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1
Q

Where do enchondromas occur?

A

Femur, humerus, tibia and small bones of hand/feet.

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2
Q

What is Reiter’s syndrome?

A

Triad of symptoms: urethritis, uveitis or conjunctivitis and arthritis.

Seen in reactive arthritis.

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3
Q

What treatment is best for mixed connective tissue disease?

A

Raynauds - calcium channel blockers.

If there is significant muscle or lung disease - immunosuppression.

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4
Q

What is an arthroplasty?

A

Removal of a diseased joint through excision or resection.

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5
Q

What is a Barlow test?

A

Dislocatable hip with flexion and posterior displacement.

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6
Q

How are undisplaced, minimally displaced and minimally angulated (stable) fractures managed?

A

Period of splintage or immobilisation.

Rehabilitation.

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7
Q

What is cauda equina syndrome?

A

Very large central disc prolapse compressing on all the nerve roots of the cauda equina - surgical emergency as the nerve roots involving defaecation and urination are affected.

Prolonged compression can cause permanent nerve damage requiring colostomy and urinary diversion.

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8
Q

What radiographic changes are seen in a late case of avascular necrosis?

A

Patchy sclerotic sclerosis of weight-bearing area of the femoral head.

Lytic zone underneath femoral head formed by granulation tissue from attempted repair.

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9
Q

What is the function of the lateral collateral ligament?

A

Resists varus force and abnormal external rotation of the tibia.

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10
Q

What are the red flags of back pain?

A

Neurological lower limb symptoms with bowel or bladder dysfunction.

Back pain in young patients (<20 years).

Sudden onset of NEW back pain in older patients (>60 years).

Nature of pain - constant, severe pain, worse at night.

Back pain with systemic symptoms of upset.

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11
Q

What is a large vessel vasculitis?

A

Primary vasculitis that causes granulomatous inflammation predominantly of the aorta and its major branches.

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12
Q

How is giant cell arteritis diagnosed?

A

Inflammatory markers (CRP, ESR or plasma viscosity) are almost always raised.

Temporal artery biopsy - mononuclear infiltration or granulomatous inflammation, usually with multinucleated giant cells.

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13
Q

What are the features suggestive of a benign soft tissue neoplasm?

A

Smaller size.

Fluctuation in size (malignant tumours don’t regress in size).

Cystic lesions.

Well-defined lesions.

Fluid-filled lesions.

Soft/fatty lesions.

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14
Q

What is carpal tunnel syndrome?

A

Swelling within the carpal tunnel resulting in median nerve compression.

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15
Q

What is the common organism that produces a late haematogenous prosthetic infection?

A

Staph. aureus.

Beta haemolytic strept.

Enterobacter.

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16
Q

What distribution of symptoms do cervical and lumbar nerve root compression give?

A

Dermatomal and myotomal distributions.

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17
Q

What are the upper limb compressive neuropathies?

A

Carpal tunnel syndrome.

Cubital tunnel syndrome.

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18
Q

What is the name of the radiographic sign associated with posterior dislocations of the humeral head?

A

The ‘lightbulb’ sign.

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19
Q

What loss of function are fractures of the distal radius that heal in a poor position (a malunion) may result in impaired grip strength associated with?

A

Loss of extension.

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20
Q

What is the action of infraspinatus?

A

External rotator.

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21
Q

What are the causes of cubital tunnel syndrome?

A

Tight band of Osborne’s fascia (fascia forming the roof of the tunnel).

Tightness at the intermuscular septum as the nerve passes through.

Tightness between the two heads at the origin of the flexor carpi ulnaris.

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22
Q

Where are the secondary lesions of osteosarcoma normally found?

A

Pulmonary mets.

Jaw, proximal humerus, proximal femur, mid-femur.

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23
Q

What is the management of proximal humeral fractures?

A

Minimally displace - conservative treatment with a sling and gradual return to mobilisation.

Displaced fractures - position often improves once muscle spasm settles.

Persistently displaced - internal fixation surgically, but stiffness, chronic pain and failure of fixation can occur particularly in the older patient.

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24
Q

Where does an acute intervertebral disc tear occur?

A

In the outer annulus fibrosis of an intervertebral disc.

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25
What is an incomplete spinal cord injury?
Some neurological function (sensory and/or motor) is present distal to the level of injury.
26
What ligament can be ruptured in a varus stress injury?
Lateral collateral ligament.
27
What blood tests are raised in someone with large-vessel vasculitis?
ESR. Plasma viscosity. CRP.
28
What arthritis has this typical pattern?
Rheumatoid arthritis.
29
What is a gibbus?
Term used for an acute angular deformity in the spine in the sagittal plane.
30
What is Dupuytren's contracture?
Palmar fascia undergoes hyperplasia with normal fascial bands forming nodules and cords progressing to contractures at the MCP and PIP joints.
31
What is the haematological presentation of SLE?
Leukopenia. Lymphopenia. Anaemia (may be haemolytic). Thrombocytopenia.
32
What is an Ortolani test?
Reducing a dislocated hip with abduction and anterior displacement.
33
How is neurogenic shock treated?
IV fluid therapy.
34
What is the treatment for slipped upper femoral epiphysis?
Urgent surgery to pin the femoral head to prevent further slippage. Greater the degree of slip the worse the prognosis, some cases may require hip replacement.
35
What investigations must you do in suspected cauda equina syndrome?
Rectal exam. Urgent MRI.
36
What are osteoblasts?
Bone forming cells found on the surface of developing bone. They have plentiful rough endoplasmic reticulum and prominent mitochondria.
37
What is the mechanism behind the pathology of Paget's disease?
Increased osteoclastic activity (possibly due to an exaggerated response to vitamin D) causes increased bone turnover. Osteoblasts become more active to compensate for this excessive bone resorption and form new bone. This bone fails to remodel sufficiently -\> despite increased thickness and bone density is brittle -\> easily fractures.
38
What is the pathogenesis of polymyositis?
T-cell mediated cytotoxic process against unidentified muscle antigens -\> CD8 T-cells and macrophages attack healthy non-necrotic muscle fibres. Autoimmune response to nuclear and cytoplasmic autoantigens detected in 60-80% of patients.
39
What is pes cavus?
Abnormally high arch of the foot.
40
What are the risk factors for type 2 osteoporosis?
Reduce sunlight exposure (vitamin D). Genetics. Smoking. Alcohol abuse. Lack of exercise. Poor diet.
41
What happens if developmental dysplasia of the hip is left untreated?
The acetabulum is very shallow. In severe cases, a false acetabulum occurs proximal to the original one with a shortened lower limb. Severe arthritis due to reduced contact area can occur at a young age and gait/mobility may be affected.
42
What investigations aid diagnosis of anti-phospholipid syndrome?
May be thrombocytopenic and prolongation of APTT. Lupus anticoagulant, anti-cardiolipin and anti-beta 2 glycoprotein antibodies may be positive.
43
What is the function of the anterior cruciate ligament?
Prevent abnormal internal rotation of the tibia.
44
What shoulder problems tend to occur in the younger adult?
Instability.
45
Which bacteria is the most common cause of septic arthritis in adults?
Staphylococcus aureus.
46
What are the classical radiological findings associated with osteoarthritis?
Loss of joint space. Subchondral cysts. Osteophyte formation. Subchondral sclerosis.
47
What arthritis has this typical pattern?
Inflammatory spondylitis.
48
What is a chrondrosarcoma?
Cartilage producing primary bone tumour.
49
What does a DAS 28 score of \>5.1 indicate?
High disease activity.
50
What are the symptoms of cauda equina syndrome?
Bilateral leg pain. Paraesthesiae or numbness (saddle anaesthesia). Altered urinary function - retention/incontinence. Faecal incontinence/constipation.
51
A patient has noticed gradually increasing tiredness of muscles on activity, particularly climbing stairs and drying her hair. She has also developed a purplish rash around her eyes and over her chest. What is the most likely diagnosis?
Dermatomyositis.
52
Where is osteomyelitis most likely to affect in children?
Metaphyses of long bones because they have many vessels that have sluggish flow resulting in an accumulation of bacteria allowing infection to spread towards the epiphysis.
53
What is gout and what usually causes it?
A crystal arthropathy caused by deposition of urate crystals within a joint, usually due to high serum uric acid levels (hyperuricaemia).
54
Which bacteria is a cause of septic arthritis in the elderly, the seriously ill and IV drug users?
Escherichia coli.
55
What is the clinical presentation of a mallet finger?
Pain. Drooped DIP joint of the affected finger. Inability to extend at the DIP joint.
56
What is a sequestrum?
Dead fragment of bone.
57
What can lead to joint instability?
Consequence of an injury. Can be related to ligamentous laxity. Can be predisposed by anatomic variation or underlying disease process (e.g. cervical spine instability in rheumatoid arthritis).
58
What types of presentation can occur in SLE?
Constitutional. Musculoskeletal. Mucocutaneous. Renal. Haematological. Neuropsychiatric. Cardiac. Gastrointestinal.
59
What is Klumpke's palsy?
Lower brachial plexus injury (C8 & T1 roots) caused by forceful adduction which results in paralysis of the intrinsic hand muscles +/- finger and wrist flexors and possible Horner's syndrome.
60
What is a Galeazzi injury?
Fracture of the radius with dislocation of the distal radio-ulnar joint (DRUJ).
61
What is the clinical presentation of gout?
intensely painful, red, hot and swollen joint which may mimic septic arthritis. Symptoms may last 7-10 days untreated.
62
What is a giant cell tumour of the tendon sheath?
Small firm swelling usually found on the flexor tendon sheath of a finger. May or may not be painful but can erode bone if large enough.
63
What can chronic gout result in?
Destructive erosive arthritis.
64
What is the treatment for scoliosis?
Mild, non-progressive - no surgery. Severe - surgery of vertebral fusions and long rods connecting the posterior elements of the spine.
65
What can cause pes cavus?
Often related to neuromuscular conditions e.g. hereditary sensory and motor neuropathy, cerebral palsy, polio (unilateral) and spinal cord tethering from spina bifida occulta.
66
What is the clinical presentation of an ACL rupture?
Pop felt or heard when it occurs. Haemarthrosis (an effusion due to bleeding in the joint) occurs within an hour of injury. Deep pain in the knee. Chronically patient complains of rotatory instability.
67
You are a general practitioner and a patient presents to you with an acutely hot, painful and swollen knee. They made an urgent appointment this morning as the pain began suddenly overnight. There is no history of significant trauma. The patient is on long-term steroids for a respiratory condition. Examination reveals the patient is pyrexial and the knee range of movement is severely reduced due to pain. What is the most appropriate management?
Urgent orthopaedic referral. This patient must be seen today as they may require washout of the joint.
68
A patient has had successful treatment of acute gout but has had 4 flares this year. What would be the most appropriate treatment to prevent further attacks?
Allopurinol.
69
When is a soft callus usually formed following a fracture?
2-3 weeks.
70
What is the management for Perthes disease?
No specific treatment. Regular xrays and observation, avoidance of physical activity. ~50% cases do well. Some cases occasionally require osteotomy of the femur or acetabulum.
71
What are the clinical features of ankylosing spondylitis?
Spinal pain. Stiffness. Knee/hip arthritis. With times there is loss of lumbar lordosis and increased thoracic kyphosis.
72
What is meant by translation of a fracture?
Translation of a distal fragment can be described as anteriorly or posteriorly, and medially or laterally translated. It is estimated with reference to the width of the bone (100% displacement is generally referred to as an 'off-ended' fracture.
73
What is the normal developmental milestone for loss of primitive reflexes (Moro reflex, stepping reflex, rooting, grasp reflex, fencing posture)?
1-6 months.
74
What is the usual treatment for primary bone tumours?
Surgery to remove a tumour with a wide margin of 3-4cm and a cuff of normal muscle all around; biopsy tract is also removed with the tumour. Adjuvant chemotherapy and radiotherapy, and neo-adjuvant if appropriate.
75
What is the pathology of Dupuytren's contracture?
Proliferation of myofibroblast cells and the production of abnormal collagen (type 3 rather than type 1).
76
What are predisposing factors of patellar dislocation?
Ligamental laxity. Female gender. Shallow trochlear groove. Genu valgum. Femoral neck anteversion. High riding patella (patella alta).
77
What is fracture disease?
Term used to describe stiffness and weakness due to the fracture and subsequent splintage in cast. Most cases resolve with time and may be helped with physio.
78
What part of the bone does localised osteomyelitis normally affect?
Affects cortex and medullary bone.
79
What are the functions of the tibialis posterior tendon?
Support the medial arch of the foot. Plantarflexor and invertor of the foot.
80
What part of the bone does diffuse osteomyelitis affect?
A segment of bone is infected resulting in skeletal instability e.g. infected non-union.
81
What joints can be affected in rheumatoid arthritis?
Early: MCPs, PIPs in the hands and feet, wrists. Late: atlantoaxial joint (C1-2), elbows, shoulders, TMJ, hips and ankles.
82
What can trigger uric acid crystals to precipitate in joints?
Dehydration. Trauma. Surgery.
83
What is the risk of recurrent shoulder dislocation following a shoulder dislocation?
Patients less than 20 have an 80% chance of re-dislocation. Patients over 30 have a 20% risk of further dislocation.
84
What is the cutaneous presentation of systemic sclerosis?
Raynauds phenomenon. Telangiectasia. Calcinosis (subcutaneous deposits of calcium in the digits). 3 phases: (1) oedematous, (2) indurative, (3) atrophic - thickened and tight skin. Major features: centrally located skin sclerosis that affects the arms, face and/or neck. Minor features: Sclerodactyly and atrophy of the fingertips, bilateral lung fibrosis.
85
What is the management of Sjogren's syndrome?
Largely symptomatic. Lubricating eyedrops. Saliva replacement products. Regular dental care. Pilocarpine can be used to stimulate saliva production - SE flushing. Hydroxychloroquine - aids arthralgia/fatigue.
86
What is the clinical presentation for slipped upper femoral epiphysis?
Pain and a limp. Pain felt in groin, but also pts can present with purely pain in the knee (due to obturator nerve supplying both the hip and knee). Loss of internal rotation of the hip is predominant sign.
87
What are the clinical features of rheumatoid arthritis?
Symmetrical synovitis (doughy swelling). Tenosynovitis. Pain. Morning stiffness.
88
What fracture is often associated with a Colles fracture?
Fracture of the ulnar styloid.
89
Where do osteosarcomas occur?
Seen in younger age groups (adolescence and early adulthood) with 60% involving the bones around the knee. Other sites include proximal femur, proximal humerus and pelvis.
90
When would a patient be put on a biologic therapy?
When a patient's DAS28 score is still \>5.1 when on 2 DMARDs.
91
What is the gender ratio for polymyositis and dermatomyositis?
Females:males = 2:1. Affects people over 20 years, especially those aged 45-60.
92
What are osteoprogenitor cells?
Located on bone surfaces, for example under the periosteum, these cells serve as a pool of reserve osteoblasts.
93
What is the treatment for a prolapsed intervertebral disc?
Analgesia and physiotherapy. ## Footnote *Symptoms usually resolve but can take 2-3 months to settle.*
94
What is the gender ratio of SLE?
Female:male = 11:1.
95
What are osteocytes?
A bone cell trapped within the bone matrix.
96
What is fibromyalgia?
Disorder of central pain processing or a syndrome of central sensitivity. Patients tend to have a lower threshold of pain and of other stimuli such as heat, noise and strong odours. Commonest in young and middle-aged women.
97
What are the 3 main patterns of injury to the pelvis?
Lateral compression fracture. Vertical shear fracture. Anteroposterior compression injury.
98
What is an anteroposterior compression injury?
May result in wide disruption of the pubic symphysis. Substantial bleeding from torn vessels occurs and the pelvis can hold several litres of blood (i.e. the entire circulating volume).
99
What are the flexor and extensor imbalances of claw toes?
Hyperextension at the MTPJ with hyperflexion at the PIPJ and DIP.
100
What is meant by angulation of a fracture?
It described the direction in which the distal fragment points towards and the degree of this deformity. It can be described as medial or lateral and posterior or anterior. Can be measured in degrees from the longitudinal axis of the diaphysis of a long bone.
101
What is the clinical presentation of Perthes disease?
Children present with pain and a limp. Unilateral normally, bilateral cases represent an underlying skeletal dysplasia or thrombophilia. Loss of internal rotation, followed by loss of abduction, followed by positive Trendelenburg test for gluteal weakness.
102
Why do neuromuscular disorders occur?
Due to abnormal or deficient motor neuron signals to skeletal muscle due to defect in either the brain, spinal cord, peripheral nerve, neuromuscular junction or muscle.
103
What is Erb's palsy?
Injury to the upper (C5 & C6) nerve roots resulting in loss of motor innervation of the deltoid, supraspinatus, infraspinatus, biceps and brachialis muscles. Internal rotation of the humerus (from unopposed subscapularis) -\> classic waiter's tip posture.
104
Where does chronic osteomyelitis tend to occur in adults?
In the axial skeleton (spine or pelvis) with haematogenous spread from pulmonary or urinary infections, or from infection of the intervertebral disc (discitis).
105
What is diffuse systemic sclerosis?
Skin changes develop more rapidly and can involve trunk. Early significant organ involvement. Anti-Scl-70 antibody association.
106
Which metacarpal fracture often occurs with a punching injury?
5th metacarpal fractures, particularly 5th MCP neck fractures (Boxer's fracture).
107
What are the clinical features of Ehlers-Danlos?
Profound joint hypermobility. Vascular fragility with ease of bruising. Joint instability. Scoliosis.
108
What fractures tend to occur in people with type 1 osteoporosis?
Colles fractures. Vertebral insufficiency fractures.
109
What is the treatment for large-vessel vasculitis?
Corticosteroids (40-60mg prednisolone with gradual reduction). Methotrexate and azathioprine may be added in.
110
What is scoliosis?
Lateral curvature of the spine which can be idiopathic or secondary to neuromuscular disease, tumour, skeletal dysplasia or infection.
111
What investigations can diagnose polymyositis?
Inflammatory markers raised. Serum creatine kinase is usually raised - often 10x normal. Autoantibodies = ANA, anti-Jo-1, anti-SRP. MRI = localise extent of muscle involvement. Electromyograph - short-duration, low-voltage, polyphasic motor unit action potentials with spontaneous fibrillation activity. Muscle biopsy - muscle fibres with varying stages of inflammation, necrosis and regeneration.
112
What is trigger finger?
Tendonitis of a flexor tendon to a digit can result in nodular enlargement of the affected tendon (usually distal to a fascial pulley over the metacarpal neck (A1 pulley). ## Footnote *Movement of the finger produces a clicking sensation, as this nodule passes under the pulley - can be painful or finger may lock in a flexed position as the nodule passes under the pulley and can't go back on extension.*
113
What is mixed connective tissue disease?
A defined condition which features symptoms seen in other connective tissue diseases.
114
What is the clinical presentation of vasculitis?
Varies according to the histological type of inflammation, the size of the involved blood vessel segment and the distribution of the involved vessels.
115
What are the risk factors for type 1 osteoporosis?
Early menopause. Genetics. Smoking. Alcohol abuse. Lack of exercise. Poor diet.
116
What does the primary survey of a major trauma include?
**A**irway management with cervical spine control. **B**reathing & ventilation. **C**irculation & bleeding control. **D**isability (neurological examination). **E**xposure & environmental control. ***ABCDE evaluation.***
117
What are the symptoms of upper motor neuron neuromuscular disorders?
Weakness. Spasticity (rate dependent increased tone). Hyperreflexia. Extensor plantar response (Babinksi sign).
118
What are risk factors for clubfoot?
Boys twice as likely to get it than girls. Potential genetic link (familial). More common in breech presentation. Oligohydramnios (low amniotic fluid).
119
What are the late local complications of a fracture?
Stiffness. Loss of function. Chronic regional pain syndrome. Infection. Non-union. Mal-union. Volkmann's ischaemic contracture. Post-traumatic osteoarthritis. Deep vein thrombosis.
120
What type of local soft tissue swellings can present to orthopaedics?
Inflammatory swellings - bursitis, rheumatoid nosules. Infection - abscess. Cystic lesions - ganglion, meniscal cyst, Baker's cyst. Benign neoplasms. Malignant neoplasms.
121
What is the treatment of bony nerve root entrapment?
Surgical decompression, with trimming od the impinging osteophytes can be performed in suitable candidates.
122
What is bursitis?
Inflammation of a bursa (small fluid-filled sac lined by synovium around a joint).
123
What is the treatment for developmental dysplasia of the hip?
Mild cases - observation. Severe cases - unstable hips are reduced and held with a Pavlik harness to keep them in comfortable flexion and abduction -\> maintaining reduction. If persists over 18 months old, open reduction may be required.
124
What are causative factors of plantar fasciitis?
Diabetes. Obesity. Frequent walking on hard floors with poor cushioning in shoes.
125
What is neurogenic shock?
Occurs secondary to temporary shutdown of sympathetic outflow from the cord from T1 to L2, usually due to injury in the cervical or upper thoracic cord leading to hypotension and bradycardia. Usually resolves within 24-48 hours. Priapism from unopposed parasympathetic stimulation may be present.
126
What is the action of supraspinatus?
Initiation of abduction.
127
What is the name given to the space that chondrocytes occupy?
The extracellular matrix termed a lacuna.
128
How are unstable injuries managed?
Surgical stabilisation.
129
What are the clinical features of spinal claudication?
Claudication distance is inconsistent. Pain is burning (rather than cramping). Pain is less walking uphill - spine flexion creates more space for the cauda equina. Pedal pulses are preserved.
130
What are the clinical features of inflammatory arthritis?
Joint pain with associated swelling. Morning stiffness. Improvement in symptoms with exercise. Synovitis on examination. Raised inflammatory markers (CRP and plasma viscosity). Extra-articular symptoms.
131
What is a fibrosarcoma?
Malignant tumour of fibrous tissue.
132
What is the normal developmental milestone for eating with fingers or using a spoon?
14 months.
133
What causes avascular necrosis?
Idiopathic. Alcoholism. Steroid (ab)use. Primary hyperlipidaemia. Thrombophilia. Sickle cells disease. Antiphospholipid deficiency in SLE. Caisson's disease (or decompression sickness).
134
Condition X is an autosomal dominant or sporadic mutation of the fibrillin gene resulting in tall stature with disproportionately long limbs and ligamentous laxity. Associated features include a high arched palate, scoliosis, pectus excavatum, eye problems (lens dislocation, retinal detachment), aortic aneurysm and cardiac valve incompetence. What is Condition X?
Marfan's syndrome.
135
What score (or below) on the GCS implies a loss of airway control and should prompt the treating doctor to perform airway manoeuvres?
8 or less.
136
What features of ankylosing spondylitis can be seen on MRI?
Bone marrow oedema and enthesitis of the spinal ligaments.
137
What are the common sites affected by osteochondritis?
Second metatarsal head (Freiburg's disease). Navicular bone (Kohler's disease). Lunate of the carpus (Kienbock's disease). Capitellum of the elbow (Panner's disease). Vertebral bones (Scheuermann's disease).
138
What is the treatment of calcium pyrophosphate deposition disease (CPPD)?
NSAIDs, corticosteroids (systemic and intra-articular) and occasionally colchicine.
139
What is an oblique fracture?
Occur with a shearing force (e.g. fall from height, deceleration). Can be fixed with an interfragmentary screw. Tend to shorten the bond and many also angulate.
140
What are the consequences of talipes equinovarus (clubfoot)?
Contractures of the soft tissues -\> deformity consisting of ankle equinus (plantarflexion), supination of the forefoot and varus alignment fo the forefoot.
141
What forms the carpal tunnel of the wrist?
Carpal bones and the flexor retinaculum.
142
What are the main categories of arthritis?
Non-inflammatory arthritis (commonly osteoarthritis). Inflammatory arthritis.
143
What are structures A and B?
A - perimysium. B - endomysium.
144
What are the structures of the extensor mechanism of the knee from most proximal to most distal?
Quadriceps muscles. Quadriceps tendon. Patella. Patellar tendon. Tibial tuberosity.
145
A Colles fracture describes a dorsally angulated or displaced fracture at what site?
Distal radius.
146
What are the clinical signs of Achilles tendon rupture?
Weakness of plantar flexion and a palpable gap in the tendon are usually apparent. ## Footnote *No plantarflexion of the foot is seen when squeezing the calf (Simmonds test).*
147
How can an ACL rupture occur?
High rotation force e.g. turning the upper body laterally on a planted foot -\> internal rotation on the tibia.
148
What is the shoulder girdle formed of?
Scapular. Clavicle. Proximal humerus. Supporting muscles including the deltoid and rotator cuff.
149
What is Henoch-Scholein purpura?
Acute IgA-mediated disorder characterised by a generalised vasculitis involving the small vessels of the skin, the GI tract, kidneys, joints, lungs (rarely) and the CNS. Commonly affects children - common history of an upper respiratory tract infection predates the symptoms by a few weeks.
150
Which tissues cannot accept a skin graft?
Bare tendon. Bone. Any exposed metalwork.
151
What factors predispose to patellar dislocations and subluxations?
Generalised ligamentous laxity. Valgus alignment of the knee. Rotational malalignment (including femoral neck anteversion). Shallow trochlear groove.
152
What is osteoporosis?
A quantitative defect of bone characterised by reduced bone mineral density and increased porosity. Causes fragility of the bone and increased fracture risk.
153
How can osteomyelitis be caused?
Organisms can infect the bone directly by penetrating trauma or surgery. Indirectly by haematogenous spread from an infection or bacteraemia at a distant site.
154
How can carpal tunnel syndrome be investigated?
Nerve conduction studies - slowing of conduction across the wrist.
155
What is joint instability?
Abnormal motion of a joint (rotation or translation) resulting in subluxation or dislocation with pain and/or giving way.
156
What is internal tibial torsion?
Tibia can be rotated inward about its vertical axis. Ignore - normal variation.
157
What investigations can aid diagnosis of SLE?
FBC - anaemia, leukopenia, thrombocytopenia. Immunology: anti-nuclear antibody, anti-dsDNA antibody (varies with disease activity), anti-Sm, anti-Ro, anti-La, anti-RNP, C3/4 (low when disease is active). Urinalysis - glomerulonephritis. CT chest - interstitial lung disease. MRI brain - cerebral vasculitis. Echocardiogram - pericardial effusion.
158
What is the most common neuromuscular disorder?
Upper motor neuron disorder. Lower motor neuron disorder.
159
What is the function of the posterior cruciate ligament?
Prevent hyperextension and anterior translation of the femur.
160
What is the normal developmental milestone for sitting alone and crawling?
6-9 months.
161
What is an arthrodesis?
Surgical stiffening or fusion of a joint in a position of function. Remaining hyaline cartilage of the joint and subchondral bone is removed and the joint is stabilised resulting in bony union.
162
What can predispose to slipped upper femoral epiphysis?
Hypothyroidism. Renal disease.
163
What is tarsal coalition?
Abnormal bridge (bony, fibrous or cartilaginous) between the calcaneus and navicular or between the talus and calcaneus. Can lead to painful fixed flat foot deformity.
164
What is a fight bite?
It is associated with punching injuries and describes a laceration sustained to the puncher's hand from the punchee's tooth.
165
What can systemic sclerosis do to the gastrointestinal tract?
Dysphagia. Malabsorption. Bacterial overgrowth of the small bowel.
166
What is a Salter-Harris I fracture?
Pure physeal separation. Best prognosis and is least likely to result in growth arrest.
167
What is the management of greenstick fractures?
These fractures may be angulated and may require manipulation and casting if there is significant deformity, particularly in the older child.
168
What is spondylolisthesis?
Slippage of one vertebra over another and can be due to a developmental defect or a recurrent stress fracture of the posterior elements which fails to heal. Usually L4/L5 or L5/S1.
169
What part of the bone does medullary osteomyelitis affect?
The medulla of the bone.
170
What arthritis has this typical pattern?
Psoriatic arthritis.
171
What is Ehlers-Danlos syndrome?
Heterogeneous condition often autosomal dominant. Abnormal elastin and collagen formation.
172
How is polymyalgia rheumatica diagnosed?
No specific diagnostic test but it is almost always associated with raised CRP and plasma viscosity/ESR.
173
What is the characteristic appearance of a giant cell tumour on an x-ray?
Soap bubble.
174
What are soft tissue procedures?
Ligament tightening/advancement. Ligament reconstruction using a tendon graft. Soft tissue reattachment.
175
What is a transverse fracture?
Occur with pure bending force where the cortex on one side fails in compression and the cortex on the other side n tension. May not shorten the bone (unless completely displaced) but may angulate or result in rotational malalignment.
176
What are the cardinal signs of muscle ischaemia?
Increased pain on passive stretching of the involved muscle. Severe pain outwith the anticipated severity in the clinical context. Loss of pulses is a feature of end-stage muscle ischaemia.
177
What is a vertical shear fracture?
Occurs due to axial force on one hemipelvis (e.g. fall from height, rapid deceleration) where the affected hemipelvis is displaced superiorly. Sacral nerve roots and lumbosacral plexus are at high risk of major injury and major haemorrhage may occur. Leg on the affected side will appear shorter.
178
How is syndactyly treated?
Surgical separation of the digits/phalanges.
179
What is the treatment of tarsal coalition?
May improve with splintage/orthotics. Pain resistant forms may require surgery to remove the abnormal connection.
180
What is the main treatment for inflammatory arthropathies?
Simple analgesia. NSAIDs. Steroids/steroid injections. Disease-modifying anti-rheumatic drugs (DMARDs). Biologic therapies.
181
What is the appearance of ganglion cysts?
Firm, smooth, rubbery and should transilluminate.
182
What risk of damage is increased in penetrating dorsal injuries to the hand?
Damage to the extensor tendons.
183
True or false: The striations present in skeletal muscle result from the orientation of the myofibrils, which run across the fibre.
False. The myofibrils are orientated longitudinally in the muscle fibre. There is nothing that runs across the fibres, but the fact that components of adjacent myofibrils are held in registry with each other (i.e. dark band adjacent to dark band, etc.) gives the appearance of a ‘stripe’ running across the cell.
184
What should be included in the assessment of an injured limb?
Is the injury open or closed? Assessment of the distal neurovascular status (pulses, capillary refill, temperature, colour, sensation, motor power). Is there compartment syndrome? Assessment of the status of the skin and soft tissue envelope.
185
What is the pathology of lateral epicondylitis?
Micro-tears in the common extensor origin.
186
What is the action of subscapularis?
Principal internal rotator.
187
What is a joint replacement?
Replacement of either part of the joint (hemiarthroplasty) or the whole joint.
188
Anti-neutrophil cytoplasmic antibody (ANCA) is associated with which condition(s)?
Small vessel vasculitis (GPA, EGPA, MPA).
189
What is pes planus?
Flat foot (loss of foot arch).
190
What is a radiograph of Paget's disease likely to show?
The affected bone is enlarged with thickened cortices and coarse, thickened trabeculae with mixed areas of lysis and sclerosis. Bone scans demonstrate marked increased uptake in the affected bone(s).
191
What is enteropathic arthritis?
Inflammatory arthritis involving the peripheral joints and sometimes spine - large joint asymmetrical oligoarthritis. Occurs in patients with inflammatory bowel disease (Crohn's disease and ulcerative colitis).
192
How can Duchenne muscular dystrophy be diagnosed?
Raised serum creatinine phosphokinase. Abnormalities on muscle biopsy.
193
What are the late local complications of total hip arthroplasty?
Early loosening. Late infection - due to haematogenous spread from a distant site. Late dislocation - due to component wear.
194
What is myositis ossifications?
Condition where heterotopic ossification (bone forming outside the skeleton) occurs in muscles usually after injury.
195
What are the clinical consequences of Paget's disease?
Arthritis (if close t the joint). Pathological fractures. Deformity. Pain. High output cardiac failure due to increased blood flow through pagetic bone.
196
A 60 year old lady presents with a complaint of right foot pain. On closer questioning, she tells you she first noticed it a month ago and it's been getting worse since. She feels it on the instep of her foot (medial arch) and it's worse if she does a lot of walking. On examination, she is acutely tender over the calcaneal tuberosity at the posterior end of the medial arch. What is the most likely diagnosis?
Plantar fasciitis.
197
How can spinal cord compression as a result of advanced spinal mets be treated?
Radiotherapy or surgical decompression (anterior or posterior).
198
How can the risk of osteoporosis be reduced?
Building up peak bone mineral density by way of exercise, good diet and healthy levels of sunlight exposure before bone density starts to decline.
199
What is the management of SLE if there is sever organ disease?
IV steroids and cyclophosphamide.
200
What is the treatment for transient synovitis of the hip?
Short course of NSAIDs and rest.
201
What is osteomyelitis?
Infection of the bone including compact and spongy bone as well as the bone marrow.
202
What is the treatment for mechanical back pain?
Analgesia. Physiotherapy. Bed rest not advised -\> stiffness and spasm of the back.
203
What are the consequences of overproduction of PTH?
Hypercalcaemia -\> fatigue, depression, bone pain, myalgia, nausea, thirst, polyuria, renal stones and osteoporosis. Fragility fractures. Lytic bone lesions (Brown tumours or osteitis fibrosa cystica).
204
What are the associated conditions of ankylosing spondylitis?
Anterior uveitis. Aortitis. Pulmonary fibrosis. Amyloidosis.
205
How can gout be diagnosed?
Analyse synovial fluid with polarised microscopy and uric acid crystals will be seen.
206
Anti-cardiolipin antibody and lupus anti-coagulant is associated with which condition(s)?
Anti-phospholipid syndrome.
207
Does rheumatoid arthritis affect one gender more than another?
Yes. Women:men = 3:1.
208
What are predisposing factors for extensor mechanism ruptures?
History of tendonitis. Chronic steroid use or abuse (bodybuilders). Diabetes. Rheumatoid arthritis. Chronic renal failure.
209
What are the two types of systemic sclerosis?
Limited. Diffuse.
210
What imaging is useful to detect large-vessel vasculitis?
MR angiography - thickened vessel walls and stenosis. PET CT - increased metabolic activity in the large vessels.
211
What is the treatment for hyperparathyroidism?
Removal of the adenomatous gland or treatment of the underlying cause (vitamin D supplements).
212
What is hallux valgus?
Deformity of the great toe due to medial deviation of the first metatarsal and lateral deviation of the toe itself.
213
What is acute calcific tendonitis?
Acute onset of severe shoulder pain. Characterised by calcium deposition in the supraspinatus tendon just proximal to the greater tuberosity.
214
What extensor mechanisms can rupture after lifting a heavy weight, a fall or spontaneously in a severely degenerate tendon?
Patellar tendon or quadriceps tendon.
215
What is systemic sclerosis?
Systemic connective tissue disease.
216
What are the principal causes of osteomalacia and rickets?
Insufficient calcium absorption from the intestine because of lack of dietary calcium. Deficiency of or resistance to vitamin D. Phosphate deficiency caused by increased renal losses.
217
What sites are most commonly affected by avascular necrosis?
Femoral head. Femoral condyles. Heaf of the humerus. Capitellum. Proximal pole of the scaphoid. Proximal part of the talus.
218
What is a mallet finger?
Avulsion of the extensor tendon from its insertion into the terminal phalanx. Caused by forced flexion of the extended DIP joint.
219
What can cause dislocation of the acromioclavicular joint?
Usually occur after a fall onto the point of the shoulder.
220
What is osteopenia?
An intermediate stage where bone mineral density is between 1 and 2.5 standard deviations below mean peak value.
221
What are the characteristics of systemic sclerosis?
Vasomotor disturbances (Raynauds). Fibrosis and subsequent atrophy of the skin and subcutaneous tissue. Excessive collagen deposition -\> skin and internal organ changes.
222
What is talipes equinovarus (clubfoot)?
Congenital deformity of the foot due to in utero abnormal alignment of the joints between the talus, calcaneus and navicular. (~50% cases are bilateral).
223
What is the presentation of giant cell arteritis?
Visual disturbances. Headache. Jaw claudication. Scalp tenderness. Fatigue. Malaise. Fever.
224
What will happen in a valgus stress injury?
Tear the medial collateral ligament. ## Footnote *Higher forces can potentially damage the ACL and risk lateral tibial plateau fracture.*
225
What are the features of carpal tunnel syndrome?
Paraesthesiae of the thumb and radial 2.5 digits - usually worse at night. Loss of sensation and sometimes weakness of the thumb or clumsiness in the areas of the hand supplied by the median nerve. Tinel's test positive (symptoms reproduced by percussing over the median nerve). Phalen's test positive (symptoms reproducible holding the wrists hyper-flexed (decreases the space in the carpal tunnel).
226
What is the constitutional presentation of SLE?
Fever. Fatigue. Weight loss.
227
What is the treatment for chronic osteomyelitis?
Antibiotics. Debridement of bone.
228
A 60 year old lady presents with a painful bunion on the medial aspect of her left forefoot at the 1st MTPJ. There is lateral angulation/deviation of the great toe causing the second toe to over-ride the great toe. What is the underlying diagnosis?
Hallux valgus.
229
What is the treatment of impingement syndrome?
NSAIDs, analgesia, physiotherapy and/or steroid injection into the subacromial space. If this doesn't work -\> subacromial decompression surgery to create more space for the tendon to pass through.
230
What diseases come under the umbrella of calcium pyrophosphate deposition disease (CPPD)?
Pseudogout. Chondrocalcinosis.
231
What is a comminuted fracture?
Fractures with 3 or more fragments. This type of fracture is very unstable and tend to be stabilized surgically.
232
What will radiographs of ankylosing spondylitis show?
Sclerosis and fusion of the sacroiliac joints. Bony spurs from the vertebral bodies (syndesmophytes) - these can bridge the intervertebral disc resulting in fusion, producing a 'bamboo spine'.
233
What is polydactyly?
An extra digit is formed.
234
Anti-Scl-70 antibody is associated with which condition(s)?
Systemic sclerosis (diffuse).
235
What is the clinical presentation of a meniscal tear?
Patient localises pain to the medial (majority) or lateral joint line. Effusion develops by the following day. Catching sensation of 'locking' = difficulty straightening the knee with a 15 degree or so block to full extension.
236
What nerve is compressed in carpal tunnel syndrome?
Median nerve.
237
A 40 year old female patient consults you regarding the appearance of their big toe. You note slight widening of the forefoot with a mild to moderate hallux valgus. There is a small, non-tender bunion. The patient tells you the foot isn't painful but they're worried that the deformity is getting worse and it's now affecting the type of shoe they can wear. What is the management for this patient?
Hallux valgus surgery should be performed for pain and restriction of function. Advice for this patient may include wearing more accommodating footwear.
238
Why can't xrays be used to diagnose developmental dysplasia of the hip?
The femoral head epiphysis is unossified until around 4-6 months.
239
What is cancellous bone?
A fine meshwork of bone that looks a bit like the inside of an Aero bar.
240
What is a liposarcoma?
Malignant tumour of fat.
241
A 20 year old girl presents with bilateral broad forefeet complaining of difficulty finding shoes that accommodate her wide feet. On examination, the toes look normal and there are no callosities but the forefeet do look wide. On xrays, the forefoot is broad with an increase in the intermetatarsal angle. What is the underlying diagnosis?
Primus varus.
242
What is a sarcoma?
Malignant soft tissue tumour of connective tissue.
243
Which condition can lead to a Popeye deformity and what is it?
Inflammation of the tendon of the long head of the biceps. Tendon spontaneously ruptures and bunches up in the bicep.
244
What is the treatment for early (pre-collapse) diagnosis of avascular necrosis?
Drill holes can be made up the femoral neck and into the abnormal area in the head in an attempt to relieve pressure (decompression), promote healing and prevent femoral head collapse.
245
What does dermatomyositis increase a patients risk for?
Malignancy is found in 25% of patients and is greatest 5 years following diagnosis; should be screened for at time of diagnosis. Common cancers = breast, ovarian, lung, colon, oesophagus and bladder.
246
What is Wolff's law?
Bone laid down along areas of stress.
247
Anti-nuclear antibody(ANA) is associated with which condition(s)?
SLE, Sjogren's syndrome, systemic sclerosis, mixed connective tissue disease (MCTD), autoimmune liver disease.
248
What is a slipped upper femoral epiphysis?
Mainly affects overweight pre-pubertal adolescent boys where the femoral head epiphysis slips inferiorly in relation to the femoral neck. Growth plate (physis) not strong enough to support body weight -\> femoral epiphysis slips due to the strain. 1/3 cases bilateral.
249
Where do aneurysmal bone cysts occur?
Metaphyses of long bones, flat bones (ribs, skull) and vertebral bodies.
250
What are the consequences of a femoral shaft fracture?
Substantial blood loss of up to 1.5L. Fat from the medullary canal can enter the damaged venous system resulting in fat embolism with confusion, hypoxia risk of ARDS.
251
Why do children's fractures heal more quickly than adults?
Children have thicker periosteum which is a rich source of osteoblasts. They have a greater potential to remodel (change shape with bone laid down along areas of stress according to Wolff's law) as they grow with bone being formed along lines of stress. Children can correct angulation up to 10 degrees per year of growth remaining in that bone.
252
What are the clinical features of renal limited vasculitis?
Pauci-immune necrotising glomerulonephritis with no apparent extra-renal features at presentation.
253
What is the level of injury in a spinal cord injury?
Determined by the most distal spinal level with partial function (after spinal shock has resolved) as determined by the presence of dermatomal sensation and myotomal skeletal muscle voluntary action.
254
What area is affected if there is a L4/5 prolapse?
L5 root entrapment. Pain down to the dorsum of the foot. Reduced power to the extensor hallucis longus and tibialis anterior.
255
What is the treatment for giant cell arteritis?
Corticosteroids (usually prednisolone 40mg if no visual impairment, 60mg if there is). Dose is gradually tapered over 2 years - by this time the condition will have resolved in most patients.
256
When would you use steroids in rheumatoid arthritis treatment?
Short term relief as a bridge awaiting the DMARDs to take affect; so the first 8 weeks of treatment. For a flare-up of rheumatoid arthritis.
257
What factors associated with fracture can lead to increased risk of infection?
Higher energy injuries. Increased amount of contamination. Delays in appropriate treatment. Problems in wound closure.
258
What are the symptoms and signs of fracture healing?
Resolution of pain and function. Absence of point tenderness. No local oedema. Resolution of movement at fracture site.
259
What visual disturbances can occur in giant cell arteritis?
Unilateral visual blurring or vision loss (often painless). Occasionally diplopia.
260
How is Sjogren's syndrome diagnosed?
Confirmation of ocular dryness (Schirmers test). Positive anti-Ro, anti-La antibodies. Typical lip features on a lip gland biopsy.
261
What are the investigations and treatment for dermatomyositis?
Same as polymyositis.
262
In patients with a prolapsed intervertebral disc, what makes pain worse?
Coughing - increases disc pressure.
263
What conditions are termed seronegative inflammatory arthropathies?
Ankylosing spondylitis. Psoriatic arthritis. Enteropathic arthritis. Reactive arthritis.
264
What is the neuropsychiatric presentation of SLE?
Seizures. Psychosis. Headache. Aseptic meningitis.
265
Which tissues can accept a skin graft?
Muscle. Fascia. Granulation tissue. Paratenon. Periosteum.
266
What nerve can be damaged in a humeral shaft fracture?
Radial nerve.
267
What conditions can also present as a lytic bone lesion?
Brodie's abscess (subacute osteomyelitis). Hyperparathyroidism (Brown tumours).
268
What other diseases may occur with Sjogren's syndrome?
Peripheral neuropathy. Interstitial lung disease. Increased risk of lymphoma.
269
Which patients are at risk of osteomyelitis of the spine?
Poorly controlled diabetics. IV drug abusers. Immunocompromised patients.
270
What is the treatment for giant cell tumours?
Intralesional excision with use of phenol, bone cement or liquid nitrogen to destroy remaining tumour material and reduce risk of recurrence.
271
Where are chondrosarcomas usually found?
Pelvis or proximal femur.
272
What are the different types of benign bone tumours?
Neoplastic. Developmental. Traumatic. Infectious. Inflammatory.
273
How are small and medium vessel vasculitis categorised?
274
What is catastrophic anti-phospholipid syndrome?
Often fatal manifestation characterised by multiorgan infarctions over a period of days to weeks.
275
At what age do children's fractures tend to be treated as an adult's fracture would and why?
When children have reached puberty (around 12-14 years). Remodelling potential is less.
276
What are the symptoms of cervical spondylosis?
Slow onset stiffness and pain in the neck radiating locally to the shoulders and the occiput.
277
What investigations can be done to diagnoses rheumatoid arthritis?
Blood tests: rheumatoid factor, anti-CCP antibody, CRP, ESR, plasma viscosity. Xrays (at onset of disease will show no abnormality) - can show peri-articular osteopenia (bone thinning), soft tissue swelling and peri-articular erosions. Ultrasound - detects synovial inflammation.
278
How are fractures described?
Site of fracture. Type of bone involved, if it extends into the joint. Fracture displacement: depends on degree of translation, angulation and rotation. Fracture pattern.
279
Where does pain from impingement syndrome tend to radiate to?
Deltoid and upper arm.
280
Anti-Sm antibody is associated with which condition(s)?
SLE.
281
Anti-centromere antibody is associated with which condition(s)?
Systemic sclerosis (limited).
282
What are the clinical signs and symptoms of rickets and osteomalacia?
Bone pain (pelvis, spine and femur). Deformities from soft bones (particularly rickets). Sustain pathological fractures easily. Symptoms of hypocalcaemia (paraesthesiae, muscle cramps, irritability, fatigue, seizures, brittle nails).
283
Which is the commonest site for a prolapsed intervertebral disc to occur?
L4-S1.
284
Which bacteria was the most common cause of septic arthritis in children but now is uncommon in areas where Haemophilus vaccination is practised?
Haemophilus influenzae.
285
What is the likely knee alignment of a child around the age of 3?
Valgus alignment of around 10-15 degrees.
286
What is patellar tendonitis?
Inflammation of the patellar tendon. Self-limiting needing rest and possibly physiotherapy.
287
How is rheumatoid arthritis diagnosed?
Clinical presentation. Radiographic findings (normal x-ray can be found in patients in the early stages of the disease so this is not definitive). DAS28 scoring.
288
What is the region of the sarcomere defined as?
The sarcomere is defined as the region from one z-line to the next.
289
A Smith's fracture describes a volarly angulated or displaced extra-articular fracture at what site?
Distal radius.
290
What serum autoantibodies can be detected in polymyositis?
ANA, anti-RNP, anti-Jo-1, anti-SRP antibodies.
291
What cell type do the arrows point to?
Chondrocytes (immature chondroblasts).
292
What is dermatomyositis?
Clinically similar to polymyositis but also has typical cutaneous manifestations: * V-shaped rash over chest. * Gottron's papules. * Heliotrope rash.
293
What conditions is fibromyalgia seen as a secondary condition?
Rheumatoid arthritis (25% patients). SLE (50% patients).
294
What is mechanical back pain?
Recurrent relapsing and remitting back pain with no neurological symptoms. Pain is worse with movement (mechanical) and relieved by rest.
295
What is bony nerve root entrapment?
Osteoarthritis of the facet joints can result in osteophytes impinging on exiting nerve roots -\> nerve root symptoms and sciatica.
296
What are the main types of inflammatory arthritis?
Seropositive arthritis (e.g. rheumatoid arthritis and connective tissue diseases). Seronegative inflammatory arthropathy. Infectious. Crystal induced.
297
What is the treatment for Achilles tendonitis?
Rest. Physiotherapy conditioning. Use of a heel-raise to offload the tendon. Splint or boot. *Resistant cases may benefit from tendon decompression and resection of paratenon, however, scars in this area can be problematic and this condition is self-limiting.*
298
Which bone in the body is one of the slowest in healing?
Tibia (takes around 16 weeks to 1 year to unite.
299
What is the treatment for ankylosing spondylitis?
Physiotherapy. Exercise. NSAIDs. Anti-TNF inhibitors. *DMARDs do not have any impact on spinal disease but can be used if there is peripheral joint inflammation.*
300
Which nerve is particularly at risk of injury in humeral shaft fractures?
Radial nerve.
301
What is a nightstick fracture?
Isolated fracture of the ulnar after a direct blow. Must be sure there is no associated Monteggia injury.
302
Which ligaments are ruptured in an acromioclavicular subluxation?
Acromioclavicular ligaments.
303
What is the treatment for enteropathic arthritis?
Medication that manages both the underlying condition and the arthritis.
304
What is a Morton's neuroma?
Plantar interdigital nerves become irritated, inflamed and swollen forming a neuroma.
305
What structures pass through the carpal tunnel?
Median nerve along with 9 flexor tendons and their synovial covering.
306
What is a pseudotumour in relation to joint replacements?
Inflammatory granuloma produced in response to metal wear particles in the context of a joint replacement, which may be locally invasive but cannot metastasise.
307
What type of bone makes up the diaphysis?
An outer shell of dense cortical bone makes up the shaft (diaphysis).
308
What is the treatment for avascular necrosis?
If articular surface has not collapsed -\> can drill to decompress the bone under fluoroscopy to prevent further necrosis and aid healing. If articular surface has collapsed -\> joint replacement required or fusion can be considered.
309
What are the causes of mechanical back pain?
Obesity. Poor posture. Poor lifting technique. Lack of physical activity. Depression. Degenerative disc prolapse. Facet joint osteoarthritis. Spondylosis (early osteoarthritis).
310
What can treat the pain from pes cavus?
Soft tissue releases and tendon transfer (lateral transfer of tibialis anterior) if supple, or calcaneal osteotomy if more rigid.
311
What is Duchenne's muscular dystrophy?
Defect in dystrophin gene which is involved in calcium transport. Muscle weakness which may only be noticed when the boy starts to walk with difficulty standing and going up stairs.
312
What investigations aid diagnosis of ANCA associated vasculitis?
ESR, PV and CRP - raised. Anaemia of chronic disease common. U and E's - look for renal involvement. Anti-neutrophil cytoplasmic antibody (ANCA). Urinalysis - look for renal vasculitis. CXR. Biopsy of affected area e.g. skin, kidney.
313
What are the associated features of Marfan's syndrome?
High arched palate. Scoliosis. Flattening of the chest (pectus excavatum). Eye problems (lens dislocation, retinal detachment). Aortic aneurysm. Cardiac valve incompetence.
314
When would you see tertiary hyperparathyroidism?
In patients with chronic secondary hyperparathyroidism (usually CKD) who develop an adenoma which will continue to produce PTH despite biochemical correction.
315
What are the clinical features of lateral epicondylitis?
Painful and tender lateral epicondyle. Pain on resisted middle finger and wrist extension.
316
Which muscle is the principle internal rotator of the shoulder?
Subscapularis.
317
What is the common name for medial epicondylitis?
Golfer's elbow.
318
What are the musculoskeletal manifestations of Trisomy 21 (Down syndrome)?
Short stature. Joint laxity with possible recurrent dislocation. Atlanto-axial instability in the cervical spine.
319
What is primary bone healing?
Occurs in anatomically reduced fractures fixed rigidly with plates and screws. Occurs with a fracture gap of less than 1mm.
320
What is ganglion cyst?
Mucinous-filled cysts found adjacent to a tendon or synovial joint. Common in hand (DIPJ - flexor tendon), wrist (dorsal or volar), knee (Baker's cyst).
321
What areas does primary lymphoma of bone tend to affect?
Pelvis or femur.
322
What is Paget's disease?
Chronic bone disorder which results in thickened, brittle and misshapen bones.
323
What is an involucrum?
Area of necrosis in bone that new bone will form around.
324
Which fractures tend to occur following a fall onto an outstretched hand?
Distal radial fractures (e.g. Colles fracture). Scaphoid fracture.
325
What is the WHO definition of osteoporosis?
Bone mineral density less than 2.5 standard deviations below the mean peak value of young adults of the same race and sex.
326
What are the clinical features of granulomatous with polyangiitis?
Granulomatous inflammation involving the respiratory tract (haemoptysis, cavitating lesions). Nosebleeds, deafness, recurrent sinusitis and nasal crusting. Necrotising vasculitis affecting small and medium vessels (e.g. capillaries, venules, arterioles and arteries). Necrotising glomerulonephritis is common.
327
Which tendon is commonly surgically repaired to optimise function?
Patellar tendon.
328
What are SLAP lesions?
Tears in the glenoid labrum where the long biceps attaches that can cause pain.
329
What are the functions of chondrocytes?
Secrete and maintain the ECM around themselves.
330
What is the end result of osteochondritis and avascular necrosis?
An area of bone undergoes localised necrosis as a result of ischaemia from a reduction in blood supply.
331
What is pseudo-locking?
Knee becomes 'stuck' with temporary difficulty in straightening the joint. Usually occurs after rising from sitting and it will either spontaneously resolve or the patient will describe a 'trick' manoeuvre that relieves the issue. *Not a sign of meniscal tear but arthritis.*
332
How do olecranon fractures commonly occur?
Fall onto the point of the elbow with contraction of the biceps muscle.
333
What is meant by rotation of a fracture?
Rotation of the distal fragment is described relative to the proximal fragment. Suggests that the fracture is more unstable.
334
What blood serum levels are normally elevated in seronegative inflammatory arthropathies?
CRP and ESR. Patients are often HLA‐B27 positive (although only a minority of HLA‐B27 positive patients develop a spondyloarthritis).
335
What is the bulbocavernous reflex?
A reflex contraction of the anal sphincter with either a squeeze of the glans penis, tapping the mons pubis or pulling on a urethral catheter. This reflex is absent in spinal shock and its return signals the end of spinal shock.
336
If a giant cell tumour was to metastasise, where would it go?
Lung.
337
What is the pathogenesis of fibromyalgia?
Not fully understood but thought to be biochemical, metabolic and immunoregulatory abnormalities.
338
What is spinal shock?
A physiologic response to injury with complete loss of sensation and motor function, and loss of reflexes below the level of injury. Usually resolves in 24 hours with return of reflexes.
339
What is the normal developmental milestone for standing?
8-12 months.
340
What structure herniates in a prolapsed intervertebral disc?
Gelatinous nucleus pulposis.
341
Which muscles make up the rotator cuff?
Supraspinatus. Infraspinatus. Subscapularis. Teres minor.
342
What is the normal developmental milestone for walking?
14-17 months.
343
A patient is diagnosed in the respiratory clinic as having pulmonary fibrosis. The chest physician notes that she has Raynaud’s phenomenon, dry eyes, facial telangiectasia and puffy hands. What is the most likely diagnosis?
Diffuse systemic sclerosis.
344
How can fibula hemimelia be treated?
Mild cases -\> limb lengthening with a circular frame external fixator. Severe cases -\> through ankle amputation at 10 months to 2 years and use of a below-knee prosthetic limb.
345
What is rheumatoid arthritis?
An auto-immune inflammatory symmetric polyarthropathy which commonly affects the small joints of the hands and feet. Larger joints such as the knees, shoulders and elbows can also be affected as the disease progresses.
346
What is the treatment for trochanteric bursitis?
Analgesia. Anti-inflammatories. Physiotherapy. Steroid injection. *No surgical treatment has proven a benefit.*
347
What is the treatment of cervical spondylosis?
Physiotherapy and analgesics.
348
What can cause patellar dislocation?
Direct blow or sudden twist of the knee. Causes a tear of the medial patellofemoral ligament and osteochondral fracture can occur as the medial facet of the patellar strikes the lateral femoral condyle.
349
What does arthralgia mean?
Pain in a joint.
350
What does calcium pyrophosphate deposition disease (CPPD) tend to affect?
Knee. Wrist. Ankle.
351
What is the treatment for late (post-collapse) diagnosis of avascular necrosis?
Total hip replacement.
352
What is Sinding-Larsen-Johanssen disease?
Inflammation of the inferior pole of the patella.
353
What is the mucocutaneous presentation of SLE?
Malar (butterfly) rash. Photosensitivity. Discoid lupus. Subacute cutaneous lupus. Oral/nasal ulceration. Raynaud's phenomenon. Alopecia.
354
What is the common organism that produces a low-grade prosthetic infection diagnosed late?
Staph. epidermidis. Enterococcus.
355
What is the treatment of clubfoot?
Early splintage (Ponseti technique). Late deformity requires extensive surgery (soft tissue +/- bony procedures) with less satisfactory results. 80% of cases require a tenotomy of the Achilles tendon to maintain full correction. Once full correction achieved - brace consisting of boots attached to a bar which is worn 23hours per day for 3 months until the age of 3-4.
356
What is the treatment for cubital tunnel syndrome?
May need surgical release of any tight structures.
357
What type of splint may be used for the temporary splintage of femoral shaft fractures?
Thomas splint.
358
What is the management of buckle fractures?
These fractures are stable and require 3-4 weeks of splintage.
359
Which clinical descriptors of fractures describe the direction of forces involved in the injury and give information about the reversed direction of forces required to reduce a fracture?
Displacement and angulation.
360
What is an osteosarcoma?
Most common form of primary bone tumour, producing abnormal bone.
361
What is impingement syndrome?
The tendons of the rotator cuff (predominantly supraspinatus) are compressed in the tight subacromial space during movement, producing pain. ## Footnote *Painful arc = 60-120 degrees of abduction -\> as the inflamed are of supraspinatus tendon passes through the subacromial space.*
362
What is the management of Henoch-Schonlein purpura?
Tends to be a self-limiting condition not requiring specific treatment. Usually settles over the course of weeks to months.
363
What are the consequences of complete knee dislocation?
Rupture of all four of the knee ligaments. Intimal tears can occur which later thrombose -\> regular checks on the circulation of the foot are mandatory.
364
What surgical operations are carried out for rheumatoid arthritis?
Synovectomy. Joint replacement. Joint excision. Tendon transfers. Arthrodesis (fusion). Cervical spine stabilisation.
365
What is the Ortolani manoeuvre?
Reducing a dislocated hip with abduction and anterior displacement.
366
What are the flexor and extensor imbalances of hammer toes?
Hyperextension at the DIPJ.
367
What is primary bone healing?
Occurs where there is a minimal fracture gap (\<1mm) and the bone simply bridges the gap with new bone from osteoclasts. Occurs in healing hairline fractures, fractures fixed with compression screws and plates.
368
What is malignant fibrous histiocytoma?
Fibrous malignant primary bone tumours which tend to occur in abnormal bone e.g. bone infarct, fibrous dysplasia, post-irradiation and Paget's disease.
369
What are the early local complications associated with fracture?
Compartment syndrome. Vascular injury with ischaemia. Nerve compression. Injury. Skin necrosis.
370
What distribution of symptoms do peripheral nerve compression neuropathies give?
Affect the peripheral nerve sensory and motor territories.
371
What is an aneurysmal bone cyst?
**A lucent, multiloculated cyst found within the medulla of many different bones, often with associated cortical expansion.** Contains lots of chambers filled with blood or serum. Can be seen on x-ray. Locally aggressive causing cortical expansion and destruction; usually painful. Risk of pathological fracture.
372
What are the consequences of a posterior shoulder dislocation?
Impaction fracture of the posterior head of the humerus (Hill-Sachs lesion).
373
What are the presenting features of small and medium vessel vasculitis?
Fever. Weight loss. Raised, non-blanching purpuric rash Arthralgia/arthritis. Mononeuritis multiplex. Glomerulonephritis. Lung opacities on x-ray.
374
What surgical treatment can be used in ankylosing spondylitis?
Hip/knee replacements. Kyphoplasty - controversial and carries considerable risks.
375
What movement is the radio-capitellar joint responsible for?
Supination. Pronation.
376
Osteoporosis can occur secondarily to which conditions?
Corticosteroid use. Alcohol abuse. Malnutrition. Chronic kidney disease. Malignancy. Rheumatoid arthritis. Cushing's syndrome. Hyperthyroidism. Hyperparathyroidism.
377
What conditions are associated with an increased risk of carpal tunnel syndrome?
Rheumatoid arthritis. Pregnancy. Chronic renal failure. Hypothyroidism. Diabetes.
378
What is the respiratory presentation of SLE?
Pleurisy. Pleural effusion. Pneumonitis. Pulmonary embolism. Pulmonary hypertension. Interstitial lung disease.
379
What is Hawkins-Kennedy test?
Internally rotating the flexed shoulder and if positive will produce pain.
380
What is the most common pattern of injury in proximal humeral fractures?
Fracture of the surgical neck with medial displacement of the humeral shaft due to pull of the pectoralis major muscle. The greater and lesser tuberosities may also be avulsed.
381
What are osteoclasts?
Large (up to 40µm or more) multinucleated cells. They are found on the surface of bone and are responsible for bone resorption.
382
What does arthritis mean?
Inflammation of the joint.
383
What is developmental dysplasia of the hip?
Dislocation or subluxation of the femoral head during the perinatal period which affects the subsequent development of the hip joint.
384
Why do claw and hammer toes occur?
Acquired imbalance between the flexor and extensor tendons.
385
Which tendon is commonly surgically managed conservatively?
Long head of the biceps.
386
What area is affected if there is a L5/S1 prolapse?
S1 root entrapment. Pain to the sole of the foot. Reduced power for plantarflexion. Reduced ankle jerks.
387
What deformities are consistent with osteoarthritis?
Squaring of the thumb base. Heberden's nodes. Bouchard's nodes.
388
What is the cause of calcium pyrophosphate deposition disease (CPPD)?
Exact cause is unknown. Coexists with hyperparathyroidism, hypothyroidism, renal osteodystrophy, haemochromatosis and Wilson's disease.
389
What can predispose to Achilles tendonitis?
Quinolone antibiotics (ciprofloxacin). Rheumatoid arthritis. Other inflammatory arthropathies. Gout.
390
What fractures tend to occur in people with type 2 osteoporosis?
Femoral neck fractures. Vertebral fractures.
391
What is ankylosing spondylitis?
Chronic inflammatory disease of the spinal and sacroiliac joints which can lead to fusion of the intervertebral joints and SI joints.
392
A 55 year old lady presents with an occasional tingling sensation in her 2nd and third toes which is often preceded by a sharp pain shooting into her forefoot. She's otherwise well with no other co-morbidities and sensation of the foot is completely normal. However, on Mulder's click test, there is a palpable 'clunk' in the forefoot and the patient complains of the shooting pain. What is the underlying diagnosis?
Morton's neuroma.
393
What is the normal variation of lower limb alignment?
Children at birth normally have varus knees (bow legs) which become neutrally aligned at around 14 months, progressing to 10 to 15° valgus (knock knees) at age 3 and then gradually regress to the physiologic valgus of 6° by around the age of 7‐9.
394
What is the main reason why joint replacements fail?
Loosening or breakage of the joint replacement components.
395
What is pseudogout and what causes it?
A crystal arthropathy causing an acute arthritis that is caused by deposits of calcium pyrophosphate crystals.
396
What is Schobers test?
Measures lumbar spinal flexion. Involves measuring 5cm below the posterior superior iliac crests and 10cm above, whilst the patient is upright, then asking them to bend forwards and remeasuring the distance. In normal situations, it should extend beyond 20cm.
397
What is osteolysis in relation to joint replacements?
Polyethylene particles can cause an inflammatory response in bone with subsequent bone resorption resulting in loosening.
398
What are the specific causes of osteomalacia and rickets?
Malnutrition. Malabsorption (low vit D absorption). Lack of sunlight exposure (no activation of vit D). Hypophosphataemia (reduced phosphate absorption, malabsorption, renal tubular acidosis). Long-term anticonvulsant use. Chronic kidney disease (reduced phosphate reabsorption and failure of activation of vit D).
399
What are the implications of performing total hip replacements in younger patients?
Higher risk of requiring revision later in life (put more demand on the prosthetic and longer life expectancy than elderly).
400
Anti-La antibody is associated with which condition(s)?
Sjogren's syndrome.
401
What are seropositive conditions?
Conditions in which auto-antibodies are found in the serum.
402
What is reactive arthritis?
Occurs in response to an infection in another part of the body, most commonly genitourinary infections (chlamydia, neisseria) or GI infections (salmonella, campylobacter). The infection triggers an autoimmune arthropathy. Most cases self-limiting; 15-30% are chronic or have relapses.
403
What is osteochondritis dissecans?
Fragmentation with separation of the bone and cartilage within a joint.
404
What are the early systemic complications associated with fracture?
Hypovolaemia. Fat embolism. Shock. Acute respiratory distress syndrome. Acute renal failure. Systemic inflammatory response syndrome. Multi-organ dysfunction syndrome. Death.
405
What are the risk factors for osteoarthritis?
Environmental factors. Hobbies e.g. intense sport. Type of work. Joints with abnormal alignment (developmental/pathological). Previous injuries.
406
What is the progression of Duchenne muscular dystrophy?
Progressive muscle weakness as the child grows. By age 10, child can no longer walk and by age 20 progressive cardiac and respiratory failure develop. Death in early 20s.
407
What are connective tissue disorders?
Genetic disorder of collagen synthesis (mainly type I found in bone, tendon and ligaments) resulting in joint hypermobility.
408
What are the clinical signs of a scaphoid fracture?
Tenderness in the anatomical snuff box. Pain on compressing (telescoping) the thumb metacarpal.
409
What is a greenstick fracture?
Occurs in children's bones with the cortex on the tension side of the fracture failing but the cortex on the compression side of the fracture remaining intact.
410
When would you do an excision or resection arthroplasty?
Effective procedure for smaller joints (e.g. first CMC joint in hand) or sometimes used after failure of a hip or shoulder replacement.
411
Where do simple bone cysts occur?
Usually proximal humerus and femur. Can occur in talus or calcaneus.
412
What can be a consequence of a herniated/prolapsed intervertebral disc?
Disc material can press (impinge) on an exiting nerve root resulting in pain and altered sensation in a dermatomal distribution as well as reduced power in a myotomal distribution.
413
What do uric acid crystals appear as under polarised microscopy?
Needle-shaped. Display negative birefringence (change from yellow to blue when lined across the direction of polarisation).
414
What can systemic sclerosis do to the respiratory system?
Pulmonary hypertension. Pulmonary fibrosis. Accelerated hypertension -\> renal crisis
415
What is a lateral compression fracture?
Occurs with a side impact (e.g. RTC) where one half of the pelvis (hemipelvis) is displaced medially. Fractures through the pubic rami or ischium are accompanied by a sacral compression fracture or SI joint disruption.
416
Which bones are easily affected by Paget's disease?
Pelvis. Femur. Skull. Tibia. Sometimes ear ossicles -\> conductive deafness.
417
What is the success of total knee replacement related to?
Accuracy of component alignment. Tension of the surrounding soft tissue envelope.
418
What are the staging investigations for primary bone cancers?
Bone scan. CT of chest. Biopsy for histological diagnosis and grading.
419
What can cause osteochondritis?
Increased physical activity with repeated stress (compression or traction). Familial predisposition.
420
What is secondary bone healing?
Fracture gap site which needs to be filled temporarily to act as a scaffold for the new bone to be laid down. Inflammatory response with recruitment of pluripotential stem cells which differentiate into different cells in healing process.
421
What is the treatment for osteoarthritis?
Pain control - simple analgesia and mild opiates. Physiotherapy. Weight loss. Exercise. In some cases, surgery e.g. hip/knee replacement.
422
Which conditions can atraumatic cervical spine instability occur in?
Down syndrome - at risk of atlanto-axial (C1/C2) instability with subluxation potentially causing spinal cord compression. Rheumatoid arthritis - atlanto-axial subluxation due to destruction of synovial joint between the atlas and the dens and rupture of the transverse ligament.
423
What are the late features of large-vessel vasculitis?
Claudicant symptoms in the upper and lower limbs.
424
What are the red flag symptoms and signs of the spine?
Back pain in patients under 20 years old - tumours, infections. New back pain in patients older 60 years old - could be metastatic or myeloma. Nature of pain = constant, severe pain, worse at night - tumour, infection. Systemic upset = fevers, night sweats, weight loss, fatigue and malaise - tumour, infections.
425
Why does loosening of one or both of the prosthetic components of a total hip replacement occur?
Due to wear particles from the bearing surface causing an inflammatory response at the implant-bone (cement-bone) interface. Causes osteoclastic bone resorption.
426
What are lower motor neuron signs?
Reflexes (a test of sensory and motor function) may be reduced. Pain and altered sensation in a dermatomal distribution. Reduced power in a myotomal distribution.
427
What is the treatment for systemic sclerosis?
Raynauds/digital ulcers - calcium channel blockers, iloprost, bosentan. Renal involvement - ACE inhibitors. GI involvement - proton pump inhibitors for reflux. Interstitial lung disease - immunosuppression usually cyclophosphamide.
428
What is osteogenesis imperfecta?
AKA brittle bone disease. Defect of maturation and organisation of type I collagen (organic composition of bone). Autosomal dominant.
429
What are the causes of primary hyperparathyroidism?
Due to benign adenoma, hyperplasia or rarely a malignant neoplasia.
430
What is the treatment for acute attacks of gout?
NSAIDs (colchicine for patients who cannot tolerate NSAIDs), corticosteroids, opioid analgesics.
431
What anatomical structure impinges in shoulder impingement?
Rotator cuff tendon.
432
What is hallux valgus?
Bunion. Can occur in late adolescence and strong FH.
433
What arthritis has this typical pattern?
Osteoarthritis.
434
What risk of damage is increased in penetrating volar injuries to the hand?
Damage to the flexor tendons, digital nerves and digital arteries.
435
What is a segmental fracture?
The bone is fractured in two separate places.
436
Which conditions are described as connective tissue diseases?
Systemic lupus erythematosus (SLE). Sjogren's syndrome. Systemic sclerosis. Mixed connective tissue disease (MCTD). Anti-phospholipid syndrome.
437
Is surgery for hip fractures avoided in patients with significant morbidities? Explain your answer.
No, it is not avoided as, despite the risk of medical complications with surgery, nearly all patients with a hip fracture undergo surgery as the risks of non-operative management are just as high.
438
What is Marfan's syndrome?
Autosomal dominant or sporadic mutation of the fibrillin gene -\> tall stature, disproportionately long limbs and ligamentous laxity.
439
What type of headache is associated with giant cell arteritis?
Continuous. Located in the temporal or occipital areas. Focal tenderness on direct palpation.
440
What is the shoulder joint formed of?
Humeral head and the scapular glenoid.
441
What is the cause of secondary hyperparathyroidism?
Physiological overproduction of PTH to hypocalcaemia usually caused by vitamin D deficiency or CKD.
442
Which ligaments are ruptured in an acromioclavicular dislocation?
Coracoclavicular ligaments (conoid and trapezoid ligaments) and the acromioclavicular ligaments.
443
What is the treatment for trigger finger?
Steroid injection within the sheath to relieve symptoms Incision of the A1 pulley - if symptoms recurrent or persistent.
444
What are the early local complications of total hip arthroplasty?
Infection. Dislocation. Nerve injury (sciatic nerve). Leg length discrepancy.
445
When would you do a PCL reconstruction?
If a multiple ligament reconstruction is required. If patient has severe, laxity, recurrent instability with frequent hyperextension or feeling unstable descending stairs.
446
What symptoms are associated with Sjogren's syndrome?
Sicca symptoms - dryness of eyes and mouth. Arthralgia. Fatigue. Vaginal dryness. Parotid gland swelling.
447
What is hallux rigidus?
Osteoarthritis of the first metatarsal phalangeal joint.
448
What is the normal developmental milestone for head control?
2 months.
449
What are typical radiographic findings of an osteoarthritic joint?
**L**oss of joint space. **O**steophytes. **S**clerosis. **S**ubchondral cysts.
450
What is the commonest skeletal dysplasia?
Achondroplasia.
451
Anti-CCP antibody is associated with which condition(s)?
Rheumatoid arthritis.
452
What are the symptoms of cubital tunnel syndrome?
Paraesthesiae of the ulnar 1.5 fingers. Tinel's test positive (percussing over the nerve to elicit a sensation of tingling or "pins and needles" in the distribution of the nerve). Froment's test positive (image).
453
What are the symptoms of Henoch-Schonlein purpura?
Purpuric rash over the buttocks and lower limbs. Abdominal pain. Vomiting. Joint pain.
454
What is the mainstay of treatment for most soft tissue injuries?
**R**est. **I**ce. **C**ompression. **E**levation. ***RICE.***
455
Where do metatarsal fractures most commonly occur?
2nd Metatarsal.
456
What is a bunion?
Inflamed bursa over the medial first metatarsal head.
457
Which bones are most frequently involved with metastases?
Vertebra. Pelvis. Ribs. Skull. Humerus. Long bones of the lower limb.
458
What are the symptoms of carpal tunnel syndrome?
Parastehiae in the thumb and radial 2.5 fingers - worse at night. Loss of sensation and sometimes weakness of the thumb/clumsiness in the areas of the hand supplied by the median nerve.
459
What is the management of SLE if there is skin disease and arthalgia?
Hydroxychloroquine. Topical steroids. NSAIDs.
460
461
What are the two types of large-vessel vasculitis?
Temporal (giant cell) arteritis (\>50 years old). Takayasu arteritis (\<50 years old).
462
What is a giant cell tumour?
Occur after the physis has fused and are locally destructive destroying the cortex. Found mainly in metaphyseal region but also epiphysis, extending to the subchondral bone adjacent to joint.
463
What is the musculoskeletal presentation of SLE?
Arthralgia. Myalgia. Inflammatory arthritis (rarely erosive/deforming; increased avascular necrosis).
464
What is a complete spinal cord injury?
No sensory or voluntary motor function below the level of the injury (reflexes should return).
465
What is transient synovitis of the hip?
Self-limiting inflammation of the synovium of a joint, most commonly a hip. Commonly occurs after an URTI (usually viral).
466
What are the main categories of vasculitis?
Large-vessel vasculitis. Medium-vessel vasculitis. Immune complex small-vessel vasculitis. ANCA-associated small-vessel vasculitis.
467
What are the symptoms of cubital tunnel syndrome?
Paraesthesiae of the ulnar 1.5 fingers. Weakness of ulnar nerve innervated muscle including the 1st dorsal interosseous (abduction index finger) and adductor pollicis. Tinel's test over the cubital tunnel is usually positive.
468
What is the surgical treatment of carpal tunnel syndrome?
Carpal tunnel decompression - division of the transverse carpal ligament.
469
What may cause a hypertrophic non-union of bone following a fracture?
Excessive movement at the fracture site with abundant hard callus formation. Too much movement will give the fracture no chance to bridge the gap. Infection.
470
When is a hard callus usually formed following a fracture?
6-12 weeks.
471
What are known triggers of rheumatoid arthritis?
Smoking. Infection. Trauma.
472
What is Ledderhose disease?
Fibromatoses conditions like Dupuytren's contracture but affecting the plantar aspect of the foot.
473
In what circumstances does brachial plexus injury during vaginal delivery occur?
Large babies (macrosomia in diabetes). Twin deliveries. Shoulder dystocia (difficult delivery of the shoulder after the head with compression of the shoulder on the pubic symphysis).
474
What is the main treatment for joint instability?
Physiotherapy to strengthen up surrounding muscles and to improve proprioception.
475
What is the treatment for Erb's palsy?
Physiotherapy -\> prevent contractures early on and prognosis of return of biceps function by 6 months is 80-90%. Surgical release of contractures and tendon transfers may be required if no recovery.
476
What is a fibrosarcoma?
Fibrous malignant primary bone tumours which tend to occur in abnormal bone e.g. bone infarct, fibrous dysplasia, post-irradiation and Paget's disease. Tends to affect adolescents/young adults.
477
What is type 1 primary osteoporosis?
Post-menopausal osteoporosis with an exacerbated loss of bone in the post-menopausal period.
478
What is the primary feature of Duchenne's muscular dystrophy?
Progressive muscular weakness.
479
What are the principles of the Advanced Trauma Life Support (ATLS) guidelines?
**Initial primary survey** - quick assessment of vital functions is made and appropriate management instigated. **Secondary survey** - head to toe survey to detect other injuries of the head, face, chest, abdomen, pelvis, genitourinary system, perineum, spine, neurological system and appendicular skeleton.
480
What is in-toeing?
When person is walking and standing, their feet will point towards the midline. Abnormality often exaggerated when running.
481
What is the normal developmental milestone for speaking a few words?
9-12 months.
482
What are the causes of in-toeing?
Femoral neck anteversion. Internal tibial torsion. Forefoot adduction.
483
What is muscular dystrophy?
Rare and usually X-linked recessive hereditary disorders resulting in progressive muscle weakness and wasting.
484
What are the 5 basic fracture patterns?
Transverse fracture. Oblique fracture. Spiral fracture. Comminuted fracture. Segmental fracture.
485
What is an osteotomy?
Surgical realignment of a bone which can be used for deformity correction or to redistribute load across an arthritic joint.
486
In a paracentral L4/L5 disc prolapse which nerve root is most likely to be impinged?
Traversing L5 nerve root.
487
What is the Salter-Harris fracture classification system?
It is used to describe and classify children's fractures occurring around the physis (growth plate). The fracture prognosis is poorer as the the classification progresses.
488
What are the primary malignant tumours which commonly metastasise to bone?
Breast carcinoma. Prostate carcinoma. Lung carcinoma. Renal cell carcinoma. Thyroid adenocarcinoma.
489
What is inflammation of the tendon of the long head of the biceps?
Anterior shoulder pain with pain on resisted biceps contraction.
490
Which patients with mechanical back pain may benefit from spinal stabilisation surgery?
Single level of the spine is affected. Patient not improved despite physio and conservative management. No other adverse secondary gain or behavioural issues which adversely affect the outcome of surgery. *Studies show no benefit from back surgery for mechanical pain 5 years post surgery.*
491
What is hyperparathyroidism?
Overactivity of the parathyroid glands with high levels of parathyroid hormone (PTH).
492
What is giant cell arteritis?
Most common systemic vasculitis in adults of unknown aetiology and occurs in older patients.
493
What are the symptoms of lower motor neuron neuromuscular disorders?
Weakness. Reduced tone. Hyporeflexia or areflexia.
494
What is the treatment for sciatica/lumbar radiculopathy?
Analgesia, maintaining mobility and physiotherapy. Occasionally drugs for neuropathic pain e.g. Gabapentin can be used if pain is severe. Very occasionally need surgery (discectomy) indicated if pain not resolving.
495
What forms the pelvic ring?
Sacrum. Ilium. Ischium. Pubic bones. Strong supporting ligaments.
496
What patterns of meniscal tears are there?
Longitudinal tears (bucket-handle tear). Radial tears. Oblique tears. Horizontal tears.
497
What is an Ewing's sarcoma?
Malignant tumour of primitive cells in the marrow. Most cases occur between the ages of 10 and 20. May be associated with fever, raised inflammatory markers and a warm swelling. May be misdiagnosed as osteomyelitis.
498
What is a synovial sarcoma?
Malignant tumour of the synovial lining of joints/tendons.
499
What features should raise suspicion of non-accidental injury or child abuse?
Multiple fractures of varying ages (with varying amounts of callus or healing). Multiple trips to A&E with different injuries. Inconsistent/changing history of events. Discrepancy of history between parent/carers. History not consistent with injury. Injuries not consistent with age of child e.g. non-walking child. Multiple bruises of varying ages. Atypical injuries e.g. cigarette burns, genital injuries, torn frenulum, dental injuries, lower limb and trunk burns. Rib fractures. Metaphyseal fractures in infants.
500
What is vasculitis?
Inflammation of blood vessels which may result in thickening, stenosis and occlusion with subsequent ischaemia.
501
Which fractures are at higher risk of developing a DVT?
Pelvic or major lower limb fractures with a period of immobility. ## Footnote *Prophylaxis of LMWH should be given to all at-risk patients.*
502
What is secondary bone healing?
Involves an inflammatory response and laying down as immature bone. Can be associated with hypertrophic non-union when the fracture is not properly stabilised.
503
What is the most common primary bone tumour?
Osteosarcoma.
504
What is the process of secondary bone healing?
Fracture occurs. Haematoma occurs with inflammation from damaged tissues. Macrophages and osteoclasts remove debris and resorb the bone ends. Granulation tissue forms from fibroblasts and new blood vessels. Chondroblasts form cartilage (soft callus). Calcium mineralisation produces immature woven bone (hard callus). Remodelling occurs with organisation along lines of stress into lamellar bone.
505
What are the symptoms of mixed connective tissue disease?
Raynauds phenomenon. Arthralgia/arthritis. Myositis. Sclerodactyly. Pulmonary hypertension. Interstitial lung disease.
506
What is the genetic inheritance of osteogenesis imperfecta?
Autosomal dominant and recessive models.
507
Where are rheumatoid nodules found?
Extensor surfaces or sites of frequent mechanical irritation.
508
What are the causes of cerebral palsy?
Genetic problems. Brain malformation. Intrauterine infection in early pregnancy. Prematurity. Intra-cranial haemorrhage. Hypoxia during birth (1 in 10). Meningitis.
509
What is the management of SLE if there the pt is unresponsive to treatment?
Biologic therapy.
510
What is the non-operative treatment of carpal tunnel syndrome?
Wrist splints at night to prevent flexion. Corticosteroid injection.
511
Which bacteria is a cause of septic arthritis in young adults?
Neisseria gonorrhoea.
512
What are the criteria for the Beighton classification of joint hypermobility?
Total of 9 points. 1 point for each side - passively touch the forearm with the thumb in the flexed position. 1 point for each hand - passive hyperextension of the fingers or the little finger beyond 90 degrees. 1 point for each - hyperextension of the elbows or knees beyond 10 degrees. 1 point - ability to touch the floor with both palms with legs straight. *Score of 4 or more suggests hypermobility.*
513
What is limited systemic sclerosis?
Skin involved and tends to be confined to the face, hands, forearms and feet. Organ involvement tends to occur later. Anti-centromere antibody association.
514
What anatomical structure impinges in hip impingement?
Acetabular labrum.
515
What is the purpose of periosteum?
Serves to increase the width/circumference of growing long bones.
516
What shoulder problems tend to occur in the elderly?
Osteoarthritis.
517
What area is affected if there is a L3/4 prolapse?
L4 root entrapment. Pain down to the medial ankle (L4). Loss of quadriceps power. Reduced knee-jerk.
518
What is the clinical presentation of trochanteric bursitis?
Pain and tenderness in the region of the greater trochanter with pain on resisted abduction.
519
What is Barton's fracture?
Intra-articular fractures of the distal radius involving the dorsal or volar rim, where the carpal bones of the wrist joint sublux with the displaced rim fragment.
520
What is the normal developmental milestone for managing stairs independently?
Age 3.
521
What is the treatment for anti-phospholipid syndrome?
Anti-coagulation - for patients with an episode of thrombosis. Low molecular weight heparin - patients with recurrent pregnancy loss.
522
Which nerve is compressed in carpal tunnel syndrome?
Median nerve.
523
What is the management for fibromyalgia?
Self-management techniques and support from clinician. Graded exercise and activity pacing. Atypical analgesia including tricyclics (e.g. amitriptyline), gabapentin and pregabalin. Psychological input - CBT.
524
What is type 2 osteoporosis?
Osteoporosis of old age with a greater decline in bone mineral density than expected.
525
What is the late local complication of a Colles fracture?
Rupture of the extensor pollicis longus tendon.
526
What is the treatment of a mallet finger?
Mallet splint holding the DIP joint extended. Should be worn continuously for a minimum of 4 weeks.
527
What is a delayed union of a fracture?
A fracture that has not healed within the expected time. Can be due to infection.
528
What can occur with severe osteoporosis of the spine?
Spontaneous crush fractures of the vertebral body -\> acute pain and kyphosis.
529
What is an osteoid osteoma?
Small nidus of immature bone surrounded by an intense sclerotic halo. Common sites = proximal femur, diaphysis of long bones and the vertebrae.
530
What are the clinical features of microscopic polyangiitis?
Necrotising vasculitis with a few or no immune deposits affecting small vessels (capillaries, venules or arterioles). Necrotising arteritis involving small and medium arteries may be present. Necrotising glomerulonephritis is very common. Pulmonary capillaritis often occurs.
531
What is the histopathology of giant cell arteritis?
Transmural inflammation of the intima media and adventitia of affected arteries. Patchy infiltration by lymphocytes, macrophages and multinucleated giant cells. Vessel wall thickening -\> arterial luminal narrowing -\> subsequent distal ischaemia.
532
What is the most common management of minimally displaced, 2-part proximal humeral fractures?
Non-operative in collar and cuff.
533
What is the treatment of polymyalgia rheumatica?
Low dose steroids (prednisolone 15mg daily) - sometimes used as a diagnostic tool as symptoms respond dramatically to this. Steroid dose gradually reduced over around 18 months - majority of cases resolved by this point.
534
What is a Salter-Harris V fracture?
Compression injury to the physis with subsequent growth arrest. Cannot be diagnosed on initial xrays and are only detected once angular deformity has occurred.
535
What is the renal presentation of SLE?
Lupus nephritis.
536
What is avascular necrosis?
Ischaemic necrosis of the bone predominantly in adults. Results in necrosis of a segment of bone resulting in patchy sclerosis before subchondral collapse and irregularity of the articular surface occur.
537
What is the normal developmental milestone for understanding 200 words and learning around 10 words/day?
18-20 months.
538
What is a ganglion cyst?
Occurs around a synovial joint or synovial tendon sheath and may form as a result of herniation or out-pouching of a weak portion of joint capsule/tendon sheath.
539
What is the normal developmental milestone for potty training?
2-3 years.
540
What is enchondroma?
**A mostly lucent lesion, with** **a patchy** **sclerosis, found within the metaphyseal region of long bones.** Intramedullary and metaphyseal cartilaginous tumour caused by failure of normal enchondral ossification at the growth plate. Usually asymptomatic. Can weaken bone -\> pathologic fracture.
541
What are the risk factors for developmental dysplasia of the hip?
Family history of developmental dysplasia of the hip. Breech position. Firstborn babies. Down syndrome. Presence of other congenital disorders (talipes, arthrogryposis).
542
What does a DAS 28 score of 2.7-3.2 indicate?
Low disease activity.
543
What is the management of shoulder dislocations?
Closed reduction under sedation or anaesthesia with neurovascular assessment before and after reduction. Sling for 2-3 weeks to allow detached capsule to heal then rehabilitation with physiotherapy.
544
Why should a steroid injection not be administered around the Achilles tendon?
Causes a risk for tendon rupture.
545
Which lymphoma can occur as a primary bone tumour?
Non-Hodgkins Lymphoma.
546
What is osteoarthritis?
Degenerative disorder as every joint is subject to wear and tear deterioration of cartilage. Imbalance exists between wear and repair of cartilage.
547
What can cause hyperuricaemia?
Renal underexcretion (can be exacerbated by diuretics or renal failure). Excessive intake of alcohol, red meat or seafood. Genetic predisposition.
548
What is a Mulder's click test?
Medio-lateral compression of the metatarsal heads (exerted by squeezing the forefoot with your hand) may reproduce symptoms or produce a characteristic 'click'.
549
What is complex regional pain syndrome (CPRS)?
Heightened chronic pain response after injury. Characteristics variable but include constant burning or throbbing, sensitivity to stimuli not normally painful (allodynia) including cold or light touch, chronic swelling, stiffness, painful movement and skin changes. Can be caused by peripheral nerve injury (type 2) but often is not (type 1).
550
What is the common organism that produces an early prosthetic infection?
Staph. aureus. Gram-negative bacilli including coliforms.
551
What is the principal clinical sign of frozen shoulder?
Loss of external rotation.
552
What is an Monteggia injury?
Fracture of the ulna with dislocation of the radial head.
553
What criteria are included in the Modified New York criteria for diagnosis of ankylosing spondylitis?
Back pain \>3 months. Back pain worse at rest relieved by movement. Xray changes of sacroiliitis.
554
What is a rhabdomyosarcoma?
Malignant tumour of skeletal muscle.
555
What factors are required for secondary bone healing?
Good blood supply for oxygen, nutrients and stem cells. Little movement or stress (compression or tension).
556
What findings on a radiograph would indicate rickets or osteomalacia?
Pseudofractures (aka Looser's zones) particularly of the pubic rami, proximal femur, ulna and ribs.
557
What bearing surfaces can be coupled together in a hip arthroplasty?
**Metal-on-polyethylene.** Metal-on-metal. Ceramic-on-ceramic. Ceramic-on-polyethylene.
558
What is inflammatory pannus?
Hypertrophied synovium which forms and then attacks and denudes articular cartilage, leading to joint destruction. As a result, tendon ruptures and soft tissue damage can occur leading to joint instability and subluxation.
559
What is the pathogenesis of rheumatoid arthritis?
Immune response against the synovium which lines synovial joints and tendons.
560
What is the prognosis of polymyositis?
Usually responds to treatment slowly. 30% patients left with some residual weakness. Older patients and those who have presented late tend to do less well.
561
What are the clinical signs of non-union of a fracture?
Ongoing pain. Ongoing oedema. Movement at the fracture site. Bridging callus may be seen on xray, however, in cases where doubt exists over bony union, CT scans may confirm or exclude bridging callus.
562
Which meniscal tear is more common?
Medial meniscal tear is more common than lateral because medial meniscus is more fixed and less mobile than the lateral meniscus and the force from pivoting movements is centred on the medial compartment.
563
How can symptoms of carpal tunnel syndrome be repoduced?
Tinel's test (percussing over the median nerve). Phalen's test (holding the wrists hyper-flexed - decreased space in the carpal tunnel).
564
A 30-year-old patient with diabetes attends the A&E department for urgent review. They report a short history of severe right knee pain. There is no history of trauma but they report feeling nauseated and feverish. On examination, their temperature is 38.2 degrees and their right knee is swollen and warm. Both active and passive range of movement is grossly reduced from 20 degrees of extension to 30 degrees of flexion, limited by severe pain. What is your initial working diagnosis?
Septic arthritis.
565
What are the symptoms of frozen shoulder and their timeline?
Pain - subsides after 2-9 months. Stiffness - increases for 4-12 months. Stiffness gradually 'thaws' out.
566
What acetabular fractures can be associated with a hip dislocation?
Posterior wall fractures due to the head of the femur being pushed out the back of the joint.
567
What are the consequences if large-vessel vasculitis is left untreated?
Vascular stenosis. Aneurysms.
568
What is psoriatic arthritis?
Usually asymmetrical oligoarthritis, but may also affects the hands in a pattern similar to rheumatoid arthritis.
569
What are the clinical signs of a fracture?
Localised bony (marked) tenderness - not diffuse mild tenderness. Swelling. Deformity. Crepitus - from bone ends grating with an unstable fracture.
570
What is radicular pain?
Pain radiating to the part of the sensory distribution of the sciatic nerve. Radicular pain is felt as a neuralgic burning or severe tingling pain, often like severe toothache radiating down the back of the thigh to below the knee.
571
Describe the process of bone remodelling?
Bone is constantly undergoing remodelling. In this process, a number of **osteoclasts** will congregate and begin to ‘drill’ into the bone, forming a tunnel. A blood vessel will grow into the tunnel bringing with it **osteoblasts** which line the tunnel and begin laying down new lamellar bone. This process continues until only the space of a Haversian canal remains.
572
What signs do malignant primary bone cancers show on x-ray?
Cortical destruction. Periosteal reaction (raised periosteum producing bone). New bone formation (sclerosis as well as lysis from destruction). Extension into the surrounding soft tissue envelope.
573
What are the clinical features of Churg-Strauss syndrome?
Eosinophil-rich and granulomatous inflammation involving the respiratory tract; necrotising vasculitis affecting small and medium vessels and associated with asthma and eosinophilia.
574
How do meniscal injuries tend to occur?
Twisting force on a loaded knee, e.g. turning at football/squatting).
575
How is polydactyly treated?
Amputating the extra digit.
576
What does arthropathy mean?
Disease of the joint.
577
Why do females tend to lose more bone mineral density after menopause?
Due to an increase in osteoclastic bone resorption with the loss of protective effects of oestrogen.
578
Do all tendon tears require surgical repair to preserve function and allow early recovery?
No, major tendon repairs may require splintage, surgical repair or tendon transfer.
579
What is the treatment of a Morton's neuroma?
Use of a metatarsal pad or offloading insole. Steroid and local anaesthetic injections may relieve symptoms and aid diagnosis. Neuroma can be excised but patients may continue to experience pain; small risk of recurrence.
580
What shoulder problems tend to occur in the middle-aged?
Rotator cuff tears (grey hair = cuff tear). Frozen shoulder.
581
What is femoral neck anteversion?
Excess femoral neck anteversion -\> in-toeing and genu valgum. Doesn't warrant surgical intervention.
582
What is Becker's muscular dystrophy?
Similar to Duchenne but milder with affected boys able to walk in their teens. Sufferers may survive into their 30s or 40s.
583
What is a segmental fracture?
Occur when bone is fractured in 2 separate places. Very unstable and require stabilisation with long rods or plates.
584
Is pregnancy possible in patients with SLE?
Pregnancy can be a difficult time in SLE patients and they need to be monitored closely, especially those with renal disease or positive ant-Ro antibodies. Premature birth, pre-eclampsia and intrauterine growth retardation are possible complications. In anti-Ro positive mothers, there is a risk of congenital heart block and neonatal lupus. Patients should plan pregnancy at a time when their disease control is good.
585
How are displaced or angulated fractures managed?
Reduction under anaesthetic. Cast application.
586
What is fibrous dysplasia?
Bone disease usually occurring in adolescence. Genetic mutation causes lesions of fibrous tissue and immature bone. Can be monostotic or polyostotic.
587
What characterises a seronegative inflammatory arthropathy?
Inflammation and/or arthritic disease of the spine (spondyloarthropathy) and asymmetric oligoarthritis. *Sacroiliitis, uveitis, dactylitis (inflammation of a digit) and* *enthesopathies* *are common (especially* *achilles* *insertional tendonitis and plantar fasciitis).*
588
Which rotator cuff muscles attach to the lesser tuberosity?
Subscapularis.
589
What is a comminuted fracture?
Fracture with 3 or more fragments. Generally, a reflection of a higher energy injury (or poor bone quality) and there may be substantial soft tissue swelling and periosteal damage with reduced blood supply to the fracture site which may impair healing. Very unstable and tend to be stabilised surgically.
590
What is anti-phospholipid syndrome?
A disorder that manifests clinically as recurrent venous or arterial thrombosis and/or foetal loss.
591
What are the consequences of intracapsular hip fractures?
Arterial supply of the femoral head can be disrupted. Risk of avascular necrosis of the femoral head and non-union fracture.
592
Which nerve is compressed in cubital tunnel syndrome?
Ulnar nerve.
593
What are causes of secondary osteoarthritis?
Congenital dislocation of the hip. Perthes. Slipped upper femoral epiphysis (SUFE). Previous intra-auricular fracture. Extra-articular fracture with malunion. Osteochondral/hyaline cartilage injury. Crystal arthropathy. Inflammatory arthritis. Meniscal tears. Genu varum or valgum.
594
What is the treatment for Duchenne muscular dystrophy?
Physiotherapy, splintage and deformity correction may prolong mobility. Severe scoliosis -\> spinal surgery.
595
What may cause an atrophic non-union of bone following a fracture?
Lack of blood supply. No movement (internal fixation with fracture gap),. Too big a fracture gap or tissue trapped in the fracture gap. Rigid fixation with a fracture gap. Chronic disease. Soft tissue interposition. Infection.
596
What are the classical radiological findings with rheumatoid arthritis?
Periarticular erosions. Loss of joint space.
597
Which gender is more affected by ankylosing spondylitis?
Males:females = 3:1.
598
What is the treatment for Paget's disease?
Bisphosphonates (inhibit osteoclasts) or calcitonin if extensive lytic disease. Joint replacement may be necessary and pathological femoral fractures should be stabilised with long intramedullary nails or plates.
599
What is Peyronie’s disease?
Fibromatoses conditions like Dupuytren's contracture but affecting the penis.
600
What is renal dystrophy?
Bone disease that occurs when the kidneys fail to maintain optimum serum calcium and phosphorus levels.
601
How are hip fractures classified?
Intracapsular. Extracapsular. * Based upon the position of the fracture in relation to the hip capsule.* * Relevance is the likelihood of disruption to the femoral head blood supply.*
602
What is the treatment for reactive arthritis?
Treatment of the underlying infectious cause and symptomatic relief, including IA or IM steroid injections. Occasionally DMARDs are required in chronic cases.
603
What does the term chondrocalcinosis mean?
Calcium pyrophosphate deposition occurs in cartilage and other soft tissues in the absence of acute inflammation.
604
What are the symptoms of osteogenesis imperfecta?
Multiple fragility fractures of childhood. Short stature with multiple deformities Blue sclerae. Loss of hearing.
605
What is the treatment for enchondroma, simple bone cyst and aneurysmal bone cyst?
Curettage of the lesion and filled with bone graft or use of bone cement.
606
What is Perthes disease?
Idiopathic osteochondritis of the femoral head which usually occurs between the age of 4-9. Femoral head transiently loses its blood supply -\> necrosis with subsequent abnormal growth and may collapse of fracture. More common in boys (5:1), particularly very active boys of short stature.
607
Where do Salter-Harris II fractures commonly occur in children?
Around the distal radial physis in older children. Angulation with deformity requires manipulation. Growth problems are highly unlikely.
608
What is the commonest benign soft tissue tumour?
Lipoma.
609
Where are giant cell tumours found?
Around the knee and in the distal radius. Can occur in other long bones, pelvis and spine.
610
What nerve can be damaged in a Colles (distal radial) fracture?
Median nerve.
611
What is cubital tunnel syndrome?
Compression of the ulnar nerve at the elbow behind the medial epicondyle.
612
Which part of the joint is the primary site of inflammation in rheumatoid arthritis?
Synovium.
613
What are the late systemic complications of a fracture?
Pulmonary embolism.
614
What are extensor mechanism ruptures of the knee?
Tibial tuberosity. Patellar tendon. Patellar. Quadriceps tendon. Quadriceps muscles.
615
A 32 year old man is diagnosed as having a pulmonary embolus with no clinical risk factors. Anticardiolipin antibodies are raised. What is the most appropriate treatment?
Lifelong warfarin.
616
How can spinal cord nerve roots be damaged by injury?
Contusion. Compression. Stretch. Laceration.
617
What part of the bone does superficial osteomyelitis affect?
Outer surface of the bone.
618
What is spinal stenosis?
Multiple nerve roots can be compressed/irritated due to the cauda equina having less space due to spondylosis, bulging discs, bulging ligamentum flavum or osteophytosis.
619
What is the systemic involvement of rheumatoid arthritis?
Lung: pleural effusions, interstitial fibrosis and pulmonary nodules. Cardiovascular morbidity and mortality increased. Occular: keratoconjunctivitis sicca, episcleritis, uveitis and nodular scleritis that may lead to scleromalacia.
620
What are the complications of scaphoid fractures?
Non-union - due to synovial fluid inhibiting fracture healing. Avascular necrosis of the proximal pole - as its blood supply comes distally from a branch of the radial artery.
621
What investigations can aid diagnosis of systemic sclerosis?
Anti-centromere and anti-Scl-70 antibodies. Organ screening, pulmonary function testing, echocardiogram and renal function monitoring performed regularly.
622
What are the consequences of an anterior shoulder dislocation?
Detachment of the anterior glenoid labrum and capsule (Bankart lesion).
623
Anti-Jo-1 antibody is associated with which condition(s)?
Myositis.
624
What are early features of large-vessel vasculitis?
Low-grade fever. Malaise. Night sweats. Weight loss Arthralgia. Fatigue.
625
What is the clinical presentation of transient synovitis of the hip?
Limp or reluctance to weight bear on the affected side. Range of motion restricted - not as much as would be seen in septic arthritis. Child may have low-grade fever but not systematically unwell or septic.
626
What are the early general complications of total hip arthroplasty?
MI. Chest infection. UTI. Blood loss. Hypovolaemia. DVT. PE.
627
What are gouty tophi?
Painless white accumulations of uric acid which can occur in the soft tissues and occasionally erupt through the skin.
628
What is the incidence of brachial plexus injury during vaginal delivery?
0.2% (2 in 1000).
629
What is the treatment for psoriatic arthritis?
DMARDs (usually methotrexate). Anti-TNF therapy. Joint replacement for large joints. DIP joint fusion.
630
What is skeletal dysplasia?
Medical term for short stature (dwarfism no longer used) and is due to genetic error (hereditary/sporadic) -\> abnormal development of bone and connective tissue.
631
What is ACL reconstruction?
Tendon graft (usually patellar tendon or semitendinosus & gracilis autograft) are passed through tibial and femoral tunnels at the usual location of the ACL in the knee and secured to the bone.
632
In a lateral L4/L5 disc prolapse which nerve root is most likely to be impinged?
L4 exiting nerve root.
633
What is the commonest site to get avascular necrosis?
Hip joint.
634
What is polymyositis?
Idiopathic inflammatory myopathy that causes symmetrical, proximal muscle weakness.
635
What is osteochondroma?
**A bony spur, originating in the metaphyseal regions of long bones, growing away from the epiphysis.** Benign bone tumour which produces a bony undergrowth on external surface with a cartilaginous cap. Any lesion growing in size or producing pain should be biopsied. Multiple osteochondromata = autosomal dominant. 1% risk of malignant transformation.
636
What are the clinical features of psoriatic arthritis?
Spondylitis. Dactylitis. Enthesitis. Nail changes - pitting, onycholysis. Arthritis of the DIP joints of the fingers and/or toes. 5% of these patients have arthritis mutilans - aggressive and destructive form.
637
638
What is the treatment of osteoporotic crush fractures?
Conservative management. Some interventional radiologists have tried balloon vertebroplasty but unknown long-term effects - risk of neurological injury.
639
How does a PCL rupture occur?
Direct blow to the anterior tibia with the knee flexed (e.g. motorcycle crash) or hyperextension.
640
What joints are most commonly affected in gout?
First MTP joint (known as Podagra). Ankle. Knee.
641
What is the action of teres minor?
External rotator.
642
Which imaging modality is useful to detect stress fractures which may fail to show up on xray before a hard callus has formed?
Technetium bone scans.
643
What is the presentation of fibromyalgia?
Persistent (\> 3 months) widespread pain/tenderness on both sides of the body above and below the waist. Fatigue, disrupted and unrefreshing sleep. Cognitive difficulties. Multiple other unexplained symptoms, anxiety and/or depression, and functional impairment of activities of daily living.
644
What is patellofemoral dysfunction?
Disorders of the patellofemoral articulation resulting in anterior knee pain.
645
Which bacteria is the second most common cause of septic arthritis in adults?
Streptococci.
646
Which joints are not affected in rheumatoid arthritis?
DIPs in the hands and feet.
647
What is the pathogenesis of SLE?
Defect in apoptosis that causes increased cell death and a disturbance in immune tolerance leading to development of autoantibodies.
648
Which is more common, primary or secondary bone malignancies?
Malignant primary bone tumours are very rare, however, secondary metastatic bone cancer is common.
649
What is Sjogren's syndrome?
Autoimmune condition characterised by lymphocytic infiltrates in exocrine organs - dryness of eyes and mouth (sicca symptoms).
650
What are the causes of carpal tunnel syndrome?
Idiopathic. Rheumatoid arthritis. Conditions causing fluid retention - pregnancy, diabetes, chronic renal failure, hypothyroidism.
651
What is achondroplasia?
Disproportionately short limbs with a prominent forehead and widened nose. Joints are lax and mental development is normal.
652
What is the common name for lateral epicondylitis?
Tennis elbow.
653
What is an angiosarcoma?
Malignant tumour of blood vessels.
654
What are Salter-Harris III and IV fractures?
Intra-articular fracture splitting the physis. Greater potential for growth arrest. Fracture should be reduced and stabilised to ensure a congruent articular surface and minimise growth disturbance.
655
How are fractures or impending fractures of bones surgically treated?
Stabilisation using long rods (intramedullary nails). If there is destruction of a joint e.g. acetabulum or femoral head, a joint replacement may be better.
656
What are the clinical signs of developmental dysplasia of the hip?
Shortening, asymmetric groin/thigh skin creases and a click or clunk on the Ortolani or Barlow manoeuvres.
657
What signs and symptoms are associated with skeletal dysplasias?
Learning difficulties. Spine deformity. Limb deformity. Internal organ dysfunction. Craniofacial abnormalities. Skin abnormalities. Tumour formation - especially haemangiomas. Joint hypermobility. Atlanto-axial subluxation. Spinal cord compression (myelopathy). Intrauterine/premature death.
658
Where does chronic osteomyelitis tend to occur in children?
Previous open fracture or internal fixation causing underlying infection.
659
You are a GP and you review a 13 year old girl in the company of her mother. She reports a 2 month history of new and progressive back pain in the lumbar region. It is stopping her from taking part in PE at school, which she has always been keen on before, and from doing her gymnastics. On examination, you note that the girl is quite flexible and it's generally quite tender around the lumbar spine but you can't pinpoint any distinct level of tenderness. The back has lost it's normal lordosis and looks quite 'flat'. What is the most appropriate course of action?
Refer to the local paediatric or orthopaedic unit for review.
660
What is the treatment for spondylolisthesis?
Mild - rest and physiotherapy. Severe - stabilisation and possibly reduction surgery.
661
What is the chief form of bone found at the epiphyses of long bones?
Cancellous or trabecular bone occupies the ends of the bone (epiphyses).
662
What can trigger autoimmune conditions?
Multifactorial. Genetic predisposition combined with environmental insults, such as infection or prolonged chemical exposure.
663
What is a spiral fracture?
Occur due to torsional forces. Interfragmentary screws potentially can be used. Most unstable fractures to rotational forces but can also angulate.
664
What movement is the humero-ulnar joint responsible for?
Flexion. Extension.
665
What is the cardiac presentation of SLE?
Pericarditis. Pericardial effusion. Pulmonary hypertension. Sterile endocarditis. Accelerated ischaemic heart disease.
666
Anti-double stranded DNA antibody (dsDNA) is associated with which condition(s)?
SLE.
667
What is a Brodie's abscess?
Children develop a subacute osteomyelitis with a more insidious onset and where the bone reacts by walling off the abscess with a thin rim of sclerotic bone.
668
What is a simple bone cyst?
AKA unicameral bone cyst. Single cavity benign fluid-filled cyst in a bone. Usually asymptomatic. Cause bone weakness -\> pathological fracture.
669
What is a lipoma?
Neoplastic proliferation of fat which usually occurs in the subcutaneous fat, but can occur in muscle.
670
What is the result of calcium pyrophosphate deposition disease (CPPD)?
Osteoarthritic change.
671
What is the presentation of polymyositis?
Symmetrical, proximal muscle weakness in the upper and lower extremities. Insidious in onset. Some patients have myalgia. Dysphagia secondary to oropharyngeal and oesophageal involvement in 1/3 of patients - poor prognostic sign. Interstitial lung disease in 5-30% (especially those with anti-Jo-1 antibody).
672
What is the management of SLE if there is inflammatory arthritis or specific organ involvement?
Immunosuppression - azathioprine/mycophenolate mofetil. Corticosteroids - moderate doses, short periods.
673
A 24 year old patient, just diagnosed with rheumatoid arthritis, is about to commence treatment with DMARDs. At this stage she informs you about her imminent plans to start a family. Which treatment would you suggest to her?
Sulfasalazine.
674
What is the characteristic presentation of polymyalgia rheumatica?
Proximal myalgia of the hip and shoulder girdles with accompanying morning stiffness that lasts more than 1 hour. Symptoms tend to improve as the day goes on with movement.
675
What is the purpose of the rotator cuff muscles?
Pulling the humeral head into the glenoid to provide a stable fulcrum for the powerful deltoid muscle to abduct the arm.
676
What are the causes of impingement syndrome?
Tendonitis subacromial bursitis. Acromioclavicular osteoarthritis with inferior osteophyte. A hooked acromion rotator cuff tear.
677
You are a GP and a 14 year-old boy , Mark, is brought in by his father for review. Mark is complaining of pain in the top of both of his shins on the anterior aspect. He is tall and thin and has grown 10 cms in the last 6 months. On examination, he has rather prominent tibial tuberosities on each side and these are a little tender to touch. He can complete a straight leg raise. Mark and his father are a bit concerned and wonder what is causing these symptoms. What do you think is the likely diagnosis?
Osgood-Schlatter's disease.
678
What is a Salter-Harris II fracture?
Physeal separation with a small metaphyseal fragment attached to the physis and epiphysis. Likelihood of growth disturbance is low. Commonest physeal fracture.
679
Which autoantibody is most specific for SLE?
Anti-dsDNA binding antibody.
680
What is the management of ANCA associated vasculitis?
IV steroids and cyclophosphamide.
681
What is the treatment of polymoysitis?
Prednisolone (initially 40mg) combined with immunosuppressive drugs e.g. methotrexate or azathioprine.
682
What is Osgood-Schlatter's disease?
Inflammation of tibial tubercle apophysis.
683
What does a DAS 28 score of 3.3-5.1 indicate?
Moderate disease activity.
684
What are the surgical strategies for the surgical management of an arthritic joint?
Arthroplast/joint replacement. Excision or resection arthroplasty. Arthrodesis. Osteotomy.
685
Anti-Ro antibody is associated with which condition(s)?
SLE, Sjogren's syndrome.
686
What is affected in upper motor neuron neuromuscular disorders?
Brain and spinal cord.
687
This 50 year old lady complains of left 1st MTPJ pain on walking, particularly when wearing thin, non-supportive shoes. She cannot wear high heels because of the pain and stiffness in the joint. On examination, active and passive range of movement of the joint is reduced (and quite tender at the end range of movement) and grind test is positive. What is the underlying diagnosis?
Hallux rigidus.
688
Which immunological blood levels should be monitored regularly in SLE and why?
Anti-dsDNA antibodies and complement levels. These vary with disease activity and may give some warning of a disease flare.
689
What is the aetiology of Paget's disease?
Viral infection (paramyxoviruses). Genetic defects.
690
A 70 year old man presents with a painful, swollen and erythematous right 1st MTPJ. This condition is relapsing and remitting. On inspection, the joint is warm but he's able to move it. There are some white nodules under the surface of the skin. The patient is systemically well. What is the underlying diagnosis?
Gout.
691
What nerve can be damaged in an anterior dislocation of the shoulder fracture?
Axillary nerve.
692
What pattern of fractures are seen in humeral shaft fractures?
Direct trauma (e.g. RTC) results in transverse or comminuted fractures. Fall with or without a twisting injury results in oblique or spiral fractures.
693
What is polymyalgia rheumatica?
Chronic inflammatory condition of unknown aetiology affecting elderly individuals.
694
What is the surgical treatment for carpal tunnel syndrome?
Carpal tunnel decompression: division of the transverse carpal ligament under local anaesthetic.
695
What is the chief indication for hip and knee joint arthroplasty?
Pain.
696
What is considered pathological varus or valgus?
Alignment is +/-6 degrees from the mean value for age.
697
Why should urate-lowering therapies be given once an acute attack of gout has settled?
As they can potentiate a further flare.
698
What is affected in lower motor neuron neuromuscular disorders?
Anterior horn cells. Nerve roots. Peripheral nerve.
699
What is the treatment for cauda equina syndrome?
Urgent discectomy.
700
What nerve is compressed in cubital tunnel syndrome?
Ulnar nerve.
701
How can painful bone lesions thought not to be at risk of fracture be treated?
Bisphosphonates and radiotherapy (if radiosensitive).
702
What is spondylosis?
The intervertebral discs lose water content with age resulting in less cushioning and increased pressure on the facet joints leading to secondary osteoarthritis.
703
What investigations would you do if you suspected underlying tumours or infection involving the spine?
Bloods - CRP, FBC, U&Es, bone biochemistry, plasma protein electrophoresis, PSA (males), blood culture (infection). Spine xray. Chest xray. Bone scan. MRI.
704
Which is proportionally thicker, the periosteum of a child's or adult's long bone?
The periosteum of a child's long bone is proportionally thicker than that of an adult and it tends to remain intact which aids stability and can assist reduction if required.
705
What can cause acquired flat foot?
Tibialis posterior tendon stretch or rupture. Rheumatoid arthritis. Diabetes with Charcot foot (neuropathic joint destruction).
706
What is osteomalacia?
A qualitative defect of bone with abnormal softening of the bone due to deficient amounts of calcium and phosphorus in adults.
707
What is the treatment for LCL tears or ruptures?
Surgical with early repair or late reconstruction with tendon graft.
708
What is the treatment for osteomalacia and rickets?
Vitamin D therapy with calcium and phosphate supplements.
709
What is SLE?
Chronic autoimmune disease that mainly involves the skin, joints, kidneys, blood cells and nervous system but can affect almost any organ system.
710
What can lead to secondary avascular necrosis?
Alcohol abuse. Steroids. Hyperlipidaemia. Thrombophilia.
711
What is the normal developmental milestone for jumping?
24 months.
712
What is cerebral palsy?
Onset before 2-3 years due to an insult to the immature brain before, during or after birth.
713
What are the causes of pathological genu varum/valgum?
Underlying skeletal disorder (skeletal dysplasia, Blount's disease). Physical injury with growth arrest (usually unilateral). Biochemical disorder (rickets).
714
What is the treatment for spinal stenosis and spinal claudication?
Analgesia, physiotherapy, weight loss if indicated. If no resolution and MRI evidence of spinal stenosis -\> surgery to decompress the spine and increase space for the cauda equina.
715
What is the function of the medial collateral ligament?
Resists valgus force.
716
What is the treatment for gout sufferers of recurrent attacks or those with joint destruction or tophi?
Allopurinol or other urate-lowering therapies to prevent attacks.
717
What are the 2 patterns of shoulder instability?
Traumatic instability. Atraumatic instability.
718
What is fibular hemimelia?
Partial or complete absence of the fibula, often with the absence of the lateral foot rays leading to a shortened limb, bowing of the tibia and ankle deformity.
719
What are the main types of ANCA associated vasculitis?
Granulomatosis with polyangiitis (Wegener's; GPA). Microscopic polyangiitis (MPA). Renal limited vasculitis (RLV). Churg-Strauss syndrome (CSS).
720
What is the pathology of medial epicondylitis?
Repeated strain or degeneration of the common flexor origin.
721
What is the Barlow manoeuvre?
Dislocatable hip with flexion and posterior displacement.
722
What is the normal developmental milestone for stacking 4 blocks?
18 months.
723
Which rotator cuff muscles attach to the greater tuberosity?
Supraspinatus. Infraspinatus. Teres minor.
724
What joints are affected by reactive arthritis?
Large joints e.g. the knee become inflamed around 1-3 weeks following the infection.
725
What is apophysitis?
Inflammation of growing tubercle where a tendon attaches.
726
Anti-phospholipid syndrome puts you at risk of what other conditions?
Stroke. MI. Recurrent pulmonary emboli -\> pulmonary hypertension.
727
What is the clinical presentation of Klumpke's palsy?
Fingers are typically flexed due to paralysis of the interossei and lumbricals which assist extension at the PIP joints.
728
What is the gastrointestinal presentation of SLE?
Autoimmune hepatitis. Pancreatitis. Mesenteric vasculitis.
729
Anti-RNP antibody is associated with which condition(s)?
SLE, mixed connective tissue disorder (MCTD).
730
What is syndactyly?
Commonest congenital malformation. Two digits (fingers or toes) are fused due to failure of separation of the skin/soft tissues. Phalanges of adjacent digits either partially or along the entire length of the digits.
731
What are the upper motor neuron signs?
Wide-based gait. Weakness. Increased tone. Upgoing plantar response.
732
What is rickets?
A qualitative defect of bone with abnormal softening of the bone due to deficient amounts of calcium and phosphorus in children. Has subsequent effects on the growing skeleton.
733
What investigations can diagnose cubital tunnel syndrome?
Nerve conduction studies.
734
What does a DAS 28 score of \<2.6 indicate?
Remission.
735
The thickest hyaline cartilage in the body is found on the articular surface of which bone?
Patella.
736
What features are suggestive of a potential malignant soft tissue neoplasm?
Larger lesions (\>5cm). Rapid growth in size. Solid lesions. Ill-defined lesion. Irregular surface. Associated lymphadenopathy. Systemic upset (weight loss, loss of appetite, fatigue).

2MBChB Musculoskeletal (17 decks)

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