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Minor injuries : Not so minor

Minor injuries : Not so minor. Mr Lee Van Rensburg. Scope. Scope. Hand and wrist Elbow Shoulder Hip Knee Ankle Foot. Soft tissues Ligaments Tendons Cartilage Muscles Nerves Vessels Bones Joints. Australian Family Physician Vol. 41, No. 4, april 2012.

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Minor injuries : Not so minor

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  1. Minor injuries : Not so minor Mr Lee Van Rensburg

  2. Scope

  3. Scope • Hand and wrist • Elbow • Shoulder • Hip • Knee • Ankle • Foot • Soft tissues • Ligaments • Tendons • Cartilage • Muscles • Nerves • Vessels • Bones • Joints

  4. Australian Family Physician Vol. 41, No. 4, april 2012

  5. office@cambridgemedicalpractice.co.uk Australian Family Physician Vol. 41, No. 4, april 2012

  6. General Approach ACTIVE Knee – SLR Elbow - triceps • History • Examination • Look • Feel • Move • Active • Passive

  7. Special investigations

  8. Hand • Tricky, basic knowledge anatomy Australian Family Physician Vol. 41, No. 4, april 2012

  9. Hand • History • Examination • Look • Feel • Move • Active • Passive

  10. Hand X ray • Bruising • Swelling • Deformity • Bony tenderness

  11. Mallet Finger 56 YO injured finger tip tucking in bed, unable to extend DIPJ Pathology? Soft tissue injury - X ray?

  12. 20 YO playing rugby • Avulsion fracture Base of proximal phalanx • Avulsion FDP, rugger jersey finger • No Fracture, small flake of bone overlying PIPJ • BEWARE SMALL FLAKE

  13. 40 YO Skiing, thumb ski pole • Tender • Laxity valgus stress Gamekeepers Thumb Or Skiers thumb

  14. Skiers Vs Gamekeepers

  15. Wrist injuries • Distal radius • Scaphoid • Radiocarpal joint • Carpal joints • Carpo Metacarpal joint • CMC base of thumb • Tendons • Dequervains • Ligaments

  16. 54 YO Male • Falls off bicycle • Pain in wrist

  17. 54 YO male • Re attends 13 days later • Persistent pain • Tender in anatomical snuff box • Repeat radiographs • Including scaphoid views D 13 Initial

  18. Scaphoid • Current NHS policy • Splint • Repeat radiographs at 10 - 14 days • Bone scan • MRI/CT • Not perfect • Good at excluding a fracture JBJS - Am. 2011;93:20-8

  19. Wrist COME BACK

  20. Elbow injuries

  21. 48 YO fireman lifting car

  22. Distal biceps rupture • Non operative • 70% - 90% Flexion strength • 60% Supination strength • Operative

  23. Acutely < 3 weeks Chronic/ Delayed

  24. 32 YO fall • Small flake of bone of tip of olecranon • BEWARE SMALL FLAKE 3 months

  25. Shoulder injuries

  26. 30 YO Female

  27. 30 YO Female • 1 week later • Still in pain • Feels popping in shoulder • 2 weeks later • Pain worse • Still popping

  28. 30 YO Female 2 weeks Initial

  29. Rupture long head of biceps • Popeye sign • Well tolerated • Some cramping/ ache

  30. 55 YO Male • Farmer • Falls from tractor • Pain and weakness in shoulder

  31. Shoulder

  32. Supraspinatus • Jobe’s

  33. 113

  34. Supraspinatus - Apley's Scratch Test - Jobes Supraspinatus test - Dawburn's sign- Sherry Party sign- Codman's Sign (Drop Arm Sign)- Rent Test- Zero Degree Abduction Test - Burkhead's Thumbs down & Burkhead's Thumbs up

  35. Shoulder • Unable to elevate arm • Full thickness tear • Supraspinatus • Infraspinatus

  36. 1961 - 51 1930 - 82 60-69 =30% FTRCT 70-79 = 50% FTRCT 80-89 = 80% FTRCT Age-related prevalence of rotator cuff tears in asymptomatic shoulders; Tempelhof et al; JSES July 1999 (Vol. 8, Issue 4, Pg 296-299

  37. Rotator cuff tear • Non operative • Relative rest • NSAID • Physio • Steroid injection (controversial) • Operative 3 months JSES - 2008;17:863-870

  38. Minor Injuries: Not So MinorAnnual GP Conference 2012 Mr Andrew D Carrothers Consultant Orthopaedic Surgeon Addenbrookes

  39. Summary Adhere to basic principles Order relevant investigations If normal/fails to resolve, then think laterally If unsure then please don’t hesitate to refer

  40. General Practice • Jordan et al. BMC Musculoskeletal Disorders 2010, 11:144. • Extensive and varied musculoskeletal workload in primary care • 1:7 consultations • Back • Knee • Hip • Foot

  41. Trauma in General Practice • Problems • Atypical or uncommon presentations • Recent injury but Xray ‘No fracture’ • Failed analgesics • Failed mother nature (ie time) • Failed physio

  42. Back to Orthopaedic Basic Principles • History • Examination • Special Tests • DDx • Investigations • Treatment +/- Referral

  43. Hip Trauma

  44. Hip – Case 1 • 76 yr old lady • Fall in garden, manages to walk to kitchen with hip pain • Not resolving 2 days later so ED with son • SHO Hip Xray ‘No fracture’ and DC with analgesics/crutches • Struggles to walk and 2 weeks later stumbles • Severe Hip pain and unable WB

  45. Differential diagnosis?

  46. ED Xray - #NOF

  47. Xray Review

  48. Hip – Case 2 12 yr old boy Overweight but enjoys football Fell 2 months ago and has mild left knee pain since Mum thinks malingering to get off school

  49. Differential diagnosis?

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