Orthopaedics, Joint Exams, Fractures & Xrays

Question 1

What are the normal angle values for hip flexion and extension?

Answer 1

Hip flexion - 120 degrees

Hip extension - 20 degrees

Question 2

Hip exam - what are the normal angles for hip abduction and adduction?

Answer 2

Hip abduction - 60 degrees

Hip adduction - 45 degrees

Question 3

Hip exam - normal angle values for internal and external rotation?

Answer 3

Internal rotation - 30 degrees

External rotation - 60 degrees

Question 4

Knee exam - What are the two tests to check for a joint effusion in the knee?

Answer 4

1. Patellar tap

2. Sweep test (aka swipe test) sweep up medially.

Question 5

What is the proper name for a bunion?

Explain how it forms.

Answer 5

Hallux Valgus

Great toe becomes abducted at the MTP metatarsophalangeal joint. Excessive pressure on the medial side can lead to formation of a bursa, called a bunion.

Question 6

How is Mallet toe different to Hammer toe?

Answer 6

Mallet toe - flexion at DIP only

Hammer toe - extension at MTP, flexion at PIP and DIP

Question 7

How is claw toe different to hammer toe?

Answer 7

Both - extension at MTP, flexion at PIP Claw toe - extension at DIP
Hammer toe - flexion at DIP

Question 8

Shoulder exam - what type of problem is indicated by normal passive movement, with painful or restricted active shoulder movements?

Answer 8

Muscle or tendon problem

Question 9

Shoulder exam - what would indicate adhesive capsulitis?

Answer 9

Adhesive capsulitis / frozen shoulder

Loss of passive external rotation and abduction (doctor doing it for patient)

Question 10

What causes winged scapula? Muscle and nerve

Answer 10

Serratus anterior dysfunction

Damage to the long thoracic nerve

Question 11

Shoulder exam - What does a painful arc indicate?

1. Middle?
2. Top?
3. Throughout?

Answer 11

1. Painful arc - pain on shoulder abduction 60-120 degrees, which reduces past 120 degrees

Indicates supraspinatus tendon impingement or subacromial bursitis

2. If patient reports pain at the end of the test it’s more likely to be a problem in the acromiocalvicular joint such as OA
3. If patient reports pain throughout the arc, it could be OA of the glenohumeral joint or frozen shoulder

Question 12

Elbow exam - where will there be pain in golfer’s elbow?

Answer 12

Medial epicondyle

Question 13

Elbow exam - where will there be pain in tennis elbow?

Answer 13

Lateral epicondyle

Question 14

Elbow exam - how to examine for medial epicondylitis?

Answer 14

Medial epicondylitis - Golfer’s elbow

Palpate medial epicondyle
Active wrist flexion against resistance

Question 15

Elbow exam - how to check for lateral epicondylitis?

Answer 15

Lateral epicondylitis - Tennis elbow

Palpate lateral epicondyle
Make a fist, Active wrist extension against resistance - patient is pushing down

Question 16

What are the risk factors for osteoporosis?

Answer 16

Question 17

Supraspinatus muscle is innervated by what nerve?

Also what movement and test

Answer 17

Suprascapular nerve

Abduction up to 15 degrees

Empty can test

Question 18

Infraspinatus muscle is innervated by what nerve?

Also what movement and test

Answer 18

Suprascapular nerve (same as supraspinatus)

External rotation

Active external rotation against resistance

Question 19

What nerve supplies subscapularis?

Also what movement and test

Answer 19

Upper subscapular nerve

Internal rotation

Lift-off test

Question 20

For what disorders would you prescribe bisphosphonates?

Answer 20

Paget’s disease of bone
Osteoporosis
Bone metastases (with or without Hypercalcemia)
Multiple myeloma 
Primary Hyperparathyroidism
Osteogenesis imperfecta 
Hypercalcemia

Question 21

How do bisphosphonates work?

Answer 21

Bisphosphonates inhibit bone resorption by osteoclasts. Preventing loss of bone density.

Fuller explanation: Bisphosphonates bind hydroxyapatite in bone, inducing apoptosis in osteoclasts

Question 22

Name 2 Risk factors for sciatica

Answer 22

Options:
Older age
Obesity
Occupation
Sedentary lifestyle 
Diabetes
Previous sciatica

Question 23

Describe the characteristic pain of sciatica

Answer 23

Radiating pain down back of leg, made worse by some movements, numbness, pins and needles

Question 24

Sciatica - describe 2 findings on examination

Answer 24

Reduced straight leg raise / positive sciatic nerve stretch test
Reduced ankle reflex (areflexia)
Sensory loss
(Normal looking leg)

Question 25

Name 2 risk factors for osteoarthritis

Answer 25

``` Older age Occupation (eg. Sports people) Previous joint injury Obesity Female gender Family history Inflammatory arthritis ```

Question 26

Describe the characteristic pain of osteoarthritis

Answer 26

Dull ache, worse at the end of the day and during exercise, progressive, chronic, can be referred pain eg hip OA presenting as knee pain

Question 27

Osteoarthritis - Findings on joint examination

Answer 27

``` Normal temperature Deformity May or may not have effusion Pain on movement Reduced range of movement Crepitus Muscle wasting ```

Question 28

Red flags for back pain What suggests cancer? What suggests cauda equina?

Answer 28

Question 29

What sign is shown in this X-ray and what does it indicate?

Answer 29

‘Winking owl’ sign | Occurs when the pedicle (circle) is destroyed due to metastasis

Question 30

What drug class (give an example) can cause spontaneous Achilles rupture?

Answer 30

CIPROFLOXACIN Quinolones eg ciprofloxacin

Question 31

What are the differential diagnoses for pain in the back or hip?

Answer 31

Question 32

What are differential diagnoses for knee pain?

Answer 32

Question 33

What are the differential diagnoses for neck pain?

Answer 33

Question 34

What are the differential diagnoses for shoulder pain?

Answer 34

Question 35

What are the differential diagnoses for elbow pain?

Answer 35

Question 36

What are the differential diagnoses for wrist and hand pain?

Answer 36

Question 37

How are ankle fractures classified?

Answer 37

Weber’s A, B and C. The Weber ankle fracture classification is a system for classifying lateral malleolar fractures, relating to the level of the fracture in relation to the distal tibiofibular syndesmosis. It has a role in determining the treatment. A - fracture is below the level of the syndesmosis. Usually transverse. Medial malleolus sometimes fractured too. Usually stable. B - fracture is at the level of the syndesmosis. some fibres of the syndesmosis may be torn. usually spiral. Variable stability, may require ORIF. C - above the level of the syndesmosis. Medical malleolus fracture or deltoid ligament injury often present. Fibular neck fracture may be present - must check all the way up the fibular. Unstable - usually requires ORIF.

Question 38

How would you class a fibular fracture at the level of the tibiofibular syndesmosis?

Answer 38

Weber’s type B.

Question 39

What classification system would you use to describe fractures through a growth plate? Can you describe the different types?

Answer 39

Salter-Harris classification - fractures through a growth plate in a child’s long bones.

Question 40

How are the different Salter-Harris fractures type I - V treated? Which is the most/least common?

Answer 40

I - cast or boot II - cast or boot + closed reduction if misalignment III - usually ORIF, sometimes Just cast IV - ORIF V - Usuallt delayed diagnosis, because X-ray may appear normal. May present with growth arrest. Surgery sometimes needed. Type II is most common by far (75%) Type V least common (<1%)

Question 41

What classification system can be used to further describe intracapsular hip fractures? Describe the stages

Answer 41

Garden classification Garden stage I - undisplaced, incomplete. Includes valgus impacted fractures. Garden stage II - undisplaced, complete Garden stage III - partially displaced, complete Garden stage IV - completely displaced, complete Generally stage I and II are stable fracture and are treated with internal fixation with cannulated hip screw with femoral head preservation, and generally stage III and IV are unstable and treated with either hemiarthroplasty or total arthroplasty, because these stages are more likely to result in avascular necrosis.

Question 42

What ‘line’ can you look for on X-ray to help diagnose a hip fracture ?

Answer 42

Shenton’s line - an imaginary curved line drawn along the inferior border of the superior ramus, along the inferomedial border of the neck of femur. It should be continuous and smooth.

Question 43

How would the different types of Garden fracture be fixed? Which types are at risk of avascular necrosis?

Answer 43

Garden stage I - undisplaced, incomplete Garden stage II - undisplaced, complete Garden stage III - partially displaced, complete Garden stage IV - completely displaced, complete Generally stage I and II are stable fracture and are treated with internal fixation with cannulated hip screws with femoral head preservation, and generally stage III and IV are unstable and treated with either hemiarthroplasty or total arthroplasty, because these stages are more likely to result in avascular necrosis.

Question 44

How would you decide what patients to offer a total arthroplasty to verses a hemiarthroplasty?

Answer 44

NICE advise that THR offered to patients who: - are able to walk independently outdoors with no more than a stick, and - are not cognitively impaired, and - are medically fit for anaesthesia and the procedure

Question 45

What blood vessels supply the femoral head?

Answer 45

1. Retinacular vessels - main blood supply. Originates from an arterial ring supplied by the medial and lateral circumflex arteries. 2. Foveal artery, only in younger people 3. Metaphyseal vessels, not a major source.

Question 46

How are intracapsular, extracapsular and subtrochanteric hip fractures treated

Answer 46

Intracapsular - usually hemiarthroplasty (because blood supply to femoral head is compromised) Extracapsular - usually dynamic hip screw Subtrochanteric - usually intra-medullary (IM) nail

Question 47

What are the Ottawa ankle rules?

Answer 47

Ottawa ankle rules help differentiate which ankle injuries require X-ray. They state that an ankle radiograph series is only required if there is pain in the malleolar zone (highlighted turquoise in below image) and one or more of the following is found: - Boney tenderness at the posterior edge or tip of the lateral malleolus OR - Boney tenderness at the posterior edge or tip of the medial malleolus OR - Inability to weight bear immediately and in the A+E department for four steps

Question 48

What is a Colles fracture? Caused by? What other fracture is commonly seen alongside this?

Answer 48

Fracture of the distal radius with dorsal angulation of the distal fragment. Caused by FOOSH - fall on outstretched hand, with wrist extended 50% of colles fractures are associated with a fracture of ulna styloid

Question 49

What type of fracture is this?

Answer 49

Colles fracture

Question 50

A Colles fracture is also called a ‘what’ deformity?

Answer 50

Dinnerfork deformity

Question 51

What is a Smith’s fracture? How is it sustained?

Answer 51

Distal radial fracture with palmar angulation of wrist joint Falling on outstretched hand with wrist flexed (Aka reverse Colles fracture)

Question 52

What is a Monteggia fracture?

Answer 52

Fracture of the proximal 1/3 ulna + proximal radial head dislocation This problem is often missed in children - radial head dislocation might not be obvious on X-ray Paediatrics - closed reduction of both Adults - Closed reduction of radial head, ORIF ulna Posterior interosseous nerve could be injured - check finger extension (Monteggia pronounced ‘mont-asia’) P’s - Proximal injury, Posterior interosseous nerve

Question 53

What is a Galeazzi fracture? What branch of what nerve might be damaged and what is the sign of that damage?

Answer 53

Fracture of distal 1/3 of radius and dislocation of distal radioulnar joint Anterior interosseous nerve can be damaged (terminal branch of median nerve, motor function only no sensory) - when asked to make a fist may show the Hand of Benediction (unable to flex 2nd & 3rd digits) also unable to make the ‘ok’ circle sign - index finger stays straight