Musculoskeletal

Cases for Finals

Dr Alastair Brown ST1
Neurosurgery CXH
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.
Case 1
 A 74 year old female DH:
presents having fallen in her Calcichew D3 Forte
bathroom at home. Amlodipine 10mg
 She is complaining of pain
Timolol eye drop 1 drop twice
in her hip.
daily
 Says slipped on the
SH:
bathroom floor, no
preceding symptoms. Lives alone, children are
around the corner
PMH:
Two- storey house
Hypertension
Non-smoker no-alcohol
Osteoporosis
Glaucoma
Examination
 Looks in pain
 Alert and orientated
 Nothing abnormal to find on examination of
RS CVS and Abdomen.
Examination
 Unable to straight leg
raise on left side
 Pain at the greater
trochanter.
 Shortened externally
rotated left leg.
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
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.
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.
Management
 Can you describe this
injury?
 Fracture of the left neck
of femur
 Intracapsular
 Displaced
 What is the
management of this
fracture?
 Hemiarthroplasty/THR
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
Management
 Can you describe this
injury?
 Fracture of left femur
 Sub-trochanteric
 Angulated
 Displaced
 What is the
management of this
fracture?
 IM Nail
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
 Fall on an
outstretched hand…
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
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.
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
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
Twisted ankles
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
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.
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
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
Sore knees
Case 10
 74 year old man DH – NKDA
 C/O pain in his left knee Asprin, Clopidogrel,
 Pain and stiffness worst in Tamsulosin, Bisoprolol,
the evening Simvastatin, Ramipril
 Gradually less mobile and
SH
now walking with a stick.
Lives with wife
PMH
Bungalow
 HTN
Ex-smoker
 IHD

 BPH
Inspection

Heberden’s nodes
Inspection

Old Right TKR scar

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
Investigation
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
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.
Painful shoulder
Case 11
 68 year old man PMH:
 Complaining of pain in Asthma
the shoulder. DH:
 Came on while lifting a NKDA
box down from a shelf. Salbutamol
 Now finding it difficult to
Beclomethasone
lift his arm above his
head. SH
Keen sportsman
Retired accountant
Non-smoker
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.
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
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)
Management
 Imaging
 US
 MRI
 Non-operative
 Analgesia and physiotherapy
 Operative
 Arthroscopic/open repair
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.
Any questions?