Joints and their injuries

Question 1

Risk factors for achilles tendon injuries

Answer 1

quinolone use (e.g. ciprofloxacin) is associated with tendon disorders
hypercholesterolaemia (predisposes to tendon xanthomata)

Question 2

What is the most common cause of posterior heel pain

Answer 2

Achilles tendon disorders are the most common cause of posterior heel pain. Possible presentations include tendinopathy (tendinitis), partial tear and complete rupture of the Achilles tendon.

Question 3

Features of achilles tendinopathy

Answer 3

gradual onset of posterior heel pain that is worse following activity
morning pain and stiffness are common

Question 4

The management of achilles tendinopathy

Answer 4

simple analgesia
reduction in precipitating activities
calf muscle eccentric exercises: this may be self-directed or under the guidance of physiotherapy

Question 5

Examination of the Simmond’s triad

Answer 5

This can be performed by asking the patient to lie prone with their feet over the edge of the bed. The examiner should look for an abnormal angle of declination; Achilles tendon rupture may lead to greater dorsiflexion of the injured foot compared to the uninjured limb.

Question 6

Acromioclavicular joint injury features

Answer 6

Injury to the AC joint is relatively common and typically occurs during collision sports such as rugby following a fall on to the shoulder or a FOOSH (falls on outstretched hand).

Question 7

AC joint injuries grades

Answer 7

I to VI depending on the degree of separation

Question 8

Which grade of injuries are the most common

Answer 8

I to II injuries are very common

Question 9

What is the name for adhesive capsulitis

Answer 9

Frozen shoulder - common cause of shoulder pain

Most common in middle-aged females

Question 10

Associations with adhesive capsulitis

Answer 10

Diabetes mellitus - up to 20% of diabetics may have an episode of frozen shoulder

Question 11

Features of adhesive capsulitis

Answer 11

external rotation is affected more than internal rotation or abduction
both active and passive movement are affected
patients typically have a painful freezing phase, an adhesive phase and a recovery phase
bilateral in up to 20% of patients
the episode typically lasts between 6 months and 2 years

Question 12

Management of adhesive capsulitis

Answer 12

No single intervention has been shown to improve outcome in the long-term
Treatment options: NSAIDs, physiotherapy, oral corticosteroid and intra-articular corticosteroids

Question 13

When only can an ankle x-ray be ordered

Ottawa Rule

Answer 13

• Any pain in the malleolar zone
• Bony tenderness at the lateral malleolar zone
• Bony tenderness at the medial malleolar zone
• Inability to walk four weight bearing steps immediately after the injury and in the ED

Question 14

Ankle injury - Weber classification

Answer 14

Type A is below the syndesmosis
Type B fractures start at the level of the tibial plafond and may extend proximally to involve the syndesmosis
Type C is above the syndesmosis which may itself be damaged

Question 15

Masoinneuve fracture- where does it occur

Answer 15

Type A is below the syndesmosis
Type B fractures start at the level of the tibial plafond and may extend proximally to involve the syndesmosis
Type C is above the syndesmosis which may itself be damaged

Question 16

Management of ankle fractures

young and old

Answer 16

• Promptly reduced to move pressure on the overlying skin and subsequent necrosis
• Young patients with unstable high velocity or proximal injuries will usually require surgical repair
  Elderly patients- conservative management

Question 17

What are the bony components of the ankle

Answer 17

-Distal tibia and fibula and superior aspect of the talus

Question 18

what is a sprain?

Answer 18

Stretching, partial or complete tear of a ligament

Question 19

Which is the most ligament to sprain

Answer 19

ATFL- anterior tibula fibular ligament

Inversion injury most common mechanism

Question 20

Treatment of ankle sprain

Answer 20

Non-operative with RICE

Occasional cast

Question 21

High ankle sprains presentation

Answer 21

Usually external rotation mechanism of injury
Weight bearing is paining
Pain when the tibia and fibula are squeezed together at the level of the mid-calf (Hopkin’s squeeze test)

Question 22

Treatment of high ankle sprain

Answer 22


Treatment:
If no diastasis then non-weight-bearing orthosis or cast until pain subsides.
If diastasis or failed non-operative management then operative fixation is usually warranted.

Question 23

Causes of avascular necrosis of the hip

Answer 23

long-term steroid use
chemotherapy
alcohol excess
trauma

Question 24

Features of AVN

Answer 24

initially asymptomatic

pain in the affected joint

Question 25

Investigation of AVN

Answer 25

X-ray may be normal initially Osteopenia and microfractures may be seen early on Crescent sign if collapse of the articular surface MRI is the investigation of choice

Question 26

Treatment of AVN

Answer 26

Join replacement may be necessary

Question 27

Baker's cysts- what are they?

Answer 27

distension of the gastrocnemius-semimembranosus bursa.

Question 28

Primary and secondary baker's cysts

Answer 28

Primary: no underlying pathology, typically seen in children Secondary: underlying condition such as osteoarthritis, typically seen in adults

Question 29

Where do Baker's cysts present

Answer 29

Swellings in the popliteal fossa behind the knee

Question 30

Biceps tendons - what are the

Answer 30

- the long tendon which attaches to the glenoid - and the short tendon which attaches to the coracoid process. - It inserts distally via another tendon onto the radial tuberosity.

Question 31

Risk factors for biceps rupture

Answer 31

Heavy overhead activities Shoulder overuse or underlying shoulder injuries which may stress the biceps tendon Smoking Corticosteroids; these weaken tendons

Question 32

What is a "Popeye" deformity

Answer 32

When the muscle bulk results in a bulge in the middle of the upper arm

Question 33

First- line investigation for a biceps tendon rupture

Answer 33

MSK US

Question 34

What is a buckle fracture

Answer 34

Incomplete fractures of the shaft of a long bone- characterised by the bulging of the cortex - usually self limiting- happens in children 5-10yrs

Question 35

Carpal tunnel syndrome

Answer 35

Caused by compression of the median nerve in the carpal tunnel

Question 36

History

Answer 36

pain/pins and needles in thumb, index, middle finger unusually the symptoms may 'ascend' proximally patient shakes his hand to obtain relief, classically at night

Question 37

Examination signs of carpal tunnel syndrome

Answer 37

weakness of thumb abduction (abductor pollicis brevis) wasting of thenar eminence (NOT hypothenar) Tinel's sign: tapping causes paraesthesia Phalen's sign: flexion of wrist causes symptoms

Question 38

Causes

Answer 38

``` idiopathic pregnancy oedema e.g. heart failure lunate fracture rheumatoid arthritis ```

Question 39

Treatment of carpal tunnel syndrome

Answer 39

``` corticosteroid injection wrist splints at night surgical decompression (flexor retinaculum division) ```

Question 40

Investigation and management of carpal tunnel syndrome

Answer 40

- Urgent MRI | - Surgical decompression

Question 41

What is Charcot joint

Answer 41

Neuropathic joint - joint that has bcome badly disrupted and damaged secondary to loss of sensation

Question 42

Classical Colles fracture - 3 features

Answer 42

Transverse fracture of the radius- distal radius fracture 1 inch proximal to the radio-carpal joint Dorsal displacement and angulation

Question 43

Two main fractures which occur in compartment syndrome

Answer 43

supracondylar fractures and tibial shaft injuries.

Question 44

Features of compartment syndrome

Answer 44

- Pain - Parasthesiae - Pallor - Arterial pulsation may/may not be felt - Paralysis

Question 45

Treatment of compartment syndrome

Answer 45

Essentially prompt and extensive fasciotomies

Question 46

Cubital tunnel syndrome - which nerve is affected

Answer 46

compression of the ulnar nerve as it passes through the cubital tunnel

Question 47

Clinical features of cubital tunnel syndrome

Answer 47

- Tingling and numbness of the 4th and 5th finger which starts off intermittent and then becomes constant. - Over time patients may also develop weakness and muscle wasting - Pain worse on leaning on the affected elbow - Often a history of osteoarthritis or prior trauma to the area.

Question 48

Ix of cubital tunnel syndrome

Answer 48

the diagnosis is usually clinical | however, in selected cases nerve conduction studies may be used

Question 49

What is De Quervain's tenosynovitis

Answer 49

Common condition in which the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed. Typically affects females 30-50

Question 50

Features of De Quervain's tenosynovitis

Answer 50

- pain on the radial side of the wrist - tenderness over the radial styloid process - abduction of the thumb against resistance is painful - Finkelstein's test: the examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction. In a patient with tenosynovitis this action causes pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus

Question 51

Management of De Quervain's tenosynovitis

Answer 51

analgesia steroid injection immobilisation with a thumb splint (spica) may be effective surgical treatment is sometimes required

Question 52

Most common organism to cause discitis

Answer 52

Staph aureus

Question 53

Dupuytren's contracture causes

Answer 53

``` manual labour phenytoin treatment alcoholic liver disease diabetes mellitus trauma to the hand ```

Question 54

Which fingers are the most affected in Dupuytren's contracture?

Answer 54

Ring and little finger

Question 55

Tennis and Golfer's elbow differentiation

Answer 55

Medial Epicondyle- Golfer's Lateral Epicondyle- Tennis MGLT

Question 56

Colles' Fracture features

Answer 56

Fall onto extended outstretched hand Classical Colles' fractures have the following 3 features: 1. Transverse fracture of the radius 2. 1 inch proximal to the radio-carpal joint 3. Dorsal displacement and angulation

Question 57

Smith's fracture (reverse Colles' fracture)

Answer 57

Volar angulation of distal radius fragment (Garden spade deformity) Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed

Question 58

Bennett's fracture features

Answer 58

Intra-articular fracture of the first carpometacarpal joint Impact on flexed metacarpal, caused by fist fights X-ray: triangular fragment at ulnar base of metacarpal

Question 59

Monteggia's fracture

Answer 59

Dislocation of the proximal radioulnar joint in association with an ulna fracture Fall on outstretched hand with forced pronation Needs prompt diagnosis to avoid disability

Question 60

Galezzi fracture

Answer 60

Radial shaft fracture with associated dislocation of the distal radioulnar joint Direct blow

Question 61

Pott's fracture

Answer 61

Bimalleolar ankle fracture | Forced foot eversion

Question 62

Barton's fracture

Answer 62

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

Question 63

Types of hip dislocation

Answer 63

- Posterior dislocation- 90% of hip dislocations Affected leg is shortened, adducted and internally rotated - Anterior dislocation: affected leg is usually abducted and externally rotated - central dislocation

Question 64

Complications of hip dislocation

Answer 64

Sciatic or femoral nerve injury Avascular necrosis Osteoarthritis: more common in older patients. Recurrent dislocation: due to damage of supporting ligaments

Question 65

Iliotibial band syndrome- what is it?

Answer 65

Common cause of lateral knee pain in runners - occurs in 1/10 people who run regularly - Features : tenderness 2-3 cm above the lateral joint line Management: activity modification and iliotibial and stretches - If not improving then physiotherapy referral

Question 66

Leriche syndrome

Answer 66

Atheromatous disease involving the iliac vessel Blood flow to pelvic viscera is compromised Patients have buttock claudication and impotence Diagnostic work up: angiography,

Question 67

Which metatarsal is the most commonly fractured bone

Answer 67

5th metatarsal - Proximal avulsion fractures at the proximal tuberosity - Lateral ankle sprain and often follow inversion injuries of the ankle

Question 68

Most common site of metatarsal stress fracture

Answer 68

2nd metatarsal shaft

Question 69

Features of metatarsal fracture

Answer 69

Pain and bony tenderness Swelling Antalgic gait

Question 70

Morton's neuroma features

Answer 70

forefoot pain, most commonly in the third inter-metatarsophalangeal space worse on walking. May be described as a shooting or burning pain. Patients may feel they have a pebble in their shoe 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 there may be loss of sensation distally in the toes

Question 71

Management of morton's neuroma

Answer 71

- Avoid high heels - Metatarsal pad - Referral is symptoms persist > 3 months despite footwear

Question 72

Osteoporosis which gender

Answer 72

Females affected more than males

Question 73

Risk factors for osteoporotic fractures

Answer 73

Advancing age is a major risk factor osteoporotic fractures: Women ≥ 65 years old and men ≥ 75 years old should be considered for fracture risk assessment. Previous history of a fragility fracture Frequent or prolonged use of glucocorticoids History of falls Family history of hip fracture Alternative causes of secondary osteoporosis e.g. Cushing’s disease, hyperthyroidism, chronic renal disease Low BMI (< 18.5) Tobacco smoking High alcohol intake: > 14 units/week for women, > 21 units/week for men

Question 74

Presentation in patients with osteoporotic vertebral fractures

Answer 74

- Asymptomatic - Acute back pain - Breathing difficulties : changes in shape and length of the vertebra puts a compressive force on organs: lungs, heart and intestine GI problems: compression of abdo organs

Question 75

Investigations for osteoporotic fracture

Answer 75

X-ray of spine first line CT spine- more detailed MRI spine- useful for differentiating osteoporotic fractures

Question 76

What is plantar fasciitis

Answer 76

Inflammation of plantar fascia

Question 77

Management of plantar fasciitis

Answer 77

rest the feet where possible wear shoes with good arch support and cushioned heels insoles and heel pads may be helpful

Question 78

Rotator cuff injury types

Answer 78

1. Subacromial impingement (also known as impingement syndrome, painful arc syndrome) 2. Calcific tendonitis 3. Rotator cuff tears 4. Rotator cuff arthropathy

Question 79

Symptoms of rotator cuff injury

Answer 79

Shoulder pain worse on abduction

Question 80

Signs of rotator cuff injury

Answer 80

Painful arc of abduction with subacromial impingement | Tenderness over anterior acromion

Question 81

Features of Ewings sarcoma

Answer 81

Commoner in males Incidence of 0.3 / 1, 000, 000 Onset typically between 10 and 20 years of age Location by femoral diaphysis is commonest site Histologically it is a small round tumour Blood borne metastasis is common and chemotherapy is often combined with surgery

Question 82

Osteosarcoma features

Answer 82

Mesenchymal cells with osteoblastic differentiation 20% of all primary bone tumours Incidence of 5 per 1,000,000 Peak age 15-30, commoner in males Limb preserving surgery may be possible and many patients will receive chemotherapy

Question 83

Liposarcoma features

Answer 83

Malignancy of adipocytes Rare Affects >40 Slow-growing

Question 84

Malignant fibrous histiocytoma features

Answer 84

Tumour with large number of histiocytes Most common sarcoma in adults Also described as undifferentiated pleomorphic sarcoma NOS (i.e. Cell of origin is not known) Four major subtypes are recognised: storiform-pleomorphic (70% cases), myxoid (less aggressive), giant cell and inflammatory Treatment is usually with surgical resection and adjuvant radiotherapy as this reduces the likelihood of local recurrence

Question 85

Which is more common- anterior or posterior shoulder dislocations?

Answer 85

Anterior- 95%

Question 86

What is the most common upper limb injury in children under the age of 6?

Answer 86

Subluxation of the radial head (pulled elbow) Due to the fact that the distal attachment of the annular ligament covering the radial head is weaker in children at this group

Question 87

What is talipes euinovarus

Answer 87

club foot, describes an inverted (inward turning) and plantar flexed foot. It is usually diagnosed on the newborn exam.

Question 88

Associations of Talipes equinovarus

Answer 88

``` spina bifida cerebral palsy Edward's syndrome (trisomy 18) oligohydramnios arthrogryposis ```