Musculoskeletal Cases for Finals

1. Musculoskeletal Cases for Finals Dr Alastair Brown ST1 Neurosurgery CXH

2. Objectives • 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.

3. A 74 year old female presents having fallen in her bathroom at home. She is complaining of pain in her hip. Says slipped on the bathroom floor, no preceding symptoms. PMH: Hypertension Osteoporosis Glaucoma DH: Calcichew D3 Forte Amlodipine 10mg Timolol eye drop 1 drop twice daily SH: Lives alone, children are around the corner Two- storey house Non-smoker no-alcohol Case 1

4. Examination • Looks in pain • Alert and orientated • Nothing abnormal to find on examination of RS CVS and Abdomen.

5. Examination • Unable to straight leg raise on left side • Pain at the greater trochanter. • Shortened externally rotated left leg.

6. Examination of the hip • Look – • muscle wasting • leg length discrepancy • scars • Feel – • Palpate greater trochanter • Move – • Flexion and extension • Internal and external rotation • Special Tests – • Thomas’ test – fixed flexion deformity • Trendelenburg test – testing gluteus minimus and medius • Gait

7. Management • What is your provisional diagnosis? • Fracture left neck of femur • How will you manage this patient • Analgesia • Investigations • Blood tests – FBC, UE, LFTs, Clotting, G+S • Radiology – Chest X-ray, AP pelvis and Lateral L Hip.

8. Management • How can you classify hip fractures? • Location • Left or Right • Intra/extracapsular • Sub-capital, base cervical, intertrochanteric, subtrochanteric. • Mechanism • Traumatic or Pathological • Displacement • Undisplaced, impacted, displaced. • Open or closed.

9. Management • Can you describe this injury? • Fracture of the left neck of femur • Intracapsular • Displaced • What is the management of this fracture? • Hemiarthroplasty/THR

10. Management • Can you describe this injury? • Fracture of left neck of femur • Extracapsular • Minimally displaced • What is the management of this injury? • Dynamic hip screw

11. Management • Can you describe this injury? • Fracture of left femur • Sub-trochanteric • Angulated • Displaced • What is the management of this fracture? • IM Nail

12. Management • What are the factors affecting the management of intracpasular fractures? • 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? • Analgesia • Attempt to mobilise • CT/MRI

13. Fall on an outstretched hand…

14. Case 2 • Describe this injury • Fracture of the distal radium and ulna • Volar angulation • Volar displacement • What is the name of this injury? • Smith’s • What is the mechanism? • Fall on flexed wrist • What is the treatment? • ORIF

15. Case 3 • Describe this injury? • Fracture of the distal radius • Minimally displaced • Shortened • Dorsal angulation • What is the name of this fracture? • Colle’s • What is the mechanism of injury? • Fall on outstretched hand with extended wrist • What is the management of this fracture? • Closed reduction and POP • ORIF/ K wire in certain circumstances.

16. Case 4 • Describe this injury • Displaced fracture of the ulna proximal 1/3 • Subluxation of the radial head. • What is the name of this fracture? • Monteggia fracture dislocation • What is the mechanism of injury? • Fall on hyperpronated arm • What is the management of the injury? • ORIF

17. Case 5 • Can you describe this injury? • Displaced fracture of the distal radius • Angulation • Disruption of the radio-ulnar joint. • What is the name of this injury? • Galeazzi fracture dislocation. • What is the mechanism of injury? • Fall on hyperpronated arm. • What is the management? • ORIF

18. Twisted ankles

19. Case 6 • Can you describe this injury? • Fracture of distal fibula • Below level of joint line • What is the Weber classification of this injury? • Weber A • What is the management of this injury? • Closed reduction and POP

20. Case 7 • Can you describe this fracture? • Fracture of distal fibula • Comminution • At the level of the joint • What is the Weber classification? • Weber B • What is the management? • Closed reduction if stable • ORIF if unstable • Stability depends on whether there is a injury to medial malleolus or deltoid ligament.

21. Case 8 • Can you descirbe this injury? • Fracture of fibula and medial malleolus • Minimally displaced on AP film • Fracture above syndesomosis. • What is the Weber classification? • Weber C • What is the management? • ORIF

22. Case 9 • Can you describe this injury? • Fracture of distal tibia and fibula? • Intra-articular component • What is the name of this injury? • Trimalleolar fracture • What is the management of this fracture? • ORIF

23. Sore knees

24. 74 year old man C/O pain in his left knee Pain and stiffness worst in the evening Gradually less mobile and now walking with a stick. PMH HTN IHD BPH DH – NKDA Asprin, Clopidogrel, Tamsulosin, Bisoprolol, Simvastatin, Ramipril SH Lives with wife Bungalow Ex-smoker Case 10

25. Inspection Heberden’s nodes

26. Inspection Old Right TKR scar

27. Examination of the knee • Look • Scars • Muscle wasting • Deformity – valgus, varus and flexion • Feel • Temperature • Popliteal fossa- aneurysms/cysts • Joint line – tenderness • Patella tap and bulge sign • Crepitus • Move • Active and passive • Flexion and extension • Special Tests • Anterior drawer – test ACL • Posterior drawer test PCL • Varus and valgus stress • McMurray’s test • Gait

28. Investigation

29. Investigation • Can you describe the previous radiograph? • AP radiograph of both knees • Joint space narrowing of medial compartment of left knee. What are the radiographic features of osteoarthritis? • Osteophytes • Joint space narrowing • Subchondral cysts

30. Management • Non-operative • Address risk factors – weight loss, smoking cessation, Vitamin D replacement. • Analgesia – injections no longer recommended. • Walking aids • Operative • Arthroplasty reserved for those with moderate to severe pain and disability.

31. Painful shoulder

32. 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 Case 11

33. Examination • 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.

34. Examination of the shoulder • Look • Deformity • Position of neck and clavicles • Muscle wasting • Winging of the scapula • Feel • Scapula • Clavicles • Acromio - and sternoclavicular joint • Move • Flexion and extension • Internal and external rotation of shoulder with elbow flexed. • Special tests • 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

35. Findings • Painful arc • Impingement due to supraspinatus tendinitis • Inability to intiate arm abduction • Supraspinatus tendon rupture • Reduced active and passive movment • OA if crepitus present • Adhesive capsulitis (frozen shoulder)

36. Management • Imaging • US • MRI • Non-operative • Analgesia and physiotherapy • Operative • Arthroscopic/open repair

37. Objectives • 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.

38. Any questions?