Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Upcoming Events Next event: Ophthalmology Thursday 27th January 2022 at 7pm Contents for T oday 1.Limping Child 7. Back pain 2.Hip Fractures 8. Nerve Injuries 3.Shoulder disorders 9. Upper Limb Fractures 4.Carpal Tunnel 10. Knee Injuries 5.Elbow Injuries 11. Ankle Injuries 6.Wrist Fractures SBA 1 A 6 year old child comes to the GP with his mother complaining of pain in his hip and having a limp. His temperature is 38.1. On examination all other findings are normal however his mother recalls that he recently recovered from a recent viral infection. What is the most likely cause of the child’s limp? a. Septic Arthritis b. Juvenile Idiopathic Arthritis c. Development dysplasia of the hip d. Perthes disease e. Transient Synovitis SBA 1 A 6 year old boy comes to the GP with his mother complaining of pain in his hip and having a limp since this morning His temperature is 38.1. On examination all other findings are normal however his mother recalls that he recently recovered from a recent viral infect. What is the most likely cause of the child’s limp? a. Septic Arthritis – possible but child would probably be more unwell and is not the most correct answer in this case b. Juvenile Idiopathic Arthritis – limp is usually painless c. Developmental dysplasia of the hip – More common in girls and mostly detected in newborns / neonates d. Perthes disease e. Transient Synovitis – Most correct answer. Fever + Recent Viral Infection + Acute Onset Limping Child Differentials Developmental Dysplasia of the Transient Synovitis Slipped upper femoral hip Acute Onset epiphysis Risk factors: Recent Viral Infection More common in boys • Birth weight > 5kg, Boys more affective than Obesity is a risk factor Oligohydramnios, Breech girls 10-15 year old Position, Female +/- Pyrexia Displacement of the Ix: femoral head epiphysis • If > 4.5 months = X-Ray postero-inferiorly • If < 4.5 months = Ultrasound Septic Arthritis/ Barlow + Ortolani tests used Osteomyelitis High fever Perthes Disease clinically Child systemically unwell More common in boys Barlow: attempts to dislocate an Due to avascular necrosis of the articulated femoral head Ortolani: attempts to relocate a femoral head dislocated femoral head Juvenile Idiopathic Ix = X-Ray Arthritis Age 4-8 years Usually more chronic Complications later in life = onset osteoarthritis, premature fusion of growth plates Limp may be painless SBA 2 •middle of the night. She has a past medical history of osteoporosis, type 2 diabetes and hypertension. She normally mobilises with a frame. A hip x-ray shows a displaced intracapsular fracture of the neck of the femur. What is the most likely management? A. Dynamic hip screw B. Hemiarthroplasty C. Internal fixation with cannulated screws D. Intramedullary nail E. Total hip arthroplasty SBA 2 •middle of the night. She has a past medical history of osteoporosis, type 2 diabetes and hypertension. She normally mobilises with a frame. A hip x-ray shows a displaced intracapsular fracture of the neck of the femur. What is the most likely management? A. Dynamic hip screw B. Hemiarthroplasty C. Internal fixation with cannulated screws D. Intramedullary nail E. Total hip arthroplasty SBA 3 •middle of the night. She has a past medical history of osteoporosis, type 2 diabetes and hypertension. On examination her leg is shortened and externally rotated. Which classification system is most likely used to manage this patient? A – Ann-Arbour B – Ottawa C – Garden D – Duke’s E - ROSIER SBA 3 •middle of the night. She has a past medical history of osteoporosis, type 2 diabetes and hypertension. On examination her leg is shortened and externally rotated. Which classification system is most likely used to manage this patient? A – Ann-Arbour – for lymphoma B – Ottawa - for ankle fractures C – Garden – for (intracapsular) hip fractures D – Duke’s – for staging of Colorectal Cancer E – ROSIER– for stoke (in a hospitl FAST is for community) Neck of Femur Fractures • First step – is the fracture intracapsular or extracapsular? • If extracapsular: • Is it trochanteric of subtrochanteric? • If intracapsular: • Is it displaced or undisplaced? The GARDEN classification is what surgeon use to classify hip fractures Management of intracapsular #NOF Intracapsular #NOF Undisplaced Displaced Significant Co- Significant Co- morbidities? morbidities? No Yes No Yes Dynamic Hip Hemiarthroplasty Total Arthroplasty Hemi-arthroplasty Screw Management of extracapsular #NOF Extracapsular #NOF Intertrochanteric Subtrochanteric Dynamic Hip Screw Intramedullary Nail Adhesive Capsulitis (Frozen Shoulder) • Presenting complaint: Supraspinatus Tendinopathy • Shoulder Pain • Impingement of • Shoulder stiffness supraspinatus tendon when is passes between the • Key Risk Factors: humeral head and acromion • Diabetes • Adults in Middle Age • Empty can test (Jobe test) • Painful arc of abduction Diagnosis between 60 and 120 degrees Tenderness over anterior • Clinical Diagnosis – Imaging not acromion required for diagnosis • Ultrasound, CT and MRI = show thickened joint capsule Acromioclavicular (AC) Joint Management Arthritis • Pain on 170 degrees + of • Analgesia e.g. NSAIDS shoulder abduction • Physiotherapy • Positive scarf test • Intra-articular steroid injections • Hydrodilation Carpal T unnel Syndrome Presenting Complaint: Diagnosis: • Pain, Numbness, Phalen’s and Tinnel’s Test can be Paraesthesia in the median useful clinically nerve distribution of the Kamath andSlothard Carpal hand Tunnel Questionnaire (CTQ) used • Weakness of Thumb to predict diagnosis Movements Nerve conduction studies = Gold • Weakness of grip strength + Standard. Electrodes run over the thumb movements median nerve • Atrophy of thenar muscles Risk Factors: Management • Majority Idiopathic • Rest • Repetitive Strain • Minimum 4 week Wrist Splint • Obesity • Steroid Injections • Perimenopause • Surgery (flexor retinaculum is • Rheumatoid Arthritis cut either endoscopically or • Diabetes openly) • Acromegaly • Hypothyroidism SBA 4 • A 48 year old man presents to the GP with elbow pain. He is a keen tennis player and has increased pain on wrist extension. Which clinical test may aid in the diagnosis? • A – Phalen’s Test • B – Tinnel’s Test • C – Mill’s Test • D – Barlow Test • E – Ortaloni Test SBA 4 • A 48 year old man presents to the GP with elbow pain. He is a keen tennis player and has increased pain on wrist extension. Which clinical test may aid in the diagnosis? • A – Phalen’s Test – Carpal Tunnel • B – Tinnel’s Test– Carpal Tunnel • C – Mill’s Test – Lateral Epicondylitis • D – Barlow Test – DDH (developmental dysplasia of the hip) • E – Ortaloni Test– DDH Elbow Pain Lateral Epicondylitis Also known as TENNIS ELBOW Pain and tenderness is localised to the lateral epicondyle Positive Mill’s Test– palpating the lateral epicondyle while stretching forearm extensor muscles PositiveCozen’s Test– resisted wrist extension triggers pain to the lateral aspect of the muscle Median Epicondylitis “Golfer’s Elbow” Pain and tenderness at the medial epicondyle Weakness in grip strength Golfer’s Elbow Test – Pressure applied to medial epicondyle SBA 5 • A 45 year old man present to his GP with intermittent tingling in his 4 and 5 finger. He find this pain to be worse when the elbow is resting on his desk at work for long periods of time. Which nerve is most likely affected? • A – Axillary Nerve • B – Median Nerve • C – Musculoskeletal • D – Radial Nerve • E – Ulnar Nerve SBA 5 • A 45 year old man present to his GP with intermittent tingling in his 4 and 5 finger. He find this pain to be worse when the elbow is resting on his desk at work for long periods of time. Which nerve is most likely affected? • A – Axillary Nerve • B – Median Nerve • C – Musculoskeletal • D – Radial Nerve • E – Ulnar Nerve – Cubital Tunnel Syndrome SBA 6 • A 45 year old man present to his GP with Elbow pain. He has swelling over the posterior aspect of the elbow. The swelling is warm to touch and is erythematous in appearance. What is the most likely diagnosis? A. Cubital Tunnel Syndrome B. Lateral Epicondylitis C. Medial Epicondylitis (Golfer’s Elbow) D. Radial Tunnel Syndrome E. Olecranon Bursitis SBA 6 • A 45 year old man present to his GP with Elbow pain. He has swelling over the posterior aspect of the elbow. The swelling is warm to touch and is erythematous in appearance. What is the most likely diagnosis? th th A. Cubital Tunnel Syndrome– intermittent tingling 4 &5 Finger B. Lateral Epicondylitis – Tennis Elbow C. Medial Epicondylitis -Golfer’s Elbow D. Radial Tunnel Syndrome – pain on pronating the forearm E. Olecranon Bursitis– swelling over posterior aspect of elbow Elbow Pain Radial Tunnel Syndrome Olecranon Bursitis Due to compression of posterior interosseous branch Swelling over the posterior aspect of the elbow of the radial nerve Associating features: Pain 4-5cm distal to the lateral epicondyle Pain Worse pain on elbow extension Erythema Worse pain on forearm protonation Warmth Middle-aged Male Patients most commonly affected Cubital Tunnel Syndrome Due to compression of the ulnar nerve Intermittent tingling in the 4 and 5 finger -> later numbness with associated weakness Worse when elbow resting on a hard surface Worse when flexed for long periods of time SBA 7 •on an outstretched hand whilst playing football. He has tendernessover over the anatomical snuffbox which he describes as 10/10. X-Rays reveals an undisplaced fracture of the scaphoid. What is the best management? • A – No action required • B – Analgesia Alone • C – Internal Surgical Fixation • D – Attempt to manually reduce the fracture • E – Cast for 6-8 weeks SBA 7 •on an outstretched hand whilst playing football. He has tendernessover over the anatomical snuffbox which he describes as 10/10. X-Rays reveals an undisplaced fracture of the scaphoid. What is the best management? • A – No action required • B – Analgesia Alone • C – Internal Surgical Fixation • D – Attempt to manually reduce the fracture • E – Cast for 6-8 weeks Scaphoid Fractures Most common causes: • Sports (e.g. Rugby, Football) • FOOSH (Fall onto an outstretched hand) On examination • Loss of grip • Pain at base of thumb • Pain on ulnar deviation of the wrist • Wrist joint effusion • Point of maximal tenderness over the anatomical snuffbox Investigations • MRI will give the definite diagnosis. But X-Rays should be requested initially; • Scaphoid View X-Rays include: • PA • Lateral • Oblique • Ziter View = PA view with the wrist in the ulnar deviation position Scaphoid Fracture Management Undisplaced fracture of scaphoid • Cast for 6-8 weeks Displaced scaphoid waist fracture • Surgical Fixation Proximal scaphoid pole fracture • Surgical Fixation Back Pain • Red Flag Symptoms of Back Pain: • Trauma • Unexplained weight loss • Neurological symptoms • Age > 50 • Fever • IVDU • Steroid Use • History of Cancer Back Pain • Red Flags of Back Pain: Spinal Fracture • Major trauma red flag Spinal Infection • IV drug use, pyrexia Ankylosing Spondylitis • Age under 40 • Gradual onset • Morning stiffness better with activity • Night time-pain Spinal Stenosis • Intermittent neurogenic claudication Cauda Equina • Saddle Anaesthesia • Neurogenic Claudication Spinal Stenosis • Gradual Onset • Back pain that is relieved by sitting down or leaning forwards • Unliteral or bilateral leg pain • Pain subsides upon sitting down • May not be found clinically • MRI = Gold standard for diagnosis Ankylosing Spondylitis • Age < 40, typically young male • Stiffness worse in the mornings • Pain improvement with exercise • Clinical Examination: • Reduced chest expansion • Schober’s Test – Reveals reduced forward flexion • Reduced lateral flexion Ankylosing Spondylitis • Associated “A”s • Plain X-Ray will show: • Apical Fibrosis • Squaring of lumbar • Anterior Uveitis vertebrae • Aortic Regurgitation • “Bamboo spine” • Achilles Tendonitis • Syndesmophytes • Apical Fibrosis (on CXR) • AV node block • Amyloidosis • Sacroiliitis – Subchondral • Peripheral Arthritis erosions, sclerosis Ankylosing Spondylitis: Management • Encourage regular activity • NSAIDS e.g. Naproxen first line • Physiotherapy is of benefit in patients • If peripheral joint involvement: • Disease-modifying drugs may be useful Median Nerve Injury • Can be caused by: • Proximal: Supracondylar Fracture of Humerus • Distal: Carpal Tunnel Compression or wrist laceration • Motor Loss: • Inability to adbuct thumb • Inability to make OK sign • Sensory Loss • Palmar aspect of thumb, index + middle fingers + Lateral Ring Finger Axillary Nerve Injury • Can be caused by: • Compression (e.g. due to an axilla mass) • Fracture of the surgical neck of the humerus • Anterior shoulder dislocation • Motor Loss: • Deltoid paralysis = impaired arm abduction • Teres Minor Paralysis = Impaired External Rotation • Sensory loss: • Lateral shoulder “regimental badge” Radial Nerve Injury • Causes: • “Saturday Night Palsy” • Mid-shaft humeral fracture • Motor Loss: • Impaired Forearm Extension • Wrist Drop • Sensory Loss: • Dorsal Aspect of Thumb + Middle Fingers + Lateral Ring Finger Upper Limb Fractures Colles’ Fracture • Caused by FOOSH • Transverse Fracture of the Radius • 1 inch proximal to the radio-carpal joint • Dorsal displacement and angulation Smith’s Fracture • Volar angulation of distal radius fragment (Garden spade deformity) Upper Limb Fractures Monteggia’s Fracture • Dislocation of the proximal radioulnar joint in association with an ulnar fracture Galeazzi Fracture • Radial shaft fracture with associated dislocation of the distal radioulnar joint SBA 8 •knee after a rugby match with some friends. He mentions that he was tackled from behind and then suddenly felt a “pop” and felt sudden 10/10 pain. On examination there is right sided knee effusion. Lachman test is positive. What is the most likely diagnosis? A – ACL Rupture B – LCL C – Meniscal Tear D – MCL Tear E – PCL Rupture SBA 8 •knee after a rugby match with some friends. He mentions that he was tackled from behind and then suddenly felt a “pop” and felt sudden 10/10 pain. On examination there is right sided knee effusion. Lachman test is positive. What is the most likely diagnosis? A – ACL Rupture B – LCL C – Meniscal Tear D – MCL Tear E – PCL RuptureKnee Injuries Knee Injuries Ruptured ACL • Sport injury - high twisting force applied to a bent knee • Symptomsà loud crack, pain, rapidjoint swelling (haemoarthrosis), instability • Give on anterior draw test • Management: intense physiotherapy or surgery Ruptured PCL • Hyperextension injuries • Tibia lies back on the femur • Give on posterior draw test/paradoxical anterior draw test Meniscal Tear • Rotational sporting injuries • Delayed knee swelling • Joint locking • Recurrent episodes of pain and effusions are common, often following minor trauma Ankle Injury • Ottowa Ankle Rules – Used to determine whether to X-Ray an Ankle or Not • Weber Classification Used to Classify Ankle Injury Ankle Injury Management Ankle Injury Ottawa Rule Discharge with RICE X-Ray AP, Lateral and Oblique Unimalleolar Bi or Trimalleolar No evidence of Evidence of ligamentous Unstable ligamentous injury on X- injury on X-Ray ray Discharge with cast and Closed reduction and refer fracture clinic follow up x- for surgical fixation rays ACE! Neck of Femur Fracture Pathophysiology Clinical Features Risk Factors • Leg is shortened and externally Fracture of the femur occurring distal rotated Osteoporosis • Limited straight leg raise Osteopenia to the femoral head • Inability to weight bear Falls • Limited internal and external Metastatic Cancer (increased risk of rotation pathological fracture) Investigations Complications Management ECG, BM FBC, U&Es, Coagulation, Group and Displaced intracapsular NOF Ensure co-morbidities optimised Save and Creatinine Kinase fractures carry the greatest risk for Analgesia Imaging: Surgery AP Pelvis and Lateral Hip X-Rays, CT avascular necrosis or MRI Pelvis 2 Line Non-union and fixation failureACE! Osteomalacia, Osteoporosis, Osteoarthritis Osteomalacia Osteoporosis Osteoarthritis Normal bony tissue but decreased • Decreased bone density “Wear and tear” mineral content • Thin and porous bone with Progressive Cartilage and bone Bone is soft and weak reduced mass degradation Bone is not properly mineralised • Bone is properly mineralised Vitamin D deficiency is the most • Increaseing age and menopause On X-Ray: Joint Space Narrowing, cause most common cause Osteophytes, Subchondral Sclerosis Investigations Investigations Investigations Serum Calcium, Phosphate, Vit D Can be diagnosed clinically. PTH DEXA: T-Score </ -2.5 Treat with conservative (exercise, Serum ALP Assess risk of fragility weight loss) Treat with Bisphosphonate, HRT is Analgesia: Paracetamol and topical U&E, LFTs premature menopause Treat with Vitamin D replacement NSIADS -> opioids -> Surgery Upcoming Events Next event: Ophthalmology Thursday 27th January 2022 at 7pm