Week 4 Flashcards
what is cause of bony nerve root entrapment
OA of the facet joints can result in osteophytes impinging on exiting nerves
Tx of bony nerve root entrapment
surgical decompression
trimming of the impinging osteophytes
what causes cauda equina syndrome
large central disc prolapse can compress all the nerve roots of the cauda equina
why is cauda equine syndrome a surgical emergency
affected nerve roots include the sacral nerve roots (mainly S4 & S5) controlling defaecation and urination
prolonged compression can potentially cause permanent nerve damage
what can be the outcome if cauda equine is not managed
colostomy and urinary diversion
Symptons/Signs of C.E syndrome
bilateral leg pain paraesthesia numbness saddle anaesthesia - numbness around sitting area and perineum urinary/faecal incontinence
what is mandatory is suspected C.E. syndrome
rectal examination (PR)
IX for C.E. syndrome
MRI
red flags of back pain
back pain 60 y/o
nature of pain - constant, severe, worse at night
systemic upset - fever, night sweats, weight loss, fatigue
what causes spontaneous crush fractures of the spine
severe osteoporosis
causes acute pain and kyphosis
what are the symptoms of cervical spondylosis
slow onset stiffness + pain in the neck
can radiate to shoulders and the occiput
Mx of cervical spondylosis
physio
analgesics
complications of cervical spondylosis
osteophytes impinge on exiting nerve roots resulting in radiculopathy involving upper limb dermatones and myotomes
what does acute/degenerative disc prolapse cause in the cervical spine and how does it present
nerve root compression
shooting pain down dermatomal distribution
loss of reflexes depending on the nerve root affected
Ix for cervical disc prolapse
MRI
why should you be wary of disc prolapses found on MRI
with age, there is a number of symptomatic disc prolapse
results in ‘false positives’
the disc prolapse is not responsible for the symptoms
needs to be considered in adjunction with clinical findings
who can get atraumatic cervical spine instability and why
RA
atlanto-axial subluxation
can compress the spinal cord and be fatal
Tx of cervical spine instability
less severe - with a collar to prevent flexion
severe - surgical fusion
what can be upper motor neurone signs of cord compression
wide based gait
weakness
increased tone
upgoing plantar response
role of the rotator cuff muscles
pulling the humeral head into the glenoid to provide a stable fulcrum for the powerful deltoid muscle to abduct the arm
roughly, what are the causes of pain in the shoulder by age group
young adult - instability
middle age - rotator cuff tear/frozen shoulder
elderly - glenohumeral OA
what is impingement syndrome
tendons of the rotator cuff (predominantly supraspinatus) are compressed in the tight sub-acromial space during movement producing pain
causes of impingement syndrome
Tendonitis Subacromial bursitis
Acromioclavicular OA with inferior osteophyte
A hooked acromion Rotator cuff tear
what does a painful arc show
Supraspinatus tendon is inflamed
Sx of impingement syndrome
pain - can radiate to deltoid and upper arm
tenderness - below lateral edge of acromion
+ve Hawkins Kennedy
Tx for impingement syndrome
NSAIDS/Analgesic/Physio
up to 3x steroid injections in subacromial
subacromial decompression surgery
classic Hx in rotator cuff tear
sudden jerk (eg holding a rail on a bus which suddenly stops) in a patient >40 years of age, with subsequent pain and weakness
features of rotator cuff tear
can be partial or full thickness and usually involve suprapinatus
Sx of rotator cuff tear
- Weakness of initiation of abduction (supraspinatus)
- internal rotation (subscapularis) - external rotation (infraspinatus)
- wasting of supraspinatus
Ix for rotator cuff tear
USS - 1st line
MRI - 2nd line
classic history of Adhesive capsulitis/frozen shoulder
disorder characterized by progressive pain and stiffness of the shoulder in patients between 40 and 60, resolving after around 18‐24 months
what is the principle clinical sign of frozen shoulder
loss of external rotation
timeline of frozen shoulder
initially pain which will subside in 2-9 months
stiffness increases from 4-12 months
stiffness gradually ‘thaws’
what is frozen shoulder associate with
diabetes
hypercholesterolaemia
Dupuytren’s disease
Tx of frozen shoulder
physio, analgesics
intra-articular injections in gleno-humeral
Hx of acute calcific tendonitis
acute severe shoulder pain
calcium deposition in the supraspinatus tendon
Ix for acute calcific tendonitis
x-ray
Tx for acute calcific tendonitis
subacromial steroid
local anaesthetic injection
self-limiting
surgical Tx for traumatic anterior dislocation
Bankart repair
who has atraumatic instability
Idiopathic ligamentous laxity
Ehlers-Danlos
Marfan’s
what are secondary causes of carpal tunnel syndrome
RA Pregnancy Diabetes Chronic renal failure Hypothyroidism Wrist Fractures e.g. Colles
presentation of carpal tunnel syndrome
parathesiae in the median nerve innervated digits (thumb and radial 2½ fingers)
usually worse at night,
loss of sensation
weakness of the thumb or clumsiness
Ex of carpal tunnel syndrome
loss of sensation
muscle wasting of the thenar exminence
Tests for carpal tunnel syndrome
Tinel’s test
Phalen’s test
Ix for carpal tunnel syndrome
NCS
Sx of CUBITAL tunnel syndrome
paraesthesiae in the ulnar 1½ fingers
weakness in ulnar nerve innervated muscle - 1st dorsal interosseous and adductor pollicis
causes of cubital tunnel syndrome
Osbourne’s fascia - tight band of fascia forming the roof of the tunnel
Tightness at the inter muscular septum
Ix of cubital tunnel syndrome
NCS
clinical feature of tennis elbow
painful and tender lateral epicondyle
pain on resisted middle finger + wrist extension
what type of elbow arthritis is more common
RA
Surgical Tx of elbow arthritis
Arthritic change at the radio‐capitellar joint - surgical excision of the radial head
Elbow severely affected - Total Elbow replacement
what is Dupuytren’s contracture associated with
Peyronie’s disease - affects the penis
Ledderhose disease - affects the feet
what degree of Dupuytren’s contracture can be tolerated by MCP joint
up to 30 degrees
pathogenesis of trigger finger
- tendonitis of flexor tendon can result in nodular enlargement
- movement of finger produces a clicking sensation as nodule catches on pulley
- can be painful, finger appears locked in flexed position
- have to forcible manipulate finger to regain extension (painful)
what fingers are commonly affected with trigger finger
middle + ring finger
Tx for trigger finger
steroid injection
division of what pulley does not affect function
A1 pulley
features of OA in the hand
DIP affected
Herberden’s nodes - stiffness and bony thickening
Mucous cyst - dorsal ganglion
PIP can also be affected
Bouchards nodes
Surgical Tx of OA in the hands
mild to moderate - removal of osteophytes and excision of mucous cyst
severe - arthrodesis (esp if in index finger to preserve pinch grip)
can also do replacement arthroplasty
1st CMCjt - arthroplasty or fusion
what are the deformities of RA that affect the hand
volar MCPJ subluxation Ulnar deviation Swan neck deformity Boutonniere deformity Z-shaped thumb
what is swan neck deformity
hyperextension at PIPJ with flexion DIPJ
what is boutonniere deformity
flexion at PIPJ with hyperextension at DIPJ
what surgery can prevent tendon rupture
Tenosynovectomy
why do we not aspirate ganglion cyst
recurrence rate is high
causes of AVN
idiopathic alcohol abuse steroids hyperlipidaemia thrombophilia
Ix of AVN
MRI - 1st line
X-ray - see classic ‘hanging rope sign’
Tx of AVN
if caught early - drill holes up femoral neck to relieve pressure/decompression
collapsed - THR
signs of Trochanteric bursitis / gluteal cuff syndrome
pain and tenderness in the region of the greater trochanter with pain on resisted abduction.
what is ‘pseudo-locking’
knee becomes stuck with temporary difficulty straightening the leg
not the same as ‘locking’ in bucket handle tear
what do people with ACL ruptures complain of
rotatory instability with their knee giving way when turning on a planted foot
if unable to examine knee, what is the Ix of choice
MRI
what type of meniscal tears should be considered for repair
fresh longitudinal tears involving the outer 1/3 of the meniscus in a younger patient
rupture of which knee ligament has the best chance of healing
medial collateral ligament
what can cause anterior knee pain, worse going down hill, grinding sensation and stiffness siting long time
patellofemoral dysfunction
Tx- physio
patellar instability
occurs with a direct blow/sudden twist of the knee
almost always dislocates laterally
may reduce when knee is straightened
what happens when the patella dislocates
medial patellofemoral ligament tears
osteochondral fracture may occur
lipohaemarthosis
what can be seen on x-ray when the patella dislocated
lipo‐haemarthrosis
what is hallux valgus
deformity of the great toe due to medial deviation of the 1st metatarsal and lateral deviation of the toe itself
who gets hallux valgus
RA
Inflammatory arthropathies
MS
Cerebral palsy
what is a bunion
inflamed bursa over the medial 1st metatarsal head
surgical Tx of hallux valgus
osteotomies - to realign bone
soft tissue procedures - to tighten slack tissues and release tight tissues
what is OA of 1st MTPJ called
Hallux rigidus
gold standard Tx of hallux rigidus
arthrodesis
what is presenting complaint of morton’s neuroma
burning pain and tingling radiating into the affected toes
Ix for morton’s neuroma
Mulder’s click test
US - first line imaging
what is most commonly affected by metatarsal stress fracture
2nd metatarsal followed by 3rd
Ix for metatarsal stress fracture
Bone scan
X-ray - may not showing anything till 3 weeks after
what antibiotics can cause achilles tendonitis/rupture
Quinolone antibiotics (ciprofloxacin etc)
Tx of achilles tendonitis
rest
physio
heel raise
splint/boot
self-limiting
what is simmonds test
No plantarflexion of the foot is seen when squeezing the calf
what are signs of plantar fasciitis
Pain with walking is felt on the instep of the foot with localized tenderness on palpation of this site.
role of tibialis posterior tendon
support the medial arch of the foot
