Trauma and Orthopedics Flashcards

Question

What are the risk factors for non-haematogenous osteomyelitis?

Answer 1

Risk factors • Diabetic foot ulcers/pressure sores • Diabetes mellitus • Peripheral arterial disease

Answer 2

``` Raised inflammatory markers Constant pain with gradual onset and worse at night Low grade pyrexia Tender to touch Warm and erythematous Slight effusion Systemic infection Inability to weight bear ```

Answer 3

Staph Aureus is the most common Pseudomonas, E. coli and streptococci Salmonella species predominate sickle cell patient

Answer 4

Routine bloods Blood cultures X-rays – show nothing in first 10-14 days but later show haziness and loss of density MRI is the most sensitive modality Bone biopsy and culture is gold standard but rarely required

Answer 5

Drain any abscess When organism and sensitivities not known – 6 weeks of IV vancomycin and cefotaxime Flucloxacillin for 6 weeks and clindamycin if penicillin allergic may also be appropriate Ciprofloxacin in pseudomonas infections

Answer 6

Chronic Osteomyelitis If osteomyelitis is poorly treated this will result in progression to chronic characterised by pain, fever, infected dead bone (sequestrum), sinus suppuration (pathognomonic) and long remissions. Suspect in vascular insufficiency with non-healing tissue ulceration overlying bony prominences. Sequestrum acts as a reservoir for infection as it is avascular and so is not penetrated by antibiotics.

Answer 7

X-rays will show thick irregular bone and if bone can be felt on probing an ulcer this is sufficient to diagnose chronic osteomyelitis.

Answer 8

Management – excision of dead bone, skeletal stabilisation, dead space management and antibiotics as for acute or modified for sensitivities.

Answer 9

Definition – build up of pressure in a muscle compartment that results in compression of blood vessels and muscles causing ischaemia and death of the muscle. Fractures at highest risk of this are supracondylar fracture and tibial shaft fractures.

Answer 10

Reperfusion of ischaemic limb Plaster cast Physical trauma especially fractures Crush injuries

Answer 11

Severe pain especially on movement Excessive requirement of breakthrough analgesia should raise suspicion Pulseless (although the presence of a pulse does not rule out compartment syndrome) Paralysis Paraesthesia Pallor Death of muscle will occur within 4-6 hours

Answer 12

Clinical diagnosis Can measure intercompartmental pressure – anything in excess of 20mmHg are abnormal and > 40mmHg is diagnostic Routine bloods including creatinine kinase Note no pathology will be seen on X-ray

Answer 13

Removal of cause if present and placement of limb at heart level Emergency fasciotomy with wound closure around 7 days afterwards Management of rhabdomyolysis with aggressive IV fluids If muscle groups are frankly necrotic at fasciotomy they should be debrided and amputation may be required

Answer 14

Definition – progressive loss of articular cartilage and remodelling of underlying bone, originally thought to be simple wear and tear now its thought it may be due to slight deformities within joints causing inflammation over time.

Answer 15

Obesity Advancing age Female Manual labour jobs

Answer 16

Painful and stiff joints – most commonly, fingers, hips and knees Reduced movements Typically insidious onset, chronic and gradually worsening Relieved by rest and worsened through activity Pain gets worse through day but stiffness improves Localised swelling Crepitus

Answer 17

Loss of joint space Subchondral Sclerosis (bright white) Osteophytes Subchondral cysts

Answer 18

X-ray | Routine blood tests to rule out other disorders

Answer 19

Education on protection and physiotherapy strengthening exercises Loss of weight First line analgesics such as Paracetamol and NSAIDs (topical NSAIDs or knee and hand only) Second line analgesics such as opioids, capsaicin cream and intraarticular steroid injections Replacement of joint in surgery

Answer 20

Osteoarthritis (OA) of the hands is sometimes referred to as nodal arthritis. The presence of hand OA increases the risk of future hip and knee OA (higher for hip OA than for knee OA)

Answer 21

``` Family history Female (M:F 1:3) Increasing age (rare to present before 55 years of age) Previous trauma of a joint Obesity Hypermobility Occupation e.g. cotton workers and farmers are more susceptible to hand OA Osteoporosis reduces the risk of OA ```

Answer 22

* Radiologic signs are more common than symptoms * Usually bilateral with one joint affected at a time over several years. * The carpometacarpal joints (CMCs), distal interphalangeal joints (DIPJs) are affected more than the proximal interphalangeal joints (PIPJs) * Episodic joint ache provoked by movement and relieved by resting the joint * Stiffness worse after long periods of inactivity such as in the morning, stiffness lasts only a few minutes compared to the morning joint stiffness seen in rheumatoid arthritis * Painless nodes – Heberden’s nodes at the DIPJs, Bouchard’s Nodes at the PIPJs, these nodes are the result of osteophyte formation * Squaring of the thumbs, deformity of the carpometacarpal joint of the thumb resulting in fixed adduction of the thumb * Functionally patients do not usually have any problems unless there is severe involvement of the DIPJs, there may be reduced grip strength which can result in disuse atrophy

Answer 23

X-ray signs as for standard OA – osteophyte and joint space narrowing

Answer 24

``` Increasing age Female gender (twice as common) Obesity Developmental dysplasia of the hip AVN of the hip ```

Answer 25

Chronic history of groin ache following exercise and relieved by rest Red flag features suggesting an alternative cause include rest pain, night pain and morning stiffness > 2 hours Oxford Hip Score is used to assess severity

Answer 26

NICE recommends that if the features are typical then a clinical diagnosis can be made otherwise, plain x-rays are the first-line investigation

Answer 27

Oral analgesia Intra-articular injections: provide short-term benefit Total hip replacement remains the definitive treatment

Answer 28

Venous thromboembolism Intraoperative fracture Nerve injury

Answer 29

Aseptic loosening (most common reason) Pain Dislocation Infection

Answer 30

* Cemented hip replacement – metal femoral component is cemented into the femoral shaft accompanied by a cemented acetabular polyethylene cup * Uncemented replacement, more popular in younger patients but expensive * Hip resurfacing – metal cap placed over the femoral head and is often used in younger patients as it preserved the femoral neck in case its needed for conventional surgery later on in life

Answer 31

* Avoid flexing hip > 90 degrees * Avoid low chairs * Do not cross your legs * Sleep on your back for first 6 weeks

Answer 32

Primary osteoarthritis appears idiopathic although research is suggesting small underling defects may be the cause. ``` Secondary Causes Post traumatic Postoperative Post-infection Malposition Mechanical instability Osteochondritis dissecans ```

Answer 33

``` Obesity Female Genetics Age Occupation ```

Answer 34

Pain on initiating movement Stiffness following inactivity but resolves in 30minutes Posterior patellar and medical compartment most affected leading to varus deformity Limited range of movement Crepitus during active and passive movement

Answer 35

NSAIDs topical or oral Physiotherapy focusing on quadriceps strengthening exercises Weight loss Steroid injections Total knee replacement – lasts about 15 years If young then osteotomies are preferred and can delay TKR for 10 years

Answer 36

A syndrome comprising two aetiologies • Subacromial impingement – impingement syndrome or painful arc syndrome • Rotator cuff tears – tear in supraspinatus tendon, subscapularis, or infraspinatus

Answer 37

Definition – supraspinatus becomes inflamed due to impingement below acromion and coraco-acromial ligament.

Answer 38

Osteoarthritis of the acromio-clavicular joint and resulting osteophytes Thickening or calcification of the coracoacromial ligament Rotator cuff injuries destabilising the joint Bursitis of the subacromial bursa

Answer 39

Painful mid arc (60-120 degrees) | Positive Neer’s impingement test or Hawkins-kennedy test

Answer 40

Positive test for rotator cuff tears (Jobe’s test, Bell-press test, infraspinatus, and teres minor tests and drop arm sign) If there is a rotator cuff tear, then there may be pain in the first 60 degree of abduction and an inability to abduct above 90 degrees Particularly pain at night disturbing sleep

Answer 41

If suspecting tear, then X-ray to exclude fracture USS scan of the arm – can determine tear or no tear MRI – size characteristic and location of tear

Answer 42

MRI used to confirm impingement

Answer 43

Conservative management of impingement with analgesia, physio, and steroid injection If after 6 months of conservative management there is no response then surgical management can be considered such as arthroscopic acromioplasty, bursectomy or repair of muscle tears

Answer 44

For tears conservative management preferred if presenting within 2 weeks of injury and especially in patients not limited by pain and those with co-morbidities and unsuitable for surgery. Surgery indicated if presenting >2 weeks since the injury or remaining symptomatic despite conservative management. Incomplete tendon tear – surgery only if symptoms persist Complete tendon tear – open or arthroscopic repair

Answer 45

Frozen Shoulder Syndrome (adhesive capsulitis) Idiopathic severe pain and then persisting stiffness. Fairly common especially in middle aged females, associated with diabetes mellitus thyroid disease, and cervical spondylosis.

Answer 46

Primary – idiopathic | Secondary – rotator cuff tendinopathy, impingements, biceps tendinopathy, previous surgery, trauma or joint arthropathy

Answer 47

External rotation affected more than internal rotation or abduction, loss of arm swing Both active and passive movements are affected Split into 3 phases that last over 6-24 months 1. Deep and constant painful freezing phase (up to 12 months) 2. Adhesive phase (6-12 months) 3. Recovery or thawing phase (12-36 months) Stiffness and pain is worse at night and often disturbs sleep Bilateral in 20% of cases

Answer 48

Typically, a clinical diagnosis | Imaging may be required in atypical or persistent symptoms and MRI scan is the modality of choice in this case

Answer 49

No single intervention has been shown to improve outcomes NSAIDs, physiotherapy, oral corticosteroids, and intra-articular corticosteroids Surgical release with manipulation under anaesthetic or arthroscopic arthrolysis

Answer 50

This is the most common joint in the body to dislocate accounting for 50% of all major dislocations. Typically young males in contact sport where arm was forced into abduction, extension, and external rotation. In the elderly may simply be a FOOSH.

Answer 51

Types of Shoulder dislocation • Glenohumeral dislocation – 95% are anterior • Acromioclavicular dislocation – next most common and clavicle loses all attachment to the scapula • Sternoclavicular – uncommon

Answer 52

Anterior – occurs due to external rotation and abduction, 40% of cases will become recurrent. Associated with greater tuberosity fracture, Bankert lesion (avulsion of glenoid labrum from the glenoid) and Hill-sachs lesion (impaction fracture of humeral head). Posterior – often misdiagnosed, Rim’s, Light bulb sign and Trough sign. Present with limited external rotation, usually occurs following epileptic seizures or electric shock

Answer 53

``` Pain Reduced mobility Asymmetry on examination Loss of contours – flattened deltoid Anterior bulge from head of humerus ```

Answer 54

Trauma X-ray of shoulders – AP, Y scapular and axial views (Lightbulb sign seen in posterior dislocation) Must check neurovascular status before and after reduction as well as an x-ray to confirm no fracture has occurred If soft tissue damage suspected such as rotator cuff tears then MRI shoulder may be indicated

Answer 55

If dislocation recent then reducing may be done without analgesia Some patients may require sedation/analgesia to make sure rotator cuffs are relaxed - usually Entonox, parenteral opioid or intra-articular local anaesthetic) Support the arm in a broad arm sling and refer to fracture clinic and physiotherapy In recurrent dislocation surgical repair will be required Simple reduction – apply longitudinal traction to the arm in abduction and replace head of the humerus with gentle pressure Kocher’s method – flex elbow to 90 degrees, abduct the shoulder, externally rotate the shoulder and then abduct the upper arm back across the body before internally rotating the shoulder

Answer 56

Common fracture that usually occurs through the surgical neck (very rare for it to happen through the anatomical neck) usually after FOOSH in the elderly causing a stable osteoporotic fracture. Can sometimes occur in the young in high energy trauma and often associated with tissue or neurovascular injuries.

Answer 57

Avascular necrosis risk if there is an anatomical neck fracture with displacement of >1cm

Answer 58

In children the most common pathology is a greenstick fracture through the surgical neck.

Answer 59

Pain Restricted arm movement Significant swelling Check neurovascular status, especially axillary distribution

Answer 60

Trauma shoulder X-ray – AP, Y scapular and axial views Neer Classification – classification based on relationship between greater tuberosity, less tuberosity, articular segments (anatomical neck) and humeral shaft (surgical neck)

Answer 61

Majority managed conservatively with immobilisation and early mobilisation. Use polysling that allows the arm to hand aiding the reduction of fragments If significantly displaced, open or neurovascular compromise then will require ORIF with use or intramedullary nailing. ORIF usually preference is head splitting fracture and intramedullary nail if fracture involved surgical neck or combined humeral fracture Hemiarthroplasty in complex injuries where ORIF and intramedullary nails are inappropriate.

Answer 62

Typically direct blow to the arm rather than a FOOSH, be aware of radial nerve injury (seen in 10%) so document neurovascular status before and after intervention. Typically occur from FOOSH or falling laterally onto an adducted arm.

Answer 63

Holstein-Lewis fracture – distal third of humerus resulting in entrapment of the radial nerve – loss of sensation in radial distribution and wrist drop deformity. Surgical management required.

Answer 64

Typically does not need surgery, simple splinting with a humeral brace and gravity traction by means of collar and cuff gives satisfactory reduction. Must immobilise for 8-12 weeks. Full union expected with 8-12 weeks. In minority of cases ORIF with a plate is required and may involve faster healing times Intramedullary nailing indicated in pathological fracture, polytrauma or severe osteoporosis

Answer 65

Most commonly occurs following direct blow to the clavicle and is common in cycling accidents. The most common location in the middle third where the medial fragment is pulled superiorly by sternocleidomastoid and the lateral fragment is displaced inferiorly from weight of the arm.

Answer 66

1. Type 1 – middle third of the clavicle (75% of all clavicular fractures), generally stable but significant deformity may be present 2. Type 2 – lateral third and make up 20% of clavicular fractures. When displaced these are often unstable 3. Type 3 – remaining 5% in the medial third of the clavicle usually involving multi system polytrauma. Must check neurovascular compromise due to proximity of mediastinum. Think pneumothorax and haemothorax

Answer 67

Broad arm sling with follow up X-ray at 6 weeks to ensure union, encourage early mobilisation of shoulder to prevent adhesive capsulitis. Sling maintained until there is pain free movement. If fragments failed to unite then ORIF ORIF if severely displaced, open fracture or bilateral

Answer 68

Inflammation of the epicondyles of the elbow termed tennis elbow if the lateral epicondyle and golfer’s elbow if the medial epicondyle.

Answer 69

Lateral Epicondylitis (Tennis elbow) Pain and tenderness localised to the lateral epicondyle Pain worse on resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended Patients in acute pain for 6-12 weeks Episodes typically last between 6-24 months Cozen’s and Mill’s tests

Answer 70

Medial Epicondylitis (Golfer’s elbow) Pain and tenderness localised to the medial epicondyle 1/5 less common than tennis elbow Pain aggravated by wrist flexion and pronation Symptoms may be accompanied by numbness/tingling in the 4th and 5th finger due to ulnar nerve involvement

Answer 71

Most cases will spontaneously resolve via restriction of activity within 1 year and analgesia Physiotherapy in motivated patients may speed this up as well as corticosteroid injections

Answer 72

Painful swollen and weak tendon that can pose a risk of rupture. This can occur proximally or distally (most common) and is most common in young active individuals or in older people with a degenerative tendinopathy.

Answer 73

Presentation – pain, worse on stressing the tendon, weakness and stiffness. Tender to examine and muscular atrophy due to disuse atrophy. Specific tests – speed test (proximal tendon) and Yorgason’s test (distal tendon)

Answer 74

Investigations – blood tests and play x-ray to exclude other causes. US and MRI may be used but are rarely warranted.

Answer 75

Management – conservative with analgesia, ICE and physiotherapy. US guided steroid injections if persistent and very rarely surgical intervention with arthroscopic tenodesis or tenotomy.

Answer 76

Two tendons, long from glenoid and the short from the coracoid process that insert distally together onto the radial tuberosity. Tendon rupture occurs when one of these separate form their attachment site or is torn across its full width. Typically, this involves the long tendon (90%) but can rarely occur at the distal tendon.

Answer 77

``` Male (3:1 ratio) Elderly – over age of 60 Distal rupture usually in 40s and almost always men Heavy overhead activities Shoulder overuse or underlying shoulder injuries Smoking Corticosteroid Bicep tendinopathy ```

Answer 78

Long tendon – typically occurs when biceps are lengthened and contracted, and a load is applying e.g. descent phase of a pull-up Distal tendon – flexed elbow is suddenly and forcefully extended whilst bicep is contracted

Answer 79

Sudden pop or tear in the shoulder or elbow followed by pain, bruising and swelling If long tendon rupture then Popeye deformity, also less reliable reverse Popeye in distal tendon rupture Weakness in shoulder and elbow especially with supination Hood test – flex elbow to 90 degrees fully supinated and attempt to hook index finger underneath lateral edge of bicep tendon (can’t be done if ruptured)

Answer 80

General examination of elbow and shoulder and assess neurovascular function Bicep squeeze test – if intact then squeeze should cause forearm supination USS by skilled clinician usually done to confirm diagnosis Urgent MRI if suspected distal tendon rupture

Answer 81

Long tendon rupture – conservative management with analgesia and physiotherapy Distal tendon rupture – surgical intervention

Answer 82

Supracondylar Fracture | Most common fracture in childhood (but very rare in adults) and usually due to FOOSH with hyperextension.

Answer 83

Clinical features – pain, swelling and inability to move elbow Neurovascular problems are common due to the proximity of surrounding structures

Answer 84

Investigations – X-ray in AP and lateral views. Look for posterior fat pad sign and displacement of the anterior humeral line which should intersect the middle of the capitellum in children > 5 years

Answer 85

Gartland Classification (lateral x-ray) 1. Anterior humeral line passes through the middle of the capitellum (undisplaced) 2. Anterior humeral line passes anterior to the capitellum (displaced with intact posterior cortex) 3. Unstable with posterior displacement, if medial then threatens the radial nerve, if lateral displacement then threatens the median nerve

Answer 86

Keep elbow in extension to minimise brachia artery damage Type 1 – above elbow back slab and sling – conservative management Type 2 – closed reduction under GA (and fixation with k wires) Type 3 – closed reduction under GA and fixation with k wires

Answer 87

Most common elbow fracture in adults usually through indirect trauma with axial load being placed on the forearm causing radial head to be pushed against the capitulum of the humerus, usually this is during extension and pronation.

Answer 88

History of FOOSH with swollen and tender elbow over the radial head Flexion/extension may be possible, but supination and pronation hurt Effusion on x-ray or sail sign

Answer 89

Mason Type 1 – non-displaced or minimally displaced Mason Type 2 – partial articular fracture with displacement > 2mm or angulation Mason Type 3 – Comminuted fracture and displacement (complete articular fracture)

Answer 90

Check for position and neurovascular compromise before and after intervention Undisplaced – collar and cuff e.g. Mason Type 1 and some Type 2 Displaced or fragments prevent supination/pronation then ORIF or excision of radial head such as in Mason Type 3 and some Type 2.

Answer 91

Almost always posterior due to fall on not quite fully outstretched hand with partially flexed elbows causing posterior ulna displacement on the humerus. Often have ulnar nerve deficit.

Answer 92

Manage with closed reduction +/- GA which is confirmed by hearing a clunk. Must have post reduction image and check neurovascular status before and after. Keep immobilised in a backslab for 10 days. Check neurovascular status and X-ray before and after. Dislocations complicated by fractures, open injury or neurovascular compromise requires ORIF of the coronoid, radial head or olecranon with appropriate soft tissue repair.

Answer 93

Terrible triad – elbow dislocation with lateral collateral ligament injury, radial head fracture and coronoid fracture. This will cause a very unstable elbow. This usually occurs with falls onto extended arm with rotation resulting in posterolateral dislocation.

Answer 94

All olecranon fracture are intraarticular and occur after direct blow or avulsion when triceps contacts during a fall on semiflexed, supinated arm.

Answer 95

Presentation is with tenderness and inability to extend the elbow against gravity

Answer 96

Conservative management if displacement < 2mm – immobilisation in 60–90-degree elbow flexion and early introduction of movement from week 1-2. Increasingly conservative management is used in elderly patients despite a larger displacement. Surgical management if displacement is > 2mm with ORIF and tension band or a plate. Often requires a high rate of removal of metal work due to how superficial everything is over the olecranon.

Answer 97

Inflammation of the olecranon bursa – sometimes referred to as student’s elbow due to it occurring from resting elbows on a desk for long periods of time. Can also have an infective cause.

Answer 98

Presents with pain and swelling over the olecranon but with range of movement preserved and can be definitively diagnosed with aspiration of the fluid. If infective manage with IV antibiotics and washout, noninfective treated with rest and analgesia.

Answer 99

Usually caused by a fall on the outstretched hand or FOOSH and is very common in elderly osteoporotic women. Be aware of compartment syndrome and injuries to ulnar, radial, and medial nerve as well as the radial and ulnar arteries.

Answer 100

Colles’ Fracture Distal transverse radial fracture (usually 1 inch proximal to the radio-carpal joint) with posterior displacement of the fragments and ulnar deviation. Described as a dinner fork type deformity.

Answer 101

Smith’s or reverse Colles’ fracture Falling onto flexed wrists (falling backwards and arms flexed behind you) or direct blow to the forearm resulting in volar angulation (anterior displacement) of the distal radial fragment described as a Garden spade deformity.

Answer 102

Barton’s Fracture Intra-articular fracture of the distal radius (Colles’/Smith’s) with associated radiocarpal dislocation, usually due to fall onto extended and pronated wrist.

Answer 103

Bennett’s Fracture Intraarticular fracture of the first carpometacarpal joint due to impact on flexed metacarpal such as in fist fight. On X-ray triangular fragment at ulnar base of metacarpal is seen.

Answer 104

Monteggia’s Fracture Dislocation of the proximal radioulnar joint in association with an ulnar fracture. Fall on outstretched hand with forced pronation. Need prompt diagnosis to avoid disability. Galeazzi Fracture Radial shaft fracture with associated dislocation of the distal radioulnar joint due to direct blow to the forearm.

Answer 105

X-ray looking for: intra articular extension and ulnar styloid fractures which indicate a more unstable fracture.

Answer 106

Analgesics will always be needed Closed reduction in ED in cases where there is neurovascular compromise or where manipulation is likely to be a definitive treatment. Plaster immobilisation for 6 weeks with below elbow backslab casts and Physiotherapy Significantly displaced or unstable fractures ORIF +/- K wires Ulnar styloid fractures often do not require fixation Smith’s fracture are more unstable and treated with a volar buttress plate in their plaster

Answer 107

Involvement of the scaphoid bone AVN Malunion or Non-union Median nerve compression

Answer 108

Must always examine for scaphoid fracture in anyone presenting with wrist pain acutely for medico legal reasons as the blood supply comes dorsally from the radial artery and so there is high risk of avascular necrosis.

Answer 109

Fall onto outstretched hand Contact sports – football and rugby (see a peak in autumn with start of school season) Road traffic accidents – holding steering wheel

Answer 110

Pain along the radial aspect of the wrist at the base of the thumb Loss of grip strength/pinch Maximal tenderness over the anatomical snuff box (sensitive but not specific) Wrist joint effusion – unless hyper acute (<4h) or delayed (>4days) presentation Pain elicited by telescoping of the thumb (longitudinal compression) Tenderness of the scaphoid tubercle Pain on ulnar deviation of the wrist

Answer 111

X-ray in AP and lateral views (can also request scaphoid views – PA, lateral oblique and ziter) – be wary as x-ray may be normal in early phases so repeat in 7-10 days’ time after wrist immobilisation CT scan is superior to X-ray MRI is definitive to confirm or exclude diagnosis and should be considered first line

Answer 112

Immobilisation with a thumb spica splint or below the elbow back slab. Undisplaced fractures – cast for 6-8 weeks, union achieved in 95%, if professional sportsman then early surgical intervention. If fracture is displaced, then surgical fixation usually with percutaneous variable-pitched screw.

Answer 113

``` Trigger Finger (Tendon nodules) Associated with abnormal flexion of the digits that is thought to occur due to disparity between the size of the tendon and the pulleys. ```

Answer 114

``` Female Rheumatoid arthritis Diabetes Prolonged gripping Increasing age ```

Answer 115

More common in thumb, middle or ring finger Stiffness, locking and snapping when extending a flexed digit Nodule may be felt at the base of the finger May become painful, especially over the volar aspect of the MCP joint

Answer 116

If mild then conservative management with advice and small splint Steroid injection works in most cases Finger splint applied after the injection and rest Surgery reserved for patients who do not respond to injections

Answer 117

Definition – inflammation of the sheath containing extensor pollicis brevis and abductor policis longus tendons.

Answer 118

Aged 20-50 Female Pregnant Activities involving repetitive wrist movement

Answer 119

Pain near the base of the thumb Tenderness and swelling over the radial styloid process Pain when grasping or pinching are particularly painful and difficult e.g. lifting a teapot Positive Finkelstein’s test

Answer 120

No investigation required as clinical diagnosis Finkelstein’s test – patient makes a fist with their thumb inside the fist then ulnar deviates, positive test if pain felt over the radial styloid region.

Answer 121

Conservative – lifestyle advice to reduce repetitive movements and a thumb splint (spica) ICE and NSAIDs Steroid injections to reduce inflammation and relieve pain in first 6 months Surgical decompression by splitting the tendon sheaths

Answer 122

Contraction of the longitudinal palmer fascia due to fibroblastic hyperplasia and altered collage matrix.

Answer 123

``` 6:1 Male to Female Smoking Alcoholic Liver disease Diabetes Occupational exposures (vibration tools or heavy manual work) ```

Answer 124

Typically starts as painless nodules Can lead to severely limited digital movement Most commonly affects the ring and little finger Heuston’s test

Answer 125

Diagnosis is clinical Good practice to check LFTs and glucose USS might be used for accuracy when applying intralesional injections

Answer 126

Conservative – hand physiotherapy, injectable collagens clostridium histolyticum Surgical – excision of disease fascia, fasciectomy

Answer 127

Noncancerous soft tissue lumps that can occur along any tendon or joint and are usually filled with synovial fluid. They are soft and transilluminate on examination.

Answer 128

Management if symptom free then conservative and simply monitor. If interfering with daily functioning, then can aspirate +/- steroid injection or excise the cyst.

Answer 129

Definition – compression of the median nerve due to raised pressure underneath the flexor retinaculum the wrist

Answer 130

``` Female Increasing age Pregnancy and the pill Obesity Previous Joint injury Diabetes Rheumatoid arthritis Hypothyroidism Gout and pseudogout Cardiac failure acromegaly Premenstrual state ```

Answer 131

``` Idiopathic Pregnancy Oedema Lunate fracture Rheumatoid arthritis ```

Answer 132

Pain/Pins and needles in the thumb, index and middle finger (palmer aspect usually spared as a result of the early cutaneous branch of the median nerve) Symptoms may ascend proximally Worst during the night Patient may shake their hand to obtain relief Weakness of thumb abduction (abductor pollicis brevis) Wasting of thenar eminence

Answer 133

Percuss over median nerve to bring back symptoms – Tinel’s test Hold wrist in full flexion for a few minutes should re-create pain – Phalen’s test Nerve conduction studies – prolongation of action potential US and MRI if required to identify lesions

Answer 134

Conservatively with wrist splint at night Corticosteroid injection and NSAIDS to reduce swelling Carpel tunnel surgery if really severe symptoms – surgical decompression (flexor retinaculum division)

Answer 135

Compression of the ulnar nerve as it passes through the cubital fossa

Answer 136

Tingling and numbness in the 4th and 5th finger Tingling starts off intermittent and then becomes constant Weakness and muscle wasting Pain worse on leaning on the affected elbow History of osteoarthritis or prior trauma

Answer 137

Clinical diagnosis Nerve conduction studies Froment’s sign – hold piece of paper between patient’s thumb and index finger – then attempt to pull it away, if ulnar palsy then adductor policis muscle doesn’t work and patient tried to compensate by flexing thumb at interphalangeal joint

Answer 138

Avoid aggravating activity Physiotherapy Steroid injections Surgery in resistant cases

Answer 139

Most are due to compression of the posterior interosseous branch of the radial nerve and though to occur due to overuse. Clinical Features Very similar to lateral epicondylitis making it difficult to diagnose Pain tends to be around 4-5cm distal to the lateral epicondyle Symptoms exacerbated by extending the elbow and pronating the forearm

Answer 140

Dorsal Column – vibration, and proprioception | Spinothalamic – pain, sensation, and temperature

Answer 141

Infection in the intervertebral disc space which can lead to serious complications such as sepsis or epidural abscess.

Answer 142

Usually due to haematogenous seeding of the vertebrae implying the patient has bacteraemia and seeding could have occurred elsewhere Bacterial – staphylococcus aureus is most common Viral TB Aseptic

Answer 143

Back pain Pyrexia, rigors, and sepsis Neurological features- changing lower limb neurology Features of epidural abscess

Answer 144

MRI is most sensitive CT guided biopsy may be required to guide microbial treatment Assess for endocarditis with transthoracic echo or TOE

Answer 145

6-8 weeks of IV antibiotics – really important to tailor to positive cultures

Answer 146

One of the most common presentations to general practice with the majority being non-specific muscle problems. When diagnosing focus on the fact you have rule out sinister causes of back pain.

Answer 147

Red Flags associated with Lower back pain • Age < 20 or > 50 – malignancy • Violent trauma or minor trauma in osteoporosis – fracture • History of previous malignancy – metastatic disease • Night pain • Systemically unwell – weight loss of fever • Faecal/urinary incontinence/saddle anaesthesia – cauda equina syndrome • Immunosuppression, ICDU and unexplained fever – infection • Chronic steroid use – fracture or infection

Answer 148

NO need for lumbar spine X-ray MRI – only if the result is likely to change management or where there is suspicion of malignancy, infection, fracture, cauda equina or ankylosing spondylitis or if symptoms persist for > 4 weeks.

Answer 149

Should be self-managed Stay physically active and exercise NSAIDs are first line (plus PPI if >45yrs) – ibuprofen, naproxen and paracetamol. Consider morphine early if pain not controlled Treat sciatica with the usual neuropathic guidance Warmth and swimming Consider exercise programmes along side manual therapy Radiofrequency denervation Epidural injections of local anaesthetic and steroid for acute and severe sciatica

Answer 150

Yellow flags that impair recovery • Belief that pain and subsequent activity is harmful • Pain behaviour – extended rest, avoidance, or normal activities • Over reliance on passive treatments such as ice packs and analgesia • Psychiatric disorders – anxiety, depression, and personality disorders • Unsupportive home environment or over protective family • Inappropriate expectations and failing to actively engage with treatment

Answer 151

Any red flags = immediate referral to secondary care Progressive/severe neurological deficit = seen be specialist within 1 week Disabling pain > 2 weeks = early referral to physio and consider corticosteroid injections Disabling pain > 6 weeks = to be seen by specialist within 2 weeks

Answer 152

Clear dermatomal leg pain and neurological deficits Pain often worse when sitting and may come on insidiously or suddenly L4/L5 and L5/S1 are the most common locations for a disc prolapse Disc may seize a few days after a back strain following severe coughing, sneezing, or twisting

Answer 153

Features based on level of prolapse • L3 root compression – sensory loss over anterior thigh, weak quadriceps, reduced knee reflex and positive femoral stretch test • L4 root compression – sensory loss anterior aspect of knee, weak quadriceps, reduced knee reflex, positive femoral stretch test • L5 root compression – sensory loss dorsum of foot, weakness in foot and big tow dorsiflexion, reflexes intact and positive sciatic nerve stretch test • S1 root compression – sensory loss posterolateral aspect of leg and lateral aspect of foot, weakness in plantar flexion of foot, reduced ankle reflex and positive sciatic nerve stretch test

Answer 154

Straight leg raising (Lasegue Test) – stretches the sciatic nerve attempting to reproduce root pain, if this pain occurs within 30-70 degrees then this is said to be a positive sign MRI indicated if radiculopathy persistent for > 6 weeks, red flags present, evidence of spinal cord compression or imaging will significantly alter management.

Answer 155

Initially brief rest with early mobilisation and pain relief works in 90% of patients Analgesia Physiotherapy Exercises If symptoms persist after 4-6 weeks, then referral for consideration of MRI Surgery – discectomy, indications: Cauda equina Progressive muscular weakness Continuing pain

Answer 156

* Previous history of a fragility fracture * Frequent or prolonged use of glucocorticoids * History of falls * Family history of hip fracture * Alternative causes of secondary osteoporosis e.g. Cushing’s disease, hyperthyroidism, chronic renal disease * Low BMI (< 18.5) * Tobacco smoking * High alcohol intake: > 14 units/week for women, > 21 units/week for men

Answer 157

Asymptomatic usually discovered incidentally Acute back pain Breathing difficulties: due to compression the lungs, heart and intestine Gastrointestinal problems due to compression of abdominal organs A minority will have a history of fall or trauma Loss of height Kyphosis (curvature of the spine) Localised tenderness on palpation of spinous processes at the fracture site

Answer 158

X-ray of the spine: This should be the first investigation ordered and may show wedging of the vertebra due to compression of the bone. An X-ray of the spine may also show old fractures (which can have a sclerotic appearance) CT spine MRI spine: Useful for differentiating osteoporotic fractures from those caused by another pathology e.g. a tumour

Answer 159

A Jefferson fracture is the eponymous name given to 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. They are often associated with head injuries and other concurrent cervical spinal injuries. These fractures are usually unstable and account for approximately a third of all C1 fractures.

Answer 160

A Hangman’s fracture, also termed as traumatic spondylolisthesis of the axis, describes a fracture through the pars interarticularis of C2 bilaterally usually with subluxation of the C2 vertebra on C3. These are caused by cervical hyperextension and distraction (historically the forces that were delivered by a noose). These fractures can be unstable; in such cases, surgical fixation will be required.

Answer 161

Odontoid peg fractures are common cervical fractures, most common in older patients. Patients can present following low-impact injuries, neck pain being common. The condition can be fatal, especially with significant displacement of the odontoid; those who survive can have no neurology.

Answer 162

Consists of curvature of the spine in the coronal plane, usually accompanied by a degree of rotation of the spine. The majority of cases are idiopathic with no serious underlying pathology and usually involves muscle spasm. This most commonly affects girls and is called adolescent idiopathic scoliosis.

Answer 163

Clinical features – later in life may have issues with pain, cosmesis and impaired lung function. As curvature continues with growth the earlier the onset the worse the prognosis.

Answer 164

Patients should be referred to specialist clinics for observation and regular measurement of Cobb’s angle (lateral curvature). Only 1/6 of patients will require treatment and only a ¼ of those require surgery.

Answer 165

Braces may be trialled if curvature is progressing to slow the progression (it will not treat) Severe, or progressive structural disease is managed surgically with bilateral rod stabilisation of the spine

Answer 166

Very common condition occurring as a result of osteoarthritis Clinical Features Neck pain +/- referred pain that can mimic headaches Radiculopathy Myelopathy

Answer 167

Clinical spectrum of presentation and severity ranging from asymptomatic to quadriparesis and sensory loss due to compression of the cord. ``` Neck stiffness Crepitus Stabbing or dull arm pain Forearm/wrist pain Limited painful neck movement Neck flexion inducing tingling down the spine (Lhermitte’s sign) ```

Answer 168

C5 (C4/5 disc) Weak deltoid and supraspinatus Reduced supinator jerks and numb elbow Neck/shoulder radiating to elbow

Answer 169

C6 (C5/6 disc) Weak biceps and brachioradialis Reduced biceps jerk, numb thumb and index finger Pain in shoulder radiating down arm to below elbow

Answer 170

C7 (C6/7 disc) Weak triceps and fingers extension Reduced triceps jerks and numb middle finger Pain in upper arm and dorsal forearm

Answer 171

C8 (C7/T1 disc Weak finger flexors and small muscles of hand. Numb 5ht and ring finger Pain in upper arm and dorsal forearm

Answer 172

Radiculopathy – root compression – pain/electrical sensations in arms or fingers at the levels of the compression. Numbness, dull reflexes, UMN weakness and wasting of muscles (long term) Myelopathy – cord compression – progressive symptoms e.g. weakness, clumsy hands and gait disturbance, UMN leg signs, LMN arms signs, incontinency, hesitancy and urgency.

Answer 173

MRI urgently and specialist referral if you suspect cord compression Analgesia via WHO ladder Encourage gentle activity but avoid driving if neck movement is restricted Cervical collars can give respite If no improvement in 6 weeks, then repeat MRI and referral Surgery if indicated – interlaminar cervical epidural injections, transforaminal injection or surgical decompression

Answer 174

This occurs when one lumbar vertebra is displaced relative to its immediate inferior vertebral body and may occur as a result of stress fracture, osteoarthritis, or spondylolysis, a congenital or acquired (usually age related) deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affecting L4/ L5.

Answer 175

Patients usually present with back pain in adolescence, patients may also have sciatica and a waddling gait due to tight hamstrings. Traumatic cases may show the classic 'Scotty Dog' appearance on plain films.

Answer 176

X-ray and MRI to assess for nerve compression

Answer 177

Management depends upon the extent of deformity and associated neurological symptoms; minor cases may be actively monitored. Individuals with radicular symptoms or signs will usually require spinal decompression and fusion/stabilisation.

Answer 178

Lumbar spinal stenosis is a condition in which the central canal is narrowed by, usually as a result of facet joint osteoarthritis and osteophytes but can also occur due to tumours, trauma, and osteoporosis

Answer 179

Patients may present with a combination of back pain, neuropathic pain and symptoms mimicking claudication. One of the main features that may help to differentiate it from true claudication in the history is the positional element to the pain. Sitting is better than standing and patients may find it easier to walk uphill rather than downhill in contrast to disc prolapse symptoms. The neurogenic claudication type history makes lumbar spinal stenosis a likely underlying diagnosis, the absence of such symptoms makes it far less likely.

Answer 180

Diagnosis is via MRI

Answer 181

Management at first is with NSAIDs, epidural injections and corsets but if these fail to help then decompressive Laminectomy.

Answer 182

Blunt trauma to the chest wall Polytrauma with chest injuries being present in 25% of major trauma Spontaneous rib fractures can occur rarely following coughing or sneezing: usually there is a past medical history of osteoporosis, steroid use or chronic obstructive pulmonary disease pathological rib fractures can also occur due to cancer metastases: the most common cancers which predispose to these are prostate in men and breast in women

Answer 183

Severe, sharp chest pain that is worse with deep breaths or coughing Significant chest wall tenderness over the site of the fractures and visible bruising Crackles or reduced breath sounds Poor oxygenation in cases of flail chest or contusion and pain limiting breathing Pneumothorax

Answer 184

CT will show the fractures in 3D as well as the associated soft tissue injuries. Chest x-rays provide suboptimal views and are rarely used

Answer 185

Majority are managed conservatively with analgesia to ensure breathing not impaired Surgical fixation can be considered to manage pain if this is still an issue and the fractures have failed to heal following 12 weeks of conservative management Flail chest segments must be urgently discussed with cardiothoracic surgery

Answer 186

Death of bone tissue secondary to loss of blood supply, most commonly this affects epiphysis of long bones such as the femur.

Answer 187

Long-term steroid use Chemotherapy Alcohol excess Trauma

Answer 188

Initially asymptomatic | Pain in the affected joint

Answer 189

Plain X-ray – may be normal initially, or osteopenia and microfracture may be seen Collapse of the articular surface may result in crescent sign MRI investigation of choice

Answer 190

Joint replacement

Answer 191

Increasing age Female Osteoporosis/osteopenia

Answer 192

Inability to weight bear (unless non-displaced or incomplete) Leg will be externally rotated and shortened (Measure from ASIS to medial malleolus) if intracapsular Pain

Answer 193

Intracapsular (subcapital, transcervical and basicervical) from edge of the femoral head to the insertion of the capsule of the hip joint Extracapsular – intertrochanteric/pertrochanteric or subtrochanteric (lesser trochanter is the dividing line). Also reverse oblique or transtrochanteric which is at right angles to an intertrochanteric fracture

Answer 194

Garden System for Intracapsular fractures This is based purely on the AP X-ray 1. Type 1 – incomplete, undisplaced fracture with inferior cortex intact 2. Type 2 – complete undisplaced fracture through the neck 3. Type 3 – complete partially displaced fracture, usually rotated and angulated but still has bony contact 4. Type 4 – fully displaced fracture Be wary of blood supply disruption in types 3 and 4 (i.e. when displaced)

Answer 195

Intracapsular Hip Fracture Undisplaced/minimal displacement – internal fixation in situ or hemiarthroplasty if unfit Displaced – if fit then total hip replacement if older and reduced mobility, then hemiarthroplasty Intracapsular hip fracture have a high risk of AVN

Answer 196

Dynamic hip screw | If reverse oblique transverse or sub trochanteric then intramedullary hip screw

Answer 197

``` Non-union Avascular necrosis Malunion Fixed deformities Septic arthritis Reduced mobility ```

Answer 198

Usually occur in young patients from high energy trauma or in older patents from low energy, pathological or osteoporotic fractures.

Answer 199

Type A = extra-articular Type B = Partial articular Type C = complete articular

Answer 200

If significant misalignment then closed reduction and realignment with immobilisation using skin traction initially. Surgical management with ORIF or retrograde nailing is usually indicated for most fractures following this

Answer 201

Classification – Winquist and Hansen Classification Type 0 – no comminution Type I – insignificant comminution Type II – greater than 50% cortical contact Type III – less than 50% cortical contact Type IV – segmental fracture with no contact between fragments

Answer 202

Fascia iliaca block for analgesia Immediate reduction and immobilisation to near anatomic alignment to ensure appropriate haematoma. Traction splinting such as Kendrick traction splint are used in isolated fractures. Most femoral shaft fractures require surgery – within 24-48 hours usually with intramedullary nails Long leg casts can be indicated in undisplaced femoral shaft fractures

Answer 203

Extremely painful condition and due to the high impact and trauma required usually associated with other potentially life-threatening injuries. Prompt diagnosis and management are important to reduce morbidity.

Answer 204

* Posterior dislocation – most common accounting for 90% of hip dislocations, the affected leg is adducted, shortened, and internally rotated * Anterior dislocation – affected leg is abducted and externally rotated without any leg shortening * Central dislocation

Answer 205

ABCDE Analgesia Reduction under general anaesthesia within 4 hours to reduce risk of avascular necrosis Long-term management – physiotherapy to strengthen the surrounding muscles Will take 2-3 months for the hip to heal after traumatic dislocation. Reducing the hip in less than 12 hours gives better prognosis

Answer 206

Sciatic or femoral nerve injury Avascular necrosis Osteoarthritis Recurrent dislocation due to damage of supporting ligaments

Answer 207

An iliopsoas abscess describes a collection of pus in iliopsoas compartment (iliopsoas and iliacus).

Answer 208

Primary Haematogenous spread of bacteria – Staphylococcus aureus: most common ``` Secondary Crohn's (commonest cause in this category) Diverticulitis, colorectal cancer UTI, GU cancers Vertebral osteomyelitis Femoral catheter, lithotripsy Endocarditis Intravenous drug use ```

Answer 209

Fever Back/flank pain Limp Weight loss Specific tests to diagnose iliopsoas inflammation: Patient in the supine position with the knee flexed and the hip mildly externally rotated • Place hand proximal to the patient's ipsilateral knee and ask patient to lift thigh against your hand. This will cause pain due to contraction of the psoas muscle. • Lie the patient on the normal side and hyperextend the affected hip. This should elicit pain as the psoas muscle is stretched.

Answer 210

CT abdomen is the investigation of choice

Answer 211

Note the mortality rate can be up to 19-20% in secondary iliopsoas abscesses compared with 2.4% in primary abscesses. Antibiotics Percutaneous drainage is the initial approach and successful in around 90% of cases Surgery is indicated if: 1. Failure of percutaneous drainage 2. Presence of another intra-abdominal pathology which requires surgery

Answer 212

Total hip replacement – both the articular surfaces of the femur and acetabulum are replaced either by conventionally be replacing femoral head and neck or simply resurfacing the femoral head. Hemiarthroplasty – on the articular surface of the femoral head is replaced, usually indicated in NOF fractures with no arthritis but high risk of avascular necrosis of the femoral head.

Answer 213

``` VTE – 4% Dislocation – 3% Deep infection – 2% Fracture – 1% Nerve palsy – 1% Limb length discrepancy – 1% Death – 0.4-0.7% ```

Answer 214

* Dislocation (mostly in hip) * Prosthetic loosening (mostly knee) presenting with chronic pain or fracture * Periprosthetic fractures (mostly hip) typically after minor trauma * Infection either early or late but either way is disastrous

Answer 215

Can present acutely with fever and systemic symptoms or more subtly with pain and loss of function.

Answer 216

``` Wound complications Obesity Increasing age Diabetes mellitus Steroid use Rheumatoid arthritis ``` Cause – most commonly coagulase negative staphylococci

Answer 217

Routine bloods Joint aspiration – showing high WCC Blood cultures Plain X-ray

Answer 218

Early debridement and antibiotics may be sufficient If later on then radical debridement with removal of all prosthetics and involved bone Antibiotics may be required for months Revision is usually in 2 stages with wash out and insertion of antibiotic loaded cement spacer (which is functionally debilitating to patient) if successful then reimplantation after 2 months if still desired.

Answer 219

Anterior – usually torn in twisting injury with foot fixed to the ground during sport, much more common in women.

Answer 220

Patient may have felt a pop or crack Pain and rapid effusion usually within an hour Difficult to examine in first 2 weeks

Answer 221

X-ray to exclude bony injury (Segond fracture (bony avulsion of lateral proximal tibia is pathognomonic of ACL injuries) Increased laxity on anterior draw test (done at 90 degrees) and positive Lachman test (done at 30 degrees and is more reliable) MRI

Answer 222

Very poor healing RICE immediately then 3-week rest and intense physiotherapy Arthroscopic graft reconstruction in young or particularly unstable joint

Answer 223

Posterior – hyperextension injuries due to high energy trauma such as direct blows to the flexed knee e.g., dashboard injury Clinical Features Increased posterior laxity on posterior draw test Management Rest with analgesics Surgery is usually required

Answer 224

Damage commonly occurs from skiing and valgus stress (lateral force)

Answer 225

Clinical Features Abnormal passive abduction of the lower leg Laxity when testing collateral ligaments and painful Effusion Tender Grade 1 – mild with minimal tearing and no loss of integrity Grade 2 – moderate with incomplete tear and increased laxity Grade 3 – severe with complete tear and gross laxity

Answer 226

X-ray | MRI is gold standard

Answer 227

Grade 1 – RICE, return to normal in 6 weeks Grade 2 – RICE, analgesia, knee brace and physiotherapy, return to normal in 10 weeks Grade 3 – RICE, analgesia, knee brace, crutches and consider surgery is distal avulsion. Return to normal in 12 weeks

Answer 228

Lateral Collateral – isolated injuries are uncommon but usually more severe Clinical Features Laxity when testing collateral ligaments and painful Effusion Tender Investigations X-ray MRI is gold standard Management Treated with rest and support can take between sever weeks to months to heal Surgery if very severe

Answer 229

Causes – twisting injury usually during sport for medial meniscus and adduction and internal rotation cause lateral meniscus tears

Answer 230

Delayed swelling but still within a few hours Sharp localised medial or lateral pain exacerbated by hyperextending/twisting of knee and this may cause it to lock or give Tender over affected joint line Recurrent episodes of pain and effusions common often following minor trauma Still good range of movement Positive McMurrays test Positive Thessaly’s test – weight bear at 20 degrees of knee flexion, support patient, positive is pain on twisting knee

Answer 231

X-ray to exclude bony injuries MRI Arthroscopy

Answer 232

Non-serious require rest elevation, compression, and ice | Serious injuries may require surgery to repair the meniscus

Answer 233

Unhappy triad injury occurs from a lateral blow to the knee and involves anterior cruciate, medial collateral and one of the meniscus (usually the medial but more recent evidence suggests lateral is actually more common). This almost always required surgery.

Answer 234

Baker’s cysts also known as a popliteal cyst are not true cysts but a distention of the gastrocnemius-semimembranosus bursa. Primary – no underlying pathology, typically seen in children Secondary – underlying condition such as osteoarthritis, typically seen in adults

Answer 235

Swelling in the popliteal fossa behind the knee Rupture may occur resulting in similar symptoms to a deep vein thrombosis such as pain, redness and calf swelling however the majority of ruptures are asymptomatic

Answer 236

Must rule out DVT In children the cysts typically resolve and do not require treatment In adults the underlying cause should be treated where appropriate

Answer 237

Prepatellar Bursitis – prolonged periods of upright kneeling (Housemaid’s knee) Infrapatellar Bursitis – prolonged kneeling (Clergyman’s knee) Causes Infection Crystal arthropathies Rheumatoid arthritis

Answer 238

Localised swelling and tenderness over patella | Normal range of movement

Answer 239

Aspiration of effusion to check for infection or crystal arthropathies if indicated

Answer 240

Rest and NSAIDS | Corticosteroid injections

Answer 241

Iliotibial band syndrome is a common cause of lateral knee pain in runners, occurring in around 1 in 10 people who run regularly. Tenderness 2-3cm above the lateral joint line

Answer 242

Activity modification and iliotibial band stretches If not improving, then physiotherapy referral Local steroid injections

Answer 243

Traumatic primary event through direct trauma or severe contraction of quadriceps with knee stretched in valgus and external rotation. Typically the patella goes laterally and the knee will be in a flexed position. 20% recurrence rate

Answer 244

Skyline x-ray view of patella required but should be clinically obvious

Answer 245

Reduction with medial pressure in an extended leg. Post reduction X-ray required to check for fracture, and check function of extensors of knee. Must immobilise the joint for next few weeks in cast or splint and refer to physiotherapy for quadricep strengthening.

Answer 246

2 Fracture types: • Direct blow to patella causing undisplaced fragments, extensor mechanism intact • Quadriceps forceful contraction can cause a transverse patella fracture and sometimes an avulsion fracture

Answer 247

Important to assess extensor function of the patella following fracture. If not too painful ask patient to attempt straight leg raising – can be made easier to lying on side to remove gravity resistance.

Answer 248

Undisplaced fracture especially vertical fracture with intact extensor mechanism can be managed non-operatively in a hinged knee brace for 6 weeks with patients allowed to weight bear. Displaced fractures and those with loss of extensor mechanisms require surgical management with ORIF plus either tension band wire, inter-fragmentary screws or cerclage wires. Patients are then put in a hinged knee brace for 6 weeks and allowed to weigh bear

Answer 249

Occur in the elderly or following significant trauma in the young. Knee forced into varus or valgus position but the bone fractures before ligament rupture. Varus injury causes medial plateau fracture whilst valgus injury causes lateral plateau fracture.

Answer 250

1. Lateral split fracture 2. Lateral split with depressed fracture 3. Lateral pure depression fracture (rare) 4. Medial plateau fracture 5. Bicondylar fracture (rare) 6. Metaphyseal – diaphyseal disassociation

Answer 251

``` Sudden onset pain Unable to weight bear Swelling of the joint Tenderness Ligament instability Full neurovascular assessment before and after intervention ```

Answer 252

Plain X-ray anterior and lateral | CT required in almost all cases unless undisplaced

Answer 253

Uncomplicated fractures can be managed without surgery – hinged knee brace with non or partial weight bearing for 8-12 weeks Complicated fractures require ORIF and post operatively a hinged knee brace with limited or no weight bearing for 8-12 weeks

Answer 254

High risk of open fracture and compartment syndrome due to the limited soft tissue compartments surrounding the tibial shaft.

Answer 255

History of trauma Severe pain inability to weight bear Usually a clear deformity and significant swelling Often associated fibular fracture as well

Answer 256

X-ray – AP and lateral | CT usually indicated as well

Answer 257

Realignment should take place as soon as possible under conscious sedation Above knee backslab in slight flexion at knee and neutral dorsiflexion at ankle Almost all are managed surgically with intramedullary nailing and post op patient are usually able to fully weight bear ORIF with locking plate required if extending into either joints

Answer 258

Osteochondritis dissecans (OCD) is a pathological process affecting the subchondral bone (most often in the knee joint) with secondary effects on the joint cartilage, including pain, oedema, free bodies and mechanical dysfunctions. OCD may progress to degenerative changes if untreated. It affects children and adolescents with open growth plates (juvenile OCD) and young adults with closed growth plates (adult OCD). Most common age of presentation is between 12 and 19 years (age of presentation is decreasing likely due to the decreasing age of children participating in active sports)

Answer 259

Trauma Male Genetic

Answer 260

Knee pain and swelling, typically after exercise Knee catching, locking and/or giving way - more constant and severe symptoms are associated with the presence of loose bodies Feeling a painful 'clunk' when flexing or extending the knee - indicating the involvement of the lateral femoral condyle Signs Joint effusion Full range of movement in the joint without signs of ligamentous instability External tibial rotation when walking – if medial femoral involvement Tenderness on palpation of the articular cartilage of the medial femoral condyle, when the knee is flexed Wilson's sign for detecting medial condyle lesion - with the knee at 90° flexion and tibia internally rotated, the gradual extension of the joint leads to pain at about 30°, external rotation of the tibia at this point relieves the pain.

Answer 261

Early diagnosis is important. Clinical signs may be subtle in the early stages hence there should be a low threshold for imaging and/or orthopaedic opinion. X-ray (anteroposterior, lateral and tunnel views) – subchondral crescent sign or loose bodies MRI – to evaluate cartilage, visualise loose bodies, stage and assess the stability of the lesion CT – used in preoperative planning and in cases where MRI is not available/contraindicated Scintigraphy – used to guide treatment as it may show increased uptake in the fragments – a sign of osteoblastic activity

Answer 262

Gradual onset of posterior heel pain that is worse following exercise Morning pain and stiffness

Answer 263

Simple analgesia Reduction of precipitating activities Calf muscle eccentric exercises – self direction or under physio guidance

Answer 264

Quinolone e.g. ciprofloxacin | Hypercholesterolaemia – predisposes to tendon xanthomata

Answer 265

Audible pop in the ankle Sudden onset significant pain in calf or ankle Likened to being kicked in the back of the foot Inability to walk or continue the sport

Answer 266

Investigation and Examination – Simmond’s triad • Patient lies prone with feet over the edge of the bed – look for abnormal angle of declination (rupture may lead to greater dorsiflexion compared to uninjured foot • Feel for gap in the tendon • Gently squeeze calf muscles – if ruptured the foot will stay in the neutral position USS of the tendon

Answer 267

If presenting within 2 weeks: Analgesia and immobilisation for 2 weeks with moon boot (able to weight bear) or splinted plaster in full equinus with no weight bearing. Then half equinus for 4 weeks and following this another 4 weeks in the neutral position Conservative management often preferred for smokers, diabetics and those > 50yrs If presenting after 2 weeks or re-rupture requires surgical end-to-end tendon repair

Answer 268

Definition – a fracture of the any of the malleoli (lateral, medial or posterior) with or without disruption of the syndesmosis.

Answer 269

Low energy – twisting, inversion/eversion injuries usually due to a fall from standing height High energy – direct blow to tibia or fibula

Answer 270

Tenderness Pain Obvious deformity

Answer 271

Check neurovascular status Ottawa Ankle rules - plain X-ray with 2 views required if pain in the malleolar zone and one of the following findings: • Bony tenderness at the lateral malleolar zone (from the top of the lateral malleolus to include the lower 6cm of posterior border of the fibular) • Bony tenderness at the medial malleolar zone (from the top of the medial malleolus to the lower 6cm of the posterior border of the tibia • Inability to walk four weight bearing steps immediately after the injury and in A&E

Answer 272

Type A – fibula fracture below syndesmosis Type B – fracture that starts at the level of the tibial plafond and may extend proximally to involve the syndesmosis Type C – above the level of the syndesmosis which may itself be damaged Subtype – Maisonneuve fracture – spiral fibular fracture of the proximal 1/3 leading to disruption of the syndesmosis with widening of the ankle joint – surgery required Pott’s Fracture – bimalleolar ankle fracture from forced foot eversion

Answer 273

Give lots of analgesics and check neurovascular status before and after intervention All ankle fractures should be reduced and realigned under conscious sedation to remove pressure on the overlying skin and subsequent necrosis Stable or minimally displaced (Weber A and B) can be treated non operatively in a below knee backslab. Elderly patients even with unstable injuries usually fare better with attempts at conservative management as their weaker bones do not hold metalwork well. ORIF is often required and indicated in: Displaced bimalleolar or trimalleolar fractures, Weber C, Weber B with talar shift and open fractures.

Answer 274

Sprain = stretching or a partial or complete tear of a ligament. In the ankle we divide this into high ankle sprains involving the syndesmosis and low ankle sprains involving the lateral collateral ligaments.

Answer 275

Most common ankle sprain (90%) with injury to the ATFL the most common cause Mechanism is usually as a result of inversion Pain swelling and tenderness over affected ligaments and sometimes bruising Usually are still able to weight bear unless severe

Answer 276

``` Grade I (mild) – stretch or micro tear, minimal bruising and swelling and normal weight bearing without pain Grade II (moderate) – partial tear with moderate welling and bruising and minimal pain on weight bearing Grade III (severe) – complete tear, severe bruising and swelling and severe pain on weight bearing ```

Answer 277

X-ray should be done according to Ottawa ankle rules as 15% of sprains are associated with a fracture. MRI if persistent pain and useful for evaluating peroneal tendons.

Answer 278

RICE protocol – Rest, ICE, Compression, and Elevation Removable orthosis, case and/or crutches may be required for short-term symptom relief If symptoms fail to settle or there is significant join instability, then MRI and surgical intervention can be considered In significant sprains with ligament rupture and inability to weight bear then below knee immobilisation is required for 10 days

Answer 279

Injuries to the syndesmosis are rare and severe Mechanism of injury is usually external rotation of the foot causing talus to push the fibula laterally Weight bearing often very painful in comparison to low ankle injury Pain when tibia and fibula are squeezed together at the lever of the mid-calf (Hopkin’s squeeze test)

Answer 280

X-ray may show widening of the tibiofibular joint (diastasis) or ankle mortise MRI if high suspicion of syndesmotic injury

Answer 281

If no diastasis then non-weight bearing orthosis or cast until pain subsides If diastasis or failed non-operative management then operative fixation is usually required

Answer 282

Morton's neuroma is a benign neuroma affecting the intermetatarsal plantar nerve, most commonly in the third inter-metatarsophalangeal space. The female to male ratio is around 4:1.

Answer 283

Forefoot pain, most commonly in the third inter-metatarsophalangeal space Worse on walking Shooting or burning pain Patients may feel they have a pebble in their shoe Loss of sensation distally in the toes Mulder's click: one hand tries to hold the neuroma between the finger and thumb. The other hand squeezes the metatarsals together. A click may be heard as the neuroma moves between the metatarsal heads

Answer 284

Diagnosis is usually clinical | USS may be helpful in confirming the diagnosis.

Answer 285

Avoid high heels Metatarsal pad CKS recommends referral if symptoms persist for > 3 months despite footwear modifications and the use of metatarsal pads Orthotists may give the patient a metatarsal dome orthotic Other secondary care options include corticosteroid injection and neurectomy of the involved interdigital nerve and neuroma

Answer 286

Definition – Not actually inflammation but due to weakness in the plantar fascia of the foot and can occur unilaterally or bilaterally. It is the most common cause of heel pain and is most common between 40-60yrs

Answer 287

Micro tears in the plantar fascia due to chronic breakdown of the structure and not just inflammation. Any anatomical abnormalities that affect the gait cycle may increase the risk of this.

Answer 288

``` Anatomical factors Weak plantar flexors Prolonged standing or excessive running Leg length discrepancy Obesity Unsupportive footwear Inactivity ```

Answer 289

Sharp pain across plantar aspect of the foot felt most severely in the heel Worst with first few steps of the day or after periods of inactivity

Answer 290

On examination look for evidence of over pronation, high arches and leg length disparity. Clinical diagnosis Plain x-ray to exclude bone injury MRI occasionally useful if uncertainty

Answer 291

Rest the foot where possible Adjust footwear to have good arch support and cushioned heels Regular analgesics, typically NSAIDs Physiotherapy is very useful Corticosteroid injection Plantar fasciotomy (results in some instability)

Answer 292

``` Hallux Valgus (Bunions) Definition – deformity at the first metatarsophalangeal joint causing deviation medially. It is the most common foot problem in the adult population – 35% in those aged >65 and is more common in women. ```

Answer 293

1st metatarsal of the foot is inherently unstable and relies heavily on the stabilising structures of muscles and tendons to keep in in place. As a result, it is at greater risk of becoming disturbed. If it does escape these stabilisers, then the extrinsic tendon slowly deform the foot. Anatomic variants, genetic predisposition, and environmental factors all further contribute

Answer 294

``` Female Connective tissue disorders Hypermobility syndromes Type of footwear (ideal is wide low-heeled shoes) Family history ```

Answer 295

Medial deviation of the first metatarsal and lateral deviation of the hallux with associated joint subluxation. Painful medial prominence For some the deformity is painless other than in shoe fitting Aggravated by walking, weight bearing and wearing narrow shoes Typically bilateral

Answer 296

Investigations Plain X-ray Management Sufficient analgesia Advice on adjusting footwear – wide and low heeled Physiotherapy providing stretching exercises and gait re-education Surgical intervention may be considered for those whose quality of life is affected