Conditions affecting Shoulder (Impingement syndrome)

Impingement syndrome

• Painful condition of the rotator cuff due to impingement 
• Repetitive compression or rubbing of tendons supraspinatus under coracoacromial arch
• Passively, when the internally rotated shoulder is moved into forward flexion, the patient will experience discomfort (Neer impingement sign)
• Thickening of ACJ, OA spurs, Swelling of cuff, bursa

• Any prolonged repetitive overhead activity such as tennis, pitching, golf, or swimming may compromise the space between the humeral head and the coracoacromial arch that includes the acromion, coracoacromial ligament, and the coracoid process
• Localised edema and swelling – tendinitis
• Scarring, Fibrosis, Calcification
• Incomplete and complete tear
• Secondary Arthropathy – Milwaukee shoulder

Clinical Features

• Depends upon the stage of disease
• Tendinitis - less than 40 years of age, anterior shoulder pain after activity, tenderness anteriorly at supraspinatus 
• Painful arc, Impingement sign,
• Chronic tenditis : 40 – 50 yrs , repeated attacks of shoulder pain, pain more at night, cannot lie on affected side, stiffness
• Tear: greater than 45 yrs, Partial/ complete, difficulty in abduction, local injection, atrophy

• Diagnosis: History, Physical examination, Imaging  X-ray, arthrography, USG, MRI

Treatment:

•         Conservative: Rest, avoiding painful activities, warm packs, physiotherapy, NSAIDs, Local steroids
•         Surgical: Acromioplasty, Debridement, Rotator cuff repair

ADHESIVE CAPSULITIS

• Frozen shoulder
• Condition characterised by progressive pain and stiffness of shoulder which resolves spontaneously in 18 to 24 months.
• Idiopathic, Fibroblastic proliferation, Association with DM, Dupuytrens disease, hyperthyroidism
• Clinical features:40 – 60 yrs, h/o trauma +/-, progressively increasing pain in shoulder and arm, night pain, Gradual stiffness and decreasing pain, Gradual regain of motion
•     Wasting of muscles, ROM- decreased in all direction

X-rays Normal, to exclude other diseases

• Diagnosis: Not every stiff shoulder is frozen shoulder
• Other causes of stiffness ruled out, painful restriction of movement with normal x rays and natural progression in three stages

Treatment:

•      Conservative: NSAIDs, ROM exercises Pendulum exercises, Local steroid injection, Large volume injection and manipulation under anaesthesia,
•     Surgical: No definitive role.

Legg Calve Perthes Disease

Definition.  

• It is degenerative disease of the hip joint, where growth/loss of bone mass that leads to some degree of collapse of the hip joint and to deformity of the ball of the femur and the surface of the hip socket
• The disease is characterized by idiopathic avascular osteonecrosis of the capital femoral epiphysis of the femoral head leading to an interruption of the blood supply of the head of the femur close to the hip joint 

Epidemiology

• Disorder of the hip in young children
• Usually ages 4-8 years
• Boys:Girls= 4:1
• Usually unilateral

Blood supply

Age related changes in blood supply to Epiphysis

Age < 4

Receives blood from the metaphyseal vessels

Age 4-8

Blood from separate epiphyseal vessels as the physis is barrier to blood flow

Age > 8

The ligamentum teres has increasing significance in supply (20%)

Radiographic Stages

Four Waldenstrom stages:

1) Initial stage

2) Fragmentation stage

3) Reossification stage

4) Healed stage

Initial Stage

Early radiographic signs:

• Failure of femoral ossific nucleus to grow
• Widening of medial joint space
• Irregular physeal plate
• Blurry/ radiolucent metaphysis

Fragmentation Stage

• Bony epiphysis begins to fragment
• Areas of increased lucency 

Reossification Stage

• Normal bone density returns
• Alterations in shape of femoral head and neck evident

Healed Stage

• Left with residual deformity from disease and repair process
• Differs from AVN(avascular necrosis) following Fx or dislocation

Presentation

• Often insidious onset of  limp
• C/O pain in groin, thigh, knee
• The typical patient has a flexion contracture of 0-30 degrees, loss of abduction compared with the opposite side and loss of internal rotation of the hip.
• Can have an acute onset
• Patients frequently have younger skeletal age than cohorts

Physical Exam

• Decreased ROM, especially abduction and internal rotation
• Trendelenburg test often positive
• Adductor contracture
• Muscular atrophy of thigh/buttock/calf
• Limb length discrepency

• Imaging

AP pelvis

Frog leg lateral

Key= view films sequentially over course of dz

Arthrography

Differential Diagnosis

• Important to rule out infectious etiology (septic arthritis, toxic synovitis)

Others:

-JRA

-Sickle Cell

-Osteomyelitis

-Traumatic AVN

-Neoplasm  

-Medication-steroid

Non-operative Tx

• Improve ROM 1st
• Bracing:

-casts

-Hips abducted and internally rotated for containment

• Wean from brace when improved x-ray healing signs

Bracing

Operative Tx

• If non-op tx cannot maintain containment

Surgical options:

• Excise lat extruding head portion to stop hinging abduction
• Acetabular (innominate) osteotomy to cover head
• Varus femoral osteotomy
• Arthrodesis 

Varus Osteotomy

Late Effects of LCP

• Physeal arrest patterns 
• Irregular head formation

Endocrine diseases list

Pituitary Hypofunction

Disorders of the thyroid gland

Thyroid neoplasms

Disorder of calcium and phosphate regulation

Endocrine pancreas

Disorders of the endocrine pancreas

Adrenal cortical hypofunction

Adrenal Medulla

Cystic disease of the kidney

Glomerular diseases

Chest radiograph of different conditions

• Pink Puffer

– Pa02 70 – 75 

– Mild C02 retention 40 – 50 torr

• Blue Bloater

– Pa02 < 70 

– Mod – Severe C02 retention

– Polycythemia

Bronchiectasis:

• Permanent dilatation of bronchi.
• Cough, copious purulent sputum.
• Lower lobes common
• Complications; 
• Pneumonia, empyema, septicemia, meningitis.
• Types:
• Cylindrical, Saccular, Fusiform (no significance)

Cardiomegaly

Causes

Numerous causes such as hypertension, renal failure, valvular lesions, cardiomyopathy,

severe anemia, thyroid disorders, hemochromatosis, and amyloidosis.

CXR Findings

Measure from the most lateral borders of the heart and compare this width to the inner border of the widest part of the inner rib; if this ratio exceeds 50%, the diagnosis can be made.

Heart size and shape

A normal Heart shadow in CXR PA view

Left atrial enlargement

Rheumatic mitral stenosis. This frontal film shows marked

enlargement of the left atrial appendage (arrow).

Penetrated chest film in the same patient double right heart border and splaying of the carina is seen

Right atrial enlargement

Right atrial enlargement. Right atrial enlargement is often difficult to detect with only subtle enlargement of the right heart border present on the PA view.

Left ventricular enlargement

Selective left ventricular enlargement in aortic incompetence. (A) Frontal view shows that the left ventricle has enlarged along its long axis, taking the apex of the heart to the left and downward (white arrow).

(B) Lateral view shows the left ventricle extending behind the line of the barium-filled oesophagus (arrow).

Congestive Heart Failure (CHF)

STAGE I CHF (PROGRESSIVE CEPHALIZATION) (Can only use this sign on an upright chest x-ray, not supine, since blood flow will redistribute.)

CAUSE

Increased mean capillary wedge pressure 10–20 mm Hg

CHEST X-RAY FINDINGS

Progressive cephalization, which means increased blood fl ow toward the top of the lung

CXR showing cardiomegaly with cephalization in a patient with pulmonary venous hypertension.

STAGE 2 CHF  (INTERSTITIAL EDEMA)

CAUSE

Increased mean capillary wedge pressure 20–25 mm Hg

CHEST X-RAY FINDINGS

Thin white lines due to interstitial edema, known as Kerley B lines (Horizontal white lines at the lung bases extending from the periphery of the lung). 

Kerley-B lines

STAGE 3 CHF (ALVEOLAR EDEMA)

CAUSE

Wedge pressure greater than 25 mm Hg

CHEST X-RAY FINDINGS

Increased opacity around the hilum in a butterfly pattern referred to as “bat wings” appearance. 

STAGE 4 CHF (CHRONIC PULMONARY VENOUS HYPERTENSION) 

CAUSE

Increased wedge pressure greater than 30 mm Hg

CHEST X-RAY FINDINGS

Bilateral interstitial infi ltrates and bilateral pleural effusions.

Note- If the patient doesn’t have cardiomegaly, consider noncardiogenic causes of CHF such as head injury or drug overdose.

CXR depicting cardiomegaly with bilateral interstitial infiltrates and bilateral pleural effusions, consistent with advanced CHF.

Enlargement of the ascending aorta can be found with Marfan's disease, aortic insufficiency, post-stenotic dilation and aortic aneurysms. 

The prominence of central pulmonary artery caused by pulmonary hypertension.

Fungal infections

Fungi (introduction)

• Study of fungi is mycology.
• All fungi are eukaryotic and its cell wall is composed of chitin,mannan and glucan.
• Ergosterol is the major membrane sterol.
• Hyphae is the filamentous cellular units of moulds and mushrooms (it can be septate and non-septate)
• Pseudo-hyphae: C.albicans

Dimorphic fungi:

Fungi which can convert from hypheal to yeast or yeast-like form.

Fungi which are in the from of mold in cold is thermally dimorphic.

Imp dimorphic fungi:

• Histoplasma
• Sporothrix
• Coccidioides
• Blastomyces

Superficial fungal infections

• Malassezia furfur
• Cutaneous fungal infection
• Yeast skin infection
• Dermatophytes

Candidiasis (Moniliasis)

• Is an infection caused by the yeast Candida albicans, or occasionally by other species of Candida. 
• C.albicans is an oval yeast 2-6 x 3-9 mm in size, which can produce budding cells, pseudohyphae and true hyphae.
• It most commonly causes superficial infections of the skin and mucous membranes.
• Can also involve internal organs as in septicemia, endocarditis and meningitis (particularly in AIDS patients and in patients in intensive care units).
• Candida albicans occurs as a normal commensal in humans and colonizes the gastrointestinal tract, vagina, intertriginous skin and the bronchial tree.

Clinical syndromes of candidiasis 

• Oral candidiasis
• Candida intertrigo (flexural candidosis)
• Vulvovaginitis (vulvovaginal thrush)
• Candidal balanoposthitis
• Napkin candidosis (diaper rash)
• Candida paronychia 

Oral candidiasis

• can occur in infants (oral thrush),
• immunocompromised patients, 
• patients wearing dentures (denture stomatitis),
• smokers & those applying intraoral steroid medications (mouthwashes,inhalers).
• Sharply defined patch of curd-like white pseudomembrane, which, when removed, leaves an underlying erythematous base.  

Candida intertrigo (flexural candidosis)

• Usually affects the skin folds in obese subjects.
• Typical lesions are moist, erythematous eroded areas with a fringed irregular edge and pustular or papular satellite lesions beyond the margins.  

Vulvovaginitis (vulvovaginal thrush)

• Itching, soreness and dusky red erythema of the vaginal mucosa and the vulval skin with a thick curdy white discharge per vagina.
• More common in pregnancy. 

Candidal balanoposthitis

• Is more commonly seen in the sexually active uncircumcised men or in patients with diabetes. 
• The sexual partners are usually carriers of candida. 
• Tiny papules or pustules develop on the glans penis a few hours after intercourse, and rupture, leaving a peeling edge, with mild soreness and irritation. 

Napkin candidiasis (diaper rash)

• Moist skin of the buttocks and genitalia infants and can cause disease in the napkin area when it is wet and occluded. 
• The affected area may show erythema with subcorneal pustules and satellite lesions.

Candida paronychia

• Candida is the most common cause of chronic paronychia. 
• condition is commonly found among those whose hands are frequently immersed in water (cooks, housemaids, washermen). 

                                        

Management of candidal infections

Remove the susceptibility factors. For example, maintenance of oral and dental hygiene and keeping the affected sites dry.

• Topical therapy

Clotrimazole, miconazole, econazole, nystatin, natamycin. These drugs are used in the form of creams, lotions, gels, mouth paints or lozenges.

• Oral therapy

The most useful treatments are with fluconazole (100-400 mg/day) and itraconazole (100-200 mg/day).

• Intravenous therapy

Amphotericin B and fluconazole are mainly used for systemic infections. 

Dermatophytes

• These are filamentous fungi and are monomorphic.
• It infect only skin, hair/nail.(Only superficial)
• Dermatophytic infections are known as Tineas or Ringworms.
• These belong to  three genera. They are:

Trichophyton: Infects skin, hair and nails.
Microsporum: Infects skin and hair.
Epidermophyton: Infects skin and nail.

Cutaneous infections:

• Tinea capitis: ringworm of scalp
• Tinea barbae: ringworm of the bearded region
• Tinea corporis: infection of the glaberous skin
• Tinea cruris: jock itch
• Tinea pedis: athlete’s foot

Tinea capitis

Ringworm of the scalp in which the essential feature is invasion of hair shafts by a dermatophyte fungus.

Have a distinct predilection for the hair shaft.

• Cause: M. audouinii, T. schoenleinii and T. violaceum

Clinical feature

• The appearance vary from a few dull grey, broken-off hairs with a little scaling, detectable only on careful inspection, to a severe, painful, inflammatory mass covering most of the scalp.
• In all types, the cardinal features are partial hair loss with inflammation of some degree.

Tinea capitis

Tinea barbae

Ringworm of the beard and moustache areas of the face with invasion of coarse hairs. It is thus a disease of the adult male.

• Causes: T. mentagrophytes  and T. verrucosum

Clinical features

• The affected men are commonly farm workers
• The clinical picture in these is that of a highly inflammatory pustular folliculitis.
• Hairs of the beard or moustache regions are surrounded by red inflammatory papules or pustules, usually with exudation or crusting.
• Many hairs within the affected areas are loose and easily removed with the forceps without causing pain. 

Tinea barbae

Tinea corporis

Dermatophytic infection of the glaberous skin, but can occur in any part of the body.

Cause:

• Microsporum canis
• Trichophyton verrucosum

Clinical features

• The lesions are erythematous, annular and scaly with a well defined edge with central clearing.
• May be single or multiple and are usually asymmetrical.
• Steroid use: leads to disguising and worsening of the signs.

Tinea corporis

Tinea cruris

Infection of the groins by a species of dermatophyte.

Cause: 

• T. rubrum is the main cause;
• T. mentagrophytes var. interdigitale and
• E. fl occosum

Clinical features

• Itching is a predominant feature.
• The lesions are erythematous plaques, curved with sharp margins extending from the groin down the thighs.

Tinea cruris

Tinea pedis

Infection of the feet or toes with a dermatophyte fungus.

Causes:

• T. rubrum,
• T. mentagrophytes var. interdigitale and
• E. floccosum

Clinical features

• The most common form of tinea pedis is an intertriginous dermatitis characterized by peeling, maceration and fissuring affecting the lateral toe clefts, and sometimes spreading to involve the undersurface of the toes.
• This picture may be produced by any of the three species. 
• Itching is a common complaint in warm weather. The condition is highly persistent. 
• In T. rubrum infections, a scaling hyperkeratotic variety, which is particularly chronic and resistant to treatment and which affects the soles, heels and sides of the feet, is often found. The affected areas are pink and covered with fine silvery white scales. If the foot is extensively involved, the term ‘moccasin foot’ or dry-type infection are sometimes applied.
• In T. mentagrophytes vesiculation or frank blistering is commonly seen.

Tinea pedis

• In all cases of suspected dermatophytic infection:

Skin scrapings/ nail clippings
Woods light examination
Direct examination
Fungal culture

Treatment

• Topical

Terbinafine or miconazole cream

• Systemic

terbinafine, griseofulvin or itraconazole