MSK5

Question 1

What are the symptoms of an ACL tear

Answer 1

Non contact injury - sidestep/pivot, land from a jump

Contact - valgus force

pop/collapse/effusion is the triad

Audible pop or crack

KNEE GIVES WAY

immediate pain, poor localisation

Difficulty weight bearing

Knee effusion

CHRONIC history

Instability and/or swelling during activities requiring a change of direction/pivoting

Question 2

What is the mechanism of injury in an anterior cruciate tear?

Answer 2

Serious and disabling injury - can result in chronic knee instability

MECH - sudden change in direction with leg already under significant momentum.

Internal tibial rotation on a flexed knee - eg during pivoting

Marked valgus force - eg rugby tackle

IMMEDIATE effusion of blood within 20 minutes

Subsequent history of knee giving way

Question 3

What examination findings would you expect with an anterior cruciate injury?

Answer 3

Gross joint effusion

Diffuse joint line tenderness

Joint may be locked due to effusion

can have signs of associated meniscal tear (usu medial)

Special tests - anterior drawer - pos or neg

Lachman - pos with no end point

pivot shift test - pos if joint instability

Question 4

Management of anterior cruciate ligament injury?

Answer 4

Surg repair reserved for complete tears

early reconstruction in young athletes

In less active ppl - conservative approach

The ACL can be trimmed and complete repair undertaken if joint becomes unstable

Question 5

How does a posterior cruciate ligament injury present? Mechanism of injury? Hx/Ex? Management?

Answer 5

Mechanisms of injury: Direct blow to the anterior tibia in flexed knee

Severe hyperextension injury

ligament fatigue plus extra stress on knee

Hx: Posterior popliteal pain radiating to calf. No/minimal swelling. Limitation of running/jumping. Pain walking down stairs.

O/E Posterior sag, Posterior draw pos

Mx - Immobilise and protect for six weeks,

Graduated weight bearing exercises

Question 6

What is the mechanism of injury of a medial collateral ligament tear?

Answer 6

Direct valgus producing force to knee (from lateral side) - eg rugby tackle from the side

External tibial rotation

Question 7

What are the clinical features of medial collateral ligament tear?

Answer 7

Depends on severity of tear/1st - 3rd degree

Pain in medial knee - agravated by twisting or valgus stress

localised swelling over medial aspect

pseudo locking - hamstring strain and effusion

no end point on valgus stress testing - 3rd degree

CHECK Lateral meniscus if Medial collateral ligament tear

Pelligrini - stieda syndrome - calcification in haematoma at upper origin of MCL may follow

Question 8

What is the management of a medial collateral ligament tear?

Answer 8

Conservative treatment with early limited motion bracing to prevent opening of the medial joint line.

Six weeks of limited motion brace at 20 to 70 degrees follwed by knee rehab - returns athlete to full activity within 12 weeks.

Question 9

What causes a lateral collateral ligament rupture?

Answer 9

Varus producing force (From medial side of knee)

Same principles of management as MCL rupture

however often cruciate ligament is also torn with LCL (So both need managment)

Question 10

What is the mechanism of a medial meniscal injury

Answer 10

Abduction of the femur on the tibia, semi knee flexion, internal rotation of the femur on the tibia

MABIR

Cause the meniscus to be compressed between tibial and femoral condyles and then subjected to twisting force on a semi flexed knee

Question 11

What is the mechnaism of a lateral meniscal injury?

Answer 11

Adduction of the femur on tibia, semi knee flexion, External rotation of the femur on the tibia

LADER

Cause the meniscus to be compressed between tibia

Question 12

When should you suspect a meniscal injury?

Answer 12

INjury with a twisting movement with the foot firmly fixed on the ground

Question 13

Which is more common medial or lateral meniscal injury?

Answer 13

Medial is three times more common

Question 14

What are the clinical features of a medial or lateral mensical injury? What is the managment?

Answer 14

Knee pain (Medial in MM, Lateral in LM)

Swelling

Locking

SIGNS (3 out of 5 needed)

• localised tenderness (Medial in MM, Lateral in LM)*
• Pain in hyperextension*
• Pain in hyperflexion*
• Pain on rotation of lower leg*
• weakened or atrophied quads*

MANAGEMENT - largely surgical

Arthroscopic partial meniscectomy

Question 15

What are the clinical features of Osgood Schlatter disease?

Answer 15

Presents in children 10-15 years old

More in boys 3:1

Very active kids

Bilateral in 1/3

Initially pain after activity

Later pain during activity and localised pain where the patellar tendon joins the tibial tuberosity

pain worse on climbing (up or down) and kneeling

ON examination - Localised tenderness and a lump can be noted

Pain can be reproduced by straighening or flexing the knee against pressure.

Ix - XRAY to exclude tumour or fracture

Question 16

What is the treatment of Osgood Schlatter disease?

Answer 16

Avoid aggravating activity

ICe and simple analgesics

Physiotherapy for graduated quadriceps stretching exercises

Graduated return to full activity

Surgery is an option if irritating ossicles remain

Question 17

What is Osteochondritis Dissecans? How does it present? Managment?

Answer 17

Common in adolescent boys age 5-15

Part of the intraarticular cartilage of the femoral epicondyle necroses and forms an intra-articular foreign body.

• This causes pain, effusion, and locking

Management - surgical reattachment

Question 18

Dorsal and radial sided wrist pain after a FOOSH

• When deviating from ulnar to radial, pressure over volar aspect of base of thumb produces a ‘clunk’

What is the injury?

Answer 18

Scapholunate ligament injury

Question 19

What is a potential complication of scaphoid fracture?

Answer 19

Non union and Avascular necrosis of the proximal pole

Question 20

What are the clinical features of De quervains tenosynovitis?

Answer 20

Typical Age 40-50

Pain AT and PROXIMAL to RADIAL border of wrist

Pain During Pinch Grasping

Pain on THUMB and WRIST movement

Dull ache or severe pain (acute flare up)

Can be disabling with inability to use hand (eg writing)

TRIAD

Tender, localised swelling at Radial styloid

Tenderness (With possible creps) on palpation over and just proximal to radial styloid

Positive finkelstein test (fold thum into palm and ulnar deviate - pain at radial wrist border)

Question 21

Treatment of De quervains tenosynovitis?

Answer 21

Rest from causative stress and and strain on thumb adductors

Use a custom made splint that involves the thumb and immobilises the wrist

Consider a trial of topical or oral NSAIDS TDS for two to three weeks

Corticosteroid injection can be curative (inject into the tendon sheath rather than the tendon)

Surgical release for chronic cases

Question 22

A patient presents with BURNING, REDNESS and SWELLING of the hands after exposure to heat or exercise?

Answer 22

Erythromelalgia

Primary or Secondary to diabetes or connective tissue disorders

TREATMENT - Trial of a) asprin b) phenoxybenzamine c) Sympathectomy

Question 23

Sudden onset of pain and cyanosis of ventral aspect of a digit - and then the whole digit.

Lasts 2-3 days - attacks can recur one or more times a year.

Answer 23

ACUTE BLUE FINGER SYNDROME (in women)

Cause is rupture of vein at base of finger.

Supportive mx

Question 24

What are the clinical features of Raynauds phenomenon

Answer 24

Acute vasospasm of small vessels of fingers (spares the thumb)

Sequential colour change - Initially WHITE, then blue, the red with return of circulation.

Mild - no tx

more severe - associated with pain and tingling

Occurs in ppl with a) connective tissue disorders - eg Scleroderma, or Rheumatoid, and people on medications such as betablockers, ergot meds or antihypertensives

Question 25

What are treatments of Raynauds phenomenon

Answer 25

TREATMENT - keep warm, stop/avoid smoking, avoid activities that put repetitive pressure on fingers Meds - GTN patch, Amlodipine 5mg OD, Nifedipine 20mg OD

Question 26

What are risk factors for Raynauds?

Answer 26

1. Cold weather 2. Stress 3. Using heavy, vibrational equipment 4. Drugs that can cause vasospasm of small vessels - eg betablockers and migraine meds

Question 27

Older person (over 45 years) Pain in lateral hip extending to the foot. Pain worse on lying down at night. Pain climbing stairs and getting in and out of car. Localised tenderness in outer border of thigh. Normal Xray

Answer 27

**Greater trochanteric pain syndrome** This is **GLUTEUS MEDIUS** tendinopathy. Often in older people after long walks or gardening. NIGHT time pain after activity. normal xray. **Management:** If safe - trial of NSAIDS Physiotherapy for graduated activity and hip strengthening Ultrasound guided Corticosteroid injection

Question 28

Lateral knee pain. Worse with running or cycling. Most intense with HEEL STRIKE. Worse with climbing stairs/hills.

Answer 28

ILLIOTIBIAL BAND PAIN SYNDROME Fascial band which extends from pelvis - over hip and knee, and inserts just below the knee.

Question 29

What is patellofemoral pain syndrome?

Answer 29

This is chondomalaciae patallae. Runners knee, joggers knee, cyclists knee. The most common **overuse injury** of the knee **ANTERIOR pain** - often presents in young girls 10-13 or in older people with osteoarthritis 50-70. Usu no trauma. They often describe pain on sitting with knees flexed. **'movie goers knee'.** Relieved by extenison. Signs: 1. **Crepitus** on knee flexion. 2. **Pain on knee flexion/squatting/** 3. **Perkins sign -** pain on the **patella facet pinch test** - patellar moved laterally and facet palpated. Pain and creps in knee on flexion. 4. **Clarkes sign**. Pain on inferior movement/pressure of the patellar during **Active Quadriceps flexion.** 5. **"Inward looking"** patellar 6. **Quads wasting.** 7. Sometimes an **effusion.** Perkins pinches Clarkes quads at movies

Question 30

Whats the management of the patellofemoral pain syndrome?

Answer 30

1. Rest from aggravating activity 2. Physiotherapy for graduated exercises 3. Trial of oral NSAIDS 4. Correct Biomechanics - if flat feet - orthotics/heel raise 5. Use of knee brace REFER IF: 1. No improvement after 8 weeks 2. Recurrent effusions. 3. Locking, instability 4. Night pain

Question 31

Gradual onset of anterior knee pain, localised just below the knee. Pain eased by rest. Pain with jumping.

Answer 31

PATELLAR TENDINOPATHY Examine for tenderness in the patella tednon by palpating under the patella - By fully extending the knee and then applying pressure to the superior pole which lifts the inferior edge and allows the tendon to be palpated. SHARP PAIN. Classic in jumpers! High jump, volleyball, basketball. Managment: 1. **Rest** from aggravating activity. 2. **Physiotherapy** for exercise based management. 3. **Training modification** - use of calf, hamstring and quadriceps muscle stretching. 4. **Modified footwear** and Patellar tendon strap.

Question 32

Anterior knee swelling in a carpet layer or housemaid?

Answer 32

Pre-patellar bursitis. Causes: 1. Repetitive pressure on the pre-patellar bursa. 2. Infectious bursitis. 3. Gout/Crystal arthropathy 4. Seronegative spondylarthropathy or inflammatory arthritis (RA) Management: 1. Rest from the aggravating activity. 2. Aspiration of fluid from bursa. 3. Corticosteroid injection.

Question 33

Anterior swelling just below the knee in a catholic priest?

Answer 33

Infrapatellar bursitis Causes: 1. Repetitive pressure on the infra-patellar bursa. 2. Infectious bursitis. 3. Gout. 4. Seronegative spondylarthropathy **Management:** 1. Rest from the aggravating activity. 2. Aspiration of fluid from bursa. 3. Corticosteroid injection.

Question 34

Management of persistent prepatellar or infrapetallar bursitis?

Answer 34

Surgical referral

Question 35

Where does a hamstring injury usually occur?

Answer 35

Proximally and laterally in the Biceps femoris usually. Can occur in sprints - at beginning or end - from lack of warm up or fatigue. Grade 1 - mild sprain , Grade 2 - moderate strain, Grade 3 - Complete tear Can be chronic strain In acute setting - sudden onset. MX of a tear - **RICE - 48 hours - 6hourly ice packs for 20 minutes** After 48 hours - Commence **mobilising with physiotherapy -graduated activity and rehabilitation** Large tears - with avulsion from the ischial origin - needs surgery

Question 36

Patient presents with burning and numbness in the lateral compartment of the anterior thigh. Pain does not cross midline. Recent weight gain/pregnancy.

Answer 36

Meralgia Paraesthetica. This is entrapment of the the LATERAL femoral cutaneous nerve of the thigh being entrapped under the inguinal ligament. Usually entrapment - 1cm medial to ASIS. From fibrosis in middle age, or from obesity, pregnancy. DOES NOT CROSS Midline L2 or L3 neuropathy would involve the buttock. Femoral neuropathy would cross the midline. Treated with **corticosteroid injection under the inguinal ligament (medial to ASIS)** **Neurolysis** if Refractory **Treat cause** - if weight related.

Question 37

Female Patient (under 50) with tight shoes presents with burning pain between 3rd and 4th metatarsals or 2nd and 3rd metatarsals?

Answer 37

Mortons neuroma Overuse and tight shoes. (not a true neuroma) Dx on ultrasound. Severe **burning pain**, sometimes **sharp and shooting** **between 3rd and 4th Metatarsal HEADS or 2nd and 3rd** - Worse on weight bearing/standing/walking and tight shoes Relieved when taking off shoes and squeezing forefoot. Localised tenderness between metatarsal heads. Mx **Avoid tight shoes** - use flat, wide based shoes **Orthotics** **NSAIDS** **Steroid injections** Surgery in refractory cases

Question 38

What are the causes of bursitis?

Answer 38

1. Direct injury or trauma 2. Overuse or strenuous activity 3. Prolonged pressure over the area 4. Crystal arthropathy - eg gout 5. Inflammatory arthritis eg RA 6. Spondyloarthropathy 7. Infection leading to septic bursitis

Question 39

Management of Olecranon Bursitis

Answer 39

1. **Avoid aggravating activity**. 2. **Aspirate fluid** from bursa. 3. **Corticosteroid injection** into the bursa 4. Joint protection with a **protective elbow orthosis** 5. **Surgery** in refractory casese

Question 40

Patient presents with pelvic pain - worse during activity, and on examination has pain in the pubic symphisis and pain on resisted testing of the adductor muscles of the thigh.

Answer 40

Osteitis Pubis Xray - widening of pubic symphysis Mx - Rest from aggravating activity Trial of oral NSAID Physotherapy for graduated activity Corticosteroid injection Surgerical managment (curretage of symphisis in refractory cases)

Question 41

What is the characteristic pathology in Pagets

Answer 41

Dense, Enlarged, Deformed bones. Pagets is characterised by incrased osteoclastic activity (increased resorption of bone) and corresponding increase in disorganised osteoblastic activity - so lots of newly formed abnormal bone which leads to lytic lesions as well as scleoritic new bone. Dense , expanded bone on Xray. Patients can be a) asymptomatic or present with b) bone pain c) bone deformity d) arthropathy or e) neurological syndromes

Question 42

How is Pagets Diagnosed?

Answer 42

1. ALP greater than 125 with no other cause identified. 2. Pagetic lesions on xray or bone scan (oftne found co-incidentally as patients are often asymptomatic)

Question 43

What other causes of elevated ALP have to be excluded in Pagets

Answer 43

1. Liver disease - any cholestatic cause 2. Vitamin D deficiency 3. Hyperparathyroidism CHECK LFT's, Vitamin D, Calcium, PTH

Question 44

Does normal ALP exclude pagets?

Answer 44

No. Could be inactive disease or mono-osteotic (single bone)

Question 45

Is there a way of differentiating elevation in APL in pagets from liver disease ?

Answer 45

You can request an iso-enzyme assay - which is bone specific

Question 46

How is the diagnosis of Pagets disease made?

Answer 46

**Elevated ALP** (with normal calcium/phospate) Over 125 suggests active dsiease **Plain Xray** - (skull and pelvis) - Dense expanded bone (lytic and sclerotic areas) CAN MIMIC prostatic cancer secondaries so **EVERY MALE PATIENT should have DRE AND PSA** **Bone Isotopic scan** - useful in locating specific areas Watch for uncommon **COMPLICATION of OSTEOGENIC SARCOMA** **Screen** - siblings and children 5 YEARLY after 40 years of age

Question 47

Whats the DDX of Pagets

Answer 47

Metastatic disease Osteomalacia Osteosarcoma

Question 48

TReatment of pagets?

Answer 48

Only in symptomatic patients or patients who have a lesion at a critical site (active disease, need ortho surg, neuro symptoms) _Bisphosphonates **(short term)**_ **IV Zoledronic acid infusion 5mg over 15 minutes** *(Vit D over 50, EGFR over 35, normal calcium, well hydrated*) OR Residronate 30mg orally daily on an empty stomach for 2 months OR Pamidronate 60mg IV infusion over 4 hours. Recheck ALP in 3 months. **ALP is best way of monitoring** **Normal levels often indicate symptom relief**

Question 49

CLinical features of a patellar dislocation

Answer 49

Usually **laterally displaced** Young women mainly- often during sports Can Also have and **osteochondral fracture which MUST be excluded by XRay** O/E Positive apprehension test (apply lateral pressure to patellar and medial instability is assumed when the patient says no/tries to stop further movement). Feel for patellar defect, joint swelling and joint line tenderness Order XRay AP and Lateral to exclude osteochondral defect. T/F to ED for Enlocation under nitrous oxide or with (diazepam/pethidine) RICE immediately Knee splint for 4 weeks Crutches

Question 50

Patellar instability/subluxation

Answer 50

Not usually dislocating but is mobile an causes pain Positive apprehension test Physiotherapy Splint for sporting activity may need surgical management if conservative management fails

Question 51

Investigations in ACL rupture and acute management

Answer 51

Xray - assess for **tibial avulsion** fracture MRI knee Early referral to physio and ortho acutely rest/ice/elevate analgesia

Question 52

Examination findings in ACL

Answer 52

Large effusion Decreased ROM 2-3 weeks post injury Posterolateral tenderness Tenderness at attachment of medial collateral ligament Positive lachmans (at 30 degrees) with soft end point positive pivot shift test

Question 53

Who needs an ACL reconstruction? When?

Answer 53

Very young recreational activities involving jumping/pivoting/side stepping expected to return to heavy work experiencing instability in every day activities IN subacute phase 2-12 weeks post injury Post surg - 6-12 months before return to sport will need a period of rehab In kids - concern is open growth plate - soft tissue grafts are graft of choice

Question 54

What are the ottawa ankle rules

Answer 54

Question 55

what are the ottawa knee rules

Answer 55

Question 56

Differential in acute knee injuries - clinical features

Answer 56