Ortho rest Flashcards
(144 cards)
1
Q
what is subacromial impingement syndrome
A
irritation and inflammation of rotator cuff tendons (esp supraspitnatus) as they pass through the subacromal space
2
Q
what are causes of subacromial impingement syndrome
A
Intrinsic:
- muscle weakness (rotator cuff weakness > imbalanced forces > humerus rotates)
- hounder overuse (inflammation > reduced space)
- degenerative tendinopathy (acromium degeneration > cuff tear)
Extrinsic
- glenohumeral instabiklity
- anatomical variation
3
Q
what are signs and symptoms of subacromial impingement syndrome
A
painful arc (esp overhead activities)
decreased range of movement
weakness
hawkins +ve
4
Q
list differentials for a painful arc
A
- subacromial
- frozen shoulder
- rotator cuff tear
- OA
- septic arthritis
- gout/pseudogout
- RhA
5
Q
How do you investigate subacromial impingement
A
XR (true AP, caudal tilt, supraspinatus outlet)
CT arthrography /USS
MRI (RCM and tendons)
6
Q
How do you manage subacromial impingement
A
conservative: rest, physio
medcal: NSAID, steroid into subacromial bursa
Surgical: arthroscopic acromioplasty
7
Q
what is calcific tendonitis
A
calcification of tendons
unknown aetiology
8
Q
stages of calcific tendonitis
A
- pre-calcific (pain free)
- calcific (pain gradually increases)
- post calcific
9
Q
S/S calcific tendonitis
A
loss of ROM
Pain (catching / locking with crepitus)
supraspinatus atrophy
Hawkins positive
10
Q
Ix calcific tendonitis
A
XR (calcific deposiits)»_space; US
11
Q
Management of calcific tendonitis
A
non-operative: analgesia, phyiso, ECST, USS guided injection
Operative: surgical decompression
12
Q
what are the four muscles in the rotator cuff
A
supraspinatus
infraspinatus
subscapularis
teres minor
13
Q
what is the function of the rotator cuff muscles
A
to STABILISE the shoulder jount
14
Q
what are RF for rotator cuff tears
A
age, smoking, FH, hypercholesteraemia
15
Q
what are symotoms of rotator cuff tear
A
painful arc (if partial tear)
if complete tear:
- shouldertip pain, full range of passve movement
- inability to abduct arm
- lowering the arm beneath 90 degrees causes a SUDDEN DROP (as this is supraspinatus role, which is torn)
16
Q
management of rotator cuff tear
A
non-operatve: analgesia, physio, steroid injection
operative: shoulder arthroscopy, rotator cuff repair
17
Q
how does rotator cuff arthropathy occur
A
rotator cuff tear > loss of joint congruence > abnormal glenohumeral joint > degeneration
18
Q
What anatomical changes occur in rotator cuff arthropathy ?
A
rotator cuff insufficiency
glenohumeral joint dsestructon
subchondral osteoporosus
humeral head collapse
19
Q
What are S/S of rotator cuff arthropathy
A
Night pain with weakness / stiffness
Limited range of movement, crepitus, inability to abduct
20
Q
management of rotator cuff arthropathy
A
non-operative (analgesia, physio, subacromial steroid injection)
operative (arthroscopic debridement, hemiarthroèlasty ( reverse shoulder arthroplasty=
21
Q
what is the medical term for frozen shoulder
A
Adhesive capsulitis
22
Q
s/sx of frozen shoulder
A
- Develops over days and lasts 6 month – 2 years
- Generalised deep, constant pain of shoulder, may -> biceps
- Pain disturbs sleep
- Joint stiffness
- Reduction in function
- Reduced ROM (active + passive): external rotation most affected
- loss of arm swing
- atrophy of deltoid muscle
23
Q
who does frozen shoulder typically occur in
A
- middle aged female with diabetes
- previous injury/surgery to shoulder
24
Q
pathophysiology of frozen shoulder
A
inflammation –> adhesions –> glenohumeral joint capsule becmes contracted and adherent to humeral head
25
what are the three stages of FROZEN shoulder
1. Freezing (gradual onset of pain, lasts up to 6 months)
2. Frosen (stiff, decreased range of movement)
3. Thawing (gradual return of range of motion, may last 5 months to 2 years)
26
How do you manage frozen shoulder?
self-limiting (recovery over months-years)
o Encourage to keep active
o Posture advice: keep upright, minimise slouching
o Hot and cold packs over affected shoulder
physiotherapy
analgesia: paracetamol/NSAIDs
27
what is the difference between a dislocation and a sublaxation
dislocation = TOTAL non-articulation of the bone head in the joint
sublaxation: PARTIAL non-articulation of the bone head in the joint
28
how does shoulder dislocation present
shoulder contour lost (square shoulder)
bulging infraclavicular fossa
arm supported by hand + severe pain
29
How do you investigate shoulder dislocation
Assess NV status (axillary nerve in Chevron area) before manipulating
also do XR before and after manipulation
30
how do you manage shoulder dislocation
1. Reduction (with sedation - traction method or stimson mthod)
2. Rest in sling for 3/4 weeks
3. Physio
31
complication of shoulder dislocation
- Axillary nerve palsy (at time of presentation due to trauma OR iatrogenic due to manipulation OR delayed onset due to hematoma)
- rotator cuff tear
- recurrent dislocation (<20yo)
32
where are bicep tendon ruptures most likely to occur
most in the LONG TENDON of the biceps
33
what are risk factors for bicep tendon ruptures
heavy overhead activities
shoulder overuse
smoking, steroids
34
what are S/S of biceps tendon rupture
POP sound
followed by pain, bruising, swe,ling
Popeye deformity (muscle bulk results in bulge in middle of upper arm)
Weakness in shoulder and elbow
35
what are ix for biceps tendon ruprure
biceps squeeze test
MSK USS
Urgent MRI if suspecged distal tendon rupture
36
what is the difference in presentation between lateral (tennis) epicondylitis and medial (golfer) epicondylitisa?
lateral (tennis) epicondylitis - pain is around LATERAL epicondyle, worse on wrist EXTENSION
medial (golfer) epicondylitis - pain is around medial epicondyle, worse on wrist FLEXION
37
How do you investgate epicondylitis
USS
38
How do you investgate epicondylitis
conservative (rest, NSAID gel, physio)
39
how does olecranon bursitis present
swelling over posterior elbow
associated pain, warmth, erythema
typically affects middle aged pts
40
what are conditions associated to carpal tunnel syndrome
Conditions causing tissue swelling:
- Pregnancy
- Acromwegaly
- AMyloidosis
Conditions causing tendon / nerve inflammation:
- DM (glycosilates the tendon=
- hypothyroidism=
- RA (esp bilateral)
41
what is carpal tunnel
compression of the median nerve within the carpal tunnel
42
how does CTS present
parasthesia in 3.5 fingers (palmar aspect)
shaking of hand relieves parasthesia
occasionally pain
weakness of hand when grasping objects
43
what does the median nerve innervate in the hand
sensory to 3.5 fingers (thumb, index, middle, 0.5 ring finger) palmar aspect
motor to flexors to hand
44
How do you assess for carpal tunnel syndrome
CLINICAL EXAM
| EMG may be necessary
45
What does CTS clinical exam reveal
- weak thumb abduction
- wasting in theminar eminence
- Tinel's sign: pressing the carpal tunnel causes parasthesia
- Phalen's sign: flexion of wrist causes parasthesia
46
How do you manage CTS
conservative: rest the hand, wrist splints at night
surgical: corticosteroid injections > surgical decompression
47
what are EMG findings for CTS
AP prolongation in sensory and motor axons > allows to grade severity
48
what is de quervain's tenosynovitis
the sheath (proximal to thumb) contaning extensor pollicis brevis and abductor pollicis longus become infected
49
symptoms of de quervain's tenosynovitis
tenderness on radial side of wrist
| Adbuction of thumb against resistance is painful
50
How does de quervain's tenosynovitis present on examination
Finkestein test: pull thumb in ulnar deviation and longitudinal tractrion > pain over radial styloid and radial side of wrist
51
how do you manage de quervain's tenosynovitis
activity modification
analgesia
steroid injection, thumb splint, surgery
52
what is a duptyren's contracture
progressive, painkless, fibrotic thickening of palmar fascia
fibroblasts are replaced by myofibroblasts which cause contraction
53
how do you manage duptyren's contracture
splinting
fasciotomy
collagenase injection
fasciecotomy
54
conditions associated with duptyren's contracture
AIDS
DM
FH
Booze
Epilepsy and epilepsy meds e.g. phenytoin
55
how can you split causes of EFFUSION in the kneee
BLOOD
- immediate: ACL, intra-articular fracture,
- delayed: menisceal tear (delayed)
- can also be spontaneous: coagulopathy
SYNOVIAL FLUID:
- synovitis
- gout, pseudogout
PUS
- septic arthritis
56
what causes joint tenderness along the joint line?
mensceal tear
57
What investigation myst you always do if suspecting cruciate ligament rupture
XR (exclude fracture) > MRI (visualise cruciates)
58
clinical features ACL injury
- hx of twisting knee whilst weight bearing
- heard a pop > signficant pain .knee gave way > unable to continue walking
- HAEMARTHROSIS: massive swelling immedately, as ligament contains an artery (becomes clear within 4-6 hours)
59
how do you manage ACL injury
immediate: **RICE** (rest, ice, compression, elevation)
if isolated: conservative mx (**quads physio**):
if nstability/ paediatric / young and sporty: reconstruction (**autologous graft from hamstring or patellar tendon**)
60
what is PCL history
```
tibia forced backwards with knee flexed
often multiligamented (rarely occurs in isolation)
```
61
how do you manage PCL injury
isolated: conservative:
| instability/concurrent injury/paediatrc: reconstruction
62
MCL/LCL injury history
extreme valgus / varus injury
63
MCL/LCL management
usually conservative
64
what is the purpose of ACL
limit anterior translation of tiba relative to femur
| provide stability in internal rotation
65
which two tests are positive for ACL injury
Lachman
| Anterior draw
66
Explain Lachman test
knee flexed at 30 degrees
| pull knee forward to see how anterior tibia moves compared to femur
67
Explain Anterior Draw test
knee at 90 degrees
| Thumbs along joint line, index along hamstrings posteriorly . Apply force to demonstrate tibial excursion
68
what is the function of menisci
joint surface contact and weightbearing
69
when is maximum loadbearing on the knee achieved
with a flexed knee at 90 degrees
70
what is hhyistory of menisci injury aand presentation
```
twisting injury (medial meniscus most common)
pain worse when loading knee in flexion (going downstairs)
pain across joint line, locking or catching of the knee
overnight effusion
```
71
how do you mange menisceal tear
```
arthroscopic debridement (risk of OA)
arthroscopic repair
```
72
how does osgood shattler present
knee pain after exercise (gradual onset), relieved by rest
| localised tenderness and swelling over tibial tuberosity
73
osgood shattle management
analgesia, ice packs, protective knee pads, stretching
reassure
advise stopping / reducing all sporting acrivities
74
what is a baker's cyst
BAKERS CYST: popliteal extension of gastrocnemius-semimebranosus bursa (NOT a real cyst)
essentially there is knee effusion from intra-articular pathology > fluid escapes from the joint membrane into the popliteal fossa region (between head of gastrocnemius and semimembranosum)
75
how does a baker's cyst present
swelling in popliteal fossa
76
what are the three important joint parts holding the ankle togeter
syndesmosis
lateral collateral ligament
medial collateral ligament
77
signs of achilles tendinopathy (tendonitis)
o **Tenderness**
o **thickening** of the Achilles tendon
o **Oedema/Haematoma**
o Presence of **crepitus with motion**
78
risk factors for achilles tendon injury
* **Quinolone** use (ciprofloxacin)
* **Hypercholesterolaemia** -> predisposes to tendon xanthomata
* cold weather
* male
* foot misalignment
79
how does an achilles rupture injury occur and present
* sudden onset **severe pain in calf or ankle** during strenuous physical activities --> **inability to walk or continue sport**
* Feel as if they were struck violently in the back of the ankle
* audible **pop** in ankle
* Absence of pain does not exclude a rupture
80
How do you investigate achilles tendon rupture
**SIMMONDS TRIAD**:
put patient prone, feet over edge of bed:
1. **Calf squeeze** (thomas' test: injury means you cannot elicit plantarflexion)
2. **Angle of declination** (injury means greater dorsiflexion in injured foot)
3. **Feel for a gap** (injury = gap in tendon)
81
what is diagnostic of achilles tendon rupture
USS
82
management of Achilles Tendon Rupture
* Acute referral to an orthopaedic specialist
* Conservative:
o Apply **ice**
o **Rest** (non-weightbearing with crutches)
o **Immobilisation** with **splint** with ankle in some plantar flexion -> Equinus cast or Controlled Ankle Motion (CAM) boot
o **Physiotherapy**
* Medical: **Analgesics**
83
management of Acute Tendinopathy
* Conservative:
o **Avoid aggravating activities**
o Apply **ice** when symptomatic
o Support Achilles with **heel lift or elastic bandage/taping**
o Basic **physiotherapy** rehabilitation once healing has begun
o **Adequate warm-up and stretching** before activity
* Medical: **simple analgesia, Short course NSAIDs**
84
how do patients describe a morton's neuroms
like walking on a marble
shooting / stabbing / burning pain in ball of foot
numb toes
85
WHAT Is a morton's neuroma
NOT a true neuroma
| is is a compression neuropathy of the common digital planntar nerve (aka benign fibrotic thickening of the nerve)
86
what does morton's neuroma commonly occur in response to
in responsse to irritation, trauma or pressure
87
how do you manage morton's neuroma
```
orthotics
change shoes (no tight / pointy shoes) > steroid injections > surgical resection
```
88
where doe morton's neuroma usually occur
3rd - 4th tarsal bone
89
what is plantar fascitiis
inflammation of plantar aponeurosis
90
S/S plantar fascitis
pain / tendernes of heel and sole of foot
| worse after periods of inactivity, better with exercise
91
what is osteoporosis
reduced bone mineral density (T score -2.5; BMD more than 2.5 st devs lower than general population)
92
RF osteoporosis
Age
Female
Steroid use
Smoking, alcohol
low BMI
FH
premature menopause
caucasian, asian
sedentary
endocrine dosorders
CKD, MM
93
What scores can you do for osteoporosis
QFracture or. FRAX (assess 10 year risk of developing fracture)
94
what do you do wth Qfracture / FRAX results
if low risk: reassure
if medium risk: BMD test
high risk: offer bone protection
95
T score meaning
BMD compared to young reference pop
96
Z score meaning
BMD compared to age, gender and ethnic matched
97
How do you manage osteoporosis
Vitamin D
Calciun suppleents
PO biphosphonates (alendronate)
98
what do you give if biphosphonates are not tolerated (e.g. eGFR<30, severe GORD)
give SC biologics (denosumab)
99
what is most common cause of OA
wear and tear
100
what are S/S of OA
pain in large, weight bearing joints and hands
crepitus, joint locking, pain after exercise
better with rest
101
what signs do you see on the hands in OA
```
Herbenden's nodes (DIPJ)
Bouchard nodes (PIPJ)
```
102
investigtions for OA
XR (loss of joint space, osteophytes, subchondral cysts, subchondral sclerosis)
CT, MRI
103
conservative management of OA
CONSERVATIVE MX OF OA:
- WL
- Physio/occupational therapy
- TENS (transcutaneous electricaal stimulation)
104
medical management of OA
Medical mx of OA:
1. Paracetamol PO, topical NSAID
2. PO NSAID + PPO or weak opioid
3. intraarticular corticosteroid or
105
what is surgical management of OA
arthroscopy (trim the cartilage, remove ostephytes, lavage)
| arthroplasty (joint replamenent)
106
what are red flag sx for back pain
age <20/ >50
malignancy hx
night pain
hx trauma
FLAWS
107
general mx of open fractures
they need URGENT washout (max 6h) and debridement in theatre
Use EXTERNAL FIXATION until soft tissues have healedd
108
what is CUBITAL TUNNEL SYNDROME
compression of the ulnar nerve
109
how does cubital tunnel syndrome present
parasthesia in 4th and 5th digit (worse on elbow flexion)
| with weakness AND ulnar claw
110
what is RADIAL TUNNEL syndrome
compresson of posterior interosseus branch of radial Nerve
111
how does RADIAL TUNNEL SYNDROME present
similar to lateral epicondylitis
| 4-5cm distal to the lateral epicondyle
112
most common organism to cause osteomyelitis
S aureus
113
how do you treat osteomyelitis?
* IMMEDIATE high dose ABX (flucloxacillin for 6 weeks)
* limb immobilisation
* analgesia
* surgical debridement (if not responding to abx or abscess formation)
114
most common causative agents of septic arthritis
* **Staphylococcus aureus** (most common overall)
* **Neisseria gonorrhoeae**: (MOST COMMON in **sexually active, young adults**)
115
how do you treat septic arthritis
**Urgent JOINT aspiration** (send synovial fluid MCS)
THEN ABX: **flucloxacillin** or ceftriaxone if (elderly, frail, recurrent UTI or recent abdo surgery)
116
when do you need to do a partial fasciectomy in duptyrens contractures
when the hand cannot be placed flat on the table
117
what is trigger finger
a tendon nodule which catches on the tendon sheath >> triggers on forced extension, leads to FIXED FLEXION deformity (uually of 3rd and fouth digits)
118
commonest method of analgesia for pts wth NOF fracture
iliofascial nerve block
| this reduces opioid analgesia required
119
sx of lumbar spinal stenosis
back pain (standing > sitting, walking uphill > downhill=)
leaning forwards relieces pain
neuropathic pain
neurogenic claudication
preserved distal pulses
120
what shoud you change alendronate to in osteoporottic lady with UGI sx
change to risedribate, etudrinate first (before biologics)
121
first line OA analgesia
Oral Paracetamol + TOPICAL NSAID
| only after trying topical you can chhange to oral
122
what test can you do to identify sciatic nerve pain
straight leg raise
123
which malignant neoplasm has onion skin appearance
EWING SARCOMA
124
who does Ewing occur in
in young people
125
what is a ganglion
'cyst' arising from a joint or tendon sheath
126
where and in whom are ganglions commonly seen
back of the wrist
| 3 times more common in women
127
how do you treat ganglion
reassure > will self resoslve
128
what is osteogenesis imperfects
a collagen disorder aka brittle bone disease
| autosomal dominant
129
presenting sx of osteogenesis imperfecta
fractures following minor trauma
dental caries
blue tinge of sclera
deafness (otosclerosis)
130
how do you manage lateral malleolus fractures that are A, B or C
A: below syndesmosis > boot weight-bearingg as able for 6 weels
B: through syndesmosis > boot NON weightbearing 6w
C: above syndesmosis = ORIF + syndesmotic repair
131
how does ulnar nerve injury differ based on whether it is damaged at elbow or at wrist?
LESS SX if DAMAGED AT ELBOW
Damage at elbow: ulnar half of flexor digitorum profundus is also affected > less marked clawing due to reduced unopposed flexion at the IPJ. Sx will get worse as nerve regenerates, once FDB starts working
Damage at wrist: FDP not damaged >claw like appearancew
132
what bacterium causes osteomyelitiss in sickle cell disease
SALMONELLA
133
investigations for osteomyelitis
bloods: **↑ WCC, ↑ ESR / CRP**
X-ray
**MRI (gold standard)**
134
what is FIRST LINE MEDICATION for back pain
NSAID (+PPI if over 45)
| paracetamol was found to be ineffective
135
how do you manage sciatica with no red flags
1. anto-neuropathic pain agent (gabapentin / pregab/ amyltriptiline) + physio
2. wait 4-6 weeks > if no response, routine referral to spinal surgery
136
what location of scaphoid fracture must you ALWAYS operate (ORIF) on
the proximal scaphoid pole
137
what does a CHARCOT JOINT look like
HOT and SWOLLEN
NOT or MILDLY TENDER (due to peripheral neuropathy)
bone remodelling with osteolysis
138
first line ix to rule out osteoporotic vertebral fracture
X ray spine
139
which rheymatoid condition is associated to carpal tunnel and why
rheumatoid arthritis
| because it causes synovitis > joint swelling> bilat carpal tunnel
140
first line meds for back pain
NSAID
NOT paracetamol alone
141
which structure is most likely compromised in a scaphoid fracture
dorsal carpal arch of radial artery
142
what does a positive straight leg raise indicate
L5 root pain (herniated disc)
143
what is the key movement impaired in adhesive capsulitis
EXTERNAL ROTATION(both active and passovre)
144
symptoms of achilles tendinopathy (tendonitis)
* **Gradual onset of posterior heel pain**
* Pain or stiffness 2-6cm above posterior calcaneus
o **Burning pain**
o **Worse with activity**
o **Relieved by rest**
o **Morning pain and stiffness are common**
