ABC of Clinical Electrocardiography 1st Edition by Francis Morris,William Brady,John Camm 1405170646 9789350257883

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ISBN 10:1405170646 
ISBN 13:9789350257883
Author: Francis Morris,William Brady,John Camm

Electrocardiography is an essential tool in diagnosing cardiac disorders. This second edition of the ABC of Clinical Electrocardiography allows readers to become familiar with the wide range of patterns seen in the electrocardiogram in clinical practice and covers the fundamentals of ECG interpretation and analysis.

Fully revised and updated, this edition includes a self-assessment section to aid revision and check comprehension, clear anatomical diagrams to illustrate key points and a larger format to show 12-lead ECGs clearly and without truncation.

ABC of Clinical Electrocardiography 1st  Table of contents:

CHAPTER 1 Introduction to Musculoskeletal Medicine

OVERVIEW

Introduction

Structure and function: the body as a machine

The skeleton

Joints

Muscles and tendons

Reciprocal groups of muscles

Figure 1.1 A crane is a very simple machine but has many elements in common with the human body. The human body is subject to the laws of mechanics like any other machine.

Nerves

Figure 1.2 The human ‘combustion engine’. (a) Fuel in a car engine is combusted with oxygen to create a force that moves the piston and turns the crankshaft. (b) Glucose in muscle cells is respired to create the ATP that drives muscle contraction.

Functions and stresses

Figure 1.3 Reciprocal muscle contraction. In gripping the finger flexor muscles contact strongly. If the wrist extensors do not ‘brace’ the wrist then the wrist would also flex and grip would be very weak (a). Strong contraction of the wrist extensors allows the finger flexors to exert maximum power (b).

Figure 1.4 Lifting a 10 kg weight the wrong way, with a bent back. Upper body weight is 40 kg. The resultant force is weight in kg × acceleration of gravity: (40 kg + 10 kg) × 10 m/s2 = 500 N. This force is acting over a 1 m lever (distance between the fulcrum at the lumbosacral joint and the shoulders), giving a resulting moment of 500 Nm. The opposing lever at the lumbosacral joint is much shorter, approximately 10 cm. The moment that needs to be generated over this short 10 cm lever is 500 Nm, thus requiring 5000 N of force over the lumbosacral joint.

Effects of age, other morbidity, drugs and training

Effects of weight

Structured assessment

Figure 1.5 The ankle inverts, stretch receptors activate (a), there is a reflex contraction of the evertor muscles, the deforming force is overcome and the ankle returns to the normal position (b).

Figure 1.6 In climbing stairs the forces acting on the patellofemoral joint are three times the body weight.

Table 1.1 Musculoskeletal assessment checklist

Mechanism of injury: trauma versus non-trauma

Symptoms and progress of the symptoms

Table 1.2 Spectrum of injury in non-traumatic musculoskeletal problems

Previous injury/problems

Past medical history including drugs and allergy

Occupation, sport and hobbies

Examination

General exam

Limb problems

Indications for investigations

Figure 1.7 (a) Look: always compare sides. (b) Feel: use a single palpating digit to localize tenderness accurately. (c) Active and passive range indicates joint function. (d) Resisted movement indicates muscle/tendon/insertion function. (e) Stress tests indicate ligament function. (f) Special tests may be the only way of making a clinical diagnosis in some conditions.

X-rays

Computed tomography (CT) scanning

Ultrasound and MR scanning

Other tests

Types of injury and treatment

Muscle body

Table 1.3 Tendon tears that may require surgical treatment

Tendon/muscle origin and insertion

Ligament

Functional impairment

Figure 1.8 Grading of ligament tears. (a) Grade 1, a partial tear of part of the ligament complex (partial tear of the anterior talo-fibular ligament; ATFL). (b) Grade 2, complete tear of part of the ligament (complete tear of ATFL). (c) Grade 3, complete tear of the whole ligament complex (tears of the ATFL, calcaneo-fibular ligament and posterior talo-fibular ligament, PTFL).

Joint injury

Dislocation

Instability and recurrent dislocation

Loose body

Nerve injury/compression

Non-injury diagnosis and treatment

Non-articular rheumatism

Arthopathy

Degenerative arthopathy

Table 1.4 Nerve root and peripheral nerve injuries

Autoimmune/reactive diseases

Crystal arthopathy

Septic arthopathy

Diabetic arthopathy

Neuropathic arthopathy

Overuse syndromes

Tumour/pathological fractures

Complex regional pain syndrome/neural pain

Further reading

CHAPTER 2 Soft Tissue Problems of the Neck

OVERVIEW

Whiplash-associated disorders

Incidence

Etiology

Clinical picture

Imaging

Table 2.1 Quebec Task Force classification of WAD

Table 2.2 Proposed subdivision of WAD grade 2

Treatment

Prognosis

Acute torticollis

Clinical picture

Imaging

Figure 2.1 The Canadian Cervical Spine Rule algorithm for clearing the C-spine. ED, emergency department; GCS, Glasgow Coma Score; MVC, motor vehicle collision.

Figure 2.2 C1–C2 fully segmented hemivertebra on the left, causing congenital torticollis.

Treatment

Cervical disc degeneration and related conditions

Table 2.3 Differential diagnosis of painful torticollis

Figure 2.3 Photograph of a patient with torticollis due to C1–C2 hemivertebra. Notice the lateral flexion of the neck towards one side and the rotation towards the contralateral side.

Figure 2.4 Anteroposterior radiogram focused on the upper C-spine of a patient with rotatory C1–C2 subluxation. Notice the difference in the distance between the two lateral masses of C1 and the odontoid process and the wink sign on the left. Due to the deformity and the pain it is frequently difficult to obtain proper open-mouth views.

Pathophysiology

Clinical picture

History

Figure 2.5 The pathophysiology of cervical disc degeneration.

Figure 2.6 The dermatomes supplied by the (a) dorsal and (b) ventral cervical roots.

Examination

Imaging

Figure 2.7 MR scan, sagittal section showing disc prolapse at C3/4 with compression of the spinal cord.

Treatment

Prognosis

Further reading

CHAPTER 3 Back Pain

OVERVIEW

Introduction

Types of back pain

Anatomy

Thoracic back pain

Figure 3.1 The muscular anatomy of a section of the spine.

Mechanical lower back pain

Cauda equina syndrome

Prolapsed intervertebral disc

Non-mechanical and referred causes of back pain

Box 3.1 Serious pathologies associated with back pain

Other causes of back pain to consider

Figure 3.2 MRI of prolapsed intervertebral disc.

Box 3.2 Tumours that commonly metastasize to the spine

Red flags in back pain

Box 3.3 Red flags that are possible indicators of serious spinal pathology

Systemic and psychological factors in back pain

Fibromyalgia

Box 3.4 Bio-psycho-social factors or yellow-flag symptoms in back pain

History and examination

History

Box 3.5 Important points to cover in history taking

Examination

Look

Feel

Move

Neurological

Table 3.1 Myotomes

Figure 3.3 Dermatomes.

Other examinations

Figure 3.4 Straight leg raise.

Investigations

Treatment

Box 3.6 Stepwise approach to pharmacological intervention in mechanical back pain

Further reading

CHAPTER 4 Shoulder: Sub-acromial Pathology

OVERVIEW

Figure 4.1 Shoulder joints and articulations.

The rotator cuff

Figure 4.2 The superficial and deep muscle layers of the shoulder. (a) Anterior. (b) Posterior.

Sub-acromial impingement

History and examination

Box 4.1 Causes of sub-acromial impingement

Primary: caused by pathology or injury to the cuff (usually in older age groups)

Secondary: caused by stability problems (usually in younger age groups)

Structural: caused by narrowing of the sub-acromial space

Figure 4.3 (a) Primary causes of impingement (older people). (b) Secondary causes of impingement (young). ACJ, acromio-clavicular joint; SLAP, superior labral anteroposterior.

Investigations

Treatment

Physiotherapy

Non-steroidal anti-inflammatory drugs (NSAIDs) and injection therapy

Surgery

Figure 4.4 (a) Neer’s sign. (b) Copeland’s impingement test. (c) Hawkin’s test.

Rotator cuff tears

Causes

History and examination

Investigations

Figure 4.5 Tests for rotator cuff weakness. (a) Supraspinatus: resisted abduction in the scapula plane below 40 degrees of abduction. (b) Infraspinatus: resisted external rotation. (c) Subscapularis: resisted internal rotation. The ‘bear hug’ test. (d) Teres minor: resisted external rotation in abduction. Green arrows, examiner’s force; red arrows, patient’s resistance.

Treatment

Calcific tendonitis

Causes

History and examination

Investigations

Treatment

Long head of biceps disorders

Causes

History and examination

Investigations

Figure 4.6 Biceps pathologies. (a) Biceps tendonitis. (b) Biceps instability. (c) Rupture.

Figure 4.7 Speed’s test.

Treatment

Further reading

CHAPTER 5 Shoulder: The Articular Structures

OVERVIEW

Introduction

Labral injuries

Causes

Figure 5.1 Glenoid labrum, showing the superior, anterior, posterior and inferior regions, with a hook demonstrating the loose anterosuperior region.

History and examination

Figure 5.2 SLAP tear with overhead sport – the superior labrum is wrenched and twisted from it’s attachment to the superior glenoid.

Figure 5.3 (a) O’Brien’s test for SLAP tears. (b) Kibler’s clunk test for labral tears. Green arrows, examiner’s force; red arrows, patient’s resistance.

Investigations

Treatment

Shoulder instability

Causes

Traumatic instability

Atraumatic instability

Motor-control instability

History

Examination

Instability tests

Investigations

Treatment

Figure 5.4 Apprehension tests. (a) Anterior. (b) Posterior. (c) Modified O’Brien’s. (d) Anteroinferior sulcus. Green arrows, examiner’s force.

Frozen shoulder

Causes

Box 5.1 Types of frozen shoulder

History and examination

Natural history

Investigations

Treatment

Neuralgic amyotrophy

Causes

History and examination

Investigations

Treatment

Suprascapular nerve palsy

Causes

Figure 5.5 Route of the suprascapular nerve in the shoulder.

History and examination

Investigations

Treatment

Further reading

CHAPTER 6 Elbow

OVERVIEW

Lateral epicondylitis (tennis elbow)

Introduction

Epidemiology

Clinical features

Figure 6.1 Provocative test for lateral epicondylitis (tennis elbow).

Differential diagnoses

Treatment

Medial epicondylitis (golfer’s elbow)

Introduction

Epidemiology

Clinical features

Figure 6.2 Provocative test for medial epicondylitis (golfer’s elbow).

Differential diagnoses

Treatment

Pearls and pitfalls

Olecranon bursitis (student’s/miner’s elbow)

Introduction

Epidemiology

Clinical features

Differential diagnosis

Treatment

Pearls and pitfalls

Complete distal biceps rupture

Introduction

Epidemiology

Clinical features

Figure 6.3 Hook test for checking distal biceps integrity.

Differential diagnosis

Treatment

Distal biceps tendinopathy

Introduction

Differential diagnosis

Treatment

Pearls and pitfalls

Ulnar neuritis (cubital tunnel syndrome)

Introduction

Clinical features

Figure 6.4 Palpation of ulnar nerve in the cubital tunnel posterior to the medial epicondyle.

Figure 6.5 Ulnar claw hand.

Figure 6.6 Froment’s sign.

Figure 6.7 Wartenberg sign.

Differential diagnoses

Treatment

Pearls and pitfalls

Further reading

CHAPTER 7 Soft Tissue Disorders at the Wrist

OVERVIEW

Basic anatomy

History

Examination

Carpal tunnel syndrome

Incidence

Basic anatomy

Figure 7.1 The extent of the flexor retinaculum which overlies the median nerve at the carpal tunnel, its most proximal border attaching to the pisiform and tubercle of the scaphoid bone.

Figure 7.2 Palmaris longus can be a useful marker to site the position of the median nerve as it enters the carpal tunnel. If the patient opposes the thumb and fifth finger the tendon becomes evident. If it is absent, the crease between the thenar and hypothenar eminence denotes the nerve’s position.

Cause

Diagnosis

Treatment

de Quervain’s tenosynovitis

Anatomy

Figure 7.3 Lower left arrow: the site of de Quervain’s tenosynovitis as the tendons of APL and EPB pass over the wrist joint. Upper right arrow: the site of intersection syndrome.

Figure 7.4 Finklestein’s test: the thumb is positioned into the palm of the hand and fingers wrapped around. The wrist is then taken gently into ulnar deviation. This puts the tendons and sheath under tension and will reproduce the patient’s symptoms.

Cause

Diagnosis

Treatment

Intersection syndrome (oarsman’s wrist)

Anatomy

Symptoms

Treatment

Triangular fibrocartilage complex (TFCC) pathology

Anatomy

Cause

Symptoms

Examination

Clinical tip

Figure 7.5 The TFCC test.

Figure 7.6 Piano key test.

Clinical tip

Investigations

Treatment

Less common soft tissue disorders

Further reading

CHAPTER 8 Soft Tissue Injuries of the Hand

OVERVIEW

Introduction

Tendon injuries at the distal interphalangeal joint (DIPJ)

Mallet finger: rupture of the extensor tendon at the DIPJ

Management

Plain radiography

Extension splint

Figure 8.1 Mallet finger.

Figure 8.2 Mallet finger extension splint.

Follow-up

Jersey finger: rupture of the flexor tendon at the DIPJ

Introduction

Management

Proximal interphalangeal joint (PIPJ) injuries

Introduction

Management

Figure 8.3 Bedford splint.

Reduction of a dislocated or subluxed PIPJ

Specialty review

Follow-up

Figure 8.4 Armchair (boutonniere) splint.

Boutonniere injury

Figure 8.5 Boutonniere deformity.

Diagnosis

Figure 8.6 UCL injury: Stener lesion. ADA, adductor aponeurosis.

Treatment

Ulnar collateral ligament (UCL) injuries of the thumb

Introduction

Management

Figure 8.7 Plastic thumb spica for UCL injury.

Immobilization

Further imaging on initial presentation

Specialty review

Follow-up

Further reading

CHAPTER 9 Common Soft Tissue Disorders of the Hip

OVERVIEW

Tendinopathies and muscle lesions

General principles of treatment

Acute muscle and tendon injury

Box 9.1 Differential diagnosis of disorders around the hip

Common causes

Less common causes

Rare but important causes

Chronic and recurrent tendinopathy

Adductor tendinopathy

History

Examination

Investigations

Treatment

Box 9.2 Rehabilitation programme for adductor tendinopathy

Module I (first 2 weeks)

Module II (from third week; module II is done twice at each training session)

Hip flexor tendinopathy

History

Examination

Figure 9.1 Thomas test.

Investigations

Treatment

Hamstring tendinopathy

History

Figure 9.2 Nordic eccentric hamstring exercise.

Examination

Investigations

Treatment

Clinical tip

Trochanteric tendinopathy and bursitis

History

Examination

Figure 9.3 Trendelenberg test.

Investigations

Treatment

Piriformis impingement

History and examination

Investigations

Treatment

Other hip disorders

Meralgia paraesthetica

History

Examination

Figure 9.4 Distribution of numbness in the thigh.

Investigations

Treatment

Figure 9.5 Cam and pincer deformities.

Acetabular labrum lesions/femoroacetabular impingement

History

Examination

Figure 9.6 The ‘FAIR’ (flexion, internal rotation and adduction) test.

Figure 9.7 X-ray of osteoarthritis of the hip.

Investigations

Treatment

Osteoarthritis of the hip

History

Examination

Investigations

Treatment

Further reading

CHAPTER 10 Soft Tissue Knee Injuries

OVERVIEW

Introduction

The approach to knee injury and knee injury triage

History

Examination

Box 10.1 Key points in examination of acute knee injury

Does the patient need an x-ray?

Triage of knee injury

Cruciate ligament injuries

Figure 10.1 A scheme for the triage of knee injuries. FWB, full weight bear; ROM, range of movement; SLR, straight leg raise.

Figure 10.2 Cruciate ligaments.

ACL injuries

History

Examination

Figure 10.3 The Lachman test. Note the degree of flexion and the hand position, allowing an anterior force on the proximal tibia.

Treatment

PCL injuries

Figure 10.4 Detecting a PCL injury. Note the posterior sag of the proximal tibia (a) and the posterior force applied for the posterior draw test (b).

Medial collateral ligament (MCL)

History

Examination

Figure 10.5 Assessing the integrity of the MCL. Note the hand position controlling the knee and permitting the application of a valgus force.

Treatment

Figure 10.6 A simple hinged knee brace allows movement but protects the MCL.

Lateral collateral ligament (LCL)

History

Examination

Treatment

Medial meniscus and lateral meniscus

History

Examination

Treatment

Patellar dislocation

Figure 10.7 Patellar dislocation.

History

Examination

Treatment

Further reading

CHAPTER 11 Non-traumatic Knee Problems

OVERVIEW

Anterior knee pain

History

Examination

Figure 11.1 The knee is subject to large forces; for example, simply going up stairs results in three times the body weight going through the patellofemoral joint.

Box 11.1 Common causes of anterior knee pain

Figure 11.2 Showing sites of quadriceps insertion entheseiopathy, bipartite patella problems, Sinding-Larsen–Johansson disease, patellar tendinitis and Osgood–Schlatter disease.

Differential diagnosis

Treatment

Bursitis

Introduction

Figure 11.3 Positions of knee bursae.

Clinical features

Differential diagnosis

Treatment

Quadriceps tendon rupture/patellar tendon rupture

Introduction

Clinical features

Table 11.1 Causes of non-traumatic knee swelling

Figure 11.4 High riding patella in case of patellar tendon rupture.

Treatment

Non-traumatic swollen knee

Introduction

Clinical features

Investigation

Differential diagnosis

Treatment

Further reading

CHAPTER 12 Calf and Shin Problems

OVERVIEW

Introduction

Muscular injury

Achilles injuries/tendinopathy

Figure 12.1 Calf anatomy, and the anatomical relationships of the anterior and posterior groups.

Table 12.1 Functional grading of muscular injuries of the calf (after Brukner and Khan 2006)

Achilles tendinopathy

Figure 12.2 Simmond’s test. When the right calf (unaffected) is squeezed, the foot plantar-flexes. When the left calf is squeezed, the foot does not move due to the left Achilles tendon being ruptured. Note the loss of tendon definition on the left due to swelling.

Treatment of Achilles rupture

Shin splints

Non-bony pathologies

Treatment of MTSS/shin splints

Common peroneal nerve injury

Baker’s cyst

Bony pathologies

Figure 12.3 Periosteal elevation over medial tibia, indicating a tibial stress fracture.

Figure 12.4 Tibial stress fracture with cortical infraction.

Further reading

CHAPTER 13 Soft Tissue Injuries of the Ankle

OVERVIEW

Anatomy of the ankle joint

Lateral ligament complex

Medial ligament complex

Tibiofibular syndesmosis

Clinical assessment of the ankle joint

Figure 13.1 The ankle joint with supporting ligaments.

Ottawa Ankle Rules: do they work?

Figure 13.2 Ottawa ankle rules.

Lateral ligament complex injuries

Classification

Ligament testing for lateral ligament complex injuries

Anterior drawer test

Talar tilt test

Table 13.1 Classification of ankle sprains

Figure 13.3 Anterior drawer test.

Figure 13.4 Talar tilt test.

ATFL stress test

CFL stress test

Medial ligament complex injuries

Medial collateral ligament stress test

Figure 13.5 (a) The ATFL test shown with examiner cupping the calcaneum with one hand and using the other hand to plantar flex and invert the ankle. (b) Axial view of the ATFL test in application with the ankle in plantar flexion and inversion.

Figure 13.6 CFL stress test.

Figure 13.7 Medial collateral ligament stress test.

High (syndesmotic) ankle sprain

External rotation stress test

Ankle instability and chronic ankle pain

Figure 13.8 External rotation stress test.

Treatment: interventions and rehabilitation

Acute/protected motion phase of rehabilitation

Progressive loading/sensorimotor training phase of rehabilitation

Further reading

CHAPTER 14 The Foot

OVERVIEW

Plantar fasciitis

Introduction

Epidemiology

Clinical features

Figure 14.1 Passive dorsiflexion of the toes.

Differential diagnoses

Treatment

Figure 14.2 Rubbing the plantar fascia with toes dorsiflexed.

Figure 14.3 Can rolling.

Figure 14.4 Toe curling.

Metatarsalgia

Introduction

Epidemiology

Clinical features

Differential diagnoses

Treatment

Figure 14.5 Calf stretch. (a) Flat on the floor; (b) on a step.

Pearls and pitfalls

Extensor tendinopathy

Introduction

Epidemiology

Clinical features

Differential diagnoses

Treatment

Pearls and pitfalls

Tibialis posterior tendinopathy

Introduction

Epidemiology

Clinical features

Figure 14.6 The single-limb heel rise test.

Differential diagnoses

Treatment

Figure 14.7 Walking boot.

Pearls and pitfalls

Stress fracture

Introduction

Epidemiology

Clinical features

Differential diagnoses

Treatment

Complex regional pain syndrome (CRPS)

Introduction

Epidemiology

Clinical features

Treatment

Pearls and pitfalls

Further reading

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Francis Morris,William Brady,John Camm,Electrocardiography,Clinical