Download - Musculoskeletal Cases for Finals
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Musculoskeletal Cases for Finals
Dr Alastair Brown ST1 Neurosurgery CXH
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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.
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Case 1 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:HypertensionOsteoporosisGlaucoma
DH:Calcichew D3 ForteAmlodipine 10mgTimolol eye drop 1 drop twice
dailySH:Lives alone, children are
around the cornerTwo- storey houseNon-smoker no-alcohol
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Examination
Looks in pain Alert and orientated Nothing abnormal to find on examination of
RS CVS and Abdomen.
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Examination
Unable to straight leg raise on left side
Pain at the greater trochanter.
Shortened externally rotated left leg.
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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
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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.
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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.
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Management
Can you describe this injury? Fracture of the left neck
of femur Intracapsular Displaced
What is the management of this fracture? Hemiarthroplasty/THR
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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
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Management
Can you describe this injury? Fracture of left femur Sub-trochanteric Angulated Displaced
What is the management of this fracture? IM Nail
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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
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Fall on an outstretched hand…
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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
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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.
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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
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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
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Twisted ankles
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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
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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.
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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
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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
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Sore knees
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Case 10
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
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Inspection
Heberden’s nodes
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Inspection
Old Right TKR scar
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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
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Investigation
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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
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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.
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Painful shoulder
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Case 11
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:AsthmaDH:NKDASalbutamolBeclomethasoneSHKeen sportsmanRetired accountantNon-smoker
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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.
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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
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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)
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Management
Imaging US MRI
Non-operative Analgesia and physiotherapy
Operative Arthroscopic/open repair
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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.
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Any questions?