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Www.cambridgefractureclinic.co.uk Mr Lee Van Rensburg Mr Alan Norrish Mr Peter Hull Mr Andrew Carrothers.

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Presentation on theme: "Www.cambridgefractureclinic.co.uk Mr Lee Van Rensburg Mr Alan Norrish Mr Peter Hull Mr Andrew Carrothers."— Presentation transcript:

1 Mr Lee Van Rensburg Mr Alan Norrish Mr Peter Hull Mr Andrew Carrothers

2 Mr Lee Van Rensburg Mr Alan Norrish Mr Peter Hull Mr Andrew Carrothers Based at Spire Next day Not just fractures

3 Mr Lee Van Rensburg Upper limb Mr Andrew Carrothers Lower limb

4 Hand and wrist Elbow Shoulder Hip Knee Ankle Foot Soft tissues Ligaments Tendons Cartilage Muscles Nerves Vessels Bones Joints

5 Australian Family Physician Vol. 41, No. 4, april 2012

6 Australian Family Physician Vol. 41, No. 4, april 2012

7 History Examination Look Feel Move Active Passive ACTIVE Knee – SLR Elbow - triceps

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9 Tricky, basic knowledge anatomy Australian Family Physician Vol. 41, No. 4, april 2012

10 History Examination Look Feel Move Active Passive

11 Bruising Swelling Deformity Bony tenderness

12 56 YO injured finger tip tucking in bed, unable to extend DIPJ Pathology? Soft tissue injury - X ray?

13 Avulsion fracture Base of proximal phalanx Avulsion FDP, rugger jersey finger No Fracture, small flake of bone overlying PIPJ BEWARE SMALL FLAKE

14 Tender Laxity valgus stress Gamekeepers Thumb Or Skiers thumb

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16 Distal radius Scaphoid Radiocarpal joint Carpal joints Carpo Metacarpal joint CMC base of thumb Tendons Dequervains Ligaments

17 Falls off bicycle Pain in wrist

18 Initial D 13 Re attends 13 days later Persistent pain Tender in anatomical snuff box Repeat radiographs Including scaphoid views

19 Current NHS policy Splint Repeat radiographs at days Bone scan MRI/CT Not perfect Good at excluding a fracture JBJS - Am. 2011;93:20-8

20 COME BACK

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23 Non operative 70% - 90% Flexion strength 60% Supination strength Operative

24 Chronic/ DelayedAcutely < 3 weeks

25 3 months Small flake of bone of tip of olecranon BEWARE SMALL FLAKE

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28 1 week later Still in pain Feels popping in shoulder 2 weeks later Pain worse Still popping

29 2 weeks Initial

30 Popeye sign Well tolerated Some cramping/ ache

31 Farmer Falls from tractor Pain and weakness in shoulder

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33 Jobes

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35 - Apley's Scratch Test - Jobes Supraspinatus test - Dawburn's sign - Sherry Party sign - Codman's Sign (Drop Arm Sign) - Rent Test - Zero Degree Abduction Test - Burkhead's Thumbs down & Burkhead's Thumbs up

36 Unable to elevate arm Full thickness tear Supraspinatus Infraspinatus

37 =30% FTRCT = 50% FTRCT = 80% FTRCT Age-related prevalence of rotator cuff tears in asymptomatic shoulders; Tempelhof et al; JSES July 1999 (Vol. 8, Issue 4, Pg

38 Non operative Relative rest NSAID Physio Steroid injection (controversial) Operative JSES ;17: months

39 Mr Andrew D Carrothers Consultant Orthopaedic Surgeon Addenbrookes

40 Summary Adhere to basic principles Order relevant investigations If normal/fails to resolve, then think laterally If unsure then please dont hesitate to refer

41 General Practice Jordan et al. BMC Musculoskeletal Disorders 2010, 11:144. Extensive and varied musculoskeletal workload in primary care 1:7 consultations Back Knee Hip Foot

42 Trauma in General Practice Problems Atypical or uncommon presentations Recent injury but Xray No fracture Failed analgesics Failed mother nature (ie time) Failed physio

43 History Examination Special Tests DDx Investigations Treatment +/- Referral

44 Hip Trauma

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46 Hip – Case 1 76 yr old lady Fall in garden, manages to walk to kitchen with hip pain Not resolving 2 days later so ED with son SHO Hip Xray No fracture and DC with analgesics/crutches Struggles to walk and 2 weeks later stumbles Severe Hip pain and unable WB

47 Differential diagnosis?

48 ED Xray - #NOF

49 Xray Review

50 Hip – Case 2 12 yr old boy Overweight but enjoys football Fell 2 months ago and has mild left knee pain since Mum thinks malingering to get off school

51 Differential diagnosis?

52 Examination Overweight Limp Knee Generally painful to movement

53 Investigations

54 GP Review 2 weeks later as not settling Limp Knee movement remains painful Hip – loss internal rotation and flexion

55 Investigations

56 Immediate referral to Orthopaedic on call registrar Think of siblings

57 Fast Facts SUFE 1 most common disorder adolescent hips (1:10,000) more common males (3:2) African Americans obese children (single greatest risk factor) during period of rapid growth bilateral up to 50% average age is 13 yrs boys 12 yrs girls associated with puberty

58 Fast Facts SUFE 2 Symptoms usually present for weeks - months Groin/thigh pain most common can present as knee pain (15-23%) patients prefer to sit in a chair with affected leg crossed over the other Physical exam externally rotated gait or Trendelenburg gait obligatory external rotation during passive flexion of hip loss of hip internal rotation, abduction, and flexion externally rotated foot progression angle

59 Knee Trauma

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61 Knee – Case 1 30 yr old footballer tackled awkwardly Sunday league game. Painful right knee. GP Mon am Able WB but limping Knee - Difficult Ex Mild effusion Tender generally medially Flexion to 70 degrees

62 Differential Diagnosis? Meniscal? MCL? ACL? #?

63 Trauma - Ottawa knee rules X-ray is only required for knee injury patients with any of these findings: age 55 or over isolated tenderness of the patella tenderness at the head of the fibula inability to flex to 90 degrees inability to weight bear both immediately and in your surgery (4 steps - unable to transfer weight twice onto each lower limb regardless of limping)

64 Xray

65 GP Review Knee less swollen/painful Giving way on occasion Tends to hold in flexion Ex Springy block to full extension

66 MRI

67 Torn meniscus

68 Knee - Case 2 50 year old man Jumped off chair and felt immediate knee pain Fail settle over next 3 days Otherwise fit and well Walks in with strange gait Ex Able Full extension but internally rotates leg

69 Diagnosis?

70 Topics Ankle sprains and fractures Achilles tendon injuries

71 ATFL CFL PTFL

72 Very common injury Majority are inversion injuries Fall down step / off curb Diagnosis History Examination ? XRs

73 History Examination Look Feel Move Radiographs

74 History Examination Look Feel Move Radiographs Medial Lateral

75 ? Tenderness Posterior border lower 6 cm of malleoli Tenderness Base 5 th Metatarsal Tenderness Navicular Unable to fully weight bear

76 Functional RICE CAM walker / Beckham boot Weight bearing as tolerated Cast Prolonged casting inferior to functional, but may be indicated for 1 st few weeks Acute surgical repair Most studies show no better, and functional treatment has faster recovery, less morbidity and more cost effective (Kannus 1992) No difference in outcome between delayed and acute repairs (Cass 1985)

77 History Pop or snapping feeling Sudden onset Difficulty walking Examination Reduced calf squeeze test Pain or gap Weakness of ankle plantar flexion

78 Same day referral 1/5 of cases are missed. More common in elderly Delay in diagnosis of more than 4 weeks deemed chronic requiring operative intervention If early diagnosis then most can be treated non-operatively with good outcome

79 Back to Orthopaedic Basic Principles History Examination Special Tests DDx Investigations Treatment +/- Referral

80 Summary Adhere to basic principles Order relevant investigations If normal/fails to resolve, then think laterally If unsure there please dont hesitate to refer

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