Orthopedics Flashcards
A 30 year old man presents with severe pain in the left hip it has been present on and off for many years. He was born at 39 weeks gestation by emergency caesarean section after a long obstructed breech delivery. He was slow to walk and as a child was noted to have an antalgic gait. He was a frequent attender at the primary care centre and the pains dismissed as growing pains. X-rays show almost complete destruction of the femoral head and a narrow acetabulum. What is the most likely underlying disease process?
Developmental dysplasia of the hip Slipped upper femoral epiphysis Extra capsular fracture of the femoral neck Rheumatoid arthritis Perthes disease
Developmental dysplasia of the hip. Usually diagnosed by Barlow and Ortolani tests in early childhood. Most Breech deliveries are also routinely subjected to USS of the hip joint. At this young age an arthrodesis may be preferable to hip replacement.
An 80 year old woman has a hip fracture. Her calcium is normal. She has never been given a diagnosis of osteoporosis. Apart from treating the hip fracture what additional intervention should be considered?
Vitamin D and calcium supplements alone Vitamin D, calcium supplements and bisphosphonates Vitamin D alone Calcium supplements alone DEXA scan
Vitamin D, calcium supplements and bisphosphonates
The osteoporosis guidelines state if a postmenopausal woman has a fracture she should be put on bisphosphonates (there is no need for a DEXA scan).
A 50 year old female slips on wet floor injuring her ankle. On examination, she has tenderness over the lateral and medial malleolus. X-rays (stress views) demonstrate an undisplaced fracture of the distal fibula at the level of the syndesmosis and a congruent ankle mortise. What is the most appropriate management?
Application of full leg cast Surgical fixation Application of below knee plaster cast Application of external fixator Bed rest, splinting and traction
This is a Weber B fracture and therefore potentially unstable. Medial malleolar tenderness indicates deltoid ligament injury. As the fracture is currently undisplaced and the ankle mortice is congruent, the injury can be initially managed conservatively in a below knee plaster but the patient should be monitored in the outpatient clinic for fracture displacement in the first few weeks.
A 78 year old man complains of a long history of shoulder pain and more recently weakness. On examination, active attempts at abduction are impaired. Passive movements are normal. What is the most likely diagnosis?
Rotator cuff tear Osteoarthritis Metastatic malignancy Adhesive capsulitis Calcific tendonitis
Rotator cuff tears are common in elderly people and may occur following minor trauma or as a result of long standing impingement. Tears greater than 2cm should generally be repaired surgically. The length of the history in this scenario is suggestive of a tear complicating impingement.
A toddler aged 3 years presents to the Emergency Department with swelling of his leg and is found to have a spiral fracture of the tibia. His mother reports that he had tripped and fallen the previous day but she had not noticed any sign of injury at the time. She is a single parent with little family support. The child is not on the child protection register. What is the most likely underlying problem?
Metabolic bone disease of prematurity Non accidental injury Hypophosphataemic rickets Osteogenesis imperfecta Rickets
Non accidental injury
Delayed presentation is unusual and should raise concern. In addition, spiral fractures are usually the result of rotational injury which is not compatible with the mechanism proposed by the parent.
A 24 year old man sustains a distal radius fracture during a game of rugby. Imaging shows a comminuted fracture with involvement of the articular surface. What is the most appropriate definitive management?
Open reduction and internal fixation Reduction under anaesthesia and place in plaster cast Reduction under haematoma block and place into plaster cast Place onto skeletal traction system Apply a futura splint and review in fracture clinic
Open reduction and internal fixation
Meticulous anatomical alignment of the fracture segments is crucial to avoid the development of osteoarthritis and risk of malunion.
A 15 year old boy is brought to the clinic by his mother who is concerned that he has a mark overlying his lower spine. On examination, the boy has a patch of hair overlying his lower lumbar spine and a birth mark at the same location. Lower limb neurological examination is normal. What is the most likely cause?
Spina bifida occulta Meningomyelocele Spondylolisthesis Scheuermanns disease Myelocele
Spina bifida occulta is a common condition and may affect up to 10% of the population. The more severe types of spina bifida have more characteristic skin changes. Occasionally the unwary surgeon is persuaded to operate on these cutaneous changes and we would advocate performing an MRI scan prior to any such surgical procedure in this region.
An 82 year old female presents to the emergency room after tripping on a step. She complains of shoulder pain. On examination there is pain on initiating shoulder abduction. What is the most likely diagnosis?
Glenohumeral dislocation Fracture of the anatomical neck of the humerus Sternoclavicular dislocation Supraspinatus tear Infraspinatus tear
A supraspinatus tear is the most common of rotator cuff tears. It occurs as a result of degeneration and is rare in younger adults.
A 35 year old mechanic is hit by a fork lift truck. He sustains a Gustilo and Anderson type IIIA fracture of the shaft of the left femur. What is the most appropriate course of action?
Amputation Debridement and external fixation Open reduction and fixation Debridement and placement of intramedullary nail Debridement and placement of long leg plaster cast
As there is no associated vascular injury the patient may be suitable for debridement of the area and external fixation. If debridement leaves a tissue defect then plastic surgical repair will be needed at a later stage. With open fractures, its best not to place intramedullary metalwork as this may become infected
A 42 year old skier falls and impacts his hand on his ski pole. On examination, he is tender in the anatomical snuffbox and on bimanual palpation. X-rays with scaphoid views show no evidence of fracture. What is the most appropriate course of action?
Admission and surgical debridement Application of tubigrip bandage and fracture clinic review Application of futura splint and fracture clinic review Admission for open reduction and fixation Discharge with reassurance
Application of futura splint and fracture clinic review
A fracture may still be present and should be immobilised until repeat imaging can be performed. If clinical suspicion persists then subsequent imaging should be with MRI scanning or CT if MRI is contra-indicated.
A 30 year old man injures his ankle playing football. On examination, he has tenderness over both medial and lateral malleoli. X-ray demonstrates a bimalleolar fracture with a displaced distal fibula fracture, at the level of the syndesmosis and fracture of the medial malleolus with talar shift. The ankle has been provisionally reduced and splinted in the emergency department. What is the most appropriate management?
Application of external fixation device Application of compression dressing and physiotherapy Application of ankle boot Surgical fixation Below knee amputation
This is an unstable fracture pattern with a Weber B fracture of the distal fibula and a fracture of the medial malleolus. Talar shift indicates loss of ankle mortice congruity. This injury should therefore be treated with surgical fixation.
A 74 year old male is admitted to the Emergency Department with a fall. He is known to have rheumatoid arthritis and is on methotrexate and paracetamol. He lives alone in a bungalow and enjoys playing golf. He is independent with his ADLs. He complains of left groin pain, therefore has a hip x-ray which confirms a displaced intracapsular fracture. What is the best course of action?
Cemented hemiarthroplasty Uncemented hemiarthroplasty Total hip replacement Dynamic hip screw Intramedullary nail
This patient has pre-existing joint disease, good level of activity and a relatively high life expectancy, therefore THR is preferable to hemiarthroplasty.
An obese 12 year old boy is referred with pain in the left knee and hip. On examination, he has an antaglic gait and limitation of internal rotation. His knee has normal range of passive and active movement. What is the most likely diagnosis?
Septic arthritis Developmental dysplasia of the hip Perthes disease Osteoarthritis of the hip Slipped upper femoral epiphysis
Slipped upper femoral epiphysis is commonest in obese adolescent males. The x-ray will show displacement of the femoral epiphysis inferolaterally. Treatment is usually with rest and non weight bearing crutches.
A 5 month baby boy presents with swelling of his right arm and is found to have a spiral fracture of the humerus. He had been in the care of his mother’s boyfriend who reported that he had nearly dropped him that day when reaching for his bottle and had inadvertently pulled on his arm to save him. He was immediately taken to the Emergency Department. What is the most likely issue?
Non accidental injury Accidental fracture Malignant bone disease Osteoporosis Osteogenesis imperfecta
Accidental fracture
The mechanism fits with the fracture pattern and the presentation is not delayed
A 26 year old man presents to the emergency department with a swelling over his left elbow after a fall on an outstretched hand. On examination, he has tenderness over the proximal part of his forearm, and has severely restricted supination and pronation movements. What is the most likely injury?
Fracture of the olecranon Fracture of the radial head Galeazzi fracture Fracture of the shaft of the radius and ulnar Fracture of the coronoid process
Fracture of the radial head is common in young adults. It is usually caused by a fall on the outstretched hand. On examination, there is marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination).
A 19 year old sportswoman presents with knee pain which is worse on walking down the stairs and when sitting still. On examination, there is wasting of the quadriceps and pseudolocking of the knee. What is the diagnosis?
Osteoarthritis Quadriceps tendon rupture Undisplaced fracture patella Chondromalacia patellae Osgood Schlatters disease
A teenage girl with knee pain on walking down the stairs is characteristic for chondromalacia patellae (anterior knee pain). Most cases are managed with physiotherapy.
A 58 year old man presents to the plastics team with severe burns to his hands. He is not distressed by the burns. He has bilateral charcot joints. On examination; there is loss of pain and temperature sensation of the upper limbs. What is the most likely diagnosis?
Potts disease of the spine Tabes dorsalis Transverse myelitis Syringomyelia Subacute degeneration of the cord
This patient has syringomyelia which selectively affects the spinotholamic tracts. Syringomyelia is a disorder in which a cystic cavity forms within the spinal cord. The commonest variant is the Arnold- Chiari malformation in which the cavity connects with a congenital malformation affecting the cerebellum. Acquired forms of the condition may occur as a result of previous meningitis, surgery or tumours. Many neurological manifestations have been reported, although the classical variety spares the dorsal columns and medial lemniscus and affecting only the spinothalamic tract with loss of pain and temperature sensation. The bilateral distribution of this patients symptoms would therefore favor syringomyelia over SCID or Brown Sequard syndrome. Osteomyelitis would tend to present with back pain and fever in addition to any neurological signs. Epidural haematoma large enough to produce neurological impairment will usually have motor symptoms in addition to any selective sensory loss, and the history is usually shorter.
A 32 year old man falls from scaffolding and sustains an injury to his forearm. Clinical examination and x-ray shows that he has sustained a radial fracture with dislocation of the distal radio-ulna joint. What eponymous name is used to describe this injury?
Galeazzi Monteggia's Smith's Colles' Barton's
Galeazzi fracture
Radial shaft fracture with associated dislocation of the distal radioulnar joint
Direct blow
A 24 year old man is brought to the emergency department having suffered a crush injury to his forearm. Assessment demonstrates that the arm is tender, red and swollen. There is clinical evidence of an ulnar fracture and the patient cannot move their fingers. Which is the most appropriate course of action?
Application of an external fixation device Closed reduction Debridement Discharge and review in fracture clinic Fasciotomy
The combination of a crush injury, limb swelling and inability to move digits should raise suspicion of a compartment syndrome that will require a fasciotomy. Paralysis is a very late sign.
A 5 year old boy presents with a painful limp. The symptoms have been present for 8 weeks. Two hip x-rays have been performed and appear normal. What is the best course of action?
Arrange a hip USS Arrange a hip CT scan Arrange a hip MRI Arrange a further hip X-ray Discharge and reassure
Perthes disease should be suspected in boys over 4 years old presenting with a limp. Early disease can be missed on x-ray. An MRI will often demonstrate areas of hypoperfusion and subtle changes that allow for earlier diagnosis. A bone scan is an alternative option.
An 8 year old boy presents with symptoms of right knee pain. The pain has been present on most occasions for the past three months and the pain typically lasts for several hours at a time. On examination; he walks with an antalgic gait and has apparent right leg shortening. What is the most likely diagnosis?
Perthes Disease Osteosarcoma of the femur Osteoarthritis of the hip Transient synovitis of the hip Torn medial meniscus
Perthes Disease
There are many causes of the irritable hip in the 10-14 year age group. Many of these may cause both hip pain or knee pain. Transient synovitis of the hip the commonest disorder but does not typically last for 3 months. An osteosarcoma would not usually present with apparent limb shortening unless pathological fracture had occurred. A slipped upper femoral epiphysis can cause a similar presentation although it typically presents later and with different patient characteristics.
A 30 year old man is admitted overnight, following a road traffic accident. He has an open tibial fracture with a 20 cm wound and extensive periosteal stripping. He is neurovascularly intact; IV antibiotics and wound dressing have been administered in the emergency department. What is the most appropriate course of action?
Immediate skeletal stabilisation and application of negative pressure dressing Skeletal fixation followed by vascular reconstruction Immediate vascuIar shunting, followed by temporary skeletal stabilisation and vascular reconstruction Combined skeletal and soft tissue reconstruction on a scheduled operating list Fasciotomy with four compartment decompression
This patient has a Gustillo-Anderson Grade 3B open fracture. He will require definitive skeletal and soft tissue reconstruction, which should be performed on a combined ortho-plastic scheduled operating list, as per the BOA/BAPRAS guidelines. The surgery does not have to be performed out of scheduled hours unless there is marine/ sewage contamination, vascular compromise or it is a polytrauma.
Whilst it is reasonable to apply an external fixator prior to definitive skeletal and soft tissue reconstruction, this should be converted to internal fixation within 72 hours.
Which of the following types of growth plate fractures may have similar radiological appearances?
Salter Harris types 1 and 5 Salter Harris types 4 and 5 Salter Harris types 3 and 5 Salter Harris types 1 and 2 Salter Harris types 1 and 3
Salter Harris injury types 1 and 5 (transverse fracture through growth plate Vs. Compression fracture) may mimic each other radiologically. Type 5 injuries have the worst outcomes. Radiological signs of type 5 injuries are subtle and may include narrowing of the growth plate.
A 60 year old male is admitted to the emergency room with a fall. He lives with his wife and still works as a restaurant manager. He has a past history of benign prostatic hyperplasia and is currently taking tamsulosin. He is otherwise fit and healthy. On examination, there is right hip tenderness on movement in all directions. A hip x-ray confirms an intertrochanteric fracture. What is the best management option?
Cemented hemiarthroplasty Total hip replacement Dynamic hip screw Percutaneous pinning Leg traction
The blood supply to the femoral head may be intact and the fracture should heal with compression type devices such as gamma nails or dynamic hip screws. The latter device being the most commonly performed therapeutic intervention.
Which of the following fractures names best accounts for the injury seen in a 14 year old boy who jumps off a 10 foot wall and lands on both feet and whose imaging shows a bimalleolar fracture of the right ankle?
Pott's Barton's Galeazzi Colles' Bennett's
Pott’s fracture
Bimalleolar ankle fracture
Forced foot eversion
A 22 year old rugby player falls onto an outstretched hand and sustains a fracture of the distal radius. The x-ray shows a dorsally angulated comminuted fracture. What is the most appropriate management?
Reduce under haematoma block and place in plaster Admit for open reduction and internal fixation Reduce using Biers block and place into plaster cast Discharge home with arm sling and review in fracture clinic Discharge home with futura splint and fracture clinic appointment
Admit for open reduction and internal fixation
Unlike an osteoporotic fracture in an elderly lady this is a high velocity injury and will require surgical fixation.
An athletic 15 year old boy presents with knee pain of 3 weeks duration. It is worst during activity and settles with rest. On examination, there is tenderness overlying the tibial tuberosity and an associated swelling at this site. What is the diagnosis?
Chondromalacia patellae Avulsion fracture of the tibial tubercle Osgood Schlatters disease Quadriceps tendon rupture Undisplaced fracture patella
Osgood Schlatters disease
Athletic boys and girls may develop this condition in their teenage years. It is caused by multiple micro fractures at the point of insertion of the tendon into the tibial tuberosity. Most cases settle with physiotherapy and rest.
A 23 year old rugby player falls directly onto his shoulder. There is pain and swelling of the shoulder joint. The clavicle is prominent and there appears to be a step deformity. What is the most likely diagnosis?
Acromioclavicular joint dislocation Glenohumeral dislocation Sternoclavicular dislocation Supraspinatus tear Infra spinatus tear
Acromioclavicular joint (ACJ) dislocation normally occurs secondary to direct injury to the superior aspect of the acromion. Loss of shoulder contour and prominent clavicle are key features. Note; rotator cuff tears rarely occur in the second decade.
A 4 year boy presents with an abnormal gait. He has a history of recent viral illness. His WCC is 11 and ESR is 30. What is the most likely cause?
Perthes disease Transient synovitis Septic arthritis Slipped upper femoral epiphysis Osteomyelitis
Viral illnesses can be associated with transient synovitis. The WCC should ideally be > 12 and the ESR > 40 to suggest septic arthritis.
An 8 year old boy falls onto an outstretched hand and is brought to the emergency department. He is examined by a doctor and a bony injury is cleared clinically. He re-presents a week later with pain in his hand. What is the most likely underlying injury?
Fracture of the distal radius Fracture of the scaphoid Dislocation of the lunate Rupture of flexor pollicis longus tendon Bennett's fracture
Scaphoid fractures in children are rare, will usually involve the distal pole and are easily missed. The initial clinical examination (and sometimes x-rays) may be normal and repeated clinical examination and imaging is advised for this reason. Whilst the other injuries may be sustained from a fall onto an outstretched hand they are less likely to be overlooked on clinical examination. In the case of a Bennetts fracture, the injury mechanism is less compatible with this type of injury.
A 45 year old man has been admitted after being knocked off his bicycle. His ankle is grossly deformed with bilateral malleolar tenderness with severe ankle swelling and tenting of the medial soft tissues. What is the most appropriate initial management?
Application of compression dressing and physiotherapy Application of external fixation device Immediate reduction and application of backslab Surgical fixation Application of full leg plaster cast
This is an unstable ankle injury that is likely to require surgical fixation. The immediate management of a displaced ankle fracture is to reduce the fracture to prevent soft tissues compromise and help reduce swelling. This can be performed before an x-ray is obtained if performing the x-ray will significantly delay reduction.
A 1 year-old is brought to the Emergency Department with a history of failure to thrive. On examination, the child is small for age and has a large head. X-ray shows a cupped appearance of the epiphysis of the wrist. What is the most likely cause?
Osteoporosis Ehlers Danlos Marfans Rickets Non accidental injury
Rickets is the childhood form of osteomalacia. It is due to the failure of the osteoid to ossify due to vitamin D deficiency. Symptoms start about the age of one. The child is small for age and there is a history of failure to thrive. Bony deformities include bowing of the femur and tibia, a large head, deformity of the chest wall with thickening of the costochondral junction (rickettary rosary), and a transverse sulcus in the chest caused by the pull of the diaphragm (Harrison’s sulcus). X- Rays show widening and cupping of the epiphysis of the long bones, most readily apparent in the wrist.
A 40 year old marine injures his ankle on an assault course. On examination he has a severely swollen ankle, as well as tenderness over the medial malleolus and proximal fibula. X-rays demonstrate a medial malleolar fracture, spiral fracture of the proximal fibula and widening of the syndesmosis. What is the most appropriate definitive management?
Surgical fixation Application of ankle boot Application of lower leg plaster cast Application of external fixation device Below knee amputation
This is a Maisonneuve fracture of the proximal fibula. It indicates an unstable ankle injury with likely injury to the interosseous membrane. In the setting of radiographic evidence of syndesmotic widening, this requires surgical fixation to reduce and stabilise the syndesmosis.
Which of the following is not a typical feature of talipes equinovarus?
Adducted and inverted calcaneus Medial displacement of the navicular bone It is nearly always unilateral Wedge shaped head of talus Severe Tibio-talar plantar flexion
It is bilateral in 50% of cases.
Which of the following statements relating to menisceal tears is false?
The medial meniscus is most often affected True locking of the knee joint may occur Most established tears will heal with conservative management In the chronic setting there is typically little to find on examination if the knee is not locked An arthroscopic approach may be used to treat most lesions
Menisci have no nerve or blood supply and thus heal poorly. Established tears with associated symptoms are best managed by arthroscopic menisectomy.
An obese 12 year old boy presents with knee pain. On examination, he has pain on internal rotation of the hip. His knee is clinically normal. What is the most appropriate investigation?
USS hip CT scan of the hip Radinucleotide scan Hip X-ray Anteroposterior pelvic x-ray
The main differential diagnosis in a boy over 10 years old is of slipped upper femoral epiphysis. Knee pain is a common presenting feature. An anteroposterior pelvic x-ray may miss a minor slip, therefore request a hip film.
