1
Q
De Quarvains patho
A
Thickening of tunnel in which APL and EPB travel through
Pregnancy known aetiology, hormones?
2
Q
Symptoms of de quarvain’s tenosynovitis syndrome
A
Pain on using thumb felt at side of wrist
Swelling
Stiffness
Trigger or catch
pain on the radial side of the wrist tenderness over the radial styloid process abduction of the thumb against resistance is painful
3
Q
Test for de quarvains tenosynovitis
A
Finkelstein’s test: with the thumb is flexed across the palm of the hand, pain is reproduced by movement of the wrist into flexion and ulnar deviation
4
Q
Treatment of de quarvain’s
A
NSAIDS Rest and Splint Steroid injection (thinning of skin at injection site Tendon release
5
Q
What is froments signs and why positive
A
- Froment’s sign
- Pinc paper
- Normally Adductor pollicis (flat and holds) with lumbricles (unless median)
- If not then Flexor policis longus and flexor digitorum profundus
6
Q
What is retropulsion and why?
A
Extensor pollicis longus spontaneous break.
Old ladies
7
Q
Important assessment in RA in hand?
A
Look at tendons
8
Q
Causes of swan neck defromity
A
Swelling/ inflammation of volar plate due to synovitis/ effusions, causes hyperextension at PIP
OR Traumatic from volar plate injury from hyperextension of digit e.g. basketball
9
Q
Causes of boutonniere deformity
A
Extention DIP
Flexion POP
Rupture of central slip over PIP joint so loss of extension of PIP (flexed), Extensor tendon slips down causing extension of DIP
ED splits into 3 at MCP joint
10
Q
Treatment boutonniere deformity
A
Spliont 6 weeks, encourage movement
Repair and relocate band
11
Q
UMN vs LMN
A
UMN
LMN
Reflexes
Increased (loss of
Absent
Tone
Increased/Spastic paralysis
Flaccid
Atrophy
None
Atrophy
Fasciculations
Absent
Present possibly
12
Q
What is Hoffman reflex?
A
- Flick middle finger
* Positive = UMNL amd flexion of terminal phalax of thumb
13
Q
How to assess motor of upper limb
A
- C5 -> Elbow flexion
- C6 -> Wrist extension
- C7 -> Elbow extension
- C8 -> like a cat
- T1 -> finger abduction
14
Q
upper limb neuro sensory
A
- Sensory – light and pin prick
- C4 -> Top of deltoid
- C5 -> anterior cubital fossa, lateral side, just proximal on bicep
- C6 -> Thumb dorsal aspect
- C7 -> Middle finger dorsal aspect
- C8 -> Little finger dorsal aspect
- T1 -> anterior cubital fossa, medial side, just proximal to elbow
15
Q
upper limb neuro motor
A
- Make easy for patient (active movements then put in full extension as easier)
- Stabilise patient – always hold appropriate joint
- C5 -> Elbow flexion
- C6 -> Wrist flexion
- C7 -> Elbow extension
- C8 -> like a cat
- T1 -> finger abduction
16
Q
Upperlimb reflexes
A
- C5,6 – Biceps tendon (pick up sticks) anjd brachioradalis
- C7,8 – Triceps tendon (lay them straight)
- Hoffman
- Flick middle finger
- Positive = UMNL amd flexion of terminal phalax of thumb
17
Q
Lower limb sensory
A
- L1 = lateral to gonad on anterior thigh
- L2 = halfway to knee anterior medial thigh
- L3 – Medial knee
- L4 – Medial malleuolus
- L5 – Just distal to dorsalis pedis
- S1 – Lateral posterior heel
- S2 – Posterior knee
- L1 = lateral to gonad on anterior thigh
- L2 = halfway to knee anterior medial thigh
- L3 – Medial knee
- L4 – Medial malleuolus
- L5 – Just distal to dorsalis pedis
- S1 – Lateral posterior heel
- S2 – Posterior knee
18
Q
Lower limb motor
A
- L2 – hip flexion
- March like soldier
- L3 – Knee extension
- Squat
- L4 – Ankle dorsi flexion
- Walk on heel
- L5 – Toe dorsiflexion
- Walk on heel barefoot
- S1 – plantarflexion ankle
- Walk on tip toes
- Anything wrong then examine on couch
19
Q
Lower limb reflexes
A
- S1/2 – ankle jerk (buckle my shoe)
* L3/4 – bicep brachii (kick the door)
20
Q
MRC power scale
A
0 No muscle contraction is seen or identified with palpatio; paralysis
1 Can’t produce joint motion even without gravity but seen or felt
2 Muscle can move joint across full range of motion if force of gravity eliminated
3 Full range against gravity but not resistnace
4 Full range of motion against moderate resistance
5 Full ROM aginst full resistance of examiner
21
Q
Where does the spinal cord end
A
L1/2
Anterior horn cells
22
Q
HOw many nerves may a disc herniation knock out
A
2 or more if central (Williams diagnram)
23
Q
hallux rigidus patho and cause
A
Unknown
Assoc
Trauma
24
Q
Hallux rigidus presentation
A
Lump
Pain
25
Hallux rigidus treatment
```
Foot orthotics, shoe modification
NSAIDS
Steroid injection
PT
Surgery
Osteotomy
Arthodesis - fusion better for men
Arthroplasty (surgical reconstruction)
Excision
Interposition (something between joint)
```
26
Hallux valgus pathophysiology/ RFs
```
RF
Female
Middle aged
Why?
Genetic element
Shoes contribute - high heels
Space between 1 and 2 MCP
Splaying
Tendon maintains line - extensor hallucis longus
Deviates and rotates toes
```
27
Hallux valgus Symptoms
```
1MCP swelling, diavtion and rotation
Hammer toe (2nd forced down)
Hyperextension of DIP, flexion of DIP
Overriding 1st toe
Callouses
```
28
Hallux valgus treatment
```
Treatment
Change shoe/ orthotics
NSAIDs
Do not operate for cosmetic reasons only if pain, second toe or ulceration
Metatarsal osteotomy
5% worse
Hypersensitivity
Stiffness
```
29
Pes planus pathophysiology
```
RF
Female
Middle age
Pathophys
Weakness/ rupture of tib post
```
30
Pes planus history
```
Progressive deformity
History of trauma
Pain behind MM
Also impingement of lateral side and pain
Pain starts medial and moves lateral
```
31
Pes planus signs
Weakness/rupture of tibialis posterior tendon
Test tibialis posterior by plantar flexing foot & inverting
Inability to invert = weakness of tibialis posterior
Too many toes (valgus - look at heel from behind)
Heels fail to turn to varus on tiptoes
32
Treatment pes planus
Insoles- medial arch support
PT
Surgery
Reconstruction if foot flexible
Planovalgus (triple fusion)/ athrodesis
No flexibility - cant walk on angle but pain free
33
Pes planus xray
Loss of straight line of talus with tarsal and metatarsal (Meary's angle)
Calcaneal pitch decreased - normally 20deg
34
Treatment of ankle arthritis
```
o Analgesia
o Modify activity
o Limit movement
o Surgical
Osteotomy
Arthrodesis (fusion) - good for pain but not movement)
Arthroplasty
• Excision (removing the joint)
• Interposition (tissue insertion between joint surfaces)
• Replacement
```
35
Causes of pes cavus
* Bilateral pes cavus in a young person Charcot-Marie-Tooth disease
* Unilateral pes cavus neurological
* High arch due to overactive tibialis posterior
36
Features of pes cavus
o Curling of 1st MTPJ
| o Heel varus at rest
37
What is Morton's neuroma and symptoms
• Benign neuroma affecting the intermetatarsal plantar nerve
o Commonly in the 3rd inter-metatarsophalangeal space
• Features
o Forefoot pain – 3rd inter-MTP space
o Worse on walking
38
Diagnosis of morton's neuroma
• Clinical diagnosis
| o USS may help
39
Management of morton's neuroma
• Management
o Avoid high-heels
o Metatarsal pad- splays two affected metatarsals/ orthotics
o Steroid injection/neurectomy of nerve & neuroma
40
Describe Weber classification of ankle
• Type A
o Fracture of the medial malleolus distal to the malleolus distal to the syndesmosis
Below level of ankle joint
Tib-fib syndesmosis intact
Deltoid ligament intact (not always
Medial malleolus often fractured
Usually stable open reduction & external fixation not needed, just do a cast
• Type B
o Fracture of fibula at level of syndesmosis
Syndesmosis intact or only partially torn
Medial malleolus may be fractured, or deltoid ligament torn
Variable stability
• Type C
o Fracture of the fibula proximal to the syndesmosis
Syndesmosis disrupted with widening of distal tib-fib articulation
Medial malleolus fractured or deltoid ligament injury
Unstable requires open reduction, internal fixation
41
Describe full course, branches and innervation of the common fib
```
Common fib L4-S2
Arises from Sciatic nerve at apex of pop fossa
Travels lateral to fibula neck- 2 cutaneous branches just before neck so spared in fracture
Sural nerve
Medial leg down to just below MM
Lat sural nerve
Lateral knee, lower thigh and leg
Slits into deep and superficial
superficial
lat compartment
Fib long and brev
After lat continues travelling round to innervate lower antlat leg and dorsum of foot (not between toes 1 and 2)
Deep
Tib ant
Extensor digitorum
Extensor hallucis longus
Fib terrt - MT5
Between toes 1 and 2 dorsum
```
42
Describe full course, branches and innvervation of tib
```
Tib nerve L4-S3
From pop fossa
Suferficial post comparment of leg
gastroc and soleus and plantaris
Tib post, flex digitorum, flex hallucis, Popliteus
Gives off sural
Posterio lateral leg
Post and inf to MM (tarsal tunnel)
Terminates by dividing:
Medial calcaneal
Medial plantar
Lateral plantar
```
43
Shoulder history key symptoms
```
• Pain (SQITARS)
o Onset – spontaneous, injury & mechanism
o Site – localised (AC joint), diffuse (cervical pain)
o Night pain
o Activity related
o VAS
o Analgesia
o Referred
• Stiffness (reduced ROM) (e.g. Frozen shoulder, arthritis)
o Loss of active movement
o Passive restriction
o Overhead activities
o Diabetes
• Weakness
o Pain
o Cuff tear
o Nerve palsy – axillary, long thoracic
• Instability
o Caused by muscle imbalance, ligament laxity
o Activities producing instability
o Trauma
o Arm ‘feeling dead’, ‘popping out’
o Voluntary – doesn’t need treatment
• Swelling
o Subdeltoid bursitis
o ACJ dislocation
o Malunion clavicle
o ACJ OA – osteophytes
o Infection
o Cuff tear arthropathy
o Dislocated head
o Fractures
• Neuropathy
o Pressure on the plexus
o Radiation from the neck
```
44
Spine red flags
```
x Age, weight loss, fever, widespread neurology
History of cancer, infection
Steroids / Drug abise
>55 <17
Non-mechanical pain
Thoracic pain
Night pain
Trauma history
```
45
Good questions if RTA
o Seatbelt/airbags/headrest?
| o Anyone ejected or killed?
46
How to present a ortho xray
• BLT LARD
o Bone, Location of bone, Type of fracture
o Lengthening, Angulation (radial inclination), Rotation, Displacement
47
Cauda equina symptoms
```
o Bilateral/unilateral sciatica
o Perianal/peri-genital numbness
o Painless retention of urine
o Urinary/faecal overflow incontinence (LMN sign)
o Loss of sexual function
```
48
Cauda equina pathogenesis and prognosis
• Commonly an extradural compression (disc compression) leading to ischaemic insult
• Progressive neuro-deficit permanent loss of sphincter control + motor paralysis + sensory loss of legs
o Prognosis better with decompression before sphincter paralysis
o Once paralysis develops recovery uncertain & likely to be incomplete
49
Cauda equina investigation
DRE
- Sensation - blunt and sharp
- squeeze
- cough
Percuss bladder
MRI
Bladder scan (post void residue)
50
Cauda equina management
Urgent decompression
51
Tumour/ mets to back investigations
T2 MRI - better for bodies/ bone marrow
| Xray - winking owl sign (loss of pedical between vertebrae and transverse process)
52
Management of back mets
o MRI – whole spine
o Staging/diagnostic CT CAP
o FBC, U&E, serum calcium, clotting screen
o Myeloma screen, other tumour markers
• Treatment
o Dexamethasone 16mg/day - decrease oedema around corn/ stop compression
o Keep patient supine if spine unstable
o Surgery indicated for
Stabilising spine
Decompress spinal cord to prevent paralysis
Severe pain from mechanical instability
53
Infection of spine name and path
infective spondylodiscitis
Inflam or vertebral disc and vertebrae (spares arch)
Worldwide - TB
UK - staph aureus
54
Complications of infective spondylodiscitis
o Vertebral collapse
o Progressive angular kyphosis - bony destruction
o Extradural & paravertebral abscess
55
Management of infective spondyldiscitis
```
o Diagnosis often delayed (avg. 12 weeks)
o Establish microbial diagnosis
Blood culture/sputum specimen
o Antibiotics
6-12 weeks in non-TB
6-12 months in TB
o Surgery indicated in
Paralysis from spinal cord/cauda equina compression
Drainage of paravertebral abscess
Mechanical instability
• Progressive deformity
• Severe pain on loading
```
Always stabalise/ decompress
56
Cervical spondlytotic myelopathy pathology
• Progressive damage to the cervical spinal cord due to
o Central stenosis – arthritic change in spinal cord, narrowing of pinal canal, pinch cancal or cauda equina
caused by wear & tear
57
Symptoms of cervical spondylotic myelopathy
o Sensory/motor loss with incoordination e.g. holding fork, but and leg weakness
o Loss of dexterity & poor balance
o Bowl/ bladder symptoms and sexual disfunction
o Progressive in over 90% of patients over a 5-yr period
o UMN signs
o LMNS at level of spinal cord compression
o Pain upper neck
58
neurogenic claudication pathophysiology
lumbar spinal stenosis impingement, ischaemia of lumbosacral nerve roots secondary to compression
59
Neurogenic claudication symptoms
Back pain worse supine/ standing e.g. relieved sitting
Better when spine is flexed e.g. walking uphill
Improves with movement
Variable distance (vasc is fixed)
Relieved in minutes (unlike vasc which is seconds)
Proximal to distal
Assoc with numbness and parasthesian
60
Neurogenic claudication treatment
```
NSAID
PT
Steroid
Weight reduction
Surgical decompression
Interspinous distraction procedure e.g. insert device
```
61
Neurogenic claudication exam
Flexed posture
Loss of lumbar lordosis
Check peripheral pulses
62
Sciatica presentation
• Sudden onset (usually)
• Specific localised pain down to foot
o L3/4 – L4 root (anterior thigh to knee, shin)
o L4/5 – L5 root (lateral calf, medial/dorsal foot)
o L5/S1 – S1 root (posterior calf, lateral/plantar foot)
• Often associated with pins & needles
• Cough-impulse pain rise in intradural pressure
63
Sciatica patho
Spondylolithesi, spinal stenosis, spondylolisthesis, piriformis syndrome
64
What is Spondylolisthesis
Slippage of one vertebrae compared to another
65
Sciatica treatment
o 80% resolve in 3 months
o Short period of bedrest (2-3 days)
o Staying active & mobile within limits
o Analgesics – NSAIDs, codeine-based opiates
o Neuromodulating drugs – gabapentin, pregabalin
o If unresolving,
Epidural/nerve root block with LA
Lumbar discectomy successful in 90% patients in relieving neuropathic leg pain
66
PAget's cause/ path
• Disturbance of both osteoblast and osteoclast activity
o Excess breakdown & formation of bone, followed by disorganised bone remodelling
o Frequently affects pelvis, spine, skull & proximal long bones
• Pathogenesis – 4 stages
o Osteoclastic activity
Increased rate of bone resorption in localised areas
Localised osteolysis seen radiologically
o Mixed osteoclastic-osteoblastic activity
Compensatory increase in bone formation by osteoblasts
o Osteoblastic activity
Accelerated deposition of lamellar bone in a disorganised fashion
• Chaotic picture of trabecular bone (‘mosaic’ pattern)
o Malignant degeneration
Resorbed bone is replaced
Marrow spaces filled with excess hyper-vascular fibrous connective tissue
• Causes
o Viral
o Genetic
67
Paget's symptoms
```
o First is raised ALP
o Bone pain/back pain
Localised pain/tenderness
o Bone weakening
o Misshapen bones
o Fractures
o Arthritis in joints near affected bones
o Increased temp due to hyperaemia
o Kyphosis/ Bowing deformity
o Decreased ROM
o Spine/ pelvis/ skull/ proximal long bones
```
68
Xray signs
```
o Spine
Cortical thickening & sclerosis
Squaring of vertebrae
o Skull
Cotton wool appearance
More b
```
69
Paget's disease treatmetn
Bisphosphonates
70
Acute disc herniation pain exaccerbated by?
Cough
71
Acute disc herniation prog?
8/10 spontaneous resolution with time
72
Diff between mech and inflam back pain
Inflammatory back pain (IBP) is typically improved with activity and not relieved by rest,
as opposed to mechanical pain which is worse with activity and is relieved by rest. IBP
can wake the patient in the early hours of the morning and sacroilieitis can radiate to the
thigh, but these features are much less specific. Morning stiffness is specific for
inflammatory back pain but not persistent daytime stiffness. IBP can occur at any age
although mechanical pain is less common in young people.
73
Commonest conditions of shoulder at different ages
* 10-30 Instability (dislocation), fractures
* 40-60 Impingement, adhesive capsulitis, inflammatory arthropathy
* 60-80 degenerative cuff tear, OA, cuff arthropathy
74
Treatment of shoulder OA
o NSAIDs
| o Shoulder replacement if rotator cuff is intact
75
Adhesive caps what and stages
Probs sleeping/ depression, RF chronic disease
3 stages
1 – ‘freezing’ stage. Slow onset of pain, ROM loss. 6 weeks 9 months.
2 – ‘frozen’ stage. Slow improvement in pain but stiffness remains. 4 9 months
3 – ‘thawing’ stage. Shoulder ROM slowly returns to normal. 526 months – doesn’t become normal in DM
76
Stabalising factors in shoulder
* Labrum
* Ligaments (sup. Mid. Inf. Glenohumeral ligaments)
* Capsule
* Muscles
* Negative pressure
* Contact
77
Adhesive caps treatment
Stage 1 – NSAIDs, painkillers, and steroid injections in the joint
Stage 2 – MUA/distension arthrogram (hydrodialtion)/leave alone
Stage 3 – leave alone
Physio may worsen condition
78
Impingement/ tendonitis symp and treat
```
Activity modification
Pain killers
Steroid + LA injection (only 1/3 improve) max. of 3, 6 weeks apart
Physiotherapy may help
Subacromial decompression
```
79
Rotator cuff injury examination and treatment
o Examination
Muscle wasting/weakness, crepitus
Reduced active movement, normal passive ROM
o Treatment
Rotator cuff repair – arthroscopic, open
Physiotherapy
80
Os Acromiale
o Failure of fusion of the acromion process
| o Asympmatic but can cause subacromial impingement syndrome
81
Anterior shoulder dislcation
```
o Bankart lesion
Injury to anterior glenoid labrum
o Hill-Sachs lesions
Humeral head compression fracture – hits posterior glen
o Treatment
Neutral/external rotation splint
Surgery
• Arthroscopic stabilisation
• Open Bankart repair
```
82
Tennis elbow treatment
```
Rest, NSAIDs
Physiotherapy
Splint
Steroid injection
Surgery
```
83
Elbow young people
```
• Young
o Pulled elbow (radial head subluxation) [annular ligament]
o Fractures
Supracondylar
Humerus
Epicondyles
Radial neck
o Infection
```
84
Elbow older people
```
• Older
o Lateral epicondylitis (micro-tear at origin of ECRB)
o Medial epicondylitis (micro-trauma of flexor pronator mass)
o OA
Elbow locking due to loose bodies
o Fractures
Radial head
Olecranon
Distal humerus
o Nerve entrapment
Ulnar nerve
Posterior interosseous nerve (deep branch of radial nerve, supplies most extensors in forearm. Trapped at angle of Frohse part of the supinator. Finger drop and radial wrist deviation on extension.
Median nerve
```
85
Elbow symptoms
* Pain
* Swelling
* Stiffness
* Locking
* Neurological
* Instability
86
When to treat elbow fractures?
treat fractures if the anterior humeral line or radiocapitellar line are no longer intact.
87
What is a Monteggia fracture/
o Proximal 1/3 ulna fracture with dislocation of the proximal radial head.
o Needs re-alignment with surgery
88
Calcific tendonitis path and symptoms
```
Path
Hydroxyapatite (CaPo4) in any tendon )often rotator cuff
Assoc with adhesive capsulitis
Symp/ sign
Pain on abduction
Pain on lying on shoudler
May wake person from sleep
Stiffness
Weakness
Can present acute on chronic
Cause
Unknown
```
89
Calcific tendinitis diag/ treatment
```
Spontaneous improvemetn
NSAID
Steroid
Physio
ECSW therapy
Surgery
High success to remove deposits
```
90
What is Personage-Turner syndrome RF and symptoms
x
91
Personage-Turner syndrome treatment and prognosis
x
92
Septic arthirtis RFs and Symptoms
```
Advancing age
RA
Bactaraemia
Immunocompromised
Prosthetic joins
Intra-articular injections
Symptoms
Severe pain on any movement
Swelling
Erythematous
Temp
Pos bloods
Irreversible joint damage after 48hrs of onset
May lead to osteonecrosis
```
93
Septic arthritis treatment and investigation
```
Investigation
XR
Adjunct if cant aspirate
Often normal
Effusion -
Juxta artic osteoporosis (hyperaemia)
Cartilage destruction in acute phase
Blood
Infection
Cultures
Ues - abx
Aspirate - purulent fluid
Gram stain and culture
```
```
T
Abx
Often IV 2 weeks or improgvement
Oral for 4 weeks
Fluclox or 2nd/3rd gen cephalosporin cerfuroxime
Aspirated to dryness, may need multiple
```
94
Trochanteric bursitis all
Greater trochanteric pain syndrome • Causes/ DDX
o Bursitis (GTPS), tendinitis, degeneration, referred back pain
• Usually localised postero-superior tenderness – walkin gor lying
• Trendelenburg test
• Cray, US, MRI may show tears or swlling but often useless
• Treatment
o Heat/cold
o NSAIDs
o Physiotherapy
o Injection
o Surgery
• Examine in lateral
95
Femoro-acetabular impingement
• Pincer
o Abnormally shaped acetabulum – over the top
• Cam
o Abnormally shaped femoral head – blocks
• Mixed
• Precursor to OA
96
AVN hip
• Gradual progression
• Cartilage gets nutrition from the synovial fluid so remains intact as the bone degenerates
• Causes
o Alcohol, steroids, transplant, liver disease, trauma, age 30-50
• Investigations
o X-ray & MRI to diagnose & stage
• Treatment
o Decompression
o Arthroplasty
97
Hip infection
```
• Common in children (septic arthritis)
o Differentiate from irritable hip/transient synovitis, growing pains
• Destroys cartilaginous hip
• Symptoms
o Severe pain
o Fever
o Systemic sepsis
o Very stiff
o Unable to weight bear
• Investigations
o XR – normal
o USS – fluid in hip
o CRP, WBC raised
o Aspiration of joint
• Treatment
o Urgent decompression/washout
```
98
DDH
• Presentation
o Femur not covered by acetabulum so risk of dislocation
o Neonate (<6wks)
Breach birth
Family history
o Starting to walk
Painless limping infant
Leg length discrepancy
Reduced ROM
• Barlow + Ortolani tests
o Barlow adduction + knee pressure (posterior force) – feel fro popping out
o Ortolani abduction + anterior pressure on greater trochanter. Confirm barlow , relocates hip after barlow
• Investigations
o <6wks – USS (femoral head has not ossified)
o XR otherwise
• Treatment
o Braces
o Surgery – put femoral head into acetabulum. Casting
o Neonates have a better outcome
99
Perthes disease
```
• AVN in a growing child
o 4-9 yrs old
• Signs/symptoms
o Hip, knee or groin pain exacerbated by movement
o ROM reduced
o Limp
• XR changes
o Widening of the joint space
o Decreased femoral head size/flattening
• Treatment
o Self-limiting – will revascularize
o Avoid weight-bearing on the affected side
Crutches for 2 years
No activity
```
100
Slipped upper femoral epiphysis (SUFE)
```
• 9-14 yr old children
o Commoner in obese boys
• Symptoms/signs
o Gradual onset
o Pain – groin, thigh, knee
o Limp
o Unable to weight bear (serious sign)
o Loss of internal rotation
o Hip may be fixed in external rotation
o Bilateral common
• Treatment
o External in-situ pinning
o Open reduction & pinning
```
101
Describe cause of petellofemoral pain syndrome and ddx
```
DDX chondromalacia patella, patellar tendonitis
Problem with PF joint
Trauma
Overuse
Anatomical/ biomech abnormaliy
e.g. runners, cyclers (runners knee)
```
102
Examination of arthritic knee
get fluid in knee - sweep or patella tap positive
Limited in movmenet
Flexion deformity
Limitation of flexion 10-90 for e.g.
May be bowed
Lateral thrust (sway to outside with weight)
103
Petellofemoral pain syndrome symptoms and treatment/
```
Signs and symptoms
Predominantly in front of knee
Downstairs/downhill
Feeling of downhill
Pain when knee flexed
Pseudolock due to grating of patellofemoral knee
Sweliing
Crepitus and irritability
Rule out other knee
Physiotherapy (80% improve), injection, PFJ replacent, TKR
```
104
Meniscal tear
```
• History
o Twisting or hyperflexion injury or degenerative knee. Twisting turning cutting
• Signs/symptoms
o Locking, swelling
o Joint line tenderness (precise)
• Examination
o MRI
• Treatment
o Arthroscopy – repair or excision
```
Swelling >24-48 hours then meniscal as less blood supply to meniscus/ <24 then ACL
105
ACL rupture
```
• History
o Planted foot injury, body takes force causing twisting (or valgus force to knee
• Signs/symptoms
o Acute swelling, cannot continue
o Giving way, lack of trust in knee
• Examination
o Lachman test, pivot shift test
o MRI
• Treatment
o Physiotherapy
o ACL reconstruction
```
106
Osteochondritis dissecans
```
• Cracks in the articular cartilage and underlying subchondral bone. Bone underneath dies and gets crushed but cartilage ok
• History
o Teenage – middle aged
o Pain in the knee
o Swelling, occasional locking
• Investigations
o XR, MRI
• Treatment
Immobilisation
o Arthroscopic stabilisation excision
```
107
Cause lipohaemarthosis
Lateral tibial plateau fracture
108
Would you ever do internal fixation for NOF?
Youung, need lots of replacments anyway
| If non-displaced then less risk of AVN
109
What is the Nottingham hip fracture score?
o Age, sex, AMTS, Hb on admission, Residence, comorbidities, active malignancy in last 20 yrs
110
Describe numbers in the wirst e.g. angles and length
* Distal radius sits 2mm more distally than the ulna.
* Radial inclination is at 22O from medial to lateral.
* Radial volar tilted at 11O
111
Flexor carpi ulnaris is where?
o Pisiform
| Next to FCU
112
Describe salter Harris classification
type I
slipped
5-7%
fracture plane passes all the way through the growth plate, not involving bone
cannot occur if the growth plate is fused cit
good prognosis
type II
above
~75% (by far the most common)
fracture passes across most of the growth plate and up through the metaphysis
good prognosis
type III
lower
7-10%
fracture plane passes some distance along the growth plate and down through the epiphysis
poorer prognosis as the proliferative and reserve zones are interrupted
type IV
through or transverse or together
intra-articular
10%
fracture plane passes directly through the metaphysis, growth plate and down through the epiphysis
poor prognosis as the proliferative and reserve zones are interrupted
type V
ruined or rammed
uncommon <1%
crushing type injury does not displace the growth plate but damages it by direct compression
worst prognosis - plate is crushed
Injuries of Types III, IV and V will usually require surgery. Type V injuries are often associated with disruption to growth.
113
Diff between intretrochanteric crest and ridge?
Intratrochanteric ridge on posteroor shows as line not intratrichanteric line
114
Other artery that may be dominant to NOF
Inferior gluteal artery also be dominant
115
What determines hip replacement over hemi
Activity, walk with more than stick? co morbidities
116
Conserve treatment for NOF
6-8 weeks of discomfort
Walking aid but can walk
Patients may not want to stay in hospital for 6 weeks
117
Conserve treatment for NOF
6-8 weeks of discomfort
Walking aid but can walk
Patients may not want to stay in hospital for 6 weeks
118
Investigations into cancer
• Urine dip
o Blood, protein, infection
• FBC
o FBC (anaemia), WBC (raised), platelets (raised in 1o blood cancer)
• U&E/glucose
o Kidney function
• Bone profile/LFT (check for liver mets)
o Serum calcium (hypercalcaemia), ALP, ALT, bilirubin
• TFT
• PSA
• ECG
• Blood cultures
• Myeloma screen – serum electrophoresis
• X-ray
```
Local CT/MR
Staging CT scan
PET?
Radioisotope bone scan - gamma - mets throughout skeleton
Myeloma no contrast in bladder
```
119
DDX cancer and history?
```
• Prostate
o Stream (dribbling, hesitancy)
o Nocturia
o Haematuria
o Prostate cancer commonly show sclerotic lesions on XR
• Renal
o Lethargy (anaemia)
• Lung (bronchus)
o Smoking history
• Thyroid
o Can be asymptomatic
o Nodules
o New onset AF
o Hyper/hypothyroid symptoms
• Breast
```
120
Commonest primary cancer
* Most common primary bone tumour is myeloma (40%)
| * XR more commonly shows osteolytic lesions
121
Describe a bone cancer on xray
```
Area shown
Bone
Part of the bone (epi/meta/diaphysis)
Primary appearance
Zone of transition
Periosteal reaction
Soft tissue involvement
```
122
Complications of a long bone pathological fracture, prevention?
* Blood loss
* Pulmonary embolus
* Fracture non-union
* Implant failure
* Slow functional recovery
* All risks reduced with prophylactic fixation
123
Treatment aims with mets
* Pain control
* Prevent and treat fractures
* Maintain & improve function
* Treat the tumour
124
Types of primary bone tumours and location
```
Osteosarcoma
• Affects younger population (20s) mainly but elderly as well.
• Distal femur and proximaln tibia
• Assoc with Pagets disease
Chondrosarcoma
Axial skeleton in older patients e.g. vertebrae, pelvis, ribs
Lymphoma
Ewing sarcoma
• Younger population
Myeloma
alcohol, obesity, fx,
cause kidney probs from abs
spine and ribs
localised pain = fracture
Treatable but incurable
```
125
Describe the Gustillo and Anderson grading of fractures
o Grade 1
Puncture from within out
Skin wound less than 1cm
No comminution (splintering)
No periosteal stripping
Minimal soft tissue injury
o Grade II
Skin wound greater than 1cm but less than 10cm
Minimal periosteal stripping
Minimal comminution
Minimal soft tissue injury
o Grade III (bad)
Any high energy injury (greater than fall from standing, walking)
Any injury with contamination (farmyard, open water)
Skin wound greater than 10cm
Periosteal stripping
Comminution present
• III A – wound can be covered from existing tissue (opposable & closable wound)
• III B – requires soft tissue cover, local or distant flap - 30-35 weeks off work
• III C – vascular injury
• Infection, amputation & fracture healing correlates with grade of injury
126
How to assess open fracture
```
• Pulses
• Nerve function
o Motor
o Sensory
• Soft tissue integrity
• Contamination
• Compartment syndrome
• X-ray
```
127
How to treat an open fracture
• IV access
o Bloods – FBC, U&E, glucose, Group & Save, INR
o Analgesia & anti-emetics
Morphine 10mg, Cyclizine or metoclopramide
o IV antibiotics + tetanus prophylaxis within 3 hrs of injury
Co-amoxiclav 1.2g TDS IV
o Fluids
• Control bleeding/remove debris
o Wash/ irrigate (not NICE guidance) obvious contam (not hours), remove leaves/ manure
o Direct pressure. Do not blindly clamp tourniquet
• Tetanus status?
• Take photograph
• Dressing
o Soaked In saline
• Stabilise
o Re-align, splint (plaster back slab)
• Repeat neurovascular exam
• Xray
• Refer to orthopaedic surgeon +/- plastic surgeon
• Anaesthatist
• Confirm NBM & document
• Hand over & admit onto ward
o Write instructions and prescriptions
128
When to operate on open fracture?
Within 24hrs or 12hrs G3 but ASAP if IIIc or dirty
129
Compartment syndrome pathophys
• Raised pressure within an enclosed fascial space leading to metabolite build up
• Pathogenesis
o Compartment syndrome has a swelling haematoma = increased compartment pressure
o Occludes veins (due to lower pressure) resulting in an outflow problem
o Arterial pressure maintained (so pulses present)
Eventually, arterial pressure shut off acute ischaemia
130
acute signs of compartment syndrome
o Pain
o Swollen tense compartment
o Paraesthesia, hypoesthesia
o Passive stretch causes compartment pain
o Pulse still present (pulseless = late sign)
131
Diagnosis of compartment syndrome
o Clinical
o Compartment pressure monitoring
>40mmHg
Pressure differential 30 mmHg below diastolic blood pressure
132
Management of compartment syndrome
```
o Get rid of backslab/ extrinsic compression
o Immediate surgical decompression
Dermatofasciotomy
2 cuts for 4 compartments
o Debridement of necrotic tissue
o Skeletal stabilisation
o Treatment of underlying cause
```
133
Non-union of bones DDX
(SPLINT)
o Soft tissue interposition
o Position of reduction (too much traction, immobilisation, movement)
o Location (e.g. lower 1/3 of tibia slow to heal)
o Infection
o Nutritional (damaged vessel)
o Tumour
134
What is clubfoot
Talipes equinovarus
```
• Common condition
• Foot inverted + plantar flexed not correctable
• Affects every level of the foot
o Ankle, subtalar joint, mid-talar joint
• Treatment
o Commence soon after birth
o Ponseti treatment
Plaster foot into correct shape
```
135
What is Chronic regional pain syndrome
• Stages: 1- acute, II-dystrophic, III-atrophic/ contractures
136
WHat is hyperalgesia/ Allodynia
```
• Central sensitisation disorder
o Hyperalgesia/allodynia
Hyperalgesia – won’t let you touch it
Allodynia – won’t let you move
• Pain catastrophisation
o High sensitivity to pain
• Yellow flags attitudes, beliefs, compensation, diagnosis, emotions, family, work (school)
```
137
What is Leriche syndrome?
1. Claudication of the buttocks and thighs
2. Atrophy of the musculature of the legs
3. Impotence (due to paralysis of the L1 nerve)
therosclerotic occlusive disease involving the abdominal aorta and/or both of the iliac arteries
138
What is a ganglion?
A ganglion presents as a 'cyst' arising from a joint or tendon sheath. They are most commonly seen around the back of the wrist and are 3 times more common in women
Ganglions often disappear spontaneously after several months
139
What i sMEralgia parasthetica
compression of lateral cutaneous nerve of thigh due to the sudden weight gain.
typically burning sensation over antero-lateral aspect of thigh
140
Osteogenesis imperfecta
Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine.
Failure of maturation of collagen in all the connective tissues.
Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.
141
Why do hip replacements need to be revised?
Aseptic loosening
142
What is a Charcot joint
The x-ray shows extensive bone remodeling / fragmentation involving the midfoot. In combination with the presence of a swollen, red, warm joint in a patient with a history of poorly controlled diabetes is highly suggestive of a Charcot's joint.
143
Osteomyelitis presdisposing feaetures
x
144
Osteomyelitis presentation
x
145
Osteomyelitis organism, investigation and treatment
x
146
investigations in pre assessment clinic
o FBC, G&S, HbA1c, U&Es + glucose, ECG, CXR, MRSA screen, urine dip + culture, X-ray of joint
147
What to do if low Hb on pre assessment?
```
• History
o GI symptoms (+/- OGD, flex sig)
o GU symptoms
• Investigations
o Haematinics
B12, folate, transferrin
• Rapid access anaemia clinic
• Postpone surgery
```
148
High glucose at pre assessment?
* Do not operate on undiagnosed diabetics
* Blood glucose control should be optimised
* Refer to diabetes team if Hba1C >8.5%
149
Risks of hip surgery?
* DVT risk 13-16%, PE risk 0.3%
* Operation failure
* Death (less than 1 in 100)
* Bleeding + blood transfusion (10-15% chance, depends on entry Hb)
* Infection 1%
* Damage to nerve & vessels
* Dislocation
150
What medication to prescribe at pre op?
```
• Existing medications
• Antibiotics – ‘at induction’ in anaesthetic room
o Co-amoxiclav (augmentin) 1.2g
3 times induction, 8 hrs post op, 16 hrs post op
o If penicillin, teicoplanin 400mg & gentamicin 1 time at induction
• Anticoagulants – Dalteparin (given 6pm following surgery in elective orthopaedic surgery)
o Early mobilisation
o Compression stockings
o LMWH or dabigatran(?)
• Analgesia
o Paracetamol 1g QDS
o Opiates (watch for constipation, resp. depression)
• Laxatives
o Fybogel or similar bulking agent first
o Senna or similar stimulant next
• Antiemetics
o Cyclizine
o Metoclopramide
o Ondansetron – more anasthetics use
• TED stockings
```
151
SubTrochanteric fracture and mobility not an issue?
Intramedullary nail
152
Talk about psoas abcess
```
Staph aureus or strep.
Immuno suppressed or IVDU
Fever and severe pain
Pain with straight legs
Abx +/- drainage
```
153
Who should be assessed for osteoporosis?
They advise that all women aged >= 65 years and all men aged >= 75 years should be assessed. Younger patients should be assessed in the presence of risk factors, such as:
previous fragility fracture
current use or frequent recent use of oral or systemic glucocorticoid
history of falls
family history of hip fracture
other causes of secondary osteoporosis
low body mass index (BMI) (less than 18.5 kg/m²)
smoking
alcohol intake of more than 14 units per week for women and more than 21 units per week for men.
154
What is a Galeazzi fracture
```
aleazzi fractures occur after a fall on the hand with a rotational force superimposed on it. On examination, there is bruising, swelling and tenderness over the lower end of the forearm. X- Rays reveal a displaced fracture of the radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint.
Get shorting of radius so ulnar protudes
G: Galeazzi
R: radius
I: inferior (distal)
M: Monteggia
U: ulna
S: superior (proximal)
```
155
What is a Monteggia fracture
Dislocation of the proximal radioulnar joint in association with an ulna fracture
Fall on outstretched hand with forced pronation
Needs prompt diagnosis to avoid disability
G: Galeazzi
R: radius
I: inferior (distal)
M: Monteggia
U: ulna
S: superior (proximal)
156
What is a Barton's fracture?
Distal radius fracture (Colles'/Smith's) with associated radiocarpal dislocation
Fall onto extended and pronated wrist
157
Describe chondromalacia patellae
Often young, sudden onset or older more arthritis picture.
| Pain going up/ down stairs
158
Tetanus symptoms
```
Muscle spasms (jaw_
Fever
Sweating
Headache
10% mortality
```
159
Tetanus bacteria
Clostridium tetani - soil, saliva, dust, manure
160
Treatment of tetanus
Tetanus immunoglobulin
Tetnus booster vaccine (if needed)
IV metronidazole
IV or oral diazepam
161
What is radicular pain?
Along a dermatome
162
Yellow flags back pain
attitudes, beliefs, compensation, diagnosis, emotions, family, work (school)
163
How to test FCU, and FCR
Stabalise elbow and flex wrist with deviation
164
What are you looking for in joint aspirate
WBC, lactate, culture, crystal studies
165
How to assess a bite wound
Signs of infection? Rubor, tumour, dolor, discharge, cellultits, lymphadenopathy, fever
MoA?
Tetnus status
Risk of BBV
Xray if clenched fist or crush injuries for fracture/ foreign body.
Photograph and record description
166
Managing human bite
```
Bleed wound if recent
Irrigate with warm runnning water
Analgesia
Abx under 72 hrs - coamox or Metronidazole and macrolide for 7 days
Tetanus prophylaxis
```
Close if no infection risk <6hours old
167
Managing a cat/ dogo bite
```
Bleed wound if recent
Irrigate with warm runnning water
Analgesia
Abx under 48hrs for cats, bits to hand, foot, face or involving joints, tendon, lig or fractures or immunocompromised - coamox or Metronidazole and macrolide for 7 days
Tetanus prophylaxis
```
Close if no infection risk <6hours old
Think about teh rabies
168
Protiens which stimulate bone healing
Bone morphogenetic proteins
| Work just as well as bone graft from iliac crest
169
Time to union in a tibial fracture
(shaft)
- low energy frx: 10-13 weeks;
- high energy frx: 13-20 weeks;
- open frx: 16-26 weeks
- type 3B & 3C open frx requires 30 to 50 weeks for sonsolidation;
170
What is a myelopathy? vs radiculopathy?
Neurological deficit related to the spinal cord. MOst commonly CSM but can be acute. INflammatory = myelitis
vs pinched spinal nerve most commonly cervical
171
Initial management of lower back pain and sciatica
Reassurance
Benign nature of condition
Return to work where applicable, physical activity and exercise.
Consider manual therapy
Oral NSAIDs
Consdier CBT for Lower back pain
Radiofrequency denervation
non-surgical treatment has not worked for them and
the main source of pain is thought to come from structures supplied by the medial branch nerve and
they have moderate or severe levels of localised back pain (rated as 5 or more on a visual analogue scale, or equivalent) at the time of referral.
Surgical
- spinal cord stimulation
172
MoA Co amox
Amoxicillin - inhibits B lactamase/ cell wall synthesis
173
MoA Teicoplanin
Glycopeptide (vacomycin), inhibits cell wall synthesis
| Gram pos
174
MoA Gentamicin
Aminoglycoside (also Streptomycin) - stops protein synthesis. Gram neg
175
Abx porphylaxis for MSK and penicillin allergic
Co amox IV, at induction, 8, 16hrs post op
If allergic - ticoplanin and gentimicin once only
176
Metronidazole MoA
Nucleic acid synthesis
177
Why check calcium in metastatic bone diseasE?
treatment
hydration (volume expansion)
loop diuretics
bisphosphonates
178
Greater tuberosity fracture management
Closed reduction if ant dislocation
| If not then treat
179
Xray findings of posterior dislocation
Shoulder - Posterior dislocation - AP
The glenohumeral joint is widened (arrowheads) and the humeral head has taken on a more rounded 'light bulb' shape
These are typical appearances of a posterior glenohumeral dislocation
internal rotation
180
Surgery in anterior shoulder dislocation
Anterior shoulder dislocations are usually managed with closed reduction and a period of immobilisation (e.g. 6 weeks) to allow adequate capsular healing, although whether this significantly changes the likelihood of recurrent dislocation is not certain 4. The key to successful healing and normal eventual function is a structured course of physical therapy aimed at reducing muscle wasting and maintaining mobility. The emphasis, especially early on, is on isometric exercises, which the glenohumeral joint remains immobilised 4.
Surgical repair is not required for dislocation per se, but rather to treat complications and associated injuries which include:
shoulder instability due to damage to the inferior glenohumeral ligament (IGHL)
Hill-Sachs lesion
Bankart lesion or other anterior glenolabral injuries
damage to the axillary artery, or brachial plexus
intraarticular loose body
181
How do you know if its a supracondylar fracture?
anterior fat pad sign (sail sign): the anterior fat pad is elevated by a joint effusion and appears as a lucent triangle on the lateral projection
posterior fat pad sign
anterior humeral line should intersect the middle third of the capitellum in most children 2 although, in children under 4, the anterior humeral line may pass through the anterior third without injury
182
Complication of supracondylar
malunion: resulting in cubitus varus (varus deformity of the elbow, also known as gunstock deformity)
183
Commonest fracture in aldults of elbow?
Radial head fracture - Fat pads - Lateral
184
What is a Greenstick fracture
A greenstick injury comprises a bend in the bone on one side and a visible break in the bone cortex on the other side
185
Scaphoid injury but no fracture?
Treat as fracture
| MRI may show
186
What is mallet finger?
A 'mallet finger' may result from a tendon tear (not visible with X-ray) or an avulsion fracture
The X-ray is taken to see if an avulsion fracture is present - as in this case
Dorsal
187
What if two ossification centres of petalle?
Bipartite - superior andf lateral ostly
188
Avulsion fracture in knee?
From ACL
189
What is a Maisonneuve injury?
Proximal fibula fracture with associated fracutre or lig injury of medial ankle
190
What does a tibial stress fracture look like?
White lump
191
What is a Lisfranc injury?
Gap between MTs - disruption of Lisfranc lig
Phase II
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