Orthopaedic for the MRCS part A Flashcards

Question

What is the location of the syndesmosis?

Answer 1

Between the distal tibia and fibula

Answer 2

(1) Holds the tibia and fibula together (2) Stability of the ankle-It is fundamental to the integrity of the ankle joint,and its disruption leads to instability

Answer 3

**Mnemonic;A TIP** It consists of(from anterior to posterior)the:- (1) ***_A_***nterior-inferior tibiofibular ligament(AITFL) (2) ***_T_***ransverse tibiofibular ligament(TTFL) (3) ***_I_***nterosseous membrane (4) ***_P_***osterior inferior tibiofibular ligament(PITFL)

Answer 4

20 degrees internal rotation

Answer 5

XRs(AP,lateral and mortise view(20 degrees internal rotation))

Answer 6

Dorsiflexed

Answer 7

used for surgical planning

Answer 8

used widely in orthopaedic practice as it is much more detailed than Denise-Weber classification

Answer 9

Commonly used

Answer 10

Management should follow ATLS principles to identify more significant injuries first

Answer 11

Management should be in line with BOAST 4 principles

Answer 12

(1) Reduce obvious deformity with appropriate analgesia or conscious sedation (2) Radiographs of clearly deformed or dislocated joints are not necessary (3) Removing the pressure on the surrounding soft tissues from the underlying bony deformity is the priority

Answer 13

+often involves (1)stress radiographs (2)a trial of mobilisation (3)repeat radiographs +defining unstability is a subject of much ongoing research

Answer 14

+often involves (1)stress radiographs (2)a trial of mobilisation (3)repeat radiographs +defining unstability is a subject of much ongoing research

Answer 15

(1)To achieve stable anatomical reduction of the talus within the the ankle mortise. (2)The type of operative procedure peformed depends on the specific type of ankle fracture sustiand

Answer 16

External fixation,or with a hind foot nail

Answer 17

Where soft tissue or bone quality is poor

Answer 18

Duration 6 weeks Reason (a)6 weeks is an appropriate time period to keep cast on in a conservatively managed patient (b) ankle fractures generally take 6 weeks to(1)unite enough (2) prevent secondary displacement

Answer 19

Ligamentous injury

Answer 20

Much more common

Answer 21

Inversion injury on a plantarflexed ankle

Answer 22

(1) High ankle sprains Injuries to the syndesmosis (2) Low ankle sprains Injuries to the: (1)Anterior inferior talofibular ligament(AITFL) (2)Calcaneofibular ligamnet(CFL)-the commonest (3)Posterior inferior talofibular ligament(PITFL)

Answer 23

Injuries to the syndesmosis

Answer 24

Injuries to the: (1)Anterior inferior talofibular ligament(AITFL) (2)Calcaneofibular ligament(CFL)-the commonest (3)Posterior inferior talofibular ligament(PITFL)

Answer 25

Calcaneofibular ligament(CFL)

Answer 26

(1)Significant ankle pain and swelling. (2)No weight bearing (3)Finger tenderness distal to the malleoli over the affected ligament

Answer 27

Plain film radiograph +the image of choice +to rule out any bony injury

Answer 28

Conservative(Mnemonic;ICE/A) (1) Early Immobilisation (2) Cold compression and ice (3) Elevation (4) Analgesia

Answer 29

**Definition** A combination of: (1)High proximal tibia fracture(high Weber C) (2)Unstable ankle injury **Significance** (1)It is a high fibula fracture which is above the syndesmsis(high Weber C).Therefore,it may be an ankle fracture. (2)Indicates unsable ankle injury with likely injury to the iterosseous membrane.Consequently,it can be associated with ankle instability **Imaging** Plain radiograph shows evidence of syndesmotic widening **Management** Surgical fixation-to reduce and stabilise the syndesmosis

Answer 30

A combination of: (1)High proximal tibia fracture(high Weber C) (2)Unstable ankle injury

Answer 31

(1)It is a high fibula fracture which is above the syndesmsis(high Weber C).Therefore,it may be an ankle fracture. (2)Indicates unsable ankle injury with likely injury to the iterosseous membrane.Consequently,it can be associated with ankle instability

Answer 32

Plain radiograph shows evidence of syndesmotic widening

Answer 33

Surgical fixation-to reduce and stabilise the syndesmosis

Answer 34

(1)Legg-Calve-Perthes disease. (2)Avascular necrosis of the femoral head

Answer 35

Idiopathic avascular necrosis of the femoral epiphysis of the femoral head causing a self limiting disease of the femoral head comprising of: (1)Necrosis. (2)Collapse (3)Repair and remodelling

Answer 36

(1) In general-approximately 1:10000 (2)Sex-males 4 times greater than females(male to female ratio 4:1) (3) Age-those who are small for their ge and between the overall age 2-12 - rare \< 4 years - common in average 4-8 years(in some other resources 5-7 years) with a limp. -the younger the age of onset,the better the prognosis

Answer 37

A transient disruption in the blood supply to the femoral head

Answer 38

(1)Limping with hip pain(may be referred to the knee) (2)Bilateral in 20% (3)Decreased abduction and internal rotation Mnemonic;PIRAB=Perthes....Internal rotation....Abduction

Answer 39

(1)Onset:starts and worsens over few weeks to months (2)On activity, especially,on internal and external rotation (3)Intermittent + no history of trauma

Answer 40

(1)Chronic (2)With normal knee examination (3)Lasts for several hours

Answer 41

(1) Plain XRs (2) Technitium-99 bone scan-shows earliest avascular change (3) MRI-Indications:a)if normal XRs b) symptoms persist

Answer 42

Clinical and histological features only

Answer 43

(1)Sclerosis with or without cystic changes (2)Preservation of the articular surface

Answer 44

Loss of structural integrity of the femoral head

Answer 45

Loss of acetabular integrity

Answer 46

Early disease can be missed on XRs

Answer 47

Fragmentation of the femoral head

Answer 48

(1)If normal XRs and (2)Symptoms persist

Answer 49

It is an alternative option

Answer 50

(1) Remove pressure from joint to allow normal development (2) Physiotherapy (3) Usually self limiting if diagnosed and treated promptly

Answer 51

To keep the femoral head within the acetabulum by cast,braces or surgery

Answer 52

Observation and symptomatic treatment

Answer 53

Brace or surgical management with moderate results

Answer 54

Surgical containment:(femoral/pelvic)osteotomy

Answer 55

Early diagnosis improves outcome

Answer 56

A type of artheritis in which there is a long term or chronic inflammation of the joints of the spine or the axial skeleton

Answer 57

Uncomplicated cases

Answer 58

Complicated cases

Answer 59

Where the spine joins the pelvis

Answer 60

e.g.,shoulder

Answer 61

Psoriatc artheritis

Answer 62

Eyes(acute unilateral anterior uveitis) and bowel(IBD,especially ulcerative colitis in which there is a strong association with HLA B27 in patient with ankylosing spondylitis)problems may also occur

Answer 63

acute unilateral anterior uveitis

Answer 64

inflammatory bowel disease(IBD),especially ulcerative colitis in which there is strong association with HLA B27 in patients with ankylosing spondylitis

Answer 65

Ulcerative colitis in which there is a strong association with HLA B27 in patients with ankylosing spondylitis

Answer 66

(1)The characteristic symptoms of ankylosing spondylitis (2)Often comes and goes(i.e.,on and off)

Answer 67

Often comes an goes(i.e.,on and off)

Answer 68

Worsens over time

Answer 69

Typical spinal features which may be seen in a young patient and are suggestive of ankylosing spondylitis: (1)loss of lumbar lordosis (2)restrictions of spinal movement (3)progressive spinal deformities (4)progressive kyphosis of the cervico-thoracic spine

Answer 70

(1)seen in young patients (2)suggestive of ankylosing spondylitis

Answer 71

young patients

Answer 72

Suggestive of ankylosing spondylitis

Answer 73

Schober test

Answer 74

HLA B27 in up to 20%

Answer 75

Ulcerative colitis

Answer 76

the classical **bamboo spine appearance**

Answer 77

the classical **bamboo spine appearance**

Answer 78

Should be carefully used in patients with IBD who may be taking steroids

Answer 79

For complicated cases with progressive neurological deficit

Answer 80

Congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body,usually affects L4/L5

Answer 81

Up to 5% of the population

Answer 82

(1) Asymptomatic (2) Spondylolysis is the commonest cause of spondylolisthesis in children

Answer 83

Asymptomatic cases do not require treatment

Answer 84

This occurs when one vertebra is displaced relative to its immediate inferior vertebral body leading to an abnormal forward slip of one vertebral body on another

Answer 85

a young atheletic female with a background of spondylolysis and presents with a sudden pain

Answer 86

(1) Stress fracture (2) Spondylolysis-is a risk factor for a young atheletic female with a background of spondylolysis and presents with a sudden pain (3) Trauma

Answer 87

Plain films-traumatic cases show the classic '**S****cotty Dog' appearance** on plain films

Answer 88

(1) Extent of deformity (2) Associated neurological symptoms

Answer 89

(1) Active observation-Minor cases may be actively monitored (2) Surgery with spinal decompression and stabilisation-Individuals with radicular symptoms or signs require spinal decompression and stabilisation

Answer 90

**Active** observation or monitoring

Answer 91

Minor cases should be actively monitored

Answer 92

Surgical decompression and stibilisation

Answer 93

Radicular symptoms or signs

Answer 94

(1)Juvenile kyphosis (2)Juvenile discogenic disease. (3)Vertebral epiphysitis

Answer 95

Epiphysitis of the vertebral joints

Answer 96

Epiphysitis of the vertebral joints

Answer 97

Predominately affects adolescents

Answer 98

(1) Back pain (2) Stiffness (3) Progressive kyphosis(at least 3 vertebrae must be involved)

Answer 99

XRs changes include (1) Epiphyseal plate (2) Anterior wedging

Answer 100

(1) Minor cases-managed with **physiotherapy** and **analgesia** (2) More severe cases-require **bracing** or **surgical stabilisation**

Answer 101

Lateral curvature of the spine in the coronal plane

Answer 102

(I)Structural +Feature:1)affects more than 1 vertebral body 2)not corrected by alterations in posture +Types:1)Idiopathic-the most common type 2)Congenital 3)Neuromuscular +Management:Severe or progressive structural disease is managed **surgically with bilateral rod stabilisation of the spine** (II)Non structural(postural) +Incidence:commonest in adolescent females who develop minor postural changes only +Feature:typically disappear on manoeuvres such as bending forwards

Answer 103

+Feature:1)affects more than 1 vertebral body 2)not corrected by alterations in posture +Types:1)Idiopathic-the most common type 2)Congenital 3)Neuromuscular +Management:Severe or progressive structural disease is managed surgically with bilateral rod stabilisation of the spine

Answer 104

1) affects more than 1 vertebral body 2) not corrected by alterations in posture

Answer 105

1) Idiopathic-the most common type 2) Congenital 3) Neuromuscular

Answer 106

Idiopathic

Answer 107

Severe or progressive structural disease is managed surgically with bilateral rod stabilisation of the spine

Answer 108

+Incidence:commonest in adolescent females who develop minor postural changes only +Feature:typically disappear on manoeuvres such as bending forwards

Answer 109

commonest in adolescent females who develop minor postural changes only

Answer 110

typically disappear on manoeuvres such as bending forwards

Answer 111

No fusion of the vertebral arches during embryonic development

Answer 112

(1) Myelomeningocele (2) Spina bifida occulta (3) Meningocele

Answer 113

(1) the most severe type of spina bifida (2) associated with neurological defects that may persist in spite of anatomical closure of the spina bifida defect

Answer 114

+Incidence:up to 10% of population +C/P:(1)the skin and tissues(but not the bone) develop over the distal cord (2)the site is identified by **a birth mark or hair batch**

Answer 115

up to 10% of population

Answer 116

(1) the skin and tissues(but not the bone) develop over the distal cord (2) the site is identified by a birth mark or hair batch

Answer 117

The incidence of spina bifida is reduced by the use of folic acid during pregnancy

Answer 118

+Feature:loss of vibration and proprioception +e.g:Tabes dorsalis,SACD

Answer 119

Loss of pain,sensation and temperature

Answer 120

Aetiology (1) Staph aureus in IVDU (2) Fungal infections in immunocompromised Features (1) Normally progressive (2) Normally cervical region affected (3) Thoracic region affected in TB

Answer 121

(1) Staph aureus in IVDU (2) Fungal infections in immunocompromised

Answer 122

(1) Normally progressive (2) Normally cervical region affected (3) Thoracic region affected in TB

Answer 123

Dorsal column signs(loss of proprioception and fine discrimination)

Answer 124

(1) UMN signs (2) Haematoma (3) Fracture (4) Malignancy

Answer 125

Usually seen in older patients with cervical spondylolysis

Answer 126

(1)Flaccid paralysis of the upper limbs | (2)Preserved motor and sensory fibres to lower limb(these are located prepherally)

Answer 127

(1) Common after compression fractures (2) Often damage to anterior spinal artery,so neurological damage is a combination of direct trauma with ischaemic damage

Answer 128

(1) Corticospinal-loss of power (2) Spinothalamic-pain and temperature

Answer 129

(1) Posterior column affected (2) Proprioception is affected-ataxia

Answer 130

Hemisection of the spinal cord

Answer 131

(1)Stab wound (2)Gun shot. (3)Lateral vertebral fractures

Answer 132

The following manifestations are because of the spinothalamic tract decussation below the level of the cord transection (1)Ipsilateral paralysis(pyramidal tract lesion) | (2)Ipsilateral loss of proprioception and fine discrimination sense(dorsal columns) (3)Contralateral loss of pain and temperature sensation(spinothalamic tract)

Answer 133

spinothalamic tract decussation below the level of the cord transection

Answer 134

a surgical emergency causing compression of the cauda equina below the connus medullaris

Answer 135

A bundle of spinal nerves that arise from the distal end of the spinal cord

Answer 136

Inferior to the spinal cord below connus medullaris

Answer 137

Lower motor neurons containing (1)Motor and sensory impulses to the lower limbs (2)Motor innervation to the anal sphincter (3)Parasympathetic innervation for the bladder

Answer 138

The spinal nerves run in the subarachnoid space

Answer 139

They taper to an end +known as the conus medullaris +approximately at the L1 +nerve roots L1-S5 leave at this region

Answer 140

(1)They pass down the spinal canal as the cauda equina (2)They exit at their respective foramina and their appropriate vertebral level

Answer 141

Approximately 4 in every 10000 patients presenting with lower back pain are ultimately diagnosed with the cauda equina syndrome

Answer 142

Peak age onset=40-50 years of age

Answer 143

40-50 years of age

Answer 144

Disc herniation(or intervertebral disc proplapse)

Answer 145

most commonly occurs between L5/S1 and L4/L5 level

Answer 146

vertebral fracture and subluxation

Answer 147

(1)Primary cord tumours (2)Metastatic(i.e.,extrinsic)cord tumours

Answer 148

The most common cancers that spread to spinal vertebrae (1)Thyroid (2)Breast (3)Lungs 🫁 (4)Renal (5)Prostate

Answer 149

Mnemonic;PAD (1)Potts disease (2)Abscess formation (3)Discitis

Answer 150

Ankylosing spondylitis

Answer 151

Haematoma secondary to spinal anaesthesia

Answer 152

If no obvious cause of cauda equina is evident,a thorough history and examination may reveal the aetiology and pathophysiology,such as (mnemonic;LAW) (1)Living in an area of endemic tuberculosis (2)A sign of metastatic disease (3)Weight loss

Answer 153

(1)Back pain with (2)Unilateral or bilateral sciatica (3)Lower limb motor weakness (4)Sensory disturbance in the saddle region (5)Loss of anal tone, and (6)Loss of urinary control

Answer 154

As cauda equina with retention, however only altered urinary sensation (e.g. loss of desire to void, diminished sensation, poor stream, and need to strain); painful retention may precede painless retention in some cases. Incomplete cauda equina has a greater potential for nuerological recovery

Answer 155

(1)Cases of severe back and leg pains with (2)Variable neurological symptoms and signs, and (3)A suggestion of sphincter disturbance

Answer 156

should be investigated during the history taking

Answer 157

Perianal or lower limb anaesthesia(the lower sacral dermatomes,termed saddle anaesthesia)

Answer 158

As part of the examination for suspeced CES,regardless of symptoms,patients will require (1)PR to check for loss of anal tone (2)Post-void bladder scan to check for urinary retention

Answer 159

usually associated with (1)hyporeflexia (2)paralysis with or without sensory loss

Answer 160

presents with radiating back pain,however there will be no faecal,urinary,or sexual dysfunction in these patients

Answer 161

a surgical emergency with a similar pathophysiology to CES, however is characterised by upper motor neurone signs

Answer 162

relating to strain of paraspinal muscles, with severe pain that may lead to limited movement, but no other focal neurological signs

Answer 163

may be required dependent on the underlying cause

Answer 164

Any confirmed case must be sent for surgical decompression wihin 36 hours of first presentation of the symptoms

Answer 165

this intervention should take place as soon as possible, including out of hours (24-36 hrs)

Answer 166

Indeed, a retrospective study examined the case for early surgery and found that patients who were in theatre within 24 hours from onset of autonomic dysfunction had reduced bladder problems at long-term follow up.

Answer 167

(1)An **early neurosurgical review** for urgent decompression must be initiated, especially for those with incomplete CES as the prognosis is potentially more favourable. (2)The neurosurgical team will discuss plans for **surgical decompression**, risks and benefits with the patient.

Answer 168

All **acute CES patients** will usually be recommended for surgical decompression, aiming to prevent permanent sphincter and lower limb dysfunction

Answer 169

In certain rarer situations, such as malignancy, radiotherapy and/or chemotherapy may be used (especially if the patient is not suitable for surgery) after consultation with specialist teams.

Answer 170

consultation with specialist teams.

Answer 171

The prognosis of cauda equina syndrome is **variable** depending on both aetiology and the time taken from symptom onset to surgery. Most cases will be progressive in nature and will cause complete compression on the cauda equina if left untreated. This is important for the management, as incomplete cauda equina syndrome has a greater potential for neurological recovery. Additionally, speed of symptom onset is important, as acute rather than subacute onset has a better prognosis when promptly treated.

Answer 172

The commonest site for sliped disc

Answer 173

Nucleus polposus

Answer 174

(1)sudden (2)radiating to one of the lower limbs

Answer 175

may occur due to spasm and contraction of prevertebral muscles

Answer 176

**Numbness** on the lower back and limbs

Answer 177

Inability to pass urine

Answer 178

Diagnostic

Answer 179

Depending upon severity of disease (1)Conservative (2)Surgery

Answer 180

Severity of the disease

Answer 181

1st/C2-C4 (1) C2-occiput and top part of the neck (2) C3-lower part of the neck to the clavicle (3) C4-the area just below the clavicle 2nd/C5-T1(situated in the arms) (1) C5-lateral arm at and above the elbow (2) C6-forearm and the radial(thumb)side of the hand (3) C7-middle finger (4) C8-medial aspect of the hand (5) T1-medial side of the forearm 3rd/T2-T12(the thoracic covers the axillary and chest regions) (1) T3-T12-chest and back to the hip girdle (2) T4-the nipples are situated in the middle of T4 (3) T10-umbilicus (4) T12-ends just above the hip girdle 4th/L1-L5 (1) L1-the cutaneous dermatome representing the hip and groin area (2) L2-L3-front part of the thighs (3) L4-L5-medial and lateral aspects of the lower leg 5th/S1-S5 (1) S1-heel and middle back of leg (2) S2-back of thighs (3) S3-medial side of buttocks (4) S4-S5-perineal region (5) S5(the lowest dermatome)-skin immediately at and adjacent to the anus

Answer 182

occiput and top part of the neck

Answer 183

lower part of the neck to the clavicle

Answer 184

The area just below the clavicle

Answer 185

Situated in the arms

Answer 186

lateral arm at and above the elbow

Answer 187

forearm and radial(thumb)side of the hand

Answer 188

middle finger

Answer 189

medial aspect of the hand

Answer 190

medial side of the forearm

Answer 191

the thoracic myotomes cover the axillary and chest region

Answer 192

chest and back to the hip girdle

Answer 193

The nipples are situated in the middle of T4

Answer 194

Ends just above the hip girdle

Answer 195

Cutaneous dermatome

Answer 196

Hip girdle and groin area

Answer 197

Front of thighs

Answer 198

Medial and lateral aspects of the lower leg

Answer 199

Heel and middle back of leg

Answer 200

Back of thighs

Answer 201

Medial side of buttocks

Answer 202

Perineal region

Answer 203

The lowest dermatome

Answer 204

Skin immediately at and adjacent to anus

Answer 205

Elbow flexors/biceps

Answer 206

Wrist extensors

Answer 207

Elbow extensors/triceps

Answer 208

Long finger flexors

Answer 209

Small finger abductors

Answer 210

Hip flexors(psoas)

Answer 211

Knee extensors(quadriceps)

Answer 212

Ankle dorsiflexors(tibialis anterior)

Answer 213

Toe extensors(hallucis longus)

Answer 214

Ankle plantar flexors(gastrocnemius)

Answer 215

Dinner fork deformity

Answer 216

Fall onto an extended outstretched hand

Answer 217

(1) Common (2) Elderly females with osteoporosis

Answer 218

Fall onto an extended outstretched hand

Answer 219

**Mnemonic;ED 1** (1) Extra-articular (2) Distal radius fracture (3) 1 inch proximal to the radio-carpal joint(wrist joint)

Answer 220

(1) Dorsal angulation and displacement of the fracture fragment (2) The distal end of the ulna is sometimes involved

Answer 221

(1) Dorsal tilt of more than 20 degrees (2) Comminuted fracture (3) Injury to ulnar styloid (4) Intra-articular disruption

Answer 222

I)Conservative (1)Reduction of the fracture under either a haematoma block or Biers block (2)Immobilisation in a cast (3)In the elderly with osteoporosis II)Surgical fixation for unstable injuries

Answer 223

(1) Reduction of the fracture under either a haematoma block or Biers block (2) Immobilisation in a cast (3) In the elderly with osteoporosis

Answer 224

Reverse Colles' fracture

Answer 225

(1) Extra-articular (2) Distal radius fracture (3) 1 inch proximal to the radio-carpal joint(wrist joint)

Answer 226

Falling backwards onto the palm of an outstretched hand or falling with wrists flexed

Answer 227

**Volar** angulation and displacement of distal radius fragment(Garden spade deformity)

Answer 228

Garden spade deformity

Answer 229

- Volar angulation and displacement of distal radius fragment - Produced by Smith's fracture

Answer 230

Colles'/Smith fracture

Answer 231

Fall onto extended and pronated wrist

Answer 232

(1) Intra-articular (2) Distal radius fracture

Answer 233

(1) **Dorsal** or **Volar** angulation and displacement of fracture segment (2) Radio-carpal(wrist joint)dislocation (3) **Involvement of the joint is the defining feature**

Answer 234

(1) Transverse radial fracture (2) 1 inch proximal to the radio-carpal joint(wrist joint) (3) Dorsal displacement and angulation

Answer 235

Impact on flexed metacarpal caused by fist fights

Answer 236

Intra-articular fracture of the first carpometacarpal joint

Answer 237

Comminuted intra-articular fracture of the first carpometacarpal joint

Answer 238

Dislocation of the proximal radioulnar joint in association with ulnar fracture

Answer 239

Fall onto an outstretched hand with forced pronation

Answer 240

Needs prompt diagnosis to avoid disability

Answer 241

(1) Radial shaft fracture (2) Distal radioulnar joint dislocation (3) Direct blow

Answer 242

(1) Ulna fracture (2) Proximal radioulnar joint dislocation

Answer 243

Fracture of the distal 1/3rd of humerus resulting in entrapment of the radial nerve

Answer 244

I)Conservative (1)Reduction (2)Functional brace II)Open surgery for vascular injury

Answer 245

(1) Reduction (2) Functional brace

Answer 246

Vascular injury requires open surgery

Answer 247

Bimalleolar ankle fracture

Answer 248

Forced foot eversion

Answer 249

Radial nerve injury(with temporary concussion of the nerve,90% of injuries recover within 3-4 months)

Answer 250

(1) Trauma(excessive forces applied to bone) (2) Stress related(repetitive low velocity injury) (3) Pathological(abnormal bone which fractures during normal use of following minimal tauma)

Answer 251

Excessive forces applied to the bone

Answer 252

Repetitive low velocity injury

Answer 253

Abnormal bone which fractures during normal use of following minimal trauma

Answer 254

**Mnemonic;STAD** (1) Site of injury (2) Type of injury (3) Associated injuries (4) Distal neurovascular deficits

Answer 255

**Mnemonic;****CARP** (1) Changes in length of the bone (2) Angulation of the distal bone (3) Rotational effects (4) Presence of material such as glass

Answer 256

Fracture lies obliquely to long axis of bone

Answer 257

\>2 fragments

Answer 258

\> 1 fracture along a bone

Answer 259

Perpendicular to long axis of bone

Answer 260

Severe oblique fracture with rotation along long axis of bone

Answer 261

(1) To distinguish between open from closed injuries (2) Mainly to classify open fractures

Answer 262

Low energy wounds\<1cm

Answer 263

(1) Greater than 1cm wound with (2) moderate soft tissue damage

Answer 264

(1) High energy wound \>10cm with (2) Extensive soft tissue damage

Answer 265

**Mnemonic;FAMSS** (1) Flaps (2) Avulsion (3) Minimum to moderate crushing component (4) Simple transverse fractures (5) Short oblique fractures with minimum comminution

Answer 266

(1) Quite clean wounds most likely from inside to outside (2) Minimum muscle contusion (3) Simple transverse fracture (4) Short oblique fracture

Answer 267

(1) Grade 3(High energy wound \>10 cm with extensive soft tissue damage) (2) Adequate soft tissue or bone coverage

Answer 268

(1) Segmental fractures (2) Gunshot injuries

Answer 269

(1) Grade 3(High energy wound \>10 cm with extensive soft tissue damage) (2) Inadequate soft tissue or bone coverage

Answer 270

(1) Periosteal stripping and bone exposure (2) Massive contamination

Answer 271

Soft tissue coverage

Answer 272

Vascular injury requires repair

Answer 273

Vascular injury requires repair

Answer 274

Started immediately Usually given by ambulance staff in the UK

Answer 275

I)Pre-hospital:initial splinting by ambulance staff II)On arrival to the hospital +1st/imaging +2nd/correction of deformities under sedation in the ED +3rd/immobilisation in splint or plaster

Answer 276

(1) Polytrauma patients (2) High energy trauma

Answer 277

I)Prior to formal debridement 1st/Allow photography 2nd/Remove gross contamination from the wound 3rd/Dress the wound with a saline soaked gauze 4th/Cover the wound with an occlusive film II)For debridement +Prerequisite:(1)should be done in theatre (2)should be performed using fasciotomy lines for wound extension +Timing:1st/immediately for-(a)highly contaminated wounds(agricultural,aquatic,sewage) (b)vascular compromise(compartment syndrome or arterial disruption producing ischaemia) 2nd/Within 12hrs of injury for-other solitary high energy open fractures 3rd/Within 24hrs of injury for-all other low energy open fractures +Method:(1)In most cases the wound is left open (2)The wound is irrigated by 6 litres of normal saline (3)Initially the fracture should be stabilised with an external fixator

Answer 278

1st/Allow photography 2nd/Remove gross contamination from the wound 3rd/Dress the wound with a saline soaked gauze 4th/Cover the wound with an occlusive film

Answer 279

+Prerequisite:(1)should be done in theatre (2)should be performed using fasciotomy lines for wound extension +Timing:1st/immediately for-(a)highly contaminated wounds(agricultural,aquatic,sewage) (b)vascular compromise(compartment syndrome or arterial disruption producing ischaemia) 2nd/Within 12hrs of injury for-other solitary high energy open fractures 3rd/Within 24hrs of injury for-all other low energy open fractures

Answer 280

Only be carried out when it can be immediately followed with definitive soft tissue cover

Answer 281

(1)the most common reason for admission to an orthopaedic trauma ward in the UK (2)over 65000 fractures annually in the UK (3)bimodal age distribution +young patients-high energy injury(e.g.,RTA,horse riding)associated with -vertical fracture orientation -femoral shaft fractures +elderly-predominantly females with osteoporotic fracture,i.e.,fragility fracture,due to low energy injury like fall from standing height

Answer 282

+young patients-high energy injury(e.g.,RTA,horse riding) +elderly-predominantly females with osteoporotic fracture,i.e.,fragility fracture,due to low energy injury like fall from standing height

Answer 283

Normal neck-shaft angle is 130+/-7 degrees,and 10+/-7 degrees of neck anteversion

Answer 284

+Retinacular branches from the medial and lateral femoral circumflex arteries(branches of profunda femoris) +These anastomose and pierce the joint capsule at the base of the neck ,mainly posteriorly +There is a small vascular contribution from the artery of the ligament teres

Answer 285

Understanding the blood supply is fundamental to the decision making process in treating neck of femur(NOF)fractures

Answer 286

A fracture of the proximal femur(proximal to 5cm below the lesser trochanter)

Answer 287

+young patients-**high energy injury**(e.g.,RTA,horse riding)associated with -vertical fracture orientation -femoral shaft fractures +elderly-predominantly females with osteoporotic fracture,i.e.,fragility fracture,due to **low energy injury** like fall from standing height

Answer 288

(a)Intracapsular fractures-femoral neck and head blood supply disruption is common with intracapsular NOF fractures and rare with extracapsular fractures (b)Extracapsular trochanteric fractures I)pertrochantric II)subtrochantric(within 5cm distal to the lesser trochanter) III)Reverse oblique fractures IV)Isolated trochanteric avulsion fractures Result from sudden violent force avulsing the insertion of:(1)gluteus medius from greater trochanter (2)iliopsoas from lesser trochanter

Answer 289

(1)Named(there has been a move away from named classification systems towards descriptive classification systems) +Elderly intracapsular-Garden classification +Young intracapsular-Pauvels(or Pauwels)classification +Extracapsular intertrochantric(or pertrochantric)-Evans +Extracapsular subtrochantric-Russell Taylor (2)Descriptive

Answer 290

Location Involve the femoral neck between the edge of the femoral head and insertion of the capsule of the hip joint Incidence Around 1/2 of all hip fractures are intracapsular Complications (1)Disrupt the blood supply to the femoral head,leading to avascular necrosis (2)Femoral neck and head blood supply disruption is common with intracapsular NOF fractures and rare with extracapsular fractures

Answer 291

Involve the femoral neck between the edge of the femoral head and insertion of the capsule of the hip joint

Answer 292

Around 1/2 of all hip/neck of femur(NOF)fractures are intracapsular

Answer 293

(1)Disrupt the blood supply to the femoral head,leading to avascular necrosis (2)Femoral neck and head blood supply disruption is common with intracapsular NOF fractures and rare with extracapsular fractures

Answer 294

Location Distal to the insertion of the capsule,involving or between the trochanters Types I)Intertrochantric or pertrochantric II)Subtrochantric(within 5 cm distal to the lesser trochanter) III)Reverse oblique fractures IV)Isolated trochanteric avulsion fractures Result from sudden violent force avulsing the insertion of:(1)gluteus medius from greater trochanter (2)iliopsoas from lesser trochanter Complication femoral neck and head blood supply disruption is common with intracapsular NOF fractures and rare with extracapsular fractures

Answer 295

Distal to the insertion of the capsule,involving or between the trochanters

Answer 296

I)Intertrochantric or pertrochantric II)Subtrochantric(within 5 cm distal to the lesser trochanter) III)Reverse oblique fractures IV)Isolated trochanteric avulsion fractures Result from sudden violent force avulsing the insertion of:(1)gluteus medius from greater trochanter (2)iliopsoas from lesser trochanter

Answer 297

within 5 cm distal to the lesser trochanter

Answer 298

Result from sudden violent force avulsing the insertion of: (1) gluteus medius from greater trochanter (2) iliopsoas from lesser trochanter

Answer 299

(1)Pain-in the outer upper thigh or in the groin -pain may be particularly aggravated by flexion and rotation of the leg -where there is a preceding stress injury or bone pathology(e.g.,metastasis)there may be a preceding history of aching in the groin or thigh (2)Inability to bear weight (3)Inability to straight leg raise (4)The affected leg may be shortened,abducted and externally rotated(due to the unopposed pull of muscles that act across hip). (5)With undisplaced fractures,signs are more subtle (6)There may be no history of injury,especially in an elderly patient with confusion or dementia

Answer 300

(1)in the outer upper thigh or in the groin (2)pain may be particularly aggravated by flexion and rotation of the leg (3)where there is a preceding stress injury or bone pathology(e.g.,metastasis)there may be a preceding history of aching in the groin or thigh

Answer 301

I)Plain films-(1)AP and cross table lateral plain:are sufficient to diagnose the majority of NOF fractures (2) Full length femur views:to plan surgery if (a)the fracture extends below the level of lesser trochanter (b)pathological fracture II)MRI-if plain films are inconclusive and hip/neck of femur(NOF)fractures are highly suspected III)CT-done if MRI is not available within 24 hrs or contraindicated(e.g.,pacemaker) -the majority of fractures can be seen with CT so it is becoming the 1st line in many hospitals

Answer 302

(1) AP and cross table lateral plain:are sufficient to diagnose the majority of NOF fractures (2) Full length femur views:to plan surgery if (a)the fracture extends below the level of lesser trochanter (b) pathological fracture

Answer 303

to plan surgery if (a)the fracture extends below the level of lesser trochanter (b)pathological fracture

Answer 304

are sufficient to diagnose the majority of NOF fractures

Answer 305

if plain films are inconclusive and hip/neck of femur(NOF)fractures are highly suspected

Answer 306

(1) done if MRI is not available within 24 hrs or contraindicated(e.g.,pacemaker) (2) the majority of fractures can be seen with CT so it is becoming the 1st line in many hospitals

Answer 307

the majority of fractures can be seen with CT so it is becoming the 1st line in many hospitals

Answer 308

Method-Treated operatively except if the patient is unlikely to survive anaesthesia Timing-Best practice tarif(BPT)dictates surgery within 36hrs as delay of more than 48hrs is associated with increased morbidity and mortality

Answer 309

Aim to preserve bone in young patients(internal fixation)or consider total hip replacement(THR)in displaced fractures with high risk of avascular necrosis(AVN)

Answer 310

Medial collateral ligament

Answer 311

Shape (1) Broad (2) Flat Attachment (1) Upper end-attaches to the medial epicondyle of the femur (2) Some fibres-project onto the adductor magnus muscle (3) The deepest fibres-are fused with the medial meniscus Direction of fibres The ligament passes downwards,forwards to the medial side of the tibia

Answer 312

(1) Broad (2) Flat

Answer 313

(1)Upper end-attaches to the medial epicondyle of the femur (2)Some fibres-project onto the adductor magnus muscle (3)The deepest fibres-are fused with the medial meniscus

Answer 314

The ligament passes downwards,forwards to the medial side of the tibia

Answer 315

Shape (1) Round (2) Cord like Attachement (1) Stands clear of the thin,lateral part of the fibrous capsule (2) It is enclosed within the fascia lata (3) It splits the tendon of biceps femoris (4) On the lateral side of the joint the fibres-are short and weak - bridge the interval between the femoral and tibial condyles (5) The popliteus tendon intervenes between the lateral meniscus and the capsule Direction of fibres (1) Downwards and backwards (2) In font of its highest point-It passes from the lateral epicondyle of the femur to the head of the fibula

Answer 316

(1) Round (2) Cord like

Answer 317

(1) Stands clear of the thin,lateral part of the fibrous capsule (2) It is enclosed within the fascia lata (3) It splits the tendon of biceps femoris (4) On the lateral side of the joint the fibres-are short and weak - bridge the interval between the femoral and tibial condyles (5) The popliteus tendon intervenes between the lateral meniscus and the capsule

Answer 318

(1) Downwards and backwards (2) In font of its highest point-It passes from the lateral epicondyle of the femur to the head of the fibula

Answer 319

Lateral collateral ligament

Answer 320

(1) Prevent disruption of the joint at the sides (2) They are most tightly stretched in extension (3) Their direction of fibres prevents rotation of the tibia laterally or the femur medially.Rotation is demonstrated in flexed knee.

Answer 321

(1) Common (2) The medial is most commonly affected (3) Associated injuries to both the tibial plateau or minisci are not uncommon

Answer 322

Significant force to strike the side of the leg such as (1) Sporting tackle (2) Motor vehicle accident

Answer 323

Sport injury

Answer 324

High twisting force applied to a bent knee(POP sound)

Answer 325

(1) Loud crack/POP sound (2) Joint pain (3) Rapid joint swelling(haemarthrosis) (4) Poor healing

Answer 326

(1) Anterior drawer test (2) Lachman test

Answer 327

Intense physiotherapy or surgery

Answer 328

Hyperextension injuries

Answer 329

(1) Tibia lies back on the femur (2) Paradoxical anterior drawer test

Answer 330

Posterior drawer test

Answer 331

Leg forced into valgus via force outside the leg

Answer 332

Knee unstable when put into valgus position

Answer 333

Rotational sporting injuries

Answer 334

(1) Delayed knee swelling (2) Joint locking(patient may develop skills to unlock the knee (3) Recurrent episodes of pain and effusions are common,often following minor trauma

Answer 335

McMurray's test

Answer 336

Teenage girls

Answer 337

Following an injury to knee e.g.,dislocation patella

Answer 338

(1) Typical of pain ongoing downstairs or at rest (2) Tenderness,quadriceps wasting

Answer 339

Most commonly occurs as a traumatic primary event,either through (1) Direct trauma or (2) severe contraction of quadriceps with knee stretched in valgus and external rotation

Answer 340

(1) Genu valgum (2) Tibial torsion (3) High riding patella

Answer 341

(1) Osteochondral fracture in 5% (2) 20% recurrence rate

Answer 342

Occurs in the elderly or following significant trauma in the young

Answer 343

(1) Direct blow to patella causing undisplaced fragments (2) Avulsion fracture

Answer 344

Knee forced into valgus or varus,but the knee fractures before the ligaments rupture

Answer 345

(1) Valgus injury affects lateral plateau causing depressed fracture (2) Varus injury affects medial plateau (3) Classified according to Schatzker classification

Answer 346

Disruption of bony cortex associated with a breach in overlying skin

Answer 347

(1) In most cases the wound is left open (2) The wound is irrigated by 6 litres of normal saline (3) Initially the fracture should be stabilised with an external fixator

Answer 348

The mangled extremity scoring system(MESS)to predict the need for primary amputation

Answer 349

I)Rickets:(1)knock-knee (2) bow leg (3) features of hypocalcaemia II)Osteomalacia:(1)bone pain (2) fractures (3) muscle tenderness (4) proximal myopathy

Answer 350

(1) Serum calcium-low or normal(high in hypophosphatasia) (2) Serum phosphate-low or normal - low or normal Ca++x Pi \>30 if albumin normal(high in renal osteodystrophy) (3) 25(OH)vitamin D:low (4) Alkaline phosphatase:elevated except in hypophosphatasia (5) Urinary calcium-normal or low(high in hypophosphatasia (6) Bone biopsy-tetracycline labels abnormal

Answer 351

Low or normal(high in hypophosphatasia)

Answer 352

(1)Low or normal | (2)Low or normal Ca++ x Pi \> 30 if albumin normal(high in renal osteodystrophy)

Answer 353

Elevated except in hypophosphatasia

Answer 354

Low or normal(high in hypophosphatasia)

Answer 355

Tetracycline labels abnormal

Answer 356

XRs 1st/Children:cupped,ragged metaphyseal surfaces 2nd/Adults:appendicular predominance-(1)translucent bands(Looser's zones or pseudofractures) (2) complete fractures

Answer 357

(1) Paget's disease of bone(rare cause) (2) Hyperparathyroidism (3) Renal osteodystrophy (4) Osteogenesis imperfecta (5) Fibrous dysplasia (6) Hypophosphatasia

Answer 358

Cortical infarctions

Answer 359

Milkman lines or Loozer's zones

Answer 360

Transverse lucencies I)wide II)with sclerotic borders:(1)travesing partway through a bone (2)perpendicular to the involved cortex (3)associated with osteomalacia

Answer 361

Bone mass variable,meneralisation decreased

Answer 362

+Symptoms-Generalised bone pain +Signs-(1)Tenderness at fracture site (2)Generalised tenderness

Answer 363

Generalised bone pain

Answer 364

(1) Tenderness at fracture site (2) Generalised tenderness

Answer 365

cupped,ragged metaphyseal surfaces

Answer 366

appendicular predominance-(1)translucent bands(Looser's zones or pseudofractures) (2) complete fractures

Answer 367

Calcium with vitamin D tablets

Answer 368

the childhood form of osteomalacia

Answer 369

(1)Vit.D deficiency(dietary or metabolic) causing failure of the osteoid to ossify (2)Intestinal malabsorption (3)Renal disease. (4)Liver disease

Answer 370

(1)Symptoms start about the age of one (2)The child is small for age. (3)History of failure to thrive

Answer 371

Bowing of the femur and tibia

Answer 372

Bossing of the skull due persistence of suture lines and fontanelles

Answer 373

Because of bossing of the skull due persistence of suture lines and fontanelles

Answer 374

Deformity of the chest wall with tickening of the costochondral junction

Answer 375

Transverse sulcus in the chest caused by the pull of the diaphragm

Answer 376

Enlarged epiphysis

Answer 377

Stunted growth

Answer 378

Delayed dentition

Answer 379

These findings are most readily apparent in the wrist: widening and cupping of the long bones

Answer 380

(1) A bony atrophy in which the volume of bone tissue per unit volume of anatomical bone is reduced (2) Bone mass decreased,mineralisation normal

Answer 381

1st classification (1) Generalised-most common (2) Localised-following pressure or disuse 2nd classification (1)Type I-incidence:most common site:Affects cancellous bone of femoral neck and vertebral body (2)TypeII-incidence:age related=70years site-both cancellous and cortical bone mass are deficient

Answer 382

Reduction of the amount of osteoid matrix which is normally mineralised

Answer 383

(1) Commoner in-old age-Generally elderly - postmenopausal women (2) Asymptomatic (3) Increased risk of pathological fracture(hip,wedge fractures of vertebrae,Colles' fracture) (4) Pain referrable to fracture site (5) Tenderness at the fracture site

Answer 384

**Mnemonic;CA/IDEA** (1) ***_C_***alcium deficiency (2) ***_A_***lcoholism (3) ***_I_***diopathic inactivity (4) ***_D_***isuse (5) ***_E_***ndocrine abnormality (6) ***_A_***ge

Answer 385

(1) Serum calcium-normal (2) Serum phosphate-normal Ca+++ x Pi \>30 (3) Alkaline phosphatase-normal (4) Urinary calcium-high or normal (5) Bone biopsy-Tetracycline labels normal

Answer 386

(1) Plain films-only visible when calcium content approximately halved - axial predominance - show osteopenia,i.e.,loss of bone density,and cortical thickening,when 30-40% of bone mass has been lost (2) DEXA scan-standard for evaluation - shows more subtle changes

Answer 387

Normal Ca+++ x Pi \>30

Answer 388

High or normal

Answer 389

Tetracycline labels normal

Answer 390

Osteomalacia-it is distinct from osteomalacia in which there is abundant osteoid which is poorly calcified

Answer 391

Osteoporosis is distinct from osteomalacia in which there is abundant osteoid which is poorly calcified

Answer 392

Pathological fracture(hip,wedge fractures of vertebrae,Colles' fracture)

Answer 393

(1) Bisphosphonate (2) Non bisphosphinate (3) Vitamin D and calcium supplements

Answer 394

50 years of age

Answer 395

(1)Elevated alkaline phosphatase(ALP) (2)Normal calcium,phosphate,and PTH

Answer 396

(1) Blindeness (2) Deafness (3) Cranial nerve entrapment (4) nerve compression

Answer 397

Both sides of cortex are breached

Answer 398

Oblique tibial fracture in infants

Answer 399

Stress on bone resulting in deformity without cortical disruption

Answer 400

The increased flexibility of paediatric bones makes them more likely to bend rather than break

Answer 401

Bowing fracture

Answer 402

Unilateral cortical breach only

Answer 403

Occur when the bone bends and partially breaks but does not extend through the width of the bone,giving it a tented appearance

Answer 404

Torus fracture

Answer 405

Incomplete cortical disruption resulting in periosteal haematoma only

Answer 406

The bones of paediatric patients are more porous than mature bone,placing them at greater risk for compression fractures

Answer 407

The tendons and ligaments in paediatric patients are proportionally much stronger than the bones, leading to an increased incidence of avulsion

Answer 408

Childhood accidental spiral tibial fracture

Answer 409

Twisting injury while (1) tripping (2) stumbling (3) falling

Answer 410

(1) Minimally or undisplaced spiral fracture (2) Usually of the tibia (3) Typically in toddlers (4) It is difficult to diagnose provided that symptoms and imaging findings are subtle

Answer 411

Limping child refusing to walk

Answer 412

Fractures involving growth plate and epiphysis in children are classified using Salter Harris classification system

Answer 413

Slip-Transverse fracture through the growth plate/physis only

Answer 414

Above-Fracture through the growth plate/physis to the metaphysis(commonest type)

Answer 415

Lower-Fracture through the growth plate/physis and epiphysis with metaphysis spared

Answer 416

Through everything-Fracture involving the growth plate/physis,metaphysis and epiphysis

Answer 417

(1) Very common injury (2) Often in the elderly(3rd most common fragility fracture in the elderly) (3) Usually through the surgical neck

Answer 418

I)Indirect violence,i.e.,fall on the shoulder,often in the elderly II)Low energy fall in elderly females III)High energy trauma in young males

Answer 419

I]Anatomical neck fractures: (a)rare (b)if displaced \>1cm carry a risk of avascular necrosis of the humeral head II]Surgical neck fractures: greenstick fracture through surgical humeral neck is the commonest in children III]Undisplaced IV]Displaced

Answer 420

I]Undisplaced or minimally displaced humerus fractures(vast majority)are treated conservatively by (a)immobilisation in a polysling with a collar and cuff(for gravitational traction)and (b)progressive mobilisation followed by physiotherapy. (c)Pendular exercise can commence at 14 days and active abduction from 4-6 weeks II]Significantly displaced avulsion of the tuberosities or anatomical neck of humerus fractures- (1)internal fixation (2)repair of rotator cuff III]Surgical neck fractures- (a)impacted:collar and cuff for 3-6weeks followed by physiotherapy (b)significantly displaced:(1)open reduction and fixation or (2)use of intramedullary device IV]Operative management indications (a)Irreducible fracture dislocation (b)Large displacement (c)Young patient (d)Head splitting(intra-articular fracture) V]PROFHER trial (a)has suggested no benefit to operative intervention on patient outcome (b)it must be applied cautiously as majority of patients were elderly with extraarticular fractures

Answer 421

Undisplaced or minimally displaced humerus fractures(vast majority)are treated conservatively by (a) immobilisation in a polysling with a collar and cuff(for gravitational traction)and (b) progressive mobilisation followed by physiotherapy. (c) Pendular exercise can commence at 14 days and active abduction from 4-6 weeks

Answer 422

Significantly displaced avulsion of the tuberosities or anatomical neck of humerus fractures- (1) internal fixation (2) repair of rotator cuff

Answer 423

(1) internal fixation (2) repair of the rotator cuff

Answer 424

(a) impacted:collar and cuff for 3-6weeks followed by physiotherapy (b) significantly displaced:(1)open reduction and fixation or (2) use of intramedullary device

Answer 425

collar and cuff for 3-6 weeks followed by physiotherapy

Answer 426

(1) open reduction and fixation or (2) use of intramedullary device

Answer 427

(1) Axillary nerve damage(common) (2) Axillary vessel damage (3) Shoulder stiffness (4) Fracture dislocation of the humeral head For the above complications detailed neurological assessment is essential for all upper limb injuries

Answer 428

(1) One of the most common types of fractures (2) Peak incidence in children between ages 5-8 years

Answer 429

1st/Extension type fracture(95-98%) +Mechanism-Typically occurs from a fall on outstretched hand with elbow in extension or hyperextension +Complication-Anterior interosseous nerve injury:causing neuropraxia 2nd/Flexion type fracture(2-5%) +Mechanism-Typically occurs from a fall onto the flexed elbow +Complications-Ulnar nerve injury:(a)the most common nerve injury from flexion type (b)iatrogenic from medial pinning

Answer 430

Typically occurs from a fall on outstretched hand with elbow in extension or hyperextension

Answer 431

Anterior interosseous nerve injury:causing neuropraxia

Answer 432

Anterior interosseous nerve causing neuropraxia

Answer 433

Neuropraxia

Answer 434

Typically occurs from a fall onto the flexed elbow

Answer 435

Ulnar nerve injury:(a)the most common nerve injury from flexion type (b)iatrogenic from medial pinning

Answer 436

Ulnar nerve injury

Answer 437

1stly/Anterior interosseos nerve(AIN) injury-from extension type supracondylar humerus fractures causing neuropraxia 2ndly/Radial nerve injury-the second most common neuropraxia after anterior interosseous nerve(AIN)palsy

Answer 438

For Baumann angle

Answer 439

(1) Examine for Baumann angle (2) We need to compare with contralateral arm

Answer 440

To see if the anterior humeral line intersects the middle 1/3rd of the capitellar ossification centre

Answer 441

Posterior fat pad displacement is always pathological and can indicate a nondisplaced fracture

Answer 442

1st/Neurovascular structures at risk I]Anterior interosseous nerve(AIN)injury-most common for extension type supracondylar humerus fractures -causing neuropraxia II]Ulnar nerve injury-the most common nerve injury from flexion type supracondylar humerus fractures -iatrogenic from medial pinning III]Angulation:(1)Posteromedial angulation-associated with radial nerve injury(the 2nd most common neuropraxia after AIN injury) (2)Posterlateral angulation-associated with(a)brachial artery injury (b)median nerve injury 2nd/Vascular injuries(1%)

Answer 443

Radial nerve injury neuropraxia after AIN injury or palsy neuropraxia

Answer 444

Radial nerve injury(the 2nd most common neuropraxia after AIN palsy)

Answer 445

(1) Brachial artery injury (2) Median nerve injury

Answer 446

Nondisplaced(beware of subtle medial comminution)

Answer 447

Treated closed in a long arm cast for 2-3 weeks

Answer 448

Displaced,posterior cortex and periosteal hinge intact

Answer 449

Completely displaced

Answer 450

(1) Battered child (2) Child abuse

Answer 451

30-50% there is a chance to repeat the child abuse if not diagnosed

Answer 452

5-10% chance of death from subsequent abuse

Answer 453

(1) Children younger than 1 year = 50% chance of fractures (2) Children younger than 3 years =30% chance of fractures

Answer 454

Non accidental injuries(child abuse)

Answer 455

Marble bone disease

Answer 456

Hard and more dense bones

Answer 457

Autosomal recessive condition

Answer 458

Commonest in young adults

Answer 459

Osteoclast dysfunction results in too much bone density

Answer 460

Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone

Answer 461

Inherited condition causing increased bone fragility

Answer 462

Type I osteogenesis imperfecta - people with type I O1 have less collagen than normal. This makes their bones fragile, but they don't have bone deformities. The first break usually happens when a child starts walking. Fractures typically decrease after puberty. Type I osteogenesis imperfecta- babies with type Il Ol usually are born with many fractures, are very small, and have severe breathing problems. As a result, most will not survive. Type Ill osteogenesis imperfecta - people with type Ill O1 usually will be shorter than their peers, and may have severe bone deformities, breathing problems (which can be life-threatening), brittle teeth, a curved spine, ribcage deformities, and other problems. Type IV osteogenesis imperfecta - people with type IV O1 can have mild to serious bone deformities, short stature, frequent fractures (which may lessen after puberty), and a curved spine.

Answer 463

Type I osteogenesis imperfecta - people with type I O1 have less collagen than normal. This makes their bones fragile, but they don't have bone deformities. The first break usually happens when a child starts walking. Fractures typically decrease after puberty.

Answer 464

The collagen is (1) normal quality (2) insufficient quantity

Answer 465

Mildest form

Answer 466

60% of all cases

Answer 467

It is an important sign caused by sceleral thinness allowing pigmented coat of the choroid to become visible

Answer 468

Can occur any time from the perinatal period onwards:- (1) In adults:There is(a)a 7x greater incidence of overall fracture rate than normal,with (b) Reduced vertebral bone mineral content in adults (2) In children:Fractures may be numerous but rarely lead to deformity

Answer 469

Type I osteogenesis imperfecta- babies with type Il Ol usually are born with many fractures, are very small, and have severe breathing problems. As a result, most will not survive.

Answer 470

Frequently occurring in utero

Answer 471

Due to faulty conversion of normal mineralised cartilage to defective bone matrix

Answer 472

Lethal form

Answer 473

Severely progressive deforming subtype

Answer 474

Type Ill osteogenesis imperfecta - people with type Ill O1 usually will be shorter than their peers, and may have severe bone deformities, breathing problems (which can be life-threatening), brittle teeth, a curved spine, ribcage deformities, and other problems.

Answer 475

Occurs during early years and increases with age

Answer 476

(1) Skull (2) Chest (3) Spine (4) Long bones (5) Pelvis

Answer 477

Triangular with (1) Large vault (2) Prominent eyes (3) Small jaw

Answer 478

Patients rarely walk,even after multiple surgical procedures

Answer 479

Due to repeated childhood fractures

Answer 480

Impaired dentition

Answer 481

Secondary to type I collagen defect

Answer 482

(1) blue in infancy (2) normal colour in childhood

Answer 483

Type IV osteogenesis imperfecta - people with type IV O1 can have mild to serious bone deformities, short stature, frequent fractures (which may lessen after puberty), and a curved spine.

Answer 484

Sufficient collagen quantity but poor quality

Answer 485

Moderately severe form

Answer 486

This may be apparent at birth with (1) Fractures (2) Recurrent fractures on walking (3) Bowing of leg

Answer 487

Normal white colour in childhood with (1) reduced stature (2) variable disability

Answer 488

Type IV is differentiated from type I by having white sclera

Answer 489

Type IV is differentiated from type I by having autosomal dominant inheritance

Answer 490

Ehlers Danlos: - Multiple sub types - Abnormality of types 1 and 3 collagen - Patients have features of hypermobility. - Individuals are prone to joint dislocations and pelvic organ prolapse. -In addition to many other diseases related to connective tissue defects.

Answer 491

Runner's knee

Answer 492

Autosomal recessive condition

Answer 493

Involves traction apophysis of tibial tubercle-due to repeated microtrauma to tibial apophysis

Answer 494

(1) Age=10-15 years (2) Sex=M\>F

Answer 495

10-15 years of age

Answer 496

Symptoms I)No history of trauma II)Knee pain after activity Signs I)Tenderness-very specific point of tenderness over the tibial tubercle II)Lump-(1)tender (2)palpable (3)over proximal tibia

Answer 497

I)No history of trauma II)Knee pain after activity

Answer 498

I)Tenderness-very specific point of tenderness over the tibial tubercle II)Lump-(1)tender (2)palpable (3)over proximal tibia

Answer 499

XRs- shows fragmentation of apophysis

Answer 500

(1) Rest (2) Plaster cast for 6-8 weeks

Answer 501

(1) At the medial aspect of the knee (2) At the level of the joint space (3) Deep to pes anserinus tendons(SGS-Sartorius,Gracilis,Semiteninosus)

Answer 502

Symptomatic inflammation of the pes anserinus bursa

Answer 503

Pain (1) Site-along the proximal medial tibia (2) Associated with-swelling (3) Exacerbated by-particular activities such as ascending and descending stairs

Answer 504

Physiotherapy-most cases resolve with physiotherapy

Answer 505

Crystal induced arthropathies

Answer 506

Monosodium urate monohydrate crystals

Answer 507

Pseudogout is a form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate in the synovium

Answer 508

I)Podagra (initial) joint manifestation in 50% of gout cases and eventually involved in 90%; also observed in patients with pseudogout and other conditions II)Gout is a form of inflammatory artheritis charaterised by recurrent attacks of a red,tender,hot and swollen joint.The joint at the base of the big toe(i.e.,1st metatarsophalangeal joint) is most commonly affected but many other joints including those of hands my be affected III)Arthritis in other sites - In gout:(1)the instep, (2)ankle, (3)wrist, (4)finger joints, and (5)knee; - In gout,the joint is (1) swollen (2) hot (3) tender (4) red (3)shows white chalky patches in the skin through which crystals can often be expressed -In pseudogout, large joints,eg.,the: (1)knee, (2)wrist, (3)elbow, or (4)ankle (5)shoulder IV)Monoarticular involvement (1)most commonly, though polyarticular acute flares are not rare, and (2)many different joints may be involved simultaneously or in rapid succession V)In gout, attacks that begin abruptly and typically reach maximum intensity within \< 8-12 hours; VI)In pseudogout, attacks resembling those of acute gout or a more insidious onset that occurs over several days VII)Without treatment, symptom patterns that change over time; attacks can (1)become more polyarticular, (2) involve more proximal and upper-extremity joints, (3)occur more often, and (4)last longer VIII)In some cases, eventual development of chronic polyarticular arthritis that can resemble rheumatoid arthritis

Answer 509

Podagra (1) initially in 50% of cases (2) Eventually in 90% of cases

Answer 510

Podagra, which in Greek translates to '**foot trap**', is gout which affects the joint located between the foot and the big toe, known as the metatarsophalangeal joint.

Answer 511

Initially 50% Eventually 90%

Answer 512

Pseudogout gout and other conditions

Answer 513

(1) instep, (2) ankle, (3) wrist, (4) finger joints, and (5) knee

Answer 514

large joints,eg.,the (1) knee, (2) ankle, (3) wrist, or (4) elbow (5) shoulder

Answer 515

Monoarticular involvement most commonly, though polyarticular acute flares are not rare, and many different joints may be involved simultaneously or in rapid succession

Answer 516

different joints may be involved simultaneously or in rapid succession

Answer 517

(1)In gout, attacks that begin abruptly and typically reach maximum intensity within 8-12 hours; (2)in pseudogout, attacks resembling those of acute gout or a more insidious onset that occurs over several days

Answer 518

In gout, attacks that begin abruptly and typically reach maximum intensity within 8-12 hours

Answer 519

in pseudogout, attacks resembling those of acute gout or a more insidious onset that occurs over several days

Answer 520

Without treatment, symptom patterns that change over time; attacks can (1)become more polyarticular, (2) involve more proximal and upper-extremity joints, (3) occur more often, and (4) last longer

Answer 521

Eventual development of chronic polyarticular arthritis that can resemble rheumatoid arthritis Chronic renal failure in gout

Answer 522

(1) Elevated uric acid (2) negative birefringent crystals on synovial fluid examination

Answer 523

(1)Joint aspiration:weakly positively birefringent rhomboid shaped crystal (2)XRs:Chondrocalcinosis

Answer 524

weakly positively birefringent rhomboid shaped crystal

Answer 525

(1) WBCs 3000-50000 in both gout and psedogout (2) good response to colchicine in gout and weak in pseudogout (3) red compensator when parallel is yellow in gout and blue in pseudogout

Answer 526

1st/Acute gout (1) NSAID (2) Colchicine 2nd/Chronic gout or for prophylaxis Allopurinol

Answer 527

(1) Aspiration of joint fluid to exclude septic arthritis (2) NSAID (3) Steroids-intra-articular or intramuscular or oral as for gout (4)Weak response to colchicine

Answer 528

(1) The commonest carpal fracture (2) Incidence of scaphoid fractures in the UK ranges from 12.4-29/100000

Answer 529

Incidence of scaphoid fractures in the UK ranges from 12.4-29/100000

Answer 530

Because surface of scaphoid is covered by articular cartilage with small area available for blood vessels

Answer 531

Forms floor of the anatomical snuffbox

Answer 532

Fall onto outstretched hand (1) tubercle (2) waist (3) proximal 1/3rd

Answer 533

1st/A series of 4 radiographs should be done (1)PA view (2)Pronated oblique view (3)Ziter view-a PA view with the wrist in ulnar deviation and beam angulated at 20 degrees (4)Lateral view 2nd/Repeat imaging should be done at 10 days 3rd/MRI-should be done in case of diagnostic uncertainty where the 4 scaphoid view radiographs can not exclude scaphoid fractures if negative

Answer 534

A PA view with (1) the wrist in ulnar deviation and (2) beam angulated at 20 degrees

Answer 535

At 10 days

Answer 536

4 Scaphoid view radiographs can not exclude scaphoid fractures if negative

Answer 537

In cases of diagnostic uncertainty where 4 scaphoid view radiographs can not exclude scaphoid fractures if negative

Answer 538

(1) Scaphoid tubercle (2) Distal pole (3) Waist (4) Proximal pole

Answer 539

(1) Staph.aureus overall (2) Neisseria gonorrhoea-in sexually active young adults (3) Staph.aureus-in paediatric patients

Answer 540

Neisseria gonorrhoea

Answer 541

Staph.aureus

Answer 542

I)Plain XRs II)Aspiration:Synovial fluids should be obtained before starting treatment III)Kocher criteria

Answer 543

\> 40 mm/hr

Answer 544

\> 12000 mm3

Answer 545

When 4/4 criteria are met,there is a 99% chance that the child has septic arthritis

Answer 546

I)Needle aspiration should be used to decompress the joint II)Arthroscopic lavage III)Repeated procedures are necessary in some cases V)Antibiotics:(1)urgent washout and antibiotics otherwise high risk of joint destruction. (2)Antibiotics should be given for 6-12 weeks (3)IV antibiotics cover gram+ve cocci.BNF currently recommends flucloxacillin or clindamycin if penicillin allergic V)Surgical drainage of the affected joint,this should be as soon as possible since permenant damage to the joint may occur

Answer 547

to decompress the joint

Answer 548

(1)Urgent washout and antibiotics otherwise high risk of joint destruction (2)Antibiotics should be given for 6-12 weeks (3)IV antibiotics cover gram+ve cocci. BNF currently recommends flucloxacillin or clindamycin if penicillin allergic

Answer 549

6-12 weeks

Answer 550

urgent washout and antibiotics otherwise high risk of joint destruction.

Answer 551

IV antibiotics cover gram+ve cocci.BNF currently recommends flucloxacillin or clindamycin if penicillin allergic

Answer 552

IV antibiotics cover gram+ve cocci.BNF currently recommends flucloxacillin or clindamycin if penicillin allergic

Answer 553

Surgical drainage of the affected joint,this should be as soon as possible since permenant damage to the joint may occur

Answer 554

(1)Flattening and fragmentation of epiphysis:due to osteonecrosis of proximal femoral epiphysis | (2)AVN....Deformity....Subsequent revascularisation(2-4 years cycles)

Answer 555

XRs normal in early stage

Answer 556

The following may result in small hairline stress fractures (1) Repetitive activity (2) Loading of normal bone

Answer 557

(1) Painful (2) Stress fractures are seldom displaced (3) Surrounding soft tissue injury is unusual (4) Stress fractures may present late following the injury,in which case callus formation may be identified on radiographs

Answer 558

(1)Stress fractures may not require formal immobilisation (2)Injuries associated with severe pain and presenting at an earlier stage may benefit from immobilisation tailored to the site of injury

Answer 559

(1) Osteogenesis imperfecta (2) Osteopetrosis (3) Osgood-Schlatter disease/Runner's knee (4) Pott's fracture (5) Bone cyst (6) Bone tumour (7) Non accidental injury(NAI) or child abuse

Answer 560

I)Non accidental injury(NAI) or child abuse II)Pathological fractures (1)Osteogenesis imperfecta (2)Osteopetrosis (3)Osgood-Schlatter disease/Runner's knee (4)Pott's fracture (5)Bone cyst (6)Bone tumour

Answer 561

Irritable hip

Answer 562

A common childhood condition affecting children between 3-8 years of age

Answer 563

(1) History of URTI or other similar viral infections (2) Fever (3) Pain-usually in the knee or thigh (4) Hip pain (5) Restricted movement in one of the hip joints

Answer 564

(1) Effusion (2) Synovitis

Answer 565

Blood tests and radiology are normal

Answer 566

(1) Self resolving (2) Analgesics (3) Rest

Answer 567

Congenital abnormality of 2 types: (1) Mild dysplasia acetabulum (2) Irreducible dislocation

Answer 568

(1) Mild dysplasia acetabulum (2) Irreducible dislocation

Answer 569

More common in (1) Extended breach babies (2) Females

Answer 570

**Mnemonic;MBC OFF** (1) Multiple pregnancies (2) Breach position (3) Certain ethnic groups-native American (4) Oligohydromnios (5) Female sex (6) First born child with prematurity

Answer 571

1st/Barlow's test(BAD) * *Mnemonic;Barlow....Adduction....Dislocation(BAD)** (1) Adduct the hip (2) Apply light pressure on the knee directing the force posteriorly trying to dislocate the joint (3) If the hip is dislocatable,the test is considered positive 2nd/Ortolani test(ABO) **Mnemonic;Abduction....Ortolani(ABO)** +Purpose:The Ortolani manoeuvre is then used,to confirm that the positive findings(positive Barlow's test,i.e.,that the hip actually dislocated) +Manoeuvre:(1)It is performed by gently abducting the infant's leg by the examiner's thumb (2)Apply anterior pressure on the greater trochanter using the examiner's index and forefinger (3)A positive sign is a distinctive **'****clunk'** which can be heard and felt as the femoral head relocates anteriorly into the acetabulum

Answer 572

Mnemonic;Barlow....Adduction....Dislocation(BAD) (1) Adduct the hip (2) Apply light pressure on the knee directing the force posteriorly trying to dislocate the joint (3) If the hip is dislocatable,the test is considered positive

Answer 573

Mnemonic;Abduction....Ortolani(ABO) +Purpose:The Ortolani manoeuvre is then used,to confirm that the positive findings(positive Barlow's test,i.e.,that the hip actually dislocated) +Manoeuvre:(1)It is performed by gently abducting the infant's leg by the examiner's thumb (2)Apply anterior pressure on the greater trochanter using the examiner's index and forefinger (3)A positive sign is a distinctive 'clunk' which can be heard and felt as the femoral head relocates anteriorly into the acetabulum

Answer 574

(1)Initially no obvious change on plain films but small femoral head may be present (2)On plain films shentons line should form a smooth arc

Answer 575

(1)The most effective (2)USS gives best resolution until 3 months of age (3)In recent years,hip ultrasonography(US)has appeared as an effective tool for the early diagnosis of developmental dysplasia of the hip(DDH)in the newborns (4)US Is an effective and noninvasive method without radiation (5)Due to the high cost of US,there are still some controversial issues to use US as a screening method

Answer 576

(1) USS gives best resolution until 3 months of age (2) The most effective method (3) Effective tool for early diagnosis of developmental dysplasia of the hip

Answer 577

(1) Pelvic harness (2) Surgery is needed in case of dislocated and irreducible cases

Answer 578

(1)Close reduction+/-adductor tenotomy (2)If fail then arthrogram+open reduction with hip spica cast 600 abduction and 900 flexion

Answer 579

OR+/-femoral varus de rotation osteotomy

Answer 580

OR+/-Femoral varus de rotation osteotomy+pelvic osteotomy

Answer 581

THR when system justify surgical intervention

Answer 582

(1)Splints and harnesses or traction (2)In later years osteotomy and hip realignment procedures may be needed (3)In arthritis a joint replacement may be needed.However,this is best deferred if possible as it will almost certainly require

Answer 583

At least until walking normally;WHO recommend up to 5 years

Answer 584

(1) Slipped upper femoral epiphysis(SUFE) (2) Displaced upper femoral epiphysis

Answer 585

Older obese male adolescents

Answer 586

Displaced upper femoral epiphysis(head)from neck

Answer 587

(1) Obese(remember,only this clue can guide you to the answer) (2) Bilateral in 20% (3) Associated with decreased GH and sex hormones (4) Pain at the thigh and knee (5) Knee pain at 2 months prior to hip slipping (6) Mild shortening of limb (7) Increased **adduction and external** rotation (8) Decreased or limitation of **abduction and internal** rotation (9) Chance of AVN increased

Answer 588

To avoid avascular necrosis

Answer 589

Cannulated hip screw

Answer 590

Percutaneous pinning of the hip

Answer 591

Femoral neck osteotomy

Answer 592

Gives an indication of the articular surface and disease severity

Answer 593

(1) Equinus of the hindfoot (2) Adduction and varus of the midfoot (3) High arch

Answer 594

(1) Most cases in developing countries (2) Incidence in the UK is 1/1000 live births (3) More common in males

Answer 595

More common in males

Answer 596

(1) Strong familial link (2) Associated with other developmental disorders such as **Down syndrome**

Answer 597

(1) Bilateral in 50% (2) **Adducted** and inverted calcaneus (3) Wedge shaped distal calcaneal articular surface (4) **Severe tibio-talar plantar flexion** (5) **Medial talar neck inclination** (6) Displacement of the navicular bone(medially) (7) Wedge shaped head of talus (8) Displacement of the cuboid(medially)

Answer 598

***_1st/Conservative(The Ponesti method)_*** \*Advantage:gives comparable results to surgery \*It consists of:(1)Serial casting-to mold the foot into correct shape (2)Achilles tenotomy-following casting around 90% requires Achilles tenotomy (3)Walking braces-done following Achilles tenotomy to maintain the correction ***_2nd/Surgical correction_*** \*Indication:reserved for those cases that fail to respond to conservative treatment \*Involves:(1)Multiple tenotomies (2)Lengthening procedures (3)Ilizarov frame-in patients who fail to respond surgically and gives good results

Answer 599

The Ponesti method \*Advantage:gives comparable results to surgery \*It consists of:(1)Serial casting-to mold the foot into correct shape (2)Achilles tenotomy-following casting around 90% requires Achilles tenotomy (3)Walking braces-done following Achilles tenotomy to maintain the correction

Answer 600

gives comparable results to surgery

Answer 601

**Mnemonic;SAW** (1) Serial casting-to mold the foot into correct shape (2) Achilles tenotomy-following casting around 90% requires Achilles tenotomy (3)Walking braces-done following Achilles tenotomy to maintain the correction

Answer 602

\*Indication:reserved for those cases that fail to respond to conservative treatment \*Involves:(1)Multiple tenotomies (2)Lengthening procedures (3)Ilizarov frame-in patients who fail to respond surgically and gives good results

Answer 603

reserved for those cases that fail to respond to conservative treatment

Answer 604

(1) Multiple tenotomies (2) Lengthening procedures (3) Ilizarov frame-in patients who fail to respond surgically and gives good results

Answer 605

in patients who fail to respond surgically and gives good results

Answer 606

Proximal humerus accounting for around 5% of all fractures.

Answer 607

The majority of proximal humeral fractures are **low energy injuries** occurring in elderly patients **falling onto an outstretched hand** from standing. These injuries occur primarily in the **context of an osteoporosis**. They also less commonly occur in younger patients usually the result of a **high energy traumatic injury**, therefore there are often associated soft tissue or neurovascular injuries.

Answer 608

The majority of proximal humeral fractures are **low energy injuries** occurring in elderly patients **falling onto an outstretched hand** from standing. These injuries occur primarily in the **context of an osteoporosis**.

Answer 609

They also less commonly occur in younger patients usually the result of a **high energy traumatic injury**, therefore there are often associated soft tissue or neurovascular injuries.

Answer 610

The **risk factors** for low energy proximal humerus fractures are **comparable to other osteoporotic fractures**, including female gender, early menopause, prolonged steroid use, recurrent falls, and frailty.

Answer 611

1st/Symptoms (1)**pain around the upper arm and shoulder**, with (2)**restriction of arm movement** and (3)an inability to abduct their arm. 2nd/On examination, there is likely to be **significant swelling** and bruising of the shoulder, which can spread to the chest and down the arm. Due to the close anatomical relationship with the **axillary nerve** and the **circumflex vessels**, is important to **check the neurovascular status** of the arm; damage to the axillary nerve can result in **loss of sensation in the lateral shoulder** (“Regimental Badge Area”) and **loss of power of the deltoid muscle**.

Answer 612

(1)**pain around the upper arm and shoulder**, with (2)**restriction of arm movement** and (3)an inability to abduct their arm.

Answer 613

On examination, there is likely to be **significant swelling** and bruising of the shoulder, which can spread to the chest and down the arm. Due to the close anatomical relationship with the **axillary nerve** and the **circumflex vessels**, is important to **check the neurovascular status** of the arm; damage to the axillary nerve can result in **loss of sensation in the lateral shoulder** (“Regimental Badge Area”) and **loss of power of the deltoid muscle**.

Answer 614

(1) Minimally displaced fractures (2) No neurovascular compromise

Answer 615

The patient requires **immobilisation** initially with **early mobilisation** including (1)pendular exercises at 14 days or 2-4 weeks post injury dependent on fracture pattern. (2)**correctly applied polysling** that allows their arm to hang; the effect of **gravity on the arm** will aid the **reduction of the fragments** of most humeral fractures. (3)Active abduction from 4-6 weeks

Answer 616

(a) Irreducible fracture dislocation (b) Large displacement (c) Young patient (d) Head splitting(intra-articular fracture) (e)Open fracture. (f)Neurovascularly compromised fracture

Answer 617

(1) Complexity of the fracture (2) Patient factors

Answer 618

(a) has suggested no benefit to operative intervention on patient outcome (b) it must be applied cautiously as majority of patients were elderly with extraarticular fractures

Answer 619

**multiple segment injuries**

Answer 620

(1) Most commonly used (2) Plate and screw fixation (3) Can reconstruct complex fractures

Answer 621

often preferred in a head splitting fracture

Answer 622

(1) Suitable for extra-articular configuration, (2) Predominately if the fracture involves surgical neck+/- greater tuberosity(GT)fractures (3)If the fracture is combined with a humeral shaft fracture

Answer 623

Used for unreconstructable fractures in the older patient who has good glenoid quality can be performed in a small number patients who experience complex injuries, or injuries that include splitting of the humeral head and are likely to have significant complications if the fracture is treated using ORIF.

Answer 624

Unconstructable fractures where high functioning shoulder is required(hemiarthroplasty will cause glenoid erosion)

Answer 625

Total shoulder arthroplasty that provides better functional outcome than conventional total shoulder replacement **Reverse shoulder arthroplasty** (RSA) is an option for low demand patients, or patients who require revision after a failed previous procedure. RSA involves a total shoulder arthroplasty in which the ball and socket portions of the shoulder joint are reversed. Usually conservative management will be attempted before arthroplasty.

Answer 626

\*Consists of I)Articular head II)Greater tuberosity III)Metaphysis IV)Diaphysis V)Anatomical neck(previous physis):between the articular head and the tuberosities VI)Surgical neck:between the tuberosities and the metaphysis \*Attachments I)Greater tuberosity-attaches the following muscles (1)Supraspinatus (2)Infraspinatus (3)Teres minor II)Lesser tuberosity-attaches the subscapularis

Answer 627

Anterior and posterior humeral circumflex arteries

Answer 628

1st/for any trauma case, **urgent bloods**, including a coagulation and Group and Save, should be sent. 2nd/Where a pathological cause is suspected, further work-up bloods, such as a 1)**serum calcium** 2)**myeloma screen**, may be warranted.

Answer 629

\*Aims (1) Delineate the fracture pattern (2) Confirm/exclude the presence of an associated dislocation \*Types of radiographs I)Plain XRs film radiographs +Feature:the required **initial imaging modality** for suspected shoulder fracture +Indication:to visulaise and classify aproximal humeral fracture +Options:1)True anteroposterior(AP) 2)Axillary lateral view and/or 3)Lateral scapular Y view II)CT 1)better define intra-articular involvement 2)aid preoperative planning 3)if the position of any of the humeral segments is unclear. III)MRI-is not useful for fracture imaging

Answer 630

The **Neer classification system**\* +Frequency:most commonly used +Uses:used to characterise proximal humeral fractures based on the relationship between **4 main segments** of the proximal humerus +Aims:(1)Describe fractures as 2,3,or 4 depending on the number main fragments (2)Comments on the degree of displacement (3)Description of the fracture-more useful than classification (4)Humeral alignment (5)Fracture displacement (6)Greater tuberosity position-rotator cuff will pull the greater tuberosity(GT)supero-posteriorly,which can cause impingement problems with malunion +Details:1st/Fragments (1)Greater tuberosity (2)Lesser tuberosity (3)Articular surface or **segment** (anatomical neck) (4)**Humeral shaft** (surgical neck) 2nd/Displacement (1) \> 1 cm or angulation (2) \> 45 degrees *\*These segments are considered separate if there is displacement \>1cm between segments, or if there is at least 45 degrees of angulation; it categorises injuries into either minimal displacement or two to four part injuries, dependent on the number of separate segments present.*

Answer 631

(1)Describe fractures as 2,3,or 4 depending on the number main fragments (2)Comments on the degree of displacement (3)Description of the fracture-more useful than classification (4)Humeral alignment (5)Fracture displacement (6)Greater tuberosity position-rotator cuff will pull the greater tuberosity(GT)supero-posteriorly,which can cause impingement problems with malunion

Answer 632

The **Neer classification system**\* +Frequency:most commonly used +Uses:used to characterise proximal humeral fractures based on the relationship between **4 main segments** of the proximal humerus +Aims:(1)Describe fractures as 2,3,or 4 depending on the number main fragments (2)Comments on the degree of displacement (3)Description of the fracture-more useful than classification (4)Humeral alignment (5)Fracture displacement (6)Greater tuberosity position-rotator cuff will pull the greater tuberosity(GT)supero-posteriorly,which can cause impingement problems with malunion +Details:1st/Fragments (1)Greater tuberosity (2)Lesser tuberosity (3)Articular surface or **segment** (anatomical neck) (4)**Humeral shaft** (surgical neck) 2nd/Displacement (1) \> 1 cm or angulation (2) \> 45 degrees *\*These segments are considered separate if there is displacement \>1cm between segments, or if there is at least 45 degrees of angulation; it categorises injuries into either minimal displacement or two to four part injuries, dependent on the number of separate segments present.*

Answer 633

Most commonly used

Answer 634

The **Neer classification system**\* +Frequency:most commonly used +Uses:used to characterise proximal humeral fractures based on the relationship between **4 main segments** of the proximal humerus +Aims:(1)Describe fractures as 2,3,or 4 depending on the number main fragments (2)Comments on the degree of displacement (3)Description of the fracture-more useful than classification (4)Humeral alignment (5)Fracture displacement (6)Greater tuberosity position-rotator cuff will pull the greater tuberosity(GT)supero-posteriorly,which can cause impingement problems with malunion +Details:1st/Fragments (1)Greater tuberosity (2)Lesser tuberosity (3)Articular surface or **segment** (anatomical neck) (4)**Humeral shaft** (surgical neck) 2nd/Displacement (1) \> 1 cm or angulation (2) \> 45 degrees *\*These segments are considered separate if there is displacement \>1cm between segments, or if there is at least 45 degrees of angulation; it categorises injuries into either minimal displacement or two to four part injuries, dependent on the number of separate segments present.*

Answer 635

**(1)reduced range of motion is the most common complication of a proximal humeral fracture** , and **extensive physiotherapy** will be required to regain full function and reduce pain. Rehabilitation time for a proximal humeral fracture is around 1 year and is very dependent on how soon the patient was allowed to mobilise their shoulder. **(2)avascular necrosis of the humeral head** following an injury disrupting the blood supply (from the anterior and posterior humeral circumflex arteries). In such cases, a hemiarthroplasty or reverse shoulder arthroplasty may be required. Damage to the neurovascular supply is thankfully rare, however it remains essential to check the axillary nerve in these injuries.

Answer 636

High energy trauma

Answer 637

(1) Scapula body(50%) (2) Spine(50%) (3) Glenoid fossa (4) Glenoid neck

Answer 638

Associated life threatening injury

Answer 639

I)Plain radiographs (1)True anteroposterior(AP) (2)Axillary lateral and/or scapula Y view II)CT scanning (1)Define intra-articular involvement,displacement (2)For three dimensional reconstruction

Answer 640

Based on the location of the fracture (1)Coracoid (2)Acromion (3)Glenoid neck-Floating shoulder:Beware of ipsilateral glenoid neck and clavicle where limb is effectively dissociated from axial skeleton (4)Glenoid fossa (5)Scapula body

Answer 641

I]Conservative-sling immobilisation for 2 weeks followed by early rehabilitation II]Surgical-(1)Floating shoulder:for fixation (2)Intra-articular and displaced/angulated glenoid fractures

Answer 642

(1) Glenohumeral dislocation (2) Acromioclavicular joint disruption (3) Sternoclavicular dislocation

Answer 643

Commonly seen in the A&E with an incidence of up to 1.7% in the general population.

Answer 644

As high as 80% in teenagers

Answer 645

Usually a traumatic cause(multi-directional instability in frequent dislocation requires discussion with orthopaedics)

Answer 646

(1) Careful history,examination,and documentation of neurovascular status of the limb,in particular the axillary nerve(regimental badge sensation) (2) This should be reassessed post manipulation (3) Early radiographs to confirm direction of dislocation

Answer 647

(1) Emergent closed reduction under entanox and analgesics,but often requires conscious sedation (2) Arm should then immobilised in a polysling (3) XRs to confirm relocation

Answer 648

(1) True anteroposterior(AP) (2) Axillary (3) Lateral and/or scapula Y view-reduced humeral head should lie between acromion and coracoid on lateral/scapula view

Answer 649

Most common dislocation(\> 90%)

Answer 650

Usually traumatic anterior force on arm when shoulder is abducted,externally rotated

Answer 651

(1) Sulcus sign-Loss of shoulder contour (2) Humeral head can be felt anteriorly

Answer 652

(1) Hippocratic (2) Milch (3) Stimson (4) Kocher-not advised due to complication of fracture

Answer 653

50% missed in A&E

Answer 654

50% traumatic,but classically post seizure or electrocution

Answer 655

(1) Shoulder locked in internal rotation (2) XRs may show lightbulb appearance

Answer 656

Gentle lateral traction to adducted arm

Answer 657

Associated with (1) pectoral and rotator cuff tears (2) glenoid fracture

Answer 658

As for primary injury

Answer 659

Management of primary injury

Answer 660

Associated with acromion/clavicle fracture

Answer 661

As for primary injury

Answer 662

Management of primary injury

Answer 663

+Avulsion of the anterior glenoid labrum with an anterior shoulder dislocation (reverse Bankart if poster labrum in posterior dislocation) +Associated with glenohumeral dislocation

Answer 664

\*Definition Chondral impaction on posteriorsuperior humeral head from contact with glenoid labrum (Reverse Hill Sachs in posterior dislocation) \*Treatment Can be large enough to lock shoulder,requiring open reduction

Answer 665

(1) Chronic subacromial impingement-in older patients (2) Avulsion injury-in younger patients

Answer 666

(1) Subacromial impingement (2) Rotator cuff tears (3) Rotator cuff arthropathy(a rtheritis)

Answer 667

The rotator cuff is composed of four muscles: * Supraspinatus – abduction * Infraspinatus – external rotation * Teres minor – external rotation * Subscapularis – internal rotation

Answer 668

Acute full thickness tear (1) In general-2.5 per 10000,approximately around 20% f the general population (2) Age-40-70 years of age

Answer 669

**1st/main risk factors** for rotator cuff tears are(mnemonic;ROTA) (1)***_A_*****ge**, (2)***_T_*****rauma**, (3)***_O_*****veruse**, and (4)***_R_*****epetitive overhead shoulder motions** (e.g. athletes, certain occupations). **2nd/Other risk factors** include(mnemonic;OSD) (1)***_O***_besity (2)_***S***_moking (3)_***D_***iabetes mellitus.

Answer 670

Rotator cuff tears are **classified** as either **1st/According to duration:(1)acute** tears(lasting \<3 months) or (2)**chronic** tears(lasting \>3 months) . **2nd/According to thickness of the tear** **(1)partial thickness tears** or **. (2)full thickness** tears;Full thickness tears can be further classified into +**small** (\<1cm), +**medium** (1-3cm), **+large** (3-5cm), or +**massive** (\>5cm or involves multiple tendons)

Answer 671

**1st/Acute tears** +commonly occur within tendons with **pre-existing degeneration** +typically occurring alone following minimal force. However, +acute tears can occur in **young individuals** subjected to a larger force; these will therefore often occur alongside **other injuries** in the young. **2nd/Chronic tears** +occur in individuals with **degenerative microtears** to the tendon +most commonly from overuse +seen in greater incidence with **increasing age**

Answer 672

**1st/Symptoms (1)history of trauma with no fracture (2)pain over the lateral aspect of shoulder localised to the acromion (3)inability to initiate abduction or abduct the arm above 90 degrees but the patient can do minimal abduction** (4)Tears are more common in the dominant arm. **2nd/On** [**examination**](https://teachmesurgery.com/examinations/orthopaedic/shoulder-joint/)**.** (1)**tenderness over the greater tuberosity** and subacromial bursa regions. (2)Supraspinatus and infraspinatus **atrophy** can be seen in massive rotator cuff tears. (3)**Specific Tests** There are **specific tests** that can be performed to help assess for the presence of a rotator cuff tear and elucidate which tendon(s) are affected: **a) Jobe’s test** (the “empty can test”, tests supraspinatus) – place the shoulder in 90° abduction and 30° of forward flexion and internally rotate fully (as if you’re ‘emptying a can’), gently push downwards on the arm. **+**A positive test is present if there is weakness on resistance **b) Gerber’s lift-off test** (tests subscapularis) – internally rotate the arm so the dorsal surface of hand rests on lower back, then ask the patient to lift hand away from back against examiner resistance **+**A positive test is weakness in actively lifting the hand away from back (compare to the contralateral side) **c) Internal rotation lag test**(test subscapularis) **d) External rotation lag test**(tests for infraspinatus) **e) Posterior cuff test** (tests infraspinatus and teres minor) – the arm positioned at patient’s side, with the elbow flexed to 90°, then the patient is instructed to externally rotate their arm against resistance **+**A positive test is present if there is weakness on resistance

Answer 673

(1) Jobe's test- positive for supraspinatus muscle (2) Internal rotation lag sign-positive for subscabularis muscle (3) Gerber's lift-off test-positive for subscabularis muscle (4) External rotation lag test-positive for infraspinatus muscle Absense of these clinical signs make rotator cuff tear less likely

Answer 674

(1) **Urgent plain film radiograph** +Patients presenting with clinical features of a rotator cuff tear should have an to exclude a fracture. +*Whilst most plain film radiographs will be unremarkable, in chronic tears, there may be evidence of reduced acromiohumeral distance or sclerosis and cyst formation the rotator cuff insertion on the greater tuberosity.* (2) **Ultrasonograhy. . +**Once fracture has been excluded, rotator cuff tears can be assessed through further imaging. +can establish the presence and size of tear. **(3)MRI imaging** +can also be used to detect the size, characteristics, and location of the tear.

Answer 675

(1)[shoulder fracture](https://teachmesurgery.com/orthopaedic/shoulder/shoulder-fracture/). (2)persistent **glenohumeral subluxation (3)**brachial plexus injury. (4)[radiculopathy](https://teachmesurgery.com/orthopaedic/spine/radiculopathy/).

Answer 676

\*Prerequisite When considering repair of a cuff tear the following should be considered when making a surgical plan (1)age of patient (2)functional status and activity of the patient (3)nature of the tear(degenerative vs. acute traumatic) (4)size and retraction of the tear (5)type of the tear \*Indications 1st/conservative (1)patients who are not limited by pain or loss of function (2)patients with significant co-morbidities (3)patients who are unsuitable for surgery (4)patients who are presenting within 2 weeks since injury (5)mild tears or tears in the elderly 2nd/surgical (1)patients who are presenting within 2 weeks since injury and remained symptomatic despite conservative management (2)Moderate tears (3)Large or massive or retracted or complex tears \*Details (1) Mild tears or tears in the elderly-managed conservatively (2) Moderate tears-repaired arthroscopically allowing for earlier recovery (3) Large or massive or retracted or complex tears-open repair(occasionally with a tendon transfer).Subacromial decompression is performed at the same time to reduce symptoms and recurrence

Answer 677

When considering repair of a cuff tear the following should be considered when making a surgical plan (1) age of patient (2) functional status and activity of the patient (3) nature of the tear(degenerative vs. acute traumatic) (4) size and retraction of the tear (5)type of the tear

Answer 678

1st/conservative (1)patients who are not limited by pain or loss of function (2)patients with significant co-morbidities (3)patients who are unsuitable for surgery (4)patients who are presenting within 2 weeks since injury (5)mild tears or tears in the elderly 2nd/surgical (1)patients who are presenting within 2 weeks since injury and remained symptomatic despite conservative management (2)Moderate tears (3)Large or massive or retracted or complex tears

Answer 679

(1)patients who are not limited by pain or loss of function (2)patients with significant co-morbidities (3)patients who are unsuitable for surgery (4)patients who are presenting within 2 weeks since injury (5)mild tears or tears in the elderly

Answer 680

(1) patients who are presenting within 2 weeks since injury and remained symptomatic despite conservative management (2)Moderate tears (3) Large or massive or retracted or complex tears

Answer 681

(1) Mild tears or tears in the elderly-managed conservatively (2) Moderate tears-repaired arthroscopically allowing for earlier recovery (3) Large or massive or retracted or complex tears-open repair(occasionally with a tendon transfer).Subacromial decompression is performed at the same time to reduce symptoms and recurrence

Answer 682

**(1)adhesive capsulitis** The **main complication** from the condition is leading to stiffness of the glenohumeral joint. **(2)enlargement of tears** Ocurrs within 5 years in 40% of those with **age-related tears**. Of those whose tears enlarge, 80% will become symptomatic.

Answer 683

**(1)Good prognosis** **Prognosis** following surgical repair overall tends to be **very good** **(2)Bad prognosis in** those with (1)large or massive tears. (2)age \>65yrs (3)poor compliance with rehabilitation programs (4)current smokers often have worse outcomes.

Answer 684

(1) Below the subacromial arch (2) Above the humeral head and greater tuberosity of the humerus

Answer 685

Consists of(lateral to medial)the: (1)acromion. (2)coracoacromial ligament(anterior to the acromioclavicular joint) (3)coracoid process

Answer 686

Within the subacromal space run the (1)rotator cuff tendons (2)long head of biceps tendon (3)coraco-acromial ligament (4)all surrounded by the subacromial bursa which helps to reduce friction between these structures.

Answer 687

1) PAINFUL ARC 2) SUBACROMION TENDINITIS 3) CHRONIC SUPRASPINATUS TENDINITIS

Answer 688

inflammation and irritation of the rotator cuff tendons as they pass through the subacromial space, resulting in pain, weakness, and reduced range of motion within the shoulder.

Answer 689

SAIS encompasses a **range of pathology** including (1)rotator cuff tendinosis (2)subacromial bursitis (3)calcific tendinitis All these conditions result in an attrition between the coracoacromial arch and the supraspinatus tendon or subacromial bursa.

Answer 690

It occurs most commonly in patients under 25 years, typically in **active individuals or in manual professions**, and accounts for around 60% of all shoulder pain presentations, making it the most common pathology of the shoulder.

Answer 691

The most common cause of shoulder pain which results from (1) Impingement of the superior cuff on the undersurface of the acromion (2) Inflammatory bursitis

Answer 692

I)Symptoms Pain-(1)insidious (2)in the anterior superior shoulder (3)progressive (4)exacerbated by overhead activities abduction in the affected shoulder (5)relieved by rest (6)associated with weakness and stiffness secondary to the pain. (7)chronic pain in mid abduction(60-120)but no pain in early or late abduction II)Two common examination signs can be elicited in cases of SAIS (specifically for subacromial impingement): * **Neers Impingement test** – The arm is placed by the patient’s side, fully internally rotated and then passively flexed, and is positive if there is pain in the anterolateral aspect of the shoulder. * **Hawkins test** – The shoulder and elbow are flexed forward to 90 degrees, with the examiner then stablising the humerus and passively internally rotates the arm, and the test is positive if pain is in the anterolateral aspect of the shoulder. III)Bigliani classification-associated with certain types of acromial morphology

Answer 693

Shoulder arthritis in the setting of rotator cuff dysfunction

Answer 694

(1)Superior migration due to the loss of rotator cuff function and integrity (2)Unopposed deltoid pulls the humeral head superiorly (3)Associated with massive chronic cuff tears

Answer 695

1st/Plain radiographs I]AP view of shoulder (1)superior migration of the humerus with a cuff tear (2)features of arthritis with arthropathy (3)other causes of pain,e.g.,calcific tendonitis/fracture II]Outlet view Useful for defining the acromial morphology 2nd/USS (1) Allows dynamic imaging of the cuff (2) inexpensive (3) very user dependent 3rd/MRI (1) Best imaging modality for cuff pathology (2) Allows imaging of the rest of the shoulder (3) When intra-articular pathology is suspected can be combined with an arthrogram for improved sensitivity and specificity

Answer 696

I]AP view of shoulder (1)superior migration of the humerus with a cuff tear (2)features of arthritis with arthropathy (3)other causes of pain,e.g.,calcific tendonitis/fracture II]Outlet view Useful for defining the acromial morphology

Answer 697

(1) superior migration of the humerus with a cuff tear (2) features of arthritis with arthropathy (3) other causes of pain,e.g.,calcific tendonitis/fracture

Answer 698

Useful for defining the acromial morphology

Answer 699

(1) Allows dynamic imaging of the cuff (2) inexpensive (3) very user dependent

Answer 700

(1) Best imaging modality for cuff pathology (2) Allows imaging of the rest of the shoulder (3) When intra-articular pathology is suspected can be combined with an arthrogram for improved sensitivity and specificity

Answer 701

(1)Physiotherapy (2)Oral anti-inflammatory medication (3)Subacromial steroid injection (3)Arthroscopic subacromial decompression-by shaving away the undersurface of the acromion,more space is created for the rotator cuff (4)Cuff integrity can be assessed at time of surgery and can be repaired

Answer 702

More common in women aged 30-60 years

Answer 703

(1) When present in the shoulder,it is associated with subacromial impingement and pain (2) Associated with diabetes and hypothyroidism (3)Calcifications are usually loctated within the supraspinatus tendon(80% of cases),followed by the infraspinatus(15% of cases)

Answer 704

1st/shoulder pain similar in presentation to subacromial impingement (1) sudden (2) acute (3) severe (4) present even at rest on alla movements (5) pain over head activities (6) a traumatic in nature (7) aggrevated by elevation of the arm above shoulder or by lying on the shoulder (8) awaken the patient from sleep 2nd/other complaints (1) stiffness (2) snapping (4) catching (5) shoulder weakness

Answer 705

Frozen shoulder

Answer 706

The following points are in order:- (1) Fibroplastic proliferation of capsular tissue (2) Soft tissue scarring and contracture (3) Pain and loss of movement of shoulder joint (4) Patient present with a painful and decreased arc of motion

Answer 707

Associated with (1) Prolonged immobilisation (2) Previous surgery (3) Thyroid disorder(AI) (4) Diabetes

Answer 708

Up to 2 years

Answer 709

(1) Osteoarthritis(1ry or 2ry to cuff tear or trauma) (2) Rheumatoid arthritis(RA)-Majority of those with RA will develop symptoms (3) As part of a spondyloarthropathy

Answer 710

More common in the elderly

Answer 711

Presents like any other arthritis-pain at night and with movement

Answer 712

To keep the femoral head within the acetabulum by cast,

Answer 713

a young atheletic female with a background of spondylolysis and presents with a sudden pain

Answer 714

shoulder pain (1)over the superior aspect of the shoulder (2)worse with internal rotation which is tested by asking the patient to place his arm behind the back

Answer 715

Direct injury to the superior aspect of the acromion

Answer 716

(1)loss of shoulder contour (2)prominent clavicle