1
Q
Describe the approach to MSK x-rays
A
- IPADS:
- Information
- Patient details
- Radiograph date, view, adequacy (RIP)
- Pattern of fracture - transverse/oblique/comminuted
- Anatomy
- Location on bone
- Intra/extra articular
- Distal fragment
- Displaced/angulated/rotated/impacted
- Soft tissues - disruption/swelling/foreign bodies
2
Q
Describe the different types of fracture pattern
A
3
Q
What are the terms used to describe displacement?
A
- Angulation
- Translation
- Shortening
- Rotation
4
Q
How is the site of fracture described?
A
- Diaphyseal (shaft)
- Metaphyseal (ossification plate)
- Intra/extra articular
- Junctional
5
Q
What is osteoarthritis?
A
Non-inflammatory degenerative joint disease characterised by loss of cartilage at synovial joints with degeneration of the underlying bone
- Commonly affects DIP joints, thumb MCP, cervical and lumbar spine, knee, hip
6
Q
Name some clinical features of osteoarthritis
A
- Joint pain and stiffness
- Worse at end of day/after activity
- Can be nocturnal
- Joint instability
- Loss of joint function / limited range of movements
- Synovitis
- Crepitus
- Nodes
- Herberdens (DIP) - outer Hebrides
- Bouchard’s (PIP)
- Squaring of the hand (CMC prominence)
7
Q
What x-ray changes are seen in osteoarthritis?
A
LOSS
- Loss of joint space
- Osteophyte formation
- Subchondral bone sclerosis
- Subchondral cyst formation
8
Q
How is osteoarthritis managed?
A
- Pain relief - paracetemol / NSAIDs (+/- omeprazole)
- Weight loss if BMI > 28
- Walking aids
- Supportive footwear
- Physiotherapy / hydrotherapy
- Steroid/LA injections (= 2 times a year)
- Surgery
9
Q
Why is surgery indicated in osteoarthritis?
A
- Pain not controlled by medication
- To improve mobility
- Correcting deformities
10
Q
What is osteoporosis?
A
Skeletal disorder characterised by decreased bone mass and increased risk of fractures due to deterioration of the microarchitecture of bone tissue.
11
Q
Name some primary causes of osteoporosis
A
- Age
- White/asian
- Female
- Early menopause
- Family history
- Low calcium / vitamin D
- Smoking / alcohol
12
Q
Name some secondary causes of osteoporosis
A
- Hyperthyroid / parathyroid
- Hypogonadism
- Cushings
- RA
- IBD
- Renal failure
- Drugs - steroids, heparin, anti-convulsants
13
Q
How is osteoporosis diagnosed?
A
- DEXA scan to measure bone mineral density
- BMD expressed as aT score (number of SDs away from mean)
- Osteoporosis < -2.5
- X-ray
- Investigations into secondary cause
- FBC
- ESR
- Serum calcium
- ALP
- TSH
14
Q
How is osteoporosis managed/prevented?
A
- Calcium rich diet
- Stop smoking
- Increase weight-bearing exercise
- Bisphosphonate (alendronic acid 10mg/ didronel)
- Inhibit osteoclast activity
- Vitamin D supplement
- HRT in women / SERM (raloxifene)
- Calcitonin
15
Q
How can falls be prevented in osteoporosis?
A
- Mobility device
- Avoidance of sedatives or hypotensive drugs
- Removal of obstacles in the home
- Ensure co-morbidity is treated
- Eyesight
- Syncope
- Cardiac arrhythmia
- OA/RA
16
Q
What is Paget’s disease / osteitis deformans?
A
Increased bone turnover associated with increased numbers of osteoclasts and osteoblasts with resultant remodelling, bone enlargement, deformity and weakness
- Autosomal dominant
- Common sites are spine, skull, pelvis, femur, tibia
17
Q
Name some clinical signs/complications of Paget’s disease?
A
- Deafness (bone overgrowth)
- Cranial nerve palsies
- Cardiac hypertrophy / high output CCF
- Spinal stenosis / spinal nerve entrapment
- Secondary OA
- Pathological fractures / osteosarcoma
- Bowing of tibia
18
Q
How is Pagets investigated?
A
- ALP (raised)
- Normal serum calcium and phosphate
- X-ray - sclerosis and osteoporosis
- Isotope bone scan = areas of focal increased uptake (hot spots)
- High urinary excretion of hydroxyproline
19
Q
How is Pagets managed?
A
- Pain relief
- Manage fractures appropriately
- Drugs that reduce bone turnover such as calcitonin or bisphosphonates
- Surgical treatment for fracture, deformity or sarcoma
20
Q
What is osteomalacia?
A
Low mineral content but normal amount of bone
- Osteomalacia after fusion of epiphyses
- Rickets during bone growth
21
Q
Name some causes of osteomalacia
A
- Vitamin D deficiency
- Malabsorption
- Poor diet
- Lack of sunlight
- Renal failure
- Drug-induced
- Anti-convulsants (induce liver enymes)
- Genetic vitamin D resistance
- Liver disease = decreased production/malabsorption
22
Q
Name some signs and symptoms of rickets/osteomalacia
A
Rickets:
- Valgus deformity
- Bow-legged
- Hypocalcaemia
Osteomalacia:
- Bone pain
- Fractures (NOF)
- Proximal myopathy (waddling)
23
Q
How is osteomalacia investigated?
A
- Bloods - dec calcium, phosphate, vit D, inc ALP, PTH
- Biopsy - incomplete mineralisation
- X-ray
- Loss of cortical bone
- Loosers zone = wide, transverse lucencies at right angles to cortical bone (pseudofracture)
- Blurred trabeculae
24
Q
How is osteomalacia managed?
A
- Treat underlying cause
- Vitamin D supplements (calciferol)
- 400 units
25
What is Developmental Dysplasia of the Hip (DDH)?
Failure of normal development of the acetabulum resulting in abnormal hip anatomy
* Dislocated = head of femur completely out
* Dislocatable = head of femur lies within the acetabulum but is easily pushed out of socket
* Subluxable = head of femur is loose in socket
26
Name some risk factors for DDH
* Girls
* First-born children
* Breech position
* Family history
* Oligohydramnios
* Foot abnormalities
27
Name some clinical features of DDH
* Loss of abduction
* Leg length discrepancy
* Asymmetrical posterior skin crease (thigh)
* Limping / toe-walking / waddling gait
28
How is DDH diagnosed?
* Barlow's = dislocate a reduced hip
* Knee 90 flexed, hip 90 flexed
* Ortolani's = reduce a dislocated hip
* Ultrasound if at risk
* X-rays in older children (6+ months)
29
How is DDH managed?
* 0-6 months = Pavlik harness
* 6-18 months = closed/open reduction of hip joint with immobilisation in a spica cast
* \> 18 months = open reduction of hip joint, hip adductor release, and femoral osteotomy
30
Name some complications of DDH
* Delay in walking
* Growth disturbance
* Risk of re-dislocation
* Osteonecrosis
* Osteoarthritis
31
What is Perthes disease?
Idiopathic avascular necrosis of the proximal femoral epiphyses
* Common onset between 4-10 years
* More common in males
32
What are the clinical features of Perthes disease?
* Gradual onset of hip/knee pain
* Limp
* Loss of hip abduction
* Fixed deformity
33
How is Perthes managed?
* Physiotherapy / exercise
* Anti-inflammatory drugs (ibuprofen)
* Casting / bracing - Petrie casts
* Tenotomy of adductus longus
* Surgery
* Osteotomy
34
What is a slipped upper femoral epiphysis (SUFE)?
Structural failure through the growth plate of an immature hip causing displacement of the femoral epiphysis in relation to the femoral neck
* Unstable = cannot walk due to pain
* Stable = weight-bear with limp
* Presents 2-3 weeks after
35
Name some risk factors for developing SUFE
* Male
* Obesity - limping obese 13 year old boy is classic
* Hormonal - hypothyroid/pituitarism/parathyroid
36
What are the clinical features of SUFE?
* Obvious limp
* Usually in overweight child
* Groin/knee pain
* Shortened and externally rotated
* Limited abduction
* Evidence of hypogonadism/pituitarism/thyroidism
37
Describe the x-ray appearance of SUFE
AP and frog-leg
* Widening of growth plate
* Irregularity and blurring of physeal edges
* If chronic - sclerosis
* Trethowan's sign = line of Klein (up lateral edge of femoral neck) does not intersect the epiphysis
38
How is SUFE managed?
* Surgical fixation / pinning
* Prevents further slipping of epiphysis
* Osteotomy / joint replacement if significant deformity
39
Name some complications of SUFE
* AVN of femoral head
* Chondrolysis = rapid progressive loss of cartilage with joint space narrowing
* Subtrochanteric fracture
* Late osteoarthritis
40
Name some risk factors for developing clubfoot
* Male
* Family history
* Congenital conditions (spina bifida, muscular dystrophy)
* Smoking during pregnancy
* TORCH infections (toxoplasmosis, rubella, CMV, herpes)
* Oligohydramnios
41
Name some clinical features of clubfoot
* Fixed varus and equinus (plantar flexed) deformity
* Under-developed calf
* High arch
* Shortened limb
42
How is clubfoot managed?
* Ponseti method = manipulation and casting 5-7 times
* Percutaneous Achilles tenotomy
* Maintenance of alignment via stretching exercises, special shoes and braces
43
Name some complications of clubfoot
* Osteoarthritis
* Abnormal gait (abnormal growth of calf muscles)
* Walking on ball/outside/top of foot
44
Name some causes of pathological fractures
* Osteoporosis
* Tumours
* Paget's disease
* Metabolic bone disease
* Osteomalacia/rickets
* Hyperparathyroidism
* Osteogenesis imperfecta
* RA
* Infection
45
Describe the general management of fractures
4 R's:
* Resuscitate (Advanced trauma life support)
* Reduce (if displaced)
* Open reduction (if intra-articular or NV damage)
* Closed reduction (Manipulation Under Anaesthetic)
* Restrict (stabilisation)
* External fixation
* Internal fixation
* Conservative immobilisation (cast/splint/brace)
* Rehabilitate (physio)
46
What are the indications for internal fixation?
* Intra-articular fracture - reduce incidence of OA
* Unstable fracture pattern
* NV damage
* Pathological fractures
* Long bone fractures
47
Describe some internal fixation methods
* Compression plates and screws
* Intra-medullary nail
* Kershner (K) wires
* Tension band wiring
48
Name some indications for external fixation
* Open fractures (tibia/femur) with significant soft tissue damage
* Comminuted fractures
* Damage control orthopaedics
* Salvage if non-union, malunion or bone loss
49
Name some complications of fractures
* Immediate
* Soft tissue injury
* Nerve palsy
* Ischaemia (damaged arteries)
* Haemorrhage - hypovolaemic shock
* Early
* Compartment syndrome
* Infection
* DVT
* Complex regional pain syndrome
* Fat embolus
* Late
* Delayed union / non-union
* Malunion (healing in abnormal position)
* OA (if intra-articular)
* Growth disturbance
50
Name some causes of back pain
* Trauma - fracture, dislocation
* Neoplastic
* Infective - infective spondylodiscitis
* Inflammatory - inflammatory spondyloarthropathy
* Metabolic - osteomalacia, osteoporosis, Paget's
* Degenerative disc disease
* Paraspinal muscle - spasm/strain
51
What are the red flag signs of back pain?
Symptoms:
* Non-mechanical back pain
* Thoracic pain
* Fever
Features:
* History of malignancy
* Age \< 16 or \>50 if new onset
* Unexplained weight loss
* Long standing steroid use
Signs:
* Saddle anaethesia
* Reduced anal tone
* Widespread/progressive neurology
* Urinary retention
52
Name a classification system for open fractures
Gustillo-Anderson classification:
* I = low energy, wound \< 1cm, no comminution
* II = 1cm \< wound \> 10cm, minimal comminution
* III = high energy, wound \> 10cm, periosteal stripping, communition, farmyard contamination
* A = wound can be covered with existing tissue
* B = requires soft tissue cover
* C = neurovascular injury
53
How are open fractures initially assessed?
* ABCDE
* + C spine
* Stop external haemorrhage
* Neurovascular exam
* AMPLE history
* Allergies
* Medications
* PMH
* Last ate/drank
* Events of injury
54
How are open fractures managed?
* Photograph wound
* Remove gross contamination only
* Moist sterile gauze / adhesive film dressing / negative pressure dressing
* IV antibiotics (within 3 hours) for 72 hours
* Co amoxiclav 1.2g / cefuroxime 600mg
* Analgesia (+ anti-emetic)
* Splint the limb
* Tetanus prophylaxis
* X-ray
* Surgery
55
What surgical options are available for open fractures? Who makes these decisions?
Team of orthopaedic, plastic and vascular surgeon
* Internal fixation if minimal contamination
* Temporary external fixation if not covered
* Amputation
* Uncontrollable haemorrhage
* 4-6 hours of ischaemia
* Muscle loss of 2 compartments
* \> 1/3 tibia bone loss
56
Name some investigations for chronic back pain
* History - unrelenting back pain, overweight, depressed, unable to work
* Blood tests all normal - FBC, LFTs, Ca2+, myeloma, ESR/CRP
* X-ray - normal/mild disc narrowing/facet joint arthritis
57
How is chronic back pain managed?
* Analgeisa - WHO ladder
* Physio
* MDT
* Avoid prolonged bed rest
* Facet joint injections
58
What is a prolapsed intervertebral disc? Common sites of prolapse?
Nucleus pulposus herniates through the annulus fibrosus and pressses on a nerve root (usually posterolaterally)
Commonly L4-5 or L5-S1
59
Name some clinical features of a prolapsed intervertebral disc
* Back pain
* Sciatica +/- parasthesia/numbness
* Abnormal posture = stooped with knee flexed
* Cauda equina
* Loss of anal tone
* Reduced perianal sensation
* Bilateral leg symptoms
* Urinary retention
* Muscle weakness
60
How is prolapsed intervertebral disc investigated?
* Bloods - exclude sinister causes
* MRI (T2)
* X-ray = normal unless other pathology
* CT myelogram = dye is injected into spinal canal
61
How is prolapsed intervertebral disc managed?
* Bed rest
* Gentle physiotherapy
* Analgesia
* Surgical discectomy if:
* Cauda equina
* Progressive neurological deficit
* \> 6 weeks of symptoms
* Nerve sheath injection
62
What is spondylolisthesis?
Slipping of 1 vertebral body onto another
Graded based on % of vertebral body slipped
* I = 25%
* II = 50%
* III = 75%
* IV = 100%
63
Name some causes of spondylolisthesis
* Physical activities - weights, gymnastics, football
* Male
* Trauma
* Congenital
* Stress fracture (overuse)
64
Name some clinical features of spondylolisthesis
* Persistent back pain
* Increased loidosis
* Sciatica
* Tight hamstrings
* Tenderness over spine
* Waddling gait
65
How is spondylolisthesis investigated?
* Oblique x-rays = collar on scottie dog
* CT
* MRI (if nerve root irritation)
66
How is spondylolisthesis managed?
* Rest and activity restriction
* Physio
* Analgesia
* Spinal brace
* Surgery = lumbar interbody fusion and decompression if:
* Persistent pain
* Radiculopathy (pinched nerve)
* Significant deformity
67
Name some risk factors for developing spinal stenosis
* Male \> 50
* Heavy manual labourers
* OA - osteophytes, soft tissue inflammation
* Herniated discs
* Tumours
* Displaced bone from fractures
68
Name some clinical features of spinal stenosis
* Pain when walking
* Referred to buttocks, calves, feet
* Numbness/parasthesia in hands, arms, legs, feet
* Muscle weakness
* Bowel or bladder dysfunction
69
How can spinal stenosis be managed?
* Weight loss
* Activity modification / physical therapy
* Analgesia
* Steroid injections
* Surgical decompression
* Laminectomy
* Laminotomy
* Laminoplasty
70
What are the common organisms of vertebral myelitis?
* Staph aureus
* Step pneumoniae
* TB
71
Name some risk factors for developing discitis/vertebral myelitis?
* IV drug use
* Degenerative spine disease
* Endocarditis
* Diabetes
* Prior spinal surgery
* Steroids
* Immunocompromised
72
What are the clinical features of discitis/vertebral myelitis?
* Pyrexia
* Unrelenting back pain
* Swelling/gibbus formation
* Reduced movement
* Possible abnormal neurology
73
How is discitis/vertebral myelitis investigated?
* Bloods - WCC, ESR/CRP
* X-ray = narrowed disc space/bony destruction
* Isotope bone scan = hot in affected areas
* MRI = detect epidural abscess
* CT guided biopsy = M, C + S
74
How is discitis/vertebral myelitis managed?
* IV antibiotics for 6 weeks
* Bracing for 6-12 weeks
* Surgery
* Abscess draining
* Stabilisation of deformity
75
How is scoliosis defined?
Abnormal lateral curvature of the spine
* Cobb angle \> 10 degrees
76
What investigations are needed following a NOF?
* FBC - WCC (infection) Hb (anaemia)
* U&E
* Glucose
* Urine dip / MSU (if confused)
* MRSA screen
* Cross match / group and save (surgery)
* ECG (fit for surgery)
* CXR (pneumonia, fit for surgery)
* Clotting (if on anticoagulant)
* Bone profile (Ca2+ if malignancy suspected)
* Serum lactate (\>3mmol/L = higher mortality)
77
What immediate management is needed for NOF/trauma?
* Pain relief
* Fascia-iliaca block
* Codeine (+ anti emetic)
* VTE assessment (green sheet)
* EWS hourly
* IV fluids
* NV assessment
* Nottingham hip score
* Discuss surgery/DNR with patient
* Draw arrow on affected limb
* Surgery within 36 hours
78
Name some risks of fracture surgery
* Infection (1/100)
* Failure - loosen/dislocation/fracture/malunion
* NV damage
* Bleeding/need transfusion
* DVT/PE
* Anaesthesia - respiratory depression/anaphylaxis
* Compartment syndrome
* Death
* UTI
* MI/LVF
* Renal failure
79
What is compartment syndrome?
Rasied pressure within an enclosed fascial space leading to localised tissue ischaemia
* Outflow problem
80
How is compartment syndrome diagnosed?
* Clinical
* Compartment pressure monitoring using an arterial line transducer / slit catheter
* \> 40mmHg or 30 below diastolic BP
81
How is compartment syndrome managed?
* Release any casts
* Immediate surgical decompression (fasciotomy)
* Debridement of necrotic tissue
* Skeletal stabilisation
* Leave wounds open and use loose, absorbent dressings
* Treat underlying cause
* Analgesia
82
Name some complications of compartment syndrome
* Muscle necrosis
* Deformity (Volkmann's Ischaemic Contracture)
* Weakness
* Joint stiffness
* Nerve fibrosis - dysaethesia
* Sensory \> motor
* Delayed fracture union
83
Name some causes of shoulder dislocation
Anterior: Forced abduction and external rotation
* Fall on outstretched arm
* 'Ball throwing' position
* Trauma
Posterior: Forced internal rotation
* Direct blow to anterior shoulder
* Epileptic fit
* Electrocutions
84
Name some features of the shoulder joint that provides stability
* Rotator cuff muscles
* Supraspinatus
* Infraspinatus
* Teres minor
* Subscapularis
* Glenoid labrum (fibrocartilagenous ridge) deepens cavity
* Ligaments
* Glenohumeral
* Coracohumeral
* Coracoacromial
* Joint capsule
85
Name some other features often associated with anterior shoulder dislocation
* Bankart lesion = anterioinferior glenoid labrum tear
* Hill-Sachs lesion = impression fracture as anterior glenoid impacts on posterior humeral head
* Often with recurrent dislocations
* Rotator cuff tears
* Greater tuberosity fractures
86
Describe the presentation on anterior shoulder dislocations
* History of trauma
* Pain
* Shoulder supported by other arm
* Abducted
* Externally rotated
* Restricted movement
* Sqaure shoulder = caused by flat deltoid and sulcus where the humeral head used to be
* Palpable glenoid and humeral head
* May have neurovascular damage
* Axillary nerve
87
Describe the x-ray appearance of anterior shoulder dislocations
AP and scapular Y view/axilla needed:
* Hill-Sachs
* Humeral head towards ribs
* Associated fractures
* Proximal humeral
* Clavicle
* Acromial
88
How is anterior shoulder dislocation treated?
* IV morphine 5-10mg and inhaled N2O
* Reduction in A&E
* Kocher's manoevre (pictured)
* Stimson's technique = patient prone, arm hanging freely off trolley and weighted
* Arm immobilised in a collar and cuff sling in internal rotation
* Repeat x-ray and NV assessment
* Physio after 3-5 days rest
* Surgery (if recurrent) = bone/labral repair
89
Name some complications of anterior shoulder dislocations
* Axillary nerve damage
* Brachial plexus damage
* Axillary artery damage
* Recurrent dislocations
* Rotator cuff injury
90
What is subacromial impingement?
Irritation/inflammation of the rotator cuff (supraspinous) tendons as it passes through the subacromial space and over the coracoacromial arch
91
Name some causes of impingement
* Os acromiale (unfused ossification centre)
* Subacromial spurs (bony projections)
* Thickening of coracoacromial ligament/tendonitis
* Shoulder instability
* Post-traumatic deformity
* Hooked acromion
92
How does impingement present?
* Gradual increase in shoulder pain
* Increased with overhead activities
* May be worse at night if lying on shoulder
* Weakness
* Loss of movement
* Only **passive** movement intact
* Painful arc between 60-120 degrees
93
How is impingement investigated?
* Pain over ACJ when arm is pushed against other shoulder
* X-ray
* Hooked/type III acromion
* Osteophytes inferiorly to AC joint
* US = abnormal contact between coracoacromial arch and peritendinous tissue during abduction
94
How is impingement treated?
* Avoid painful activities
* Ice
* Ibuprofen (2 weeks)
* Physio
* Steroid injections
* Subacromial decompression
95
What is rotator cuff tendonitis?
Deposits of hydroxyapatite in the rotator cuff tendons (mainly supraspinatous) that causes inflammation
96
Describe the clinical presentation of rotator cuff tendonitis
* Pain on movement (elevation of arm)
* Stiffness
* Snapping/catching of tendons
* Weakness
* Restriction of movement
97
How is rotator cuff tendonitis investigated?
* X-ray = calcific deposits along tendon line
* MRI = calcium deposits, thickened tendon
* US = calcific deposits
98
How is rotator cuff tendonitis treated?
* Analgesia
* Subacromial steroid injections
* Aspiration of mineralised material
* Shock wave therapy
* Arthoscopic removal of deposits
99
What is frozen shoulder?
Adhesive capsulitis = thickening and contraction of the joint capsule and synovium
100
What is the presentation of frozen shoulder?
* Freezing (painful) stage 3-9 months
* Restricted passive **and** active movements
* ESPECIALLY external rotation
* Frozen (transitional) stage 4-12 months
* Pain at end of range of movements
* Limited movement = muscular disuse
* Thawing stage 12-46 months
101
Name some causes of frozen shoulder
* Primary/idiopathic
* Secondary
* Repetitive trauma
* Endocrine (diabetes, thyroid)
* Rheumatological
* Shoulder surgery
102
How is frozen shoulder investigated?
* MR arthrography
* Thickened joint cause
* Coracohumeral ligament thickening
* Abnormal soft tissue
* US
* Limited movement of supraspinatus
* Thickened coracohumeral ligament
* Investigate cause - TFT, glucose, rheumatological bloods etc
103
How is frozen shoulder managed?
* NSAIDs
* Physio
* Steroid injections
* Glenohumeral hydrodilation
* Closed manipulation
* Arthroscopic capsular release
104
What is lateral epicondylitis?
Tennis elbow = overuse syndrome of the common extensor tendon (lateral epicondyle)
* Predominantly affects extensor carpi radialis brevis
* Commonly in 4th-5th decades
105
How does lateral epicondylitis present?
* Lateral elbow pain
* Exacerbated when grasping objects during wrist extension with resistance
* Tenderness at lateral humeral condyle
106
How is lateral epicondylitis investigated?
* Mainly clinical diagnosis
* MRI = abnormal thikening of common extensor tendon
* Partial/full tear of ECRB
* Abnormal thickening/separation of radial collateral ligaments and ECRB
* X-ray = may see calcification around lateral epicondyle
* US = intratendinous calcification, tendon thickening
107
How is lateral epicondylitis treated?
* Activity restriction
* Pain relief
* Physio + exercise
* Isometric grip exercises
* Steroid injections (triamcinolone)
* Autologous blood injection
* Surgery if 3-6 months
108
What is cubital tunnel syndrome?
Ulnar nerve compression neuropathy at the cubital tunnel (between medial epicondyle and medial ulna)
109
Describe elbow (ulnohumeral) dislocation characteristics (cause, anatomy, classification)
* Caused mainly by FOOSH
* Mainly posterior dislocation
* Classification
* Simple = no fracture
* Complex = with fracture
110
What is the terrible triad of elbow dislocation?
Posterior dislocation with:
* Coronoid process fracture
* Radial head fracture
* Lateral collateral ligament tear
Requires surgical stabilisation (ORIF)
111
Describe the x-ray appearance of an elbow dislocation
* Anterior humeral and radiocapitellar lines do not intersect at the centre of the capitulum
* Associated fractures
* Radial head
* Coronoid process
* Lateral condyle
* Olecranon
* Capitulum
112
How is elbow dislocation treated?
* Reduce under GA to allow thorough assessment of stability
* Closed
* 2 weeks immobilisation in collar and cuff
* If fractures - ORIF
* X-ray to confirm reduction
113
Name some complications of elbow dislocation
* Limited movement
* Recurrent instability
* Neurovascular injury
* Brachial artery
* Ulnar nerve
* Compartment syndrome
* Heterotropic ossification (bone in soft tissue)
* Ligament/capsule damage
114
What is pulled elbow syndrome?
Subluxation of the radial head into the annular ligament
* Affects young children aged 6 months - 3 years due to pulling on arm longitudinally
* Lifting child by arms
* Pulling child away from something
* Only affects children due to laxity of ligament
115
What is carpal tunnel syndrome?
Compression of the median nerve as it passes through the carpal tunnel at the wrist
116
What are the contents of the carpal tunnel?
* Flexor digitorum superficialis
* Flexor digitorum profundus
* Flexor pollicus longus
* Median nerve
117
What are the borders of the carpal tunnel?
* Post = carpal bones
* Ant = transverse carpal ligament/flexor retinaculum
* Lat = scaphoid and trapezium tubercle
* Med = pisiform and hook of hamate
118
Name some causes of carpal tunnel syndrome
MEDIAN TRAP:
* Myxoedema (hypothyroidism)
* Ethanol
* Diabetes
* Idiopathic (most common)
* Amyloidosis
* Neoplasia
* Trauma
* RA
* Acromegaly
* Pregnancy
119
What are the clinical features of carpal tunnel syndrome?
* Pain +/- parasthesia in median nerve distribution (radial 3 1/2 fingers and palm
* Can radiate towards elbow
* Worse at night - wakes up
* Relieved by shaking hand
* Sensory loss in median nerve distribution
* Weak/wasted thenar muscles
120
How is carpal tunnel syndrome investigated?
* Phalen's = symptoms within 60s of passive flexion of wrist
* Tinnel's = symptoms with tapping over median nerve at wrist
* Nerve conductions study
* Investigations into cause
* TFTs
* Glucose
* dsDNA
* Urine dip
121
How is carpal tunnel syndrome managed?
3 S': splint, steroids, surgery
* Avoidance of precipitating factors
* NSAIDs
* Splint
* Corticosteroid injection
* Surgical decompression
122
What is De Quervain's Tenosynovitis? Causes?
Inflammation of the synovium around the extensor pollicis brevis and abductor pollicis longus tendons and under the tight fibrous bridge proximal to the radial styloid process
Caused by repeated twisting movements and pregnancy
123
How is De Quervain's Tenosynovitis treated?
* Elimination of trigger activity
* Steroid injection
* Surgical decompression (divide fibrous bridge)
124
What is trigger finger?
Inflammation of the tendon sheath around flexor digitorum profundus, causing the tendon to get stuck in a flexed position unless extended passively
* Repetitive trauma
* RA
125
How is trigger finger treated?
* Inactivity/stretching
* Ice
* NSAIDs
* Steroid injections
* Surgical release
126
What is a ganglion?
A mucinous cyst swelling that can arise from a tendon sheath or joint.
Caused by synovial cells secreting into soft tissues rather than a joint cavity
127
What is Dupuytren's disease?
Progressive thickening of the palmar and digital fascia that may lead to contractures
Begins at the base of the ring or little finger which pulls the fingers into flexion
128
Name some causes of Dupuytren's disease
POT FACED
* Peyronie's disease = development of fibrous scar tissue inside the penis
* Occupation
* Trauma
* Familial
* Alcohol
* Cirrhosis
* Epilepsy
* Diabetes
129
Name some clinical features of Dupuytren's disease
* Thickened palmar and digital fascia forms nodules and cords
* Contractures of the MCPJs and PIPJs
* Garrods pads on knuckles (PIPJs)
* Fibrous nodules on soles of feet (Ledderhose's disease)
130
What are the indications for surgery in Dupuytren's disease?
* Over 30 degrees fixed flexion contracture at MCPJ or PIPJ contracture
* Rapidly progressing contracture
* Tabletop test = hand will not lie flat on table
* Pain in nodules or Garrods pads
Injection with steroids or excision
131
What is a digital ring block?
1ml 1% lignocaine (short lasting) or 0.5% bupivacaine (long lasting) with NO adrenaline
* End arterial supply
* Adrenaline only used for vascular sites to reduce bleeding via vasoconstriction
132
Describe the clinical features of OA in the hip
* Pain
* Worse on weight-bearing and movement
* Disturbs sleep
* In groin - thigh - knee
* Loss of movement (due to osteophytes)
* Causes flexion, adduction and external rotation deformity
* Hyperextension of lumbar spine - backache
* Shortened leg
* Abnormal gait
* Antalgic
* Bent knee
* Turned out foot
* Valgus
* Trendelenberg
133
How is OA in the hip treated?
* NSAIDs
* Weight reduction
* Stick (opposite hand)
* Shoe raise
* Arthroscopic washout
* Surgical debridement
* THR
* Osteotomy
134
What is the difference between THR and hemiarthroplasty?
* THR = replacement of acetabulum and femoral head
* Hemiarthroplasty = replacement of femoral head
135
Describe the different types of hip fracture and generally how to treat them
* Extracapsular = involving or distal to intertrochanteric line
* Fix
* DHS
* IMN
* Intracapsular = proximal to intertrochanteric line
* Fix (if young)
* Replace
* Hemiarthroplasty
* THR
136
What is the NICE criteria for THR eligibility?
* Able to mobilise independently outdoors with 1 stick or less
* Not cognitively impaired
* Midically fit for surgery and anaesthesia
137
Name a hip fracture classification system
Garden classification of intracapsular hip fracture:
* I = incomplete fracture
* II = complete but not displaced
* III = displaced
* IV = completely displaced
138
Describe the features of a hip fracture on x-ray
* Intra or extracapsular?
* Intertrochanteric line
* Displaced?
* Shortened - line from centre of femoral head
* Rotated - Lesser trochanter
* Shenton's line
* Ilio-ischio line
139
Name some complications of hip fracture
* Mortality - 20% of elderly at 90 days
* AVN of femoral head
* Damage to medial circumflex artery
* Dislocation of arthroplasty
* Loss of fixation
* Non-union
* Lower limb thromboembolic disease
140
What hand muscles does the median nerve innervate?
LLOAF:
* Lumbrical 1
* Lumbrical 2
* Opponens pollicis
* Abductor pollicis brevis
* Flexor pollicis brevis
141
What is septic arthritis? Common organism?
Destructive arthropathy caused by an intra-articular (joint space and synovium) infection
Mainly staph aureus
142
Name some risk factors for septic arthritis
* Bacteraemia
* Old age
* Immunosuppression
* RA
* Intra-articular injection
* IV drug use
* Prosthetic joint
143
Name some clinical features of septic arthritis
* Painful, swollen and red joint
* Fever
* Purulent synovial fluid
* Preceding history of trauma or infection
* Acute onset
* Irritability
144
How is septic arthritis investigated?
* FBCs (inc WCC, ESR/CRP, U&E, LFT, glucose
* Temperature
* Joint aspiration - M, C & S, urate crystals, gram stain
* X-ray
* Joint space widening
* Subluxation or dislocation
* Soft tissue swelling
* Destruction of sub-chondral bone
* US - effusion
145
How is septic arthritis treated?
Emergency!
* IV antibiotics
* Broad spectrum then specific
* 2 weeks IV then 4 weeks oral
* NSAIDs
* Open/arthroscopic drainage of affected joint with irrigation
* Gentle mobilisation after 5 days
146
Name some causes of AVN of femoral head
* Trauma
* Chronic steroid use
* Alcoholism
* Smoking
* SLE
* Chronic renal failure
* Diabetes
* HIV
147
Name some red flags of hip pain
* Night pain
* Inability to weight bare
* History of malignancy
* Rapid deterioration
148
What are the clinical features of meniscal tears?
* History of injury during sport (but able to carry on) after a tackle or twisting movement
* Painful, locked knee
* Can be chronic, nagging pain
* effusion
* Swelling **after** 24 hours
* Joint line tenderness
* Meniscal cyst (palpable over lateral joint line)
149
How are meniscal tears investigated?
* MRI - hyperintense line in meniscus
* X-ray (exclude RA)
* Arthroscopy
150
How are meniscal tears managed?
* RICE
* Physio
* Surgical arthroscopy
* Open meniscectomy
151
What are the clinical features of ACL tears?
* History of twisting or valgus strain injury
* Football/skiing/basketball/netball
* Unable to carry on
* Hearing/feeling a pop inside knee
* Swelling **within** a few hours
* Knee 'giving way' when turning
* Tense effusion
152
How are ACL tears investigated?
* Positive anterior drawer, Lachman's and pivot shift tests on examination
* MRI
* X-ray = potential avulsion of tibial attachment
153
How are ACL tears managed?
* RICE
* Analgesia
* Physo
* ACL reconstruction (arthroscopic) using hamstring tendon graft
154
What is osteocondritis dissecans?
Blood deprivation in the subchondral bone (AVN) causes fragmentation of cartilage and bone and free movement of this fragment inside the knee joint
155
How does osteochondritis dissecans present?
* Non-specific knee pain
* 'Mouse' in knee
* Locking
* Effusion
* Synovitis
* Movement restriction
* Crepitus
156
Name some predisposing conditions for a quadriceps tendon rupture
* Connective tissue diseases
* RA
* SLE
* Gout
* Renal impairment
* Steroids
157
What is a Baker's cyst?
Benign swelling of semimembranosus bursa which usually resolves spontaneously
158
What are the red flags of soft tissue lumps?
* \> 5 cm
* Deep to deep fascia
* Painful
* Enlarging
159
What are the red flags when considering a bone tumour?
* Night pain
* Rapid deterioration
* Pain out of proportion to what is expected
* Markedly raised inflammatory markers
* Significant weight loss
* \> 5% over 6-12 months
* Burning/parasthesia/numbness/weakness
* Abnormal FBC
* Pervious malignancy
160
What tumours metastasise to bone?
* Breast
* Prostate
* Kidney
* Lung
* Thyroid
(pairs)
161
Name some benign bone tumours and how they present
* Osteochondroma = cartilaginous outgrowth from cortex
* Pain-free lump
* Chondroma = cartliaginous growth in medulla or cortex of tubular bones (phalages/metacarpals)
* Osteoid osteoma = benign osteoblast tumour
* Progressive night pain in long bone
* Relived by NSAIDs
* Non ossifying fibroma
162
Name and describe some primary malignant tumours of bone
* Osteosarcoma
* Long bones of young adults (10-20yrs)
* Progressive night pain
* Can be caused by Paget's, familial or fibrous dysplasia
* Chondrosarcoma
* Flat bones of older adults (30-75yrs)
* Ewing's Sarcoma
* Long bones, pelvis, scapula of patients \<20yrs
* Onion skin appearance
* Small, round, blue cell tumour
163
How are human bites asssessed?
* Document appearance, location and damage to underlying structures (NC, tendons, joints)
* Assessif infected - red, swollen, discharge, fever
* Tetanus status
* Risk of infection?
* Risk of acquiring blood-borne viral infection?
* X-ray
164
How are human bites managed?
* Encourage bleeding
* Irrigate with warm water
* Analgesia
* Tetanus prophylaxis
* 7 day course of co-amoxiclav
* If risk of HIV - post-exposure prophylaxis
* Send pus/wound swab for culture
165
Name some common organisms in human bites
* Eikenella corrodens
* Staph aureus
* Streptococcus
* Corynebacterium
166
How are animal bites managed?
* Remove foreign bodies
* Encourage bleeding
* Irrigate
* Analgesia
* Prophylactic antibiotics
* Co-amoxiclav
* Metronidazole + doxycycline
* Tetnaus prophylaxis
* Assess rabies risk - bat bite/abroad
* Pus/wound swab cultures
167
Name some complications of bites
* Wound infection (cat\>human\>dog)
* Anxiety
* Fractures
* Sepsis
* Osteomyelitis
* Tetanus
* Scarring/disfigurement
* Viral infection (humans)
* Endocarditis
168
Name some common organisms in animal bites
* Pasteurella (multicoda/canis)
* Staph aureus/epidermidis
* Streptococcus
169
What is winged scapula?
Damage to the long throacic nerve causes winged scapula due to the inability of serratus anterior to hold the scapula against the ribcage
170
What is popeye sign?
Bulge in the belly of biceps muscle due to ruptured tendon
171
What does the musculocutaneous nerve innervate?
BBC
* Brachialis (flexion at elbow))
* Biceps brachii (supination/flexion of forearm)
* Coracobrachialis (flexion/adduction at shoulder)
172
What does the radial nerve innervate?
* Triceps bracii (elbow extension)
* Brachioradialis (elbow flexion)
* ECRL/B (wrist extension and abduction
* Extensor digitorum (MCP/IP extension of medial 4 fingers)
* Extensor digiti minimi (little finger extension)
* ECU (wrist extension and adduction)
* Anconeus (abduction of ulna during pronation)
* Supinator (supination of forearm)
* Abductor pollicis longus
* EPB (MCP/CMC thumb extension)
* EPL (extensor of all thumb joints)
* Extensor indicis proprius (extension of index)
173
What does the ulnar nerve innervate?
* Flexor carpi ulnaris (wrist flexion/adduction)
* Medial half of flexor digitorum profundus (DIP/MCP/wrist flexion)
* Hypothenar muscles
* Opponens digiti minimi
* Abductor digiti minimi
* Flexor digiti minimi brevis
* Medial 2 lumbricals (flex at MCP, extend at IPJ)
174
What does the median nerve innervate?
* Palmaris longus (wrist flexion)
* Flexor carpi radialis (wrist flexion/abduction)
* Pronator teres (pronation of forearm)
* Flexor digitorum superficialis (MCP/PIP flexion)
* Lateral half of FDP (DIP/MCP/wrist flexion)
* Flexor pollicis longus (thumb MCP/IP flexion)
* Pronator quadratus (forearm pronation)
* Thenar muscles
* Opponens pollicis
* Abductor pollicis brevis
* Flexor pollicis brevis
* Lateral 2 lumbricals
175
Draw out the brachial plexus
176
What is Erb's palsy?
Damage to C5 and C6 roots of brachial plexus
* Caused by birth injury/falling on shoulder
* Paralyses biceps, deltoid,brachilais and brachioradialis
* Policeman's tip
177
What is Klumpke's palsy?
Damage to the C8 and T1 roots of the brachial plexus
* Caused by clutching with hand falling from a height or birth injury
* Paralysis to intrinsic hand muscles and ulnar wrist flexors
* Claw hand
* Can cause Horner's syndrome
178
Describe the sensory distribution in the hand
179
Name the roots of the 5 upper limb nerves
* Musculocutaenous = C5-7
* Axillary = C5-6
* Median = C6-T1
* Radial = C5-T1
* Ulnar = C8-T1
180
What does the axillary nerve innervate?
* Teres minor
* Deltoid
* Sensory = regimental badge area
181
What muscles abduct the shoulder?
* Supraspinatus (0-15)
* Deltoid (15-90)
* Serratus anterior/latissimus dorsi (90-180)
182
What is the ulnar paradox?
* Distally damage = denervation to 2 medial lumbricals causing unopposed extension of MCP and flexion of IPJ
* Proximally = denervation to 2 medial lumbricals AND FDP
* FDP flexion of IPJ
* Less flexion = better looking claw
Closer to the paw, worse the claw
183
Name the branches of the Aortic arch
184
What is Volkmann's Ischaemic Contracture
Damage to the brachial artery causes fixed flexion deformity
185
What is Trendelenberg sign?
Damage to superior gluteal nerve (gluteus medius) causes hip drop to the opposite side
Gait = torso leans towards affected side
186
What does the femoral nerve innervate?
Anterior thigh muscles:
* Iliopsoas (flexion of hip)
* Quadriceps femoris (knee extension)
* Sartorius (hip flexion and knee extension)
* Pectineus (hip adduction and flexion)
187
What does the obturator nerve innervate?
Medial thigh (hip adductors)
* Adductor magnus
* Adductor longus
* Adductor brevis
* Obturator externus
* Gracilis
188
What does the sciatic nerve innervate?
Posterior thigh (hamstrings) = hip extension and knee flexion
* Biceps femoris
* Semitendinosus
* Semimembranosus
189
What does the deep fibular nerve innervate?
Anterior leg (dorsiflexion and inversion)
* Tibialis anterior
* Extensor digitorum longus (+ toe extension)
* Extensor hallucis longus (+ great toe extension)
* Fibularis tertius (+ eversion)
Dorsum of fott (toe extension)
* Extensor digitorum brevis
* Extensor hallucis brevis
190
What does the superficial fibular nerve innervate?
Lateral leg (eversion)
* Fibularis longus (+ plantarflexion)
* Fibularis brevis
191
What does the tibial nerve innervate?
Superficial posterior leg: Plantarflexion
* Gastrocnemius (+ knee flexion)
* Plantaris (+ knee flexion
* Soleus
Deep posterior leg:
* Popliteus (lateral rotation of femur on tibia)
* Tibialis posterior (inversion)
* Flexor digitorum longus
* Flexor hallucis longus
192
Name the roots of the lower limb nerves
* Femoral = L2-4
* Obtruator = L2-4
* Sciatic = L4-S3
* Common fibular = L4-S3
* Deep fibular = L4-5
* Superficial fibular = L4-S1
* Tibial = L4-S3
193
Name the dermatomes of the lower limb
194
Name the upper limb dermatomes
195
Name the upper limb myotomes
* Shoulder Abduction – C5 (axillary)
* Shoulder Adduction – C678
* Elbow Flexion – C5 (musculocutaneous)
* Elbow Extension – C7 (radial)
* Wrist Flexion & Extension – C67 (radial)
* Finger Flexion – C8 (median)
* Finger Extension – C7 (radial – posterior interosseous)
* Finger Abduction – T1 (ulnar)
* Abductor pollis brevis – T1 (median)
196
Name the lower limb myotomes
* Hip Flexion – L2 (femoral)
* Hip Extension – L5 (inferior gluteal)
* Knee Extension – L34 (femoral)
* Knee Flexion – S1 (sciatic)
* Ankle Dorsiflexion – L4 (deep peroneal)
* Ankle Plantarflexion – S1 (tibial)
* Great toe flexor – L5 (deep peroneal)
197
Describe the lower limb arterial anatomy
198
Describe the lower limb venous anatomy
199
Describe the upper limb arterial anatomy
200
Name the special tests of the shoulder exam
* Jobe's (supraspinatus) = resistance against 90º abduction and 30º flexion
* Painful arc
* Infraspinatus = external rotation against resistance
* Gerber lift off (subscapularis) = push against resistance with hand behind back
* Biceps = flexion against resistance
* Scarf test (ACJ) = push arm against opposite shoulder
* Hawkin's (impingement) = arm down in 90º
* WInged scapula = push against wall
201
Describe the process of fracture healing
202
What is Bennett's fracture?
Intra-articular fracture of the base of the 1st (thumb) metacarpal
* Usually via hyperabduction
* Treat with closed reduction and K wire fixation
203
What is Boxer's fracture
Fracture to 5th (little) metacarpal neck
* Posterior displacement of distal fragment
204
Name some clinical features of a scaphoid fracture
* History of FOOSH with forced dorsiflexion
* Tenderness in anatomical snuffbox and palmar/volar surface of scaphoid
* Fullness in snuffbox = effusion
* Pain when gripping
205
How should scaphoid fractures be investigated?
Scaphoid series films (PA wrist in ulnar deviation)
206
How are scaphoid fractures managed?
* Below elbow cast, in neutral position for 8 weeks
* Displacement of \>1mm or angulation requires ORIF with compression screw
207
Name some complications of scaphoid fractures
* Non union
* Increase with proximal fractures due to distal to proximal blood supply
* Avascular necrosis
* Increased with proximal and displaced fractures
* Treat with IF and bone graft
* Degenerative change
208
What nerve is at risk in a lunate fracture?
Median
209
What is a Colle's fracture?
Fracture of distal radius with posterior displacement of wrist/hand
* Dinner fork deformity
* Caused by FOOSH, forced dorsiflexion
210
Describe the x-ray appearance of colle's
22, 11, 22 rule: Any loss of:
* Volar tilt 22º
* Radial height 11mm
* Radial incline 22º
211
What are the major complications of Colle's?
* Ulnar styloid fracture
* Scapholunate dissocation
* Median nerve damage
212
What is a Smith's fracture
Fracture of distal radius with ANTERIOR displacement of wrist/hand
* Garden space deformity
213
How are Colle's/Smiths fractures managed?
* Undisplaced and stable = below elbow plaster immobilisation for 6 weeks
* Displaced and stable = closed reduction and plaster for 6 weeks
* Displaced and unstable = closed reduction and K wires/EF/ORIF with plates and screws
* Intra-articular = locking plates
214
What are Galeazzi's and Monteggia's fractures?
Fractures of the radius and ulnar shaft
* Galeazzi's = proximal radial fracture with dislocation of ulna at radio-ulnar joint
* Monteggia's = proximal ulna fracture with anterior dislocation of radial head
215
How are fractures of the ulna/radius managed?
* Undisplaced = above elbow cast
* DIsplaced = ORIF
216
Name some complications of supracondylar fractures
* Ulnar nerve damage (most common) = ulnar claw
* Brachial artery damage = Volkmanns
* Median nerve damage = Hand of Benediction
* Compartment syndrome
* Cubitus varus
217
How are fractures involving the growth plate (epiphyseal plate) in children classified?
Salter Harris classification (SALTR)
* Slip
* Above
* beLow
* Through
* cRush
218
Name some complications of clavicle fracture
* Non union
* NV injury - brachial plexus
* Neurovascular compression - costoclavicular syndrome/thoracic outlet syndrome
* Pneumothorax from bony penetration into pleura
219
How are ankle fractures classified?
Weber classification
The more proximal the fracture the higher risk of syndesmotic disruption and ankle instability
* A = below syndesmosis
* B = at level of syndesmosis
* C = above syndesmosis
220
What are the Ottawa ankle rules?
Determine if a patient with a traumatic ankle/foot requires a radiograph. Ankle:
* Point tenderness at posterior edge (of distal 6 cm) or tip lateral malleolus
* Point tenderness at posterior edge (of distal 6 cm) or tip medial malleolus
* Inability to weight bear (four steps) immediately and in emergency department
Foot:
* Point tenderness at the base of the fifth metatarsal
* Point tenderness at the navicular
* Inability to weight bear (four steps) immediately and in emergency department
221
What is the difference between a unimalleolar, bimalleolar and trimalleolar fracture?
* Unimalleolar = medial or lateral malleolus fracture
* Bimalleolar = medial AND lateral malleolus fracture
* Trimalleolar = medial, lateral AND posterior malleolus (distal posterior aspect of tibia)
222
How are ankle fractures managed?
* Reduce immediately in A&E
* Apply below-knee cast
* Stable (Weber A/B) - below-knee cast for 6 weeks
* Unstable (Weber B/C with talar shift) - ORIF
223
Name the signs and symptoms of cauda equina syndrome
* Severe back pain
* Lower motor neurone deficit
* Sensory loss
* Saddle anaethesia
* Urinary retention/overflow incontinence
* Constipation/overflow faecal incontinence
* Decreased anal tone
224
How is cauda equina treated?
* Urgent MRI spine within 4 hours
* Immediate neurosurgical referral
* Urgent spinal decompression with 1 day
IPE
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