MSK Flashcards

Question

Paget's disease

Answer 1

chronic disorder which results in thickened, brittle and mis‐shapen bones • Viral infection (paramyxoviruses) and genetic defects have been implicated in the aetiology. • Increased osteoclast activity (possibly due to an exaggerated response to vitamin D) results in increased bone turnover. • Osteoblasts become more active to try to correct excessive bone resorption. • The osteoblasts form new bone however the new bone fails to remodel sufficiently and the resulting bone despite its increased thickness and bone density is brittle and can fracture easily. • This excessive turnover is not coordinated, leading to patchy areas of high density (sclerosis) and low density (lysis). This results in enlarged and misshapen bones with structural problems that increase the risk of pathological fractures. It particularly affects the axial skeleton (the bones of the head and spine).

Answer 2

* Bones commonly affected include the pelvis, femur, skull, tibia and sometimes the ear ossicles (resulting in conductive deafness). * Paget’s disease of the bone can be asymptomatic and present as an incidental finding on X-ray. * It can also cause arthritis (if close to the joint), pathologic fractures, deformity, pain and high output cardiac failure (due to increased blood flow through pagetic bone).

Answer 3

• Serum ALK raised, Ca and P normal • X- ray Findings o Bone enlargement and deformity o “Osteoporosis circumscripta” describes well defined osteolytic lesions that appear less dense compared with normal bone o “Cotton wool appearance” of the skull describes poorly defined patchy areas of increased density (sclerosis) and decreased density (lysis) o “V-shaped defects” in the long bones are V shaped osteolytic bone lesions within the healthy bone • Bone scans – increased uptake

Answer 4

• Bisphosphonates (inhibit osteoclasts) or calcitonin (reduce calcium levels in blood) if extensive lytic disease • NSAIDs for bone pain • Calcium and vitamin D supplementation, particularly whilst on bisphosphonates • Surgery is rarely required for fractures, severe deformity or arthritis o Joint replacement, long intramedullary nails or plates for femoral fractures Monitor ALP, osteosarcoma and spinal stenosis

Answer 5

Brittle bone disease, osteogenesis imperfect is a defect of the maturation and organization of type 1 collagen

Answer 6

* Multiple fractures of childhood, short stature with multiple deformities, blue sclerae and loss of hearing. * Bones tend to be thin (gracile) with thin cortices and osteopenic * Mild = normally x rays with history of low energy fractures

Answer 7

* Double jointed and voluntary dislocation * More prone to soft tissue injuries e.g. ankle sprains and recurrent dislocations of joints e.g. shoulder and patella – painful

Answer 8

* AD or sporadic mutation of the fibrillin gene * Tall stature with disproportionately long limbs and ligamentous laxity * High arched palate, scoliosis, pectus excavtum, lens dislocation, retinal detachment, aortic aneurysm and cardiac valve incompetence (premature death) Mx: surgery for scoliosis and joint instability e.g. fusions

Answer 9

autosomal dominantly inherited with abnormal elastin and collagen formation * Profound joint hypermobility * Vascular fragility with ease of bruising, joint instability and scoliosis

Answer 10

* Defect in the dystrophin gene involved in calcium transport * Absence of the gene product dystrophin * Dystrophin is essential for cell membrane stability

Answer 11

• ages of 2 and 5 years. • results in muscle weakness which may only be noticed when the boy starts to walk with difficulty standing (Gower’s) and going up stairs. • Progressive proximal muscle weakness, aged of 10 can no longer walk, by 20 progressive cardiac and respiratory failure develop o Death early 20s • Initial proximal muscle weakness with calf pseudohypertrophy. • Myocardium is also affected

Answer 12

* Raised serum CK (100 times more) * Abnormal muscle biopsy: variation in muscle fibre size, necrosis, regeneration and replacement of fat. * Absence of dystrophin on immunochemical staining

Answer 13

* Physiotherapy, splintage and deformity correction – prolong mobility * Spinal scoliosis – spinal surgery correction * Portable respiratory support improves life expectancy * Prednisolone slows the decline in muscle strength and function in the short term. Gene therapy

Answer 14

* Neuromuscular disorder with onset before 2‐3 years of age due to an insult to the immature brain before, during or after birth * Causes: genetic problems, brain malformation, intrauterine infection in early pregnancy, prematurity, intra‐cranial haemorrhage, hypoxia during birth and meningitis

Answer 15

Spastic CP • 80% of cases with injury to motor cortex upper motor neurons or corticospinal tract resulting in weakness and spasticity which may worsen as the child grows Ataxic CP • Ataxic (which affects the cerebellum) which reduces co‐ordination and balance Athetoid CP • Affecting the extrapyramidal motor system, the pyramidal tract and basal ganglia which results in an uncontrolled writhing motion, sudden changes in tone and difficulties controlling speech.

Answer 16

* Affects one limb (monoplegic) * one ipsilateral upper and lower limb (hemiplegic – the most common) * both legs only (diplegic) * all 4 limbs usually with learning difficulties (total body involvement).

Answer 17

weakness, fatigue, poor balance and sensory deficits spascitiy hyperreflexia clonus cocontraction

Answer 18

* Physiotherapy, splintage (orthotics) to prevent contractures * Baclofen (injection- intrathecally) – subarachnoid space – lower dose and fewer SE – spasticity * Boxtox also for spasticity Surgical: o Hip excision or replacement to treat painful hip dislocation • contracture joint release • correction of severe scoliosis (cobb angle >45 degrees) o protect respiratory function and help careers – seating and comfort • joint fusions and tend/on transfers

Answer 19

Congenital disorder where the two halves of the posterior vertebral arch fail to fuse, probably in the first six weeks of gestation. * Mild: Spina Bifida Occulta: No associated problems apart from tethering of spinal cord and roots – high arched foot (Pes cavus) and clawing of toes * Severe: Spina Bifida Cystica: contents of the vertebral canal herniate through the defect with either herniation of the meninges alone (a meningocele) or with the spinal cord or cauda equina (myelomeningocle)

Answer 20

o A meningocele is not usually associated with neurological sequelae o myelomeningocele usually has a neurological deficit (motor and sensory) below the lesion and most will never function independently. o associated with hydrocephalus (excess CSF around the brain raising intracranial pressure) and the degree of disability depends on the spinal level affected.

Answer 21

viral infection which affects motor anterior horn cells in the spinal cord or brainstem resulting in a lower motor neurone deficit. Mx Vaccination • residual paralysis can be treated with splintage (caliper, orthotics) and shortening of a leg can be helped with a shoe raise Tendon transfers may improve function whilst some deformities especially of the foot or ankle can be treated with fusion (arthrodesis) • Flail joints may also be treated with arthrodesis in a position of maximal function and shortening can be treated with lengthening of the short side or shortening of the long side

Answer 22

Syndactyly: two digits are fused together Polydactyly: extra digit

Answer 23

injury to the upper (C5 & C6) nerve roots resulting in loss of motor innervation of the deltoid, supraspinatus, infraspinatus, biceps and brachilais muscles.

Answer 24

Internal rotation of humerus: waiters tip Mx: Physio and surgery: release contractures and tendon transfers

Answer 25

lower brachial plexus injury (C8 &T1 roots) caused by forceful adduction •paralysis of the intrinsic hand muscles +/‐ finger and wrist flexors and possible Horner’s syndrome (due to disruption of the first sympathetic ganglion from T1). Mx • no specific treatment • Total brachial plexus palsy after birth carries the poorest prognosis

Answer 26

• Children at birth normally have varus knees (bow legs) which become neutrally aligned at around 14 months, progressing to 10 to 15° valgus (knock knees) at age 3 and then gradually regress to the physiologic valgus of 6° by around the age of 7‐9.

Answer 27

* A valgus deformity at the knee will result in a more of a knock knee appearance with a larger gap than normal between the feet/ankles. * A varus deformity will result in a larger gap between the knees Most resolved at 10

Answer 28

Growth disorder of the medial proximal tibial physis known as Blount’s disease resulting in marked and persisting (beyond 4‐5 years) varus deformity Other causes of genu varum include: rickets, tumour (osteochondroma), traumatic physeal injury and skeletal dysplasia.

Answer 29

rickets, tumours (osteochondroma and endochondroma), trauma and neurofibromatosis whilst some cases are idiopathic. o Refer if asymmetric, painful or severe (over 2sd) o >8cam intermalleolar distance at age of 11 - refer

Answer 30

• Surgical Osteotomy or growth plate manipulation surgery o External fixator o 8 plate

Answer 31

Femoral neck anterversion the femoral neck is slightly anteverted (pointing forwards). Internal tibial torsion – the bone can be rotated inward about its vertical axis but as this is a normal variation, it should ignored. Forefoot adduction – can cause the apparent in‐toeing. There remains debate about whether surgery is useful in cases which persist after 7 or 8 years of age. Certainly surgery should not be considered before this age as the majority resolve in time.

Answer 32

* Flat feet are part of normal variation and usually do not reflect underlying pathology * We are born with flat feet but most develop medial arch once walking as tibialis posterior strengthens * Flat feet usually asymptomatic and some people will have it in adulthood * Usually by age of 3 * Need to determine if flexible (fine) or fixed (usually bone reason for it to be flat)

Answer 33

``` • Mobile/flexible flat feet are those where the flattened medial arch forms with dorsiflexion of the great toe (Jack test) o Related to ligamentous laxity (familial or idiopathic) o Dynamic (present weight bearing only) o Normal variant ```

Answer 34

* Arch remain flat regardless of load or great toe dorsiflexion – underlying bony abnormality * tarsal coalition where the bones of the hindfoot have an abnormal bony or cartilaginous connection * underlying inflammatory or neurological disorder Mx: surgery

Answer 35

Minor overlapping of the toes and curling of toes is common with the fifth toe is most frequently affected. Mx: most will correct without intervention but they can occasionally cause discomfort in shoes and persistent cases in adolescence may require surgical correction

Answer 36

very high arch. This causes an excessive amount of weight is placed on the ball and heel of the foot when walking or standing - can lead pain and instability Mx: refer if getting progressive

Answer 37

dislocation or subluxation of the femoral head during the perinatal period which affects the subsequent development of the hip joint. Untreated = shallow acetabulum, false one occurs proximal to the original one with a shortened limb Severe OA – reduced contact area, gait affected

Answer 38

* positive family history of DDH, breech presentation, first born babies, Down’s syndrome and the presence of other congenital disorders (talipes, arthrogryposis). * Over 4kg

Answer 39

shortening, asymmetric groin/thigh skin creases and a click or clunk on the Ortolani or Barlow manoeuvres.

Answer 40

* Barlow test (dislocatable hip with flexion and posterior displacement) * Unstable hips with a positive Ortolani test (reducing a dislocated hip with abduction and anterior displacement) * Require further evaluation with ultrasound which should detect a dislocated hip, an unstable hip or a shallow acetabulum. * X-rays cannot be used for the early diagnosis of DDH as the femoral head epiphysis is unossified until around 4‐6 months but x-rays are the investigation of choice after this age.

Answer 41

Dislocated or unstable hips – Pavlik harness (hips in flexion and abduction – maintains reduction) • 23-24 hours a day for up to 12 weeks until USS is normal (6 weeks full time and 6 weeks part time). Be wary of AVN. 4-6 months in age 18 months and older: o CR spica (close reduction) o OR spica (open surgery) o pelvic osteotomy to deepen and re-orientate acetabulum

Answer 42

* Inflammation of synovium often secondary to viral illness (self-limiting) - URTI * 2-10 ages and boys more

Answer 43

* History of URTI * Limp, reluctance to weight bear, ROM may be restricted * May present with referred pain to knee (but less common) * Hip lying flexed/externally rotated * Radiographs – exclude perthes disease, normal or near normal CRP. If in doubt, aspiration NSAIDs and rest

Answer 44

• idiopathic osteochondritis of the femoral head • ages of 4 to 9, common in boys, particularly very active boys of short stature. • The femoral head transiently loses its blood supply resulting in necrosis with subsequent abnormal growth. • The femoral head may collapse of fracture. • Subsequent remodelling occurs however the shape of the femoral head and congruence of the joint is determined by age of onset and the amount of collapse - older children fare worse - lead to hip arthritis and hip replacement

Answer 45

* Pain and limp – unliteral * Loss of internal rotation is usually first clinical sign followed by loss of abduction and later on a positive Trendellenburg test from gluteal weakness.

Answer 46

* None * Regular x-ray and avoidance of PA * Some cases the femoral head becomes aspherical, flattened and widened. * The lever arm of the abductor muscles is altered resulting in weakness (Trendelenburg positive). * Occasionally the femoral head may sublux (partially dislocate) requiring an osteotomy of the femur or acetabulum.

Answer 47

condition mainly affecting overweight pre‐pubertal adolescent boys where the femoral head epiphysis slips inferiorly in relation to the femoral neck. • Girls are less commonly affected and hypothyroidism or renal disease may predispose to SUFE. • The growth plate (physis) is not strong enough to support body weight and the femoral epiphysis slips due to the strain (1/3 are bilateral)

Answer 48

The pain may be felt in the groin (like other hip pathology) and purely in knee (obturator nerve) Loss of internal rotation (hip is in external rotation) shortened and loss of flexion and abduction

Answer 49

X ray Mx • Internal fixation (pin femoral head) to stabilise any slippage and physeal closure o AVN is an complication (femoral head) • Bolt in (pin) or hip replacement – going to keep revising the hip replacement if done

Answer 50

Osgood‐Schlatter’s disease

Answer 51

Sinding‐Larsen‐Johanssen disease.

Answer 52

self‐limiting conditions requiring rest +/‐ physiotherapy. | • Patients may be left with a bony prominence which does not require surgery

Answer 53

* The aetiology is unclear and may be due to muscle imbalance, ligamentous laxity and subtle skeletal predisposition (genu valgum, wide hips, femoral neck anteversion). * There may be softening of the hyaline cartilage of the patella (chondromalacia patellae). Mx: rest and physiotherapy Surgery for resistance cases to shift forces on patella (tibial tubercle transfer)

Answer 54

• fragment of hyaline cartilage with variable amount of bone fragments and breaks off the surface of the joint e.g. medial femoral condyle of knee

Answer 55

congenital deformity of the foot • Utero abnormal alignment of the joints between the talus, calcaneus and navicular (50% bilateral) • The abnormal alignment of these joints results in contractures of the soft tissues (ligaments, capsule & tendons) resulting in a deformity consisting of ankle equinus (plantarflexion), supination of the forefoot and varus alignment of the forefoot which are not immediately correctable. Late diagnosis: Fixed deformity – child walks on outside of their foot – very difficult to correct and extensive surgery (soft tissue +/- bony procedures) with less satisfactory results

Answer 56

Ponseti technique • commenced as soon as possible after birth and the deformities are corrected progressively in stages and held in plaster casts with 5 or 6 weekly cast changes • Tenotomy of the Achilles tendon – maintains full correction • Once full correction is achieved the child is then placed in a brace consisting of boots attached to a bar which is worn 23 hours a day for 3 months and used during sleep until the age of 3 to 4 to try to prevent recurrence.

Answer 57

``` abnormal bridge (bony, fibrous or cartilaginous) between the calcaneus and navicular or between the talus and calcaneus. • painful fixed flat foot deformity in older children. ```

Answer 58

* Symptoms may improve with splintage / orthotics | * Resistant pain may require surgery to reTarsal move the abnormal connection

Answer 59

lateral curvature of the spine (and also rotational deformity) which can be idiopathic (most common) or secondary to neuromuscular disease, tumour (e.g. osteoid osteoma), skeletal dysplasia or infection • Younger children with scoliosis usually have an underlying cause and may progress more readily to a severe curve. • Any painful scoliosis warrants urgent investigation (MRI for tumour or infection).

Answer 60

* Mild, non-progressive scoliosis does not require surgery * Larger curves may require surgery for cosmesis or to improve wheelchair posture (neuromuscular disease such as cerebral palsy) * Severe curves – restrictive lung defect and surgery to prevent breathing difficulties * Correction of larger curves carries a risk of spinal cord injury (intraoperative monitoring may be used).

Answer 61

• slippage of one vertebra over another and usually occurs at the L4/L5 or L5/S1 level. • It can be due to a developmental defect or a recurrent stress fracture (Spondylolysis) of the posterior elements which fails to heal. o pars interarticularis of the vertebral arch

Answer 62

low back pain • may have a radiculopathy with severe slippage. • They may have a paradoxical “flat back” due to muscle spasm and can present acutely with a characteristic waddling gait. Mx: • Minor: Rest and physiotherapy • Severe: stabilisation and possibly reduction – risk of neurological injury

Answer 63

recurrent relapsing and remitting back pain with no neurological symptoms. Worse with movement and relived with rest Causes • Obesity, poor posture, poor lifting, poor PA, depression, degenerative disc prolapse, facet joint OA and spondylosis • Spondylosis is where the intervertebral discs lose water content with age resulting in less cushioning and increased pressure on the facet joints leading to secondary OA.

Answer 64

analgesia, rest and physio • Spinal stabilisation for single level (2 adjacent vertebrae) OA or instability or patient has not improved despite physio/conservative management

Answer 65

* An acute tear can occur in the outer annulus fibrosis of an intervertebral disc which classically happens after lifting a heavy object (e.g. lawnmower). * The periphery of the disc is richly innervated and pain can be severe * Pain is characteristically worse on coughing (which increases disc pressure). * Symptoms usually resolve but can take 2‐3 months to settle. * Analgesia and physiotherapy

Answer 66

radicular pain is felt as a neuralgic burning or severe tingling pain, often like severe toothache radiating down the back of the thigh to below the knee. o L3/4 prolapse > L4 root entrapment > pain down to medial ankle (L4), loss of quadriceps power, reduced knee jerk o L4/5 prolapse > L5 root entrapment > pain down dorsum of foot, reduced power Extensor Hallucis Longus and tibialis anterior o L5/S1 prolapse > S1 root entrapment > pain to sole of foot, reduced power plantarflexion, reduced ankle jerks

Answer 67

* Analgesia, maintaining mobility and physiotherapy * Gabapentin if severe leg pain * Can resolve in 3 months * Surgery (discectomy

Answer 68

• Spondylosis and combination of bulging discs, bulging ligamentum flavum and osteophytosis results in the cauda equina of the lumbar having less space

Answer 69

• 60 years and over and claudication in legs when walking o the claudication distance is inconsistent o the pain is burning (rather than cramping) o pain is less walking uphill (spine flexion creates more space for the cauda equina) or cycling o pedal pulses are preserved Mx • conservative: analgesia, physiotherapy and weight loss • Surgery: MRI evidence and no improvement from above – decompression surgery to increase space for cauda equina

Answer 70

very large central disc prolapse can compress all the nerve roots of the cauda equina • Surgical emergency as affected nerve roots include the sacral nerve roots (mainly S4 & S5 but variable and others contribute) controlling defaecation and urination • Prolonged compression can potentially cause permanent nerve damage requiring colostomy and urinary diversion and urgent discectomy way prevent this catastrophe

Answer 71

bilateral leg pain, paraesthesiae or numbness and complain of “saddle anaesthesia” – numbness around the sitting area and perineum. • Altered urinary function is typically urinary retention but incontinence can also occur. • Faecal incontinence and constipation can also occur. • A rectal examination (PR) is mandatory and it is considered negligent not to perform this is a cauda equine syndrome is missed. Mx: MRI and urgent discectomy

Answer 72

severe osteoporosis, spontaneous crush fractures of the vertebral body can occur leading to acute pain and kyphosis Mx • Conservative: analgesia, physiotherapy • Surgical: balloon vertebroplasty

Answer 73

Spondylosis can occur with disc degeneration leading to increased loading and accelerated OA of the facet joints. slow onset stiffness and pain in the neck which can radiate locally to shoulders and the occiput. Mx: physio and analgesia

Answer 74

RA (atlanto-axial subluxation - destruction of synovial joint) and down syndrome (atlanto‐axial (C1/C2) instability with subluxation) Screen with flexion/extension X rays

Answer 75

Back pain in <20 years and >60 years Nature of pain: constant, severe and worse at night Systemic upset

Answer 76

primary OA or arthritis due to RA, seronegative inflammatory arthropathy, AVN, dysplasia, Perthes or SUFE

Answer 77

local reaction to metal debris resulting in an inflammatory “pseudotumour” which can cause necrosis of muscle and bone

Answer 78

* Level of pain and disability * Conservative: simple analgesics, physiotherapy, use of a stick (which reduces the joint force by 15%), weight reduction and modification of activities

Answer 79

hip joint is one of the commonest sites of AVN which as previously discussed may be primary / idiopathic or secondary to alcohol abuse, steroids, hyperlipidaemia or thrombophilia. necrosis because of failure of the blood supply to the femoral head • idiopathic (most common) or associated with trauma (injury to femoral head blood supply (medial femoral circumflex)

Answer 80

* Irradiation * Trauma * Haemolytic diseases * Dysbaric disorders: nitrogen embolism from diving * Diabetes * Alcoholism * Steroid use Insidious onset of groin pain – exacerbated by impact or stairs • Normal examination (unless disease has advanced to collapse/OA)

Answer 81

* Early: MRI changes only * Later: patchy sclerosis of the weight bearing area of the femoral head with a lytic zone underneath formed by granulation tissue from attempted repair.

Answer 82

Bisphosphonates Drill holes in femoral neck into abnormal area to decompress area * Curettage and bone grafting * Vascularised fibular bone graft * Rotational osteotomy * Late/collapse: THR

Answer 83

* The broad tendinous insertion of the abductor muscles (predominantly the gluteus medius) is under considerable strain and is subject to tendonitis and degeneration leading to tendon tears. * The trochanteric bursa can also become inflamed. * It usually occurs in females, young runners and older patients (linked to gluteal cuff syndrome).

Answer 84

* Pain and tenderness in greater trochanter region with pain on resisted abduction * Pain on lateral aspect of hip Mx Analgesic, anti‐inflammatories (NSAIDs), physiotherapy (to strengthen other muscles and avoid abductor weakness) and steroid injection.

Answer 85

rare condition that causes temporary bone loss in the upper portion of the thighbone (femur). People with transient osteoporosis of the hip will experience a sudden onset of pain that intensifies with walking or other weight-bearing activities. • This is incredibly rare and is due to local hyperaemia and impaired venous return with marrow oedema and increased intramedullary pressure. • It is more common in males but there are two main presenting groups; middle aged men and pregnant women (third trimester).

Answer 86

* Progressive groin pain (over weeks) * Difficulty weight bearing * Usually unilateral

Answer 87

* Blood tests – elevated ESR * x-ray (osteopenia, thinning of cortices, preserved joint space) * MRI (Gold standard) * bone scan Mx • It is a self-limiting condition (resolves 6-9 months) so management is supportive (protected weight bearing to prevent stress fracture and analgesia).

Answer 88

bone obstructing the normal hip movement (altered morphology of femoral neck and/or acetabular). It causes impingement of the femoral neck on the edge of the acetabulum during movement (flexion, adduction and internal rotation mainly). CAM/PINCER AND MIXED

Answer 89

Labrum/tears damage to cartilage OA in later life * Activity related pain in the groin (particularly on flexion and rotation) * Difficulty sitting * Positive C-sign (patient places hands on groin when asked to pinpoint groin) * FADIR (flexion, adduction internal rotation) positive provocation test

Answer 90

* Observation (if asymptomatic) * Arthroscopic or open surgery – remove CAM or debride labral tears * Peri-acetabular osteotomy/debride labral tears – in pincer impingement * Arthroplasty - in older patients with secondary OA

Answer 91

* The principal role of the ACL is to prevent abnormal internal rotation of the tibia (although it is clinically tested by assessing anterior translation of the tibia). * The PCL prevents hyperextension and anterior translation of the femur (although it is tested by assessing posterior translation of the tibia). * The MCL resists valgus force * LCL resists varus force and abnormal external rotation of the tibia.

Answer 92

* occur with a twisting force on a loaded knee (e.g. turning at football, squatting). * The patient localizes pain to the medial (majority) or lateral joint line and an effusion develops by the following day. * The patient then complains of pain and usually has mechanical symptoms – either a catching sensation or "locking" where they have difficulty straightening the knee with a 15° or so block to full extension. * Medial x10 more common than lateral due to medial being more fixed and less mobile than lateral and force from pivoting movements is centred on the medial compartment

Answer 93

* Effusion, joint line tenderness and pain on tibial rotation localizing to the affected compartment (Steinmann's test). * A locked knee with a displaced bucket handle meniscal tear will have a 15° or so springy block to full extension. * MRI will confirm the clinical suspicion.

Answer 94

Longitudinal tears (can cause bucket handle), radial tears, oblique tears and horizontal tears.

Answer 95

• Age weakens meniscus • Common • Tear spontaneously or innocuous injury • First stage in OA • Steinmanns negative • Should not be treated with resection (arthroplasty) o Inflammation from initial onset may settle o Injection may help

Answer 96

* Arthroscopic repair: acute peripheral tears in younger patient: suturing it to its bed – repair – longer recovery e.g. longitudinal tear and not a radial tear * Arthroscopic menisectomy for mechanical symptoms for irreparable tears or failed meniscal repair * Acute tears - pain or mechanical symptoms do not settle within around 3 months then arthroscopic partial menisectomy * Steroids – degenerative – early period

Answer 97

anterior subluxation of the tibia and internal rotation of the tibia in extension • Higher rotational force (rotatory instability)– upper body laterally on a planted foot (leading to internal rotation force on the tibia) • Rotatory instability with their knee giving way when turning on a planted foot (excessive internal rotation of tibia)

Answer 98

* Pop and hemarthrosis (bleeding effusion from vascular ACL supply) * Knee swelling, excessive anterior translation of tibia (anterior draw test) and Lachman test

Answer 99

Physiotherapy (3 months) to strengthen give proprioceptive training to the quadriceps and hamstrings muscles may help compensation. * Professional sportsmen or women who need to get back to their profession as quick as possible usually proceed straight to ACL reconstruction and those whose knees give way on sedentary activity or those who have a strong desire to get back to high impact sport but cannot do so despite physiotherapy are good candidates for ACL reconstruction. * ACL reconstruction involves tendon graft (usually patellar tendon or semitendinosis & gracilis autograft) being passed through tibial and femoral tunnels at the usual location of the ACL in the knee and secured to the bone.

Answer 100

direct blow to the anterior tibia with the knee flexed (eg motorcycle crash) or hyperextension may rupture the PCL whilst hyperextension. Popliteal knee pain and bruising

Answer 101

PCL reconstruction is usually performed for reconstruction of the multiple ligament injured knee • With isolated PCL rupture only those with severe laxity and recurrent instability with frequent hyperextension or feeling unstable descending stairs (with anterior subluxation of the femur) are considered for surgical reconstruction (usually with cadaveric achilles tendon allograft).

Answer 102

• Valgus stress injuries (eg rugby tackle from the side) will usually tear the medial collateral ligament (MCL) with higher forces also potentially damaging the ACL and risking lateral tibial plateau fracture (unlucky triad)

Answer 103

• Patients may have laxity and pain on valgus stress with tenderness over the origin or insertion of the MCL. * Healing expected in the majority of partial and complete tears and little or no instability. * Acute tears are usually treated in a hinged knee brace, with early motion and physio * Chronic MCL instability can be treated with MCL tightening (advancement) * Reconstruction with tendon graft

Answer 104

* A varus stress injury may rupture the lateral collateral ligament (LCL) with or without damage to the PCL. * Hyperextension and varus giving rise to the injury also gives a high incidence of common peroneal (fibular) nerve injury from excessive stretch. * LCL injuries are often part of multiple ligament knee injuries with a high incidence of vascular injury (popliteal artery intimal or complete tear).

Answer 105

• Surgical o early repair o late reconstruction with tendon graft.

Answer 106

* Popliteal artery injury (tear, intimal tear & thrombosis) – below the knee amputation * Nerve injury – common fibular nerve * Compartment syndrome

Answer 107

Reduced – emergency and external fixation • Intimal tears can occur which later thrombose and therefore regular checks on the circulation of the foot are mandatory e.g. dorsalis pedis • Reperfusion can result in compartmental syndrome – esp after prolonged ischaemia and fasciotomies needed • Early: o Vascular repair (6hr window) o Nerve repair • Definitive: o Sequential ligamentous repair

Answer 108

* impaction or shear of the articular surfaces or due to a direct blow. * The defect in the surface of the knee may fill in with fibrocartilage (scar type hyaline cartilage) which is not as good as hyaline cartilage but performs a reasonable job * Ongoing pain and effusion after a knee injury warrants further investigation

Answer 109

• The patellar tendon or quadriceps tendon can rupture with rapid contractile force which can occur after lifting a heavy weight, after a fall or spontaneously in a severely degenerate tendon

Answer 110

* history of tendonitis, chronic steroid use or abuse (body builders), diabetes, rheumatoid arthritis and chronic renal failure. * Quinolone antibiotics (eg ciprofloxacin) can cause tendonitis and can risk tendon ruptures * Steroid injections for tendonitis of the extensor mechanism of the knee should be avoided due to high risk of tendon rupture.

Answer 111

SLR palpable gap US Mx: surgery

Answer 112

disorders of the patellofemoral articulation resulting in anterior knee pain. • It encompasses and in many cases is synonymous with various diagnoses including chondromalacia patellae (softening of the hyaline cartilage), adolescent anterior knee pain and lateral patellar compression syndrome. • The pull of the quadriceps muscle tends to pull the patella in a slight lateral direction. In some people, excessive lateral force produces anterior knee pain and the lateral facet of the patella is compressed against the lateral wall of the distal femoral trochlea.

Answer 113

* Physiotherapy – rebalancing quadriceps muscles – vastus medialis obliquus * Taping * Surgery (last resort) – release lateral retinaculum or if there is a relatively lateralised tibial tubercle, tibial tubercle transfer to aid patellar tracking

Answer 114

* Patellar dislocation can occur with a direct blow or sudden twist of the knee. * Patella dislocations usually occur from a sudden quads contraction with a flexing knee and it almost always dislocates laterally.

Answer 115

ligamentous laxity, female gender, shallow trochlear groove, genu valgum, increased Q angle, femoral neck anteversion and a high riding patella (patella alta).

Answer 116

* When the patella dislocates, the medial patellofemoral ligament tears and osteochondral fracture may occur as the medial facet of the patella strikes the lateral femoral condyle which may be suggested by a small opacification on Xray. * A lipo‐haemarthrosis occurs with characteristic X-ray appearance. * Pain medially (form torn medial retinaculum) * Effusion (haemarthrosis) * Positive patella apprehension test

Answer 117

* Reduce (with knee extension) * Aspiration * Brace * Physiotherapy strengthen quadriceps * Surgery (if repeat dislocations) – lateral release/medial reefing, patella tendon realignment * If recurrent dislocation is frequent, tibial tubercle transfer or medial patellofemoral ligament (MPFL) reconstruction with tendon autograft may help.

Answer 118

Cheilectomy for removal of anterior osteophytes Arthrodesis: joint fusion Ankle replacement

Answer 119

deformity of the great toe due to medial deviation of the 1st metatarsal and lateral deviation of the toe itself - Some familial (?joint laxity, bony alignment) o Shoes? o General joint laxity/CTDs o Rheumatoid o Splayed forefoot assoc with loss of muscle tone and age

Answer 120

* Joint incongruence and a widened forefoot may cause rubbing of the foot with shoes resulting in an inflamed bursa over the medial 1st metatarsal head known as a bunion. * The great toe and second toe may rub causing ulceration and skin breakdown. In severe cases, the hallux may override the second toe.

Answer 121

* wearing of wider and deeper “accommodating” shoes to prevent painful bunions and the use of a spacer in the first web space to stop rubbing between the great and second toes. * Surgical management involves osteotomies to realign the bones and soft tissue procedures to tighten slack tissues and release tight tissues.

Answer 122

OA of the first MTPJ. It can be primary (degenerative) or secondary to osteochondral injury. pain and stiffness in the joint, and with time, it gets increasingly harder to bend the toe. Mx: conservative (metal bar in sole of shoe) cheilectomy of dorsal osetophytes arthrodesis 1st MTP joint replacments

Answer 123

* Plantar interdigital nerves (from the medial and lateral plantar nerves) overlying the intermetatarsal ligaments can be subjected to repeated trauma * Degenerative fibrosis of digital nerve near it’s bifurcation

Answer 124

* Patients complain of a burning pain and tingling radiating into the affected toes * Reveal loss of sensation in the affected web space * Medio‐lateral compression of the metatarsal heads (exerted by squeezing the forefoot with your hand) may reproduce symptoms or produce a characteristic "click"; this is Mulder's click test * US – swollen nerve

Answer 125

* Conservative management: involves the use of a metatarsal pad or offloading insole. * Steroid and local anaesthetic injections may relieve symptoms and aid diagnosis. * A neuroma can be excised

Answer 126

most commonly occur in the 2nd metatarsal followed by the 3rd. • Occur in runners, soldiers, dancers or during distance walking (not conditioned to this) - x ray - Bone scan •Prolonged rest – 6-12 weeks in a rigid soled boot – healing and resolution

Answer 127

``` • Rest, physiotherapy, heel raise (offload tendon) and use of splint/boot o Activity modifications/analgesia o NSAIDS o Shockwave therapy o Orthotics o Physio ``` * Surgery: Resistant cases: tendon decompression and resection of paratenon. * DO NOT GIVE STERIOD INJECTION – RISK OF RUPTURE

Answer 128

* Patients often think somebody has hit them * Weakness of plantarflexion * No plantarflexion of the foot is seen when squeezing the calf (Simmonds test). * sudden pain and difficulty in weight bearing * a palpable gap in the tendon are usually apparent.

Answer 129

* Suture repair of the damaged tendon to restore the tension of the tendon more accurately and repair may have a slightly lower re‐ rupture rate. * Non operative: series of casts in the equinous position: the ankle plantarflexed with the toes pointing down, as this closes the gap in the torn tendon (again over 8 weeks or so).

Answer 130

self‐limiting repetitive stress/overload or degenerative condition of the foot. Causes • Physical overload – excessive exercise, excessive weight • Seronegative arthropathy • Diabetes • Abnormal foot shape – planovalgus or cavovarus • Improper footwear? • frequent walking on hard floors with poor cushioning in shoes

Answer 131

* Start-up pain after rest and can be worse after exercise * Tenderness over plantar aspect of heel and/or plantarmedial aspect of heel * Tinel’s test positive for Baxter’s nerve – impingement of the nerve – abductor muscle

Answer 132

* Rest, NSAIDs, Achilles and plantar fascia stretching exercises and a gel filled heal pad help (ice hockey ball) * Physiotherapy * Corticosteroid injection may also help into fascia not the tendon * Surgical release of plantar fascia – risk injuring nerves

Answer 133

Tibialis posterior tendon inserts predominantly onto the medial navicular, plantar aspect of medial and middle cuneiforms and serves to support the medial arch of the foot (as well as being a plantarflexor and invertor of the foot). • Tendon is under repeated stress and particularly with degeneration can develop tendonitis, elongation and eventually rupture. * Synovitis from RA can also result in tendon rupture. * Rupture – loss of medial arch and flattening (acquired flat foot), secondary OA of hind and midfoot * Most common cause of acquired flatfoot deformity in adult

Answer 134

* Obese middle aged female – hypermobility could be related to the female incidence * Increases with age * Flat foot * Hypertension * Diabetes * Steroid injection * Seronegative arthropathies * Idiopathic tendonosis

Answer 135

* Pain and/or swelling posterior to medial malleolus – very specific * Change in foot shape – slightly more valgus on heel raise. Normal tendon allows you too go into varus position when standing on toes. Remain in valgus in PTT * Diminished walking ability/balance * Dislike of uneven surfaces * More noticeable hallux valgus * Lateral wall “impingement” pain * Midfoot & ankle pain – natural history of it

Answer 136

* Bespoke footwear * Splint with a medial arch to avoid rupture * Surgical decompression and tenosynvectomy may prevent rupture * Tendon transfer to prevent secondary OA with calcaneal osteotomy to reduce stress * OA – arthrodesis – triple fusion for example

Answer 137

hyperextension at the MTPJ with hyperflexion at the PIPJ and DIP

Answer 138

hyperextension at the DIPJ.

Answer 139

III and IV

Answer 140

``` diagnosed early (within the first 2‐3 weeks) surgical washout & debridement and prolonged parenteral antibiotic therapy (around 6 weeks) can be attempted to salvage the artificial joint. – 50% successful • Deep infections present for longer than 3 weeks or so tend not to be salvageable by washout as the infecting bacteria adhere to the foreign surfaces and form a Biofilm which prevents the patient’s immune system attacking. o removal of the infected implants and all foreign material (including cement) which requires extensive surgery is usually required. The patient is usually left without a joint for around 6 weeks and given parenteral antibiotics. Once the infection is under control (wound healed, clean and dry, CRP reduced) a revision (re‐do) joint replacement is performed with more complex joint replacement components ```

Answer 141

* Immunocompromised patients * chronic disease * elderly and the young are most prone to osteomyelitis

Answer 142

dead fragment of bone new bone will form around area of necrosis

Answer 143

* Children: The metaphyses of long bones contain abundant tortuous vessels with sluggish flow which can result in accumulation of bacteria and infection spreads towards the epiphysis. * Children can also develop a subacute osteomyelitis with a more insidious onset and where the bone reacts by walling off the abscess with a thin rim of sclerotic bone. This is known as a Brodie’s abscess. * In neonates and infants: certain metaphyses are intra‐articular including the proximal femur, proximal humerus, radial head and ankle and infection can spread into the joint causing co‐ existent septic arthritis. * Additionally, infants have loosely applied periosteum and an abscess can extend widely along the subperiosteal space

Answer 144

* In adults: infection tends to be in the axial skeleton (spine or pelvis) with haematogenous spread from pulmonary or urinary infections, or from infection of the intervertebral disc (discitis). * Children or adults: peripheral from previous open fracture or internal fixation.

Answer 145

* “best guess” antibiotics intravenously * Unless there is abscess formation which mandates surgical drainage. * If the infection fails to resolve, second line antibiotics may be used or surgery may be performed to gain samples for culture, remove infected bone and washout the infected area.

Answer 146

• cannot be cured or eradicated by antibiotics alone • Active infection can be suppressed with antibiotics but this may prove unsuccessful. • Surgery is usually recommended to gain deep bone tissue cultures, to remove any sequestrum and to excise any infected or non‐ viable bone (known as debridement). • If debridement of bone results in instability, the bone must be stabilized by internal or external fixation o External fixation can help lengthened the bone if it has been shortened • Other strategies may include local antibiotic delivery systems and bone grafting. • Plastic surgery may be required if skin and soft tissue coverage of bone is not possible. • Intravenous antibiotics are continued for several weeks after surgery.

Answer 147

* Insidious onset, constant and unremitting /systemic upset * Severe cases may have an associated neurologic deficit (lower motor neurone & cauda equina syndrome below L1 and upper motor neurone / myelopathy above L1). * Pus may extrude forming a paravertebral or epidural abscess. * As the vertebral end plates weaken, vertebrae may collapse leading to kyphosis or vertebra plana (flat vertebra) and disc space may reduce

Answer 148

* MRI – extent of infection and abscesses * Blood culture – staph aureus but look for atypical in immunocompromised * Endocarditis considered Mx • High IV dose antibiotics after CT guided biopsy to obtain tissue culture • Required for several months - clinically assessed and serial CRP • Surgery Debridement

Answer 149

``` o Supraspinatus (1) - greater tuberosity – initiation of abduction o Infraspinatus (2) - greater tuberosity – external rotation o Teres Minor (3) - greater tuberosity – external rotation o Subscapularis (4) - lesser tuberosity – internal rotation ```

Answer 150

* tendons of the rotator cuff (predominantly supraspinatus) are compressed in the tight subacromial space during movement producing pain. * Painful arc around 60-120 degrees of abduction (variable) as inflamed area of supraspinatus tendon passes through subacromial space ``` Causes include: • Tendonitis • Subacromial bursitis • Acromioclavicular OA with inferior osteophyte • A hooked acromion • Rotator cuff tear ```

Answer 151

* Pain radiates to deltoid and upper arm * Tenderness felt below lateral edge of the acromion * Hawkins-Kennedy test (internally rotating the flexed shoulder) recreates patients’ pain * Cervical radiculopathy should be excluded from history and examination

Answer 152

Conservative (minimum of 6 months) • NSAIDS, analgesia, physiotherapy and subacromial injection of steroid (up to 3) Surgery (if no improvement) • Subacromial decompression surgery

Answer 153

* The tendons of the rotator cuff can tear with minimal or no trauma as a consequence of degenerate changes in the tendons. * Classic history is of a sudden jerk (e.g. holding a rail on a bus which suddenly stops) in a patient >40 years of age, with subsequent pain and weakness. * Rotator cuff tendons can tear in young patients due to a significant injury (including shoulder dislocation) although this is very uncommon.

Answer 154

* Intrinsic factors such as degeneration and tendon vascularity * Extrinsic factors such as anatomical factors e.g the morphology of the acromion and biomechanical factors e.g kinetics and performance.

Answer 155

* Weakness of initiation of abduction (supraspinatus), internal rotation (subscapularis) or external rotation (infraspinatus) may be detected and wasting of supraspinatus may be seen. * Achy pain down arm gradually increases (usually present on all four tendons) * Tenderness around glenohumeral joint and AC joint * Difficulty sleeping on affected side, reaching overhead & on lifting * Painful arc +/- RC weakness * Positive impingement tests such as Hawkins-Kennedy test, jobe’s and scarf test

Answer 156

USS and MRI ``` Mx •Non-operative o Rest and analgesia o physiotherapy to strengthen up the remaining cuff muscles which can compensate for the loss of supraspinatus. o Subacromial injection: steroid ``` •Surgery o Rotator cuff repair (open or arthroscopic) with subacromial decompression

Answer 157

This is a disorder characterized by progressive pain and stiffness of the shoulder in patients between 40 and 60, resolving after around 18‐24 months. * Initially complain of pain * Which subsides (after around 2‐9 months) * Stiffness increases (for around 4‐12 months) * Stiffness gradually “thaws” out over time, usually with good recovery of shoulder motion. * The principal clinical sign is loss of external rotation (along with restriction of other movements) which can also occur in OA, however OA tends to affect older patients.

Answer 158

Non operative: o Physiotherapy and analgesics o Intra‐articular (gleno‐humeral rather than subacromial) injections can help in the painful phase Surgical: can’t tolerate the functional loss due to stiffness o manipulation under anaesthetic (MUA which tears the capsule) o surgical capsular release (usually done arthroscopically) which divides the capsule leading to improved motion.

Answer 159

• This condition results in the acute onset of severe shoulder pain and is characterized by calcium deposition in the supraspinatus tendon x ray: proximal to greater tuberosity Mx: • Pain relief: subacromial steroid and local anaesthetic injection. • The condition is self‐limiting with pain easing as the calcification resorbs

Answer 160

tendonitis, tendonosis, rupture or tenosynovitis • Predominantly the long head of biceps is affected where it passes through the bicipital groove located anteriorly on the proximal humerus. This is where most inflammation occurs which is usually friction related. • It is common in occupations where heavy lifting or overhead work is typical. It also has a higher incidence in athletes who are involved in throwing events, swimmers and gymnasts

Answer 161

* Pain anterior shoulder radiating to elbow. Aggravated by shoulder flexion, forearm pronation and elbow flexion * Snapping with shoulder movements if subluxation Ix clinical exam: pop-eye USS

Answer 162

Conservative: rest & physio Surgical division of the tendon with or without attachment to the proximal humerus may be required to relieve symptoms (becareful of neurovascualr bundle at distal end) • The tendon can spontaneously rupture resulting in relief of symptoms however some are left with a bunched up biceps muscle (“Popeye deformity”). • Tears in the glenoid labrum where the long biceps tendon attaches (known as SLAP lesions) can also cause pain. Ix - MRI arthrogram

Answer 163

* Supination: Biceps and supinator muscles * Pronation: pronator teres and pronator quadratus distally * Lateral epicondyle: common extensor origin * Medial epicondyle: common flexor origin

Answer 164

* Repetitive strain injury: regularly perform resisted extension at the wrist. * It can also be a degenerative enthesopathy (inflammation of the origin or insertion of a tendon or ligament into bone).

Answer 165

* Painful and tender lateral epicondyle * Pain on resisted middle finger and wrist extension. * Pain is worse when stretching the muscles e.g. opening a jar

Answer 166

clinical USS and MRI Nerve conduction studies Mills test is positive: This is where pain is reproduced by resisted wrist extension with palm pronated whilst moving the palm sideways in the direction of the thumb Mx • Rest from activities and physiotherapy • NSAIDS, steroid injections (be careful of ulnar nerve though) and brace (elbow clasp) • Ultrasound therapy • Surgical (refractory cases): Division and/or excision of some fibres of the common extensor origin

Answer 167

* Repeated strain or degeneration of the common flexor origin. * Can be associated with ulnar neuropathy – avoid injecting due to the ulnar nerve * The pain is aggravated by wrist flexion and pronation which is the basis for testing on examination. It is also worse upon grasping eg opening a jar

Answer 168

* Physiotherapy, rest & NSAIDs. * Injection in this area carries a risk of injury to the ulnar nerve. * Surgical release – last resort

Answer 169

* When it has failed non-operative management can be treated with surgical excision of the radial head which affords good pain relief with minimal functional limitation. * Can also replace the radial head

Answer 170

Total elbow replacement (2.5kg restriction)

Answer 171

* Compression of ulnar nerve at elbow behind medial epicondyle * Compression can be due to a tight band of fascia forming the roof of the tunnel (known as Osborne’s fascia) * Or tightness at the intermuscular septum as the nerve passes through or between the two heads at the origin of flexor carpi ulnaris.

Answer 172

• Paraesthesia in the ulnar 1½ fingers • Tinel’s test over the cubital tunnel is usually positive. • Weakness of ulnar nerve innervated muscles may be present o the 1st dorsal interosseous (abduction index finger) o Adductor pollicis: assessed with Froment’s test.

Answer 173

* Elbow splintage, physiotherapy, nerve gliding and NSAIDs | * Surgical release of tight structures

Answer 174

• The carpal tunnel of the wrist is formed by the carpal bones and the flexor retinaculum. • The median nerve passes through the carpal tunnel along with 9 flexor tendons (FDS & FDP to 4 digits + FPL) with their synovial covering. - any swelling (idiopathic most common) but secondary to many conditions including rheumatoid arthritis (synovitis > less space) and conditions resulting in fluid retention – pregnancy (resolves after birth), diabetes, chronic renal failure, hypothyroidism (myxoedema). Colles fracture can cause it

Answer 175

• Parathesiae in the median nerve innervated digits (thumb and radial 2½ fingers) • is usually worse at night due to flexion of the wrist • loss of sensation • sometimes weakness of the thumb • clumsiness in the areas of the hand supplied by the median nerve • Motor to LOAF muscles o Lumbricals I and II (lateral) o Opponens pollicis (thenar muscles) o Abductor pollicis brevis (thenar muscles) o Flexor pollicis brevis (thenar muscles) * loss of sensation and muscle wasting of the thenar eminence * Tinel’s test – positive for symptoms * Phalens test - holding the wrists hyper‐flexed (which decreases space in the carpal tunnel) * Abductor policis brevis test – resisting abduction: suggest motor loss as the thumb can’t resist upwards

Answer 176

Nerve conduction studies Mx Non-operative treatment o Wrist splints at night to prevent flexion. o Physiotherapy o Injection of corticosteroid can also be used. Can be diagnostic Surgical treatment: • Carpal tunnel decompression (transverse carpal ligament)

Answer 177

* Proliferative connective tissue disorder where the specialized palmar fascia undergoes hyperplasia with normal fascial bands forming nodules and cords progressing to contractures at the MCP and PIP joints. * Proliferation of myofibroblasts and production of abnormal collagen (type 3 rather than type 1) * thickening and contracture of subdermal fascia leading to fixed flexion deformity of fingers

Answer 178

* Skin of the hand may be adherent to the disease fascia and puckered. * Palpable nodules may be present. * Contractures most commonly affect the ring and little fingers. * MCP/PIP joint involvement * Table-top test – 30 degree contracture Mx • Conservative: Stretches and activity modification • Surgery (interfering with function) o removal of all diseased tissue (fasciectomy) o division of cords (fasciotomy). o dermofasciectomy - Amputation Newer treatments o collagenase injection – enzyme that eats at collagen. Small amount, inject into cord o percutaneous needle fasciotomy

Answer 179

• Tendons run within flexor tendon sheath • Any swelling on tendon leads to irritation o more swelling o tendon gets caught on edge on A1 pulley o Swelling of the tendon or the pully • Tendonitis of a flexor tendon to a digit can result in nodular enlargement of the affected tendon, usually distal to a fascial pulley over the metacarpal neck (the A1 pulley).

Answer 180

* Pain over A1 pulley (MC head). “Triggering” = sticking of finger (usually in flexion) * Pain in the morning due to the build up of fluid * May need other hand to extend. Use force but pain to extend back * Finger movement – clicking sensation, nodule catches underneath the pulley. * Can be painful and finger maybe locked in a flexed position as nodules passes through pulley and can’t go back through on extension * Middle and ring most common

Answer 181

• Conservative o Analgesia and physiotherapy/rest o Splint: To prevent flexion • Injection of steroid and LA around the tendon within the sheath • Surgery: recurrent and persisting o incision of the pulley to allow the tendon to move freely o A1 division does not affect function o Not A2/A4 – vital to prevent bowstring and reduction in power

Answer 182

DIP: • Mild-moderate: Treated with removal of osteophytes and excision of any mucous cyst • Severe: Arthrodesis PIP • Index finger – arthrodesis to maintain pinch grip • Other fingers – arthroplasty MCP • MCP joint replacements – relieve pain and improve ROM 1st carpo‐metacarpal joint (trapziometacarpal joint) treatment • Inject steroid for acute flare up, splints, rest, analgesia, capsaicin gel • Excision arthroplasty (trapeziectromy) • Fusion

Answer 183

* Swan neck deformity (hyperextension at PIPJ with flexion DIPJ) * Boutonniere deformity (flexion at PIPJ with hyperextension at DIPJ)

Answer 184

Outpouching of synovial fluid from DIPJ OA Mx: Left alone Excision

Answer 185

• Common mucinous filled cysts found adjacent to a tendon or synovial joint. • Outpouchings of synovial cavity - transulluminate

Answer 186

Needle aspiration Surgical excision Dorsal wrist ganglion: radial nerve Flexor sheath underneath finger on ganglion: ulnar nerve

Answer 187

First extensor compartment: APL & EPB • Women aged 30-50 o Pregnancy o RA * Repetitive strain injury with pain over radial styloid process * Finklestein’s test: whereby the patient makes a fist over the thumb and the hand is ulnar deviated to reproduce pain • Mx: splint, rest, physio, analgesics, inject, surgical decompression

Answer 188

Primary: minimal fracture gap (less than about 1mm) and the bone simply bridges the gap with new bone from osteoblasts. This occurs in the healing of hairline fractures and when fractures are fixed with compression screws and plates. Secondary: There is a gap at the fracture site which needs to be filled temporarily to act as a scaffold for new bone to be laid down. inflammatory response with recruitment of pluropotential stem cells which differentiate into different cells during the healing process.

Answer 189

 Fracture occurs  Haematoma occurs with inflammation from damaged tissues  Macrophages and osteoclasts remove debris and resorb the bone ends  Granulation tissue forms from fibroblasts and new blood vessels  Chondroblasts form cartilage (soft callus)  Osteoblasts lay down bone matrix (collagen type 1) – Endochondral ossification  Calcium mineralisation produces immature woven bone (hard callus)  Remodelling occurs with organization along lines of stress into lamellar bone

Answer 190

 Transverse fractures occur with pure bending force where the cortex on one side fails in compression and the cortex on the other side in tension.  Oblique fractures occur with a shearing force (eg fall from height, deceleration).  Spiral fractures occur due to torsional forces.  Comminuted fractures are fractures with 3 or more fragments.  A segmental fracture occurs when the bone is fractured in two separate places.

Answer 191

* Bleed and inflammatory exudate from fracture or injury causes pressure to rise * Rising pressure can compress the venous system resulting in congestion within the muscle and secondary ischaemia as oxygenated arterial blood cannot supply the congested muscle. * Pressure rises can also compress nerves resulting in paraesthesiae and sensory loss Cardinal signs: o Increased pain on passive stretching of the involved muscle o Severe pain out with the anticipated severity in the clinical context o Tensely swollen limb and tender muscle to touch o Loss of pulses = end stage ischaemia. DIAGNOSIS TOO LATE o CK rise

Answer 192

• Removal of tight bandages for temporary relief • Emergency fasciotomies: Incisions though skin and fascia to relieve constriction o Open wound left for a few days before secondary closure  Many require skin split grafting o Left untreated: muscle necrosis resulting in fibrotic contracture known as Volkmann’s ischaemic contracture and poor function

Answer 193

* Neurapraxia occurs when the nerve has a temporary conduction defect from compression or stretch and resolve over time with full recovery * Axonotmesis occurs from either a sustained compression or stretch or from a higher degree of force. * Neurotmesis is a complete transection of a nerve and is rare in closed injuries but can occur in penetrating injuries.

Answer 194

Urgent angiography • Temporary restoration of circulation can be achieved with use of a vascular shunt or vascular repair with either a bypass graft or endoluminal stent can be performed. • Skeletal stabilization with internal or external fixation should be performed to protect the repair from shearing force. • Ongoing haemorrhage from arterial injury in the pelvis can be controlled by angiographic embolization performed by interventional radiologists.

Answer 195

Acute onset of a severely painful red, hot, swollen and tender joint with severe pain on any movement are the typical presenting features of a septic arthritis. * Bacterial infections can irreversibly damage hyaline articular cartilage within days and therefore septic arthritis is considered an emergency to try to avoid chronic arthritic damage * young, elderly, IVDUs and immunocompromised patients are most prone to infection. * neonates and infants have some intra‐capsular metaphyses and septic arthritis can evolve in some joints from metaphyseal osteomyelitis

Answer 196

* Aspirated under aseptic technique before antibiotics are given to confirm diagnosis and identify organism * Frank pus is aspirated * Treatment: surgical washout via open surgery or arthroscopic techniques * Open washout best to decrease the bacterial load throughout t

Answer 197

X-rays (AP, lateral views and odontoid peg open mouth) CT scan Full trauma and neurological assessment Mx: immobilization with a hard collar and sandbags or blocks on a spinal board in any high energy injury or head injury Unstable injuries may require immobilization in a “halo vest” • Some unstable injuries require surgical stabilization including fusions, wiring or internal fixation. • Subluxations and dislocations may require traction for reduction and halo application or operative stabilization • burst fractures with neurologic deficits may require traction to decompress the spinal canal

Answer 198

* majority from RTA or falls from height * In the elderly with osteoporosis osteoporotic “wedge” insufficiency fractures Thoracic: brace Lumbar: plaster jacket Surgery (neurological deficit and unstable injury) o stabilization with pedicle screws and rods o spinal fusion and decompression (creation of space around the cord or nerve roots) in the presence of a neurologic deficit.

Answer 199

• physiologic response to injury with complete loss of sensation and motor function and loss of reflexes below the level of the injury. • Spinal shock usually resolves in 24 hours with return of reflexes and the severity of a spinal cord injury may not be determined until after spinal shock has resolved. • The bulbocavernous reflex is a reflex contraction of the anal sphincter with either a squeeze of the glans penis, tapping the mons pubis or pulling on a urethral catheter o The bulbocavernous reflex is absent in spinal shock and its return signals the end of spinal shock.

Answer 200

secondary to temporary shutdown of sympathetic outflow from the cord from T1 to L2, usually due to injury in the cervical or upper thoracic cord leading to hypotension and bradycardia which usually resolves within 24‐48 hours. • Priapism (prolonged persistent and painful erection) from unopposed parasympathetic stimulation may be present. - IV fluids

Answer 201

* A Salter‐Harris I fracture is a pure physeal separation. * A Salter‐Harris II fracture is similar but has a small metaphyseal fragment attached to the physis and epiphysis. * Salter‐Harris III and IV fractures are intra‐articular and with the fracture splitting the physis, there is greater potential for growth arrest. * A Salter‐Harris V injury is a compression injury to the physis with subsequent growth arrest.

Answer 202

* Inconsistent / changing history of events * Discrepancy of history between parents / carers * History not consistent with injury * Injuries not consistent with age of child e.g. non walking child * Multiple bruises of varying ages * Atypical injuries e.g. cigarette burns, genital injuries, torn frenulum, dental injuries, lower limb and trunk burns * Rib fractures * Metaphyseal fractures in infants

Answer 203

3-4 weeks of splintage

Answer 204

may be angulated | • may require manipulation and casting if there is significant deformity, particularly in the older child

Answer 205

* commonly occur around the distal radial physis in older children. * Angulation with deformity requires manipulation.

Answer 206

<2 years: Gallows traction and early hip spica cast 2-6: thomas splint and hip spica cast 6-12: flexible intramedullary nail >12: adult type intramedullary nail

Answer 207

Cast (up to 10 degrees of angulation is accepted). If >10, manipulation and casting Very unstable or open: intramedullary nail plates, plate screws and external fixation Adolescents with a closed proximal tibial physis can have an adult type intramedullary nail.

Answer 208

* lateral compression fracture occurs with a side impact (eg RTA) where one half of the pelvis (hemipelvis) is displaced medially. * vertical shear fracture occurs due to axial force on one hemipelvis (eg fall from height, rapid deceleration) where the affected hemipelvis is displaced superiorly. anteroposterior compression injury may result in wide disruption of the pubic symphysis the pelvis opening up like the pages of a book – the so‐called open book pelvic fracture.

Answer 209

• Blood loss treated with fluids and blood reduce the displacement and minimizing the pelvic volume to allow tamponade of bleeding to occur e.g. external fixator Ongoing haemodynamic instability despite these measures may require angiogram and embolization or open packing of the pelvis if laparotomy is required for co‐existing intra‐abdominal injuries.

Answer 210

high energy injuries in the younger patient but can be low energy in the older patient. • Posterior wall fractures may be associated with a hip dislocation. • The posterior wall is fractured as the head of the femur is pushed out the back of the joint (RTA). Young: ORIF Older: THR

Answer 211

depends on good or poor function - fixation (gardens I and II) - DHS with additional screw for rotation Hemiarthroplasty (replace femoral head alone) Total hip arthroplasty (replace the acetabulum as well as femoral head)

Answer 212

o Intertrochanteric – dynamic hip screw o Basecervical fracture: DHS again o Subtrochanteric fracture (reverse oblique fracture): Intramedullary nail for both types

Answer 213

``` o Fall o Pain in hip and groin o Unable to weight bear o Shortening o External rotation ```

Answer 214

* After initial resuscitation includes optimizing analgesia with a femoral nerve block * Application of a Thomas splint which stabilizes the fracture minimizing further blood loss and fat embolism. * Usually closed reduction and stabilization with an intramedullary nail * However minimally invasive plate fixation with minimal disruption to the fracture site blood supply can also be used

Answer 215

Surgery: reduction of articular surface and rigid fixation with bone grafting external fixator intially

Answer 216

• Up to 50% displacement and 5° of angulation in any plane can be accepted with conservative management in an above knee cast. Internal fixation: intramedullary nailing

Answer 217

* Intra‐articular fractures of the distal tibia are termed 'Pilon' fractures. These fractures generally require ORIF to ensure a congruent articular surface. * High energy fractures of distal tibia plafond (ceiling) cause by a fall from height or rapid deacceleration * Pilon fracture the talus acts like a pestle and is driven into the distal tibial articular surface (the mortar) causing usually substantial disruption, comminution or impaction of the articular surface. * Pilon fractures are surgical emergencies treated with very early internal fixation if the soft tissue envelope is satisfactory or in most cases with temporary external fixation with delayed internal fixation once the swelling settles.

Answer 218

• Sprains of the lateral ankle ligaments (anterior & posterior talofibular ligaments and calcaneofibular ligament) are commonplace and are characterized by pain, bruising and mild to moderate tenderness over the involved ligaments.

Answer 219

Stable: walking cast or splint for 6 weeks Unstable (Distal fibular fractures with rupture of the deltoid ligament): ORIF

Answer 220

* This is an uncommon but often overlooked injury where a fracture of the base of the 2nd metatarsal is associated with dislocation of the base of the 2nd metatarsal with or without dislocation of the other metatarsals at the tarso‐metatarsal joints. * The ligament from the medial cuneiform to the base of the 2nd metatarsal no longer holds the metatarsal in joint. * Closed or open reduction with fixation using screws is recommended.

Answer 221

* These can be more problematic as this area has a relatively poor blood supply and risk of non‐union is higher (around 25%) even in undisplaced fractures * Displaced fractures or fractures in the very active may undergo fixation, usually with a single screw. * Non‐ unions require bone grafting and fixation.

Answer 222

• minimally displaced proximal humerus fractures are treated conservatively with a sling and gradual return to mobilization. Persistently displaced fractures are usually treated with internal fixation (plate, screws, wires or intramedullary nail) shoulder replacement

Answer 223

excessive external rotation force or a fall onto the back of the shoulder. • Often results in detachment of the anterior glenoid labrum and capsule known as a Bankart lesion • The posterior humeral head can impact on the anterior glenoid producing an impaction fracture of the posterior head (Hill‐Sachs lesion). • The axillary nerve can be stretched as it passes through the quadrilateral space whilst other nerves of the brachial plexus as well as the axillary artery can be stretched or compressed

Answer 224

* Loss of symmetry is seen with loss of roundness of the shoulder and the arm held in an adducted position supported by the patients other arm. * axillary nerve injury is loss of sensation in the regimental badge area.

Answer 225

* Closed reduction under sedation or anaesthetic: Hippocratic manoeuvre (inline traction) * Radiographs are repeated to confirm reduction. * The patient is placed in a sling for 2‐3 weeks to allow the detached capsule to heal * Followed by rehabilitation with physiotherapy. * Delayed presentation dislocations (e.g. alcoholics) may be difficult to reduce by closed means and may require open reduction.

Answer 226

• Recurrent dislocations can be stabilized by a Bankart repair with reattachment of the torn labrum and capsule by arthroscopic or open means.

Answer 227

humeral head moves posteriorly to the glenoid and shows the ‘light bulb’ sign on x-ray. Need an oblique x ray • posterior force on the adducted and internally rotated arm - light blub sign on x ray * Closed reduction and a period of immobilization * followed by physiotherapy are again the mainstay of treatment.

Answer 228

* Uncomplicated dislocations require closed reduction (traction in extension with pressure over olecranon) under sedation assessing neurovascular status pre‐ and post‐reduction. * A short period in sling (1‐3 weeks) followed by elbow exercises is typically required. ORIF for bony fractures such as radial head

Answer 229

fracture of the ulna occurs with dislocation of the radial head at the elbow. • ORIF of the ulna fracture (even in children) which should result in reduction of the radio‐ capitellar joint.

Answer 230

* Fracture of the radius with dislocation of the ulna at the distal radioulnar joint * ORIF of the radius is required which should allow the DRUJ to reduce..

Answer 231

extra‐articular fracture of the distal radius within an inch of the articular surface and with dorsal displacement or angulation. • Associated fracture of the ulnar styloid

Answer 232

• Splintage for minimally displaced or angulated fractures • Any angulation past neutral (distal radius articular surface = normally 10 degrees vulgarly angulated – manipulation • The fracture may be held with a plaster cast alone or if the fracture has dorsal comminution o If particularly unstable after reduction, percutaneous wires may be used to pin the distal fragment in place o ORIF with plate & screws may be preferred.

Answer 233

* This is a volarly displaced or angulated extra‐articular fracture of the distal radius which usually occurs after falling onto the back of a flexed wrist. * All Smith’s fractures should undergo ORIF using a plate and screws as they are highly unstable injuries. * Also grip strength and wrist extension are greatly reduced if there is a malunion with excessive volar angulation.

Answer 234

* Barton’s fractures are intra‐articular fractures of the distal radius involving the dorsal or volar rim, where the carpal bones of the wrist joint sublux with the displaced rim fragment. * They can be classified as volar Barton's fractures (an intra-articular Smith's fracture) or a dorsal Barton's fracture (an intra-articular Colles' fracture). Require ORIF

Answer 235

* Tenderness in anatomical snuff box (between APB/EPB and EPL tendons) * pain on compressing thumb metacarpal * Hard to see on x ray and 4 views are needed (AP, lateral and 2 oblique) * Not seen but clinical suspicion, x ray 2 weeks later after resorption of the fractures (first stage of fracture healing)

Answer 236

* Undisplaced fractures – plaster cast for 6-12 weeks * Displaced fractures – fixed with special compression screw sunk into the bone to avoid non union * Non unions – screw fixation and bone grafting

Answer 237

50% or more usually require surgical repair with splintage in extension for 6 weeks as any flexion within this period may cause failure of the repair.

Answer 238

* Mallet finger is an avulsion of the extensor tendon from its insertion into the terminal phalanx and is caused by forced flexion of the extended DIPJ, often from a ball at sport. * Mallet splint holding the DIPJ extended which should be worn continuously for a minimum of 4 weeks.

MSK Flashcards

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