Musculoskeletal Cases for Finals

Dr Alastair Brown ST1 Neurosurgery CXH

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.

Case 1 A 74 year old female

presents having fallen in her bathroom at home.

She is complaining of pain in her hip.

Says slipped on the bathroom floor, no preceding symptoms.

PMH:HypertensionOsteoporosisGlaucoma

DH:Calcichew D3 ForteAmlodipine 10mgTimolol eye drop 1 drop twice

dailySH:Lives alone, children are

around the cornerTwo- storey houseNon-smoker no-alcohol

Examination

Looks in pain Alert and orientated Nothing abnormal to find on examination of

RS CVS and Abdomen.

Examination

Unable to straight leg raise on left side

Pain at the greater trochanter.

Shortened externally rotated left leg.

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

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.

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.

Management

Can you describe this injury? Fracture of the left neck

of femur Intracapsular Displaced

What is the management of this fracture? Hemiarthroplasty/THR

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

Management

Can you describe this injury? Fracture of left femur Sub-trochanteric Angulated Displaced

What is the management of this fracture? IM Nail

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

Fall on an outstretched hand…

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

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.

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

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

Twisted ankles

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

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.

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

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

Sore knees

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

Inspection

Heberden’s nodes

Inspection

Old Right TKR scar

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

Investigation

Investigation

Can you describe the previous radiograph? AP radiograph of both knees Joint space narrowing of medial compartment of

left knee.

What are the radiographic features of osteoarthritis? Osteophytes Joint space narrowing Subchondral cysts

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.

Painful shoulder

Case 11

68 year old man Complaining of pain in

the shoulder. Came on while lifting a

box down from a shelf. Now finding it difficult to

lift his arm above his head.

PMH:AsthmaDH:NKDASalbutamolBeclomethasoneSHKeen sportsmanRetired accountantNon-smoker

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.

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

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)

Management

Imaging US MRI

Non-operative Analgesia and physiotherapy

Operative Arthroscopic/open repair

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.

Any questions?