1
Q
X ray features of Rheumatoid arthritis
A
LESS - Loss of joint spaces - Erosions - Soft bones (osteopenia) - Soft tissue swelling
2
Q
DDx symptoms and signs of RhA vs OA
A
3
Q
DDx investigations of RhA vs OA
A
4
Q
Tx of RhA
A
Acute flare
- Corticosteroids
- +/- NSAIDs
Conservative
- PT/OT
- Splints
Medical
- DMARDs (Methotrexate, Sulphasalazine, Hydroxycholoquine)
- Biologics (Infliximab)
Surgical
- Arthrodesis
- Arthroplasty
- Carpal tunnel decompression
5
Q
Gout vs Pseudogout
(crystals, shape, Ix, Joint)
A
6
Q
Carpal bones
A
Some Lovers Try Positions That They Cannot Handle
Scaphoid
Lunate
Triquetrium
Pisiform
Trapizium
Trapizoid
Cuneate
Hamate
7
Q
Spondyloarthropathies
A
(PEAR)
Psoriatic arthritis
Enteropathic arthritis
Ankylosing spondylitis
Reactive arthritis
8
Q
X-ray changes in Ankylosing Spondylitis
A
X-ray (Pelvis)
Sacroillitis
X-ray (Spine)
Squaring of Vertebrae
Bamboo spine
Syndesmophytes (calcified outgrowths on ligaments)
CXR: Apical fibrosis
9
Q
Diagnosis of Ankylosing Spondylitis
A
X-ray (Pelvis): Sacroillitis (diagnostic)
or MRI showing axial inflammation
10
Q
Associations with Ankylosing Spondylitis
A
Associations (As)
Anterior uveitis
Apical pulmonary fibrosis
AV node block
Aortic regurgitation
Achilles tendonitis
Aortitis
May cause dilatation of aortic root –> aortic regurgitation
IgA nephropathy
Amyloidosis
ProstAtitis
Atlanto-axial subluxation
11
Q
Sx of Ankylosing Spondylitis
A
Inflammatory back pain
- Early morning back stiffness
- Improves with exercise
- Insidious onset
- Age < 40 years old
- Back pain > 3 months
Loss of lumbar lordosis
Kyphosis
Shober’s test +ve (15cm –> 20cm)
Patrick’s test +ve (indicates sacroillitis)
12
Q
Inflammatory back pain
Criteria (5)
A
Inflammatory back pain (umbrella term – 4 out of 5 for diagnosis)
- Early morning back stiffness
- Improvement of stiffness with exercise
- Better at end of the day
- Insidious onset
- Age at onset < 40 years
- Back pain lasting > 3 months
13
Q
Tx for Gout and Pseudogout
A
Acute Gout or Pseudogout
- (1) NSAID
- (2) Colchicine (if NSAID C/I)
Recurrent gout
- (1) Allopurinol (xanthine oxidase inhibitor)
- (2) Probenacid (increase renal excretion of uric acid)
- (3) Pegloticase (metabolises uric acid into allantoin)
- Lifestyle changes
14
Q
DEXA scan T score vs Z score
A
T score = BMD compared to healthy young reference population
T score is used to define osteoporosis (T score < -2.5)
Z score = BMD compared with age-matched control
15
Q
Tx for Osteoporosis
A
Conservative
- Smoking cessation
- Reduce alcohol
Medical
(1) Bisphosphonate (Alendronate) (binds to hydroxapatite)
- S/E: Oesophagitis, Osteonecrosis of jaw, Atypical fractures
- Taken on emptying stomach and sit for at least 30min
(2) Denosumab (RANKL inhibitor –> reduce osteoclast activation)
(3) Teriparatide (recombinant PTH) - osteoblast > osteclasts
Strontium ranelate
SERMs (Tamoxifen) - ER agonist in bone but antagonist in breast
HRT
16
Q
Fracture assessments tools
A
FRAX score
QFRACTURE
17
Q
Associations with Ank Spond
A
Associations (As)
Anterior uveitis
Apical pulmonary fibrosis
AV node block
Aortic regurgitation
Achilles tendonitis
Aortitis
May cause dilatation of aortic root –> aortic regurgitation
IgA nephropathy
Amyloidosis
ProstAtitis
Atlanto-axial subluxation
18
Q
Tetrad of Henoch Schonlein purpura
A
Palpable purpuric rash (on buttocks and extensor surfaces of arms and legs)
Arthralgia / Arthritis
Abdominal pain
Glomerulonephritis
19
Q
SLE Sx
SOAPBRAINMD
A
4 for diagnosis
- Serositis (pericarditis)
- Oral ulcers
- ANA +ve / anti-dsDNA +ve
- Photosensitivity
- Blood cell deficiency (low Hb, low WBC, low Plt)
- Renal disorders (Lupus nephritis)
- Arthritis / Arthralgia
- Immunological disorders (other auto-antibodies)
- Neurological disorders (CN palsies)
- Malar rash (spares nasolabial folds)
- Discoid rash
20
Q
Tx of SLE
A
Acute
- High dose prednisolone
- IV Cyclophosphamide
Chronic
- Lifestyle advice (avoid sun exposure)
- Skin manifestations –> Hydroxychloroquine
- Arthritis –> NSAIDs
21
Q
Salter-Harris classification
A
22
Q
R shoulder pain
Worse when elevating arm above head
Pain on abduction and internal rotation
No trauma
No deformity
No tenderness
No loss of range of movement
Diagnosis? Treatment?
A
Supraspinatus tendinopathy
Treatment: Physiotherapy
Managed in community
23
Q
Extra-articular features of RhA
A
24
Q
Tx Osteoarthritis
A
- Conservative
- Modification of ADLs
- Weight loss
- Walking aids
- Physiotherapy / Occupational therapy / Orthotics
- Medical
- Analgesia
- Intra-articular corticosteroids injections
- Surgery
- Arthroplasty (joint replacement)
- Osteotomy
- Arthrodesis
25
Septic arthritis
Cause
Ix
Tx
Cx
\< 30 years --\> N. gonorrhoea
\> 30 years --\> S. aureus
Ix: **URGENT Joint aspiration --\> MC&S**
Tx: IV Antibiotics (Vencomycin + Clindamycin)
Cx: Secondary OA
26
Tx of psoriatic arthritis
* _Symptomatic relief_
* **NSAID**
* **Intra-articular steroid injection**
* **Immunosupressants**
* **DMARDs** (Methotrexate)
* **Biologics** (Anti-TNF)
27
Tx for Ank Spond
* Conservative
* **Physiotherapy**
* Medical
* (1) **NSAID**
* +/- Intra-articular corticosteroid injections
* (2) **Biologics** (Etanercept)
* **+/- DMARDs** (only helpful for peripheral arthritis)
* **+/- Bisphosphonates**
* +/- Surgical
* If Hip involvement --\> +/- Hip arthroplasty
28
Reactive arthritis
Cause
Triad
Tx
Cause
* After GU infection (Chlamydia) - most common
* After GI infection
Sx
* **Conjunctivitis, Urethritis, Arthritis** (aymmetrical, peripheral arthritis or back)
* Keratoderma blennorrhagicum
*_Tx_*: **Symptomatic relief**
* Splint
* **NSAID**
* **+/- Intra-articular corticosteroids**
* +/- DMARDs (if chronic)
29
Amyloidosis
Types
Protein
Associated with
Presentation
30
Histology
Congo Red
Green birefringence under polarised light
Amyloid
31
Periorbital purpura
Peripheral oedema
Macroglossia
AL Amyloidosis
32
**Clots (arterial, venous)**
**Livedo reticularis (mottled rash)**
**Obstetric complications (recurrent miscarriage)**
**Thrombocytopaenia**
Diagnosis? Ix? Tx?
Antiphospholipid syndrome
Anticardiolipin antibodies
Lupus anticoagulant
Anti-B2-GPI antibodies
Tx: LMWH + Warfarin
33
**Proximal myopathy**
**Raynaud's**
**Gottren's papules**
**Heliotrope rash**
**Shawl sign**
Diagnosis? Risk factors? Ix? Tx?
**Dermatomyositis** - associated with malignancy
**Polymyositis** - assocated with systemic sclerosis
Investigations
* **Anti-Jo-1 +ve**
* **ANA +ve**
* **CK**: ↑↑↑↑
* **Muscle biopsy**: definitive diagnosis
Tx: **IV Methylprednisolone +/- IVIG**
34
Ix for SLE
**Anti-dsDNA** (most specific)
**ANA** (most sensitive)
**Anti-Smith antibodies**
Complement: decreased in active disease
ESR/CRP: increase in active disease
35
**Dry eyes**
**Dry mouth**
**Enlarged salivary glands**
Diagnosis? Cause? Ix? Tx?
Sjogren's syndrome
* Primary
* Secondary: Rheumatoid arthritis, Scleroderma, SLE, Polymyositis, Other Autoimmune
Ix
* **Anti-Ro**
* **Anti-La**
* **Schirmer's test**
Tx
* Dry eyes --\> **Artificial tears +/- Cholinergics** (Cevimeline, Pilocarpine)
* Dry mouth **--\> Salivary substitute +/- Cholinergics** (Cevimeline, Pilocarpine)
36
Diffuse vs Limited systemic sclerosis
**Diffuse SS** = CREST + Truncal involvement
**Limited SS** = CREST + Limited skin involvement (Face, Limbs)
Tip: When the antibodies grow up, they DIFFUSE and go to school ∴ Anti-Scl70
37
Tx for Raynaud's
(1) Conservative - gloves
(2) **CCBs** (Nifedipine)
(3) ACEi / ARB / SSRI / Nitrates
+/- Prostacyclins
+/- Phosphodiesterase-5 inhibitors
38
**Acute onset**
**Shoulder/Hip stiffness or pain**
**Normal power**
**Sx of Giant Cell Arteritis**
Diagnosis? Ix? Tx? Cx?
**Polymyalgia rheumatica**
↑ ESR
Tx:
* (1) **Corticosteroids**
* Rapid response (\<72hr) confirms diagnosis
* + Bisphosphonates + Calcium + Vitamin D
* +/- NSAID
Cx: **Giant Cell Arteritis** (15%)
39
**Chronic \> 3 months**
**Widespread body pain**
**Diffuse tenderness**
**Fatigue**
**Sleep disturbance**
**Mood disturbance**
Diagnosis? Ix? Tx?
**Fibromyalgia**
Clinical diagnosis, normal ESR
Tx: CBT +/- Antidepressants
40
**Hx of trauma**
**Bone pain**
**Fever**
**Signs of inflammation**
**Reduced range of movement**
Diagnosis? Cause? Ix? Tx?
**Osteomyelitis**
Staphylococcus aureus (most common)
Salmonella spp in Sickle Cell Disease
Ix: MRI (Bone) = imaging of choice (highest sensitivity)
Tx: IV ABx (Flucloxacillin or Clindamycin) +/- Surgical debridement
41
**Histology - non-caseating granuloma**
**Fever**
**Dry cough**
**Progressive SOBOE**
**Erythema nodosum**
**Lupus pernio**
**Bilateral parotid swelling**
**Bilateral facial nerve palsy**
Diagnosis? Ix? Tx?
**Sarcoidosis** (pulmonary, cutaneous, cardiac, neurosarcoidosis, ocular)
Ix:
* **Serum ACE**: ↑
* CXR: **bilateral hilar lymphadenopathy**
* **Bronchoscopy + Endobronchial biopsy + Bronchoalveolar lavage**: --\> DIAGNOSTIC
* Non-caseating granuloma
Tx
* **Oxygen**
* **Corticosteroids**
* +/- Immunosupressants
42
**FLAWS**
**Fainting**
**Absent upper and lower limb pulses**
**Claudication**
**Hypertension (RAS)**
**Angina**
**Asymmetrical BP**
Diagnosis? Ix? Tx?
**Takayasu's arteritis**
## Footnote
Affecting **branches of aortic arch**
**CT angiography** (diagnostic)
Tx: **Corticosteroids**
43
**Conjunctivitis (non-purulent)**
**Maculopapular rash**
**Cervical lymphadenopathy**
**Strawberry tongue**
**Hands and Feet red and swollen**
**Fever \> 5 days (unresponsive)**
Diagnosis? Ix? Tx? Cx?
**Kawasaki's disease** - affects coronary arteries
## Footnote
CRASH and Burn
Ix: Clinical diagnosis + Echo
Tx: **IVIG + Aspirin**
Cx: Coronary artery aneurysm
44
**Hepatitis B**
**FLAWS**
**Haematuria**
**Renal failure**
**Hypertension**
**Abdominal pain**
**"String of beads" (Rosary sign) on Angiography**
Diagnosis? Tx?
**Polyarteritis nodosa**
Molecular mimicry with **Hepatitis B**
Affects renal, skin and mesenteric arteries
Tx: Corticosteroids + Cyclophosphamide
45
**Pale limb**
**Pulseless**
**Cold**
**Rest pain / Claudication**
**Paraesthesia**
**Ulceration / Gangrene**
**Allen test +ve**
**DSA shows tortuous "corkscrew" collaterals**
Diagnosis? Ix? Tx
Buerger's disease (Thromboangiitis obliterans)
Ix
* **Arerial doppler**: absence of pulses
* **DSA**: corkscrew-shaped collaterals
Tx
* **Smoking cessation**
* _if ischaemia_
* **CCB**
* +/- IV ABx
* +/- Surgical debridgement
* +/- Surgical revascularisation
46
**Allergic stage ==\> Eosinophilia**
**Respiratory symptoms**
**Haemoptysis**
**Vasculitis ==\> Glomerulonephritis**
**p-ANCA**
**Biopsy shows Granuloma**
Diagnosis? Tx?
Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss)
Tx: Corticosteroids + Cyclophosphamide
47
**Upper respiratory tract involvement**
Saddle nose
Nosebleeds
**Lower respiratory tract involvement**
Cough
Haemoptysis
**Glomerulonephritis**
Microscopic haematuria
**c-ANCA** (proteinase 3)
Biopsy shows **Granulomas**
Diagnosis? Tx?
**Granulomatosis with Polyangiitis** (Wegener's)
Tx: Corticosteroids + Cyclophosphamide
48
**Haemoptysis**
**Rapidly progressive glomerulonephritis**
**p-ANCA without evidence of granulomas**
No involvement of nasopharynx
No granuloma
**Microscopic polyangiitis**
Tx: Corticosteroids + Cyclophosphamide
49
Tx of HSP
Corticosteroids +/- Cyclophosphamide
Analgesia
50
**Oral ulcers**
**Genital ulcers**
**Uveitis**
**Erythema nodosum**
Diagnosis? Ix?
**Behcet's disease**
Clinical diagnosis
Pathergy testing +ve (pustule forms with skin prick)
Treatment
* (1) **Triamcinolone paste** (for mouth ulcers)
* (2) **Corticosteroid** or (2) **Colchicine**
51
Only skin manifestations
Palpable purpura affecting lower extremities
Diagnosis? Ix? Tx?
**Cutaneous leukocytoclastic vasculitis**
Ix: Skin biospy (charcteristic findings)
Tx: Corticosteroids
52
Tx of a Fracture
General principles
**Resuscitate**
**Reduce**
**Rest (Hold)**
**Rehabilitate**
53
Types of reduction
Closed reduction
* Manipulation
* Traction
* Skin
* Skeletal (requires pins in bone)
Open reduction
* Percutaneous
* Arthroscopically-assisted
* Small incision
* Full exposure (large incision)
54
Types of fixation
55
Tx of open fracture
* In A&E
* **Resuscitate**
* **Neurological assessment**
* **Vascular assessment**
* **IV Antibiotics**
* **Tetanus**
* **+/- Manual reduction**
* **+/- Splint**
* In Theatre
* **Explore + Debride + Wash out**
* If cannot cover it ==\> **_External fixation_** (majority)
* If able to cover ==\> **Internal fixation** (definitive Tx)
56
Grading for Open Fractures
Gustilo Anderson Classification for Open Fractures
57
Types of NOF fractures
**Extracapsular** = distal to intertrhocanteric line (blood supply preserved)
* **Intratrochanteric** extracapsular fracture
* **Subtrochanteric** extracapsular fracture
**Intracapsular** = proximal to intertrhocanteric line (blood supply affected)
* **Undisplaced** (Garden Stage I/II)
* **Displaced** (Garden Stage III/IV)
58
**Hip pain / Knee pain**
**Worse on internal rotation**
**Inability to weight bear**
**Shortened externally rotated leg**
**Loss of range of movement**
**Limb shortening**
**Thomas test +ve**
**Trendenlenburg test +ve**
Diagnosis? Ix?
NOF fracture
Ix:
* **X-ray (Pelvis, Hip, AP, Lateral)**
* Loss of Shenton's line
* +/- Displacement (STAR)
* If -ve X-ray --\> MRI
59
Tx for extracapsular fractures
If displaced --\> Reduce
If *_Intertrochanteric fracture_* ==\> **Dynamic Hip Screw**
Unstable fracture (e.g. reverse oblique, transverse or *_subtrochanteric_*) → **Intramedullary nail**
60
If intracapsular fracture
Undisplaced
* **Cannulated hip screw**
Displaced
* If _young \< 65 years old_
* **ORIF** or **Cannulated hip screws**
* If signs of avascular necrosis --\> **Total Hip Replacement**
* If _older \> 65 years old_
* If *_less fit_* OR *_\> 80 years old_* ==\> **Hemiarthroplasty**
* If *_fit and mobile_* and *_65-80 years olds_* ==\> **Total Hip Replacement**
61
Pros and Cons of Hemi vs THR
**Hemiarthroplasty**
* _Pros_
* ↓ risk of dislocation
* ↓ Surgical Risk
* _Cons_
* Does NOT last as long as THR
* ↑ risk of wearing of acetabulum
**Total Hip Replacement**
* _Pros_
* Lasts longer
* _Cons_
* ↑ risk of dislocation
62
**1-3 days post-hip fracture**
**SOB**
**Fever**
**Hypoxia**
**Tachypnoea**
**Non-blanching rash**
**Acute confusion**
Diagnosis? Tx?
Fat embolism
## Footnote
Fixation of fracture
DVT prophylaxis
63
Hip pain
↓ Range of Movement
Haemodynamically unstable / Shock
Diagnosis? Ix? Tx
**Pelvic fracture**
X-ray: fracture +/- widening of pubic symphysis
**Resuscitate**
* ABCDE
* **Pelvic binders**
* +/- Vessel ligation
* +/- Pelvic packing
**Reduce**
**Rest / Hold**
* External fixation / Internal fixation / Traction
**Rehabilitate**
64
Types of hip dislocation
Tx
* **Posterior dislocation** (90%)
* Affected leg is shortened, adducted, and internally rotated
* **Anterior dislocation**
* Affected leg is abducted and externally rotated
* No leg shortening
* **Central dislocation**
*
*_Tx_***: Reduction under general anaesthetic** (under 4 hours to reduce risk of AVN)
65
**Non-contact deceleration** or **change in direction**
**Sudden onset knee pain**
**RAPID joint swelling**
**Audible pop**
**Limited ROM**
**Anterior draw test +ve**
**Lachman's test +ve**
Diagnosis? Ix? Tx?
ACL tear
MRI (knee)
Conservative
* **PRICE** (Physiotherapy, Rest, Ice, Compression, Elevation)
Medical
* **Analgesia**
Surgical
* **ACL reconstruction**
66
Tx of MCL, LCL and PCL injuries
**_Medial Collateral Ligament_**
* PRICE
* **Crutches** + non-weight bearing
**_Lateral Collateral Ligament_**
* PRICE
* **Knee brace** (lock in full extension) + weight bearing
**_Posterior Cruciate Ligament_**
* PRICE
* **Crutches AND long leg brace**
67
**Insidious onset after 24 hours from rotational injury**
**Knee pain**
**Delayed swelling**
**Joint line tenderness (most sensitive)**
**Locking**
**Popping**
**Giving way**
**McMurray +ve**
Diagnosis? Ix? Tx?
Meniscus injury
Ix:
* **MRI (Knee)** (most sensitive)
* **Arthroscopy**: definitive + therapeutic
Tx:
* Conservative and Medical
* PRICE (protect, rest, ice, compress, elevate)
* Physiotherapy
* Crutches
* Analgesia
* Surgery
* **Arthroscopic meniscus repair**
* **Arthroscopic partial menisectomy**
Cx: Osteoarthritis
68
Popliteal bulge (behind knee)
Knee pain
Leg swelling
Diagnosis? Ix? Tx?
**Baker's cyst**
Ix: **Duplex USS** (confirm Baker's cyst and exclude DVT)
Tx:
* If asymptomatic --\> **Analgesia**
* If symptomatic --\> **Direct aspiration under USS guidance**
69
Classification of Ankle Fractures
**Lateral malleolus fracture**
**Bimalleolar fractures** = lateral malleolus + medial malleolus
**Trimalleolar fractures** = lateral malleolus + medial malleolus + tibia
70
Tx for Ankle Fracture
Resuscitate
Reduce
Rest (hold) ==\> Backslab clast (**Controlled Ankle Motion boot**) *_or_* **Surgical ORIF**
Rehabilitate
71
**Running marathons**
**Gradual worsening forefoot pain**
**2nd metatarsal tenderness**
**Inability to weight bear**
**No soft tissue injury**
Diagnosis? Tx?
**Metatarsal stress fracture**
PRICE
Immobilisation
Analgesia
72
**_Plantar ecchymosis_**
**Pain and swelling of midfoot**
**Unable to weight bear**
Diagnosis? Ix? Tx?
**Lisfranc injury** (to TMTJ)
*_Ix_*: CT/MRI
*_Tx_*: PRICE + Surgical referral
73
**Mallet toe** vs **Hammer toe** vs **Claw toe**
Trauma ==\> **Mallet toe**
Hallux valgus ==\> **Hammer Toes**
Neurological ==\> **Clow toes**
**Tx: Proper foot ware (high toe box shoe)**
74
**Pain over 1st MTPJ**
**Worse during walking and with shoes**
**Medial deviation of metatarsal**
**Lateral deviation of hallux**
**Hammer toe deformity**
Diagnosis? Tx?
**Hallux valgus** (Bunoin)
* Shoe modification
* Orthotics
* Bunoin pads
* Analgesia
* Surgical realigment or arthrodesis
75
1st MTP pain and swelling
Worse with dorsiflexion of big toe
Pain on toe off part of gait cycle
Diagnosis? Ix? Tx?
**Hallux rigidus**
OA of big toe
Ix: X-ray changes
Tx: same as OA
76
Foot deformity
Inverted
Not passively correctable
Newborn
Diagnosis? Tx?
**Club foot**
Ponseti method = maniputation and **progressive casting**
77
**Diabetes**
**Red, Hot, Swollen**
**Deformity**
(rocker bottom deformity
collapse of medial arch)
**Pain**
Diagnosis? Ix? Tx?
**Charcot Foot**
Ix: X-ray
Tx
* Total contact cast
* Orthotics (Charcot restraint orthotic walk / CROW boot)
* +/- Surgical correction
78
**Posteromedial heel pain (sharp, worse with weight bearing)**
**Insidious onset**
**Tender medial tuberosity of calcaneus**
**Limited ankle dorsiflexion**
Diagnosis? Tx?
**Plantar fasciitis**
Physiotherapy
Night splints (keep gastrocmenius stretched)
+/- Surgical release with plantar fasciotomy
79
**Acute onset severe pain**
**Pop**
**Palpable gap**
**Antalgic gait**
**Weakness of plantarflexion**
**+ve Simmond's test**
Diagnosis? Tx?
**Achilles tendon rupture**
PRICE + Achilles' tendon repair
80
pain between metatarsal heads
Worse with weight bearing
Numbness on plantar aspect of webspace
"Feel like walking on a pebble"
Palpable mass
Click when squeezing metatarsal together
Diagnosis? Ix? Tx?
**Morton's neuroma**
Benign neuroma of intermetatarsal plantar nerve
Ix: USS
**Tx: Wide shoe box with firm sole and metatarsal pad**
+/- Surgical release of transverse intermetatarsal ligament
81
**Abducted externally rotated arm**
**Loss of rounded appearance of shoulder**
Diagnosis? Complications?
**Anterior shoulder dislocation**
* Axillary nerve dysfunction
* Hill-Sachs deformities (indentation of humeral head against glenoid edge)
* Bankart lesions (tear in labrum of glenoid rim)
82
**Adduction + internally rotated arm**
**Loss of rounded appearance of shoulder**
Diagnosis? Complications?
**Posterior shoulder dislocation**
Hill-Sachs deformities = indentation of humeral head on glenoid edge
83
X-ray changes in shoulder dislocation
Anterior shoulder dislocation
* Dislocated humeral head
* Humeral head medial to "Y"
Posterior shoulder dislocation
* Light bulb sign
* It now points posteriorly
* Normal = points into glenoid fossa
84
Tx for shoulder dislocation
**Reduction** (Kocher's method)
Rest = Immobilisation in **Sling** +/- Surgery
Rehabilitation
85
**Diabetes**
**Loss of external rotation of shoulder**
**Global restriction of shoulder movements**
**Non-dominant shoulder affected**
Diagnosis? Tx?
**Frozen shoulder**
Physiotherapy (majority self-resolve)
Surgery
86
Rotator cuff muscles and actions
Supraspinatus ==\> initial shoulder abduction (\<20, rest is Deltoid)
Infraspinatus ==\> external rotation
Teres minor ==\> external rotation + aDDuction
Subscapularis ==\> internal rotation + aDDuction
87
**Painful arc 60-120 degree (glenohumeral)**
**Empty beer can test +ve**
Diagnosis? Tx?
Weak supraspinatus
**Subacromial impingement**
Physiotherapy
Analgesia + Steroids injection
**Subacromial decompression** (shave the bone)
88
Galeazzi vs Monteggia fracture
Tip: GRUsome MURder
* **G-aleazzi R-adius #, U-lnar-Radial joint disloc**
* ****FOOSH injury
* Distal 1/3 of radius
* Dislocation of distal radio-ulnar joint
* **M-onteggia U-lnar #, R-adial head dislocation**
* FOOSH injury
* Proximal 1/3 of ulnar
* Dislocation of radial head
89
**Colles' vs Smith's fracture**
Mechanism
Definition
Complications
Tx:
If stable (majority) --\> **Closed reduction +/- Cast**
if unstable --\> **ORIF**
90
Barton fracture and Chauffeur fracture
91
**Wrist pain**
**Radial styloid tenderness**
**Difficulty with gripping**
**Finkelstein test +ve (pain on thumb flexion + ulnar deviation)**
Diagnosis?
**De Quervain's tendinopathy**
Clinical diagnosis
USS: thickened APL and EPB tendons
Tx: Splint + Analgesia
+/- Surgical excision of common tendon sheath
92
**Locked finger after flexion**
**nodule at base of finger**
**Pressure at nodule allows extension**
Diagnosis? Tx?
**Trigger finger**
Splint + Analgesia
+/- Surgery release of A1 pulley ligament
93
**Multiple fracture**
**Blue sclerae**
**Conductive hearing loss**
**Osteoporosis**
**Normal blood biochemistry**
Diagnosis? Ix? Tx?
**Osteogeneis imperfecta**
Ix: X-ray - translucent bones, multiple fractures
Tx: Bisphosphonates
