Phase 4 Question Knowledge > T+O > Flashcards

T+O Flashcards

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1
Q

Osteoarthritis (OA)

A
  • wear + tear of joints
  • loss of cartilage, osteophyte formation, inflammation
  • hips, knees, DIPJ, CMC base of thumb, lumbar spine, c-spine
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2
Q

OA Px

A
  • joint pain
  • stiffness, <30mins morning, worse after activity
  • reduced ROM
  • crepitus
  • effusions
  • bulky/bony enlargement of joint

Hands

  • Heberdens nodes - DIPJ
  • Bouchards nodes - PIPJ
  • DIPJ>PIPJ
  • Squaring at base of thumb (CMC joint)
  • weak grip, reduced ROM
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3
Q

OA Ix

A

Dx

  • > 45yo, typical pain, <30mins morning stiffness

XR - LOSS

Loss of joint space

Osteophytes

Subarticular sclerosis

Subchondral cysts

Oxford Hip Score

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4
Q

OA Mx

A
  • OT/PT, lose weight, exercise
  • topical NSAIDs
  • oral NSAIDs (+PPI)
  • weak opiates, paracetamol - short-term
  • intra-articular steroid injections
  • arthroplasty
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5
Q

Hip replacement Cx

A
  • VTE, intraoperative fracture, nerve injury, infection
  • Leg length discrepancy
  • posterior dislocation
  • aseptic loosening
  • prosthetic joint infection
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6
Q

XR interpretation

A

Initial approach

  • patient details, XR details
  • adequacy - 2 views, joint above+below, rotation, penetration
  • previous imaging

ABCS approach

  • alignment, joint space
  • bone texture
  • cortices
  • soft tissues
  • what bone, area, articular surface involvement
  • type of fracture
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7
Q

Types of fractures

A

COMPLETE – fracture extends all the way through bone

  • Closed – no break in skin
  • Open – break in skin
  • Transverse – right angle to shaft
  • Oblique – angle to shaft

· Eg Toddler’s fracture – oblique tibial fracture in infants

  • Spiral – twisting
  • Segmental – more than one fracture along bone
  • Comminuted – 2+ bone fragments
  • Compression – involving vertebrae in spine
  • Impacted – fractured bone forced together

INCOMPLETE (not all the way through cortex) – commonly children

  • Greenstick – bending of shaft, fracture on convex surface
  • Buckle (torus) – fracture of shaft of bone characterised by bulging of cortex
  • Salter-Harris – involving growth plate
  • Bowing – bend in bone shaft – plastic deformity
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8
Q

Fracture displacement

A
  • Describe in terms of distal fragment to body (eg anterior/posterior)
  • Angulation – change in axis of bone – dorsal / palmar, varus/valgus, radial/ulnar
  • Translation – movt of fractured bones away from each other – use width of bone, eg 25% - if >100% - describe as off-ended
  • Rotation – difficult to see on XR
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9
Q

Fracture causes

A
  • trauma - excessive force
  • stress-related - repetitive low velocity injury
  • pathological - abnormal bone, fractures during normal use
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10
Q

Fracture healing

A
  • Haematoma formation, dead bone removed
  • Fibrocartilaginous callus formed, then bony callus, then replaced by trabecular bone
  • Remodelled into lamellar bone
  • Fracture healing delayed if bone ends are mobile, infected, misaligned, avascular
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11
Q

Fracture Px

A
  • pain
  • deformity
  • loss of function
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12
Q

Fracture Ix

A
  • check for other injuries
  • NV status of limb
  • XR - 2 views, inc joint above + below
  • CT +/- angio maybe
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13
Q

Fracture Mx

A
  • immobilise, inc joints above + below
  • reduce if necessary
  • analgesia
  • open - IV abx, tetanus, debride + lavage <6hrs, avoid internal fixation
  • simple - fracture clinic follow up
  • complex - NBM, add to trauma list for morning
  • mechanical alignment - manipulation / surgery
  • stability - casts, wires/plates/screws, ORIF, external frame
  • rehab early
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14
Q

Fracture Cx

A

Early

  • damage to local structures
  • haemorrhage
  • compartment syndrome
  • fat embolism
  • VTE

Long-term

  • delayed union, malunion, non-union, avascular necrosis, osteomyelitis, joint instability, stiffness, arthritis, chronic pain
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15
Q

Paediatric fractures

A

Complete – both sides of cortex breached

Toddler’s fracture – oblique tibial fracture in infants

Bowing – plastic deformity, no break

Greenstick fracture – bending of shaft, fracture on convex surface

Buckle / torus fracture – incomplete cortical disruption resulting in periosteal haematoma

Growth plate fractures – fracture of growth plate – Salter-Harris classification

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16
Q

Paediatric fractures NAI

A
  • Delayed presentation
  • Delay in attaining milestones
  • Lack of concordance between proposed and actual mechanism of injury
  • Multiple injuries
  • Injuries at sites not commonly exposed to trauma
  • Children on the at risk register
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17
Q

Paediatrics pathological fractures

A

eg osteogenesis imperfecta

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18
Q

Fat embolism

A
  • fat globule released into circulation after long bone fracture
  • lodges in pulm arteries
  • causes systemic inflammatory response
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19
Q

Fat embolism Px

A
  • 24-72hrs after fracture

Gurd’s major criteria

  • Respiratory distress
  • Petechial rash
  • Cerebral involvement – confusion, agitation

Gurd’s minor criteria

  • Jaundice, thrombocytopenia, fever, tachycardia, retinal haemorrhages,, renal signs, high ESR, anaemia….
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20
Q

Fat embolism Ix

A
  • imaging may be normal
  • CTPA - may not show occlusion
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21
Q

Fat embolism Mx

A
  • supportive
  • operate early to reduce risk
  • VTE prophylaxis
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22
Q

Compartment syndrome

A
  • high pressure in fascial compartment - cuts off blood supply
  • associated with fracture / crush injury - bleeding/swelling in compartment
  • restrict capillaries, then venous, then arterial - ischaemia + necrosis
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23
Q

Compartment syndrome Px

A
  • pain - disproportionate
  • paraesthesia
  • pale - initially warm + swollen
  • pressure high
  • paralysis - late
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24
Q

Compartment syndrome Ix

A
  • clinical dx
  • needle manometry
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25
Compartment syndrome Mx
- remove dressings, elevate to heart level - emergency fasciotomy
26
Osteomyelitis
- infection of bone
27
Osteomyelitis patho
- S aureus most commonly (salmonella in SCA) Haematogenous - from blood infection - eg vertebral osteomyelitis - RFs - SCA, IVDU, immunosuppression, IE Contigous - from adjacent tissues - RFs - diabetic foot ulcers, pressure sores, DM, PAD Direct inoculation - direct trauma / surgery - RFs - open fractures, surgery
28
Osteomyelitis Px
- fever, rigors, sweats, malaise, N+V - dull pain, tender, warm, erythema, swelling - maybe non-healing ulcers, non-healing fractures
29
Osteomyelitis Ix
- Bloods - cultures, FBC, CRP - XR - potential periosteal reaction, osteopenia, bone destruction - MRI - Bone cultures
30
Osteomyelitis Mx
Abx - flucloxacillin 6wks (clindamycin) - +/- rifampicin/fusidic acid for first 2wks - vancomycin/teicoplanin MRSA - chronic - >3mo abx Surgery - debridement, hardware removal
31
Septic arthritis
- infection in joint - rapidly destroys joint, systemic illness - S aureus most commonly - also N gonorrhoea, H influenzae, E coli RFs - prosthetic joints, DM, immuno, RA, low SES, IVDU, osteomyelitis, surgery, joint injections
32
Septic arthritis Px
- Single joint, often knee - Hot, red, swollen - Stiff, reduced ROM - Non-weight bearing - Fever, lethargy - Sepsis sx
33
Septic arthritis Ix
- joint aspiration - to MC+S, gram staining, crystal microscopy - FBC - raised WCC, CRP - Blood cultures - STI screen, HIV - XR joint
34
Septic arthritis Mx
- empirical IV abx, then continue for 4-6wks (oral after 2wks) - flucloxacillin / clindamycin - vancomycin - MRSA - ceftriaxone - gonorrhoea - arthroscopic lavage
35
Sarcoma
malignant tumour originating from mesenchymal (connective) tissue
36
Bone sarcomas
osteosarcoma chondrosarcoma Ewing's sarcoma
37
Osteosarcoma
- most common primary malignant bone tumour - mainly children, adolescents - mostly metaphyseal region of long bones - XR - Codman triangle, sunburst pattern
38
Chondrosarcoma
- malignant tumour of cartilage - middle-aged - axial skeleton
39
Ewing's sarcoma
- small round blue cell tumour - children/adolescents - from mesenchymal stem cells - pelvis, long bones - severe pain - XR - onion skin appearance
40
Soft tissue sarcoma
Liposarcoma – from adipose Rhabdomyosarcoma – skeletal muscle Synovial sarcoma – from soft tissue around joints Fibrosarcoma Angiosarcoma – blood and lymph vessels Leiomyosarcoma – smooth muscle Kaposi’s sarcoma – cancer caused by HHV 8, mostly seen in end-stage HIV
41
Bone tumours patho
- primary bone tumours rare - would mets to lung - most commonly secondary - osteolytic - mets from breast, prostate, kidney, lung, thyroid
42
Benign bone tumours
Osteoma - benign overgrowth of bone Osteochondroma - cartilage-capped bony projection on external surface of bone - metaphysis of long bones Giant cell tumour - tumour of multinucleated giant cells in fibrous stroma - epiphysis of long bones - XR - double bubble / soap bubble appearance Osteoblastoma / osteoid osteomas - from osteoblasts
43
Bone tumour Px
- depends on location / size - pain, swelling, palpable mass - impaired function - pathological fractures - fatigue, wt loss, fever, anaemia - aches/pains - hypercalcaemia
44
Bone tumour Ix
- Scans - XR, CT, MRI, PET, skeletal isotope scan - USS for soft tissue lumps - Biopsy - fine needle / core / incisional - TNM staging - Bloods - high Ca, ALP
45
Bone tumour Mx
- surgical resection - radio/chemo - targeted therapy - immunotherapy - hormonal therapy - bisphosphonates - alendronate
46
Osteochondritis dissecans (OCD)
- pathological process affecting subchondral bone - secondary effects on joint cartilage - bone fragments, creates defect between lesion + parent bone, lack of blood supply to fragment - pain, oedema, free bodies, degenerative changes if untreated
47
OCD Px
- subacute - knee pain, swelling, after exercise - catching, locking, giving way - painful click flexing / extending knee ...
48
OCD Ix
- XR - subchondral crescent sign, loose bodies - MRI
49
OCD Mx
Non-surgical - Modify activity - Partial / non-weight bearing - Immobilise – promote healing Surgical - Arthroscopic drilling - Pins to secure flap - …
50
Rib fracture
- may have underlying injury / flail chest RFs - blunt trauma - osteoporosis, steroids, COPD - pathological - cancer Px - severe, sharp chest wall pain, tenderness - bruising - haemopneumothorax Ix - CT chest - CXR Mx - pain control - surgical fixation - Mx cx, consider ventilation
51
Lower back pain (non-specific)
- pain in lumbosacral region, no specific cause - aka mechanical back pain - may come from pathology of vertebrae, facet joints, intervertebral discs, muscles / ligaments RFs - obesity, sedentary, heavy lifting, stress, depression, low SES, smoking
52
Lower back pain (non-specific) Px
- Pain in lower back - Exacerbated by movt - Varies with time and posture - No red flag features
53
Back pain DDx
- Cauda equina - Spinal fracture - malignancy - spinal infections - discitis, vertebral osteomyelitis, epidural abscess - spinal stenosis - radicular pain - radiculopathy - spondylolisthesis - OA of spine - facet joint pathology - aseptic necrosis of femoral head - pyelo, renal stones, prostatitis, PID, endometriosis, pancreatitism PAD, AAA
54
Back pain red flags
- <20yo, >50yo - Hx of malignancy - Nocturnal pain - Hx of trauma - Systemically unwell - fever, weight loss, night sweats - IVDU - Immunocompromise - eg HIV, meds - Bilateral leg pain, neuro deficits - Urinary incontinence / retention - Faecal incontinence - Early morning stiffness or at rest - Current / recent infection - TB, staph etc - Abdo mass - malignancy - Acute onset in elderly - osteoporotic - Pain when lying down (usually resolves pain) - Leg claudication
55
Back pain Ix
- bloods - CRP, WCC, FBC, U/E, ESR, bone, LFTs - urine dip - MRI - spinal XR - STarT back tool- bloods - CRP, WCC, FBC, U/E, ESR, bone, LFTs - urine dip - MRI - spinal XR - STarT back tool
56
Back pain Mx
- exercise, heat - NSAIDs + PPI - codeine +/- paracetamol (short term) - diazepam - muscle spasms - physio - massage - CBT - radiofrequency denervation
57
Prolapsed L3 disc
- Sensory loss anterior thigh - Weak hip flexion, knee extension, hip adduction - Reduced knee reflex - Positive femoral stretch test
58
Prolapsed L4 disc
- Sensory loss anterior knee, medial malleolus - Weak knee extension, hip adduction - Reduced knee reflex - Positive femoral stretch test
59
Prolapsed L5 disc
- Sensory loss dorsum of foot - Weakness in foot / big toe dorsiflexion - Reflexes intact - Positive sciatic nerve stretch test
60
Prolapsed S1 disc
- Sensory loss posterolateral aspect of leg, lateral aspect of foot - Weakness in plantarflexion of foot - Reduced ankle reflex - Positive sciatic nerve stretch test
61
Disc prolapse Px
- back pain - dermatomal leg pain - worse when sitting - sensory/motor deficit
62
Disc prolapse Mx
- analgesia (NSAIDs), physio, exercises - if sx >4-6wks, consider MRI
63
Spinal stenosis
- narrowing of central canal in spine - compresses spinal cord / nerve roots - from tumour, disc prolapse, degenerative changes
64
Spinal stenosis Px
- gradual onset - lower back pain, buttock pain - neuropathic pain, leg weakness - sciatica / radiculopathy - sx better when sitting - easier walking uphill than downhill - struggle sitting on bike
65
Spinal stenosis Ix
- MRI spine - R/o PAD - ABPI, CT angio
66
Spinal stenosis Mx
- exercise, wt loss, physio - surgery - laminectomy
67
Sciatica
- irritation / compression of sciatic nerve - eg herniated disk, spinal stenosis, spondylolisthesis, piriformis syndrome... - L4-S3 form sciatic, sensation to lateral lower leg, foot, motor to posterior thigh, lower leg, foot
68
Sciatica Px
- unilateral shooting pain from buttock, radiating down back of thigh to knee/foot - paraesthesia, numbness, weakness - may affect reflexes
69
Sciatica Ix
- sciatic stretch test
70
Sciatica Mx
- physio, exercise, simple analgesia - consider amitriptyline, duloxetine - specialist mx - epidural corticosteroid injections, LA injections, radiofrequency denervation, spinal decompression
71
Cauda equina syndrome (CES)
- compression of cauda equina - surgical emergency - spinal cord terminates L2/3 Causes - herniated disc - tumours - spondylolisthesis - abscess - trauma
72
CES Px
- low back pain - bilateral sciatica / weakness, numbness, paraesthesia - loss of sensation in bladder/rectum - saddle anaesthesia - urinary retention / incontinence - faecal incontinence - gait disturbance / difficulty walking - reduced anal tone (PR) - reduced tone / reflexes
73
CES Ix
- urgent MRI
74
CES Mx
- neurosurgical - lumbar decompression surgery
75
Discitis
- infection of intervertebral disc space - S aureus most commonly
76
Discitis Px
- back pain - fever, rigors, sepsis - if epidural abscess develops - lower limb neurology
77
Discitis Ix
- MRI - CT guided biopsy - bloods, inc cultures - ECHO - IE
78
Discitis Mx
- 6-8wks IV abx
79
Osteoporotic vertebral fracture
- spinal fracture in osteoporosis
80
RFs for osteoporotic fractures
- older - post-menopause - Hx of fragility # - Hx of falls - steroids - FHx NOF - secondary osteoporosis - low BMI - smoking, drinking
81
Osteoporotic vertebral fracture Px
- asym - acute back pain - breathing difficulties, GI problems - Hx fall / trauma - minority - loss of height, kyphosis - localised tenderness
82
Osteoporotic vertebral fracture Ix
- XR spine - CT / MRI - DEXA, FRAX
83
Osteoporotic vertebral fracture Mx
- paracetamol, NSAIDs, opioids - bed rest, mobilisation, physio - Ca + vit D supplements - bisphosphonates - maybe intervention - eg vertebral augmentation
84
NOF
- neck of femur / hip fracture - head of femur has retrograde blood supply - intracapsular # can lead to avascular necrosis RFs - older, osteoporosis, F>M, fall
85
NOF categories
intracapsular - # in femoral neck, proximal to intertrochanteric line - Garden classification - non-displaced - may have intact blood supply - displaced - disrupted blood supply Extracapsular - blood supply to head of femur intact Intertrochanteric - # between greater + lesser trochanter Subtrochanteric - distal to lesser trochanter, but <5cm
86
Garden classification of intracapsular #
Grade I – incomplete #, non-displaced Grade II – complete #, non-displaced Grade III – partial displacement (trabeculae at angle) Grade IV – full displacement (trabeculae are parallel)
87
NOF Px
- Pain in groin / hip, may radiate to knee - Unable to weight bear - Shortened, abducted, externally rotated leg - Unable to straight leg raise - Bruising, swelling around hip
88
NOF Ix
- look for fall cause - eg bloods, MI, HF, stroke, chest infection - Bloods... - CXR, ECG - XR hip - disruption of Shenton's line - MRI / CT - if XR negative, but still ?# - NV status of limb
89
NOF Mx
- analgesia - fascia iliaca block - OT/PT - mobilise ASAP after op Surgery - <48hrs of admission - intracapsular - hemiarthroplasty (limited mobility) / total hip replacement (fitter) - intertrochanteric - DHS - Subtrochanteric - IM nail
90
NOF Cx
Malunion, blood loss, VTE, fat emboli, avascular necrosis, infection of metalwork
91
Hip dislocation
- more likely in total hip replacement / major trauma Px - posterior - 90% - shortened, adducted, internally rotated leg - anterior - abducted, externally rotated leg Ix - XR Mx - analgesia - reduction <4hrs (avascular necrosis risk) - OT/PT Cx - sciatic / femoral nerve injury - avascular necrosis - OA - recurrence
92
Acetabular labral tear
- tear to labrum (cartilage) in hip socket - direct trauma, sports, degenerative change - pain in hip / groin, locking, catching, snapping - MRI, arthroscopy - rest, physio, surgery
93
Avascular necrosis of hip
- death of bone tissue from lack of blood supply -> destruction + loss of joint function Causes - long term steroids, chemo, alcohol, trauma Px - asym - pain in affected joint Ix - XR - MRI - definitive Mx - surgical - joint replacement
94
Iliopsoas abscess
- collection of pus in iliopsoas compartment Causes - primary - haematogenous - S aureus - Secondary - Crohn's, diverticulitis, cancer, UTI, GU cancer, IVDU.... Px - fever, back/flank pain, limp, wt loss - flexion at hip against resistance causes pain - hyperextension of hip causes pain Ix - CT abdo Mx - abx - percutaneous drainage - surgery
95
Meralgia paraesthetica
- localised sensory sx of outer thigh caused by compression of lateral femoral cutaneous nerve (LFCN) - mononeuropathy - eg pressure, deformity, trauma - at any point along nerve RFs - obesity, pregnancy, ascites, trauma, sports, iatrogenic, idiopathic
96
Meralgia paraesthetica Px
- abnormal sensations - dysaesthesia - loss of sensation - anaesthesia - burning, numbness, pins + needles - cold sensation - hair loss - sx worsened by standing/walking/hip extension - sx mild / persist for yrs
97
Meralgia paraesthetica Ix
- clinical dx - pelvic compression test - inject nerve with LA - NCS - Ix to r/o spinal/pelvic pathology
98
Meralgia paraesthetica Mx
- rest, loose clothing, wt loss, physio Medical - paracetamol, NSAIDs - neuropathic pain meds - local steroid / anaesthetic injections Surgical - decompression, nerve transection/resection
99
Greater trochanteric pain syndrome
- pain in outer hip from trochanteric bursitis - eg IT band, trauma, RA, septic bursitis
100
Greater trochanteric pain syndrome Px
- pain over lateral hip, may radiate down thigh - gradual onset - aching / burning - worse after activity / standing still / cross-legged - tender on palpation of GT - infection - warm, red, swelling, pain, fever
101
Greater trochanteric pain syndrome Ix
Clinical examination - pain on resisted abduction of hip - pain on internal / external rotation of hip against resistance - Positive Trendelenburg test
102
Greater trochanteric pain syndrome Mx
- Rest, ice - analgesia - physio - steroid injections - abx for infection - 6-9mo recovery
103
Iliotibial band syndrome
- common cause of lateral knee pain in runners - irritation of IT band - tenderness 2-3cm above lateral joint line at knee - physio, activity modification to tx
104
Meniscal tear
- damage to meniscus - cartilage in knee joint - often twisting movts, young pt, sports
105
Meniscal tear Px
- pop sensation - pain, swelling, stiffness, reduced ROM - pain worse straightening knee - locking of knee, knee instability - maybe referred to hip/lower back
106
Meniscal tear Ix
- McMurray's test - Apley grind test - XR if Ottawa knee rules - MRI - arthroscopy
107
Meniscal tear Mx
- A+E / fracture clinic referral - RICE - NSAIDs - physio - surgery - arthroscopy - repair/resection of meniscus
108
ACL injury
- most common - stops tibia sliding forwards - typically twisting injury
109
ACL injury Px
- pain, swelling - pop sensation - instability of knee joint
110
ACL injury Ix
- anterior draw - Lachman's - MRI - arthroscopy
111
ACL injury Mx
- RICE - NSAIDs - crutches / knee braces - physiotherapy - arthroscopic surgery - reconstruct ligament
112
Patella fracture
- patella protects knee, forms part of extensor mechanism - direct trauma - usually undisplaced crack/comminuted fracture - indirect - quad contracts against something, transverse patella fracture Px - swelling, bruising, pain - palpable gap - if extensor mechanism injured - unable to SLR Ix - XR Mx - undisplaced - hinged knee brace - displaced - surgical - wires/screws
113
Ruptured PCL
- hyperextension / dashboard injuries - tibia lies back on femur - paradoxical anterior draw, positive posterior sag
114
Ruptured MCL
- When leg forced into valgus from force from outside - Knee unstable when put into valgus position
115
Chondromalacia patellae
- damage to cartilage at back of kneecap - Typically teenage girls, after injury to knee - Pain on going downstairs, or at rest - May see tenderness, quad wasting - Physio, analgesia - Rarely, surgery
116
Patella dislocation
- after trauma / severe quad contraction (with knee in valgus + external rotation) - clinically obvious, or skyline XR for sx - 5% have osteochondral # - 20% recurrence - reduce with analgesia
117
Tibial plateau fracture
- fracture of tibia just below knee - knee fractures before ligaments rupture - may need pins / plates
118
Patellofemoral pain syndrome
- pain in front of knee Causes - injury, overuse, maltracking of patella, weak hips/foot issues, overweight Px - pain around knee, intermittent - worse going up/down stairs - crepitus - swelling Ix - clinical dx Mx - physio - analgesia
119
Prepatella bursitis
- housemaid's knee - inflammation of bursa in front of patella - injury, prolonged kneeling, infection, gout/RA Mx - RICE, NSAIDs - abx for infection
120
Baker's cyst
- fluid-filled bursa in popliteal fossa - primary / secondary (eg OA, meniscal tears) Px - asym - swelling - pain, discomfort - fullness, pressure - rupture - can cause compartment syndrome Ix - Lump biggest when standing - USS - MRI Mx - tx cause - analgesia - NSAIDs - physio - US-guided aspiration - steroid injections
121
Osgood-Schlatter disease
- inflammation at tibial tuberosity at patella tendon insertion - multiple small avulsion #'s where patella ligament pulls away bits of bone -> growth of tibial tuberosity Px - gradual onset - lump at tibial tuberosity - pain in ant knee - pain worsened by movt, kneeling, extension of knee Mx - reduce activity - Ice - NSAIDs - stretching, physio
122
Achilles tendinopathy
- inflammation of achilles tendon - connects gastroc + soleus to calcaneus Types - insertion - <2cm of insertion - mid-point - 2-6cm RFs - sports, RA, DM, cholesterol, ciprofloxacin
123
Achilles tendinopathy Px
- gradual onset - pain / ache in heel, worse with activity - stiff, tender, swelling - nodule on palpation
124
Achilles tendinopathy Ix
- clinical dx - exclude rupture - Simmond's
125
Achilles tendinopathy Mx
- rest, ice - analgesia - physio - insoles - Extracorporeal shock-wave therapy (ESWT) - surgery
126
Achilles tendon rupture
- sudden onset rupture of tendon RFs - sports, older, tendinopathy, FHx, cipro, steroids
127
Achilles tendon rupture Px
- sudden onset pain in achilles/calf - snapping - swelling, tender - weak plantarflexion - cannot stand on tiptoes - Simmond's positive
128
Achilles tendon rupture Ix
- USS
129
Achilles tendon rupture Mx
- same day T+O review - RICE - surgical reattachment - consider non-surgical....
130
Ankle fracture
- Involve lateral malleolus (distal fibula) or medial malleolus (distal tibia) - tibiofibular syndesmosis important for ankle stability - if disrupted, surgery more likely
131
Ankle fracture Weber Classification
Type A – below ankle joint, intact syndesmosis Type B – at level of ankle joint, syndesmosis intact / partially torn Type C – above ankle joint – syndesmosis disrupted
132
Maisonneuve fracture
Spiral fibular fracture which widens ankle joint, disrupts syndesmosis
133
Pott's fracture
Bimalleolar ankle fracture, from forced foot eversion
134
Ankle fracture Mx
- reduce - plates/screws for younger pts - elderly - conservative
135
Ankle sprain
- stretching, partial/complete tear of ligament in ankle Types - low - lateral collateral ligaments (between distal fibula and talus) - high - syndesmosis (between tibia/fibula) - deltoid ligament (between tibia/talus) - maisonneuve
136
Low ankle sprain
- >90%, injury to ATFL - inversion of foot Px - pain, swelling, tenderness, bruising - weight bear usually Ix - XR if Ottawa rules - MRI if persistent pain Mx - RICE / MEAT (move, exercise, analgesia, tx) - orthosis, cast, crutches - surgery if unstable
137
High ankle sprain
- syndesmosis injury - rare - external rotation of foot Px - pain, swelling, tenderness, bruising - pain weight bearing - pain when tibia / fibula squeezed together at mid-calf Ix - XR, MRI Mx - orthosis, cast - if diastasis - surgery
138
Ottawa ankle rules
XR for ankle injury only necessary if – pain in the malleolar zone and one of: - Inability to weight bear 4 steps - Bony tenderness at lateral malleolar zone – tip of lateral malleolus to lower 6cm of posterior border of fibula - Bony tenderness in medial malleolar zone – tip of medial malleolus to lower 6cm of posterior border tibia
139
Charcot foot
- neuropathic joint - joint badly disrupted secondary to loss of sensation - diabetics Px - some pain - joint swollen, red, warm - change in foot shape Mx - keep in cast (keep still whilst recovering) - surgical mx
140
Plantar fasciitis
inflammation of plantar fascia Px - gradual onset pain at heel - worse walking / standing - tender on palpation Mx - rest, ice - physio - analgesia - supportive shoes, insoles - consider steroid injections, shockwave therapy, surgery
141
Fat pad atrophy
- wasting of fat pad under calcaneus - older, repetitive jumping, obesity, local steroid injections Px - pain, tenderness over plantar aspect of heel Ix - USS - measure thickness Mx - comfortable shoes, insoles - avoid high heels - lose weight
142
Morton's neuroma
- dysfunction of nerve in intermetatarsal space at top of foot - usually 3-4th - irritation of nerve, eg high heels Px - pain at front of foot - feels like lump in shoe - burning, numbness, paraesthesia in distal toes Ix - deep pressure causes pain - metatarsal squeeze - pain - Mulder's sign - USS / MRI Mx - analgesia, insoles, wt loss steroid injections, radiofrequency ablation, surgery
143
Bunions (hallux valgus)
- bony lump - deformity at MTPJ base of toe - 1st metatarsal angles medially, big toe angles laterally - MTPJ inflamed, enlarged, OA over time Px - +/-pain, gradual, lump Ix - wt bearing XR Mx - wide, comfortable shoes - analgesia - bunion pads - surgery
144
Metatarsal fracture
- 5th metatarsal - most commonly fractured - proximal avulsion fractures / Jones fractures - also metatarsal stress fractures (2nd most commonly) Px - pain, bony tenderness - swelling - antalgic gait Ix - XR - isotope scan / MRI
145
Ottawa foot rules
Foot XR required if pain in midfoot zone and any one of: - Bony tenderness at navicular zone - Bony tenderness at base of 5th metatarsal - Inability weight bear 4 steps
146
Frozen shoulder
- adhesive capsulitis - middle-aged females - primary (no trigger) / secondary (trauma, surgery...) - inflammation + fibrosis in joint capsule -> adhesions, restriction of movt
147
Frozen shoulder Px
- painful shoulder, worse at night - stiff - active/passive - mostly external rotation - thawing - gradual sx improvement - bilateral 20%
148
Frozen shoulder Ix
- clinical dx - XR - normal - US / CT / MRI - thickened joint capsule
149
Frozen shoulder Mx
Non-surgical - analgesia - physio - intra-articular steroid injections - hydrodilation Surgical - manipulation under anaesthesia - arthroscopy
150
Rotator cuff injury
- Subacromial impingement / supraspinatus tendinopathy - calcific tendonitis - rotator cuff tears - rotator cuff arthropathy
151
Subacromial impingement / supraspinatus tendinopathy
- inflammation of supraspinatus - impingement where it passes between humeral head + acromion Px - shoulder pain - painful abduction arc 60-120deg - tender over anterior acromion - empty can test Mx - rest, physio, steroid injection
152
Rotator cuff tears
- acute injury / degenerative Px - shoulder pain - abduction weakness - night pain Ix - XR - USS / MRI Mx - physio, rest, analgesia - surgery
153
Shoulder tests
Neer’s impingement test - Anterolateral shoulder pain during forward flexion of arm whilst internally rotated Hawkin’s test - Forced internal rotation of arm at shoulder height, elbow bent 90 – causes anterolateral shoulder pain Empty can test - Supraspinatus - Abduct arm to 90, internally rotate arm, apply downward pressure – creates pain / weakness Posterior cuff test - Infraspinatus - Weakness / pain on resisted external rotation Gerber’s lift off test - Subscapularis - Lift hand off back, whilst resistance applied – weakness / pain with tear
154
AC joint arthritis
- AC joint tender - pain worse at extremes of shoulder abduction, 170 onwards - positive scarf test
155
AC joint injury
- eg rugby collision, fall onto shoulder, FOOSH - conservative/surgical mx
156
Shoulder dislocation
- Humeral head dislodges from glenoid cavity of scapula - >90% anterior, but also posterior, inferior - Subluxation - partial dislocation
157
Shoulder dislocation patho
- anterior - arm forced backwards whilst abducted/extended at shoulder - posterior - arm forced back whilst outstretched, internally rotated (electrocution/seizures) Associated damage - glenoid labrum tear - Bankart lesion - Hill-Sachs lesions - axillary nerve damage - fractures - rotator cuff tear
158
Shoulder dislocation Px
- beware after acute injury - holding arm - shoulder pain - assess NV status, fractures
159
Shoulder dislocation Ix
- XR - posterior (lightbulb sign) - MRI - arthroscopy - apprehension test
160
Shoulder dislocation Mx
- reduce dislocation, analgesia/sedation - sling - post-reduction XR - fracture clinic follow up - recurrent - physio, shoulder stabilisation surgery
161
Cervical spondylosis
- degenerative changes in spine - from OA - vertebrae + discs
162
Cervical spondylosis Px
- neck pain, worse on movt - shoulder pain - stiffness - headaches
163
Cervical spondylosis Mx
- gentle exercises - physio - analgesia - amitriptyline
164
Olecranon bursitis
- inflammation + swelling of bursa over elbow Causes - friction/repetitive movts, trauma, RA/gout, infection
165
Olecranon bursitis Px
- swelling over posterior aspect of elbow - warm, tender, fluctuant - infection - hot, tender, erythema, fever, sepsis
166
Olecranon bursitis Ix
- if infected - aspirate - MC+S
167
Olecranon bursitis Mx
- RICE/MEAT - compression - analgesia - steroid injections - abx if infected
168
Repetitive strain injury
- soft tissue injury/strain from repetitive activities Px - pain, aching, weakness, cramping, numbness, tender on palpation Ix - clinical dx - XR to r/o OA - USS - Bloods - RA Mx - RICE/MEAT - occie health (if work related) - analgesia - physio - steroid injections
169
Epicondylitis
- inflammation at insertion of tendons into epicondyles at elbow Lateral - tennis elbow - pain in lateral epicondyle, insertion of wrist extensors, pain with wrist extension against resistance Medial - Golfer's elbow - pain in medial epicondyle, flexors, pain with wrist flexion against resistance
170
Epicondylitis Px
- gradual onset - pain in epicondyle - can radiate down forearm - weakness in grip strength - medial can have ulnar nerve involvement
171
Epicondylitis Ix
- clinical dx
172
Epicondylitis Mx
- rest, NSAIDs - physio - braces, straps - steroid injections - rarely, surgery, shockwave therapy, plasma injections
173
Radial tunnel syndrome
- compression of posterior interosseous branch of radial nerve - Overuse injury Px - Similar to tennis elbow - Pain 4-5cm distal to lateral epicondyle - Pain worse extending elbow, pronating forearm
174
Cubital tunnel syndrome
- compression of ulnar nerve as it passes through cubital tunnel Px - intermittent tingling in 4/5th finger, later numbness / weakness - worse with elbow flexed - often hx of OA/trauma Ix - clinical dx - ?NCS Mx - physio - steroid injections - surgery
175
Biceps rupture
- rupture of biceps tendon - 90% long tendon proximally, 10% distal tendon - proximal MOI - biceps lengthened, contracted, load applied - distal MOI - flexed elbow suddenly extended with biceps contracted RFs - heavy lifting, shoulder overuse, smoking, steroids
176
Biceps rupture Px
- sudden pop/tear - pain, bruising, swelling - Proximal - Popeye deformity - distal - reverse Popeye - weakness in shoulder/elbow
177
Biceps rupture Ix
- examination - Biceps squeeze test - USS - MRI
178
Biceps rupture Mx
- proximal - conservative - distal - surgical repair
179
Pulled elbow
- subluxation of radial head - <6yo Px - elbow pain - limited supination / extension Mx - analgesia - passively supinate elbow whilst flexed at 90
180
De Quervain's tenosynovitis
- Sheath containing extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons is inflamed - repetitive movt -> inflammation/swelling of tendon sheaths
181
De Quervain's tenosynovitis Px
- pain on radial side of wrist - aching, burning, weakness, numbness, tingling - tender over radial styloid process - abduction of thumb against resistance painful
182
De Quervain's tenosynovitis Ix
- Finkelstein's test
183
De Quervain's tenosynovitis Mx
- analgesia - steroid injection - immobilise - surgical tx - cut extensor retinaculum
184
Trigger finger
- Pain / difficulty moving a finger - aka stenosing tenosynovitis - thickening of tendon / tightening of sheath prevents tendon moving smoothly, may be nodule also
185
Trigger finger Px
- finger painful/tender - does not move smoothly - popping / clicking sound - stuck in flexed position - sx worse in morning, improve during day
186
Trigger finger Ix
- clinical dx
187
Trigger finger Mx
- rest - analgesia - splinting - steroid injections - surgery
188
Dupuytren's contracture
- Fascia of hand becomes thickened, tight, leading to finger contractures RFs - age, FHx, manual labour, epilepsy, alcoholic liver disease, smoking, phenytoin, trauma Px - hard nodules on palm - ring/little fingers flexed Ix - table top test Mx - conservative - surgical - needle fasciotomy / fasciectomy
189
Ganglion cyst
- sac of synovial fluid arising from joint / tendon sheath Px - Firm, well-circumscribed mass, transilluminates Ix - clinical dx - XR - USS Mx - conservative - needle aspiration / surgical excision
190
Carpal tunnel syndrome (CTS)
- compression of median nerve in carpal tunnel - swelling of tendon sheaths / narrowing of tunnel
191
CTS causes
- Idiopathic - Pregnancy - Oedema, eg HF - Lunate fracture - RA - Acromegaly - bilateral sx - Repetitive strain - Perimenopause - Diabetes
192
CTS Px
- gradual onset, intermittent, worse at night - pain / paraesthesia in thumb, index, middle finger - numbness, burning - shake hands for relief, at night - weak thumb abduction, wasting of thenar eminence - difficulty with fine movts / grip strength - Tinels / Phalens positive
193
CTS Ix
- clinical dx - NCS - Carpal tunnel questionnaire
194
CTS Mx
- corticosteroid injections - wrist splints - surgical decompression
195
Midshaft humerus fracture
radial nerve injury, wrist drop
196
Colles fracture
- FOOSH, dinner-fork deformity Features - transverse fracture of radius - 1in proximal to radiocarpal joint - dorsal displacement / angulation Cx - median nerve injury - compartment syndrome - NV compromise - malunion, tendon rupture, OA
197
Smith's fracture
- fall onto flexed wrist - volar / palmar angulation of distal radius fragment (Garden spade deformity)
198
Bennett's fracture
- intra-articular fracture of metacarpal, at base of thumb - punching - XR - triangular fragment at base of metacarpal
199
Monteggia's fracture
- dislocation of proximal radioulnar joint, ulnar fracture - FOOSH with forced pronation - prompt dx to avoid disability
200
Galeazzi fracture
- radial shaft fracture with dislocation of distal radioulnar joint - fall on hand + rotational force - bruising, swelling, tenderness over lower end of forearm - XR - displaced radial fracture, prominent ulnar head from dislocation
201
Barton's fracture
- distal intra-articular radius fracture with radiocarpal dislocation in direction of fracture segment - dorsal / palmar - fall onto extended + pronated wrist
202
Scaphoid fractures
- from FOOSH - risk of avascular necrosis Px - pain, swelling in anatomical snuffbox - pain on wrist movts, eg ulnar deviation - pain on longitudinal compression of thumb - loss of grip / pinch strength Ix - XR - need ulnar deviation AP - CT - MRI Mx - Immobilise - futuro splint / below elbow backslab - T+O referral - undisplaced - 6-8wk cast - displaced - surgical fixation - proximal scaphoid pole - surgical fixation
203
Radial head fracture
- usually FOOSH Px - marked local tenderness over radius head - impaired elbow movts - sharp pain at lateral side of elbow at extremes of pronation / supination
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