Bone And Joint Conditions

Front 1

Inflammatory processes that involve the musculoskeletal system include:

Back 1

bone and joint infection
rheumatoid and related arthritis
non-specific monoarthropathy.

Front 2

Bone and joint infection

Bone and joint infection can occur at any age but

Back 2

is primarily a disease of childhood.

Front 3

Infection of bones and joints can occur by:

Back 3

direct inoculation
haematogenous seeding
spread from surrounding tissue.

Front 4

Bone and joint infection
Blood-borne infection is

Back 4

by far the most common mechanism of infection

Front 5

Organisms frequently causing osteomyelitis include:

Staphylococcus aureus
Haemophilus influenzae
Streptococci (especially Strep. Pneumoniae)

Back 5

Salmonella
Pseudomonas aeruginosa
Mycobacterium tubercolisis

Front 6

Acute osteomyelitis

Following the localisation of bacteria in bone, they begin to multiply and set up an acute inflammatory reaction.

Staph. aureus is the causative organism

Back 6

in 80% of cases. In infants and neonates H. influenzae is one of the more common organisms. If infection is secondary to penetrating injury through training shows suspect Pseuodomonas.

Front 7

Brodie’s abscess is a localised area of low-grade chronic infected bone usually caused by

Back 7

Staph. aureus. The typical appearance of a Brodie’s abscess is a well-circumscribed lesion surrounded by denser, necrotic bone.

Front 8

Septic arthritis

Infection can start in joints as a result of direct haematogenous spread, spread from bone infection or

Back 8

by direct inoculation from a penetrating injury or therapeutic procedure.

Front 9

What might be the presenting symptoms of metabolic bone disease?

Back 9

pathological fracture
symptoms of hypercalcaemia
bone pain
incidental finding on x ray
deformity

Front 10

Disorders of mineralisation - osteomalacia

Back 10

This condition is probably quite common in the elderly population and may present in combination withosteoporosis as a proximal femoral fracture.

Front 11

Disorders of mineralisation - osteomalacia
It should always be considered where there is a history of poor diet, other disease or

Back 11

where immobility leads to lack of exposure to daylight.

Front 12

Osteomalacia is a disorder of parathyroid hormone function,

Back 12

which results in deficient calcium deposits in the protein matrix.

Front 13

Septic arthritis

Following the onset of infection within a joint,

Back 13

a tense purulent effusion develops
If not treated this thickens over a few days to become frank pus with intense inflammation of the synovium and capsule.
extensive damage to the articular surface of the joint.

Front 14

Osteoporosis

The commonest presentation of this condition is

Back 14

with a fracture of the proximal femur, the distal radius or a vertebral body.

Front 15

Osteoporosis
It should be suspected in the elderly female population and may be picked up incidentally on

Back 15

X-ray.

Front 16

Osteoporosis
Women who have had a premature menopause are particularly at risk unless

Back 16

they have received hormone replacement therapy.

Front 17

Paget’s disease

This condition may be asymptomatic until it presents with

Back 17

deformity of a single bone (monostotic).

Front 18

Paget’s disease
The aetiology is not clear, but it is possibly due to a

Back 18

viral infection

Front 19

Paget’s disease
Paget’s is characterised by excessive resorption of bone followed by excessive bone formation. The bone that is formed is histologically quite disorganised due to the

Back 19

uncoordinated overactivity of osteoclasts and osteoblasts. Because of its disorganised structure, microfractures develop in the tension side of the weight-bearing bones

Front 20

Paget’s disease
It may affect more than one bone (polyostotic), in which case it can cause secondary effects such as high output cardiac failure and nerve compression syndromes.

Back 20

In the polyostotic form up to 10% of patients may developosteogenic sarcoma.

Front 21

child with osteomyelitis or septic arthritis may be septicaemic and extremely ill.
In these circumstances you must:
be aware of musculoskeletal infection as a cause of septicaemia
measure temperature, pulse rate and arterial blood pressure
establish intravenous access and start rehydration with crystalloids
take the first of a series of blood cultures

Back 21

take blood samples for urea and electrolytes and full blood count
splint the affected joint and give analgesia as required.

Front 22

Orthopaedic examination should follow the principle of

Back 22

‘Look– Feel–Move’.

Front 23

Magnetic resonance imaging (MRI) is now one of the preferred investigations of orthopaedic pathology due to the anatomical detail that can be visualised, its sensitivity in demonstrating pathology and lack of radiation exposure. Uses include

Back 23

demonstrating meniscal tears in the knee, disc protrusion in the lumbar spine and imaging of bone lesions

Front 24

Arthrography

Contrast, and sometimes air, is injected into a joint and imaging done with plain X-ray, computed tomography (CT) or digital subtraction techniques. Its main uses are in

Back 24

imaging rotator cuff and labral tears in the shoulder, the hip in infants with DDH and loose implants.

Front 25

Bone density measurement
dual energy X-ray absorptiometry (DEXA scanning)

Back 25

Bone density measurement

Front 26

DDH
The principles of treatment are to reduce,

Back 26

hold reduced and await development of stability and the acetabulum.

Front 27

DDH
If detected in the neonatal period, simply holding the hip abducted and flexed reduces the hip and maintaining this position maintains reduction. This is most easily and safely accomplished with a

Back 27

Pavlik harness

Front 28

Osteomalacia

Osteomalacia
is treated with calcium and vitamin D supplements. The precipitating cause, such as

Back 28

a dietary problem, should also be examined and treated appropriately

Front 29

Osteoporosis
often presents at a late stage where achieving a clinically significant increase in bone mass can be difficult.

Back 29

Early detection in an at risk population is the best hope for preventing complications.

Front 30

osteoporosis
The following measures are of some value in the prevention and treatment of osteoporosis:

Back 30

exercise - particularly weight-bearing exercise
avoidance of smoking l good dietary intake of calcium
biphosphonates
hormone replacement therapy - valuable if started in the first five years after the menopause.

Front 31

Prompt effective treatment with antibiotics and, if indicated, surgery

.

Back 31

should result in complete healing with no long-term sequelae in all cases.

Front 32

Osteomyelitis
Multiple organ failure and death may result from overwhelming infection

Back 32

if the diagnosis or treatment is delayed, or if the patient is immunocompromised.

Front 33

Osteomyelitis
Abnormalities of growth can occur. Overgrowth can result from stimulation of the blood supply to the epiphysis. Retardation of growth may occur from Chronic osteomyelitis can occur. It is most likely if a large sequestrum has formed before effective treatment has begun

Back 33

destruction of the epiphyseal plate by infection. Angular deformities can result from partial growth arrest.

Front 34

Metabolic bone disease treatment
The treatment of the much more common established osteoporosis is less satisfactory

Back 34

and hence a lot of emphasis is placed onearly detection and prevention.

Front 35

Metabolic bone disease treatment
Suppression of the activity of Paget’s disease with biphosphonates and calcitonin can relieve bone pain but the long-term problems of

Back 35

neoplasia, fracture and deformity are more difficult to prevent and treat.

Front 36

Osteoarthritis

Osteoarthritis (OA) may be

Back 36

primary or secondary.

Front 37

Primary osteoarthritis will affect us all provided we live long enough. Although the underlying cause is not known, mechanical factors are important and that it is more common in the

Back 37

obese, in heavy manual workers and where there are misalignments increasing the forces on a joint.

Front 38

Osteoarthritis
The joints most commonly affected are the lower limb joints especially the hips and knees. In the upper limb

Back 38

the distal interphalangeal joints of the fingers and the carpometacarpal joint of the thumb are often affected and may require treatment.

Front 39

Secondary osteoarthritis occurs when the joint has been previously damaged in some way. By definition, it will affect whichever joint has been damaged. However,

Back 39

it is more likely to be of clinical significance in the weight-bearing joints of the lower limbs.

Front 40

Pathological features of osteoarthritis include:

Back 40

loss of articular cartilage
cyst formation in the subchondral bone
osteophytes growing from the joint margin
fragmentation of the articular cartilage may set up inflammation in the lining of the joint.

Front 41

Causes of secondary osteoarthritis include:

Back 41

infection
a fracture involving the joint surface
a fracture altering the joint alignment • previous ligament injury
childhood diseases, e.g. Perthes’ disease and slipped upper femoral epiphysis

Front 42

Rheumatoid arthritis

This is one of a group of diseases which are characterised by

Back 42

an inflammatory chronic polyarthritis

Front 43

Rheumatoid arthritis
Because of the underlying autoimmune nature of the condition, there is considerable overlap between rheumatoid arthritis,&

Back 43

the other chronic polyarthritides

Front 44

chronic polyarthritides include,

Back 44

Rheumatoid arthritis
Psoriaticarthropathy
Systemic lupus erythematosus
Ankylosing spondylitis.

Front 45

Rheumatoid arthritis
This is a systemic disease whose onset is frequently heralded by malaise, fever and fatigue. The peak time of presentation is between

Back 45

35 and 45 years-of-age
It is much more common in females than males.

Front 46

criteria for diagnosis of rheumatoid arthritis (according to the American Rheumatism Association

Back 46

Morning stiffness
Pain on motion or tenderness in a joint
Joint swelling due to fluid
or soft tissue
Typical ‘rheumatoid’ nodules
Typical X-ray changes including periarticular osteopenia
Positive test for serum rheumatoid factor
Synovial fluid forming poor mucin clot with dilute acetic acid
Swelling of a second joint
Symmetrical (i.e. right and left) joint swelling

Front 47

criteria for diagnosis of rheumatoid arthritis (according to the American Rheumatism Association

Back 47

Characteristic synovial histology

Front 48

criteria for diagnosis of rheumatoid arthritis (according to the American Rheumatism Association

Back 48

Characteristic histology of rheumatoid module

Front 49

Presentation

Rheumatoid arthritis
The classical presentation is as a symmetrical polyarthritis in the small joints of the hands and feet. However,

Back 49

it may present as a monoarthropathy or in asymmetrical larger joints as well.

Front 50

Rheumatoid arthritis
Signs and symptoms
In the early stages of the disease, the patients complain of stiffness particularly in the early morning. They are also aware of

Back 50

swelling of the joints and this is associated with a restriction in the range of movements.

Front 51

Crystal-induced arthropathies
Gout and pseudogout are the two conditions seen in clinical practice which are due to the deposition of .

Back 51

crystals in the joints

Front 52

Gout,usually affects small peripheral joints (classically, the first metatarsophalangeal joint [MTPJ] in the foot); the Pseudogout more often

Back 52

larger joints such as the wrist or knee.

Front 53

During an acute attack of gout the serum uric acid is often raised. However, a normal level does not exclude the diagnosis the joint fluid

Back 53

contains uric acid crystals visible on microscopy and X-rays show no abnormality in the initial phases of the disease.

Front 54

There are no biochemical tests for pseudogout. The joint fluid contains

Back 54

acute inflammatory cells and crystals of calcium pyrophosphate dihydrate (CPPD).

Front 55

Gout and Pseudogout
In an acutely painful swollen joint it is essential to exclude infection because it is impossible to cure septic arthritis. Delay in making the diagnosis

Back 55

will make secondary arthritis more likely.

Front 56

What is the difference between the crystals of gout and pseudogout under polarised light microscopy?

uric acid crystals are negatively birefringent.

Back 56

CPPD crystals show weak positive birefringence.

Front 57

What tests would you arrange as an emergency if you suspected infection in a swollen joint?

Back 57

Full Blood Count
microscopy and culture of an aspirate of the joint fluid
CRP
ESR

Front 58

Back pain
In mechanical back pain the patient complains of pain in

Back 58

the lower lumbar spine, which is worse after exercise.If the pain is in the distribution of the sciatic nerve, it is called sciatica. It is usually very severe and is due to pressure on a nerve root by a disc herniation or an adjacent osteophyte.

Front 59

Remember that not all pain in the back arises from the spine or spinal cord

Back 59

pelvic reproductive organs
the renal tract
abdominal aortic aneurysm
retroperitoneal tumours (especially the pancreas).

Front 60

Types of back pain:

Back 60

mechanical (degenerative discs and facet joints)

nerve root pain (compression, disk protrusion)

serious pathology (osteomyelitis, metastatic malignancy).

Front 61

What are some causes of chronic spinal cord compression?

Back 61

degenerative change usually from cervical spondylitis ( visible on X ray)
Benign tumours such as neurofibromas and meningiomas
Soft disc herniation

Front 62

Enthesopathies
Muscle origins may be subject to microtears, which result in pain and inflammatory change. Continued use results in a

Back 62

cycle of pain and inflammation that never gets a chance to settle. This leads to chronic pain that can be quite debilitating. Examples of this type of condition are ‘Tennis elbow’ and ‘Golfer’s elbow’.

Front 63

What are other sites of enthesopathy?

Back 63

Insertion of Achilles tendon into calcaneum
At the origin of the hip flexors from the anterior superior and anterior inferior iliac spines
At the adductor origin

Front 64

Rotator cuff disorders

A common example of this type of inflammation is in the .

Back 64

rotator cuff at the shoulder

Front 65

Rotator cuff disorders
The tendinous insertion of the supraspinatus, infraspinatus, subscapularis and teres minor muscles into the proximal humerus is broad and extensiveThe structure gets its blood supply from the muscle proximally and from the bone distally,

Back 65

creating a watershed where these two supplies meet. Theoretically, this area may be subject to ischaemia due to insufficient blood supply.

Front 66

Rotator cuff disorders Furthermore, the rotator cuff passes beneath the acromial arch and is subject to (

Back 66

pressure in this region when the arm is abducted. This combination may result in inflammatory changes in the cuff at this vulnerable point. It will give rise to referred pain, which is felt over the point of the shoulder and extending down on to the badge area of the upper arm When these factors are compounded by trauma, even relatively minor trauma, the cuff may tear.

Front 67

Hilton’s law: The motor nerve to muscle tends to give a branch of supply to the joint that the muscle moves and another branch to

Back 67

the skin over the joint.

Front 68

Why is the pain of rotator cuff impingement felt at the deltoid insertion rather than over the acromion?

Back 68

this is the referred pain in the distribution of the C5 dermatome

Front 69

Frozen shoulder

Many painful conditions of the shoulder are called ‘frozen shoulder’, but the term should be applied only to the fibrous contracture of the

Back 69

coracohumeral ligament and the rotator interval of the capsule.

Front 70

Frozen shoulder
Pain is felt near the

Back 70

insertion of the deltoid and there is restriction of elevation and external rotation of the joint. The patient is usually unable to sleep on the affected side.

Front 71

Frozen shoulder
Pain is accompanied by progressive stiffness which remains as the pain itself subsides. Eventually,

Back 71

the stiffness resolves and the majority of patients return to normal levels of activity. However, the time course for this is usually around two years.

Front 72

Meniscal pathology
The medial meniscus is relatively immobile compared to the lateral and this is the main reason why it is more commonly affected by

Back 72

degenerative problems.

Front 73

Meniscal pathology
Degeneration may result in a radial or

Back 73

flap tear, which causes pain and clicking in the joint.

Front 74

Meniscal pathology
Occasionally, and generally in the younger person playing sport, the tear is of the

Back 74

‘bucket handle’ type, giving rise to locking of the knee. Both these conditions may be associated with swelling of the knee, the swelling being a response to the irritation within the joint.

Front 75

In a haemarthrosis not due to fracture, ACL rupture is the cause in

Back 75

80% of cases.

Front 76

KNEE
Other causes of joint swelling include synovial thickening due to

Back 76

inflammatory arthritides

Front 77

KNEE
Swelling and locking may be due to a loose body in the joint and this is often caused by

Back 77

osteochondritis dissecans.
This is a localised form of avascular necrosis which commonly affects the lateral aspect of the medial femoral condyle. Occasionally it may affect a significant part of the weight-bearing surface. A fragment of hyaline cartilage, often with an underlying piece of subchondral bone will separate off as a loose body. This may be visible on X-ray or it may be palpable within the joint.

Front 78

If the cause of back pain is infection, then this usually affects the disc space

Back 78

Some of the more common organisms causing disc space infection include:

Staphylococcus aureus
Streptococcus species
Salmonella species
Mycobacterium tuberculosis
Brucella species.

Front 79

Sciatica
degeneration in the soft tissues of the lumbar spine with resultant

Back 79

compression on the nerve root
levels most commonly affected are L 4/5 causing L5 root pain, and L5/S1 causing S1 root pain.

Front 80

In the lumbar spine, if the nucleus prolapses centrally, there is pressure on the cauda equina. What would be the result of this?

Back 80

pain in both legs
perinneal numbness
loss of bladder control

Front 81

Another cause of sciatic pain is

Back 81

neurogenic claudication
In this condition, the spinal canal or the nerve root canals are narrowed congenitally or by degeneration with osteophyte formation

Front 82

Disc prolapses can also occur in the cervical spine. Pressure on a nerve root will result in pain down the

Back 82

arm in the distribution of the root that is being compressed.

Front 83

Peripheral nerve compression syndromes

Back 83

can arise from direct trauma, for example a fall or fracture
Another cause is sustained pressure as in ‘Saturday night palsy’
may arise from penetrating injuries

Front 84

Seddon’s classification of nerve injuries:
Neurapraxia -

Back 84

absent or diminished function due to pressure on the nerve

Front 85

Seddon’s classification of nerve injuries:
Axonotmesis -

Back 85

interruption of the axons and their myelin sheaths but not of the surrounding connective tissues

Front 86

Seddon’s classification of nerve injuries:
Neurotmesis -

Back 86

irreparable damage by section, traction, ischaemia or intraneural injection .

Front 87

There are many examples of neurapraxia The commonest example is compression of the

Back 87

median nerve at the wrist (carpal tunnel syndrome).
The aetiology may be thyroid disease, obesity or pregnancy, all of which cause a rise in the pressure within the carpal tunnel resulting in symptoms

Front 88

Other examples of nerve compression are ulnar nerve symptoms in the hand as a result of pressure in the cubital tunnel at the elbow, compression of the T1 root over a cervical rib causing thoracic outlet syndrome and a foot drop

Back 88

due to compression of the common peroneal nerve at the neck of the fibula.

Front 89

Bankart lesion - In a person under 30, an anterior shoulder dislocation will lift the capsule of the anterior aspect of the glemoid, creating a

Back 89

redundant sac in to which the humeral head tends to displace in recurrent dislocations.

Front 90

Isotope bone scanning

Technetium isotope scans remain a useful screening test for infection and neoplasia,

Back 90

especially metastatic disease

Front 91

Is MRI or CT essential in the diagnosis of prolapsed intervertebral disc?

Back 91

No -diagnosis is made on clinical grounds, but it is essential to confirm the level of pathology if you are considering surgery

Front 92

Nerve conduction studies (NCS)

These tests are usually carried out on peripheral nerves

Back 92

As a rule, NCS are very sensitive and specific in carpal tunnel syndrome but can be less helpful in the diagnosis of other entrapment neuropathies
The best diagnostic test for carpal tunnel syndrome is the response to surgical release

Front 93

Osteoarthritis of joints
Advice
This will depend on the severity of the condition.

Back 93

weight loss, intermittent use of analgesics, including non-steroidal anti-inflammatory drugs (NSAIDs) and the use of a walking stick.

Front 94

OA treatment
Contraindications to NSAIDs include:

Back 94

previous or current peptic ulcer disease
asthma
anticoagulant therapy.

Front 95

OA treatment
Physiotherapy

Physiotherapy is quite useful for knee and ankle joints, but relatively little help for

Back 95

osteoarthritis of the hip.

Front 96

OA
Steroid injection

These may be helpful in providing temporary relief in up to 50% of patients with OA of the

Back 96

knee.

Front 97

OA
Arthroscopy

In the knee joint, arthroscopy may provide temporary symptomatic relief. It also provides an opportunity to

Back 97

assess the joint surfaces

Front 98

OA treatment
Osteotomy

This is one of the traditional treatments. There are many ways of performing the procedure, but all involve dividing the bone near the joint and altering the alignment. Then the bone may be held in position by internal fixation. It is a less predictable operation than joint replacement, but still used in

Back 98

younger patients.

Front 99

OA treatment
Arthrodesis

This is especially useful in small joints of the hands and feet where stability is more important than a range of movement. Very occasionally it is indicated for a major joint, usually in a young patient or after

Back 99

a failed joint replacement. The functional limitations are considerable.

Front 100

OA treatment
Total joint replacement
This is one of the most common operations in orthopaedics. It provides excellent relief of pain in at least 80% of patients in the short- to medium-term

Back 100

(up to five years).

Front 101

OA treatment
Total joint replacement
Eventually, however, all joint replacements fail by loosening and the operation should not be offered indiscriminately. By far the most important indication is pain unrelieved by conservative treatment and significantly interfering with activities of daily life.

Back 101

There are no absolute indications for a joint replacement. It is a symptomatic treatment not a curative one.

Front 102

indications for a joint replacementThe younger the patient is, the stricter should be the indications for surgery. The probability of long-term problems in the replacement joint increases in the younger patient because they tend to

Back 102

load and test the joint more than an older person will

Front 103

Mechanical back pain

This type of pain is very common At least 80% of us will suffer from it to some extent during our life. If there is a ‘pathological’ cause it is due to

Back 103

degeneration in the discs and facet joints.

Front 104

Mechanical back pain

Back 104

Most attacks are self-limiting and settle within four to six weeks, although recurrence is common. A relatively small number of patients have persistent symptoms.

Front 105

Mechanical back pain
Physical therapies including manipulation and conventional physiotherapy will help both acute and chronic problems. A very small proportion need to be considered for further investigation. These include people with

Back 105

lumbar instability and spondylolisthesis

Front 106

Joint pain and swelling
In the acute situation where there is no clear indication of a traumatic cause for the swelling. It is essential to consider infection. Check the full blood count, the erythrocyte sedimentation rate, the C-reactive protein level and the uric acid level.

Back 106

Send a specimen of the aspirate for microscopy, including looking for crystals, and culture. If the diagnosis remains unclear, further investigations such as isotope bone scanning, white cell scans and/or magnetic resonance scans may be indicated

Front 107

Soft tissue problems in the shoulder
Acute calcification will usually respond to steroid and local anaesthetic injection, but

Back 107

ultimately may require surgical management.

Front 108

rotator cuff disorders. Surgery may be necessary to decompress the rotator cuff or repair a tear if

Back 108

the injection therapy is unsuccessful.

Front 109

Frozen shoulder
can be treated by steroid injection with variable success. Manipulation under anaesthetic disrupts the fibrosis and

Back 109

improves the active and passive range of movement. It may also shorten the period during which the patient is in pain.

Front 110

Soft tissue problems in the knee

Steroid injection is particularly useful in the case of the inflammatory arthritides,

Back 110

where it can give long lasting relief of symptoms. However, the symptoms usually recur.

Front 111

Soft tissue problems in the knee
If the patient has significant instability in the knee as a result of deficiency of the anterior cruciate ligament, then surgery to reconstruct the ligament is usually successful in restoring stability. The most successful procedure uses a composite graft taken from

Back 111

the patella, the patellar ligament and the tibial tuberosity.

Front 112

Soft tissue problems in the knee
Arthroscopy is useful in that it confirms the diagnosis and allows treatment. If the problem is mainly degenerative, then the treatment may be only a washout which will provide temporary relief in a proportion of patients with osteoarthritis. In the case of meniscal pathologies, the torn meniscus may be repaired. In other cases, it is possible to remove part or all of a meniscus,

Back 112

carry out a synovectomy, debride the joint, remove loose bodies and reconstruct ligaments. These procedures may also be done through an arthrotomy, but in most cases rehabilitation will take longer.

Front 113

Nerve conduction studies (NCS)

These tests are usually carried out on

Back 113

peripheral nerves

Front 114

In general, electrophysiological tests are indicated:

Back 114

to confirm the diagnosis
to help reach a diagnosis in confusing clinical situations
to give baseline information prior to surgery.

Front 115

Unfortunately, the sensitivity of the tests is variable depending on the location of the entrapment. As a rule, NCS are very sensitive and specific in carpal tunnel syndrome .

Back 115

but can be less helpful in the diagnosis of other entrapment neuropathies

Front 116

Soft tissue problems in the knee
Steroid injection is particularly useful in the case of the inflammatory arthritides, where it can give long lasting relief of symptoms. However,

Back 116

the symptoms usually recur.

Front 117

Soft tissue problems in the knee
Arthroscopy is useful in that it confirms the diagnosis and allows treatment. If the problem is mainly degenerative, then the treatment may be only a washout which will provide temporary relief in a proportion of patients with osteoarthritis. In the case of meniscal pathologies,

Back 117

the torn meniscus may be repaired. In other cases, it is possible to remove part or all of a meniscus, carry out a synovectomy, debride the joint, remove loose bodies and reconstruct ligaments. These procedures may also be done through an arthrotomy, but in most cases rehabilitation will take longer.

Front 118

Soft tissue problems in the knee
If the patient has significant instability in the knee as a result of deficiency of the anterior cruciate ligament, then surgery to reconstruct the ligament is usually successful in restoring stability. The most successful procedure uses

Back 118

a composite graft taken from the patella, the patellar ligament and the tibial tuberosity

Front 119

Nerve root pain

Over a period of several weeks the majority of nerve root pains resolve spontaneously. There are

Back 119

treatments available which may hasten the recovery.
Rest There is no evidence, however, that more than a few day’s rest is beneficial.
Analgesics

Initially the pain may be very severe and require strong analgesics. Opiates may well be required
Physiotherap
Surgical treatment

Surgery in nerve root problems is for failed conservative treatment except in cauda equina problems. If there is no significant improvement in the symptoms after six weeks of adequate conservative treatment, surgical removal of the disc prolapse is appropriate

Front 120

Indications for surgery in disc prolapse:

Back 120

Pain in the distribution of a nerve root.
Neurological signs: sensory, motor or reflex deficit. Bladder or bowel dysfunction.
Persisting symptoms and/or signs after adequate conservative treatment.
CT or MRI evidence of a disc prolapse at a site consistent with the clinical features.

Front 121

Spinal cord and cauda equina compression

This is a surgical emergency. The longer there is pressure on the nerves the less likely it is that there will be a recovery of function. Imaging is necessary to localise the level and then an open surgical procedure to remove the cause.

Back 121

Acute problems are usually due to disc prolapses or to metastatic disease.

Posterior decompression is almost always inappropriate in metastatic disease. The treatment is either by urgent radiotherapy or by anterior decompression and stabilisation by a surgeon experienced in such procedures.

Front 122

Peripheral nerve compressions

In the first instance, these lesions should be treated by avoiding obvious causes of irritation, for example,

Back 122

leaning elbows on tables as a cause of pressure on the ulnar nerve, avoiding the use of vibrating tools which can give rise to carpal tunnel syndrome.

Front 123

Peripheral nerve compressions
Physiotherapy, in the form of local treatments and manipulations may help resolve the problem.
Steroid injections can help by suppressing local inflammation which may be contributing to the neurapraxia.

Back 123

Surgery may be required when all other forms of treatment have failed, or when there is clear evidence of significant loss of function of the nerve. The procedure may only result in relief from pain in late cases, with persistent numbness and weakness despite surgery.

Front 124

Cervical and lumbar disc prolapses

These patients require regular monitoring in order to pick up the small proportion of patients who will go on to

Back 124

spinal cord or cauda equina compression. This devastating complication will usually be made apparent by changing neurological signs and symptoms. Urgent treatment is required.

Front 125

Joint arthroplasty
Eighty percent of arthroplasty patients are satisfied with the outcome of the surgery in terms of pain relief and improved mobility. However, 20% have some dissatisfaction. This may range from .

Back 125

infection in the joint, through recurrent dislocation of the hip to dissatisfaction with the scar on the hip
On average, hip arthroplasty will last 10 years and the results in knee replacement are even better with an average life span in excess of 11 years.

Front 126

Joint arthroplasty failure usually presents with

Back 126

pain, and on radiographs there will be evidence of loosening. Sometimes they will present with a fracture around the prosthesis or a dislocation.

Front 127

When arthroplasty patients are reviewed regularly, a small number are found to have evidence of osteolysis at the bone-cement interface. This condition may result in When arthroplasty patients are reviewed regularly, a small number are found to have evidence of osteolysis at the bone-cement interface. This condition may result in weakening of the bone with a subsequent pathological fracture. It is also likely to result in loosening of the prosthesis

Back 127

When arthroplasty patients are reviewed regularly, a small number are found to have evidence of osteolysis at the bone-cement interface. This condition may result in weakening of the bone with a subsequent pathological fracture. It is also likely to result in loosening of the prosthesis

Front 128

A fracture usually achieves stability by producing callus which develops from the

Back 128

fracture haematoma.

Front 129

Principles of fracture healing
The haematoma is gradually invaded by chondrocytes, which in turn

Back 129

produce cartilage which is changed into bone.

Front 130

Open fractures
The significance of this is that there is an increase in the risk of

Back 130

infection at the fracture site. The consequences of infection at the fracture site are considerable in terms of morbidity and failure of union

Front 131

Gustilo.Classification of open fractures

Back 131

Grade 1 Skin wound 1 cm or less; low-energy trauma
Grade 2 Extensive wounds but with little devitalised soft tissue and reltively little foreign material
Grade 3A Extensive soft tissue wounds, but with adequate soft tissue to cover bone
Grade 3B Wounds with extensive soft tissue injury and bone exposure
Grade 3C Open fractures associated with arterial or nerve injuries requiring repair

Front 132

Epiphyseal injuries

Back 132

Salter-Harris classification of epiphyseal injuries

Front 133

The significance of epiphyseal injuries lies in their capacity for

Back 133

interrupting normal growth and causing deformity.

Front 134

Salter-Harris classification of epiphyseal injuries

Back 134

Type I - separation of the epiphysis. This usually occurs in very young children and at puberty as a slipped femoral epiphysis

Front 135

Salter-Harris classification of epiphyseal injuries

Back 135

Type II - fracture through the physis and metaphysis. This is the most common and occurs in older children. Rarely does it result in abnormal growth

Front 136

Salter-Harris classification of epiphyseal injuries

Back 136

III - intra-articular fracture of the epiphysis. Reduction must be precise to restore the joint surface.

Front 137

Salter-Harris classification of epiphyseal injuries

Back 137

Type IV - splitting of the physis and epiphysis. Thee is damage to the articular surface and may result in abnormal growth. Reducation should be open if there is a displacement

Front 138

Salter-Harris classification of epiphyseal injuries

Back 138

Type V - crushing of the physis. This will result in stoppage of growth.

Front 139

Osteoporosis
The problem is one of increasing bone loss in the postmenopausal female population. One of the commonest fractures in the UK is the

Back 139

proximal femoral fracture. Along with fractures of the distal radius and crush fractures of the dorsolumbar spine, it is commonest in the elderly female population.

Front 140

Other conditions which have a high risk of osteoporosis include: •

Back 140

renal disease • steroid treatment for asthma, irritable bowel disease, rheumatoid arthritis, transplants.

Front 141

The distal radial (or Colles’) fracture is a common fracture in the .

Back 141

postmenopausal female which can often be managed as an outpatient

Front 142

The dorsolumbar compression fracture is very painful and may need in-patient care until the pain has settled. In most cases the patient is able to get home to their preinjury lifestyle. The significance of these fractures is that

Back 142

they require management of more than just the fracture. The technical procedure of dealing with the fracture is probably the simplest part of the whole process.

Once the fracture has been stabilised, there is a need to consider the possibility of preventing further loss of the bone mass by augmenting the diet with supplementary calcium and vitamin D. Increasing the bone mass in postmenopausal women is difficult, but may be attempted by considering the use of bisphosphonates and hormone replacement therapy.

Front 143

Proximal femoral fracture
These fractures can be divided into three categories:

Back 143

subcapital
intertrochanteric subtrochanteric

Front 144

Proximal femoral fracture
The difference between the intertrochanteric and subcapital fractures is based principally on The

Back 144

their blood supply.

Front 145

Proximal femoral fracture
blood supply of the proximal end of the femur is made up of three groups.

Back 145

The first group is an extracapsular arterial ring around the base of the femoral neck, which is formed anteriorly by a branch from the lateral femoral circumflex artery and posteriorly by a large branch of the medial femoral circumflex artery.

Front 146

Proximal femoral fracture
blood supply of the proximal end of the femur is made up of three groups.

Back 146

The second group is the ascending cervical branches that arise from the arterial ring to pass along the surface of the neck of the femur in to the femoral head.

Front 147

Proximal femoral fracture
blood supply of the proximal end of the femur is made up of three groups.

Back 147

Finally there is a blood supply to the head of the femur that passes through the artery of the ligamentum teres.

Front 148

The blood supply to the femoral head is not interrupted where the fracture is intertrochanteric (or extracapsular). However, if the fracture is subcapital, or within the capsule of the joint, the blood supply will be interrupted and

Back 148

there is a significant risk of avascular necrosis of the femoral head. The probability of avascular necrosis is thought to be about 40%.

Front 149

Distal radial fracture
Colles’
takes place at about an inch and a half above the carpal extremity of the radius… The carpus and base of the metacarpus

Back 149

appear to be thrown backwards

Front 150

Other fractures of the distal radius may be

Back 150

intra-articular

Front 151

fractures of the distal radius
Other fractures of the distal radius may be

Back 151

displaced in a volar direction (Smith’s fracture).

Front 152

Vertebral compression fracture

Back 152

common in the elderly female population,

Front 153

Vertebral compression fracture
acutely painful in the early stages and causes progressive deformity in the form of a kyphosis If it is very severe, this deformity can affect

Back 153

respiratory function.

Front 154

A spiral fracture to a long bone usually means an indirect force with a twisting element

Back 154

in the long axis of the bone

Front 155

A comminuted fracture is one that has more than .

Back 155

two fragments. This is usually an indication of significant force

Front 156

A comminuted fracture
This type of fracture is usually unstable . If the fracture is open

Back 156

this will usually mean a higher energy injury with consequent effects on the surrounding soft tissues.

Front 157

Compartment syndrome
consequence of soft tissue injury is the development of a compartment syndrome. This condition can arise in both .

Back 157

closed and open fractures

Front 158

Compartment syndrome
The commonest sites for development of this condition are the leg the forearm and the thigh. If untreated, compartment syndrome leads to

Back 158

ischaemic damage to the affected muscle group and subsequent fibrosis and contracture.

Front 159

compartment syndrome
The predominant symptom that will raise the possibility of a compartment syndrome is pain. A later symptom is paraesthesia.

Back 159

This pain is unremitting and will usually require strong analgesics in the form of opiates. This is unlike the pain of a fracture that normally settles once the fracture has been immobilised

Front 160

Compartment syndrome does not usually lead to ischaemia of a whole limb. However ischaemia of a whole limb may lead to compartment syndrome particularly if

Back 160

that limb is reperfused after a period of ischaemia. The ischaemia causes increased permeability at the capillary level which increases the possibility of swelling occurring in the compartment.

Front 161

Causes of non-union include:

Back 161

soft tissue interposition
excessive movement
soft tissue damage/loss
avascular necrosis
infection.

Front 162

Dislocation

Dislocation of a joint is the result of significant force - at least on the first occasion. The shoulder is the commonest joint to be dislocated, the reason being that

Back 162

the intrinsic stability of the joint is low to allow for a greater degree of mobility. The hip joint is seldom dislocated, but when it is the force required is very great, e.g. a road traffic accident. In this and other joints the dislocation will often be associated with a fracture.

Front 163

Assessment of limb injuries

Back 163

look
feel
move (if possible)
X-ray

Front 164

When you are dealing with a patient who has multiple injuries, three standard X-rays should be obtained:

Back 164

lateral cervical spine
chest
pelvis

Front 165

Treatment of fractures

The immediate treatment of most fractures is to splint the affected limb in order to prevent movement of broken bones. This will reduce the pain The splint may take the form of a simple wooden or plastic support, or a plaster of Paris slab. In some cases a neighbouring limb or digit will provide adequate splintage.

Back 165

A Thomas splint can be used for femoral fractures.

Front 166

Is it an open fracture?

If the fracture is open then the patient will require admission to hospital. The wound will need surgical debridement under a general anaesthetic. Because there is a higher risk of infection with an open fracture, it is generally accepted that these fractures should be debrided within six hours of injury.

Back 166

This is based on the knowledge that the bacterial growth in an open fracture increases dramatically with time after the injury.

Front 167

Is it an open fracture?
The management of the underlying fracture will depend on circumstances. It may be treated with external support (plaster cast), external or internal fixation with an intramedullary nail or plate and screws. In some cases the patient will be referred to a specialist centre

Back 167

for the management of the particularly complex Grade 3 B and C fractures.

Front 168

Does the fracture involve the joint surface?
Any involvement of a joint surface increases the risk of

Back 168

secondary degenerative change later on.

Front 169

Does the fracture involve the joint surface?
It is generally accepted that any displacement of a joint surface of more than two millimetres should be

Back 169

reduced anatomically and fixed so that further displacement will not occur

Front 170

Is the fracture stable?
The stability of a fracture depends on the

Back 170

initial force applied to the fracture, the degree of comminution of the fracture and the muscle and weight-bearing forces that will be applied across a fracture site during the healing process.

Front 171

Is the fracture stable?
If the fracture is displaced, it will require to be reduced. If it is a transverse fracture it may be intrinsically stable once it is reduced. If it is comminuted, it will require external support to maintain length and stability. If the force applied to the fracture is considerable,

Back 171

the surrounding soft tissues will be disrupted and this will further reduce the stability of any fracture, irrespective of its pattern.

Front 172

Is the fracture position acceptable?
If the fracture is:
angulated more than 100 in any plane
completely displaced
rotated on its longitudinal axis
it will usually require

Back 172

manipulation or open reduction depending on individual circumstances

Front 173

Immobilisation of a limb in a cast may result in a number of problems for the patient. These include

Back 173

stiff joints, wasted muscles and disuse osteoporosis. The Association for the Study of Internal Fixation (ASIF) has called this ‘fracture disease’.

Front 174

Application of a cast

Back 174

must be well-padded and applied smoothly to prevent pressure points forming in the cast
must be moulded to prevent deformity recurring
must be strong enough to support the limb
must immobilise the joint above and below the fracture.

Front 175

External fixation
useful with open fractures
rapid stabilisation of the fracture while allowing access to the wound for dressings

Back 175

percutaneous pins require meticulous attention on an almost daily basis to prevent pin site infections

Front 176

Open reduction and internal fixation (ORIF) allows for rigid fixation of fractures
allows early movement of the joints above and below the fracture and helps to prevent joint stiffness and wasting of the muscle

Back 176

also allows anatomical reduction of intra-articular fractures, which should help to prevent the development of secondary osteoarthrosis.

Front 177

A less rigid method of internal fixation involves intramedullary nailing. a pin is inserted along the intramedullary canal from one end of the bone, across the fracture site and into the distal fragment.

Back 177

In most cases the pin is fixed in position with interlocking screws at both proximal and distal ends

Front 178

intramedullary nailing
The advantage of this technique is that it is often possible to reduce the fracture and insert the pin across the fracture without opening the fracture site itself. The problem with this technique is that

Back 178

it is quite time-consuming, particularly inserting the interlocking screws at the distal end of the pin.

Front 179

Operating on fractures does have potential problems.

Back 179

Firstly, it converts a closed fracture into an open one, albeit under aseptic conditions. This increases the risk of infection.

Front 180

Operating on fractures does have potential problems.

Back 180

Open reduction of fractures usually requires some stripping of the soft tissues. This inevitably reduces the blood supply to the fracture site.

Front 181

Operating on fractures does have potential problems.

Back 181

Internal fixation of a fracture may involve a second operation to remove the metal when the fracture has united, or if infection or other complications arise.

Front 182

Preoperative assessment of Proximal femoral fractures

Back 182

these, often elderly, patients may have co-existing cardiovascular and respiratory pathology. require careful assessment before being presented for surgery.

Front 183

Preoperative assessment of Proximal femoral fractures

Back 183

careful attention to fluid balance, serum biochemistry and haemoglobin is required. Postoperative rehabilitation is often prolonged

Front 184

Preoperative assessment of Proximal femoral fractures

Back 184

Rehabilitation involves a multidisciplinary team of specialists from geriatric medicine, physiotherapy, occupational therapy and the social work department. To get the best results the team should start work as soon as possible after the patient’s admission to hospital.

Front 185

Colles’ fracture
The usual management for this fracture is to manipulate the fracture under some form of anaesthesia.

Back 185

The anaesthetic technique may be a haematoma block, an intravenous Biers’ block, an axillary block or a general anaesthetic.

Front 186

Colles’ fracture
The fracture is reduced (manipulated in to an anatomical position) and held with an external support (e.g. a Charnley U-slab or a Colles’ cast). If the fracture is very unstable it may require

Back 186

K-wire fixation and, occasionally, dorsal bone grafting

Front 187

Colles’ fracture
In some cases where there is severe comminution, and particularly if the fracture is intra-articular,

Back 187

there may be an indication for an external fixator.

Front 188

Colles’ fracture
Because of the osteoporotic nature of the bone, these fractures are often intrinsically unstable. It is easy to manipulate them into a satisfactory position and to hold the position for a brief period with some form of external support, such as a plaster cast. However,

Back 188

as the swelling settles the cast becomes looser and the fracture often reverts to its previous malposition.

Front 189

Scaphoid fracture

Back 189

falls on to the outstretched hand.
tenderness on the radial aspect of the wrist

Front 190

Scaphoid fracture

Back 190

The difficulty with the scaphoid is that it lies obliquely in two planes and as a consequence it is difficult to get a good view of this bone

Front 191

Scaphoid fracture

Back 191

The standard three or four views of the scaphoid are designed to show this small bone in the wrist in profile

Front 192

Scaphoid fracture

Back 192

The difficulty with the scaphoid is that it lies obliquely in two planes and as a consequence it is difficult to get a good view of this bone

Front 193

Scaphoid fracture
In most cases the treatment of this injury, even in the presence of normal films is to immobilise the wrist in a back slab or Colles’ cast for approximately 10 days and then to take further films. If at this stage the wrist is free of pain and there is no evidence of a fracture on X-ray then

Back 193

it can be assumed that the scaphoid is not fractured

Front 194

Scaphoid fracture

Back 194

If the scaphoid is fractured and this is seen on the initial film the usual procedure is to immobilise the wrist in a Colles’ cast for six weeks. In most cases, if the fracture is undisplaced, it will heal without difficulty.

Front 195

Why is there a high incidence of non-union with scaphoid fractures?

Back 195

Blood supply of the proximal pole comes from the distal pole and may be disrupted by the injury.

Front 196

Scaphoid fracture

Back 196

If it is displaced it will usually require open reduction and internal fixation with a cannulated screw and possibly bone grafting.

Front 197

Scaphoid fracture
In a proportion of cases, avascular necrosis of the proximal pole occurs. This will require bone graft in order to encourage union and reconstitution of the proximal pole. This complication is more likely to occur in fractures of the

Back 197

waist of the scaphoid which are displaced. The reason for this is that the blood supply of the scaphoid enters the distal pole and proceeds proximally.

Front 198

Tibial fractures
If the fracture is closed, not displaced and stable, then it can be treated in a long leg cast.

Back 198

Usually the cast is plaster of Paris and, therefore, very heavy when wet. The patient will be admitted for bed rest and elevation and for observation in order to detect compartment syndrome early if it should arise. A plaster of Paris cast usually takes 72 hours to dry out completely.

Front 199

Tibial fractures
After 24 hours, the patient will be mobilised non-weight bearing on crutches. Thereafter, they will be reviewed regularly in the outpatient clinic with

Back 199

X-rays to establish that the position of the fracture has been maintained.

Front 200

Tibial fractures

Back 200

At about one month after injury, the long-leg cast will be changed to a below-knee patella tendon bearing cast (Sarmiento cast). This cast will be maintained until the fracture unites. The patient will be encouraged to bear full body-weight through the fractured limb while using this cast.

Front 201

Fractures that are not suitable for conservative management by virtue of displacement or instability are usually treated by

Back 201

reduction and stabilisation with an intramedullary nail, or by open reduction and internal fixation with a plate and screws.

Front 202

open reduction and internal fixation
This form of treatment has the advantage of

Back 202

allowing the patient to move the joints above and below the fracture very early. Patients are also encouraged to begin weight bearing at an early stage.

Front 203

open reduction and internal fixation

Back 203

disadvantages with internal fixation, which include the risk of infection and non-union with the risk of fatigue fracture of the plate or nail.

Front 204

Spinal injuries

You will usually suspect a spinal injury from the

Back 204

history and because the patient may have altered sensation below a particular spinal level.

Front 205

Spinal injuries
management of this patient will follow the ATLS principles,

Back 205

with particular care being taken to immobilise the spine.

Front 206

Spinal injuries
suspect a spinal injury from the history
patient may have altered sensation below a particular spinal level.

Back 206

management of this patient will follow the ATLS principles, with particular care being taken to immobilise the spine.

Front 207

Spinal injuries

Back 207

assessment to exclude any other injuries, particularly abdominal ones, which may require urgent surgical management

Front 208

Spinal injuries
perform a careful neurological examination and record whether there is any sacral sparing. This is important as it indicates the possibility of some neurological recovery. Transection of the cord will result in a complete flaccid paralysis below the level of the injury.

Back 208

Any sensation below this level suggests an incomplete injury to the cord. Therefore, recovery of function is possible to a variable degree and surgical stabilisation and decompression must be considered.

Front 209

Spinal injuries
Once the patient’s condition is stable and the diagnosis is confirmed, they should be transferred to

Back 209

spinal injuries unit for stabilisation of the fracture and further rehabilitation. Such patients will require a urinary catheter.

Front 210

Dislocations
Usually the patient will tell you the diagnosis,
but it is essential to take a history and carry out a careful clinical examination to exclude

Back 210

possibility of associated neurological and vascular injury.reduction can be achieved using a combination of adequate pain relief and muscle relaxation with an opiate and intravenous benzodiazepine. In some cases a general anaesthetic may be necessary.

Front 211

Management of non-union
If it is decided that delayed or non-union is occurring in a fracture, it is usual to treat the fracture by

Back 211

internal fixation with bone grafting to encourage union.

Front 212

Management of non-union
As with a new fracture, there are a number of methods which may be used. Intramedullary nailing is useful in that the reaming of the medullary cavity in effect puts a lot of autograft at the fracture site. However, it is usually necessary to open the fracture site in order to pass the nail across the fracture because the medullary canal is often occluded by the frustrated attempt to heal the fracture.

Back 212

Open reduction and compression plating along with allograft taken from the iliac crest is often preferred if the fracture has to be exposed to achieve reduction.
It would be unusual to treat a delayed union by external fixation, but this technique has been used in the past.

Functional bracing can also be used to treat tibial and femoral shaft fractures if there is the suspicion that delayed union is developing.

Front 213

delayed-union or non-union

Back 213

The definition of delayed and non-union is usually made in retrospect. It is generally held that delayed union has occurred if the fracture is not healed by six months, but there is still evidence of an attempt at fracture union taking place. Non-union is the later stage where there is no evidence of any attempt at healing and the situation is clearly static.

Front 214

Proximal femoral fractures

The Scottish Hip Fracture Audit has shown a mortality rate of 7.6 % for proximal femoral fractures during the acute period . This rises to 10.7% at one-month post-fracture. At four months post-fracture the figure is 22%.

The mortality rate at 12 months is approximately 34% in Scotland.

Back 214

This high mortality rate is probably inevitable in this age group. Nevertheless, the effort involved in rehabilitation is well worthwhile for those patients who do get home and are able to continue living independently.

The average mortality at 12 months following a hip fracture is 34% (Scottish Hip Fracture Audit).

Front 215

Scaphoid fractures

If a scaphoid fracture is missed and goes on to non-union, it is virtually inevitable that

Back 215

radiocarpal degenerative change will occur within about 15 years.

Front 216

Spinal injuries

Where the spinal cord has been transected, there is no prospect for recovery of neurological function. In some cases where sacral sparing is found in the initial assessment, there may be recovery of neurological function to a greater or lesser extent. Particular expertise is required to

Back 216

prevent the development of pressure sores, manage bladder function, and deal with the psychological aspects of this type of injury. The management of these patients from the time of the injury through into rehabilitation is very specialised and best dealt with in a spinal injuries unit.

Front 217

Dislocations

In young patients (under 30-years-old) with a first dislocation, the risk of redislocation of the shoulder is about 60%. This decreases with increasing age so that an elderly patient (over 60-years-old) with a first dislocation is unlikely to have a recurrence. This is because the dislocation in the young patient strips the capsule off the anterior aspect of the scapula to create the Bankart lesion - a large sac in to which the humeral head can displace easily. In the older patient

Back 217

the dislocation will tear the capsule of the joint, allowing healing by scar tissue, leaving no large sac anteriorly.

Front 218

How best could you prevent redislocation?

Back 218

following immobilization of the joint for between four and six weeks, this patient should receive physiotherapy to build up muscle strength and control, he should be made aware, however,that there is a high likelihood of redislocation of his shoulder by his dislocating it just once.