Orthopaedics and Traumatology

Question 1

Osteoarthritis

Answer 1

• Most common type of Arthritis; Characterised by Cartilage loss with Periarticular Bone
Response; Multifactoral process with Mechanical factors
o Significant inflammation of Articular and Periarticular structures
o Most common cause of Disability in the Western world in older adults
• Increasing prevalence with age; Uncommon <50yrs; Most >60yrs have radiological evidence
but only 1/4 symptomatic; Geographical Variation (e.g. Hip OA more common in Eurasians,
Knee OA more common in Asians)
• Joint Pain, Morning Joint Stiffness, Functional Limitation, Crepitus, Restricted Movement,
Bony Enlargement, Joint Effusion and Inflammation, Bone Instability and Muscle Wasting

Question 2

Pathophysiology of Osteoarthritis

Answer 2

• OA is a result of active, sometimes inflammatory, potentially reparative
processes rather than inevitable result of trauma and ageing
• Predisposing Factors – Obesity, Hereditary, Gender, Hypermobility, Trauma, Congenital Joint Dysplasia or Dislocations, Occupation, Sport
• Abnormal local mechanical factors that
affect loading and wear
• Inflammation starting at Periarticular Entheses in inflammatory phase; Focal Destruction of
Articular Cartilage commonly seen
o Spectrum between Atrophic disease (Cartilage destruction without Subchondral bone
response) to Hypertrophic disease (Massive new bone formation on joint margins)
o Focal Synovitis due to fragments of shed bone or cartilage
• Under normal circumstances, Cartilage degradation by wear and
production by Chondrocytes is balanced; In OA, balance is lost and focal erosion develops
o Disordered repair from adjacent cartilage, failure of ECM
synthesis and Fibrillation and Fissuring of joint surface
o Cartilage ulceration lead to exposure of bone to
increased stress, leading to Microfractures and Cysts;
Attempted repair leads to Abnormal Sclerotic
Subchondral bone formation and Osteophytes

Question 3

Nodal OA

Answer 3

DIPs more often affected than PIPs; Often start
around female menopause; Can co-exist with Thumb-base OA
o Painful, associated with Tenderness, Swelling,
Inflammation and Impairment
o Inflammatory phase can settle over time, leaving painless
bony swellings posterolaterally (Heberden’s Nodes on
DIPs, Bouchard’s nodes on PIPs)
o XR: Marginal Osteophytes and Joint space loss

Question 4

Hip OA

Answer 4

7-25% of Adult Caucasians; Less common in African and Asians
o Superior-pole Hip OA – Joint space narrowing and Sclerosis
affecting weight-bearing upper surface of Femoral Head and
Acetabulum; More common in men
▪ Early onset assoc Acetabular Dysplasia or Labral tears
o Medial Cartilage Loss – More common in women and associated
with hand involvement (=Nodal Generalised OA); Bilateral and
rapidly disabling

Question 5

Knee OA

Answer 5

40% >75yrs; More common in women
o Strongly linked to Obesity; Typically, bilateral
o Medial compartment most commonly affected leading to Varus
deformity; Retropatellar OA may co-exist; Marrow involvement
predicts progression and eventual joint replacement
o RF: Previous Trauma, Meniscal and Crucial Ligamental tears

Question 6

Crystal Associated OA

Answer 6

CPPD in Cartilage (= Chondrocalcinosis); Knees
and Wrist TFCC most commonly affected; Patchy, linear Calcification on XR
o Chronic Arthropathy (Pseudo-OA) especially in Elderly women with severe CPPD
o Marked Osteophyte and Cyst formation
o Associated with Pseudogout (Acute Crystal Arthritis)
o Presence of Calcium Apatite in Bloody Joint Effusion has poor outlook, joints require
early surgical replacement

Question 7

Rarer Forms of OA

Answer 7

Primary Generalised OA (NGOA = Nodal OA typically with either Knees, first
MTP, Hip or Intervertebral; Sudden and severe onset; Female with familial tendency) and
Erosive OA (DIPs, PIPs equally affected; Poor functional
outcomes, marked radiological Osteolysis; Destructive phases
followed by remodelling

Question 8

Management of Osteoarthritis: Investigations

Answer 8

Investigations – ESR might be normal, CRP mildly raised; RF
and ANA negative
o XR changes usually only when damage is advanced;
Useful for preop planning
o MR – Meniscal tears, Early Cartilage Injury and
Osteochondral changes
o Arthroscopy – Identify Early Fissuring and Surface
Erosion; Aspiration of Synovial Fluid during painful effusion shows viscous fluids with
few Leukocytes

Question 9

Management of Osteoarthritis: Treatment

Answer 9

• Guiding principle to treat Symptoms and Disability ≠ Radiological appearance
o Education about disease reduces Pain, Distress and Disability, and improves
Compliance with treatment; Psychosocial factors to be considered

• Physical Therapy – Weight Loss, Strength and Stability-building Exercises, Hydrotherapy
o Local Heat and Ice packs, Massages, Local NSAID gels
o Insoles for flat feet, Contralateral walking sticks
• Analgesia and Anti-inflammatories – Paracetamol before NSAIDs; NSAIDs and COX-2 Inhibitors
used intermittently when possible; Cautious use of Opioids in elderly
• Intraarticular Corticosteroids – Short term improvement during Painful Effusions
o Frequent injections to same joint should be avoided
• No clinical benefit from Glucosamine and Chondroitin; Unclear benefit of Intraarticular
Hyaluronan; No proven DMARDs for OA

Question 10

Surgical Management of Osteoarthritis

Answer 10

o Replacement Arthroplasty (E.g. THR, TKR);
1% Complication rate; Prosthesis Loosening
and Late Infection most serious
o Novel Arthroplasty Techniques – Hip
Resurfacing, Unicompartmental Knee
Replacement (less major)
o Other Surgical techniques include
Realignment Osteotomy, Excision MTP
Arthroplasty, MTP Joint Fusion

Question 11

Perthe’s Disease

Answer 11

Idiopathic (possibly Avascular)
Necrosis of Proximal Femoral Epiphysis
o Presents as a painless limp usually in boys 3
– 12yrs; Occasionally Bilateral
o If Severe, might require Surgical correction

Question 12

Transient Synovitis of the Hip (Irritable Hip)

Answer 12

Painful
limitation of movement typically Unilateral; After
URTI usually in boys
o Usually resolves after few weeks; 2 – 3% develop Perthe’s disease
o Treatment with Rest and NSAIDs until pain resolves, typically 7 – 10/7

Question 13

Trochanteric Bursitis

Answer 13

Trauma or Unaccustomed exercise, also in Inflammatory Arthritis
o Worse on walking up the stairs; Tender to lie on
o Exercise, Steroid Injection although poor evidence base; Surgery often necessary
o Gluteus Medius Tendonopathy at Insertion into trochanter can cause similar
syndrome, but does not respond to injection; Demonstrated on MRI

Question 14

Sacroiliac Joint Dysfunction

Answer 14

Caused by abnormal motion of SIJ; Presents with LBP, Buttock,
Sciatic Leg, Groin and Hip pain; Bending, Stairs and Rising from seat can provoke
o Hypermobility – Typically, Extra-articular due to weakened, injured or sprained
ligaments; Joint degeneration occurs over time
o Post-pregnancy Pelvic Joint pain believed to be due to stretched out ligaments (due
to Relaxin) failing to return to normal tautness
o Hypomobility – Locks due to wearing down with age or OA; Also, can occur with
Ankylosing Spondylitis or RA
o Treatment with Rest, Ice/Head, NSAIDs, Corticosteroid Injections (If benefit reported,
confirms the diagnosis); Surgical fixation of SIJ

Question 15

Meniscal Injury

Answer 15

• Menisci are partially attached Fibrocartilages that stabilise the Femoral Condyles on the flat
Tibial Plateaux; Resilient to injury but more vulnerable with age
o Torn by injury, commonly in sports which involve twisting and bending
o Immediate Medial or Lateral Knee Pain and Swelling within hours; Affected side is
tender; The Knee might lock flexed if large tear

• Immediate treatment to apply Ice Compress; MRI will demonstrate the tear
• Early Arthroscopic repair or Trimming of torn meniscus is essentially, especially in active
sportspeople; Reduces Recurrent pain, Swelling and Locking but not risk of Secondary OA
• Post-op Quadriceps exercises aid return to sport and activity
• Clinically examined with Apley’s Grind Test

Question 16

Cruciate Ligament Injury

Answer 16

• ACL resists Anterior Translation and Medial Rotation of Tibia
on Femur, while PCL resists Posterior Translation and Lateral
Rotation of Tibia on Femur
• Torn Cruciate accounts for around 70% of Haemarthrosis in
young people; Often co-exists with Meniscal tears; Clinically
examined with Anterior Draw Test, Posterior Sag
• MRI is investigation of choice; Requires urgent Orthopaedic
referral, with reconstructive surgery necessary; Significant
incidence of Secondary OA

Question 17

Collateral Ligament Injury

Answer 17

• Medial Ligament more commonly affected than Lateral; Pain typically at insertion into Upper
Medial Tibia, worsened by standing or stressing (Varus and Valgus stress at 0 and 30deg)
• Physiotherapy and Local Corticosteroid Injection

Question 18

OSTEOCHONDROSIS

Answer 18

• Focal disturbance of the Ossification Centre of the ends of bones
• Osgood-Schlatter Disease – Localised pain and Swelling, over Tibial
Tubercle or Patella Tendon Insertion; Usually athletic teens;
Responds to local treatment and changes in sports
• Sever’s Disease – Osteochondritis of Achilles insertion into Calcaneus

Question 19

PATELLOFEMORAL PAIN SYNDROME

Answer 19

• Knee pain ranging from Mild to Severe Discomfort, seeming originating from Posterior surface
of Patella and Femur; Excluding Intra-articular and Peri-Patellar Pathology
• Runners, Cyclists, Basketball players; Thought to be due to increased pressure on joint
• Discomfort worsened by sitting with bent knees or descending stairs
• Managed with Exercise therapy, NSAIDs, Rest; Surgery only in extreme cases

Question 20

Chondromalacia Patellae

Answer 20

Patellar Articular Cartilage Softening; Fibrillated Retropatellar Cartilage seen on Arthroscopy
o Patellar Misalignment, or Recurrent Dislocation (Typically, Adolescent girls) = Surgery

Question 21

ILIOTIBIAL BAND SYNDROME

Answer 21

• Common injury to knee associated with Running, Cycling, Hiking and Weight-
lifting; Range from stinging sensation superolateral to knee joint, to Swelling
and Thickening of IT band
o Most commonly pain felt during foot strike, and might persist
• Can result from Abnormal leg or feet anatomy, Unaccustomed exercise, or
abnormal loading, for example, “toeing in” while cycling
• Manage with RICE followed by stretching; Muscle strengthening of Gluteus and Medial Quadriceps by Exercise therapy

Question 22

CONDITIONS OF THE SHOULDER

Answer 22

Shoulder is a shallow joint with large ROM; Humeral head held by Rotator cuff (Supraspinatus, Infraspinatus, Teres Minor, Subscapularis) which is part of the joint capsule
o Rotator cuff, especially Supraspinatus, prevents Humeral head blocking against the Acromion during Abduction; Deltoid pulls up, Supraspinatus pulls in, allowing for turning movement; Greater Tuberosity glides under Acromion without impingement

Question 23

Rotator Cuff (Supraspinatus) Tendonosis (=Impingement Syndrome)

Answer 23

• Common cause of shoulder pain in all ages; Follows trauma in 30%, Bilateral in <5%
• Pain radiates to Upper arm, made worse by Arm Abduction and Elevation; Worst during
middle of Abduction range (‘Painful arc’)
• Painful spasm of Trapezius can occur; Passive elevation reduces impingement
• Might have associated Subacromial Bursitis; Isolated Bursitis can occur in direct trauma, such
as Falling-on-outstretched Arm or Elbow; Acromioclavicular Osteophytes increase the risk of
impingement, might require surgical removal
• Treatment with Analgesia, NSAIDs and PT; Severe pain response to US-guided Injection of
Corticosteroids into Subacromial Bursa; 10% with develop worse pain 24-48hrs after injection
o 70% will improve and self-mobilise; PT reduces Persistent Stiffness

Question 24

Rotator Cuff Tear

Answer 24

• Caused by trauma but also spontaneously in Elderly and Rheumatoid Arthritis
• Prevents Active Abduction of arm; Initiation of elevation assisted by other arm; Deltoid
muscle can hold in place once elevated
• Surgical tear repair in younger people; Not always possible in Elderly or RA

Question 25

ADHESIVE CAPSULITIS (=FROZEN SHOULDER)

Answer 25

• Inflammation and Stiffness of the capsule around the Glenohumeral joint • Uncommon; Can develop with Rotator Cuff lesions or following Hemiplegia, Chest or Breast Surgery, or MI; Severe Shoulder pain and Complete loss of all shoulder movements, including Shoulder rotation; Constant pain, Worse at night and in the cold • High dose NSAIDs, Intra-articular Local Anaesthetics and Corticosteroids might be helpful • Arthroscopic release speeds functional recovery

Question 26

BICEPS TENDINOPATHY

Answer 26

• Inflammation of tendon around Long Head of Biceps muscle; May occur due to sudden overuse, especially in older patients; Repeated trauma of overuse which might be accompanied by impingement beneath Coracoacromial arch by Osteophyte o Primary Biceps Tendinopathy if Inflammation within Bicipital groove of Humerus • May be associated with Rotator Cuff tears, especially is Subscapularis tendon is involved • Typically present with Insidious onset of discomfort around tendon in the anterior shoulder • RICE, NSAIDs, PT, Injection of Local Anaesthetic and Steroids; Surgery if partial rupture; Alternatively, Arthroscopic decompression

Question 27

EPICONDYLITIS

Answer 27

• Inflammation of the tendon insertion (Enthesitis) of extensors (Lateral Epicondylitis =Tennis Elbow) or Flexors (Medial Epicondylitis =Golfer’s Elbow); Local tenderness, pain radiating onto affected muscles; Pain at rest might also be present o LE – Gripping or holding a heavy bag; Most painful with Wrist Flexion of Pronated arm ME – Carrying a tray • Rest and PT; Local Corticosteroid Injection into point of maximum tenderness when pain is severe, requires PT F/U to prevent recurrence; Brace might help o Avoid Ulnar nerve when injecting for Medial Epicondylitis o Might require surgical release if persistent and resistant to treatment

Question 28

OLECRANON BURSITIS

Answer 28

• =Student’s Elbow; Bursitis following pressure, pain and swelling behind Olecranon; Rule out Septic and Gouty Bursitis; Bursa should be aspirated for Gram stain and Microscopy for crystals; If Infective cause ruled out, injection of Hydrocortisone can be performed • Septic Bursitis requires formal drainage and course of Antibiotics

Question 29

ULNAR NEURITIS (CUBITAL TUNNEL SYNDROME)

Answer 29

• Narrowing of the Ulnar groove (secondary to OA or RA), or due to frictional damage from Cubitus Valgus deformity (possibly complication from childhood fractures) • Initially sensory symptoms (E.g. Reduced sensation over little finger and medial half of ring finger; Clumsiness and weakness of small muscles of hand innervated by Ulnar nerve (Adductor Pollicis, Interossei, Abductor Digiti Minimi, Opponens Digiti Minimi) • Nerve conduction studies to identify site of lesion; Surgical decompression ± Transposition of nerve in front of elbow (if Subluxation occurs)

Question 30

CARPAL TUNNEL SYNDROME

Answer 30

• Median Nerve Compression within limited space of Carpal Tunnel; Thickened ligaments, Tendon sheaths or Bony Enlargement, but typically unknown aetiology • Early morning Numbness, Tingling and Pain in Median nerve distribution; Radiates to forearm • Fingers feel swollen; Wasting in later disease of Abductor Pollicis Brevis, and sensory loss of radial three and a half fingers • Pain elicited by Tinel’s sign (tapping nerve) or Phalen’s Test (Holding wrist in flexion) • Treatment – Splint wrist in Dorsiflexion overnight (relieves symptoms and is diagnostic), used nightly for several weeks often leads to full recovery o Otherwise Corticosteroid injection into Carpal Tunnel (avoiding the nerve) helps in 70%, although pain can recur o Persistent symptoms or nerve damage (resulting in prolonged latency across Carpal Tunnel evidenced by Nerve Conduction studies) require Surgical Decompression

Question 31

TENOSYNOVITIS

Answer 31

• Finger flexor tendons run through synovial sheaths and loops; Inflammation occurs with repeated or unaccustomed use or in Inflammatory Arthritis, leading to sheath thickening which are often palpable • Trigger Finger – Finger remained in flexed position in the morning, or after gripping, and needs to be manually reduced; Tender tendon nodule palpable, usually in distal palm o More common in Diabetic patients • Dorsal Tenosynovitis – Hourglass distribution of swelling from the back of the hand and under the Extensor Retinaculum; Less common, except in RA • De Quervain’s Tenosynovitis – Pain and swelling around Radial Styloid where Abductor Pollicus Longus is held in place of retaining band o Local Tenderness and Pain of styloid worsened by Thumb Flexion into palm • Treatment of Tenosynovitis – Resting, Splinting and NSAIDs might help; Local Corticosteroid injections alongside the Tendon under low pressure (Not into tendon itself) o Surgical release might be needed if symptoms persist

Question 32

WRIST GANGLIONS

Answer 32

Jelly filled, often painless swelling caused by Partial Tear of joint capsule or tendon sheath; Treatment is not essential as they resolve or cause little trouble; Surgical excision otherwise

Question 33

DUPUYTRENS CONTRACTURE

Answer 33

``` • Painless, Palpable Fibrosis of Palmar Aponeurosis; Fibroblasts invading Dermis due to Abnormal Signalling of Wnt pathway; Males, Caucasians, Diabetes and ETOH XS o Associated with Peyronie’s Disease (Inflammatory Disorder of Corpora Cavernosa) ``` • Puckering of Skin and Gradual flexion, usually in Ring and Little Fingers; Can also occur in the feet, where it is more aggressive • Intralesional Steroid Injections may help in early disease; Surgical release only for severe deformity; Transcutaneous Needle Aponeurotomy, Collagenase Injections under investigation

Question 34

HEEL PAIN

Answer 34

• Plantar Fasciitis – Enthesitis at insertion of Tendon into Calcaneus; Local pain under the heel when standing and walking with local Tenderness • Plantar Spurs – Traction Lesions at insertion of Plantar Fascia; Usually asymptomatic; Painful after traumatic injury • Calcaneal Bursitis – Pressure-induced Bursa that produces Diffuse Pain and Tenderness under the heel; Compression of heel pad from sides is painful (C/f Plantar Fascia Pain) • Treated with Heel Pads and Reduced Walking; Often Self-limiting; Dorsiflexion splint at night to stretch the Fascia might be helpful o Medial approach Ultrasound-guided Corticosteroid Injection if required

Question 35

ARCHILLES TENDONOSIS

Answer 35

• Painful, Tender swelling a few cm above Tendon insertion (C/f Sever’s Disease); Tendon damage or rupture more likely if on Quinolones; Therapeutic ultrasound is helpful; Avoid walking barefoot and jumping o Local Injections might cause tendon rupture o Autologous Platelet Concentrate Injection may be used but poor evidence

Question 36

Achilles Bursitis

Answer 36

Clearly anterior to Tendon; Can be safely injected with Steroids

Question 37

MORTON’S METATARSALGIA

Answer 37

• Typically, due to Neuroma between Third and Fourth Metatarsal heads; Pain, Burning and Numbness in adjacent surfaces of affected toes when walking • Wider, Cushion-soled shoes can help; Steroid Injections or Excision might be necessary

Question 38

HALLUX VALGUS (BUNIONS)

Answer 38

• Lateral migration of the big toe; Commonly a complication of Rheumatoid Arthritis; Modern shoe shapes delay onset • Either due to Bursitis or Bony lesion of MTP Joint; Majority of the deformity contributed by the head of the first Metatarsal bone; OA, Reduced ROM or Discomfort with • Treatment with Footwear, Orthotics, RICE, NSAIDs, Paracetamol; If severe deformity or for Cosmesis, Surgical correction possible (Bunionectomy)

Question 39

LOWER BACK PAIN

Answer 39

• Often Traumatic and work-related; Episodes generally short-lived and self-limiting; Chronic Back Pain responsible for 14% of Long-term disability in the UK • Reg Flags – Age (<20 or >50yrs), Persistent, Severe Traumatic Mechanisms, Worst at night or in the morning (Inflammatory Arthritis, Infection or Spinal Tumours), Associated with Systemic Signs, Associated with Neurological Signs o Spinal XR only for red flags; MRI preferable to CT if Neurological Signs; CT for bony pathology; Specialist interpretation o Bone Scans (Infective or Malignant lesions suspected) o FBC, ESR (Useful for identifying PMR, especially in Elderly), Ca, Myeloma Screen (Serum Protein Electrophoresis, Free Light Chain Assay, Beta-2 Microglobulin, etc) • If between 20-50yrs likely Mechanical Back Pain – Early Analgesia and Rest, Activity within limits of pain, Advice and Exercise Programmes to prevent Chronic Pain Syndromes o Physical Manipulation of uncomplicated back pain produces short-term relief

Question 40

MECHANICAL BACK PAIN

Answer 40

• Stiff back, Scoliosis might be present; Muscle spasm visible and palpable, causing Local Pain and Tenderness; Lessens on sitting or lying • RF for recurrent episodes – Female, Elderly, Pre-existing Chronic Pain Syndrome, Psychosocial Factors; Chronic LBP is a major cause of Disability and Time off work • Lower Back Pain is common in pregnancy – Altered Spinal Posture and Increased Ligamental Laxity; Usually Hyperlordosis on standing o Weight control, Pre- and Post-Natal Exercise; Analgesia and NSAIDs best avoided in Pregnancy and Breastfeeding; Not associated with Epidural injections

Question 41

Lumbar Spondylosis

Answer 41

• Intervertebral discs are fibrous joints comprising a tough capsule that inserts into rim of adjacent vertebrae; Joint allows twisting and bending • Changes in the disc occasionally start in teenage years, and increase with age; Changing disc composition, breakage, shrinkage and loss of compliance occurs o Surrounding fibrous zones develop Circumferential or Radial Fissures o Visible on MRI as decreased disc hydration, but typically asymptomatic o Thinning and loss of compliance leads to Bulging of Disc • Reactive changes in Adjacent Vertebrae – Sclerotic bone, Osteophyte formation along rim; Most commonly at L5/S1 and L4/L5 o Schmorl’s node – Disc prolapse through adjacent vertebral endplate; Painless, but may accelerate disc degeneration • Spondylosis leads to Episodic Mechanical Back Pain, Progressive Spinal Stiffening, Facet Joint Pain, Acute Disc Prolapse, Nerve Root Irritation, Spinal Stenosis and Spondylolisthesis

Question 42

Facet Joint Syndrome

Answer 42

• Secondary OA of the misaligned Facet Joints, which can be secondary to Spondylosis; Pain typically worse on Back Extension, which may radiate to buttocks o OA, Effusion or Ganglion Cyst on MRI • Direct Steroid injections under imaging may help but unknown long-term benefit; PT can help reduce Hyperlordosis; Weight loss is helpful in the obese population

Question 43

ACUTE DISC PROLAPSE

Answer 43

• Central Disc Gel may extrude into fissure in surrounding fibrous zone, causing Acute Pain and Muscle Spasm; Often Self-limiting; Extrusion beyond limits of fibrous zone =Disc Prolapse • Weakest Posterolaterally, where the Disc may impinge onto Nerve Roots; Pain often starts dramatically during lifting, twisting or bending; Associated with Paraesthesia, Numbness, Neurological signs typically in one leg o Back pain typically Diffuse, Unilateral and Radiates to Buttock; Muscle Spasm leads to Scoliosis that reduces when lying down 85 • Central, High Lumbar Disc Prolapse may cause Spinal Cord Compression and Pyramidal Tract signs (UMN Signs – Spasticity, Hyperreflexia, etc); Below L2/L3 produces LMN lesions • Straight-Leg-Raise test is positive in Lower Lumbar Disc Prolapse (Raising above 30deg); Pain in affected leg produced by raise of contralateral leg associated with large or central prolapse • Upper Lumbar Disc prolapse produces positive Femoral-Stretch-Test (Pain on Anterior Thigh when Knee flexed in Prone Position)

Question 44

Sciatica (Pain radiating from Back to Buttock and Leg)

Answer 44

• L5 and S1 Nerve Root compressed by Lateral Prolapse of L4/L5 and L5/S1 Disc; Acute onset of pain that may follow physical activity or minor injury, although unlikely causative • Most resolves with initial rest and analgesia following early mobilisation

Question 45

Treatment of Disc Prolapse

Answer 45

• Short period of Bed Rest, lying flat (Lower disc injury) or Semi-recline (High lumbar disc); Analgesia and Muscle Relaxants • Once pain tolerable, encourage Mobilisation and PT; Guided Epidural or Nerve Root Canal Injection reduces pain rapidly but unknown place in therapy • Referral for Microdiscectomy/Hemilaminectomy if Severe Neurological signs, Pain >6-10/52, or if Disc is central; Neurosurgical Emergency if Bladder or Anal Tone Affected

Question 46

SPONDYLOLISTHESIS

Answer 46

• Adolescents and Young Adults with Bilateral Congenital Pars Interarticularis Defects which cause Instability and lead to Vertebral Slip, with or without preceding injury o Rarely can lead to Cauda Equina Syndrome o Requires careful monitoring during growth spurt • Degenerative Spondylolisthesis – May occur in Older People with Lumbar Spondylosis and OA of the Facet Joints

Question 47

SCOLIOSIS

Answer 47

• Lateral Spinal Curvature; 3% of people, more common and typically more severe in girls; • Might be stable or progressive over time; Mild Scoliosis mostly asymptomatic, but severe cases can interfere with breathing • Unknown aetiology; Associated with Muscle Spasms, Cerebral Palsy, Marfan Syndrome, Neurofibromatosis • Minor curves may just involve observation; Treatment can involve bracing (worn until end of growth) or Surgical Fusion; Lack of evidence for Chiropractors, Dietary supplements

Question 48

BACK PAIN IN THE CHILD

Answer 48

• Back Pain is a symptom of concern in young and pre-adolescent children, as causes are more likely to be identified; The younger the child, the more significant the pathology o Red Flags – Young Age, Febrile (Infection), Persistent Pain or Pain causing Waking at Night (Malignancy), Painful Scoliosis, Focal Neurological Signs, Systemic Signs • Mechanical Causes – May have Muscle Spasm or Soft Tissue Pain from Injury • Tumour – Spine is common site for Osteoid Osteoma, or other primary tumours and mets • Osteomyelitis or Discitis – Localised Tenderness, Reluctance to Walk or Weight-bear along with Fever and Systemic Upset; XR might suggest abnormalities but MRI required; IV Abx • Cord or Nerve Root Entrapment – Tumour or Disc Prolapse • Spondylolysis and Spondylolisthesis – Stress Fracture of Pars Interarticularis; Increased risk in certain sporting activities (Cricket Bowling, Gymnastics); If Bilateral, Forward Slip of Vertebral Disc can occur, potentially leading to Cord or Nerve Root Compression o Pain on Spinal Extension and Localised Tenderness; Changes on XR but CT required • Scheuermann Disease – Osteochondrosis of Vertebral Body leading to Fixed Thoracic Kyphosis ± Pain; XR for Diagnosis; Often Incidental Finding • Complex Regional Pain Syndrome – Diagnosed if no physical cause found; May be exacerbated by Psychological stress

Question 49

LIMP IN THE CHILD | Age: 1-3

Answer 49

``` Acute Painful Limp: Infection: septic arthritis, osteomyelitis of hip or spine Transient synovitis Trauma-accidental/non accidental Malignant disease Chronic/Intermittent DDH, talipes Neuromusuclar JIA ```

Question 50

Limp in the Child | Age: 3-10 years

Answer 50

``` Acute painful limp: Transient synovitis Septic arthritis Trauma and overuse injuries Perthes JIA Malignant disease Chronic Intermittent Limp: Perthes disease NMD: DMD Tarsal coalition ```

Question 51

Limp in the Child | Age: 11-16years

Answer 51

``` Acute Painful Limp: Mechanical Slipped capital femoral epiphysis Avascular necrosis of the femoral head Reactive arthritis JIA Septic arthritis/osteomyelitis Bone tumours and malignancy Chronic/ intermittent: Slipped capital femoral epiphysis (chronic) JIA Tarsal coalition ```

Question 52

Compartment Syndrome

Answer 52

• Increased pressure within fascial compartment resulting in vascular insufficiency of tissues within; Leg or Arms more commonly involved; Presents as Severe Pain (Classically Disproportionate), Poor Pulses, Mobility, Numbness or Pallor of affected compartment o Commonly due to Physical trauma, such as Fracture or Crush Injury o Acute Compartment Syndrome requires Urgent Fasciotomy to relieve pressure ▪ Typically, all compartments of limb are released regardless of involvement o Anterior Tibial Syndrome – Severe Pain occasionally with Foot Drop o Untreated Acute Compartment Syndrome can lead to limb loss or disability (E.g. Supracondylar Fractures leading to Volkmann’s Ischaemic Contracture) • Complications include Ischaemia and Necrosis, Rhabdomyolysis and Renal Failure

Question 53

Chronic Compartment Syndrome

Answer 53

Pain with exercise; Symptoms typically resolve with rest;

Question 54

Neurapraxia

Answer 54

Temporary loss of Nerve Conduction often due to Ischaemia following pressure; Axonotmesis – Damage to Nerve Fibre (Axon) with the Epineural tube still intact; Good recovery as nerve regrowth is guided; Neurotmesis – Division of the whole nerve o Regrowth fibrils can cause a Traumatic Neuroma if unable to bridge o Epineural repair with nylon sutures; if gaps cannot be repaired without excessive tension, Nerve-cable Interfascicular Autografts used; 50% regain function

Question 55

Median Nerve

Answer 55

Injury above Antecubital Fossa; Ochsner’s Test (Clasping test for FDS), FPL test, Loss of Sensation over Thenar palm; APB test most reliable

Question 56

Ulnar Nerve

Answer 56

Instability to cross fingers (Adduction); Froment’s Paper Test, Ulnar half sensory

Question 57

Radial Nerve

Answer 57

Wrist Drop (When Elbow Flexed, Forearm Pronated); Snuffbox Sensory loss

Question 58

Sciatic Nerve

Answer 58

All muscles below the knee, and sensation below Lateral Knee

Question 59

Common Fibular Nerve

Answer 59

Commonest LL Nerve Injury; Inability to Dorsiflex Foot and Toes, Sensory loss of Dorsum of foot

Question 60

Tibial nerve

Answer 60

Calcaneovalgus, Inability to stand on tiptoe or Invert Foot; Sensory loss of Sole

Question 61

Arterial Injury

Answer 61

Pressure and Elevation; Examination of distal pulses; Exploration and Vascular Repair may be needed; Complications include Gangrene, Contractures, False Aneurysms (Dissections) and AV Fistulae

Question 62

Septic Arthritis

Answer 62

• Consider for any Acutely Inflamed Joint; Rapid destruction under 24hr; Mostly in Knee; Less overt inflammation if immunocompromised, or underlying Joint Disease • RF: Pre-existing Joint Disease, DM, Immunosuppression, CKD, Recent Joint Surgery, Arthroplasty complication, IVDU, >80yrs age • Urgent joint aspiration for Synovial Fluid MC+S (NB: If Joint implant, needs to be done in theatre); Blood cultures might be useful • IV Abx (After aspiration) empirical therapy until sensitivities known; Most commonly due to S aureus, Strep, N gonorrhoea and Gram-Negative Bacilli (E.g. Coliforms) o Flucoxacillin 1g/6h IV, or Clindamycin if Pen-Allergic; Vancomycin if MRSA suspected, Cefotaxime if Gonococcal or Gram-Negative suspected • Orthopaedic advice regarding Arthrocentesis, Lavage, Debridement; Splint for <48h, Provide Analgesia and consider early mobilisation with PT

Question 63

Osteomyelitis

Answer 63

• Infection of Bone; Acute Haematogenous, Contiguous Local Infection, or Vertebral; • All forms can progress to Chronic Osteomyelitis – Pain, Fever and Suppuration with long remissions; Thick Irregular Bone on Radiographs; Radical Excision, Skeletal Stabilisation and Plastics input for Dead-space management, plus Antibiotics for >12/52 • Raised ESR, CRP, WCC; Positive BC in 60%; Bone Biopsy and Culture is gold standard but rarely required in Acute Osteomyelitis; MRI is sensitive and specific • Drain abscesses, Removal of Dead Bone (Sequestra) by Open Surgery o Vancomycin 1g/12h and Cefotaxime 1g/12h IVI until sensitivities; Continue 6/52

Question 64

Tuberculosis of the Bone (Vertebral Body =Pott’s Disease)

Answer 64

1-3% of all TB; Haematogenous or Local Lymphatic spread; Local Pain, Swelling and ‘Cold Abscess’ Formation with Joint Effusion; Systemic symptoms of Weight Loss, Malaise, Fever, Lethargy o DDx – Malignancy, Other Infections, Gout, RA o Loss of Bone Density, Periosteal Changes and Cyst Formation; May have associated Soft Tissue Inflammation (E.g. Tenosynovitis, Bursitis), especially on MRI o PET is superior for imaging; Bone scans useful for diagnosing Dactylitis, which is more common in Childhood TB of the Bone o Abscess Drainage, Immobilisation of Joints, RIPE; Joint Repair or Replacement might be needed for if Joint Destruction

Question 65

SPINAL TRAUMA

Answer 65

• Assume spinal injury in any serious accident and in all where MOI unknown, or if patient is unconscious; C-collar, Head blocks and Spinal board o Suspect if – Dermatomal Sensory Loss, Strenuous Diaphragmatic Breathing, Hypotonia, Hyporeflexia, Paralysis, Bradycardia and Hypotension in Normovolaemia, Priapism, Urinary Retention, Unexplained Ileus, Poikilothermia o Graded by ASIA scale (based on Motor and Sensory function) • Initial Resuscitation and treatment of Shock; Serial Neurological observations • If clear Cord injury and patient stable – CT first line • Early Treatment of Spinal Cord Injury – Controversial use of Steroids; Early Surgical Decompression, Skeletal Traction o Anticoagulation – Acute Cord injury patients at right of developing VTE

Question 66

Complications of Cord Injury

Answer 66

• Respiratory Insufficiency (Might require Ventilation), Hypotension (Likely below level of Lesion due to Sympathetic Interruption and Neurogenic Shock; Avoid overload), Skin ulcers from immobility, Bladder overstretching • Spinal Shock (≠Neurogenic) – Anaesthesia and Flaccid Paralysis with Urinary Retention followed by Reflex Emptying; Riddoch’s Mass Reflexia in response to stimuli (e.g. Temperature); Legs may become permanently flexed, with dorsiflexion (Spastic Paraplegia in Flexion); Unpredictable duration for recovery • GU Complications – UTI, Detrusor-Sphincter Dyssynergia, Autonomic Dysreflexia

Question 67

Spinal Cord Injury Patterns

Answer 67

• Narrowest diameter is within Thoracic spine, where injury more likely to be complete; Ischaemic injury often spreads below level of mechanical injury • Root pain and LMN at level of lesion, and UMN and Sensory Changes below (Spastic Weakness, Hyperreflexia, Upgoing Plantars, Loss of Coordination, Proprioception, Vibration, Temperature and Nociception)

Question 68

Brown-Séquard Syndrome

Answer 68

Ipsilateral loss of Dorsal Column modalities and Motor loss below level of lesion plus Contralateral loss of Spinothalamic sensation from a few levels below

Question 69

Anterior Cord Syndrome

Answer 69

Infarction of Cord supplied by ASA, leading to Complete Loss of Motor Function, Pain and Temperature sensation below lesion; Dorsal Column modalities (Soft touch, Vibration, Proprioception) intact

Question 70

Central Cord Syndrome

Answer 70

Hyperextension Injury with Pre-existing Spinal Stenosis; Greater Loss of Motor Power in Upper Extremities compared to Lower Extremities, combined with varying patterns of Sensory loss and Sphincter Dysfunction

Question 71

Cauda Equina Syndrome

Answer 71

• Saddle-area Anaesthesia, Incontinence/Retention of Faeces and Urine, Poor Anal Tone, Paralysis ± Sensory Loss • Requires MRI within 4hrs and Urgent Neurosurgical Referral • Compression can be due to Extrinsic tumours, Primary Cord tumours, Spondylosis, Spinal Stenosis, Achondroplasia, Fluorosis, Central Disc Herniation, Trauma, Spinal SAH, Abscess, TB or Pathological Fracture due to Malignancy

Question 72

CHEST TRAUMA

Answer 72

• ABCDE Approach; Senior Traumatology if major trauma • Oxygen for all via NRB Mask 15L/min; Stridor indicates possible upper airway compromise, requiring urgent Definitive Airway • Assume Spinal Instability – C-spine Precautions required o Tension Pneumothorax – Breath sounds, Respiratory Distress, Tracheal Deviation (away from Tension), Cyanosis, Distended Neck Veins, Asymmetry o Large cannula decompression in second Intercostal Space in the Mid-Clavicular line o Haemopneumothorax – Large (adult 32G) Chest Drain; If >1500ml =Massive, or >300/hr requires Thoracotomy o Sucking Chest Wounds – Three-sided dressing o Respiratory Embarrassment due to Pain, Flail Chest or Diaphragmatic Injury require Intubation and Ventilation; Chest Drain if chance of Bronchial, Lung and Chest tear • Control Haemorrhage – Pressure and Elevation; Crossmatch; 2 Wide-bore cannula IVI; 2L Crystalloid fluid challenge if <90mmHg and likely Hypovolaemic o Cardiac Tamponade – Beck’s Triad of JVP, Hypotension, Quiet Heart Sounds ± Pulsus Paradoxus (abnormally large drop in SV/BP/Pulse Waveform in Inspiration o Pericardial Aspiration by Needle left of Xiphoid; Aim for Left shoulder with needle angled 45deg to Horizontal o XM >6u, 2 large bore IVI, Monitoring, ITU care and facilitates for Thoracotomy • Neurological - GCS, AVPU, Pupillary Light Reflex • Regular Observations, ECG, CXR, Secondary Survey, Tetanus ± Anti-Tetanus Ig

Question 73

ABDOMINAL TRAUMA

Answer 73

• ABCDE, XM ±Theatre for Exploratory Laparotomy if not responding quickly • Penetrating Injury mostly require Laparotomy/Laparoscopy; Laparotomy if Posterior Rectus has been breached – Assess degree under LA, Wound Extension if necessary with expert o Liver most commonly involved; Also, Small Bowel, Diaphragm and Colon • Blunt Trauma – Splenic Injury and Rupture (Shock, Abdominal Tenderness, Distention, Left Shoulder-tip Pain, Overlying Rib Fracture), Mesenteric tear, Liver, Bladder and Aorta

Question 74

Fractures

Answer 74

• Described based on Site (Bone and part of Bone fractured), Obliquity (Transverse, Oblique, Spiral or Multi-fragmentary), Displacement and Soft Tissue Involvement (Open/closed, Neurovascular Status, Compartment Syndrome) • Healing Time – ‘Rule of 3’ – Closed, Paediatric, Metaphyseal, UL fracture will heal in 3 weeks; Complicating factors (Adult, Diaphyseal, LL, Open) will double healing times • Pathological Fracture =Occurs in Diseased or Abnormal Bone; Suspect if energy for trauma is abnormally low; Commonest causes Osteoporosis, Bony Mets (E.g. Breast, Bone); Also, Osteomalacia, Osteomyelitis, Bone Tumours and Osteogenesis Imperfecta) o Search for Primary Cancer is unclear cause; Osteoporosis Prevention; Prevention of met deposits with EBRT and Prophylactic IM Nails

Question 75

Emergency Management of Open Fractures

Answer 75

• ATLS Management (ABCDE) • Assessment – Neurovascular Status, Soft Tissues, Photograph Wound • Antisepsis – Wound swab, Copious Irrigation and Antiseptic Dressing • Alignment – Reduction plus Splint • Anti-Tetanus – Check status and Immunise appropriately • Antibiotics – Third Generation Cephalosporin ± Metronidazole if Grossly contaminated • Analgesia – IV Opiates titrated to effect

Question 76

Complications of Fractures

Answer 76

• Bleeding, Organ Injury, Neurovascular Injury, Skin issues, Infection, Malunion/Non-Union/Contractures, Embolism, Stone disease • Fat Embolism (Days 3 – 10) – Confusion, Dyspnoea, Tachycardia, Hypoxaemia, Seizures, Febrile, Petechial Rash; ITU, Expert help, Shock Management, Monitor CVP and UO; Treat Respiratory Failure • Crush/Compartment Syndromes – Renal failure due to Fluid Loss, DIC, Myoglobin release

Question 77

General Management of Fractures

Answer 77

• Displaced Fractures require Reduction unless function and appearance satisfactory o MUA under Radiographic Screening; Traction may be used (e.g. Femoral Shaft Fractures, Spinal Injury); Open Reduction (± Internal Fixation) o ORIF especially if fractures involve Joint Articulations, due to high risk of Osteoarthritis o Prompt Internal Fixation of all fractures in Polytrauma leads to large reductions in serious complications (Fat Embolism, ARDS), and reducing mechanical ventilation time ▪ K-wire or Bone clamp; ±Plates, Pilot hole drilled and Screws Inserted ▪ Lag screw technique most appropriate for Oblique fractures • Immobilisation – E.g. using Plaster of Paris o Immobilisation can lead to Muscle Atrophy, Stiff Joints and Osteoporosis; Return to normal function as soon as possible • External Fixation useful if Burns, loss of Skin and Bone, or Open Fracture as part of DCS

Question 78

FEMORAL FRACTURES

Answer 78

• 75,000 Patients with Hip Fractures annually in the UK; 10% die within 1/12 of #, >30% 1yr • Intracapsular Fractures occur just below Femoral head, causing External Rotation, Adduction and Shortening due to action of Iliopsoas o Disruption of Medial Femoral Circumflex can lead to Ischaemic Necrosis of Femoral Head, especially if there is excessive displacement

Question 79

Management of Neck of Femur Fractures

Answer 79

• ABCDE, Treat Shock with Crystalloids • Analgesia – E.g. Morphine IVI, Femoral Nerve Block, Antiemetic • Imaging – XR Hip or CT • Preparation for Theatre – Blood (FBC, U/Es), CXR, ECG, NBM, XM, Consent • Orthogeriatric opinion for concurrent Medical issues • Surgery – Intracapsular requires Hemiarthroplasty (with native acetabulum, unless fractured) due to risk of Avascular Necrosis if native femoral head is retained; If previously good mobility and high chance of recovery of mobility, consider Total Hip Replacement (esp if younger) o Intertrochanteric/Extracapsular – Dynamic Hip Screw; Allows for stability of fracture but allows compression during load; Reduced hospital stay and improved rehab

Question 80

Femoral Shaft Fracture

Answer 80

• Requires considerable force; Look for other fractures • Check Distal Pulses and look for swelling – Risk of Compartment Syndrome, Sciatic Nerve Injury and Femoral Artery Injuries • Definitive Treatment with locked Intramedullary Nail across fracture

Question 81

PELVIC FRACTURES

Answer 81

• Single Fractures are often stable and require just a few weeks rest; ≥2 Fractures leads to Pelvic Ring instability, 25% of which associated with internal injuries o Leg Length Discrepancy, Abdominal Distention, Bruising, Perineal or Scrotal Haematoma or Urethral Trauma o Tenderness of Iliac Crests, Pubic Symphysis, Sacrum and SI Joints o Diagnosis by Pelvic Radiograph/CT • ABCDE, Analgesia; Cystogram before Cath if Urethral Trauma suspected alt: Suprapubic • Complications include – Haemorrhage, Genitourinary Tract Trauma, Paralytic Ileus, Sciatic Nerve Entrapment • Malgaigne’s Fracture – Disruption Anteriorly and Posteriorly with Displacement of a fragment containing the Acetabulum • Acetabular Fractures – Posterior Lip or Transverse; ORIF and Reconstruction of Articular Surface required to delay onset of Secondary Osteoarthritis

Question 82

Clavicular Fracture

Answer 82

• Most seem to occur after direct blow to shoulder (prev thought FOOSH); Most common in Middle third; • Broad arm sling, Follow-up XR at 6/52 to ensure union • Internal Fixation is non-union of Lateral # • Complications include Brachial Plexus injury, Subclavian Vascular injury and PTX

Question 83

AC Joint Dislocation

Answer 83

• Tender prominence over AC joint; Adduction across body cause increased pain; XR might appear normal and require weight-carrying views • Sling support and Mobilisation; Surgery if persistent symptoms

Question 84

Shoulder Dislocation

Answer 84

• Anterior Shoulder Dislocation – Following fall on Arm or Shoulder; Loss of Shoulder contour, Anterior Bulge due to Humoral head o Check Neurovascular status (Axillary Nerve to Deltoid); Radiograph prior to reduction to ensure no associated fracture o Analgesia and Simple Reduction (Longitudinal Traction in Abduction), or Kocher’s Method o Radiograph post-reduction; Broad arm sling; Surgery if Recurrent Dislocation or Young/Athletic • Posterior Shoulder Dislocation – Rare; Limitation of External Rotation; Lateral Radiographs essential for diagnosis; Refer to Orthopaedics

Question 85

Biceps Tendon Rupture

Answer 85

Discomfort midway while lifting or pulling; Mass appears on Elbow Flexion like ‘Popeye’; Repair rarely indicated as function remains

Question 86

Humeral Fracture

Answer 86

• Supracondylar Fracture =Most common in Childhood; Peaks 5-7yrs • Compromise of Brachial Artery, Median, Radial or Ulnar Nerve • Keeping Elbow in Extension prevents exacerbating damage; Avoid flexion, if non-displaced, Back-slab and Sling, if angulated with intact Posterior Cortex, Reduction Under Anaesthetic, and if Posteriorly Displaced, ORIF

Question 87

Radial Head Fracture

Answer 87

• Elbow Swollen and Tender over Radial Head; Tender when Pronation and Supination; Undisplaced fractures can be kept in Collar and Cuff Sling; Displacement requires ORIF • 3-14% Associated with “Terrible Triad” – Radial Head Fracture, Elbow Dislocation and Coronoid Process Fracture leading to Joint Instability

Question 88

Elbow Dislocation

Answer 88

• FOPOSH with Elbow Flexed causes Posterior Ulnar displacement on Humerus; Reduction under Anaesthetic/Analgesia • Flex Elbow to relax Biceps Brachii; With fingers on Epicondyles and thumbs on Olecranon, Push thumbs forward and down onto Forearm; Chunk should be heard • Post-reduction Radiograph, Immobilise in Back slab • If Olecranon Fracture – ORIF if displaced

Question 89

Colle’s Distal Radial #

Answer 89

Common in Osteoporotic, Post-menopausal women with FOOSH; Dorsal Angulation and Displacement (=Dinner-Fork deformity); Avulsion of Ulna might occur o Reduction under Anaesthesia and Tourniquet (=Bier’s Block Method) o Median nerve injury will resolve over time; Other complications include Tendon injury (especially EPL), Malunion and Non-union

Question 90

Smith’s Distal Radial # Fracture

Answer 90

Distal Radial Fragment Anteriorly Angulated and Displaced | o More commonly requires fixation due to migration of fracture fragments

Question 91

Bennett’s Fracture

Answer 91

CMC Fracture/Thumb Dislocation; Managed with Percutaneous Wire Fixation to reduce risk of secondary OA

Question 92

Scaphoid Fracture

Answer 92

Common, easily missed on Radiography; Results from FOOSH o Tender in Anatomical Snuffbox and Scaphoid Tubercle; Pain on Axial Thumb Compression and Ulnar Deviation of Pronated Wrist o Scaphoid Series imaging; If negative but clinical suspicion, MRI may be used, or if unavailable Cast and Re-XR in 2/52 o Avascular Necrosis of the proximal pole can occur, as it relies on Interosseous supply from Distal portion

Question 93

Hand Fractures

Answer 93

• Base of Second and Third Metacarpals, where movement is centred; Less tolerant of Malalignment and Imperfect reduction; Fifth most commonly involved, especially in Punching • Stable closed fractures splint/cast for 2/52, Unstable require K-wire or ORIF • Longer periods of splinting can lead to Stiffness – Adhesions, Contracture, Fibrosis and Ligament Shortening • Refer for any with Rotational Deformity (Clinically), as well as multiple fractures • Proximal Phalanx – Likely associated with Rotational Deformity, requiring surgery • Middle Phalanx – Control rotation by Malleable Metal Splint and Neighbour-Strapping • Distal Phalanx – Often open; If closed, Trephining the nail reduces swelling; Partial Fingertip amputations might require Split Grafts from Thenar Eminence • Gamekeeper’s Thumb – Laxity of Ulnar Collateral Ligament of the Thumb; Leads to weakness of Pincer Grip, crucial to ensure complete tears are managed surgically o Might require Examination under Anaesthetic; XR might show Bone Avulsion

Question 94

Tendon Injury

Answer 94

• Failure to extend MCP = Extension Tendon division; 75% are closed injury • Failure to flex DIP against resistance = FDP division; Failure to flex PIP against resistance = FDS; Flexor Tendon injuries by Primary Repair; Staged repair with plus graft if Loss of Tendon Substance or Delayed presentation

Question 95

Patella Injury

Answer 95

• Patella Dislocation – Typically Lateral due to Twisting Motion of LL combined with Quadriceps Contraction; Reduction with gentle medial pressure and Extension o Radiographs post-reduction to ensure no fractures o Immobilisation in Cast/Brace to allow recovery • Recurrent Dislocation – Associate Developmental Abnormalities; Might require Surgery to strengthen Medial Expansion • Patella Fracture – Fall on Flexed Knee or due to Dashboard Injury; Non-displaced Fractures can be splinted; Displacement warrants ORIF

Question 96

Ankle Fractures

Answer 96

• Rotation causes Oblique Lateral Malleolar Fractures, or proximal fracture of Fifth Metatarsal due to Fibularis Brevis Avulsion • If Stable Fracture involving one side of ankle, Cast; Unstable or Displaced require surgery • Maisonneuve’s Fracture – Proximal Fibular plus Syndesmosis Rupture, and Medial Malleolus Fracture or Deltoid Ligament Rupture; Surgery

Question 97

Lisfranc Fracture Dislocation

Answer 97

• One or more Metatarsals displaced by Tarsals • Commonly missed in Polytrauma, but can also be caused by mis-stepping off kerb; May cause Compartment Syndrome, Secondary OA and Persistent pain • ORIF may be required to achieve precise anatomic reduction

Question 98

Metatarsal Stress Fracture

Answer 98

• =March Fracture; Distal third of Metatarsal due to recurrent stress; Most commonly second or third Metatarsal • Common cause of foot pain, especially if new activity • Reduce movement 6-12/52; Cast or special shoes;

Question 99

Achilles Tendon Rupture

Answer 99

• Sudden pain at back of Ankle during Running or Jumping as injury occurs; Might be perceived like a kick; Possible to walk with limp • Unable to Plantarflex against stress; Gap may be palpated in tendon course, esp after 24h • Simmonds Squeeze Test – Pain and Less Plantarflexion on affected side • Percutaneous or Open Tendon Repair; Later onset rupture might require reconstruction • Conservative treatment more suitable for Smokers, Diabetics and >50yrs due to infection and recurrence risk