Medical song: RAAS
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Difficult to say medical words@uninvitedguest@piefed.ca
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NeuroSurgSpinal Stenosis
Doctor Instruction:
Your next patient is a 51-year-old woman called Rebecca, presenting with lower back pain. Please take a history and perform an appropriate examination.
Patient History:
Rebecca, a 51-year-old female, nurse
You have always been having lower back pain for the past few years, but this has been getting gradually worse. The pain is dull and intermittent. Very often, the pain can diffuse and radiate towards the buttocks, back of the thighs, and feet - when this happens, the pain feels like a burning or cramping sensation. It can be associated with weakness in both legs. The symptoms can be triggered or worsened by sitting down, standing straight and walking downhill. It goes away after a few minutes after being at rest. Bending forward improves symptoms. You tried paracetamol, which only helped a little with pain.
If you walk for more than 50 yards, you will start noticing numbness and weakness in your legs.
No previous injury/trauma. Waterworks normal. The bowels are working normally. No other abnormal sensations or weaknesses. No incontinence. No stiffness. No fever. No weight loss. No night sweats.
Ideas, Concerns, Expectations:
You think because you often have to bend your back due to work, the pain may be caused by poor posture. You are concerned because it is starting to affect your ability to work in the hospital as a nurse. You would like to see if you can get stronger painkillers and possibly have a scan of your back.
Past Medical History:
Obesity, hypercholesterolemia, acromegaly, T2DM.
No past relevant surgical history.
Drug History:
Atorvastatin, metformin NKDA.
Family History:
Father has ankylosing spondylitis.
Social History:
You work as a senior nurse in a local hospital.
You smoke around ten cigarettes daily for over ten years but don't drink alcohol.
Live with husband in a semi-detached house.
Independent.
Examination Findings:
Lower spinal tenderness on palpation at L4-5 region.
Complete motor and sensory neurological examinations are normal.
Features of acromegaly e.g. enlarged hands, feet and facial features.
Lower limb vascular examination is normal.
No cervical tenderness or restricted movement. Gait normal.
No cauda equina syndrome features.
Peripheral pulses and ABPI normal.
Differentials:
Lumbar spinal stenosis - likely to be due to degenerative changes
Osteoarthritis of the spine
To rule out cauda equina syndrome
Ankylosing spondylitis/spondylolisthesis
Rule out peripheral arterial diseases
Other causes of back pain: spinal tumour, disc herniation, trauma, fracture, and epidural abscess.
Investigations:
Imaging:
XR Lumbar spine (may show degenerative changes/spondylolisthesis)
MRI Spine. Alternatively, CT myelography/spine when MRI is not available or unsuitable.
Consider ABPI / CT angiogram to exclude peripheral arterial disease where intermittent claudications are present.
Special tests:
Consider electromyographic (EMG) walking test - increased F latency values in lumbar spinal stenosis
Consider electromyographic paraspinal mapping
Management:
Conservative:
Exercise
Weight loss if overweight
Physiotherapy e.g. exercises that minimally stress the back, such as walking, swimming, or bicycling. Exercise may also strengthen the paraspinal muscles.
NSAIDSs e.g. naproxen, celecoxib +/- PPI cover / antacids
Paracetamol
Medication for neuropathic pain e.g. amitriptyline, gabapentin, pregabalin.
Consider oral steroids for acute exacerbation of painful symptoms.
Activity modification e.g. limit heavy lifting/prolonged sitting/repetitive bending/twisting of the back.
Consider deep heat therapy with massage to relieve spasms associated with back pain
Surgical:
Consider decompression surgery +/- fusion e.g. laminectomy ( removal of the lamina from affected vertebra) followed by physiotherapy
Consider interspinous distraction procedure to reduce backward movement of the spine.
Consider epidural injections with local anaesthetic and corticosteroids under specialist guidance for short/long-term pain relief.
Viva Questions:
Explain the pathophysiology of spinal stenosis.
Spinal stenosis is the narrowing of the spinal canal, which holds the spinal cord and nerves. It's often due to age-related disc degeneration, arthritis, and thickened ligaments. This narrowing can compress the spinal cord and nerves, leading to pain, numbness, and weakness. Factors like herniated discs and inflammation worsen the compression. Treatment involves pain management, physical therapy, and sometimes surgery to relieve pressure on the nerves and spinal cord.
At what level of the spine does spinal stenosis occur most commonly?
Spinal stenosis most commonly occurs in the lumbar (lower back) region of the spine. This is because the lumbar spine bears the most weight and undergoes significant movement, which can contribute to degenerative changes over time. Lumbar spinal stenosis can result in compression of the spinal cord and nerve roots, leading to symptoms such as lower back pain, leg pain, numbness, and weakness. However, spinal stenosis can also occur in the cervical (neck) and thoracic (mid-back) regions of the spine, albeit less frequently.
What are the causes of spinal stenosis?
Degeneration of spinal structures due to aging.
Disc degeneration and herniation.
Osteoarthritis and bone spurs.
Thickened ligaments.
Congenital factors and genetics.
Injuries and trauma.
Tumors or abnormal growths.
These factors narrow the spinal canal, compressing nerves and causing stenosis symptoms.
What are the risk factors of spinal stenosis?
Age: Risk increases with aging.
Genetics: Family history matters.
Congenital: Narrow canal from birth.
Injuries: Past spine trauma or surgery.
Lifestyle: Heavy lifting, certain jobs.
Obesity: Excess weight strains spine.
Diseases: Arthritis, diabetes, etc.
Scoliosis: Abnormal spine curvature.
What are the red flag symptoms/signs of back pain?
Neurological Issues: Weakness, numbness, or tingling.
Bladder/Bowel Problems: Loss of control.
Severe Pain: Unbearable or unrelenting.
Fever: Along with back pain.
Unexplained Weight Loss: Rapid and unintended.
Cancer History: Especially if pain is new.
Night Pain: Worse at night.
Trauma: After injury or accident.
Age Over 50: New-onset pain.
Steroid Use: Especially long-term.
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NeuroSurgStroke
Doctor Instruction:
Your patient is Charlie, a 63-year-old man presenting with problems with speech. Please take a history and carry out a relevant examination.
Patient History:
Charlie, 63y/o M, Engineer.
Your partner noticed a few hours ago that you were difficult to understand while speaking during dinner. Your speech has been slurred, according to your partner, and it happened very suddenly. Your partner was really worried about this and therefore called an ambulance.
You have noticed you cannot see things on your left which is “kinda weird” – you have never experienced this before in the past – you have to constantly rotate your neck to the side to see more. You also feel tired and not “really yourself”. You noticed you could not pick up your fork with your left hand or lift your left leg up when you tried to walk. These symptoms have not settled since then.
You are unsure whether you have swallowing difficulties, but you ate fine before slurred speech kicked in. No dizziness/ unsteadiness/ numbness/ headache/ confusion/ loss of consciousness/fever.
Ideas, Concerns, Expectations:
You think this might be another "ministroke". You had this last year which quickly resolved. You think you are likely to get better because of this. You have no concerns – you don't know why your partner was so concerned about this. You just want to go home and don't want to miss out on watching your favourite TV show.
Past Medical History:
Hypertension, atrial fibrillation, obesity, hypercholesteremia, previous “ministroke” x1 last year. Had a hernia operation in 2014.
Drug History:
Atorvastatin, aspirin, amlodipine, ramipril, apixaban.
NDKA
Family History:
Father had a heart attack when he was 50
Social History:
You live with your partner in a semi-detached house.
You work as an engineer.
You smoke 10 cigarettes a day since when you were a teenager (can't remember for how long exactly).
you drink a pint of beer every weekend.
Examination Findings:
Slurred speech
Left-sided weakness for arm and leg
Left homonymous hemianopia
No higher cerebral dysfunction (dysphasia, visuospatial disorder)
Differentials:
Stroke – likely ischaemic PACS ( Ischaemic stroke (87%) vs Haemorrhagic stroke (13%) )
Stroke – other forms
TIA
Investigations:
Observations + neuro observations
ECG / Echo – to rule out cardiac cause
Bloods: glucose (exclude hypoglycaemia), U&Es (neurological signs + exclude renal failure), FBC (r/o anaemia or infection), coagulation screen with INR
USS doppler carotids – rule out aortic stenosis
Non-contrast CT Scan (immediate) – to determine management: ischaemia vs haemorrhage
For further investigations: MRI Scan/CTA/MRA
Management:
Conservative:
Smoking cessation
Dietary changes
Lose weight
Exercise
Alcohol Control
Manage risk factors/co-morbidities: hypertension, hypercholesteremia, diabetes, AF, obesity, high cholesterol level…etc.
Rehabilitation (MDT: PT + OT + SALT + Nurses+ Dietician + social services + Optometry/Opthalmology + psychology + Orthotics)
Neuro observations + monitor with supportive care.
Maintain target oxygen saturation
Medical:
Referral to hyperacute/acute stroke unit.
Ischaemia:
Thrombolysis (<4.5 hours from onset) – alteplase if ischaemic and intracranial haemorrhage has been excluded (repeat CT scan needed post-thrombolysis to rule out haemorrhage complication).
Alternative: mechanical thrombectomy (6-24 hours of onset)
Antiplatelet therapy with PPI (e.g. STAT aspirin 300mg after CT and continued for 2 weeks – to be switched to clopidogrel 75mg lifelong for secondary prevention of stroke)
Statin e.g. atorvastatin 80mg life-long for secondary prevention
Haemorrhagic:
Withhold blood thinners
Urgent referral for neurosurgical assessment
Control blood pressure.
Consider reversal of anticoagulation.
Viva Questions:
What are the risk factors for stroke?
High blood pressure (hypertension)
Smoking
Diabetes
High cholesterol levels
Heart disease
Obesity and lack of physical activity
Poor diet
Excessive alcohol consumption
Age and gender (risk increases with age and is higher in men)
Family history and genetics
Previous stroke or transient ischemic attack (TIA)
Certain medical conditions (e.g., sickle cell disease)
Sleep apnea
Certain medications (e.g., hormone-based contraceptives)
What is the ROSIER scale?
The ROSIER (Recognition of Stroke in the Emergency Room) scale is a clinical tool used to aid in the early recognition and diagnosis of stroke, particularly within the emergency room setting. It's designed to help healthcare professionals quickly assess the possibility of a patient experiencing a stroke and facilitate prompt intervention. The scale evaluates specific signs and symptoms commonly associated with stroke.
The ROSIER scale typically considers various criteria, including facial weakness, arm weakness, speech disturbance, and age, to determine the likelihood of a patient having a stroke.
What are the indications for immediate CT Head?
Acute Head Trauma: Significant head injury.
Stroke or TIA: Focal neurological deficits or suspected stroke.
Subarachnoid Hemorrhage: Sudden severe headache.
Intracerebral Hemorrhage: Sudden severe neurological symptoms.
Mass Lesion or Tumor: New-onset or worsening neurological symptoms.
Infections or Abscesses: Suspected intracranial infections.
Hydrocephalus: Symptoms of increased intracranial pressure.
Vascular Abnormalities: Suspected aneurysms or AVMs.
Altered Mental Status: Sudden mental status changes.
Seizures: Prolonged or atypical seizures.
Severe Headaches: Sudden severe or atypical headaches.
Ophthalmologic Symptoms: Acute visual disturbances.
Post-Operative Patients: Recent neurosurgery with acute symptoms.
What are the key cerebellum defect signs?
Ataxia: Uncoordinated movements and balance issues.
Dysmetria: Difficulty judging distances accurately.
Intention Tremor: Shaking during purposeful movements.
Speech Disturbances: Slurred or abnormal speech rhythm.
Nystagmus: Involuntary rhythmic eye movements.
Vertigo or Dizziness: Sensation of spinning or unsteadiness.
Wide-Based Gait: Feet spaced apart for stability.
Incoordination of Movements: Difficulty with precise motions.
Tremor: Rhythmic shaking or quivering movements.
Reflex Abnormalities: Altered reflex responses (reduced or increased).
Tell me about the Bamford classification of ischaemic stroke.
The Bamford classification categorizes ischemic strokes into four types based on their clinical presentation:
Total Anterior Circulation Infarct (TACI): Severe deficits involving at least two areas (leg, arm, face, higher cortical functions).
Partial Anterior Circulation Infarct (PACI): Moderate deficits that don't meet TACI criteria.
Posterior Circulation Infarct (POCI): Involves brainstem and/or cerebellum, causing specific symptoms.
Lacunar Infarct (LACI): Small, deep infarcts causing motor or sensory deficits.
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OrthopedicCauda Equina Syndrome
Doctor Instruction:
You are currently a senior surgical doctor on call. Your next patient is a 45-year-old gentleman, Adam, who presents back pain after being hit by a slow-moving car yesterday. Please take a history and perform an appropriate examination.
Patient History:
Adam, a 45-year-old gentleman, banker
You came in today following a small car collision towards your back while walking across the road last night. You brushed this off – thinking it was no big idea. However, you started noticing lower back pain with weakness in your lower limbs.
Back pain is located centrally in the lower back – can sometimes radiate down both legs. You describe the pain as sharp, rating it 10/10. You tried many things to ease the pain without success e.g. paracetamol and ibuprofen. Back pain can be triggered by simple back movement but not worsened by coughing or straining. You have numbness and tingling sensation running down both of your legs.
Also, while wiping yourself afterwards in the toilet, you couldn’t feel the sensation around your bottom as well as your genitals– it was very strange, and at that point, you knew you needed to go and seek medical attention. You developed incontinence for passing urine and faeces. You no longer have the urge to go the toilet, and they can come out involuntarily, which is very concerning for you—no other previous back injuries.
Idea, Concern, Expectation:
You have no idea what is going on, but you think it is related to yesterday's injury. You are very concerned and don’t want to be paralysed – you are still very young! You would like to find out what is going on. You are very scared if you need any surgery for this.
Past Medical History:
Hypertension, obesity
Drug History:
Ramipril, Atorvastatin
NKDA
Family History:
Ankylosing Spondylitis
Social History:
Smoke 10 cigarettes/day for over 20 years
Drink around 2-3 pints of beer every weekend
Work as a banker
Live with a wife and two kids in a semi-detached house
Examination Findings:
Both lower limbs power 4/5 with reduced sensations, tone, and reflexes.
Lower back spinal tenderness at L3/4 region.
PR Examination: Reduced anal tone and sensation.
No upper motor neurone signs
Differentials:
Caudal Equina Syndrome caused by trauma
Prolapsed lumbar disc
Conus medullaris syndrome
Mechanical back pain
Peripheral neuropathy
Spinal tumour
Investigations:
Basic observations
Routine bloods for baseline and pre-assessment e.g. FBC, U&Es, LFT, Bone Profile, CRP
Consider blood culture if suspected infection.
Emergency MRI to confirm and exclude cauda equina syndrome
Consider CT myelography/spine
Consider XR spine
Consider Urodynamic studies -to monitor bladder function
Management (Cauda Equina Syndrome):
Hospital Admission
VTE prophylaxis
Prevention of further damage e.g. Immobilise spine if CES is due to trauma
Neurosurgical input for consideration of lumbar decompression surgery – the earlier this is performed, the higher the chance of regaining functions.
Surgery may involve removing bone fragments, tumour, herniated disc, blood, debulking for SOL e.g. tumour abscess…etc.
Anti-inflammatories such as steroids, if due to inflammatory cause
For infectious causes, patients should be treated with antibiotics
Postoperative care includes physiotherapy, occupational therapy, and addressing lifestyle issues e.g. obesity.
Treatment for metastatic spinal cord compression includes analgesia, high-dose dexamethasone, surgery, radiotherapy, and chemotherapy. Investigations include biopsy, staging CT, PET scan…etc.
Viva Questions:
Explain the pathophysiology of cauda equina syndrome.
Cauda equina syndrome is caused by compression of nerve roots at the base of the spine. This pressure leads to severe back pain, leg pain, numbness, weakness, and bladder/bowel dysfunction.
Why is cauda equina syndrome a surgical emergency?
Cauda equina syndrome is a surgical emergency because the compression of nerve roots can cause permanent and severe neurological damage. Prompt surgery is essential to prevent irreversible loss of sensation, muscle function, and bladder/bowel control. The urgency is to minimize lasting deficits and improve patient outcomes.
Where does the spinal cord terminate (at what level)?
The spinal cord typically terminates around the level of the first or second lumbar vertebra (L1-L2) in most adults. Below this point, the spinal cord transitions into a bundle of nerve roots known as the cauda equina, which continues down the vertebral canal and provides innervation to the lower extremities and pelvic organs
What is conus medullaris?
The conus medullaris is the tapering, lower end of the spinal cord. It is located at the termination of the spinal cord, usually around the level of the first or second lumbar vertebra (L1-L2). Below the conus medullaris, the spinal cord transitions into the cauda equina, a bundle of nerve roots that extend further down the spinal canal. The conus medullaris is an important anatomical landmark and holds significance in medical imaging, surgical procedures, and discussions related to spinal cord and neurological health.
What are the causes of cauda equina syndrome?
Cauda equina syndrome is caused by conditions that compress or damage the nerve roots at the base of the spinal cord. Common causes include herniated discs, spinal tumors, spinal stenosis, trauma, infections, inflammatory conditions, and postoperative complications. Immediate medical attention is crucial to prevent permanent nerve damage.
Does cauda equina syndrome show lower or upper motor neurone signs or both?
Cauda equina syndrome leads to signs and symptoms characteristic of lower motor neuron involvement. These include bilateral reduction in sensation of the lower limbs, impaired bladder and bowel function, weakness in the lower limb muscles, intense back pain, and potential issues with sexual function.
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OrthopedicAdhesive Capsulitis (Frozen Shoulder)
Doctor Instruction:
You are currently a senior surgical doctor on call. Your next patient is called Bob, a 41-year-old gentleman presenting with shoulder stiffness. Please take a history and perform an appropriate examination.
Patient History:
Bob, a 41-year-old gentleman, construction worker.
A few weeks ago, your left shoulder started becoming stiffer than usual, affecting movements in all directions; stretching exercises help with stiffness slightly, but stiffness is the same throughout the day. This is causing problems for you as you now need help with overhead activities and putting on your clothes. You feel like your left shoulder can no longer move as it used to with a limited range of motions.
Six months ago, you had a gradual worsening, constant left shoulder pain, which is often worse at night affecting your sleep- however, this is slowly getting better, so you are not too concerned, and you have a high pain tolerance. You describe the pain as a dull ache - rating it 2/10 currently. No radiation. No previous recent injury or known trigger. You tried many painkillers, such as paracetamol, with only minimal effects.
Idea, Concern, Expectation:
You have no idea what is going on. You work in construction, so this may be related. You had a few injuries towards your left shoulder in the past but nothing major. You are concerned as your work often involves very active use of your left shoulder, and you now have problems at work due to stiffness. You would like to see if you can have a sick note for this.
Past Medical History:
Type 2 diabetes, hypothyroidism
Previous left shoulder rotator cuff injury, which was treated conservatively three years ago.
No previous surgical history
Drug History:
Metformin, levothyroxine.
Allergic to fish - Rash.
Family History:
Mother has osteoarthritis affecting both hips.
Social History:
Work as a builder
Non-smoker
Drink around 3-5 units a week over a weekend.
Live with wife in a flat
Examination Findings:
Left shoulder stiffness on both active and passive movement in all directions with limited range of motions. However, external rotation is most affected. The whole shoulder joint is mildly tender to palpation.
Positive coracoid pain test - tenderness with direct pressure on the coracoid
Positive shoulder shrug test - inability to abduct arm to 90degree in the plan of body and to hold the position.
No tenderness at acromioclavicular joint. No painful arc on shoulder abduction.
Negative for other manoeuvres or shoulder tests.
Differentials:
Adhesive capsulitis (pain phase transitioning to stiff phase)
Supraspinatus tendinopathy
Acromioclavicular joint arthritis
Glenohumeral joint arthritis
Things to consider: septic arthritis, inflammatory arthritis, malignancy e.g. osteosarcoma, bony mets, fractures, shoulder dislocation, rotator cuff injury...etc.
Investigations:
Clinical diagnosis
Consider routine bloods if indicated to rule out other pathologies
Consider shoulder XR shoulder e.g. may show signs of arthritis
Consider ultrasound, CT, MRI (may show thickened joint capsule in adhesive capsulitis)
Management:
Conservative:
Continue using the left arm but don't exacerbate the pain
Encourage active/passive exercises and stretching
Analgesia e.g. paracetamol, NSAIDs
Physiotherapy
Psychosocial support
Consider transcutaneous electrical nerve stimulation (TENS) machine for pain management
Consider referral to pain clinic/orthopaedics if significant disability and poor pain control despite conservative/ medical management
Medical:
Intra-articular steroid injections
Consider short-term oral steroids
Surgical:
Hydrodilation (injecting fluid into joint to stretch capsule)
Manipulation under anaesthesia to improve range of motion
Arthroscopy, e.g. keyhole to remove adhesions and release shoulder
Arthroscopic capsulotomy
Viva Questions:
Explain the pathophysiology of adhesive capsulitis.
Adhesive capsulitis, or frozen shoulder, involves inflammation in the shoulder joint. This triggers collagen buildup and adhesion formation in the joint capsule, leading to stiffness and restricted movement. Over time, inflammation subsides, but adhesions persist, causing ongoing limited range of motion. Physical therapy and treatments aim to break down adhesions and improve shoulder function. In severe cases, medical interventions may be necessary.
What are the different phases of adhesive capsulitis?
Freezing Phase: Pain and stiffness increase as inflammation sets in.
Frozen Phase: Pain stabilizes, stiffness intensifies due to scar tissue and adhesions.
Thawing Phase: Pain and stiffness decrease, range of motion improves gradually.
How long can adhesive capsulitis generally last?
Adhesive capsulitis can last from a few months to a couple of years, with treatment playing a role in its duration. Early intervention and therapy can help shorten the recovery time.
What manoeuvre/ test can be used to test for supraspinatus tendinopathy?
The Empty Can Test (Jobe's Test) is used for supraspinatus tendinopathy. The person raises arms forward at 90 degrees, thumbs down. Downward pressure is applied, and pain or weakness suggests a potential issue with the supraspinatus tendon.
What are the complications of frozen shoulder?
Complications of frozen shoulder include prolonged stiffness, pain, loss of function, muscle imbalances, reduced quality of life, secondary issues in other body parts, chronic pain, limited work and activities, and emotional distress. Timely treatment and therapy can help prevent or minimize these complications.
What is the usual prognosis for frozen shoulder?
The prognosis for frozen shoulder varies, but with proper treatment and therapy, most individuals can expect gradual improvement over several months to years. Early intervention and consistent care can lead to full or nearly full recovery of range of motion and function. In some cases, residual stiffness or recurrence can occur, and underlying health conditions can influence outcomes.
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OrthopedicDupuytren's Contractur
Doctor Instruction:
You are currently a senior surgical doctor on call. Your next patient is a 65-year-old female called Mary, presenting with restricted hand movements. Please take a history and perform an appropriate examination.
Patient History:
Mary, a 65-year-old female, retired.
Over the last few years, you have been developing increasing difficulty using your right hand. You are unable to straighten your right ring and little fingers fully at all. You tried to flick your finger back but it didn't help. Because of this, you have been dropping things easily on the floor as you couldn't let go of things properly - how embarrassing! You now have difficulties using your right hand, for example, washing your face or fitting your hand into a glove to do gardening. Because you are mostly right-handed - you are becoming more frustrated day by day! You haven't noticed any pain in your hands as of yet. No stiffness. No previous hand trauma/injury.
Idea, Concern, Expectation:
You think this might be arthritis, as your mother got it. You are concerned as you are struggling with activities at home. You often have to ask your husband to help. You want to become more independent and not rely on others. You would like to free up your hand to do more things on your own.
Past Medical History:
T1DM, epilepsy, hyperlipidaemia
No previous surgeries.
Drug History:
Insulin injections, carbamazepine, atorvastatin
NKDA
Family History:
Arthritis - mother
Social History:
Retired. Used to work in sewing for clothes for most of your life.
You don't smoke, but you used to smoke around ten cigarettes for over 20 years.
You drink a glass of gin and tonic a few times a week.
You live with your husband in a small bungalow.
Examination Findings:
Skin thickening/ puckering/ pitting tethering/ dimpling in the palm of the right hand. Restricted extension of 4th and 5th digits of the right hand and appear in a flexed position at rest. 4th and 5th digits of right MCP joints are limited to 30°, and PIP joints are limited to 10° in the axis.
Firm, longitudinal thickening cords can be palpated from the palm into the affected fingers.
Firm nodules can be felt in the palm of the right hand - fixed to the skin and deep fascia at the distal palmar crease.
Hueston's table-top test is positive - the patient is unable to lay their right hand completely flat on the table.
Neurovascular intact upper limbs
Differentials:
Dupuytren's contracture
Callus
Ganglion
Trigger finger
Epithelioid sarcoma
Ulnar nerve palsy
Investigations:
Clinical diagnosis
Consider monitoring risk factors such as hba1c/glucose for diabetes
Consider ultrasound of the hand
Management:
Conservative:
Do nothing/reassurance if there is no contracture or loss of function
Referring to plastic / orthopaedic surgery for specialist assessment
Medical:
Corticosteroid injections for those with painful nodules (without contracture/loss of function)
Consider collagenase injection for ≤30° MCP joint contracture with no PIP joint contracture
Surgical (usually done under regional block or GA as a day case):
Needle fasciotomy/needle aponeurotomy - using a needle to divide and loosen the cord causing the contracture
Percutaneous fasciotomy - using a scalpel to divide and loosen the cord causing the contracture
Limited fasciectomy- removing abnormal fascia and cord to release the contracture
Dermofasciectomy - removing abnormal fascia and cord and associated skin. A skin graft is used to replace the removed skin.
Peri-operative antibiotic
Surgery is generally followed by splinting and physiotherapy of the affected hand.
In severe cases, consider finger amputation.
Viva Questions:
Explain the pathophysiology of Dupuytren's contracture.
Dupuytren's contracture is a hand condition driven by genetic factors and abnormal tissue response. Fibroblasts, responsible for producing collagen, become overactive due to genetic triggers. This leads to excessive collagen production, forming nodules and cords in the palm. These cords exert a contractile force, causing finger bending. Myofibroblasts, with contractile abilities, contribute to this force. Inflammation and microvascular changes may also play roles. Overall, genetics, fibroblast activity, collagen accumulation, and contractile forces underlie the condition.
What are the complications of Dupuytren's contracture surgery?
Recurrence: Contracture can return after surgery.
Scarring: Surgery can lead to visible scars.
Infection: Risk of post-surgery infection.
Nerve or Vascular Damage: Nearby structures can be harmed.
Stiffness: Hand movement may be limited.
Pain and Discomfort: Pain during recovery is common.
Hematoma: Blood collection can occur.
Skin Issues: Wound healing problems or skin changes.
Complex Regional Pain Syndrome: Rare, severe pain condition.
Joint Stiffness: Hand joints can become stiff.
Allergic Reactions: Allergies to surgical materials.
Cosmetic Changes: Hand appearance might alter.
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OrthopedicEpicondylitis
Doctor Instruction:
Your patient is a 45-year-old woman, Susan, presenting with elbow pain. Please take a history and perform an appropriate examination.
Patient History:
Susan - a 45-year-old female - farmer
You have been experiencing elbow pain for the last few months. This pain is gradually getting worse. This pain is located at the lateral side of your right elbow. The pain is sharp and constant and can radiate down the forearm. Pain is not worsened by grasping objects, wrist flexion or pronation. It is made worse when bending your right wrist upwards (extension). You tried ibuprofen which improved the pain.
You noticed the gripping strength of your right hand has reduced. You now find opening a jar of jam more difficult than usual. No known recent injuries. No abnormal sensation.
Ideas, Concerns, Expectations:
You think this might be related to your work as a farmer, as you often have to use heavy vibrating tools on the farm. You are concerned as you are beginning to have difficulty managing at home and at work due to the pain. You would like to find out what is going on and have strong painkillers.
Past Medical History:
Osteoarthritis affecting both hips and knees
COPD
Previous left Achilles tendon rupture
Drug History:
Ibuprofen as required for pain
Fostair inhaler
NKDA
Family History:
Inflammatory bowel disease
Social History:
You work on a farm involving raising animals and growing crops.
You live with your husband in a detached house.
You are usually independent at home. No carers.
You smoke ten cigarettes a day for 20+ years.
You drink a glass of wine every day during dinner.
You play tennis when you are free, but you have been playing less than usual due to elbow pain.
Examination Findings:
Tenderness at the right lateral epicondyle of the humerus on palpation.
Elbow pain is worsened on resisted dorsiflexion of the right wrist
Weak right wrist extension and reduced grip strength of the right hand
Mill's test positive
Cozen's test positive
Tinel's sign is negative
Good range of movement of the right elbow.
Normal sensation
Differentials:
Lateral epicondylitis (Tennis Elbow)
Olecranon bursitis
Elbow arthritis
Cervical nerve root entrapment
Radial tunnel syndrome
Investigations:
Clinical diagnosis
Consider Elbow XRay/MRI/US if the diagnosis is uncertain
Consider nerve conduction study and electromyography if ulnar nerve involvement is suspected in patients with golfer's elbow
Consider Infra-red thermography and laser doppler flowmetry in difficult suspected cases of tennis elbow
Management (Epicondylitis):
Conservative:
Self-limiting; resolving with time
Rest
Modifying activities that exacerbate symptoms e.g. avoid tasks that involve high force, hand-gripping/ pinching/ use of high-amplitude vibrating handheld tools
Rehabilitation exercises - increase the strength
Analgesia e.g. oral or topical NSAIDs/ paracetamol
Apply heat/ ice to help relieve pain
Physiotherapy
Orthotics e.g. elbow braces, forearm strap
Medical:
Consider steroid injections for short-term relief
Consider topical GTN for tendinopathies for up to six months
Review in 6 weeks and reassess management and symptoms - may require a specialist referral if the diagnosis is in doubt, severe pain/functional impairment, symptoms non-responding for 6-12 months.
Secondary Care:
Platelet-rich plasma (PRP) injections
Hyaluronan gel injections
Biologic treatment may be considered
Botulinum toxin in very severe cases
Extracorporeal shock wave treatment
Surgical:
Debridement
Release or repair of damaged tendons
Prevention:
Modify activities that led to overuse injury.
Proper ergonomic positioning and functioning in both workplace and recreational environments.
Viva Questions:
Explain the pathophysiology of epicondylitis.
Epicondylitis, commonly known as tennis or golfer's elbow, is a repetitive strain injury affecting the tendons at the elbow's bony prominences. It stems from microscopic tendon damage due to repeated wrist and forearm motions, like gripping and twisting. This leads to inflammation, impaired blood flow, and altered collagen structure in the tendons. Overuse strains the tendon attachments, causing pain, weakness, and limited function. Inflammation further exacerbates the issue. If untreated, chronic degeneration can occur.
What are the differences between tennis vs golfer's elbows?
Tennis elbow (lateral epicondylitis) affects the outer elbow and extensor tendons, caused by repetitive wrist extension motions. Golfer's elbow (medial epicondylitis) affects the inner elbow and flexor tendons due to repeated wrist flexion movements. Both cause pain and inflammation at tendon attachments.
What are the risk factors for epicondylitis?
Epicondylitis risk factors: Repetitive motions, occupational demands, sports involvement (tennis, golf), poor technique, age (30-50), gender (men for tennis elbow), fitness level, obesity, prior elbow issues, genetics. Prevent with proper form, ergonomic tools, warm-ups, and exercises.
What is the usual prognosis for epicondylitis?
The prognosis for epicondylitis varies. With early diagnosis and appropriate treatment, such as rest, physical therapy, and lifestyle adjustments, many individuals recover within a few weeks to a few months. However, if not managed properly, the condition can become chronic, leading to persistent pain and functional limitations. In some cases, more intensive treatments like corticosteroid injections or even surgery might be considered. To enhance prognosis, timely intervention, adherence to treatment recommendations, and preventive measures to avoid repetitive strain are crucial.
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OrthopedicCarpal Tunnel Syndrome
Doctor Instruction:
You are currently a Foundation Year Doctor working in the Emergency Department. Your next patient is a 44-year-old woman called Candy, who presents with hand numbness. Please take a history and perform an appropriate examination.
Patient History:
Your name is Candy (44-year-old woman) – office worker.
Over the last few months, you noticed worsening numbness in your right hand – mainly affecting your right hand's thumb, index, and middle fingers. Sometimes around these sites, you will notice some pins and needles/ a burning sensation / aching pain, which tend to come up intermittently and worsen at night-time and can wake you up from sleep. You tried multiple methods of relieving symptoms, such as hanging your hand out of bed at odd angles or shaking your hand multiple times – which helped slightly. You occasionally have stiffness in the fingers of both hands, especially in the morning, lasting around 30-45 minutes, improving throughout the day.
You also noticed you have been becoming clumsier as usual in the last few months. You feel weak in doing things with your right hand i.e. opening a jar or turning a wrench. Sometimes items just slip out from your right hand! Because of this, you dropped and broke a few cups in the kitchen, how embarrassing!
Ideas, Concerns, Expectations:
You think you might have arthritis but are not too sure. You are concerned because you are becoming less able to cope at home due to clumsiness. You would like to see if you can be seen by a rheumatologist about this.
Past Medical History:
Obesity, Hypothyroidism, Type 2 Diabetes, previous fracture at the right wrist when you were a child - this was managed conservatively.
Drug History:
Atorvastatin, levothyroxine, metformin
NKDA
Family History:
Dad also has similar symptoms in the past – all you know is that he has acromegaly. Mother has arthritis, but you do not know which one.
Social History:
You work as an office worker (if asked specifically, your job involves heavily typing on a keyboard for various clients).
Smoke five cigarettes daily for five years.
Don't drink alcohol.
Examination Findings:
Overgrowth features of acromegaly might include large nose/tongue/hands/feet/ protruding jaw/ prominent forehead + brow
Wasting/loss of sensation around the thenar muscles (right)
Weaknesses in flexion of the index and middle fingers of the right hand. Weakness on right thumb abduction/opposition/ flexion. Weakness in grip strength(right hand).
Difficulty with fine movement involving thumb (right)
Reduced sensory innervation of the median nerve distribution of the right palm and full fingertips of the right hand's thumb, index and middle finger.
Positive for Phalen’s test, Tinel’s test and carpal tunnel compression test of the right hand.
Differentials:
Carpal Tunnel Syndrome / Median Nerve Palsy
Rheumatoid / Osteoarthritis
Underlying undiagnosed acromegaly
Tendonitis/ fibrositis
Investigations:
Bedside:
Observations
Perform a Carpal Tunnel Questionnaire
Imaging:
Consider XR of the hands for arthritis
Ultrasonography Wrist + Hand (space-occupying lesion may be identified)
MRI scan (space-occupying lesion may be identified)
Special Test:
Nerve conduction studies e.g. electroneurography/ electromyography (focal slowing of conduction velocity in median sensory nerves + prolongation of median distal motor latency)
Management (Carpal Tunnel Syndrome):
Conservative:
Patient Education about the condition
Rest
Minimise activities that can exacerbate symptoms
Wrist splints (to maintain a neutral position of the wrist at night)
A trial of NSAIDs +/- PPI cover
Acupuncture (symptom relief/ grip strength/ electrophysiological function)
Physiotherapy (to improve strength/flexibility/mobility of median nerve)
Secondary prevention: ergonomic changes to workplace e.g. ergonomic keyboards, wrist, rest, frequent breaks, wrist splint…etc.)
Consider referring patients to orthopaedics or rheuamtology if e.g. uncertain about diagnosis or severe symptoms e.g. persistent motor/ sensory disturbance, or for long-term management
Medical:
Steroid injections (symptom relief)
Surgical:
Carpal tunnel decompression surgery (open or endoscopically) with rehabilitation treatment following surgery e.g. immobilisation of wrist orthosis, dressings, exercise, controlled cold therapy, multimodal hand rehabilitation, electrical modalities, scar desensitisation, arnica, laser therapy.
Sonographically guided carpal tunnel release (new technique)
Viva Questions:
Explain the pathophysiology of carpal tunnel syndrome.
Carpal Tunnel Syndrome (CTS) occurs when the median nerve in the wrist is compressed due to factors like inflammation and anatomical constraints in the carpal tunnel. Repetitive movements or medical conditions can cause swelling and increased pressure. This pressure on the nerve leads to symptoms such as pain, tingling, and weakness in the hand's thumb, index, and middle fingers. Over time, this compression can damage the nerve, causing further sensory and muscle issues. Treatment options range from conservative measures to surgery, depending on the severity of the condition.
What nerve is affected in carpal tunnel syndrome?
In carpal tunnel syndrome (CTS), the median nerve is the nerve that is primarily affected. The median nerve runs from the forearm into the hand through a narrow passageway called the carpal tunnel, which is located on the palm side of the wrist. Compression or irritation of the median nerve within the carpal tunnel leads to the characteristic symptoms of CTS, including pain, numbness, tingling, and weakness in the thumb, index finger, middle finger, and half of the ring finger.
What are the risk factors/causes of carpal tunnel syndrome?
Carpal tunnel syndrome (CTS) risk factors include repetitive hand motions, jobs with wrist strain, anatomy variations, diabetes, arthritis, hormonal changes (pregnancy, menopause), age (over 50), female gender, obesity, wrist injuries, genetics, fluid retention, and lifestyle factors like smoking and inactivity.
What are the advantages of endoscopic surgery compared to open surgery?
Endoscopic surgery has advantages over open surgery: smaller incisions, less tissue trauma, faster recovery, reduced blood loss, shorter hospital stay, lower infection risk, improved cosmetic outcome, enhanced visualization, less disruption to tissues, quicker return to activities, and potentially lower hernia risk. The approach depends on the procedure and patient, ensuring personalised and efficient treatment.