Unit 4 - Minor adult disorders

Question 1

What is an enthesis?

Answer 1

Short fibrous origin of a muscle

Enthesopathy refers to inflammation of muscle origin

Question 2

What are 2 common sites of enthesopathies in the arm & what are they known as?

Answer 2

Common origin of flexor muscles of forearm (Golfer’s elbow)

Common origin of extensor muscles of forearm (Tennis elbow)

Question 3

What is the management for entheopathies?

Answer 3

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

Question 4

What is neuropraxia?

Answer 4

Nerve damage from compression or stretching

Question 5

Name some extrinsic causes of nerve entrapment

Answer 5

When there is LoC & patient presses on nerve

Patients in beds

Plaster casts (common peroneal nerve particularly at risk)

Question 6

Name 4 common sites of intrinsic nerve compression

Answer 6

Median nerve at wrist

Ulnar nerve at elbow

Ulnar nerve at wrist

Posterior tibial nerve at ankle

Question 7

What symptoms may be present in a nerve compression?

Answer 7

Numbness/tingling

Weakness

Sensory loss

Question 8

What should the management aim to do in a nerve compression?

Answer 8

Decompress nerve (extrinsically/intrinsically through surgery)

Question 9

What condition is tenosynovitis associated with?

Answer 9

RA

However mostly arises spontaneously through overuse

Question 10

What is a bursa?

Answer 10

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

Question 11

Where is the most common site of bursitis?

Answer 11

Knee

Question 12

What is the presentation of bursitis?

Answer 12

Discomfort over bursa (usually associated with the causative element such as movement/pressure)

Swelling of bursa

Infection of bursa - tense swelling, cellulitis, malaise

Question 13

What is the management for bursitis?

Answer 13

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

Question 14

What may a painful spasmodic flat foot be associated with?

Answer 14

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

Question 15

How may painful flat feet be managed?

Answer 15

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

Question 16

What is a bunion and how do they form?

Answer 16

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

Question 17

What are corns?

Answer 17

Painful excessive corny skin that develops in response to areas of high pressure

May be removed by will return if underlying cause not addressed

Question 18

What is hallux valgus?

Answer 18

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

Question 19

How do you manage hallux valgus on its own?

Answer 19

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

Question 20

What is hallux rigidus?

Answer 20

OA of metatarsophalangeal joint

Question 21

What are the management options for hallux rigidus in adolescents & adults?

Answer 21

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

Question 22

How is hallux valgus with rigidus managed?

Answer 22

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

Question 23

What are claw toes?

Answer 23

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

Question 24

What are hammer toes?

Answer 24

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

Question 25

What is Morton’s neuroma?

Answer 25

When cutaneous nerves to the toes become trapped/irritated between metatarsal heads giving rise to a neuroma (benign overgrowth of nerve tissue)

Question 26

What is the clinical presentation of Morton’s neuroma?

Answer 26

Dull throbbing pain often with sharp exacerbations

Tingling of toes

Sideways compression of foot produces palpable click, reproducing symptoms

Question 27

What is the treatment for Morton’s neuroma?

Answer 27

Excision (may be accompanied by subsequent sensory disturbances)

Recurrence common

Question 28

What is the clinical presentation of plantar fasciitis?

Answer 28

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

Question 29

What is the management for plantar fasciitis?

Answer 29

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

Question 30

What is the most common cause of neuropathic feet in:

• the west?
• the far east?

Answer 30

Diabetes

Leprosy

Question 31

What 2 groups is Achilles tendinitis seen?

Answer 31

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

Question 32

How is a ruptured Achilles tendon managed?

Answer 32

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

Question 33

What 5 structures are commonly involved in shoulder discomfort?

Answer 33

Subacromial bursa

Supraspinatus tendon

Acromioclavicular joint

Biceps tendon

Rotator cuff

Question 34

What is the management of shoulder discomfort?

Answer 34

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

Question 35

What is frozen shoulder?

Answer 35

Condition in which there is little/no glenohumeral movement

Question 36

What causes frozen shoulder?

Answer 36

Occurs rarely in those who have had specific trauma incident (epileptic fit, electric shock)

Question 37

Management of frozen shoulder?

Answer 37

Recover in 18 months - 2 yrs

Require a lot of psychological support & physio

May be helped my MUA