MSK CORTEXT Flashcards
(127 cards)
1
Q
You are the orthopaedic registrar in the fracture clinic. An 8 year old girl has been referred from A + E with a fracture to her right clavicle. She did this when she fell from a swing onto her outstretched hand. She’s comfortable in the broad arm sling she has been given and she’s neurovasularly intact in the right arm. She had no preceding symptoms, such as pain, in the shoulder or collar bone prior to the accident. She is fit and well. On examination, there is a mild deformity in the middle 1/3 of the clavicle at the site of the fracture but the skin is intact. So far, there is nothing atypical about this girl’s story or injury. However, when you look at the x-ray, you notice that the bone at the fracture site isn’t completely normal. There is a lucent lesion in the middle 1/3 of the clavicle with a smooth edge where it meets the more normal looking bone. There is mild expansion of the cortex. What do you suspect has caused this pathological fracture?
A
A simple bone cyst
A simple bone cyst (aka unicameral bone cyst) is a single cavity benign fluid filled cyst in a bone. They are probably a growth defect from the physis and are therefore metaphyseal in long bones (usually in the proximal humerus and femur) although they can occur in the talus or calcaneus. They may be asymptomatic and an incidental finding on xray (usually a child or young adult), however, they can cause weakness leading to pathological fracture. Treatment with curettage and bone grafting with or without stabilization may be required. Pathological fractures caused by a weakness due to a simple bone cyst usually heal with normal treatment for that fracture, so this patient would be treated conservatively as is usual for a clavicle fracture. However, the patient should be seen in clinic until the fracture has definitely healed. After the fracture has healed, the bone will be stronger than before as the bone cyst will have filled with normal bone!
2
Q
You are the orthopaedic reigistrar in the out-patient clinic. You are referred an 11 year old boy by his GP because he is concerned about a lump which has appeared on the outside of his thigh, just above his knee. The boy and his father tell you it has grown in size and they’re quite concerned. The lump itself is painless although it sometimes catches on the ilio-tibial band on the lateral aspect of his thigh. The boy is well, he doesn’t complain of any other symptoms and doesn’t have any significant past medical history. There is no family history of similar problems. On examination, the boy is slim and you can feel a firm, bony lump on the lateral aspect of the distal femoral metaphysis. The skin and soft tissues overlying the lump are healthy. You do an x-ray and it shows a bony spur originating from the distal femoral metaphysis. The cortex is otherwise normal. What is the diagnosis?
A
Osteochondroma The commonest benign bone tumour is an osteochondroma which produces a bony outgrowth on the external surface with a cartilaginous cap (which isn’t visible on the x-ray). These do not usually cause any problems but can produce local pain. There is a very small (1%) risk of malignant transformation and any lesion growing in size or producing pain may require excisional biopsy. Multiple osteochondromata can occur as an autosomal dominant hereditary disorder.
3
Q
A malignant primary bone tumour which tends to occur in abnormal bone (bone infarct, fibrous dysplasia, post irradiation, Paget’s disease), most commonly in adolescents or young adults
A
Fibrosarcoma
4
Q
A malignant tumour of endothelial cells in the marrow. Most cases occur between the ages of 10 and 20. It may be associated with fever, raised inflammatory markers and a warm swelling and may be misdiagnosed as osteomyelitis
A
Ewing’s sarcoma
5
Q
The most common form of primary bone tumour, producing abnormal bone. Most cases are seen in younger age groups (adolescence and early adulthood) with 60% involving the bones around the knee
A
Osteosarcoma
6
Q
What is the name given to the space chondrocytes occupy?
A
Lacuna
The cell found in cartilage are called chondrocytes (chondroblasts when immature)
7
Q
Condition X is a qualitative defect of bone with abnormal softening of the bone due to deficient mineralization of osteoid (immature bone) secondary to inadequate amounts of calcium and phosphorus
A
Osteomalacia (Ricketts is the same disease occurring in children)
8
Q
A
A - Haversian canal
B - Cement line
9
Q
Malignant soft tissue tumours of muscles? Fat? Blood vessels?
A
Skeletal Muscle = rhabdomyosarcoma
Fat = liposarcoma
Blood vessels = angiosarcoma
10
Q
Inflammation of the usually present, small fluid filled sac lined by synovium around joints which prevents friction between tendons, bones, muscle and skin. This inflammation commonly occurs after repeatedpressure or trauma and, therefore, may present as a soft tissue swelling.
A
Bursitis
11
Q
A cystic swelling which occurs around a synovial joint or tendon sheath, as a result of herniation or out‐pouching of a weak portion of joint capsule or tendon sheath.
A
Ganglion
12
Q
A collection of pus which can be formed secondary to a penetrating wound
A
Abscess
13
Q
What is the name of the layer of thin connective tissue that surrounds individual muscle fibres, such as shown at ‘B’?
A
B = endomysium
14
Q
The sacromere is defined as the region from one [blank] to the next
A
z-line
15
Q
A
Skeletal muscle
(top left = transverse section, peripheral nuclei)
(top right = long fibres + striations)
16
Q
The radiographic features of which biochemical bone disorder include: bone enlargement, thickened cortices, thickened trabeculae with mixed areas of lysis and sclerosis?
A
Paget’s disease
17
Q
“The chief form of bone found at the epiphyses of long bones is ____ bone.”
A
Trabecular bone
18
Q
A
Chrondrocytes (chondroblasts when immature)
19
Q
A mostly lucent lesion, with a patchy sclerosis, found within the metaphyseal region of long bones
A
Enchondroma
20
Q
A bony spur, originating the in metaphyseal regions of long bones, growing away from the epiphysis.
A
Osteochondroma
21
Q
A lucent, multi-loculated cyst found within the medulla of many different bones, often with associated cortical expansion.
A
Aneurysmal bone cyst
22
Q
Avascular necrosis is a cause of??
A
Secondary osteoarthritis
23
Q
Osteochrondromas are always benign?
A
NO
The commonest benign bone tumour is an osteochondroma which produces a bony outgrowth on the external surface with a cartilaginous cap. These do not usually case any problems but can produce local pain. However, there is a very small (1%) risk of malignant transformation and any lesion growing in size orproducing pain may require excisional biopsy. Multiple osteochondromata can occur as an autosomal dominant hereditary disorder!!!
24
Q
Multiple osteochondromata can occur as?
A
autosomal dominant hereditary disorder.
25
Which of the following is NOT a recognised feature of anti-phospholipid syndrome
Select one:
a. livedo reticularis
b. recurrent pregnancy loss
c. migraine
d. thrombocytosis
e. venous thrombosis
Thrombocytosis
\* Thrombocytopenia (as well as neutropenia and lymphopenia) are features of most connective tissue diseases (with the exception of rheumatoid arthritis)
\* In rheumatoid arthritis thrombocytosis and a moderate neutrophilia can occur as markers of inflammation)
26
Which of the following tests may help in the diagnosis of Sjogren’s syndrome?
Select one:
a. Schrodinger’s test
b. Schober test
c. Schirmer test
d. Schilling test
e. Schubert’s test
Schirmer test
\* Schirmer test involves placing a strip of filter paper under the lower eye lid to assess tear production.
\* Schober test is a measure of spinal flexion in ankylosing spondylitis.
\* Schilling test is a test to measure Vit B12 absorption
27
Which of the following best describes the therapeutic approach to connective tissue diseases?
Select one:
a. Discharge to general practitioner with a request for rereferral if major organ involvement occurs
b. Start high dose steroids on diagnosis
c. Immunosuppression with an aim to normalise antibody levels
d. Physiotherapy and if necessary surgery to stabilise the joints
e. Treat symptomatically and monitor closely for major complications
Treat symptomatically and monitor closely for major complications
\* Treatment should be tailored to the individual patient (although generally in SLE hydroxychloroquine would be started routinely).
28
Which would be the most appropriate first test to do in a patient with suspected SLE?
Select one:
a. Urinalysis
b. Anti-mitochondrial antibody
c. MRI brain
d. Nerve conduction studies
e. Renal biopsy
Urinalysis
It is essential to screen for renal disease in SLE and urinalysis is a simple bedside test. If there is evidence of blood or protein in the urine then further investigations such as renal biopsy may be indicated.
Anti-mitochondrial antibody is associated with Primary Biliary Cirrhosis.
MRI brain and nerve conduction studies may be performed in a patient with SLE displaying neurological symptoms.
29
Which of the following is true of primary Sjogren’s syndrome?
Select one:
a. It is commoner in males
b. It has the worst prognosis of all the connective tissue diseases
c. There is an increased incidence of lymphoma in patients with primary Sjogren’s syndrome
d. The best treatment for dry mouth is total dental clearance
e. There are no antibody tests to aid diagnosis
There is an increased incidence of lymphoma in patients with primary Sjogren’s syndrome
Compared to other connective tissue diseases overall, life threatening or major organ complications are relatively rare and there is a massive ‘iceberg effect’ – most cases go undiagnosed.
Anti-Ro and anti-La antibodies frequently occur in primary Sjogren’s syndrome, ANA and Rheumatoid Factor may also occur.
The best approach to dry mouth is artificial saliva and meticulous attention to dental hygiene.
30
A 69 year old woman complains of pain at the base of her thumbs. On examination she has bony swelling of her thumb carpometacarpal (CMC) joints and finger distal interphalangeal (DIP) joints. Blood tests show a positive anti-nuclear antibody and a positive anti-RNP antibody. Hand radiographs show loss of joint space, subchondral sclerosis, subchodral cysts and osteophytes at thumb CMC and finger DIP joints. What is the most likely cause of her joint pain.
Select one:
a. Primary Sjogren’s syndrome
b. Systemic lupus erythematosus
c. Osteoarthritis
d. Mixed connective tissue disease
e. Limited systemic sclerosis
Osteoarthritis
The clinical and radiological features are classic for osteoarthritis.
False positive immunological tests are common and immunology should only be checked if there is reason to suspect a connective tissue disease. If the immunology was relevant then the immunology would be most consistent with SLE or MCTD
31
In SLE, patients will likely be on oral steroids long term
Select one:
True
False
Steroids should only be used when required and for short periods to suppress disease activity whilst other agents are introduced. Long term use of steroids is associated with an increased risk of cardiovascular disease, T2 diabetes and osteoporosis amongst others
32
Which of the following is NOT a recognised feature of limited systemic sclerosis?
Select one:
a. Anti-centromere antibody
b. Butterfly rash
c. Raynaud's phenomenon
d. Calcinosis
e. Pulmonary hypertension
Butterfly rash
Butterfly rash is classically a feature of systemic lupus erythematosus.
Although not included in the previous acronym ‘CREST’ pulmonary hypertension is the most serious complication of limited systemic hypertension.
Anti-centromere antibodies, Raynaud’s phenomenon and calcinosis are all characteristics of limited systemic sclerosis
33
Which of these autoantibodies is most specific for SLE?
Select one:
a. Anti-Scl-70
b. Anti-smooth muscle antibody
c. Anti-nuclear antibody
d. Anti-DNA binding antibody
e. Anti-Ro antibody
Anti-DNA binding antibody
\* ANA and Anti-Ro antibody are seen in SLE but can be seen in other conditions and are less specific.
\* Anti Scl-70 is associated with systemic sclerosis and anti smooth muscle antibody with autoimmune hepatitis
34
Which of the following would be most likely to make you suspect antiphospholipid syndrome?
Select one:
a. Pregnancy loss at 32 weeks with evidence of placental insufficiency
b. Deep venous thrombosis in a 80 year old man with pancreatic cancer
c. A single pregnancy loss at 8 weeks
d. Ectopic pregnancy
e. Myocardial infarction in a 64 year old man who smokes 20 cigarettes per day
Pregnancy loss at 32 weeks with evidence of placental insufficiency
\* Criteria for antiphospholipid syndrome include preganacy loss prior to 34 weeks due to eclampsia, pre-eclampsia or with evidence of placental insufficiency.
\* Other criteria are 3 pregnancy losses before 10 weeks or one between 10 and 34 weeks with no other explanation.
\* Thrombosis is a feature but both of these patients have other much more likely explanations.
35
Which of the following tests is not useful in a patient who presents with symmetrical, small joint swelling. On examination there is a nodule on his elbow but there are no other skin changes. Systemic examination reveals features of pulmonary fibrosis.
Select one:
a. PV and /or CRP
b. Chest X-ray
c. Hand and feet X rays
d. Anti-ds DNA antibody
e. Anti-CCP antibody
Anti dsDNA antibodies
\* PV and CRP are not specific for any condition but may suggest inflammation.
\*A chest x-ray may reveal pulmonary fibrosis.
\* Anti CCP antibodies are specific for rheumatoid arthritis which is what seems likely from the clinical picture.
\* X-rays may give prognostic information in rheumatoid arthritis.
\* Anti dsDNA antibodies are useful for diagnosis of SLE
36
The following medications are appropriate treatments for acute gout (under 4 weeks duration)
Select one or more:
a. Flucloxacillin
b. Allopurinol
c. Colchicine
d. Prednisolone
e. Non-steroidal anti-inflammatory drugs (eg. Naproxen)
c. Colchicine
d. Prednisolone
e. Non-steroidal anti-inflammatory drugs (eg. Naproxen)
37
Classical radiological findings associated with rheumatoid arthritis include which of the following features? There may be more than one correct answer.
Select one or more:
"Bamboo spine"
Subchondral sclerosis
Periarticular erosions
Loss of joint space
Osteophye formation
Subchondral cysts
Periartiular erosions + loss of joint space
38
Which of the following statements about changes on X-ray is correct?
Select one:
a. Peri-articular osteopenia and erosions are seen in rheumatoid arthritis
b. Chondro-calcification is a typical feature in gout
c. Punched out lesions are seen often in osteoarthritis
d. Pencil-in cup change is characteristic of pseudogout
e. Subchondral sclerosis is seen in psoriatic arthritis
a. Peri-articular osteopenia and erosions are seen in rheumatoid arthritis
39
HLA B27 positivity is a definite diagnostic test for Ankylosing Spondylitis
Select one:
True
False
False
40
Which of the following is the description of uric acid crystals as seen under polarised light microscopy?
Select one:
a. Hexagonal crystal structure without birefringence
b. Positively birefringent, needle shaped crystals
c. Positively birefringent, rhomboid shaped crystals
d. Negatively birefringent, rhomboid crystals
e. Negatively birefringent, needle shaped crystals
Negatively birefringent, needle shaped crystals
41
Which of the following clinical features would be most suggestive of rheumatoid arthritis?
Select one:
a. Early morning stiffness
b. Symmetrical small joint swelling
c. Pulmonary fibrosis
d. Peripheral neuropathy
e. Fever and weight loss
Symmetrical small joint swelling
42
A 45 year old non-smoking woman has been referred to you with very painful joints since 12 weeks. She has significant early morning stiffness and swelling in the small joints of her hands. On enquiry, she has lost 2 stones in weight during that time and has been feeling tired and ill. She also complains of numbness in her feet . She has also developed a cough lately and has had a couple of episodes of haemoptysis. Her medical history includes bilateral hearing loss and blocked sinuses for which she has been seeing an ENT consultant since a year.
On examination, you notice that her nasal bridge looks flat. She also has a left sided foot drop, absent reflexes and reduced sensation in a stocking distribution bilaterally. Her blood results are as follows:
Hb: 9.9 g/dl (12-16).
CRP 87(normal less than 5).
Plasma Viscosity 2.00(normal less than 1.72)
Eosinophil count 0.0
Her urine shows: Blood +
Protein +++
A CXR requested by her GP was reported as showing a cavity. She has had a CT scan and which has excluded a lung malignancy and infection.
What is the test that you would like to do next?
Select one:
a. Anti-nuclear antibody
b. Anti-mitochondrial antibody
c. Anti-CCP antibody
d. ANCA
e. Anti-centromere antibody
ANCA
The diagnosis here is most likely to be granulomatosis with polyangiitis (Wegener`s) and therefore ANCA is the most appropriate screening test. This patient is likely to have c-ANCA with anti PR3 positivity
43
Fibromyalgia syndrome can be treated successfully with a reducing course of prednisolone
Select one:
True
False
False
Treatment of fibromyalgia is complex and combines medical therapies such as atypical analgesics (amitriptyline, gabapentin) with graded exercise and psychological approaches such as cognitive behavioural therapy. There is no indication for steroids
44
You are asked to see a gentleman with weight loss, night sweats, anorexia and persistent nasal crusting and epistaxis.He has also been bothered with cough with haemoptysis .A CT scan of the chest, abdomen and pelvis organised by the admitting team has excluded a malignancy.Clinically, you are suspicious that this gentleman has a small vessel vasculitis.What is the most appropriate immunological test to request in this scenario?
Select one:
a.
Anti-nuclear antibody
b.
Anti-neutrophil cytoplasmic antibody
c.
Anti-Jo-1 antibody
d.
Anti-cyclic citrullinated peptide antibody
e.
Anti-centromere antibody
b.
Anti-neutrophil cytoplasmic antibody
ANCA
ANCA is the appropriate screening test for medium-small vessel vasculitis
45
Tenderness over the medial epicondyle?
Tenderness over the greater trochanter?
Tenderness in the heel on walking?
Tenderness over the lateral epicondyle of the elbow?
Restricted rotation of the shoulder?
\* Golfer's elbow
\* Trochanteric bursitis
\* Planter fasciitis
\* Tennis elbow
\* Adhesive capsulitis
46
In Polymyositis which of the following is most likely to be positive?
Select one:
a. Anti-DNA binding antibody
b. Anti-mitochondrial antibody
c. Anti-centromere antibody
d. Anti-Jo-1
e. Anti-La
Anti-Jo-1 antibody.
Anti-DNA binding antibody is associated with SLE, Anti-centromere with systemic sclerosis and Anti-La with Sjogrens syndrome
47
Which of the following is true?
Select one:
a. All of the above.
b. The starting dose of prednisolone in PMR is 15 mg/day.
c. The proximal limb girdle muscles are the predominant site of symptoms in PMR.
d. Polymylagia rheumatic (PMR) is seen in 50% of patients with giant cell arteritis (GCA).
e. GCA is seen in 15% of patients with PMR
All of the above
48
Polymyalgia rheumatica principally affects patients over the age of 50 years
Select one:
True
False
true
49
Which of the following statements are false?
Select one:
a. Biological agents are generally more expensive than synthetic DMARDs.
b. Anti-TNF agents are more effective in combination with standard DMARDs.
c. Anti-Tumour Necrosis Factor (TNF) agents are 1.5 times more effective than standard synthetic DMARDs
d. Biological agents are associated with a higher risk of infections than synthetic DMARDs.
e. All patients with inflammatory arthritis should be given biological agents.
All patients with inflamamtory arthritis should be given biological agents
50
Febuxostat is a uricosuric agent.
Select one:
True
False
False
Febuxostat, like allopurinol is a xanthine oxidase inhibitor, which reduces the production of uric acid
51
Osteogenesis imperfectica? Ax?
s/s?
brittle bone disease - defect of the maturation and organization of type 1 collagen
\* Ax: autosomal dominant disease
s/s
\* multiple fragility fractures of childhood
\* short stature
\* multiple deformities
\* blue sclerae
\* loss of hearing
52
Skeletal dysplasia? Ax?
Most common form?
short stature (dwarfism is no longer used)
\* Ax: genetic error (hereditary or sporadic mutation) resulting in abnormal development of bone and connective tissue
\* achondroplasia - disproportionately short limbs with aprominent forehead and widened nose. Joints are lax and mental development is normal
53
Congenital paediatric connective tissue disorders of musculoskeletal system? (4)
\* Generalised (familial) joint laxity - hypermobility which runs in families and is inherited in a dominant manner
\* Marfan's syndrome - autosomal dominant or sporadic mutation of the fibrillin gene resulting in tall stature with disproportionately long limbs and ligamentous laxity
\* Ehlers-Danlos syndrome - autosomal dominantly inherited with abnormal elastin and collagen formation
\* Down syndrome - Musculoskeletal manifestations of Trisomy 21 include short stature and joint laxity with possible recurrent dislocation (especially patella) which may require stabilization
54
s/s Marfans? (7)
\* disproportionately long limbs
\* limb laxity
\* high arched palate
\* scoiliosis
\* flattening of the chest (pectus excavatum)
\* eye problems (lens dislocation, retinal detachment)
\* aortic aneurysm and cardiac valve incompetence
55
Ehlers-Danlos syndrome s/s? (4)
\* joint hypermobility
\* vascular fragility with ease of bruising
\* joint instability
\* scoliosis
56
Duchenne muscular dystrophy?
defect in the dystrophin gene involved in calcium transport results in muscle weakness (only affects boys - x linked)
\* may only be noticed when boy starts to walk with difficulty standing (Gower’s sign) and going up stairs
\* Progressive muscle weakness follows and by the age of 10 or so he can no longer walk and by age 20 progressive cardiac and respiratory failure develop with death typically in the early 20s
57
Cerebral palsy? Ax? (6)
neuromuscular disorder with onset before 2‐3 years of age due to an insult to the immature brain before, during or after birth
\*genetic problems
\* brain malformation
\* intrauterine infection in early pregnancy
\* prematurity, intra‐cranial haemorrhage
\* hypoxia during birth
\* meningitis
58
Obstetric Brachial Plexus Palsy epidemiology? (3)
Commonest form?
\* large babies (macrosomia in diabetes)
\* twin deliveries
\* shoulder dystocia (difficult delivery of the shoulder after the head with compression of the shoulder on the pubic symphysis)
Commonest form = Erb’s palsy - injury to C5 & C6 nerve roots resulting in loss of motor innervation of the deltoid, supraspinatus, infraspinatus, biceps and brachilais muscles (leads to internal rotation of the humerus)
59
Developmental Dysplasia of the Hip (DDH)?
S/s?
Tx?
dislocation or subluxation of the femoral head during the perinatal period which affects the subsequent development of the hip joint
\* shortening
\* asymmetric groin/thigh skin creases
\* click or clunk on the Ortolani or Barlow manoeuvres
Tx = Pavlik harness
60
Transient synovitis of the hip?
Ax?
S/s?
Tx?
self‐limiting inflammation of the synovium of hip
\* Ax: occurs shortly after an upper respiratory tract infection (usually viral)
S/s
\* Fever
\* Limp
Tx = NSAIDs + rest
61
Perthes disease (aka Legg‐Calve‐Perthes disease)?
Epidemiology?
S/s?
Tx?
idiopathic osteochondritis of the femoral head (femoral head transiently loses its blood supply resulting in necrosis with subsequent abnormal growth)
\* Ex = very active boys of short stature
S/s
\* Loss of internal rotation (stiffness)
\* loss of abduction (stiffness)
\* **painless** limp (trendelenburg)
\* sometimes intermittent groin pain
\* positive Trendellenburg test
Tx = restrict weight-bearing, maintain ROM with physio (process will self-terminate)
in severe cases surgery is req
62
Slipped Upper Femoral Epiphysis?
S/s?
Dx?
Tx?
condition mainly affecting overweight pre‐pubertal adolescent boys where the femoral head epiphysis slips inferiorly in relation to the femoral neck
s/s
\* **patients can present purely with pain in the knee!!!**
\* **Loss of internal rotation of the hip is the predominant clinical sign**
**\*** antalgic limp
\* groin pain
Dx = x-ray (ice cream falling off cone)
Tx **= URGENT** surgery to pin the hip
+ pin other side as prophylaxis
63
Talipes Equinovarus?
Epidemiology?
Tx?
Clubfoot - in utero abnormal alignment of the joints between the talus, calcaneus andnavicular
\* Boys are twice as commonly affected than girls
\* Tx = technique of splintage, known as the Ponseti technique
64
Hallicus valgus?
Ax?
deformity of the great toe due to medial deviation of the 1st metatarsal and lateral deviation of the toe itself
Ax = idiopathic
65
Epidemiology hallicus valgus? (5)
\* Females \> males
\* FH
\* Elderly
\* RA
\* MS and cerebral palsy
66
Tx hallicus valgus? (3)
\* Wider + deeper shoes
\* Spacer in 1st web space to stop toes rubbing
\* Surgery (however 30% patients dissatisfied following surgery)
67
Hallicus rigidus?
Tx? (3)
OA of the 1st MTP
\* Tx = stiff-soles shoes to limit movement of MTP, cheilectomy (removal of osteophytes), **gold standard is surgical arthrodesis** (fusion)
68
Morton's neuroma?
S/s? (3)
Ax?
Irritated nerves become inflamed and swollen forming a neuroma
\* Burning/tingling in affected toes
\* Loss of sensation in affected web space
\* Mulder's click test - squeeezing forefoot with hand produces characteristic **click**
**Females \> men due to high heels D:**
69
Tx Morton's neuroma? (3)
\* Offloading insole
\* Steroid/local anaesthetic injections
\* Nueroma can be excised (however, not always successful)
70
Metatarsal stress fractures affect?
Epidemiology?
Dx?
Tx?
most commonly occur in the 2nd metatarsal followed by the 3rd
\* Epidemiology = runners, soldiers, dancers
\* Dx = x-rays may not show fracture for `3 weeks so **bone scan** most useful
\* Tx = REST + rigid sole boot
71
Ax tendonitis of achilles tendon? (4)
S/s?
\* repetitive strain (from sports)
\* Quinolone antibiotics (ciprofloxacin etc)
\* rheumatoid arthritis,
\* gout
S/s = pain in heel (duh)
72
Tx achilles tendonitis? (4)
\* Rest
\* Physio
\* Heel raise to offload tendon
\* Spinlt/boot
(decompression surgery is contraversial)
73
Achilles tendon rupture risk factors?
s/s achilles tendon rupture? (5)
Tx? (2)
Risk factors = tendonitis + steroid injection
\* Sudden pain (like being kicked)
\* Difficulty weight bearing
\* Weakness of planter flexion
\* Palpable gap in tendon
\* **Simmonds test** (no planterflexion of foot when squeezing calf)
Tx = contraversial
\* Non-operative e.g. casts
\* Operative = repair of tendon
74
Plantar fasciitis s/s? (2)
Ax? (3)
Tx? (4)
Pain when walking + tender of palpation
\* Diabetes, obesity + walking on hard floors
Tx (symptoms can take up to 2 years to resolve)
\* Rest
\* Stretching exercises
\* Gel heel pad
\* Corticosteroid injection
75
Pes planus?
Ax acquired pes planus? (3)
Flat foot - can be normal variation
\* Ax acquired = tibialis posterior rupture, RA, diabetes with Charcot foot (joint destruction)
76
Tibialis posterior tendonitis tx? (3)
Consequences of untreated tibialis posterior tendonitis?
Tx for consequence?
Tx = splint w medial arch support
\* If fails = surgical decompression and tensocynovectomy
Consequences = flattening of medial arch of foot + secondary OA
\* Once OA occurs, best treatment is **arthrodesis**
77
Pes cavus?
Ax?
Tx? (2)
abnormally high arch of the foot
\* can be idiopathic but is often related to neuromuscular conditions: Hereditary Senory and Motor Neuropathy, cerebral palsy, polio (unilateral) and spina bifida
\* Tx = soft tissue releases if supple + calcaneal osteotomy if rigid
78
Ax claw and hammer toes?
Features of claw toes?
Hammer toes?
acquired imbalance between the flexor and extensor tendons
\* Claw toes = hyper**extension** at the MTPJ + hyper**flexion** at the PIPJ and DIP
\* Hammer toes = same thing but hyper**extension** at DIP
79
Tx claw and hammer toes? (4)
\* Tenotomy (cut overactive tendon)
\* Tendon transfer
\* Arthrodesis of PIP
\* Toe amputation
80
Surgical strategies for arthritis?
\* Arthroplasty/joint replacement
\* Excision or resection arthroplasty
\* Arthrodesis
\* Osteotomy
81
True or false: Acute osteomyeltis, in the absence of previous surgery, is more common in children than adults
True
82
Match the correct nerves at risk of compression at he following anatomic sites in the upper limb
1 = cubital tunnel
2 = carpal tunnel
1 = ulnar nerve
2 = median nerve
83
Serious complications of joint replacement? (5)
\* Infection
\* PE
\* Pneumonia
\* MI
\* Dislocation of prosthesis
84
What is a pseudotumour?
an inflammatory granuloma produced in response to metal wear particles in the context of a joint replacement, which may be locally invasive but cannot metastasise
85
What is the **chief indication** for hip and knee joint arthroplasty?
Pain (**not stiffness**)
86
What type of joint procedure is being described below?
"The surgical stiffening or fusion of a joint in a position of function."
Arthrodesis
87
A 60 year old lady presents with a painful bunion on the medial aspect of her left forefoot at the 1st MTPJ. There is lateral angulation/deviation of the great toe causing the second toe to over-ride the great toe.
Hallux valgus
88
A 70 year old man presents with a painful, swollen and erythematous right 1st MTPJ. This condition is relapsing and remitting. On inspection, the joint is warm but he's able to move it. There are some white nodules under the surface of the skin. The patient is systemically well.
Gout
89
This 50 year old lady complains of left 1st MTPJ pain on walking, particularly when wearing thin, non-supportive shoes. She cannot wear high heels because of the pain and stiffness in the joint. On examination, active and passive range of movement of the joint is reduced (and quite tender at the end range of movement) and grind test is positive.
Hallux rigidus
90
A 20 year old girl presents with bilateral broad forefeet complaining of difficulty finding shoes that accommodate her wide feet. On examination, the toes look normal and there are no callosities but the forefeet do look wide. On xrays, the forefoot is broad with an increase in the intermetatarsal angle.
Primus varus
91
A 55 year old lady presents with an occasional tingling sensation in her 2nd and third toes which is often preceded by a sharp pain shooting into her forefoot. She's otherwise well with no other co-morbidities and sensation of the foot is completely normal. However, on Mulder's click test, there is a palpable 'clunk' in the forefoot and the patient complains of the shooting pain.
Morton's neuroma
92
A 60 year old lady presents with a complaint of right foot pain. On closer questioning, she tells you she first noticed it a month ago and it's been getting worse since. She feels it on the instep of her foot (medial arch) and it's worse if she does a lot of walking. On examination, she is acutely tender over the calcaneal tuberosity at the posterior end of the medial arch.
What is the most likely diagnosis?
Plantar fasciitis
93
True or false: A metatarsal stress fracture can be quickly and easily ruled out by a prompt xray of the affected foot.
FALSE
Xrays may not demonstrate a fracture for around 3 weeks until resorption at the fracture ends occurs or callus begins to appear. Bone scan or MRI may be useful to confirm the diagnosis
94
You are an orthopaedic registrar in the orthopaedic clinic. You are asked to review a 12 year old boy referred by his GP with a lump in his thigh.
The boy is systemically well and has no significant past medical history. He reports that the lump started about 9 months ago after he fell off his bike and bruised his thigh. Initially it was soft but has hardened. He reports the size was increasing but it hasn't grown in some time now.
On examination, the mass is very hard and is somewhat mobile in the anterior compartment of the thigh but it feels tethered within the muscle. It isn't tender.
What is the likely diagnosis?
Myositis ossificans (usually occurs in muscles after injury)
95
A quadricep tendon rupture is a relatively common injury in the patient over 40 and rarely requires surgical intervention.
False - almost always surgically managed
96
The thickest hyaline cartilage in the body is found on the articular surface of which bone?
Patella
97
Hallmark of shoulder impingement syndrome?
Ax? (3)
Tx? (4)
What about persistent cases?
Painful arc
\* Tendonitis subacromial bursitis
\* Acromioclavicular OA with inferior osteophyte
\* Rotator cuff tear
Tx: analgesics, NSAIDs, physio, steroid injection
\* Persistent cases treated with subacromial decompression surgery
98
Tx rotator cuff tears?
Contraversial
\* Surgery
\* Non-operative: physio, steroid injections
99
Acute calcific tendonitis?
acute onset of severe shoulder pain characterized by calcium deposition in the supraspinatus tendon (seen on xray just above greater tuberosity)
100
2 types of shoulder instability?
\* Traumatic instability = mostly anterior dislocation
\* Atraumatic instability = ligamentous laxity (EDL, Marfan's)
101
What can be considered as an alternative surgical option to joint replacement for knee arthritis in a young patient?
Tibial osteotomy
102
What anatomical structure is inpinged in shoulder impingement? Hip impingement?
Shoulder impingement = rotator cuff tendon
Hip impingement = acetabular labrum
103
The principle sign on examination of shoulder impingement is restriction of shoulder movement in which direction?
External rotation
104
Risk of recurrent shoulder dislocation following a traumatic shoulder dislocation increases with age of patient at first-time dislocation. True or false?
FALSE!! - after reduction may settle along with physio
105
Hueston Table Top Test?
What degree of fixed flexion deformity is required at the MCPJ for a patient to fail the Hueston Table Top Test?
For Dupuytrens disease
\* \>30 degrees
106
What conditions and risk factors increase the liklihood of carpal tunnel syndrome? (6)
\* RA
\* Wrist fracture
+ conditions resulting in fluid retention:-
\* pregnancy
\* diabetes
\* Chronic renal failure
\* Hypothyroidism
107
Froment's test?
Weakness of which muscle will give rise to a positive froment's test?
positive test reflects ulnar nerve dysfunction
\* Adductor pollicus (supplied by ulnar nerve) - abductor pollicus brevis and opponens pollicus are supplied by median nerve
108
Fracture patterns
109
What is the pelvic ring composed of? (4)
Sacrum, ilium, ischium and pubic bones with strong supporting ligaments
110
What are the dangers with pelvic ring fractures? (2)
\* Branches of internal iliac artery and venous plexus are prone to injury and HYPOVOLAEMIA
\* Nerve roots of lumbo-sacral plexus also prone to injury
111
Patterns of pelvic injury? (3)
\* Lateral compression fracture - side impact (one half of pelvis displaced medially)
\* Vertical shear fracture - axial force (fall from height) - hemipelvis displaced superiorly
\* Anteroposterior compression injury - open book pelvic fracture
112
Risks with displaced femoral shaft fractures? (2)
\* Blood loss
\* Fat embolism
113
Tx femoral shaft fracture?
\* Analgesia
\* Thomas splint
\* `Closed reduction + stabilisation with intramedullary nail
114
Why is a knee dislocation a surgical emergency?
(REMEMBER = knee is NOT the same as patella!!!!)
High incidence of vascular injury, nerve injury + compartment syndrome
115
Knee dislocation tx? (3)
\* Reduction
\* Revascularisation
\* Ligament reconstruction
116
Predisposition to patellar dislocation? (5)
\* Females
\* Ligamentous laxity
\* Valgus alignment
\* Femoral neck anteversion
\* Shallow trochlear groove
117
Plateau fractures?
Tx?
Proximal tibia fractures - intra articular fractures
\* Tx = plates and screws
118
Tx tibial shaft fractures? (2)
\* Non-operative = above knee cast
\* Operative = internal fixation (i**ntramedullary nailing is most common method!**!)
119
Types of tibial shaft fracture? (4)
\* bending (transverse fracture)
\* rotational energy (spiral fracture)
\* compressive force from deceleration (oblique fracture)
\* high energy injuries (comminuted fracture - require surgical stabilisation)
120
Ottawa criteria ankle fractures?
severe localized tenderness (known as bony tenderness) of the distal tibia/fibula or inability to weight bear for four steps merits an xray
121
What is it important to distinguish with ankle fractures?
What are these?
Tx?
distinction needs to be made between **stable** and **unstable fractures**
**\*** Stable = isolated distal fibular fractures with no medial fracture or rupture of the deltoid ligament
\* Tx = cast or splint for 6 weeks
\* Unstable = distal fibular fractures with rupture of the deltoid ligament
\* Tx = ORIF (plates + screws)
122
When would you suspect deltoid ligament rupture in ankle fractures? (2)
\* bruising and tenderness medially
\* talar shift
123
Example of unstable ankle fracture?
Bimalleolar fractures (req ORIF)
124
Which metatarsals are commonly fractured?
Uncommonly?
\* 5th metatarsal - inversion injury
\* 2nd metatarsal - stress fracture during exercise
\* First metatarsal **uncommonly** fractured due to thickness and strength
125
Tx toe (phalynx) fractures?
Dislocations?
Fractures
\* Closed = stout boot
\* Open = wires
Dislocations
\* closed reduction + neighbour strapping
126
limited features systemic sclerosis?
127
ANCA antibodies and respective small vessel vasculitis?
GPA = cANCA + PR3
EGPA = pANCA
MPA = pANCA + MPO
