General Practice: Orthopaedics Flashcards
KEY - Nearly all soft tissue injuries can be managed with how (4+3) (Repetitive strain injuries, Bursitis, Achilles tendinopathy, rotator cuff tear, plantar fascitis, meniscal tear, ACL injury, epicondylitis…)
- RICE
- altered activity
- Analgesia - NSAIDs first line
- physiotherapy
Some:
- steroid injection (never in achilles tendinopathy -> rupture)
- Surgery
- splinting/crutches
What is frozen shoulder and what is it caused by? What is the typical presentation?
Pain and stiffness in the shoulder joint, commonly affecting people in middle age or with diabetes. In adhesive capsulitis, inflammation and fibrosis in the joint capsule lead to adhesions (scar tissue). The adhesions bind the capsule and cause it to tighten around the joint, restrict movement in the joint.
Adhesive capsulitis can be:
- Primary– occurring spontaneously without any trigger
- Secondary– occurring in response to trauma, surgery or immobilisation
There is a typical course of symptoms, with three phases:
- Painful phase–shoulder painis often the first symptom and may be worse at night
- Stiff phase–shoulder stiffnessdevelops and affects both active and passive movement (external rotationis the most affected) – the pain settles during this phase
- Thawing phase– there is a gradual improvement in stiffness and a return to normal
The entire illness lasts 1 – 3 years before resolving (e.g., 6 months in each phase). However, a large number of patients (up to 50%) have persistent symptoms.
Differential diagnosis for shoulder pain
The main differentials in a patient presenting with shoulder painnotpreceded by trauma or an acute injury are:
- Frozen Shoulder - adhesive capsulitis - Dx is clinical, Imaging not required
- Supraspinatus tendinopathy -due to impigenement (empty can test)
- Acromioclavicular joint arthritis (positive scarf test)
- Glenohumeral joint arthritis - Dx w/ X-rays
Rare but important differentials to keep in mind are:
- Septic arthritis
- Inflammatory arthritis
- Malignancy(e.g., osteosarcoma or bony metastasis)
Shoulder pain preceded by trauma or an acute injury may be due to:
- Shoulder dislocation
- Fractures(e.g., proximal humerus, clavicle or rarely the scapula)
- Rotator cuff tear
what is bursitis? give 4 locations of bursa? what are the 4 causes of bursitis
Bursitisrefers toinflammationof abursa. This causes thickening of the synovial membrane and increased fluid production, causing swelling and pain.
Bursaeare sacs created bysynovial membranefilled with a small amount ofsynovial fluid. They are found at bony prominences (e.g., at the greater trochanter, knee, shoulder and elbow). They act to reduce friction between the bones and soft tissues during movement.
This inflammation can have several causes:
- Friction from repetitive movements
- Trauma
- Inflammatory conditions (e.g., rheumatoid arthritis)
- Infection – referred to as septic bursitis
How does trochanteric bursitis present? How is it diagnosed?
The typical presentation is a middle-aged patient with gradual-onset lateral hip pain (over the greater trochanter) that may radiate down the outer thigh. The pain is described as aching or burning. It is worse with activity, standing after sitting for a prolonged period and trying to sit cross-legged. It may disrupt sleep and be difficult to find a comfortable lying position.
On examination, there is tenderness over the greater trochanter. There is not usually any swelling (unlikely bursitis in other areas).
The NICE clinical knowledge summaries (updated 2016) suggest special tests to establish the diagnosis:
- Trendelenburg test
- Resistedabductionof the hip (ask the patient to resit while you move their hip → pain)
- Resistedinternal rotationof the hip
- Resistedexternal rotationof the hip
Olecranon bursitis presentation? If caused by an infection?
The typical presentation is a young/middle-aged man with an elbow that is:
- Swollen
- Warm
- Tender
- Fluctuant (fluid-filled)
It is important to identify where bursitis is caused by infection. Features of infection are:
- Hot to touch
- More tender
- Erythema spreading to the surrounding skin
- Fever
- Features of sepsis (e.g., tachycardia, hypotension and confusion)
An important differential diagnosis isseptic arthritis. Consider septic arthritis if there is:
- Swelling in the joint (rather than the bursa)
- Painful and reduced range of motion in the elbow
Sidenote on bursitis with athritis - bursitis is on the posteroir forearm (below ulner), not in the middle of the joint, look at pictures
Diagnosis and Management of suspected infectious bursitis
When infection is suspected or cannot be excluded, management involves:
- Aspiration of the fluid for microscopy and culture (straw colour is the normal)
- Antibiotics - flucloxacillin first-line, with clarithromycin as an alternative.
just learn above ^
Side note…Patients that are systemically unwell (e.g.,immunocompromised or have sepsis) need admission to hospital for further management, including:
- Bloods (including lactate)
- Blood cultures
- IV antibiotics
- IV fluids
Slightly different management - how is frozen shoulder managed?
Differs from other soft tissue injuries because the joint capsule needs to be stretched
Non-surgical options for improving symptoms and speeding up recovery are:
- Continue using the arm but don’t exacerbate the pain
- Analgesia(e.g., NSAIDs)
- Physiotherapy
- Intra-articular steroid injections
- Hydrodilation(injecting fluid into the joint to stretch the capsule)
Surgery may be used in particularly resistant or severe cases. The options are:
- Manipulation under anaesthesia– forcefully stretching the capsule to improve the range of motion
- Arthroscopy– keyhole surgery on the shoulder to cut the adhesions and release the shoulder
What is a rotator cuff tear? What causes it? Presentation?
Partial or full tear of the tendons of the rotator cuff muscles. Occurs due to acute injury (fall, tennis, lifting) or degenerative changes with age
Rotator cuff tears may present either with an acute onset of symptoms after an acute injury, or with a gradual onset of symptoms.Patients typically present with: - Shoulder pain - Weakness and pain with specific movements relating to the site of the tear (e.g., abduction with a supraspinatus tear)
How are rotator cuff tears diagnosed?
X-rayswill not show soft tissue injuries such as rotator cuff tears. They may be helpful for excluding bony pathology, such as osteoarthritis.
***Ultrasound***or***MRI scans***can diagnose a rotator cuff tear.
What is a shoulder dislocation - not a GP issue
Shoulderdislocationis where the ball of the shoulder (head of the humerus) comes entirely out of the socket (glenoid cavity of the scapula).
Define Epicondylitis
Epicondylitis refers toinflammationat the point where thetendonsof the forearm insertinto theepicondylesat the elbow.It is a specific type of repetitive strain injury.
Epicondylitis is the result of repetitive use and injury to the tendons at the point of insertion. Symptoms gradually worsen over weeks to months. It most commonly affects patients in middle age.
Epicondylitis - mnemonic time, how do you remember the functions of the muscles with tendons that insert at the medial vs lateral epicondyle?
Gays Flex, medially
Flexion is the bend wrist gay thing, medial epicondyl
The tendons of the muscles that insert into the:
- Medial epicondyleact toflexthe wrist
- Lateral epicondyleact toextendthe wrist
What tissues are affected in repetitive strain injuries?
Repetitive strain injury is an umbrella term that refers to soft tissue irritation, microtrauma and strain resulting from repetitive activities. It can affect the muscles, tendons and nerves.
For example - Lateral epicondylitis (tennis elbow) is a specific example of a repetitive strain injury.
6 symptoms of repetitive strain injuries
- Pain, exacerbated by using the associated joints, muscles and tendons
- Aching
- Weakness - this is what threw you
- Cramping
- Numbness - this also threw you
- tenderness- may be tender to palpation
