biceps tendon rupture ?
Reverse pop eye sign - proximal muscle belly retracts due to loss of counter traction and a bulge becomes evident
What special test is used when suspecting a biceps tendon rupture ?
Hook test - The elbow is actively flexed to 90º and fully supinated, the examiner attempts to ‘hook’ their index finger underneath the lateral edge of the biceps tendon (which cannot be done in a ruptured biceps tendon)
What investigations are performed when suspecting bicep tendon rupture ?
USS - confirmation and localise the distal end of the biceps tendon
If USS is inconclusive MRI may be used.
What is the management of a biceps tendon rupture ?
Conservative - Analgesia and physiotherapy
Surgical - forming a bone tunnel in the radius and re-inserting the ruptured end.
What is adhesive capsulitis ?
A condition in which the glenohumeral joint capsule becomes contracted and adherent to the humeral head. This can result in shoulder pain and a reduced range of movement in the shoulder.
Who is more commonly affected by adhesive capsulitis ?
Women
40-70 yrs
Previous episodes ( in the contralateral shoulder )
What are some causes of adhesive capsulitis ?
Primary adhesive capsulitis - idiopathic
Secondary adhesive capsulitis -
. Rotator cuff tendinopathy
. Shoulder Impingement
. Previous surgery or trauma
Inflammatory disease
What are some clinical features of adhesive capsulitis ?
Generalised deep and constant pain in the shoulder
Disturbance of sleep
Stiffness and reduction in function
What is seen on examination in adhesive capsulitis ?
Loss of arm swing
Atrophy of the deltoid muscle
Generalised tenderness on palpitation
Limited range of motion
What investigations are performed for adhesive capsulitis ?
Usually diagnosis is clinical
Plain radiographs - generally unremarkable
MRI - thickening of the glenohumeral joint capsule
More common in diabetic patients so measure HbA1c and blood glucose
What is the management of adhesive capsulitis ?
Usually self limiting
Education and reassurance
Physiotherapy
Simple analgesics or corticosteroid injections if no improvement
Surgical - joint manipulation under general anaesthetic to remove capsular adhesions
What are some complications of adhesive capsulitis ?
Some patients will never regain full range of motion
Recurrence in contralateral shoulder
What is subacromial impingement syndrome ?
Refers to the inflammation and irritation of the rotator cuff tendons as they pass through the subacromial space resulting in pain, weakness and reduced range of motion within the shoulder.
Where is the subacromial space ?
Below the coracoacromial arch and above the humeral head and greater tuberosity of the humerus.
what runs in the subacromial space ?
Rotator cuff tendons
Long head of the biceps tendon
Coraco-acromial ligament
What are some causes of shoulder impingement ?
Overuse of the shoulder
Degenerative tendinopathy
Congenital variations of the acromion
Glenohumeral instability
What are some clinical features of shoulder impingement ?
Progressive pain in the anterior superior shoulder
Pain is exacerbated by abduction and relieved by rest
Weakness
Stiffness
What are some special tests for shoulder impingement ?
Neers impingement test - arm is placed by the patient’s side, fully internally rotated and then passively flexed, and is positive if there is pain in the anterolateral aspect of the shoulder
Hawkins test - shoulder and elbow are flexed to 90 degrees, with the examiner then stablising the humerus and passively internally rotates the arm, and the test is positive if pain is in the anterolateral aspect of the shoulder.
What is the management of shoulder impingement ?
Conservative - NSAIDs and physiotherapy
Corticosteroid injections
If it persists longer than 6 months with conservative management surgical intervention is recommended.
What are some complications of shoulder impingement ?
Rotator cuff degeneration and tear
Adhesive capsulitis
What is a common paediatric elbow injury ?
Supracondylar humeral fracture
What is the most common mechanism of action of a supracondylar humeral fracture ?
FOOSH with the elbow extended
What are some clinical features of a supracondylar humeral fracture ?
Sudden onset severe pain
Reluctance to move arm
Gross deformity
Swelling
Limited range of motion
What should be examined for in a supracondylar humeral fracture ?
Neurovascular compromise -
Assess the median nerve, radial nerve and ulnar nerve.
Check the hand for features of vascular compromise - cool temp, pallor, delayed capillary refill or absent pulses
What are some subtle changes seen on a plain film radiograph for a supracondylar humeral fracture ?
Posterior fat pad sign
Displacement of the anterior humeral line
What is the management of a supracondylar humeral fracture ?
With associated neurovascular compromise - immediate closed reduction which is then secured with K wire fixation
Conservative management can be trialled in less severe fractures.
Open fractures - open reduction and percutaneous pinning
What are some complications of a supracondylar humeral fracture ?
Nerve palsies
Mal-union
Volkmann’s contracture
What inserts at the olecranon ?
Triceps muscle
What is the typical cause of an olecranon fracture ?
Indirect trauma - FOOSH
Does an olecranon fracture involve the joint ?
Yes its an intra-articular fracture
What are some clinical features of an olecranon fracture ?
Elbow pain
Swelling
Lack of mobility
Tenderness when palpating the posterior aspect of the elbow
Inability to extend elbow
What should be assessed for when a patient has an olecranon fracture ?
Neurovascular status
Wrist ligament or bone injuries
Radial head fracture or dislocation
What are some investigations for an olecranon fracture ?
Routine bloods + coag screen and group and save
Plain AP and lateral radiograph of the elbow ( + shoulder and wrist )
What is seen on x ray in an olecranon fracture ?
Displacement due to the pull of the triceps on a lateral projection.
What is the management of an olecranon fracture ?
Analgesia
Treatment depends on degree of displacement
Non-surgical - little displacement, over 75 and immobilise joint
Surgical - tension band wiring or olecranon plating may be used
What blood vessels supplies the scaphoid bone and describe the route ?
Branches of the radial artery
The dorsal branch of the radial artery enters in the distal pole and travels in a retrograde fashion towards the proximal pole.
What blood vessels supplies the scaphoid bone and describe the route ?
Branches of the radial artery
The dorsal branch of the radial artery enters in the distal pole and travels in a retrograde fashion towards the proximal pole.
What blood vessels supplies the scaphoid bone and describe the route ?
Branches of the radial artery
The dorsal branch of the radial artery enters in the distal pole and travels in a retrograde fashion towards the proximal pole.
What blood vessels supplies the scaphoid bone and describe the route ?
Branches of the radial artery
The dorsal branch of the radial artery enters in the distal pole and travels in a retrograde fashion towards the proximal pole.
Why is a scaphoid fracture a concern ?
Fractures can compromise the blood supply leading to avascular necrosis and subsequent degenerative wrist disease. The more proximal the scaphoid fracture the higher the risk of AVN.
What are some clinical features of a scaphoid fracture ?
Usually from high energy trauma
Sudden onset wrist pain
Bruising
Tenderness in the floor of the anatomical snuffbox
Pain on palpating the scaphoid tubercle
Pain on telescoping of the thumb
What are some investigations of a scaphoid fracture ?
Initial plain radiographs should be taken - AP, lateral and oblique.
Not always detectable on initial radiographs
Repeat radiograph in 10-14 days
What is the management of a scaphoid fracture ?
Undisplaced fracture - strict immobilisation in a plaster with a thumb spica splint.
All displaced fractures should be fixed operatively - percutaneous variable pitched screw - placed over the fracture site to compress it.
What are some complications of a scaphoid fracture ?
Avascular necrosis
Non-union - due to poor blood supply
When do radial head fractures usually occur ?
Via indirect trauma with axial loading of the forearm causing the radial head to be pushed against the capitulum of the humerus.
What are some clinical features of a radial head fracture ?
History of falling on an outstretched hand followed by elbow pain.
Bruising and swelling
Tenderness over palpation over the lateral aspect of the elbow and radial head.
Pain and crepitation on supination and pronation
What are some investigations that should be carried out after a radial head fracture ?
Routine blood tests ( + clotting screen and group and save )
Plain AP + lateral radiographs
CT can be used if severe fracture
MRI can be sued to assess suspected associated ligament injuries.
What can be seen on a lateral radiograph in a radial head fracture ?
Sail sign - elevation of the anterior fat pad
What is the management of a radial head fracture ?
Analgesia
Less severe - immobilisation with sling
More severe - ORIF
What are some potential future complications of a radial head fracture ?
Secondary osteoarthritic changes may be encountered later in life
What is epicondylitis ?
A chronic symptomatic inflammation of the forearm tendons at the elbow.
It’s an overuse syndrome in the elbow caused by microtears in the tendons attaching to the epicondyles of the elbow following repetitive injury.
What are the common types of epicondylitis ?
Lateral epicondylitis ( tennis elbow )
Medial epicondylitis ( golfers elbow )
What attaches to the lateral epicondyle ?
Common extensor tendon
What are some risk factors of lateral epicondylitis ?
Occupations and hobbies that are associated with excessive use of extensive forearm muscles ( including tennis ).
What are some clinical features of lateral epicondylitis ?
Pain affecting the elbow radiating down the forearm.
Mainly in the dominant arm
Local tenderness on palpation over the lateral epicondyle.
May have reduced grip strength
What are some managemetnt options for lateral epicondylitis ?
Modify activity
Simple analgesics
If symptoms persist corticosteroids injections can be administered every 3 - 6 months
Physiotherapy can be provided for longer term relief via stretching and strengthening exercises for wrist and forearm extensors.
What are the most commonly affected muscles in medial epicondylitis ?
Pronator teres and flexor carpi radialis
What clinical features are there in medial epicondylitis ?
Tenderness over the pronator teres and flexor carpi radialis tendons and their insertion
What is carpal tunnel syndrome ?
A condition involving compression of the median nerve within the carpal tunnel of the wrist due to raised pressure within the compartment.
What are some risk factors of carpal tunnel syndrome ?
Female
Increased age
Pregnancy
Obesity
Previous injury to the wrist
DM
RA
What are the clinical features of carpal tunnel syndrome ?
Pain, Numbness and Paraethesia throughout the median nerve sensory distribution.
Palm is often spared
Typically worse at night
What are some special tests for carpal tunnel syndrome ?
Tinel’s test - percussing over the median nerve
Phalen’s test - holding the wrist in full flexion for one minute
What can be seen in later stages of carpal tunnel syndrome ?
Weakness of thumb abduction due to denervation atrophy of the thenar muscles
Wasting of the thenar eminence
What is the management of carpal tunnel syndrome ?
Worst splint
Corticosteroid injections or trial NSAIDs
Surgical treatment - carpal tunnel release surgery decompresses the carpal tunnel - cutting through the flexor retinaculum - reducing pressure on the median nerve.
What are some complications of carpal tunnel surgery ?
Recurrence
Persistent CTS symptoms
Infection
Scar formation
Nerve damage
Trigger thumb
What are some complications of carpal tunnel syndrome ?
Permanent neurological impairment that will not improve with surgery
What is dupuytren’s contracture ?
A common condition involving contraction of the longitudinal palmar fascia
What is the pathophysiology of dupuytren’s contracture ?
There is a compositional change of the palmar fascia causing painless nodules, fibrous cords and flexion contractures that develop at the MCP and interphalangeal joints limiting movement.
What are the risk factors of dupuytren’s contracture ?
Smoking
Alcoholic liver cirrhosis
DM
Occupational exposures
What are the clinical features of dupuytren’s contracture ?
Reduced range of motion
Nodular deformity
Or complete loss of movement
( ring and little finger commonly affected )
what is the special test used for dupuytren’s contracture ?
Hueston’s test - patient lays their palm flat on a table top
If they can’t this a positive test
What are some investigations for dupuytren’s contracture ?
Diagnosis is clinical
Routine bloods ( + LFT’s and random glucose )
No imaging is required
What is the management of dupuytren’s contracture ?
Conservative - hand therapy ( keeping and active with multiple exercises throughout the day )
Injectable collagenase clostridum histolyticum
Surgical - excision of fascia - fasciectomy
What is De Quervain’s tenosynovitis ?
Inflammation of the tendons within the first extensor compartment of the wrist resulting in wrist pain and swelling.
What are the risk factors De Quervain’s tenosynovitis ?
Age
Female
Pregnancy
What are the clinical features of De Quervain’s tenosynovitis ?
Pain near of the base of the thumb
Swelling
Grasping or pinching are particularly painful
Swelling and palpable thickening of the tendons
What is the management of De Quervain’s tenosynovitis ?
Conservative management - lifestyle advice and wrist splint
Steroid injections will reduce swelling and relieve pain
Surgical decompression - incision made and tendon sheath split
What are some complications of surgical decompression in De Quervain’s tenosynovitis ?
Failure to resolve
Reduce range of movements in wrist or hand
Neuroma formation
Nerve impingement
What is radiculopathy ?
A conduction block in the axons of a spinal nerve or its roots with impact on motor axons causing weakness and on sensory axons causing paraesthesia and / or anaesthesia
What is the difference between radiculopathy and radicular pain ?
Radiculopathy - state of neurological loss and may not be associated with radicular pain
Radicular pain - pain deriving from damage or irritation of the spinal nerve tissue, particularly the dorsal root ganglion.
What can cause radiculopathy ?
Intervertebral disc prolapse
Degenerative disease of the spine
Fracture
Malignancy
Infection
What are the red flags of cauda equina syndrome ?
Faecal incontinence
Urinary retention
Saddle anaesthesia
What are the red flags of infection ?
Immunosuppression
IV drug abuse
Unexplained fever
What is a red flag for fractrues of the spine ?
Chronic steroid use
Significant trauma
Osteoporosis or metabolic bone disease
What are some clinical features of radiculopathy ?
Paraesthesia and numbness
Weakness of muscles
Burning, deep, strap like narrow pain - radicular pain
What is the symptom management of radiculopathy ?
Analgesia
Amitriptyline ( or pregabalin )
Physiotherapy
Muscle spasms are treated by benzodiazepines
What is degenerative disc disease ?
It refers to the natural deterioration of the intervertebral disc structure such that they become progressively weak and begin to collapse.
What are some clinical features of degenerative disc disease ?
Local spinal tenderness
Hypomobility
Painful extension of the back or neck
Disc degeneration - more severe pain
What examination should be performed when you suspect degenerative disc disease ?
Complete neurological examination ( assess for evidence of spinal cord compression or cauda equina syndrome )
What is the gold standard investigation for suspected degenerative disc disease ?
MRI
What is seen on investigation in degenerative disc disease ?
Signs of degeneration
Reduction of disc height
Presence of annular tears
Endplate changes
What is the management of degenerative disc disease ?
Analgesia - simple
Encouraging mobility
Physiotherapy
If pain continues after 3 months of analgesia refer to pain clinic
No evidence to support surgical intervention
What does the cervical spine do ?
Support the head and provide mobility
What are the most common vertebrae fractured in the cervical spine ?
C2
C7
What is a Jefferson fracture ?
A burst fracture of the atlas. It is caused by axial loading of the cervical spine resulting in the occipital condyles being driven into the lateral masses of C1.
These are very unstable fractures. ( C1 fracture )
What is a Hangman’s fracture ?
(Or traumatic spondylolisthesis )
describes a fracture through the pars interarticularis of C2 bilaterally usually with subluxation of the C2 vertebrae on C3.
These are caused by cervical hyperextension and distraction.
These fractures are unstable and require surgical fixation.
What is an odontoid peg fracture ?
More common in older patients
Follow a low impact injury
Can be fatal especially with significant displacement of the odontoid
What are the investigations performed for a cervical spine fracture ?
Perform a CT scan in adults ( MRI in children )
MRI is helpful for concurrent injury to soft tissues
What is the management of a cervical spine fracture ?
3 point C spine immobilisation
Restrict movement of spine
Non operative management for stable injuries - rigid collars or halo vests
Operative management - unstable fractures - stabilisation where there is fixation using pedicle screws and rods.
What is a burst fracture ?
A burst fracture occurs when there is a substantial compressive force acting through the anterior and middle column of the vertebrae resulting in retro-pulsion of bone into the spinal canal. These fractures can involve one end plate or both end plates.
What are some risk factors for a quadricep tendon rupture ?
Increasing age
CKD
DM
RA
Medications such as corticosteroids and fluoroquinolones
What are some clinical features of a quadricep tendon rupture ?
Hearing a pop
Tearing sensation
Pain in anterior knee
Difficulty weight bearing
Localised swelling
What is seen in a complete tear of the quadricep tendon on examination ?
Inability to perform a straight leg raise
What are some investigations that can be performed when suspecting a quadriceps tendon rupture ?
Can be diagnosed on a clinical suspicion alone
Plain film radiographs show a caudally displaced patella in complete tears
USS can be used to measure the degree of rupture
What is the management of a partial quadricep tendon rupture ?
Non-operatively - immobilisation of the knee joint in a brace + intensive rehabilitation
What is the management of a complete quadricep tendon tear ?
Surgical intervention
What is the role of the ACL ?
It’s an important stabiliser of the knee joint.
Responsible for limiting anterior translation of the tibia ( relative to the femur )>
Contributes to rotational stability
What is the most common cause of a ACL rupture ?
An athlete with a history of twisting the knee whilst weight bearing.
Usually no contact and results from a sudden change of direction.
What are some clinical features of an ACL rupture ?
Inability to weight bear
Rapid joint swelling
Significant pain
Leg ‘ giving way’
What are the specific clinical tests to identify a potential ACL rupture ?
Lachman test
Anterior draw test
What is the lachman’s test ?
Placing the knee in 30 degrees of flexion and with one hand stabilising the femur, pulling the tibia forward to assess the amount of anterior movement of the tibia compared to the femur.
What is the anterior draw test ?
Flexing the knee to 90 degrees placing the thumbs on the joint line and their index finger on the hamstring tendon posteriorly. Force is then applied to demonstrate any tibial movement.
What are the investigations for an ACL rupture ?
Plain film radiograph - AP and lateral - to exclude any bone injuries or joint effusions.
MRI is gold standard to confirm diagnosis.
What is the immediate management of a suspected ACL rupture ?
RICE
What is the conservative management of an ACL tear ?
Rehabilitation - strength training
What are the surgical options for an ACL tear ?
Surgical reconstruction - use of a tendon or artificial graft ( follows a period of prehabilitation )
Acute surgical repair of the ACL - GA knee arthroscopy then acute repair such as suturing the ends of the torn ligament together.
What is a complication of an ACL rupture ?
Post-traumatic osteoarthritis
What is the primary function of the MCL ?
It’s a valgus stabiliser of the knee
What movement most commonly injures the MCL ?
External rotational forced applied to the lateral knee - impact to the outside of the knee
What are some clinical features of an MCL tear ?
Hearing a pop with immediate joint line pain
Swelling
Increased laxity when testing the MCL
Tender along the medial joint line
May be able to weight bear
What are some investigations for a MCL rupture ?
Plain radiograph to exclude any fractures
MRI is gold standard
What is the management of an MCL tear ?
Less severe - RICE + NSAIDs, strength training
More severe - knee brace and potentially crutches, analgesia
What are the main complications from a MCL tear ?
Instability in the joint
Damage to the saphenous nerve
What are the main functions of the meniscus ?
Shock absorbers
Increase articular surface area
What is the anatomy of the meniscus like ?
Medial meniscus is less circular than the lateral and is attached to the MCL whilst the lateral isn’t attached to the LCL.
What is the pathophysiology of a meniscal tear ?
Trauma related injury - twisted their knee whilst its flexed and weight bearing
Degenerative disease
The most common tear is a longitudinal tear
What are some clinical features of a meniscal tear ?
Tearing sensation in the knee
Intense sudden onset pain
Swells slowly
Locked in flexion and unable to extend
what are some features seen on examination of a meniscal tear ?
Joint line tenderness
Joint effusion
Limited knee flexion
What are some investigations to perform when someone presents with a meniscal tear ?
Plain film radiograph to exclude fracture
MRI is gold standard to confirm the diagnosis
What is the management of a meniscal tear ?
Rest and elevation with compression and ice.
For larger tears arthroscopic surgery may be needed.
What is a complication of a meniscal tear ?
Secondary osteoarthritis
What are complications of performing a knee arthroscopy ?
DVT
Damage to the saphenous nerve and vein, the peroneal nerve and popliteal vessels.
What causes a patella fracture ?
Direct trauma to the patella
Less commonly it can be caused by rapid eccentric contraction of the quadriceps muscle
What are some clinical features of a patella fracture ?
Anterior knee pain
Worse with movement
Unable to perform a straight leg twice
Swollen and bruised
What are the investigations for a patella fracture ?
Plain film radiograph ( AP, lateral and skyline )
CT may be indicated in comminuted fractures
What is the conservative management of a patella fracture ?
Used in non displaced fractures
Brace or cylinder cast
Early weight bearing
What is the surgical management for a patella fracture ?
Used in significant displacement
ORIF with tension band wiring is usually used
What are the complications of a patella fracture ?
Loss of range of motion
Secondary osteoarthritis
Why is there a greater risk of open fractures and compartment syndrome with tibial fractures ?
Lack of a significant soft tissue envelope and fascial compartments present
How can a tibial fracture occur ?
Direct injures from a fall or a direct blow
Indirect injuries through twisting or bending forces
What are some clinical features of a tibial fracture ?
History of trauma
Severe pain in leg
Inability to weight bear
Clear deformity
Significant swelling or bruising
What are the investigations that should be performed when suspecting a tibial fracture ?
Urgent bloods ( coag screen + group and save )
Full length AP and lateral plain film radiograph of the tibia and fibula - should include knee and ankle
What is the immediate management of a tibial fracture ?
Realignment with analgesia
Above knee backslab should be applied to control rotation
Limb should be elevated
Post manipulation plain radiograph is needed
Neuorvascular status should be assessed
What is the surgical management of a tibial fracture ?
Intramedullary nailing
Proximal or distal fractures may require ORIF
What are the complications of a tibial fracture ?
Compartment syndrome
Ischaemic limb
Open fractures
Malunion
Non union is uncommon
What is the ankle joint comprised of ?
Talus bone articulating with the mortise ( medial malleolus - distal end of the tibia and the lateral malleolus - distal end of the fibula ).
The tibia and fibula are joined at the syndesmosis. What is this ?
A very strong fibrous structure comprised of the anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament and the intra-osseous membrane.
What is the definition of an ankle fracture ?
A fracture of any malleolus ( lateral, medial or posterior ) with or without disruption to the syndesmosis.
What classification is used for ankle fractures and what are the types ?
Weber classification
Type A - below the syndesmosis
Type B - at the level of the syndesmosis
Type C - above the level of the syndesmosis
What are the clinical features of an ankle fracture ?
Ankle pain following trauma
Associated deformity
what investigations should be performed when suspecting an ankle fracture ?
A plain radiograph AP + lateral views
Check for uniformity and any talar shift
What is the immediate management of an ankle fracture ?
Immediate fracture reduction to realign the fracture
Then placed in a below the knee back slab
Request repeat x ray
When will conservative management be opted for in an ankle fracture ?
Non-displaced medial malleolus fracture
Weber A or Weber B fracture without talar shift
Those unfit for surgery
What is the surgical management for those requiring it for an ankle fracture ?
ORIF to achieve stable anatomical reduction of the talus within the ankle mortise.
When is surgery required for an ankle fracture ?
Displaced bimalleolar or trimalleolar fracture
Weber C fracture
Weber B fractures with talar shift
Open fractures
What are the complications of having ORIF ?
Infection
DVT or PE
Neurovascular injury
Non-union
Metal work prominence
What is the main complication of an ankle fracture ?
Increased risk of post-traumatic arthritis
What are the most common reasons for a calcaneal fracture ?
Fall from a height
Significant axial loading directly onto the bone
What are some clinical features of a calcaneal fracture ?
Recent trauma
Pain and tenderness around the calcaneal area
Inability to weight bear
Swollen and bruised
May have varus deformity
What are the investigations for a calcaneal fracture ?
Plain film radiograph ( AP + lateral + oblique )
CT is gold standard
What is the management of a calcaneal fracture ?
Intra-articular will require surgical intervention while extra-articular don’t usually.
Minimally displaced - closed reduction with percutaneous pinning
ORIF is usually used
What are some complications of a calcaneal fracture ?
Subtalar arthritis
What is the anatomy of the Achilles tendon ?
It unites the gastrocnemius, soleus and plantaris muscle. It inserts into the calcaneus.
What is Achilles tendonitis ?
Inflammation of the Achilles tendon. It is most common in those who engage in high intensity activities which chronically overload the tendon.
What are some risk factors for Achilles tendonitis ?
Unfit individuals who suddenly increase exercise frequency
Poor footwear
Male
Obesity
Recent fluoroquinolone use
What are some clinical features of Achilles tendonitis ?
Gradual onset of pain and stiffness in the posterior ankle
Worse with movement
Tenderness on palpation
What is the management of Achilles tendonitis ?
Supportive measures - anti-inflammatory medications
Rehabilitation and physiotherapy
What is hallux valgus ?
Deformity at the first metatarsophalangeal joint. It is characterised by medial deviation of the first metatarsal and lateral deviation of the hallux with associated joint subluxation.
What are the risk factors for developing hallux valgus ?
Female
Connective tissue disorder
Hypermobility
what are the clinical features of hallux valgus ?
Painful medial prominence
Lateral deviation of the hallux
What are some differentials for hallux valgus ?
Gout
OA
RA
What is the main investigation for hallux valgus ?
Radiographic imaging to assess the degree of lateral deviation and signs of joint subluxation
What is the management of hallux valgus ?
Sufficient analgesia
Adjust foot wear
Physiotherapy
What are some complications of hallux valgus ?
Avascular necrosis
Non-union
Displacement
Reduced ROM
What is plantar fasciitis ?
Inflammation of the plantar fascia
Causes infracalcaneal pain
what is the pathophysiology of plantar fasciitis ?
The plantar fascia is a thick fibrous band of connective tissue originating from the medial process of the calcaneal tuberosity. It extends to the proximal phalanges.
There are theories that suggest there are micro-tears to the plantar fascia causing an inflammatory process.
What are some risk factors of plantar fasciitis ?
High arches
Weak plantar flexors
Prolonged standing or excessive running
Leg length discrepancy
Obesity
Unsupportive footwear
What are the clinical features of plantar fasciitis ?
Sharp pain across plantar aspect of foot.
Tends to be worse with the first few steps of the day of after periods of inactivity.
What is the management of plantar fasciitis ?
Activity moderation
Regualtion analgesia
Adjusted footwear
Physiotherapy
Corticosteroid injections
If nothing improves it plantar fasciotomy can be considered.
What is the choice of management of a intracapsular NOF for patients with a good pre-morbid status ?
Internal fixation
What is compressed in cubital tunnel syndrome ?
Ulnar nerve
what are some clinical features of cubital tunnel syndrome ?
Tingling / numbness of the 4th and 5th finger
What does a L5 radiculopathy cause ?
Weakness of hip abduction and foot drop
No specific reflex is lost
What is the management for all proximal scaphoid fractures ?
Surgical fixation
What nerve injury is common in a posterior hip dislocation ?
Sciatic nerve injury
What is previous chemotherapy a significant risk for ?
AVN
What is medial epicondylitis aggravated by ?
Wrist flexion and pronation
What is the most likely diagnosis if there is painful click on McMurray’s test ?
Meniscal tear
What is the likely cause of a patella dislocation ?
Direct trauma
What is the likely diagnosis if a person falls hard onto a bent knee ?
It can injure the posterior cruciate ligament
What can a hyperextension knee injury cause ?
ACL rupture
What can a twisting knee injury cause ?
A meniscal tear
What are some features of an S1 lesion ?
Sensory loss of posterolateral aspect of the leg and lateral aspect of the foot
Weakness in plantarflexion of the foot
Positive sciatic nerve stretch test
What is the typical presentation of De Quervain’s tenosynovitis ?
Pain on the radial side of the wrist / tenderness over the radial styloid process
What are the features of a L5 lesion ?
Loss of foot dorsiflexion + sensory loss of the dorsum of the foot
What are some features of L3 nerve root compression ?
Sensory loss of anterior thigh
Weak hip flexion
Weak knee extension
Weak hip adduction
Reduced knee reflex
What are some features of a L4 nerve root compression ?
Sensory loss of anterior aspect of knee and medial malleolus
Weak knee extension and hip adduction
Reduced knee reflex
What is the management of an undisplaced patella fracture with an intact extensor mechanism ?
Conservative management with knee immobilisation
What is the strongest risk factor for avascular necrosis of the femoral head ?
High dose steroids
What vessel is likely to be affected in buttock pain which arises when walking and is relieved when resting ?
Iliac stenosis
What is the likely diagnosis if a patient has bilateral calf pain that is reduced when walking uphill and bending forwards ?
Lumbar canal stenosis
What is the initial imaging modality of choice for suspected Achilles tendon rupture ?
USS ankle
Why do patients with type 2 diabetes have abnormally high ABPI’s ?
They may have vessel calcification.
What is the most appropriate initial management for a iliopsoas abscess ?
Percutaneous drainage and prompt administration of IV antibiotics
how does an iliopsoas abscess present ?
Risk factors - DM and renal failure
Back pain
Discomfort hip extending
What joints are affected by OA causing Heberdens nodes ?
DIP
What are some features of perthes disease ?
More likely in boys
4 - 8 years old
Flattened head of femur
What is the treatment for a newborn baby with bilateral clubfoot ?
Manipulation and progressive casting starting soon after birth
What is the Leriche triad ?
Claudication of the buttocks and thighs
Atrophy of the musculature of the legs
Impotence
