Orthopaedics

Question 1

What is the difference between osteoporosis and osteomalacia in terms of…

Pathology

Blood results

Bone density

Answer 1

Osteoporosis // osteomalacia

Fragile bones due to reduced density // Soft bones due to abnormal mineralisation

Normal bone profile and vitamin D // Abnormal bone profile and low vitamin D

Reduced bone density // Normal bone density

Question 2

How do you decide who gets a DEXA scan in osteoporosis?

Answer 2

Offer FRAX/Q-fracture to those…

All over 75

Those >50 who…

• Personal falls or fragility fracture history
• Malabsorption (inc HPT) or steroids
• Skinny, drinkers (>4U)

Question 3

What is diagnostic of osteoporosis?

Answer 3

DEXA T-score of -2.5 or below

Question 4

What is the medical management of osteoporosis

Answer 4

Ensure adequate Ca2+ and vitamin D then…

1st: Alendronate OR Risendronate/etidronate if alendronate not suitable

If not tolerated: strontium ranelate/raloxifene pending T score

+ Denosumab if further needed

+ HRT if post-menopausal with vasomotor symptoms

Question 5

What is the action of…

bisphosphonates

Strontium ranelate

raloxifene

Desonumab

Answer 5

Block osteoclastic breakdown

Increase osteoblastic activity + inhibit osteoclastic breakdown

Modulates oestrogen receptors to reduce vertebral fracture risk

RANKL inhibitor that prevents osteoclastic maturation

Question 6

What lifestyle acivities reduce osteoporosis risk?

Answer 6

Stop smoking and diabetes

Weight bearing excercise

Hip protectors in nursing homes

Question 7

What are the side effects of bisphosphonates

Answer 7

Osteonecrosis of the jaw and ear canal

Reflux –> Prescribe a PPI

Atypical femoral fractures

Question 8

Leg twisted outwards and shortened indicates what?

How do you investigate this?

Answer 8

Hip fracture

AP and lateral hip XR +/- MRI to confirm

Question 9

Whaat is seen in this X-ray?

Answer 9

Normal hip XR

Question 10

What is the significance of intracapsular vs extracapsular fractures?

Answer 10

Intracapsular more likely to lose blood supply resulting in AVN

Question 11

What does this XR show?

Answer 11

Intraacapsular (subcapital)

Shenton’s line disrupted

Femoral neck shortening

Increased view of lesser trochanter

Question 12

What does this XR show?

Answer 12

Intertrochanteric fracture

Fracture runs between greater and lesser trochanter

Femoral neck intact

Question 13

What does this XR show

Answer 13

Subtrochanteric fracture

Fracture distal to trochanters

Femoral neck remains intact

Question 14

What garden staging of hip fracture is AVN likely to occur in?

Answer 14

3-4: Indicates displacement

Question 15

What surgery do you perform a hip fracture is

Intracapsular

Extracapsular

Answer 15

Intra: THR if fit, hemi if not

Intertrochanteric: Dynamic screw

Subtrochanteric (<5cm distal to lesser): IM nail

Question 16

How does hip dislocation characteristically differ from fracture in presentation?

Answer 16

Dislocation: Internal rotation if posterior, external with no shortening if anterior

Fracture is external rotation WITH shortening

Question 17

How do you manage hip dislocation?

Answer 17

ABCDE with 4hr reduction with GA

Question 18

What nerve injuries occur in hip dislocation?

Answer 18

Sciatic: Foot drop, loss of external rotation + abduction of hip

Femoral: Poor hip flexion, sensation loss over medial leg

Question 19

How do you differ between acute and chronic osteomyelitis?

Answer 19

Acute: Fever, pain swelling and redness of surgical joint site

Chronic: History of pain, persistently draining wound, diabetics

Question 20

How do you investigate and treat osteomyelitis?

Answer 20

Image with MRI, biopsy is definitive

Treat with fluclox (clindamycin)

Acute: 4-6 weeks

Chronic: 3-6 months

–> IVOST once stable or 2 weeks post surgery

Question 21

Severly painful, paraesthetic leg following trauma suggests what?

How do you treat this?

Answer 21

Compartment syndrome

Raise, fasciotomy and fluids

Question 22

What are the red flags for back pain?

Answer 22

Age < 20 years or > 50 years

History of previous malignancy

Night pain

History of trauma

Systemically unwell e.g. weight loss, fever

Question 23

What are the key things to examine in the back?

Answer 23

LNDN

Localised spinal tenderness (esp thoracic)

Neurological deficits bilaterally

Distended bladder

No or reduced anal tone

Question 24

How can you tell between a prolapsed disc at L3 and L4?

Answer 24

Both have + ve femoral stretch test and reduced knee reflex

L3: sensation over thigh

L4: Sensation over knee

Question 25

How do L4 and L5 compressions compare?

Answer 25

L4: Sensory over knee, knee reflex, femoral stretch L5: Dorsal foot, foot and 1st toe dorsiflexion, sciatic stretch

Question 26

How do L5 and S1 compression compare?

Answer 26

L5: Sensory dorsal foot, weakness in foot and big toe, ANKLE REFLEX INTACT S1: Posterolateral leg and lateral foot, weak plantar flexion, Ankle reflex lost

Question 27

How do you manage a prolapsed disc?

Answer 27

Analgesia, physio, exercise 4-6 weeks persistence: MRI

Question 28

How does mechanical back pain present and what is the pain ladder for it/

Answer 28

Pain brought on by actvity 1. NSAIDs 2. Codeine + Benzos for spasm for 5 days

Question 29

What drugs are avoided in mechanical back pain?

Answer 29

Opioids, antidepressants or atypicals

Question 30

How do you differentiate between cauda equina and metastatic spinal cord compression?

Answer 30

MSCC worse on valsalva movements

Question 31

For cauda equina what is the... most common mechanism Imaging Treatment

Answer 31

L3-4 OR L5-S1 herniation Admite then emergency MRI Surgical compression

Question 32

Tender swollen knee following twisting movement, extension causes locked knee indicates what?

Answer 32

Meniscal tear

Question 33

How do investigate and treat a meniscal tear?

Answer 33

Can do an Apley grind test MRI if cant weight bear or flex to 90 degrees RICE, arthroscopic repair if severe

Question 34

How do anterior and posterior cruciate ligaments differ in terms of mechanism?

Answer 34

Anterior: Popping noise following twisting injury, can have rapid swelling Posterior: Anterior force to tibia (eg dashboard injury)

Question 35

How do you differentiate between tendinopathy and rupture of the achilles tendon? How does management differ?

Answer 35

Simmond's calf squeeze, US RIPE and orthotics for tendon, NO STEROIDS Plantarflexion boot, surgical reattachment

Question 36

What are the rules for XR in ankle injuries

Answer 36

- Tenderness along the lateral malleolar zone - Tenderness along the medial malleolar zone - Can't walk 4 weight bearing steps

Question 37

What is this X ray of?

Answer 37

Normal shoulder XR Glenoid and humeral head aligned

Question 38

What does this XR show?

Answer 38

Anterior dislocation Humeral head overlaps glenoid more has moved below coracoid

Question 39

What does this XR show?

Answer 39

Posterior dislocation Humeral head does not touch glenoid Internal rotation means you can see more rounded part of head causing the lightbulb sign

Question 40

How do you manage shoulder dislocation?

Answer 40

Recent: Reduction Less recent: Analgesia and sedation Sling immobilisation 1-3 weeks

Question 41

What nerve injury is most associated with shoulder dislocation?

Answer 41

Axillary nerve (C5,6) Deltoid weakness and 'badge patch' sensation loss

Question 42

Compare medial and lateral epicondylitis and radial tunnel syndrome in terms of: Mechanism/worsening pain

Answer 42

Medial (Golfer's) // Lateral (Tennis) // Radial tunnel Wrist flexion and pronation // wrist extension or supination with extended elbow // pain distal to lateral elbow, worse on PRONATION

Question 43

Compare cubital and carpal tunnel syndrome in terms of affected area?

Answer 43

Cubital: 4th and 5th finger, following elbow trauma Carpal: pain in lateral hand, THENAR wasting; autoimmune, pregnant or lunate fracture

Question 44

How do you treat carpal tunnel?

Answer 44

6 weeks rest and splints Day case surgery and steroids if resistant

Question 45

How do you disntinguish Colle's and Smith's fracture

Answer 45

Colle's // Smith Distal Displaced Dorsally // Volar displacement Dinner fork deformity // garden spade deformity

Question 46

What does this XR show?

Answer 46

Colle's fracture Tranverse fracture radius +/- ulnar styloid fracture

Question 47

What does this XR show?

Answer 47

Smith fracture

Question 48

How to tell difference between monteggia and galeazzi fracture?

Answer 48

Monteggia: Ulnar fracture, prox radioulnar joint dislocation Galeazzi: Radial fracture, distal radioulnar joint fracture

Question 49

How does facet joint pain differ from prolapse?

Answer 49

No straight leg test in facet joint, worse on back extension

Question 50

Hypoxaemia, neuro changes and petechial rash post op suggests?

Answer 50

Fat embolism syndrome

Question 51

How can you differ between PAD and spinal stenosis?

Answer 51

PAD will have CVD history SS will improve on sitting and bending back

Question 52

For avascular necrosis, what are the Risk factors Investigations Management

Answer 52

RFs: Steroids, chemo, alcohol excess, trauma Investigations: XR shows normal or crescent sign; MRI most sensitive. Joint replacement may be necessary