Clinical Flashcards
(257 cards)
1
Q
What fraction of the general population consults a GP about a musculoskeletal problem each year?
A
1 in 5
2
Q
What type of shoulder/elbow problems typically present clinically for a patient in their teens/20s?
A
Fractures and instability
3
Q
What type of shoulder/elbow problems typically present clinically for a patient in their 30s/40s?
A
Rotator cuff injuries and capsultitis
4
Q
What type of shoulder/elbow problems typically present clinically for a patient in their 50s/60s?
A
Impingement and AC joint problems
5
Q
What type of shoulder/elbow problems typically present clinically for a patient in their 70s onwards?
A
Degenerative rotator cuff and joint problems
6
Q
What is the general causes of upper limb fractures?
A
- Young high energy injuries
- Elderly osteoporotic injuries
7
Q
What does upper limb fracture management depend on?
A
Fracture configuration and patient biology
Surgery vs non-surgical methods
8
Q
What is the most common type of traumatic shoulder dislocation?
A
Anterior (90%)
9
Q
What treatments are available for traumatic shoulder dislocation?
A
Manipulation
Immobilisation
Physiotherapy
Surgery
10
Q
What occurs in subacromial impingement?
A
Pain and dysfunction from any pathology that decreases the volume of the subacromial space or increases the size of its contents
11
Q
What treatments are available for subacromial impingement?
A
- Subacromial steroid injection
- Physiotherpay
- Arthroscopic subacromial decompression
12
Q
What is another name for frozen shoulder?
A
Adhesive capsulitis
13
Q
How is frozen shoulder diagnosed?
A
Clinical diagnoses based on findings
A normal radiograph would be seen
14
Q
What is a treatment for early presentation of frozen shoulder?
A
Hydrodilatation
15
Q
What is a treatment for late presentation of frozen shoulder?
A
Surgery
16
Q
What is the natural timecourse of frozen shouder?
A
Pain>Stiffness»‘Thawing’
17
Q
What are two types of causes of rotator cuff tear injuries?
A
Traumatic
Degenerative
18
Q
What is the treatment for acute rotator cuff tears?
A
Early surgery
19
Q
What is the treatment for chronic degenerative rotator cuff tears?
A
Surgery if symptomatic
20
Q
What does treatment for rotator cuff tear depend on?
A
Size, Time, Age
21
Q
What is an option for massive irreparable rotator cuff tears?
A
Superior Capsular Reconstruction
uses cadaveric skin graft to reconstruct capsule
22
Q
What are some causes of shoulder arthritis?
A
Osteoarthritis
Inflammatory arthritis
Post-traumatic arthritis
23
Q
What surgical option may exist for severe shoulder arthritis?
A
Shoulder replacement using custom made implants
24
Q
What tends to cause elbow problems in younger patients?
A
Fractures and dislocations
25
What tends to cause elbow problems in middle age patients?
Tendinopathies
26
What tends to cause elbow problems in elderly patients?
Degenerative disease
27
When may cubital tunnel syndrome present in patients?
Any age
28
List the GALS Screening Questions for MSK History in systematic enquiry?
- Do you have any pain or stiffness in your muscles, joints or back?
- Can you dress yourself completely without any difficulty?
- Can you walk up and down stairs without any difficulty?
29
What are common orthopaedic symptoms when something FEELS wrong?
Pain, Dysaesthesiae, Weakness
30
What are common orthopaedic symptoms when something MOVES wrong?
Stiffness, Reduced RoM (eg locking), limp, instability/collapsing, crepitus
31
What are common orthopaedic symptoms when something LOOKS wrong?
Swelling, Deformity, Wasting, Shortening, Discolouration (Redness, pallor, bruising), wounds
32
What are the cardinal presenting orthopaedic symptoms?
```
Pain
Stiffness
Swelling
Deformity
Discolouration
```
33
What questions may be asked in history of a typical day in MSK history?
```
Wake at normal time or woken by pain?
How are they first thing in the morning? Is this when pain/swelling/stiffness is worst?
How long does it take to get going? Do they have to do exercises?
Dressing etc?
Walking distance on flat?
Driving?
Shopping?
Work, Hobbies?
```
34
What are some red flags from history taking that may suggest serious pathology?
- Severe and worsening pain
- Night pain disturbing sleep
- Non-mechanical pain
- General malaise, febrile, rigors
- Unexplained weight loss, anorexia, night sweats
- Past history of malignant disease
35
What is in the GALS Screening system for musculoskeletal examination?
Gait
Arms
Legs
Spine
36
What angle are the joints at in anatomical position?
0 degrees
37
In hand and forearm, what terms should be used as an alternative to lateral and medial?
Radial and ulnar
38
In hand and forearm, what terms should be used as an alternative to posterior and anterior?
Dorsal and volar (palmar)
39
What is the system used in local musculoskeletal examination?
Look
Feel
Move
X-Ray
(If possible, look at available xrays first - don't move fresh fracture!)
40
What should be considered in Look?
```
Posture - of patient, limb
Relevant negatives and obvious positives
Gait - limp?
Skin - scars, wounds etc
Colour - redness, bruising, pallor, vascular markings
Swelling
Wasting (In lower limb, look at proximal muscles to joint problem)
Deformity
Limb lengths - real and apparent
```
41
How are real limb lengths measured?
FRom ASIS/greater trochanter/tibial tuberosity to medial malleolus
42
How are apparent limb lengths measured?
Xiphisternum or umbilicus to medial malleolus
43
What should be considered in Feel?
Skin - temp, sweating, cap refill
Tenderness (Localised, diffuse)
Swelling
Deformity
44
What should be considered in Move?
Active movements
Passive movements
Special tests - abnormal movement, joint laxity, tests
Range, rate, rhythm
RoM's - degrees or % vs normal side, comparisons
Accompanied by pain, crepitus, stiffness
Rhythm/smoothness, laxity/hypermobility, tenodess,
Muscle tone
Power/strength
Joint laxity/hypermobility
45
What else needs to be considered in MSK examination?
- Must examine joints above and below, and examine spine for any limb symptoms
- +Neurovascular examination of whole limb
- Consider other relevant systematic examination - chest, abdomen, neuro
Record findings - xray?
Re-examine and compare
46
What sort of presentation may be seen with C5/6 Brachial Plexus Damage?
Erb-Duchenne paralysis (Porter's tip)
Caused by downward traction eg fall on side of neck
47
What sort of presentation may be seen with T1 Brachial Plexus Damage?
Klumpke's paralysis (hand 'clawed')
Caused by upward traction eg breech delivery
48
What presentation may be seen with motor deficit of the axillary nerve?
Loss of shoulder abduction
49
What presentation may be seen with sensory deficit of the axillary nerve?
Sensory loss in 'badge' area
50
What is saturday night palsy'?
Pressure on posterior cord of brachial plexus, resulting in damage to axillary nerve/radial nerve.
51
What presentation may be seen with motor deficit of the radial nerve?
Wrist drop (Extensor damage)
52
What presentation may be seen with sensory deficit of the radial nerve?
Sensory loss in 1st web space dorsally
53
What can median nerve damage arise as a complication of?
Carpal tunnel syndrome
| Wrist lacerations
54
What presentation may be seen with motor deficit of the median nerve?
Thenar wasting (Monkey hand), Pointing finger
55
What presentation may be seen with sensory deficit of the medial nerve?
Sensory loss of volar aspect of thumb
56
What can ulnar nerve damage arise as a complication of?
Fractures of humeral condyles
| Wrist lacerations
57
What presentation may be seen with motor deficit of the ulnar nerve?
Claw hand, Hypothenar and 1st dorsal interossus wasting
58
What presentation may be seen with sensory deficit of the ulnar nerve?
Sensory loss of little finger
59
What condition does compression of lateral femoral cutaneous nerve cause?
Meralgia Paraesthetica
| It is sensory to lateral aspect of thigh
60
What presentation may be seen with motor deficit of the common fibular nerve?
Foot drop
| Slapping gait
61
What is the most commonly injured nerve in the lower limb?
Common fibular nerve
62
What test may be used to investigate ulnar nerve palsy?
Froment's Test
63
What clinical conditions may result in axillary nerve damage?
Shoulder dislocation
| Fractured surgical neck of humerus
64
Weakness of what muscle may cause winging of scapula?
Serratus anterior
65
What are some mechanisms for achilles tendon rupture?
- Pushing off with weight bearing foreforr whilst extending knee (sprint starts, jumping)
- Unexpected dorsiflexion of ankle
- Violent dorsiflexion os plantarflexed foot
66
What are some examples of nerve compression?
Carpal tunnel syndrome
Sciatica
Morton's neuroma
67
List some clinical features in nerve injury?
Sensory - dysaethesiae (anaesthetic, hypo/hyperaesthetic, paraesthetic)
Motor - paresis/paralysis/wasting
dry skin
Reflexes - diminished/absent
68
What clinical sign may be used to monitor nerve recovery?
Tinel's sign
| Also via nerve conduction studies
69
What methods may be used in nerve repair?
Direct repair
| Nerve grafting
70
When should surgery ideally be performed for clean and sharp nerve injuries?
Immediately within 3 days
71
When should surgery ideally be performed for blunt/contusive nerve injuries?
Within 3 weeks
72
When should surgery ideally be performed for closed nerve injuries?
Within 3 months
73
In what three directions can the shoulder dislocate?
Anterior
Posterior
Inferior
74
What are some common crystal deposition diseases?
Gout (Monosodium urate)
Pseudogout (Calcium pyrophosphate dihydrate (CPPD))
Calcific periarthritis/tendonitis (Basic calcium phosphate hydroxy-apatite (BCP))
75
In gout, what it a tophi?
Massive accumulation of uric acid
76
Degradation of what molecule makes up the majority of urate production in the body?
Purine metabolism
77
How does gout arise in the majority of people with gout?
Reduced efficiency of renal urate clearance
78
How does HPGRT deficiency lead to gout?
HPGRT normally recycles purine bases - deficiency leads to build up
79
List some connective tissue multi-system autoimmune diseases?
```
Systemic Lupus Erythematosus (SLE)
Scleroderma
Sjogren's syndrome
Auto-immune myositis
Mixed connective tissue disease
```
80
List some systemic vasculitis autoimmune diseases?
Giant cell arteritis
Granulomatosis polyangitis (Wegeners)
Microscopic polyangiitis
Eosoniphilic granulomatosis polyangiitis (Churg-Strauss)
81
What are some mimics to systemic autoimmune diseases?
Drugs - cocaine, minocyline, PTU
Infection - HIV, endocarditic, Hepatitis, TB
Malignancy - lymphoma
Cardiac myxoma
Cholesterol emboli
Scurvy
82
What is used for diagnosis of systemic autoimmune diseases?
```
Cardinal clinical features: History & Exam
Immunology
Imaging
Tissue
Exclusion of differential diagnosis
```
83
List some type of large vessel vasculitis?
Takayasu Arteritis
| Giant Cell Arteritis
84
List some type of medium vessel vasculitis?
Polyartertis Nodosa
| Kawasaki Disease
85
List some type of small vessel vasculitis?
ANCA-Associated Vasculitis
- Microscopic Polyangiitis
- Granulomatosis with polyangiitis
- Eosoniphilic Granulomatosis with Polyangitis
Immune Complex SSV
- Anti-GBM Disease
- Cryoglobulinemic Vasculitis
- IgA Vaculitis (Henoch-Schonlein)
- Hypocomplementemic Urticarial Vasculitis (Anti-C1q Vasculitis)
86
In what conditions is a positive ANA test not helpful?
Rheumatoid Arhritis (30-40% +)
MS (25%)
Infection (Varies)
Normal (30%!)
87
In children's orthopaedics, what hip problems tend to present around 0-5yrs?
```
'Normal variant'
Trauma
Transient synovitis
Osteomyelitis
Septic arthritis
DDH (Developental dysplasia of hip)
JIA
```
88
In children's orthopaedics, what hip problems tend to present around 5-10yrs?
```
Trauma
Transient synovitis
Osteomyelitis
Septic arthritis
Legg-Calve-Perthes disease
```
89
In children's orthopaedics, what hip problems tend to present around 10-15yrs?
```
Trauma
Osteomyelitis
Septic arthritis
SUFE
Chondromalacia
Neoplasm
```
90
What may excessive anterior displacement in a Drawer test suggest?
Injury of the ACL ligament
91
What may excessive posterior displacement in a Drawer test suggest?
Injury of the PCL ligament
92
What is the normal angle of the neck shaft of the hip joint?
~130degrees
93
What is the normal angle of femoral anteversion of the hip joint?
15 degrees
94
What is the normal angle of acetabular anteversion of the hip joint?
20 degrees
95
What can be some clinical signs of hip pathology?
```
-C sign
Exacerbating Factors
Worse Weight Bearing
Difficulty tying shoe laces
Site of pain - Trochancteric, buttock, groin, referred
```
96
What is shenton's line?
Shenton's line is formed by the medial edge of the femoral neck and the inferior edge of the superior pubic ramus.
Loss of contour is a sign of neck of femur fracture
97
What is the clinical management of extra-capsular hip fracture?
Always fix
| The blood supply is intact
98
What is the clinical management of intra-capsular hip fracture?
Management based on age of patient, and displacement.
Blood supply compromised
Undisplaced - Fix
Displaced and Young - Fix
Displaced and old - replace (either hemiarthroplasty or THR)
99
What is the normal ROM for the knee joint?
5-130 degrees
100
What are some common knee injuries?
```
Meniscal tears
Ligament injuries
OCD lesions
Loose bodies
Fractures
Quads/patellar tendon ruptures
```
101
What are some presentations of ACL injury?
```
Knee buckles during pivot
Unable to play on
Immediate haemarthrosis
Recurrent instability
X-ray - Haemarthrosis, segond fracture
```
102
What is the hip Q angle in males?
14 degrees
103
What is the hip Q angle in females?
17 degrees
104
What does genu varum deformity refer to?
Bow legs
105
What does genu valgum deformity refer to?
Knock knees
106
What type of invasive imaging can be used at the knee joint?
Arthroscopy
107
What meniscii of the knee is more commonly damaged?
Medial menisci
108
How may a meniscal tear present?
- “Pop” or crack, delayed swelling
- Locked knee - soft, painful block to full extension (displaced “bucket handle” tear)
- Tender on affected side, sometimes feel click
109
What is the definition of a limp?
Abnormal gait commonly due to pain, weakness or deformity
| Shorter stance phase on the affected limb
110
List some common causes of limp in a child?
```
Toxic synovitis
Septic arthritis
Trauma
Osteomyelitis
Viral syndrome
Perthes disease
Fracture
JRA etc
```
111
Where is the most common source of origin of limp in children?
Hip
112
What questions should be asked in history of a limping child?
Duration and progression of limp?
Recent trauma and mechanism?
Associated pain and its characteristics?
Accompanying weakness?
Time of day when limp is worse?
Can the child walk or bear weight?
Has the limp interfered with normal activities?
Presence of systemic symptoms like fever, weight loss?
Medical history, —birth history, immunisation history, nutritional history, and developmental history
Drug history, allergies
Family history
113
What may be revealed in examination of an antalgic gait?
Tenderness
| Reduced range of motion
114
List some common examples of antalgic gait?
```
Trauma
Toddler's fracture
Overuse syndrome
Infection
Inflammations
```
115
What may be revealed in examination of an abductor lurch gait?
Trendelenburg sign
116
List some common examples of abductor lurch gait?
Hip dysplasia
| Cerebral palsy
117
What may be revealed in examination of an equinus gait?
Heel-cord contraction
| Neurological exam needed
118
List some common examples of equinus gait?
Cerebral palsy
Idiopathic toe walker
Clubfoot
119
What may be revealed in examination of an circumduction gait?
Assess limb lengths
Neurological exam
Check range of motion
120
List some common examples of circumduction gait?
Painful foot
| Leg length inequality
121
What should take place in the examination of a limping child?
Look –
Check sole of foot for foreign bodies !
Deformity? Erythema? Swelling? Effusion?
limitation of active ROM, asymmetry.
Assess shoes for unusual wear on the soles, asymmetry, point of initial foot strike, and also assess the fit.
In older children look for scoliosis, midline dimples, and hairy patches, which could indicate spinal pathology.
Assess gait with the child barefoot.
Assess thigh or calf circumference for asymmetry
Leg length assessment
Feel & Move– Spine, Hip, Knee, Ankle, Foot
Neurological assessment
122
What are some potential infection/inflammatory causes of limp in a child?
Septic arthritis
Osteomyelitis
Transient synovitis
123
What history may suggest infective/inflammation cause of acute limping in a child?
```
Limp (age dependent)
Pain
General malaise/ loss of appetite/ listless
Temperature
Recent URTI/ ear infections
Trauma
Pseudoparalysis
Listen to the parent, they are usually right
```
124
What are differential diagnoses to infection/inflammation causing limping in a child?
Transient synovitis
Osteomyelitis
Septic arthritis
Soemthing else
- Sarcoma
- Myositis
- Osteoid osteoma
- Abscess
- Inflammatory arthropathy
125
What initial investigations may you do to investigate infection/inflammation causing limp in a child?
Temperature
Xray
USS
Bloods - WCC, CRP, ESR, CK, Cultures
126
What features in a limping child may raise concern of neoplasm?
```
Night pain
Often incidental trauma
Strops doing sport/going out
Sweats and fatigue
Abnormal blood results - low Hb, atypical blood film, atypical platelets
Get a paediatrician/oncology opinion
```
127
What is the most common cause of death in children?
Trauma
128
What are some risk factors for children's fractures?
Boys>Girls (60%)
Age - increased physeal injury w age
Previous fracture
Metabolic bone disease
129
List some reasons children's fractures often heal quickly
Metabolically active periosteum
Cellular bone
Plastic
-Therefore do not over immobilise/treat!
130
What are some principles surrounding children's fractures?
- Often simple, incomplete and heal quickly,
- Remodel well in plane of joint movement
- Thick periosteal hinge is helpful
- Fractures involving physes can result in progressive deformity (Deformity - elbow, Arrest - knee, ankle, Overgrowth - femur)
131
What type of forearm fractures can arise from low energy impact?
- Buckle
| - Greenstick
132
What type of forearm fractures can arise from high energy impact?
Open, displaced, soft tissue injury
133
What would be taken into account on assessment of a children's fracture?
History - mechanism
Deformity
Soft tissue - Whole limb, wounds, sensation, motor function, vascular status
Document findings, and repeat post-intervention
134
List some complications from children's fractures of the forearm
Compartment syndrome (Eg Volkmann's fracture)
-Nonunion (5%)
-Refracture (5%)
Radioulnar synostosis (Abnormal connection)
PIN injury
Superficial radial nerve injury
DRUJ/Radiocapitellar problems
135
List some differential diagnosis for knee trauma?
```
Infection
Inflammatory arthopathy
Neoplasm
Apophysitis
Hip
Foot
Sickle, Haemophilia
'Anterior knee pain'
```
136
What type of bony injuries may affect the knee?
```
Physeal/Metaphyseal
Tibial spine
Tibial tubercle
Patellar fracture
Sleeve fracture
Patellar dislocation
Referred
```
137
What may be required for physeal arrest?
```
Monitoring - Harris lines, angulation and length
Resect Bar
Complete epiphysiodesis
Contralateral epiphysiodesis
Corrective osteotomy
```
138
List some warning signs of non accidental injuries in children?
```
Incongruent hx
Bruising – pattern
Burns
Multiple fractures, multiple stages of healing
Metaphyseal #, Humeral shaft #
Rib #
Non-ambulant #
```
139
What is used in a undisplaced patellar fracture?
Cylinder cast
140
What is used in a displaced patellar fracture?
Open reduction internal fixation (ORIF)
141
List some risk factors for patella dislocation
```
Laxity
Poor vastus Medialis
Q angle
Femoral anterversion
Tibial external rotation
Patella alta
```
142
What is used in patellar dislocation management?
```
Cast 2 wks
Repair medial ligament
Mobilise
Lateral release
VM exercises
```
143
What is the name of the set of rules used to determine if ankle xrays are required?
Ottawa rules
144
What are some pitfalls in ankle fracture assessment?
Missed fractures
Normal variation
Persistent displacement
145
What are some management techniques fro ankle fractures
Pop
MUA (Mobilisation under anaesthetic)
Reduction and interfrag screw
Open reduction internal fixation (ORIF)
146
What is the commonest ankle fracture?
SH2 (Salter Harris type 2)
147
When do transitional ankle fractures take place?
Around the age of growth plate closing (13-14)
148
Name some transitional ankle fractures
Tillaux
| Triplane
149
Name some types of overuse injuries in children
Osgood-Schlatter's Disease
| Sever's Disease
150
What is a sarcoma?
Malignant tumour arising from connective tissue
151
List some bone forming tumours
Benign - Osteoid osteoma, osteoblastoma
| Malignant - Osteosarcoma
152
List some cartilage forming tumours
Benign - Enchondroma, osteochonroma
| Malignant - Chondrosarcoma
153
List some fibrous tissue tumours
Benign - Fibroma
| Malignant - Fibrosarcoma, malignant fibrous histiocytoma (MFH)
154
List some vascular tissue tumours
Benign - Haemangioma, Aneurysmal bone cyst
| Malignant - Angiosarcoma
155
List some adipose tissue tumours
Benign - Lipoma
| Malignant - Liposarcoma
156
List some marrow tissue tumours
Benign - Ewing's sarcoma, lymphoma, myeloma
157
What are the characteristics of Giant Cell tumours (GCT)?
Benign, Locally destructive, and can rarely metastasise
158
What should happen to all patients with a soft tissue tumour suspected of malignancy?
Referred to a specialist tumour centre
159
What are potentially suspicious signs of soft tissue tumours?
Deep tumours of any size
Subcutaenous tumours >5cm
Rapid growth, hard, craggy, non-tender
Recurrence after previous excision
160
What is a bony tumour in someone over the age of 50 likely to be?
Bony metastases - much more common than malignant skeletal tumour
161
What is the most common primary malignant bone tumour in a younger patient?
Osteosarcoma
162
What is the most common primary malignant bone tumour in a older patient?
Myeloma
163
What would be described in the history of bony/soft tissue tumour?
Pain
Mass
Abnormal Xrays - incidental
Bone tumours - pain
164
What would be looked at in the examination of a bony tumour?
```
General health
Measurements of mass
Location
Shape
Consistency
Mobility
Tenderness
Local temperature
Neuro-vascular deficits
```
165
What are some cardinal features of malignant primary bone tumours?
```
Increasing pain
Unexplained pain
Deep-seated boring nature
Night pain
Difficulty weight-bearing
Deep swelling
```
166
What are the most common bone sites for metastatic bone disease?
Vertebrae>Proximal femur>Pelvis>Ribs>Sternum>Skull
167
What are the most common primary cancers to metastasise to bone?
```
Lung
Breast
Prostate
Kidney
Thyroid
GI tract
Melanoma
```
168
What can be used to prevent pathological fracture in bone/soft tissue cancers?
Early chemo/DXT
Prophylactic internal fixation
Use of bone cement
Embolisation before surgery
Aim for early painless weight bearing and mobilisation
Treat non weight bearing fractures conservatively
169
What risk assessment may be used for pathological fracture?
Mirel's Scoring System
170
In soft tissue tumours, what increases the likelihood of sarcoma?
If over 5cm (80% of sarcoma >5cm)
171
What type of tarsal coalitions may take place in the foot?
Talocalcaneal
Calcaneonavicular
Other
Results in stiff hindfeet
172
What may lead to ankle arthritis?
Commonly post-traumatic
| Consider haemochromatosis if no trauma and under 50
173
What are differences between ankle arthritis and hip arthritis?
Ankle arthritis starts earlier and is harder to treat
174
What examinations are used in the assessment of achilles tendon?
Silvferskiold test
Lunge test
Thompson's or Simmonds'
Matle's (Angle of Dangle)
175
What types of conditions lead to cavovarus feet?
Neurological
Congenital - Club foot, idiopahtic familial
Post-traumatic
176
What muscle weakness can lead to clawing of toes?
Weakness of intrinsic muscles
177
What can lead to the 'plunger effect' by proximal phalanges?
Plantarflexion of MTs
| 'Overaction' of Peroneus longus
178
What muscle weakness can lead to hindfoot varus?
Weakness of peroneus brevis
179
What muscle weakness can lead to equinus?
Weakness of tibilais anterior
180
What can lead to adduction of forefoot?
Overpull of tibilais posterior
181
What can clawing of toes and plantarflexion of metatarsals manifest as clinically?
Plantar callosities and shoe problems
182
What can weakness of peronenus brevis/hindfoot varus result in clinically?
Ankle instability
183
What can weakness of tibilais anterior/equinus result in clinically?
Altered gait
184
What can overpull of tibilais posterior/adduction of forefoot result in clinically?
Stress fractures of lateral metatarsals
185
What questions needs to be asked during investigation of feet deformity?
```
Progressive?
Family history?
Muscle pain/weakness?
Elevated creatinine kinase?
Altered sensation?
```
Undiagnosed - requires neurology opinion.
186
What is the Coleman Block Test used for?
Differentiates between forefoot driven hindfoot varus and hindfoot driven varus
187
What are the general treatment options for common foot and ankle problems?
```
Non operative management
-Analgesia
-Shoe wear modification
-Activity modification
-Weight loss
-Physiotherapy
-Orthotics including insoles and bracing
Operative management (If non-op management fails)
```
188
What pathological grouping exist for foot and ankle problems?
```
Vascular (ischaemic)
Infective
Traumatic
Autoimmune
Metabolic (endocrine /drugs)
Inflammatory
Inherited (congenital)
Neurological
Neoplastic
Degenerative
Idiopathic
```
189
List some common forefoot problems?
```
Hallux valgus
Hallux rigidus
Lesser toe deformities
Morton’s neuroma
Metatarsalgia
Rheumatoid Forefoot
```
190
List some causes of metatarsalgia
Synovitis, bursitis, arthritis, neuralgia, neuromata, Freiberg's disease
Tight gastrocnemius
191
List some treatments for rheumatoid forefoot?
Non-operative - shoewear/orthotics/activity
Operative
-Current gold standard - 1st MTPJ arthrodesis
-2-5th toe excision arthroplasty
192
List some hindfoot problems?
```
Achilles tendonitis/tendinosis
Plantar fasciitis
Ankle OA
Tibilalis posterior dysfunction
Cavovarus foot
```
193
What is the clinical significance of intracapsular neck of femur fracture?
Blood supply is disrupted
194
What is the clinical significance of extracapsular neck of femur fracture?
Blood supply maintained
195
In a knee injury, what does early swelling suggest?
Haemarthrosis
196
What may be indications for surgery for knee problems?
```
Failure of conservative Rx
Demands of work
Demands of sport
Problems with daily activities
Prevention of further joint injury
Prevention of falls
```
197
What factors affect intensity of force in injury?
- Mass of object
- Velocity
- Area on which force acts
198
What can excessive mechanical force cause?
Compression
Traction
Torsion
Tanegital (shearing)
199
What defines a contusion?
Burst blood vessels in the skin
Eg bruise
200
What defines an abrasion?
Scraping of skin surface
Eg graze, scratch
201
What defines an laceration?
Tear/split of skin due to crushing
202
What factors affect prominence of bruising?
```
Skin pigmentation
Depth and location
Fat - more subcut fat, easily bruise
Age
Resilient areas
Coagulative disorders - thrombocytopenia, von willebrand's disease, haemophilia, liver disease (alcoholics), bone marrow disease
```
203
What is the definition of an incised wound?
Superficial sharp force injury caused by slashing motion
Longer on skin surface than it is deep
204
What is the definition of an stab wound?
Penetrating injury resulting from thrusting motion
Wound depth greater than length on the surface
205
What type of signs can be seen as a result of blunt force injury?
Contusions
Abrasions
Lacerations
206
What type of signs can be seen as a result of sharp force injury?
Incised wounds
| Stab wounds
207
What type of injuries may be suggestive of passive defense type injuries?
Slices backs of hands, forearms etc
208
What type of injuries may be suggestive of active defense type injuries?
Slices incised wounds on palmer aspects of hands and web spaces between fingers
209
What type of injuries may suggest self-inflicted injury?
Commonly sharp force
Site of election - usually wrists/forearms, chest and abdomen
Parallel, multiple and tentative incisions
210
What factors do the consequences of injury depend on?
- Type of mechanical insult
- Nature of target tissue
- Forces involved
- Number of impacts
211
What types of bleeding over the brain may present after a head injury?
Subarachnoid
Subdural
Extradural
212
What causes traumatic subarachnoid haemorrhage?
Rapid rotational movement of head - single punch to jaw/upper part of neck/sudden unexpected twisting movement
213
What is the result of traumatic subarachnoid haemorrhage?
Traumatic rupture of vessels at base of brain
| Immediately unconscious and in cardiac arrest
214
What is the result of diffuse axonal injury?
Immediate and prolonged coma with no apparent mass lesion or metabolic abnormality
215
What can be suggestive of post mortem injury?
Lack of vital reaction
Parchmentation
Animal predation
Insect predation
216
What is involved in primary survery of trauma patients?
ABC - detect and treat immediate threats to life
| Uses a team approach
217
What is involved in secondary survey of trauma patients?
Identification of all injuries and more detailed history
218
What is involved in ABC approach?
```
Airway with C-spine control
Breathing with O2
Circ. with haemorrhage control
Disability
Expose and environment
```
Catastrophic haemorrhage control in CABC for battlefield ATLS
219
What is involved in airway assessment in trauma?
- Noise assessment (Speech, gurging, stridor)
| - Visual assessment (Swelling/deformity)
220
What is involved in airway management in trauma?
- Airway manouvres
- Suction
- Adjuncts (OPA etc)
- Advanced procedures
221
When may you assume C-spine injury in trauma?
- Dangerous mechanism
- Reduced conscious level
- Injury above clavicles
- Neurological signs
222
What is involved in breathing assessment in trauma?
Expose the chest
- Look - Visible injuries, RR, Effort/expansion
- Feel - Palpate, Percuss
- Listen - Auscultate
223
What is involved in circulation assessment in trauma?
HR, Cap Refill, BP, Palpable pulses, Pulse pressure narrows, Urine output, Confusion
Blood tests - HB, Lactate
Imaging - US, CT
224
Where are 5 sites for blood loss in trauma?
```
Floor
Chest
Abdomen
Pelvis
Long bones
```
225
What can be used as an alternative to IV in trauma patients if access is difficult?
IO access (Intraosseus)
226
What can be used in trauma to monitor volume replacement?
Vital signs
Urine output
Lactate
227
What is the lethal triad to prevent in trauma circulation?
Coagulopathy
Acidosis
Hypothermia
228
What is used in disability assessment in trauma patients?
-Neurological examination
(AVPU, GCS, Pupils, Tone/reflexes, Log roll)
-Glucose (DEFG!)
229
What bedside tests could be considered in trauma patients?
- ECG
- Arterial blood gas
- Urine dipstick
230
What is the definition of a dislocation?
Complete joint disruption
231
What is the definition of a subluxation?
Partial dislocation - not fully out of joint
232
How is diagnosis made of dislocation?
Clinical and radiological diagnosis
233
What is the appearance of an anterior shoulder dislocation?
Shoulder is squared off
234
What is the appearance of an posterior elbow dislocation?
Olecranon is prominent
235
What is the definition of an open fracture?
Direct communication between external environment and the fracture
(Not always break the skin - pelvic fracture can penetrate rectum etc)
236
What is a type 3 open fracure in gustilo classification?
Extensive soft-tissue damage, complex fracture pattern, wound >10cm
237
What is a type 1 open fracure in gustilo classification?
<1cm wound, low energy, clean
238
What is contemporary management of open fracture?
MD standardised Approach
| Referral to specialist centres if lack expertise
239
List some indications for emergency urgent surgery in open fracture?
```
Polytraumatised patient
Marine/farmyard environment
Gross contamination
Neurovascular compromise
Compartment syndrome
```
240
List some indications for amputation in open fracture?
Dual consultant decision
Insensate limb/foot
Irretrievable soft tissue or bony damage
Other life threatening injuries
241
What are the characteristics of complete spinal cord injury?
- No motor or sensory function distal to lesion
- No anal squeeze
- No sacral sensation
- ASIA Grade A
- No chance of recovery
242
What is tetraplegia?
- Partial/total loss of use of all four limbs
- Loss of motor/sensory function in cervical segments of the spinal cord
- Respiratory failure due to loss of diaphragm innervation
- Spasticity (^Tone)
243
What is paraplegia?
- Partial or total loss of use of the lower limbs
- Impairment or loss of motor/sensory function in thoracic, lumbar or sacral segments of the spinal cord
- Arm function soared
- Possible impairment of function in trunk
244
List some partial cord syndromes
Central cord syndrome
Anterior cord syndrome
Brown-Sequard syndrome
245
What are the characteristics of central cord lesion?
Older patients (arthritic neck)/Hyperextension injuries
- Centrally cervical tracts more involved
- Weakness of arms > legs
- Perianal sensation + lower extremity power preserved
246
What are the characteristics of anterior cord syndrome?
- Hyperflexion injury
- Anterior compression fracture
- Damaged anterior spinal artery
- Fine touch and proprioception preserved
- Profound weakness
247
What are the characteristics of brown-sequard syndrome?
Hemi-section of cord
- Penetrating injuries
- Paralysis on affected side (corticospinal)
- Loss of proprioception and fine discrimination (dorsal columns)
- Pain and temperature loss on opposite side below the lesion (spinothalamic tract)
248
What is the management of SCI patients?
- Prevention of secondary insult
| - ABCD/ATLS
249
What are signs of spinal shock in SCI?
Not circulatory in nature!
- Transient depression of cord function below level of energy
- Flaccid paralysis
- Areflexia
- Last several hours to days after injury
250
What are signs of neurogenic shock in SCI?
Circulatory in nature
- Hypotension
- Bradycardia
- Hypothermia
- Injuries above T6
- Secondary to disruption of sympathetic outflow
251
What is the preferred method of surgical fixation in SCI?
Pedicle screw fixation
252
What is the long term management of SCI?
Spinal cord injury unit - intermediate term
- Physio
- Occupational therapy
- Psychological support
- Urological/Sexual counselling
253
What is the management of spinal nerve root pain?
- Most will settle in 3 months
- Physio
- Strong analgesia
- Referral after 12 weeks
- Imaging -MRI
254
What are some potential spinal disc problems?
- Bulge
- Protrusion
- Extrusion
- Sequestration
255
What signs may be observed in Cervical/lumbar spondylosis (OA)?
If severe can compress whole cord causing myelopathy
| -UMN signs in limbs (increased tone, brisk reflexes etc)
256
What are some characteristics of spinal claudication?
- Usually bilateral
- Sensory dysaesthesiae
- Possible weakness (drop foot - tripping)
- Takes several minutes to ease after stop walking
- Worse walking down hills - spinal cord becomes smaller in extension
257
What is the treatment for spinal stenosis?
Non-operative
- Nerve root injection (for lateral/foraminal stenosis)
- Epidural injection
- Surgery
