11 MUSCULOSKELETAL & 12 RHEUMATOLOGY 12.03 With skin problems 15 CHILD HEALTH / PAEDIATRICS 15.12-13 Neurological disorders
ORTHOPAEDIC CONDITIONS • Systemic lupus erythematosus • Epilepsy • Status epilepticus
12.01 • Rheumatoid arthritis • Systemic sclerosis (scleroderma) 15.01 • Paediatric life support • Brain tumours
11.01 Orthopaedic emergencies • Osteoarthritis • Dermatomyositis • Polymyositis • Newborn life support [15.13] • Neural tube defects
• Septic arthritis • Psoriatic arthritis • Sjogren syndrome • Intraosseous infusion • Anaphylaxis • Autism spectrum disorder
• Compartment syndrome
• Spinal cord compression 12.02 With muscular problems 12.04 Vasculitis 15.02-03 Infections 15.14-15 Haemonc disorders
- Cauda equina syndrome • Ankylosing spondylitis • Wegener's • Churg-Strauss • Traffic light assessment of kids • Anaemia • Iron deficiency
• Open fractures • Gout • Pseudogout • Giant cell arteritis • Takayasu arteritis • Meningitis • Encephalitis • Sickle cell disease
• Tendon sheath infection (hand) • Reactive arthritis • Fibromyalgia • Microscopic polyangitis • Hereditary spherocytosis
• Polymyalgia rheumatica • Polyarteritis nodosa [15.03] • Measles • Mumps • Rubella • Henoch-Schonlein purpura
11.02 Upper limb orthopaedic issues • Chronic fatigue syndrome • Henoch-Scholein • Behcet's • Erythema infectiosum • HFMD [15.15] • Immune thrombocytopaenia
• Shoulder • Elbow • Roseola infantum • Chickenpox • Acute lymphoblastic leukaemia
• Fractures: Colles', Smith's, Barton's, • HIV in children • Primary immunodeficiencies
13 EAR NOSE THROAT 14 PSYCHIATRY
Monteggia's, Galeazzi • Severe combined immunodeficiency
15.04 Respiratory disorders
11.03 Hand & foot 13.01 Ear 14a Substance abuse / overdose
• Upper respiratory tract infections 15.16-18 Endocrine disorders
• Otalgia • Discharging ear • Cannabis • MDMA/Ecstasy
• Hand • Ganglions - Croup - Epiglottitis • Diabetes mellitus + MODY • DKA
© quackquackmed.com
• Otitis externa • Otitis media • Cocaine • Nitrous oxide
• Foot, incl club foot - Bacterial tracheitis - Diphtheria • Hypothyroidism
• Glue ear • LSD / acid • Opioid misuse
• Lower respiratory tract infections [15.17] • Hyperthyroidism
11.04 Hip, including neck of femur • Overdose / poisoning
- Bronchiolitis - Viral-induced wheeze • Inherited metabolic diseases
13.02 Ear • Hearing loss
fractures - Pneumonia - Whooping cough • Glycogen storage disorders
• Tinnitus • Vertigo 14.01 Mood disorders
• Asthma • Cystic fibrosis [02.04] • Phenylalanine ketonuria
11.05 Knee & ankle issues • Depression • Suicide
• Lysosomal storage diseases
13.03 Ear • Childhood deafness • Bipolar disorder 15.05-06 Cardiovascular disorders [15.18] • Precocious puberty
• Deafness in adults • Otosclerosis
09.06 Spinal orthopaedics • Ventricular septal defect (VSD) • Congenital adrenal hyperplasia
• Vestibular schwannoma 14.02 Anxiety & related disorders
Including rib fractures, autonomic • Atrial septal defect (ASD) • Genetic disorders summary
dysreflexia • Benign paroxysmal positional vertigo • Generalised anxiety disorder
• Patent ductus arteriosus
• Meniere's disease • Panic disorders • OCD • PTSD • Coarctation of the aorta 15.19 Developmental disorders
• Vestibular neuronitis • Labyrinthitis • Acute stress disorder • (Others)
09.07 Miscellaneous • Congenital aortic valve stenosis • Developmental milestones
• Dermatomes • Fat embolism • Eisenmenger's syndrome • Speech delay • Cerebral palsy
• Osteomalacia • Osteomyelitis 13.04 Nose 14.03 Psychotic disorders [15.06] • Tetralogy of Fallot (ToF) • Muscular dystrophies (incl Duchenne)
• Rhinosinusitis (acute & chronic) • Features that define psychotic
• Osteochondritis dissecans • Transposition of great arteries (TGA) • Global developmental delay
• Nasal fractures • CSF rhinorrhoea disorders
• Charcot joint • Ebstein's anomaly • Kawasaki disease
• Epistaxis • Nasal cancers • Schizophrenia • Psychosis
• Murmurs and heart sounds in children 15.20-21 Genetic disorders
09.08 Miscellaneous • Antipsychotics
• Down + other trisomies
13.05 Throat
• Joint replacements 15.07-09 GI disorders • Klinefelter • Triple X • Turner
• Sore throat (includes tonsilitis) 14.04 Personality disorders
• Paget's disease of the bone • Abdominal pain • Neuroblastoma [15.21] • Cri du chat • DiGeorge
• Osteoporosis • Obstructive sleep apnoea • A: Paranoid, schizoid, schizotypal
• Coeliac disease • Malnutrition • Williams • Achondroplasia
• Pathological fractures • Stridor – causes • Croup • B: Antisocial, borderline, histrionic, • Diarrhoea & vomiting • Marfan • Noonan • Fragile X
• Acute epiglottitis • Laryngomalacia narcissistic
• Fracture types [15.08] • Appendicitis • Intussusception
• C: Avoidant, dependent, obsessive-
• Pyloric stenosis • Hirschsprung 15.22-23 Neonates
09.09 Malignancies & trauma 13.06 Throat convulsive
• Oesophageal atresia • Neonatal sepsis • Seizures
• Dysphonia • Dysphagia
• Osteosarcoma • Chondrosarcoma [15.09] • Congenital diaphragmatic hernia • Respiratory distress • Jaundice
• Head and neck squamous cell 14.05 Eating disorders & miscellaneous
• Ewing's sarcoma • Giant cell tumour • Inguinal hernia • Imperforate anus [15.23] • Necrotising entercolitis
carcinoma (HNSCC) • Bell's palsy psychiatric disorders
• Bone metastases • Trauma surgery • Mid-gut malrotation • Hypoglycaemia • Hypotonia
• Anorexia nervosa • Bulimia nervosa
• Gastroschisis & omphalocele • Minor problems, including skin issues
13.07 Throat • Insomnia • Unexplained symptoms
09.10 Paediatric orthopaedics • Meckel's diverticulum
• Neck lumps • Xerostomia • Electroconvulsive therapy
• Juvenile idiopathic arthritis • Infant feeding problems 15.24 Miscellaneous
• Transient synovitis of the hip • Salivary gland problems
• Non-accidental injury
• Developmental dysplasia • Rickets • Teeth problems 14.06 Drugs used in psychiatry & 15.10-11 Renal & urological disorders • Screening schedule (perinatal)
• Perthes' • SCFE/SUFE • Osgood- Mental Health Act / Sectioning • UTIs • Nephrotic syndrome • Sudden infant death syndrome
• Paediatric fractures Schaltter’s • Acute glomerulonephritis - Brief unexplained resolved event
[15.10] • Phimosis • Cryptorchidism • Vaccination schedule
• Hypospadias • Horseshoe kidney
• Wilms' tumour (nephroblastoma)
• Haemolytic uraemic syndrome
, Septic arthritis Compartment syndrome Spinal cord compression Open fractures
D: infxn of ≥1 joints caused by pathogenic D: elevated interstitial pressure in a A: trauma, vertebral fracture, interver- Cauda equina syndrome D: fracture with skin breach
inoculation of microbes closed osteofascial compartment tebral disc herniation, tumours, infection = refers to any smx below AND radiolo-
causing microvascular compromise gical confirmation of compression
Gustilo-Anderson classification
R: underlying joint disease, prosthetic joint, S/Smx • Most commonly caused by central disc
Type I
↑age (esp >80yo), immunosuppression (eg HIV, R: trauma, bleeding disorder, compression • sensory: Δ sensation below affected prolapse at L4/L5 or L5/S1
• wounds ≤1cm, minimal contamination
DM), IVDU, contiguous spread (eg via skin infxn support (e.g. tight casts, dressings), level • S/Smx:
or ulcers), exposure to ticks thermal injury (burns), intense muscular
activity (chronic)
- ❗️ pain & hemi-sensory loss - low back pain (common)
- bilateral sciatica (50% cases)
or muscle damage
Type II
• motor: weakness or paralysis • wounds 1-10cm, moderate soft tissue
• autonomic symptoms - impotence
A/P: 90% staph or strep - direct or injury
haematogenous inoculation. ❗️
Neiserria S/Smx: 6Ps - pressure (earliest), pain (esp - constipation
- urinary retention
- saddle anaesthesia
- sensorimotor loss in lower extremities
Type IIIA
• >10cm, high-energy, extensive soft
gonorrhea in young sexually active on movement, even passive), parasthesia ±
- neurogenic bladder dysfunction –
pallor, ↓pulse, paralysis - dizziness (hypotension)
usually overflow incontinence (later
tissue damage + contaminated
- cold, shivering, drowsiness • adequate tissue for flap coverage
S/Smx: hot, swollen, acutely painful joint sign that is a/w poorer prognosis)
Ix/Dx: • measure intracompartmental - erectile dysfunction • farm injuries are automatically at least
with restriction of movement = septic arthritis - ± bowel dysfunction
- abd pain and distention (ileus) IIIA
until proven otherwise. Usually single joint, but pressure (>20 mmHg is abnormal,
- syncope (bradycardia) Notes on anatomy: conus medullaris ends Type IIIB
do not r/o in ≥2 joint. More insidious onset if TB. >40 mmHg is diagnostic)
± fever. • Imaging (eg XR) not useful as pathology at L1-L2, and the cauda equina extends • same as type 3a but with extensive
BACK PAIN red flags → urgent MRI periosteal stripping
unlikely to show up
🚩 <20yo or >50yo
from L2 to Co1
• inadequate tissue for flap coverage
Ix: synovial fluid sampling (prior to abx if 🚩 Progressive pain
T12
Type IIIC
🚩
© quackquackmed.com
possible; under US guidance), blood cultures, Mx: • relieve pressure!!
Night/supine pain that prevents or Conus L1 • with vascular injury requiring vascular
joint imaging. Bloods (WCC, ESR, CRP, etc) - Release dressing
disturbs sleep, or rest pain repair (regardless of degree of soft
- Fasciotomy (within 6h of smx onset)
🚩 Pain aggravated by straining
medullaris
tissue injury)
🚩
L2
• Rhabdomyolysis
Thoracic back pain
Mx: IV abx covering Gram+ cocci – fluclox or
clindamycin IV (2w) then PO. Needle aspiration
- Check CK + U&Es (for kidney function)
- Aggressive hydration and NaHCO3
🚩 Mechanical pain (↑ when standing, Cauda L3
Mx
sitting, moving) equina
to decompress joint – "aspirate to dryness".
❗️ ± haemodialysis
🚩 Localised spinal tenderness
• ABCDE - full exposure to look for
Joint washout may be needed. Ref to ortho:
🚩
L4 associated injuries
• If necrotic tissue found, consider
Claudication
prosthetics, hip debridement ± amputation
🚩 No symptomatic improvement with L5
• Abx required + tetanus booster (if no
booster in last 5y)
therapy
P: delayed or inadequate tx can cause
🚩 Unexplained wt loss S1 • Definitive Mx is surgical
irreversible joint destruction, fatality
Tendon sheath infection (hand) 🚩 Past Hx of cancer
- ideally in theatre within 6h of injury
🚩 IVDU / steroid use
- remove foreign material
Septic arthritis of a replaced joint
** REF TO ORTHOPAEDICS
Kanavel's cardinal signs 🚩 S/smx hinting of cauda equina
- remove devitalised tissue
- extensive irrigation of wound
1. Exquisite tenderness over sheath, limited syndrome (see right)
- stabilise & set fracture
• usually Staph epidermidis, other coagulase
to sheath
-ve Staph, or Staph aureus See also NICE's page on red flags for sciatica
2. Finger sits in resting flexed position
• Requires aspiration/biopsy in sterile Mx of closed fractures
3. Exquisite pain on extending finger
environment – 5 samples passively, more marked proximally Physical exam: Reflexes Spinal tumours • Immobilise fracture including proximal
• Debridement abx and implant retention
4. Fusiform (sausage) swelling of whole
↳ Absent reflexes ↑↑suspicion • Most often 2/2 metastatic cancer and distal joints
• Two stage revision
finger
• Anal wink – contraction of anal ↳ more common in lung, breast, • Monitor and document neurovascular
- Op to remove infected replacement and all If all 4 present, >90% sensitive for flexor sphincter on stimulation of perianal area prostate cancers status esp after reduction and
suspected tissue, joint washout, abx spacer • Bulbocavernous reflex – tapping the • S/smx as with other spinal cord lesions immobilisation
tenosynovitis
and IV abx dorsum of penis causes contraction of - back pain is the earliest and most • No abx needed if closed
- Op to remove abx spacer, joint wash out, pelvic floor muscles common symptom
new total joint replacement inserted Mx: REF TO HAND SURGEONS. Elevation, • Cremasteric reflex – stimulus to upper • Ix: whole spine MRI
- Success rates ~88-96% IV abx. Open drainage and washout required thigh causes scrotal elevation • Mx: high dose PO dexamethasone
• Single stage revision - infected replacement • Babinski's sign +ve is abnormal - urgent onco assessment to consider
removed, washout, and replacement inserted P: delayed tx can lead to fibrosis, joint radiotherapy or surgery
in one op contracture or extension of infxn to deep - palliation if not feasible
palmar spaces and other structures
See also Kocher criteria on 11.10 for
paediatric septic arthritis
11.01 Ortho & MSK – Orthopaedic emergencies
ORTHOPAEDIC CONDITIONS • Systemic lupus erythematosus • Epilepsy • Status epilepticus
12.01 • Rheumatoid arthritis • Systemic sclerosis (scleroderma) 15.01 • Paediatric life support • Brain tumours
11.01 Orthopaedic emergencies • Osteoarthritis • Dermatomyositis • Polymyositis • Newborn life support [15.13] • Neural tube defects
• Septic arthritis • Psoriatic arthritis • Sjogren syndrome • Intraosseous infusion • Anaphylaxis • Autism spectrum disorder
• Compartment syndrome
• Spinal cord compression 12.02 With muscular problems 12.04 Vasculitis 15.02-03 Infections 15.14-15 Haemonc disorders
- Cauda equina syndrome • Ankylosing spondylitis • Wegener's • Churg-Strauss • Traffic light assessment of kids • Anaemia • Iron deficiency
• Open fractures • Gout • Pseudogout • Giant cell arteritis • Takayasu arteritis • Meningitis • Encephalitis • Sickle cell disease
• Tendon sheath infection (hand) • Reactive arthritis • Fibromyalgia • Microscopic polyangitis • Hereditary spherocytosis
• Polymyalgia rheumatica • Polyarteritis nodosa [15.03] • Measles • Mumps • Rubella • Henoch-Schonlein purpura
11.02 Upper limb orthopaedic issues • Chronic fatigue syndrome • Henoch-Scholein • Behcet's • Erythema infectiosum • HFMD [15.15] • Immune thrombocytopaenia
• Shoulder • Elbow • Roseola infantum • Chickenpox • Acute lymphoblastic leukaemia
• Fractures: Colles', Smith's, Barton's, • HIV in children • Primary immunodeficiencies
13 EAR NOSE THROAT 14 PSYCHIATRY
Monteggia's, Galeazzi • Severe combined immunodeficiency
15.04 Respiratory disorders
11.03 Hand & foot 13.01 Ear 14a Substance abuse / overdose
• Upper respiratory tract infections 15.16-18 Endocrine disorders
• Otalgia • Discharging ear • Cannabis • MDMA/Ecstasy
• Hand • Ganglions - Croup - Epiglottitis • Diabetes mellitus + MODY • DKA
© quackquackmed.com
• Otitis externa • Otitis media • Cocaine • Nitrous oxide
• Foot, incl club foot - Bacterial tracheitis - Diphtheria • Hypothyroidism
• Glue ear • LSD / acid • Opioid misuse
• Lower respiratory tract infections [15.17] • Hyperthyroidism
11.04 Hip, including neck of femur • Overdose / poisoning
- Bronchiolitis - Viral-induced wheeze • Inherited metabolic diseases
13.02 Ear • Hearing loss
fractures - Pneumonia - Whooping cough • Glycogen storage disorders
• Tinnitus • Vertigo 14.01 Mood disorders
• Asthma • Cystic fibrosis [02.04] • Phenylalanine ketonuria
11.05 Knee & ankle issues • Depression • Suicide
• Lysosomal storage diseases
13.03 Ear • Childhood deafness • Bipolar disorder 15.05-06 Cardiovascular disorders [15.18] • Precocious puberty
• Deafness in adults • Otosclerosis
09.06 Spinal orthopaedics • Ventricular septal defect (VSD) • Congenital adrenal hyperplasia
• Vestibular schwannoma 14.02 Anxiety & related disorders
Including rib fractures, autonomic • Atrial septal defect (ASD) • Genetic disorders summary
dysreflexia • Benign paroxysmal positional vertigo • Generalised anxiety disorder
• Patent ductus arteriosus
• Meniere's disease • Panic disorders • OCD • PTSD • Coarctation of the aorta 15.19 Developmental disorders
• Vestibular neuronitis • Labyrinthitis • Acute stress disorder • (Others)
09.07 Miscellaneous • Congenital aortic valve stenosis • Developmental milestones
• Dermatomes • Fat embolism • Eisenmenger's syndrome • Speech delay • Cerebral palsy
• Osteomalacia • Osteomyelitis 13.04 Nose 14.03 Psychotic disorders [15.06] • Tetralogy of Fallot (ToF) • Muscular dystrophies (incl Duchenne)
• Rhinosinusitis (acute & chronic) • Features that define psychotic
• Osteochondritis dissecans • Transposition of great arteries (TGA) • Global developmental delay
• Nasal fractures • CSF rhinorrhoea disorders
• Charcot joint • Ebstein's anomaly • Kawasaki disease
• Epistaxis • Nasal cancers • Schizophrenia • Psychosis
• Murmurs and heart sounds in children 15.20-21 Genetic disorders
09.08 Miscellaneous • Antipsychotics
• Down + other trisomies
13.05 Throat
• Joint replacements 15.07-09 GI disorders • Klinefelter • Triple X • Turner
• Sore throat (includes tonsilitis) 14.04 Personality disorders
• Paget's disease of the bone • Abdominal pain • Neuroblastoma [15.21] • Cri du chat • DiGeorge
• Osteoporosis • Obstructive sleep apnoea • A: Paranoid, schizoid, schizotypal
• Coeliac disease • Malnutrition • Williams • Achondroplasia
• Pathological fractures • Stridor – causes • Croup • B: Antisocial, borderline, histrionic, • Diarrhoea & vomiting • Marfan • Noonan • Fragile X
• Acute epiglottitis • Laryngomalacia narcissistic
• Fracture types [15.08] • Appendicitis • Intussusception
• C: Avoidant, dependent, obsessive-
• Pyloric stenosis • Hirschsprung 15.22-23 Neonates
09.09 Malignancies & trauma 13.06 Throat convulsive
• Oesophageal atresia • Neonatal sepsis • Seizures
• Dysphonia • Dysphagia
• Osteosarcoma • Chondrosarcoma [15.09] • Congenital diaphragmatic hernia • Respiratory distress • Jaundice
• Head and neck squamous cell 14.05 Eating disorders & miscellaneous
• Ewing's sarcoma • Giant cell tumour • Inguinal hernia • Imperforate anus [15.23] • Necrotising entercolitis
carcinoma (HNSCC) • Bell's palsy psychiatric disorders
• Bone metastases • Trauma surgery • Mid-gut malrotation • Hypoglycaemia • Hypotonia
• Anorexia nervosa • Bulimia nervosa
• Gastroschisis & omphalocele • Minor problems, including skin issues
13.07 Throat • Insomnia • Unexplained symptoms
09.10 Paediatric orthopaedics • Meckel's diverticulum
• Neck lumps • Xerostomia • Electroconvulsive therapy
• Juvenile idiopathic arthritis • Infant feeding problems 15.24 Miscellaneous
• Transient synovitis of the hip • Salivary gland problems
• Non-accidental injury
• Developmental dysplasia • Rickets • Teeth problems 14.06 Drugs used in psychiatry & 15.10-11 Renal & urological disorders • Screening schedule (perinatal)
• Perthes' • SCFE/SUFE • Osgood- Mental Health Act / Sectioning • UTIs • Nephrotic syndrome • Sudden infant death syndrome
• Paediatric fractures Schaltter’s • Acute glomerulonephritis - Brief unexplained resolved event
[15.10] • Phimosis • Cryptorchidism • Vaccination schedule
• Hypospadias • Horseshoe kidney
• Wilms' tumour (nephroblastoma)
• Haemolytic uraemic syndrome
, Septic arthritis Compartment syndrome Spinal cord compression Open fractures
D: infxn of ≥1 joints caused by pathogenic D: elevated interstitial pressure in a A: trauma, vertebral fracture, interver- Cauda equina syndrome D: fracture with skin breach
inoculation of microbes closed osteofascial compartment tebral disc herniation, tumours, infection = refers to any smx below AND radiolo-
causing microvascular compromise gical confirmation of compression
Gustilo-Anderson classification
R: underlying joint disease, prosthetic joint, S/Smx • Most commonly caused by central disc
Type I
↑age (esp >80yo), immunosuppression (eg HIV, R: trauma, bleeding disorder, compression • sensory: Δ sensation below affected prolapse at L4/L5 or L5/S1
• wounds ≤1cm, minimal contamination
DM), IVDU, contiguous spread (eg via skin infxn support (e.g. tight casts, dressings), level • S/Smx:
or ulcers), exposure to ticks thermal injury (burns), intense muscular
activity (chronic)
- ❗️ pain & hemi-sensory loss - low back pain (common)
- bilateral sciatica (50% cases)
or muscle damage
Type II
• motor: weakness or paralysis • wounds 1-10cm, moderate soft tissue
• autonomic symptoms - impotence
A/P: 90% staph or strep - direct or injury
haematogenous inoculation. ❗️
Neiserria S/Smx: 6Ps - pressure (earliest), pain (esp - constipation
- urinary retention
- saddle anaesthesia
- sensorimotor loss in lower extremities
Type IIIA
• >10cm, high-energy, extensive soft
gonorrhea in young sexually active on movement, even passive), parasthesia ±
- neurogenic bladder dysfunction –
pallor, ↓pulse, paralysis - dizziness (hypotension)
usually overflow incontinence (later
tissue damage + contaminated
- cold, shivering, drowsiness • adequate tissue for flap coverage
S/Smx: hot, swollen, acutely painful joint sign that is a/w poorer prognosis)
Ix/Dx: • measure intracompartmental - erectile dysfunction • farm injuries are automatically at least
with restriction of movement = septic arthritis - ± bowel dysfunction
- abd pain and distention (ileus) IIIA
until proven otherwise. Usually single joint, but pressure (>20 mmHg is abnormal,
- syncope (bradycardia) Notes on anatomy: conus medullaris ends Type IIIB
do not r/o in ≥2 joint. More insidious onset if TB. >40 mmHg is diagnostic)
± fever. • Imaging (eg XR) not useful as pathology at L1-L2, and the cauda equina extends • same as type 3a but with extensive
BACK PAIN red flags → urgent MRI periosteal stripping
unlikely to show up
🚩 <20yo or >50yo
from L2 to Co1
• inadequate tissue for flap coverage
Ix: synovial fluid sampling (prior to abx if 🚩 Progressive pain
T12
Type IIIC
🚩
© quackquackmed.com
possible; under US guidance), blood cultures, Mx: • relieve pressure!!
Night/supine pain that prevents or Conus L1 • with vascular injury requiring vascular
joint imaging. Bloods (WCC, ESR, CRP, etc) - Release dressing
disturbs sleep, or rest pain repair (regardless of degree of soft
- Fasciotomy (within 6h of smx onset)
🚩 Pain aggravated by straining
medullaris
tissue injury)
🚩
L2
• Rhabdomyolysis
Thoracic back pain
Mx: IV abx covering Gram+ cocci – fluclox or
clindamycin IV (2w) then PO. Needle aspiration
- Check CK + U&Es (for kidney function)
- Aggressive hydration and NaHCO3
🚩 Mechanical pain (↑ when standing, Cauda L3
Mx
sitting, moving) equina
to decompress joint – "aspirate to dryness".
❗️ ± haemodialysis
🚩 Localised spinal tenderness
• ABCDE - full exposure to look for
Joint washout may be needed. Ref to ortho:
🚩
L4 associated injuries
• If necrotic tissue found, consider
Claudication
prosthetics, hip debridement ± amputation
🚩 No symptomatic improvement with L5
• Abx required + tetanus booster (if no
booster in last 5y)
therapy
P: delayed or inadequate tx can cause
🚩 Unexplained wt loss S1 • Definitive Mx is surgical
irreversible joint destruction, fatality
Tendon sheath infection (hand) 🚩 Past Hx of cancer
- ideally in theatre within 6h of injury
🚩 IVDU / steroid use
- remove foreign material
Septic arthritis of a replaced joint
** REF TO ORTHOPAEDICS
Kanavel's cardinal signs 🚩 S/smx hinting of cauda equina
- remove devitalised tissue
- extensive irrigation of wound
1. Exquisite tenderness over sheath, limited syndrome (see right)
- stabilise & set fracture
• usually Staph epidermidis, other coagulase
to sheath
-ve Staph, or Staph aureus See also NICE's page on red flags for sciatica
2. Finger sits in resting flexed position
• Requires aspiration/biopsy in sterile Mx of closed fractures
3. Exquisite pain on extending finger
environment – 5 samples passively, more marked proximally Physical exam: Reflexes Spinal tumours • Immobilise fracture including proximal
• Debridement abx and implant retention
4. Fusiform (sausage) swelling of whole
↳ Absent reflexes ↑↑suspicion • Most often 2/2 metastatic cancer and distal joints
• Two stage revision
finger
• Anal wink – contraction of anal ↳ more common in lung, breast, • Monitor and document neurovascular
- Op to remove infected replacement and all If all 4 present, >90% sensitive for flexor sphincter on stimulation of perianal area prostate cancers status esp after reduction and
suspected tissue, joint washout, abx spacer • Bulbocavernous reflex – tapping the • S/smx as with other spinal cord lesions immobilisation
tenosynovitis
and IV abx dorsum of penis causes contraction of - back pain is the earliest and most • No abx needed if closed
- Op to remove abx spacer, joint wash out, pelvic floor muscles common symptom
new total joint replacement inserted Mx: REF TO HAND SURGEONS. Elevation, • Cremasteric reflex – stimulus to upper • Ix: whole spine MRI
- Success rates ~88-96% IV abx. Open drainage and washout required thigh causes scrotal elevation • Mx: high dose PO dexamethasone
• Single stage revision - infected replacement • Babinski's sign +ve is abnormal - urgent onco assessment to consider
removed, washout, and replacement inserted P: delayed tx can lead to fibrosis, joint radiotherapy or surgery
in one op contracture or extension of infxn to deep - palliation if not feasible
palmar spaces and other structures
See also Kocher criteria on 11.10 for
paediatric septic arthritis
11.01 Ortho & MSK – Orthopaedic emergencies
