Limb Pain for Medical Finals (based on Newcastle university learning outcomes)

8/14/2019 Limb Pain for Medical Finals (based on Newcastle university learning outcomes)

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Hospital Based Practice Limb pain.

Orthopaedic history.

What specific problem has caused patient to attend?

Duration of problem

Changes in symptoms

Exacerbating and alleviating factors?

Limitations of Activities of Daily Living.

Previous treatments tried.

Impact of previous treatments.

Trauma history.

Need for pain relief now?

o Allergies

o History of.

Peptic ulcers

Asthma

Opiate abuse.o Beware of opiates causing drowsiness and limiting ability to report history.

Cause of injury.

o Drop attacks leading to fractures may suggest an underlying cardiac pathology.

o High velocity car crashes need screening for injuries of.

Head

Chest

Abdomen

Direction of any falls.

Any neurological signs

Investigations

Plain X rays.

o Always obtain at least 2 views at right angles to each other. AP view

Lateral view

o Also view joint above and below.

Exclude dislocation

Bloods.

o Baseline.

FBC

U&E

o Other investigations as required.

LFTs

Clotting studies

CRP/ESR G&S

Crossmatch

o Blood cultures should be taken if osteomyelitis is suspected.

Fluoroscopy.

o Real time X rays to view bones and fractures.

o Allows manipulation to be watched on a monitor.

o Often used in theatre to check alignment when fixating fractures.

CT and MRI.


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o Used with increasing frequency in diagnosis and monitoring.

o CT very good for looking at bone.

o MRI normally better for looking at soft tissues.

Ultrasound.

o Shows joint effusions well.

o Gives some indication about articular surfaces.

o Can demonstrate free fluid in the pelvis. Suggests pelvic fracture.

Joint aspiration.

o Establishes cause of swollen joint.

o Identifies pathogen in septic arthritis.

o Examine fluid for crystals in crystal arthropathies.

Arthroscopy washout.

o Often undertaken in day case.

o Allows direct visualisation of inside of joint to help confirm diagnosis.

Commonly.

Knee

Ankle

Wrist.o Allows washing out of effusion and loose bodies.

o Many knee procedures now undertaken by arthroscopy alone.

Cruciate ligament repair

Meniscal surgery.

DXA/DEXA scan.

o Dual energy X ray absorptiometry.

o Used to assess bone mineral density.

Deteriorates with age and osteoporosis.

Other investigations.

o Depend on clinical need.

o Include.

Microbiological cultures.

Histological examination of biopsy and excision tissue.

Electrophysiological studies of

Nerve transmission

Muscle response

Radio isotope uptake studies.

The pelvic radiograph.

Confirm patient details and date of film.

Does the film include a good view of both hips joints.

Check to identify cortical break.

o Inner bony ring

o Obturator foramina Is symphysis pubis.

o Abnormally wide

o Asymmetrical

Are sacro iliac joints equal and visable.

Contours of acetabulum.

o Smooth?

o Equal on both sides.

Follow outline of both femurs.


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o Checking for breaks in the cortex.

Check remaining bones individually for breaks in cortex.

o Ilium

o Ischium

o Pubis.

Hip fractures.

Presenting symptoms.

o Pain

o Decreased range of movements.

o Limitation of activities of daily living.

Walking

Rising from seated position.

Past medical & drug history.

o Previous episodes or surgery.

o Arthritis

o Trauma/ infections of the joint

o Problems as a childo Steroid therapy

o Medical reasons for falls.

Examination.

o Inspection.

Leg shortening

Deformity at rest.

Internal rotation of hip

o Hip dislocation

External rotation of hip.

o Fractured neck of femur

Examine skin over joint.

Surgical scars Sinuses

Cellulitis

Bruising.

o Palpation.

Feel for bony landmarks.

Greater trochanter

Anterior iliac crest.

Are bony landmarks at same height on both sides.

Palpate joint during movement.

Crepitus

Clicks

o Supine. Allow patients to demonstrate active range of movements.

Passively move joint.

Check for fixed flexion deformity.

Place hand in lumbar lordosis.

Extend hip so popliteal fossa touches couch.

o Trendelenberg gait.

o Use of stick on side opposite to diseased hip.


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Type I Best outcome.

Impacted into each other.

Facilitates vascular regrowth.

Type II Minimal displacement from anatomical

position.

Bones unimpacted, and so less stable.

Good outcome. Type III Complete fracture.

Only partial displacement.

Type IV Complete fracture.

Total displacement of bone ends withcomplete separation.

Surgery can be performed under spinal anaesthetic, so suitable for frail patients.

Prognosis without surgery is poor.

o Intracapsular fractures.

Occur just below femoral head.

Often causes.

External rotation

Leg adduction Injuring force may be trivial

Patient may be able to walk, with difficulty.

As medial femoral circumflex artery supplies head via femoral neck, ischaemic

necrosis of the head may occur.

Particulalry if there is much displacement.

Femur fractures occupy 20% of UK orthopaedic beds, and numbers are rising.

1:100/year in females aged 75 84.

Mortality is about 50%

Treatment

Assess vital signs

Treat shock with Haemaccel.

o Beware incipient heart failure.

o If present, monitor CVP.

Relieve pain.

o Morphine 0.2 mg/kg IM

o Prochlorperazide 12.5 mg IM

Imaging.

o Good quality lateral film is essential for diagnosis if there is

impaction or minimal displacement.

o 5% are missed unless CT is used.

Prepare for theatre.

o FBC

o U&E

o CXRo Crossmatch 2 units

o Consent

If displacement is minimal.

o Multiple screw fixation in situ.

If displaced fracture.

o `Excise head

o Insert prosthesis.


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o Intertrochantic extracapsular fractures.

Occurs between greater and lesser trochanters.

Occur in younger age group.

Blood supply is adequate, so non union is rare.

Treatment.

Dynamic hip screw fixation

Principle of DHS is to fix the fracture, but allow compression bysliding.

Surgery associated with decreased length of hospital stage and

improved rehab.

o Femoral shaft fracture.

Risk of femoral artery also being torn.

Swelling.

Loss of distal pulses.

Sciatic nerve injury may also occur.

The proximal bone fragment is.

Flexed by iliopsoas

Abducted by gluteus medius

Laterally rotated by gleuteus maximus.

Distal bone fragment.

Pulled superior by hamstrings

Adducted and laterally rotated by adductors.

Treatment.

Normally with a locked intramedullary nail.

Introduced proximally over a guide wire.

o Manipulated across fracture under fluoroscopic control.

This management allows early mobilisation.

Alternatively, manipulation under anaesthesia.

o Exact reduction is not needed.

Followed up with traction.

o Fixed traction with Thomas knee splint

o Skeletal traction

o Sliding traction with thigh supported on a frame or cast brace

with hinge at knee.

Also can weight bear early. Union takes 3 4 months.

o Condylar or tibial plateau fractures

As these are intra articular, they require accurate joint reconstruction to

minimise later osteoarthritis.o Posterior

o Hip dislocation.

Commoner in patients with prosthetic hips.


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Can occur in non prosthetic hips when large force applied through knee

through flexed hip.

Front seat passengers whos knees hit the dashboard in high speed

crashes.

Feel for femoral head in buttock.

Leg is.

Flexed Adducted

Shortened

Sciatic nerve may be damaged due to.

Alceration

Stretching

Compression

Early MRI diagnosis may prevent later equines foot deformity.

Treatment.

Reduction under GA by lifting head back into the joint.

Traction for 3 weeks promotes join capsule healing.

o Referred pain.

Common between hip and knee. Important to examine both during consultation.

Emergency management of open fractures: The 6 As

o Assessment.

Neurovascular status

Soft tissue status

Photograph wound.

Reduces number of wound inspections.

o Antisepsis.

Cover wound with large antiseptic soaked dressing.

o Alignment.

Align fracture and splint.

Also provides analgesia by reducing fracture site movement.o Anti tetanus.

Check status and immunize appropriately.

o Antibiotics.

IV 3rd generation cephalosporin.

Plus metronidazole if wound grossly contaminated.

o Analgesia.

IV opiates titrated to effect.

Gustilo classification of open fractures.

o Type I: Low energy wounds < 1 cm long.

Eg. caused by bone piercing skin.

o

Type II: Low energy wounds > 1 cm causing moderate soft tissue damage.o Type III: All high energy injuries, irrespective of wound size.

Type IIIA: Adequate local soft tissue coverage.

Type IIIB: Inadequate soft tissue coverage.

Type IIIC: Secondary arterial injury needing repair.

Preventing hip fractures.

o Prevent falls.

Good lighting.


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Less sedation

Keep fit training.

Improves balance

Reduces fear of falling.

Halves rate of multiple falls.

o Prevent osteoporosis.

Exercise Bisphosphonates.

o Ensure good vitamin D & calcium intake.

Ensure plasma levels of vitamin D > 30 nmol/L

Especially in northern countries.

Low vitamin D and calcium levels are associated with hip fractures, even in

absence of osteoporosis.

Preventing complications after hip injuries.

o Early mobilization.

Prevents thromboembolism & stiffness

o Co ordinated multidisciplinary inpatient rehabilitation.

o Good nutrition. Meta analysis doesnt support specific multi nutritional commercial food

supplements.

The limping child.

Common causes.

o Transient synovitis

o Septic arthritis

o Perthes disease

o Slipper Upper Femoral Epiphysis

o Inflammatory arthritis

o Apophyseal avulsion.

Investigations.

o Ultrasound & Arthrocentesis.

Based on clinical examination.

Kochers critera.

Non weight bearing on affected side.

ESR > 40 mm/hr

Fever

WCC > 12 x 109/L

4/4 criteria gives 99% probability of septic arthritis.




No point in simple US to detect fluid.

Hip aspiration is diagnostic procedure of choice.

o Bone scintigraphy.

Highly sensitive for bone disease.


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Very poor specificity

No good for distinguishing between aetiologies.

Mildly elevated uptake.

May demonstrate transient decrease of technetium 99 phosphate.

o Isotope Bone scan.

Diffusely increased activity in synovitis.

Perthes disease Decreased activity in capital femoral epiphysis.

Irritable hip (transient synovitis)

Most common cause of painful hip in children.

Average of onset is 5 6 years.

Suspected causes.

o Viral infection

o Trauma

o Allergy

Child rarely appears ill

Irritability subsides quickly.

Resent history of respiratory infection in 50% Viral antibody titres raised in 84%

X rays are normal

o 58% show Waldenstroms sign.

Lateral displacement of femoral epiphyses

Surface flatterning.

Need to exclude infection.

o WCC

o CRP

o ESR

Examination.

o Movement is possible

o Rotation restricted. Management.

o Bed rest for 7 10 days.

o Until limp and pain have resolved.

Dont weight bear

Avoid full unrestrictive activities.o Repeat radiograph in 6 months.

Exclude LCP disease.

Septic arthritis

Children are acutely ill

Patient presents with.

o Generalised symptoms of acute systemic infection. Fever

Chills

Malaise.

o Child resists all attempts to move the hip.

o Investigations.

ESR > 20 mm/hr & fever > 37.5 oC.

97% sensitive for septic hip.

MRI.


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Signal intensity alteration in bone marrow.

Can be differentiated from irritable hip.

o Treatment.

Surgical emergency.

Risk of hip being destroyed.

Requires urgent irrigation and debridement.

No place for medical management. Concomitant use of IV antibiotics.

Monitor ESR.

Perthes disease Idiopathic infarction of bony epiphysis of femoral head.

Cause remains unknown.

o Possibly a sequence of.

Venous thrombosis

Increased intraosseous venous pressure

Reduced arterial flow

Hypoxia

Linked to.

o Thrombophilia

o Maternal smoking

o Deprevation.

Investigations.

o Plain X ray.

Main modality for evaluation.

Crescent sign in head of femur is seen.

Early signs.

Widened joint space

Subchondral linear lucency

Late findings.

Fragmentation of femoral epiphysis


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Increased sclerosis

Loss of height.

o Scintigraphy.

Useful in early disease when X rays may still be normal.

Catterall staging.

o Stage I Histological and clinical diagnosis.

No radiological changeso Stage II Sclerosis.

With or without cystic changes.

Preservation of the contour and surface of femoral head.

o Stage III Loss of structural integrity of femoral head.

o Stage IV Loss of structural integrity of acetabulum.

Treatment.

o Basic idea is to contain femoral head in acetabulum.

o Mild cases.

No treatment needed.

Self healing

o Severe cases.

Need surgery to keep head in acetabulum. In the past.

Cast

Brace legs widely apart.

Now.

Intertrochanteric osteotomy of femur.

Rotational osteotomy of acetabulum.

Bisphosphonates

Range of Movement exercises.

Slipped upper femoral epiphysis.

Most common adolescent disorder of the hip.

Suggested by unilateral waddling gait in male teenager.

Consider SUFE in adolescent presenting with knee pain.

Pathogenesis.

o Unknown

o Associated with several endocrine disorders.

Although rare, consider hypothyroidism in patients with SUFE.

Associated with.

o Short statureo Obesity

o Delay in skeletal maturity.

Investigations.

o Frog leg lateral gives better visualisation than AP X ray films.

o Trethowans sign.

Epiphysis moved posterior inferiorly.

Straight line down to greater trochanter.

Normal femur will overlap line at some point.


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o Unstable slip.

Sudden onset severe pain

Walking not possible, even with crutches.

Duration of preceding symptoms doesnt determine stability.

o Stable slips have much better prognosis than unstable slips.

Prognosis improved by early recognition of unstable slip.

Treatment.o Pinning

o Aims to prevent further slipping.

o Minimizes risk of later OA of the hip.

Secondary degeneration of hip joint.

Management.

o Arthrosesis

o Cemented THR

o Uncemented THR S ROM

o Hip resurfacing.

Back pain.

About 5% of all consultations in the UK are for back and neck pain.

In the majority, there is no definite anatomical abnormalities.

o Non specific back pain.

It is important not to miss sinister causes of back pain.

Causes.

o Mechanical back pain. Spondylolisthesis

Spondylosis

Intervertebral disc prolapse

Spinal stenosis.

Caludication type pain

Apophyseal joint disease.

Exacerbated by.

o Lumbar extension


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o Thoracic rotation

o Cervical rotation.

Non specific back pain.

Trauma.

o Inflammatory back pain.

Rheumatoid arthritis

Seronegative spondyloarthritidies. Psoriatic

Ankylosing Spondylitis

Rewiters

Enteropathic

Behets

o Serious causes.

Infection.

Discitis

Epidural abscess

Malignancy

Myeloma

Osteoporotic crush fractures

Pagets disease.

o Referred pain.

Aortic aneurysm

Pyelonephritis

Renal stones

Pancreatitis.

History.

o First consideration is whether pain is likely to be mechanical, inflammatory or sinister in

origin.

Mechanical back pain.

Exacerbated by prolonged sitting or standing. Relieved by movement.

Can be precipitated by trauma.

Inflammatory back pain.

Prolonged early morning stiffness.

Allieviated by exercise.

Sinister back pain.

Pain at night

Local bony tenderness


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Accompanied by systemic symptoms.

o Sensory or motor symptoms.

o Changes in urinary or bowel function.

Examination.

o General examination for evidence of malignancy.

o Palpate spine and para spinal regions for tenderness.o Check shape of spine.

o Look for muscle spasm.

o Cervical spine.

Flexion

Extension

Lateral flexion

Rotation

o Thoracic spine.

Rotation

o Lumbar spine.

Flexion

Extension Lateral flexion

o Palpate sacroiliac joints.

o Neurological exam.

Absent ankle jerks suggest slipped disc.

Central disc prolapse in the lumbar region can cause S1 signs.

Weak hip extension

o Push heel into couch with flexed knee.

Weak knee flexion.

o PR exam

o Check perineal sensation.

Tumour is suggested by.o Acute onset back pain.

o Signs of L1 L4 lesions

o Weak thighs

o Absent knee jerks.

Age can suggest the most likely causes..

o 15 30 years Prolapsed disc

Trauma

Fractures

Ankylosins spondylitis

Spondylolisthesis.

Forward shifting of one vertebrae over another.

Can be congenital or due to trauma.

Pregnancy.


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o 30 50 years.

Degenerative spinal disease

Prolapsed disc.

Malignancy.

Primary

Lung

Breast Prostate

Thyroid

Kidney

o > 50 years.

Degrenerative

Osteoporotic vertebral collapse

Pagets

Malignancy

Myeloma

Spinal stenosis

Investigations.o Patient requiring investigation are those with.

Pain at night

Neurological signs.o X rays.

Spine

CXR

o Bloods.

FBC

ESR

Calicum

Phosphate

LFTs.

Particularly alkaline phosphatase.

PSA

o Urine protein electrophoresis.

o Bence Jones protien

o Myeloma markers.

Immunoglobulins

Protien electophoresis

o Acid phosphate.

o Further investigations.

CT screen

MRI scan.

Better than CT for imaging spinal cord and roots.

Technetium bone scan.

Hot spots identify neoplastic or inflammatory lesions.

Myelography


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Radiculography.

Cord compression

Root compression.

Management.

o Analgesia

NSAIDS

o Bed rest until acute pain settles.

o Physiotherapy and mobilization.

May be managed at home

Review with GP or specialist in 2 3 weeks.o Appropriate referral to specialist

If X ray reveals fracture refer to orthopaedics

If severe pain from inflammatory arthritidies, refer to rheumatologists.

o Most patients respond to conservative management.

Red Flag symptoms.

o Age < 20 or > 55

o Acute onset in elderly patiento Constant or progressive pain

o Nocturnal pain

o Increased pain on lying down

o Morning stiffness

o Systemic symptoms.

Fever

Night Sweats

Weight loss

o History of malignancy

o Thoracic back pain

o Bilateral or alternating symptoms

o Neurological disturbanceso Sphincter disturbances

o Leg cluadication.

Spinal stenosis

o Current or recent infection

o Immunosuppression.

Steroids

HIV

o Abdominal mass

Yellow flag symptoms.

o Belief that pain and activity is harmful.

o Sickness behaviour, such as extended rest.

o Social withdrawl


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o Emotional problems.

Low or negative mood

Depression

Anxiety

Stresso Problems/ dissatisfaction or time off work

o Problems with claims or compensation.o Overprotective family or lack of support.

o Inappropriate expectations of treatment.

Low active participation in treatment.

Disc prolapse.

Acute postero lateral herniation of lumbar disc.

o Usually

L4 L5

Weakness of

o Extensor hallus longus.

o Dorsiflexion

o

Ankle eversion Altered sensation

o Lateral aspect of calf

o Dorsum of foot

L5 S1.

Weakness of.

o Plantarflexion

o Ankle eversion

Reduced ankle jerk

Altered sensation.

o Big toe

o Sole of foot

o Posterior calf.

Common cause of incapacitating lower back pain.

Often a clear precipitating event.

o Eg. lifting

Pain may radiate in L5 or S1 distribution.

Patients should be carefully examined for.

o Paraspinal muscle spasm

o Reduced straight leg raising on affected side.

o Nerve root signs.

o Sacral sensation

o Perineal sensation.

Prolapse at L2 L3 can causeo Bilateral multiple root lesions

o Altered bladder and bowel function

Cauda equine syndrome

o Neurosurgical emergency that requires immediate investigation and management for.

Acute cauda equina compression

Acute cord compression.


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Acute cauda equine compression

o Alternating or bilateral root pain in legs.

o Saddle anaesthesia

o Loss of anal tone on PR.

o Urinary and/or faecal incontinence.

Causeso Tumours

Primary.

Intradural + extramedullary.

o Schwannoma

o Meningioma

Intradural + intrameduallary

o Astrocytoma

o Ependymoma

Metastatic.

Usually extradural

Most common cause of cord compression.

Look for missing pedicles on X ray. Breast

Prostate

Lung

Thyroid

GI tract

Lymphoma

Meyloma

o Large disc protrusion

o Infection

TB

Staphylococcal abscess

Infected dermoid.o Cyst.

Arachnoid

Syringomyelia

o Haemorrhage

o Skeletal deformity.

Kyphscoliosis

Achodroplasia

Spondylothiasis


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Acute cord compression.

Presentation.

o Back pain.

Usually first symptom.

Often starts several weeks before other symptoms

Become progressively unremitting and keeping patient awake at night.

Can also radiate to chest and abdomen.

o Sensory symptoms.

Often next problem to follow back pain.

Parasthesia

Limb heaviness

Limb pulling

Sensory loss may be present at sensory level at testing.

The height of sensory loss denotes the lowest possible level fo the

lesion, the lesion could actually be higher than this.

Check for both.

o Pink prick sensation (spinothalamic tracts)

o Proprioception/ vibration (dorsal columns)

Anterior or posterior aspects of the cord may be selectively

compressed.

Sacral sparing is when sensation is preserved in the S3 S5 dermetones.

Relatively reliable sign of an intramedullary lesion

Due to initial sparing of lateral spinothalamic tract fibres which serve

sacral sensation.

o Weakness.

Often initially reported as clumsiness.

Soon progresses to clear loss of power.o Autonomic dysfunction.

Occurs if sympathetic fibres are involved.

Occurs especially in high thoracic and cervical lesions.

Hypotension

Bradycardia

Cardiac arrest.

Symptoms may be triggered by Noxious stimuli

Pain

UTI

Abdominal distension,

o Constipation

o

Bladder outflow obstructiono Sphincter dysfunction.

Starts as hesitance or urgency of micturation.

May progress to painless urinary retention with overflow.

Can also cause constipation.o Fever.

Should alert one to the possibility of an infectious cause.

o Respiratory failure.

Occurs with high cervical cord lesions.


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Can present as acute neuromuscular respiratory paralysis.

o Conus medullaris lesions.

Compresses sacral segments of cord.

Leads to relatively early

Disturbancees of micturation

Constipation

Impotence

Reduced perianal sensation

Reduced anal reflex

Rectal and genital pain are later signs.

Plantar response are extensor.o Cauda equine lesions.

Can be caused by lesions at or below L1.

Leads to paraparesis that is:

Flaccid

Areflexic

Often asymmetric.

Lubosacral pain is an early sign.

Bladder and bowel dysfunction are late signs.

Sensory disturbances can stretch to L1 level.o Combined Conus medullaris and caude equine lesions.

Can show signs of bothe LMN an d UMN lesions.

Severity is assessed on degree of:

o

Weaknesso Sensory loss

o Sphincter dysfunction.

Management.

Depends on diagnosis and condition of patient.

If diagnosis unknown, make the diagnosis quickly and discuss case with regional neurosurgical

centre.

If diagnosis not apparent, and immediate neurosurgical action not indicated.

o Discuss CT guided biopsy with radiology.

If the patient is known to have neoplastic disease and malignant compression is likely.

o Urgent radiotherapy is first line treatment.

o Not always appropriate to make interventions apart from giving analgesia.

o Always discuss with a senior oncologist.

Obtain urgent spine X rays.

o May show.

Vertebral collapse

Lytic lesions

Sclerosis

Perform CXR to look for malignancy.


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MRI or CT is next line of investigation

o Arrange urgently

o If facilities not available, discuss with regional neurosurgical centre

Use of high dose steroids is controversial

o No definite evidence of benefit in malignancy

o May trigger fatal tumour lysis syndrome in some high grade lymphomas

o Discuss with senior collegues. If cause of compression appears to be infective take blood and urine cultures

o Fever

o Raised WCC

o Raised CRP

Monitor haemodynamic status and watch for autonomic dysfunction.

Catheterise if there is bladder dysfunction.

If immobile, give prophylactic SC heparin.

o 5000 units TDS

If compression is high, or there appears to be respiratory dysfunction.

o Check Force vital capacity.

FVC < 30 ml/kg implies reduced ability to clear secretions.

FVC < 15 ml/kg is indication for immediate intubation and ventilation,regardless of other respiratory parameters.

o Monitor ABGs

Hand and wrist fractures.

Classification of fractures.

o Open/ closed.

Skin broken/ skin intact

o Intra articular/ Extra articular

Involving articulating surface of bone/ Not involving articulating surface

o Displaced/ undisplaced.

Any movement of bone fragments.

Impaction

Angulation

o Direction of tilt of distal fragment in degrees.

Opposition

Rotation

Subluxation.

o With reference to distal fragment.

o Site.

Described as.

Proximal third

Medial third

Distal third.

Patterns of fractures.


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.

Distal radial/ ulnar fractures.

Mechanism normally by fall onto outstretched hand.

Tends to occur in two peak ages.

o 5 14 years

o 60 70 years

Paediatric distal arm fractures.

o Plastic deformation.

Commonly ulnar

o Torus fracture.

Diaphysis causes metaphysic to buckle under compression forces.

o Greenstick fractures.

Tension on side of bone that cracks.o Complete.

Propegates through entire bone.

Oblique

Transverse

Spiral

o Epiphyseal fractures.

Distal radial physis is most frequently injured.

Older patients tend to fracture their wrist in a Colles or Smiths fracture.

o Colles fracture.

Most common extension fracture.

Fracture through distal metaphysic.

Approximately 4 cm proximal to articular surface of

Fracture fragments are displaced dorsally.

Causing dinner fork deformity.

Ulnar styloid fractures also occur in 60% of cases

Needs reduction if significant displacement.

Especially backwards and proximal shifting of distal fragment.

Classified according to the Association of Osteosynthesis or Frykman

classifications.

Normal Transverse Oblique Spiral Comminuted

Segmental Avulsed Impacted Torus Greenstick


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Type A: Extra articular

Type B: Partial articular

Type C: Complete articular.

1. Simple articular and metaphyseal fracture.

2. Simple articular and complex metaphyseal fracture.

3. Complex articular and metaphyseal fracture.

Treatment.

Operate under a Biers block.

o Place a loose torniquet around the upper arm.

o Empty blood from the arm by elevating it above the heart for 1

minute, or by squeezing with a esmarch bandage.

o Inflate cuff to 100 mmHg above SBP

o Inject 30 40 ml 0.5% prilocaine into a dorsal hand vein.

Never use bupivacaine for a Beirs block due to risk

of cardiotoxicity if cuff accidentally released.o Allow anaesthesia to develop over 20 30 minutes and

manipulate the fracture.

o Release cuff 30 minutes after injection

Sudden early release of prilocaine into the circulation

can cause fits .

o Bruners 9Ps for minimising ischemic limb changes.

sPan of tourniquet

10 cm for arm

15 cm for leg.

Position

Apply to upper arm or mid/upper thigh

Padding. Use > 2 layers of orthopaedic wool beneath

cuff.

Make sure it doesnt get wet with skin prep.

Use aqueous based skin prep so, if the wool

does get wet, it wont cause burns.

Pressure.

Arm: 50 100 mmHg above SBP

Leg: Double SBP


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Period of time

Deflate within 2 hours.

temPerature.

Keep limb as cool as possible.

Perfusion.

Be cautious if limb is unhealthy.

Allow time for adequate perfusion andrecovery before reapplying if needed.

aPparatus.

Calibrate weekly

Maintain well

Pen.

Document duration and pressure of

tourniquet.

Other methods, such as haeamatoma blocks, are less effective.

Alternative is general anaesthesia.

Manipulation.

o Prepare plaster back slab up to the knuckles.

o Ask an assistant to hold the elbow.

o Apply traction to

Disimpact the fragment

Push it forwards

Push it to the ulnar side.o Maintaining traction, apply back slab with wrist slightly flexed

and in ulnar deviation.

o Support in a sling once X ray has shown good position.

o Re X ray in 5 days, when swelling has reduced.

o If no problems, complete the plaster.

Complications.

Median nerve symptoms.

o Should resolve with good reduction.

Ruptured tendons.

Malunion

Sudecks atrophy.

o AKA. Algodystrophy.

Osteodystrophy

Reflex sympathetic dystrophy

Sympathetically maintained pain syndrome

Post traumatic sympathetic atrophy

Shoulder hand syndrome

Minor causalgia.

Causalgia is burning pain


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Post traumatic painful osteoporosis

Complex regional pain syndrome, Type I

o Complex disorder of.

Pain

Sensory abnormalities

Abnormal blood flow

Sweating Trophic changes in superficial or deep tissues.

o Central event is lack of vascular tone or supersensitivity to

sympathetic neurotransmitters.

o Diagnostic criteria were defined in 1994, but of unclear

validity.

At least one symptoms from each of the following

categories

At least one sign from at least 2 of the followingcategories.

Sensory

Vasomotor

Sudomotor/ oedema

Motor/ trophic

o Presentation.

May be weeks months after an insult.

Minor trauma

Fracture Herpes zoster

MI

May occur in neighbouring areas to original insult,

rather than are of insult.

Lancinating pain, which may have a trigger point,

accompanies vasomotor dysfunction.

Limb may be.

Cold and cyanosed

Hot and sweating

Temperature sensitivity may be heightened.

Skin of affected limb may become oedematous.

Later can become atrophic and shiny. Motor signs may occur.

Hypereflexia

Dystonic movements

Contractures.

No systemic signs.

Timid, neurotic personalitiers are particularly

affected.


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May be due to poor mobilization following

original insult.

o Tests.

Patchy osteoporesis on X ray.

No joint space narrowing

o This would suggest thinning of

cartilage Bone scintigraphy shows characteristic uniform

uptake.

o Treatment.

Refer to pain clinic.

Standard pain killers often have limited effect.

Consider.

Physiotherapy

NSAIDs

Calcitonin and postganglionic sympathetic blockade

has been suggested.

Guanethidine

Bretylium Condition is ultimately self limiting.

Right Colles plaster is unlikely to affect driving.

o Smiths Fracture.

Flexion fracture

Much less common than Colles fracture.

Full thickness fracture of distal radius.

1 2 cm proximal to wrist

Volvar displacement of distal fragments.

Classification is by the Thomas system.

Type I:

o Most stable

o Extra articular

o Transverse distal radial fracture.

o

Palmar and proximal displacement. Type II.

o Barton, palmar lip fracture of distal radius.

o Displacement of the carpus.

Type III.

o Unstable

o Oblique juxta articular fracture of distal radius

o Fragments tilted palmar.

Manipulate with forearm in full supination


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Fixation often required.

o Bennetts fracture.

Carpometacarpal fracture/ dislocation of the thumb.

Management.

Percutaneous wire fixation.

Exactreduction reduces risk of secondary OA.

o Carpal fractures.

Scaphoid.

Most frequently injured carpal bone.

Due to hyperextension of the wrist.

25% occur at the waist of the scaphoid

Can be easily missed on X ray.

o Ask for special scaphoid view if fracture is suspected.

o If X ray negative, and fracture likely, ask for long axis CT.

Also shows unstable fractures.

o If imaging unavailable, put in plaster and image in 2 weeks.

Fracture more likely to be visible by this point. Diagnosis is mainly clinical.

o Tenderness in anatomical snuffbox is suggestive.

Treatment.

o Non displaced fractures involving the wrist or proximal pole

Long arm thumb spica cast for several weeks.

Follow with short arm thumb spica cast until

untion.

Percutaneous Acutrak screw fixation allows faster

return to work, but have no impact on long term

outcome.

As nutrient artery enters distally, main complication is avascularnecrosis of proximal fragment.

o Leads to late wrist degeneration.

Other carpal fractures.

Bone Incidence Mode Diagnsois Complications

Lunate Relatively

common

Hyperextension of

wrist.

Impact of heel of

hand on hard

surface.

Clinically.

Weakness of wrist

with pain,

aggrevated by

pressure on 3rd

digidal tayTrapezium Relatively

common

Hyperextension

and ulnar deviation

of the wrist

Avulsion fracture

of trapezium on X

ray

Capitate Relatively

common

Forced

dorsiflexion with

radiat deviation of

the wrist.Crush injuries.

Clinical suspicion.

Visable fracture on

X ray normally

transverselyorientated.

AVN


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Wrist dislocations.

o Eg. scapho lunate or luno triquetral.

o May be anterior or posterior.

o Require

Manipulation and reduction.

Often open.

Plaster immobilization for about 6 weeks.

o Median nerve compression may occur.

Radiological studies.

o Get 3 views.

PS

Lateral

Oblique

o Can visualise soft tissue and bones.

o Check anatomical alignments.

Radial width on PA view > 10 mm

Ulnar angle on PA view between 15 30 degrees. Palmar angulation on lateral view between 10 25 degrees

o Check for invovlvement of.

Radiocarpal joint.

Distal radio ulnar joint.

Ulnar bone.

o Scaphoid views should be taken if scaphoid fracture suspected.

o Carpal view should be taken if suspected fracture of:

Hamate

Trapezium

o Further imaging may be required.

CT

MRI

Management.

o Resuscitate.

Analgesia

Attend to broken skin.

Give prophylactic antibiotics if an open fracture.

o Reduce.

If displaced.

Open

In theatre by opening jont.

Closed.

Without cutting into joint.

Traction

o Immobilise


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o Rehabilitate

Physiotherapy

Occupational therapy

Job retraining

Social services.

Complications.o Early.

Damage to blood vessels and bleeding.

Damage to nerves.

Eg. median nerve damage causing carpal tunnel syndrome

Damage to ligaments and tendons.

o Intermediate.

Infection of open fracture.

Infection of surgical interventions.

Nerve problems.

AVN

o Late.

Malunion

Non union

Ostheoarthritis

Deformity

Limited movement.

Follow up.

o Prognosis depends on.

Complexity of the fracture.

Restitution of fracture ligaments

Complete immobilisation in early stages.

o Generally.

Distal radiaul/ ulnar fractures are put in casts for 6 8 weeks after swelling

subsides.

Carpal bone fractures require spica casts fro 10 12 weeks.

o Factors that affect bone healing include.

Diabetes mellitus

Osteoporosis

Smoking

Excessive alcohol

o Advise calcium and Vitamin D supplements.

o Rehabilitate aggressively.

o Prevent future fractures, eg. wearing protective gear when doing dangerous activities.

Fractures in the hand.

Metacarpal fractures.o Require manipula to do this is bytion if grossly displaced or angulated.

o 5th metacarpal is often involved.

Often due to a pounching injury (Boxers fracture)

o Immobilization for 10 days in wool and crepe bandage may be all that is required.

Encourage finger movement after 2 3 days.

o Closed reduction and cast immobilization is also used.

o Longer periods of immobilizing can cause the hand to stiffen up.


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o Refer any fractures which clinically have an obvious rotational deformity.

These can be disabling if not set right.

Recognisable as cause finger rotation when fingers flexed and looked at nail on.

Usually require plate and screw fixing in theatre.

o Fractures of more than a single metacarpal also require fixing in theatre.

o Beware wounds overlying MCP joints.

Often from the teeth of the punched victim, so require sepsis cover.

Fractures of proximal phalanx.

o Spiral or oblique fractures at this site are likely associated with rotational deformity.

This must be found and corrected.

o Often the best way to do this is by open reduction and fixation with a single compression

screw.

Middle phalanx fractures.

o Manipulate.

o Splint in flexion over malleable metal splint to its neighbour (buddy splinting)

o Aim is to control rotation which would interfere with finger flexion later.

Distal phalanx fractures.

o May be caused by crush injuries.

o Are often open.o Symptoms may be relieved by trepanning the nail to reduce swelling.

o Split skin grafts from thenar eminence may be required for partial amputations of the

finger tip.

o If subluxation is a problem, joint stiffness may be reduced by open fixation.

Mallet finger.

o Finger tip will droop due to avulsion of the extensor tendon attachment to the terminal

phalanx.

o If avulsed tendon also contains bone union is easier.

Special splint with no extension

Use splint for 6 weeks.o Interphalangeal arthrodesis may be needed if active extension remains limited.

o Poor outcome associated with.

Delay in splinting.

Age > 50

Gamekeepers thumb.

o Rupture of ulnar collateral ligament of metacarpophalangeal joint of thumb.

Sustained during forced thumb abduction when wringing a pheasants neck.

o Also can occur in dry ski slopers who fall and catch their thumb in the matting

(Hill end thumb)

o Diagnosis can be difficult as thumb is so painful to examine.

Missing this injury can condemn patient to weak pincer grip.

Inject 1 2 mL 1% plain lignocaine around ligament to facilitate examination.

o Differentiation of complete vs. partial tears is crucial, as complete tears have to be treated

surgically.

o X ray will detect any bony avulsion fragments.o Partial tears or those associated with undisplaced avulsion fractures of proximal phalanx

can be treated using short arm thumb spica casting.Pelvic fractures.

Fracture of the pelvis can be serious as it can threaten the integrity of the organs that are contained

within it.

Due to the ring structure, a single fracture is often stable and need only a few weeks rest.

In contrast, if there is more than one fracture it can destablise the ring and is very serious.


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o Even more so if one is above and one is below the hip.

o Internal injuries in 25%

o Eg. Fractures of ileum and pubic ramus.

o Eg. Fractures through sacroiliac joint and pubic ramus.

The force producing the fracture may be.

o Anteroposterior

o Lateral compressiono Veritcle shear

Signs to look for that suggest pelvic fractures include.

o Bruising

o Perineal or scrotal haematoma

o Blood at the urethral meatus.

Malgaignes fracture.

o 20% of all pelvic fractures.

o 60% of unstable fractures.

o Disruption of pelvis anterioposteriorly

o Displacement of fragment containing hip joint.

Acetabular fractures.o Common sites.

Posterior lip

Transverse

o Two 45o oblique X rays are needed to define injuries exactly.

Consider CT as well

Single films easily miss fractures.

o Treatment.

Open reduction and reconstruction fo articular surfaces.

Delay the onset of secondary ostheoarthritis.

Examining patients with suspected pelvic fractures.

o

Diagnosis mainly made from serial pelvic X rayso Even gentle palpation can disturb retroperitoneal haematomas and exacerbate

haemorrhage.

Complications.

o Haemorrhage.

Eg. internal iliac artery


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Check and regularly monitor

Foot pulses

BP

CVP

Urine output

Transfusion is often needed.

o Shock.

Mortality of 14 55%

Towards higher end if base excess > 5

Even more problematic if patient is pregnanct.

Huge haemorrhage from increased pelvic blood flow.

Resuscitate vigerously and meticulously.

Ways to reduce blood loss.

Avoid manipulation of pelvis

Internally rotate both legs to close open book fractures.

Apply pelvic binder

Suspend patient in pelvic sling.

o Patinet lies supine with pelvis over slings webbing.

o Exerts upwards and medial trqaction via weights and runnerssuspended above the bed.

Compresses haemorrhage.

o An alternative is an external fixation frame.

Apply traction to legs.

Surgical reconstruction can start after bleeding reduced.

Look for associated abdominal and pelvic injury.

Spleen 37%

Diaphragm 21%

Intestine 17%

Kidney rupture 8%

Diagnosis is sometimes hard.

Prompt spiral CT identifies patients and lesions which may benefit

from specialist procedures, such as angiographic embolization.

The order of intervention is important.

Laprorotomy, if indicated, to perform open fixation.

Follow ith angiographic ambolization.

Inter disciplinary co operation is vital.

o Bladder rupture.

Can be intra or extraperitoneal.o Urethral rupture.

Often at junction of prostatic and membranous urethra in males.

Appearance of blood at the end of urethra is suggestive.

May be unable to pass urine.

Avoid repeated attempts.

On PR.

Prostate may be elvated out of reach

CT is imaging of choice in trauma patients with haematuria.

o Vaginal and rectal perforation may occur.

Rare

Look for bleeding.


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o Trapping of sciatic nerve causes perisistnat pain.

Treatment.

o Relieve pain and replace blood.

o If urethral rupture is suspected.

Check with urethrogram before catheterizing.

Avoid urethral catheters as they may make a false passage.

Suprapubic catheter may be needed. Get urological help.

o Small urine volume suggests bladder rupture.

Cystogram or CT is needed.o If no pelvic fluid seen on CT, bladder rupture is unlikely.

Reassuring signs on pelvic X ray.

o Symphysis pubis separation < 1 cm

o Integrity of superior and inferior rami

o Integrity of acetabula & femoral necks.

o Symmetry of illium and sacroiliac joints.

Eg. evaluate the arcuate lines.

o No fracture of transverse process of L5.

Rheumatoid arthritis

Chronic systemic inflammatory disease.

Characterised by polyarthritis that is

o Symmetrical

o Deforming

o Peipheral

Peak onset is in 30s and 40s

Female: Male ratio is > 2:1

Prevalence of 1%.

o Increased in smokers

o Increased and more severe in HLA DR4/DR1

Presentation.

o Typically sympetrical, swollen, painful and stiff small joints of hands and feet.

o Worse in morning, ease with movement.

o Can fluctuate and large joints become involved.

o Less commonly presents as a sudden onset of widespread arthritis or.

Recurrant mono/polyarthritis of various joints.

Persistent monoarthritis.

Often of one knee, shoulder or hip.

Systemic illness with extra articular symptoms.

Fever

Fatigue

Weihgt loss

Pericarditis

Pleurisy

Minimal joint problems at first.

This form is commoner in males.

Polymyalgic onset.

Vague limb girdle aches.


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Signs.

o

Early. Inflammation, but no joint damage.

Joint swelling

Especially.

Symmetrical MCP

PIP

Wrist

Metatarsal joints

Look for.

Tenosynovitis

Bursitis

o Later.

Joint damage and deformity. Ulnar deviation of fingers

Dorsal wrist subluxation

Boutonniere or swan neck deformity of fingers

Z deformity of thumb.

Rupture of hand or foot extensor tendon

Larger joints may also be involved.

Atlanto axial joint subluxation may threaten the spinal cord.

Extra articular.

o Nodules.

Elbow

Lungso Lymphadenopathy

o Vasculitis

o Fibrosisng alveolitis

o Obliterative bronchiolitis

o Pleural & pericardial effusions.

o Raynauds disease

o Carpal tunnel syndrome

o Peipheral neuropathy

o Splenomegaly.

In 5%

1% have Felty syndrome.

RA

Splenomegaly

Neutropaenia

o Episcleritis

o Scleritis

o Scleromania

o Keratoconjunctivitis

o Sicca

o Osteoporosis

o Amyloidosis


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Tests.

o Rheumatoid factor is positive in 70%

High titre associated with.

Severe disease

Erosions

Extra articular disease.

o Citrullinated peptide antibodies (anti CCP).

Highly specific

Not widely available.

o Often anaeamia of chronic disease

o Inflammation can cause.

Increased platelets

Increased ESR

Increased CRP

o X ray show.

Soft tissue swelling

Juxta articular osteopaenia

Reduced joint space

Later there may be.

Bony erosions

Subluxation

Carpal destruction.

Diagnostic criteria.o Only used in research.

o Include 4 out of 7.

o Morning stiffness

> 1 hour

> 6 weeks

o Arthritis of > 2 joints

o Arthritis of hand joints

o Symmetrical arthritis

o Rheumatoid nodules

o Positive rheumatoid factors

o Radiographic changes.


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Management.

o Refer early to a rheumatologist for specialist assessment.

o Early use of disease modifying drugs.

Improves symptoms

Improves long tem outcome.

Chief biological event is inflammation.

Monocytes traffic into joints.

Cytokines are produced

o Erode cartilage and bone.

o Also produce systemic effects.

Fatigue

Accelerated atherosclerosis

Accelerated bone turnover.

Fibroblasts and endothelial cells are activated

Tissue proliferates.

Fluid is generated as effusions.

DMARDs modulate the above reaction and slow or stop disease progression

Early therapy associated with better long term prognosis.

Can take 6 12 weeks to get a sympathetic relief.

First line therapies are typically.

o Methotrexate.

o Sulphasalazine

Can be used together

Regular blood test monitoring is required.

Methotrexate.

o Given weekly.

o Avoid in.

Liver disease

Pregnancy

High alcohol consumption

o Caution if Pre existing lung disease.

o Side effects.

Oral ulcers

Nausea

Lethargy.

Myelosuppression

Hepatotoxicity

Pneumonitis

Rare, but can be life threatening.

o Give Folic acid 5 mg 2/3 times a week.


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Reduces side effects.

Sulphasalazine.

o Side effects.

Myelosuppression

Nausea

Rash

Oral ulcers Reduced sperm count

Leflunomide.

o May be used as alternative to sulphasalazine

o Side effects.

Rash

Oral ulcers

Diarrhoea

Hypertension

Myelosuppression

Hepatotoxicity.

o Contraindicated in pregnancy.

Gold.

o Used by IM injection.

o More toxic that methotrexate or sulphasalazine.

o Side effects.

Myelosuppression

Renal toxicity

Rash

Mouth ulcers

Photosensitivity.

Penicillamine.

o Side effects.

Myelosuppression

Renal toxicity

Loss of taste

Oral ulcers

Myasthenia gravis like symptoms.

Hydroxychloroquine.

o Least toxic

o Least effective.

o Side effects.

Rash Retinopathy.

Check vision with Amsler chart every 12

months.

Azathioprine.

o Side effects.

Myelosuppression

Nausea

Raised LFTs


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Screen before starting therapy

Consider prophylaxis.

Worsening of heart failure

ANA and reversible SLE like illnesses may evolve.

o Long term safety is unknown.

No clear increased cancer risk.o Neutralizing antibodies may decrease the efficacy of

infliximab.

o Steroids.

Rapidly reduce inflammation and controls symptoms in the short term.

Useful for treating acute exacerbations of disease.

IM depot of methylprednisolone 80 120 mg.

Intra articular steroids have a rapid but short term effect.

Oral steroids.

Prednisolone 7.5 mg OD

May control difficult symptoms

Not routinely recommended for long term therapy due to side effects

profile.

o Analgesia.

Most will require NSAID to cover symptoms.

Paracetamol with weak opiate is rarely effective.

NSAIDS contra indicated if active peptic ulcer

Give lansoprazole 30 mg PO as gastric protection if patient.

o > 65 years

o Previous history of peptic ulcers.

Not possible to predict which patients will respond to which NSAID.

Try a variety until you find one which works.

NSAIDs dont affect disease progression.

o

Encourage regular exercise. Review with physiotherapy and occupational therapy for aids, splints etc.

o Surgery may be considered in the long term.

Relieve pain

Improve function

Prevent complications.

For example.

Ulna stylectomy

Joint replacement.

o Risk of cardiovascular and cerebrovascular disease is increased due to acceleration of

atherosclerosis in RA.

Manage other risk factors.

Stopping smoking will help CVD and RA.

Osteoarthritis.

Commonest joint condition.

Female: Male ratio is 3:1

Usually affects >50 year olds

Usually primary.

o Sometimes is secondary to joint disease or other conditions.

o Eg. Haemochromatosis.


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Signs & symptoms.

o In localised disease.

Usually knee or hip.

Pain on movement

Crepitus

Worse at end of day.

Background pain at rest Joint gelling.

Stiffness after rest up to 30 minutes.

Joint instability.

o In generalised disease.

Commonly affected joints.

DIP joints

Thumb carpo metacarpal joints

Knee

o May be.

Joint tenderness

Joint derangement

Heberdens nodes.

Bony lumps at DIP joints

Seen mainly in post menopausal women

Bouchards nodes.

Affect PIP joints.

Squared thumb

Reduced range of movment

Mild synovitis

Tests.

o X ray shows.

Loss of joint space.

Subchondral sclerosis

Cysts

Marginal osteophytes.


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o CRP may be slightly elevated.

Treatment.

o Exercises.

Quadriceps exercises increase muscle power and so stabilise the joint in knee

OA.

o Regular codeine, with or without codeine for pain.

Consider oral NSAIDs.

Only prescribe NSAIDs after careful risk benefit analysis

individualised for each patient.

o Consider.

Indication

Proposed dose

Proposed duration of therapy.

Co morbidities.

Main serious side effects are.

o GI bleeding

o Renal impairment

Many patients prescribed NSAIDs dont actually need them all the

time.o Tell patient to take them only when they need them and not as

regular medication.

Patients who know more about their drugs are less likely to suffer side

effects.

Explain that.o Drugs are for relief of symptoms, on good days they shouldnt

need them.

o Abdominal pain may be a sign of impending gut problems.

Stop the tablets

Seek medical advice if symptoms dont resolve.

o Ulcers may occur with no warning.

Seek advice if stools turn black.

Osteophytes

Subarticular

sclerosis

Bone cystsSoft tissue

swelling

Joint space

narrowing

Periarticular

erosion


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o Dont supplement prescribed NSAIDs with ones bought over

the counter.

Eg. ibruprofen

Mixing NSAIDs can increase risk of bleeds 20 fold.o Smoking and alcohol increase NSAID risk.

COX 2 inhibitors should only be considered if NSAID is essentialand there is a history of peptic ulceration.

o Risk of bleeding reduced, but not eliminated.

o Bleeds that do occur may be very serious.

Consider COX 2 over normal NSAID if.

o NSAID + omeprazole is problematic.

o Over 65 years (and not on aspirin)

o Needing high dose NSAID over a long period.

PPIs can also be given with COX 2 inhibitors.

o Not known if this has any effect.

Problems with COX 2 inhibitors, and possibly NSAIDs, are increased

risk of.

o Heart failureo MI

o CVA

Avoid in.

o Vascular disease

o Renal failure.

Insufficient evidence for newer COX -2 inhibitors to recommend them

as first line therapy.

o Etoricoxib

o Parecoxib

o Lumiracoxib.

Topical NSAIDs and capsaicin may help.

o

Reduce weight if BMI > 28.o Walking aids.

o Role of Hyaluronic acid is unclear.

o Study in 2006 showed no improvement with.

Glucosamine

Chondroitin sulphate

o Intra articular steroid injections.

Temporarily relieve severe symptoms.o Joint replacement.

Only fully curative treatment for OA.

Osteoporosis.

Defined as reduction in amount of bone mass, leading to fractures after minimal trauma.

o WHO define it as bone density > 2.5 standard deviations below mean for healthy 20

year old female.

o Measured with DXA scan.

o Occurs when osteoclast activity is more than osteoblast activity.

Epidemiology.

o By the age of 90, a related fracture affects.

50% of women


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15% of men

o Cost of fracture treatment alone costs NHS 1 billion per year.

Osteoblast activity stimulated by.

o TGF

o IGF

o LRP5 Osteoclast activity.

o Stimulated by.

Age

Oestrogen withdrawl

Calcitonin

IL1

TNF

RANK/ RANKL

o Inhibited by.

Oestrogen

Bisphosphonate

Osteoprotegerin

Classification.

o Primary.

o Secondary.

Endocrine.

Cushings

Thyrotoxicosis

Rheumatological

Especially steroid treatment

Gastroenterological.

Malabsorption

Neoplasia Genetic.

Osteogenesis imperfecta.

Risk factors.

o Elderly women.

Late menarche

Early menopause

Long hisotyr of oligomenorrhoea

o Smoking

o Alcohol


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o Sedentary lifestyle

o Family history

o Lean body type.

o Steroids.

Decreases calcium absorption through the kidney.

Decreases oestrogen levels.

Increased trabecular bone loss

Clinical features.

o Low impact fractures.

Colles

Femoral neck

Wedge fractures of vertebrae.

Thoracic region

Loss of height

Exaggerated kyphosis.

o Dowagers hump

Pain.

Investigations.

o X ray

o DEXA

o Calcium

o Serum CTX

o Alkaline phosphatase

o Hormones

Estradiol

Gonadrotrophins

LH

FSH

SHGB PSA

o Serum EPP

o Endomysial Antibodies.

DEXA scans.

o Dual energy X ray absorptionmetry.

o Involves X rays

o Measures bone density


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Measured in g/cm2.

Z score

Number of standard deviations above or below the mean for the

patients age and sex

o Used in.

Pre menopausal women

Men < 50 years

Children

T score.

Number of standard deviations above or below the mean for a healthy

20 year old of the same sex as the patient.

o Used in.

Post menopausal women

Men > 50 years.

o Better predictor of future fractures.

Normal is < 1

Osteopaenia is defined as 2.5 to 1

Osteoporosis is defined as < 2.5

o Lasts 10 20 minutes.

o Central DEXA scans

Large machines

Measure bone density in centre of skeleton.

Hip

Spine

o Peripheral DEXA scans

Small, mobile machines.

Measure bone density in peripheries.

Wrist

Heel

Finger

o Indicated for.

All women > 65 years.

Younger post menopausal women with at least one risk factor.

Post menopausal women who present with fractures.

Confirm diagnosis

Determine disease severity.

Oestrogen deficient women at clinical risk of osteoporosis.

Individuals with vertebral abnormalities.

Individuals on, or planning, steroid therapy.

Patients with primary hyperparathyroidism.

Individuals being monitored to assess response or efficacy of approvedosteoporesis drug therapy.

Management.


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o Prevention.

Stop smoking

Reduce alcohol

Weight bearing exercises.

o Reduce rate of bone loss.

Calcium

Vitamin D Bisphosphonates

Various drugs.

o Alendronate

o Etidronate

o Risedronate

Recommended to be used in women who are.

o > 75, without need for DEXA scan.

o 65 74, if osteoporosis confirmed by DEXA scan.

o < 65, if T score is in negatives, or if osteoporosis diagnosed

in presence of.

BMI < 16

Mother with hip fracture when < 75

Early, untreated menopause

Co morbidity that increases risk of osteoporesis

Immobile.

Side effects.

o Abdominal pain

o Dyspepsia

o Diarrhoea

o Constipation.

o Oesophagitis.

Must remain upright for 30 minutes after taking

tablet.

HRT

o Prevention of fractures.

Prevent falls

Review need for hypotensive drugs.

Give hip protectors.

o Other drugs.

Strontium ranelate

Recombinant PTH

Calcitonin.


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Peripheral artery disease.

Presentation

o Can be asymptomatic

o Can give signs of transient ischemia, like claudication.

Aching pain in the leg muscles Usually felt in the calf

Precipitated by walking

Relieved by rest.

o Can cause persistent ischemic limb.

Pale

Pulseless

Painful

Perishingly cold

Paralysed

Paresthetic

Assess by feeling the 4 arteries in the lower limb.o Femoral

o Popliteal

o Dorsalis pedia

o Posterior tibial

The main sites of atherosclerosis are.

o Proximal coronary arteries

o Thoracic arteries

o Internal carotid arteries

o Abdominal aorta

o Illiac arteries

o Femoral arteries

o Popliteal arteries.

o Vertebrobasilar system.

Investigations.

o Ankle Brachial pressure index

o ECG

o Doppler ultrasound with ABPI

o FBC

o Glucose

o Lipids

o Angiography.

Management.o Conservative

o Surgery.

Important to involve patient in decision

Have to weight up risk benefit analysis

Balloon angioplasty

Percutaneous transluminal angioplasty

Bypass graft


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Arterial reconstruction

Complications.

o Atherosclerosis. IHD

Gangrene and eventual amputation

Erectile dysfucntion

o Surgical.

General.

Bleeding

Infection

Thromboembolism

Specific.

Allergic reaction to angiography dye

Stoke

MI Embolus

Ischemia


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Claudication

Evidence of vasculardisease?

Limb acutelythreatened?

Diagnosis is caudaequina syndrome

Angiography

Severe symptomsModerate symptoms

Stop smoking

Symptoms improve Symptoms deteriorateAngioplasty Stenting

YesNo

Yes

No

Documents

Limb Pain for Medical Finals (based on Newcastle university learning outcomes)