Cambridge Fracture Clinic (cfc) Presents Minor injuries : Not so minor

1. Cambridge Fracture Clinic (cfc)PresentsMinor injuries : Not so minor Mr Lee Van Rensburg Mr Alan Norrish Mr Peter Hull Mr Andrew Carrothers

2. Cambridge Fracture Clinic • Mr Lee Van Rensburg • Mr Alan Norrish • Mr Peter Hull • Mr Andrew Carrothers • Based at Spire • Next day • Not just fractures • 01223 400150

3. Scope • Mr Lee Van Rensburg • Upper limb • Mr Andrew Carrothers • Lower limb

4. Scope • Hand and wrist • Elbow • Shoulder • Hip • Knee • Ankle • Foot • Soft tissues • Ligaments • Tendons • Cartilage • Muscles • Nerves • Vessels • Bones • Joints

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

6. office@cambridgemedicalpractice.co.uk Australian Family Physician Vol. 41, No. 4, april 2012

7. General Approach ACTIVE Knee – SLR Elbow - triceps • History • Examination • Look • Feel • Move • Active • Passive

8. Special investigations

9. Hand • Tricky, basic knowledge anatomy Australian Family Physician Vol. 41, No. 4, april 2012

10. Hand • History • Examination • Look • Feel • Move • Active • Passive

11. Hand X ray • Bruising • Swelling • Deformity • Bony tenderness

12. Mallet Finger 56 YO injured finger tip tucking in bed, unable to extend DIPJ Pathology? Soft tissue injury - X ray?

13. 20 YO playing rugby • Avulsion fracture Base of proximal phalanx • Avulsion FDP, rugger jersey finger • No Fracture, small flake of bone overlying PIPJ • BEWARE SMALL FLAKE

14. 40 YO Skiing, thumb ski pole • Tender • Laxity valgus stress Gamekeepers Thumb Or Skiers thumb

15. Skiers Vs Gamekeepers

16. Wrist injuries • Distal radius • Scaphoid • Radiocarpal joint • Carpal joints • Carpo Metacarpal joint • CMC base of thumb • Tendons • Dequervains • Ligaments

17. 54 YO Male • Falls off bicycle • Pain in wrist

18. 54 YO male • Re attends 13 days later • Persistent pain • Tender in anatomical snuff box • Repeat radiographs • Including scaphoid views D 13 Initial

19. Scaphoid • 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

20. Wrist COME BACK

21.  Elbow injuries

22.  48 YO fireman lifting car

23. Distal biceps rupture • Non operative • 70% - 90% Flexion strength • 60% Supination strength • Operative

24.  Acutely < 3 weeks Chronic/ Delayed

25.  32 YO fall • Small flake of bone of tip of olecranon • BEWARE SMALL FLAKE 3 months

26. Shoulder injuries

27. 30 YO Female

28. 30 YO Female • 1 week later • Still in pain • Feels popping in shoulder • 2 weeks later • Pain worse • Still popping

29. 30 YO Female 2 weeks Initial

30. Rupture long head of biceps • Popeye sign • Well tolerated • Some cramping/ ache

31. 55 YO Male • Farmer • Falls from tractor • Pain and weakness in shoulder

32. Shoulder

33. Supraspinatus • Jobe’s

34. 113

35. Supraspinatus - 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

36. Shoulder • Unable to elevate arm • Full thickness tear • Supraspinatus • Infraspinatus

37. 1961 - 51 1930 - 82 60-69 =30% FTRCT 70-79 = 50% FTRCT 80-89 = 80% FTRCT Age-related prevalence of rotator cuff tears in asymptomatic shoulders; Tempelhof et al; JSES July 1999 (Vol. 8, Issue 4, Pg 296-299

38. Rotator cuff tear • Non operative • Relative rest • NSAID • Physio • Steroid injection (controversial) • Operative 3 months JSES - 2008;17:863-870

39. Minor Injuries: Not So MinorAnnual GP Conference 2012 Mr Andrew D Carrothers Consultant Orthopaedic Surgeon Addenbrookes

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

41. General Practice • Jordan et al. BMC Musculoskeletal Disorders 2010, 11:144. • Extensive and varied musculoskeletal workload in primary care • 1:7 consultations • Back • Knee • Hip • Foot

42. Trauma in General Practice • Problems • Atypical or uncommon presentations • Recent injury but Xray ‘No fracture’ • Failed analgesics • Failed mother nature (ie time) • Failed physio

43. Back to Orthopaedic Basic Principles • History • Examination • Special Tests • DDx • Investigations • Treatment +/- Referral

44. Hip Trauma

46. 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

47. Differential diagnosis?

48. ED Xray - #NOF

49. Xray Review

50. Hip – Case 2 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