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:
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
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




Mechanism


Traumatic or Pathological
Displacement


Left or Right
Intra/extracapsular
Sub-capital, base cervical,
intertrochanteric,
subtrochanteric.
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




What is the name of this
injury?


Smith’s
What is the mechanism?


Fracture of the distal radium
and ulna
Volar angulation
Volar displacement
Fall on flexed wrist
What is the treatment?

ORIF
Case 3

Describe this injury?





What is the name of this fracture?


Colle’s
What is the mechanism of injury?


Fracture of the distal radius
Minimally displaced
Shortened
Dorsal angulation
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



What is the name of this
fracture?


Monteggia fracture dislocation
What is the mechanism of
injury?


Displaced fracture of the ulna
proximal 1/3
Subluxation of the radial head.
Fall on hyperpronated arm
What is the management of
the injury?

ORIF
Case 5

Can you describe this
injury?




What is the name of this
injury?


Galeazzi fracture dislocation.
What is the mechanism of
injury?


Displaced fracture of the distal
radius
Angulation
Disruption of the radio-ulnar
joint.
Fall on hyperpronated arm.
What is the management?

ORIF
Twisted ankles
Case 6

Can you describe this
injury?



What is the Weber
classification of this injury?


Fracture of distal fibula
Below level of joint line
Weber A
What is the management of
this injury?

Closed reduction and POP
Case 7

Can you describe this fracture?




What is the Weber
classification?


Fracture of distal fibula
Comminution
At the level of the joint
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?



What is the name of this
injury?


Fracture of distal tibia and
fibula?
Intra-articular component
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




Feel







Active and passive
Flexion and extension
Special Tests





Temperature
Popliteal fossa- aneurysms/cysts
Joint line – tenderness
Patella tap and bulge sign
Crepitus
Move


Scars
Muscle wasting
Deformity – valgus, varus and flexion
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:
Asthma
DH:
NKDA
Salbutamol
Beclomethasone
SH
Keen sportsman
Retired accountant
Non-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


Inability to intiate arm abduction


Impingement due to supraspinatus tendinitis
Supraspinatus tendon rupture
Reduced active and passive movment


OA if crepitus present
Adhesive capsulitis (frozen shoulder)
Management

Imaging



Non-operative


US
MRI
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?