Orthopaedics Flashcards
(239 cards)
1
Q
How long do joint replacements typically last?
A
10-15 years
2
Q
What are some of the different types of joint replacement?
A
- Total-> both articular surfaces
- Hemiarthroplasty
- Partial joint resurfacing-> only part of surface
3
Q
What are some of the indications for joint replacement?
A
- Severe OA
- Fractures
- Sepsis
- Osteonecrosis
- Tumours
- RA
4
Q
How is a total hip replacement performed?
A
- Head of femur removed + metal/ceramic replacement in with cement or pushed in
- Acetabulum hollowed + replaced by metal with cement or screw
- Spacer between new joint
5
Q
How is a total knee replacement performed?
A
- Vertical anterior incision
- Patella rotated out of way
- Articular surfaces, femur + tibia removed
- New metal surface in with cement or by pushing
- Spacer between
6
Q
How is a total shoulder replacement performed?
A
- Anterior incision along deltoid + dislocated
- Head of humerus replaced-> metal ball, stem or screws
- Glenoid replaced
- May do reverse-> sphere where glenoid + spacer with cup for humerus
7
Q
What should be done before total joint replacements?
A
- Bloods-> include G+S and crossmatch
- Scans
- VTE prophylaxis
- Fasting
8
Q
What may be done/given during total joint replacements?
A
- GA or spinal
- Prophylactic antibiotics
- May give tranexamic acid-> minimise blood loss
9
Q
What may be done after total joint replacements (post op care)?
A
- Analgesia
- Post op imaging + bloods (eg anaemia)
- VTE prophylaxis
10
Q
What usually causes joint replacement infection?
A
- Staph aureus
- More common in revision surgery
11
Q
What are the risk factors for developing joint replacement infection?
A
- Prolonged operation
- Obesity
- Diabetes
12
Q
What are the symptoms of joint replacement infection?
A
Fever, pain, swelling, erythema, warm
13
Q
How is joint replacement infection diagnosed?
A
- Clinically
- X ray
- Bloods
- Cultures-> blood +/- synovial
14
Q
How is joint replacement infection managed?
A
- Repeat surgery-> irrigation, debridement, replacement
- Antibiotics
15
Q
What is a compound fracture?
A
Skin broken + fracture exposed to air
16
Q
What is a stable fracture?
A
Bone sections are in alignment in the fracture
17
Q
What is a pathological fracture?
A
Fracture due to abnormality in the bone-> tumour, osteoporosis, Paget’s
18
Q
What are the different types of fracture?
A
- Transverse
- Oblique
- Spiral
- Segmental
- Comminuted-> multiple
- Compression-> vertebral spine
- Greenstick
- Buckle-> torus
- Salter-Harris-> growth plate
19
Q
What is a Colle’s fracture?
A
- transverse distal radius fracture
- causes ‘dinner fork deformity’ as distal radius displaces posteriorly
20
Q
What causes a scaphoid fracture?
A
Fall on outstretched hand
21
Q
What is a key sign of a scaphoid fracture>
A
Tender anatomical snuffbox
22
Q
Why can scaphoid fractures be difficult to heal?
A
- Retrograde blood supply ie from only 1 directed
- Fracture-> cut off supply
- Avascular necrosis + non-union
23
Q
What fractures can be obtained in the ankle?
A
- Lateral malleolus-> distal fibula
- Medial malleolus-> distal tibia
24
Q
What is the Weber classification system?
A
- For lateral malleolus fractures
- In relation to syndesmosis (fibrous joint) between tibia + fibula
- More likely to need surgery if disrupted-> affects stability + function
25
What are the different types of ankle fracture?
- Weber type A-> below ankle + leaves syndesmosis intact
- Weber type B-> at level of joint so syndesmosis intact or partially torn
- Weber type C-> above joint to syndesmosis interrupted
26
What happens with a pelvic ring fracture?
If fracture in one place will cause fracture elsewhere
27
What are the risks with a pelvic ring fracture?
Intra-abdominal bleeding from vascular injury or cancellous bone-> shock + death
28
What cancers commonly cause pathological fractures?
PoRTaBLe
- Prostate
- Renal
- Thyroid
- Breast
- Lung
29
How can fragility be assessed?
- History + exam
- FRAX score-> risk of fragility fracture over next 10 years
- DEXA scan + T score-> for bone mineral density
30
What are the side effects of bisphosphonates?
Reflux + oeseophageal erosions, atypical fractures, osteonecrosis of the jaw, external auditory canal problems
31
Why is it important to get 2 images when taking an X-ray for suspected fracture?
Because it's easy to miss things if just one is taken
32
How are fractures managed?
- Mechanical realignment
- Closed reduction-> manipulation
- Surgery
- Fix bone-> external cast, K wires, intramedullary nails or wires, screws, plates + screws
- May need trauma meeting + plan if complex
33
What are the immediate complications of fractures?
Damage to structures, haemorrhage, compartment syndrome, fat embolism, VTE
34
What are the long-term complications of fractures?
Delayed union, malunion, non-union, avascular necrosis, infection, instability, stiffness, contractures, arthritis, pain
35
When do fat embolisms usually occur?
24-72 hours after long bone fracture
36
What is fat embolism?
Globule released into circulation + gets lodged in BVs-> obstruction
37
How can fat embolism be prevented?
Early operation to fix fractures
38
How are fat embolisms managed?
- Supportive
| - Monitor for multi-organ failure
39
What is Gurd's criteria?
For diagnosis of fat embolism
- Major-> respiratory distress, petechial rash, cerebral involvement
- Minor-> jaundice, thrombocytopaenia, fever, tachycardia
40
What are the major risk factors for NOF#?
Older, osteoporosis, female
41
When should surgery be performed in NOF#?
Within 48 hours
42
What is the 30 day mortality for NOF#?
5-10%
43
What is the anatomy of the hip joint?
- Femur (head + neck)
- Greater trochanter (lateral)
- Lesser trochanter (medial)
- Intertrochanteric line
- Shaft
- Capsule-> fibrous + attaches to rim of acetabulum + IT line
44
What is the blood supply to the head of the femur?
- Medial + lateral circumflex femoral arteries
| - Join neck proximal to intertrochanteric line
45
When can avascular necrosis of the femoral head occur?
Intra-capsular NOF#-> damage + remove blood supply
46
What is an intracapsular NOF#?
Break in NOF within hip joint capsule-> proximal to intertrochanteric line
47
What is the Garden classification system?
For intracapsular NOF#
- Grade I-> incomplete fracture + non displaced
- II-> complete + non-displaced
- III-> partially displaced
- IV-> fully displaced
48
What is a non-displaced intracapsular NOF# and how should it be managed?
- May have intact blood supply
| - Internal fixation
49
What is a displaced intracapsular NOF# and how should it be managed?
- Blood supply disrupted
| - Head of femur needs removing + replacing
50
When is hemi-arthroplasty performed?
More risky patients-> co-morbidities or limited mobility
51
When is total hip replacement performed?
Patient is able to walk independently + is fit for surgery
52
What is extra-capsular NOF# and how is it managed?
- Distal to intertrochanteric line
- Blood supply intact
- Don't need head of femur replacement
53
What is intertrochanteric NOF# and how is it managed?
- Between lesser + greater trochanters
| - Dynamic hip screw-> through head + neck with plate and barrel to outside shaft
54
What is sub-trochanteric NOF# and how is it managed?
- Distal to lesser trochanter (within 5cm)
| - Intramedullary nail
55
How does NOF# usually present?
- Often 60+ and after fall
- Pain in groin/hip + can radiate to knee
- Unable to weight bear
- Shortened + abducted + externally rotated leg
56
How is NOF# investigated?
- AP + lateral X ray views
- Shenton's line on AP hip disrupted-> curving line formed by medial border of femoral neck
- CT/MRI when -ve X ray but suspect
57
When should patients mobilise after surgery to fix NOF#?
Immediately-> allow mobilisation + rehabilitation
58
What is compartment syndrome?
- Increased pressure in fascia compartment
- Cut off blood flow to compartment
- Muscles, nerves + BVs surrounded by fascia (fibrous connective tissue sheet)
59
What causes acute compartment syndrome?
Acute injury-> bleeding + tissue swelling
60
How does acute compartment syndrome present?
- Legs, forearm, feet, thigh, buttocks
- 5P's-> pain, paraesthesia, pale, high pressure, paralysis (late)
- Pain disproportional + worsened by passive muscle stretches
61
How can you tell the difference between acute compartment syndrome and limb ischaemia?
- Disproportionate pain
| - Not pulseless
62
How is acute compartment syndrome managed?
- Orthopaedic emergency
- Manometry to measure pressure
- Escalate, remove dressings, elevate leg to heart
- Emergency fasciotomy-> within 6 hours
- Debride any necrotic tissue-> few times over few days
63
What causes chronic compartment syndrome?
Exertion-> pressure rise-> blood flow restricted-> symptoms + resolved at rest
64
What are the symptoms of chronic compartment syndrome?
Pain, numb + paraesthesia on exertion
65
How is chronic compartment syndrome managed?
- Not emergency
- Needle manometry
- Fasciotomy
66
What bacteria usually causes osteomyelitis?
Staph aureus infection
67
What causes osteomyelitis?
- Inflammation of bone + marrow
- Haematogenous-> pathogen in blood seeds in bone
- Direct contamination-> fracture or operation
- Can be acute or chronic
68
What are the risk factors for osteomyelitis?
Open fracture, operations, diabetes, ulcers, PAD, IVDU, immunosuppression
69
How does osteomyelitis present?
Fever, pain, tenderness, erythema, swelling, systemic symptoms
70
How is osteomyelitis investigated?
- MRI best
- Bloods-> inflammatory
- Cultures of blood + bone
- X-ray-> periosteal reaction (change to surface), localised osteopenia, destruction
71
How is acute osteomyelitis managed?
- Surgical debridement
- 6 weeks of flucloxacillin-> may + rifampicin or fusidic acid in 1st 2 weeks
- If prosthetic-> may need revision surgery
72
How is chronic osteomyelitis managed?
- Surgical debridement
- 3+ months of antibiotics
- If prosthetic-> may need revision surgery
73
What is osteosarcoma?
A common bone cancer
74
What is chondrosarcoma?
Cartilage cancer
75
What is Ewing sarcoma?
Bone + soft tissue cancer that presents mostly in kids
76
What is rhabdomyosarcoma?
Skeletal muscle cancer
77
What is sarcoma?
Connective tissue cancer
78
What is leiomyosarcoma?
Smooth muscle cancer
79
What is liposarcoma?
Adipose/fat tissue cancer
80
What is synovial sarcoma?
Cancer of soft tissues around joints
81
What is angiosarcoma?
Cancer of blood or lymph vessels
82
What is Kaposi's sarcoma?
- Red/purple raised skin lesions
- Due to HHV 8
- Often in end stage HIV
83
How does sarcoma present?
- Growing, painful, large lump
| - Swelling and persistent pain
84
How is sarcoma investigated?
- X ray for bony lumps
- US for soft tissue lumps
- CT/MRI-> more detail + look for mets (esp lungs)
- Biopsy + histology
- Staging-> TNM or grade 1-4
85
How is sarcoma managed?
- MDT + specialist centres
- Surgery
- Radiotherapy
- Chemo
- Palliative
86
When should acute back pain improve?
Within 1-2 weeks
87
When should sciatica improve?
In 4-6 weeks
88
What are the causes of mechanical back pain?
- Muscle/ligament sprain
- Facet joint dysfunction
- SIJ dysfunction
- Herniated disc
- Spondylolisthesis-> anterior displacement of vertebrae
- Scoliosis
- Degenerative change
89
What are the potential causes of neck pain?
- Muscle/ligament strain
- Torticollis-> unilateral stiffness + pain due to spasms
- Whiplash
- Cervical spondylosis-> degenerative change
90
What are the red flag/serious causes of back pain?
- Spinal fracture
- Spinal infection
- Cauda equina
- Spinal stenosis
- Ankylosing spondylitis-> eg age <40 with morning stiffness
- Cancer
91
How does back pain in ankylosing spondylitis present?
Stiff in the morning or rest, age <40, gradual onset, night pain
92
How does back pain in cancer present?
Gradual, night pain, weight loss, local tenderness, age 50+ usually
93
How does cauda equina present?
- Bilateral symptoms, saddle anaesthesia, urinary retention, incontinence, reduced anal tone on PR, back pain
- LMN signs-> reduced tone + reflexes
94
How does back pain in infection present?
Local tenderness, IVDU, fever
95
How is back pain investigated?
- Clinical
- STaRT Back screening tool
- Xrays + CT-> fractures
- Emergency MRI in suspected cauda equina
- Ankylosing spondylitis-> inflammatory markers, XR, MRI
96
What sign is often present on an X-ray in ankylosing spondylitis?
Fused bamboo spine
97
What is the STaRT back pain screening tool?
- Assesses risk of acute turning to chronic back pain
- Guides intensity of initial interventions
- 9 questions-> function + psych response to pain
- Low risk-> <3 for total + psych questions
- Medium risk
- High risk-> >3 for both
98
How is acute back pain managed?
- Exclude emergencies
- Low risk-> self management, analgesia, mobilising
- Medium/high risk-> physio, group exercise, CBT
- Analgesia-> NSAIDs 1st line, codeine, benzos
- Safety-netting for red flags
- Radiofrequency denervation
99
What causes sciatica?
Herniated disc, spondylolisthesis, spinal stenosis
100
What is the anatomy of the sciatic nerve?
- Formed from spinal nerves L4-S3
- Exists posterior pelvis through greater sciatic foramen
- Goes through buttocks
- Goes to back of leg + at knee divides to tibial + common peroneal nerves
101
What does the sciatic nerve supply?
- Sensation-> lateral lower leg + foot
| - Motor-> posterior thigh, lower leg + foot
102
How does sciatica present?
- Unilateral pain-> bum to back of thigh + below knee/feet
- Pain-> electric, shooting, paraesthesia, numbness
- Motor weakness + reflexes affected
- Bilateral-> red flag for cauda equina
103
How is the sciatic stretch test performed?
- Lie on back with leg straight
- Lift leg from ankle with knee extended + hip flexed
- Dorsiflex ankle
- Positive test-> sciatica pain in buttocks/posterior thigh due to nerve root irritation + improves when knee flexed
104
How is sciatica managed?
- Acute lower back pain management-> NSAIDs, not opioids if chronic
- Neuropathic meds-> amitriptyline or duloxetine (NOT gabapentin or pregabalin)
- Specialist-> epidural steroids, local anaesthetic, radiofrequency denervation, spinal decompression
105
What is the pathophysiology of cauda equina syndrome?
- Nerve roots through spinal canal after SC ends (L2/3)
- Tapers at end to conus medullaris + roots exit and vertebral level (L3-S5)
- Compression-> herniated disc, spondylolisthesis, spinal stenosis, tumours, mets, abscess
106
What do the roots of the cauda equina supply?
- Sensation-> perineum, bladder, rectum
- Motor-> legs, anal + urethral sphincters
- Parasympathetic-> bladder + rectum
107
How is cauda equina syndrome managed?
- Admission
- Emergency MRI
- Lumbar decompression (neurosurgery)
108
What can cauda equina syndrome leave patients with?
- Bladder, bowel and sexual dysfunction
- Leg weakness
- Sensory impairment
109
What are the symptoms of metastatic spinal cord compression?
- Similar to cauda equina
- Back pain worse on coughing + steaining
- UMN signs
110
How is metastatic spinal cord compression managed?
- Rapid imaging
- High dose dexamethasone-> reduce swelling
- Analgesia
- Surgery
- Radiotherapy
- Chemo
111
What is spinal stenosis?
- Narrowing of spinal canal-> compression of cord + nerve roots
- Usually lumbar
112
What are the types of spinal stenosis?
- Central (canal)
- Lateral (nerve root canals)
- Foramina stenosis
113
What is radiculopathy?
Compression of nerve roots as exit cord + column
114
What causes spinal stenosis?
Congenital, degenerative change, herniated discs, thickened ligamentum flava or posterior longitudinal ligament, spinal fractures, spondylolisthesis, tumours
115
How does spinal stenosis present?
- Gradual onset
- Mild to severe
- When stand or walk
- Improved by rest or bending forward (flex spine + extend canal)
- Intermittent neurogenic claudication-> lower back pain + buttock/leg pain + leg weakness
116
How is spinal stenosis investigated?
- MRI
| - Exclude PAD with ABPI or CT angiogram
117
How is spinal stenosis managed?
- Exercise and weight loss
- Analgesia
- Physio
- Decompression
- Laminectomy-> remove all/part of lamina (bony) from vertebrae
118
What is trochanteric bursitis?
- Inflammation of bursa over greater trochanter causing pain in outer hip
- Inflammation-> thickened synovial membrane + fluid production
119
What is a bursa?
- Sac from synovial membrane filled with fluid
| - On bony prominences to reduce friction between bones + soft tissues when move
120
What causes trochanteric bursitis?
- Friction-> repetitive movement
- Trauma
- Inflammation-> RA
- Infection-> sepsis
121
How does trochanteric bursitis present?
- Typically middle aged + gradual onset
- Pain-> lateral thigh, radiate down, ache/burn
- Worse with activity or standing or sitting cross legged
- Difficulty sleeping or finding a comfy position
122
What examination findings might be present in trochanteric bursitis?
- Tender + not swollen
- +ve Trendelenburg
- Resisted abduction, internal and external rotation-> cause pain
123
How is trochanteric bursitis managed?
- Rest, ice, analgesia, physio, steroids
| - Infection-> may need antibiotics
124
What are the menisci in the knee?
- Between femur + tibia
- Medial + lateral
- Condyles (rounded bones) don't match so menisci help femur + tibia fit together
- Shock absorber + distribute weight
125
What does the patellofemoral joint consist of?
- Patella in trochlea (PF groove)
| - Quadriceps tendon-> attached to patella + when contracts causes knee extension
126
How does meniscal tear present?
- Younger-> sports or twisting
- Older-> minor twist
- Pain, swelling, stiffness, restricted ROM, locking, giving way, 'pop' sound, referred pain to hip/lower back
- Local tenderness on joint line
- Positive McMurray's + Apley grind test-> not used as causes pain
127
What are the Ottawa knee rules?
Differentiating between meniscal tear + bone fracture-> does pt need an X ray?
- 55+
- Patella tender only
- Fibular head tender
- Can't flex knee to 90 degrees
- Can't weight bear for 4 steps
128
How is meniscal tear investigated?
- MRI
| - Arthroscopy-> visualise + repair/remove damage
129
How is meniscal tear managed?
- RICE-> rest, ice, compression, elevate
- NSAIDs
- Physio
- Surgery-> arthroscopy + repair/resection
130
What is the main complication of meniscal tear?
Osteoarthritis
131
What knee ligament injury is most common?
ACL injury
132
Where is the Anterior Cruciate Ligament (ACL)?
- Attaches to anterior part of intercondylar area (between medial + lateral condyles)
- Originate from lateral aspect of intercondylar notch (groove between 2 femur condyles)
133
Where is the Posterior Cruciate Ligament (PCL)?
- Attaches to posterior part of intercondylar area (between medial + lateral condyles of tibia)
- Originate from medial aspect of intercondylar notch (groove between 2 femur condyles)
134
How does Anterior Cruciate Ligament (ACL) injury present?
- Twisting injury
- Pain + swelling
- Hear a 'pop'
- Tibia moves anteriorly-> buckle + weakness
- Positive anterior draw test + Lachman test
135
How is Anterior Cruciate Ligament (ACL) injury investigated?
- Exam-> anterior draw + Lachman tests
- Arthroscopy
- MRI scan
136
How is Anterior Cruciate Ligament (ACL) injury managed?
- Urgent referral
- RICE
- NSAIDs
- Crutches, knee brace
- Physio
- Arthroscopic surgery-> reconstructive, new ligament using graft of tendon
137
How is Anterior Cruciate Ligament (ACL) injury managed?
- Urgent referral
- RICE
- NSAIDs
- Crutches, knee brace
- Physio
- Arthroscopic surgery-> reconstructive, new ligament using graft of tendon
138
What is Osgood-Schlatter disease?
Inflammation to tibial tuberosity where patella ligament inserts
139
What is the pathophysiology of Osgood-Schlatter disease?
- Patella tendon into tibial tuberosity
- Minor avulsion fractures-> patellar ligament tears away tiny bone pieces
- Tibial tuberosity grows + visible lump below knee
- Tender then heals + becomes non-tender
140
How is Anterior Cruciate Ligament (ACL) injury managed?
- Urgent referral
- RICE
- NSAIDs
- Crutches, knee brace
- Physio
- Arthroscopic surgery-> reconstructive, new ligament using graft of tendon
141
What is Osgood-Schlatter disease?
Inflammation to tibial tuberosity where patella ligament inserts
142
What is the pathophysiology of Osgood-Schlatter disease?
- Patella tendon into tibial tuberosity
- Minor avulsion fractures-> patellar ligament tears away tiny bone pieces
- Tibial tuberosity grows + visible lump below knee
- Tender then heals + becomes non-tender
143
How does Osgood-Schlatter disease present?
- Gradual onset
- Hard + tender lump at tibial tuberosity
- Less tender as heals
- Anterior knee pain-> worse on activity, kneeling + extension
144
How is Osgood-Schlatter disease managed?
- Reduced activity
- Ice
- NSAIDs
- Stretching + physio when settled
- May need surgery if avulsion fractures
145
What is a Baker's cyst?
Cyst in the popliteal fossa due to degenerative changes in the knee
146
How does Baker's cyst present?
- Pain, fullness, pressure, lump, swelling, restricted ROM-> popliteal fossa
- Foucher's sign-> most apparent when knee extended + less when flex to 45 degrees
- Oedema-> when compress venous drainage
147
What are some differentials for Baker's cyst?
DVT, abscess, aneurysm, ganglion cyst, lipoma, varicose vein, tumour
148
What are some differentials for Baker's cyst?
DVT, abscess, aneurysm, ganglion cyst, lipoma, varicose vein, tumour
149
What are the complications of Baker's cyst?
- Rupture-> pain + swollen calf muscle + tissues
| - Compartment syndrome
150
How is Baker's cyst investigated?
- US-> rule out DVT
| - MRI-> underlyign pathology
151
What is the Achilles tendon?
- Attached gastrocnemius + soleus to calcaneus (heel) bone
| - Flex calf muscles + cause plantarflexion of ankle
152
What is Achilles tendinopathy?
- Damage, swelling, inflammation + reduced function
- Insertion-> within 2cm of insertion on calceneus
- Mid portion-> 2-6cm above insertion
153
What antibiotics can cause Achilles tendinopathy?
Fluoroquinolones-> ciprofloxacin
154
How does Achilles tendinopathy present?
- Gradual onset pain/ache in tendon/heel
- Increased with activity
- Stiff, tender, swollen
- Nodularity on palpation
155
How is Achilles tendinopathy managed?
- Clinical
- Exclude tendon rupture-> US + Simmond's calf squeeze test
- RICE
- Analgesia
- Physio
- Orthotics
- Extracorporeal shock-wave therapy
- Surgery-> remove nodules + adhesions
156
What are the risk factors for achilles tendon rupture?
- Sudden onset injury
- Sports
- Existing tendinopathy
- FH
- Fluoroquinine antibiotics
- Systemic steroids
157
How does achilles tendon rupture present?
- Sudden onset pain + snap sound/sensation
- Feel like hit on back of head
- Exam-> dorsiflexed, palpable gap, weakness of plantar flexion, unable to stand on tiptoes
- Positive Simmond's calf squeeze test
158
What is Simmond's calf squeeze test?
- Prone/kneel with feet off end of ben
- Squeeze calf-> should plantar flex
- Ruptured achilles tendon-> won't (+ve)
159
How is achilles tendon rupture managed?
- US diagnosis
- Same day ortho referal
- Immediate RICE + VTE prophylaxis
- Non-surgical-> boot, full plantar flexion to neutral, for 6-12 weeks
- Surgery-> reattach then boot
160
What is plantar fasciitis?
Inflammation of plantar fascia-> thick connective tissue attaching to calcaneus + branches out to flexor tendons of toes
161
How does plantar fasciitis present?
- Gradual onset pain in plantar heel
| - Worse on-> pressure, walking, standing, palpation
162
How is plantar fasciitis managed?
- RICE
- Analgesia
- Physio
- Steroid injections
- ECST
- Surgery
163
What is frozen shoulder?
Adhesive capsulitis-> pain + stiffness
164
What causes frozen shoulder?
- Usually middle age + diabetic
- Primary-> spontaneous
- Secondary-> trauma, surgery, immobility
165
What is the pathophysiology of frozen shoulder?
- Inflammation + fibrosis of capsule (connective tissue)
| - Adhesions bind to capsule-> tighten + restrict movements
166
How does frozen shoulder present?
- 3 phases-> last 1-3 years before resolve but some persist
- Painful phase-> worse at night
- Stiff-> active + passive movement (especially external rotation), pain settles
- Thawing-> gradual improvement + return to normal
167
What are the differentials for frozen shoulder?
- Tendinopathy (eg supraspinatus)
- ACJ/glenohumeral arthritis
- Septic joint
- Inflammation
- Malignant
- Injury-> dislocation, fracture, rotator cuff tear
168
What is supraspinatus tendinopathy?
Impingement where passes between humeral head + acromion
169
What sign is present in supraspinatus tendinopathy?
Empty can test positive
170
What sign is present in ACJ arthritis?
- Scarf test positive
- Tender palpation
- Pain at extreme of abduction
171
How is frozen shoulder investigated?
- Clinical
- X rays look normal
- Other scans-> thickened joint capsule
172
How is frozen shoulder managed?
- Analgesia
- Physio
- Intra-articular steroids
- Hydrodilation
- Manipulation under anaesthetic
- Arthroscopy-> cut adhesions
173
What causes rotator cuff tears?
- Injury of tendons or muscles (partial/full tear)
- Acute injury
- Degenerative change
- Overhead activity
174
What are the 4 muscles of the rotator cuff?
- Supraspinatus
- Infraspinatus
- Teres minor
- Subscapularis
175
What does the supraspinatus do?
Abducts the arm
176
What does the infraspinatus do?
External rotation
177
What does the teres minor do?
External rotation
178
What does subscapularis do?
Internal rotation
179
How does rotator cuff tear present?
- Acute or gradual shoulder pain
- Uncomfortable at night
- Disrupted sleep
180
How is rotator cuff tear investigated?
US or MRI-> doesn't show on X-ray
181
How is rotator cuff tear managed?
- Conservative if degenerative or high risk for surgery
- Non-medical-> rest, adaptive activity, analgesia, physio
- Surgical-> arthroscopic rotator cuff repair (re-attach tendon)
182
What happens in shoulder dislocation?
Humeral head comes entirely out of glenoid cavity of scapula
183
What happens in shoulder subluxation?
- Partial dislocation
| - Naturally pops back in after
184
What type of shoulder dislocation is most common?
Anterior (90%)
185
How does anterior shoulder dislocation occur?
- Arm forced backwards whilst abducted + extended-> eg catch a heavy rock
- Ball forward on socket
186
When does posterior shoulder dislocation occur?
Electric shocks + seizures
187
What associated damage can occur in shoulder dislocation?
- Glenoid labrum tear
- Bankart lesions-> anterior labrum
- Hill-Sachs lesions-> compression fracture of humeral head
- Axillary nerve damage-> C5-6 roots-> regimental badge sensory loss
- Fractures-> humeral head, greater tuberosity, acromion, clavicle
- Rotator cuff tear
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How does shoulder dislocation present?
- Acute injury
- Dislocates then muscle spasms + tightens
- Hold arm at side of body
- Flat deltoid
- Bulge at front of shoulder-> humeral head
- May have fractures, vascular or nerve damage
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What is the apprehension test?
For anterior shoulder instability
- Abduct shoulder to 90 degrees + flex elbow at 90 degrees
- Slowly externally rotate
- Anxious + apprehensive as worried will dislocate
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How is shoulder dislocation investigated?
- Clinical
- X rays before + after treatment
- Arthroscopy
- MRI + contrast into joint-> check for lesions + plan surgery
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How is shoulder dislocation managed acutely?
- Relocate ASAP-> muscle spasm can make more difficult + more likely to get neurovascular injury
- Analgesia
- Muscle relaxants
- Broad arm sling for support
- Closed reduction-> need X ray after
- Surgery
- Immobilisation
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How is shoulder dislocation managed long-term?
- Physio
- Shoulder stability surgery-> open or arthroscopic
- 3+ months recovery after surgery
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What causes olecranon bursitis?
- Friction from repeated movement
- Trauma
- Inflammation
- Septic
- Students/plumbers/drivers elbow-> leaning for long time
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How does olecranon bursitis present?
- Usually young/middle aged man
- Swollen, warm, tender, fluid elbow
- Infection signs-> fever, hot to touch etc
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What happens on aspiration of olecranon bursitis?
- Do when infection suspected
- Pus
- Straw coloured-> less likely infection
- Blood stained
- Milky-> gout or pseudogout
- Ideally beforr antibiotics-> microscopy + culture
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How is olecranon bursitis managed?
- RICE
- Analgesia
- Protect from pressure/trauma
- Aspirate fluid-> relieve pressure
- Steroid injections
- Antibiotics-> flucloxacillin or clarithromycin
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What is repetitive strain injury?
- Umbrella term for soft tissue irritation, microtrauma, strain
- Muscle, tendon or nerve
- Eg lateral epicondylitis (tennis elbow)
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What causes repetitive strain injury?
- Small repetitive activity eg computer mouse use
- Vibration
- Awkward positions + posture
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How does repetitive strain injury present?
- Pain + ache exacerbated by use
- Weakness, cramping, numbness
- Tender, swollen
- Exam-> ask to repeat movement
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How is repetitive strain injury diagnosed?
- Clinical
| - Rule out other diagnoses-> X rays, bloods etc
201
How is repetitive strain injury managed?
- RICE
- Adaptive activity
- Occupational health at work
- Analgesia
- Physio
- Steroid injections
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What is tennis elbow?
- repetitive strain injury
- inflammation where tendon inserts into lateral epicondyle
- due to wrist extension
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What are the symptoms of tennis elbow?
Pain, tenderness, radiation down forearm, weak grip strength
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What is Mill's test?
For lateral epicondylitis (tennis elbow)
- Extend elbow, supinate forearm + extend wrist/fingers
- Hold elbow with pressure on lateral epicondyle
- Positive if painful
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What is Cozen's test?
For lateral epicondylitis (tennis elbow)
- Elbow extended + forearm pronated
- Deviate wrist to radius with hand in fist
- Hold with pressure on lateral epicondyle + resistance to back of hand
- Positive if painful
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What is golfer's elbow?
- repetitive strain injury
- medial epicondylitis
- inflammation where tendon inserts into medial epicondyle
- due to wrist flexion
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What are the symptoms of golfer's elbow?
Pain, tenderness, radiation down forearm, weak grip strength
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How do you test for golfer's elbow?
- Extend elbow + supinate forearm
- Extend wrist + fingers
- Hold condyle with pressure
- Positive-> painful
209
How is epicondylitis (tennis/golfer's elbow) managed?
- Clinical diagnosis
- Can take years to resolve
- Rest
- Adaptive activity
- Analgesia
- Physio
- Steroid injections
- Platelet-rich plasma injections
- ECST
- Surgery
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What is De Quervain's Tenosynovitis?
- Swelling + inflammation in tendon sheaths of wrist
- Often abductor pollicis longus (APL) + extensor pollicis brevis (EPB)
- Repetitive strain injury
- Bilateral-> 'mummy thumb' ie repeated picking up of babies
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What is the pathophysiology of De Quervain's Tenosynovitis?
- Tendon sheath (synovial membrane + fluid) protects tendons
- Extensor retinaculum-> fibrous band across dorsal wrist + APL + EPB pass underneath
- Repeat movement-> inflammation + swelling of sheath
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How does De Quervain's Tenosynovitis present?
- Pain, ache, weakness, burning, numbness, tenderness
- At radial aspect of weist near thumb base
- Tests-> Finkelstein's + Eichhoff's
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How is De Quervain's Tenosynovitis managed?
- Rest
- Adaptive movement
- Splints
- Analgesia
- Physio
- Steroids
- Surgery
214
What is the pathophysiology of trigger finger?
- Thickened tendon or tightening of sheath-> stenosing tenosynovitis
- Prevents smooth movement when finger flexed/extended
- Nodule-> gets stuck when extended and causes locking/stuck in position then released with sudden painful pop
- Usually 1st annular pulley (A1) at MCP
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What are the risk factors for trigger finger?
- Age 40-50
- Women
- Diabetes
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How does trigger finger present?
- Pain + tender around MCPJ or palm side of hand
- Finger doesn't move smoothly, stuck when flexed, pop/click sound when released
- Worse in morning
- Improve during day
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How is trigger finger managed?
- rest
- analgesia
- splints
- steroid injections
- surgery to release
218
What is Dupuytren's contracture?
Fascia of the hand tightens + thickens causing contractures-> fixed flexion
219
What is the pathophysiology of Dupuytren's contracture?
- Palmar fascia of hand forms strong connective tissue triangle
- Thicker + nodules develop-> cords extend to fingers + pull into flexion
- Inflammatory response to microtrauma
220
What are the risk factors for developing Dupuytren's contracture?
Older age, FH (autosomal dominant), male, manual labour, diabetes, epilepsy, smoking, alcohol
221
How does Dupuytren's contracture present?
- Hard nodules on palm
- Skin thick + pitting
- Held in flexion
- Usually ring finger (index is rare)
- No pain but affects function
- Table-top test-> can't rest hand flat
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How is Dupuytren's contracture managed?
- Conservative
- Needle fasciotomy-> divide + loosen cord
- Limited fasciectomy-> remove abnormal fascia + cord
- Dermofasciectomy-> remove fascia, cord + skin and add skin graft
223
What nerve is affected in carpal tunnel syndrome?
Median nerve-> compressed from contents swelling or narrow tunnel
224
What is the anatomy of the carpal tunnel?
- Between flexor retinaculum (fibrous band around front of wrist) and carpal bones
- Median nerve + flexor tendons run through
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What does the median nerve supply?
- Palmar digital cutaneous branch-> sensory to palmar aspects + fingertips (thumb, index, middle, lateral 1/2 of ring)
- Palmar cutaenous branch-> sensory to palm
- Motor-> thenar muscles (APB, opponens, pollicis, flexor pollicis brevis)
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What are the risk factors/causes for carpal tunnel syndrome?
Idiopathic, repetitive strain, obesity, peri-menopause, RA, DM, acromegaly (bilateral), hypothyroidism
227
What can cause bilateral carpal tunnel syndrome?
Acromegaly
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How does carpal tunnel syndrome present?
- Gradual onset + intermittent numbness, paraesthesia, burning, pain
- Often worse at night
- Sensory-> palmar digital cutaneous branch-> sensory to palmar aspects + fingertips (thumb, index, middle, lateral 1/2 of ring)
- Motor-> thenar muscle weakness/wasting, grip strength problems, fine movement difficulty
- Phalen's + Tinel's tests
229
What questions are included in the carpal tunnel syndrome questionnaire?
Predicts likelihood of diagnosis-> need nerve conduction studies?
- Do symptoms wake at night?
- Trick movements (eg shaking hand) to improve it?
- Little finger affected-> negative scoring
230
What is the primary investigation for carpal tunnel syndrome ?
Nerve conduction studies-> small current made by electrode to median nerve + record how well signalled
231
How is carpal tunnel syndrome managed?
- Rest
- Alternate activity
- Splints-> 4+ weeks at night
- Steroid injections
- Surgery-> day case under local to cut flexor retinaculum + release pressure
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What are ganglion cysts?
- Sacs of synovial fluid from tendon sheath or joint
- Usually wrist or finger
- Synovial membrane herniates + form pouch-> fluid into cyst
233
How do ganglion cysts present?
- Rapid or gradual
- Usually not painful
- Lump-> 0.5-5cm, firm, non-tender, well circumscribed, transilluminates
234
How is ganglion cyst diagnosed?
- Clinical
- X rays-> normal
- US
235
How is ganglion cyst managed?
- 40-50% spontaneously resolve
- Needle aspiration-> high recurrence
- Surgical excision
236
What is meralgia paraesthetica?
- Compression of lateral femoral cutaneous nerve-> mononeuropathy
- Due to pressure, deformity or trauma
237
How does meralgia paraesthetica present?
- Dysesthesia (abnormal sensation) and anaesthesia in nerve distribution
- Upper-outer thigh
- Burning, numb, pins + needle, cold, local hair loss
- Worsened by-> walking, standing for a long time, hip extension
- Improve-> when sit down
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How is meralgia paraesthetica diagnosed?
- Clinical
| - May exclude other causes
239
How is meralgia paraesthetica managed?
- Mild to severe
- Conservative-> rest, looser clothes, weight loss, physio
- Medical-> NSAIDs, paracetamol, neuropathics, local injections
- Surgical-> decompression, transection, resection
