Orthopaedics Unit 4 Flashcards Preview

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Flashcards in Orthopaedics Unit 4 Deck (75):

what is an enthesopathy

inflammation of a muscle origin

possible to have multiple inflammations at one point causing many aches and pains


what is golfer's elbow

inflammation of origin of the flexor muscles of the forearm at the medial epicondyle


what is tennis elbow

inflammation of origin of the extensor muscles of the forearm at the lateral epicondyle


what are features of enthesopathies

may arise spontaneously but mostly commonly associated with repetitive movements or overuse

most recover spontaneously with rest


Tx for an enthesopathy that becomes chronic or severe


local steroid injections [have to ensure steroid is injected into the enthesis with no leaked into subcut fat or skin, as this would exacerbate pain]


what is the surgery for enthesopathies in severe cases

scraping the origin of the muscle from the bone and permitting it to slide distally thus “decompressing” the area

[although patients should be encourage to wait as, spontaneous recovery is likely]


what is neuropraxia

continued pressure that has lead to atrophy of the nerve

takes a long time to recover and can be permanent


what are the 2 types of nerve entrapments

1) extrinsic
- i.e. LOC and patient presses on a nerve or patients in bed or plaster casts
- most common site is common peroneal nerve as it winds around the head of the fibula

2) intrinsic
- causes by structural local anatomical variations or inflammatory swelling


where are common sites of intrinsic nerve entrapments

median nerve at the wrist

ulnar nerve at the elbow

ulnar nerve at the wrist

posterior tibial nerve at the ankle


Sx for nerve entrapments

sensory loss

Ix = nerve conduction study


Mx for nerve entrapments

need to reduce pressure

surgical relief of pressure may be required
- cutting skin and fascia


what is tenosynovitis and what is it associated with

Inflammation of tendons and their associated synovial sheaths

associated with RA


when does tenosynovitis occur spontaneously

usually it is precipitated by unusual levels of activity, or overuse


what is a bursa

small sac of fibrous tissue lined with synovial membrane and filled with fluid


what is the function of a bursa

natural form of "bearing" aimed at improving muscle and joint function

reduces friction, usually where tendons and ligaments pass over bones

new ones can form in response to pressure


what causes inflammation of a bursa

repetitive movement or strain, or from being subject to abnormal loads


where are the most common sites of bursitis

greater trochanter at the hip


Sx of bursitis

chronic discomfort over the bursa, associated with causative elements such as movement or pressure

swelling of the bursa


what is housemaid's knee

swelling of pre-patellar bursa


what are Sx of an infection of the bursa

tense swelling associated with infection of the skin (cellulitis) and general ill health (malaise).


Tx for chronic bursae

need no Tx unless patient demands so

if tender, may be excised


Tx for infected bursae

incised and drained
- leads to spontaneous recovery through scarring and fibrosis


features of a painful spasmodic flat foot

associated with infection or chronic inflammatory disease

can occur acutely in middle age
- o/e painful and tender swelling over tibialis posterior insertion
- may indicate acute or impending degenerative rupture
- warrants early intervention


if a flat foot in an adult is associated with pain, what is a possible Tx

a medial heel lift
- will correct the deformity of the hind part of the foot and stabilise the medial arch.


if a flat foot in an adult is associated with PERSISTENT pain, what is a possible Tx

fusion of subtalar joint
- will disturb foot and ankle profoundly


what are bunions

fluid filled bursae found around bone prominences

commonly over the distal part of the 1st metatarsal and occasionally over the 5th


Tx of bunions

form as a natural response to pressure from underling abnormality
- Tx this

if bunion becomes infected
- drainage


what are corns and what is the Tx

painful corny skin formed in response to high pressure

- can be removed
- need to Tx underling cause and remove cause of high pressure


what is hallux valgus

turning away of the phalanges of the big toe from the mid-line


what is hallux rigidus

OA of the metatarsophalangeal joint


what is the relationship between hallux valgus and hallux rigidus

can occur separately or together


who gets hallux rigidus alone

can occur in adolescents and adults


who gets hallux valgus alone

may occur at any age.


in cases of hallux rigidus in adolescents, what is the cause thought to be

osteochondral fracture [not easy to prove]


Tx of hallux rigidus in adolescents

conservative Tx
- use of a metatarsal bar to provide a rocker at the front of the foot so that the toe need not bend in normal walking

surgical Tx
- same as adults


why does conservative Tx of hallux rigidus in adolescents normally fail

do not accept the cosmetic consequences on their shoes


Tx of hallux rigidus in adults

in minor cases
- surgical removal of the osteophytes with an osteotomy of the proximal phalanx
- surgical fusion in a neutral position

alternative option
- Inter- position arthroplasty with a silicone plastic (silastic) spacer [mixed results]


in cases of hallux valgus alone, what are the features of the condition

F > M

Many, but not all, sufferers have a short first metatarsal, often in varus.


Mx of hallux valgus

can depend on age

any age
- Realignment of the first metatarsal to a more lateral position and excision of any bony prominence (an exostosis) over the first metatarsal head

- Keller's procedure = Excision of the metatarsophalangeal joint
- avoid in the young
- unnecessary if joint is not painful


who gets Hallux valgus with also Hallux rigidus

older people where joint degeneration is usually secondary to the valgus deformity


Mx of Hallux valgus with also Hallux rigidus

in older patients
- may be satisfied by having their pain relieved by well fitting shoes

if this fails
- Keller’s arthroplasty = excision of metatarsophalangeal joint then put in an artificial joint


why should you try to avoid Keller’s arthroplasty

severely disrupts normal foot mechanics

should be reserved for the older, less active patient.


what is claw foot

wasted muscles of the foot make the bones and the toe nails appear more prominent

implies muscle weakness or deficiency


what is claw foot associated with

weak or denervated small muscles of the feet

minor spinal abnormalities such as spina bifida occulta


what is hammer toe

top of the toe looks like the end of a hammer

secondary to the disruption of the metatarsophalangeal joints


Sx of hammer toe

- generally sore forefoot


Tx of hammer toes

good pair of soft, comfortable shoes

- fusion of the interphalangeal joints in a straight position, so that they do not rub on the shoes


what is a neuroma

when the cutaneous nerves to the toes become trapped or irritated between the metatarsal heads there is a benign growth of nervous tissue

a.k.a Morton's neuroma when in the foot

secondary to repetitive trauma


Sx of neuroma

dull and throbbing pain
sharp exacerbations

accompanied by tingling of the toes

difficult to localise


what is the classic clinical sign of Morton's neuroma

sideways compression of the foot produces a palpable click, reproducing the symptoms.


Tx of Morton's neuroma

- s.e. = sensory disturbance to affect toes

recurrence is common


what causes ingrowing toenails

curved nail grows into the nail fold and digs in

trauma to skin can lead to secondary skin infection

can lead on to secondary blood bourne infections
[big issue it patient has prosthetic joints or heart values]


Tx of ingrowing toenails

remove the nail to clear up chronic infection

Wedge resection of the nail bed may retain the toe nail and remove the problem.

if keeps recurring
- remove the nail bed using phenol after removing the nail


what is plantar fascia

a tough later of fibrous tissue which runs from the os calcis to each toe base


Sx of plantar fascia

soreness of the instep, often worse first thing on rising, or after sitting for a few hours

minimally relieve by walking, but then persist as a debilitating ache

exacerbated by change of direction, or walking on rough ground

- tenderness at the origin of the plantar fascia medially


Tx for plantar fascia

- but may last few months to years

Sx relief
- Soft shoes and insoles, particularly modern sports trainers

if marked tender spot
- local injection of steroids and long acting local anaesthetic

- stripping of the fascia from the os calcis
- results unpredictable


what are neuropathic feet

feet without sensation (sensory neuropathy)

most common cause is diabetes [in western world] and leprosy [in developing world]


what are the issues that can develop because of sensory neuropathy

developing sores
- due to inability to perceive minor trauma

ulcers and secondary infection
- can lead to amputation


who gets achilles tendinitis

2 groups

1) Young athletes
- from over use
- area may be tender or swollen

2) Middle aged men
- phase of discomfort may precede rupture of the tendon achilles
- due to degeneration within the tendon tissue


Tx for achilles tendinitis in young athletes


if recurrent however,
- surgical decompression of the tissue surrounding the tendon


why is steroid injections avoided in achilles tendinitis

injection into the tendon will lead it to rupture


why is it thought that the achilles tendon tissue degenerates

has a poor blood supply


Tx for tendon rupture

1) ankle is kept in an equinus plaster for a minimum of eight weeks


2) tendon can be sutured either by a closed technique or by open suture
- has high risk complication

both methods have a significant risk of re-rupture, although this decreases with time


what does arcomioclavicular joint consist of

joint between the acromion process of the scapula and the clavicle


what are Sx of shoulder pathology

pain, particularly on movement

limited ROM

Sx associated with recent incident


what are the structures involved in shoulder discomfort

the subacromial bursa,
􏰀 the supraspinatus tendon,
􏰀 the acromioclavicular joint,
􏰀 the biceps tendon, and
􏰀 the rotator cuff as a whole.


Mx of shoulder discomfort

1st line
- rest, gentle exercise, anti-inflammatory drugs


what does tenderness under active movement of the shoulder suggest

painful arc
= supraspinatus tendon inflammation or a subacromial bursitis


Tx of supraspinatus tendon inflammation or a subacromial bursitis

steroid injection into the bursa or around the tendon


what happens in Calcific tendinitis of the shoulder

get calcified material within the SUPRASPINATUS tendon that can be seen on imaging

causes very severe pain

Tx = removal of material


what is frozen shoulder

condition in which there is little or no glenohumeral movement

cause often obscure

can be caused by specific trauma incident, such as a fit


Mx of frozen shoulder

people eventually recover
- 18months to 2 years


Tx of supraspinatous tendon inflammation

steroid injection into the bursa


who gets frozen shoulder and what is the Sx

[what is the principal sign]

characterised by progressive pain and stiffness of shoulder in patients aged 40-60 y/o over 18-24 months

[loss of external rotation]


what age group gets what pathology of shoulder discomfort

young - instability, dislocation

middle age - rotator cuff tear, frozen shoulder

elderly - glenohumeral OA