1. Musculoskeletal Cases for Finals Dr Alastair Brown ST1 Neurosurgery CXH

2. Objectives Be able to describe common fractures Understand the management of common fractures Understand the principles of major joint examinations Understand the clinical features and management of osteoarthritis of the hip and knee.

3. Case 1 A 74 year old female presents having fallen in her bathroom at home. She is complaining of pain in her hip. Says slipped on the bathroom floor, no preceding symptoms. PMH: Hypertension Osteoporosis Glaucoma DH: Calcichew D3 Forte Amlodipine 10mg Timolol eye drop 1 drop twice daily SH: Lives alone, children are around the corner Two- storey house Non-smoker no-alcohol

4. Examination Looks in pain Alert and orientated Nothing abnormal to find on examination of RS CVS and Abdomen.

5. Examination Unable to straight leg raise on left side Pain at the greater trochanter. Shortened externally rotated left leg.

6. Examination of the hip Look – muscle wasting leg length discrepancy scars Feel – Palpate greater trochanter Move – Flexion and extension Internal and external rotation Special Tests – Thomas’ test – fixed flexion deformity Trendelenburg test – testing gluteus minimus and medius Gait

7. Management What is your provisional diagnosis? Fracture left neck of femur How will you manage this patient Analgesia Investigations Blood tests – FBC, UE, LFTs, Clotting, G+S Radiology – Chest X-ray, AP pelvis and Lateral L Hip.

8. Management How can you classify hip fractures? Location Left or Right Intra/extracapsular Sub-capital, base cervical, intertrochanteric, subtrochanteric. Mechanism Traumatic or Pathological Displacement Undisplaced, impacted, displaced. Open or closed.

9. Management Can you describe this injury? Fracture of the left neck of femur Intracapsular Displaced What is the management of this fracture? Hemiarthroplasty/THR

10. Management Can you describe this injury? Fracture of left neck of femur Extracapsular Minimally displaced What is the management of this injury? Dynamic hip screw

11. Management Can you describe this injury? Fracture of left femur Sub-trochanteric Angulated Displaced What is the management of this fracture? IM Nail

12. Management What are the factors affecting the management of intracpasular fractures? Displacement – Garden 1 and 2 can be managed with cannulated screws Age – ORIF may be attempted in patient aged under 60 Mobility and cognitive impairment – Those who were walking unaided and have no cognitive impairment should be offered THR If x-rays showed no fracture but you still suspected one how would you manage the patient? Analgesia Attempt to mobilise CT/MRI

13. Fall on an outstretched hand…

14. Case 2 Describe this injury Fracture of the distal radium and ulna Volar angulation Volar displacement What is the name of this injury? Smith’s What is the mechanism? Fall on flexed wrist What is the treatment? ORIF

15. Case 3 Describe this injury? Fracture of the distal radius Minimally displaced Shortened Dorsal angulation What is the name of this fracture? Colle’s What is the mechanism of injury? Fall on outstretched hand with extended wrist What is the management of this fracture? Closed reduction and POP ORIF/ K wire in certain circumstances.

16. Case 4 Describe this injury Displaced fracture of the ulna proximal 1/3 Subluxation of the radial head. What is the name of this fracture? Monteggia fracture dislocation What is the mechanism of injury? Fall on hyperpronated arm What is the management of the injury? ORIF

17. Case 5 Can you describe this injury? Displaced fracture of the distal radius Angulation Disruption of the radio-ulnar joint. What is the name of this injury? Galeazzi fracture dislocation. What is the mechanism of injury? Fall on hyperpronated arm. What is the management? ORIF

18. Twisted ankles

19. Case 6 Can you describe this injury? Fracture of distal fibula Below level of joint line What is the Weber classification of this injury? Weber A What is the management of this injury? Closed reduction and POP

20. Case 7 Can you describe this fracture? Fracture of distal fibula Comminution At the level of the joint What is the Weber classification? Weber B What is the management? Closed reduction if stable ORIF if unstable Stability depends on whether there is a injury to medial malleolus or deltoid ligament.

21. Case 8 Can you descirbe this injury? Fracture of fibula and medial malleolus Minimally displaced on AP film Fracture above syndesomosis. What is the Weber classification? Weber C What is the management? ORIF

22. Case 9 Can you describe this injury? Fracture of distal tibia and fibula? Intra-articular component What is the name of this injury? Trimalleolar fracture What is the management of this fracture? ORIF

23. Sore knees

24. Case 10 74 year old man C/O pain in his left knee Pain and stiffness worst in the evening Gradually less mobile and now walking with a stick. PMH HTN IHD BPH DH – NKDA Asprin, Clopidogrel, Tamsulosin, Bisoprolol, Simvastatin, Ramipril SH Lives with wife Bungalow Ex-smoker

25. Inspection Heberden’s nodes

26. Inspection Old Right TKR scar

27. Examination of the knee Look Scars Muscle wasting Deformity – valgus, varus and flexion Feel Temperature Popliteal fossa- aneurysms/cysts Joint line – tenderness Patella tap and bulge sign Crepitus Move Active and passive Flexion and extension Special Tests Anterior drawer – test ACL Posterior drawer test PCL Varus and valgus stress McMurray’s test Gait

28. Investigation

29. Can you describe the previous radiograph? AP radiograph of both knees Joint space narrowing of medial compartment of left knee. What are the radiographic features of osteoarthritis? Osteophytes Joint space narrowing Subchondral cysts

30. Management Non-operative Address risk factors – weight loss, smoking cessation, Vitamin D replacement. Analgesia – injections no longer recommended. Walking aids Operative Arthroplasty reserved for those with moderate to severe pain and disability.

31. Painful shoulder

32. Case 11 68 year old man Complaining of pain in the shoulder. Came on while lifting a box down from a shelf. Now finding it difficult to lift his arm above his head. PMH: Asthma DH: NKDA Salbutamol Beclomethasone SH Keen sportsman Retired accountant Non-smoker

33. Examination No deformity of shoulder Some tenderness along the top of the humeral head. Pain on abduction of the arm between 45 and 100%. Normal power in shoulder muscles.

34. Examination of the shoulder Look Deformity Position of neck and clavicles Muscle wasting Winging of the scapula Feel Scapula Clavicles Acromio - and sternoclavicular joint Move Flexion and extension Internal and external rotation of shoulder with elbow flexed. Special tests Neers signs – internally rotated arm and then elevating arm Hawkins test – abdocut shoulder to 90 degrees and internally rotate Scarf test draw arm across body at 90 degrees to torso to see if exacerbates AC joint pain

35. Findings Painful arc Impingement due to supraspinatus tendinitis Inability to intiate arm abduction Supraspinatus tendon rupture Reduced active and passive movment OA if crepitus present Adhesive capsulitis (frozen shoulder)

36. Management Imaging US MRI Non-operative Analgesia and physiotherapy Operative Arthroscopic/open repair

37. Objectives Be able to describe common fractures Understand the management of common fractures Understand the principles of major joint examinations Understand the clinical features and management of osteoarthritis of the hip and knee.

38. Any questions?