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MSK acute scenarios + XRs/ fractures BY LAUREN SMITH AND LIAM RUDD Acute Septic Arthritis u ORTHOPAEDIC EMERGENCY u Where infection occurs in a joint, most commonly the knee/ hip u The most common and important complication of a recent joint replacement u Common bacteria: u S. aureus u Strep species u N. gonorrhoeae (most common in sexually active adults) u Presentation: § Single joint affected § Rapid onset of: Risk Factors: § Arthritis § Hot, red, swollen and painful joint § Diabetes Immunocompromised § Stiffness and reduced ROM § IV drug users § Systemic sx; fever, generally unwell § Prosthetic joints Acute Septic Arthritis Investigations: Management: Complications: • Aspiration of the joint • IV antibiotics for up to 6 • Sepsis • send for gram weeks, usually with oral • Irreversible joint staining, culture and switch after around 2 damage sensitivities weeks • Death (11%) • If there is a joint • Arthroscopic lavage replacement, it has to be done in theatre • Joint USS • Consider blood cultures Acute Compartment Syndrome SURGICAL EMERGENCY! u Raised pressure within a closed anatomical space, cutting off blood supply to the tissues in the compartment leading to necrosis. u Complication of fractures u Supracondylar and tibial shaft fractures u Presentation: u Bone fractures u Crush injuries u 5 P’s: u 1. Pain u Disproportionate u Especially on movement u 2. Paresthesia u 3. Pale u 4. Pressure (high) u 5. Paralysis u Pulselessness is not a feature u Differentiating it for acute limb ischaemia (pulses remain intact)Acute Investigations: Compartment • Needle manometry Syndrome • >20mmHg is abnormal • >40mmHg is diagnostic Management: • Emergency fasciotomy (within 1h of diagnosis) Complications: • Irreversible neurovascular damage of the affected limb Giant cell/ temporal arteritis A systemic vasculitis that Strong link with PMR Presentation: affects both medium and >50y/o, female large-sized vessels Severe unilateral headache Typically, the temporal arteries = around temple temporal arteritis Scalp tenderness Jaw claudication Affected visionInvestigations: Management: Complications: Raised ESR Urgent referral to a • >50mm/h = significant rheumatologist (<24h) Vision loss Any vision loss – urgent Raised CRP ophthalmology referral Temporal artery USS 1. Vision loss •500mg-1g IV • Show thickening of methylprednisolone OD for artery wall 3 days Temporal artery biopsy Stroke 2. No vision loss •Will sgiant cellscleated • 40-60mg prednisolone daily u Form of inflammatory arthritis u Associated with high uric acid levels in the blood u Urate crystals deposit in the joint u Presentation: Gout u Single acute hot, swollen and painful joint u Episodes lasting days and asymptomatic between u Important DDx is septic arthritis u MTP joint of the big toe (70% of 1 presentations) u Wrists u CMC joint of the thumbu Investigations: u Diagnosed clinically 1. Joint synovial fluid aspiration u Needle-shaped crystals u Negatively birefringent of polarised light u Monosodium urate crystals 2. Joint XR u Lytic lesions in bone u Punched out erosions u Sclerotic borders with overhanging edges1) Joint space is maintained 2) Lytic lesions 3) Punched out erosions • Sclerotic borders • Overhanging edges Acute flare Prophylaxis 1. NSAIDS 1. Allopurinol Gout 2. Colchicine (when 2. Lifestyle changes management NSAIDS may be inappropriate) 3. Steroids Cauda Equina Syndrome u SURGICAL EMERGENCY u When the nerve roots of the cauda equina are compressed u Below L3 u Causes: u Central disc prolapse uL4/L5, L5/S1 u MSCC Think anything compressing the spinal cord! u Infection u Traumau Presentation: u Severe back pain u Bilateral sciatica u Saddle anaesthesia u Reduced anal tone u Bowel/bladder dysfunction uUrinary retention u LMN signsInvestigations Management Complications • Emergency MRI spine • Urgent surgical • Paraplegia decompression • Chronic urinary • Laminectomy, retention/ discectomy incontinenceOrthopaedic red flags Thoracic back Urinary/bowel Perineal sensory pain Bilateral sciatica dysfunction loss Night pain Unexplained PMH of Fever weight loss malignancy Pain disproportionate Unilateral hot, History of steroid <18y and >50y to clinical swollen joint use contextHip fractures A common presentation in T&O with significant morbidity and mortality Presentation: •>60y •Low-energy trauma •Osteoporosis •Frail •Pain in hip/ groin •Cannot weight bear •Shortened, abducted and externally rotated leg •Cannot perform a SLR Investigations: u Pelvic and lateral hip XR u 2 views are essential Management: u VTE prophylaxis Hip u Surgery Fractures u Urgent reduction and internal fixation followed by early mobilization u < 36 hours Complications: u Avascular necrosis of hip (intracapsular fractures) u DeliriumHip fractures – classifications u Garden classification: Ø INTRACAPSULAR FRACTURES u I – undisplaced, incomplete u II – undisplaced, complete u III – displaced, complete u IV – very displaced, completeHip fractures, what surgery and when? Hip fractures Intracapsular Extracapsular Undisplaced Displaced DHS IM nail FIX REPLACE Frail, old, Young, DHS not mobile? mobile? Hemiarthroplasty THRInterpretating Patient details Orthopaedic Penetration of film XRs View (AP/ lateral) What joint/ bone A – alignment B – bone texture C – cortices S – soft tissueDescribing fractures “OLD ACID” O – open vs closed L – location D – degree of break A – articular involvement (dislocations) C – comminuted and pattern I – intrinsic bone pathology D- displacement, angulation, rotationSalter – Harris fractures u SALTR mnemonic u Type 1 – Straight across u Type 2 – Above (75%) u Type 3 – beLow u Type 4 – Through u Type 5 - cRushExtra THINGS TO KNOW u Colle’s fracture: - Typically fall onto outstretched hand (FOOSH) Transverse fracture of the radius, dorsal displacement and angulation, and they occur 1 inch proximal to the radio-carpal joint. Common Fracture Ankle fractures: - Ottawa rules: Types Inability to weight bear for 4 steps Tenderness over distal tibia Bone tenderness over distal fibula - All ankle fractures need prompt reduction - Unstable or high velocity fractures need surgical repair u - - - - Shoulder - Pathology u - -Osteomyelitis: - Infection of bone - Similar risk factors to septic arthritis - Staph aureus, rarely fungal - CRP, ESR can be useful - MRI best - Long course of abx Epicondylitis u Lateral Epicondylitis – Tennis elbow u Commonly caused by overuse – not just tennis! u Around 90% will recover with no treatment within 1 year u Medial Epicondylitis – Golfer’s elbow u Commonly caused by overuse – not just golf! u Unknown pathophysiologies – imaging not usually helpful u Supportive management u Surgery Hip X ray Interpretation 1. Confirm patient details (Name, date, anatomical site) (Hip fracture usually should in AP or lateral) ABCS Alignment – coccyx and pubic symphysis should be in the midline Bones – cortical outline, bony texture, symmetry. (Lytic/Sclerotic) Cartilage and joints – Location of femoral head, acetabular joint space Soft tissue – Effusions, calcification, foreign bodies Shenton’s line – if interrupted this may suggest a fractureLytic ScleroticOpen vs closed Location Degree of break Articular involvement Comminuted and Pattern Intrinsic bone pathology Displacement, angulation and rotationExam practiceXR interpretation 1 A 79-year-old presents to ED after falling. Please interpret the patient’s hip XR.What’s the most likely diagnosis? Ø Right intracapsular NOF Describe the typical symptoms of this diagnosis Ø Pain Ø Difficulty weight bearing What clinical signs might someone have with this diagnosis? Ø Shortened, externally rotated leg Describe the management of this condition Ø Analgesia Ø Surgery Ø THR/ hemi Describe some complications of this condition Ø Avascular necrosis of the femoral head Ø Nonunion Ø DislocationData interpretation station A 56-year-old women presents with a hot and swollen knee. Please interpret the patient’s joint fluid analysis.Joint fluid analysis Result Colour Yellow WBCs 2000-50,000 cells/mm3 Neutrophils >50% Gram stain Negative Crystals Positive Needle negative birefringent crystalsWhat is the most likely diagnosis? GoutXR interpretation A 27-year-old man presents with right shoulder pain, following a fall whilst running. Interpret the XR.What is the most likely diagnosis? Anterior shoulder dislocation Describe the typical signs/symptoms of this diagnosis 1. Shoulder pain 2. Reduced mobility 3. Feeling of instability 4. Asymmetry of both shoulders and anterior bulge of humeral head Describe the acute management of this condition 1. Sedation and analgesia 2. Reduction Describe some complications of this condition 1. Adhesive capsulitis 2. Rotator cuff injury 3. Neurovascular damage to limb - axillary nerve