Final MSK II

Question 1

What are the differences and how do you differentiate between cervical spondylosis and radiculopathy? [2]

Which test can you use? [1]

Answer 1

The pain pattern in cervical radiculopathy is typically more localised compared to cervical spondylosis, which often manifests as diffuse neck pain.

Positive Spurling’s test:
- neck extension and lateral rotation towards the symptomatic side exacerbates symptoms

Question 2

Most cases of malignant cord compression (85-90%) occur secondary to metastatic extension from the [spinal anatomy]. This means pressure on the thecal sac tends occurs [direction].

Answer 2

Most cases of malignant cord compression (85-90%) occur secondary to metastatic extension from the vertebral bodies.

This means pressure on the thecal sac tends occurs anteriorly.

Question 3

Which scoring system is used to determine prognosis (and therefore suitability for surgical intervention)? [1]

Answer 3

revised Tokuhashi scoring system:
* Overall health
* The number of non-vertebral bone metastases
* The number of vertebral metastases
* The number of metastases to other internal organs
* Primary cancer
* Neurological deficit

Each parameter is scored 0-2

Question 4

Which investigational technique should be used to investigate for bone mets. [1]
Describe what results might indicate bone mets [2]

Answer 4

Bone scintigraphy
- increased uptake of the Technetium-99 or it is asymmetrical
- If the kidneys and bladder are not seen on the scan, this is a worrying sign and may be due to a severe bone disease or bone metastases which are taking up all of the Technetium-99 so none is needed to be excreted

Question 5

What is the bulbocavernosus reflex and why is it useful? [1]

Answer 5

squeezing the penis or the clitoris in a patient and monitoring the internal and external anal sphincter contraction in response
- useful test for checking whether the patient is in spinal shock after spinal trauma
- During the phase of shock, the bulbocavernosus reflex is absent and its return indicates the end of spinal shock.

Question 6

What is the Lazarevic’s sign? [1]

Answer 6

Lazarevic’s sign is the positive result of a straight leg raise, which indicates an underlying disc herniation, most likely at the L5 level.

Question 7

Treatment of Achilles tendinopathy (tendinitis)? [1]

Treatment of Achilles tendon rupture? [1]

Answer 7

Achilles tendinopathy (tendinitis):
- simple analgesia and reduction in precipitating activities.

Achilles tendon rupture
- An acute referral should be made to an orthopaedic specialist following a suspected rupture.

Question 8

How would movement person be affected in a Achilles tendon rupture? [2]

What other symptoms would be present? [4]

Answer 8

Unable to stand on tiptoes on the affected leg alone

Weakness of plantar flexion of the ankle (dorsiflexion is unaffected)

Pain and swelling in heel and lower calf
Inability to stand on tiptoe
Inability to plantarflex foot
Positive Thompson test: loss of plantarflexion on squeezing the calf

Question 9

Describe the clinical presentation of plantar fasciitis [3]

Answer 9

Inferior heel pain on pressure (100%).
- Usually worse on the first steps out of bed in the morning or after period of inactivity
- pain on medial aspect of heel
- May ease on walking but worse with heavy activity or standing
- Tenderness to palpate
- Pain that worsens after exercise, not during

Question 10

Describe a clinical test can perform to diagnose PF [1]

Answer 10

Positive ‘windlass test’ (sensitivity 31.8%, specificity 100%):
- if there is pain at the heel area when the toes are passively dorsiflexed (upwards)

Question 11

How does fat pad atrophy present? [1]

How can you meaure the level of fat pad atrophy? [1]

Answer 11

Symptoms are similar to plantar fasciitis, with pain and tenderness over the plantar aspect of the heel. Symptoms are worse with activities, particularly when barefoot on hard surfaces.

The thickness of the fat pad can be measured with an ultrasound scan.

Question 12

What is Mulder’s click? [1]

Answer 12

Mulder’s click:
- one hand tries to hold the neuroma between the finger and thumb.
- The other hand squeezes the metatarsals together.
- A click may be heard as the neuroma moves between the metatarsal heads

Question 13

What is a March Fracture? [1]

Answer 13

March fractures are a subtype of fatigue/stress fractures. They occur due to repeated concentrated trauma to a normal bone, classically the 2nd metatarsal of the foot but can occur in other weight-bearing bones of the lower limb and pelvis.

NB: Jo March = 2nd oldest sister; stressed

Question 14

Describe the specific location of pain in:
- plantar fasciitis [2]
- fat pad atrophy [1]

Answer 14

Plantar fasciitis:
- pain on the bottom of the foot, around the heel and arch
- pain on medial aspect of calcaneus

Fat pad atrophy:
- central heel pain: ‘deep bruising like pain’

Question 15

Describe the three types of hip dislocation [2]

Which is most common? [1]

Answer 15

Posterior dislocation:
- Accounts for 90% of hip dislocations.
- The affected leg is shortened, adducted, and internally rotated.

Anterior dislocation:
- The affected leg is usually abducted and externally rotated. No leg shortening.

Central dislocation

Question 16

How do you manage hip dislocations [4]

Answer 16

• ABCDE approach.
• Analgesia
• A reduction under general anaesthetic within 4 hours to reduce the risk of avascular necrosis.
• Long-term management: Physiotherapy to strengthen the surrounding muscles.

Question 17

Describe associated fractures that occur in 25% of dislocations [4]

Answer 17

Fractures of the tuberosity or surgical neck:
- these dislocations may not be suitable for closed reduction in the emergency department

Bankart lesions:
- are tears to the anterior portion of the labrum
- these develop when the glenoid labrum is damaged; they may sometimes be associated with an avulsion fracture (bony Bankart)
- These occur with repeated anterior subluxations or dislocations of the shoulder.

Hill-Sachs lesions:
- compression fractures of the posterolateral humeral head
- commonly occurring in anterior dislocations
- shoulder dislocates anteriorly, the posterolateral part of the humeral head impacts with the anterior rim of the glenoid cavity

Reverse Hill-Sachs lesions:
- an impaction fracture of the anteromedial humeral head commonly occurring in posterior dislocations

Question 18

Which type of fracture are labelled as A & B? [2]

Answer 18

A: Hill-Sachs
- compression fractures of the posterolateral humeral head commonly occurring in anterior dislocations
:

B: Bankart

Question 19

If you had to describe the change in position of the shoulder in an anterior shoulder dislocation - what would it look like? [2]

If you had to describe the change in position of the arm in an anterior shoulder dislocation - what would it look like? [2]

Answer 19

Shoulder:
- loss of rounded appearance (humeral head) and sharp prominence of the acromion (“squaring”)

Arm:
- arm is abducted and externally rotated

Question 20

If you had to describe the change in position of the shoulder in an posterior shoulder dislocation - what would it look like? [2]

If you had to describe the change in position of the arm in an posterior shoulder dislocation - what would it look like? [2]

Answer 20

Arm:
- adducted and internally rotated

Shoulder:
- prominent posterior shoulder and coracoid for acute posterior dislocation

Question 21

What is an Acromioclavicular Joint Injury and how do you differentiate this from a shoulder dislocation? [2]

Answer 21

ACJ injuries involve disruption between the acromion and clavicle - hence they are sometimes referred to as ‘separated shoulders’; Injuries here are most commonly caused by a fall onto or direct blow to the shoulder.

Shoulder dislocations have displaced humeral head from glenoid socket

Question 22

What should you do after performing shoulder joint reduction? [1]

Answer 22

It is important to obtain an anteroposterior and lateral x-ray after reduction techniques have been performed
- This will both confirm that the humeral head has reduced back into the glenoid fossa, as well as to ensure there are no fractures present

Question 23

Shoulder dislocations commonly cause axillary nerve damage.

Which nerve roots does the axillary nerve come from? [2]

How does this manifest in a patient?

Answer 23

Axillary nerve damage is a key complication. The axillary nerve comes from the C5 and C6 nerve roots.

Damage causes a loss of sensation in the “regimental badge” area over the lateral deltoid.

It also leads to motor weakness in the deltoid and teres minor muscles (external roation)

TOM TIP: Axillary nerve damage is a common association with anterior dislocations to remember for your exams. This knowledge may be tested in MCQs, where you are asked to identify the nerve, location of sensory loss or muscle affected by weakness.

Question 24

Describe what the following types of shoulder stabilisation surgery are:

• Latarjet procedure
• Remplissage procedure

Answer 24

Latarjet procedure:
- Bone graft using bone from the coracoid process to correct a bony injury to the glenoid rim

Remplissage procedure
- Correcting Hill-Sachs lesions

Question 25

The most common vertebral levels affected are [] followed by []

Answer 25

The most common vertebral levels affected are **L5/S1** followed by **L4/L5**

Question 26

**[]** **test**: from 30 to 70 degree (known to be the most sensitive examination for lumbar disc herniation, especially nerve root L4-S1). This will reproduce a shooting electrical sensation down the affected dermatome.

Answer 26

**Straight leg test positive** from 30 to 70 degree (known to be the most sensitive examination for lumbar disc herniation, especially nerve root L4-S1). This will reproduce a shooting electrical sensation down the affected dermatome.

Question 27

What the is main motion [1] and reflex [1] impacted by an L3 prolapse What the is main motion [1] and reflex [1] impacted by an L4 prolapse

Answer 27

**L3** - Hip adduction - No reflex affected **L4**: - Knee extension - Knee jerk affected

Question 28

What the is main motion [1] and reflex [1] impacted by an L5 prolapse What the is main motion [1] and reflex [1] impacted by an S1 prolapse

Answer 28

**L5**: - Ankle dorsiflexion - No reflex affected **S1**: Feet plantar flexion * Achilles relfex affected

Question 29

Most prolapsed discs are treated conservatively. In which scenarios would indicate surgery? [3] What type of surgery is most commonly used? [1]

Answer 29

**Cauda equina** (emergency referral to a neurosurgeon) **Progressive neurological weakness** **Pain lasting > 6 weeks** which does not respond to conservative management Surgery most commonly used: - **laminectomy + micro-discectomy**.

Question 30

Describe the non-surgical treatment of slipped disc [4]

Answer 30

**Analgesics** (NICE recommend **NSAIDs** instead of paracetamol as first-line for pain relief) If **radiculopathy** is present, NICE recommends the use of the following medications as first-line; **amitriptyline, duloxetine, gabapentin or pregabalin.** **Corticosteroid epidural injection** can be offered in a specialist clinic. **Radiofrequency denervation** may be an option in patients with chronic low back pain originating in the facet joints. Radiofrequency is used to target and damage the medial branch nerves that supply sensation to the facet joints associated with the back pain. This is done under a local anaesthetic.

Question 31

Describe the clinical features of spinal cord injury [+]

Answer 31

**Sudden** **onset** of **neurological deficits,** primarily **motor** and **sensory** **dysfunction**, which are often associated with **pain** or **discomfort** in the **back, neck or head** **Motor**: * **Spasticity**: Increased muscle tone leading to stiffness and involuntary spasms. * **Hyperreflexia**: Overactive or overresponsive reflexes. * **Babinski sign** **Pain** **Autonomic Dysregulation:** * **Cardiovascular instability**: Fluctuations in blood pressure and heart rate due to disruption of sympathetic control. * **Respiratory compromise:** Reduced ability to cough or breathe deeply leading to increased risk of respiratory infections. * **Bladder and bowel dysfunction:** Incontinence or retention due to loss of voluntary control. * **Sexual dysfunction:** Impaired sexual function or fertility issues in both genders. **Spinal shock**

Question 32

Describe what is meant by central cord syndrome [1] What type of injuries cause this? [1]

Answer 32

**Central Cord Syndrome**: - More **motor** **impairment** in **upper** than lower **limbs** along with variable sensory loss; often seen in elderly patients following **hyperextension** **injuries**. - **Motor** more than **sensory** - **Distal** more than **proximal**

Question 33

Describe what is meant by spinal shock [1]

Answer 33

In the **acute phase after injury**, a state known as **spinal shock** may occur. This is characterized by **flaccid paralysis, loss of reflexes**, and **loss of sensation below the level of injury** . It is a **temporary** **condition** that lasts from **several hours to several weeks post-injury.**

Question 34

Describe what is meant by Brown-Sequard Syndrome [1] What type of injuries cause this? [1]

Answer 34

**Brown-Sequard Syndrome**: - **Ipsilateral motor function loss** and **contralateral pain/temperature sensation loss**; typically caused by **penetrating injuries.**

Question 35

Describe what is meant by Anterior Cord Syndrome [1] What type of injuries cause this? [1]

Answer 35

**Anterior Cord Syndrome:** - **Loss of motor function** and **pain/temperature sensation** but **preservation** of **proprioception**; usually results from **anterior spinal artery occlusion.**

Question 36

Describe the managment of spinal cord injuries [5]

Answer 36

**Acute Resuscitation:** * Maintain airway, breathing, and circulation (ABCs). Administer oxygen as required to maintain SpO2 ≥94%. Avoid hypotension (systolic BP should be maintained >90 mmHg). **Steroid Therapy:** * High-dose methylprednisolone can be considered within 8 hours of injury. **Surgical Management:** * Early surgical decompression and stabilisation may improve neurological outcomes in selected patients. **Rehabilitation:** * A multidisciplinary team approach involving physiotherapy, occupational therapy, clinical psychology, dietetics and social work is essential for optimal patient outcomes. **Long-Term Care:** * The management of chronic complications such as pressure sores, urinary tract infections, deep vein thrombosis and autonomic dysreflexia is crucial.

Question 37

Segund fracture is associated with which injury MCL LCL ACL PCL Meniscus tear

Answer 37

Segund fracture is associated with which injury **ACL**

Question 38

What are the cardinal features of acetabular labral tears? [3]

Answer 38

The cardinal clinical features of acetabular labral tears are **hip pain, locking and instability**: - **Pain** is felt in the **groin/hip region**: specifically in the **anterior** **hip** or **groin region.** - **Clicking, locking, catching** and giving way of the hip

Question 39

Describe which clinical tests you can perform to test an ACL injury [2]

Answer 39

**Anterior drawer test**: - Increased anterior translation, along with a soft or absent endpoint, suggests an ACL injury **Lachman test:** - patient is positioned supine with the knee flexed to 20-30 degrees - The examiner stabilizes the femur with one hand and grasps the proximal tibia with the other hand - The tibia is then pulled anteriorly while stabilizing the femur - **Increased** **anterior** **translation** and a soft or absent endpoint compared to the contralateral side indicate an ACL injury. ## Footnote **NB**: The Lachman test is considered more sensitive and specific than the anterior drawer test for detecting ACL injuries

Question 40

An **iliopsoas abscess** describes a collection of pus in iliopsoas compartment (iliopsoas and iliacus). What is the most likely causative agent? [1]

Answer 40

**Staphylococcus aureus**: most common

Question 41

What is the gold standard for testing for an iliopsoas abscess? [1]

Answer 41

**CT is the gold standard.**

Question 42

Describe what is meant by meralgia paraesthetica [1]

Answer 42

**syndrome** of **paraesthesia** or **anaesthesia** in the **distribution of the lateral femoral cutaneous nerve (LFCN).** - **compression of this nerve** anywhere along its course can lead to the **development of meralgia paraesthetica.**

Question 43

The **[]** test is highly sensitive, and often, meralgia paraesthetica can be diagnosed based on this test alone. **Describe this test [1]**

Answer 43

The **pelvic compression test** is highly sensitive, and often, meralgia paraesthetica can be diagnosed based on this test alone **deep palpation just below the ASIS:** - causes pain; numbness; coldness or burning

Question 44

Tx for meralgia parasethetica? [1]

Answer 44

**Injection** of the **nerve** with **local anaesthetic** will abolish the pain. Using **ultrasound** is effective both for **diagnosis and guiding injection therapy** in meralgia paraesthetica

Question 45

What is the pathognomonic fracture associated with ACL tears? [1]

Answer 45

**Segund fracture** - this is an avulsion fracture of the proximal lateral tibia.

Question 46

What the classical feature of a NOF? [1]

Answer 46

the classic signs are a **shortened and externally rotated leg**

Question 47

Describe how you manage **closed** tibial plateau fractures [2]

Answer 47

**Nonoperative management:** - generally involves a **hinged knee brace.** - Can **partial** **weight** **bear** for **8-12 weeks** **Operative management**: - open reduction and internal fixation (ORIF).

Question 48

Describe how you manage **open** tibial plateau fractures [1]

Answer 48

External fixators are often used as a temporising measure in severe open fractures with contamination. Staged procedures to wash, debride and later fix the fracture can be arranged.

Question 49

Describe the managment plans for the following options for AVN of the hip **Conservative Management:** - Pharmacological therapy [3] - Physiotherapy **Surgical Management**: * Core decompression surgery: * Osteotomy * Bone grafting * Arthroplasty

Answer 49

**Conservative Management:** - **Pharmacological therapy:** **NSAIDS**; **Bisphosphonates** (may slow the progression of bone necrosis and disease-related osteoporosis); **Vasodilators** such as **iloprost** can be used to improve blood flow to the affected area. - **Physiotherapy** **Surgical Management**: **Core decompression surgery:** - reduces intraosseous pressure, relieves pain, promotes vascular infiltration **Osteotomy**: - repositioning the necrotic segment away from the weight-bearing zone - typically reserved for younger patients with good remaining articular cartilage **Bone grafting** - Autograft or allograft options can be used to support the subchondral bone and reduce collapse risk. **Arthroplasty** - Total hip replacement or hemiarthroplasty is usually reserved for patients with advanced disease.

Question 50

How do you manage a Colles' fracture? [4]

Answer 50

Choice of management of a Colles' fracture depends on the severity of the fracture. The most common treatment method is **closed reduction with immobilisation with a plaster cast** **open reduction and internal fixation (ORIF)** used if: * Unstable fracture * Significant angulation of the distal fragment of the radius * Usually defined as >10 degrees dorsal angulation * Closed reduction is unsuccessful * Comminuted fracture

Question 51

Describe some complications of a Colles' fracture [3]

Answer 51

**Malunion** - Lead to dinner-fork deformity **Median nerve damage** - May lead to post-traumatic carpal tunnel syndrome **Rupture of EPL tendon** - Clinical features of an EPL tendon rupture include the inability to extend the interphalangeal joint of the thumb

Question 52

Describe what is meant by a Barton fracture [1]

Answer 52

**Barton Fracture:** - Distal radius fracture (Colles'/Smith's) with associated radiocarpal dislocation - Fall onto extended and pronated wrist

Question 53

Describe the management for a scaphoid fracture

Answer 53

**Initial management** * **immobilisation** with a **Futuro splint** or standard **below-elbow backslab** * referral to **orthopaedics**: clinical review with further imaging should be arranged for7-10 days later when initial radiographs are inconclusive **Orthopaedic management**: * **undisplaced fractures** of the scaphoid waist: cast for 6-8 weeks * **displaced scaphoid waist fractures**: requires surgical fixation * **proximal scaphoid pole fractures**: require surgical fixation

Question 54

Describe what is meant by the Ottawa ankle rules [1]

Answer 54

**The Ottawa ankle rules help differentiate ankle injuries that require radiographic assessment from those that do not**: only required if there is pain in the malleolar zone AND one or more of the following is found: * **Boney tenderness** at the posterior edge or tip of the **lateral** **malleolus** OR * **Boney tenderness** at the posterior edge or tip of the **medial malleolus** OR * **Inability to weight bear immediately and in the A+E department for four steps**

Question 55

Describe a very basic overview for Weber A-C fracture management [3]

Answer 55

**Weber A fractures**: - Generally stable so surgical management is rarely indicated and they can be **discharged from A&E in a walking boot with analgesia** - Full weight bearing - 6 weeks **Weber B & C**: - Require open reduction and internal fixation and likely to need syndesmosis repair - Non-weight bearing following surgery - Immobilisation in cast following surgery until bony healing has occurred (usually 6-8 weeks)

Question 57

What is meant by a pilon fracture? [1]

Answer 57

**Pilon fractures**: Involve the distal end of the tibia and may extend into the ankle joint.

Question 58

What is a Jones' fracture? [1] What is the main complication of Jones' fracture? [1]

Answer 58

A **Jones fracture** is a fracture of the **proximal metadiaphyseal junction** of the **fifth metatarsal bone** that involves the **4th-5th metatarsal articulation.** - **High risk of non-union** for that reason (15-30%).

Question 59

What is a Lisfranc fracture? [1]

Answer 59

**Lisfranc fracture** or injury is an injury to the tarsometatarsal complex. It often occurs due to **displacement between the second metatarsal and the middle cuneiform**, which also affects the third, fourth and fifth metatarsals.

Question 60

What is a Pott's fracture? [1] How does it occur? [1]

Answer 60

**Pott's fracture** is used to **describe a bimalleolar fracture** (fracture of both medial and lateral malleoli) or **trimalleolar fracture** (fracture of medial and lateral malleoli plus distal tibia). * **It occurs with forced eversion of the foot.**

Question 61

What is the commonest soft tissue injury associated with Colles' fracture? [1]

Answer 61

Injury of the **triangular fibrocartilage complex (TFCC)** is seen in up to 40% of Colles' fracture cases.

Question 62

What is the gold standard imaging method for calcaneal fractures? [1]

Answer 62

CT

Question 63

**Fracture**: - Intra-articular fracture at the base of the thumb metacarpal - Impact on flexed metacarpal, caused by fist fights **Name? [1]**

Answer 63

**Bennett's fracture**