Ortho

Question 1

Carpal Tunnel

Answer 1

Compression of the median nerve (palmar digital branch) as it travels between carpals and flexor retinaculum

RF - repetitive strain, pregnancy, perimenopause, obesity, RA, DM, acromegaly, hypothyroid

= sensory symptoms from thumb to lateral ring finger, reduced thumb abduction, wasting of thenar eminence, Tinel’s (tapping), Phalen’s (pray)

Question 2

Carpal Tunnel: Management

Answer 2

Inv - nerve conduction (prolonged AP in motor and sensory fibres)

-> 6wks conservative management (steroid injection, wrist splint), surgical decompression if severe

Question 3

Hip Dislocation

Answer 3

Posterior (90%) = shortened, adducted, internally rotated

Anterior: abducted, externally rotated, no shortening

-> reduce under GA <4hrs, physio

Comp - sciatic nerve injury (foot drop), femoral nerve injury (anterior thigh sensation), avascular necrosis, OA, recurrent dislocation

Question 4

Bisphosphonate Holiday

Answer 4

MOA - inhibit osteoclasts

SE: oesophagitis, oes ulcers, osteonecrosis of the jaw, atypical stress fractures, APR, v Ca

After 5 years PO or 3 years IV, re-assess with FRAX score and DEXA scan

Continue if; >75yrs, prev hip/ vertebral fracture, high risk FRAX, new fractures whilst on drugs, T score <2.5

Can stop for 2 years and reassess again

Question 5

Paget’s Disease

Answer 5

Increased uncontrolled bone turnover, mostly affects skull, spine, pelvis and leg long bones

RF - age, M

= bone pain

Inv - isolated rise in ALP, normal Ca/ PO4, XR (osteolysis and sclerosis), skull XR (thick vault, OP circumscripta,cotton wool), bone scintigraphy (^uptake)

-> bisphosphonates if symptomatic

Comp - skull bossing, deaf, fractures, high-output HF, tibial bowing, sarcoma

Question 6

Colles’ Fracture

Answer 6

Fracture of distal radius with dorsal displacement

Cause - FOOSH

= dinner fork deformity

Comp - median nerve palsy, compartment syndrome, vascular compromise, malunion, EPL rupture

Question 7

Smith’s Fracture

Answer 7

Reverse Colles’, volar angulation of distal radius fragment

Cause - fall backwards onto palm

= garden spade deformity

Question 8

Monteggia Fracture

Answer 8

Dislocation of proximal radioulnar joint and ulnar fracture

Cause - FOOSH (forced pronation)

Question 9

Bennett’s Fracture

Answer 9

Intra articular fracture of 1st CMC (thumb)

Cause - impact on flexed metacarpal (fist fight)

Comp - abductor pollicis longus makes it hard to maintain reduction (unopposed pull)

Question 10

Other Fractures

Answer 10

Galeazzi
= radial shaft fracture + dislocation of distal radioulnar joint

Bartons
= distal radial fracture (C/S) + radiocarpal dislocation

Radial Head Fracture
= tender head of radius, impaired elbow movement

Pott’s
= bimalleolar ankle fracture

Question 11

OP Vertebral Fracture

Answer 11

Fragility fracture: mechanical force causes a fracture where in a normal person it would not, common in spine

= acute back pain, breathing issues, GI compressive symptoms, v height, kyphosis, local tenderness

Inv - XR spine (wedging, old sclerotic fractures), CT, MRI

? Future risk - DEXA, FRAX/ Qfracture tools (10yr)

Question 12

Psoas Abscess

Answer 12

Cause - primary (blood, staph aureus) or secondary (Crohn’s, CRC, IVDU, UTI, osteomyelitis, IE)

= fever, back/ flank pain, limp, weight loss, pain on hyperextension and resisted flexion of the hip, may lie in mild external rotation (knee flexed)

Inv - CT abdo

-> Abx and PC drainage

Question 13

Acetabular Labral Tear

Answer 13

Cause - 2nd to trauma or degenerative change

= hip/ groin pain, snapping/ locking sensation

Question 14

Achilles Tendon Rupture

Answer 14

RF - ^age, FHx, quinolones (-floxacin), steroids, high cholesterol, inflammatory conditions, DM

= audible pop, sudden pain, loss of function, Simmond’s (angle of declination/ dorsiflexion, palpable gap, calf squeeze)

Inv - US

-> referral to ortho

Tendinitis: gradual onset posterior heel pain, try analgesia and eccentric calf exercises

Question 15

AC joint injury

Answer 15

1-2: very common, rest in sling

3: depends on the individual

4-6: rare, surgery

Question 16

Adhesive Capsulitis

Answer 16

Frozen shoulder, inflammation and fibrosis of the joint capsule leads to adhesions which restrict movement

RF - middle-age F, DM

= external rotation worst, active and passive effected, painful freezing, adhesive and recovery phase, 20% bilateral

-> NSAIDs, physio, steroids (PO/ IA)

Question 17

Weber Classification

Answer 17

Describes level of fibula fracture in ankle injuries

A - below the syndesmosis
B - fractures start at tibial plafond, may extend proximally to involve the syndesmosis
C - above the syndesmosis

-> all ankle fractues should be promptly reduced, surgery if young and unstable/ high velocity/ proximal injuries

Question 18

Ottawa Rules for Ankle XR

Answer 18

Required only if pain in the malleolar zone + one of;

Bony tenderness at lateral malleolar zone

Bony tenderness at the medial malleolar zone

Inability to walk four weight-bearing steps immediately after the injury and in ED

Question 19

Ankle Sprains

Answer 19

Low: involving lateral collateral ligaments, most common, ^ATFL
Cause - inversion
Grade 1-3 based on ligament disruption, bruising, pain

High: involving syndesmosis
Cause - external rotation
= more painful, Hopkins squeeze +ve

Inv - XR (widening), MRI if suspect syndesmotic or persistent pain

-> fixation if widening, cast or orthosis if not

Question 20

Avascular Necrosis of the Hip

Answer 20

Death of bone tissue 2nd to loss of blood supply, leads to bone destruction and v joint function

Causes - steroids, chemo, alcohol, trauma

Inv - MRI best, XR (osteopenia, microfractures)

-> may need joint replacement

Question 21

Baker’s Cyst

Answer 21

Distension of bursa

= swelling in popliteal fossa, rupture leads to pain, redness, calf swelling

Question 22

Biceps Rupture

Answer 22

Long tendon to glenoid and short tendon to coracoid process

RF - heavy overhead activity, shoulder overuse, smoking, steroids

Proximal Rupture (90%, long)
= >60yrs, load applied when bicep is lengthened and contracted (descent of pull up)

Distal Rupture (short)
= 40yrs, flexed elbow suddenly extended when biceps are already contracted

= pop, pain, bruising, swelling, popeye in proximal, -ve squeeze (no supination)

Inv - US, urgent MRI for distal

Question 23

Cervical Spondylosis

Answer 23

Extremely common, 2nd to OA (narrowing of IV spaces)

= neck pain, may refer (headaches)

Comp - radiculopathy, myelopathy

Question 24

Charcot Joint

Answer 24

Neuropathic joint, disrupted and damaged 2nd to loss of sensation

Cause - DM, syphilis

= extensive bone remodeling / fragmentation involving the midfoot, may be painful, red, hot

Question 25

Cubital Tunnel Syndrome

Answer 25

Compression of ulnar nerve in the cubital tunnel = tingling and numbness in fingers 4/5, weakness and wasting with time, worse when leaning on elbow -> physio, steroids

Question 26

De Quervain's Tenosynovitis

Answer 26

Inflammation of sheath containing EPB and AbPL RF - F, 30-50yrs = radial wrist pain, tender radial styloid, pain on resisted thumb abduction, Finkelstein's (pull thumb in ulnar deviation and longitudinal traction) -> analgesia, steroid injection, immobilise thumb

Question 27

Discitis

Answer 27

Infection of the intervertebral disc space Cause - bacterial (staph aureus), viral, TB, aseptic = back pain, fever, rigors, neuro features (suggests epidural abscess) Inv - MRI, CT-guided biopsy (for Abx), need TT ECHO or TOE to assess for IE -> 6-8wks IV Abx Comp - sepsis, epidural abscess

Question 28

Dupuytren's

Answer 28

Fascia of the hand becomes thickened and tight RF - ^age, FHx, M, manual labour (vibrating tools), DM, smoking, alcohol, phenytoin Cause - inflammatory process related to microtrauma = cords of dense connective tissue extend into fingers, pulled into flexion, ring/ little finger (rarely Index) -> consider surgery when MCP can't be straightened

Question 29

Fat Embolism

Answer 29

= ^HR, ^RR, v sats, fever, red/ brown flat petechial rash, oral bleeds, confusion, agitation, retinal bleeds Inv - lipuria -> fixation of fracture, supportive, DVT prophylaxis

Question 30

Greater Trochanteric Pain Syndrome

Answer 30

Trochanteric bursitis Cause - repeated movement of IT band causing inflammation of the bursa = 50-70yr F, pain over lateral side of hip/ thigh, tender over greater trochanter

Question 31

Hip Fracture

Answer 31

= hip pain, shortened, externally rotated, may weight bear if non-displaced, blood supply risk if displaced Garden system 1 - stable fracture 2 - complete fracture, not displaced 3 - displaced but still boney contact 4 - complete boney disruption Intracapsular -> Undisplaced: internal fixation, hemiarthroplasty if unfit -> Displaced: THR/ hemiarthroplasty Extracapsular -> Stable intertrochanteric: dynamic hip screw -> Reverse oblique, transverse or subtrochanteric: intramedullary device Surgery <48hrs, weight bear asap after

Question 32

IT Band syndrome

Answer 32

= lateral knee pain in runners, tender 2-3cm above joint line -> modify activity, stretches, physio

Question 33

Knee Ligament injuries

Answer 33

Unhappy triad: ACL, MCL and meniscus ACL Cause - twisting with bent knee = loud crack, pain, rapid joint swelling, +ve lachman and anterior drawer PCL Cause - dashboard injuries (hyperextension) MCL Cause - leg forced into valgus e.g., skiing = abnormal passive abduction of the knee Meniscus Cause - twisting = locking and giving way, delayed swelling, Thessaly's test (weight bear at 20° knee flexion, twisting causes pain)

Question 34

Chondromalacia Patellae

Answer 34

Common in teenage girls, following an injury = pain going downstairs or at rest, tender, quad wasting

Question 35

Osteochondritis Dissecans

Answer 35

Mainly affects subchondral bone = kid/ young adults, subacute knee pain and swelling, locking of the knee, painful clunk Inv - XR (subchondral crescent, loose bodies), MRI

Question 36

Tibial Plateau Fractures

Answer 36

Knee forced into varus or valgus, knee fractures before ligaments rupture RF - elderly, sig trauma in young Schatzker Classification 1) vertical split of lateral condyle 2) lateral condyle + load bearing part 3) depression of articular surface 4) medial tibial condyle 5) both condyles 6) condylar and subcondylar fractures

Question 37

Le Riche Syndrome

Answer 37

Atheromatous disease of iliac vessels, comprises blood flow to pelvic viscera = buttock claudication, impotence Inv - angiography -> endovascular angioplasty, stent

Question 38

Lower Back Pain: Red Flags

Answer 38

<20yrs or >50yrs Hx cancer Night pain Hx trauma Weight loss, fever

Question 39

Lower Back Pain: Management

Answer 39

Inv - MRI only if likely to change management. -> NSAIDs 1st line (w/ PPI if >45), exercise programme, manual therapy with this

Question 40

Prolapsed Disc

Answer 40

= dermatomal leg pain, associated neuro defects L3: sensory loss of anterior thigh, weak hip flexion/ hip adduction/ knee extension, v knee reflex, +ve femoral stretch L4: sensory loss of anterior knee and medial leg, weak knee extension/ hip adduction, v knee reflex, +ve femoral stretch L5: sensory loss of dorsum of foot, weak hip abduction/ foot dorsiflexion, normal reflexes, +ve sciatic S1 - sensory loss of posterolateral leg and lateral foot, weak plantar flexion, v ankle reflex, +ve sciatic Inv - consider MRI if persist 4-6wks

Question 41

Femoral, Obturator and LCN

Answer 41

Femoral Motor: knee extension, hip flexion Sensory: anterior and medial thigh, lower leg Cause - hip/ pelvis fracture Obturator Motor: thigh adduction Sensory: medial thigh Cause - anterior hip dislocation LCN of the Thigh (L2/L3) Sensory: lateral and posterior thigh Cause - compression near ASIS (meralgia paresthetica, RF incl. obesity, pregnancy, trauma)

Question 42

Gluteal, Tibial, Common Peroneal Nerves

Answer 42

Superior Gluteal Motor: hip abduction Cause - posterior hip dislocation, IM injection, hip surgery, pelvic fracture (= Trendelenburg) Inferior Gluteal Motor: hip extension, external rotation Cause - with sciatic nerve (= can't stand from seat or jump) Tibial Motor: plantarflexion, inversion Sensory: sole of foot Cause - uncommon, popliteal laceration Common Peroneal Motor: dorsiflexion, eversion, EHL Sensory: dorsum of foot, lateral lower leg Cause - neck of fibula, tight cast

Question 43

Spinal Stenosis

Answer 43

Narrowing of the central lumbar canal Cause - tumour, prolapse/ herniated disc, degenerative changes, fractures = back pain, claudication-like symptoms, better when sitting/ bending/ walking uphill (canal widens) Inv - MRI -> laminectomy

Question 44

Metatarsal Fracture

Answer 44

Proximal 5th is most common, 1st is least likely Types Proximal avulsion (pseudo-Jones): ^common, proximal tuberosity fracture 2nd to lateral ankle sprain/ inversion Jones: transverse fracture at meta-diaphyseal junction Stress: athletes, ^2nd shaft Inv - XR (non/displaced, periosteal change at 2-3wks), MRI

Question 45

Froment's Sign

Answer 45

Test for ulnar nerve palsy = pull piece of paper out from between thumb and index finger, can't hold and try to compensate with FPL

Question 46

Management of Open Fractures

Answer 46

-> image the area, check NV status distally, cover with dressing, Abx, early debridement, 6L saline to irrigate, stabilise the fracture

Question 47

OA

Answer 47

RF - FHx, F, >55yrs, prev. trauma, obesity, hypermobility, occupation, DDH, (OP is protective) Hand = bilateral, CMC and DIP, episodic ache, worse with movement, better with rest, short periods of stiffness *Heberden's DIP, Bouchard's PIP, thumb squaring Hip 2nd most common area (after knee) -> THR (SE: VTE, posterior dislocation, aseptic loosening needs revision) Gradual mobilisation over 6wks

Question 48

Osteomyelitis

Answer 48

Infection of the bone Haematogenous: kids (metaphysis), vertebral if adults RF - sickle cell, IVDU, IS, HIV, IE Non-haematogenous: adults, polymicrobial RF - DM foot ulcers/ pressure sores, PAD Cause - staph aureus, salmonella in sickle cell Inv - MRI -> flucloxacillin for 6wks (clindamycin if not)

Question 49

Osteoporosis Risk Assessment

Answer 49

Assess if; F>65 or M>75 or younger with RF FRAX: 10yr fracture risk, age 40-90 -> low risk (lifestyle), moderate (DEXA), high (treat) With BMD -> reassure, consider, strongly consider Qfracture: 10yr fracture risk, age 30-99, uses more RF BMD Assessment with DEXA - when starting sex hormone deprivation - <40yrs with major RF (Hx of multiple/ major fracture, high dose steroids >3m) Recalculate risk after 2 years or change of RF

Question 50

Risk factors for OP fractures

Answer 50

Age Prev fragility fracture Steroids Falls FHx of hip fracture 2nd OP (Cushing's, hyperthyroid, renal disease) Low BMI Smoking Over 14 units alcohol

Question 51

Growth Plate Fractures

Answer 51

Salter Harris system 1) through physis only (XR may be normal) 2) physis and metaphysis 3) physis and epiphysis 4) all three 5) crush injury (XR may be normal) Straight through Above Low Through Erasure

Question 52

Common fractures in children

Answer 52

Complete - both sides of cortex breached Toddlers - oblique tibial fracture Plastic - deformity with no cortex disruption Greenstick - unilateral cortical breach

Question 53

Patella Fracture

Answer 53

Inv - XR (AP and lateral) -> 6wk hinged knee brace if non-displaced, consider surgery if displaced (lose extensor mechanism) then brace

Question 54

Plantar Fasciitis

Answer 54

Inflammation of the plantar fascia, connective tissue attaching calcaneus to flexor tendons = most common heel pain in adults, worse at medial tuberosity -> rest, supportive shoes, insoles

Question 55

Rib Fractures

Answer 55

= severe sharp chest pain, tender chest wall, bruising Inv - CT best -> resolve on own, pain relief, deep breathing Flail chest: 2+ fractures along 3+ consecutive ribs, paradoxical movement during respiration

Question 56

Rotator Cuff Injury

Answer 56

Encompasses subacromnial impingement (60-120°), calcific tendonitis, cuff tears and arthropathy = pain on abduction, tender anterior acromion

Question 57

Sarcoma

Answer 57

Malignant tumours of mesenchyme, bone or soft tissue = painful, growing mass, fractures, v function Osteosarcoma - 20% of primary (most common), ^meta of long bones, kids, Rb, XR (Codman triangle, sunburst) Ewing's sarcoma - small round blue cell tumour, ^pelvis and long bones, kids, t(11:22), XR (onion skin) Chondrosarcoma - tumour of cartilage, middle-age, ^axial skeleton

Question 58

Scaphoid Injury

Answer 58

Most common carpal fracture, dorsal carpal branch of radial artery supplies 80% of blood (risk of AVN) Cause - FOOSH, contact sport = pain on radial side of wrist, v grip strength, tender snuffbox and scaphoid tubercle, effusion (4hrs-4d), pain on telescoping thumb and ulnar deviation of wrist Inv - XR, CT, MRI definitive -> Futero splint/ elbow backslab to immobilise, ortho review <7-10d if imaging inconclusive Non-displaced: cast for 6-8wks Displaced/ proximal scaphoid pole: surgical fixation

Question 59

Shoulder Dislocation

Answer 59

Most common dislocation, 95% anterior -> if recent then may reduce with no analgesia/ sedation

Question 60

Subluxation of the Radial Head

Answer 60

Most common upper limb injury <6yrs, weak annular ligament covering radial head = elbow pain, limited supination and extension -> pain relief, passive supination of the elbow whilst flexed to 90 degree

Question 61

Talipes Equinovarus

Answer 61

Club foot, inverted and plantarflexed RF - 2M:1F, 50% bilateral -> Ponsetti method, manipulation and casting from soon after birth, 85% need Achilles tenotomy

Question 62

Trigger Finger

Answer 62

Thickening of tendon or tightening of the sheath, MCP joint A1 pulley RF - F, RA, DM = thumb, middle and ring finger, stiffness and snapping when extending, nodule at base of finger -> steroid injection and splint, surgery

Question 63

Msc, Axillary and Radial Nerve

Answer 63

Musculocutaneous (C5-C7) Motor: elbow flexion, supination Sensory: lateral forearm Cause - part of brachial plexus injury Axillary (C5-C6) Motor: shoulder abduction Sensory: inferior region of deltoid Cause - humeral neck fracture (collar and cuff for non-displaced) Radial (C5-C8) Motor: elbow, wrist, finger extension Sensory: small area between dorsal 1st and 2nd MC Cause - humeral midshaft fracture (= wrist drop)

Question 64

Median, Ulnar and Long Thoracic Nerve

Answer 64

Median (C6, C8, T1) Motor: LOAF Sensory: palmar aspect of lateral 3.5 fingers Cause - carpal tunnel = (at wrist) paralysis of thenar muscles and opponens pollicis, (at elbow) v pronation and wrist flexion Ulnar (C8, T1) Motor: intrinsic hand excl. LOAF, wrist flexion Sensory: medial 1.5 fingers Cause - medial epicondyle fracture (= claw hand) Long Thoracic (C5-C7) Motor: serratus anterior Cause - blow to ribs, mastectomy (= winged scapula)

Question 65

Benign Bone Tumours

Answer 65

Osteoma - overgrowth of bone, ^skull, link to FAP/ Gardner's syndrome Osteochondroma (exostosis) - most common benign, M <20yrs, cartilage-capped bony projection Giant cell tumour - 20-40yrs, ^epiphysis of long bones, XR (double bubble, radiolucent)

Question 66

Management of Ankle fractures

Answer 66

Weber A and B - cast / boot and weight bear as tolerated Weber C or unstable - ORIF

Question 67

Femoral Neck: Blood Supply

Answer 67

Medial and lateral circumflex femoral arteries join the femoral neck proximal to intertrochanteric line, and run along the surface of the femoral neck within the capsule I.e., an intracapsular fracture can affect blood supply

Question 68

Sciatica

Answer 68

L4-S3, travels down back of leg, divides at knee into tibial and common peroneal Causes - spinal stenosis, herniated disc, spondylolisthesis (anterior displacement of a vertebra) *if bilateral think cauda equina = pain from buttock down back of thigh, to below knee or foot, paraesthesia, numbness, motor weakness

Question 69

Cauda Equina Syndrome

Answer 69

Compression of lumbrosacral nerve roots that extend below the spinal cord (terminates at L2/ L3) Causes - prolapsed disc (L4/5 or L5/S1), tumour, abscess, discitis, trauma, haematoma, spondylolisthesis = low back pain, bilateral sciatica, v perianal sensation, v anal tone, incontinence Inv - urgent MRI -> surgical decompression

Question 70

Metastatic SCC

Answer 70

Oncological emergency, 5% of cancer patients RF - lung, breast, prostate cancer = back pain, worse coughing/ lying down/ straining, lower limb weakness, sensory loss (UMN signs if above L1, LMN signs below L1), ^reflexes below the lesion -> high dose PO dex, surgery or radiotherapy

Question 71

Osgood-Schlatter

Answer 71

Inflammation of the tibial tuberosity Cause - traction apophysitis due to repeated avulsion where patella tendon inserts

Question 72

Fat Pad Atrophy

Answer 72

Wasting of the fat pad under heel of foot = presents like plantar fasciitis

Question 73

Morton's Neuroma

Answer 73

Dysfunction of a nerve in the intermetatarsal space, ^between 3rd and 4th = sensation of lump in shoe, pain at front of foot, p+n

Question 74

Injuries with Ant. Shoulder Dislocation

Answer 74

Bankart lesions: tear to anterior portion of labrum Hill-Sachs: compression fractures of the posterolateral head of humerus Axillary nerve damage: C5/6, v sensation over lat deltoid, weak deltoid

Question 75

Epicondylitis

Answer 75

Inflammation where tendons of forearm insert onto the epicondyles Lateral (Tennis) - worse on wrist extension or supination Medial (Golfer's) - worse on wrist flexion and pronation

Question 76

Ganglion

Answer 76

Sac of synovial fluid originating from tendon sheath or joint = ^dorsal wrist, F, firm well-circumscribed mass, transilluminates -> disappear over months, excise if severe symptoms

Question 77

Nerve Supply to Hand

Answer 77

Rock - finger flexion - median Paper - finger extension - radial Scissors - abduction and adduction - ulnar

Question 78

Volkmann's Ischaemia

Answer 78

Cause - supracondylar fracture of the humerus leading to vascular compromise = persistent pain first (worse on passive extension of fingers), pallor, poor CR, absent radial pulse, paraesthesia in median nerve area Comp - contracture (claw), gangrene

Question 79

Supracondylar Humeral Fracture

Answer 79

Common paeds elbow injury -> urgent ortho review Comp - nerve palsy (ant. interosseus nerve, ulnar post-op), posterior displacement of the distal fragment is common, varus deformity due to malunion, Volkmann's