Orthopedic
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Osteoarthritis
Doctor Instruction:
You are currently a senior surgical doctor on call. Your next patient is Jane, a 35-year-old woman presenting with joint pain. Please take a history and conduct a relevant examination.
Patient History:
Jane, 35 y/ F, dog trainer.
For 8 months, you have been getting worsening knee pain in both knees. The pain is present on most days and worsens towards the end of the day. You spend most of the day on your feet as part of your job, and recently you have been progressively becoming less able to keep up with the demands of your work. To seek relief from the pain, you have to take frequent breaks throughout your work day, and this slows you down so much that you have been forced to cut down on the number of clients you see daily. You try to keep off your feet on the weekend and find that this helps limit the pain.
Besides brief stiffness in your knees lasting less than 30 minutes in the morning, you don't have any other symptoms. You deny symptoms of locking or giving way, shortness of breath, chest pain, palpitations, rashes, visual problems, or changes in bowel habits. You have not had any recent short-lived episodes of illness.
Ideas, Concerns, Expectations:
You are worried that you have rheumatoid arthritis, as this is what your mother has. She is currently fully dependent on others for activities of daily living - this terrifies you as you do not want to be in her position when you reach her age. You would like to begin treatment as soon as possible to preserve your independence.
Past Medical History:
Obstructive sleep apnoea
Polycystic ovarian syndrome
Asthma – well-controlled. You haven’t used an inhaler in years!
If asked about previous trauma, reveal that you tore your right knee meniscus during a hockey game as a teenager.
Drug History:
Lansoprazole
No known drug allergies.
Family History:
Mother has rheumatoid arthritis.
Father has oesophageal cancer.
Social History:
Non-smoker
No recreational drug use
You live at home with 3 dogs. You are independent in activities of daily living like shopping, cooking and cleaning.
You work full-time as a dog trainer. As working has become increasingly difficult, lately you have been considering engaging in part-time work instead.
Examination Findings:
On general inspection:
Large body habitus
Gait is slow but symmetrical.
On examination of the knees:
There is no evidence of redness, swelling or heat bilaterally.
No effusions can be detected on the patellar tap or sweep tests.
Bilateral crepitus is ascertained on passive movement.
There is pain in passive and active movement throughout the range of motion of both knees.
Differentials:
Osteoarthritis of the knees
Rheumatoid arthritis
Referred pain from the hip joint e.g. osteoarthritis of the hip, greater trochanteric pain syndrome
The above history and examination are strongly suggestive of osteoarthritis. This is the most likely diagnosis despite the family history of rheumatoid arthritis. The presence of a past meniscal tear and current obesity can confer a higher risk of developing early-onset osteoarthritis – do not be deceived by the patient's age or family history!
Investigations:
Bedside:
Measurement of BMI (obesity is associated with the development of osteoarthritis)
Bloods:
Inflammatory markers (usually normal in osteoarthritis)
Serum autoantibodies (serum autoantibodies like rheumatoid factor and anti-CCP antibodies are negative in osteoarthritis )
Imaging:
X-rays of affected joints
The 4 radiological features of osteoarthritis are:
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
Other investigations:
Synovial fluid aspiration - carried out to investigate painful effusions
Management:
Conservative:
Lifestyle measures
Weight loss– obesity is a risk factor for osteoarthritis.
Muscle strengthening exercises
Walking aids: Shock-absorbing footwear, walking sticks
Transcutaneous Electrical Nerve Stimulation
Occupational health assessment: help with adapting work to the patient’s functional limitations.
Physiotherapy: help with muscle strengthening exercises, stretching and provision of aids like joint supports.
Podiatry: advice on footwear.
Analgesia:
Paracetamol and/or topical NSAIDs
Consider substituting paracetamol or topical NSAIDs with oral NSAIDs +/- PPI co-prescription
Add an opioid e.g. codeine
Topical capsaicin
Intra-articular corticosteroid injections
Surgical:
Surgical management of osteoarthritis can be considered if the patient's quality of life and pain control remain poor on conservative and medical management alone. The options include:
Replacement arthroplasty
Joint fusion
Arthroscopic lavage and debridement
Viva Questions:
What are the ‘red flags’ of joint pain?
Sudden, Severe Pain: Abrupt onset of intense joint pain that is not easily explained by an injury or overuse.
Swelling and Redness: Unexplained swelling, warmth, or redness around the joint, which might be a sign of inflammation or infection.
Fever and Chills: Joint pain accompanied by fever or chills could be indicative of an infection.
Loss of Function: Significant loss of mobility or function in the joint, such as difficulty moving the joint, bending, or weight-bearing.
Unexplained Weight Loss: Joint pain accompanied by unexplained weight loss could indicate systemic issues such as autoimmune diseases or malignancies.
Multiple Joints Affected: If multiple joints are affected simultaneously or in quick succession, it might suggest conditions like rheumatoid arthritis, lupus, or other systemic autoimmune disorders.
History of Cancer or Immunosuppression: Individuals with a history of cancer or those with weakened immune systems are at higher risk for certain joint-related complications.
Pain at Rest or Night Pain: Joint pain that worsens at night or disturbs sleep might indicate inflammatory conditions.
Numbness or Tingling: If joint pain is accompanied by numbness or tingling, it could indicate nerve involvement, such as in conditions like peripheral neuropathy.
Skin Changes: Any changes in the skin overlying the joint, like rashes or lesions, might indicate a systemic issue affecting the joint.
What are some examples of the different types of arthritis?
Osteoarthritis (OA): This is the most common type of arthritis. It occurs due to the breakdown of cartilage in the joints, causing pain, stiffness, and reduced mobility.
Rheumatoid Arthritis (RA): An autoimmune disorder that primarily affects the joints, causing inflammation, pain, and joint deformity.
Psoriatic Arthritis: Associated with the skin condition psoriasis, it leads to joint pain, swelling, and stiffness, often affecting those with psoriasis.
Juvenile Idiopathic Arthritis (JIA): Arthritis that affects children, causing joint inflammation and stiffness.
Infectious/Septic Arthritis: Occurs due to a bacterial, viral, or fungal infection in the joints, leading to inflammation.
Reactive Arthritis: Develops as a reaction to an infection in another part of the body, causing joint pain, swelling, and stiffness.
What are the risk factors for osteoarthritis?
Age: Risk increases with age.
Obesity: Excess weight stresses joints.
Joint Injuries: Previous injuries raise risk.
Genetics: Family history can contribute.
Occupation and Overuse: Repetitive stress in certain jobs or activities.
Gender: More common in women, especially after menopause.
Muscle Weakness: Weak muscles strain joints.
Other Medical Conditions: Conditions like gout or rheumatoid arthritis can increase risk.
Bone Deformities or Joint Alignment Issues: Misaligned joints or unusual bone shapes.
Joint Stress: High-impact sports and activities can contribute.
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Achilles' Tendinopathy
Doctor Instruction:
You are currently a senior surgical doctor on call. Your next patient is Ed, a 26-year-old gentleman presenting with ankle pain. Please take a history and perform a relevant examination.
Patient History:
Your name is Ed, a 26-year-old professional tennis player.
Over the past few weeks, you noticed that your left ankle pain has gradually worsened. It's getting more painful at the heel and worsens whenever you try to play more tennis. You tried to use some ibuprofen gel which only improved the pain slightly. You rate the pain as 5/10 on average, but when it is worse, it can go up to a 7/10. The pain doesn't radiate anywhere. Your left ankle is also becoming gradually more swollen than usual. Because of this, you have been having trouble walking and running especially during tennis practices.
The movement of your left ankle is limited due to pain in all directions. You feel your left foot has gotten weaker, especially while pushing off the ground. You are not sure if you have ruptured any tendons - you hope not, as your profession is being a sportsman. No injuries you can recall, but you play tennis a lot.
No fever, but recently, you were diagnosed with prostatitis and were given antibiotics.
Ideas, Concerns, Expectations:
You don't know, but you think you might have accidentally injured your left ankle without yourself noticing. You are concerned that it is becoming more difficult to continue playing tennis because of the pain and swelling in your left ankle. You want to know what is causing the problem and have a scan or some sort.
Past Medical History:
Ankylosing spondylitis, type 1 diabetes
Drug History:
Ciprofloxacin (for recent prostatitis five days ago).
Allergic to penicillin (Rash)
Family History:
Rheumatoid Arthritis
Social History:
You live with your parents. You think you are very healthy.
You do not smoke or drink.
You currently play tennis professionally.
Generally independent at home.
Examination Findings:
When Achilles is relaxed in a dangled position, the ankle is hyper-dorsiflexed
Altered gait (weakness in pushing off with the affected left foot; worse during tiptoeing)
Tenderness is noted in the left ankle region with posteriorly localised swelling
A palpable defect in the Achilles tendon (but no rupture)
Limited movement in ankle movement due to pain.
Weakness in left ankle plantar flexion
Simmond 's calf squeeze test / Thompson test – negative in tendinopathy (but positive in rupture)
No tenderness or warmth palpating the calcaneus region. No crepitus. No obvious deformity, no nodularity or thickening on palpation of the Achilles tendon.
Differentials:
Achilles Tendinopathy
Tendon Rupture
MSK sprains and strains
Retro calcaneal bursitis
Investigations:
Clinical diagnosis
Observations
XR foot/ankle: fractures/ calcific tendinopathy / talar shift
US ankle – to rule out Achilles tendon tendinopathy /rupture
MRI ankle – if the diagnosis is unclear (to rule out tendinopathy/rupture)
Consider diagnostic arthroscopy if appropriate
Management (Achilles Tendinopathy):
Conservative:
Rest + immobilisation e.g. applying specialist boot first involving from full plantar flexion of the ankle to neutral position - can take 6-12 weeks for Achilles tendon to heal in tendinopathy
Night splints to hold the foot in a neutral position to dorsiflexion to main passive dorsiflexion
Ice / Analgesia e.g.. NSAIDs
Elevation to reduce swelling
Heel lifts (orthotic devices to prevent gait imbalance)
VTE prophylaxis
Protective footwear
Physiotherapy input + rehabilitation e.g. gentle stretching, eccentric heel-drop exercises…etc.
Consider casting for resistant Achilles tendinopathy
If ruptured:
Period of non-weight bearing and a brace (orthosis) or plaster cast, surgical review for intervention, followed by early weight-bearing and mobilisation using removable orthosis for 4- 6 weeks.
Medical:
Consider glyceryl trinitrate transdermal (to decrease pain by improving tendon healing)
Surgery (especially those with a high level of physical activity/ competitive athletes/ recurrent rupture):
Orthopaedic referral
Reattaching / repair of Achilles Tendon
Excision of fibrous adhesion/ degenerative nodules
Tendon stripping
Percutaneous tenotomy
Other considerations:
Consider autologous blood injection (whole blood/ platelet-rich plasma containing growth factors)
Consider low-level laser therapy to treat pain/disability in short-term
Consider Extracorporeal shock wave therapy (ESWT) to reduce pain from tendinopathy
Future Prevention:
Stretching, warm-up exercises, and rehabilitation following minor injuries. Steroid injections are avoided due to increasing risk of tendon rupture.
Viva Questions:
What is the function of the Achilles tendon?
The Achilles tendon is a strong fibrous band of tissue that connects the calf muscles (the gastrocnemius and soleus muscles) to the heel bone (the calcaneus). The primary function of the Achilles tendon is to facilitate movement by enabling the contraction of the calf muscles, allowing the foot to point downwards (plantarflexion) and providing the power necessary for activities such as pushing off the ground while walking or running.
What are the risk factors for Achilles tendinopathy/rupture?
The key risk factors for Achilles tendinopathy or rupture include:
Overuse or sudden increase in physical activity.
Age, with increased risk as individuals get older.
Participation in sports, especially those involving jumping or sudden movements.
Muscular imbalances, weakness, or tightness in the calf muscles.
Improper footwear, training techniques, or biomechanical issues.
Certain medical conditions or medications that weaken tendons.
Previous history of tendon problems or injuries.
Explain the pathophysiology of Achilles tendinopathy/ rupture.
The pathophysiology of Achilles tendinopathy and rupture involves:
Tendinopathy: Gradual breakdown due to repetitive stress, causing microtears and collagen fiber degeneration.
Degeneration: Weakened tendon structure due to chronic overuse, leading to decreased capacity to handle stress.
Inflammation: Early stages might involve inflammation, but chronic cases focus on failed healing responses.
Rupture: Severe force or trauma, often in an already weakened tendon, can cause a partial or complete tear.
Vascular Changes: Chronic tendinopathy can alter blood supply, impacting tendon health and healing.
Describe the anatomy surrounding the Achilles tendon.
The Achilles tendon, linking the calf muscles to the heel bone, is surrounded by:
Gastrocnemius and Soleus Muscles: These form the tendon, enabling movement.
Calcaneal Bursae: Fluid-filled sacs reducing friction.
Paratenon: Thin sheath reducing friction around the tendon.
Surrounding Ligaments, Muscles, Skin: Supporting structures and tissue of the ankle and heel region.
What are the complications associated with Achilles tendinopathy/rupture?
Complications associated with Achilles tendinopathy or rupture may include:
Chronic Pain: Tendinopathy can cause persistent pain, discomfort, and stiffness, affecting mobility and daily activities.
Reduced Functionality: Both tendinopathy and rupture can impair movement, such as walking, running, or jumping.
Re-injury Risk: After healing, the Achilles tendon might remain vulnerable to re-injury or continued degeneration.
Muscle Weakness: Reduced strength and function of the calf muscles due to limited use during recovery.
Surgical Risks: In cases of severe rupture or chronic tendinopathy requiring surgery, potential risks associated with surgical intervention exist, including infection, nerve damage, or prolonged rehabilitation.
Scar Tissue Formation: Following a rupture or surgery, scar tissue may form, affecting tendon flexibility and strength.
Altered Gait: During recovery, individuals may experience changes in their gait, leading to imbalances or stress on other joints or muscles.
Risk of DVT (Deep Vein Thrombosis): Immobilization or reduced mobility after a rupture or surgery might increase the risk of blood clot formation in the legs.
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Rotator Cuff Tear
Doctor Instruction:
You are currently a senior surgical doctor on call. Your next patient is Joe- a 45-year-old gentleman presenting with shoulder pain. Please take a history and perform an appropriate examination.
Patient History:
Your name is Joe 45 year old – construction worker.
Your right shoulder has been getting gradually worse every day. The right shoulder pain first started around a few months ago. The pain is sharp and does not radiate. You rate the pain as 7/10. It is worsened by movement and improved with rest.
You play tennis regularly (if asked specifically, you are right-handed) but since the pain started, you no longer play as much with your mates, which is bothering you. You also have night pain around your right shoulder, which sometimes can make it difficult to fall asleep.
You feel your right shoulder has weakened since the pain started, and you now struggle to lift your right arm up from your waist.
No numbness/ tingling/ abnormal sensations in the limbs. You haven't noticed any shoulder mass, swelling, or deformity. No fever. No red skin. Other than the pain and shoulder weakness. You feel well in general. No night sweats/weight loss. No shortness of breath. No recent trauma or fall. No neck pain. No previous history of fracture/ dislocation. No stiffness.
Ideas, Concerns, Expectations:
You have no idea what is going on - you are usually fit as a fiddle. You are concerned that the pain is causing many physical problems at work ( you work as a construction worker). You are now unable to lift any heavy objects with your right arm due to the pain. You hope to get better as soon as possible.
Past Medical History:
Nil
Drug History:
Nil
NDKA
Family History:
Rheumatoid arthritis
Type 2 diabetes
Social History:
You work as a construction worker, which often involves lifting heavy objects.
You smoke around 5-10 cigarettes a day for ten years.
You occasionally drink around 1-2 pints of beer when going out with friends for a meal.
Examination Findings:
Pain and weakness in initiating shoulder abduction – indicating supraspinatus tear. Tenderness over rotator cuff structure on palpation. Muscle wasting at regions of the right rotator cuff muscles might be present.
Drop arm test positive (passively abduct shoulder, then ask patient to lower abducted arm slowly to the waist. If arm drops after reaching 90degree- indicates massive rotator cuff tear)
Pain elicited and range of movement limited by pain in shoulder movements.
Cross-arm test – negative (acromioclavicular problems). No shoulder pain arc elicited (70° – 120°) (subacromial impingement). No localised pain/tenderness over the acromioclavicular joint and no restriction of passive, horizontal movement of the arm across the body when the elbow is extended (acromioclavicular disorder).
Differentials:
Rotator cuff disorders: rotator cuff Injury/ tear, tendonitis…etc.
To rule out rotator cuff rupture
Other considerations:
Fracture
Adhesive capsulitis
Osteoarthritis
To rule out joint infection/dislocation
Investigations:
Bedside:
Observations
Bloods:
Consider routine blood tests for baseline
Imaging:
Consider XR Shoulder to exclude bony pathology e.g. fracture/osteoarthritis/dislocation/opacities in calcific tendonitis/ anatomical abnormalities such as superior migration of humeral head relative to glenoid, pseudo subluxation of the humeral head relative to glenoid.
U/S to assess rotator cuff structure / detect tears, effusion
MRI shoulder to look for any underlying soft tissue shoulder pathology, i.e. shoulder instability, full/ partial tears, effusion…etc.
MR/CT arthrography – to look for tears/effusion if appropriate
If referred neck pain is suspected, consider cervical spine XR
Management (Rorator Cuff Injury):
Conservative:
Patient Education
Consider psychosocial support if appropriate i.e. stress, job pressure, job satisfaction
Rest and adapted activities e.g. at work/home/hobbies – avoid overhead activities
Analgesia e.g. NSAID (ibuprofen, diclofenac, naproxen) / opioids +/- PPI cover
Ice Packs – reduce pain
Physiotherapy to optimise shoulder function
Consider occupational therapy input
Consider sling if an acromioclavicular joint injury is suspected
Surgical:
Consider referral to orthopaedics for rotator cuff disorder or in suspected joint infection, unreduced dislocation or acute trauma
Consider subacromial steroid injections – symptomatic relief (Avoid if significant rotator cuff tear is suspected) – patient will continue to have weakness despite pain relief.
Consider suprascapular nerve block
Arthroscopic rotator cuff repair depending on the degree of tendon damage
Consider joint aspiration or lavage in patients with calcified tendonitis
Viva Questions:
Explain the pathophysiology of a rotator cuff tear.
A rotator cuff tear involves:
Mechanical Stress: Repetitive use or acute injury causes stress on the rotator cuff tendons, leading to microtears.
Degeneration: Cumulative wear and tear can weaken the tendons, making them more prone to tearing.
Acute Trauma: Sudden force or injury can also cause an immediate tear in the tendons.
Reduced Healing Capacity: Tendons may have limited blood supply, hindering their natural healing process, leading to a partial or complete tear.
Explain the anatomy of the shoulder joint and surrounding structure.
The shoulder joint and surrounding structures include:
Bones: Humerus, scapula, and clavicle.
Glenohumeral Joint: Where the humerus fits into the scapula's socket.
Rotator Cuff: Group of muscles and tendons stabilizing the joint.
Labrum: Cartilage rim supporting the joint.
Bursae: Fluid-filled sacs reducing friction.
Ligaments, Muscles, Tendons: Supporting and connecting structures for stability and movement.
Name the rotator cuff muscles and their function.
Supraspinatus: Located on the top of the shoulder blade, this muscle initiates the abduction (raising the arm sideways) of the arm and assists in stabilizing the shoulder joint.
Infraspinatus: Positioned on the back of the shoulder blade, it aids in external rotation of the arm (outward rotation) and contributes to shoulder joint stability.
Teres Minor: Situated beneath the infraspinatus, this muscle also contributes to the external rotation of the arm and helps in stabilizing the shoulder.
Subscapularis: Positioned on the front of the shoulder blade, it is responsible for internal rotation of the arm and stabilization of the shoulder joint.
What are the risk factors for shoulder pain?
Age: As individuals get older, the risk of shoulder pain due to wear and tear on the joints increases.
Overuse and Repetitive Movements: Activities involving repetitive overhead motion or lifting can strain the shoulder muscles and tendons, leading to pain.
Poor Posture: Incorrect posture while sitting or standing can contribute to shoulder strain and discomfort.
Muscle Imbalances: Weakness or imbalance in the muscles around the shoulder can lead to instability and pain.
Trauma or Injury: Falls, accidents, or direct impact can result in shoulder injuries and subsequent pain.
Medical Conditions: Conditions like arthritis, tendonitis, bursitis, or rotator cuff tears can lead to shoulder pain.
Lifestyle Factors: Factors such as smoking, obesity, and inadequate physical conditioning can contribute to shoulder issues.
Which soft tissues heal slowly and why?
Tendons: Tendons are the connective tissues that attach muscles to bones. They have relatively poor blood supply, which can slow down the healing process. Limited blood flow restricts the delivery of nutrients and oxygen necessary for efficient healing.
Ligaments: Ligaments are another type of connective tissue that connects bones to other bones, providing joint stability. Similarly, they have a relatively low blood supply, hindering the healing process.
Cartilage: Cartilage is a firm, rubbery tissue found in joints, providing cushioning and facilitating smooth movement. Due to its avascular nature (lack of blood vessels), cartilage has a limited ability to repair itself, leading to slow healing in case of injury.
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Acute Compartment Syndrome
Doctor Instruction:
You are currently a senior surgical doctor on call. Your next patient is a 26-year-old gentleman presenting with leg pain. Please take a history and perform an appropriate examination.
Patient History
Your name is Joe – a 26-year-old rugby player.
While playing rugby 1-2 hours ago, you tripped and fell over while running at high speed after being tackled. Afterwards, You noticed severe pain in your right lower leg following the accident – rating it 10/10. The pain also tends to radiate up and down the leg. It is worsened by any movement. Your coach thinks you fractured one of your bones in the leg and therefore called for an ambulance. Since then, you put a tight splint in place to help stabilise a potential fracture and stop it from getting any worse. You were given morphine in the ambulance which helped a bit.
Since the injury, you can feel numbness and tingling sensation over the lower right leg, it is also becoming increasingly pale and swollen. You are unsure if there's any weakness as it is too painful to move your leg. Your calf feels extremely tight.
No fever. No recent infection. No rigours. No involvement in joints.
Ideas, Concerns, Expectations:
You think you have a fracture for sure because of the pain you are having. You are concerned because it is getting worse, and you start to not be able to feel the leg, and it is getting more swollen. You hope to get this fixed as soon as possible in any way and want a stronger pain killer. You cannot bear this anymore!
Past Medical History:
Von Willebrand disease
Drug History:
Nil Adverse reaction to penicillin (sickness)
Family History:
Nil significant
Social History:
You work as a chef in a busy restaurant in town.
You do not smoke or drink.
You live with your partner in a flat currently.
Examination Findings:
Tenderness on palpation on the lower leg (right) with swelling and paleness. Pulses are present at the posterior tibialis + dorsalis pedis and popliteal/femoral region. Weakness and limited movement in active/passive movement below the right ankle due to pain and swelling. Increased capillary refill time at right lower leg. Reduced sensation below the right ankle.
Differentials:
Compartment Syndrome secondary to trauma + worsened by splint
Fracture
Other soft tissue injuries
Haematoma
Investigations:
Clinical diagnosis
Urine dip (urine dip/urine myoglobin if rhabdomyolysis/ tissue necrosis is suspected)
Bloods (routine bloods, blood culture if infection suspected, CK + U&Es)
Needle manometry/ slit catheter/infusion techniques (to measure compartment pressure)
XR (rule out fracture as a cause)
US with doppler (exclude thrombus/occlusion)
Consider MRI scan if unsure
Management:
Urgent orthopaedic referral for fasciotomy to relieve pressure within the compartment and restore blood flow + prevent tissue necrosis/permanent damage (to be done as soon as possible – within 6 hours) compartment is then explored to identify and debride necrotic tissues.
Analgesia i.e. morphine sulphate
Oral hydration +/- sodium bicarbonate (to achieve urine output of >0.5ml /kg + target urine pH 6.5)
Remove any external dressing/bandages
Elevate leg to heart level
Maintain good blood pressure (avoiding hypotension)
Continuous compartment pressure monitoring
All potentially constricting dressing, splints, cases…etc. must be removed
Amputation in delayed diagnosis / significant muscle necrosis
Consider haemodialysis if patients are anuria unresponsive to hydration
Viva Questions:
Explain the pathophysiology of compartment syndrome.
Compartment syndrome occurs when increased pressure within a muscle compartment restricts blood flow due to swelling from injury or exertion. This reduced blood flow leads to tissue damage and can become a medical emergency if not promptly treated.
What are the four compartments of the lower leg?
The lower leg subdivides into four compartments which are the anterior, lateral, superficial posterior and deep posterior compartments.
What is chronic compartment syndrome?
Chronic compartment syndrome involves increased pressure in a muscle compartment during exercise, leading to pain or cramping. Symptoms occur during activity and improve with rest. It often affects athletes and is managed with rest, activity modification, and sometimes surgery to release the pressure.
What are the causes of acute compartment syndrome?
Trauma or Injury: Fractures, crush injuries, severe bruising, or significant trauma that damages muscles, blood vessels, or nerves within a compartment can lead to swelling and increased pressure.
Prolonged Compression: Prolonged pressure on a limb due to tight bandages, splints, or immobilization can restrict blood flow and lead to compartment syndrome.
Reperfusion Injury: Restoration of blood flow following a period of reduced or absent circulation (as seen after a prolonged surgery or treatment for blocked arteries) can cause swelling and increased pressure in the compartment.
Bleeding Disorders: Bleeding within a compartment due to coagulation disorders or anticoagulant therapy can cause increased pressure, especially if not adequately managed.
Excessive Exercise: Rarely, extreme exertion or unaccustomed, vigorous exercise may lead to acute compartment syndrome, particularly in athletes.
What are the complications of compartment syndrome?
Tissue Damage: Insufficient blood flow due to increased pressure can cause tissue damage and cell death (necrosis) within the affected compartment.
Nerve Damage: Prolonged pressure on nerves can result in sensory and motor deficits or even permanent nerve damage.
Muscle Dysfunction: Severe cases can lead to impaired muscle function or muscle death, affecting strength and movement.
Ischemia-Reperfusion Injury: When pressure is suddenly released, the influx of blood to the compromised tissue can lead to further damage or inflammation.
Infection: In severe cases or if left untreated, tissue death can lead to an increased risk of infection or gangrene.
Complications from Treatment: Surgical procedures to relieve compartment syndrome can lead to potential risks, such as infection or nerve damage.
Long-Term Disability: Severe or untreated cases may result in long-term disability, affecting limb function and potentially requiring extensive rehabilitation.
What are the late signs of compartment syndrome?
Paresthesia: Numbness, tingling, or a "pins and needles" sensation in the affected area. This can indicate nerve damage due to compromised blood flow.
Weakness or Paralysis: In advanced cases, there may be weakness or inability to move the affected area due to muscle and nerve damage.
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Anterior Cruciate Ligament (ACL) Injury
Doctor Instruction:
You are an Emergency Department Doctor. Your next patient is a 28-year-old gentleman, Glen, presenting with knee pain. Please take a history and perform an appropriate examination.
Patient History:
Your name is Glen - a 28-year-old male- accountant.
You remember while playing football on a grass pitch about 2 hours ago when you were tackled by an aggressive player wearing cleats from your front. It was raining heavily, and you slipped following the tackle and heard a pop sound. Following this, you suddenly developed pain in your right knee, which is worsening. 9/10 pain score. No radiation. Pain is worsened by movement, and you try to take some simple pain killers i.e. paracetamol and ibuprofen, without much effects. Your knee has also been getting more swollen rapidly at the same time when the pain started, and you were unable to carry on with the match and therefore decided to go to the hospital.
You feel unsteady in the right knee. You do not have the confidence to walk without any support. You feel your right knee is weak and is giving way.
No locking. No fever. No weight loss. No previous night pains. No previous knee pain before the injury. No back pains. No other previous injuries. No neurological symptoms
Ideas, Concerns, Expectations:
You think you might have snapped a tendon or something, but you are not sure. You are concerned about how this will affect your future ability to play sports and walk. You hope to find out what is happening – maybe have a scan or something.
Past Medical History:
Nil significant
Drug History:
Nil NKDA
Family History:
Osteoarthritis
Social History:
You work as an accountant. You live by yourself. You smoke 5 cigarettes daily for 2 years but aim to stop smoking. You occasionally drink a few pints of beer over the weekend.
Examination Findings:
Right knee – swelling, tenderness on touch + worsened by movement.
Anterior drawer test (right) – positive (tibia moving excessively anterior with no clear endpoint while being pulled).
Lachman test (right)- positive (increased movement/laxity between tibia and femur).
Pivot shift test (right) – positive (internally rotate foot and tibia and apply abduction force at the knee + then flex the knee from 0° to 30° to detect any reduction between femur and tibia).
Antalgic Gait/ unsteady gait. Tenderness at lateral femoral condyle, lateral tibial plateau. (right)
McMurray Test negative (to check for a tear in the meniscus).
Differentials:
ACL Tear / Damage
Fracture
Patellar subluxation / dislocation
Meniscal Tear
Posterior capsular sprain
To rule out other ligament / articular chondral/ osteochondral injuries
Investigations:
MRI Scan (first-line imaging for evaluating internal derangement of the knee)
XR knee (can use Ottawa Knee Rules to decide if this is indicated: if patient unable to bear weight, flex knee to 90°, tenderness at the head of the fibula, isolated tenderness in patella, age 55 or over) – to look for impaction fracture of lateral femoral condyle + posterior aspect of lateral tibial plateau, anterior subluxation of tibia on femur, effusion, bony avulsion of ACL
Arthroscopy (to visualise ligaments – gold standard).
Consider knee joint aspiration for both diagnostic i.e. infection + therapeutic
Management:
Referral to orthopaedics
Conservative:
PRICER (Protect, Rest, Ice, Compression, Elevation, Rehabilitation)
Analgesia i.e. NSAID: diclofenac, ibuprofen, naproxenKnee braces/ Crutches (protect knee while mobilising + non-weight bearing restriction)
Physiotherapy
Surgical:
Ligament reconstruction (arthroscopic surgery) – In complete rupture where no local healing is detectable, a graft of tendon from another ligament is used to form a new ligament. The type and timing of surgery depend on patient activity levels + severity of ligament injury. Some patients can be managed conservatively alone.
Viva Questions:
Explain the pathophysiology of an ACL tear.
An ACL tear typically occurs due to sudden trauma, such as a forceful twist or direct impact to the knee during sports or activities. This stress leads to the ligament partially tearing or completely rupturing.
Describe the anatomy of the knee.
Bones: Femur (thigh bone), Tibia (shinbone), and Patella (kneecap).
Articular Cartilage: Provides a smooth surface for movement.
Menisci: Cartilage discs acting as shock absorbers.
Ligaments: ACL and PCL inside the joint, MCL and LCL on the sides, providing stability.
Muscles and Tendons: Quadriceps, hamstrings, and associated tendons for movement and support.
Name the ligaments of the knee and their roles.
ACL (Anterior Cruciate Ligament): Prevents excessive forward movement and rotational instability in the knee.
PCL (Posterior Cruciate Ligament): Limits excessive backward movement and stabilizes the knee against various forces.
MCL (Medial Collateral Ligament): Resists inward forces and stabilizes the inner part of the knee.
LCL (Lateral Collateral Ligament): Provides stability against outward forces and supports the outer part of the knee.
What are the complications of ACL Injury?
Knee instability, making movements challenging.
Increased risk of secondary knee injuries.
Potential early development of osteoarthritis.
Reduced knee mobility and function.
Muscle weakness and possible psychological impact.
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Fractured Neck of Femur
Doctor Instruction:
You are a Foundation Year Doctor working in the Emergency Department. Your next patient is a 65-year-old woman, Mary, presenting following a fall. Please take a history and perform an appropriate examination.
Patient History:
Your name is Mary. You are 65 years old woman – retired.
While walking down the stairs 2 hours ago, you slipped accidentally and fell down the stairs, and suddenly, you heard a crack at your left hip. Since then, you have had this sudden, ongoing severe pain and your husband called the ambulance. You can't remember how long you have been lying on the ground. You are not sure if you have hit your head during the fall. No dizziness/vertigo. No palpitation. No loss of consciousness. No chest pain/ palpitation. No shortness of breath. No neurological symptoms. No fits/ incontinence/ tongue biting. No weakness/ slurred speech/ vision change. No warning signs. Waterworks/bowel normal.
You note you have pain in the groin and hip, which radiates to the knee. The pain is excruciating 10/10 – worsening by any movement, especially rotation. You have been given some morphine in the ambulance which helped. You are unable to stand or bear weight on the left side. You have some swelling in your left hip.
Ideas, Concerns, Expectations:
You think you have cracked a bone or something as your GP previously said you have brittle bones! You are concerned that you may need an operation! You want to avoid surgery as much as possible and get your pain under control.
Past Medical History:
Osteoporosis, Parkinson's disease. Diabetes type 2, paroxysmal atrial fibrillation, heart failure
Drug History:
Levodopa, alendronic acid weekly, metformin, furosemide, apixaban, omeprazole, vitamin D supplement
Family History:
Atrial fibrillation
Social History:
Drink 2-3 glasses of wine every other night
Ex-smoker – used to smoke around 5-10cigarettes a day for 10 years
Examination Findings:
Left leg shortened, abducted, and externally rotated. Pain palpating the greater trochanter.
Differentials:
Neck of femur fracture
Acetabular fracture
Pubic rami fracture
Femoral shaft or subtrochanteric femur fracture
Femoral head fracture
To rule out causes for falls e.g. Parkinson's, anaemia, electrolyte imbalance, arrhythmias, heart failure, MI, stroke, UTI, chest infection, dehydration, incorrect eyewear, poor footwear, obstacles at home…etc.
Investigations:
Bedside:
Primary Survey (ABCDE)
Observation including lying and standing BP
ECG / 24-48h Holter monitor (arrhythmias e.g. AF)
Consider Echo (aortic stenosis? fall)
Assess fluid status
Urine dip (rule out infection, +++blood in rhabdomyolysis)
Dix-Hallpike test if suspecting BPPV for cause of fall
Bloods:
Bloods (FBC, CRP, anticoagulation screen, electrolytes, bone profile, LFTs – rule out potential causes for fall/ fracture e.g. anaemia, electrolyte imbalance, underlying infection, plan for surgery…etc.) + group and save/ cross-match for surgery + CK (potential long lie/rhabdomyolysis) + glucose (hypoglycaemia is a cause of falls)
Imaging:
XR hip (AP + Lateral) – look for fractures, disruption of Shenton's line/ trabeculae, inferior/superior cortices…etc
MRI/ CT may be indicated if XR is negative, but fracture is suspected
Consider CT head for head injuries if indicated e.g. on anticoagulants
Consider XR Chest if suspecting pneumonia contributing to fall
Management:
Conservative :
Appropriate analgesia e.g. opioids, nerve block
VTE risk assessment + prophylaxis e.g. LMWH / stocking
Prophylactic antibiotics (those at risk of MRSA/ open wound)
Nutrition support if appropriate
Review medications
Review functional status
Measure cognitive impairment/signs of delirium
Prevention of pressure ulcers
Patient/family education
Falls assessment
PT / OT input
Medical:
Treat any underlying infection if appropriate
Management of co-morbidities
Surgery:
Refer to orthopaedics / orthogeriatric
Pre-operative assessment for surgery
Aim surgery within 48hours of admission for hip fractures
Post-surgical care: analgesia, VTE prophylaxis, rehabilitation/ PT/ OT, fall risk assessment, treat the underlying cause for falls/fracture
Intracapsular Hip Fracture:
Undisplaced Intracapsular fracture – internal fixation with screws, otherwise arthroplasty in those who are less fit
Displaced intracapsular fracture – arthroplasty (total / partial)
Consider extramedullary implants such as sliding hip screw in preference to intramedullary nail in patients with trochanteric fractures above and including the lesser trochanter.
Extracapsular Hip Fracture:
Intramedullary nail used to treat subtrochanteric fracture
Extracapsular fractures by internal fixation using intramedullary nails but hip arthroplasty is used if internal fixation fails in unstable fractures.
Those not suitable for surgery but not receiving end-of-life care:
Bed rest/non-weight bearing + regularly reassess suitability for surgery
Not currently suitable for surgery + receiving end of life:
Palliative care / symptomatic relief, ensure bed rest and non-weight bearing.
Prevention of falls:
Eye test/suitable eyewear, ensure good fitting footwear, remove environmental hazards e.g. rugs/ turn on lights, ensure good hydration, review medication, hearing assessment and correction,
Viva Questions:
Explain the pathophysiology of a fracture.
A fracture occurs when a bone breaks due to trauma or excessive force. The body responds with an inflammatory phase, forming a blood clot (hematoma) at the site. A callus made of collagen and cartilage stabilizes the bone and eventually remodels into new bone tissue, healing the fracture.
Tell me the different types of fractures.
Fractures can manifest in various forms, each classified based on the pattern and characteristics of the break. The main types of fractures include:
Simple or Closed Fracture: The bone breaks without puncturing the skin.
Compound or Open Fracture: The broken bone protrudes through the skin, increasing the risk of infection.
Transverse Fracture: The break occurs horizontally across the bone.
Oblique Fracture: The break is at an angle across the bone.
Comminuted Fracture: The bone shatters into multiple pieces.
Greenstick Fracture: Common in children, where the bone bends and cracks but doesn't fully break.
Compression Fracture: Common in the spine, involving a loss of height in the vertebral body.
Stress Fracture: Tiny cracks in the bone due to repetitive stress or overuse, often seen in athletes.
Describe the anatomy of a hip joint.
Acetabulum: The socket-shaped cavity in the pelvis, formed by the fusion of three bones: ilium, ischium, and pubis. It accommodates the rounded head of the femur.
Femoral Head: The ball-shaped top of the femur that fits into the acetabulum, creating the ball-and-socket joint.
Articular Cartilage: Covers the surfaces of the acetabulum and the femoral head, providing a smooth, low-friction surface for movement.
Ligaments: Several strong ligaments provide stability and support to the hip joint, including the iliofemoral, pubofemoral, ischiofemoral, and ligamentum teres.
Labrum: A ring of cartilage that surrounds the acetabulum, deepening the socket and providing stability to the joint.
Synovial Membrane: The inner lining of the joint capsule that produces synovial fluid, reducing friction and providing nourishment to the joint.
What are the differences between an intracapsular and extra-capsular hip fracture? How does this affect management?
Intracapsular Fracture:
Location: Occurs at or within the hip joint capsule, specifically involving the femoral neck or the head of the femur.
Effect on Blood Supply: Intracapsular fractures may disrupt the blood supply to the femoral head, potentially leading to avascular necrosis (loss of blood flow and subsequent death of bone tissue).
Management Challenges: These fractures might necessitate surgical intervention, such as pinning, screw fixation, or replacement. However, the blood supply concerns can make healing more complex.
Extracapsular Fracture:
Location: Occurs outside the joint capsule, typically along the trochanteric or subtrochanteric region of the femur.
Effect on Blood Supply: As these fractures are outside the capsule, the blood supply to the femoral head remains unaffected.
Management: Extracapsular fractures are often more stable and tend to heal better than intracapsular fractures. Surgical treatment usually involves fixation using devices like screws, plates, or nails.
When are total hip replacements preferred more than partial hip replacements? Vice-versa.
Total Hip Replacement (THA):
Preferred when the entire hip joint is damaged due to conditions like severe osteoarthritis, rheumatoid arthritis, avascular necrosis, or fractures that involve both the femoral head and acetabulum.
Generally suitable for cases where both the femoral head and the acetabulum are significantly affected, requiring complete joint replacement.
THA replaces both the femoral head and the hip socket (acetabulum) with artificial components.
Partial Hip Replacement (Hemiarthroplasty):
Preferable when only the femoral head is damaged or fractured, such as femoral neck fractures, and the acetabulum or hip socket is healthy.
Appropriate for older, less active patients, especially with femoral neck fractures, where replacing only the femoral head may be sufficient.
Hemiarthroplasty involves replacing the femoral head with a prosthesis, leaving the natural socket intact.
How does a bone heal?
Bone healing involves stages:
Inflammation and blood clot formation.
Soft callus formation with collagen.
Hard callus formation with new bone.
Bone remodeling to restore original form.
What are the risk factors for fractures?
Osteoporosis: Weakening of bones, especially in older individuals, which makes them more susceptible to fractures.
Age: Advanced age increases the risk due to bone density reduction and the potential for reduced balance and coordination.
Gender: Women are at a higher risk, particularly after menopause due to decreased estrogen levels that can lead to bone loss.
Trauma or Falls: Accidents, falls, or high-impact injuries can lead to fractures, especially in vulnerable populations like the elderly.
Medical Conditions: Certain medical conditions, such as osteogenesis imperfecta, cancer, or conditions affecting bone strength, can increase fracture risk.
Medications: Prolonged use of certain medications like corticosteroids can weaken bones, elevating the risk of fractures.
Lifestyle Factors: Lack of physical activity, poor nutrition, smoking, excessive alcohol consumption, and inadequate calcium and vitamin D intake can also contribute to increased fracture risk.
What is the garden classification, e.g. for an intra-capsular neck of femur fracture?
Garden I: This stage represents an incomplete fracture with minimal displacement or an incomplete fracture without any displacement.
Garden II: It refers to a complete fracture with minimal displacement. The bone is completely fractured but remains relatively aligned.
Garden III: In this stage, a complete fracture shows moderate displacement. The bone alignment is partially shifted.
Garden IV: This stage indicates a complete fracture with severe displacement. The bone fragments are significantly displaced or completely separated.
What are the complications of hip fractures?
DVT (Deep Vein Thrombosis) and Pulmonary Embolism: Blood clots in the deep veins of the legs may form and travel to the lungs, causing a potentially life-threatening pulmonary embolism.
Infection: Surgery and hospitalization increase the risk of infections, such as urinary tract infections or surgical site infections.
Bedsores (Pressure Ulcers): Immobile patients are at risk of developing pressure ulcers due to prolonged bed rest.
Pneumonia: Reduced mobility, particularly in elderly patients, can lead to an increased risk of developing pneumonia.
Heterotopic Ossification: Abnormal bone formation in the soft tissues around the hip joint, leading to restricted movement.
Muscle Weakness and Atrophy: Lack of mobility after a hip fracture can cause muscle weakness and wasting in the affected limb.
Dislocation or Mal-union of Fracture: Improper healing or displacement of the fracture fragments can lead to mal-union or dislocation, affecting function.
Chronic Pain or Disability: Inadequate healing, complications, or delayed rehabilitation may lead to chronic pain or permanent disability.
What medications can increase the chances of falls/fractures?
Benzodiazepines and Sleep Medications: These drugs used for anxiety, insomnia, or sedation can cause drowsiness, impaired coordination, and balance issues.
Opioids: Medications like morphine, oxycodone, or hydrocodone used for pain relief can cause dizziness, sedation, and a higher risk of falls.
Antidepressants: Some antidepressants, especially tricyclic antidepressants, can cause dizziness and orthostatic hypotension, increasing the risk of falls.
Antipsychotics: Certain antipsychotic medications can affect balance and increase the risk of falls, particularly in the elderly.
Antihypertensive Medications: Blood pressure medications might lead to orthostatic hypotension, causing dizziness upon standing and increasing the risk of falls.
Antiepileptic Drugs: Medications used to manage seizures can cause dizziness or drowsiness, increasing the risk of falls.
Corticosteroids: Long-term use of corticosteroids may decrease bone density, leading to an increased risk of fractures.
What does fall assessment involve?
Medical History: Reviewing medical conditions, medications, previous falls, and any specific concerns related to balance or mobility.
Physical Examination: Assessing gait, balance, muscle strength, joint mobility, vision, and neurological functions.
Home Safety Evaluation: Examining the home environment for potential hazards that might contribute to falls, such as loose rugs, poor lighting, or slippery surfaces.
Medication Review: Evaluating the medications an individual is taking, as certain drugs can increase the risk of falls.
Cognitive Assessment: Checking cognitive functions, especially in older adults, to assess mental alertness and decision-making abilities that might impact fall risk.
Footwear Evaluation: Assessing the suitability of footwear, ensuring proper support and comfort.
Functional Assessment: Evaluating an individual's ability to perform activities of daily living, such as standing from a seated position or walking up and down stairs.
Balance and Mobility Testing: Conducting specific tests to evaluate balance, mobility, and risk of falls.
Nutritional Assessment: Assessing nutritional status, particularly deficiencies that might affect muscle strength and bone health.
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Carpal 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.
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Epicondylitis
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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Dupuytren'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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Adhesive 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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Cauda 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.