Unit 4 - Minor adult disorders Flashcards
What is an enthesis?
Short fibrous origin of a muscle
Enthesopathy refers to inflammation of muscle origin
What are 2 common sites of enthesopathies in the arm & what are they known as?
Common origin of flexor muscles of forearm (Golfer’s elbow)
Common origin of extensor muscles of forearm (Tennis elbow)
What is the management for entheopathies?
Rest (associated with repetitive movements)
Anti-inflammatory drugs
Local steriod injections at point of max tenderness (ensure no leakage into subcutaneous fat or skin, as this results in pain being exacerbated and patient is left with an unsightly dimple)
Small number require surgery - scraping origin of muscle from bone& permitting it to slide distally, decompressing the area
What is neuropraxia?
Nerve damage from compression or stretching
Name some extrinsic causes of nerve entrapment
When there is LoC & patient presses on nerve
Patients in beds
Plaster casts (common peroneal nerve particularly at risk)
Name 4 common sites of intrinsic nerve compression
Median nerve at wrist
Ulnar nerve at elbow
Ulnar nerve at wrist
Posterior tibial nerve at ankle
What symptoms may be present in a nerve compression?
Numbness/tingling
Weakness
Sensory loss
What should the management aim to do in a nerve compression?
Decompress nerve (extrinsically/intrinsically through surgery)
What condition is tenosynovitis associated with?
RA
However mostly arises spontaneously through overuse
What is a bursa?
Small sac of fibrous tissue lined with synovial membrane & filled with synovial fluid
Acts as a bearing aimed at improving muscle & joint function by reducing friction (usually where tendons/ligaments pass over bone)
May form in response to pressure
Where is the most common site of bursitis?
Knee
What is the presentation of bursitis?
Discomfort over bursa (usually associated with the causative element such as movement/pressure)
Swelling of bursa
Infection of bursa - tense swelling, cellulitis, malaise
What is the management for bursitis?
Chronic bursitis with no symptoms are benign & need no treatment (patient may demand excision for appearance)
If tender they may be excised (encourage to remove underlying cause first)
Infected bursae should be incised & drained - leads to spontaneous recovery through scarring & fibrosis
What may a painful spasmodic flat foot be associated with?
Infection or chronic inflammatory disease
May occur acutely in middle age
Examination reveals painful and tender swelling over insertion of tibialis posterior. May indicate acute/impending degenerative rupture and warrants early intervention
How may painful flat feet be managed?
Medial heel lift will correct deformity of hindfoot and stabilise medial arch
If pain is a persistent problem, fusion of subtalar joint will help, although this is not something to be undertaken lightly as it disturbs foot and ankle function
What is a bunion and how do they form?
Fluid filled bursae found around bony prominences (commonly over distal part of 1st metatarsal)
Form as natural respond to pressure & indicate underlying abnormality which should be treated rather than the bunion
What are corns?
Painful excessive corny skin that develops in response to areas of high pressure
May be removed by will return if underlying cause not addressed
What is hallux valgus?
Turning away of hallux from midline (usually due to deformity at joint line)
May occur at any age, women>men
Many have short 1st metatarsal often in varus
How do you manage hallux valgus on its own?
Depends on age
Realignment of 1st metatarsal to a more lateral position and excision of any bony prominence (an exostosis) over the 1st metatarsal head gives satisfactory results at almost any age
Excision of metatarsophalangeal joint (Keller’s procedure) to be avoided in young and is unnecessary if joint not painful
What is hallux rigidus?
OA of metatarsophalangeal joint
What are the management options for hallux rigidus in adolescents & adults?
Adolescents (said to be result of osteochonrdal fracture):
- metatarsal bar to provide rocker at front of the foot so toe need not bend in walking
- usually fails as youngsters do not accept cosmetic consequences on shoes and so the same surgical treatment given as adults
Adults:
- conservative rarely sufficient and surgery is required:
- surgical removal of osteophytes with osteotomy of proximal phalanx
- surgical fusion in neutral position is most reliable
- inter- position arthroplasty with a silicone plastic (silastic) spacer is an alternative which gives mixed results
How is hallux valgus with rigidus managed?
Usually in older people where joint degeneration is secondary to valgus deformity
May be satisfied by having pain relieved by well fitting, extra-depth shoes.
Keller’s arthroplasty is a safe and rapid way of giving relief. Severely disrupts normal foot mechanics & should be reserved for older, less active patient
What are claw toes?
Wasted muscles make bones & toe nails appear more prominent (implies muscle weakness/deficiency)
Often associated with minor spinal abnormalities (spina bifida occulta)
Should be approached with caution with regards to surgery
What are hammer toes?
Secondary to disruption of metatarsophalangeal joints
Patient may present with sore forefeet (metatarsalgia)
Cause of the primary lesion is unknown, and treatment is often unsatisfactory. Surgery to hammer toes includes fusion of interphalangeal joints in a straight position, so that they do not rub on shoes. Often a good pair of soft and comfortable shoes is all that is required
What is Morton’s neuroma?
When cutaneous nerves to the toes become trapped/irritated between metatarsal heads giving rise to a neuroma (benign overgrowth of nerve tissue)
What is the clinical presentation of Morton’s neuroma?
Dull throbbing pain often with sharp exacerbations
Tingling of toes
Sideways compression of foot produces palpable click, reproducing symptoms
What is the treatment for Morton’s neuroma?
Excision (may be accompanied by subsequent sensory disturbances)
Recurrence common
What is the clinical presentation of plantar fasciitis?
Pain of instep
Worse in morning/sitting for hours
Minimally relieved by walking
Exacerbated by change of direction or walking on rough ground
May be tenderness at point on hindfoot, origin of plantar fascia medially. Discomfort is often more diffuse
What is the management for plantar fasciitis?
Most settle spontaneously (symptoms may last months/years)
Insoles that are hollowed out under tender area may help but may cause discomfort around edge of the hollow. Soft shoes and insoles can relieve symptoms
If there is a marked tender point, local injection of steroids and long acting local anaesthetic can be very effective, although rather painful to administer.
Surgical stripping of fascia from the os calcis is practised. The results of this are entirely unpredictable
What is the most common cause of neuropathic feet in:
- the west?
- the far east?
Diabetes
Leprosy
What 2 groups is Achilles tendinitis seen?
Young athletes:
- signifying over-use
- area may be tender/swollen
- rest is usually adequate to recover, but if recurrent, surgical decompression of tissue surrounding tendon will eradicate symptoms
- injecting steroids is to be avoided as penetration of tendon may lead to rupture
Middle aged men:
- phase of discomfort may precede rupture and this indicates degeneration within tendon tissue
- cause not understood, although we know that the lower part of the tendon has poor blood supply and is often a point of weakness in some people who keep particularly active into middle age
How is a ruptured Achilles tendon managed?
Ankle kept in equinus plaster for minimum of 8 weeks
Tendon can be sutured either by closed technique or open suture. Latter technique has high risk of complication.
Significant risk of re-rupture, although this decreases with time. Wearing a felt raise inside the heel of the shoe, for as long as possible, will help
What 5 structures are commonly involved in shoulder discomfort?
Subacromial bursa
Supraspinatus tendon
Acromioclavicular joint
Biceps tendon
Rotator cuff
What is the management of shoulder discomfort?
Rest, gentle exercise, anti-inflammatories
Painful arc suggests supraspinatus tendon inflammation/subacromial bursitis – steroid injection into bursa around tendon can be effective
Injection/surgery to remove calcified material from supraspinatus tendon if present (seen on radiograph)
Many only respond temporarily to injection. Further investigation often shows degenerative change, and osteophytes in AC joint. This may lead to rupture of supraspinatus muscle. Such rotator cuff tears can become large and even small ones cause a lot of pain. Surgery to relieve cause and repair rotator cuff, will bring effective pain relief and some return of function.
Repetitive injections can result in further degeneration of rotator cuff
What is frozen shoulder?
Condition in which there is little/no glenohumeral movement
What causes frozen shoulder?
Occurs rarely in those who have had specific trauma incident (epileptic fit, electric shock)
Management of frozen shoulder?
Recover in 18 months - 2 yrs
Require a lot of psychological support & physio
May be helped my MUA
