MDD Flashcards

Question

Indications for paracetamol

Answer 1

mild-moderate pain and pyrexia.

Answer 2

Dose is 1g PO/IV q.d.s to a maximum of 4g/day. This dose is reduced in patients <50kg. 3g/day maximum is recommended if there is a risk of hepatotoxicity

Answer 3

= inhibition of COX enzymes, which normally promote the production of prostaglandins and thromboxane. Anti-inflammatory and analgesic effects (good for inflammatory pain), with some antipyretic effect.

Answer 4

COX-1 is expressed in most tissues, with the PGs produced involved in tissue homeostasis => Platelet aggregation, renal blood flow autoregulation, GI protection COX-2 is induced in active inflammatory cells by IL-1 and TNF-alpha => Sensitises nociceptors to inflammatory mediators peripherally => Sensitises afferent pain fibres in dorsal horn centrally.

Answer 5

• Dyspepsia & gastric ulceration • Bronchospasm (in “aspirin sensitive asthmas”) • Renal insufficiency • Cardiotoxicity • Decreased platelet count • Skin reactions

Answer 6

- Severe heart failure - History of GI bleeds/ulceration

Answer 7

asthma, the elderly, coagulopathies renal/hepatic/cardiac impairment

Answer 8

Less GI side effects Licensed for use in RA/OA, however risk of serious adverse cardiac events needs to be considered

Answer 9

act on mu-opioid receptors in the CNS and throughout the body, decreasing neuro-excitability.

Answer 10

- Respiratory depression - Nausea & vomiting - Constipation - Sedation/depression of cough reflex - Gall bladder contraction (not recommended in gallstone disease) Tramadol also has MAOI effects, and thus can lead to serotonin syndrome if used in conjunction with other serotonergic drugs.

Answer 11

- Acute respiratory depression - Acute alcoholism - Risk of paralytic ileus - Raised ICP

Answer 12

Anti-emetics => Metoclopramide is usually co-prescribed Laxatives => Senna & lactulose are also co-prescribed

Answer 13

Weak opioids (codeine/tramadol) have full-strength opioid side effects so laxatives and anti-emetics should be prescribed.

Answer 14

In patients over 12 with respiratory depression due to opioid administration, give 400 micrograms naloxone IV. If no response after 1 minute, give a further 800 mcg. If no response after 2 minutes, give a further 800 mcg. 2mg / 4mg doses can be given in severely poisoned patients

Answer 15

= post-op or oncology.

Answer 16

Splinting => Very effective analgesic technique in trauma. Cold therapy: => Very effective around joints post-surgery. TENS => Electrical current applied via hand-held generator to activate nerve fibres in tissues below. Acupuncture: => Can be effective in certain conditions. CBT

Answer 17

Include methotrexate, sulfasalazine, hydroxychloroquine, penicillamine and gold compounds. Can reduce the pain score, disability score and RF level Their clinical effect is often slow, thus steroids are used to cover the induction phase. Combination therapies are generally superior to monotherapy.

Answer 18

= Folic acid antagonist Quickest onset of action of DMARDs Once weekly dosing (oral/IM) => Folic acid should be taken on the other 6 days of the week Not suitable in pregnancy, or in males trying to conceive (stop for 6 months before)

Answer 19

= Methotrexate

Answer 20

Once WEEKLY dosing (oral/IM) Folic acid should be taken on either the other 6 days of the week or one other day Patients should be educated on signs of toxicity: => Bruising, infection, shortness of breath

Answer 21

nausea, headaches, tingling

Answer 22

FBC, LFT, U&Es are required every 10 weeks once settled on the drug.

Answer 23

Takes ~8 weeks to have a clinical response. FBC, U&E, LFT should be monitored monthly for the 1st 3 months. SEs – nausea, dyspepsia, rashes, blood dyscrasias, azoospermia, yellow-orange discolouration of urine/contact lenses.

Answer 24

Least effective but least toxic Takes 6 weeks for a clinical response Only monitoring required = baseline visual acuity and annual re-check SEs – rash, GI disturbances, peripheral neuropathy, retinal damage.

Answer 25

Anti-TNF agents are the most common (e.g. infliximab, etanercept) Adverse effects = opportunistic infections, non-melanoma skin cancers and injection site reactions Infusion reactions can also occur, so many are given in hospital (at least initially)

Answer 26

= active infection, latent TB, malignancy, pulmonary fibrosis, severe heart failure. => CXR required prior to commencing treatment

Answer 27

Act by inhibiting transcription of COX-2, cytokines and ILs Also increase annexin-1 production, which has anti-inflammatory effects.

Answer 28

There are widespread side effects associated with steroids: - Infection / poor wound healing - Peptic ulceration - Acute adrenal insufficiency upon withdrawal (thus dose tapered down) - Cushing’s Syndrome - DM - Osteoporosis - Avascular necrosis - Psychological effects (depression, psychosis) - Inter-scapular fat pad (“buffalo hump”)

Answer 29

Any patient on long-term corticosteroids should be co-prescribed gastroprotection (most commonly PPIs), vitamin D and bisphosphonates.

Answer 30

Can be given orally (prednisolone), but many rheumatology centres prefer IM (methylprednisolone). => IM has a depot effect that self-tapers down.

Answer 31

Can have a diagnostic and therapeutic effect => the preparation often contains local anaesthetic, so if the pain resolves within a short period of time then we can be reasonably confident that the pain is coming from the structure injected. Do not repeat more than 3x in 6 months There can be systemic absorption and side effects Injections may be into joints or peri-articular structures to provide pain relief.

Answer 32

Education Physiotherapy Physical Treatments - heat/cold, aids, splints Coping strategies - e.g. relaxation techniques

Answer 33

"BLT KP nuts" Breast, Lung, Thyroid, Kidney, Prostate

Answer 34

Can involve a mixture of bone resorption and bone formation and can thus take on one of three patterns, depending on the dominant process: 1. Lytic (osteolytic) metastases 2. Sclerotic (osteoblastic) metastases 3. Mixed lytic and sclerotic metastases

Answer 35

• Vertebrae => Lumbar spine more than thoracic spine and cervical spine • Pelvis • Proximal femur • Proximal humerus • Skull (Metastases distal to the elbow and knee are distinctly uncommon)

Answer 36

• Unremitting, dull pain – may be sharp on weight bearing; worse at night • Pathological fractures • B symptoms More rarely – spinal cord compression (leading to radicular pain and autonomic dysfunction).

Answer 37

• Bone tenderness • Reduced ROM of the joints • Local lymphadenopathy

Answer 38

Skeletal radioisotope scans – shows mets as “hot areas” before radiological changes occur Skeletal XR => Sclerotic or lytic areas once the tumour reaches a certain size. CT/MRI => To define bone loss, marrow involvement and tumour extension => Imaging for location of the primary tumour. General bloods +/- tumour markers

Answer 39

Establish the primary diagnosis + treat Analgesia / local radiotherapy to control the pain Bisphosphonates to reduce fracture risk Prophylactic surgical stabilisation may be indicated to prevent pathological fractures.

Answer 40

= a type of bone marrow cancer. It's called multiple myeloma as the cancer often affects several areas of the body, such as the spine, skull, pelvis and ribs.

Answer 41

Bone destruction leads to pathological fractures => Particularly in the vertebrae, leading to backache. Signs of bone marrow infiltration and renal impairment => Can present with CKD signs, recurrent infections, signs of anaemia, hypercalcaemia, etc.

Answer 42

XR will show "punched-out" lytic lesions.

Answer 43

Radiotherapy for local disease control Spinal decompression and fusion if necessary

Answer 44

= Malignant tumour of osteoblasts Grow rapidly to invade surrounding soft tissues, metastasising early Often advanced at presentation Mets are often to the lungs.

Answer 45

Very poor prognosis (5-10% 5-year survival)

Answer 46

Occurs in children, most commonly around the knee. Rarely can occur in the elderly, associated with long-standing Paget’s

Answer 47

Malignant cartilage-forming lesion. Grows slowly and metastasises late Can be large at presentation, but generally stay within a defined border. Occur in adults, most commonly around the pelvis.

Answer 48

Pain / mechanical symptoms / occasionally a pathological fracture.

Answer 49

osteoma, chondroma, and osteochondroma

Answer 50

Further imaging and biopsy are always indicated to determine the nature of a lesion detected on XR (2WW pathway)

Answer 51

Generally life > limb: En-bloc resection with adjunctive chemo/radiotherapy is commonly seen.

Answer 52

= a person’s fullest potential

Answer 53

= the level a person is currently at

Answer 54

When the person is limited in participating in society as they want to (participation is lost/reduced)

Answer 55

= the development of a person to their fullest potential, within the limitations of their underlying condition and the resources available. It is goal-directed - need to identify the person's specific requirements and activity limitations.

Answer 56

1. Review of pathology and impairment 2. Environment 3. Participation 4. Activity 5. Important others 6. Risk

Answer 57

Involves excessive uncontrolled resorption of bone by large abnormal multinucleated osteoclasts. The destruction of cortical and trabecular bone comes in waves, with each wave followed by an osteoblastic response, occurring in a haphazard fashion. => Bone architecture becomes distorted Although there may be an increase in bone bulk, it is paradoxically weaker than normal. The new bone has a characteristic woven, non-lamellar pattern, with fibrosis of the marrow spaces

Answer 58

Up to 80% are asymptomatic => Diagnosis may follow an incidental finding on XR or LFTs (raised ALP). Symptoms: - Waxing and waning bone pain - Bone deformities (bowed tibia / skull changes) - Cranial nerve palsies due to compression (classically CNVIII) - Cardiac failure due to increased bone blood flow.

Answer 59

1. Bone pain, 2. Pathological fractures 3. Deafness (CNVIII palsy)

Answer 60

Bloods => ALP raised, calcium and phosphate normal. (Can be a mild hypercalcaemia in widespread disease) Urine => Raised hydroxyproline due to increased bone turnover XR => Variable presentation, with lytic and sclerotic lesions Bone scans => Used to show extent of bone involvement – but cannot differentiate between Paget’s and sclerotic metastases.

Answer 61

Simple analgesics Bisphosphonates for disease modification Monitor serum ALP as a disease marker Asymptomatic patients may be treated if there are significant risk factors for complications Surgery may be required to deal with secondary joint disease or neurological complications.

Answer 62

pain / stiffness leading to a loss of function.

Answer 63

untreated joint sepsis

Answer 64

Young age, Co-morbid diseases (including obesity).

Answer 65

Elective replacement in OA Emergency replacement (young/fit patient) – Garden 3/4 intracapsular NOF #

Answer 66

Has 2 components: => Acetabular component => Femoral component

Answer 67

Emergency replacement of Garden 3/4 intracapsular NOF # (unless particularly young/fit)

Answer 68

Has only the femoral component => Bipolar – an endo-prosthetic “bipolar” head component and an inner metal bearing => Unipolar – a large single endo-prosthetic head component Can be cemented/uncemented

Answer 69

The femoral component will be more uniformly and more securely ﬁxed within the femoral canal

Answer 70

Cement confers the risks of cardiac arrhythmias and cardio-respiratory compromise, secondary to fat embolism and cement reaction phenomena.

Answer 71

- Leg length discrepancy - Dislocation (highest risk in the first 3 months) - Infection - Periprosthetic fracture - Persistent pain - Polyethelene wear of the acetabular compartment (if THR) - Neurovascular injury

Answer 72

A rare but devastating complication => Joint-salvage rates are 30% if caught early. Often presents subclinically, with little systemic upset. If suspected, the joint will be aspirated in aseptic conditions (ideally on 3 separate occasions). Mx – usually involves removal of the prosthesis and lengthy courses of ABX to clear the infection before a new prosthesis can be inserted.

Answer 73

= a disease characterised by reduced bone mineral density and microarchitectural deterioration of bone tissue, leading to increased bone fragility and an increased risk of fracture WHO Definition = bone mineral density >2.5 SDs below that of a young adult male (T-score)

Answer 74

T- score below -2.5 = osteoporosis T score between -1 and -2.5 = osteopaenia

Answer 75

In normal individuals, bone mass increases during childhood to reach a peak between 20-30, when there is a period of consolidation before it falls thereafter. Women have an accelerated phase of bone loss after menopause, as a result of oestrogen deficiency.

Answer 76

Age Female Sex Genetics => 80% of peak bone mass determined by genetics, also rate of bone turnover. Low peak bone mass: => Limited early exercise => Limited early calcium intake => Low BMI in childhood Disuse – leading to “disuse atrophy” => E.g. following a fracture Steroid use Endocrine - Cushing's, hyperPTH, hyperthyroid, hypogonadism Chronic inflammatory disease / neoplastic disease Smoking and alcohol

Answer 77

The risk is directly related to dose/duration of therapy. Steroids cause decreased intestinal calcium absorption and increased renal calcium excretion, leading to secondary hyperparathyroidism. This is combined with direct inhibition of osteoblast activity and stimulation of osteoblast apoptosis.

Answer 78

Clinically the disease is mainly asymptomatic and often picked up incidentally if patients have an X-ray for another condition. If symptoms occur, they may be: - Fragility fractures - Back pain - Height loss - Kyphosis

Answer 79

The bones will appear more radiolucent than normal and loss of bony trabeculae.

Answer 80

wrist, NOF, spine (crush/wedge #)

Answer 81

measuring bone mineral density (BMD) with DEXA scan

Answer 82

at the lumbar spine and iliac crest.

Answer 83

T-score = how many standard deviations the BMD deviates from a young adult male Z- score = how many SDs BMD deviates from an age-matched control

Answer 84

DEXA scan to confirm Once osteoporosis has been confirmed: - History – to identify predisposing causes. - Physical examination – including a search for endocrine disease and inflammatory disease - Bloods – calcium, phosphate, TFTs, ESR - Sex hormone panel in men and amenorrhoeic women below 50. Further studies requested based on clinical suspicion

Answer 85

The FRAX tool should be used in GP for patients over 50 to estimate the risk of fragility fracture Uses multiple demographic details to give “high”, “intermediate” or “low” risk of fragility fracture.

Answer 86

If the 10-year risk is low – reassurance If 10-year risk is high – treatment is advised. If 10-year risk is intermediate – DEXA scan should be offered.

Answer 87

Patients with osteopaenia should be given advice on lifestyle factors: - Stop smoking and limit alcohol - Increase exercise and dietary calcium intake Repeat DEXA scans should be offered to this group.

Answer 88

Patients with BMD in the osteoporotic range should be offered treatment: - Weekly bisphosphonates (alendronic acid) are 1st line. - Vitamin D should also be given as an adjunct for those not exposed to much, as well as calcium if the person’s calcium intake is judged to be inadequate. => Adcal is a combined calcium and VitD supplement. - HRT should be considered in women with premature menopause to reduce the risk of fragility fractures (and for the relief of menopausal symptoms). - Testosterone replacement can be given in males with hypogonadism. Fracture risk and BMD should be re-measured at 2 years.

Answer 89

Act to decrease bone resorption and allow mineralisation of existing bone to increase. Can give troublesome GI side effects A rarer complication is osteonecrosis of the jaw.

Answer 90

Calcitonin – osteoclast inhibitor Recombinant PTH (daily s.c. injection, beneficial due to the daily peaks and troughs mimicking a circulating hormone, rather than sustained elevation as in hyperPTH)

Answer 91

inadequate bone mineralisation (i.e. soft bones), usually caused by vitamin D deficiency in adults. => Rarer causes include hypophosphataemia, bisphosphonates, fluoride or aluminium intoxication.

Answer 92

Characterised by bone pain, bone fragility and fractures. Often more insidious in onset, presenting with malaise and general weakness. Rickets is the syndrome resulting from osteomalacia in the growing skeleton. => These patients develop bone deformity in addition to the above features.

Answer 93

Full-blown osteomalacia is rare in developed countries, but subclinical disease is still common in patients with poor diet, or little sun exposure. => Features in adults will present insidiously, with many cases only picked up on biochemistry.

Answer 94

Vit D (cholecalciferol) can be ingested directly (high levels in oily fish, eggs, and fortified cereals) Most is synthesised from 7-dehydrocholesterol in the skin, providing there is adequate UV sunlight exposure. Ingested/synthesised Vitamin D is hydroxylated in the liver to form 25-hydroxycholecalciferol. There is a second hydroxylation in the kidney, to produce 1,25-hydroxycholecalciferol (“Calcitriol”) Calcitriol circulates as a hormone in the blood to help maintain skeletal calcium balance

Answer 95

Main action = promotion of calcium absorption from the intestines

Answer 96

Inadequate dietary intake (rare in developed world, but can occur in vegans/patients with malabsorptive disease) Inadequate UV exposure for synthesis of VitD – e.g. housebound patients, muslim women. Renal disease – e.g. CKD Liver disease – a rare cause Drugs

Answer 97

Bloods: - U&Es – screen for renal anomalies - ALP – raised (indicates increased osteoblast activity) - Plasma calcium – normal/low - Serum phosphate – low - Serum PTH levels – high - Serum 25-OH-D – low X-Ray: - Often normal, may show “looser zones” of defective mineralisation in long bone/pelvis/ribs. - In children, the pathognomic feature is widening of the epiphyseal plate. An ILIAC CREST BIOPSY may be necessary if tests do not confirm diagnosis.

Answer 98

Oral VitD replacements – high dose for 4 weeks, then maintenance. => IV if the issue is malabsorption => Activated form if the issue is renal/hepatic disease The disease usually responds fairly rapidly to a restoration of VitD

Answer 99

Bone marrow cells die within 12 hours Bone cells (osteoblast, osteoclast, osteocytes) die between 12-24 hours

Answer 100

typically described as bone infarction only involves the trabecular bone and bone marrow in the medulla (the cortex has blood supply from the periosteum).

Answer 101

called avascular necrosis this may involve the cortical bone as the epiphyses are covered by cartilage and thus do not have periosteal supply.

Answer 102

• The head of femur – following fracture NOF of hip dislocation • The proximal scaphoid – following displaced wrist fracture • The lunate – following dislocation • The body of the talus – after talus neck fracture

Answer 103

Interrupted arterial supply (e.g. fractures) Interrupted venous drainage and retrograde arterial stoppage (e.g. thrombosis, or bone marrow swelling compressing vessels).

Answer 104

Fracture – e.g. intracapsular NOF fracture, scaphoid fracture Idiopathic – e.g. Perthe’s disease, AVN of femoral head Bone marrow infiltration (malignancy) Alcohol abuse Cushing’s / exogenous corticosteroids / chemotherapy Infection – septic arthritis

Answer 105

Osteonecrosis is often well advanced at presentation. Symptoms are: • Pain • Stiffness • Swelling in a local joint or over the bone (depending on location)

Answer 106

X-ray will show a distinctive segment of increased bone density (due to new bone formation), however this will only be present after 6 months. MRI/radionucleotide scans can show earlier changes.

Answer 107

1. Eliminate the cause 2. Prevent complications (e.g. fracture) 3. Potentially surgical intervention

Answer 108

Vascular disease (= most common cause). Infection Trauma Neoplastic disease

Answer 109

1. Transtibial (below knee) 2. Transfemoral (above-knee) Transtibial amputations are the most common => ratio of 2:1 – TTA:TFA

Answer 110

= to amputate at the most distal level that will remove the diseased tissue, whilst preserving functional residual limb length and creating the best environment for rapid return of mobility and function.

Answer 111

• Appropriate length • Knee joint preserved (if sound) • Smooth, bevelled bone => To prevent bony pressure points • No soft tissue excess / constant volume • Healthy sensate skin • Healed wound with mobile scar • Good muscle power • Full movement at proximal joints • Free of pain?

Answer 112

Have markedly reduced peri-operative mortality and better prognosis. ~70% of TT amputees will walk again => Walking with a TT prosthesis is much less energy consumed than TFA.

Answer 113

most commonly occur in severe vascular disease. Only ~40% of adult Transfemoral amputees will walk again

Answer 114

Because multiple joints (Knee and ankle) are being replaced with a prosthesis, the patient has to cope with more challenges to balance due to near total loss of proprioceptive and sensory input from the affected leg.

Answer 115

= Pain in the residual portion of the limb Pathophysiology is unclear Generally resolves with wound healing, but 15-30% report persistent pain Other causes - prosthesis causing damage, stump pathology, referred pain from back/sciatica/arthritis in nearby joint.

Answer 116

= any sensation felt in the amputated limb, except pain.

Answer 117

= Painful sensation of the missing limb Occurs in 55-85% Develops a few days after the amputation, and usually improves with time but may be permanent

Answer 118

1st line Tx = PREVENTION => Pre and peri-op epidural to get the pain under control. For a patient with established phantom limb pain: - Antidepressants/anticonvulsants, - Massage of contralateral limb - Psychological support

Answer 119

After an amputation, everybody is entitled to an assessment for a prosthetic limb should they want one. The assessment is performed by the specialist MDT. A prosthetic limb will then require intensive physiotherapy and gait training for the patient to become mobile on that limb.

Answer 120

Cognitive ability Motivation Previous mobility level Expectations / goals Physical strength Condition of contralateral leg Wound healing post-surgery Co-morbidities

Answer 121

Hopping is not generally promoted, due to the potential for falls, damaging the remaining foot, and increased joint pressure on the “hopping side”

Answer 122

Pressure sores Skin rashes/allergies Neuroma development Contralateral joint issues Poor patient acceptance (doesn’t meet expectations).

Answer 123

Around 75% of people with amputation experience low mood +/- anxiety. Psychological function can deteriorate over time and many find psychological support more useful later in their rehabilitation journey.

Answer 124

GCS 13-14 Post-traumatic Amnesia <6 hrs LOC <15 minutes

Answer 125

GCS 8-12 Post-traumatic Amnesia 6 – 24 hours LOC 15 mins to 6 hours

Answer 126

GCS <7 Post-traumatic Amnesia - 24 hours to one week LOC 6 – 48 hours

Answer 127

Coma (2-4 weeks) Brain death Vegetative state Minimally conscious state Concussion Post-concussion syndrome “Locked in syndrome”

Answer 128

Considered permanent if lasts >1 year in a TBI (>6 months in anoxic brain injury)

Answer 129

Used to categorise severity of TBI Main feature = inability to remember events; also confusion and disorientation. Most recover over hours to days. Often have no recollection of the accident

Answer 130

IMPOTENCE Introduction Mental State Pain Observations Thromboprophylaxis Eating & Drinking & Elimination Neurovascular Status Cut Exercise

Answer 131

Name, age What surgery? How many days post-op (operation day = day 0) Anaesthetic type? +/- sedation Intra-operative complications?

Answer 132

Alert & orientated? If not, why? => GCS / AVPU => consider AMT

Answer 133

Where is the pain? – SOCRATES (consider other sites!!) Is analgesia effective? Consider ice packs (good for knees) N&V – anti-emetics? Laxatives

Answer 134

NEWS = 0? If not, why? +/- CVS / resp exam +/- Glucose measurement

Answer 135

Calves SNT? Compression stockings LMWH/aspirin? Foot pumps? Mobilise ASAP

Answer 136

Diet & Fluids Fluid balance chart? Passing urine / catheter (colour & amount) ?Bowels opened – if not, passing flatus? Bowel sounds / abdo SNT

Answer 137

Check distal neurological & vascular status and document Consider anaesthetic & surgery (e.g. nerve block still ongoing?)

Answer 138

Surgical wound site – is dressing clean and dry and intact? If not, why not? Drains? IV ABX? Bleeding? Incontinence?

Answer 139

Has the patient been up and mobilising? Any walking aids?

Answer 140

Bloods – FBC, U&E, (clotting?) Check X-ray – any fractures caused by joint replacement surgery? Any others relevant to PMH

Answer 141

Commonly affects the hip, knee, DIP, PIP, thumb, CMJ, and hallux MTP joints. Classically spares the MCPJs

Answer 142

Progressive pain => Initially activity related, then finally a constant rest pain Stiffness => Characteristically worse after periods of rest (“gelling”), but lasts <30mins Symptoms classically follow a waxing and waning course Later features: - Muscle wasting - Loss of mobility - Deformity - Joint instability

Answer 143

Look – bony swelling, muscle wasting Feel – joint line tenderness, possible effusion, crepitus Move – limited range of movement

Answer 144

Age Obesity FHx Gender (more common in women, particularly after menopause) Hypermobility Occupation (miners, farmers, etc.)

Answer 145

Due to: - Pre-existing joint damage – inflammatory / septic / crystal arthritis, AVN, trauma - Metabolic disease – acromegaly, chondrocalcinosis, haemochromatosis - Systemic disease – haemophilia (leading to haemarthroses), haemoglobinopathies, neuropathies

Answer 146

More common in males Unilateral presentation Generally does poorly and requires arthroplasty O/E: => Painful, decreased internal and external rotation of the hip => Positive Trendelenburg test

Answer 147

Strong relationship with obesity Other RFs = previous trauma, or soft knee tissue injuries. Often bilateral Most often leads to genu varus deformities due to medial disease. O/E – classically moderate effusion, decreased ROM, crepitus and quadriceps wasting.

Answer 148

Generlised OA - nodal/ erosive/ crystal-associated Hip OA Knee OA

Answer 149

Joints of the hands are affected one by one over many years. => DIPs affected much more than PIPs First presenting with painful swelling and impairment of function. Then inflammatory phase settles after months/years to leave painless bony swellings posterolaterally => Heberden’s (DIPs) and Bouchard’s (PIPs) nodes OA of the CMC and MCP joints of the THUMB also occur, with bony swelling and fixed adduction leading to the classical “squared hand” in OA => Other MCPJs are generally spared. There is generally also large joint involvement.

Answer 150

Rare characteristic cysts seen on XR and a poor prognosis.

Answer 151

Calcium pyrophosphate deposition in the cartilage leads to chondrocalcinosis (pseudogout). This can be asymptomatic, or leads to signs/Sx or OA Knees and wrists are most commonly affected.

Answer 152

In OA, wear and tear leads to splitting and erosion of the articular cartilage, leading to narrowing of the joint space. There is associated inflammation, with thickening of the joint capsule and synovium and eventually capsular fibrosis. The loss of cartilage is progressive, leading to constant friction of two naked bone surfaces. Small cysts develop beneath this abnormal bone surface, and osteophytes form as irregular outgrowths of the peripheral unstressed cartilage. As the joints become less mobile and less used, there may be secondary atrophy of the associated muscles.

Answer 153

1. L – loss of joint space 2. O – Osteophytes 3. S – Subchondral Sclerosis 4. S – Subchondral cysts

Answer 154

Bloods: - CRP/ESR, - RF & ANA to r/o other pathologies XR – two views to confirm the presence of OA CT/MRI if XR does not correlated with clinical picture.

Answer 155

Early OA is managed conservatively More severe symptoms leading to loss of function are managed surgically.

Answer 156

Patient education Weight loss Physiotherapy – strength/stability/ROM exercises Reduction of mechanical factors – e.g. cushioned footwear, walking aids Splints for ankles/wrists Analgesia => Paracetamol and topical NSAIDs = 1st line => Oral NSAIDs (+PPI) and topical capsaicin second line. Intra-articular XR-guided corticosteroid injections

Answer 157

Usually XR-guided Provide short-term relief if there is a painful joint effusion Variable length of relief – usually <6 weeks

Answer 158

Total replacement arthroplasty: => Common in the knee/hip => Delayed for longer in the knee due to poorer outcomes One compartment arthroplasty: => Can occur in the knee if one side of the articular surface is diseased Young patients may benefit from arthroscopy and joint washout, to delay definitive Mx for months/years Arthrodesis (= the fusion of two or more bones in a joint) can be used for the ankle, spine or hand. Realignment osteotomies are also sometimes performed (hip/knee)

Answer 159

= abnormal neuroinflammatory response to a traumatic event Classically occurs post injury or surgery. The key symptoms are allodynia and persistent pain in the area affected, out of proportion to the initial injury. There is also stiffness and swelling along with abnormal hair/nail changes.

Answer 160

Must attempt to r/o common causes of polyarthritis/muscle stiffness (e.g. polymyalgia rheumatica, RA, ankylosing spondylitis, fibromyalgia, viruses, connective tissue diseases, etc) Bone scans demonstrate increased activity in the affected limb.

Answer 161

Once it has happened – specialist Mx, involving the pain team, psychological support and physiotherapy. The focus of Mx is on PREVENTION – adequate analgesia at the time of injury and early mobilisation post-fracture.

Answer 162

Prevalence of 2-3% in the UK, but up to 7% in females over 70. Affects F:M 10:1

Answer 163

Wide variety of life events associated with life distress (e.g. divorce, alcoholism in the family, traumatic injury, low income).

Answer 164

= DIAGNOSIS OF EXCLUSION Despite intensive investigation, no structural/ inflammatory/ metabolic or endocrine abnormality has been identified. It is thought to be due to sleep abnormalities and abnormal pain processing.

Answer 165

Fibromyalgia sufferers have reduced delta sleep (deep, non-REM sleep), distinct from sleep abnormalities seen in depression. Deprivation of this delta sleep in normal volunteers produces the signs and symptoms of fibromyalgia.

Answer 166

Fibromyalgia sufferers have reduced pain tolerance at characteristic sites throughout the body. This is evidenced by exaggerated skin flare reactions to substances such as capsaicin and frequent occurrence of allodynia.

Answer 167

• Multiple regional pain • Marked fatigue • Low affect, irritability, weepiness • Poor concentration, forgetfulness • Non-restorative sleep.

Answer 168

• Early morning stiffness • Subjective swelling of fingers only • Numbness/tingling of all fingers.

Answer 169

• Tension headache • IBS • irritable bladder • Hyperacusis, dyspareunia, discomfort when touched (allodynia) • Common side effects with drugs • Chronic Fatigue Syndrome

Answer 170

1. Take a thorough history – ruling out underlying pathology (red flags) and depression 2. Bloods – may help to r/o underlying pathology • FBC – anaemia • ESR/CRP – inflammatory disease • Consider RF/ANA if raised inflammatory markers • TFTs – hypothyroidism • Calcium, ALP – hyperPTH / osteomalacia DIAGNOSTIC CRITERIA: => Widespread pain for more than three months => Pain elicited by digital pressure at 11 or more defined pressure points (out of 18; L+R side are separate points)

Answer 171

1. Patient Education = central to management 2. Lifestyle Advice 3. Low-dose amitryptilline (10-75mg nocte) 4. Self-help strategies: => Cognitive behavioural approach, relaxation techniques and other “coping strategies” should be encouraged.

Answer 172

Explain that the disease does not reflect inflammation or damage. The model of a self-perpetuating cycle involving loss of sleep and pain is often readily accepted. Sensible increases in activity level to help improve sleep and thus reduce symptoms. => Graded exercise therapy is a more formal approach

Answer 173

Can be very effective, reducing the excessive transmission of pain signals and increasing restorative sleep. Many people with fibromyalgia will be intolerant to even small doses of amitryptilline

Answer 174

- Trauma (incl. whiplash injury) - Mechanical neck pain - Cervical spondylitis - Cervical myelopathy - Ankylosing spondylitis - Fibromyalgia

Answer 175

Acceleration-deceleration forces applied to the neck Usually occurs in a RTA, with a patient wearing a seatbelt being struck from behind. Presentation: => Complex pattern with pain in the neck, shoulder and arm as well as headache, dizziness and memory loss. Can take months to settle

Answer 176

radiology only indicated for those with suspected bony injury.

Answer 177

Can take months to settle => Provide reassurance to the patient that this is normal Encourage early return to usual non-provocative, pre-accident activities and early mobilisation Simple oral analgesics Consider referral to physiotherapy

Answer 178

= general neck pain that cannot be attributed to a specific issue - Injury - Sleeping in an awkward position - Poor Posture

Answer 179

Due to compression of the cervical nerve roots. Usually caused by osteophytes in older patients More rarely, acute cervical disc prolapse following minor trauma in younger patients

Answer 180

- Aching pain in the neck, going down the arm. - Progressing to a mild loss of grip strength - Dermatomal sensory loss - Occasional sudden sharp pains down the arm

Answer 181

Confirm diagnosis with XR/MRI

Answer 182

Refer to neurosurgery

Answer 183

= compression of the cervical spinal cord. Can be due to: - Osteophytes - Cervical disc degeneration - Malignancy

Answer 184

Presents in older patients, initially with problems with fine motor control in the hands (e.g. can’t chop food). There is a slowly developing spastic gait Pain is not a predominant presenting feature.

Answer 185

UMN signs below the level of compression LMN signs at the level of compression: => E.g. C5/6 lesion – wasting and fasciculation on the deltoids & biceps with a hypo-reflexive bicep reflex by hyper-reflexive tricep reflex and spastic leg with upgoing plantars. Hoffman’s sign will be positive

Answer 186

“flicking” the distal phalanx leads to flexion of the other fingers (UMN sign)

Answer 187

Confirm with XR/MRI Refer to neurosurgery for conservative/surgical interventions

Answer 188

1. Rule out life-threatening visceral pathology (AAA, MI, Pancreatitis) => Observations, targeted abdominal and cardio-respiratory examination => ECG / bloods 2. Assess history for red flag symptoms that indicate more severe pathology (TUNAFISH) 3. Examine for red flag symptoms that indicate more severe pathology => Saddle Anaesthesia (Cauda Equina) => Midline tenderness on palpation (Malignancy)

Answer 189

- Age <20 or >55 - Constant or progressive pain (including pain at night) - B symptoms - Bladder/bowel symptoms - History of TB/HIV/malignancy - Pain in the thoracic spine - History of significant trauma

Answer 190

Saddle Anaesthesia (Cauda Equina) Midline tenderness on palpation (Malignancy)

Answer 191

= 90% of back pain cases A diagnosis can be reached when the clinician is satisfied there is no specific cause for the pain.

Answer 192

Pain in lumbosacral region 20-55 years old Pain came on suddenly when lifting Pain classically varies with physical activity, posture, time May be referred to buttocks/thighs O/E – palpable muscular spasm, which can cause local pain/tenderness

Answer 193

Simple analgesia Advice to continue with normal activities plus physiotherapy exercises Prognosis is good – 90% recover from the acute attack within 6 weeks => Reassess at 6 weeks if the pain has not resolved

Answer 194

Generally occurs between age 20-40 The nucleus pulposus of the disc herniates into the spinal canal Most commonly occurs at L4/5, or L5/S1 If the herniation is to the extent that it causes compression of one of the nerve roots, then radicular pain will occur. If the herniation of the disc is central rather than lateral, this can cause cauda equina syndrome (a neurosurgical emergency)

Answer 195

Can be precipitated by lifting, or even something minor like a sneeze or triggering event unknown. After which, patient is seized with pain and unable to straighten up. => The pain will be worse on coughing/straining. => Pain moves into the buttock within hours and into the leg within a day or two. Radicular pain will be present: => Severe piercing/stabbing pains and paraesthesia in one leg due to compression of sciatic nerve root. => Rarely, this can affect both legs. ALWAYS ask about bladder/bowel symptoms that may suggest cauda equina (e.g. retention/incontinence)

Answer 196

Patient may walk with a flexed leg, or with obvious scoliosis. On spinal examination there may be scoliosis and palpable muscle spasm Straight leg raising to 30 degrees produces pain: => If positive raising the contralateral leg, suggests a very large lesion. Femoral stretch test may be positive (pain in anterior thigh). Neurological exam will show muscle weakness, some loss of sensation and diminished reflexes at the affected level. Always examine to r/o cauda equina: => PR – no sensation, loss of anal tone => Palpate the bladder – signs of retention (this will be painless and can be confirmed with a post-void bladder scan) => Check sensation on saddle area.

Answer 197

The most common muscles affected are extensor hallucis longus and tibialis anterior (L4; extension of great toe; dorsiflexion of foot). Peroneus longus and brevis may also be affected (L4/5; foot eversion) Gastrocnemius/soleus are affected in lower lesions (S1/2; plantar flexion).

Answer 198

Thorough history to separate referred pain in simple lower back pain from “true” nerve root pain. => The natural history of disease is relapsing and remitting episodes of pain. Examination - red flags? Initial Mx = conservative: - Anti-inflammatories and bed rest with knees slightly flexed. - Bed rest for two weeks reduces herniation in more than 90% - Rehabilitation with the physio is a vital part of Mx. If symptoms persist at 2 weeks: - Epidural injections are useful to treat radicular symptoms, these can be repeated fairly frequently - MRI & surgical referral is indicated - For single level disease, microdiscectomy may be performed (removal of the herniating material).

Answer 199

RARE (occurs in ~2% of disc prolapses) BUT EMERGENCY Presentation = pain as per disc prolapse, PLUS bladder/bowel symptoms, saddle anaesthesia Ix = Emergency MRI Mx = Urgent surgical intervention required to prevent long-term bladder/bowel/reproductive problems.

Answer 200

Stenosis of the lumbar canal compresses the cauda equina roots, leading to symptoms of spinal claudication Generally caused by degeneration of the spine. - Facet joint hypertrophy - Ligamentum flavum hypertrophy - Disc degeneration - OA

Answer 201

Sx of spinal claudication => Aching pain in the legs on walking, most commonly posteriorly. => Pain recovers fairly slowly on sitting/bending forwards (this creates a more spacious canal). => There may also be numbness, stiffness and weakness in the leg. => Symptoms are variable day to day. This can have a stable or progressive course (which can influence choice of Tx )

Answer 202

Sx can have a stable or progressive course (which can influence choice of Tx – i.e. conservative vs surgical) => Conservative = activity modification, physiotherapy => Surgical = laminectomy

Answer 203

Facet joints are responsible for keeping vertebrae in antero-posterior alignment. In spondylolisthesis, one vertebra is displaced (either anteriorly or posteriorly) on the vertebra below it – anterolisthesis or posterolisthesis Almost always occurs between L4-L5 or L5-S1

Answer 204

Almost always occurs between L4-L5 or L5-S1

Answer 205

Spondylolysis = most common cause; stress fracture of lumbar pars articularis. Dysplasia of the lumbosacral facet joints (in adolescents) OA of the facet joints In extreme athletes

Answer 206

Intermittent back ache, precipitated by exercise/strain O/E – often can find a “step” Cauda equina syndrome can develop

Answer 207

Usually managed conservatively – as per mechanical back pain. Spinal fusion can be performed if the patient is young or there are disabling symptoms

Answer 208

= Highly common cause of lower back pain presenting to the GP. Causes: - The facet joints are synovial, so can develop OA/RA. - More commonly the joints are affected by minor trauma.

Answer 209

Can lead to acute or chronic back pain Typically worse on extension of the back, in the morning and on standing. NO history of pain in the legs OE – there may be local tenderness over the facet joints

Answer 210

Inflammatory (spondyloarthropathies) Infection (discitis) Metabolic (wedge fractures) Neoplastic (primary or secondary)

Answer 211

can present as a complication of spinal surgery/injections. Localised pain and raised inflammatory markers Admit Pt for IV ABX

Answer 212

Can be primary tumours, or most commonly secondary metastases (BLT KP) Sx = progressive pain, particularly at night with no exacerbating/relieving factors; there may be pain over a particular bony segment.

Answer 213

Pre-menopausal women are affected more than men, but there are no gender differences post-menopause. Classic presentation is in a 30-50 year old woman

Answer 214

Classically presents as a symmetrical polyarthritis => Typically in a 30-50 year old female. Red, warm, painful & swollen peripheral joints (typically of the hands and feet) This then progresses to larger joints (still symmetrical) Symptoms worse in the morning Tends to evolve over weeks/months (but in 15% of cases there is rapid onset of Sx over days/overnight.) General malaise, weight loss and disturbed sleep are common Extra-articular features may be present

Answer 215

• Palindromic RA (recurring mono/polyarthritis) • Persistent monoarthritis • Systemic illness with extra-articular symptoms

Answer 216

Involvement of the small joints of the hands is most common, with joint erosion leading to deformities as the disease progresses. => DIPJs are classically spared in RA There are certain characteristic deformities: - Ulnar deviation at the MCPJs - Radial deviation at the wrist - Boutonniere deformity - Swan neck deformity - Z-deformity of the thumb – - Subluxation is a late deformity – volar subluxation at the MCPs/wrist Severe disease can lead to ankylosis (fusion) across the joint, leading to severe and fixed deformities. Carpal tunnel syndrome is also very common due to inflamed tendon sheaths.

Answer 217

= hyperflexed PIPJs, hyperextended DIPJs

Answer 218

= hyperflexed DIPJs, hyperextended PIPJs

Answer 219

= flexed MCPJs, extension at IPJ

Answer 220

- Ulnar deviation at the MCPJs - Radial deviation at the wrist - Boutonniere deformity - Swan neck deformity - Z-deformity of the thumb - Subluxation is a late deformity – volar subluxation at the MCPs/wrist

Answer 221

MTPJ swelling is one of the earliest manifestations. The foot becomes broader and hammer-toe deformity develops Ulcers/callouses can occur due to exposure of the metatarsal heads to pressure, due to migration of the protective fat pad.

Answer 222

The knee is most commonly affected, then the shoulder/hip.

Answer 223

The knee is most commonly affected, then the shoulder/hip. In the knee, genu valgus deformity and secondary OA can develop. Once severely affected, large joints require total joint replacement to restore function.

Answer 224

History & Examination Bloods - FBC, CRP/ESR, RF, Anti-CCP, ANA X-Ray

Answer 225

• FBC – leucocytosis & thrombocytosis in acute inflammatory phase; normocytic anaemic of chronic disease. • CRP/ESR – elevated in active disease • Rheumatoid Factor (RF) – elevation in 70%, but non-specific. • Anti-CCP – more specific, rises predate clinical disease by several years. • Anti-nuclear Antibody – if suspecting connective tissue disease

Answer 226

Early findings – soft tissue swellings around the PIPJs and MCPJs => DIPJs usually spared L – loss of joint space (uniform joint space narrowing) E – erosions S – Soft tissue swellings S – soft bones (osteopaenia) Subluxation/ dislocation may also be seen

Answer 227

1. First change = rheumatoid synovitis => Swollen synovium showing a villous pattern and neutrophil infiltration. 2. This leads to an exudative effusion within the joint. => Presents clinically as a boggy, swollen joint. 3. As the disease progresses, vascular granulation tissue grows from the peripheries inwards, destroying articular cartilage. => Also causes focal destruction of the bone, causing “erosions” seen on radiographs. => Clinically this can lead to deformities. 4. In long-standing disease, the whole cartilage may be destroyed and replaced by fibrous pannus, leading to secondary OA changes.

Answer 228

thought to be either due to the cortisol trough, or the build-up of inflammatory mediators during non-activity.

Answer 229

Seen in 20% of patients with RA. Formed of necrotic inflammatory tissue Occur over bony prominences at sites of recurrent mechanical stress => E.g. the olecranon, calcaneum and MCP joints Associated with underlying erosions Vary in size from a few mm to cm in diameter More common in smokers ONLY occur in seropositive disease

Answer 230

RHEUMATOID NODULES PULMONARY - pulmonary fibrosis, pleural effusions VASCULITIS - cutaneous, mesenteric, etc. CARDIAC - subclinical pericardial involvement; higher rates of atherosclerosis NERVOUS SYSTEM - • Entrapment neuropathies such as carpal tunnel are common. • Glove & stocking sensory loss can also occur due to vasculitis of the vasa nervorum. EYES • Keratoconjunctivitis sicca • Scleritis and episcleritis KIDNEYS - amylodoisis => renal failure HAEMATOLOGY • Felty’s Syndrome = splenomegaly + anaemia + neutropaenia associated with RA • Normocytic chormochromic anaemia.

Answer 231

Felty's Syndrome = splenomegaly + anaemia + neutropaenia associated with RA

Answer 232

= is radiologically identified increased mobility or laxity between the body of the first cervical vertebra (atlas) and the odontoid process of the second cervical vertebra (axis). It occurs in 50-80% of patients with RA of the cervical spine, as the transverse and apical ligaments are destroyed by pannus.

Answer 233

Localised pain & deformity Cervical radiculopathy

Answer 234

Investigations: - XR – APO, lateral and odontoid peg views required - MRI of the cervical spine Management: - Surgical decompression of the spinal cord - Stabilise involved segment of the spine.

Answer 235

Once diagnosis is confirmed: 1. Methotrexate is 1st line, usually combined with hydroxychloroquine (as they have different side effect profiles). 2. Short-term glucocorticoids (IM methylprednisolone) are also prescribed at diagnosis to reduce inflammation before the DMARDs become effective. => Further short-term glucocorticoid courses may be required to deal with flares. 3. NSAIDs are often also essential in a patient’s management to relieve night pain and morning stiffness. 4. Lifestyle measures are also very important => Stopping smoking, hydrotherapy, etc. 5. MDT management is essential

Answer 236

Reduces CV risk and increases DMARD effectiveness

Answer 237

The prevalence of gout is ~1%. There is a strong male predominance (10:1) => the most common inflammatory arthritis in men over 40.

Answer 238

A pathological reaction of the joint/periarticular tissues due to presence of monosodium urate monohydrate (MSUM) crystals. These preferentially deposit in the peripheral connective tissues in and around synovial joints, initially favouring the lower limb. => It will classically first present in the 1st MTP joint. As the crystal deposits slowly increase, there is progressive involvement of more proximal sites, and the potential for development of secondary OA.

Answer 239

Hyperuricaemia is not alone sufficient to cause gout => 95% of hyperuricemic people never develop gout. ALSO a normal uric acid level during an acute attack does not exclude gout (levels fall as part of the acute reaction).

Answer 240

• Hyperuricaemia • Age • Metabolic syndrome • High protein diet • High alcohol intake (predominantly beer) Secondary Causes of Gout: 1. Factors that impair excretion of uric acid => e.g CKD, drugs (NSAIDs, thiazides), HTN, HyperPTH, hypothyroidism 2. Factors that increase production of uric acid: => e.g. Metabolic conditions, myelo-/lympho- proliferative disorders

Answer 241

Severe pain, often described as the “worst ever” Rapid onset of symptoms, often waking the patient Maximum severity reached in 2-6 hours Associated extreme tenderness (patient unable to wear a sock) and marked swelling and erythema. There may be accompanying malaise, fever or confusion (more common if large joint affected). The joint will be held in the “loose pack” position.

Answer 242

= a position of a joint in which the joint surfaces are not congruent and the joint capsule is lax.

Answer 243

may be precipitated by excess food/alcohol or dehydration.

Answer 244

It is generally self-limiting over 5-14 days with a complete return to normality (although desquamation of overlying skin is common).

Answer 245

main DDx of gout = septic arthritis Septic arthritis = more subacute onset, progressing in severity until treated, ROM will be limited, systemic Sx.

Answer 246

Large MSUM crystal deposits produce irregular, firm nodules (“tophi”) at classical sites. Usually located at extensor surfaces of fingers, hands, elbows, and Achilles tendon The white colour may allow distinction from rheumatoid nodules. Large nodules may ulcerate, discharging white, gritty material and associated with local inflammation.

Answer 247

Bloods: => FBC, U&E, serum urid acid. Aspiration of the joint effusions => For MCS and polarised light microscopy X-Ray: => Can assess the degree of joint damage In the longer-term, it may be relevant to search for an underlying cause – e.g. BP, urine dip, blood glucose/lipids, and FBC/ESR performed during remission.

Answer 248

Fast-acting oral NSAID (e.g. naproxen / diclofenac) Oral Colchicine is used instead of NSAIDs in certain patients => e.g. Renal patients, patients with CCF, patients on chemotherapy Early aspiration of the joint combined with corticosteroid injection can effectively abort the acute attack = Only really in secondary care with immediate microscopy. EARLY MOBILISATION is important after an episode of gout.

Answer 249

LIFESTYLE ADVICE: - Reduce alcohol and total calorie/cholesterol intake; maintain a healthy weight. - Avoid some foods that are high in purines (offal, seafood, red meat, asparagus, spinach) / smaller portions of these. ALLOPURINOL => reduces uric acid production

Answer 250

- Recurrent attacks of gout - Tophaceous gout - Evidence of bone/joint damage - Associated renal disease - Greatly elevated uric acid levels

Answer 251

Tx with allopurinol is only initiated when an acute attack has settled (usually after 4 weeks), so as not to exacerbate/prolong the attack. The aim of Tx is to bring serum uric acid level into the lower half of normal range. => The serum level should be measured every month, and the dose increased in 100mg increments, to maximum of 900mg daily, until uric acids are within this range. After this, monitoring can move to yearly.

Answer 252

In acute gout, synovial fluid shows increased turbidity due to the elevated cell count. Urate crystals will be negatively birefringent and needle shaped in polarised light microscopy

Answer 253

Calcium pyrophosphate crystal deposition in hyaline/fibrocartilage of joints leads to chondrocalcinosis

Answer 254

May be sporadic, familial or associated with metabolic diseases: => HyperPTH, hypophosphatasia, hypomagnesaemia, Wilson’s disease. - Associated with aging - More common in women

Answer 255

Often asymptomatic can present as an acute self-limited synovitis (pseudogout) or chronic arthritis showing a strong overlap with OA. Typically occurs at the knee or wrist Typically in elderly women. O/E – signs of OA with superimposed synovitis.

Answer 256

= AS PER GOUT Ix Bloods Polarised light microscopy of joint aspirate will show positively bifringent, rhomboid shaped crystals. XR may show chondrocalcinosis

Answer 257

Acutely is treated very similarly to gout Often responds well to joint aspiration

Answer 258

= acute juxta-articular soft tissue deposition of calcium hydroxyapatite crystals leading to an acute inflammatory response. => Periarticular tissues – particularly tendons, causing calcific tendonitis => Hyaline cartilage (in association with OA; will make OA more severe) => S.c. Tissue / muscle – in connective tissue diseases

Answer 259

= a scoring system that helps to determine whether a spinal cord injury is complete or incomplete. Myotome and dermatome function are recorded in the upper/lower limb. Preservation of any myotome/dermatome function in S4/5 represents an incomplete spinal cord injury, with potential for recovery. => E.g. anal tone, or feeling of pressure

Answer 260

= a scale used to assess a patient’s performance in 10 functions/ADLs A higher score = a reflection of greater ability to function independently following hospital discharge.

Answer 261

- Bladder continence - Bowel continence - Grooming - Toilet use - Feeding - Transfer - Mobility - Dressing - Stairs - Bathing

Answer 262

A dislocation occurs when the joint surfaces are completely displaced and no longer in contact

Answer 263

History Examination: => obvious deformity, with displaced bony landmarks. => Other neurovascular features/injuries should be checked for in these patients (always check for neurological deficiencies prior to reduction). Ix = XR is normally the investigation of choice.

Answer 264

= urgent joint reduction to maintain vascularity of the joint stabilisation of any associated fractures.

Answer 265

90% being anterior dislocations. => Often due to FOOSH or occasionally direct trauma.

Answer 266

Posterior dislocations are rarer Seen in direct trauma to the front of the shoulder, or patients who have had a seizure (or been electrocuted). => Classical “lightbulb” sign on XR

Answer 267

The axillary nerve should be tested before and after reduction, as it is commonly injured => Provides dermatomal sensation to the “regimental badge” area of the shoulder.

Answer 268

= a rapidly progressing destructive process, occurring in the foot/ankle joints in people with peripheral neuropathy.

Answer 269

EARLY STAGES – local oedema, and warmth LATER STAGES – obvious deformities => “rocker bottom” foot if midfoot affected => Toes can curl under (like claws) => Heel deformities

Answer 270

DM = most common Tabes Dorsalis (syphilitic myelopathy) Alcoholic neuropathy Cauda equina lesions Leprosy

Answer 271

X-RAY - Can be normal initially - Then shows initial local osteoporosis - Progresses to show osseus destruction and collapse.

Answer 272

Well-fitting cast to prevent weight-bearing in early stages. => Until the redness, swelling, and heat are resolved. Then prescription footwear Surgical Mx of severe deformities.

Answer 273

Bladder dysfunction due to neurological damage. Can present with a range of symptoms => Injury above T12 usually leads to a reflex bladder => Injury below L1 usually leads to a flaccid (acontractile) bladder

Answer 274

Usually due to injury above T12 Autonomic control but no voluntary control – the bladder contracts when reaching a certain level of fullness Mx = regular “tapping” (tapping the suprapubic area with the side of the hand to stimulate the autonomic reflex) or intermittent catheterisation.

Answer 275

Usually due to injury below L1 leads to a flaccid (acontractile) bladder => there is no bladder tone, so looks clinically like overflow incontinence. Mx = intermittent self catheterisation.

Answer 276

= bowel dysfunction due to neurological damage => Spinal Cord Injury above T12 leads to reflex bowel. => Injury below L1 leads to areflexic bowel. Mx: - Keeping the correct stool consistency - Routine defecation at set times of day (triggered by enema, digital stimulation, postural changes or abdominal massage).

Answer 277

Usually due to spinal Cord Injury above T12 The feeling of rectal fullness is lost Reflex bowel movements cause emptying at inconvenient times

Answer 278

Usually due to injury below L1 Defecation reflex and anal sphincter contraction is lost.

Answer 279

= a potentially dangerous clinical syndrome that develops in individuals with spinal cord injury at T6 or above. => Results in acute, uncontrolled HTN due to sympathetic overactivity. Can be precipitated by any noxious stimulus below the level of the injury (e.g. full bladder/bowel, skin irritation, sexual activity or minor trauma).

Answer 280

a clinical emergency in individuals with spinal cord injury Sx: - Pounding headache - Sweating - Blotching of the skin above the injury, with cold & clammy skin below. O/E: - HTN (above 200/100) and bradycardia.

Answer 281

= infection of a joint SURGICAL EMERGENCY - mortality rate of 10% and high morbidity (infection is rapidly destructive of joint)

Answer 282

Patients with septic arthritis invariably also have a bacteraemia, as spread is generally haematogenous (most commonly from the skin/respiratory tract). Direct infection following joint aspiration is uncommon.

Answer 283

- Extremes of age - Pre-existing joint disease (principally RA) - IVDU - DM / immunosuppression - Recent operative / injective procedures on the joints

Answer 284

Most likely causative organism = Staph. aureus, In young adults, disseminated gonococcal infection is an important cause. In children, Strep. pneumoniae or H. influenzae may be the causative organism in children.

Answer 285

Acute/subacute monoarthritis – a hot, swollen, erythematous joint. The joint is held in the “loose pack” position (e.g. knee flexed) O/E: - Fever and systemic Sx - Demonstratable effusion - Loss of movement of the joint - Extreme pain with even passive movement. The knee/hip joints are most commonly affected.

Answer 286

crystal arthritis, osteomyelitis, reactive arthritis, overlying cellulitis, monoarticular presentation of RA/CTD/seronegative arthritis.

Answer 287

The joint is invaded by haematological spread, by eruption of a bone abscess or directly through a penetrating wound. Infection spreads through the joint and cartilage is destroyed. Pus bursts out of the joint to form abscesses and sinuses. With healing, the raw articular surfaces may adhere to produce ankylosis.

Answer 288

Joint Aspiration = essential first step => For gram stain and culture => Aspirated fluid may look normal, or can often be turbid/blood-stained. If the joint is not readily accessible (e.g. hip, spine, SIJ) aspiration should be performed in theatre under image guidance. Blood Cultures: => Ensure sample has been received by the lab before commencing ABX Other bloods – FBC, ESR/CRP, uric acid, clotting. (Imaging - XR of no value in acute phase )

Answer 289

X-rays are of no value in the acute diagnosis of septic arthritis, but there are characteristic changes related to the disease pathophysiology. Soft tissue swelling in the first two weeks, with widening of joint space due to effusion. Later X-rays will then show narrowed joint space as the cartilage is destroyed, with signs of bone destruction and finally ankylosis if severe.

Answer 290

- A to E Resuscitation and Sepsis 6 - Admission under orthopaedics - Once the joint has been aspirated and blood cultures taken, start Empirical IV ABX - Adequate pain relief - Early source control with in-theatre washout - Early active rehabilitation improves outcomes. IV ABX is usually continued for 2-3 weeks, followed by 6 weeks of oral Tx => Duration of Tx is guided by CRP/ESR monitoring

Answer 291

IV ABX is usually continued for 2-3 weeks, followed by 6 weeks of oral Tx => Duration of Tx is guided by CRP/ESR monitoring

Answer 292

Osteomyelitis = infection of the bone. Common target sites for acute infection are: - the long bones in children - the vertebrae in immunosuppressed adults. Chronic infection in adults or children can occur following open fractures or operative procedures.

Answer 293

generally carries the same risk factors and organisms as septic arthritis.

Answer 294

Usually in a child Continuous pain, often throbbing and worse at night. Fever and general malaise Local swelling, erythema, warmth and oedema (late signs) May be unable to weight-bear

Answer 295

1. Inflammation – acute inflammatory response, leading to increased intraosseous pressure and intense pain. 2. Suppuration – pus appears in the medulla (day 2) and forces its way to the surface to form a subperiosteal abscess, which can form a sinus to drain to the surface or drain into soft tissues/joints. 3. Necrosis – compromised blood supply leads to necrosis by day 7. 4. New bone formation – osteoblasts stimulate new bone formation. 5. Resolution – bone will eventually heal (although remain thickened) with ABX and controlled intraosseous pressure.

Answer 296

X-rays often do not show any changes, particularly in early disease. => They cannot be used to exclude osteomyelitis. MRI = best imaging for establishing a diagnosis. Bloods – FBC, CRP/ESR => Will show raised inflammatory markers Blood cultures may be positive for the causative organism. Bone cultures from bone biopsy at debridement = gold standard

Answer 297

MOST OFTEN NO CHANGES The potential signs of osteomyelitis on an x-ray are: • Periosteal reaction/ thickening (changes to the surface of the bone) • Localised osteopenia (thinning of the bone) • Destruction of areas of the bone, endosteal scalloping

Answer 298

Bone cultures from bone biopsy at debridement => can establish the causative organism and the antibiotic sensitivities.

Answer 299

Mx involves a combination of surgical debridement and antibiotic therapy. ABX: - 6 weeks of flucloxacillin +/- rifampicin or fusidic acid added for the first 2 weeks (Alternatives to flucloxacillin are clindamycin in allergy or vancomycin or teicoplanin for MRSA) SURGERY: Osteomyelitis associated with prosthetic joints may require complete revision surgery to replace it Curretage of the area may be required if: - the patient clinically deteriorates, - the limb shows evidence of deterioration, - imaging shows progressive bone destruction,

Answer 300

Viral arthralgia can be caused by basically any viral infection. It tends to occur during the prodromal phase, along with a viral rash. It tends to be symmetrical and is NON-DESTRUCTIVE so does not lead to any form of chronic disease.

Answer 301

- Trauma (incl. whiplash injury) - Mechanical neck pain - Cervical spondylitis - Cervical myelopathy - Ankylosing spondylitis - Fibromyalgia

Answer 302

Acceleration-deceleration forces applied to the neck => Usually occurs in a RTA, with a patient wearing a seatbelt being struck from behind. Presentation: - Pain in the neck, shoulder and arm - as well as headache, dizziness and memory loss.

Answer 303

Ix – radiology only indicated for those with suspected bony injury. Can take months to settle => patient education, analgesia, try to move as normal

Answer 304

- Injury - Sleeping in an awkward position - Prolonged keyboard working.

Answer 305

Pain is associated with palpable muscle spasm Can radiate up to the occiput and can be associated with tension headache.

Answer 306

Also known as brachial neuralgia = Pain due to compression of the cervical nerve roots. Usually caused by: - osteophytes in older patients - More rarely, acute cervical disc prolapse following minor trauma in younger patients

Answer 307

Aching pain in the neck, going down the arm. Progressing to a mild loss of grip strength Dermatomal sensory loss Occasional sudden sharp pains down the arm

Answer 308

Ix: = Confirm diagnosis with XR/MRI Mx: = Refer to neurosurgery

Answer 309

= compression of the cervical spinal cord. Causes: - Osteophytes - Cervical disc degeneration - Malignancy

Answer 310

Presents in older patients, initially with problems with fine motor control in the hands (e.g. can’t chop food). There is a slowly developing spastic gait Pain is not a predominant presenting feature.

Answer 311

UMN signs below the level of compression LMN signs at the level of compression: E.g. C5/6 lesion – wasting and fasciculation on the deltoids & biceps with a hypo-reflexive bicep reflex but hyper-reflexive tricep reflex and spastic leg with upgoing plantars. Hoffman’s sign will be positive: => “flicking” the distal phalanx leads to flexion of the other fingers (UMN sign)

Answer 312

“flicking” the distal phalanx leads to flexion of the other fingers (UMN sign)

Answer 313

Confirm with XR/MRI Refer to neurosurgery for conservative/surgical interventions.

Answer 314

History: T – trauma U – unexplained weight loss (and other B symptoms) N – Neurological symptoms A – Age >50 or <20 F – Fever I – IVDU S – steroid use H – History of cancer O/E: => Saddle Anaesthesia (Cauda Equina) => Midline tenderness on palpation (Malignancy)

Answer 315

Pain in lumbosacral region 20-55 years old Pain came on suddenly when lifting Pain classically varies with physical activity, posture, time May be referred to buttocks/thighs O/E – palpable muscular spasm, which can cause local pain/tenderness

Answer 316

A diagnosis of non-specific lower back pain can be reached when the clinician is satisfied there is no specific cause for the pain. Mx: - Simple analgesia - Advice to continue with normal activities plus physiotherapy exercises => Reassess at 6 weeks if the pain has not resolved.

Answer 317

Generally occurs between age 20-40 The nucleus pulposus of the disc herniates into the spinal canal Most commonly occurs at L4/5, or L5/S1 If the herniation is to the extent that it causes compression of one of the nerve roots, then radicular pain will occur. If the herniation of the disc is CENTRAL rather than lateral, this can cause cauda equina syndrome

Answer 318

Can be precipitated by lifting, or even something minor like a sneeze or triggering event unknown. => After which, patient is seized with pain and unable to straighten up. The pain will be worse on coughing/straining. Pain moves into the buttock within hours and into the leg within a day or two. Radicular pain will be present: => Severe piercing/stabbing pains and paraesthesia in one leg due to compression of sciatic nerve root. (Rarely, this can affect both legs) ALWAYS ask about bladder/bowel symptoms that may suggest cauda equina (e.g. retention/incontinence)

Answer 319

- there may be scoliosis and palpable muscle spasm - Straight leg raising produces pain - Femoral stretch test may be positive (pain in anterior thigh). - Neurological exam will show muscle weakness, some loss of sensation and diminished reflexes at the affected level. ALWAYS examine to r/o cauda equina: => PR – no sensation, loss of anal tone => Palpate the bladder – signs of retention (this will be painless and can be confirmed with a post-void bladder scan) => Check sensation on saddle area.

Answer 320

Emergency MRI and urgent surgical intervention required to prevent long-term bladder/bowel/reproductive problems.

Answer 321

Stenosis of the lumbar canal compresses the cauda equina roots, leading to symptoms of spinal claudication Generally caused by degeneration of the spine. - Facet joint hypertrophy - Ligamentum flavum hypertrophy - Disc degeneration - OA

Answer 322

Aching pain in the legs on walking, most commonly posteriorly. Pain recovers fairly slowly on sitting/bending forwards (this creates a more spacious canal). There may also be numbness, stiffness and weakness in the leg. Symptoms are variable day to day.

Answer 323

= when one vertebra is displaced (either anteriorly or posteriorly) on the vertebra below it => anterolisthesis or posterolisthesis Almost always occurs between L4 and L5 or L5 and S1.

Answer 324

Intermittent back ache, precipitated by exercise/strain O/E – often can find a “step” Cauda equina syndrome can develop

Answer 325

Spondylolysis = most common cause; stress fracture of lumbar pars articularis. Dysplasia of the lumbosacral facet joints (in adolescents) OA of the facet joints In extreme athletes

Answer 326

Usually managed conservatively – as per mechanical back pain. Spinal fusion can be performed if the patient is young or there are disabling symptoms

Answer 327

The facet joints are synovial, so can develop OA/RA. More commonly the joints are affected by minor trauma.

Answer 328

Can lead to acute or chronic back pain Typically worse on extension of the back, in the morning and on standing. NO history of pain in the legs OE – there may be local tenderness over the facet joints

Answer 329

inflammatory (spondyloarthropathies) infective (discitis) metabolic (osteoporosis) neoplastic (1o or 2o)

Answer 330

Discitis can present as a complication of spinal surgery/injections. Localised pain and raised inflammatory markers Admit Pt for IV ABX

Answer 331

May be asymptomatic, or cause localised pain (can radiate around the ribs). Multiple fractures lead to increased thoracic kyphosis. XR shows wedging and loss of anterior vertebral body height.

Answer 332

= progressive pain, particularly at night with no exacerbating/relieving factors; There may be tenderness over a particular bony segment

Answer 333

both are types of large vessel vasculitis 15-30% of patients with PMR will develop GCA 50-70% of patients with GCA will develop PMR

Answer 334

Patient always >50 Sudden onset, severe pain and stiffness in the shoulders, neck, hips and lumbar spine. Worse in the morning, lasting for over 30 minutes. Systemic features of tiredness, fever and weight loss.

Answer 335

muscles may be tender to palpate, especially in the upper arm (e.g. when measuring BP)

Answer 336

Symptoms of bilateral shoulder/pelvic girdle aching alongside morning stiffness and evidence of an acute phase response must be present for over 2 weeks for diagnosis to be made. After a diagnosis has been made, it is essential to assess for GCA

Answer 337

- Severe headaches - Scalp (when combing hair) or temporal tenderness - Jaw claudication whilst eating. If untreated, there will be sudden painless loss of vision due to ischaemia of the optic nerve.

Answer 338

may be tenderness/swelling of one or both temporal arteries; the overlying scalp may be inflamed.

Answer 339

- Normocytic, normochromic anaemia - Raised ESR/CRP - Often raised ALP/GGT on LFTs - RF/ANA/anti-CCP negative - CK negative - MRI/USS will show evidence of peri-articular inflammation (bursitis/tenosynovitis) in PMR If there are features of GCA, a TEMPORAL BIOPSY should also be taken as a definitive diagnostic test (although often not performed in practice).

Answer 340

= the definitive diagnostic test => Intimal hypertrophy, with giant cells and inflammatory infiltrate Skip lesions occur, so negative biopsy does not exclude the diagnosis.

Answer 341

Oral Prednisolone – high dose initially to prevent GCA developing 15mg o.d. Response to steroids is usually rapid – consider alternative diagnosis if there is no response within 48 hours. Dose reduction occurs over a long time in line with disease response (determined by regular ESR/CRP levels). => Most PMR patients require treatment for 2 years Always prescribe bone protection and PPIs!!!!

Answer 342

Oral Prednisolone – high dose initially to reduce the risk of permanent optic damage 60mg o.d. if visual symptoms, 40mg o.d. if no visual symptoms Response to steroids is usually rapid – consider alternative diagnosis if there is no response within 48 hours. Dose reduction occurs over a long time in line with disease response (determined by regular ESR/CRP levels). => Most GCA patients require treatment for up to 5 years Always prescribe bone protection and PPIs!!!!

Answer 343

Same day referral to ophthalmology

Answer 344

= dry eyes (keratoconjunctivitis sicca) in the absence of any autoimmune disease.

Answer 345

= presence of sicca symptoms, in the presence of autoimmune disease. => Most commonly RA, but also SLE, scleroderma and polymyositis.

Answer 346

= a long-term disease that affects the body's moisture-producing (lacrimal and salivary) glands. Affects F:M – 10:1 Can affect anyone, but most commonly women during middle age or after menopause.

Answer 347

• Fatigue • Dry eyes and mouth • Salivary and parotid gland enlargement • Vaginal dryness Associated systemic features: - Arthralgia - Raynaud’s - Oesophageal motility issues

Answer 348

Schirmer’s Tear Test - <5mm = dry eyes. - >15 mm = normal - 5-15 mm = grey area Bloods: - RF usually raised - ANA – raised in 70% - Anti-Ro – positive in 70% - Anti-La – positive in 30%

Answer 349

Specialised filter paper placed inside lower eyelid and the eyes are closed The strip of paper will absorb any tears and indicate the volume of water present. Distance checked after 5 mins <5mm = dry eyes. 5-15 mm = grey area >15 mm = normal

Answer 350

Patient Education Avoid prolonged screen use Reduce smoking & alcohol, avoid smoky/dry environments Maintain good oral hygiene Analgesia for pain Artificial Tears & Saliva & vaginal lubricants Mx of any underlying condition (e.g. SLE, scleroderma, etc). Hydroxychloroquine to halt progression of the disease

Answer 351

Need close monitoring for risk factors and development of non-Hodgkin B cell lymphoma => 1 in 6 patients will develop this

Answer 352

GENERAL – malaise, fever, weight loss, myalgia, arthralgia SKIN – palpable purpura, ulceration GI – mouth ulcers, abdominal pain, diarrhoea RESP – haemoptysis, dyspnoea ENT – epistaxis, crusting CARDIAC– chest pain NEURO - Neuropathies

Answer 353

can be primary, or secondary to malignancy/ infection/ connective tissue diseases

Answer 354

GCA Takayasu’s arteritis

Answer 355

Classic Polyarteritis Nodosa Kawasaki Disease

Answer 356

Granulomatosis with Polyangiitis (Wegener’s Granulomatosis) Churg-strauss Syndrome Microscopic Polyangiitis

Answer 357

HSP Cryoglobulinaemia

Answer 358

= vasculitis of large vessels (typically the aorta and its main branches) Typically affects young adults of Asian descent Presents with: - Pulseless upper limbs - Upper limb claudication - Stroke

Answer 359

= vasculitis affecting medium-sized muscular arteries Multi-systemic symptoms Sometimes associated with HepB/C infection

Answer 360

= medium vessel vasculitis Fever, rash, lymphadenopathy and palmar erythema in children. Can affect the coronary arteries.

Answer 361

= vasculitis of medium/small vessels Commonly affects the lung, kidney, and ENT systems - Mouth ulcers, - saddle nose, - proptosis, - Lung granulomas (=> erosive, causing haemoptysis), - petechial haemorrhages. Granuloma formation seen on biopsies, granulomas are very invasive

Answer 362

= vasculitis of medium/small vessels Associated with late-onset asthma/atopy

Answer 363

BEDSIDE - BP & urine dip = essential (renal involvement often determines prognosis). - Microscopy if abnormalities BLOODS - FBC – leucocytosis in primary disease/infection, leucopaenia in CTDs - LFTs – hepatitis is a common secondary cause of vasculitis - Inflammatory markers IMMUNOLOGY: => c-ANCA associated with Wegener’s => p-ANCA associated with Churg-strauss syndrome and microscopic polyangiitis FURTHER TESTS: - Tissue biopsy – essential to confirm diagnosis (exclude infection) before treatment with potentially toxic immunosuppressants. - Skin biopsy - Renal biopsy if there are urine dip abnormalities

Answer 364

Depends on the size of vessel involved. - Corticosteroids are the mainstay of treatment. => Prolonged dose reduction over 12 months - Cyclophosphamide (low-dose or pulse) is often used in ANCA-positive disease to induce remission (but can lead to infertility) - IVIG is often used in Kawasaki disease - Plasma exchange may be used in life-threatening disease.

Answer 365

= the ability to move the joints more than the normal population. Can be asymptomatic, or can cause some people pain, fatigue, and injuries to joints and ligaments

Answer 366

Up to 10% of the population are hypermobile, particularly women. It is generally an inherited trait. Certain diseases are associated with hypermobility: => E.g. Marfan’s, Ehlers-Danlos syndrome, Down’s syndrome

Answer 367

Beighton Score – scores >6 indicate hypermobility

Answer 368

1. A to E Assessment 2. History & Examination • Ascertain mechanism and site • Associated injuries • Joint symptoms • Neurovascular status • Contaminated? 3. Radiology: • Order two plain film orthogonal views (as well as the joints above and below the injury) • CT/MRI if the fractures are poorly visualised on XR

Answer 369

1. Skin => Open or closed fracture? 2. Bone => Which side? => Where? – mid-shaft / base / head / neck => Joint involvement? – intra or extra-articular 3. Configuration: => Simple or multi-fragmentary (>3 pieces)? => If simple, is it transverse / spiral / oblique? 4. Displacement: => Is there any? => Type of displacement (described in terms of distal part related to proximal part). 5. Mobilisation / immobilisation: => Is it stable or does it require immobilisation?

Answer 370

• Angulation = fragments are tilted in relation to each other • Translation = bones shifted sideways/back/forwards • Rotation = rotation of the distal fracture fragment (often hard to see on XR) • Shortening = bones overlap

Answer 371

can occur in children due to their malleable bones. The bone fractures on one side and buckles/is bent on the other side. Reduction is easy and healing is quick.

Answer 372

= used for fractures at the growth plate I (S) Straight through growth plate II (A) Above growth plate III (L) Lower than growth plate IV (T) Through Growth Plate V (ER) Erasure of Growth Plate I, II => Splinting or Casting III, IV => ORIF V => Surgery

Answer 373

Osteoporosis /osteomalacia /Paget’s Primary / metastatic neoplasia Bone cysts Congenital diseases (e.g. osteogenesis imperfecta)

Answer 374

1. INFLAMMATION (1-7 days) – the fracture ends bleed, leading to haematoma formation around the fracture site and an inflammatory response creating a fibrin & capillary network. 2. SOFT CALLUS (1-3 weeks) – as movement of the fracture ends is reduced, the vascular network expands, and fibrous tissue replaces the haematoma. Subperiosteal new bone formation begins. 3. HARD CALLUS (1-4 months) – calcification of the soft callus takes over 1-4 months, forming rigid calcified tissue. 4. REMODELLING – once the fracture is solidly united, remodelling takes place over the following months to years, with the new woven bone being replaced by lamellar bone, and medullary canal being restored.

Answer 375

1. INFLAMMATION (1-7 days) – the fracture ends bleed, leading to haematoma formation around the fracture site and an inflammatory response creating a fibrin & capillary network. 2. SOFT CALLUS (1-3 weeks) – as movement of the fracture ends is reduced, the vascular network expands, and fibrous tissue replaces the haematoma. Subperiosteal new bone formation begins. 3. HARD CALLUS (1-4 months) – calcification of the soft callus takes over 1-4 months, forming rigid calcified tissue. 4. REMODELLING – once the fracture is solidly united, remodelling takes place over the following months to years, with the new woven bone being replaced by lamellar bone, and medullary canal being restored.

Answer 376

If surgical intervention leads to ABSOLUTE STABILITY of the fracture site, the bone ends that are in contact with each other heal without callus formation.

Answer 377

Compartment syndrome Visceral injury – e.g pneumothorax in rib fracture, bladder injury in pelvic injury Nerve injury Vascular injury (suggested by the 6Ps; perform angiogram if suspected) Infection (more likely with open fractures) Rhabdomyolysis => Screened for with a CK in all patients with a crush injury or a long lie Bleeding – large amounts of blood can be lost from long bone fractures.

Answer 378

Bleeding, oedema or inflammation can cause increased pressure in an osteofascial compartment, resulting in muscle ischaemia +/- nerve necrosis The forearm and lower leg flexor compartments are most commonly affected.

Answer 379

“Worst ever” pain, may be described as “bursting” Pain not relieved by strong opioid analgesia. There is often still a pulse as the pathology is capillary/venous based and the limb is often still warm and red.

Answer 380

CLINICAL DIAGNOSIS If the diagnosis is in doubt, compartmental pressure catheters can be used. => If compartment pressure is >30mmHg over DBP then immediate decompression is required.

Answer 381

Remove casts / bandages / dressings Elevate limb Immediate fasciotomy if high clinical suspicion or positive pressure readings. Debridement if any necrosis present Aggressive IV fluids (due to risk of myoglobinuria and AKI) Leave wound open and inspect after 2 days for potential closure.

Answer 382

Infection (including HAP) DVT/PE Pressure sores Delayed union Non-union Malunion Avascular necrosis Joint instability OA Complex regional pain syndrome

Answer 383

= When a fracture takes longer than expected to heal for an injury of its type RFs = same as those for poor healing Clinical features: - Persisting fracture tenderness - On XR => fracture line still visible, with very little callous formation. Tx: => Eliminate any possible cause, immobilise in plaster but promote muscular exercise within the cast to encourage union.

Answer 384

= when the fracture will never unite without intervention. => Diagnosed when not healed after 2x the usual expected time Clinical features: - Movement that can be elicited at the site. - Pain diminishes as the site gap becomes a pseudoarthrosis

Answer 385

On XR the fracture is clearly visible 1. Hypertrophic non-union – fracture ends are enlarged 2. Atrophic non-union – fracture ends tapered, with no suggestion of new bone formation.

Answer 386

Conservative = splinting or functional bracing Surgical = rigid fixation +/- bone grafting

Answer 387

The bones unite, but in an unsatisfactory position (rotation / angulation / shortening), due to inadequate reduction or immobilisation. There is usually an obvious deformity, although rotation deformities can be missed. Tx: - Re-manipulation, osteotomy and internal fixation - Or Limb-lengthening procedures.

Answer 388

AKA Colles' type fracture = a fracture of the distal radius with dorsal displacement of the distal fragment Classically caused by a FOOSH

Answer 389

= Colles' type fracture

Answer 390

A fracture within 4cm of the radio-carpal joint

Answer 391

Dorsal displacement of the radius and radial impaction (leading to a shortened radius compared to the ulna). => “Dinner fork deformity”

Answer 392

Should initially be manipulated, with traction and application of a moulded plaster to maintain the reduction If a good position has been achieved, then a trial of conservative management may be appropriate, with X-rays at week 1 and 2 to confirm position. Unstable/comminuted fractures usually need definitive management (ORIF)

Answer 393

median nerve damage post-traumatic carpal tunnel syndrome.

Answer 394

AKA Smith's type fracture = a fracture of the distal radius with volar displacement of the distal fragment Caused by fall onto flexed wrist Much less common than Colles’ fractures, and usually much more unstable

Answer 395

Generally always require ORIF

Answer 396

Typically caused by violent hyperextension of wrist (e.g. FOOSH) Pain is maximal in the anatomical snuff box and the pinch grip is weak.

Answer 397

IMAGING = Scaphoid XR series should be ordered => AP, lateral and two oblique views. notoriously difficult to pick up on X-ray !!!

Answer 398

If the initial X-rays look normal, but clinical suspicion is still very high => Pt should still be treated as a fracture patient with repeat X-rays out of plaster at 2 weeks and repeat clinical examination. UNDISPLACED FRACTURES: - Conservative – immobilisation in thumb spica (forearm plaster including the thumb) for 6-8 weeks. - The patient should be warned that there is up to 10% risk of non-union which may require surgical intervention.

Answer 399

If the initial X-rays look normal, but clinical suspicion is still very high => Pt should still be treated as a fracture patient with repeat X-rays out of plaster at 2 weeks and repeat clinical examination. UNDISPLACED FRACTURES: - Conservative – immobilisation in thumb spica (forearm plaster including the thumb) for 6-8 weeks. - The patient should be warned that there is up to 10% risk of non-union which may require surgical intervention.

Answer 400

Avascular Necrosis is a common complication due to retrograde blood supply

Answer 401

Can be simple, or associated with dislocations. Most commonly a Monteggia fracture => Proximal ulna fracture + radial head dislocation Galeazzi fractures are less common => Fracture of radius => Dislocation of distal radio-ulnar joint

Answer 402

radial nerve injury, or extensor tendon injuries leading to wrist drop

Answer 403

usually post-fall in the elderly If the fracture is displaced, the patient lies with the limb shortened and externally rotated Hip pain on passive movements

Answer 404

1. Intramedullary vessels – run inside the medullary canal 2. Medial/lateral circumflex artery anastomoses – from the profunda femoris, run proximally through the joint capsule up to the femoral head. => MOST IMPORTANT SUPPLY 3. Artery of ligamentum teres – makes up <10% of normal blood supply

Answer 405

All fractures of the neck of femur disrupt the intramedullary blood supply. Any displaced fractures will also disrupt blood supply from the circumflex arteries within the capsule The remaining supply from the ligamentum teres is insufficient.

Answer 406

Occur proximal to the capsular insertion on the femoral neck (just above the intertrochanteric line). Garden criteria are used to grade these fractures from 1-4, based on the degree of displacement

Answer 407

Garden 1 = Incomplete; impacted fracture Garden 2 = Complete fracture across the neck, but not displaced. Garden 3 = Complete fracture; some continuity between the fracture ends. Garden 4 = Complete fracture; no continuity between fracture ends.

Answer 408

(depends on degree of displacement and fitness of patient) Garden 1-2 – ORIF; low-risk of AVN so fixed with cannulated hip screws. Garden 3-4 – Hemiarthroplasty** (or THR); high risk of AVN Young Trauma Patients should have ANY fracture screwed (due to the need for multiple revisions should they have a hemiarthroplasty) => If AVN develops, they will tolerate the revision surgery much better than elderly patients => Need follow up for 2 YEARS for AVN. ** Patients that are mobilising well outside and good with ADLs should have a THR rather than hemiarthroplasty, due to their high functional demands giving this surgery better outcomes Conservative Mx may be used if elderly, non-ambulatory, with multiple co-morbidities.

Answer 409

Fracture lies between the trochanters, and are therefore extracapsular. => No threat to blood supply of femoral head

Answer 410

Dynamic hip screw => fracture reduced on a traction table in theatre, then a guide-wire positioned under fluoroscopic guidance before the DHS then fixed.

Answer 411

Occur below the trochanters, thus again are extracapsular and do not pose a threat to femoral head blood supply. Generally occur in high energy trauma, or as a result of lytic lesions.

Answer 412

Intramedullary nail and hip screw

Answer 413

1. A full “falls history” 2. Ask about any previous fractures / bone pain prior to fall 3. Ask how long the patient was on the floor for 4. Investigations: a. Bloods – including coagulation and G&S b. ECG & CXR c. AP Pelvis / lateral hip X-Ray => Image whole femur if suspecting pathological fracture

Answer 414

10-20% of patients will require a change to a more dependent residential status. Patients should mobilise within the 1st 24h for best outcomes.

Answer 415

can occur with minimal trauma in osteoporosis. Mechanism of injury = excessive spinal flexion, whilst posterior ligaments remain intact, leading to anterior fractures. Presentation: - Marked pain, worse on movement and weight-bearing - Pain will slowly improve over months. The fracture is very stable (as only the anterior column is affected), however multiple of such fractures can lead to a kyphotic deformity of the lumbar spine

Answer 416

AP and lateral X-rays of the spine

Answer 417

Bed rest for 1-2 weeks Conservative – mobilisation and muscle strengthening exercises; (brace if >25% anterior height reduction). Surgical – kyphoplasty (cement is percutaneously injected into the collapsed vertebrae)

Answer 418

Jefferson’s fracture (C1) Hangman’s Fracture (C2) Odontoid fractures

Answer 419

XR: => Remember to ensure whole length of tibia and fibula are imaged, as well as the knee and ankle joints.

Answer 420

MINIMALLY / UNDISPLACED can be treated with a full-length cast => Mid-thigh to metatarsal necks, knee slightly flexed, ankle at 90o. DISPLACED will require reduction under GA with XR guidance before full-length cast application. - The limb is elevated and observed for 48h for signs of compartment syndrome. - The position should be checked with XR at 2 weeks. - At 4 weeks, change to a below knee cast to allow some weight bearing (promotes healing).

Answer 421

OE – intense pain and inability to stand

Answer 422

AP, lateral and “mortoise” (oblique film facing inferior tibiofibular joint) X-ray views

Answer 423

Fracture below level of syndesmosis; syndesmosis remains intact.

Answer 424

Fracture at level of syndesmosis; may remain partially intact.

Answer 425

Fracture above level of syndesmosis; syndesmosis will generally not be intact.

Answer 426

Weber A fractures – generally stable and thus rarely require operative Mx; 6 weeks POP cast usually sufficient. Weber C fractures – never stable; thus require ORIF if the patient is fit for surgery. Weber B fractures – a trial of conservative Mx is often tried; with repeat X-rays at week 1, 2 and sometimes 3. Fractures of >1 malleoli are almost always unstable and thus management is surgical.

Answer 427

An X-ray of the ankle is required only if the patient is unable to weight bear, has pain AND bony tenderness at the lateral or medial malleolus. An X-ray of the foot is required only if the patient is unable to weight bear AND has bony tenderness over the navicular or base of 5th metatarsal.

Answer 428

1. ABCDE resuscitation 2. Pain relief 3. Image the length of the bone, as well as the joint above and below. 4. Manipulation & stabilisation in POP 5. Re-image to check positioning 6. Check for complications – distal neurovascular status 7. Further Mx depends on positioning after manipulation. => If the fracture has been well-reduced, conservative Mx may be used. => If not, surgical Mx will be indicated.

Answer 429

1. ABCDE Resuscitation 2. Pain relief 3. Check distal neurovascular status, and assess degree of soft tissue injury 4. IV ABX started immediately +/- tetanus prophylaxis 5. Imaging 6. Theatre within 6 hours for definitive management and irrigation => Plastic surgery input may be required

Answer 430

= an autoimmune condition, with autoantibodies directed at a range of tissues Affects young and middle aged women, particularly of Asian descent.

Answer 431

Presentation is extremely varied, due to the number of organ systems involved FATIGUE and PAIN are often a predominant feature alongside various other symptoms (Skin, CNS, renal, MSK, Lung, Heart. haematological)

Answer 432

Chronic discoid LE – red, scaly plaque, usually on the face/scalp. Malar rash – symmetrical, raised erythematous rash across the cheeks and bridge of nose (spares nasal cleft). Photosensitivity reactions – rashes in sun-exposed areas (in either malar or discoid patterns). Alopecia 20% will also have oral mucosal lesions, with superficial erosions and ulcers.

Answer 433

Non-organic disorders are most common – e.g. depression and anxiety. Organic brain disorders – e.g. epileptic seizures. Vascular occlusion and infarction can occur in APL syndrome.

Answer 434

Glomerular disease that can follow many patterns (most commonly interstitial nephritis).

Answer 435

Normocytic hypochromic anaemia. Thrombocytopaenia – due to antiplatelet antibodies Leucopaenia Occasionally can be autoimmune haemolytic anaemia due to red cell antibodies (positive Coomb’s test).

Answer 436

Arthritis (90%), usually beginning in the fingers, wrists and knees (often misdiagnosed as RA). Myalgia (50%)

Answer 437

Recurrent pleurisy and pleural effusions Pulmonary fibrosis.

Answer 438

Most commonly pericarditis Rarer = aortic valve lesions and cardiomyopathy. SLE patients are also at higher risk of atherosclerosis.

Answer 439

BLOODS: - FBC, U&E, ESR/CRP - ANA - RF - Anti-dsDNA - serum complement levels - APL antibodies (? comorbid APL syndrome) Urine dip & BP to check for renal involvement HISTOLOGY: Characteristic histology/immunofluorescence seen in skin/kidney biopsies.

Answer 440

FBC – normocytic hypochromic anaemia, thrombocytopaenia, leukopaenia. ESR/CRP – ESR raised; CRP often normal. U&Es may be deranged if renal involvement Serum ANA – almost always positive Serum RF – positive in 25% Anti-dsDNA – specific for SLE, but sensitivity of 50% (fluctuates with disease activity). RNA antibodies (anti-Ro/anti-La) often present Serum complement levels – C3/4 levels reduced in active disease APL antibodies – positive if comorbid APL syndrome.

Answer 441

Patient education Avoid sunlight / high SPF sunscreen Modify CV risk factors MILD DISEASE - NSAIDs and Hydroxychloroquine. => Combination therapy helps skin disease, arthralgia and fatigue. MORE SEVERE DISEASE (e.g. cardiac/renal involvement): - Prednisolone, with DMARDs such as azathioprine for steroid sparing. Regular Monitoring for signs of active disease: => History & examination => FBC, U&E, C3/4, urine dip

Answer 442

= the presence of autoantibodies that have a specificity for phospholipids, leading to a thrombotic tendency. It can be a primary syndrome, or occur secondary to SLE.

Answer 443

Venous thrombosis – most commonly in the arms/legs, leading to a risk of PE Arterial thrombosis => Less common than venous thrombosis Miscarriages Splinter haemorrhages Livedo reticularis (classical “lace-like” rash) May also have – thrombocytopaenia, migraines, epilepsy

Answer 444

History & Examination => Including obstetric history (miscarriages). ESR – usually normal ANA – usually negative APTT – increased Coomb’s test – positive Anticardiolipin antibodies = diagnostic => Need high titres required on 2 occasions, 12 weeks apart. Lupus anticoagulant antibodies – present in 20% => Represent an increased risk of thrombosis

Answer 445

Anticardiolipin antibodies

Answer 446

Those with a history of severe thrombosis: => Warfarin – target INR 3-4 to stop arterial thrombosis. Those without a thrombotic history: => Low-dose aspirin => Lifestyle advice to avoid prolonged immobilisation and oestrogen-containing drugs. LMWH and aspirin are given in pregnancy, and an early delivery is often planned for under specialist care.

Answer 447

Long-term prognosis is poor, with 1/3rd having organ damage within 10 years of diagnosis.

Answer 448

- Polymyositis - Dermatomyositis - Inclusion body myositis

Answer 449

HLA-B8/DR3 genotype SLE, RA or systemic sclerosis Both are associated with various malignancies.

Answer 450

= Inflammation of striated muscle, causing proximal muscle weakness. - Generally causes weakness in the absence of pain - There may be associated muscle wasting - Onset can be insidious or acute - It is associated with malaise, weight loss and fever - The patient will have difficulty squatting or climbing stairs. If left untreated, respiratory muscle involvement can lead to respiratory failure.

Answer 451

Polymyositis with associated skin involvement. Classic heliotropic rash (i.e. purple discolouration around the eyelids). Associated periorbital oedema. Vasculitic patches over the knuckles (Gottron’s papules).

Answer 452

Bloods: - Serum CK – raised, reflecting muscle damage. - ESR – rarely raised - ANA – most are positive - RF – 50% are RF positive - Myositis specific antibodies Electromyography: - EMG shows a characteristic pattern MRI: - To detect areas of abnormal muscle. Needle Muscle Biopsy: - Shows fibre necrosis with inflammatory infiltrate. Further investigations as appropriate to screen for malignancy.

Answer 453

Prednisolone / DMARDs until myositis is clinically inactive. IVIG therapy may be used in some cases.

Answer 454

Typically affects white males over 50 Insidious onset of proximal and distal muscle wasting, which may be symmetrical. Ix: - ANA is less frequently positive - Myositis-specific antigens will not be positive. - Muscle biopsy shows inflammatory infiltrate and vacuoles containing beta-amyloid (“inclusion bodies”) It is progressive, and rarely responds to prednisolone/DMARD combinations.

Answer 455

?acute bacterial septic arthritis => send for MC&S ?crystal associated disease => send for polarised light microscopy

Answer 456

= normal synovial fluid

Answer 457

indicates inflammation (due to an increase in cell count (particularly neutrophils) will be less viscous than normal (degranulation of inflammatory cells digests the normal proteins) Turbid fluid should be analysed with an urgent gram stain, and then culture. => Culture takes 48h, so treat sepsis first.

Answer 458

may be due to trauma, severe inflammation of any kind, or bleeding tendencies.

Answer 459

indicates a traumatic aspiration.

Answer 460

MSU Crystals – needle shaped, negatively birefringent = GOUT CPPD Crystals – rhomboid shaped, positively birefringent = PSEUDOGOUT.

Answer 461

Due to: - disease activity in SLE/APL - Felty’s Syndrome in RA - drugs such as methotrexate.

Answer 462

Due to: - chronic disease, - iron deficiency, - megaloblastic anaemia (due to methotrexate) - haemolysis (SLE/drugs).

Answer 463

= IgM antibody against IgG, forming immune complexes that contribute to the disease process.

Answer 464

Positive in 70% of people with RA => 78% specific – also raised in SLE/Sjogren’s => Can be transiently raised in infections or just in normal population Indicates a worse prognosis (and extra-articular manifestations) if positive at diagnosis.

Answer 465

= 90-98% specific for RA; 60% sensitive It may precede the onset of RA by 12 years. Indicates a worse prognosis if raised at presentation.

Answer 466

Titres >1:80 are considered positive but are generally >1:320 in autoimmune disease. Useful to r/o SLE, which has nearly 100% ANA positivity. Also can be raised in RA, Sjogren’s, Scleroderma, polymyositis.

Answer 467

Specific for SLE, but often only present in severe disease. Marker for poor prognosis (indicates renal involvement). Level changes with disease activity, so can be used as a marker

Answer 468

Anti-Sm is specific to SLE Anti-Ro & Anti-La are often present in Sjogren’s (but also SLE) Some ENAs can be used to indicate specific tissues involved: - E.g. Anti-Jo1 in myositis indicates pulmonary fibrosis. - E.g. Antitopoisomerase in scleroderma indicates pulmonary/cardiac involvement. Generally there is no use for longitudinal ENA monitoring

Answer 469

= A multi-system autoimmune disease, characterised by skin sclerosis and Raynaud’s disease. 1. Limited Cutaneous Systemic Scleroderma (~70% cases) 2. Diffuse Cutaneous Systemic scleroderma (~30% cases)

Answer 470

Patients present with a long history of Raynaud’s phenomenon, then skin tightening at the extremities => Typically the fingers and toes are affected; Can also occur on the face, leading to microstomia. EARLY: Fatigue GORD Ulcers on digital tips LATE: Oesophageal strictures Small bowel malabsorption Pulmonary fibrosis / pulmonary HTN

Answer 471

Previously known as CREST Syndrome - C – Calcinosis - R – Raynaud’s - E – Oesophageal dysmotility - S – Sclerodactyly - T – Telangiectasia This term was abandoned as it under-emphasises life threatening complications such as pulmonary HTN.

Answer 472

Digital sympathectomy / vasodilators Removal of calcinoses Tx of oesophageal problems

Answer 473

Patients have a short Hx of Raynaud’s disease, and skin sclerosis is rapidly progressive. Systemic symptoms are greater, including lethargy, weight loss and anorexia. Complications will occur within the first 3 years: - Myocardial fibrosis - Pulmonary fibrosis - Renal fibrosis

Answer 474

Immunosuppression – aiming to prevent complications, so can be gradually withdrawn over years as the disease stabilises. Again, sympathectomy and vasodilators are helpful for symptoms.

Answer 475

Limited cutaneous systemic scleroderma: => Anti-centromere antibodies positive (60%) Diffuse cutaneous systemic scleroderma: => Anti-Scl-70 antibodies (40%) and RNA polymerase antibodies

Answer 476

Systemic sclerosis has the highest mortality of any of the autoimmune rheumatic diseases. Limited cutaneous scleroderma has a higher survival (70% at 10 years), due to less severe internal organ damage.

Answer 477

• Exact time/mechanism of injury can be identified. • Pain is non-progressive and produced by one/few movements. • O/E: => localised tenderness => pain reproduced on resisted active movement/stress testing.

Answer 478

= Painful inflammation of the abductor pollicis longus and extensor pollicis brevis tendons in the 1st dorsal compartment of the wrist. The 1st dorsal compartment is just proximal to the anatomical snuff box. unknown cause

Answer 479

- Often acute pain over the 1st dorsal compartment when using the thumb - Swelling/tenderness over the area. - Most common after unaccustomed intensive activity (e.g. painting a fence) - Classically affects middle-aged, post-partum women.

Answer 480

LOOK – often normal, may have swelling over radial border. FEEL – may be normal; or tender over radial border. MOVE – active thumb abduction/opposition and active ulnar deviation may be affected. TEST – Finklestein’s test positive.

Answer 481

Conservative: • Most presentations respond well to rest, analgesia and splints • Thumb immobilisation with splints for 3 weeks • Steroid injections can also be used. Surgical: • Rarely used; longitudinal compartment release.

Answer 482

= a compression neuropathy of the median nerve as it passes though the carpal tunnel. (It is technically median nerve compression until there is thenar eminence wasting, at which point it can be called carpal tunnel syndrome.)

Answer 483

The carpal tunnel consists of the carpal bones, covered by the floor of the flexor retinaculum. It contains 9 flexor tendons (4 FDP, 4 FDS, and 1 FPL) and the median nerve

Answer 484

Most cases are idiopathic Entrapment often seen in a range of conditions – DM, RA, hypothyroidism, acromegaly, trauma (Colles’ fracture).

Answer 485

Pain/paraesthesia in the hand, worst in the morning (due to wrist flexion when asleep). May wake the patient from sleep, and they shake the hand/hang it over the side of the bed for relief. Thenar muscle weakness/wasting => First noticed as clumsiness, due to loss of opposition strength. Sensory loss in palm / radial 3 ½ fingers (rarely noticed).

Answer 486

LOOK – thenar wasting in advanced cases, otherwise nil. FEEL – potentially reduced thenar bulk MOVE – active thumb abduction and active thumb opposition affected. TEST • Positive Tinel’s • Positive Phalen’s • Test sensation between sides and between dermatomes on same side.

Answer 487

Typically diagnosed from Hx and Examination Nerve conduction studies can show slowing at the wrist, but can also be normal.

Answer 488

Conservative – rest, night time splinting, NSAIDs / steroid injections to reduce inflammation around the tunnel. Surgical – division of flexor retinaculum (carpal tunnel release) => leads to scar on wrist.

Answer 489

Compression neuropathy of the ulnar nerve at the cubital tunnel of the elbow. This can be compressed if the patient has flexed elbows for long periods or due to tight fascial bands, ulnar fracture, valgus deformities of the elbow or other pathology.

Answer 490

Pain near elbow joint, may radiate down ulnar border of forearm Paraesthesia and sensory loss over ulnar distribution. Hand clumsiness and reduce pinch / grip strength If severe, clawing of the hand due to wasting of hypothenar and interosseus muscles.

Answer 491

LOOK – guttering between metacarpals, hypothenar wasting. FEEL – tenderness around cubital tunnel MOVE – elbow movements may be limited; the Pt may be unable to actively extend at the IPJs or actively abduct/adduct the finger TEST • Loss of sensation • Reduced first dorsal interosseus power • Positive Tinel’s test along length of ulnar nerve • Positive elbow flexion test (sustained elbow flexion, with arm supinated and wrist extended reproduces symptoms)

Answer 492

X-rays may show pathogenic osteophytes Nerve conduction studies may show slowing at the elbow.

Answer 493

Conservative – night time splints, NSAIDs, activity modification. Surgical – simple cubital tunnel decompression, or anterior transposition of the nerve.

Answer 494

Soft tissue swellings filled with a degenerative myxoid fluid that stems from an underlying joint capsule or ligament of tendon sheath. Can be idiopathic or caused by trauma.

Answer 495

Lump in hand/wrist => cosmetic concerns Sometimes pain

Answer 496

LOOK – most common sites are dorsum of wrist (scapholunate joint), volar aspect of wrist (scaphotrapezial joint), at the base of finger from the flexor sheath or at the DIPJ. FEEL – may be hard or soft, but are never fixed to the skin MOVE – may become more obvious with joint movements or limit end range. TEST – will transilluminate.

Answer 497

Conservative – NSAIDs and reassurance; aspiration +/- steroid injections have a 40% success rate. Surgical – excision leads to a 40% recurrence rate.

Answer 498

Idiopathic fibrosis of the flexor tunnel, leading to an intra-tendinous nodule that interrupts normal finger movement. Usually involves ring/middle finger The Pt complains that the finger gets stuck in flexion, then on further effort (can involve using the other hand) can snap into extension. In severe cases the finger can be permanently locked.

Answer 499

Occurs most commonly in women >40. RA DM

Answer 500

LOOK – potential flexion at the PIPJ/DIPJ FEEL – can feel the triggering of the flexor tendons by placing your finger in the palm and asking the patient to flex the finger; a nodule is often felt at the base of the finger MOVE – jerky, hesitant active flexion/extension

Answer 501

Conservative – usually resolves spontaneously with: - Activity modification, - NSAIDs, - Tendon sheath corticosteroid injection. Surgical: - Release of the A1 pulley - Tenosynovectomy in RA

Answer 502

Progressive, painless thickening of the palmar fascia causes flexion deformities of fingers and functional difficulties.

Answer 503

More common in males, Nordics & those with FHx May be linked to trauma, diabetes, alcoholism, phenytoin, liver cirrhosis

Answer 504

LOOK – nodules/cords in the palm and fingers, flexion of MCP and PIP joints, classically affecting the middle and ring fingers FEEL – thickened palmar fascia, “Garrod’s” pads on the dorsum of PIPJs MOVE – loss of active and passive extension of involved joints TEST – n/a

Answer 505

No specific Tx required if the patient has no functional impairment Surgical – needle aponeurotomy, enzymatic fasciotomy, fasciotomy, fasciectomy, dermo-fasciectomy.

Answer 506

Patients present with pain on activities involving gripping/pinching, with swelling, deformity and tenderness at the CMCJ.

Answer 507

LOOK – “squaring” of thumb, base of thumb swelling, wasting of thenar muscles. FEEL – may be pain/warmth in the joint, reduced thenar bulk MOVE – global pain/stiffness of CMCJ movements (adduction, palmar/radial adduction, opposition).

Answer 508

Conservative – as for any OA patient Surgical – denervation, trapeziectomy, basal thumb arthroplasty or joint fusion.

Answer 509

GLOFER'S ELBOW Tendinopathy of the common flexor-pronator origin, just distal to the bony prominence of the medial epicondyle. Caused by recurrent microtrauma (such as golf swings placing stress on the elbow joint).

Answer 510

Pain develops subacutely over a period of weeks to months, exacerbated by use and settled with rest. The pain can be very severe, and can radiate up/down the arm (especially when using the affected muscles, e.g. carrying a tray).

Answer 511

Tenderness around the medial epicondyle Pain triggered by resisted flexion of the hand. Normal ROM, no neurological Sx (such as tingling/numbness, if so, consider ulnar nerve entrapment).

Answer 512

CONSERVATIVE: - Simple Analgesia (NSAIDs) and rest - Referral to physiotherapy (strengthening exercises) - Epicondylar clasp (provided by splint department). - Steroid injection If all of the above unsuccessful => X-ray of joint to r/o OA. If conservative measures fail, golfer’s elbow release can be performed surgically.

Answer 513

TENNIS ELBOW Tendinopathy of the common extensor tendon origin, just distal to the lateral epicondyle. Can be caused by repetitive gripping/grasping movements. Much more common than Golfer's Elbow

Answer 514

- Peak incidence ~40-60 years. - Obesity, - Smoking - Carpal tunnel syndrome and other tendinopathies.

Answer 515

Pain around the lateral epicondyle, develops subacutely. Typically exacerbated by movement and relieved by rest. Pain may radiate up/down the arm, worse by holding heavy bags etc.

Answer 516

Point tenderness distal to the lateral epicondyle Pain can be reproduced on resisted extension of wrist. Passive ROM is normal

Answer 517

Conservative = as for medial epicondylitis. Surgical intervention = tennis elbow release (if conservative measures fail).

Answer 518

Conservative = as for medial epicondylitis. Surgical intervention = tennis elbow release (if conservative measures fail).

Answer 519

Olecranon bursa becomes enlarged as a result of pressure or friction. It is NOT a painful condition => If pain is present, consider differentials such as gout/RA/infection

Answer 520

• Acute (calcific) rotator cuff tendonitis • Chronic rotator cuff tendonitis • Rotator cuff tear • Adhesive capsulitis • Subacromial bursitis • Cuff arthropathy • Osteoarthritis • RA • Polymyalgia rheumatica

Answer 521

= Deposition of apatite (basic calcium phosphate) in the supraspinatus tendon, leading to an intense inflammatory reaction and swelling.

Answer 522

- Young patients, complaining of aching pain following over-use. - Pain increases to an intense climax, before resolving in a few days. - The arm is held immobile and the joint is often too tender to palpate. - XR will show calcification just above the greater tuberosity.

Answer 523

- Resting the arm in a sling - NSAIDs - More severe pain may require intra-capsular corticosteroid/lignocaine injection. Usually resolves after 1-3 weeks.

Answer 524

Over-use or minor tears of the rotator cuff initiate a subacute/chronic vascular response leading to pain and stiffness

Answer 525

Pain in the shoulder, characteristically worse at night and when abducting/elevating the arm. Tenderness beneath the anterior edge of the acromion Painful arc present (60-120 degrees), with less pain when passively abducted. Power is normal despite pain (separates it from a tear).

Answer 526

XR may show calcification from former events, but MRI/USS are diagnostic.

Answer 527

NSAIDs Corticosteroids and physiotherapy if severe If conservative measures fail, arthroscopic “decompression” of the rotator cuff can take place. => Excision of the coraco-acromial ligament and any osteophytes.

Answer 528

Caused by trauma in the younger patient (e.g. falling on arm) or can happen spontaneously in the elderly (e.g. lifting something up). PARTIAL tears frequently occur with (and may precipitate) chronic tendonitis, but can repair naturally. COMPLETE tears will not naturally repair.

Answer 529

Patient will describe a “sprain” of the shoulder, with limited abduction after the event.

Answer 530

Tenderness over the anterior acromion. Once the arm has been lifted over the shoulder, it can be held there by the deltoid (the abduction paradox), but when they lower the arm it suddenly drops.

Answer 531

Diagnosis confirmed with USS, MRI or arthroscopy. Intra-articular anaesthetic injections can distinguish between full and partial tears: => Partial tears will regain abduction when the pain is abolished. => Similarly, partial tears will regain the ability to abduct within a few weeks, whereas full tears will not.

Answer 532

Acute phase – heat, exercises and local anaesthetic injections. After 3 weeks, the extent of the rupture can be assessed. Complete tears in younger individuals are usually surgically repaired. Partial tears are conservatively treated to allow natural healing.

Answer 533

= "frozen shoulder" - Initial progressive “deep” pain that stops the patient sleeping on the affected side, but starts to subside after a few months. - Increasing stiffness, worsening as the pain subsides, and may last for 6-12 months.

Answer 534

- There are limited signs OE, as the joint cannot be moved due to pain. - Limited external rotation is classic.

Answer 535

- Reassurance - NSAIDs - PT referral (start ASAP, usually 6 weeks) Intra-articular steroid injections if no progress with conservative Tx The process tends to resolve spontaneously after about 18 months.

Answer 536

Often due to repetitive overhead lifting, pulling or trauma.

Answer 537

- Classically causes a “burning” pain (rather than a dull ache of rotator cuff pathology) - Worse pain when lifting above the head - Stiffness when passively abducting the arm

Answer 538

USS/MRI to differentiate from rotator cuff pathology.

Answer 539

Conservative – NSAIDs and avoiding exacerbating movements.

Answer 540

Umbrella term for pathologies such as subacromial bursitis, adhesive capsulitis, rotator cuff tear, acute/chronic rotator tendonitis this term is used until the exact diagnosis has been confirmed radiologically.

Answer 541

- Subluxation of humeral head – loss of the cuff’s stabilising effects - Cuff arthropathy – rotator cuff pathology leads to a less stable humeral head in the GHJ and secondary arthritis.

Answer 542

rotator cuff syndrome pathologies lead to swelling and oedema, and decrease the space between the humeral head and acromion. This leads to a painful arc (from 60-120 degrees) = IMPINGEMENT

Answer 543

ARTICULAR => painful on both active and passive movements. PERI-ARTICULAR => pathology is less painful on passive movements.

Answer 544

classically causes a painful high arc - 170-180 degrees (alongside crepitus and global pain/stiffness) => Scarf test can be used to confirm diagnosis

Answer 545

Inflammation of the bursa between the greater trochanter and the fascia lata, caused by acute/repetitive trauma More common in women and active patients, bilateral in 50% Complicates many THRs

Answer 546

“Hip” pain, that may radiate down the lateral aspect of the thigh to the knee. Pain worse on movement and at night, especially when lying on affected side.

Answer 547

Point tenderness when palpating the greater trochanter. Active abduction of a slightly flexed hip will exacerbate the pain (as it tightens the fascia lata over the bursa).

Answer 548

1st line = Corticosteroid injections => If the patient is presenting post-THR, the injection should be performed in a laminar flow theatre. Physiotherapy referral after presentation and 1st injection. => Exercises to stretch the fascia lata, thus relieving excessive pressure on the bursa (e.g. cross body adduction). The above will resolve symptoms in over 2/3rd of patients. Refractory trochanteric bursitis can be treated with surgical release of the fascia lata and excision of the bursa.

Answer 549

Common in adolescents = A traction injury of the patellar ligament, leading to a prominent and tender tibial tuberosity. Mx: - Spontaneous recovery takes time - Restriction of sporting activities is advised. - Paracetamol +/- NSAIDs - Ice packs on tibial tuberosity up to TDS (after exercise)

Answer 550

Classically occur when there is a twisting strain on a flexed, weight-bearing knee (hence common in footballers) Relatively little force is required in older adults (due to fibrosis) Degenerative tears are seen in knee OA.

Answer 551

The meniscus is mainly avascular (apart from the outer 1/3rd) so will not repair spontaneously after a tear, or heal after a surgical repair. Can be associated with ACL tears If not repaired, small avascular tears may propagate to cause secondary arthritis

Answer 552

Symptoms are initial pain, which can be intermittent and variable amounts of swelling hours later. Swelling subsides with rest, but may recur after further trivial injury. The loose tag of meniscus can act as a mechanical irritant if it finds its way into the intercondylar notch, causing symptoms: => Locking of the knee => Spontaneous “giving way” of the knee

Answer 553

Acutely, often effusion and fixed flexion deformity, with medial joint line tenderness.

Answer 554

X-ray (AP, lateral and skyline views are essential) – will be normal but to r/o fractures/OA MRI = mainstay of imaging, picks up >90% of tears.

Answer 555

Arthroscopic repair is indicated in many patients (especially if young/active) Tears in the vascular zone are amenable to repair If in the avascular zone (more common), then a partial meniscectomy is the Tx of choice, to prevent ongoing mechanical symptoms Total meniscectomy is avoided due to high risk of secondary OA

Answer 556

occur when a force greater than the tensile strength of the ligament occurs (e.g. sporting injuries/trauma). most common injury = ACL Tear (MCL = 2nd most common) it is possible for multiple ligaments to be involved The collateral ligaments are tight in extension and loose in flexion, thus injury is most common when the knee is extended.

Answer 557

It is key to elicit the full mechanism (position of the knee and direction of any force applied). Swelling in the first hour indicates complete rupture Patients may describe a “pop” at the time of injury

Answer 558

There will not be a “firm” end point when testing the ligament, rather a “soft” end point as the surrounding soft tissues stop the force. Partial tears do not give increased mobility, but instead there is pain on testing. Lachman’s test is significantly more sensitive than anterior drawer test for ACL pathology.

Answer 559

X-ray (lateral, AP, skyline) – to show any displacements, exclude OA, show any fractures. MRI – will pick up 90% of ligament injuries Diagnostic arthroscopy – occasionally used if MRI shows intact ACL, however clinically the patient has ACL dysfunction.

Answer 560

Sprains/partial tears will spontaneously heal with physiotherapy, as the intact fibres splint the torn ones. Adhesions will complicated this process if the joint is rested, so ACTIVE MOVEMENT with a brace is encouraged. Conservative Mx is almost always the option of choice in collateral ligament pathology, unless part of multi-level injuries.

Answer 561

ACL – arthroscopic tendon graft repair, with the hamstring or semitendinosus used as the donor tendon. Collateral ligaments – if being fixed surgically, should be performed within 2 weeks of the injury.

Answer 562

1. Pre-patellar Bursitis 2. Infra-patellar bursitis 1&2 present with anterior knee pain and a fluctuant swelling 3. Anserine bursitis => Can be seen in a similar position to infra-patellar bursa, but more medial (insertion of the MCL into the upper tibia)

Answer 563

Both caused by unaccustomed kneeling Mx: - avoidance of kneeling - Corticosteroid injection for troublesome symptoms

Answer 564

- Physiotherapy - Local corticosteroid injection.

Answer 565

Bulging of the posterior capsule of the knee, with synovial herniation leading to a swelling in the popliteal fossa. It is most often caused by RA or OA Occasionally can rupture into the muscle planes causing swelling and pain in the calf similar to DVT. Tx if non-ruptured = aspiration, and hydrocortisone injection.

Answer 566

The bursa between the semimembranosus and the medial head of the gastrocnemius becomes enlarged, presenting as a painless lump behind the knee

Answer 567

= Enthesitis at the insertion of the plantar fascia tendon into the calcaneum Sx: - Localised pain on walking/standing - Midline tenderness - pain is worse when weight-bearing in the morning Can occur alone, or in seronegative spondyloarthropathies.

Answer 568

Heel pads and reduced walking Splinting of the foot in a dorsiflexed position to stretch the plantar fascia. Most recover spontaneously over 1 year.

Answer 569

= A pressure-induced bursa under the heel, often due to tight shoes. Symptoms: - Similar to plantar fasciitis - Pain is worse when weight-bearing in the morning - However, O/E – compression of the heel pad from the sides is painful.

Answer 570

Heel pads Reduced walking

Answer 571

= Enthesitis at the insertion of the Achilles tendon into the calcaneus. Can be caused by trauma, or complicated seronegative spondyloarthropathies Sx = Pain behind the heel and leg Mx = - Raising shoe heel to reduce the pain - Low pressure corticosteroid injection near the enthesis.

Answer 572

Leads to sudden pain and valgus deformity, with tenderness around the medial malleolus.

Answer 573

each vertebra has a single spinous process, centred posteriorly at the point of the arch. => In cervical spine, the spinous processes are bifid. => In thoracic spine, these is oriented obliquely inferiorly and posteriorly. => In lumbar spine, these do not extend inferiorly below the level of the vertebral body.

Answer 574

each vertebra has two transverse processes, which extend laterally and posteriorly from the vertebral body. In the thoracic vertebrae, the transverse processes articulate with the ribs.

Answer 575

run the full length of the vertebral column to strengthen the joints of the vertebral bodies

Answer 576

Trapezius, Latissimus dorsi, Levator scapulae Rhomboids (major and minor)

Answer 577

Serratus Posterior Superior Serratus Posterior Inferior

Answer 578

Splenius Capitis Splenius Cervicis Erector Spinae Muscles Transversospinales Muscles

Answer 579

Consists of Iliocostalis, Longissimus and Spinalis muscles (in order of most lateral to most medial). These muscles act unilaterally to laterally flex the vertebral column and bilaterally to extend the vertebral column and head.

Answer 580

1. arises cranially as a continuation of the medulla oblongata. 2. travels inferiorly within the vertebral canal, surrounded by the spinal meninges containing cerebrospinal fluid. 3. At the L2 vertebral level the spinal cord tapers off, forming the conus medullaris. 4. The spinal nerves that arise from the end of the spinal cord are bundled together (= the cauda equina).

Answer 581

1. The Cervical enlargement: - It represents the origin of the brachial plexus. 2. The Lumbar enlargement: - Representing the origin of the lumbar and sacral plexi.

Answer 582

- Epidural space - Dura Mater - Arachnoid Mater - Subarachnoid Space - Pia Mater

Answer 583

Mainly L1, L2, L3 and L4. It also receives contributions from T12.

Answer 584

1. Iliohypogastric (L1, with contributions from T12) 2. Ilioinguinal (L1) 3. Genitofemoral (L1, L2) 4. Lateral Cutaneous Nerve of thigh (L2, L3) 5. Femoral (L2, L3, L4) 6. Obturator (L2, L3, L4)

Answer 585

S1, S2, S3 and S4. It also receives contributions from L4 and L5.

Answer 586

1. Superior Gluteal (L4, L5, S1) 2. Inferior Gluteal (L5, S1, S2) 3. Sciatic (L4, L5, S1, S2, S3) 4. Posterior Femoral (S1, S2, S3) 5. Pudendal (S2, S3, S4)

Answer 587

MOTOR Hip flexors Knee extensors (quadriceps femoris) SENSORY cutaneous branches to the anteromedial thigh (anterior cutaneous branches of the femoral nerve) and the medial side of the leg and foot (saphenous nerve)

Answer 588

MOTOR Muscles of posterior thigh Indirectly innervates (via its terminal branches) all the muscles of the leg and foot. SENSORY No direct sensory functions. Indirectly innervates (via its terminal branches) the skin of the lateral leg, heel, and both the dorsal and plantar surfaces of the foot

Answer 589

Arises from lumbosacral plexus. Enters the gluteal region via greater sciatic foramen. It emerges inferiorly to the piriformis muscle and descends in an inferolateral direction. Enters the posterior thigh by passing deep to the long head of the biceps femoris. When the sciatic nerve reaches the apex of the popliteal fossa, it terminates by bifurcating into the tibial and common fibular nerves.

Answer 590

MOTOR posterior compartment of the leg the majority of the intrinsic foot muscles. SENSORY the skin of the posterolateral leg, lateral foot and the sole of the foot.

Answer 591

= a set of seven irregularly shaped bones, in 3 rows: 1. Proximal = Talus, calcaneus 2. Intermediate = Navicular 3. Distal = cuboid and the three cuneiforms

Answer 592

It transmits the weight of the entire body to the foot. Articulates superiorly with the tibia & fibula (= ankle joint). Articulates inferiorly with the calcaneus (= subtalar joint) Articulates anteriorly with the navicular (= talonavicular joint)

Answer 593

Articulates superiorly with the talus – subtalar (talocalcaneal) joint Articulates anteriorly with the cuboid – calcaneocuboid joint It protrudes posteriorly and takes the weight of the body as the heel hits the ground when walking. The posterior aspect of the calcaneus is marked by calcaneal tuberosity, to which the Achilles tendon attaches.

Answer 594

Articulates with the talus posteriorly, all three cuneiform bones anteriorly, and the cuboid bone laterally. On the plantar surface of the navicular, there is a tuberosity for the attachment of part of the tibialis posterior tendon.

Answer 595

Cuboidal in shape Lies anterior to the calcaneus and behind the fourth and fifth metatarsals.

Answer 596

= Three wedge shaped bones. They articulate with the navicular posteriorly, and the metatarsals anteriorly. The shape of the bones helps form a transverse arch across the foot. They are also the attachment point for several muscles

Answer 597

They are numbered I-V (medial to lateral). They have three or four articulations: - Proximally – tarsometatarsal joints – between the metatarsal bases and the tarsal bones. - Laterally – intermetatarsal joint(s) – between the metatarsal and the adjacent metatarsals. - Distally – metatarsophalangeal joint – between the metatarsal head and the proximal phalanx.

Answer 598

The phalanges are the bones of the toes. The second to fifth toes all have proximal, middle, and distal phalanges. The great toe has only 2; proximal and distal phalanges.

Answer 599

10 intrinsic muscles located in the sole of the foot => act collectively to stabilise the arches of the foot, and individually to control movement of the digits. All the muscles are by branches of the tibial nerve.

Answer 600

a hinge-type joint, permitting dorsiflexion and plantarflexion of the foot. Formed by three bones: the tibia and fibula of the leg, and the talus of the foot => The body of the talus fits snugly into the mortise formed by the bones of the leg.

Answer 601

Medial/Deltoid Ligament – attached to the medial malleolus; primary action is to resist over-eversion of the foot. Lateral Ligament – comprised of three distinct and separate ligaments (anterior and posterior talofibular and calcaneofibular); resists over-inversion of the foot.

Answer 602

An articulation between the talus and calcaneus. the interosseous talocalcaneal ligament – acts to additionally bind the talus and calcaneus together The joint is formed on an oblique axis and is therefore the chief site within the foot for generation of eversion and inversion movements

Answer 603

1. Medial longitudinal 2. Lateral Longitudinal 3. Anterior transverse arch each are formed by different bones, but all supported by muscles, plantar ligaments, plantar aponeurosis

Answer 604

= the most lateral palpable projection of bone; originates from the anterior aspect Site of attachment for many of the muscles in the gluteal region – e.g. gluteus medius, gluteus minimus and piriformis. The vastus lateralis originates from this site.

Answer 605

projects from the posteromedial side of the femur, just inferior to the neck-shaft junction. It is the site of attachment for iliopsoas

Answer 606

LINE = - anterior surface of the femur, - site of attachment for the iliofemoral ligament - anterior attachment of the hip joint capsule CREST = - posterior surface of the femur

Answer 607

The posterior and inferior surfaces articulate with the tibia and menisci of the knee The anterior surface articulates with the patella.

Answer 608

= bony elevations on the non-articular areas of the condyles medial and lateral collateral ligaments originate here

Answer 609

Connected inferiorly to tibial tuberosity via PATELLAR LIGAMENT Connected superiorly to the QUADRICEPS TENDON posterior surface of the patella articulates with the femur

Answer 610

two main functions: 1. Leg extension – Enhances the leverage that the quadriceps tendon can exert on the femur, increasing the efficiency of the muscle. 2. Protection – Protects the anterior aspect of the knee joint from physical trauma.

Answer 611

= a deep fascial investment of the musculature of the thigh. It begins proximally around the iliac crest and inguinal ligament It ends distal to the bony prominences of the tibia. Formed of tensor fascia lata and Iliotibial Tract

Answer 612

= a gluteal muscle that acts as a flexor, abductor, and internal rotator of the hip. It also has a role for tensing the fascia lata (hence its name) originates from the iliac crest and inserts into the iliotibial tract => superior gluteal nerve innervation

Answer 613

= a longitudinal thickening of the fascia lata, which is strengthened by fibres from the gluteus maximus. Acts as an extensor, abductor and lateral rotator of the hip, with an additional role in providing lateral stabilisation to the knee joint.

Answer 614

Gluteus Maximus Gluteus Medius Gluteus Minimus

Answer 615

Piriformis Obturator Internus The Gemelli (superior and inferior) Quadratus Femoris

Answer 616

The superior gluteal nerve and vessels emerge into the gluteal region superiorly to the piriformis (and vice versa for the inferior gluteal nerve). The sciatic nerve enters the gluteal region directly inferior to the piriformis

Answer 617

1. Anterior – innervated by the femoral nerve (L2-L4); act to extend the leg at the knee joint. 2. Medial – innervated by the obturator nerve, act to adduct the hip. 3. Posterior – innervated by the sciatic nerve (L4-S3); act to extend at the hip, and flex at the knee.

Answer 618

Vastus Lateralis Vastus Intermedius Vastus Medius Rectus Femoris => unite proximal to the knee and attach to the patella via the quadriceps tendon Main extensor of the knee All 4 muscles are innervated by the femoral nerve

Answer 619

Iliopsoas Quadriceps Femoris Sartorius Pectineus

Answer 620

Adductor Magnus Adductor Longus Adductor Brevis Obturator Externus Gracilis

Answer 621

Biceps Femoris Semitendinosus Semimembranosus

Answer 622

Tibialis Anterior Extensor Digitorum Longus Extensor Hallucis Longus

Answer 623

Fibularis Longus Fibularis Brevis

Answer 624

SUPERFICIAL Gastrocnemius Plantaris Soleus DEEP Popliteus Tibialis Posterior Flexor Digitorum Longus Flexor Hallucis Longus

Answer 625

= only intracapsular ligament of hip joint it encloses a branch of the obturator artery (artery to head of femur), a minor source of arterial supply to the hip joint.

Answer 626

1. Tibiofemoral – medial and lateral condyles of the femur articulate with the tibial condyles. => It is the weight-bearing component of the knee joint. 2. Patellofemoral – anterior aspect of the distal femur articulates with the patella. => It allows the tendon of the quadriceps femoris (knee extensor) to be inserted directly over the knee – increasing the efficiency of the muscle.

Answer 627

= Anterior cruciate ligament attaches at the anterior intercondylar region of the tibia where it blends with the medial meniscus. It ascends posteriorly to attach to the femur in the intercondylar fossa. PREVENTS ANTERIOR DISLOCATION

Answer 628

= Posterior cruciate ligament attaches at the posterior intercondylar region of the tibia ascends anteriorly to attach to the anteromedial femoral condyle. It prevents posterior dislocation

Answer 629

PROXIMAL = an articulation between the head of the fibula and the lateral condyle of the tibia. DISTAL = an articulation between the fibular notch of the distal tibia and the fibula. A fibrous joint, where the joint surfaces are by bound by tough, fibrous tissue.

Answer 630

Articulation of humeral head with glenoid fossa of scapula

Answer 631

Articulation of the clavicle with the acromion of the scapula

Answer 632

= the area below the spine of the scapula, the infraspinatus muscle originates from this area.

Answer 633

= the area above the spine of the scapula; the supraspinatus muscle originates from this area

Answer 634

located laterally on the humerus It serves as an attachment site for three of the rotator cuff muscles – supraspinatus, infraspinatus and teres minor

Answer 635

much smaller, and more medially located It provides attachment for the last rotator cuff muscle – the subscapularis.

Answer 636

The axillary nerve and circumflex humeral vessels lie against the bone here => important to test for in a fracture there

Answer 637

The radial nerve and profunda brachii artery

Answer 638

Ulna = stabilising bone Radius = pivots to produce movement

Answer 639

Proximally, the ulna articulates with the trochlea of the humerus at the elbow joint. Proximal Radio-ulnar joint Distal radio-ulnar joint.

Answer 640

Elbow joint – partly formed by an articulation between the head of the radius, and the capitulum of the humerus. Proximal radioulnar joint – an articulation between the radial head, and the radial notch of the ulna. Wrist joint – an articulation between the distal end of the radius and the carpal bones. Distal radioulnar joint – an articulation between the ulnar notch and the head of the ulna.

Answer 641

Deltoid Teres Major Supraspinatus Infraspinatus Teres Minor Subscapularis

Answer 642

Biceps Brachii Brachioradialis Coracobrachialis => They are all innervated by the musculocutaneous nerve.

Answer 643

Triceps Brachii Radial nerve.

Answer 644

• SUPERFICIAL: flexor carpi ulnaris, palmaris longus, flexor carpi radialis, pronator teres. • INTERMEDIATE: flexor digitorum superficialis. • DEEP: flexor pollicis longus, flexor digitorum profundus and pronator quadratus.

Answer 645

They are mostly innervated by the median nerve (except for the flexor carpi ulnaris and medial half of flexor digitorum profundus, which are innervated by the ulnar nerve).

Answer 646

SUPERFICIAL - Brachioradialis; Extensor Carpi Radialis Longus and Brevis Extensor Digitorum Communis Extensor Digiti Minimi Extensor Carpi Ulnaris DEEP Supinator APL EPB EPL Extensor Indicis Proprius

Answer 647

APL + EPB = lateral border EPL = medial border

Answer 648

Nerve roots – C5 and C6. SENSORY – Gives rise to the upper lateral cutaneous nerve of arm, which innervates the skin over the lower deltoid ('regimental badge area'). MOTOR – Innervates the teres minor and deltoid muscles

Answer 649

Nerve roots – C5-C7 MOTOR – muscles in the anterior compartment of the arm (BBC). SENSORY – gives rise to the lateral cutaneous nerve of forearm, which innervates the lateral aspect of the forearm.

Answer 650

Nerve roots – C6 - T1 (also contains fibres from C5 in some individuals). MOTOR: - Innervates the flexor and pronator muscles in the anterior compartment of the forearm (except the flexor carpi ulnaris and part of the FDP) - Also supplies innervation to the thenar muscles and lateral two lumbricals in the hand. SENSORY: - Palmar cutaneous branch innervates the lateral aspect of the palm, - Digital cutaneous branch innervates the lateral three and a half fingers on the anterior (palmar) surface of the hand

Answer 651

Nerve roots – C5-T1. SENSORY – Innervates most of the skin of the posterior forearm, the lateral aspect of the dorsum of the hand, and the dorsal surface of the lateral three and a half digits. MOTOR – Innervates the triceps brachii and the extensor muscles in the forearm

Answer 652

Spinal roots – C8-T1. It passes posterior to the elbow through the cubital tunnel. It enters the hand via the ulnar canal (Guyon’s canal). MOTOR: - Two muscles of the anterior forearm - flexor carpi ulnaris and medial half of flexor digitorum profundus - Intrinsic muscles of the hand (apart from the thenar muscles and two lateral lumbricals) SENSORY Medial one and half fingers and the associated palm area.

Answer 653

Indicates a meniscus tear => pain, snapping / clicking/ locking = positive Internal rotation of the tibia + Varus stress = lateral meniscus External Rotation of the tibia + Valgus stress = medial meniscus

Answer 654

Fibrillin-1

Answer 655

1. Heel strike 2. Foot flat, 3. Mid stance, 4. Toe off 5. Swing WALKING => the swing phase accounts for 40% of the cycle. => brief double stance phase when both feet are in contact with the ground. RUNNING => includes a flight phase when neither foot is in contact with the ground.

Answer 656

there are 4 compartments, but only 2 incisions are needed

Answer 657

Apical fibrosis Anterior uveitis Aortic valve incompetence Achilles tendonitis

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