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218 Cards in this Set
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- Back
Inflammatory processes that involve the musculoskeletal system include:
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bone and joint infection
rheumatoid and related arthritis non-specific monoarthropathy. |
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Bone and joint infection
Bone and joint infection can occur at any age but |
is primarily a disease of childhood.
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Infection of bones and joints can occur by:
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direct inoculation
haematogenous seeding spread from surrounding tissue. |
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Bone and joint infection
Blood-borne infection is |
by far the most common mechanism of infection
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Organisms frequently causing osteomyelitis include:
Staphylococcus aureus Haemophilus influenzae Streptococci (especially Strep. Pneumoniae) |
Salmonella
Pseudomonas aeruginosa Mycobacterium tubercolisis |
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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 |
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.
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Brodie’s abscess is a localised area of low-grade chronic infected bone usually caused by
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Staph. aureus. The typical appearance of a Brodie’s abscess is a well-circumscribed lesion surrounded by denser, necrotic bone.
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Septic arthritis
Infection can start in joints as a result of direct haematogenous spread, spread from bone infection or |
by direct inoculation from a penetrating injury or therapeutic procedure.
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What might be the presenting symptoms of metabolic bone disease?
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pathological fracture
symptoms of hypercalcaemia bone pain incidental finding on x ray deformity |
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Disorders of mineralisation - osteomalacia
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This condition is probably quite common in the elderly population and may present in combination withosteoporosis as a proximal femoral fracture.
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Disorders of mineralisation - osteomalacia
It should always be considered where there is a history of poor diet, other disease or |
where immobility leads to lack of exposure to daylight.
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Osteomalacia is a disorder of parathyroid hormone function,
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which results in deficient calcium deposits in the protein matrix.
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Septic arthritis
Following the onset of infection within a joint, |
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. |
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Osteoporosis
The commonest presentation of this condition is |
with a fracture of the proximal femur, the distal radius or a vertebral body.
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Osteoporosis
It should be suspected in the elderly female population and may be picked up incidentally on |
X-ray.
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Osteoporosis
Women who have had a premature menopause are particularly at risk unless |
they have received hormone replacement therapy.
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Paget’s disease
This condition may be asymptomatic until it presents with |
deformity of a single bone (monostotic).
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Paget’s disease
The aetiology is not clear, but it is possibly due to a |
viral infection
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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 |
uncoordinated overactivity of osteoclasts and osteoblasts. Because of its disorganised structure, microfractures develop in the tension side of the weight-bearing bones
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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. |
In the polyostotic form up to 10% of patients may developosteogenic sarcoma.
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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 |
take blood samples for urea and electrolytes and full blood count
splint the affected joint and give analgesia as required. |
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Orthopaedic examination should follow the principle of
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‘Look– Feel–Move’.
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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
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demonstrating meniscal tears in the knee, disc protrusion in the lumbar spine and imaging of bone lesions
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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 |
imaging rotator cuff and labral tears in the shoulder, the hip in infants with DDH and loose implants.
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Bone density measurement
dual energy X-ray absorptiometry (DEXA scanning) |
Bone density measurement
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DDH
The principles of treatment are to reduce, |
hold reduced and await development of stability and the acetabulum.
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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 |
Pavlik harness
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Osteomalacia
Osteomalacia is treated with calcium and vitamin D supplements. The precipitating cause, such as |
a dietary problem, should also be examined and treated appropriately
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Osteoporosis
often presents at a late stage where achieving a clinically significant increase in bone mass can be difficult. |
Early detection in an at risk population is the best hope for preventing complications.
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osteoporosis
The following measures are of some value in the prevention and treatment of osteoporosis: |
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. |
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Prompt effective treatment with antibiotics and, if indicated, surgery
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should result in complete healing with no long-term sequelae in all cases.
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Osteomyelitis
Multiple organ failure and death may result from overwhelming infection |
if the diagnosis or treatment is delayed, or if the patient is immunocompromised.
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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 |
destruction of the epiphyseal plate by infection. Angular deformities can result from partial growth arrest.
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Metabolic bone disease treatment
The treatment of the much more common established osteoporosis is less satisfactory |
and hence a lot of emphasis is placed onearly detection and prevention.
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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 |
neoplasia, fracture and deformity are more difficult to prevent and treat.
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Osteoarthritis
Osteoarthritis (OA) may be |
primary or secondary.
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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
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obese, in heavy manual workers and where there are misalignments increasing the forces on a joint.
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Osteoarthritis
The joints most commonly affected are the lower limb joints especially the hips and knees. In the upper limb |
the distal interphalangeal joints of the fingers and the carpometacarpal joint of the thumb are often affected and may require treatment.
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Secondary osteoarthritis occurs when the joint has been previously damaged in some way. By definition, it will affect whichever joint has been damaged. However,
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it is more likely to be of clinical significance in the weight-bearing joints of the lower limbs.
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Pathological features of osteoarthritis include:
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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. |
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Causes of secondary osteoarthritis include:
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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 |
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Rheumatoid arthritis
This is one of a group of diseases which are characterised by |
an inflammatory chronic polyarthritis
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Rheumatoid arthritis
Because of the underlying autoimmune nature of the condition, there is considerable overlap between rheumatoid arthritis,& |
the other chronic polyarthritides
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chronic polyarthritides include,
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Rheumatoid arthritis
Psoriaticarthropathy Systemic lupus erythematosus Ankylosing spondylitis. |
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Rheumatoid arthritis
This is a systemic disease whose onset is frequently heralded by malaise, fever and fatigue. The peak time of presentation is between |
35 and 45 years-of-age
It is much more common in females than males. |
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criteria for diagnosis of rheumatoid arthritis (according to the American Rheumatism Association
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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 |
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criteria for diagnosis of rheumatoid arthritis (according to the American Rheumatism Association
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Characteristic synovial histology
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criteria for diagnosis of rheumatoid arthritis (according to the American Rheumatism Association
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Characteristic histology of rheumatoid module
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Presentation
Rheumatoid arthritis The classical presentation is as a symmetrical polyarthritis in the small joints of the hands and feet. However, |
it may present as a monoarthropathy or in asymmetrical larger joints as well.
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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 |
swelling of the joints and this is associated with a restriction in the range of movements.
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Crystal-induced arthropathies
Gout and pseudogout are the two conditions seen in clinical practice which are due to the deposition of . |
crystals in the joints
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Gout,usually affects small peripheral joints (classically, the first metatarsophalangeal joint [MTPJ] in the foot); the Pseudogout more often
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larger joints such as the wrist or knee.
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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
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contains uric acid crystals visible on microscopy and X-rays show no abnormality in the initial phases of the disease.
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There are no biochemical tests for pseudogout. The joint fluid contains
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acute inflammatory cells and crystals of calcium pyrophosphate dihydrate (CPPD).
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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 |
will make secondary arthritis more likely.
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What is the difference between the crystals of gout and pseudogout under polarised light microscopy?
uric acid crystals are negatively birefringent. |
CPPD crystals show weak positive birefringence.
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What tests would you arrange as an emergency if you suspected infection in a swollen joint?
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Full Blood Count
microscopy and culture of an aspirate of the joint fluid CRP ESR |
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Back pain
In mechanical back pain the patient complains of pain in |
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.
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Remember that not all pain in the back arises from the spine or spinal cord
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pelvic reproductive organs
the renal tract abdominal aortic aneurysm retroperitoneal tumours (especially the pancreas). |
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Types of back pain:
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mechanical (degenerative discs and facet joints)
nerve root pain (compression, disk protrusion) serious pathology (osteomyelitis, metastatic malignancy). |
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What are some causes of chronic spinal cord compression?
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degenerative change usually from cervical spondylitis ( visible on X ray)
Benign tumours such as neurofibromas and meningiomas Soft disc herniation |
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Enthesopathies
Muscle origins may be subject to microtears, which result in pain and inflammatory change. Continued use results in a |
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’.
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What are other sites of enthesopathy?
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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 |
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Rotator cuff disorders
A common example of this type of inflammation is in the . |
rotator cuff at the shoulder
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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, |
creating a watershed where these two supplies meet. Theoretically, this area may be subject to ischaemia due to insufficient blood supply.
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Rotator cuff disorders Furthermore, the rotator cuff passes beneath the acromial arch and is subject to (
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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.
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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
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the skin over the joint.
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Why is the pain of rotator cuff impingement felt at the deltoid insertion rather than over the acromion?
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this is the referred pain in the distribution of the C5 dermatome
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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 |
coracohumeral ligament and the rotator interval of the capsule.
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Frozen shoulder
Pain is felt near the |
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.
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Frozen shoulder
Pain is accompanied by progressive stiffness which remains as the pain itself subsides. Eventually, |
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.
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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 |
degenerative problems.
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Meniscal pathology
Degeneration may result in a radial or |
flap tear, which causes pain and clicking in the joint.
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Meniscal pathology
Occasionally, and generally in the younger person playing sport, the tear is of the |
‘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.
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In a haemarthrosis not due to fracture, ACL rupture is the cause in
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80% of cases.
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KNEE
Other causes of joint swelling include synovial thickening due to |
inflammatory arthritides
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KNEE
Swelling and locking may be due to a loose body in the joint and this is often caused by |
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. |
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If the cause of back pain is infection, then this usually affects the disc space
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Some of the more common organisms causing disc space infection include:
Staphylococcus aureus Streptococcus species Salmonella species Mycobacterium tuberculosis Brucella species. |
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Sciatica
degeneration in the soft tissues of the lumbar spine with resultant |
compression on the nerve root
levels most commonly affected are L 4/5 causing L5 root pain, and L5/S1 causing S1 root pain. |
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In the lumbar spine, if the nucleus prolapses centrally, there is pressure on the cauda equina. What would be the result of this?
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pain in both legs
perinneal numbness loss of bladder control |
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Another cause of sciatic pain is
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neurogenic claudication
In this condition, the spinal canal or the nerve root canals are narrowed congenitally or by degeneration with osteophyte formation |
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Disc prolapses can also occur in the cervical spine. Pressure on a nerve root will result in pain down the
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arm in the distribution of the root that is being compressed.
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Peripheral nerve compression syndromes
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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 |
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Seddon’s classification of nerve injuries:
Neurapraxia - |
absent or diminished function due to pressure on the nerve
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Seddon’s classification of nerve injuries:
Axonotmesis - |
interruption of the axons and their myelin sheaths but not of the surrounding connective tissues
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Seddon’s classification of nerve injuries:
Neurotmesis - |
irreparable damage by section, traction, ischaemia or intraneural injection .
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There are many examples of neurapraxia The commonest example is compression of the
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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 |
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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
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due to compression of the common peroneal nerve at the neck of the fibula.
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Bankart lesion - In a person under 30, an anterior shoulder dislocation will lift the capsule of the anterior aspect of the glemoid, creating a
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redundant sac in to which the humeral head tends to displace in recurrent dislocations.
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Isotope bone scanning
Technetium isotope scans remain a useful screening test for infection and neoplasia, |
especially metastatic disease
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Is MRI or CT essential in the diagnosis of prolapsed intervertebral disc?
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No -diagnosis is made on clinical grounds, but it is essential to confirm the level of pathology if you are considering surgery
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Nerve conduction studies (NCS)
These tests are usually carried out on peripheral nerves |
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 |
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Osteoarthritis of joints
Advice This will depend on the severity of the condition. |
weight loss, intermittent use of analgesics, including non-steroidal anti-inflammatory drugs (NSAIDs) and the use of a walking stick.
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OA treatment
Contraindications to NSAIDs include: |
previous or current peptic ulcer disease
asthma anticoagulant therapy. |
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OA treatment
Physiotherapy Physiotherapy is quite useful for knee and ankle joints, but relatively little help for |
osteoarthritis of the hip.
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OA
Steroid injection These may be helpful in providing temporary relief in up to 50% of patients with OA of the |
knee.
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OA
Arthroscopy In the knee joint, arthroscopy may provide temporary symptomatic relief. It also provides an opportunity to |
assess the joint surfaces
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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 |
younger patients.
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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 |
a failed joint replacement. The functional limitations are considerable.
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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 |
(up to five years).
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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. |
There are no absolute indications for a joint replacement. It is a symptomatic treatment not a curative one.
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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
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load and test the joint more than an older person will
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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 |
degeneration in the discs and facet joints.
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Mechanical back pain
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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.
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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 |
lumbar instability and spondylolisthesis
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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. |
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
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Soft tissue problems in the shoulder
Acute calcification will usually respond to steroid and local anaesthetic injection, but |
ultimately may require surgical management.
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rotator cuff disorders. Surgery may be necessary to decompress the rotator cuff or repair a tear if
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the injection therapy is unsuccessful.
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Frozen shoulder
can be treated by steroid injection with variable success. Manipulation under anaesthetic disrupts the fibrosis and |
improves the active and passive range of movement. It may also shorten the period during which the patient is in pain.
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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, the symptoms usually recur.
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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 |
the patella, the patellar ligament and the tibial tuberosity.
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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, |
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.
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Nerve conduction studies (NCS)
These tests are usually carried out on |
peripheral nerves
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In general, electrophysiological tests are indicated:
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to confirm the diagnosis
to help reach a diagnosis in confusing clinical situations to give baseline information prior to surgery. |
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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 .
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but can be less helpful in the diagnosis of other entrapment neuropathies
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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, |
the symptoms usually recur.
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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, 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.
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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 the patella, the patellar ligament and the tibial tuberosity
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Nerve root pain
Over a period of several weeks the majority of nerve root pains resolve spontaneously. There are |
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 |
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Indications for surgery in disc prolapse:
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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. |
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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. |
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. |
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Peripheral nerve compressions
In the first instance, these lesions should be treated by avoiding obvious causes of irritation, for example, |
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.
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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. |
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.
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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 |
spinal cord or cauda equina compression. This devastating complication will usually be made apparent by changing neurological signs and symptoms. Urgent treatment is required.
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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 . |
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. |
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Joint arthroplasty failure usually presents with
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pain, and on radiographs there will be evidence of loosening. Sometimes they will present with a fracture around the prosthesis or a dislocation.
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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
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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
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A fracture usually achieves stability by producing callus which develops from the
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fracture haematoma.
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Principles of fracture healing
The haematoma is gradually invaded by chondrocytes, which in turn |
produce cartilage which is changed into bone.
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Open fractures
The significance of this is that there is an increase in the risk of |
infection at the fracture site. The consequences of infection at the fracture site are considerable in terms of morbidity and failure of union
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Gustilo.Classification of open fractures
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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 |
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Epiphyseal injuries
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Salter-Harris classification of epiphyseal injuries
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The significance of epiphyseal injuries lies in their capacity for
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interrupting normal growth and causing deformity.
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Salter-Harris classification of epiphyseal injuries
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Type I - separation of the epiphysis. This usually occurs in very young children and at puberty as a slipped femoral epiphysis
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Salter-Harris classification of epiphyseal injuries
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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
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Salter-Harris classification of epiphyseal injuries
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III - intra-articular fracture of the epiphysis. Reduction must be precise to restore the joint surface.
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Salter-Harris classification of epiphyseal injuries
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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
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Salter-Harris classification of epiphyseal injuries
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Type V - crushing of the physis. This will result in stoppage of growth.
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Osteoporosis
The problem is one of increasing bone loss in the postmenopausal female population. One of the commonest fractures in the UK is the |
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.
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Other conditions which have a high risk of osteoporosis include: •
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renal disease • steroid treatment for asthma, irritable bowel disease, rheumatoid arthritis, transplants.
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The distal radial (or Colles’) fracture is a common fracture in the .
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postmenopausal female which can often be managed as an outpatient
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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
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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. |
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Proximal femoral fracture
These fractures can be divided into three categories: |
subcapital
intertrochanteric subtrochanteric |
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Proximal femoral fracture
The difference between the intertrochanteric and subcapital fractures is based principally on The |
their blood supply.
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Proximal femoral fracture
blood supply of the proximal end of the femur is made up of three groups. |
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.
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Proximal femoral fracture
blood supply of the proximal end of the femur is made up of three groups. |
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.
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Proximal femoral fracture
blood supply of the proximal end of the femur is made up of three groups. |
Finally there is a blood supply to the head of the femur that passes through the artery of the ligamentum teres.
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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
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there is a significant risk of avascular necrosis of the femoral head. The probability of avascular necrosis is thought to be about 40%.
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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 |
appear to be thrown backwards
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Other fractures of the distal radius may be
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intra-articular
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fractures of the distal radius
Other fractures of the distal radius may be |
displaced in a volar direction (Smith’s fracture).
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Vertebral compression fracture
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common in the elderly female population,
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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 |
respiratory function.
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A spiral fracture to a long bone usually means an indirect force with a twisting element
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in the long axis of the bone
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A comminuted fracture is one that has more than .
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two fragments. This is usually an indication of significant force
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A comminuted fracture
This type of fracture is usually unstable . If the fracture is open |
this will usually mean a higher energy injury with consequent effects on the surrounding soft tissues.
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Compartment syndrome
consequence of soft tissue injury is the development of a compartment syndrome. This condition can arise in both . |
closed and open fractures
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Compartment syndrome
The commonest sites for development of this condition are the leg the forearm and the thigh. If untreated, compartment syndrome leads to |
ischaemic damage to the affected muscle group and subsequent fibrosis and contracture.
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compartment syndrome
The predominant symptom that will raise the possibility of a compartment syndrome is pain. A later symptom is paraesthesia. |
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
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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
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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.
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Causes of non-union include:
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soft tissue interposition
excessive movement soft tissue damage/loss avascular necrosis infection. |
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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 |
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.
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Assessment of limb injuries
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look
feel move (if possible) X-ray |
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When you are dealing with a patient who has multiple injuries, three standard X-rays should be obtained:
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lateral cervical spine
chest pelvis |
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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. |
A Thomas splint can be used for femoral fractures.
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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. |
This is based on the knowledge that the bacterial growth in an open fracture increases dramatically with time after the injury.
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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 |
for the management of the particularly complex Grade 3 B and C fractures.
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Does the fracture involve the joint surface?
Any involvement of a joint surface increases the risk of |
secondary degenerative change later on.
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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 |
reduced anatomically and fixed so that further displacement will not occur
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Is the fracture stable?
The stability of a fracture depends on the |
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.
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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, |
the surrounding soft tissues will be disrupted and this will further reduce the stability of any fracture, irrespective of its pattern.
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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 |
manipulation or open reduction depending on individual circumstances
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Immobilisation of a limb in a cast may result in a number of problems for the patient. These include
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stiff joints, wasted muscles and disuse osteoporosis. The Association for the Study of Internal Fixation (ASIF) has called this ‘fracture disease’.
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Application of a cast
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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. |
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External fixation
useful with open fractures rapid stabilisation of the fracture while allowing access to the wound for dressings |
percutaneous pins require meticulous attention on an almost daily basis to prevent pin site infections
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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 |
also allows anatomical reduction of intra-articular fractures, which should help to prevent the development of secondary osteoarthrosis.
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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.
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In most cases the pin is fixed in position with interlocking screws at both proximal and distal ends
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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 |
it is quite time-consuming, particularly inserting the interlocking screws at the distal end of the pin.
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Operating on fractures does have potential problems.
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Firstly, it converts a closed fracture into an open one, albeit under aseptic conditions. This increases the risk of infection.
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Operating on fractures does have potential problems.
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Open reduction of fractures usually requires some stripping of the soft tissues. This inevitably reduces the blood supply to the fracture site.
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Operating on fractures does have potential problems.
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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.
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Preoperative assessment of Proximal femoral fractures
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these, often elderly, patients may have co-existing cardiovascular and respiratory pathology. require careful assessment before being presented for surgery.
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Preoperative assessment of Proximal femoral fractures
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careful attention to fluid balance, serum biochemistry and haemoglobin is required. Postoperative rehabilitation is often prolonged
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Preoperative assessment of Proximal femoral fractures
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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.
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Colles’ fracture
The usual management for this fracture is to manipulate the fracture under some form of anaesthesia. |
The anaesthetic technique may be a haematoma block, an intravenous Biers’ block, an axillary block or a general anaesthetic.
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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 |
K-wire fixation and, occasionally, dorsal bone grafting
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Colles’ fracture
In some cases where there is severe comminution, and particularly if the fracture is intra-articular, |
there may be an indication for an external fixator.
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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, |
as the swelling settles the cast becomes looser and the fracture often reverts to its previous malposition.
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Scaphoid fracture
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falls on to the outstretched hand.
tenderness on the radial aspect of the wrist |
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Scaphoid fracture
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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
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Scaphoid fracture
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The standard three or four views of the scaphoid are designed to show this small bone in the wrist in profile
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Scaphoid fracture
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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
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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 |
it can be assumed that the scaphoid is not fractured
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Scaphoid fracture
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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.
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Why is there a high incidence of non-union with scaphoid fractures?
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Blood supply of the proximal pole comes from the distal pole and may be disrupted by the injury.
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Scaphoid fracture
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If it is displaced it will usually require open reduction and internal fixation with a cannulated screw and possibly bone grafting.
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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 |
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.
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Tibial fractures
If the fracture is closed, not displaced and stable, then it can be treated in a long leg cast. |
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.
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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 |
X-rays to establish that the position of the fracture has been maintained.
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Tibial fractures
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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.
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Fractures that are not suitable for conservative management by virtue of displacement or instability are usually treated by
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reduction and stabilisation with an intramedullary nail, or by open reduction and internal fixation with a plate and screws.
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open reduction and internal fixation
This form of treatment has the advantage of |
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.
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open reduction and internal fixation
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disadvantages with internal fixation, which include the risk of infection and non-union with the risk of fatigue fracture of the plate or nail.
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Spinal injuries
You will usually suspect a spinal injury from the |
history and because the patient may have altered sensation below a particular spinal level.
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Spinal injuries
management of this patient will follow the ATLS principles, |
with particular care being taken to immobilise the spine.
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Spinal injuries
suspect a spinal injury from the history patient may have altered sensation below a particular spinal level. |
management of this patient will follow the ATLS principles, with particular care being taken to immobilise the spine.
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Spinal injuries
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assessment to exclude any other injuries, particularly abdominal ones, which may require urgent surgical management
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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. |
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.
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Spinal injuries
Once the patient’s condition is stable and the diagnosis is confirmed, they should be transferred to |
spinal injuries unit for stabilisation of the fracture and further rehabilitation. Such patients will require a urinary catheter.
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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 |
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.
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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 |
internal fixation with bone grafting to encourage union.
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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. |
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. |
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delayed-union or non-union
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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.
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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. |
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). |
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Scaphoid fractures
If a scaphoid fracture is missed and goes on to non-union, it is virtually inevitable that |
radiocarpal degenerative change will occur within about 15 years.
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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 |
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.
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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 |
the dislocation will tear the capsule of the joint, allowing healing by scar tissue, leaving no large sac anteriorly.
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How best could you prevent redislocation?
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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.
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