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1

Stages of Fracture Healing

- Haematoma
- Inflammation --> Granulation tissue
- Cartilage callus
- Lamellar bone (primary
- Remodelling --> secondary bone

2

Factors that affect fracture healing

- Age
- malnourished
- local pathology
- neurological condiitons
- NSAIDs
- smoking
- DM
- Hormones - Cortisol, GH, Oestrogen, T3 &4, PTH

3

Describing a fracture

- Patient details
- Pattern of fracture
- anatomical location
- Intra/extra - articular
- Deformity (translation/ angulation)
- Soft tissue involvement
- Specific # classification

4

General priniciples of fractures management

4R's
Resuscitation - & assess NV status
Reduction
Restriction
Rehabilitation (PT, OT, home help)

5

Open fracture management

 Analgesia: M+M
 Assess: NV status, soft tissues, photograph
 Antisepsis: wound swab, copious irrigation, cover with
betadine-soaked dressing.
 Alignment: align # and splint
 Anti-tetanus: check status (booster lasts 10yrs)
 Abx - Fluclox 500mg IV/IM or Co-amox

Mx: debridement and fixation in theatre

6

Gustillo's classification of open fractures

1. Wound <1cm in length
2. Wound ≥1cm c¯ minimal soft tissue damage
3. Extensive soft tissue damage
a) periosteal stripping
b) requires free tissue flap
3) NV damage

7

Major complication of open fractures

 Wound infections and gas gangrene (clostridium perfringes)
 ± shock and renal failure

Rx: debride, benpen + clindamycin

8

Methods of reduction in fractures

Manipulation / Closed reduction
 Under LA, RA, GA
 Traction to disimpact
 Manipulation to align

Traction
 Employed to overcome contraction of large
muscles: e.g. femoral #s
 Skeletal traction vs. skin traction

Open reduction (and internal fixation)
 Accurate reduction vs. risks of surgery
 Intra-articular #s
 Open #s
 2 #s in 1 limb
 Failed conservative Rx
 Bilat identical #s

9

General complications of fractures

Tissue Damage
 Haemorrhage and shock
 Infection
 Muscle damage → rhabdomyolysis

Anaesthesia
 Anaphylaxis
 Damage to teeth
 Aspiration

Prolonged Bed Rest
 Chest infection, UTI
 Pressure sores and muscle wasting
 DVT, PE
 ↓ BMD

10

Specific fracture complications

Immediate
 Neurovascular damage
 Visceral damage
Early
 Compartment syn.
 Infection (worse if metal)
 Fat embolism → ARDS
Late
 Problems - union
 AVN
 Growth disturbance
 Post-traumatic OA
 CRPS
 Myositis ossificans

11

Pathophysiology of compartment syndrome

Raised pressure within any enclosed facial space leading to localised tissue ischaemia
 Oedema following # → ↑ compartment pressure → ↓
venous drainage → ↑ compartment pressure
 If compartment pressure > capillary pressure →
ischaemia
 Muscle infarction →
- Rhabdomyolysis and ATN
- Fibrosis → Volkman’s ischaemic contracture

12

Presentation of compartment syndrome

 Pain > clinical findings (not relieved by analgesia)
 Pain on passive muscle stretching
 Warm, erythematous, swollen limb
 ↑ CRT and weak/absent peripheral pulses
 shiny skin
 tense compartment
 +/- paraesthesiae

13

Prevention of compartment syndrome

avoid repeated manipulation
use open plaster initially
elevate leg
mobilise early

14

Rx of compartment syndrome

 Elevate limb
 Remove all bandages and split/remove cast
 Get senior help
 Prophylactic Abx and Analegesia
 Fasciotomy

15

Problems with union

Delayed Union: union takes longer than expected

Non-union: # fails to unite
- Hypertrophic
 Bone end is rounded, dense and sclerotic
- Atrophic
 Bone looks osteopenic

Malunion: # healed in an imperfect position
 Poor appearance and/or function

16

Causes of non/delayed union

 Ischaemia: poor blood supply or AVN
 Infection
 ↑ interfragmentary strain
 Interposition of tissue between fragments
 Intercurrent disease: e.g. malignancy or malnutrition

17

Management of delayed/ non-union

 Optimise biology: infection, blood supply, bone
graft, BMPs
 Optimise mechanics: ORIF

18

Features of AVN

 Death of bone due to deficient blood supply.
 Sites: femoral head, scaphoid, talus
 Consequence: bone becomes soft and deformed
→ pain, stiffness and OA.
 X-ray: sclerosis and deformity.

19

Features of myositis ossificans

 Heterotopic ossification of muscle @ sites of
haematoma formation
 → restricted, painful movement
 Commonly affects the elbow and quadriceps
 Can be excised surgically

20

Definition of complex regional pain syndrome

 Complex disorder of pain, sensory abnormalities,
abnormal blood flow, sweating and trophic changes in
superficial or deep tissues.
 No evidence of nerve injury.
(type 2 - persistent pain following injury caused by nerve lesions)

21

Causes and presentation of CRPS

Causes
 Injury: #s, carpal tunnel release, ops for Dupuytren’s
 Zoster, MI, Idiopathic

Presentation
 Wks – months after injury
 NOT traumatised area that is affected: affects a
NEIGHBOURING area.
 Lancing pain, hyperalgesia or allodynia
 Vasomotor: hot and sweaty or cold and cyanosed
 Skin: swollen or atrophic and shiny.
 NM: weakness, hyper-reflexia, dystonia, contractures

22

Rx of CRPS

 Usually self-limiting
 Refer to pain team
 Amitryptilline, gabapentin
 Sympathetic nerve blocks can be tried.

23

Salter harris classification

1. Straight across physis
2. Above (metaphysis)
3. Lower (epiphysis)
4. Through (all 3)
5. CRUSH

TYPE 2 most common

24

Risk factors for osteoporosis

SHATTERERED
 Steroids
 Hyper- para/thyroidism
 Alcohol and Cigarettes
 Thin (BMI<22)
 Testosterone low
 Early Menopause
 Renal / liver failure
 Erosive / inflame bone disease (e.g. RA, myeloma)
 Dietary Ca low / malabsorption, DM

Age

25

Presentation of a hip fracture

Shortened and externally rotated
Pain

26

Initial management of a hip fracture

- Resuscitate: dehydration, hypothermia
- Analgesia
- Assess NV status of limb
- Imaging: AP and lateral films

27

Garden classification of intracapsular fractures

1. Incomplete #, undisplaced
2. Complete #, undisplaced
3. Complete #, partially displaced
4. Complete #, completely displaced

28

Classification of hip fractures

 Intracapsular: subcapital, transcervical, basicervical
 Extracapsular: Intertrochanteric, subtrochanteric

29

Blood supply to the femoral head

1. Intramedullary vessels in femoral neck - Interrupted by #
2. Ascending branches of medial (Major contributor) and lateral circumflex femoral arteries, which travel in the capsular retinaculum. - Can be torn if # is displaced
3. Vessels of the ligamentum teres - Insufficient in adults.

30

Specific complications of hip fractures

 AVN of fem head in displaced #s (30%)
 Non / mal-union (10-30%)
 Infection
 OA
 Intracapsular haematoma (garden 3&4)

31

Surgical management of hip fractures

Intracapsular
 1,2: ORIF (cancellous/transcervical screws)
- hemi if unfit
 3,4:
<55: ORIF c¯ screws.
- arthroplasty if AVN
55-75: total hip replacement
>75: hemiarthroplasty

Extracapsular
 ORIF - dynamic hip screw

32

What score is used to predict the outcomes of hip fractures

Nottingham hip fracture score
- Age
- SEx
- Hb
- Residence
- Co-morbidities
- Malignancy

- additionally high venous lactate is a predictor of early death

33

Features of a colles fracture

 Fall onto an outstretched hand
 Most common in elderly females c¯ osteoporosis
 Dinner fork deformity

34

Radiographic features of a colles fracture

 Extra-articular transverse # of dist. radius (w/i 1.5” of radio-carpal joint)
 Dorsal displacement and angulation of distal fragment
- Normally 11° volar tilt
- ↓ radial height (<11mm)
- ↓ radial inclination (<22°)
 ± avulsion of ulna styloid
 ± impaction

35

Management of colles fracture

- Examine for NV injury (median N and radial A)
- displacement → reduction
 RA/ GA.
 Disimpact and correct angulation.
 Position: ulnar deviation + some wrist flexion
 Apply dorsal backslab: provide 3-point pressure
- Re X-Ray – satisfactory position?
 No: ortho review and consider MUA ± K wires
 Yes: home c¯ # clinic f/up w/i 48hrs for completion
of POP
- 6 wks in POP + physio
- If comminuted, intra-articular or re-displaces:
 Surgical fixation c¯ ex-fix, Kirschner-wires or
ORIF and plates.

36

Specific complications of colles fracture

 Median N. injury
 Frozen shoulder / adhesive capsulitis
 Tendon rupture: esp. EPL
 Carpal tunnel syn.
 Mal- /non-union
 Sudek’s atrophy / CRPS

37

What is a Barton's fracture

Oblique intra-articular # involving the dorsal aspect of
distal radius and dislocation of radio-carpal joint

38

Management of a Buckle and greenstick fracture

Buckle - 2 weeks plaster, 2 weeks reduced activity
Greenstick - closed reduction and arm immobilisation f r6 weeks

39

Clinical features of a scaphoid fracture

 FOOSH
 Pain in anatomical snuffbox
 Pain on telescoping the thumb

40

Management of a scaphoid fracture

 Sscaphoid x-ray view
 initially treat even if hx suggestive
- If initial x-ray is negative, pt. returns to # clinic after 10
days for re-xray (as localised decalcification)
 Place wrist in scaphoid plaster (beer glass position)
 # visible → plaster for 6 wks
 No visible # but clinically tender → plaster for 2
wks
 # not visible and not clinically tender → no plaster

41

Specific complications of a scaphoid fracture

AVN of the scaphoid as blood supply runs
distal to proximal.
 → stiffness and pain at the wrist

42

Classification of ulna shaft fractures

Monteggia
 # of proximal 3rd of ulna shaft
 Anterior dislocation of radial head at capitellum
 May → palsy of deep branch of radial nerve →
weak finger extension but no sensory loss

43

Classification of radial shaft fractures

Galleazzi
 # of radial shaft between mid and distal 3rds
 Dislocation of distal radio-ulna joint

44

Management of ulnar and radial shaft fractures

Unstable fractures
 Adults: ORIF
 Children: MUA + above elbow plaster

Fractures of forearm should be plastered in most stable
position:
 Proximal #: supination
 Distal #: pronation
 Mid-shaft #: neutral

45

Most common form of shoulder dislocation

Humeral head dislocates antero-inferiorly
- direct trauma/ falling on hand

46

Lesions associated with shoulder dislocation

Bankart Lesion
 Damage to anteroinferior glenoid labrum.

Hill-Sachs Lesion
 Cortical depression in the posterolateral part of the
humeral head following impaction against the glenoid
rim during ant dislocation.

47

Presentation of shoulder dislocation

 Shoulder contour lost: appears square
 Bulge in infraclavicular fossa: humeral head
 Arm supported in opposite hand
 Severe pain

48

Management of shoulder dislocation

 Assess for neurovascular deficit: esp. axillary N.
- Sensation over regimental badge before and after reduction
 X-ray: AP and transcapular view
 Reduction under sedation
 Rest arm in a sling for 3-4wks
 Physio

49

Complications of shoulder dislocation

 Recurrent dislocation
- 90% of pts. <20yrs with traumatic dislocation
 Axillary N. injury

50

Pathology of painful arc syndrome

Entrapment of supraspinatus tendon and subacromial
bursa between acromion and grater tuberosity of
humerus → subacromial bursitis and/or supraspinatous
tendonitis

51

Presentation of painful arc syndrome

 Painful arc: 60-120O
 Weakness and ↓ ROM

52

Ix and Rx of painful arc syndrome

 Plain radiographs: may see bony spurs
 US
 MRI arthrogram

Rx
 Rest
 Physiotherapy
 NSAIDs
+/- Subacromial bursa steroid ± LA injection

Surgery - Arthroscopic acromioplasty

53

Differentials of painful arc

 Impingement
 Supraspinatous tear or partial tear
 Adhesive capsulitis - joint OA

54

Presentation of frozen shoulder

Progressive ↓ active and passive ROM
 ↓ ext. rotation <30O
 ↓ abduction <90O
Shoulder pain, esp. @ night (can’t lie on affected side)
- assoc DM

55

Rx of painful arc

Conservative: rest, physio
Medical
 NSAIDs
 Subacromial bursa steroid ± LA injection

56

Features of rotator cuff tears

Partial tears → painful arc

 Shoulder tip pain
 Full range of passive movement
 Inability to abduct the arm
 Active abduction possible following passive
abduction to 90°

Supraspinatous --> Lowering the arm beneath 30° → sudden drop
Subscapularis - weak int rotation
Infraspinatous - pain on resisted ext rotation

Rx - open/ arthroscopic repair

57

Supracondylar # of humerus presentation

 Common in children after FOOSH
 Elbow very swollen and held semi-flexed.
 Sharp edge of proximal humerus may injure brachial
artery which lies anterior to it.

58

Supracondylar # of humerus classification

Extension (Commonest type)
 Distal fragment displaces posteriorly

Gartland further classified extension type:
 Type 1: non-displaced
 Type 2: angulated - intact posterior cortex
 Type 3: displaced - no cortical contact

Flexion
 Distal fragment displaces anteriorly

59

Supracondylar # of humerus management

Ensure there is no NV damage
 If radial pulse absent or damage to brachial
artery suspected, take urgently to theatre for
reduction ± on-table angiogram.
 Median nerve is also vulnerable

 Restore the anatomy
- No displacement → flex the arm as fully as
possible and apply a collar and cuff for 3wks –
triceps acts as sling to stabilise fragments.
- Displacement → MUA + fixation with K-wires +
collar and cuff with arm flexed for 3wks.

60

Specific complications of Supracondylar # of humerus

NV injury
 Brachial A;  Radial and median N (esp. ant interosseous branch of med- Supplies deep forearm flexors (FPL, lateral half
of FDP and PQ))

Compartment syndrome
 Monitor closely first 24h
 Pain on passive extension of the fingers early sign.
 Mx: try extension of the elbow, surgical Rx may be
needed.
 Volkmann’s ischaemic contracture can result → fibrosis of flexors → claw hand.

Gunstock Deformity
 Valgus, varus and rotational deformities in the coronal plane do not remodel and → cubitus varus

61

Management of femoral and tibial fractures

 Resus and Mx life-threatening injuries first.
- X-Match
 Tibial #: 2 units
 Femoral #: 4 units

- Assess NV status: esp. distal pulses
 If open
- Abx and ATT then Take to theatre urgently for debridement, washout and stabilisation

Fixation methods
 Intramedullary nail
 Ex-fix
 Plates and screws
 MUA c¯ fixed traction for 3-4mo

62

Specific complications of femoral and tibial fractures

 Hypovolaemic shock
 Neurovascular
- SFA: swelling and check pulses
- Sciatic nerve
 Compartment syndrome
 Respiratory complications
- Fat embolism
- ARDS
- Pneumonia

63

Ankle fracture rules and classification

Ottowa Ankle Rules
 X-ray ankle if pain in malleolar zone + in any of:
 Tenderness along distal 6cm of posterior tib / fib
including posterior tip of the malleoli.
 Inability to bear weight both immediately and in
ED

Weber Classification
 Relation of fibula # to joint line
 A: below joint line
 B: at joint line
 C: above joint line

64

Mx of ankle fracture

Weber A
 Boot or below-knee POP 6 wk

Non-displaced Weber B/C
 Below-knee POP 6-8 wk

Displaced Weber B/C
 Closed reduction and POP if anatomical
reduction achieved
 ORIF if closed reduction fails (and crutch 6-12 wk)

65

Achilles rupture signs on examination

Simmonds triad
- abnormal angle of declination
- feel for gap
- calf squeeze

66

Common ankle ligament strain

Typically twisting inversion injury - Strains anterior talofibular part of lateral collateral ligament

67

What is trochanteric bursitis

Pain and tenderness in lateral thigh due to repeated movements of IT band

68

what is meralgia paraesthesiae

 Entrapment of lat. cutaneous nerve of thigh between ASIS and inguinal ligament
 Pain ± paraesthesia on the antero lateral thigh
 No motor deficit
 ↑ risk c¯ obesity: compression by belts, underwear
 Relieved by sitting down
 Can occasionally be damaged in lap hernia repair

69

Unhappy triad for knee injuries

 ACL
 MCL
 Medial Meniscus

70

What is the likely diagnosis if there is swelling after a knee injury

 Immediate = haemarthrosis = # or torn cruciates
 Overnight = effusion = meniscus or other lgt

71

What is the likely diagnosis if there is pain/tenderness after a knee injury

 Joint line = meniscal
 Med/lateral margins = collateral lgts.

72

What is the likely diagnosis if there is locking after a knee injury

meniscal tear → mechanical obstruction

73

Causes of knee haemarthrosis (rapid joint swelling)

1°: spontaneous bleeding
 Coagulopathy: warfarin, haemophilia
2°: trauma
 ACL injury: 80%
 Patella dislocation: 10%
 Meniscal injury: 10%
 Outer third where its vascularised
 Osteophyte #

74

Mx of an acutely injured knee

 Full examination of acutely swollen knee after injury is
difficult.
 Take x-ray to ensure no #s
- Fluid level indicates a lipohaemarthrosis and
indicates either a # or torn cruciate.
 If no # → RICE + later re-examination for pathology
 If meniscal or cruciate injury suspected → MRI

75

Mc of ruptured ACL

Conservative
 Rest
 Physio to strengthen quads and hamstrings
 Not enough stability for many sports

Surgical
 Gold-standard is autograft repair - Usually semitendinosus ± gracilis
 Tendon threaded through heads of tibia and femur and
held using screws.

76

Pathology of Osteochondritis

 Idiopathic condition in which bony centres of
children/adolescents become temporarily softened due
to osteonecrosis.
 Pressure → deformation
 Bone hardens in new, deformed position

77

features of osteochondritis on Xray

Initially: ↑ density / sclerosis
 Then: patchy appearance

78

Main types of traction apophysitis

Osgood-Shlatter’s
 Tibial tuberosity apophysitis + patellar tendonitis
 Children 10-14yrs, M>F=3:1
 Assoc. c¯ physical activity
 Symptoms: pain below knee, esp c¯ quads contraction
 X-ray: tuberosity enlargement ± fragmentation
 Rx: rest, consider POP

Sever’s Disease
 Calcaneal apophysitis
 8-13yrs
 Symptoms: pain behind heal + limping
 Rx: physio and temporary cushioned heel support

79

Pathology and mx of Osteochondritis Dissecans

 Piece of bone and overlying cartilage dissects off into joint space (AVN of subchondral bone)
 Commonly knee (med. fem. condyle), also elbow, hip and ankle.
 Young adult / adolescent
 Symptoms: pain, swelling, locking, ↓ ROM, crepitus
 X-ray: loose bodies, lucent crater
 Mx: arthroscopic removal of loose body

80

Causes of avascular necrosis

 # or dislocation
 SCD, thalassaemia
 SLE
 Gaucher’s
 Drugs: steroids, NSAIDs

81

Differentials for a limbing child

 Developmental dysplasia of the hip
 Transient synovitis
 Septic arthritis
 Perthes’
 Slipped Capital Femoral Epiphyses
 JIA / Still’s Disease

82

Predisposing factors for Developmental dysplasia of the hip

 FH
 Breach presentation
 Oligohydramnios

83

Presentation of Developmental dysplasia of the hip

Congenital hip joint deformity in which the femoral head is or can be completely / partially displaced.
 Screening
 Asymmetric skin folds
 Limp / abnormal gait

84

Ix, Mx and complications if Developmental dysplasia of the hip isnt treated

Ix - US
-+ve Barlow and Ortolani's
Mx: maintain abduction
 Pavlik harness (birth)
 Plaster hip spica (>2m)
 Open reduction: derotation varus osteotomy (>6m)

85

Presentation of transient hip synovisitis

 2-12yrs
 Sudden onset hip pain / limp
 Often following or with viral infection
 Not systemically unwell

86

Ix and Mx of transient hip synovitis

Ix
 PMN and ESR/CRP are normal
 -ve blood cultures
 May need joint aspiration and culture

Mx
 Rest and analgesia
 Settles over 2-3d

87

Pathology and presentation of Perthes Disease

 Osteochondritis of the femoral head 2O to AVN.
 4-10yrs  M>F=5:1

Presentation
 Insidious onset
 Hip pain initially, then painless
10-20% bilateral

88

Ix and Mx of Perthes disease

Ix
 X-rays normal initially
 ↑ density of femoral head
- Becomes fragmented and irregular
- Flattening and sclerosis
 Bone scan is useful

Mx
 Detected early and < half femoral head affected
- Bed rest and traction
 More severe
- Maintain hip in abduction c¯ plaster
- Femoral or pelvic osteotomy

89

Pathology and presentation of SUFE

 Postero-inferior displacement of femoral head epiphysis
 10-15yrs
 Two main groups
- Fat and sexually underdeveloped
- Tall and thin

Presentation
 Slip may be acute, chronic or acute-on-chronic
Acute
 Groin pain
 Shortened, externally rotated leg
 All movements painful and limited abduction
 20% bilateral
Confirm on X-Ray

90

Mx of SUFE

 Acute: reduce and pin epiphysis
 Chronic: in situ pinning
- Epiphyseal reduction risks AVN

91

Complications of SUFE

 Chondrolysis: breakdown of articular cartilage
 AVN
 OA
 Subtrochanteric # (pinned too low)

92

Complications of Perthes

-OA
- premature fusion of growth plates

93

Common organism of acute osteomyelitis

 Staph. aureus
 Strep
 E. coli
 Pseudomonas
 Salmonella (in SCD)

94

Risk factors for developing acute osteomyelitis

 Vascular disease
 Trauma
 SCD
 Immunosuppression (e.g. DM)
 Children
- Rich blood supply to growth plate

95

Presentation of acute oseomyelitis

 Pain, tenderness, erythema, warmth, ↓ROM
 Effusion in neighbouring joints
 Signs of systemic infection

96

Ix for acute osteomyelitis

 ↑ESR/CRP, ↑WCC
 +ve blood cultures in 60%

X-ray:
 Changes take 10-14d
 Haziness + ↓ bone density
 Sub-periosteal reaction
 Sequestrum and involucrum
 MRI is sensitive and specific

97

Mx of acute osteomyelitis

 IV Abx: Flucloxacylin until MCS known
 Drain abscess and remove sequestra
 Analgesia
 Elevate Limb

98

Complication of acute osteomyelitis

- Brodies abscess - infection can partly be overcome by natural defences - confined in abscess lined by cortical bone

- Chronic osteomyelitis (adults) - pus spreads under periosteum and dies. Perisoteum forms new bone around abscess. Need to eradicate dead bone and give abx

99

Commonest benign bone tumours

- osteochondroma (often knee) - cartilage capped by bony outgrowth
- chondroma
- osteoid osteoma (lytic lesions and central nidus with sclerotic limb)
- osteoblastoma
- osteoclastoma (soap bubble appearance

100

Types of malignant bone tumours

- Chrondrosarcoma (lytic lesion, fluffy calcification)
- Osteosarcoma (commonest) - periosteal elevation (sunburst appearance)
- Ewings (lytic tumour, onion-skin)

101

Commonest cancers to metastasise to bone

- thyroid
- breast
- lung
- kidney
- prostate

102

Causes of pathological #

- oestomyelitis
- osteoporosis
- osteogenesis imperfecta
- Paget's
- Malignancy

103

Features of Erb's palsy and Klumpke's paralysis

High (C5/6): Erb’s Palsy
 Abductors and external rotators paralysed
 Waiter’s tip position
 Loss of sensation in C5/6 dermatomes

Low (C8/T1): Klumpke’s
 Paralysis of small hand muscles
 Claw hand
 Loss of sensation in C8/T1 dermatomes

104

Presentation of radial nerve injuries

Low Lesions: posterior interosseous nerve
 Site: # around elbow or forearm
 E.g. # head of radius
 Loss of extension of CMC joints (finger drop)
 No sensory loss

High Lesions
 Site: # shaft of humerus where N. is in radial groove.
 Wrist drop
 Loss of sensation to dorsum of thumb root (snuff box)
 Triceps functions normally

Very High Lesions
 Site: axilla – e.g. crutches or Sat night palsy
 Paralysis of triceps and wrist drop

105

Presentation of ulnar nerve injuries

 Elbow: cubital tunnel
 Wrist: in Guyon’s Canal
Effects

 Intrinsic hand muscle paralysis → claw hand
 Ulnar paradox: lesion at elbow has less clawing as
FDP is paralysed, decreasing flexion of 4th/5th digits.
 Weakness of finger ad/abduction (interossei)
 Sensory loss over little finger

Tests
 Can’t cross fingers for luck
 flexion of thumb IPJ when trying to hold paper held between thumb & finger.
 Indicates weak adductor policis.

106

Presentation of medial nerve injuries

Injury Above the Antecubital Fossa
 Can’t flex index finger IPJs (e.g. on clasping hands)
 Can’t flex terminal thumb phalanx (FPL)
 Loss of sensation in median distribution

Injury at the Wrist
 Typically affects abductor pollicis brevis

CTS

107

Anatomy of carpal tunnel

 Carpal tunnel formed by flexor retinaculum and carpal
bones.
 Contains
 4 tendons of FDS
 4 tendons of FDP
 1 tendon of FPL
 Median N.

Median N. supplies LLOAF (aBductor pollicis brevis)
 Palmer cutaneous branch travels superficial to flexor
retinaculum → spares sensation over thenar area.

108

Features of Dupuytren’s Contracture

Progressive, painless fibrotic thickening of palmar fascia.

 M>F
 Middle age / elderly
 Skin puckering and tethering
 Fixed flexion contracture of ring and little fingers
 Often bilateral and symmetrical
 MCP and IP joint flexion

109

Associations of Dupuytren’s Contracture

Associations: BAD FIBERS
 Bent penis: Peyronies (3%)
 AIDS
 DM
 FH: AD
 Idiopathic: commonest
 Booze: ALD
 Epilepsy and epilepsy meds (phenytoin)
 Reidel’s thyroiditis and other fibromatoses
 Ledderhose disease
 Smoking

110

Mx and differentials of Dupuytren's contractures

Mx
 Conservative: e.g. physio / exercises
 Fasciectomy - when hand can’t be placed flat on table.
- Z-shaped scars: prevent contracture
- Can damage ulnar nerve
- Usually recurs

Differential
 Skin contracture: old laceration or burn
 Tendon fibrosis, trigger finger
 Ulnar N. palsy

111

Pathology of trigger finger

 Tendon nodule which catches on proximal side of
tendon sheath → triggering on forced extension → Fixed flexion deformity
 Usually ring and middle fingers
 Assoc. c¯ RA

Rx: steroid injection (high recurrence) or surgery

112

Pathology of DeQuervain's tenosynovitis

- Sheath containing EPB and APL inflammed
- pain on radial side of wrist and tenderness over radial styloid process
- abd thumb agaisnt resistance painful

Mx - analgesia, steroif injection, splint, surgery

113

Pathology of flexor tenosynovitis

infection of tendon sheath (s.aurues)
kanavel's sings
- tenderness along tendon sheath
- finger held in flexion
- fusiform swelling
- pain with passive extension

Mx - incisional drainage/ Abx

114

Pathology of chondromalacia patellae

Softening of cartilage of patella
- young women
- patellar aching after prolonged sitting/climbing stairs
- pain on patellofemoral compression. Clarke's test

No abnormality on X-Ray
Rx - vastus medialis strengthening

115

Pathology of Baker's cyst

 Popliteal swelling arising between the medial head of
gastrocnemius and semimembranosus muscle
 Herniation from joint synovium
 Usually 2O to OA

Rupture: acute calf pain and swelling
 DVT differential

116

Common organisms causing infection after bite

- Human - s.aureus/ streptococcus
- dog/cat - pasteurella multocida

117

Mx of bites

- remove any foreign bodies
- encourage to bleed
- irrigate
- swab
- splint
- elevate
- abx- 7d co-amox
- tetanus prophylaxis
- close is <6h and no signs of infection

118

Complications of bites

- abscess
- cellulitis
- joint infection
- septicaemia
- tenosynovitis