Upper Limb Ortho Flashcards
(188 cards)
1
Q
What are the functions of the upper limb?
A
Protection.
Actions & detexerity.
Mobility.
2
Q
What bones are involved in the upper limb?
A
Shoulder girdle (clavicle, scapula).
Humerus.
Radius.
Ulna.
Wrist.
Carpus.
Hand.
3
Q
What injury is the acromioclavicular joint susceptible to?
A
Dislocation.
4
Q
Which muscles move the shoulder girdle?
A
Superficial (extrinsic) muscles of the back.
5
Q
What are the origin, insertions and innervation of the trapezius muscle?
A
Origin: spinous processes (C1-T12).
Insertions: occiput, spine of scapula.
Innervation: accessory nerve (CN XI).
6
Q
What are the functions of the trapezius?
A
Elevates and depresses scapula.
Retracts scapula.
7
Q
How is trapezius function tested?
A
Shrug shoulders.
8
Q
What pathologies can occur at the glenero-humeral joint?
A
Osteoarthritis.
Rheumatoid arthritis.
Dislocation.
Adhesive capsulitis (frozen shoulder).
9
Q
What is the purpose of the labrum in the glenoero-humeral joint?
A
Increases capture of the humeral head -> increases stability of the joint.
10
Q
What injuries can cause a slap tear of the labrum in the glenero-humeral joint?
A
Throwing injuries e.g. throwing a ball in baseball.
11
Q
What injuries can cause a bankart tear of the labrum in the glenero-humeral joint?
A
Often occur from an anterior dislocation and can tear off a bit of glenoid bone during the process.
12
Q
What is the function of the rotator cuff muscles?
A
Stabilise the shoulder girdle.
Move the arm.
13
Q
Which muscles are your rotator cuff muscles?
A
Subscapularis.
Supraspinatous.
Infraspinatous.
Teres minor.
14
Q
What are the origin, insertion and innervation of the supraspinatus muscle?
A
Origin: supraspinatus fossa.
Insertion: greater tuberosity of humerus.
Innervation: suprascapular nerve (C5/C6).
15
Q
What is the function of the supraspinatus muscle?
A
Abducts arm.
16
Q
What are the origin, insertion and innervation of the infraspinatus muscle?
A
Origin: infraspinatus fossa.
Insertion: greater tuberosity of humerus.
Innervation: suprascapular nerve (C5/C6).
17
Q
What is the function of the infraspinatus muscle?
A
Externally rotates the arm.
18
Q
What are the origin, insertion and innervation of the teres minor muscle?
A
Origin: dorsal surface of lateral border of scapula.
Insertion: greater tuberosity of humerus.
Innervation: axillary nerve (C5/C6).
19
Q
What is the function of the teres minor muscle?
A
Externally rotates the arm.
20
Q
What are the origin, insertion and innervation of the subscapularis muscle?
A
Origin: anterior surface of scapula (subscapular fossa).
Insertion: lesser tuberosity of humerus/shoulder capsule.
Innervation: upper and lower subscapular nerve (C5/C6).
21
Q
What is the function of the subscapularis?
A
Internally rotates the arm.
22
Q
What pathologies can occur in the rotator muscles?
A
Tears.
Impingement.
23
Q
What are the origin, insertion and innervation of the deltoid muscle?
A
Origin: clavicle, acromion, spine of scapula.
Insertion: deltoid tuberosity on lateral aspect of humerus.
Innervation: axillary nerve (C5/C6).
24
Q
What is the function of the deltoid muscle?
A
Abducts the arm.
25
What are the origin, insertion and innervation of the biceps brachii muscle?
Origin: coracoid process (short head); labrum/glenoid (long head).
Insertion: tuberosity of radius.
Innervation: musculocutaneous nerve (C5/C6).
26
What are the functions of the biceps brachii?
Flexes elbow.
Supinates forearm.
27
What pathologies is the biceps brachii susceptible to?
Tendonitis.
Tendon rupture.
28
What pathologies is the elbow joint susceptible to?
Radial head/neck fractures.
Osteoarthritis.
Rheumatoid arthritis.
Elbow dislocation.
Olecranon fracture.
29
Which direction does an elbow dislocation typically occur in?
Ulnar dislocates posteriorly.
30
What pathology is the supracondylar region of the elbow susceptible to?
Fractures, particularly in children.
31
What pathology tends to occur in the olecranon bursa?
Bursitis.
32
What ligaments are found in the elbow?
Medial (ulnar) collateral ligament (posterior and anterior bundle).
Lateral (radial) collateral ligament.
Annular ligament (encircles radius).
33
What is the importance of the lateral epicondyle?
Site of insertion for all of the extensor muscles of the forearm.
*Susceptible to* *enthesiopathies* *(lateral epicondylitis - Tennis elbow).*
34
What is the importance of the medial epicondyle?
Site of insertion for all of the flexor muscle of the forearm.
## Footnote
*Susceptible to enthesiopathies (medial epicondylitis - Golfer's elbow).*
35
What is the alternative name given to the extensor compartment of the forearm?
Dorsal compartment of the forearm.
36
What is the alternative name given to the flexor compartment of the forearm?
Volar compartment of the forearm.
37
Which direction is the palm when it is in supination?
Supination - palm is up *because you're accepting a bowl of soup.*
38
Which direction is the palm when it is in pronation?
Pronation - palm is down.
39
Which bones in the body have a retrograde blood supply (doubles back on itself)?
Scaphoid.
Talus.
Femur.
40
Where are intrinsic muscles of the hand found and what is their function?
Located within the hand itself.
Responsible for the fine motor functions of the hand.
41
Where are extrinsic muscles of the hand found and what is their function?
Located in the anterior and posterior compartments of the forearm.
Control finger flexion and extension, and movements of the wrist.
42
What are the thenar muscles?
Opponens pollicis.
Flexor pollicis brevis.
Abductor pollicis brevis.
43
What is the function of the thenar muscles and what is their innervation?
Move the thumb.
Median nerve.
44
Which muscles are the hypothenar muscles?
**Abductor** **digiti** **minimi****.**
Flexor digiti minimi brevis.
45
What is the function and innervation of the hypothenar muscles?
Move the little finger.
Ulnar nerve.
46
What is the function of the interossei muscles?
Flex the fingers at the MCPs.
Extend the fingers at the IPJs.
47
What is the innervation of the interossei muscles?
Ulnar nerve.
48
What is the action of the dorsal interossei muscles?
4 **d**orsal interossei muscles.
**Ab**duct the fingers at the MCPJs.
***DAB**.*
49
What is the action of the palmar interossei muscles?
3 **p**almar interossei muscles.
**Ad**duct the fingers at the MCPJs.
***PAD***.
50
What is the innervation of the flexor digitorum superificialis?
Median nerve (C7/C8/T1).
51
What are the flexor tendons of the hand?
**Flexor digitorum superficialis** - flexes fingers at PIPJs.
**Flexor digitorum profundus** - flexes fingers at DIPJs.
52
What is the innervation of the flexor digitorum profundus?
Median nerve (via interosseus; C8/T1) - 2nd and 3rd digits.
Ulnar nerve (C8/T1) - 4th and 5th digits.
53
What are the annular ligaments and what is their function?
5 of them.
A2 and A4 are critical to prevent bowstringing.
A1, A3 and A5 over the MP, PIP and DIP joints, respectively.
54
Which annular ligament is most commonly involved in trigger finger?
A1.
## Footnote
*Can be injected with steroids or released surgically for trigger finger treatment.*
55
What is the function of the cruciate pulleys in the fingers?
Prevent sheath collapse and expansion during digital motion.
56
What is the purpose of the palmar fascia?
Separates the palmar muscle bellies and flexor tendons from the skin.
57
What pathologies is the palmar fascia susceptible to?
Hypertrophy and fibrosis (Dupuytren's contracture).
58
How are the arteries and nerves in the digits named?
Named after the side of the digit, not the artery they originate from e.g. ulnar digital artery is found on the ulnar side of the finger.
59
Which areas of the hand test for cutaneous sensation of the median nerve?
Tip of the index finger and base of the thenar muscles.
60
Which areas of the hand test for cutaneous sensation of the ulnar nerve?
Dorsum and volar aspects of the little finger.
61
Which areas of the hand test for cutaneous sensation of the radial nerve?
Dorsum of first webspace.
62
Where could right shoulder tip pain be coming from other than MSK?
Gallbladder.
63
During physical examination of shoulder pain, what do you look for?
Watch how the patient undresses.
Check both shoulders (? asymmetry).
Deformity.
Scars.
64
During physical examination of shoulder pain, what do you feel for?
Bony landmarks.
Any tenderness.
Check axilla.
Get patient to pinpoint site of pain
65
During physical examination of shoulder pain, what do you move?
Abduction (check scapular movement).
Active and passive.
External rotation.
Internal rotation.
66
What is the management of shoulder pain in GP setting?
Explanation of problem.
Mobilise as early as possible.
NSAIDs - in the short-term.
Local steroid injection.
Physiotherapy.
Time (months to years to resolve).
Referral if not resolving, instability.
67
What are the common shoulder problems seen in GP setting?
Rotator cuff problems esp. supraspinatus tendonitis (35-65 years).
Sub-acromial bursitis.
Acromioclavicular disease (trauma in young adults, arthritis in older adults).
68
What are the less common shoulder problems seen in GP setting?
Frozen shoulder (age 40-60, more common in diabetics).
Osteoarthritis/rheumatoid arthritis.
Recurrent dislocation.
69
Where is subacromial pain often felt?
In the deltoid region.
70
Why could there be muscle loss due to chronic pain?
Nerve impingement causing muscle wasting.
Atrophy due to disuse.
Tendon of the muscle ruptures.
71
What are the causes of arthritis?
Degenerate (osteoarthritis).
Inflammatory (rheumatoid, psoriatic arthritis, gout).
Post-traumatic (mainly osteoarthritis).
Septic.
72
What are the basic treatment principles of arthritis in an upper limb joint?
Nothing.
Rest/analgesia/splintage.
Steroid injections (temporary; don't do at similar time of replacement).
Replace.
Fuse.
Excise.
73
What is the treatment of arthritis in the sternoclavicular joint?
Physiotherapy.
Steroid injection.
Excision (rare - must be carried out somewhere with cardiothoracic surgeons due to major organs underlying).
74
What is the treatment of arthritis in the acromioclavicular joint?
Steroid injection.
Excision (Mumford procedure; as long as coraco ligaments are intact this is possible).
75
What can cause osteoarthritis in the glenohumeral joint?
Cuff tear.
Instability.
Previous surgery.
Idiopathic.
76
What conditions does loss of external rotation in the glenohumeral joint suggest?
Arthritis.
Frozen shoulder.
77
What are the complications of shoulder replacement?
Infection.
Instability.
Stiffness.
Nerve damage (axillary nerve damage affects deltoid).
Loosening.
78
Why is there immobilisation following a shoulder replacement?
Subscapularis needs to be cut to access the shoulder so it has to be repaired and tendon repairs require immobilisation.
79
Why does rotator cuff tear arthropathy occur?
Rotator cuff centres the humeral head on the glenoid.
If torn, the deltoid pulls the head upwards so there are abnormal forces on glenoid that lead to osteoarthritis.
Anatomic shoulder replacement will fail because the alignment is not good.
80
What type of shoulder replacement is done for rotator cuff tear arthropathy?
Reverse shoulder replacement.
81
Why does the reverse shoulder replacement work?
Reverses ball-socket which increases the lever arm of the deltoid, lengthens the deltoid, resurfaces the joint and prevents upward migration of the humeral head from the glenoid.
82
What can be done if a reverse shoulder replacement fails?
Excision (loss of ROM and a lot of pain).
Fusion (lose a lot of ROM).
83
What is the treatment of arthritis in the radiocapitellar joint?
Excision (quite successful).
Replacement (often loosens).
84
What is the treatment for osteophyte impingement of the olecranon?
OK procedure - make the olecranon fossa bigger by making a hole in the olecranon fossa of the humeral head to remove the osteophytes.
85
What are the features of osteoarthritis?
Monoarticular.
Localised.
Osteophytes/sclerosis.
Early joint space narrowing.
Base of thumb.
PIP + DIP joints.
86
What are the features of rheumatoid arthritis?
Polyarticular.
Systemic.
Erosions.
Later joint space narrowing.
Synovitis.
Spontaneous tendon rupture.
MCP joint.
Carpus.
87
What are the surgical treatments for rheumatoid arthritis?
Synovectomy.
Tendon realignment.
Fusion.
88
What is this showing?
Scapholunate advanced collapse.
89
What is this?
Scaphoid nonunion advanced collapse (SNAC wrist) following scaphoid fracture.
90
What is the treatment for thumb CMC joint osteoarthritis?
Rest.
Analgesia.
Splints.
Capsaicin gel.
Steroid injection.
Surgery.
91
What is a boutonniere?
Extensor hood of the PIP joint becomes attenuated causing slip of the extensor tendon.
92
What radiological views are taken for xrays of the cervical spine?
AP.
Lateral.
Odontoid peg.
93
What radiological views are taken for xrays of the scaphoid?
AP.
Lateral.
Two obliques.
94
How can fractures appear on xray?
Lucency crossing bone.
Cortical extension.
Spiral/transverse.
Comminution.
Joint involvement.
Angulation.
Displacement.
Impaction.
Avulsion.
95
What normal appearances can mimic acute avulsion fractures?
Sesamoid bones.
Accessory ossification centres.
Old non-united fractures.
96
What radiographic signs on an xray suggest a supracondylar fracture?
Loss of humerocapitellar line meeting middle 1/3 of capitellar.
Posterior fat pad sign (visible posterior fat pad).
97
What foreign materials cannot be seen on xray?
Wood.
Plastic.
*They look like soft tissue.*
98
What types of fractures are often seen in children?
Buckle fracture.
Plastic bowing.
Greenstick fracture.
*Their bones are soft, so bend or bow rather than snap and splinter and the fractures are often incomplete.*
99
What are Salter-Harris fractures?
Epiphysis is not centred on the metaphysis, due to a fracture involving the growth plate.
100
What foreign bodies can be seen on xray?
Metal.
Glass.
*Only dense foreign bodies.*
101
What is a mucous cyst?
Outpouching of excess synovial fluid from DIP joint osteoarthritis.
## Footnote
*May be painful, fluctuate/discharge, deform nail, cause ridge.*
102
What is the treatment of a mucous cyst?
It can be left alone.
Excision under local anaesthetic and want to take it down to the joint because you want to remove the osteophyte - risk of recurrence.
103
What is a ganglion?
Outpouching of the synovial cavity filled with synovial fluid.
Most common in areas where there is a high concentration of synovial joints e.g. wrist.
104
What are the clinical symptoms of a ganglion?
Fluctuate.
Usually painless but may feel tight.
105
What is the treatment of a ganglion?
Usually resolve with time - leave it alone.
Aspiration with big bore needle (viscous fluid) or excision - ~50% recurrence rate.
106
Which is the most important blood supply to the hand?
Ulnar artery is primary blood supply to the hand.
107
What is a trigger finger?
Tendons run within the tendon sheath (holds tendon to bones), so any swelling on tendon leads to irritation causing more swelling and tendon gets caught on the A1 pulley.
This causes sticking of finger (usually in flexion).
108
Which condition puts you at higher risk of getting trigger finger?
Diabetic patients.
109
How can Dupuytren's be distinguished from trigger finger?
Dupuytren's contracture finger doesn't ever open.
Trigger finger does extend.
110
How is a trigger finger examined?
Ask patient to demonstrate triggering.
Tender over A1 pulley and feel nodule pass beneath the pulley.
111
What is the treatment of trigger finger?
Conservative (often resolves spontaneously; splint to prevent flexion).
Tendon sheath injection (steroid + local anaesthetic; treats 90% of cases, may be repeated up to 3 times).
Surgery (under general or local anaesthetic; divide the A1 pulley).
112
In surgical treatment of trigger pulley, why is only the A1 pulley divided?
If you cut the A2 of A4 pulleys you will get bowstringing of the tendon as these pulleys are vital.
113
What is DeQuervain's tenosynovitis?
Inflammation of the sheath of the extensor encasing the pollicis brevis and abductor pollicis longus tendons.
114
What are the clinical features of DeQuervain's tenosynovitis?
Usually see swelling, local tenderness and pain on extension.
Finklestein's test positive (bend your thumb down across the palm of your hand, and then cover your thumb with your fingers; next, bend your wrist toward your little finger - pain = positive).
115
What is the treatment of DeQuervain's tenosynovitis?
NSAIDs, splint, rest.
Steroid injection.
Surgery - decompression.
116
What is Dupuytren's contracture?
Thickening and contractures of the subdermal fascia leading to fixed flexion deformity of fingers (normally the little and ring fingers; medial to lateral).
## Footnote
*Tendon is entirely normal.*
117
What are the clinical features of Dupuytren's contracture?
Fixed flexion deformity of the little and ring fingers.
Painless.
Gradual progression.
Usually starts as palmar pit/nodules.
118
What is the function of the palmar aponeurosis?
To strengthen grip.
## Footnote
*Aponeurosis runs longitudinally as well as deep to superficial.*
119
What is the pathogenesis of Dupuytren's contracture?
Metaplasia from fibroblasts to in the palmar aponeurosis.
120
What is Dupuytren's diathesis?
Contractures elsewhere in the body, not just in the hand.
Lederhosen's (in the plantar fascia of the feet).
Peyronie's (in the penis).
121
What are the risk factors of Dupuytren's contracture?
Genetics.
Diabetes.
Smoking.
Alcohol/cirrhosis.
Epilepsy/anti-epileptic medication.
Trauma.
122
Why is it important if there is PIP joint involvement in Dupuytren's contracture?
Doesn't correct well the longer the contracture is left as it can become irreversible.
123
Dupuytren's contracture of which joint is well reversed in which joint?
MCP joint.
124
What is the treatment of Dupuytren's contracture?
Conservative (stretches, activity modification).
Surgery (segmental fasciectomy, fasciectomy, dermofasciectomy, amputation).
Newer treatments (collagenase injection, percutaneous need fasciotomy [recurrence rate is high; but can do many revisions]) - no need for rehab with these techniques.
125
What is the table-top test and which condition does it test?
Palm placed on a table-top and see if MCP/PIP joint contractures are observed.
Dupuytren's contracture.
126
Why is a zigzag incision done in procedures to treat Dupuytren's contracture?
The scar that forms from an incision perpendicular (following the path of the tendon) to the tendon can cause a contracture itself.
Zigzag incision improves function.
127
What is paronychia?
Infection within the nail fold.
Often in children.
128
What is the management of paronychia?
Elevate.
Antibiotics.
Incise and drain.
129
What is a flexor tendon sheath infection serious?
Infection within the sheath can track up the palm and arm.
If this causes scarring in the sheath it means the tendons cannot glide causing contractures.
130
What are the clinical features of flexor tendon sheath infection?
Infection in hand.
Extremely painful and will be very painful to extend.
May have tracking up palm and arm and swollen lymph nodes.
131
What is the management of flexor tendon sheath infection?
Wash out the tendon sheath (emergency operation).
Elevate hand.
132
What features should be described on examination of trauma to the hand?
Wound.
Nails.
Deformity.
Swelling.
Point of tenderness.
Movement.
Neurological.
133
How would you describe a wound in hand trauma?
Where is it?
How long is it?
How deep is it? Is the base of the wound seen?
Is it clean or dirty?
Is there skin loss?
Are there any obvious structures in the wound (bone, tendon, foreign bodies, dirt/grit)?
134
What is the treatment of a subungal haematoma?
If pain-free just leave it.
If painful perform a trephine - heat a paperclip and then put a hole in the nail to allow the pressure to release.
135
How would you describe a fracture?
Which bones are involved?
Is there joint involvement?
Is there any deformity?
What is the stability like?
136
How do you examine for a rotational deformity in hand trauma?
Ask the patient to close their hand/clench their fist and if there is a rotational deformity it will be seen.
137
What are the zones of the hand involved in tendon injuries?
Zone I - distal to FDS tendon and contains only FDP tendon.
Zone II - both FDS and FDP tendons found here.
Zone III - lumbrical origin.
Zone IV - carpal tunnel.
Zone V - muscle-tendon junction.
138
Why do tendon injuries within zone II of the hand require specialist surgery?
To prevent scarring within the tendon sheath so that function and movement are maintained.
Early mobilisation required to achieve this.
139
What are the principles of treating mutilating injuries in the hand?
Preserve amputated parts on ice and note the time.
Early debridement.
Establish stable bony support.
Establish vascularity.
Repair all tissues that you can - nerve, tendon repairs.
Establish skin cover - graft, flaps.
Prevent/treat infection.
Aggressive mobilisation.
140
What is the standard burns treatment?
Respiratory.
Infection.
Dehydration.
Pain relief.
141
How are burns treated specific to hands?
Excise damaged skin and perform split skin grafts early.
Aggressive mobilisation to prevent finger stiffness.
Escharotomy (surgical removal of eschar).
142
What is eschar?
Thick, leathery, inelastic skin which can form after burns.
May require surgical release to allow movement.
143
What is a tendinopathy?
Disease of a tendon (best term for tendon-related pain).
144
What is tendonitis?
Inflammation of a tendon.
145
What is tendonosis?
Chronic tendon injury with damage to a tendon extracellular matrix.
146
What is tenosynovitis?
Inflammation of the tendon sheath surrounding the tendon.
147
What is an enthesopathy?
Inflammation of the tendon origin or the insertion into bone.
148
What is the function of a tendon?
Transmit load from muscle to bone.
149
What is the blood supply to tendons?
Poor.
Watershed areas linked to tendon pathology and rupture.
150
What cells are found within a tendon?
Fibroblasts which produce collagen and proteoglycan.
Relatively acellular.
151
What is the composition of tendons?
Water.
Collagen (type I - 85% of the dry weight).
Proteoglycans.
152
What is the cellular organisation of tendons?
Microfibrils -\> subfibrils -\> fibrils -\> fascicles -\> tendon unit.
153
What is an endotendon?
Fascicles in a tendon are surrounded by an endotendon and contain nerves and small blood vessels.
154
What is an epitenon?
The outer connective tissue layer which lies within loose areolar tissue (paratenon) or within the tendon sheath.
155
What are the intrinsic aetiologies of tendinopathy?
Age.
Gender.
Obesity.
Pre-disposing diseases e.g. rheumatoid arthritis.
Anatomical factors e.g. mal-alignment, leg length discrepancy.
156
What are the extrinsic aetiologies of tendinopathy?
Trauma/injury.
Repetitive injury.
Drugs e.g. steroids, antibiotics (ciprofloxacin).
Sports-related factors.
157
What are the principles in conservative management of tendinopathies?
Rest (R.I.C.E. - raise, ice, compression, elevation).
Physio - eccentric strengthening.
Analgesics (anti-inflammatories).
Steroid injections (e.g. rotator cuff, tennis elbow, NOT Achilles tendon or extensor knee mechanism).
Splinting (e.g. Achilles tendon).
158
What are the principles in surgical management of tendinopathies?
Debridement (removal of damaged tissue).
Decompression (supraspinatus tendonitis and subacromial decompression).
Synovectomy (helps to prevent rupture; e.g. extensor mechanisms of wrist in RA, tibialis posterior).
Tendon transfer (e.g. tibialis posterior or extensor pollicis longus).
159
What is the pathophysiology of rotator cuff pathology?
Extrinsic compression & intrinsic degeneration.
Inflammation of the subacromial bursa.
160
What are the clinical findings of rotator cuff pathology?
Achy pain down arm.
Difficulty sleeping on affected side, reaching overhead and on lifting.
Painful arc +/- weakness.
Positive impingement tests.
161
What is the management of rotator cuff pathology?
Conservative - physio, steroid injections.
Surgical - subacromial decompression.
162
What are the clinical features of biceps tendinopathy?
Pain in the anterior shoulder radiating to the elbow that is aggravated by shoulder flexion, forearm pronation and elbow flexion.
There is snapping with shoulder movements it there is a subluxation.
163
What is the management of biceps tendinopathy?
Mainly conservative with rest and physio.
Surgery, if indicated because it carries a high risk of neurovascular complications.
164
What is the pathophysiology of lateral epicondylitis?
Peritendinous inflammation leading to angiofibroblastic hyperplasia which causes breakdown and fibrosis.
165
What are the clinical features of DeQuervain's tenosynovitis?
Pain whilst using thumb and tender over compartment.
Pain on resisted active thumb extension.
Finklestein's test positive - tends to be sore for most people, but in these patients it's excruciating.
166
What is the management of DeQuervain's tenosynovitis?
Splint.
Rest.
Physio.
Analgesics.
Steroid injections.
Surgical decompression - try to avoid this due to risk of nerve damage.
167
What tendon rupture is associated with typically undisplaced distal radius fractures?
Extensor pollicis longus.
168
What actions of the thumb can be done if there is an extensor pollicis longus rupture?
All thumb actions except thumb extension (thumbs up).
169
Why is A1 pulley release contraindicated for trigger thumb management in patients with rheumatoid arthritis?
It may exacerbate ulnar drift so a synovectomy is preferred.
170
What is the presentation of septic arthritis?
Acute monoarthropathy.
Very reduced range of movement +/- swelling.
Systemic upset.
Raise WCC and inflammatory markers.
171
What is the management of septic arthritis?
Urgent orthopaedic review.
Aspirate the joint - M, C and S.
Urgent open/arthroscopic washout and debridement.
172
What is the management of bursitis?
NSAIDs/analgesia.
Antibiotics.
Incision and drainage (secondary infection).
Very rarely excision in chronic cases.
173
What are the names given to bony swellings of the interpharyngeal joints in the hands?
Bouchard's nodes (PIP joints; OA or RA).
Heberden's nodes (DIPS joints; OA).
174
What is the presentation of giant cell tumour of the tendon sheath?
Slowly enlarging.
Firm, discreet swelling, usually on volar aspect of digits.
Can occur in toes.
May or may not be tender.
175
What is an osteochondroma?
Benign tumour most commonly occurring near the knee (distal femur/proximal tibia metaphyseal regions).
Growth usually parallels that of the patient.
1% can become malignant.
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What is the presentation of osteochondroma?
Adolescents.
Painless, hard lump.
Symptoms with activity (pain from tendons; numbness from nerve compression).
Rarely can be painful due to fracture.
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What is the management of osteochondroma?
Close observation.
Surgical excision.
178
What is Ewings sarcoma?
Malignant primary bone tumour of the endothelial cells in the marrow.
Most common age 10-20 years and location is diaphysis/metaphysis of long bones and pelvis.
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What is the presentation of Ewings sarcoma?
Hot, swollen, tender joint or limb with raised inflammatory markers.
Can mimic infection - ask about night pain and duration of symptoms.
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What is the management of Ewings sarcoma?
Poor prognosis.
Surgical excision can be problematic.
Often radio- and chemo-sensitive.
181
What is a lipoma?
Benign neoplastic proliferation of fat; often subcutaneous.
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What is the presentation of lipoma?
Can be discreet or less well defined.
Slow growing and painless/non-tender.
Can be large (several cms).
Characteristic consistency - soft, movable mass.
No overlying skin changes.
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What is the management of lipoma?
Can be left alone.
Surgical excision if causing symptoms.
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What is myositis ossificans?
Abnormal calcification of a muscle haematoma.
Usual history of trauma followed by an initial soft swelling then hardness develops over several weeks.
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What would an MRI of myositis ossificans show?
Peripheral mineralisation.
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What is the management of myositis ossificans?
Observation.
Intervene only if symptoms demand.
Must wait until maturity of ossification, otherwise risk of recurrence (6-12 months).
187
What are the extrinsic muscles of the shoulder?
Deltoid.
Trapezium.
Pectoris major.
Latissimus dorsi.
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What injuries are associated with shoulder dislocation?
Fracture of glenoid (bony Bankart).
Labral lesions (Bankart).
Fracture humeral head (Hill Sachs).
Rotator cuff tear (older patients).
