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Transcript of Www.cambridgefractureclinic.co.uk Mr Lee Van Rensburg Mr Alan Norrish Mr Peter Hull Mr Andrew...
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Mr Lee Van Rensburg
Mr Alan Norrish
Mr Peter Hull
Mr Andrew Carrothers
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Mr Lee Van Rensburg Mr Alan Norrish Mr Peter Hull Mr Andrew Carrothers
Based at Spire Next day Not just fractures
01223 400150
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Mr Lee Van Rensburg Upper limb
Mr Andrew Carrothers Lower limb
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Hand and wrist Elbow Shoulder Hip Knee Ankle Foot
Soft tissues Ligaments Tendons Cartilage Muscles Nerves Vessels
Bones Joints
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Australian Family Physician Vol. 41, No. 4, april 2012
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Australian Family Physician Vol. 41, No. 4, april 2012
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History Examination
Look Feel Move
Active Passive
ACTIVEACTIVEKnee – SLRKnee – SLRElbow - tricepsElbow - triceps
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Tricky, basic knowledge anatomy
Australian Family Physician Vol. 41, No. 4, april 2012
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History Examination
Look Feel Move
Active Passive
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Bruising Swelling Deformity Bony tenderness
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56 YO injured finger tip tucking in bed, unable to extend DIPJPathology?
Soft tissue injury - X ray?
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Avulsion fracture Base of proximal phalanx Avulsion FDP, rugger jersey finger
No Fracture, small flake of bone overlying PIPJ BEWARE SMALL FLAKE
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Tender Laxity valgus stress
Gamekeepers ThumbOr
Skiers thumb
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Distal radius Scaphoid Radiocarpal joint Carpal joints Carpo Metacarpal joint
CMC base of thumb Tendons
Dequervains Ligaments
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Falls off bicycle Pain in wrist
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Initial D 13
Re attends 13 days later Persistent pain Tender in anatomical snuff box Repeat radiographs
Including scaphoid views
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Current NHS policy Splint Repeat radiographs at 10 - 14 days Bone scan
MRI/CT Not perfect Good at excluding a fracture
JBJS - Am. 2011;93:20-8
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COME BACK
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Non operative 70% - 90% Flexion strength 60% Supination strength
Operative
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Chronic/ DelayedAcutely < 3 weeks
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Small flake of bone of tip of olecranon BEWARE SMALL FLAKE
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1 week later Still in pain Feels popping in shoulder
2 weeks later Pain worse Still popping
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2 weeks
Initial
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Popeye sign Well tolerated Some cramping/ ache
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Farmer Falls from tractor
Pain and weakness in shoulder
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Jobe’s
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- 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
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Unable to elevate arm
Full thickness tear Supraspinatus Infraspinatus
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60-69 =30% FTRCT
70-79 = 50% FTRCT
80-89 = 80% FTRCT
1961 - 51
1930 - 82
Age-related prevalence of rotator cuff tears in asymptomatic shoulders; Tempelhof et al; JSES July 1999 (Vol. 8, Issue 4, Pg 296-299
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Non operative Relative rest NSAID Physio Steroid injection (controversial)
Operative
JSES - 2008;17:863-870
3 months
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Mr Andrew D Carrothers
Consultant Orthopaedic Surgeon Addenbrookes
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Adhere to basic principles Order relevant investigations If normal/fails to resolve, then think laterally If unsure then please don’t hesitate to refer
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Jordan et al. BMC Musculoskeletal Disorders 2010, 11:144.
Extensive and varied musculoskeletal workload in primary care
1:7 consultations Back Knee Hip Foot
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Problems Atypical or uncommon presentations Recent injury but Xray ‘No fracture’ Failed analgesics Failed mother nature (ie time) Failed physio
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History Examination Special Tests DDx Investigations Treatment +/- Referral
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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
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ED Xray - #NOF
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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
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Overweight Limp Knee Generally painful to movement
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Investigations
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• Review 2 weeks later as not settling
• Limp
• Knee movement remains painful
• Hip – loss internal rotation and flexion
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Immediate referral to Orthopaedic on call registrar
Think of siblings
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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
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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
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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
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Meniscal? MCL? ACL? #?
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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)
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Knee less swollen/painful Giving way on occasion Tends to hold in flexion Ex
Springy block to full extension
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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
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Topics Ankle sprains and fractures
Achilles tendon injuries
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ATFL
CFL
PTFL
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Very common injury
Majority are inversion injuries Fall down step / off curb
Diagnosis History Examination ? XRs
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History Examination
Look Feel Move
Radiographs
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History Examination
Look Feel Move
Radiographs
Medial
Lateral
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?
•Tenderness Posterior border lower 6 cm of malleoli•Tenderness Base 5th Metatarsal•Tenderness Navicular•Unable to fully weight bear
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Functional RICE CAM walker / Beckham boot Weight bearing as tolerated
Cast Prolonged casting inferior to functional, but may be
indicated for 1st 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)
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History Pop or snapping feeling Sudden onset Difficulty walking
Examination Reduced calf squeeze test Pain or gap Weakness of ankle plantar flexion
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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
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History Examination Special Tests DDx Investigations Treatment +/- Referral
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Adhere to basic principles Order relevant investigations If normal/fails to resolve, then think laterally If unsure there please don’t hesitate to refer
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