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

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www.cambridgefractureclinic.co.ukwww.cambridgefractureclinic.co.uk

Mr Lee Van Rensburg

Mr Alan Norrish

Mr Peter Hull

Mr Andrew Carrothers


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

Based at Spire Next day Not just fractures

01223 400150


Mr Lee Van Rensburg Upper limb

Mr Andrew Carrothers Lower limb


Hand and wrist Elbow Shoulder Hip Knee Ankle Foot

Soft tissues Ligaments Tendons Cartilage Muscles Nerves Vessels

Bones Joints


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


[email protected]



History Examination

Look Feel Move

Active Passive

ACTIVEACTIVEKnee – SLRKnee – SLRElbow - tricepsElbow - triceps


Tricky, basic knowledge anatomy



History Examination

Look Feel Move

Active Passive


Bruising Swelling Deformity Bony tenderness


56 YO injured finger tip tucking in bed, unable to extend DIPJPathology?

Soft tissue injury - X ray?


Avulsion fracture Base of proximal phalanx Avulsion FDP, rugger jersey finger

No Fracture, small flake of bone overlying PIPJ BEWARE SMALL FLAKE


Tender Laxity valgus stress

Gamekeepers ThumbOr

Skiers thumb


Distal radius Scaphoid Radiocarpal joint Carpal joints Carpo Metacarpal joint

CMC base of thumb Tendons

Dequervains Ligaments


Falls off bicycle Pain in wrist


Initial D 13

Re attends 13 days later Persistent pain Tender in anatomical snuff box Repeat radiographs

Including scaphoid views


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


COME BACK


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

Operative


Chronic/ DelayedAcutely < 3 weeks

www.cambridgefractureclinic.co.ukwww.cambridgefractureclinic.co.uk3 months

Small flake of bone of tip of olecranon BEWARE SMALL FLAKE


1 week later Still in pain Feels popping in shoulder

2 weeks later Pain worse Still popping


2 weeks

Initial


Popeye sign Well tolerated Some cramping/ ache


Farmer Falls from tractor

Pain and weakness in shoulder


Jobe’s


- 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


Unable to elevate arm

Full thickness tear Supraspinatus Infraspinatus


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


Non operative Relative rest NSAID Physio Steroid injection (controversial)

Operative

JSES - 2008;17:863-870

3 months


Mr Andrew D Carrothers

Consultant Orthopaedic Surgeon Addenbrookes


Adhere to basic principles Order relevant investigations If normal/fails to resolve, then think laterally If unsure then please don’t hesitate to refer


Jordan et al. BMC Musculoskeletal Disorders 2010, 11:144.

Extensive and varied musculoskeletal workload in primary care

1:7 consultations Back Knee Hip Foot


Problems Atypical or uncommon presentations Recent injury but Xray ‘No fracture’ Failed analgesics Failed mother nature (ie time) Failed physio


History Examination Special Tests DDx Investigations Treatment +/- Referral


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


ED Xray - #NOF


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


Overweight Limp Knee Generally painful to movement


Investigations


• Review 2 weeks later as not settling

• Limp

• Knee movement remains painful

• Hip – loss internal rotation and flexion


Immediate referral to Orthopaedic on call registrar

Think of siblings


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


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


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


Meniscal? MCL? ACL? #?


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)


Knee less swollen/painful Giving way on occasion Tends to hold in flexion Ex

Springy block to full extension


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


Topics Ankle sprains and fractures

Achilles tendon injuries

www.CambridgeFractureClinic.co.uk


ATFL

CFL

PTFL


Very common injury

Majority are inversion injuries Fall down step / off curb

Diagnosis History Examination ? XRs


History Examination

Look Feel Move

Radiographs


History Examination

Look Feel Move

Radiographs

Medial

Lateral


?

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


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)

www.CambridgeFractureClinic.co.uk


History Pop or snapping feeling Sudden onset Difficulty walking

Examination Reduced calf squeeze test Pain or gap Weakness of ankle plantar flexion


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


History Examination Special Tests DDx Investigations Treatment +/- Referral


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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