Ortho Med Unit 4

Question 1

What is an enthesopathy?

Give an example

Answer 1

Inflammation of a muscle origin
(enthesis = muscle origin)

Golfers elbow; flexor muscles
Tennis elbow; extensor muscles

Question 2

How are enthesopathies managed?

Answer 2

Usually managed by a rheumatologist

Good prognosis and usually recovers spontaneously

Anti-inflammatory drugs (speed up recovery process)
Local steroid injections
May occasionally require surgery to scrape the origin from the bone and decompress the area (should wait as long as poss as spontaneous recovery is very likely)

Question 3

What is neuropraxia? What are the causes?

Answer 3

Nerve entrapment, causes compression + stretching of nerves

Extrinsic: after an accident where consciousness is lost + victim presses on a nerve, or if in a plaster cast at risk of nerve pressure (especially perineal n at head of femur)
Intrinsic: (more common) due to a structural anatomical variation or inflammatory swelling

Question 4

Give examples of intrinsic neuropraxia

Answer 4

Median nerve at wrist,
Ulnar nerve at elbow,
Ulnar nerve at wrist,
Post tib nerve at ankle

Question 5

How is neuropraxia diagnosed and what is the management?

Answer 5

Numbness or tingling in an area supplied by a nerve (creates a specific pattern)
Nerve conduction studies

If left unmanaged, there will be atrophy of the nerves with permanent damage (so early diagnosis is important)

Remove any obvious causes (bandage/cast)
Surgical relief - cutting of skin and fascia

Question 6

What is tenosynovitis?

Answer 6

Inflammation of tendons + their synovial sheaths

Question 7

What are the causes of tenosynovitis?

Answer 7

Often associated with RA

Can arise spontaneously - associated with unusual levels of activity or overuse

Question 8

What is bursitis? Why do they occur naturally and pathologically?

Answer 8

Small sac of fibrous tissue filled with fluid (lined with synovial membrane)

Natural: ‘bearing’ to reduce friction of tendons and ligaments over bone
Pathological: form in response to pressure - usually from disorders of repetitive movement or strain (exposure to abnormal loads)

Question 9

Where are bursae most commonly found? How do they present?

Answer 9

Elbow, Knee, greater trochanter

Chronic discomfort over bursa (associated with the causative element - movement or pressure)
Swelling of the bursa
Infected bursae - tense swelling associated with general ill health + cellulitis

Question 10

How is bursitis managed?

Answer 10

If chronic with no symptoms - benign + don’t require treatment
If tender - excision (encourage to remove the underlying cause of the pressure - kneel on a mat etc)
If infection - incision + drainage

Question 11

How are flat feet managed in adults? (what are the causes?)

Answer 11

If symptoms free = benign + should ignore

If painful: very rare, may be due to infection or chronic inflammatory disease
Usually presents in middle age with acute painful and tender swelling of the tib post insertion (indicates acute degenerative rupture)
Medial heel lift: corrects deformity of the hind part of the foot + stabilises medial arch
Subtalar fusion: will help if pain is persistent, however other profound effects on function

Question 12

What is the difference between bunions + corns?

Answer 12

Bunions: bony prominence at base of big toe (1st metatarsophalangeal jt - hallux valgus)

Corns: small lumps of hard skin in response to pressure (can be removed in the short term but the underlying cause should be removed or will recur)

Question 13

What are hallux valgus and hallux rigidus?

Answer 13

Hallux valgus: deformity of the joint line, toes point away from the midline
Hallux rigidus: Osteoarthritis of the 1st metatarsophalangeal joint

Question 14

What are the causes of hallux rigidus? How is it managed?

Answer 14

In adolescents: due to an osteochondral fracture
Mx: metatarsal bar to provide a rocker at the front of the foot so the toe doesn’t need to bend during normal walking (often not cosmetically accepted so require surgery)

In adults:
Minor - surgical removal of osteocytes + osteotomy of proximal phalanx
Major - surgical fusion in a neutral position (doesn’t affect women’s heel height)

Question 15

How is hallux valgus managed?

Answer 15

Dependent upon age
Young - excision of any bony prominences over first metatarsal head, realignment of big toe to a more lateral position

Older - excision of the metatarsophalngeal joint (Kellers procedure) - affects function so should be saved for older less active patents

Question 16

How does hallux valgus occur with hallux rigidus? How is it managed?

Answer 16

Older patents where rigidus is secondary to valgus deformity
Mx: Pain relief, well fitting shoes
Kellers procedure if above fail

Question 17

What is claw foot/toes and how is it managed?

Answer 17

Wasting of the muscles on the toes where the bones and the nails appear more prominent
A sign of muscle weakness or denervation (may be associated with minor spinal abnormalities like spina bifida occulta)

Surgery should be approached with caution

Question 18

How do hammer feet present and what is the cause?

How is it managed?

Answer 18

Top of the toes look like a hammer, generally sore feet (metatarsalgia)

Unknown cause
Secondary to disruption of the metatarsophalangeal joints
Foot abnormalities cause prolapse of the metatarsal heads and joint disruption

Mx: good pair of soft comfortable shoes
fusion of interphalangeal joints in a straight position (don’t rub on shoes)
Very often unsatisfactory treatment

Question 19

What is mortons neuroma and how does it present?

How is it managed?

Answer 19

Cutaneous nerves to the toes become trapped or irritated between metatarsal heads
Unknown cause

Dull throbbing pain with sharp exaccerbations
Tingling of the toes
Sideways compression of the foot causes a palpable click which can reproduce symptoms

Mx: excision of the neuroma, may cause sensory disturbance
Warn patients that recurrence is common

Question 20

How do ingrown toenails present? How do they occur?

How is it managed?

Answer 20

Long term nagging infection with acute + painful flare ups

Unclear cause but associated with poor nail care - curved nail grows into the nail fold and digs in - may cause a secondary infection (can lead to blood borne infections)

Mx: careful nail care - straight cutting
If chronic infection, remove the nail - recurrence common
Definitive: remove the nail bed using phenol after nail removal (may require cosmetic surgery)

Question 21

What is the presentation of plantar fasciitis? What is the cause

Answer 21

Soreness on the instep
Tenderness at the origin of the planter fascia on the hind foot
Worse in the morning or after sitting for a few hours
Relieved slightly by walking (will then persist as a debilitating ache)
Can last months or years

Occurs spontaneously with sudden onset - cause unknown

Question 22

How is plantar fasciitis managed?

Answer 22

Self limiting (however can last for along time)
Some insoles/soft shoes can relieve symptoms
Local injection of steroids/long acting local anaesthetic can help if a marked tender point - although very painful to administer
If severe can surgically strip the fascia - outcomes are completely unpredictable

Question 23

What are the causes of neuropathic feet? How should it be managed?

Answer 23

Sensory neuropathy of the feet

Occur most commonly in areas where leprosy is seen
In Western world, due to diabetes

Should regularly inspect feet and nails and ensure they are well cared for
If there is an ulcer they heal poorly and secondary infection leading to amputation is risky so must be careful

Question 24

Where is pain from achilles tendonitis most common?

Answer 24

Around the os calcis - where the achilles tendon inserts

Question 25

What are the causes of achilles tendonitis in young athletes vs middle aged men?

Answer 25

Young athletes: a sign of overuse (tender or swollen area), usually recovers with rest
Injection of steroids should be avoided as penetration of the tendon may cause rupture

Middle aged men: due to degeneration within the tendon tissue,
Present with a phase of discomfort followed by rupture
Unknown cause - lower tendon achilles has a poor blood supply and may be a point of weakness in those who are very active into middle age

Question 26

How is achilles tendon rupture managed?

Answer 26

Ankle kept in equinus plaster for >8 weeks will heal naturally

Can be sutured closed however there is a high risk of complications

Re-rupture is common but risk decreases with time
Should continue to wear a felt raise in the heel of a shoe for as long as possible

Question 27

What structures are the common causes of shoulder discomfort? How is differential diagnosis made?

Answer 27

Subacromial bursa, 
Supraspinatus tendon, 
Acromioclavicualr joint, 
Biceps tendon, 
Rotator cuff

Very difficult to diagnose the cause without arthrography/arthroscopy
Differential diagnosis often not necessary as most settle with rest and time

Question 28

What are common causes of shoulder discomfort?

Answer 28

A recent incident - ie pull

Period of unusual activity - ie DIY

Question 29

How is shoulder discomfort managed?

Answer 29

Rest, gentle exercise + NSAIDs

Painful arc = supraspinatus tendon inflammation or subacromial bursitis - steroid injection into bursa or around the tendon (NOT into it)

Calcifucation within supraspinatus tendon - injection or surgery to remove calcification (repetitive injections cause further degeneration)

Rotator cuff tear - surgery to relieve the cause + repair rotator cuff

Question 30

What are the causes of frozen shoulder and how des it present?

Answer 30

Usually caused by one of the main causes of shoulder discomfort - leads to little/no glenohumeral movement
(subacromial bursa, supraspinatus tendon, acromioclavicular joint, biceps tendon, rotator cuff)

Question 31

How is frozen shoulder managed?

Answer 31

Will recover spontaneously in 1.5-2 years
Require significant of psychological support + physio
(may be helped by manipulation under anaesthetic)