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Orthopaedics

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André Almeida

on 23 June 2013

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Transcript of Orthopaedics

Orthopaedics
Shoulder
Rotator cuff
Supraspinatus - initiates abduction
Infraspinatus
Teres minor
Subscapularis
Impingement syndromes
Compression of rotator cuff - pain
Commonest site - subacromial - painful arc between 70º and 120º abduction
Acute - young sportsmen
Chronic - older patient with degenerative changes in the acromioclavicular joint
Common in haemodialysis patients due to subacromial amyloid deposits
Rotator cuff tears
Young athletic patient - trauma
Older patient - minor trauma (sudden arm traction)
Common - supraspinatus involvement - difficulty initiating abduction
or the torn rot cuff impinges on the acromion - painful arc
"Frozen shoulder"
Idiopathic adhesive capsulitis
Middle-aged people (degenerative changes)
Limitation of movements of the shoulder - plus pain (can be severe and disturb sleep)
Often history of minor trauma
Commoner of the left side and may follow prolonged rest of the arm after a Colle's fracture
Commoner in diabetics
Winged scapula - weakness of serratus anterior - muscular (progressive muscular dystrophy) or after traumatic paralysis of the long thoracic nerve
Elbow
Tennis elbow
Lateral epidondylitis
Commonest cause of elbow pain
Strain of the common extensor origin (ECRB, EDC, ECRL, ECU)
35 to 50 age group
Pain in the lateral side of the elbow
+ difficulty holding heavy objects
Note: in golfer's elbow pain and tenderness involve the common flexor origin (FCR, PT and FCU) on the medial side of the elbow (medial epidondylitis)
Normal carrying angle: men - 11º; women - 13º
Cubitus valgus - increased carrying angle; cubitus varus - decreased carrying angle
Cubitus valgus - Turner's and Noonan's
Wrist
Fractures
de Quervain's
Tenosynovitis of abductor pollicis longus and extensor pollicis brevis
Anatomical snuff box
Posterior - extensor pollicis longus
Anterior - ext. pol. brevis + abuductor pol. longus
Carpal tunnel
Women between 30-60 years old
Compression of the median nerve
Associated with myxoedema, acromegaly and pregnancy
Paraesthesia in the hand - all fingers are claimed to be affected (in theory at least the little finger should be spared)
Also pain and weakness in the hand
D.Dx cervical spondylosis
Symptoms may be worse in the morning
Median nerve - supplies the LOAF muscles (lateral 2 lumbricals, opponens pollicis, abductor pollicis brevis and flexor pollicis brevis)
Colles'
Fracture of the radius within 2.5 cm of the wrist
Commonest of all fractures (after clavicle) and seen in middle-aged and elderly women
Osteoporosis
Results from a fall on an outstretched hand
Deformities
1.Loss of normal 5º forward tilt of the joint surface (ant. angulation)
2.Dorsal displacement of distal fragment
3.Impaction of radial shaft onto the distal fragment
4. Lat. displacement of distal fragment
5. Ulnar angulation (lateral tilt of distal fragment)
X-ray = 'dinner fork' deformity
Pain and tenderness over the distal end of radius
Treatment - reduction if grossly displaced (anaesthesia, either general or regional is necessary)
Plaster should be removed at 5 weeks (6w in badly displaced fractures in the elderly)
Smith's
Reversed Colles'
Distal radial fragment is tilted into posterior angulation
May be volar displacement of distal fragment
Greenstick fractures of Smith's pattern are common
Rx: reduction, traction in suppination
Above elbow cast
Barton's
Ant. portion of the radius is involved
Volar displacement of fragment
Fracture through the joint surface
NOF
Intracapsular - subcapital and transcervical
Extracapsular - intertrochanteric or basal fractures; pertrochanteric fractures (fracture line involves the trochanters, one or both may be fractured or separated)
Risk factors: old age, osteoporosis
Commoner in women in later life, commoner in men <60
Features
Inability to bear weight after a fall
External rotation may be present
Femoral neck tenderness
Pain on hip rotation
Bruising (late sign)
Intracapsular #s (problems)
Avascular necrosis of the femoral head
Difficulty in obtaining good fixation - may lead to non-union (grades 3 and 4)
Garden classification (IC #s)
Type 1 - incomplete transverse fracture; inf. cortex not completely broken (no major displacement)
Type 2 - complete fracture line (no major displacement)
Type 3 - displacement of proximal fragment (abducted + int. rotated)
Type 4 - full displacement; femoral head tends to lie in the neutral position in the acetabulum
Treatment
Reduction and internal fixation - young and middle-aged adults
Primary replacement of the femoral head (hemiarthroplasty)
Total hip replacement
(last two done if high risk of avascular necrosis/non-union)
Treatment (extracapsular)
Basal neck #s - internal fixation with dynamic hip screw
Pertrochanteric #s - with little fragmentation use a DHS with a long plate; in unstable fractures may be possible to use a DHS tensioned in a sleeve, a dynamic condylar screw or use a Russel-Taylor reconstruction nail. (also a gamma nail)
Knee
Thickened synovial membrane and large effusions - RA
In long-standing meniscus lesions and OA, the synovial membrane may not be affected - no effusion
The menisci are avascular - tear may not cause haemarthrosis
Rapid wasting of the quadriceps is seen in all painful and inflammatory conditions of the knee
Unhappy triad (O'Donoghue's triad) - ACL, medial meniscus (normally happen together) and medial ligament
Osteoarthritis occurs first in the medial compartment
Patella and EMK
Patella fracture (direct or indirect violence e.g. sudden muscular contraction)
Rupture of quadriceps tendon
Rupture of patellar ligament
Avulsion of tibial tubercle - reduced and fixed with screw if displaced
There is instability to extend the knee
EMK - extensor mechanism of the knee
Look for in patella fractures
Bruising and abrasions
Presence and site of tenderness
Palpable gap below and above the patella
Proximal displacement of the patella
Do not mistake a congenital bipartite patella for a fractures
Osgood-Schlatter's disease - recurrent pain, tenderness and swelling over the tibial tubercle; onset may be acute and be associated with a fracture of the tongue-like downward projecting tibial epiphysis
Ligaments
Medial
Blow to the lat. side of the knee - valgus stress
Other structures that can be affected with increased force of impact (in order) - post. ligament, medial meniscus, one or both cruciates
Bruising on the lateral side + medial tenderness
Lateral
Complications - late valgus instability, persistent rotatory instability
Part of a complex that includes the biceps femoris tendon and the fascia lata
Damage in response to a varus stress
With enough force - the cruciates may tear
The common peroneal nerve may be stretched or torn
On X-ray look for avulsion fracture of the head of the fibula
Anterior cruciate
Posterior cruciate
Fall on some object or dashboard impact in a road traffic accident - tibia is forced backwards
Associated damage to the medial or lateral ligaments
Sag sign - striking alteration in the profile of the knee when placed in flexion
Associated with a false ant. drawer test
Isolated tears are uncommon - result from forced flexion or hyperextension of the knee
Frequently there are associated tears of the medial collateral ligament and the medial meniscus (O'Donoghue's triad)
Confirmed by the drawer and Lachman tests
Meniscus
Young adult - rotational stress applied to the flexed, weight bearing knee
Infants and children - menisci are plate-like instead of C-shaped - congenital discoid meniscus
Middle-aged - horizontal tears sometimes without history of trauma
Patterns
1. Longitudinal tear
2. Bucket handle tear - free edge displacing centrally (increased joint space on X-ray)
3. Racket tear of post. or ant. horns
4. Parrot-beak tear - rupture of central edge
5. Peripheral detachments - part or all may displace centrally
Presentation
Young - incident of weight-bearing stress (exercise i.e. footbal); pain and difficulty weight bearing
Women - meniscal tears are very uncommon; exclude dislocation of the patella or chondromalacia patellae
Peripheral tears - haemarthrosis (not with longitudinal tears)
Joint line tenderness and springy block to full extension (diagnostic of a displaced bucket handle tear)
X-rays to exclude other pathology
Ix: arthroscopy, MRI scan or arthrography
Complications: stiffness of fingers (most common)
Ankle
Achiles tendinopathy
Tendinitis - inflammation involving the tendon
Tendinosis - collagen degeneration within the tendon
Paratendinitis - inflammation in the tendon sheath
Insertional tendinitis - affects the tendon at the calcaneal insertion (middle aged and overweight pts)
Tenosynovitis
Inflammation in the tendon sheaths behind the maleoli
Assoc. with excessive exercise, degenerative changes, RA and flat foot
Commonest: tibialis ant. and peroneus longus
Inversion and eversion of the foot - pain
Footballer's ankle - repeated forced plantar flexion, ant. capsule tear, characteristic exostosis in lat. x-rays
Primary OA of the ankle is rare. Secondary after fratures, avascular necrosis and osteochondritis of the talus
RA of the ankle not uncommon. Not usually a primary manisfestion of the disease
Fractures
Pott's classification (obsolete?!)
First degree - fracture a single maleolus (medial or lat.)
Second degree - fracture of both medial and lat. maleoli
Third degree - medial, lateral and posterior maleoli are affected
Weber's classification
Type A - fractures distal to the syndesmosis
Type B - fractures start at the level of the tibial plafond; often spiral in a proximal direction; involve the syndesmosis
Type C - fractures proximal to the syndesmosis (variable damage)
AO system (simplified)
A - transverse fibular fracture at or below the joint line
B - spiral fibular fracture starting at the joint line +- medial maleolus injury
C1 - Oblique fibula fracture above a ruptured tibiofibular ligament + medial maleolus injury
C2 - Maisonneuve's fracture, only the fibular fracture is more distal
Dupuytren's - distal fibula fracture + distal rupture of tibiofibular ligament +- fracture of the back of the lower end of the tibia
Maisonneuve's fracture - Proximal fibular fracture + syndesmosis rupture and medial malleolus fracture or deltoid rupture
Compartment syndrome (6 P's)
Pain out of proportion
Paraesthesia
Pallor
Paralysis
Pulselessness
Poikilothermia
Rx - fascitotomy
Sprain
Grade I - Bruising (Rx: RICE)
Grade II - Partial rupture (Rx: RICE)
Grade III - Complete rupture (Rx: Plaster of Paris for 6w)
In ligament ruptures - increased joint space in X-rays
Snap or pop may be felt or heard
Slow onset of swelling (overnight)
Knee may be locked
Knee may give away - feels unstable and unsafe
Reffered pain - cervical spondylosis, mediastinal pathology and cardiac ischemia
Young people - instability
Middle age - rotator cuff disorders/adhesive capsulitis
Old age - rotator cuff disorders and OA
Management
Analgesia/NSAIDs
Local injection
Physiotherapy
Acromioplasty/Subacromial depression
ACJ excision
Instability
Traumatic - TUBS (Traumatic, Unilateral, Bankart lesions, Surgical treatment)
Atraumatic - AMBRI (Atraumatic, Multidirectional, Bilateral, responds to Rehab, Inferior capsular shift)
Management
Traumatic- Bankart repair, arthroscopic (repair of Bankart labral tear)
Atraumatic - inferior capsular shift surgery
Management
Local injection
Physiotherapy
Manipulation under anaesthesia
Arthroscopic surgical release
Other causes of lat. elbow pain: Lat. ulnar collateral ligament injury, radial nerve entrapment, radio-capitellar syndrome
Other causes of medial elbow pain: MCL injury, ulnar neuropathy
Rx: conservative, physio, local injection or surgery
Read paper notes too!!!!!
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