Leriche Syndrome
- What is it?
- What clinical features are seen?
- atheromatous disease of the iliac vessels
- impotence
- buttock claudication
What are the red flags for back pain and therefore must be screened for in OSCE?
- age <20 or >50
- night pain
- history of malignancy
- general: weight loss, fever, night sweats
Spinal Stenosis
- What clinical features are seen?
- What investigation is done?
- How is it generally differentiated from claudication?
- How is spinal stenosis caused by degenerative changes managed?
- gradual onset symptoms of:
- back pain
- unilateral or bilateral neuro symptoms in leg: weakness, pain, numbness
- symptoms relieved by sitting, crouching or bending down
NOTE examination can often be normal
- MRI
- in a patient with spinal stenosis symptoms improve when walking uphill
- laminectomy
What clinical features can be seen in ankylosing spondylitis?
- typically young man presenting with lower back pain and stiffness
- inflammatory - therefore worst in morning and improves throughout the day
- peripheral arthritis (seen in 20%)
- a) What is the first line analgesia for back pain?
b) What should be prescribed with this?
- a) NSAIDs
b) PPI if patient >45 years old
Prolapsed Disc
- What clinical features are seen with compression of the following nerve roots
a) L3
b) L4
c) L5
d) S1
- How is a prolapsed disc managed?
NOTE: all L2-3/4 function = femoral nerve damaged
all L4/5-S3 function = sciatic nerve damaged
- a)
sensation: sensory loss over anterior thigh
strength: weak quads
reflex: reduced knee reflex
positive femoral stretch test
b)
sensation: sensory loss over anterior knee
strength: weak quads
reflex: reduced knee reflex
postive femoral stretch test
c)
sensation: sensory loss over dorm of foot
strength: weakness of dorsiflexion of foot and big toe
reflex: reflexes in tact
positive sciatic nerve stretch test
d)
sensation: sensory loss of lateral foot and posterolateral leg
strength: weakness in plantar flexion of foot
reflex: reduced ankle reflex
positive sciatic nerve stretch test
NOTE:
femoral stretch test: patient prone, knee flexed, hyperextending hip causes pain
sciatic nerve stretch test: patient prone, knee straight, hyperextending hip causes pain, at point where pain starts dorsiflexion of foot causes further pain
- analgesia + physiotherapy
if after 4-6 weeks symptoms persist send for MRI
Thigh anatomy
State the following details for nerve named
a) motor function
b) sensory function
c) common mechanism of injury
- femoral nerve (L2-4)
- obturator nerve (L2-4)
- lateral cutaneous nerve of the thigh (L2-3)
- superior gluteal nerve (L4-S1)
- inferior gluteal nerve (L5-S2) (clinical features for c)
- a) knee extension, thigh flexion
b) anterior and medial aspect of thigh and lower leg
c)
- hip and pelvic fractures
- stab / gunshot wounds - a) thigh adduction
b) medial aspect of thigh
c) anterior hip dislocation - a) none
b) lateral and posterior aspect of thigh
c) compression of nerve near ASIS - known as neuralgia parasthetica - a) hip abduction
b) none
c)
- hip fracture
- posterior hip dislocation
- hip surgery
- misplaced IM injection
NOTE: positive trendelenburg test
- a) hip extension + lateral rotation
b) none
c)
clinical features: difficulty rising from a chair, jumping and climbing stairs
Meralgia Parasthetica
- What is it?
- What clinical features can be seen?
- compression of lateral femoral cutaneous nerve
- numbness on posterior and lateral aspect of thigh
- burning, tingling, coldness or shooting pain
- symptoms improved by sitting
O/E: symptoms reproduced by palpation just below ASIS (known as pelvic compression test)
Metatarsal fracture
- a) What is the most common metatarsal to be fractured?
b) What is the most common presentation of this? - a) What is the most common site of stress fracture?
b) Who can this be seen in?
- a) proximal 5th metatarsal
b) avulsion fracture (pseudo-Jones fracture) often associated with inversion of ankle and therefore can present with lateral ankle sprain symptoms as well - a) 2nd metatarsal shaft
b) runners
Morton’s Neuroma
- Where is it commonly seen?
- What clinical features are seen?
- How is it managed?
- 3rd interphalangeal space in females (4x more common)
- pain in forefoot which can be shooting or burning in nature
- patient feels like they have a pebble in their shoe
O/E: Mulders click test: hold neuroma in thumb and fore finger, squeeze metatarsal heads causes a click
- avoid high heels
- metatarsal pads
if still pain after 3 months of these refer
What is Froment’s sign
assesses for ulnar nerve palsy
hold paper between forefinger and thumb - if positive patient cannot hold it when you try to pull away and will see thumb flexing to try compensate
OA of the hand
What clinical features are seen?
Who - females (3x more likely), people with trauma, hyper mobility or obesity
What - pain worse on movement, squaring of the thumbs
Where - Herbeden’s nodes at DIPJs, Bouchard’s nodes at PIPJs
When - on movement [as above] stiffness in the morning (lasts minutes and not hours like inflammatory)
Why - XR - osteophytes + loss of joint space
What is the benefit of intra-articular injections in OA?
short term symptom relief (6 weeks - 3 months)
What are the complications of total hip replacement
- perioperative: surgical site infection, intraopertive fracture, nerve injury, VTE
- posterior hip dislocation
- aseptic loosening (most common reason for revision)
- leg length discrepancy
mnemonic: complications are not your PPAL, perioperative sin
Joint Replacement
- What is the outlook for joint replacement in obesity?
- Instead of replacement, what can be done in younger patients?
- What advice and information should patients receive after surgery?
- What thromboprophylaxis is given?
- slight increase in short term complications, same time of joint survival
- hip resurfacing - preserves femoral head for replacement in later life
think Andy Murray
- usually require crutches for 6 weeks
- avoid low chairs
- do not cross legs or flex hip >90 degrees
- sleep on back for 6 weeks
- 4 weeks LMWH
What is seen with compression of the following:
- common fibular nerve (L4-S1)
- tibial nerve (L4-S3)
- foot drop
- loss of sensation over lateral leg below thigh and dorsum of foot
- loss of plantar flexion - unable to stand on tip toes
- loss of foot inversion and flexion of big toes
- loss of sensation over sole of foot
