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1
Q

Describe fracture healing

A

Heamatoma formation - release of cytokines, growth factors, heamatoma forms, swelling, inflammation, macrophages/neutrophils remove necrotic tissue
Fibrocartilaginous callus formation (1-2 weeks) - granulation tissue forms, angiogenesis, osteoblasts begin forming spongy bone
Bony callus formation (2 months) - osteoblasts continue, fibrocartilaginous callus converted to bony (cancellous) callus, endochondral and intramembranous ossification
Bone remodelling (<7 years) - bone remodelled into compact bone, osteoclasts aid
*Wolff’s law - bone can remodel and adapt to the loads placed on it

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2
Q

Describe factors that affect bone healing

A

Patient factors - children (stem cells, thicker periosteum), smoking (nicotine/CO causes vasospasm and vasoconstriction), diabetes (defective collagen production), vitamin deficiency (vitamin D, C), corticosteroids, hyperparathyroidism (stimulates osteoclasts), hyperthyroidism (stimulates osteoclasts)
Fracture characteristics - excessive movement (disrupts repair), interposed tissues (blocking/delaying reunion), infection (osteomyelitis), large surrounding soft tissue injury (damage to blood supply, limited delivery of factors)

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3
Q

Describe management of hip fractures

A

Intracapsular displaced - THR (mobile, young, minimal comorbidities) or hemiarthroplasty
Trochanteric - sliding hip screw
Subtrochanteric - intramedullary nail

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4
Q

What is the Nottingham hip fracture score?

A

Determines risk of death/poor outcomes

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5
Q

Describe the Garden classification of hip fractures

A

Predicts Dec elopement of AVN
I - undisplaced, incomplete fracture
II - undisplaced, complete fracture
III - incompletely displaced, complete fracture
IV - completely displaced, complete fracture

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6
Q

Describe the Gustilo classification of open fractures

A

I - puncture from within to out, <1cm, minimal comminution
II - 1-10cm, moderate soft tissue damage/comminution
III - high energy trauma, farmyard/canal/sea contamination
A - adequate soft tissue damage of bone
B - extensive soft tissue loss, periosteal stripping, requires reconstructive surgery
C - vascular injury

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7
Q

Describe treatment of an open fracture

A

Initial management:
ATLS, analgesia, antiemetic, IV ABx within 3hrs, tetanus prophylaxis, control bleeding, assess soft tissue damage, neurovascular, debridememt/irrigation, photo, cover , stabilise/splint, reassess neurovascular
Surgical management:
Theatre within 24h unless vascular injury/gross contamination/compartment syndrome, aggressive debridement and irrigation, fracture stabilisation, coverage/closure

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8
Q

List scenarios where primary amputation is necessary

A 
Uncontrollable haemorrhage
Incomplete traumatic amputation
4-6 hours ischaemia
Segmental muscle loss of two compartments
Bone loss > 1/3 tibia
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9
Q

List signs and treatment of acute compartment syndrome

A 
Pain (+ on passive stretch)
Swollen tense compartment
Paraesthesia
Pressure >40mmHg 
--> dermatofasciotomy
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10
Q

What is the most common primary bone neoplasia?

A

Myeloma (40%)

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11
Q

Describe types of changes on X-ray in keeping with neoplasia

A

Lyric
Sclerotic
Mixed

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12
Q

What cancers cause lytic bone changes?

A 
Renal
Thyroid
Adrenal
Uterine
GI
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13
Q

What cancers cause sclerotic bone changes?

A

Prostate
Breast
Renal (TCC)

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14
Q

What cancers cause mixed sclerotic/lytic bone changes?

A

Primary bone tumour (Ewing’s sarcoma/osteosarcoma/chondrosarcoma)

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15
Q

Which cancers metastasise to bone?

A 
Thyroid
Breast
Lung
Renal
Prostate
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16
Q

List red flag symptoms of back pain

A

Age <16 or >50 new onset
Non mechanical
Thoracic
Malignancy history, unexplained weight loss
Long term steroid use
Fevers/rigors, recent significant infection
Difficulty passing urine (retention), urine/faecal incontinence, bilateral sciatica, saddle anaesthesia, decreased anal tone

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17
Q

List yellow flag symptoms of back pain

A 
Attitudes
Beliefs
Compensation
Diagnosis
Emotions
Family
Work
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18
Q

Describe the conditions cauda equina syndrome, myelopathy, radiculopathy

A

Cauda equina - pressure on nerve roots at cauda equina of spinal cord due to prolapsed disc/infection/cancer/lumbar spinal stenosis
Myelopathy - injury to spinal cord due to severe compression
Radiculopathy - pinched nerve

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19
Q

Describe how you would undertake an examination of the spine

A

Look - posture, asymmetry, scoliosis, muscle wasting, soft tissue abnormalities, cafe au lait spots, cervical lordosis/thoracic kyphosis/lumbar lordosis
Feel - temperature, spinous processes, sacroiliac joints, paraspinal muscles
Move - lateral flexion, lumbar flexion and extension cervical spine flexion and extension/rotation/deviation, thoracic rotation
Special tests - modified shobers test, femoral nerve stretch test, straight leg raise

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20
Q

Describe the shoulder joints and how it is stabilised

A

Ball and socket joint
Joints - sternoclavicular, acromioclavicular, glenohumeral, scapulothoracic
Stabilised by - rotator cuff muscles, labrum, glenohumeral ligaments

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21
Q

List the functions and innervations of the rotator cuff muscles

A

Supraspinatus - abducts humerus, suprascapular nerve
Infraspinatus - external rotation, suprascapular nerve
Teres minor - external rotation, axillary nerve
Subscapularis - internal rotation, adducts humerus, subscapular nerve

22
Q

List the common shoulder problems in different age groups

A

Young - instability, fractures, dislocations
Middle (40-60) - impingement, frozen shoulder, rotator cuff tears, tendinitis, bursitis
Older (60-80) - arthritis

23
Q

Describe the difference between impingement syndrome and frozen shoulder

A

Impingement syndrome - tendons of the rotator cuff muscles become irritated and inflamed as they pass through a narrowed subacromial space
Frozen shoulder - benign, self limiting condition (freezing, frozen, thawing stages) where the connective tissue surrounding the glenohumeral joint becomes inflamed and stiff

24
Q

Describe signs and symptoms of impingement syndrome

A

Pain, weakness, loss of movement
Pain worsened by overhead activities
Worse at night, particularly if lying on the affected shoulder
Pain during abduction from 60-120 (painful arc)
Positive empty cans, Hawkins-Kennedy test, scarf test

25
Describe signs and symptoms of frozen shoulder
Constant pain, worse at night and with cold weather Severely restricted range of movement (active and passive) Lack of external rotation on affected side Positive scarf test *Risk factors - diabetes, stroke, connective tissue disease, thyroid disease, heart disease
26
List short term complications of anterior shoulder dislocations
Bankhart lesion Hill Sachs lesion Axillary nerve damage
27
What is a Bankhart lesion?
Tear to anterio-inferior glenoid labrum +/- avulsion fracture
28
What is a Hill Sachs lesion?
Compression to postero-lateral humeral head
29
List long term complications of anterior shoulder dislocation
Recurrence Glenohumeral arthritis Deltoid muscle wasting
30
Describe how you would undertake an examination of the shoulder
Look (front, side, behind) - asymmetry, rotation (internal = posterior shoulder dislocation), bony prominences, scars, bruising, swelling, muscle wasting, large effusions Feel - temperature, bony landmarks, muscle bulk, tendons Move (active first, passive if necessary) - forward flexion, extension, abduction, adduction, external rotation, internal rotation Special tests - muscle power (push against wall, empty cans, bubble, napoleon), Hawkins-Kennedy, apprehension test, scarf test *Function - getting hands behind head and behind back
31
List red flag symptoms of hip pain
Severe night pain Inability to weight bear Malignancy history Rapid deterioration
32
List common hip problems and how they may present
Arthritis - groin/buttock pain, stiffness, decreased ROM, loss of internal rotation Trochanteric bursitis - lateral pain over greater trochanter Fracture - pain, shortened leg, externally rotated
33
Describe how you would undertake an examination of the hip
Gait - walking phases, stride length, arm swing, trendelenburg, antalgic, high steppage, waddling, short leg Tremdelenburg test Look (standing) - straight stance, pelvic tilt, deformities, stoop, lumbar lordosis, scoliosis, gluteal atrophy, scars, true/apparent leg length Feel - temperature, effusions, bony landmarks (greater trochanter, ASIS, pubic rami) Move (active then passive) - flexion, internal/external rotation, abduction/adduction, extension Special tests - Thomas test, trendelenburg
34
List red flag symptoms of knee pain
Inability to weight bear, worsening pain, acutely very stiff, fever, night pain, malignancy history
35
List common knee problems and how they may present
ACL tear - sport injury, high twisting force applied to a bent knee, loud crack, pain, rapid joint swelling (haemoarthrosis), poor healing, increased laxity on anterior drawer test PCL tear - high energy trauma/hyperextension injury, tibia lies back on femur, increased laxity on posterior drawer test Meniscal tears - sport injury, rotational, delayed knee swelling, joint locking/gives way, recurrent pain and effusions, tender over joint line, +ve McMurray's test Collateral ligament tears - effusion, tenderness over ligaments, varus laxity (LCL)/valgus laxity (MCL) OA - pain, stiffness, decreased ROM, crepitus Prepatellar bursitis - localised swelling over patella, precipitated by period of kneeling, tender over patella, normal ROM Osteochondritis dissecans - swelling, occasional locking
36
Describe how you would undertake an examination of the knee
Gait - phases (looking at knee), limp, movement restriction Look (standing) - alignment, varus/valgus deformity, fixed flexion deformity, hyperextension, baker's cyst Look (lying) - scars, bruising, swelling, effusions, RA nodules, psoriasis, alignment, position, knobbly knees, quadriceps bulk Feel - temperature, tibial lag, joint line, synovial thickening, effusions (sweep test, patella tap test) Move (active then passive) - flexion, extension, hyperextension Special tests - collateral tests, drawer test, lachman's, McMurray's, patellofemoral apprehension test Function - squat test
37
List common orthopaedic paediatric conditions including presentation and management
Clubfoot - feet rotated inwards and downwards --> ponseti method (manipulation and casting) Septic arthritis - unable to weight bear, fever >38.5, raised WCC/CRP Development dysplasia of the hip (DDH) - limping toddler (1-3 years), neonate checks (Barlow/Ortolani) --> pavlik harness *Risk factors - breech birth, family history, female, oligohydramnios Perthes - limping child (4-9 years), AVN of femoral head/epiphysis, can lead to OA, premature fusion of growth plates, *Catterall staging 1-4 --> cast/braces/observation/surgery Transient sinovitis - limping child (2-10), associated with viral infection Slipped upper femoral epiphysis (SUFE) - limping child (10-15), obese, M>F, knee/distal thigh pain, displacement of femoral head epiphysis posters-inferiorly, loss of internal rotation *xray = melting ice cream --> bed rest, no weight bearing/percutaneous pinning Juvenile idiopathic arthritis (JIA) - arthritis in <16 year old for >3 months, pauciarticular = <4 joint affected - pain, swelling, limp, ANA +ve, anterior uveitis
38
Describe the Salter Harris classification of fractures
``` Involves growth plate I - straight across physis II - above physics III - lower than physis IV - through metaphysics, physis and epiphysis V - rammed, crushed physis 50% are salter Harris II ```
39
Describe when paediatric elbow ossification occurs
``` CRITOL Capitellum - 1 Radial head - 3 Internal epicondyle - 5 Trochlea - 7 Olecranon - 9 Lateral epicondyle - 11 ```
40
Describe physiological genu varus/valgus
Infant - varus 18 months - normal 3.5 years - valgus 7 years - normal
41
List causes of intoeing
Femoral neck anteversion Tibial torsion Metatarsal adductus
42
Describe how to interpret a radiograph
1. Describe the film - type of radiography, views, patient demographics 2. The abnormality (fracture): Type - complete (transverse/oblique/spiral/comminuted), incomplete (buckle/greenstick) Location - epiphysis/metaphysics/diaphysis/apophysis, specific part of bone (e.g. neck of femur) 3. Complications/other - evidence of compound fracture/fracture enters joint/another fracture
43
Describe X-ray changes of osteoarthritis
Loss of joint space Osteophytes Subchondral sclerosis Subchondral cysts
44
Describe X-ray changes of rheumatoid arthritis
``` Loss of joint space Erosions Osteopenia Soft tissue swelling Ulnar deviation of hands ```
45
What is Shenton's line?
Imaginary curved line along superior border of obturator foramen and inferior border of femoral neck Disruption = fracture/dislocation of neck of femur
46
Name the likely organism in an animal bite injury
Pasteurella multocida
47
Describe different wrist fractures
Colles - distal radial fracture with dorsal displacement Smith - distal radial fracture with volar displacement Barton - fracture dislocation of the radiocarpal joint Monteggia - ulnar shaft fracture with radial heal dislocation Galaezzi - distal radius fracture with distal radio-ulnar joint dislocation
48
Describe Weber’s classification of ankle fractures and their management
Weber A - fracture of lateral malleolus distal to syndesmosis (usually stable) Weber B - fracture at level of syndesmosis (may require ORIF) Weber C - fracture above level of syndesmosis (requires ORIF)
49
Describe the presentation, investigations, management and complications of a scaphoid fracture
FOOSH in an adolescent/young adult CFs - pain/tenderness in anatomical snuffbox Ix - X-ray (repeat in 7-10 days if no fracture seen), CT/MRI Rx - cast immobilisation, internal fixation if unstable Complications - malunion, secondary OA, avascular necrosis (of proximal part)
50
Describe the treatment options for a Boxer's fracture
Conservative K-wire fusion Closed reduction

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