Trauma ortho 3

Question 1

What shoulder problem is commonly seen in patients in their teens/20s?

Answer 1

Fractures and instability

Question 2

What shoulder problem is commonly seen in patients in their 30s and 40s?

Answer 2

Rotator Cuff problems and capsulitis

Question 3

What shoulder problem is commonly seen in patients in their 50s and 60s?

Answer 3

Impingement

AC joint problems

Question 4

What shoulder problem is commonly seen in patients in their 70s?

Answer 4

Degenerative rotator cuff problems and degenerative joints

Question 5

Subacromial impingement definition (3)

Answer 5

Pain and dysfunction resulting from

• pathology which decreases volume of subacromial space
• pathology which increases size of subacromial content

Question 6

Subacromial impingement treatment - 3 modalities

Answer 6

Subacromial steroid injection
Physiotherapy
Arthroscopic subacromial decompression

Question 7

4 modalities of treatment in traumatic shoulder injury

MIPS

Answer 7

Manipulation
Immobilisation
Physiotherapy
Surgery

Question 8

Rotator cuff injury - the 4 diseases in the spectrum

Rotator cuff tears can be acute or chronic - what’s the difference?

Answer 8

1. Subacromial impingement aka impingement syndrome or painful arc syndrome
2. Calcific tendonitis
3. Rotator cuff tears
4. Rotator cuff arthropathy

Acute tears happen when there is violent injury e.g. FOOSH

Chronic tears happen as we grow older (inability to heal fully) and in chronic overuse (baseball pitchers)

Question 9

Rotator cuff tear vs impingement

Answer 9

Patients will normally describe weakness as well as pain in tears
Impingement - no weakness

Question 10

Types of shoulder dislocation [3] - which is most common?

Answer 10

*Glenohumeral dislocation
Acromioclavicular dislocation
Sternoclavicular dislocato

Question 11

Types of glenohumeral dislocation [4]

Answer 11

Anterior shoulder dislocation
Inferior shoulder dislocation
Posterior shoulder dislocation
Superior shoulder dislocation

Question 12

Anterior shoulder dislocation
Mechanism of injury [2]
Clinical features [3]

Answer 12

External rotation and abduction, greater tuberosity #
35-40% recurrent
Bankart lesion, Hill-Sachs defect

Question 13

Inferior shoulder dislocation is also known as

Answer 13

Luxatio erecta

Question 14

Posterior shoulder dislocation. What are the 3 signs?

Answer 14

Rim’s sign, light bulb sign.

Associated with Trough sign

Question 15

Adhesive capsulitis
Presentation of pain
SOCRATES

Answer 15

The pain is usually located over the outer shoulder area and sometimes the upper arm.
Dull or aching
It is typically worse early in the course of the disease and when you move your arm.

Question 16

What are the 3 stages of adhesive capsulitis

Answer 16

Freezing - pain
Frozen - less pain but stiff
Thawing - recovery

Question 17

Adhesive capsulitis
Early presentation - treatment?
Late stages - treatment?

Answer 17

Early presentation - inject steroids

Late stages - surgery

Question 18

Rotator cuff tears can be traumatic or degenerative.
Acute rotator cuff tears = treatment?
Chronic degenerative tears = treatment?

Answer 18

Acute rotator cuff tears warrants early surgical treatment

Chronic degenerative tears should only be treated surgically if symptomatic

Question 19

Elbow injuries
State the diseases that are most commonly found in these age groups:
Young
Middle age
Elderly
CTS

Answer 19

Young - fractures, dislocations
Middle age - tendinopathies
Elderly - degenerative diseases
CTS - any age

Question 20

Elbow pain differentials [4]

Answer 20

Lateral epicondylitis (tennis)
Medial epicondylitis (golfers)
Radial tunnel syndrome
Cubital tunnel syndrome
Olecranon bursitis

Question 21

Lateral vs medial epicondylitis

Answer 21

Lateral:

• pain worse on resisted wrist extension with elbow extended
• pain worse on supination of forearm with elbow extended

Medial:
- opposite of this

Question 22

Medial epicondylitis features [3]

Answer 22

1. pain and tenderness localised to the medial epicondyle
2. pain is aggravated by wrist flexion and pronation
3. symptoms may be accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement

Question 23

Duration of symptoms for lateral epicondylitis
Etiology
Ep
Mx [4]

Answer 23

6m - 2 years
Acute pain 6-12w
Ax: typically follows unaccustomed activity such as house painting or playing tennis 
Ep: 45-55 yo
Mx:
advice on avoiding muscle overload
simple analgesia
steroid injection
physiotherapy

Question 24

Radial tunnel syndrome
Ax [2]
Characteristics of pain [2]

Answer 24

Most commonly due to compression of the posterior interosseous branch of the radial nerve. It is thought to be a result of overuse.
Pain:
- pain tends to be around 4-5 cm distal to the lateral epicondyle
- symptoms may be worsened by extending the elbow and pronating the forearm

Question 25

Cubital tunnel syndrome can cause elbow pain Ax Symptoms [2]

Answer 25

Ax: Due to the compression of the ulnar nerve. Symptoms: - initially intermittent tingling in the 4th and 5th finger may be worse when the elbow is resting on a firm surface or flexed for extended periods - later numbness in the 4th and 5th finger with associated weakness

Question 26

Olecranon bursitis Symptoms [2] Ep

Answer 26

Swelling over the posterior aspect of the elbow. There may be associated pain, warmth and erythema. It typically affects middle-aged male patients.

Question 27

``` Psoas abscess Define Complications [2] Causative organism [2] RF [4] ```

Answer 27

``` Collection of pus within psoas muscle Cx: septicemia, multiple organ failure Causative organism: Staph or Strep RF: - HIV, cancer, DM - TB - previous surgery - IVDU ```

Question 28

Psoas abscess presentation [5]

Answer 28

Presentation: - no ppt trauma/injury with pain that increases over several days - pain on hip movement - +/- fever - Comfortable lying on back with slightly flexed knees - inability to WB

Question 29

Psoas abscess Ix [2] Mx [2]

Answer 29

Investigation: - septic screen - MRI gold standard Management: - ab therapy +/- drainage

Question 30

Iliopsoas abscess Define Causes: primary and secondary [6] Increased mortality rate in secondary abscesses

Answer 30

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

Question 31

Iliopsoas abscess Symptoms [4] Position Specific tests [2]

Answer 31

Symptoms - Fever - Back/flank pain - Limp - Weight loss Position: supine with the knee flexed and the hip mildly externally rotated Specific tests: 1. 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. 2. Lie the patient on the normal side and hyperextend the affected hip. This should elicit pain as the psoas muscle is stretched.

Question 32

Iliopsoas abscess Ix Mx [5]

Answer 32

Investigation CT is the gold standard ``` Management > Antibiotics > Percutaneous drainage (successful 90%) > Surgery indicated: - failure of perc. drainage - presence of other intra-abdominal pathology requiring surgery ```

Question 33

Discitis Define Complications [2] Features [3]

Answer 33

Discitis is an infection in the intervertebral disc space. Cx: sepsis or an epidural abscess Features: - Back pain - General: pyrexia, rigors, sepsis - Neuro: e.g. changing lower limb neurology, if epidural abscess develops

Question 34

Discitis causative organism [4] | Dx [2]

Answer 34

Bacterial: Staph aureus is the most common cause of discitis Viral TB Aseptic Imaging: - MRI has the highest sensitivity - CT guided biopsy may be required to guide antimicrobial treatment

Question 35

Discitis mx

Answer 35

The standard therapy requires six to eight weeks of intravenous antibiotic therapy Choice of antibiotic is dependent on a variety of factors. The most important factor is to identify the organism with a positive culture (e.g. blood culture, or CT guided biopsy)