Ortho

Question 1

Fracture Healing phases?

Answer 1

1. Reactive Phases (injury - 48hr). Can be a haematoma from bleeding into the site, or from inflammation via cytokines and GF, vasoactive mediator release.
2. Reparative Phase (2 days-2 weeks)
   - Proliferation of osteoblasts + fibroblasts –> Cartilage + woven bone –> Callus
   - Consolidation (endochondral ossification) of woven bone –> Lamellar bone.
3. Remodelling Phase (1 week-7yrs)
   - Remodelling of lamellar bone to cope with mechanical forces applied to it (Wolff’s law: form follows function).

Question 2

Which fractures heal in 3 weeks?

Answer 2

Closed, Paediatric, metaphyseal, upper limb: 3 weeks.

Question 3

Which fracture heals in 6 weeks

Answer 3

• Adult
• Lower limb
• Diaphyseal
• Open
• Smoking slows healing time.

Question 4

Types of a traumatic fracture?

Answer 4

Traumatic fracture

• Direct
• Indirect e.g FOOSH –> Clavicle fracture (fall on outstretched hand)
• Avulsion

Question 5

What is a stress fracture?

Answer 5

• Bone fatigue due to repetitive strain
• E.g foot fractures in marathon runners

Can get it in in tibia.

Would be unwise to discharge therefore need an X-ray initially.

Question 6

What is a pathological fracture?

Answer 6

Normal forces but diseased bone

• Local: tumours
• General: osteoporosis, Cushing’s, Paget’s.

Question 7

Classifications of fractures?

Answer 7

Stress
Pathological
Traumatic

Question 8

How does one describe a fracture?

Answer 8

Radiographs must be orthogonal: request AP and lat. films.
Need images of joints above and below fracture.

PAIDSS

1. Demographic
   = Pt details, date radiograph was taken
   = Orientation and content of image
2. Pattern
   - transverse
   - Oblique = fracture lies obliquely to long axis of bone.
   - Spiral = severe oblique fracture with rotation along long axis of bone.
   - Multifragmentary
   - Crush
   - Greenstick - young, soft bone breaks (one cortex is ok, the other isn’t as it is more bendy)
   - Avulsion - occurs when a fragment of bone tears away from the main mass of bone as a result of physical trauma.

Plastic deformity - stres on bone resulting in deformity without cortical disruption

Buckle Fracture - incomplete cortical disruption leading to bulging of the cortex.

3. Anatomical location
   - Diaphyseal, metaphyseal, epiphyseal
4. Intra/extra-articular
   - Dislocation or subluxation (incomplete or partial dislocation)
5. Deformity (distal relative to proximal)
   - Translation
   - Angulation or tilt (normal axis of the bone is different) (dorsal, palmar). Distal portion of bone points off in a different direction.
   - Rotation - Rotation of distal fracture fragment in relation to proximal part.
   - Impaction (–> shortening)
6. Soft tissue
   - Open or closed
   - Neurovascular status
   - Compartment syndrome
7. Specific classification type
   - Salter Harris
   - Garden
   - Colles’, Smith’s, Monteggia

Question 9

What are the 4 Rs for Fracture Management?

Answer 9

• Resuscitation
• Reduction
• Restriction
• Rehabilitation

Question 10

What are the principles of Resuscitation?

Answer 10

ATLS Guidelines
- Trauma in primary survey: C-spine, chest and pelvis
- # usually assessed in 2dry survey
- Assess neurovascular sttus and look for dislocations
- Consider reduction and splinting before imaging
(decreased pain, bleeding, risk of neurovascular injury)
- X-ray once stable.

Question 11

Urgent management of an open fracture (once which breaks the skin)?

Answer 11

• Analgesia: M+M (morphine)
• Assess: NV status, soft tissues, photograph
• Antisepsis: wound swab, copious irrigation, cover with betadine-soaked dressing
• Alignment: align fracture and splint
• Anti-tetanus: check status (booster lasts 10yrs)
• Antibiotics: co-amoxiclav or cefuroxime

Fracture is stabilised and an external fixator is often used in the first instance.

Management: Debridement and fixation in theatre and should be delayed until soft tissues have recovered. Should be done within 6hr of injury.

Long-term = Definitive skeletal and soft tissue reconstruction. Avoid internal fixation until thoroughly debrided.

Remember: Vascular impairment requires immediate surgery and restoration of circulation, ideally within 3-4 hrs. FOllow the sequence of shunting, temporary skeletal stabilisation and then vascular reconstruction.

Question 12

Classification of open fractures?

Answer 12

Gustillo's 
1. Wound <1cm in length
2. Wound >1cm with minimal soft tissue damage
3. Extensive soft tissue damage 
a - adequate soft tissue coverage
b - inadequate soft tissue coverag
c(implies vascular compromise) fos

Question 13

Most dangerous complication of open #?

Answer 13

Clostridium perfringes

• Wound infection + gas gangrene
• ± shock and renal failure
• Management: debride, benpen + clindamycin

Question 14

Principles of Reduction?

Answer 14

Displaced #s should be reduced

• Unless no effect on outcome (ribs)
• Aim for anatomical reduction (if articular surfaces involved - correct alignment)

Question 15

What are the methods of reduction?

Answer 15

Manipulation/Closed reduction

• Under Local, regional or general anaesthetic
• Traction to disimpact
• Manipulation to align

Traction (generally pulling)

• Not typically used now
• Employed to overcome contration of large muscles e.g femorals #s
• Skeletal traction vs skin traction

Open reduction (and internal fixation)

• Accurate reduction vs risk of surgery
• Intra-articular #s
• open #s
• 2# in 1 limb
• Failed conservative management
• Bilateral identical fractures

Question 16

Principle of restriction?

Answer 16

• Interfragmentary strain hypothesis dictates that tissue formed @ #site depends on strain it experiences
• Fixation –> decreased strain –> Bone formation
• Fixation also –> Decreased pain, increased stability, increased ability to function

Question 17

Methods of restriction?

Answer 17

Non-rigid

• Slings
• Elastic supports

Plaster

• POP
• In first 24-48hrs use back-slab or split case due to risk of compartment syndrome

Functional bracing
- Joints free to move but bone shafts supported in cast segments

Continuous traction
- E.g collar-and-cuff

Ex-Fix

• Fragments held in position by pins/wires which are then connected to an external frame
• Intervention is away from field of injury.
• Useful in open fractures, burns, tissue loss to allow wound access and decrease infection risk
• Risk of pin-site infection

Internal fixation

• Pins, plates, screws, IM Nails
• Usually perfect anatomical alignment
• Increased stability
• Aid early mobilisation

Question 18

Principles of Rehabilitation?

Answer 18

Immobility –> decreased muscle and bone mass, joint stiffness

• Need to maximise mobility of uninjured limbs
• Quick return to function decrease later morbidity

Question 19

Methods of Rehabilitation?

Answer 19

Physiotherapy: Exercises to improve mobility
OT: Splints, mobility aids, home modification
Social services: meals on wheels, home help.

Question 20

General complications of fractures?

Answer 20

• Tissue Damage
• Anaesthesia
• Prolonged Best Rest

Question 21

Problems with tissue damage?

Answer 21

• Haemorrhage and shock
• Infection
• Muscle damage –> Rhabdomyolysis

Question 22

Problems with anaesthesia?

Answer 22

• Anaphylaxis
• Damage to teeth
• Aspiration

Question 23

Problems with bed rest?

Answer 23

• Chest infection
• UTI
• Bed sore and pressure sores
• DVT
• Decreased bone mineral density

Question 24

Specific complications for fractures?

Answer 24

• Immediate
• Early
• Late

Question 25

Immediate complications of fractures?

Answer 25

- Neurovascular damage | - Visceral damage

Question 26

Early complications of fractures?

Answer 26

- Compartment syndrome - Infection (worse if associated with metalwork) - Fat embolism --> ARDS Recent injury and physical signs that would be concordant with fat embolism syndrome. Normally within 3 days. Triad = Hypoxaemia, neurological abnormalities, petechial rash. Resp = Early persistent tachycardia, tachypnoea, dyspnoea hypoxia, pyrexia. Derm: red/brown impalpable petechial rash. Subconjunctival and oral haemorrhage. CNS - confusion + agitation. Retinal haemorrhage and intra-arterial fat globules on fundoscopy. Management - Prompt fixation of long bone fracutre - Some debate vs medullary reaming in femoral shaft. - DVT prophylaxis - General supportive care.

Question 27

Late complications with fractures?

Answer 27

- Problems with union - AVN - Growth disturbance - Post-traumatic osteoarthritis - Complex regional pain syndromes - Myositis ossificans

Question 28

Neurological complications of fractures?

Answer 28

- Severance is rare, stretching over bone edge commoner | - Seddon classification describes three types of injury?

Question 29

Seddon classification of 3 neurological complications?

Answer 29

Neuropraxia - Temporary interruption of conduction w/o loss of axonal continuity Axonotmesis - Disruption of nerve axon -> distal Wallerian degeneration. - Connective tissue framework of nerve preserved - Regeneration occurs and recovery is possible Neurotmesis - Disruption of entire nerve fibre - Surgery required and recovery not usually complete

Question 30

Palsy as a result of anterior shoulder dislocation or humeral surgical neck?

Answer 30

Axillary Nerve damage --> Numb chevron and weak abduction Check pulses and nerves. Always do X-ray.

Question 31

Palsy as a result of #humeral shaft?

Answer 31

Radial nerve --> Waiter's tip (Erb's Palsy)

Question 32

Palsy as a result of elbow dislocation?

Answer 32

Ulnar nerve --> Claw Hand (Klumpke's Palsy)

Question 33

Palsy as a result of hip dislocation?

Answer 33

Sciatic Nerve --> Foot drop

Question 34

Palsy as a result of #neck of fibula or knee dislocation?

Answer 34

Fibular Nerve --> Foot drop

Question 35

Compartment syndrome pathophysiology?

Answer 35

- Osteofacial membranes divide limbs into separate compartments of muscle. - Oedema following # --> increased the compartment pressure --> decreases venous drainage --> increased compartment pressure - If compartment pressure > capillary pressure --> Ischaemia. - Muscle infarction --> - Rhabdomyolysis and ATN - Fibrosis --> Volkman's ischaemic contracture

Question 36

Presentation of compartment syndrome?

Answer 36

Due to supracondylar fracture and tibial shaft fracture. - Pain > clinical findings - Pain on passive muscle stretching - passive ankle dorsiflexion - Warm, erythematous, swollen limb - Increased CRT and weak/absent peripheral pulses - Remember presence of pulse does not rule out compartment syndrome. Diagnosis - Intracompartmental pressure measurement - Pressure excess of 20mmHG are abnormal and >40mmHG is diagnostic. - Compartment syndrome will show nothing on x-ray

Question 37

Management of compartment syndrome?

Answer 37

- Elevate limb - Remove all bandages and split/remove cast - Fasciotomy

Question 38

Complications of fractures: problems with union?

Answer 38

Delayed union: union takes longer than expected? | Non-union: # fails to unite

Question 39

Causative factors of malunion: 5 Is

Answer 39

Ischaemia: poor blood supply or AVN Infection Increased interfragmentary strain Interposition of tissues between fragments Intercurrent disease: e.g malignancy or malnutrition

Question 40

Non-union classification?

Answer 40

- Hypertrophic: bone end is rounded, dense and sclerotic | - Atrophic: Bone looks osteopenic

Question 41

Management for non-union?

Answer 41

Management - optimise biology: infection, blood supply, bone graft, BMPs - Optimise mechanics: ORIF

Question 42

What is malunion?

Answer 42

healed in imperfect position - Poor appearance and/or function - Gunstock deformity (varus)

Question 43

What is avascular necrosis?

Answer 43

- Death of bone due to deficient blood supply - Sites: femoral head, scaphoid, talus - Consequences = Soft + deformed bone --> pain, stiffness and OA - X-ray shows sclerosis and deformity.

Question 44

What is Myositis ossificans?

Answer 44

- Heterotopic ossification of muscles @ site of haematoma formation. - Leads to restricted, painful movement - Commonly affects the elbow and quadriceps - Can be excised surgically

Question 45

What is Pellegrini-Stieda disease?

Answer 45

- Form of MO | - Calcification of the superior attachment of MCL @ knee following traumatic injury

Question 46

Complex Regional Pain Syndrome Type 1 (Reflex Sympathetic Dystrophy, Sudek's Atrophy)

Answer 46

- Complex disorder of pain, sensory abnormalities, abnormal blood flow, sweating and trophic changes in superficial or deep tissues. - No evidence of nerve injury

Question 47

Causes of complex regional pain syndrome type 1?

Answer 47

- Injury: #s, carpal tunnel release, ops for Dupuytren's contracture - Zoster, MI, Idiopathic

Question 48

Presentation of CRPS T1

Answer 48

- Wks - months after injury - Not traumatised area that is affected: affects a neighbouring area - Lancing pain hyeralgesia or allodynia - Vasomotor: hot and sweaty or cold and cyanosed - Skin: swollen or atrophic and shiny - NM: weakness, hyper-reflexia, dystonia, contractures.

Question 49

Management of CRPS

Answer 49

- Usually self-limiting - Refer to pain team - Amitryptilline, gabapentin - Sympathetic nerve blocks can be tried.

Question 50

CRPS Type II?

Answer 50

Causalgia | - Persistent pain following injury caused by nerve lesions.

Question 51

Growth disturbances classification?

Answer 51

Salter-Harris Classification for growth plate injuries - In children - S = Straight across (type 1) = physis (can be completely slipped. - A = Above + across (type 2) = metaphysis and physis - L = Lower (type 3) include joint. = physis and epiphysis - T = Through (Type 4 ) - CRUSH = Type 5

Question 52

Examples of a Salter Harris Type 1?

Answer 52

SUFE. Normal growth with good reduction (re duce = Bring back to normal). Through physis

Question 53

Examples of a Salter Harris Type 4?

Answer 53

Union across physis may interfere with bone growth

Question 54

Examples of a Salter Harris Type 5?

Answer 54

Crush --> Physis injury --> Growth arrest

Question 55

Epidemiology of hip fractures?

Answer 55

- 80/100,000 - 50% in >80 yrs old - It is a disease of old age - F>M = 3:1

Question 56

Pathophysiology of hip fracture?

Answer 56

``` Old = Osteoporosis with minor trauma (e.g fall) Young = Major trauma ```

Question 57

Osteoporosis risk factors: age + SHATTERED..

Answer 57

- Steroids - Hyper-parathyroidism - Alcohol and Cigarettes - Thin (BMI <22) - Testosterone low - Early Menopause - Renal/Liver failure - Erosive/inflammatory bone disease (RA, myeloma) - Dietary Ca low/malabsorption

Question 58

Presentation of hip fracture?

Answer 58

Anterior O/E: shortened leg and externally rotated If internally rotated = posterior hip dislocation.

Question 59

Key questions in a hip fracture history?

Answer 59

- Mechanism of injury - Risk factors for osteoporosis/pathological fractures - Premorbid mobility - Premorbid independence - Comorbid independence - Comorbidities - MMSE

Question 60

Initial Management for hip fracture?

Answer 60

- Resuscitate: dehydration, hypothermia - Analgesia: M+M (morphine/iliofascial block recommended and midazolam) - Assess neurovascular status of limb - Imaging: AP and lateral films - Prep for theatre If patient has clinical signs of hip fracture, do further imaging. MRI is first line recommended.

Question 61

What does prepping for theatre entail?

Answer 61

ABCDEFG - Inform Anaesthetist and book theatre - Bloods: FBC, U+E, Clotting, X-mathc (2U) - CXR - DVT (prophylaxis: TEDS, LMWH) - ECG - Films: orthogonal X-rays - Get Consent

Question 62

Imaging for hip fracture?

Answer 62

- Ask for AP and lateral films - Look @ Shenton's lines - Intra- and extra-capsular - Displaced or non-displaced - Osteopaenic

Question 63

What are Shenton's lines

Answer 63

- Imaginary curved line drawn along inferior border of superior pubic ramus and along inferomedial border of neck of femur. - In the joint capsule (up to the neck) or outside. (extracapsular)

Question 64

Key anatomy of the hip?

Answer 64

- Capsule attaches proximally to acetabular margin and distally to intertrochanteric line.

Question 65

Blood supply to the femoral head?

Answer 65

- Retinacular vessels, in capsule, distal --> Proximal - Intramedullary vessels - Artery of ligamentum teres

Question 66

What happens if the retinacular vessels are damaged?

Answer 66

Risk of AVN at the femoral head --> leads to pain, stiffness and OA.

Question 67

Classification of a hip fracture?

Answer 67

- Intracapsular: Subcapital (junction of head and neck), transcervical, basicervical (base of femoral neck) - Extracapsular: Intertrochanteric, subtronchanteric

Question 68

Garden Classification of INTRACAPSULAR FRACTURES?

Answer 68

1. Incomplete #, undisplaced 2. Complete #, undisplaced 3. Complete #, partially displaced 4. Complete #, completely displaced

Question 69

Surgical management of intracapsular Garden 1,2 #?

Answer 69

Painkillers - Iliofascial nerve block - reduced need for morphine or opioids. ORIF with multiple cannulated screws. Undisplaced fracture = internal fixation or hemiarthroplasty if unfit/major illness.

Question 70

Surgical management intracapsular Garden 3, 4#?

Answer 70

<70: ORIF with screws. Follow- up in OPD and do arthroplasty if AVN develops (in 30%). (young people need hip for long time - therefore hip prosthesis require one or more revisions). Follow up for AVN. Independently mobile, does not use more than a stick. >70: Total hip replacement If major/immobile. >70: Hemiarthroplasty (can be total too): - Mobilises: cemented Thompson's - mainly cemented. - Non-mobiliser: non-cemented Austin Moore. Consider Bipolar vs Unipolar (swivelling of head in bipolar). Post surgery - Full weight bearing immediately post-op. This reduces length of stay and complications associated with prolonged immobility.

Question 71

What is a hemiarthroplasty?

Answer 71

Placing half the joint, not the internal capsule.

Question 72

Management of extracapsular hip fracture?

Answer 72

If intertrochanteric - ORIF with Dynamic Hip Screws - For unstable inter-trochanteric fracture can use intra-medullary nails (cephalomedullary). Subtronchanteric = Intramedullary nail.

Question 73

What is a dynamic hip screw?

Answer 73

- Large cancellous lag screw that glides freely in a metal sleeve. - Sleeve attached to a plate which is fixed to the lateral femoral cortex.

Question 74

Discharge of hip fracture patients?

Answer 74

- Involves OT and physios | - Discharge when mobilisation and social circumstances permit

Question 75

Specific complications with hip fracture?

Answer 75

- AVN of femoral head in displaced #s due to damage to the retinacular vessels. - Non/mal-union (10-30%) - Infection - Osteoarthritis

Question 76

Prognosis of a hip fracture?

Answer 76

30% mortality @ 1 yr 50% never regain pre-morbid functioning >10% unable to return to premorbid residence - Majority will have some residual pain or disability

Question 77

Distal Forearm fracture examples?

Answer 77

- Colles' Fracture - Smith's - Barton's Fracture

Question 78

Clinical features of Colles' fracture?

Answer 78

- Fall onto an outstretched hand - Most common in elderly females with osteoporosis - Dinner fork deformity

Question 79

Radiographic features of a Colles' Fracture?

Answer 79

- Extra-articular # of distal radius (w/i 1.5 inches of joint) - Dorsal displacement of distal fragment - Dorsal angulation of distal fracture 11 degrees volar tilt - Decreased radial height (norm = 11mm ) - Decreased radial inclination (norm = 22 deg) = ± avulsion of ulnar styloid ± impaction

Question 80

Specific management of a Colles' Fracture?

Answer 80

- Examine for neurovascular injuries as median and radial artery lie close - if much displacement --> reduction (under haematoma block, IV regional anaesthesia (Bier's block) or GA. Disimpact and correct angulation. Position: ulnar deviation + some wrist flexion - Apply dorsal backslab: provide 3-point pressure. When you want to prevent flexion or extension. - Repeat X-ray - If comminuted, intra-articular or re-displaced: Surgical fixation with ex-fix, Kirschner-wires or ORIF and plates. This is a significant fracture at high velocity therefore will need ORIF.

Question 81

Colles Fracture - Re X-ray - Satisfactory position?

Answer 81

No: Ortho review and consider MUA ± K wires Yes: home with # f/up within 48hr for completion of POP.

Question 82

Specific complications with Colles Fracture?

Answer 82

- Median N.injury - Frozen Shoulder/adhesive capsulitis - Tendon Rupture: Esp EPL (extensor pollux longus) - Carpal Tunnel Syndrome - Mal/non-union - Complex regional pain atrophy

Question 83

Anatomy of the hand nerves

Answer 83

- Median Nerve THUMB | - Ulnar Nerve (Little finger)

Question 84

What is a Smith's Fracture?

Answer 84

- Fall on back of flexed wrist - Fracture of distal radium with volar displacement and angulation of distal fragent - Reduce to restore anatomy and POP for 6 weeks

Question 85

What is a Barton's Fracture?

Answer 85

- Oblique intra-articular # involving the dorsal aspect of the distal radius and dislocation of radio-carpal joint. Smiths/Colles with radiocarpal. - Reverse Barton's Involves the volar aspect of the radius

Question 86

Clinical features of a scaphoid fracture?

Answer 86

- FOOSH - Pain in anatomical snuffbox - Pain on telescoping the thumb

Question 87

Specific management of a scaphoid fracture?

Answer 87

- Request scaphoid X-ray view - If clinical history and exam suggest a scaphoid #, it should initially be treated even if the x-ray is normal - # may become apparent after 10 days due to localised decalcification - Therefore immobilise straight away. - Place wrist in scaphoid plaster (beer glass position) - Can use futura splint. - If initial x-ray is negative, pt return to # clinic after 1- days for re-xray. - # visible --> Plaster for 6 weeks - No visible # but clinically tender --> plaster for 2 weeks. - # not visible and not clinically tender --> no plaster

Question 88

Specific complications of scaphoid fracture?

Answer 88

- Main risk of AVN of the scaphoid as blood supply runs distal to proximal. Dorsal carpal branch of the radial artery is the main neurovascular structure that is compromised in a scaphoid fracture. - -> Stiffness and pain at the wrist.

Question 89

Bones of the hand distal to proximal

Answer 89

``` Distal Phalanx Middle Phalanx Proximal Phalanx Metacarpal Carpal bones ```

Question 90

Mnemonic for carpal bones?

Answer 90

``` Some - Scaphoid Lovers - Lunate Try - Triquetrum Positions - Pisiform That - Trapezium They - Trapezoid Can't - Capitate Handle - Hamate ```

Question 91

Radial and Ulna Shaft Fractures Classification?

Answer 91

Monteggia - #of proximal 3rd of ulnar shaft. (ulnar - Anterior dislocation of radial head at capitellum - May lead to a palsy of deep branch of radial nerve - weak finger extension but no sensory loss. Galleazzi - Fracture of radial shaft between mid and dital 3rd. - Dislocation of distal radio-ulnar joint. GRUsome MURder G-aleazzi R-adius fracture, ULnar radial dislocation Monteggia Ulnar fracture, radial dislocation Normal radial head fracture - usually caused by fal on outstretched hand. Marked local tenderness over head of radius, impaired movement at the elbow, sharp pain at the lateral side of the elbow and sharp pain at the lateral side of the elbows on pronation and supination. Radial head subluxation - during pulling injuries. - Signs are limited supination and extension of elbow. - Managed with reduction of radial head into position by passive supination of the elbow joint at 90 degrees.

Question 92

Management of Radial and ulnar shaft fractures?

Answer 92

- Unstable fractures Adults: ORIF Children: MUA + above elbow plaster - Fractures of forearm should be plastered in most stable position Proximal #: Supination (S for Sky) Distal #: pronation Mid-shaft: Neutral

Question 93

Classification of a shoulder dislocation?

Answer 93

Anterior | Posterior

Question 94

What is an anterior shoulder dislocation?

Answer 94

- 95% of shoulder dislocation - Direct trauma of falling on hand - Humeral head dislocated anterio-inferiorly.

Question 95

What is a posterior shoulder dislocation?

Answer 95

- Caused by direct trauma or muscle contraction (seen in epileptics)

Question 96

Associated lesions with shoulder dislocation?

Answer 96

Bankart lesion - Damage to anteroinferior glenoid labrum . Leads to a glenohumeral dislocation. - See on x-ray displacement of the glenoid labrum - Usually due to recurrent dislocation and may need to be surgically repaired. Hill-Sach's Lesion at top cos hill. - Cortical depression in the posterolateral part of the humeral head following impaction against the fleniod rim during anterior dislocation. - When the humerus is driven from the glenoid cavity, its relatively soft head impacts against the anterior edge of the glenoid. The result is a divot or flattening in the posterolateral aspect of the humeral head, usually opposite the coracoid process.

Question 97

What is the presentation of shoulder dislocation?

Answer 97

- Shoulder contour lost :appears square - Bulge in infraclavicular fossa: humeral head - Deltoid is flat. - Arm supported in opposite hand - Severe pain

Question 98

Specific management of a shoulder dislocation?

Answer 98

- Assess for neurovascular deficit: do this by assessing the 'chevron' area of the shoulder for axillary nerve damage. - DO an X-ray: AP and transcapular. - Reduction under sedation (e.g propafol) 1) Hippocratic: longitudinal traction with arm in 30 degrees abduction and counter traction at the axilla. 2) Kocher's: External rotation of adducted arm, anterior movement, internal rotation. - Rest arm in sling for 3-4 weeks - Physio Posterior dislocation - Rare, caused by seizure or electrocution - Lightbulb sign on X-ray - Refer to orthopaedic surgeons.

Question 99

Why is an Transcapular X-ray good?

Answer 99

It is a pertinent projection to assess suspected dislocations, scapula fractures, and degenerative changes.

Question 100

Complications of shoulder dislocations?

Answer 100

- Recurrent Dislocation - 90% have traumatic dislocations in less than 20 yrs. - Axillary N.injury.

Question 101

Recurrent Shoulder Instability management?

Answer 101

TUBS: Traumatic Unilateral dislocations with a Bankart Lesion often require surgery. - Surgery involves a Bankart Repair. AMBRI: Atraumatic Multidirectional Bilateral shoulder dislocation is treated with Rehabilitation, but may require inferior capsular shift.

Question 102

What is painful arc/Impingement syndrome?

Answer 102

- Entrapment of supraspinatus tendon and subacromial bursa between acromion and greater tuberosity of humerus --> Subacromial bursitits and or supraspinatous tendonitis.

Question 103

Anatomy of the shoulder posterior muscles?

Answer 103

- Supraspinatus - Infraspinatus - Teres Minor

Question 104

Anatomy of shoulder anterior

Answer 104

- Supraspinatus - Subscapularis - Infraspinatus

Question 105

Rotator cuff muscles?

Answer 105

- Supraspinatus - Abducts to humerus. On top of your shoulder and runs parallel to your deltoid. - Subscapularis - Internally rotates the humerus. Medially. - Infraspinatus - Externally rotates the shoulder joint.Rotates arm laterally. - Teres Minor - External Rotation. Adducts and rotates laterally.

Question 106

Function of the rotator cuff?

Answer 106

Maintaining stability of the glenohumeral joint. Hold the cuff in the glenoid fossa of the scapula.

Question 107

Presentation of impingement syndrome?

Answer 107

Painful arc: 60-120 Weakness and decreased ROM +ve Hawkin's Test

Question 108

Investigations for impingement syndrome?

Answer 108

- Plain X-ray: Bony spurs? - US - MRI arthrogram

Question 109

Management for impingement syndrome?

Answer 109

- Conservatively: Rest and Physiotherapy - Medical: NSAIDS/Steroid injections - Surgical: Acrthroscopic acromioplasty.

Question 110

Differentials for painful arc?

Answer 110

- Impingement - Supraspinatous tear or partial tear - AC joint OA.

Question 111

Frozen shoulder presentation?

Answer 111

- Progressive decreased active and passive ROM (range of movement) - Decreased external rotation <30 - Decreased abduction <90 - Shoulder pain especially at night (unable to lie on painful side) Tendonitis? - Inflammation as muscles pass through the subacromial space - Symptoms: pain decreased ROM, weakness Diagnosis: clinical Treatment :rest, physiotherapy, steroids, surgery

Question 112

Causes of frozen shoulder presentation?

Answer 112

- May be due to trauma in the elderly | - Associated with T2DM

Question 113

Management of a frozen shoulder?

Answer 113

- Conservative: rest, physio | - Medical: NSAIDS, Subacromial bursa steroid ± LA injection.

Question 114

What is a rotator cuff tear?

Answer 114

- 2ndry to degen or sudden jolt or impingement syndrome. - A partial tear presents with painful arc - Complete tear : Passive movement full range Shoulder tip pain Cannot abduct the arm After passive motion may be able to abduct to 90, then drop, drop arm sign.

Question 115

Supracondylar Fractures of the Humerus presentation?

Answer 115

Common in children after FOOSH Elbow very swollen and held semi-flexed. Sharp edge of proximal humerus may injure brachial artery which lies anterior to it.

Question 116

Classification of supracondylar fracture of the humerus?

Answer 116

Extension - Distal fragment displaces posteriorly Type 1: non-displaced Type 2: anglated with intact posterior cortex Type 3: Displaced with no cortical contact. Flexion - Less common - Distal fragment displaces anteriorly

Question 117

Specific management of SC # Humerus?

Answer 117

- Ensure there is no neurovascular damage (if the radial pulse is absent or there is damage to a brachial artery, take to theatre for open reduction + on-table angiogram - Median nerve is also vulnerable Restore anatomy - No displacement --> flex the arm as fully as possible and apply a collar and cuff for 3 weeks --> triceps acts as sling to stabilise fragment - Displacement --> MUA + Fixation with K-wires + collar and cuff with arm flexed for 3 weeks.

Question 118

Specific complications for supracondylar fractures of the humurus?

Answer 118

Neurovascular injury? - Brachial artery - Radial nerve - Median nerve esp anterior interosseous branch (Supplies deep forearm flexors (FPL, Lateral half of FDP and pronator quadratus). Compartment syndrome - Monitor closely during the first 24hrs - Pain on passive extension of the fingers (stretches flexor compartment) is earl sign - Mx: try extension of elbow, surgical management may be needed. - Volkmann's ischaemic contracture can result --> fibrosis of flexors --> claw hand. Gunstock deformity - Valgus, varus and rotiational deformities in the coronal plane do not remodel and --> cubitus varus. - Cubitus varus deformity is referred to as a gunstock deformity.

Question 119

Femoral and Tibial Fractures management?

Answer 119

- Resuscitation and management of life-threatening injuries first. - X-match Tibial #: 2 units Femoral #: 4 units - Assess neurovascular status: esp distal pulses. - If open Abx and ATT Take to theatre urgently for debridement, washout and stabilisation - Fixation methods Intramedullary nail Ex-fix Plates and screws MUA with fixed traction for 3-4 months.

Question 120

Specific complications of femoral and tibial fractures?

Answer 120

- Hypovolaemic shock - Neurovascular : SFA: swellign and check pulses Sciatic nerve - Compartment syndrome - Respiratory complications Fat Embolism ARDS Pneumonia

Question 121

Ankle Injuries - Ligament strain?

Answer 121

- Typically twisting inversion injury - Strains anterior talofibular part of lateral collateral ligament - Medial deltoid ligament strains are rare - May be associated with malleolar avulsion #s Management - RICE (Rest, ice, compression, elevation. NSAIDS

Question 122

Ankle fracture - Ottawa ankle rules?

Answer 122

X-ray ankle if pain in malleolar zone + in any of: - Tenderness along distal 6cm of posterior tib/fib including posterior tip of malleoli. - Medial or Lateral malleolus, Base of the 5th metatarsal, Navicular - Bony tenderness at the medial malleolar zone - INability to walk four weight bearing steps immediately after the injury and in an emergency department.

Question 123

Bones of the ankle?

Answer 123

Below TIbia - Talus - Navicular - Cuneiform Bones - Metatarsal bones - Phalanges Fibula - Calcaneus - Cuboid

Question 124

Weber Classifications for ankle fractures?

Answer 124

- Relation to fibula # to the joint line. Below the level of the tibiofibular syndesmosis. - A: below the joint line - B: at the joint line - C: above the joint line Weber's B and C represent possible injury to the syndesmotic ligaments between tibia and fib --> instability. Modified Weber? - A = Infra-syndesmotic or below syndesmosis - B = Trans-syndesmotic or level of syndesmosis - C = Supra-syndesmotic

Question 125

Management of Weber A?

Answer 125

All fractures should be promptly reduced to remove pressure on overlying skin + subsequent necrosis. VERY IMPORTANT. - Boot or below-knee POP. Use an Below knee POP once radiological union is achieved.

Question 126

Management of non-displaced Weber B/C

Answer 126

- Below-knee POP

Question 127

Management of displaced Weber B/C?

Answer 127

- Closed reduction and POP if anatomical reduction achieved - ORIF if closed reduction fails. If these is disruption of the tibio-fibular syndesmosis the surgical repair is warranted. This is very important initial management. If displaced must reduce. Once reduced it can then be classified.

Question 128

Diagnostic factors of an ankle fracture?

Answer 128

- Pop heard on fall - Ankle deformity - Tenderness of proximal fibula - Inability to weight-bear - Medial or lateral malleolus swollen and tender to palpation

Question 129

Other types of classifications of ankle injuries?

Answer 129

``` Displaced vs undisplaced Talar shift vs no talar shift Reducible vs non-reducible Open vs closed bimalleolar vs trimalleolar ```

Question 130

Knee injury history and presentation?

Answer 130

Knee Swelling - If immediate = haemarthrosis = # or torn cruciates - Overnight = effusion = meniscus or other ligaments Pain/tenderness - Joint line = meniscal - Med/lateral margins = collateral ligaments Locking: meniscal tear --> mechanical obstruction Giving way: instability following ligament injury.

Question 131

Anatomy of the knee?

Answer 131

Quadriceps - - Rectus femoris - Vastus lateralis - Vastus medialis - Vastus Intermedius ``` Above - Femur with patella. Within the knee - Lateral collateral ligament - Medial collateral ligament - ACL from front (injured in twisting sports) - PCL from back (hyperextension) ``` Lateral meniscus and medial meniscus Fibula and tibia.

Question 132

ACL injury definition

Answer 132

- Occurs as a result of acute non-contact deceleration injury, - forceful hyperextension, - excessive rotational forces about knee

Question 133

ACL history?

Answer 133

- Acute trauma - Using spikes - Audible pop - Rapid knee swelling - Sensation of knee instability - Pain - Most accurate = Positive Lachman's test - Lifting up.

Question 134

Management of ACL?

Answer 134

Sedentary patients? - Protected weight bearing, rest, ice, compression, elevation. medicine (PRICEM) - Physio to strengthen quads and hamstring - Moderate intensity demands? Formal physiotherapy + customised bracing - High intensity Bone-patellar tendon-bone autograft. Hamstring tendon grafts (bundling/augmentation and tunnelling approaches).

Question 135

What is the unhappy triad of O'Donoghue

Answer 135

- An injury of the ACL, PCL and lateral meniscus/medial meniscus. - Pain in affected knee - Stiffness + swelling - Locking of knee - Instability of knee = Injury due to lateral force on knee whilst fixed on the ground. - Pivot Shift mechanism

Question 136

Management of acutely injured knee?

Answer 136

- Full examination of acutely swollen knee after injury is hard - Take x-ray to ensure no #s Fluid level indicates a lipohaemarthrosis and indicates either a # or torn cruciate. - If no # --> RICE + later re-exam for pathology - If meniscal or cruciate injury suspected --> MRI

Question 137

Knee Arthroscopy?

Answer 137

Direct vision of inside of knee joint by arthroscope. Can examine knee under anaesthesia (decreased muscle tone) - Meniscal tears can be trimmed or repaired/suturing

Question 138

Osteoarthritis definition?

Answer 138

Degenerative joint disorder in which there are progressive loss of hyaline cartilage and new bone formation at the joint surface and its margin

Question 139

OA Aetiology/Risk Factor?

Answer 139

- Age (80% >75yrs) - Obesity - Female gender - Joint abnormality

Question 140

Classifications of OA?

Answer 140

Primary: no underlying cause Secondary: due to obesity, joint abnormality/damage, rheumatoid arthritis, gout.

Question 141

Symptoms of osteoarthritis?

Answer 141

- Affects: Knees, hips, DIPs, PIPs, thumb CMC. (carpometacarpal). Joint above CMC is the MCP - Pain: Worse with movement, background rest/night pain, worse at the END of the day. - Stiffness: especially after rest, lasts around 30 mins (e.g AM) - Deformity - Decreased Range of Movement.

Question 142

Which joint of the hand does osteoarthritis spare?

Answer 142

MCP. Involves the PIP and DIP

Question 143

OA Signs in the hand?

Answer 143

- B(P)ouchards (prox) and Heberdens (dips) (distal). - thumb CMC squaring - Fixed flexion deformity (knee)

Question 144

History in OA

Answer 144

- Pain severity, night pain - Walking distance - Analgesic requirements - ADLs and social circumstances - Co-morbidities - Underlying causes: trauma, infection, congenital.

Question 145

Pathophysiology of Osteoarthritis?

Answer 145

- Softening of articular cartilage --> Fraying and fissuring of smooth surface --> underlying bone exposure. - Subchondral bone becomes sclerotic with cysts. (fluid-filled hole). - Proliferation and ossification of cartilage in unstressed areas --> Osteophytes.

Question 146

Differential for OA?

Answer 146

- Septic Arthritis - Crystal Arthropathies - Trauma - Rheumatoid arthritis - Psoriatic Arthritis

Question 147

X-ray changes of osteoarthritis?

Answer 147

LOSSD ``` Loss of joint spaces Osteophytes Subchondral sclerosis Subchondral cysts Deformity ```

Question 148

Bloods in OA?

Answer 148

- CRP may be mildly elevated | - Ca, Po4 and ALP all normal

Question 149

Management of OA?

Answer 149

MDT - GP, Physio, OT, Dietician, Orthopod Conservative: - Lifestyle: decreased wt, increased exercise - Physio: muscle strengthening/quads strengthing - OT: walking aids, supportive footwear, home mods. Medical - Analgesia local topical: Capsaicin topical, methylsalicylate, diclofenac Then add Paracetamol NSAIDS: eg arthrotec (diclofenac + misoprostol) Tramadol Joint injections: local anaesthetic and steroids If persistent pain despite multiple treatment modalities or with severe disability Surgical - Arthroscopic washout (not recommended) Mainly knees trim cartilage remove loose bodies - Realignment osteotomy Small area of bone cut out useful in younger pts with medial knee OA High tibilar valgus osteotomy redistributes weight. - Arthroplasty: replacement

Question 150

Definition of mechanical back pain?

Answer 150

- Soft tissue injury --> dysfunction of whole spine --> muscle spasm --> pain. - May have inciting event e.g lifting - Younger patients with no sinister features

Question 151

Management of mechanical back pain?

Answer 151

Acute < 4 weeks. Conservative - Max 2d bed rest - Education: keep active, how to life/stop - Physiotherapy - Psychosocial issues re chronic pain and disability - Warmth e.g swimming in a warm pool - Can use spinal manipulation. Medical - Analgesia: NSAIDS ± codeine. First line is naproxen. - Muscle relaxant: low-dose diazepam (short-term) Chronic : CBT, acupuncture, TCI, Opioids.Exercise programme. Manual therapy.

Question 152

History in lower back pain + Red flags?

Answer 152

Onset, duration, location, radiation, character, Aggravating + relieving factors, severity. Absence of red-flag symptoms: - Thoracic pain - recent trauma, - milder trauma in age >50, - unexplained weight loss, - immunosuppression, - history of cancer, prolonged - used of steroids, osteoporosis, - duration ?6 weeks, - focal neurological deficit with progression. Investigation for suspected osteoporotic vertebral fracture - X-ray spine. Most common site for osteoporotic fracture = spine. FRAX = for patients 40-90. 10 yr risk of fragility. If intermediate result = do a DEXA. If high risk = offer bone protection treatment. = Advancing age is a major risk for osteoporotic fracture. Women >65 yrs old and men >75 yrs old should be considered for fracture risk assessment. Think FRAX. Presentation of osteoporotic vertebral fracture - Asymptomatic: osteoporotic vertebral fracture may be diagnosed through an incidental finding on X-ray. Acute back pain, breathing difficulties. GI problems. Signs - Loss of height. - kyphosis - Localised tenderness on palpation. Then do X-ray then describe if CT or MRI (for tumours). FRAX tool or QFracture used to estimate 1-yr risk.

Question 153

Diagnostic algorithm for back pain?

Answer 153

Group 1: Associated with spinal stenosis and radiculopathy. Group 2: lower back pain from cauda equina, neoplasia, infection, vertebral fracture, arthritis. Group 3: Non specific. Group 1-2 require MRI/Consultant review. Group 3 do not require imaging if pain lasted <4 weeks.

Question 154

Physical exam in back pain?

Answer 154

Inspection: Obvious deformities, abnormal curvature. Palpation of spinous processes: Feeling for taut bands, trigger points. A+P ROM: Pain on flexion that radiates to leg suggests disc herniation with impingement on nerve root. Pain on extension suggests facet arthropathy or spinal stenosis. Special tests Schober's: PSIS and 1-cm above and 5cm below. Ask patient to flex forward macimally. Distance between 2 marked. +ve test is when the distance between these 2 marks is <20cm. +ve Schober's test in combo with +ve findings on sacroiliac exam prompt referral to rheumatologist. FABER: (flexion, aduction, external rotation of hip): Patient supine, flexion, abduction and external rotation. Gaenslen test: Patients lie supine at edge of exam table, asking them to flex one hip (bring knee to chest) while extending the other hip over the edge of the exam table.

Question 155

Disc prolapse definition? (Herniated nucleus pulposus)

Answer 155

Herniation of nucleus pulposus through annulus fibrosus.

Question 156

Presentation of Disc prolapse?

Answer 156

- L5 and S1 roots most commonly compressed by prolapse of L4/5 and L5/S1 disc. - May present as severe pain on sneezing, coughing or twisting a few days after low back strain. - Lumbago: low back pain - Sciatica: shooting radicular pain down buttock and thigh.

Question 157

Signs of disc prolapse?

Answer 157

- Limited spinal flexion and extension - Free lateral flexion - Pain on straight-leg raise: Lesague's Sign - Lateral herniation --> radiculopathy - Central herniation --> Corda equina syndrome

Question 158

History of disc prolapse?

Answer 158

Check for red flags like night pain, weight loss, fever, GI, urinary or cardioresp signs. Could have discitis from IV drug abuse, TB. Pain from disc normally presents with history of previous episodes of acute pain, trauma. Pain referred to paraspinal muscles, buttocks, back of thigh. - May be associated pain in the dermatomal distribution.

Question 159

Signs of L5 Root compression?

Answer 159

- Weak hallux extension + foot drop - In foot drop due to L5 radiculopathy, weak inversion (tib. post) helps distinguish from peroneal N palsy. - Decreased sensation on inner dorsum of foot. L3 = Sensory loss over anterior thigh Weak quadriceps Reduced knee reflex Positive femoral stretch test L4 = Sensory loss anterior aspect of knee Weak quadriceps Reduced knee reflex Positive femoral stretch test

Question 160

Signs of S1 Root compression?

Answer 160

- Weak foot plantarflexion and eversion - Loss of ankle-jerk - Calf pain - Decreased sensation over sole of foot and back of calf

Question 161

Investigations of Disc prolapse?

Answer 161

- Erect Lumbar spine X-ray | - MRI (emergency if cauda equina)

Question 162

Management of disc herniation?

Answer 162

- Brief rest, analgesia and mobilisation effective in >90%. - Conservative: brief rest, mobilisation - Medical: analgesia (paracetamol + oral NSAID), transforaminal steroid, consider diazepam as a muscle relaxant, or injection. - Surgical: discectomy, laminectomy may be needed in cauda-equina, continuing pain or muscle weakness. Can also consider decompression surgery (Lumbar Microdiscectomy) - Commonest procedure for disc prolapse - Microscopic resection of protruding nucleus pulposus - Posterior approach with pt in prone position - May be performed endoscopically.

Question 163

What is spondylolisthesis?

Answer 163

- Displacement of one lumbar vertebra on another - Usually forward - Usually L5 on S1 - May be palpable.

Question 164

Causes of Spondylolisthesis?

Answer 164

- Congenital malformation - Spondylosis (Spondylosis is the degeneration of the vertebral column from any cause.) - Osteoarthritis

Question 165

Presentation of spondylolisthesis?

Answer 165

- Onset of pain usually in adolescence or early adulthood Worse on standing - ± sciatica, hamstring tightness, abnormal gait. - Examination with exaggerated lordosis.

Question 166

Investigations for Spondylolisthesis?

Answer 166

- Plain xray (in the spondylolysis - Deficiency in the pars interarticularis of the neural arch of a vertebral body). Refers to a small segment of bone that joins the facet joints in the back of the spine - May see a Scotty Dog Appearance.

Question 167

Management of Spondylolisthesis?

Answer 167

- Corset - Neve release - Spinal fusion

Question 168

What is spinal stenosis?

Answer 168

- Developmental predisposition ± facet joint osteoarthritis | - generalised narrowing of lumbar spinal canal.

Question 169

Presentation of spinal stenosis?

Answer 169

- Spinal claudication Aching or heavy buttock and lower limb pain on walking (activity related) - positional related. - Rapid onset - May c/o paraesthesiae/numbness - Pain eased by leaning forward (on bike) (stooped posture when walking) Pain on spine extension

Question 170

Investigations for spinal stenosis?

Answer 170

- X-ray (narrowing of disc space, osteophyte formation) | - MRI (compression of neural elements) - most accurate.

Question 171

Management of spinal stenosis?

Answer 171

- Corsets - NSAIDs - Epidural steroids injection - Canal decompression surgery - laminectomy.

Question 172

Neurosurgical emergencies for back pain?

Answer 172

- Acute cord compression | - Acute cauda equina compression

Question 173

What is acute cord compression?

Answer 173

- Process of compression or displacement of arterial, venous and cerebrospinal fluid spaces as well as cord itself. - Can occur due to extrinsic or intrinsic cause.

Question 174

Causes of acute cord compression

Answer 174

- Trauma - vertebral fracture - intervertebral disc herniation - primary or metastatic spinal tumour - Infection

Question 175

Classes of SCI?

Answer 175

Acute Sub-acute Chronic

Question 176

History of SCC?

Answer 176

Patients should be immobilised with cervical collar. - History of trauma - Bilateral pain: back and radicular - LMN signs at compression level - UMN signs and sensory level below compression - Sphincter disturbance

Question 177

Symptoms of SCC

Answer 177

- Altered sensation (pin, touch, vibration) Hemisensory loss. - Motor hemiplegia/tetrapelgia - Bladder or bowel dysfunction - Hyperreflexia - SYmmetrical sensory loss - Hypotonia below level of injury - Neurogenic shock (hypotension and bradycardia, dry extremities, peripheral vasodilation).

Question 178

High cervical complete cord transection?

Answer 178

- Quadriplegia - Resp insufficiency - Loss of bladder + bowel function - Anaestheia below affected level - Neurogenic shock

Question 179

Lower cervical transection

Answer 179

Spares resp muscles | Horner's syndrome (miosis, anhydrosis, ipislateral ptosis)

Question 180

High thoracic lesions

Answer 180

- Paraparesis + autonomic function loss | - Lower thoracic, lumbar and sacral cord transection.

Question 181

Symptoms of acute cauda equina compression

Answer 181

Due to disc compression + stenosis of spinal canal. | - Syndrome consists of saddle anaesthesia, bladder retention, leg weakness.

Question 182

Management of back neurosurgical emergencies?

Answer 182

Acutely - Immobilisation + decompressive surgery. (consider steroids) - - Large prolapse/disc compression: Laminectomy/disectomy - Tumours: Radiotherapy and steroids - Abscesses: decompression

Question 183

What is osteochondritis?

Answer 183

- Idiopathic condition in which bony centres of children become temporarily softened due to osteonecrosis. - Pressure --> Deformation - Bone hardens in new, deformed position.

Question 184

Radiography on osteochondritis?

Answer 184

Initially: increased density/sclerosis Then: Patchy appearance

Question 185

What is Scheuermann's Disease?

Answer 185

- Affecting adolescents - Vertebral ring epiphyses - Leads to kyphosis - due to wedge shaped thoracic vertebrae on X-ray. Progressive kyphosis with at least 3 vertebrae invovled. - Back pain and stiffness. - Vertebral tenderness

Question 186

Kohler's Disease?

Answer 186

Pain in mid-tarsal region Navicular bone (loses its blood supply temporarily). Children 3-5 yrs.

Question 187

Kienboch's Disease?

Answer 187

- Lunate bone - Adults - Pain over lunate esp on active movement - Impaired grip

Question 188

Friedburg's disease?

Answer 188

- 2nd/3rd metatarsal head - Around puberty - Forefoot pain worse with pressure

Question 189

Panner's Disease?

Answer 189

- Capitulum of humerus

Question 190

Perthes' Disease?

Answer 190

Hip

Question 191

Acute Osteomyelitis organisms?

Answer 191

Infants - S aureus - Group B strep Children - S aureus - Strep pyogenes - Haem infl (non-immunised) Adults - Gram negative bacilli (E.coli, Pseudomonoas) - S aureus Sickle Cell = Salmonella

Question 192

Risk factors for Acute osteomyelitis?

Answer 192

RFs - Vascular disease - Trauma - Sickle Cell Disease ( S aureus or Salmonella) - Diabetes

Question 193

Signs and symptoms of osteomyelitis?

Answer 193

- Pain, tenderness, erythema, warmth, decreased ROM. - Effusion in neighbouring joints - Signs of systemic infection Typically affects the metaphysis in children. Epiphysis in adults. Adults = Elders = Epiphysis .

Question 194

Investigations for osteomyelitis?

Answer 194

- ESR/CRP/ WCC - +ve blood cultures in 60% - X-ray : - Changes take 10-14ds - Haziness + decreased bone density - Sub-periosteal reaction - Sequestrum and involucrum - Osteopenia - Fallen leaf sign 1st line: MRI sensitive + specific

Question 195

Management of Acute Osteomyelitis?

Answer 195

- Local Guidelines - IV Abx Vanc + Cefotaxime until MCS Known - Drain abscess + remove sequestrae - Analgesia

Question 196

Pathophysiology of septic arthritis?

Answer 196

- From direct injection or haematogenous route. - Mostly Staph or Strep. - Consider Gonococcal arthritis. - Gram -ve bacilli.

Question 197

Risk factors for septic arthritis?

Answer 197

- Joint disease - RA - CRF - Immunosuppression (DM) - Prosthetic joints.

Question 198

Symptoms of septic arthritis?

Answer 198

- Acutely inflamed tender, swollen joint - Decreased ROM - Systemically unwell

Question 199

Investigations for septic arthritis?

Answer 199

- Joint aspiration for MCS (Shows High WCC (>50,000/mm): Mostly PMN. - Increased ESR/CRP, increased WCC, Blood cultures. - X-ray

Question 200

Management of septic arthritis

Answer 200

IV abx: Vanc + cefotaxime - Consider joint washout under GA - Splint joint - Physiotherapy after infection resolved

Question 201

Complications of septic arthritis?

Answer 201

Osteomyelitis Arthritis Ankylosis: fusion

Question 202

Differential for septic arthritis?

Answer 202

- crystal arthropathy | - Reactive arthritis

Question 203

Anatomy of the Brachial Plexus?

Answer 203

- Consists of C5-T1. - Roots leave between scalenus anterior and medius. - Divisions occur under the clavicle, medial to coracoid process. - Plexus has intimate relationship with subclavian and brachial arteries.

Question 204

C5-C6

Answer 204

Forms Lateral trunk, splits to form anterior part of median and the musculocutaneous

Question 205

C7

Answer 205

Forms posterior trunk, and then the axillary and radial nerve. (Also form C5-T1 for Radial).

Question 206

C8-T1

Answer 206

Forms Median trunk, and ulnar nerve + posterior part of median.

Question 207

Causes of brachial plexus injuries?

Answer 207

Direct: shoulder girdle #, penetrating or iatrogenic injury. Indirect: e.g avulsion (body structure torn off) or traction injuries.

Question 208

What is the Leffert Classification of brachial plexus injuries?

Answer 208

1. Open 2. Closed a - Supraclavicular b - Infraclavicular 3. Radiation-induced 4. Obstetric a. Upper b. Lower c. Mixed

Question 209

High C5/C6 Injury?

Answer 209

Erbs Palsy - Abductors and external rotators paralysed - Waiter's tip position - Loss of sensation in C5/C6 dermatomes. C6 entrapment = weakness in biceps or reduced biceps reflex.

Question 210

Low C8/T1 injury?

Answer 210

Klumpke's Paralysis - Paralysis of small hand muscles - Claw hand - Loss of sensation in C8/T1 dermatomes.

Question 211

Radial Nerve injury (C5-T1) - Low Lesion?

Answer 211

``` Posterior interosseous nerve. - Site: # around elbow or forearm - E.g #head of radius. Loss of extension of CMC joint (thumb drop) - No sensory loss. ```

Question 212

Radial Nerve injury (C5-T1) - High Lesion?

Answer 212

- Site: # shaft of humerus where N. is in radial groove. - Wrist Drop - Loss of sensation to dorsum of thumb root (snuff box) - tricep functions normally

Question 213

Radial Nerve injury (C5-T1) - V. High Lesion.

Answer 213

Site: Axilla - crutches or Sat Night Palsy | - Paralysis of tricep and wrist drop

Question 214

Ulnar Nerve (C8-TI)

Answer 214

Site: Elbow: cubital tunnel Wrist: Guyon's Canal Effects: Intrinsic hand muscle paralysis --> claw hand Ulnar paradox: lesion at elbow has less clawing as FDP is paralysed, decreasing flexion of 4th/5th digits. - Weakness of finger ab/adduction (interrosei) - Sensory loss over little finger. The closer to the paw, the bigger the claw. Ulnar nerve supplies ulnar border of hand and mdial forearm. Thumb flexion is not affected by ulnar nerve lesions

Question 215

Test for Ulnar Nerve Damage?

Answer 215

Can't cross fingers for luck Froment's sign: Flexion of thumb IPJ when trying to hold onto paper held between thumb and finger - Indicates weak adductor policis.

Question 216

Median Nerve (C5-T1)

Answer 216

Injury above the Antecubital fossa? - Can't flex index finger IPJ (e.g on clasping hand) - Can't flex terminal thumb phalanx (FPL) - Loss of sensation in median distribution. Injury at wrist - Typically affects abductor pollicis brevis.

Question 217

Carpal Tunnel Syndrome Anatomy?

Answer 217

Carpal Tunnel formed by flexor retinaculum and carpal bones - Contains 4 tendons of FDS (flexor digitorum superficialis) 4 tendons of FDP (flexor digitorum profundus) 1 tendon of flexor pollicis longus) Median Nerve Burning in the night, numbness and tingling of thumb, index, middle and inner side of ring finger. Amyloidosis - blue nerve.

Question 218

What does Median Nerve supply?

Answer 218

LOAF - Lumbricals - Opponens pollicis - Abductor pollicis brevis - Flexor pollicis Brevis Palmar cutaneous branch travels superficial to flexor retinaculum --> Spares sensation over thenar area.

Question 219

Causes of CTS?

Answer 219

F>M - Primary/idiopathic - Secondary Water: preganncy, hypothyroidism, Acromegaly Radial # Inflammation: RA (younger patient) , gout Soft tissue swelling: lipomas, acromegaly, amyloidosis Toxic: DM, ETOH, Obesity

Question 220

Symptoms of CTS

Answer 220

- Tingling/pain in thumb, index and middle finger - Pain worse at night or after repetitive actions - Relieved by shaking/flicking - Clumsiness

Question 221

Signs of CTS

Answer 221

- Decrease sensation over lateral 3.5 fingers. -Decreased 2-point touch discrimination Early sign of irreversible damage - Wasting of thenar eminence late sign of irreversible damage Phalen's flexing test and Tinel's tapping test.

Question 222

Investigations for CTS?

Answer 222

Not usually performed Nerve conduction test US

Question 223

Non-surgical management CTS

Answer 223

``` Treat underlying cause Wrist splints - Neutral position - Esp. @ night Local steroid injections ```

Question 224

Surgical Mx CTS

Answer 224

Carpal tunnel decompression by division of the flexor retinaculum

Question 225

Complications of surgery CTS

Answer 225

Scar formation: high risk for hypertrophic or keloid Scar tenderness: up to 40% Nerve injury - Palmar cutaneous branch of the median nerve - Motor branch to the thenar muscle Failure to relieve symptoms

Question 226

Other locations of median nerve entrapment?

Answer 226

Pronator syndrome (supernate to the sky) - Entrapment between two heads of pronator teres Anterior interroseous syndrome - Compression of the anterior interosseous branch by the deep head of pronator teres. Muscle weakness only - Pronator quadratus - FPL - Radial half of FDP

Question 227

Minor Hand conditions - Dupuytren's Contractures

Answer 227

Progressive, painless fibrotic thickening of palmar fascia.

Question 228

Signs in patients with Dupuyrtren's Contracture?

Answer 228

- M>F - Middle Age / Elderly - Skin Puckering and tethering - Fixed Flexion Contracture of ring and little fingers - Often bilateral and symmetrical - MCP and IP joint flexion.

Question 229

Dupuytrens Associations?

Answer 229

BAD FIBERS - Peyronies (3%) - AIDS - DM - FH: AD - Idiopathic - Booze: ALD - Epilepsy and epilepsy meds (phenytoin) - Reidel's thyroiditis and other fibromatoses : Ledderhose disease (fibrosis of plantar aponeurosis) - Smoking

Question 230

Management of Dupuytrens

Answer 230

- Conservative: e.g physio/exercise - Fasciectomy e.g When hand can't be placed flat on the table - refer to surgery. Z-shaped scar: prevent contracture - Can damage ulnar nerv - Usually recurs

Question 231

Differential for Dupuytren's Contracture

Answer 231

- Skin contracture: old laceration or burn - Tendon fibrosis, trigger finger - Ulnar N.palsy

Question 232

Trigger Finger

Answer 232

- Tendon Nodules which catches on proximal side of tendon sheath --> triggering on forced extension. Leaves a fixed flexion deformity. - Usually ring and middle finger - Associated with RA, and diabetes. Idiopathic in the majority.

Question 233

Management of Trigger Finger

Answer 233

- Steroid injection (high recurrence) or surgery

Question 234

What is a ganglion?

Answer 234

- Smooth, multiocular cystic swellings - Mucoid degeneration of joint capsule or tendon sheath - May be in communication with joint capsule/tendons.

Question 235

Presentation of ganglion

Answer 235

90% located dorsum wrist Subdermal, fixed to deeper structures - Limits planes of movement May cause pain or nerve pressure symptoms.

Question 236

Management Ganglion?

Answer 236

- 50% disappear spontaneously - Aspiration ± steroid and hyaluronidase injection - Surgical excision

Question 237

Differential for ganglion?

Answer 237

- Lipoma - Fibroma - Sebaceous cyst

Question 238

Minor Leg and Foot conditions? -Meralgia paraesthetica

Answer 238

- Entrapment of lateral cutaneous nerve of thigh - Between ASIS and inguinal ligament - Pain ± paraethesia on lateral thigh - Increased risk with obesity: compression by belts, underwear. Relieved by sitting down - Can occasionally be damaged in lap hernia repair.

Question 239

Chondromalacia Patella

Answer 239

- Predominantly young women - Patellar aching after prolonged sitting or climbing stairs - Pain on patellofemoral compression: Clarke's test - Ix: no abnormality on X-ray - Rx: vastus medialis strengthining

Question 240

Baker's Cyst

Answer 240

- Popliteals swelling arising between medial head of gastrocnemius and semimembranous muscles - Herniation from joint synovium - Usually 2ndry to OA or gout. Following minor trauma to knee. - Rupture: acute calf pain and swelling: DVT Differential.

Question 241

Hallux Valgus (Bunion)

Answer 241

- Great toe deviates laterally @ MTP joint. - Pressure of MTP against shoe --> Bunion. - Increased wt bearing @ metatarsal head. - -> Pain: Transfer metatarsalgia - -> Hammer toe (at second metatasal head)

Question 242

Aetiology of Hallux Valgus?

Answer 242

Pointed shoes | Wearing high heels

Question 243

Management of Hallux Valgus?

Answer 243

Conservative: bunion pads, plastic wedge between great + second toes. Surgical: Metatarsal osteotomy

Question 244

Other toe deformities

Answer 244

Hammer Toe Claw Toe Mallet Toe

Question 245

Morton's Neuroma

Answer 245

- Pain from pressure on an interdigital neuroma between metatarsals - Affects the intermetatarsal plantar nerve in the inter-metatarsophalangeal space. - Pain radiates to medial side of one toe and lateral side of another - Investigations is used for US. - Management: neuroma excision. Features - Forefoot pain, most commonly in the third inter-metatarsophalangeal space. - Worse on walking. May be described as shooting or burning pain. May feel like they have a pebble in their shoe. - Mulder's click: one hand tries to hold the neuroma between finger and thumb. One hand squeezes the metatarsal together. A click may be heard as the neuroma moves between the metatars sal heads. Loss of sensation distally. Management - Avoid high-heels - Metatarsal pad - CKS recommends referral if symptoms persist for >3 months despite footwear - Orthotist may give patient metatarsal dome orthotic - Can use steroid injection and neurectomy of involvement interdigital nerve. Stress fracture - unlikely if not doing regular exercise.

Question 246

Where you would use an MRI over CT?

Answer 246

Soft Tissue

Question 247

Straight leg raise

Answer 247

Compare side to side Active and Passive Fracture NOF on Active (won't happen). Do it passively and more helpful. Knee effusion - Active is useful.

Question 248

Strain and Sprain

Answer 248

Strain - Pull in muscle due to excessive stretch, pain, spasm, oedema. Sprain - Ligament tear (3 degrees based on severity).

Question 249

Dislocation

Answer 249

Complete loss of congruity of joint surface. | Younger the patient is, the more prone they are for further dislocations.

Question 250

Subluxation

Answer 250

Partial loss of congruity of joint surface

Question 251

Describing a fracture

Answer 251

``` Anatomical location - bone and bone site (distal/proximal) - Direction of fracture line (transverse, oblique, spiral) - Linear/comminuted - Fragments - one or more segments - Displaced/undisplaced Open/Closed Stable/unstable (spinal fracture) ``` Articular involvement/epiphyseal injury - Fracture extends to involve joint, dislocation. Soft tissue injury.

Question 252

Children's fractures?

Answer 252

Bowing fracture /plastic fracture Torus or Buckle Fracture Toddler's Fracture - Swelling and pain with screaming.

Question 253

Soft tissue injury - De Quervain's Tenosynovitis

Answer 253

De Quervain's = common condition in which the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflammed. 30-50. Pain on the radial side of the wrist Tenderness over the radial styloid process Painful abduction of the thumb. FInkelstein's = Finkelnstein Test = the examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction. In a patient with tenosynovitis this action causes pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus Management - Analgesia - Steroid injection - Immobilsation with thumb splint - Surgical treatment

Question 254

Achilles Tendon

Answer 254

Can present as tendinopathy, partial tear and complete rupture of the Achilles tendon. RF: Ciprofloxacin and hypercholesterolaemia - predisposes to tendon xanthomata. Tendonitis - Gradual onset of posterior heel pain worse following activity. - Morning pain and stiffness - Calf muscle excercises. Rupture - IN a person describing an audible pop in the ankle whilst playing sport. Simmond's triad - le prone with their feet over edge of bed. Look for abnormal angle of declination. GREATER DORSIFLEXION ON INJURED FOOT. GAP IN THE TENDON AND GENTLY squeeze calf Distance between both parts of the tendon. Conservatively or surgically. Diagnosis: Palpation-gap can be felt, swelling at back of heel, decreased active plantar flexion, increased passive dorsifleciton, inability to heel rise. Impaired gait, positive Thompson test. Investigation = MRI/CT. Treatment: surgical suture and conservative (cast in 30 plantar flexion).

Question 255

Tennis Elbow

Answer 255

Lateral epicondylitis - Causes: overuse of forearm extensor Symptoms: pain, increasing with movements. Medial wrist pain on resisted wrist pronation with elbow extended. Diagnosis: clinical, imaging to rule out fracture - Treatment; rest, physiotherapy, NSAIDs

Question 256

Golfer's elbow

Answer 256

Golfer's elbow - Medial epicondylitis (less common) - Causes: overuse of forearm flexors - Symptoms: pain, increasing with movements - Diagnosis: clinical, imaging in to rule out fractures - TReatment: rest physiotherapy, NSAIDS

Question 257

Patella Dislocation

Answer 257

Commonly occurs as traumatic primary event. Genu valgum, tibial torsion and high riding patella are risk factors. Common cause of haemarthrosis and many will spontaneously reduce when the leg is straightened. In the chronic setting physiotherapy is used to strengthen the quadriceps muscle. X-ray/CT scan - Skyline X-ray views of patella are required, although displaced patella may be clinically obvious.

Question 258

Fracture at the neck of talus is associated with what?

Answer 258

AVN due to retrograde blood supply.

Question 259

Foot anatomy?

Answer 259

Longitudinal arch higher on medial than lateral. Posterior part of calcaeneum form a posterior pillar to support the arch. Head of talus marks the summit of this arch.

Question 260

Intertarsal joints?

Answer 260

Sub talar joint - Formed by the cylindrical facet on the lower surface of the body of the talus and the posterior facet on the upper surface of the calcaneus. The facet on the talus is concave anteroposteriorly, the other is convex. The synovial cavity of this joint does not communicate with any other joint.

Question 261

Talocalcaeneonavicular

Answer 261

The anterior part of the socket is formed by the concave articular surface of the navicular bone, posteriorly by the upper surface of the sustentaculum tali. The talus sits within this socket

Question 262

Calcaneocuboid joint

Answer 262

Highest point in the lateral part of the longitudinal arch. The lower aspect of this joint is reinforced by the long plantar and plantar calcaneocuboid ligaments.

Question 263

Muscles of the foot?

Answer 263

Abductor hallucis Medial side of the calcaneus, flexor retinaculum, plantar aponeurosis Medial plantar nerve. Abducts the great toe.

Question 264

Flexor Digitorum brevis?

Answer 264

Flexes all the joints of the lateral 4 toes except for the interphalageal joint. Medial plantar nerve.

Question 265

Abductor digit minimi

Answer 265

Abducts the little toe at the metatarsophalangeal joint Lateral plantar nerve

Question 266

Flexor hallucis brevis

Answer 266

Flexes the metatarsophalangeal joint of the great toe. Medial plantar nerve

Question 267

Adductor hallucis

Answer 267

Adducts the great toe towards the second toe. Helps maintain the transverse arch of the foot. Lateral planar nerve

Question 268

Lateral plantar nerve

Answer 268

Passes anterolaterally towards the base of the 5th metatarsal between flexor digitorum brevis and flexor accessorius. On the medial aspect of the lateral plantar artery. At the base of the 5th metatarsal it splits into superficial and deep branches.

Question 269

Medial plantar nerve

Answer 269

Passes forwards with the medial plantar artery under the cover of the flexor retinaculum to the interval between abductor hallucis and flexor digitorum brevis on the sole of the foot.

Question 270

Meniscal tear?

Answer 270

Usually caused by twisting the knee and on examination - McMurray's will be positive. Not able to extend knee, locked in flexion - VERY IMPORTANT. Features - Pain worse on straightening the knee - Knee may give way - Displaced meniscal tears may cause knee locking - tenderness along the joint line - Thessaly's test - weight bearing at 20 degrees of knee flexion patient supported by doctor, positive if pain on twisting knee. Knee held in one hand, which is placed along the joint line and flexed while the sole of the foot is held with the other hand. Investigation - MRI is most appropriate imaging modality to diagnose mensical tears.

Question 271

Osteoarthritis of the knee?

Answer 271

Patient is typically > 50 years, often overweight Pain may be severe Intermittent swelling, crepitus and limitation of movement may occur

Question 272

Infrapatellar bursitis | Clergyman's knee

Answer 272

Associated with kneeling

Question 273

Prepatellar bursitis | Housemaid's knee

Answer 273

Associated with more upright kneeling

Question 274

Anterior Cruciate ligament?

Answer 274

Twisting of the knee - popping Rapid onset of knee effusion Positive draw test or Postive lachman's Poor healing - Management: intense physiotherapy or surgery.

Question 275

Posterior cruciate ligament

Answer 275

May be caused by anterior force applied to the proximal tibia (knee hitting dashboard during accident) Paradoxical anterior draw test.

Question 276

Collateral ligament

Answer 276

Tenderness over the affected ligament Knee effusion may be seen Lateral collateral - direct blow to the medial aspect of the leg with lateral joint line tenderness.

Question 277

Meniscal lesion?

Answer 277

May be caused by twisting of the knee Locking and giving way are common feature Tender joint line.

Question 278

Menisceal tear

Answer 278

Rotational sporting injuries Delayed knee swelling Joint locking Recurrent episode of pain and effusions are common, often following minor trauma.

Question 279

Chondromalacia patellae?

Answer 279

Teenage girls following an injury to knee - Dislocation patella Typical history of pain on going downstairs or at rest. Tenderness, quadriceps wasting.

Question 280

Dislocation of patella?

Answer 280

Most commonly occurs as a traumatic primary event, either through direct trauma or through severe contraction of quadriceps with knee stretched in valgus and external rotation Genu valgum, tibial torsion and high riding patella are risk factors Skyline x-ray views of patella are required, although displaced patella may be clinically obvious An osteochondral fracture is present in 5% The condition has a 20% recurrence rate

Question 281

Fractured patella

Answer 281

2 types: i. Direct blow to patella causing undisplaced fragments ii. Avulsion fracture

Question 282

Tibial plateau fracture

Answer 282

Occur in the elderly (or following significant trauma in young) Mechanism: knee forced into valgus or varus, but the knee fractures before the ligaments rupture Varus injury affects medial plateau and if valgus injury, lateral plateau depressed fracture occurs Classified using the Schatzker system (see below) Type 1 - Vertical split of lateral condyle 2 - Vertical split of the lateral condyle combined with an adjacent load bearing part of the condyle 3- Depression of the articular surface with intact condylar rim 4 - Fragment of the medial tibial condyle 5- Fracture of both condyles 6- Combined condylar and subcondylar fractures

Question 283

Acromioclavicular joint injury

Answer 283

Injury to the AC joint is relatively common and typically occurs during collision sports such as rugby following a fall on to the shoulder or FOOSH. Positive scarf test, with swelling, popping, clicking or grinding (on degeneration). Grade 1 and 2 are very common. Managed conservatively including resting the joint using a sling. IV V and VI require surgical intervention.

Question 284

Adhesive capsulitis?

Answer 284

Common cause of shoulder pain. Mostly affects middle-aged females. Aetiology of frozen shoulder is not fully understood. - Associated with diabetes mellitus: Up to 20% of diabetics may have an episode of frozen shoulder. Features - external rotation is affected more than internal rotation or abduction - both active and passive movement are affected patients typically have a - painful freezing phase, an adhesive phase and a recovery phase bilateral in up to 20% of patients the episode typically lasts between 6 months and 2 years Management - No single intervention has been shown to improve outcome in the long-term - Treatment options include NSAIDs, physiotherapy, oral corticosteroids, intra-articular corticosteroids.

Question 285

Bennett's Fracture? = Boxer

Answer 285

Intra-articular fracture of the first carpometacarpal joint Impact on flexed metacarpal X-ray: triangle fragment at ulnar base of metacarpal

Question 286

Pott's Fracture - Like a pot.

Answer 286

Bimalleolar ankle fracture | Forced foot eversion

Question 287

Femoral nerve damage

Answer 287

Weakness in knee extension Loss of patella reflex Numbness of the thigh Damage in hip and pelvis fractures

Question 288

Lumbosacral trunk

Answer 288

Weakness in ankle dorsiflexion, numbness of the calf and foot

Question 289

Sciatic nerve

Answer 289

Weakness in knee flexion and foot movement, pain and numbness from gluteal region.

Question 290

Obturator nerve

Answer 290

Weakness in hip adduction Numbness over medial thigh Damage in anterior hip dislocation Most nerve injuries recover within 6-8 weeks, occassionally can be permanent.

Question 291

Lateral cutaneous nerve of the thigh

Answer 291

Compression of the nerve near the ASIS --> Meralgia paraesthetica - condition characterised by pain, tingling and numbness in the distribution of the lateral nutaneous nerve.

Question 292

Tibial nerve

Answer 292

Foot plantar flexion and invesion -Not commonly injured as deep and well protected. Popliteal laceration, posterior knee dislocation. Tibialis posterior is responsible for plantar flexion and eversion of foot.

Question 293

Common peroneal nerve

Answer 293

Foot dorsiflexion and eversion Extensor hallucis longus Injury often occurs at the neck of the fibula Tightly applied lower limb plaster cast Injury causes foot drop More likely to be injured in a surgical damage for a TKR.

Question 294

Superior gluteal nerve

Answer 294

Misplaced intramuscular injection Hip surgery Pelvic fracture Posterior hip dislocation Injury results in a positive Trendelenburg sign

Question 295

Inferior gluteal nerve

Answer 295

Generally injured in association with the sciatic nerve Injury results in difficulty rising from seated position. Can't jump, can't climb stairs

Question 296

Ganglion

Answer 296

Cyst arising from the joint or tendon sheath. Most commonly seen around the back of the wrist and are 3x more common in women. Ganglions often disappear spontaneously after several months.

Question 297

Plantar Fasciitis?

Answer 297

Exacerbated by walking on tip toes unlike subcalcaneal bursitis. Most common cause of heel pain in adults. Pain is worse around the medial calcaneal tuberosity. Management - rest the feet where possible, wear shoes with good arch support and cushioned heels. Insoles and heel pads may be helpful. Try ibuprofen. Patients with persistent symptoms that have failed 6-12 months worth of conservative management should be referred to orthopaedics for consideration of surgical intervention as well as physiotherapy.

Question 298

Achilles tendonitis?

Answer 298

Pain is at the calcaneal insertion of the tendon or further up the tendon depending on the area affected.

Question 299

Slipped Upper Femoral Epiphysis?

Answer 299

Typical age group = 10-15 yrs More common in obese children and boys. Displacement of the femoral head epiphysis postero-inferiorly. May present acutely following trauma or more commonly with chronic, persistent symptoms. Features - Knee or distal thigh pain is common - Loss of internal rotation of the leg in flexion.

Question 300

Radial tunnel syndrome?

Answer 300

Most commonly due to compression of the posterior interosseous branch of the radial nerve. Thought to be a result of overuse. Similar to lateral epicondylitis. Pain tends to be 4-5 cm disral to the lateral epicondyle. - Symptoms may be worsened by extending the eblow and pronating the forearm.

Question 301

Cubital Tunnel Syndrome?

Answer 301

Due to the compression of the ulnar nerve. Features initially intermittent tingling in the 4th and 5th finger may be worse when the elbow is resting on a firm surface or flexed for extended periods later numbness in the 4th and 5th finger with associated weakness

Question 302

Olecranon bursitis?

Answer 302

Swelling over the posterior aspect of the elbow | Associated with pain, warmth and erythema. Typically affects middle-aged male.

Question 303

Hand disease?

Answer 303

Dupuytrens contracture - Fixed flexion contracture of the hand where the finger bends towards the palm and cannot be fully extended. - Caused by underlying contracture of the palmar aponeurosis. - Ring and little finger affectred the most. - Associated with liver disease, alcoholism. - treatment is surgical and fasciectomy.

Question 304

Carpal tunnel syndrome?

Answer 304

Idiopathic median neuropathy at the carpal tunnel. Characterised by altered sensation of the lateral 3 fingers. Symptoms occur mainly at night in early stages of the condition. Examination may demonstrate wasting of the muscles of the thenar eminence and symptoms may be reproduced by Tinels test (compression of the contents of the carpal tunnel). Formal diagnosis is usually made by electrophysiological studies. Treatment is by surgical decompression of the carpal tunnel, a procedure achieved by division of the flexor retinaculum. Non - surgical options include splinting and bracing.

Question 305

Osler Nodes

Answer 305

Osler's nodes are painful, red, raised lesions found on the hands and feet. They are the result of the deposition of immune complexes.

Question 306

Bouchard's nodes

Answer 306

Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of fingers or toes.) They are a sign of osteoarthritis, and are caused by formation of calcific spurs of the articular cartilage.

Question 307

Heberden's nodes

Answer 307

Typically develop in middle age, beginning either with a chronic swelling of the affected joints or the sudden painful onset of redness, numbness, and loss of manual dexterity. This initial inflammation and pain eventually subsides, and the patient is left with a permanent bony outgrowth that often skews the fingertip sideways.

Question 308

Ganglion

Answer 308

Swelling in association with a tendon sheath commonly near a joint. They are common lesions in the wrist and hand. Usually they are asymptomatic and cause little in the way of functional compromise. They are fluid filled although the fluid is similar to synovial fluid it is slightly more viscous. When the cysts are troublesome they may be excised.

Question 309

L3 nerve root compression

Answer 309

Sensory loss over anterior thigh Weak quadriceps Reduced knee reflex Positive femoral stretch test.

Question 310

L4 nerve root compression

Answer 310

Sensory loss anterior aspect of knee Weak quadriceps Reduced knee reflex Positive femoral stretch test

Question 311

L5 nerve root compression

Answer 311

Sensory loss dorsum of foot Weakness in foot and big toe dorsiflexion Reflexes intact Positive sciatic nerve stretch test

Question 312

S1 nerve root compression

Answer 312

Sensory loss posterolateral aspect of leg and lateral aspect of foot Weakness in plantar flexion of foot Reduced ankle reflex Positive sciatic nerve stretch test

Question 313

Osteomyelitis?

Answer 313

Describes infection of the bone Staph A is the most common cause except in patients with sickle cell anaemia. Predisposing conditions - DM - Sickle cell - IVDU - Immunosuppression or HIV - Alcohol excess. image = MRI most sensitive. Manage with Fluclox.

Question 314

Leriche syndrome

Answer 314

Atherosclerotic occlusive disease involving the abdominal aorta and/or both iliac arteries. Management involves correcting underlying risk factors such as hypercholesterolaemia + stopping smoking. - Claudication of the buttocks and thighs - Atrophy of the musculature of the legs - Impotence due to paralysis of the L1 nerve.

Question 315

Osteoarthritis of the hip?

Answer 315

- Second most common presentation of OA after the knee. - RF = increasing age, female gender, obesity, DDH. Features - Chronic history of groin ache following exercise and relieved by rest. - Red flag features suggesting an alternative cause including rest pain, night pain and morning stiffness > 2hrs. Investigations = clinical (maybe X-ray) Management - Oral analgesia - Intra-articular injections: provide short-term benefit - Total hip replacement remains the definitive treatment Complications of total hip replacement - VTE - Intraoperative fracture - Nerve injury Reasons for total hip replacement - Aseptic loosening - Pain - Dislocation - Infection

Question 316

Cauda Equina syndrome?

Answer 316

Features - lower back pain - urinary incontinence/retention - reduced sensation in the perianal area - decreased anal tone Investigation - urgent MRI Needs urgent investigation. Most common cause is herniation of an intravertebral disc compressing the cauda equina.

Question 317

Dorsal column lesions?

Answer 317

- Loss vibration and proprioception | - Tabes dorsalis, SACD

Question 318

Spinothalamic tract lesions?

Answer 318

Loss of pain, sensation and temperature

Question 319

Central cord lesions?

Answer 319

Flaccid paralysis of the upper limbs.

Question 320

Osteomyelitis

Answer 320

Normally progressive Staph aureus in IVDU, normally cervical region affected Fungal infections in immunocompromised Thoracic region affected in TB

Question 321

Infarction spinal cord

Answer 321

Dorsal column signs (loss of proprioception and fine discrimination

Question 322

Cord compression

Answer 322

UMN signs Malignancy Haematoma Fracture

Question 323

Brown-sequard syndrome

Answer 323

Hemisection of the spinal cord Ipsilateral paralysis Ipsilateral loss of proprioception and fine discrimination Contralateral loss of pain and temperature

Question 324

Hip flexors

Answer 324

L1 and L2

Question 325

Knee extensors (quadriceps)

Answer 325

L3

Question 326

Ankle dorsiflexors (tibialis anterior)

Answer 326

L4 and L5

Question 327

Toe extensors (hallucis longus)

Answer 327

L5

Question 328

Ankle plantar flexors (gastrocnemius)

Answer 328

S1

Question 329

Elbow flexor/Bicep?

Answer 329

C5

Question 330

Wrist extensors

Answer 330

C6

Question 331

Elbow extensors/Triceps

Answer 331

C7

Question 332

Long finger flexors

Answer 332

C8

Question 333

Small finger abductors

Answer 333

T1

Question 334

Sciatic neuropathy?

Answer 334

Commonly confused with this would cause a loss of an ankle jerk and plantar response and loss of knee flexion and power below the knee.

Question 335

L5 radiculopathy?

Answer 335

Weakness of hip abduction and foot drop. Does not affect the reflex loop.

Question 336

Stress fracture?

Answer 336

Repetitive activity and loading of normal bone may result in small hairline fractures. Whilst these may be painful they are seldom displaced. They may present late following the injury in which case callus formation may be identified on radiographs. Such cases may not require formal immoblisations.

Question 337

Positioning in the Lloyd Davies stirrups carry risk?

Answer 337

Peroneal nerve neuropraxia.

Question 338

Ilioinguinal nerve?

Answer 338

Entrapment in a mesh causing a neuroma

Question 339

Sciatic nerve?

Answer 339

Posterior approach due to a total hip replacement.

Question 340

Which muscles does deep peroneal supply?

Answer 340

Tibialis anterior Extensor digitorum longus Peroneus tertius Extensor hallucis longus Dorsiflexion ankle, inversion of the foot. Extends lateral four toes Dorsiflex ankle joint Extends big toe.

Question 341

Which muscles does superficial peroneal nerve supply?

Answer 341

Peroneus longus Peroneus brevis Evertion of the foot and plantar flexion

Question 342

Tibial nerve?

Answer 342

Gastrocnemius Soleus Plantar flexion Flexion of lateral four toes, and great toe.

Question 343

Musculocutaneous nerve (C5-C7)

Answer 343

Elbow flexion = supplies biceps and supination

Question 344

Axillary nerve (C5-C6)

Answer 344

Shoulder abduction (Deltoid) Damage due to humeral neck fracture/dislocation. Flattened deltoid.

Question 345

Radial nerve (C5-C6)

Answer 345

Extension (forearm, wrist, fingers, thumb) Humeral midshaft fracture.

Question 346

Median nerve? (C6,C8,T1)

Answer 346

LOAF muscles. Carpal tunnel syndrome.

Question 347

Ulnar nerve (C8-T1)

Answer 347

Intrinsic hand muscles except loaf Wrist flexion Medial epicondyle fracture - Claw hand

Question 348

Psoas abscess?

Answer 348

Psoas abscess is a collection within the psoas muscle. It is commonly missed or diagnosed late due to its numerous differential diagnoses and a high index of suspicion is required in those with risk factors. The psoas muscle extends from T12 - L5 caudally, inserting on the lesser trochanter of the femur. It can be of primary origin or a result of spread from local sources such as pyelonephritis or inflammatory bowel disease. Left untreated it can lead to septicaemia and multi organ failure. Caused by Staph or Strep. Pain is usually non specific initially but increases over several days. It is worth suspecting if there is no history of trauma or injury. Fever may be present but not always. Psoas irritation is evidenced when the position of comfort is the patient lying on their back with slightly flexed knees. Inability to weight bear or pain when moving the hip is usually evident. Secondary to Crohns, Diverticulitis, UTI, GU cancer, Vertebral osteomyelitis, femoral catheter, Endocarditis. CT abdomen may identify the abscess but MRI is the gold standard. Management is with antibiotic therapy +/- drainage. Alongside managing any predisposing risk factors if appropriate.

Question 349

Iliotibial band syndrome?

Answer 349

Iliotibial band syndrome - common cause of pain in runners. Tenderness 2-3cm above lateral joint line. Management - activity modification and iliotibial band stretches. - If not improving then physiotherapy referral.

Question 350

Osgood Schlatter's

Answer 350

Tibial apophysitis, typically causes pain and swelling over tibial tubercle.

Question 351

Patellar tendonitis

Answer 351

Pain after exercise - normally be located at the lower aspect of the patella

Question 352

Patellofemoral pain syndrome

Answer 352

Anterior knee pain worsening by going up or down stairs.

Question 353

Charcot's joints?

Answer 353

Bone remodelling Fragmentation of midfoot. Presence of swollen, red, warm joint in patient with history of poorly controlled diabetes highly suggestive of Charcot's joints. Also in alcoholic neuropathy. Damaged due to loss of sensation due to diabetes. Before we caused by neuropathy secondary to syphilis (tabes dorsalis). X-ray shows osteolysis of the distal metatarsals and wide-spread joint dislocation in the forefoot.

Question 354

Hip OA?

Answer 354

Total hip replacement remains the definitive treatment

Question 355

Pagets?

Answer 355

- Focal bone resorption followed by excessive and chaotic bone deposition - Affects (in order): spine, skull, pelvis and femur Serum alkaline phosphatase raised (other parameters normal) - Abnormal thickened, sclerotic bone on x-rays Risk of cardiac failure with >15% bony involvement Small risk of sarcomatous change Bisphosphonates

Question 356

Osteoporosis?

Answer 356

- Excessive bone resorption resulting in demineralised bone - Commoner in old age Increased risk of pathological fracture, otherwise asymptomatic - Alkaline phosphatase normal, calcium normal Bisphosphonates, calcium and vitamin D

Question 357

Secondary bone tumours

Answer 357

Bone destruction and tumour infiltration Mirel scoring used to predict risk of fracture Appearances depend on primary (e.g.sclerotic - prostate, lytic - breast) Elevated serum calcium and alkaline phosphatase may be seen Radiotherapy, prophylactic fixation and analgesia

Question 358

Posterior hip dislocation?

Answer 358

Sciatic nerve injury in 10-20% of posterior hip dislocations.

Question 359

AVN?

Answer 359

During fractures. Less during dislocations.

Question 360

Types of hip dislocation

Answer 360

Posterior dislocation: Accounts for 90% of hip dislocations. The affected leg is shortened, adducted, and internally rotated. Anterior dislocation: The affected leg is usually abducted and externally rotated. No leg shortening. Central dislocation Management - ABCDE approach. Analgesia A reduction under general anaesthetic within 4 hours to reduce the risk of avascular necrosis. Long-term management: Physiotherapy to strengthen the surrounding muscles.

Question 361

Complications of hip dislocation?

Answer 361

Sciatic or femoral nerve injury Avascular necrosis - increased risk with previous chemotherapy. Also due to steroids or alcohol. Can see osteopenia, microfractures and collapse of articular surface in the crescent sign. MRI is investigation of choice. Osteoarthritis: more common in older patients. Recurrent dislocation: due to damage of supporting ligaments

Question 362

Proximal humerus fracture?

Answer 362

Very common. Usually through the surgical neck (around the neck of the bone) - Rare to have fracture through the anatomical neck - Anatomical neck fractures which are displaced by 1cm or more carry a risk of avascular necrosis to the humeral head. - Impacted fractures of the surgical neck are managed with a collar and cuff for 3 weeks followed by physio.

Question 363

Parsonage-Turner Syndrome

Answer 363

Peripheral neuropathy that may complicate viral illness and resolves spontaneously.

Question 364

Talipes Equinovarus

Answer 364

Talipes equinovarus, or club foot, describes an inverted (inward turning) and plantar flexed foot. It is usually diagnosed on the newborn exam.

Question 365

Rotator cuff injury?

Answer 365

Spectrum of disease - Subacromial impingement - Calcific tendonitis - Rotator cuff tear - Rotator cuff arthropathy Rotator cuff tear pain is in first 60 degree. Subacromial impingement = 60-120.

Question 366

Facet joint

Answer 366

Acute or chronic Pain worse in the morning and on standing On examination there may be pain over the facts Pain is typically worse on extension of the back

Question 367

Patient who is worried about osteoporosis?

Answer 367

Check her risk factors - +ve family history - Smoking - Excess alcohol intake.

Question 368

Straight leg raise?

Answer 368

Distribution of the sciatic nerve then the test is positive. Therefore L5 or Sciatic nerve. Can be due to underlying herniated disc.

Question 369

Posterior ankle impingement

Answer 369

Pain on forced plantar flexion - common in footballers or gymnasts.

Question 370

Discitis?

Answer 370

Infection in the intervertebral disc space. Leads to serious complications such as sepsis or an epidural abscess. Due to Staph, Viral, TB, Aseptic. MRI/CT guided biopsy.

Question 371

Scoliosis

Answer 371

Curvature of the spine in the coronal plane Structual or non-structural = Postural scoliosis will typically disappear on manoevures such as bending forward.

Question 372

Spina bifida?

Answer 372

Non fusion of the vertebral arches during embryonic development Three categories; myelomeningocele meningocele - may have fluid in bulge. Spina Bifida Occulta - hair, no bone over spinal cord. Myelomeningocele is the most severe type with associated neurological defects that may persist in spite of anatomical closure of the defect Up to 10% of the population may have spina bifida occulta, in this condition the skin and tissues (but not not bones) may develop over the distal cord. The site may be identifiable by a birth mark or hair patch The incidence of the condition is reduced by use of folic acid supplements during pregnancy

Question 373

Giant cell tumour of bone?

Answer 373

Soap bubble appearance Present as pain or pathological fractures Mets to the lungs. Pain and swelling of the left shoulder. Large radiolucent lesion in the head.

Question 374

Ewings Sarcoma?

Answer 374

Most common in males between 10-20. Can occur in girls. Lytic lesion with a lamellated or onion type periosteal reaction is classical finding.