MSK Flashcards
(203 cards)
1
Q
Describe the presentation of an Iliopsoas Abscess?
A
Pain relieved by hip flexion
Pain worse on extension and internal rotation, can be lower back pain
Patient is sitting on back with knees flexed and hips externally rotated slightly.
2
Q
What imaging is used in an Iliopsoas abscess?
A
CT is first line
3
Q
What is the commonest organism causing an Iliopsoas Abscess?
A
S. Aureus
4
Q
What is the managment of an Iliopsoas abscess?
A
Surgical drainage and IV abx for 4-6 weeks
5
Q
How is a non displaced patellar fracture with no extensor mechanism issues managed?
A
Hinged knee brace with weight bearing. 6 weeks
6
Q
How is a displaced patellar fracture or one with an affected extensor mechanism managed?
A
Surgically fixed then hinged knee brace with weight bearing.
7
Q
Signs and Symptoms of Iliotibial Band Syndrome
A
Runner
Lateral Knee pain
Extension and Flexion can induce a snapping feeling
8
Q
What imagining is used in SUFE?
A
AP and Lateral Frog Leg X-ray
9
Q
Clinical sign of SUFE
A
Reduced internal rotation especially when leg is flexed . Leg is sitting externally rotate.
10
Q
What fracture is likely to present following a FOOSH
A
Colles Fracture - Dinner Fork Deformity
Distal Dorsally Displaced Radius.
11
Q
Falling onto a flexed wrist or backwards onto outstretched hand is likely to result in what kind of fracture?
A
Smiths Fracture - Garden Spade Deformity
Distal Volar displacement of Radius.
12
Q
A painful thumb occurring after a fist fight is likely to be what?
A
Bennets Fracture
Interarticular fracture at he base of the thumb metacarpal
13
Q
What is a Monteggia Fracture?
A
Ulnar Fracture
Radial Head Dislocation - pain at elbow
14
Q
What is a Galeazzi Fracture?
A
Radial Fracture
Distal Radioulnar Dislocation
15
Q
If a young person presents with pain over radial head after a FOOSH. What could it be?
A
Radial Head Fracture
16
Q
McMurrays test is positive in what?
A
Meniscal Tear - Pain on crouching is also common
17
Q
Extracapsular / Intertrochanteric - Stable Fracture
A
Dynamic Hip Screw
18
Q
Extracapsular / Intertrochanteric - Oblique, Reverse or Sub-trochanteric
A
Intramedullary Device
19
Q
Damage to the median nerve at the level of the wrist presents with.
A
Carpal Tunnel like syndrome
20
Q
Damage to the median nerve at the level of the elbow present with.
A
Carpal Tunnel symptoms Reduced forearm pronation Weak wrist flexion Ulnar devotion of the arm sign of benediction
21
Q
Damage to the Anterior Interosseus Nerve
A
Reduced pronation of the forearm
Cant make the OK sign due to reduced thumb and forefinger flexion.
22
Q
What fracture is likely to damage the anterior interosseus nerve?
A
Supracondylar Fracture - paediatric - direct blow to elbow or falling on elbow
23
Q
A tibial fracture is likely to be associated with what nerve being damaged?
A
Sural nerve - posteriolateral distal 1/3 lower leg
- lateral foot and ankle
24
Q
Sural nerve damage will present like this.
A
Sensory loss only
Posterolateral distal 1/3 of lower leg
Lateral foot
25
Finger fixed in flexion + Fusiform swelling + Tenderness
Tendon Flexor Tenosynovitis
| IV abx + elevation +/- surgical debridement
26
What is the commonest reason for a THR revision and how does it present?
Aseptic loosening
Pain radiating to the knee and on weight bearing
Still able to walk and weight bear.
27
What is affected in De Quervians Tenosynovitis?
Extensor Pollicus Brevis and Abdcutor Pollicus Longus tendon sheath
28
If a post menopausal women presents with a fracture do they require a DEXA scan?
No
| Bisphosphonates are used and no need for a DEXA atm
29
What is gold standard for rib fractures but what is usually enough?
CT scan is gold standard but X ray is usually enough
30
Management of rib fractures
Adequate analgesia
| 12 weeks and no repair -> surgery
31
Who do you refer a patient to if they present with a flail chest?
Cardiothorasic surgeon
32
```
4-8 years
Male
Reduced ROM
Limp
Pain
```
Perthes
33
Perthes Management
X ray is diagnostic
<6 - monitor
>6 or severe disease - surgery
34
Describe the classification of Ankle fractures.
Webers A- below syndesmoses - generally stable = moon boot
Webers B - level of syndesmoses - can be unstable observe taller shift
Webers C - Above level of sydesmoses - requires open surgery and fixation
35
List two bad things that would indicate an unstable ankle fracture on X - ray ?
Bi malleolar fracture - observe medial malleolus
| Talar Shift look for a widened gap
36
Tibial Shaft Fracture - describe
Open fracture are common
| Risk of compartment syndrome
37
Tibial Shaft Fracture - Management
Above the knee cast - conservative
| IM nailing, ORIF - surgical
38
Tibial Plateau # what nerve is at risk?
Common peroneal nerve
Sensory lateral lower leg and top of the foot
Dorsiflexion
Eversion
39
Tibial Plateau - Management
ORIF, External Fixator, Delayed Total Knee Replacement - surgical
Above Knee cast - conservative
40
What splint is used in a femoral shaft fracture ?
Thomas Splint
41
In an old patient with a suspected pelvic fracture, where is usually affected? and how does this affect management?
Inferior and superior Pubic rami fracture
| Usually managed conservatively
42
How are most humeral shaft fractures managed?
Conservatively
Distal = cast
Proximal = Humeral brace sling
43
What nerve is at risk in a proximal humeral fracture?
Axillary Nerve - badge patch dermatome
44
What nerve is at risk in a humeral shaft fracture?
Radial nerve
45
Neuropraxia
Temporary block - symptoms last up to 28 days
46
Axonotmesis
Demyelination distal to injury
| Takes a long time as nerve regenerates 1mm a day
47
Neurotmesis
Nerve transection - no recovery without surgical repair
48
What is you concern with a intracapsular fracture?
Risk of avascular necrosis
| Retinacular arteries get torn
49
What vessel supplies the retinacular arteries
Medial circumflex femoral artery
50
Hip fracture - what X-ray and what are you looking for?
AP and Lateral
| Loss of Shentons line and prominent lesser trochanter
51
What nerve is at risk in a Hip fracture
Sciatic nerve damage
52
Sciatic nerve damage will present with what?
Weak Knee flexion
| Weak Ankle dorsiflexion and plantar flexion
53
Hip fracture - presentation
Acutely shortened and externally rotated leg
54
Hip dislocation - presentation
Pain and inability to bear weight
Posterior - Internally rotated
Anterior - Externally rotated
55
Posterior Dislocation - hip
Commonest type
| Dashboard injury - leg internally rotated, adducted and flexed
56
Anterior Dislocation - hip
Less common - more likely if linked to motor bike accident
| Hyperabducted and extended
57
What nerve is at risk during a posterior hip dislocation?
Sciatic
58
Point tenderness over greater trochanter
Generalised pain over lateral leg
Pain reproducible by resisting lateral abduction
Trochanteric Bursitis
59
Point tenderness over greater trochanter
Generalised pain over lateral leg
Pain reproducible by resisting lateral abduction
Trochanteric Bursitis
60
What is a major risk with femoral artery catheterisation?
Retroperitoneal bleed - posterior wall of common femoral or external iliac artery.
Surgery is only life saving method
61
What trauma is a femoral artery at risk of rupture?
Proximal femur fracture
62
What nerve is responsible for a trendelenburg gait?
Superior Gluteal Nerve - supplies gluteus minimus medius and tensor fascia lata
63
Describe a trendelenburg gait and how this can tell you what side is affected.
When standing on affected side the opposite leg and pelvis drop down
Body tilts towards affected side
64
What other non neuro causes of a Trendelenburg gait is there?
Muscle weakness
Perthes disease
osteonecrosis of the hip
Developmental dysplasia
65
What nerve is affected in meralgia parasthetica ?
Lateral Femoral cutaneous nerve
66
Obese pregnant Diabetic lady wearing tight jeans
| Anterolateral thigh pain and paraesthesia
Meralgia Paraesthetica
67
A patient who cant sit on their wallet for along period of time without pain.
Pain tingling and numbness over buttocks and sciatica distribution
Piriformi syndrome
| Muscle injury or hypertrophy
68
In a severe hamstring tear what fracture may occur?
Avulsion fracture of the ischial tuberosity
69
Where is the safe space to administer an IM injection in the buttocks?
Superiolateral quadrant
70
In a tibiofemoral dislocation what are you worried about?
Neurovascular compromise as displace bone compresses popliteal fossa and its contents
71
What is your management of a tibifemoral dislocation?
Immediate reduction
Neurovascular exam
ABPI
CT angiogram
72
Lateral epicondyle pain in a keen runner and cyclist
| Knee pain on flexion extension
Iliotibial band syndrome
73
What artery supplies the ACL?
Distal Medial Geniculate Artery
74
Whats the unhappy triad?
MCL ACL Medial Meniscus
75
Whats the commonest combination of soft tissue injury in the knee?
ACL MCL and Lateral Meniscus
76
Pain Erythema Boginess over patella
| Person kneels a lot
Prepattelar bursitis
77
Pain over distal patellar ligament
| Kneels a lot
Superficial infrapatellar bursitis
78
Patient generally kneels a lot but with a more upright back
| Pain over patellar ligament laying over tibial tuberosity
Deep infra patellar bursitis
79
Suprapatellar Bursitis
Supra patellar pain selling redness warmth and reduced ROM
| Generally there will have been a preceding superficial wound and bacterial infection.
80
Ruptured Bakers Cyst
Calf pain, warmth, erythema and swelling.
| USS required to rule out DVT
81
Anterior knee pain on stairs
Prolonged stiffness
Teenage girl
Chondromalacia Patellae
| - patellar cartilage is softened
82
Pain after exercise with intermittent swelling and locking
Osteochondritis Dissecans
83
Septic Arthritis in young sexually acitve
N.Gonorrhoea
84
Septic arthritis in sickle cell patient
Salmonella
85
Commonest septic arthritis
S.Aureus
86
Septic arthritis <6 week joint replacement
Stap Epidermidis
87
Common in younger
Haemophilus
| Strep. Pyogenes
88
A history of young child being pulled by the arm
Elbow pain
Limited supination and extension of the elbow
Radial Head subluxation
89
Management of a radial head subluxation
Anaelgasia
| Passive supination of elbow joint whilst elbow is flexed
90
The tibial nerve is a branch of what nerve?
Sciatic -> common fibular -> tibial nerve
91
At what two levels can the tibial nerve be injured?
Popliteal fossa - posteror dislocations, trauma, surgery
Tarsal tunnel - Talus, calcaneus or medial malleolar fractures
- compression
92
How would damage to the tibial nerve at the level of the popliteal fossa present?
Inability to plantar flex, invert foot or toe flexion
| Sensory loss to sole of the foot
93
Injury to the tibial nerve at the level of the tarsal tunnel will resent with?
Sensory loss to the sole of the foot
| Motor function is preserved.
94
Where does the fibular nerve come from?
Divides from the sciatic nerve at the apex of the popliteal fossa.
95
Describe the branches of the femoral (peroneal) nerve
Superficial - sensory innervation to the lateral compartment of the lower leg and the dorsum of the foot.
Deep - Motor - dorsiflexes and everts the foot
- sensory - 1st web space
96
Where is the likely point of injury to the fibular nerve going to occur and how would this present?
At the head of the fibular - compression trauma
Foot drop and loss of foot eversion and sensory loss to lateral leg and whole dorsum of the foot.
Plantar flexion and inversion remain intact.
97
Commonest site of a tibial fracture
Distal 1/3
98
Where is the commonest compartment to be affected in lower leg compartment syndrome.
Anterior
| Anterior Tibial Artery + Deep fibular nerve
99
How will anterior compartment syndrome in the lower leg present.
Compartment syndrome symptoms +
| Foot drop and loss of first webspace sensation
100
Lateral Compartment syndrome in lower leg
Superficial fibula nerve is affected - loss of sensation to lateral lower leg + dorsum of the foot
First webspace sensation is intact
101
Deep Posterior Compartment syndrome
Tibial nerve - Reduced plantar flexion, foot inversion
| Posterior Tibial artery - reduced pulse detected
102
Superficial Posterior compartment syndrome
Least likely to be affected as no artery
103
Name the 4 compartment in the lower leg
Anterior
Lateral
Superficial Posterior
Deep Posterior
104
What is the commonest ankle sprain?
Lateral ankle - anterior talofibular ligament
105
What force is associated with an anterior talofibular ligament tear?
Extreme inversion and plantar flexion
106
What should be looked for in an anterior talofibular ligament injury?
Lateral Malleolus fracture
107
Why are medial ankles sprains less common?
As the deltoid ligaments are the strongest in the ankle.
108
In a medial ankle sprain what should be looked for if the deltoid ligaments have been torn?
Medial Malleolus avulsion
109
What is the energy applied in a medial ankle sprain?
Eversion
110
What is affected in a high ankle sprain. Syndesmotic Sprain.
Anterior Posterior and transverse tibiofibular ligament
| Interossues membrane
111
Common MOA for clavicle fracture.
FOOSH
| Direct fall onto the shoulder
112
What test is used to detect for acromioclavicular joint issues?
Scarf test
113
What test is used to detect for a rotator cuff tear or AC impingement?
Empty can test
114
The upper brachial plexus is made up of what nerve roots?
C5/6
115
Damage to the upper brachial plexus results in what injury and how might this occur?
Erbs palsy -
| Generally by increasing the angle between the shoulder and neck i.e pulling on babies head during delivery
116
What nerves are affected in an Erbs palsy?
Auxiliary
Musculucutaneous
Suprascapular nerves
117
Erbs palsy
Waiters tip
Arm adducted and internally rotated
Wrist flexed
+/- HORNERS SYNDROME
118
What makes up the lower brachial plexus?
C8/T1
119
A lower brachial plexus injury will present with?
Klumpkes palsy - increased angle between trunk and shoulder
| Medial and Ulnar nerve palsy
120
A klumpkes palsy will present with?
Clawed hand
| Medial sensory distribution loss
121
How does thoracic outlet syndrome present?
Upper extremity swelling
| Exertional arm pain
122
Surgical neck of the humerus fracture - nerve and artery affected
Axillary nerve - badge patch sensation lost
| Anterior and posterior circumflex arteries
123
Humeral shaft fracture - nerve and artery affected
Radial - wrist drop, loss of sensation to dorsum of the hand and forearm
Deep brachial artery
124
Supracondylar fracture - nerves
Median - medially displaced
| Radial - laterally displaced
125
What is the commonest cause of damage to the ulnar nerve at the level of guyons canal?
Hook of hamate fracture
| Compression i.e riding a bike
126
A boxers fracture is usually due to?
5th metacarpal fracture
127
Ape Hand
Recurrent medial nerve
128
Recurrent medial nerve
Innervates thenar muscles
Thumb flexion and opposition
'inability to button up a shirt'
129
What do lumbricals do?
Flex MCP
| Extend DIP and PIP
130
Median nerve damage at the level of the wrist.
At rest the index and middle finger are flexed
| Medial Claw
131
Why does a medial claw occur in a distal median nerve injury?
Because the median nerve innervates the lumbricals of the 1st and 2nd digits
As a result at rest there is MCP flexsion and DIP /PIP extension of those digits
132
What occurs in medial nerve damage at the level of the elbow?
Sign of benediction
| When making a fist only the 4th and 5th finger can flex
133
Why does proximal median nerve injury result in the sign of benediction?
Distal presentation +
| Finger flexors - FDP laterally and all FDP are affected.
134
A distal ulnar nerve injury will present with
Ulnar claw
| At rest, as 4/5th digits lumbricals are paralysed - MCP extended DIP/PIP flexed
135
What does the ulnar nerve damage affect in the hand?
```
Abductors and Adductors of digits 2-5
Adduction of the thumb
Weak 4/5 flexion
Hypothenar atrophy
Froments test - thumb will bend when pinching paper
```
136
Proximal ulnar nerve damage is likely due to?
Medial epicondyle fracture
| Leaning or sleeping on the elbow
137
How will a proximal ulnar nerve injury present?
Okay sign
| On making a fist there is the inability to flex 4/5th digits
138
Why does a proximal ulnar nerve injury result in a Okay sign?
Same as distal lesion +
| Flexor digitorum profundus is lost to the 4/5th digits
139
Finger drop is due to?
Excessive pronation or supination
| Radial nerve
140
What nerve is affected to cause finger drop?
Deep radial nerve - supplies extensor indices
| Passes through supinator muscles - compressed during supination
141
A mid humeral shaft fracture will present with
Reduced supination and extension of the wrist
142
If someone presents with elbow and wrist reduced flexion where has the injury occurred?
Above the level of the triceps usually at brachial plexus
143
A patient presents with dizziness and vertigo.
They also complain of arm pain.
Both the pain and the dizziness is made worse when they use the arm.
Subclavian steal syndrome
A stenosis in the subclavian artery means blood flow is stolen an reversed from the vertebral arteries- producing the posterior cerebral symptoms and the claudication like pain in the arm.
144
What test will illicit pain in an iliopsoas abscess?
Lay patient on unaffected side. Hyperextend their hips. This will stretch their Iliopsoas muscle causing pain.
145
Causes of Iliopsoas abscess
Primary - Haematogenous spread of bacteria - S.Aureus
| Secondary - Crohns #, Diverticular disease, UTI, Cancer, PWID
146
```
Male under 25
Metaphysic of long bones - around knee
Exostoses with a cartilaginous cap on X-Ray
Rare risk of malignant potential
Formed or growth plate tissue
```
Osteochondroma
| Can become chondrocarcinoma
147
20-40 year sold
Previous bone trauma or radiation
Epiphysis of long bones
Soap Bubbles on x -ray and local invasion
Giant Cell
148
Male
No response to NSAID for pain
X ray shows >2cm nidus a disorganise amass of blood vessels and trabecular tissue
Affects vertebrae
Osteoblastoma
149
Male under 25
Severe pain particularly at night
NSAIDs are very effective
X ray shows <2cm nidus with a sclerotic halo
Osteoid Osteoma
150
Middle aged
Surface of the facial bones
No malignant transformation
Link to gardeners syndrome - colonic polyps
Osteomas
151
Arising from chondocytes
| Affects small bones of hand and feet
Chondroma
152
Male under 20
Arising from osteoblasts
Metaphysis of long bones very aggressive
X ray shows - Lytic sunburst lesion
osteosarcoma
153
What two conditions are linked with osteosarcoma
Li Fraumeni syndrome
| Familial Retinoblatoma
154
```
Male causasian under 15
Diaphysis of long bones or pelvis
Pain and systemically unwell
Locally aggressive
Onion skin on xray
Responds to chemotherapy
```
Ewings sarcoma
155
What bone tumour is commonest in the elderly?
Chondrosarcoma
156
When do you assess for osteoporosis and how?
FRAX score
Women >65
Male >75
Younger if risk factors like smoking FH falls
157
```
Commonest bone tumour in 40-50 years
Hypercalcaemia
Renal disease
Anaemia
Bone pain
```
Multiple Myeloma
158
Osteomyelitis from haematogenous spread where is it likely to occur?
Metaphysis - young
| Epiphysis - old
159
Describe Salter Harris fractures
Type 1 - Straight across the physis
Type 2 - Passes through physis and into the metaphysis
Type 3 - Passes through physis and into epiphysis
Type 4 - Vertical fracture through metaphysis epiphysis and physis
Type 5 - Crush injury across physis
160
Lericke syndrome
Claudication of buttocks and legs
Impotence
Absent femoral pulses
+/- leg muscle atrophy
Due to severe atherosclerosis of distal aorta iliac of femoral arteries
161
Marfans
```
Autosomal dominant defect in fibrillin 1 gene
Upward lense dislocation
Pneumothhorax
Aortic issues
Mitral valve prolapse
Dural ectasia
```
162
Painful on external rotation with both passive and active movement.
Pain present in internal and abduction but not as severe.
Middle aged female
Adhesive capsulitis
| Painful phase -> frozen -> normal
163
What is the first line investigation into a query osteoporotic vertebral fracture?
X ray spine
164
What muscles of the hand does the median nerve supply?
Lumbricals 2 and 3rd = Flexors or MCP
Opponens Pollicis = Brings thumb across hand
Abductor Pollicis = Abducts thumb
Flexor Pollicis Brevis = flexes thumb
165
What does the guideline now say about starting allopurinol for gout prophylaxis?
Start when all signs of inflammation and pain have stopped.
166
Carpal Tunnel
6 week conservative - wrist splints + steroid injections
| Severe or failure of conservative measures = Flexor Retinacular Division
167
```
Carpal Tunnel that is resistant to treatment
Lower limb stiffness and weakness
Autonomic dysfunction
Paraesthesia
+ve Hoffmans
```
Degenerative Cervical Myelopathy
168
Commonest Metatarsal Stress Fracture
2nd
169
Management of sciatica
4-6 weeks conservative - gabapentin + physiotherapy
| No results - referral to neurosurgery
170
Leg shortened and internal rotated
Posterior Hip dislocation
171
Ulnar nerve supplies in the hand
```
Medial Lumbricals
Abductor Digiti minimi
Flexor digiti minimi
Adductor Pollicis
Interossei
Flexor Carpi Ulnaris
```
172
What scoring system is used to diagnose Ehlers-Danlos?
Beighton Score
>6/9 in children is diagnostic
>5/9 in adults is diagnostic
173
Perthes Disease - management
<6 years = Observe
| >6 years = surgical management
174
```
Female 4:1
Forefoot pain - burning or shooting
Loss of sensation distally in foot
Mulders click
# 3rd inter tarsal space
```
Mortons neuroma - clinical diagnosis -> USS can be helpful
175
Mortons Neuroma - Management
Avoid high heals
Metatarsal pads
Refer if three months no improvement
- Steroid injection or surgery
176
Septic arthritis management
Aspirate for culture ASAP - before abx
IV antibiotic - Flucloxacillin for two weeks - 2 weeks oral. Vancomycin if pen allergic
Surgical washout
177
Management of Osteochondritis Dissecans
Early orthopaedic involvement is key
| X-Ray and MRI
178
What imagining is used in osteomyelitis?
MRI
179
A positive femoral stretch test in the context of hip pain could indicate what?
Lumbar spine source of the pain
180
Musculocutaneous
C5-C7
Elbow flexion and supination
Sensory to lateral forearm
Brachial plexus injury
181
Axillary
C5 C6
Shoulder abduction
Badge patch
Humeral neck fracture
182
Radial
C5/C8
Extension of forearm wrist fingers and thumb
Humeral mid shaft fracture
183
Median
C6 C8 T1
LOAF
Wrist - thenar muscles and opponens pollis
Elbow - reduced pronation and wrist flexion
184
Ulnar
C8 T1
Intrinsic hand muscles - LOAF
Wrist flexion
Medial epicondyle fracture
185
LOAF
Lumbricals - lateral
Opponens pollis
Abductor pollis brevis
Flexor pollis brevis
186
Management of frozen shoulder syndrome
Only physio is deemed to be effective
187
Acromioclavicular injury grade I or II - management
Sling and analgesia
188
Acromioclavicular injury grade IV V VI - management
Surgery
189
Three key points in achilles rupture
Calf squeeze - doesn't illicit plantar flexion
Observe angle of declination
Palpation of tendon
190
When is scaphoid imaging repeated?
7-10 days later if not initially visualised
191
L3 - motor and sensory
Motor - weak quadriceps and knee reflex
| Sensory - Anterolateral thigh
192
L4 - motor and sensory
Motor - weak quadriceps and knee reflex
| Sensory - Anterior knee
193
L5 - motor and sensory function
Motor - Ankle and big toe dorsiflexion. Ankle reflex intact
| Sensory - Dorsum of the foot
194
S1 - Motor and sensory function
Motor - Plantar flexion and inversion
| Sensory - posteriolateral leg and lateral foot.
195
Gold standard investiation in degenerative cervical myelopathy.
MRI c-spine
196
Commonest Metatarsal fracture and the common cause
5th metatarsal
| Inversion of foot
197
What test can differentiate short femur from a short tibia?
Galleazi test
198
Femur Fracture Garden Classification
1. Undisplaced Incomplete
2. Undisplaced complete
3. Partial displacement
4. Fully displaced
199
A patient with a good premorbid function presents with an undisplaced NOF #. What is the management.
Internal fixation with a cannulated screw.
THR - displaced fracture
Hemiarthroplasty - poor premorbid function
200
What is the imagining of choice in avascular necrosis of the femoral head
MRI as X ray may not show any signs
201
Nerve block commonly used in a neck of femur fracture.
Iliofascial nerve block
202
Lateral Epicondylitis
Tennis elbow
| Extended and supinated + resisted extension
203
Medial Epicondylitis
Golfers elbow
