Orthopedics

Question 1

11- year old boy + limping + affected leg is shorter than the other + externally rotated hip that increases with hip flexion + painful knee/hip/thigh/groin

Answer 1

SUFE (slipped upper femoral epiphysis)

Question 2

What is the likely foot bone to fracture in a vertical fracture?

Answer 2

calcaneus

Question 3

The likely affected foot bone in a stress fracture?

Answer 3

Metatarsals

Question 4

Bone pain in young people unrelated to activity + responds quickly to NSAIDs (aspirin)

Answer 4

Osteoid osteoma

Question 5

Sensory loss responsible in the groin and pelvic girdle

Answer 5

L1

Question 6

Sensory loss responsible in the anterior thigh

Answer 6

L2

Question 7

Responsible for sensory loss in the anterior thigh

Answer 7

L2

Question 8

Responsible for sensory loss in the inner (medial) thigh and distal anterior thigh

Answer 8

L3

Question 9

Responsible for sensory loss in the inner shin

Answer 9

L4

Question 10

Responsible for sensory loss in the lateral shin and dorsum of the foot

Answer 10

L5

Question 11

Responsible for sensory loss in the lateral foot

Answer 11

S1

Question 12

Known case of prostate cancer + perianal/groin numbness (saddle paresthesia) + inability to initiate voiding + back pain

Answer 12

Cauda equina syndrome

Question 13

Sciatica + saddle paresthesia + urinary retention + fecal incontinence
Diagnostic?

Answer 13

Urgent MRI
Urgent referral to orthopedic surgeon
Urgent surgical decompression

Question 14

Severe low back pain radiating to the leg + positive straight leg raising test + when getting up from a lying position INCREASES PAIN + lying down relieves pain
Diagnosis?
Next step?

Answer 14

Lumbosacral Disc Herniation
Reassure
(MRI spine if with red flags)

Question 15

Shooting electric shock pain moving down a leg

Treatment?

Answer 15

Sciatica

Amitriptyline (then Gabapentin, Pregabalin)

Question 16

Shoulder weakness + pain esp on raising arm above the shoulder

Answer 16

Supraspinatus tendinitis

Question 17

Elderly with osteoporosis + history of fall + painful hip + shortened, externally rotated leg
Likely diagnosis?

Answer 17

Fracture of the NECK of the femur

Question 18

Young male 11-15 years old + limping + shortened leg + externally rotated leg
Diagnosis?

Answer 18

Slipped Upper Femoral Epiphysis

Question 19

Young girl + breech presentation + limping + painless leg that is shorter than the other = unequal skin folds
Diagnosis?

Answer 19

Developmental dysplasia of the hip

Question 20

Painful base of thumb + tender anatomic snuffbox + pronation followed by ulnar deviation produced pain
Diagnosis?
Diagnostic?
Treatment?

Answer 20

Scaphoid Fracture

X-ray

POSITIVE X-ray - scaphoid cast for 6 weeks
NEGTIVE X-ray - cast and repeat X-ray in 2 weeks

Question 21

Management of developmental dysplasia of the hip

Answer 21

Spontaneously stabilise - 3-6 weeks of age
Pavlik harness - for children younger than 4-5months
Surgery - older children

Question 22

T

Question 23

What is Thompson test and what is its significance?

Answer 23

Ask the patient to lie prone with their feet dangling over the edge of bed.
Gently squeeze the calf muscle.
Normal response is plantar flexion. Absence of plantar flexion upon squeezing the calf muscle is positive for THOMPSON TEST.
It is present in achilles tendon rupture

Question 24

Audible pop in the ankle + sudden onset of significant pain in the calf or ankle + inability to walk or continue sport
What’s next?

Answer 24

Same-day referral to ortho (achilles tendon rupture)

Question 25

Unable to extend and straighten 4th and 5th fingers + firm nodule found in the distal palmar crease + father has the same condition Likely diagnosis? Likely mechanism? Management?

Answer 25

Dupuytren’s contracture Formation of thickened fibrous tissue within the palmar fascia Fasciotomy

Question 26

More common in the thumb, middle or ring finger + stiffness of a finger + snapping or clicking sound when extending a flexed digit

Answer 26

Trigger finger (stenosing tenosynovitis)

Question 27

Monoarthritis + pain following use + improves with rest + unilateral symptoms + no systemic upset

Answer 27

Osteoarthritis

Question 28

Inovlves more than 1 joint + morning stiffness + improves with use + bilateral symptoms + systemic upset

Answer 28

Rheumatoid arthritis

Question 29

X-ray findings: loss of joint space + Osteophytes forming at joint margins + subchondral sclerosis + subchondral cysts

Answer 29

Osteoarthritis

Question 30

First-line management of osteoarthritis

Answer 30

Paracetamol + Topical NSAIDS ***second line is oral NSAIDS or COX-2i plus PPI; consider codeine if pain persists

Question 31

Differentiate Colles fracture from Smith fracture.

Answer 31

Both Colles and Smith fracture are both fracture of the distal radius. Colles = dinner fork deformity = distal radius is posteriorly displaced Smith = garden spade deformity = reverse Colles = distal radius is anteriorly displaced *** Si P Diddy ay may Colles (PD - posteriorly displaced, D - dinner fork deformity; Colles) Si Smith ay may member ng ADG, nagpapractice sa garden. (ADG - anteriorly displaced; garden spade deformity; Smith fracture)

Question 32

Child presenting with painful hip + mild fever + normal or mildly elevated WBC and ESR + happy and systemically well child

Answer 32

Transient synovitis

Question 33

Child with painful hip + fever + leukocytosis + elevated ESR + tenderness, redness and swelling of hip and leg + systemically unwell

Answer 33

Septic Arthritis

Question 34

In any fracture, if there is 1. Absence of pulses = neurovascular compromise 2. Obvious deformity Next action?

Answer 34

Urgent reduction under sedation or analgesia ***Then refer to neurovascular/orthopedics

Question 35

Following a femur fracture, the absence of proximal and distal pulses in a lower limb indicates an injury in this structure:

Answer 35

Femoral artery

Question 36

Differentials for elevated ALP:

Answer 36

BBP Bone + Biliary Tract + Pregnancy Bone: Pagets, Osteomalacia, hyperparathyroidism, bone mets

Question 37

X-ray findings in Paget’s disease of the bone

Answer 37

Mutifocal SCLEROTIC patches Blade of grass lesion (V-shape pattern bet healthy and diseased long bone) ***Remember sclerotic lesions of Paget’s disease of the bone vs. lytic (punched-out) lesions of multiple myeloma

Question 38

Bone pain + elevated alkaline phosphatase + normal Ca and Phosphate + multifocal patches on X-ray + heart failure

Answer 38

Paget’s Disease of the bone ***Remember the presence of hearing loss and heart failure with bone manifestations favours the diagnosis of Paget’s disease of the bone

Question 39

Dislocation of the head of the radius + fracture of the proximal 1/3 of the ulna Likely structure affected? Diagnosis?

Answer 39

Radial nerve | Monteggia fracture

Question 40

Dislocation of the radio-ulnar joint + fracture of the distal 1/3 of the radius

Answer 40

Galeazzi fracture

Question 41

Painful swelling/bruises + weakness and pain when grasping things with the thumb + tenderness over MCP joints Diagnosis? Mechanism?

Answer 41

Gamekeeper’s thumb | Injury to ulnar collateral ligament

Question 42

Important management of colles fracture in the elderly

Answer 42

Closed reduction followed by plaster of paris cast below elbow

Question 43

Bone marrow biopsy finding seen in multiple myeloma

Answer 43

Abundant plasma cells

Question 44

Findings in a serum protein electrophoresis of multiple myeloma

Answer 44

Increased spike of monoclonal Ig

Question 45

Findings in a urine protein electrophoresis of multiple myeloma

Answer 45

Bence Jones protein

Question 46

Findings in blood film of multiple myeloma

Answer 46

Rouleaux formation

Question 47

Wrist drop | Structure affected?

Answer 47

Radial nerve

Question 48

Structure affected in foot drop

Answer 48

Common peroneal or sciatic nerve

Question 49

Structure affected in claw hand

Answer 49

Ulnar nerve

Question 50

Structure affected in paresthesia of thumb, index and middle finger

Answer 50

Median nerve

Question 51

Structure affected in paresthesia of little and ring finger

Answer 51

Ulnar nerve

Question 52

Paresthesia of the dorsal aspect of the thumb +/- a small area over the (dorsal) area between 1st and 2nd index fingers

Answer 52

Radial nerve

Question 53

Numbness on superior aspect of upper arm just below the shoulder joint

Answer 53

Axillary nerve

Question 54

Fibular neck fracture - likely structure affected?

Answer 54

Common peroneal nerve

Question 55

Femur neck fracture - structure that is likely affected?

Answer 55

Sciatic nerve

Question 56

Fracture of the acetabulum - structure that is likely affected

Answer 56

Sciatic nerve

Question 57

Posterior dislocation of the hip - which structure must have been affected?

Answer 57

Sciatic nerve

Question 58

Fracture of the humeral shaft - which structure is likely affected?

Answer 58

radial nerve

Question 59

Colles fracture - structure likely affected?

Answer 59

Median nerve

Question 60

Most initial test for metastasis to bone?

Answer 60

Calcium (it would show hypercalcemia)

Question 61

Most appropriate test for metastasis to bone

Answer 61

Bone scintigraphy (or MRI) ***remember that DEXA is for osteoarthritis while skeletal survey is for multiple myeloma

Question 62

Chronic use of steroids + history of multiple fractures | Best modality?

Answer 62

DEXA scan

Question 63

Young boy + painful knee + gait abnormality + tender, smooth, fixed mass over a side of the knee

Answer 63

Osteosarcoma

Question 64

Young boy + painful knee + gait abnormality + tender, smooth, fixed mass over a side of the knee + other systemic symptoms (fever, weight loss, tiredness)

Answer 64

Ewing sarcoma ***Remember osteosarcoma (most common) + systemic symptoms

Question 65

Lateral elbow swelling + limited ROM of elbow + passive rotation of elbow More common in adults? How about in children?

Answer 65

Radial head fracture - in adults Radial neck fracture - in children

Question 66

Femur fracture + deteriorating level of consciousness and o2 saturation 24-72 hours after surgery

Answer 66

Fat embolism

Question 67

``` Fracture of distal radius + posteriorly displaced (dorsal angulation) fragments Diagnosis? Likely injured structure? Rx in the elderly Rx in the young? ```

Answer 67

Colles fracture Median nerve Elderly - Closed reduction followed by POP casting below elbow Young - above the elbow backslab cast

Question 68

Numbness and tingling of the thumb, index and middle fingers Diagnosis? Structure likely affected? Treatment?

Answer 68

Carpal Tunnel Syndrome Median nerve (due to compression of the transverse carpal ligament) Cut the transverse carpal ligament or Release flexor retinaculum ***Also remember median nerve association with colles fracture (dinner fork deformity)

Question 69

Pregnant with Carpal Tunnel Syndrome

Answer 69

Wear wrist splints until delivery

Question 70

Most common cause of septic arthritis?

Answer 70

Staphylococcus aureus

Question 71

Fever, pain, swelling and limited movement of the knee + risk factor: DM, steroid, HIV, rheumatoid arthritis Diagnosis? Cause? Diagnostic? Management?

Answer 71

Septic Arthritis Staphylococcus aureus Aspiration of synovial fluid Blood culture Management: Flucloxacillin (Clindamycin if allergic)

Question 72

Seronegative + no fever + young adult + following a urogenital infection or dysenteric infection + migratory OLIGOarthritis

Answer 72

Reactive arthritis

Question 73

Child (4-10 years old) fell on his outstretched arm + absent radial/brachial pulse Diagnosis? Likely structure damaged?

Answer 73

Angulated supracondylar fracture of the humerus | Brachial artery

Question 74

Meniscal tears are best seen by

Answer 74

MRI scan

Question 75

A player jumps and lands on a slightly twisted knee, presents with locking or locked leg

Answer 75

Meniscal tear

Question 76

A player jumps and lands on a slightly twisted knee, presents with positive Apley and McMurray test

Answer 76

Meniscal Tear

Question 77

A player jumps and lands on a slightly twisted knee, presents with popping

Answer 77

ACL injury

Question 78

A player jumps and lands on a slightly twisted knee, presents with immediate swelling

Answer 78

ACL injury

Question 79

A player jumps and lands on a slightly twisted knee, presents with delayed swelling

Answer 79

Meniscal Tear

Question 80

Direct impact to the lateral side, which ligament is most likely injured?

Answer 80

Medial collateral ligament injury

Question 81

Direct impact to the lateral side, which stress test turns positive?

Answer 81

Valgus ***Remember valgus = lateral side = MCL

Question 82

Direct impact to the medial side of the knee. Likely structure to be involved?

Answer 82

Lateral Collateral Ligament Injury

Question 83

Direct impact to the medial side of the knee. Which stress test is likely positive?

Answer 83

Varus stress test ***Remember: medial side = LCL = varus stress test

Question 84

3-9 years of age + Hip pain (progressive over the weeks) + limping + stiffness with decreased ROM + X-ray: flattening and radiolucency of the proximal metaphysis

Answer 84

Perthes disease