Musculoskeletal Cases for Finals Dr Alastair Brown ST 1 Neurosurgery CXH
Objectives l l Be able to describe common fractures Understand the management of common fractures Understand the principles of major joint examinations Understand the clinical features and management of osteoarthritis of the hip and knee.
Case 1 A 74 year old female presents having fallen in her bathroom at home. l She is complaining of pain in her hip. l Says slipped on the bathroom floor, no preceding symptoms. PMH: Hypertension Osteoporosis Glaucoma l DH: Calcichew D 3 Forte Amlodipine 10 mg Timolol eye drop 1 drop twice daily SH: Lives alone, children are around the corner Two- storey house Non-smoker no-alcohol
Examination l l l Looks in pain Alert and orientated Nothing abnormal to find on examination of RS CVS and Abdomen.
Examination l l l Unable to straight leg raise on left side Pain at the greater trochanter. Shortened externally rotated left leg.
Examination of the hip l l l Look – l muscle wasting l leg length discrepancy l scars Feel – l Palpate greater trochanter Move – l Flexion and extension l Internal and external rotation Special Tests – l Thomas’ test – fixed flexion deformity l Trendelenburg test – testing gluteus minimus and medius Gait
Management l What is your provisional diagnosis? l l Fracture left neck of femur How will you manage this patient l l Analgesia Investigations l l Blood tests – FBC, UE, LFTs, Clotting, G+S Radiology – Chest X-ray, AP pelvis and Lateral L Hip.
Management l How can you classify hip fractures? l Location l l Mechanism l l Traumatic or Pathological Displacement l l Left or Right Intra/extracapsular Sub-capital, base cervical, intertrochanteric, subtrochanteric. Undisplaced, impacted, displaced. Open or closed.
Management l Can you describe this injury? l l Fracture of the left neck of femur Intracapsular Displaced What is the management of this fracture? l Hemiarthroplasty/THR
Management l Can you describe this injury? l l Fracture of left neck of femur Extracapsular Minimally displaced What is the management of this injury? l Dynamic hip screw
Management l Can you describe this injury? l l l Fracture of left femur Sub-trochanteric Angulated Displaced What is the management of this fracture? l IM Nail
Management l What are the factors affecting the management of intracpasular fractures? l l Displacement – Garden 1 and 2 can be managed with cannulated screws Age – ORIF may be attempted in patient aged under 60 Mobility and cognitive impairment – Those who were walking unaided and have no cognitive impairment should be offered THR If x-rays showed no fracture but you still suspected one how would you manage the patient? l l l Analgesia Attempt to mobilise CT/MRI
Fall on an outstretched hand…
Case 2 l Describe this injury l l What is the name of this injury? l l Smith’s What is the mechanism? l l Fracture of the distal radium and ulna Volar angulation Volar displacement Fall on flexed wrist What is the treatment? l ORIF
Case 3 l Describe this injury? l l l What is the name of this fracture? l l Colle’s What is the mechanism of injury? l l Fracture of the distal radius Minimally displaced Shortened Dorsal angulation Fall on outstretched hand with extended wrist What is the management of this fracture? l l Closed reduction and POP ORIF/ K wire in certain circumstances.
Case 4 l Describe this injury l l l What is the name of this fracture? l l Monteggia fracture dislocation What is the mechanism of injury? l l Displaced fracture of the ulna proximal 1/3 Subluxation of the radial head. Fall on hyperpronated arm What is the management of the injury? l ORIF
Case 5 l Can you describe this injury? l l What is the name of this injury? l l Galeazzi fracture dislocation. What is the mechanism of injury? l l Displaced fracture of the distal radius Angulation Disruption of the radio-ulnar joint. Fall on hyperpronated arm. What is the management? l ORIF
Twisted ankles
Case 6 l Can you describe this injury? l l l What is the Weber classification of this injury? l l Fracture of distal fibula Below level of joint line Weber A What is the management of this injury? l Closed reduction and POP
Case 7 l Can you describe this fracture? l l What is the Weber classification? l l Fracture of distal fibula Comminution At the level of the joint Weber B What is the management? l l l Closed reduction if stable ORIF if unstable Stability depends on whethere is a injury to medial malleolus or deltoid ligament.
Case 8 Can you descirbe this injury? l l Fracture of fibula and medial malleolus Minimally displaced on AP film Fracture above syndesomosis. What is the Weber classification? 1. 1. Weber C What is the management? 2. 1. ORIF
Case 9 l Can you describe this injury? l l l What is the name of this injury? l l Fracture of distal tibia and fibula? Intra-articular component Trimalleolar fracture What is the management of this fracture? l ORIF
Sore knees
Case 10 74 year old man l C/O pain in his left knee l Pain and stiffness worst in the evening l Gradually less mobile and now walking with a stick. PMH l HTN l IHD l BPH l DH – NKDA Asprin, Clopidogrel, Tamsulosin, Bisoprolol, Simvastatin, Ramipril SH Lives with wife Bungalow Ex-smoker
Inspection Heberden’s nodes
Inspection Old Right TKR scar
Examination of the knee l Look l l Feel l l l Active and passive Flexion and extension Special Tests l l l Temperature Popliteal fossa- aneurysms/cysts Joint line – tenderness Patella tap and bulge sign Crepitus Move l l Scars Muscle wasting Deformity – valgus, varus and flexion Gait Anterior drawer – test ACL Posterior drawer test PCL Varus and valgus stress Mc. Murray’s test
Investigation
Investigation l Can you describe the previous radiograph? l l AP radiograph of both knees Joint space narrowing of medial compartment of left knee. What are the radiographic features of osteoarthritis? l l l Osteophytes Joint space narrowing Subchondral cysts
Management l Non-operative l l Address risk factors – weight loss, smoking cessation, Vitamin D replacement. Analgesia – injections no longer recommended. Walking aids Operative l Arthroplasty reserved for those with moderate to severe pain and disability.
Painful shoulder
Case 11 l l 68 year old man Complaining of pain in the shoulder. Came on while lifting a box down from a shelf. Now finding it difficult to lift his arm above his head. PMH: Asthma DH: NKDA Salbutamol Beclomethasone SH Keen sportsman Retired accountant Non-smoker
Examination l l No deformity of shoulder Some tenderness along the top of the humeral head. Pain on abduction of the arm between 45 and 100%. Normal power in shoulder muscles.
Examination of the shoulder l Look l l l Deformity Position of neck and clavicles Muscle wasting Winging of the scapula Feel l Scapula Clavicles Acromio - and sternoclavicular joint l Move l Flexion and extension l Internal and external rotation of shoulder with elbow flexed. Special tests l l Neers signs – internally rotated arm and then elevating arm Hawkins test – abdocut shoulder to 90 degrees and internally rotate Scarf test draw arm across body at 90 degrees to torso to see if exacerbates AC joint pain
Findings l Painful arc l l Inability to intiate arm abduction l l Impingement due to supraspinatus tendinitis Supraspinatus tendon rupture Reduced active and passive movment l l OA if crepitus present Adhesive capsulitis (frozen shoulder)
Management l Imaging l l l Non-operative l l US MRI Analgesia and physiotherapy Operative l Arthroscopic/open repair
Objectives l l Be able to describe common fractures Understand the management of common fractures Understand the principles of major joint examinations Understand the clinical features and management of osteoarthritis of the hip and knee.
Any questions?
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