Rheumatology + Orthopaedics Flashcards

Question

Crystals seen in pseudogout

Answer 1

Positive birefringement of polarised light Calcium pyrophosphate crystals Rhomboid shaped

Answer 2

Chondrocalcinosis - thin white line in middle of joint space caused by calcium deposition (pathognomonic) Other changes - LOSS L - loss of joint space O - osteophytes S - subarticular sclerosis S - subchondral cysts

Answer 3

* Symptomatic management - NSAIDs, colchicine, joint aspiration, steroid injections, oral steroids * Arthrocentesis in severe cases

Answer 4

* Subcutaneous deposits of uric acid * Small joints and connective tissue of hands, elbows, ears * DIP joints in hands most commonly affected

Answer 5

Joint aspiration to remove purulent material + for symptomatic relief - closed aspiration or arthroscopic drainage, aspirate to dryness, may need serial aspiration Empirical IV antibiotics until organism/sensitivities known - * Native joint - IV flucloxacillin * Penicillin allergy or MRSA suspected - IV vancomycin * High risk for gram negative - add IV gentamicin * Prosthetic joint - IV vancomycin (+/- IV gentamicin) * Gonococcal infection suspected - cephalosporin Native joint - 2 weeks IV, 4 weeks oral Prosthetic joint - 6 weeks IV

Answer 6

Gout, pseudogout or septic arthritis - can be co-existent

Answer 7

Symmetrical Polyarticular Distal small joints - hands + feet * Hands - MCP, PIP * Wrist * Ankle * Can be larger joints e.g. knees, shoulders, elbows

Answer 8

* Pain - worse after rest, improves with activity (opposite to OA) * Swelling * Warmth * Redness * Tenderness * Stiffness - early morning stiffness >1 hour * Persistent - generally accumulates joints over time * Systemic symptoms - fatigue, weight loss, flu-like illness, muscle aches and weakness

Answer 9

Synovitis - boggy on palpation Positive squeeze test - pain when squeezing metacarpal/tarsal joints Deformity * Swan neck - MCP flexion, PIP hyperextension, DIP flexion * Boutonniere's - PIP flexion, DIP hypertextension * Z-thumb - CMC flexion, MCP hypertextension, PIP flexion * Ulnar deviation - deformity of MCP joints, fingers deviate towards ulnar side Rheumatoid nodules - firm, hard swellings over extensor surfaces Extra-articular features * Ocular - scleritis, episcleritis, Sicca syndrome (secondary Sjogren's) * Cardiorespiratory - pleural effusions, pulmonary nodules, pulmonary fibrosis, pericarditis, serositis * Splenomegaly * Peripheral neuropathy * Anaemia of chronic disease * Amyloidosis * Lymphadenopathy * Carpal tunnel syndrome * Felty's syndrome - RA, neutropaenia, splenomegaly

Answer 10

* Psoriatic arthritis - small joints of hand and feet but less symmetrical, DIP involved, skin/nail symptoms * Polyarticular gout - tophi, risk factors for gout * Osteoarthritis - worse with movement, better with rest, <1 hour early morning stiffness, less symmetrical, larger joints * SLE - polyarthritis in small joints of hands and feet but usually non-deforming, additional signs e.g. rash, mouth ulcers, alopecia, Raynaud's, Sicca syndrome * Polymyalgia rheumatica - shoulder pain and stiffness primarily, older woman * Reactive arthritis - recent infection, can cause symmetric hand and feet arthritis * Sarcoidosis - CXR * Septic arthritis - acutely painful, hot, swollen joint, signs of sepsis e.g. fever * Seronegative spondyloarthritis - history of psoriasis, back pain, bowel problems

Answer 11

Self-limiting short episodes of inflammatory arthritis with joint pain, stiffness, swelling typically affecting only a few joints. Last 1-2 days, then completely resolve. Positive antibodies (RF, anti-CCP) with palindromic rheumatism --> progression to full RA more likely

Answer 12

Atlantoaxial subluxation * C2 (axis) and odontoid peg shift within C1 (atlas) * Due to local synovitis and damage to ligaments and bursa around odontoid peg * Can cause spinal cord compression and is an emergency * Important if having GA requiring intubation - MRI pre-op to assess

Answer 13

* CRP and ESR - usually elevated in RA (40% normal) * Rheumatoid factor - present in 60-70% RA * Anti-CCP if negative for RF - present in 80% RA * Imaging - US (synovitis), X-ray (hands and feet), MRI

Answer 14

Early * Peri-articular osteopaenia * Soft tissue swelling * Loss of joint space Late * Peri-articular joint erosion * Joint destruction * Subluxation

Answer 15

* Rheumatoid factor vs anti-CCP * Similar sensitivity but anti-CCP higher specificity (90-95%) * Test for anti-CCP in patients with suspected RA who are RF negative

Answer 16

Circulating antibody (usually IgM) that reacts with the Fc portion of own IgG Detected by either: Rose-Waaler test - sheep red cell agglutination Latex agglutination test (less specific) Positive in 70-80% of RA, high titre associated with severe progressive disease (not a marker of disease activity)

Answer 17

* Rheumatoid arthritis * Felty's syndrome (RA, splenomegaly, neutropaenia) - 100% * Sjogren's syndrome - 50% * Infective endocarditis - 50% * SLE - 20-30% * Systemic sclerosis - 30% * General population - 5% * Rarely - TB, HBV, EBV, leprosy

Answer 18

* Refer for appointment within 3 weeks for persistent synovitis of unknown cause * Urgent referral (within 3 working days) if small joints of hand or feet affected, more than one joint affected, delay of 3 months or longer from onset of symptoms to presentation Even if CRP/ESR, negative anti-CCP or RF

Answer 19

American College of Rheumatology/European League Against Rheumatism (ELAR) Score based on * Joints involved - more and smaller joints score higher * Serology - rheumatoid factor and anti-CCP * Inflammatory markers - ESR, CRP * Duration of symptoms - more or less than 6 weeks (longer scores) Score of 6 or more - diagnostic for RA

Answer 20

DAS28 - disease activity score * Assessment of 28 joints * Points given for swollen joints, tender joints, ESR/CRP result * Used to monitor disease activity and response to treatment HAQ-II - health assessment questionnaire disability index * Patient reported - difficulty with ADLs SF-36 - short form 36 * Patient reported * Health-related quality of life

Answer 21

* Younger onset * Male * More joints and organs affected * Presence of RF and anti-CCP * Erosions seen on X-ray

Answer 22

Induction/initiation therapy * Step-up approach - introduce and escalate single drug to maximum tolerated dose, if ongoing disease activity add a further drug * Step-down approach - several drugs started at once then gradually withdrawn * Parallel - combination introduced at same time and maintained Monitor response to treatment with CRP and disease activity score (e.g. DAS28) Treat acute flare-ups

Answer 23

Oral NSAIDs for pain/stiffness - ibuprofen, naproxen, diclofenac (+ PPI) COX-2 inhibitors e.g. etoricoxib Glucocorticoids - oral prednisolone, IM/intra-articular methylprednisolone or triamcinolone acetonide

Answer 24

CsDMARDs - offer first line and within 3 months of symptom onset * Methotrexate * Leflunomide * Sulfalazine * Hydroxychloroquine if mild or palindromic disease

Answer 25

* Folate metabolism antagonist - inhibits dihydrofolate reductase * Injection or tablet once a week, also folic acid 5mg once a week on a different day * Side effects - mouth ulcers, mucositis, liver toxicity, bone marrow suppression and leukopaenia, ?pulmonary fibrosis * Monitoring - FBC, LFTs * Contraindicated in pregnancy - teratogenic * Interactions - trimethoprim/co-trimoxazole increases risk of marrow aplasa, high dose aspirin increased risk of methotrexate toxicity as reduced excretion

Answer 26

Avoid pregnancy for at least 6 months after treatment stopped Men using methotrexate need to use effective contraception for 6 months after treatment

Answer 27

* Interferes with pyrimidine production - component of RNA and DNA * Side effects - mouth ulcers, mucositis, hypertension, rashes, peripheral neuropathy, liver toxicity, bone marrow suppression and leukopaenia * Contraindicated - pregnancy (teratogenic), women and men

Answer 28

* Immunomodulatory - immunosuppressive and anti-inflammatory, against folate, T and B cells * Daily dosing * Side effects - GI, headache, rash, temporary male infertility (reduced sperm count), bone marrow suppression * Monitoring requirements - FBC, U+Es, LFTs * Safe in pregnancy - folic acid 10mg daily, started 3 months pre-conception

Answer 29

* Immunosuppression via interaction with toll-like receptors, disrupting antigen presentation and increasing pH in lysosomes of immune cells * Daily dose * Side effects - nightmares, reduced visual acuity (macular toxicity), liver toxicity, skin pigmentation, headache, nausea, muscle pain, rash * Monitoring requirements - ocular after 5 years * Safe in pregnancy

Answer 30

* Second line - combination of two conventional DMARDs * Third - methotrexate plus biological therapy, usually TNF inhibitor * Fourth - methotrexate plus rituximab

Answer 31

* Anti-TNF - adalimumab, inflixumab, etanercept, golimumab, certolizumab pegol * Anti-CD20 - rituximab * Anti-IL6 - sarilumab * Anti-IL6 receptor - tocilizumab * JAK inhibitors - tofacitinib, baricitinib

Answer 32

British society rheumatology/NICE guidelines * Failed on at least two conventional DMARDs, one of which must be methotrexate unless contraindicated * Severe disease - DAS28 >5.1 on at least two occasions one months apart * Continue only if adequate response within first six months, defined as reducting in DAS-28 of >1.2

Answer 33

* Viral hepatitis and HIV (including anti-core Ab) * Varicella * CXR and IGRA (TB) * Vaccination - influenza, pneumococcal

Answer 34

* Active infection * Active or latent TB * Pregnancy * Malignancy * Diverticular disease (IL-6)

Answer 35

* Infections * Malignancy * Bloods (FBC, LFTs) * Awareness with vaccination

Answer 36

* Vulnerability to severe infections and sepsis * Reactivation of TB and hepatitis B

Answer 37

* Vulnerability to severe infections and sepsis * Night sweats * Thrombocytopaenia (low platelets) * Peripheral neuropathy * Live and lung toxicity

Answer 38

Cortical (compact/tubular) bone * Shafts of long bones * Slow turnover rate * Stiffer, more resistant to torsion and bending Cancellous (spongey/trabecular) bone * Ends of long bones, cuboidal/flat bones * Higher turnover rate, more remodelling * More elastic Matrix - organic (collagen, proteins) and inorganic (calcium, phosphorus) Cells - osteoprogenitor, osteocytes, osteoblasts, osteoclasts

Answer 39

* Epiphysis - end of bone * Diaphysis - shaft, where nutrient artery enters bone * Metaphysis - transitional flared area between diaphysis and epiphysis * Physis (growth plate) - in children only, between metaphysis and epiphysis

Answer 40

* Indirect healing (secondary) - more common, no anatomical reduction or rigid stabilisation, more similar to endochondral bone formation with fibrocartilaginous soft callus --> bony hard callus then osteoclastic remodelling * Direct healing (primary)- when bone fragments are 'artificially' fixed together (surgically) with compression, no callus formation just new bone formation through osteoblastic formation and osteoclastic resorption

Answer 41

Inflammation --> repair --> remodelling 1. Fracture haematoma and inflammation (6-8 hours post-injury) - blood from broken vessels form clot, swelling and inflammation at fracture site 2. Fibrocartilage (SOFT) callus (3 weeks post-injury) - granulation tissue formed, fibroblasts and osteogenic cells produce collagen, chondrocytes begin to produce fibrocartilage which gives stability 3. Bony (HARD) callus (3-4 months post-injury) - osteoblasts make woven bone 4. Bone remodelling - osteoclasts remodel woven bone --> compact and trabecular bone

Answer 42

* Movement and weight bearing are important in healing - bone laid down in relation to stress put across it * A degree of movement desirable but excessive movement disrupts healing tissue and affects cellular differentiation (stabilisation useful)

Answer 43

* Direct formation of bone without callus formation * Inflammation --> formation of bone via osteoclastic absorption and obsteoblastic formation via cutting cones at fracture site * Initially randomly laid down then remodelled

Answer 44

1. Widened fracture line (10-14 days) - blurring of fracture ends, finding in both normal and abnormal healing (should narrow in normal healing) 2. Callus formation (2 weeks) - initially immature, fluffy, indistinct --> dense, organised, bridges, ossified, endosteal callus obliterates the fracture line 3. Radiologic union - mature external bridge callus across fracture, very variable time depending on fracture site

Answer 45

Increased * Larger bones * Diaphyseal fracture * More motion - cast vs surgical fixation * Comminution * Infection * Steroids Decreased * Smaller bones * Metaphyseal fracture * Impaction * Rigid fixation

Answer 46

Fracture union - clinical diagnosis * No tenderness at fracture site * No motion at fracture site * Stable - weightbearing without support (Identifiable before radiologic union - too little bridging bone to see on X-ray) Radiologic union - much later * Continuous external bridge mature callus * Re-established medullary space

Answer 47

* Local soft tissue trauma * Fragment vascularity * Patient age * Method of treatment - rigid fixation heal faster * Fracture gap * Motion - longer if moving * Infection * Underlying bone disease * Intra-articular fracture slower (synovial fluid slows new bone formation) * Steroids

Answer 48

* Acute osteoporosis which occurs as a result of normal fracture healing * At and distal to fracture site * Occurs 5-7 weeks after immobilisation * Reversal takes 4+ weeks * Risk of fragility fractures esp. in elderly

Answer 49

Open fracture - skin overlying fracture is broken, allowing communication between the fracture and external environment Compound from within (inside-out) * Broken end of bone breaks through or pierces the skin Compound from without (outside-in) * External violence causes laceration or tissue trauma * Higher likelihood of contamination

Answer 50

Gustillo-Anderson classification * Type 1 - <1cm * Type 2 - 1-10cm, >1cm wound with moderate soft tissue damage * Type 3 - >10cm or high energy, extensive soft tissue damage (or segmental fractures, extensive contamination, high velocity injuries) * 3A - adequate tissue for coverage * 3B - extensive periosteal stripping, requires flap (inadequate soft tissue coverage) * 3C - vascular injury requiring vascular repair

Answer 51

Mangled extremity severity system (MESS) * Limb ischaemia - time (>6 hours) and clinical signs (pulse, temperature, sensation) * Patient age (<30, 30-50, >50) * Shock - hypotension * Injury mechanism - low - very high energy

Answer 52

* Soft tissue infection * Osteomyelitis * Tetanus * Crush syndrome - traumatic rhabdomyolysis (shock and kidney failure after crushing of skeletal muscle) * Skin loss * Non-union * Amputation

Answer 53

BOAST guideline * Control bleeding * Remove gross debris * Cover with sterile dressing - photograph before so dressing can stay on until definitive management in theatre * Realignment and splinting * IV antibiotics * Tetanus prophylaxis * Assessment of vascular and neurological status - repeat systematically, especially after reduction/splinting * Imaging - may require trauma CT, angiography

Answer 54

* Debridement using fasciotomy lines for wound extension - timing dependant on level of contamination of wound (e.g. immediately if agricultural, sewage) * Irrigation - 6L saline * ?Delayed primary amputation * Stabilisation - often requires external fixator * Multidisciplinary approach - orthropaedic, plastics, rehabilitation

Answer 55

* Fall onto outstretched hand * Direct blow to shoulder * Middle third/midshaft is most easily fractured - thinnest with no ligamentous/muscle attachments * Middle 1/3 - 80% * Lateral 1/3 - 15% * Medial 1/3 - 5%

Answer 56

* Usually conservative - depends on location, shortening, displacement, patient fractures * Conservative management - immobilisation with simple triangular sling, analgesia * If more than 2cm of shortening, lateral, comminuted/Z pattern - may need open reduction with internal fixation (ORIF)

Answer 57

* Delayed union * Malunion * Non-union * Palpable bump * Stiffness * Infection * Palpable metalwork

Answer 58

* Frontal (AP) * Cephalic tilt (15-45 degree)

Answer 59

Fracture * Location of fracture along shaft * Angulation and fracture end displacement (including direction) * Comminution * Degree of overlap - measure Associated findings and relevant negatives * Acromioclavicular joint and sternoclavicular joint alignment * Coracoclavicular distance * Glenohumeral joint Associated traumatic injuries * Rib fractures * Vertebral fractures * Scapular fractures - floating shoulder * Pneumothorax

Answer 60

* Anterior (>90%) - head of humerus moves anteriorly in relation to glenoid cavity * Occurs when arm if forced posteriorly while abducted and extended at the shoulder, trauma e.g. fall on an outstretched arm, sports injuries * Posterior (2-4%) - associated with uncoordinated muscle contraction e.g. seizure or electric shock * Inferior (luxatio erecta, <1%) - high-energy, hyperabduction force to arm

Answer 61

* Present acutely after injury - usually aware of dislocation * Severe pain and restriction of movement of shoulder * Prominent acromion, shoulder flattened (loss of symmetrical roundness), prominent humeral head, arm slighly abducted, elbow flexed, forearm internally rotated and supported by other hand * Empty glenoid fossa - palpable dent where head of humerus should be * Inferior dislocation - arm fixed, abducted, overhead position

Answer 62

Shoulder - approximately 50%

Answer 63

Damage to the glenoid labrum - rim of cartilage around glenoid cavity which creates deeper socket for head of humerus * Bankart lesions - tears to anterior labrum, occurs with repeated anterior subluxations or dislocations * Hill-Sachs lesions - compression fractures of posterolateral part of head of humerus when shoulder dislocates anteriorly, makes shoulder less stable and at risk of further dislocations * Axillary nerve damage - loss of sensation in 'regimental badge' area over lateral deltoid, motor weakness in deltoid and teres minor muscles Fractures * Humeral head * Greater tuberosity of humerus * Acromion of scapula * Clavicle * Rotator cuff tears - especially in older patients * Brachial plexus injuries

Answer 64

Xray - may not be required before reduction * Frontal (AP) * Y-view (lateral) * Axillary film, arm abducted at 70-90 degrees, taken from angle of 45 degrees through axilla - for posterior dislocation MRI arthrogram * MRI with contrast injected into shoulder joint * To assess soft tissue damage e.g. Bankart and Hill-Sachs lesions Arthroscopy - camera into joint to visualise structures

Answer 65

Apprehension test - shoulder instability, often positive after previous anterior dislocation or subluxation Shoulder abducted to 90 degress, elbow flexed to 90 degrees, shoulder externally rotated while watching patient Patient will be anxious/apprehensive if unstable shoulder

Answer 66

Partial dislocation of joint

Answer 67

Anterior * AP view - humeral head lies medial and inferior to glenoid fossa * Lateral view - humeral head anterior and inferior to glenoid fossa * Humeral head also inferior to coracoid process Posterior * AP view - glenohumeral joint widened and humeral head has 'light bulb' appearance due to forced internal rotation of humerus * Lateral view - humeral head posterior to glenoid fossa

Answer 68

Anterior rami of spinal nerves C5, 6, 7, 8 and T1

Answer 69

* Roots leave spinal cord via intervertebral foramina of vertebral column * Pass between anterior and medial scalene muscles to enter the base of the neck * Roots converge at base of neck to form trunks - superior (C5 + 6), middle (C7), inferior (C8 + T1) * Trunks cross posterior triangle of neck * Trunks divide into anterior and posterior divisions, leave the posterior triangle and pass into axilla * Anterior and posterior divisions combine to form three cords named by position relative to axillary artery * Lateral cord - anterior division of superior trunk, anterior division of middle trunk * Posterior cord - posterior divisions of superior, middle and inferior trunk * Medial cord - anterior division of inferior trunk * Major branches - musculocutaneous nerve, axillary nerve, median nerve, radial nerve, ulnar nerve

Answer 70

* Roots - C5, 6, 7 --> superior + middle trunks --> lateral cord * Motor functions - brachialis, biceps brachii, coracobracialis (elbow/shoulder flexion) * Sensory functions - gives off lateral cutaneous branch of forearm, innervates lateral half of anterior forearm and small lateral portion of posterior forearm

Answer 71

* Roots - C5 + 6 --> superior trunk --> posterior cord * Motor function - teres minor and deltoid muscles, abduction (15-90 degrees), flexion, extension and rotation of shoulder * Sensory function - gives off superior lateral cutaneous nerve, innervates inferior deltoid region (regimental badge area)

Answer 72

* Roots - C6, 7, 8 and T1 --> superior, middle and inferior trunks, lateral and medial cords * Motor functions - most flexor muscles of forearm, thenar muscles, lateral lumbricals associated with index and middle fingers (wrist and 2rd and 3rd digit flexion, thumb opposition and flexion, pronation) * Sensory functions - gives off palmar cutaneous branch which innervates lateral palm and digital cutaneous branch which innervates the lateral three and a half fingers on the palmar surface of the hand

Answer 73

* Roots - C5, 6, 7, 8, T1 --> superior, middle and inferior trunks --> posterior cord * Motor functions - triceps brachii, muscles in posterior compartment of forearm (extension of elbow and wrist) * Sensory functions - posterior of arm and forearm, posterolateral aspect of hand, proximal half of posterior thumb, index finger and lateral half of middle finger

Answer 74

* Roots - C8 + T1 --> inferior trunk --> medial cord * Motor function - muscles of hand (except thenar muscles and two lateral lumbricals), flexor carpi ulnaris and medial half of flexor digitorum profundus (abduction of fingers, flexion of medial digits, adduction of thumb) * Sensory function - anterior and posterior surfaces of medial one and a half fingers and associated palm area

Answer 75

Assess for * Fractures * Vascular damage - pulses, CRT, pallor * Nerve damage - loss of sensation in regimental patch area (axillary nerve damage)

Answer 76

* Relocate/reduce shoulder as soon as safely possible - muscle spasm which occurs over time makes it harder to relocate and increases risk of neurovascular injury during relocation * Various methods of closed reduction * Relocation usually done in ED * Exclude fractures before reduction * Analgesia, muscle relaxants and sedation used during relocation as appropriate, gas and air may be used * Broad arm sling used to support arm after relocation * X-ray performed post-reduction to ensure success * Immobilisation after reduction * May require surgical management

Answer 77

* Unsuccessful closed reduction * Displaced Bankart lesion * Recurrent shoulder dislocations * If young and active early surgery may be required to prevent recurrent dislocations in the future

Answer 78

* High risk of recurrent dislocations, especially in young patients * Physiotherapy to reduce risk of further dislocations * May require shoulder stabilisation surgery - prolonged recovery peroid (3+ months)

Answer 79

* Elderly - >65 * F>M * Osteoporosis * High energy trauma

Answer 80

Neer classification - describes the number of fracture parts and their displacement Parts: * Articular surface (humeral head) * Greater tuberosity * Lesser tuberosity * Humeral shaft Displacement for each part if * >1cm * 45 degree angulation

Answer 81

* Anatomical - residual epiphyseal plate, oblique angle, divides the head of the humerus from the greater and lesser tubercles * Rare to have fractures through anatomical neck, if displaced by >1cm risk of avascular necrosis to the humeral head * Surgical - distal to greater tubercle and lesser tubercle, proximal to deltoid tuberosity * Most proximal humerus fractures through surgical neck (in children most common is greensick fracture through surgical neck)

Answer 82

* Older patients - fall on an outstretched hand * Younger patients - high-energy trauma

Answer 83

* Pain and swelling * Decreased motion * Ecchymosis of chest, arm and forearm

Answer 84

Neurovascular examination * Axillary nerve injury most common - determine deltoid muscle function and lateral shoulder sensation * Arterial injury may be masked by extensive collateral circulation preserving distal pulses Examine for concomitant chest wall injuries X-rays - AP of scapula and glenohumeral joint (Grashey), axillary view, lateral Y view of scapula Sometimes requires CT, rarely MRI for soft tissue injury

Answer 85

Conservative - sling immobilisation followed by progressive rehabilitation: * Minimally displaced * <2 parts * Not a surgical candidate * Severely comminuted, 4 parts Open reduction, internal fixation * 2 parts, displaced * Greater tuberosity displaced >5mm * 3/4 parts in young patient Arthroplasty * Hemiarthroplasty - young patient with fracture not suitable for fixation (poor outcomes) * Reverse shoulder replacement - unable to fix and rotator cuff defunctioned due to tuberosity involvement

Answer 86

* Decreased ROM * Pain * Non-union * Axillary nerve palsy

Answer 87

Bimodal distribution * Young - high energy trauma * Elderly - osteopaenic, low energy

Answer 88

Location * Proximal * Middle * Distal 1/3 Pattern * Spiral * Transverse * Comminuted Holstein-Lewis * Spiral fracture of the distal 1/3 of shaft associated with radial nerve palsy

Answer 89

* Examine limb alignment - shortening and varus deformity * Pre-operative/reduction neurovascular exam is critical - examine and document status of radial nerve pre- and post-reduction * X-ray - AP and lateral

Answer 90

* Usually conservative with humeral brace * Open reduction, internal fixation - open, vascular injury, plexus injury, forearm fracture (floating elbow), polytrauma * Radial nerve palsy - only an indication for surgery if palsy occurs after an intervention or manipulation of the fracture

Answer 91

Humeral shaft - especially middle and middle-distal parts Transverse and spiral fractures more likely to be associated with radial nerve palsy than oblique and comminuted patterns of fracture

Answer 92

Fall onto outstretched hand with pronated forearm

Answer 93

* Lateral collateral ligament injury (up to 80%) * Medial collateral ligament injury * Essex-Lopresti injury - radial head fracture, distal radioulnar joint injury, interosseus membrane injury * Coronoid fracture * Olecranon fracture * Monteggia fracture/dislocation * Scaphoid fracture

Answer 94

Mason types 1-4 * Type 1 - non-displaced or minimally displaced (<2mm), no mechanical block to rotation * Type II - displaced >2mm or angulated, possible mechanical block to forearm rotation * Type III - comminuted and displaced, mechanical block to motion * Type IV - radial head fracture with associated elbow dislocation

Answer 95

* Scars - traumatic, carpal tunnel * Swelling e.g. ganglions * Skin colour - erythema, rashes * Nails - pitting, onycholysis, nail fold infarction * Muscle wasting - thenar, hypothenar and interosseous * Skin thinning or bruising - steroids * Psoriatic plaques * Deformity - Z-thumb, swan neck, Boutonnieres, mallet finger, ulnar drift, clawed hand * Elbows - psoriatic plaques, rheumatoid nodules

Answer 96

* Temperature * Radial and ulnar pulses * Capillary refill time * Thenar and hypothenar eminence muscle bulk * Palmar thickening - Dupuytren's * Joint palpation - distal radio-ulnar joint, radio-carpal joint, thumb CMC, MCP, IPJ * MCP joint squeeze * Anatomical snuffbox - scaphoid fracture * Radial nerve sensation - first dorsal webspace * Median nerve sensation - thenar eminence * Ulnar nerve sensation - hypothenar eminence

Answer 97

Active * Finger extension and flexion * Finger abduction and adduction * Wrist extension and flexion * Pronation and supination * Thumb flexion and extension * Thumb abduction and adduction * Pronation and supination Passive if active reduced Screening test for radial, ulnar and median nerve * Wrist and finger extension against resistance - radial * Index finger abduction against resistance - ulnar * Thumb abduction against resistance - median

Answer 98

* Power grip * Pincer grip * Pick up a small object * Tinel's test - tap over carpal tunnel, tingling/pain in distributation of median nerve = carpal tunnel syndrome * Phalen's test - wrist in forced flexion, tingling or pain in median nerve distribution = carpal tunnel syndrome * Tinel's test at elbow - tap over ulnar nerve behind medial epicondyle, tingling and pain over ulnar distribution = ulnar compression

Answer 99

* Cubitus valgus/varus * Scars - operative or traumatic * Bruising * Swelling - effusion, inflammatory arthropathy, dislocation * Muscle wasting * Rheumatoid nodules * Psoriatic plaques * Popeye sign - ruptured biceps tendon

Answer 100

* Temperature * Palpate joints - proximal radio-ulnar joint, ulno-trochlear joint, radial head, radiocapitellar joint, lateral (Tennis) and medial (Golfer) epicondyle of humerus, olcecranon * Biceps tendon * Bend to 90 degrees to look for effusion

Answer 101

Active and passive * Elbow flexion/extension * Pronation/supination * Feel for crepitus

Answer 102

* Medial epicondylitis (Golfer's elbow) - active wrist flexion against resistance, palpate medial epicondyle * Lateral epicondylitis (Tennis elbow) - active wrist extension against resistance, palpate lateral epicondyle * Can hand reach mouth

Answer 103

* Glenohumeral joint - glenoid fossa of scapula and head of humerus * Acromioclavicular joint - acromion of scapula and clavicle

Answer 104

* Glenohumeral joint - head of of the humerus with glenoid fossa of the scapula * Elbow joint - capitulum articulates with head of the radius and trochlea articulates with the trochlear notch of the ulna

Answer 105

* Trochlear notch of ulna articulates with trochlea of humerus * Proximal radio-ulnar joint - radial head and radial notch of ulna * Distal radio-ulnar joint - distally the ulnar head articulates with the ulnar notch of the radius

Answer 106

* Elbow joint - head of radius articulates with capitulum of the humerus * Proximal radioulnar joint - radial head and radial notch of ulna * Wrist joint - distal radius and carpal bones (scaphoid and lunate * Distal radioulnar joint - articulation between ulnar notch and head of the ulna

Answer 107

* Carpal bones (proximal) - 8 * Metacarpals - 5 (one per digit) * Phalanges (distal) - three per finger (proximal, middle, distal), two per thumb (proximal and distal)

Answer 108

Proximal bones (lateral to medial) * Scaphoid * Lunate * Triquetrum * Pisiform Distal bones (lateral to medial) * Trapezium * Trapezioid * Capitate * Hamate

Answer 109

* Supraspinatus * Infraspinatus * Teres minor * Subscapularis

Answer 110

* Supraspinatus - supraspinous fossa of the scapula to greater tubercle of the humerus * Infraspinatus - infraspinous fossa of scapula to greater tubercle of humerus * Subscapularis - subscapular fossa of scapula to lesser tubercle of humerus * Teres minor - posterior surface of scapula to greater tubercle of humerus

Answer 111

Lateral third of the clavicle, acromion and spine of the scapula --> deltoid tuberosity on the lateral aspect of the humerus

Answer 112

Axillary nerve

Answer 113

Shoulder abduction - >15 degres Shoulder flexion and extension Shoulder medial and lateral rotation

Answer 114

Posterior surface of the inferior angle of the scapula --> medial lip of the intertubercular groove of the humerus

Answer 115

* Medial rotation * Adduction * Extension of flexed arm

Answer 116

Lower subscapular nerve

Answer 117

Abducts arm 0-15 degrees, assists deltoid beyond 15 to 90

Answer 118

Subprascapular nerve

Answer 119

Lateral rotation

Answer 120

Suprascapular nerve

Answer 121

Medial rotation

Answer 122

Upper and lower subscapular nerves

Answer 123

Laterally rotates arm

Answer 124

Axillary nerve

Answer 125

* Clavicular head - anterior medial clavicle * Sternocostal head - anterior surface of the sternum, superior six costal cartilages, aponeurosis of the external oblique muscle * Distally - intertubercular sulcus of the humerus

Answer 126

Adducts and medially rotates arm Draws scapula anteroinferiorly Clavicular head - arm flexion

Answer 127

Lateral and medial pectoral nerves

Answer 128

3rd-5th ribs, inserts into coracoid process of scapula

Answer 129

Stabilises scapula, draws it anteroinferiorly against thoracic wall

Answer 130

Medial pectoral nerve

Answer 131

* Lateral aspects of ribs 1-8 * Attach to costal surface of the medial border of the scapula

Answer 132

Rotates scapula to allow arm to be raised above 90 degrees Holds scapula against ribcage

Answer 133

Long thoracic nerve

Answer 134

* Junction of 1st rib and its costal cartilage, inserts onto inferior surface and middle third of clavicle

Answer 135

Anchors and depresses the clavicle

Answer 136

Nerve to subclavius

Answer 137

Winged scapula - loss of serratus anterior muscle anchoring Usually from traction injuries - upper limb stretched violently Axillary lymph node clearance (e.g. breast cancer) can also cause

Answer 138

* Apex - lateral border of 1st rib, superior border of scapula, posterior border of clavicle * Lateral - intertubercular groove of the humerus * Medial - serratus anterior and thoracic wall (ribs and intercostals) * Anterior - pectoralis major, underlying pectoralis minor and subclavius muscles * Posterior - subscapularis, teres major, latissimus dorsi

Answer 139

* Axillary artery * Axillary vein - cephalic and basilic veins drain into * Brachial plexus * Axillary lymph nodes * Biceps brachii (short head) and coracobrachialis

Answer 140

Superficial * Trapezius * Latissimus dorsi Deep * Levator scapulae * Rhomboid major * Rhomboid minor

Answer 141

* Attachments - skull, nuchal ligament, spinous processes of C7-T12 --> clavicle, acromion, scapula spine * Actions - upper fibres elevate and rotate scapula during abduction of arm, middle fibres retract scapula, lower fibres pull scapula inferiorly * Innervation - accesory nerve, proprioception from C3/4

Answer 142

* Atachments - spinous processes of T7-T12, iliac crest, thoracolumbar fasci and inferior three ribs --> intertubercular sulcas of humerus * Actions - extends, adducts and medially rotates arms * Innervation - thoracodorsal nerve

Answer 143

* Attachments - transverse processes of C1-4 --> medial border of scapula * Actions - elevates scapula * Innervation - dorsal scapular nerve

Answer 144

* Attachments - spinous processes T2-5 --> medial border of scapula * Actions - retracts and rotates scapula * Innervation - dorsal scapular nerve

Answer 145

* Attachments - spinous processes C7-T1, attaches to medial border of scapula at level of spine of scapula * Actions - retracts and rotates the scapula * Innervation - dorsal scapular nerve

Answer 146

Anterior compartment * Muscles - biceps brachii, brachialis, coracobrachialis * Innervation - musculocutaneous nerve * Blood supply - brachial artery Posterior compartment - triceps brachii * Innervation - radial nerve * Blood supply - profunda brachii artery

Answer 147

* Attachments - long head from supraglenoid tubercule of scapula, short head from coracoid process of the scapula --> radial tuberosity and fascia of forearm via bicipital aponeurosis * Function - supination, flexion at elbow and shoulder

Answer 148

* Coracoid process of scapula --> medial humerus shaft * Function - flexion of arm at shoulder, weak adduction

Answer 149

* Medial/lateral humeral shaft --> ulnar tuberosity * Function - flexion at elbow

Answer 150

* Long head from infraglenoid tubercle * Lateral head from humerus, superior to radial groove * Medial head from humerus, inferior to radial groove * Converge and insert into olecranon of ulna

Answer 151

* Superficial - flexor carpi ulnaris, palmaris longus, flexor carpi radialis, pronator teres * Intermediate - flexor digitorum superficialis * Deep - flexor pollicis longus, flexor digitorum profundus, pronator quadratus Pronation, flexion of wrist and fingers Innervated by median nerve except flexor carpi ulnaris, medial half of flexor digitorum profundus (ulnar nerve)

Answer 152

* Superficial - brachioradialis, extensor carpi radialis longus and brevis, extensor digitorum communis, extensor digiti minimi, extensor carpi ulnaris, anconeus * Deep - supinator, abductor pollicis longus, extensor pollicis brevis, extenor pollicis longus, extensor indicis Generally - extension of wist and fingers * Brachioradialis - flexion at elbow * Abduction/adduction of wrist/thumb * Supination All innervated by the radial nerve

Answer 153

Damage to the radial nerve proximal to the elbow - loss of extensor muscle innervation * Axilla - humeral dislocations or fractures of the proximal humeus * Radial groove of humerus - humeral shaft fracture

Answer 154

Posterior compartment - lateral epicondyle of the humerus Anterior compartment - medial epicondyle of the humerus

Answer 155

* Thenar muscles - opponens pollicis, abductor pollicis brevis, flexor pollicis brevis (median nerve) * Hypothenar muscles - opponens digiti minimi, abductor digiti minimi, flexor digiti minimi brevis (ulnar nerve) * Lumbricals - flexion at MCP, extension at IP joints, lateral two lumricals innervated by median nerve, medial two lumbricals innervated by ulnar nerve * Interossei - dosal and palmar (dorsal do abduction, palmar do adduction), both innervated by ulnar nerve * Palmaris brevis - grip (ulnar nerve) * Adductor pollicis - adducts thumb (ulnar nerve)

Answer 156

* Subclavian artery --> axillary artery --> brachial artery --> radial and ulnar arteries --> superficial and deep palmar arches * Superficial veins - cephalic vein + basilic vein (connected by median cubital vein) --> axillary vein --> subclavian vein * Deep veins - ulnar veins + radial veins --> brachial vein --> axillary vein --> subclavian vein

Answer 157

* Scars - operative / traumatic * Asymmetry * Swelling * Muscle wasting - deltoid, trapezius, supraspinatus, infraspinatus * Winged scapula - push hands against wall

Answer 158

* Temperature * Palpate joints - sternoclavicular joint, clavicle, acromioclavicular joint, acromion, coracoid process, head of humerus, greater and lesser tubercle of humerus, spine of scapula

Answer 159

Compound movements (screening) * Arms behind head - external rotation and abduction * Arms behind back, reach up - internal rotation an adduction Active movement * Shoulder flexion/extension * Shoulder abduction/adduction * Internal rotation * External rotation * Abduct and palpate scapula for smoothness of scapular movement Passive movement - feel for crepitus

Answer 160

Supraspinatus * Supraspinatus assessment (empty can test/Jobe's test) - abduct to 90 degrees, angle forwards at 30 degrees, point thumb to floor, push down on arm (abduction against resistance) * Impingement - painful arc, pasively move to maximum abduction, pain from 60-120 degrees Infraspinatus/teres minor * External rotation against resistance * External rotation in abduction - 90 degree abduction, bend elbow to 90 degress, passively externally rotate shoulder (inability to maintain = Hornblower's sign) Subscapularis * Internal rotation against resistance - hand behind back, press against hand while lifting off back Acromioclavicular joint * Scarf test - flex shoulder to 90, place hand on contralateral shoulder, apply resistance to elbow in contralateral direction

Answer 161

* Scars * Swelling * Asymmetry * Quadriceps, gluteal wasting * Leg length discrepancy * Pelvic tilt * Flexion abnormalities * Gait - ROM, limping, leg length, turning, waddling, Trendelenburg's gait

Answer 162

* Temperature * Palpate joint - greater trochanter * Leg length assessment - apparent (umbilicus to medial malleolus), true (ASIS to medial malleolus)

Answer 163

Active * Flexion * Extension Passive * Flexion * Internal rotation * External rotation * Abduction * Adduction * Extension

Answer 164

* Thomas's test - for fixed flexion deformity, lie flat with hand under lumbar spine, passively flex other hip and observe contralateral hip *DON'T DO IF HAVE HIP REPLACEMENT - DISLOCATION RISK)* * Trendelenburg's test - for hip abductor weakness, stand with hands on shoulders, fingers on iliac crests, stand on one leg and observe for lateral pelvic tilt

Answer 165

* Scars * Swelling * Psoriasis plaques * Valgus (apex medial) or varus (apex lateral) * Quadriceps wasting * Hyperextension or fixed flexion deformity * Popliteal swellings * Patellar position * Gait - ROM, limping, leg length, turning, high stepping

Answer 166

* Temperature * Measure quadriceps bulk * Palpation of extended knee - patella, patellar ligament, medial and lateral joint lines * Assess for effusion - patellar tap, sweep test * Palpation of flexed knee - patella, patellar ligament, medial and lateral joint lines, tibial tuberosity, popliteal fossa

Answer 167

Active * Flexion * Extension Passive * Flexion * Extension

Answer 168

Cruciate ligament assessment * Posterior sag sign - PCL * Anterior drawer test - ACL * Posterior drawer test - PCL * Lachman's test - ACL Collateral ligament assessment * Varus stress test - LCL * Valgus stress test - MCL * Can repeat if stable with knee flexed to 30 degrees Mensci assessment * McMurray's test - medial meniscus, lateral meniscus

Answer 169

* Gait - ROM, limping, leg length, turning, height of steps * Scars * Swelling * Psoriasis plaques * Fixed flexion deformity of toes * Big toe misalignment * Calluses * Foot arch * Heel - valgus or varus * Muscle wasting * Achilles tendon

Answer 170

* Temperature * Pulses - posterior tibial, dorsalis pedis * MCP joint squeeze * Ankle and foot palpation - metatarsal and tarsal bones, tasral joint, ankle joint, subtalar joint, calcaneum, medial/lateral malleoli, distal fibula * Achilles tendon and gastrocnemius

Answer 171

Active + passive * Plantarflexion * Dorsiflexion * Toe flexion * Toe extension * Ankle/foot inversion * Ankle/foot eversion Passive only * Subtalar joint * Midtarsal joint

Answer 172

* Simmonds' test - achilles tendon rupture

Answer 173

* Scars * Muscle wasting * Scoliosis * Asymmetry * Pelvic tilt * Gait - ROM, limping, leg length, turning, Trendeleburg's gait, waddling gait

Answer 174

* Spinal processes and sacroiliac joints * Paraspinal muscles

Answer 175

* Cervical spine - flexion, extension, lateral flexion, rotation * Lumbar spine - flexion, extension, lateral flexion * Thoracic spine - rotation

Answer 176

* Schober's test - 5cm below PSIS, 10cm above, should increase to >20cm * Sciatic stretch test - straight leg raise * Femoral nerve stretch test

Answer 177

* Osteoarthritis * Osteomyelitis * Osteonecrosis * Sepsis

Answer 178

* Mildest form of traumatic peripheral nerve injury * Focal segmental demyelination at site of injury without disruption of axon continuity

Answer 179

Usually due to blunt injury - external blow, causes: * Compression * Ischaemia * Inflammation

Answer 180

* Motor/sensation deficit * Numbness/tingling/burning * Flaccid paralysis of muscles innervated by injured nerves/nerve * Transient symptoms - usualy resolve days-weeks after injury

Answer 181

* More severe than neuropraxia, less than neurotmesis * Damage to axons and myelin sheath, endoneurium, perineurium and epineurium intact

Answer 182

* More severe injury than neuropraxia - crush or sretch usually

Answer 183

Seddon's/Sunderland's classification First degree (class I) * Neurapraxia - temporary interruption of conduction without loss of axonal continuity * No Wallerian degeneration * Full recovery within days to weeks Second degree (class II) * Axonotmesis - loss of relative continuity of axon and myelin, preservation of connective tissue framework of nerve * Wallerian degeneration distal to site of injury * Recovery possible without surgical treatment, although sometimes required Third degree (class III) * Neurotmesis - endoneurium lesion, epineurium and perineurium intact * Wallerian degeneration distal to injury * Surgical intervention often necessary Fourth degree (class III) * Same as third degree but only epineurium remain intact * Surgical intervention necessary Fifth-degree (class III) * Same as third degree but complete transection of nerve * No recovery without surgical treatment

Answer 184

Degeneration of the axon distal to an injury when nerve fibre is cut or crushed

Answer 185

Nerve and nerve sheath severed

Answer 186

* Pain * Dysesthesias * Complete loss of sensory and motor function of the affected nerve

Answer 187

* Hemiplegia = spastic flexion of the upper limb and extension of the lower limb, extended leg is elongated so patients have to circumduct leg to prevent foot from dragging on ground * Caused by lesion in the CNS, resulting in unilateral weakness and spasticity Causes * Unilateral cerebral lesion - stroke, space-occupying lesion, trauma, multiple sclerosis * Hemisection of the spinal cord - trauma

Answer 188

* Increased tone ith clasp knife spasitcity * Hyperreflexia withor without clonus * Upgoing plantars i.e. positive Babinski * Reduced power * Sensory deficit - pattern of sensory loss depends on the site of the lesion in the nervous system

Answer 189

* Similar to hemiplegic gait but bilateral in nature * Spasticity worse in lower limbs compared with upper limb * Hips and knees flexed and abducted and ankles are extended and internally rotated * Knees forced together due to spasticity in adductor muscles resulting in leg overlap when walking (scissoring) * Circumduction of both legs during swing phase * Upper limb may have flexor posturing of the elbows and wrist with shoulders and fingers in adduction * Lack swinging movements present in normal gait

Answer 190

* Increased tone with clasp-knife spasticity * Hyperreflexia with or without clonus * Upgoing plantars (i.e. positive Babinski) * Reduced power * Sensory deficit – if a diplegic gait is caused by spinal cord pathology, the ‘sensory level’ (ie. the lowest dermatome level with normal sensation) correlates with the level of spinal cord pathology * Wasting and fasciculations (consider motor neuron disease)

Answer 191

Spinal cord lesion (sensation usually affected): * Prolapsed intervertebral disc * Spinal spondylosis * Spinal tumour * Transverse myelitis * Spinal infarct * Syringomyelia * Hereditary spastic paraparesis Bilateral brain lesion: * Cerebral palsy * Multiple sclerosis * Bilateral brain infarcts * Midline tumour (e.g. paraspinal meningioma) * Motor neuron disease: associated with lower motor neuron findings

Answer 192

* Initiation: typically slow to start walking due to failure of gait ignition and hesitancy. * Step length: reduced stride length with short steps is common (shuffling gait). Each step may get progressively smaller as the patient attempts to retain balance (known as festinant gait). * Arm swing: reduced arm swing on one or both sides (often an early feature of Parkinson’s disease). * Posture: flexed trunk and neck causing a stooped appearance. * Tremor: resting tremor can be observed when the patient is distracted by walking. * Turning: impaired balance on turning or hesitancy is common due to postural instability.Initiation: typically slow to start walking due to failure of gait ignition and hesitancy.

Answer 193

Tremor Rigidity Bradykinesia Hypomimia

Answer 194

* Idiopathic Parkinson's disease * Vascular Parkinson’s disease * Dementia with Lewy bodies * Parkinson’s plus syndromes (e.g. multisystem atrophy and progressive supranuclear palsy) * Drug-induced Parkinsonism (e.g. antipsychotics, antiemetics) * Dementia pugilistica

Answer 195

* Stance: a broad-based ataxic gait is typically associated with midline cerebellar pathology (e.g. a lesion in multiple sclerosis or degeneration of the cerebellar vermis secondary to chronic alcohol excess). * Stability: a staggering, slow and unsteady gait is typical of cerebellar pathology. In unilateral cerebellar disease, patients will veer towards the side of the lesion. * Turning: patients with cerebellar disease will find the turning manoeuvre particularly difficult.

Answer 196

Clinical features associated with cerebellar ataxia: * Nystagmus * Ataxic dysarthria * Dysmetria * Intention tremor * Dysdiadokokinesia Clinical features associated with sensory ataxia: * Positive Romberg’s sign * Impaired proprioception * Impaired vibration sensation * Absence of other cerebellar signs (e.g. dysmetria, nystagmus, dysarthria) Clinical features associated with vestibular ataxia: * Vertigo * Nausea * Vomiting

Answer 197

Cerebellar ataxia: * Cerebellar stroke (ischaemic or haemorrhagic) * Space-occupying lesion * Multiple sclerosis * Alcoholism * B12 deficiency * Drugs (e.g. phenytoin, carbamazepine, barbiturates, lithium) * Genetic disease (e.g. Frederich’s ataxia, spinocerebellar ataxia) * Paraneoplastic disease Sensory ataxia: * Peripheral neuropathy (e.g. diabetes mellitus) * Vestibular ataxia: * Labyrinthitis * Meniere’s disease * Acoustic neuroma

Answer 198

* Weakness of the dorsiflexors of the foot * Causes foot drop and dragging of the toes during the swing stage * To prevent toes dragging on the floor, knee and hip flex excessively, creating a 'high stepping' gait

Answer 199

Peripheral vascular disease Peripheral sensory impairment Distal muscle weakness Reduced or absent reflexes

Answer 200

* Isolated common peroneal nerve palsy (e.g. secondary to trauma or compression) * L5 radiculopathy (e.g. disc prolapse) * Generalized polyneuropathy involving multiple nerves (e.g. diabetic neuropathy, motor neurone disease, Charcot-Marie Tooth disease)

Answer 201

Hip abductor weakness results in an inability to stabilize the pelvis during the stance phase. As a result, the pelvis tilts downwards towards the unsupported side during the swing phase of the gait cycle. The body compensates to prevent the swinging foot from dragging by: * Laterally flexing the torso away from the leg in swing phase; this draws the pelvis and leg up off the floor (causing the characteristic ‘waddling’ appearance) * Circumducting the leg

Answer 202

* Difficulty standing from a seated position without the use of the arms * Difficulty standing from a squat or sitting up from a lying position * Positive Trendelenburg’s sign; when the patient stands on one leg, the pelvis drops towards the contralateral side

Answer 203

Systemic disease: * Hyperthyroidism * Hypothyroidism * Cushing’s syndrome * Acromegaly * Polymyalgia rheumatica * Polymyositis * Dermatomyositis Muscular dystrophies: * Duchenne’s muscular dystrophy * Becker’s muscular dystrophy * Myotonic dystrophy

Answer 204

Involuntary movements such as: * Oro-facial dyskinesia (grimacing or lip-smacking) * Choreic movements of the upper and lower limbs (writhing, dance like semi-purposeful movements) The involuntary movements are usually present at rest, however, walking can accentuate the movements.

Answer 205

Basal ganglia disease: * Huntington’s disease * Sydenham’s chorea * Cerebral palsy (choreiform type) * Wilson’s disease * Dopaminergic medications (e.g. Parkinson’s medications)

Answer 206

* Abnormal gait pattern which develops as a result of pain * Typically the stance phase is reduced on the affected leg resulting in a limping appearance

Answer 207

Any cause of lower limb pain such as: * Osteoarthritis * Inflammatory joint disease * Lower limb fracture * Nerve entrapment (e.g. sciatica)

Answer 208

* Lower limb pain - osteoarthrtitis, inflammatory joint disease etc. * Neurological disease - Parkinson's, peripheral neuropathy, stroke etc.

Answer 209

Critical pressure increase within a confined compartmental space, intra-compartmental pressure in a fascial compartment becomes elevated beyond the capillary perfusion pressure

Answer 210

Can be any but most commonly leg, thigh, forearm, foot, hand and buttock

Answer 211

* Typically occurs follwing high energy trauma, crush injuries or fractures that cause vascular injury * Other causes - iatrogenic vascular injury, tight casts//splints, DVT, post-reperfusion swelling * Fascial compartments are enclosed by a tough fascia which is resistant to expansion, any swelling or fluid accumulated will increase the intra-compartmental pressure * As pressure increases, veins are compressed, increasing hydrostatic pressure which pushes fluid out of veins and into the compartment, increasing the pressure further * Traversing nerves are compressed, causing a sensory +/- motor deficit in the distal distribution (paraesthesia) * As intra-compartmental pressure reaches the diastolic pressure, the arterial inflow will be compromised and the limb will become ischaemic

Answer 212

* Major surgical procedures (e.g. orthopaedic repair, post-embolectomy, post-laparotomy) * Blunt trauma * Burns * Reperfusion injury * Crush injury * Fractures: closed or open * Tight casts * Ongoing intra-abdominal bleeding * Penetrating trauma (e.g. vascular injury) * Malignancy

Answer 213

* Syptoms usually within hours but can present up to 48 hours post-insult * Most reliable symptom is severe pain, disproportionate to injury, not relieved by initial measures * Pain worse with passively stretching of muscle across fascial compartment * Compartment feels tense (but not generally swollen - not able to extend) * Paraesthesia - evolving neurology * Can progress to acute limb ischaemia - pain, pallor, perishingly cold, paralysis, pulselessness (pulse can be present even at late stages)

Answer 214

Analgesia e.g. IV morphine Elevation of limb to level of heart Removal of any tight bangaes/dressings/casts If pain persists after 30 minutes - highly suggestive of compartment syndrome

Answer 215

* Usually diagnosed clinically * Can use intra-compartmental pressure monitoring - especialluy useful in nconscious patients/those with nerve blocks * <30mmHg difference between diastolic BP and compartment pressure - increased risk of compartment syndrome * Intra-compartment pressure of >40mmHg with clinical signs is diagnostic of acute compartment syndrome * Creatinine kinase trending upwards may aid diagnosis

Answer 216

* Initial management - remove external dressings/bandages/casts, IV analgesia, maintain blood pressure (IV fluids) * Urgent fasciotomy is definitive management * Leave incisions open for 24-48 hours, then debride any dead tissue and close wounds (leave subtending fascia open) * Monitor renal function closely due to potential rhabdomyolysis or reperfusion injury - IV fluids

Answer 217

* Irreversible neuroascular damage to affected limb * Rhabdomyolysis, reperfusion injury - renal impairment * Muscle/joint contracture e.g. Volkmann's contracture * Infection * Amputation * Long term disability

Answer 218

* Associated with exertion, during which pressure in compartment rises, blood flow to compartment is restricted and symptoms start * Resolves during rest * Symptoms - pain, numbness, paraesthesia * Needle manometry can be used to measure pressure increase during exertion * May require faciotomy to treat

Answer 219

* Anterior * Lateral * Superficial posterior * Deep posterior

Answer 220

* Anterior * Medial * Posterior

Answer 221

Superficial volar compartment Deep volar compartment Dorsal compartment Mobile wad compartment

Answer 222

* Cervical - 7 * Thoracic - 12 * Lumbar - 5 * Sacrum 5 (fused) * Coccyx - 4 (fused)

Answer 223

* Terminates at level of L2, region called conus medillaris, continues as filum terminale which anchors the spinal cord to the coccyx * Cauda equina is a collection of nerves inferior to the conus medillaris that continue to travel through the vertebral collum to the coccyx

Answer 224

Occupies the lumbar cistern, a subarachnoid space inferior to the conus medullaris Surrounded by CSF Begins at vertebral level of L1

Answer 225

* L2-L5 * S1-S5 * Coccygeal nerve * Innervation of pelvic organs, motor innervation of hips, knees, ankles, feet, internal and externalanal sphincter, sensory innervation of the perineum, parasympatheitc innervation of the bladder

Answer 226

* Central disc prolapse/herniation - L5/S1 and L4/5 most common * Trauma - vertebral fractures or subluxation * Malignancy - primary or metastatic * Spinal infection - abscess, meningitis, tuberculosis/Pott's disease, discitis * Inflammation - ankylosing spondylitis * Iatrogenic - spinal anaesthesia, post-operative haematoma, manipulation

Answer 227

* Lower motor neurone signs and symptoms * Reduced lower limb sensation (often bilateral) - including saddle anaesthesia * Bladder/bowel dysfunction - retention, incontinence, reduced anal tone * Lower limb motor weakness * Lower limb hyporeflexia * Severe back pain * Impotence

Answer 228

Urgent lumbar-sacral MRI spine Pre- and post-voiding bladder scan looking for retention and incomplete bladder empyting

Answer 229

1. Cauda equina syndrome with retention - back pain with unilateral or bilateral sciatica, lower limb motor weakness, sensory disturbance in the saddle region, loss of anal tone and loss of urinary control 2. Incomplete cauda equina syndrome - as above, only altered urinary sensation (e.g. loss of desire to void, diminshed sensation, poor stream, need to strain), painful retention may precede painless retention in some cases 3. Suspected cauda equina syndrome - severe back and leg pains with neurological symptoms and signs and a suggestion of sphincter disturbance Most will progress to complete compression if untreated

Answer 230

Radiculopathy – presents with radiating back pain, however there will be no faecal, urinary, or sexual dysfunction in these patients Cord compression – a surgical emergency with a similar pathophysiology to CES, however is characterised by upper motor neurone signs Muscloskeletal pain – relating to strain of paraspinal muscles, with severe pain that may lead to limited movement, but no other focal neurological signs

Answer 231

* Adequate analgesia, catheter if urinary retention * Urgent surgical decompression within 24 hours of symptom onset - laminectomy +/- discectomy * Radiotherapy/chemotherapy may be used if malignant cause

Answer 232

Paraplegia Lower limb numbness Chronic urinary retention or incontinence Chronic sexual dysfunction

Answer 233

(C)ABCDE Catastrophic haemorrhage Airway (with c-spine protection) Breathing Circulation Disability Exposure

Answer 234

High risk criteria - requires imaging and immobilisation * Age 65 or older * Dangerous mechanism of injury (fall from over one metre or down five or more steps, or an axial loading injury) * Paraesthesia in any limb(s) Low risk - none of the high risk criteria, one or more of * Involved in a minor rear-end motor vehicle collision * Comfortable sitting * Ambulatory since the injury * No midline cervical spine tenderness * Delayed onset of neck pain Low risk doesn't require imaging/immobilsation unless can't rotate head 45 degrees to left and right

Answer 235

TOM CAT Tension pneumothorax Open pneumothorax Massive haemothorax Cardiac tamponade Airway injury Tracheobronchial injury

Answer 236

* On the floor - external wound * Chest cavity * Abdominal cavity * Pelvis * Long bones

Answer 237

Hypothermia: keep warm with blankets, warmed air, use a blood warmer to give blood, and when examining the patient, limit their exposure to the minimum necessary Acidosis: maximise oxygenation and treat/prevent hypoventilation to prevent respiratory acidosis. Avoid giving crystalloids as this can exacerbate acidosis. Coagulopathy: avoid crystalloids or unbalanced blood products as they can cause dilutional coagulopathy. Permissive hypotension (aiming for a target systolic of 80-100mmHg) can be used to avoid excessive fluid administration and prevent dilutional coagulopathy.

Answer 238

Beck's triad * Jugular venous distension * Quiet heart sounds * Hypotension

Answer 239

* After all life-threatening injuries have been identified and addressed * History (AMPLE) - allergies, medication, PMH including tetanus status, last meal, events leading to injury * Head-to-toe examination - head and face, neck, chest, abdomen, limbs, back , buttocks and perineum, genitalia

Answer 240

C - catastrophic haemorrhage * Direct pressure, haemostatic dressing, touniquets A - airway * Definitive airway if patient cannot support own airway or will not be able to - rapid sequence induction of anaesthesia and intubation * May require surgical airway via surgical cricothyroidotomy * While awaiting definitive airway can due jaw thrust to support airway (avoid head-tilt chin-lift due to risk of c-spine injury or nasopharyngeal airway due to risk of basal skull fracture) C-spine * Immobilise with hard collar or head blocks B - breathing * Oxygen * Treat e.g. tension pneumothorax, haemothorax C - circulation * Pharmacological - tranexamic acid, reverse antigcoagulation * Cannulation * Blood tests - FBC, U&Es, LFTs, coagulation screen, group + save, toxicology screen, lactate * Blood product transfusion - 1:1:1 packed red cells, fresh frozen plasma, platelets * ECG D - disability * CT head * Raised ICP - IV mannitol, hypertonic saline * Surgical intervention? E - exposure * Analgesia * Wound care * Fractures

Answer 241

* Septic shock - bacterial infections e.g. appendicitis, pneumonia, necrotising fasciitis * Haemorrhagic shock - blood loss * Neurogenic shock - high level spinal cord transection * Cardiogenic shock - ischaemic heart disease, myocardial trauma/contusion * Anaphylactic shock

Answer 242

Mechanical theory – Fatty tissue is directly released into the vascular circulation as a result of trauma Biochemical theory – Inflammatory response to the trauma causes release of free fatty acids into the venous system from the bone marrow Causes * Acute long bone fractures * Intramedullary instrumentation - intramedullary nailing, hip/knee arthroplasty

Answer 243

Systemic manifestations of fat emboli within the microcirculation

Answer 244

* Usually following trauma * Worsening shortness of breath * Confusion * Drowsiness * Petechial rash * Signs - tachypnoea, tachycardia, hypoxia, confusion, low-grade pyrexia

Answer 245

Gurd’s criteria can be used for the diagnostic aid for fat embolism syndrome. The presence of 2 Major or 1 Major + 4 Minor criteria is deemed diagnostic Major criteria = Petechial Rash, Respiratory Insufficiency, Cerebral Involvement Minor criteria = Tachycardia, Pyrexial, Retinal Changes, Jaundice Thrombocytopaenia, Anaemia, Raised ESR, Fat macroglobulinaemia

Answer 246

* Routine bloods, including FBC, CRP, U&Es, LFTs, and a clotting screen * ABG - type 1 respiratory failure * Blood film may show the presence of fat globules * CXR will classically show diffuse bilateral pulmonary infiltrates * CTPA scan - ground-glass changes with a global distribution

Answer 247

* Supportive * Often requires mechanical ventilation

Answer 248

* Early fracture stabilisation (within 24 hours) of long bone fracture * Close monitoring - pulse oximetry

Answer 249

Manual in-line stabilisation

Answer 250

Transverse fracture through the proximal humerus (surgical neck of humerus) with displacement of the distal component

Answer 251

A transverse, comminuted fracture of the surgical neck of humerus is accompanied by a fracture line separating the greater tubercle from the rest of the humeral head

Answer 252

* Dislocation of the right acromioclavicular joint, with the clavicle displaced superiorly * Widening of the coracoclavicular distance - 23mm

Answer 253

AP view of the shoulder Humeral head is dislocated from the glenoid of the scapula and is now inferior to the coracoid of the scapula - anterior dislocation

Answer 254

Shoulder AP The glenohumeral joint is widened and the humeral head has taken on a more rounded 'light bulb' shape = posterior glenohumeral dislocation

Answer 255

Rockwood classification * Type 1 - clavicle not elevated above acromion * Type II - clavicle elevated but not above superior border of acromion * Type III - clavicle elevated above superior border of acromion but coracoclavicular distance less than twice normal (<25) * Type IV - clavicle displaced posterior into trapezius * Type V - clavicle markedly elevated and coracoclavicular distance more than double normal (>25mm) * Type VI- clavicle inferiorly displaced behind coracobrachialis and biceps tendons - rare

Answer 256

* Primary static stsabilisers - humeroulnar joint and medial and collateral ligaments * Secondary static stabilisers - radiocapitellar joint, joint capsule, common flexor and extensor origin tendons * Dynamic stabilisers - anconeus, brachialis, triceps brachii muscles

Answer 257

* Typically present following a high-energy fall * The joint will be painful and deformed, with associated swelling and decreased function (usually near immobile in near full extension with disruption of the equilateral triangle of the elbow)

Answer 258

Ulnar nerve * Pain/numbness/tingling on ulnar side of arm/hand * Claw-like deformity - hyperextension at MCP and flexion at proximal and distal IP of 4th and 5th fingers * Reduced finger abduction

Answer 259

* Medial lumbricals, DIP and PIP flexion, MCP extension, ulnar nerve * Flexor digitorum profundus and superficialis, flexor pollicis longus and brevis, MCP, DIP and PIP extension, median nerve * Extensor muscles (extensor carpi ulnaris, extensor digiti minimi, extensor digitorum, extensor indicis, extensor carpi radialis brevis, extensor carpi radialis longus), wrist joint, radial nerve Claw hand - when extending fingers Hand of Benediction - when flexing fingers Wrist drop - when extending wrist

Answer 260

Posterolateral

Answer 261

10-20 years old

Answer 262

Typically - axial loading, supination and valgus force

Answer 263

Capillary refill - good capillary refill can be found even in those with an arterial injury, due to the elbow having a rich collateral circulation Pulse - any concern over the pulse of the limb will warrant a Doppler ultrasound for further assessment

Answer 264

* Anatomical location of olecranon in relation to the humerus * Simple vs complex - simple has no associated fracture, complex has associated fracture

Answer 265

* Elbow dislocation associated with a LUCL tear, radial head fracture, and coronoid tip fracture * Causes very unstable elbow and is associated with a poor outcome * Likely to have recurrent problems with instability, stiffness, and arthrosis

Answer 266

X-rays - AP and lateral (loss of the radiocapitellar and ulnotrochlea congruence) CT only if associated fractures

Answer 267

Closed vs open reduction +/- ORIF and soft tissue repair (if fracture) Closed reduction * Requires sufficient analgesia/sedation * In-line traction or manipulation of the olecranon (in distal and anterior direction) * Elbow then flexed to 90 degrees with back slab * X-ray to confirm reduction * Neurovascular status re-assessed and documented * If the lateral collateral ligament is damaged the elbow will be more stable in pronation, if the medial collateral ligament is disrupted the elbow will be more stable in supination Initially immobilisation then rehabilitation

Answer 268

* Early stiffness with loss of terminal extension * Ulnar nerve stretch injury * Recurrent instability - reuccrence rate low (<2%) * Heterotophic ossification

Answer 269

Fall on an outstretched hand

Answer 270

Ligament injury * Lateral collateral ligament (LCL) injury most common (up to 80% on MRI) * Medial collateral ligament (MCL) injury Essex-Lopresti injury * Radial head fracture * Distal radioulnar joint (DRUJ) injury * Interosseus membrane injury

Answer 271

Mason classification Type 1 - non-displaced or minimally displaced, no mechanical block to rotation Type 2 - Displaced >2mm or angulated, possible mechanical block to forearm rotation Type 3 - comminuted and displaced, mechanical block to motion Type 4 - radial head fracture with associated dislocation

Answer 272

* Pain * Tenderness along lateral aspect of elbow * Limited elbow or forearm motion - supination/pronation * Ecchymosis * Swelling

Answer 273

Fully examine the wrist, elbow and shoulder - can have bone or soft tissue injuries of any of these * Inspection * Palpation * Movement * Stability testing - ligaments, drawer tests, interosseous mebrane * Neurovascular examination May require imaging (plain films) - AP and lateral elbow, forearm/wrist, shoulder CT for more complex injuries and to determine degree of comminution MRI for soft tissue injuries

Answer 274

Radial head fractures can be easily missed on plain radiographs and occasionally only an elbow effusion may be seen Elbow effusions on a lateral projection is termed a “Sail sign”, shown as an elevation of the anterior fat pad, in keeping with an occult fracture

Answer 275

Mason type 1 injuries – treated non-operatively, with a short period of immobilization with sling (less than 1 week) followed by early mobilisation Mason Type 2 injuries – if no mechanical block then can be treated as per a type 1 injury, whilst if a mechanical block is present then these may need surgery (typically ORIF) Mason Type 3 injuries – will nearly always warrant surgical intervention, either via ORIF or radial head excision or replacement (especially in highly comminuted fractures)

Answer 276

Elbow stiffness and loss of forearm rotation Radiocapitellar joint arthritis Heterotopic ossification

Answer 277

* An isolated fracture of the ulnar shaft * Direct blow to forearm, often when putting forearm in front of face to defend against weapon e.g. police nightstick, bat, fist * Can also occur due to fall

Answer 278

* Infection - ORIF, open fractures * Compartment syndrome - high risk in these injuries, especially if open, crush injjuries, vascular injuries * Non-union * Malunion

Answer 279

A Monteggia fracture is defined as a proximal 1/3 ulna fracture with an associated radial head dislocation. A galeazzi fracture is a distal 1/3 radial shaft fracture with an associated distal radioulnar joint (DRUJ) injury.

Answer 280

* Monteggia - direct blow to posterior elbow * Galeazzi - direct dorsolateral wrist trauma * Fall on an outstretched hand, arm pronated

Answer 281

Children - 4-13 years

Answer 282

Bado classification Type 1 - fracture of proximal or middle ulna with anterior dislocation of radial head (60%) Type 2 - fracture of proximal or muddle ulna with posterior dislocation of the radial head (more common in adults, 15% overall) Type 3 - fracture of ulnar metaphysis with lateral dislocation of radial head Type 4 - fracture of proximal or middle third of ulna and radius with dislocation of radial head in any direction (rare)

Answer 283

Symptoms - pain, swelling Monteggia - may be obvious dislocation at radiocapitellar joint, loss of ROM at elbow, PIN neuropathy Galeazzi - point tenderness over fracture site, instability with pronation/supination, wrist/midline forearm pain with DRUJ stress

Answer 284

PIN neuropathy - posterior interosseous nerve (deep branch of the radial nerve in the forearm) Symptoms: Radial deviation of hand with wrist extension Weakness of thumb extension Weakness of MCP extension Usually spontaneously resolves within 2-3 months, nerve conduction studies if not

Answer 285

X-ray - AP and lateral views of the forearm, elbow and wrist

Answer 286

Ulnar styloid fx Widening of joint on AP view Dorsal or volar displacement on lateral view Radial shortening (≥5mm)

Answer 287

Closed reduction - more common and successful in children, if greenstick, complete transverse/short oblique fracture ORIF of ulnar fracture - most adults, children if open, long oblique, comminuted After ORIF of ulnar injury radial head dislocation can usually have closed reduction, may require open if closed unsuccessful

Answer 288

Classified according to direction of radial displacement Type I - dorsal displacement Type II - volar displacement

Answer 289

All require ORIF of radius with reduction and stabilisation of DRUJ (unstable injury) Stabilisation of DRUJ can be with immobilisation in supination (6 weeks, if stable after radius ORIF), percutaneous pin fixation (if reducible but unstable after radius ORIF), open surgical reduction (if reduction is blocked), ORIF (if large ulnar styloid fragment)

Answer 290

Non-operative - cast/brace, rarely done in completely non-displaced fractures in patients who are not surgical candidates External fixation if severe soft tissue injury ORIF - most common ORIF with bone grafting - significant bone loss IM nailing - if very poor soft tissue integrity, high rate of non-union

Answer 291

Lateral view of elbow/forearm Monteggia fracture/dislocation - proximal 1/3 ulnar fracture and anterior radial head dislocation (type 1)

Answer 292

Lateral view of forearm/wrist Galeazzi fracture/dislocation - distal 1/3 radial fracture and dorsal dislocation of distal ulna (type I)

Answer 293

Transverse fracture through the proximal humerus with displacement of the distal component - surgical neck fracture

Answer 294

A transverse fracture of the surgical neck of humerus is accompanied by a fracture line separating the greater tubercle from the rest of the humeral head. Comminuted fracture.

Answer 295

Oblique fracture of the humerus shaft Distal component is markedly displaced

Answer 296

Colles fracture

Answer 297

Fall on an outstretched hand - especially in older, osteoporotic patients High energy in younger patients

Answer 298

Colles' fracture - extra-articular distal radius fracture with dorsal comminution, dorsal angulation, dorsal displacement, radial shortening, and an associated avulsion fracture of the ulnar styloid (not always seen in fractures described as Colles), occurs due to low energy, typically a 'fragility fracture' in osteoporotic bone Smith's fracture - extra-articular distal radius fracture with volar angulation, with or without volar displacement, usually due to falling backwards causing forced pronation, low energy Barton's fracture - intra-articular distal radius fracture with associated radio-carpal dislocation, either dorsal or volar depending on which lip of the radius is involved Chauffer's fracture - radial styloid fracture Die-punch fracture - depressed fracture of the lunate fossa of the articular surface of the distal radius

Answer 299

The main risk factors for distal radius fractures are related to osteoporosis: Increasing age Female gender Early menopause Smoking or alcohol excess Prolonged steroid use

Answer 300

History of trauma Immediate pain +/- deformity Swelling Reduced ROM due to pain Neurological involvement - paraesthesia or weakness

Answer 301

Examine hand, wrist, elbow +/- shoulder Neurovascular examination of arm - CRT and pulses Median, radial and ulnar nerve motor and sensory function If DIPJ of 2nd digit and IPJ of thumb extend when doing an okay sign - AIN involvement X-ray - AP, lateral, oblique CT if intra-articular, for surgical planning MRI - soft tissue injury

Answer 302

Radial height - normal 11mm, <11 Radial inclination - normal 22 degrees, <22 degrees Radial (volar) tilt - normal 11 degrees, <11

Answer 303

All require closed reduction - traction and manipulation under anaesthetic Non-operative - closed reduction and splint/cast immobilisation with below-elbow back slab cast Indications - extra-articular, <5mm radial shortening, dorsal angulation <5 degrees Operative Closed reduction, percutaneous pinning - extra-articular fracture with stable volar cortex ORIF External fixation - open, highly comminuted, medically unstable

Answer 304

Radiographic instability Dorsal angulation >5 degrees Vorsal or dorsal comminution Displaced intra-articular fractures >2mm Radial shortening >5mm Associated ulnar fracture - other than ulnar styloid fracture Severe osteoporosis Articular margin fractures Comminuted and displaced extra-articular fractures Die-punch fractures Progressive loss of volar tilt and radial length following closed reduction and casting

Answer 305

Malunion - poor realignment leads to shortened radius compared to ulnar, leads to reduced wrist motion, wrist pain and reduced forearm rotation Median nerve compression - especially if malunion Osteoarthritis - especially if intra-articular

Answer 306

Median nerve neuropathy Acute carpal tunnel release performed if progressive paresthesia, weakness in thumb opposition, paresthesias that do not respond to reduction and last >24-48 hours

Answer 307

Local or systemic analgesia and/or anaesthetic Sedation - nitrous oxide +/- fentanyl, propofol + fentanyl, ketamine Bier's block Haematoma block US guided block Reduction - prolonged traction on distal fragment, hyperextend the distal fragment, flex back into position Plaster to maintain position

Answer 308

Trasverse fracture of the distal radius Dorsal angulation and displacement Shortening creating a very narrowed ulnocarpal space = Colle's fracture

Answer 309

Oblique fracture of the distal radius Volar displacement and angulation Shortened radius = Smith's fracture

Answer 310

Comminuted intra-articular distal radius fracture and displaced fracture of the ulnar styloid = Barton's fracture

Answer 311

Radial head fracture - fracture line not visible Effusion indicated by raised fat pads is only sign of fracture

Answer 312

Radial head fracture - fracture line extends into articular surface of radial head

Answer 313

Effusion - raised fat pads Subtle buckling of the radial head cortex anteriorly = radial head fracture

Answer 314

Ulna dislocated posteriorly from the trochlea of the humerus Radius has dislocated from the capitulum of the humerus

Answer 315

Elbow dislocation - ulna and radius dislocated from humerus

Answer 316

Blood supply from the radial artery Dorsal branch 80% of blood supply, enters in the distal pole and travels. ina retrograde fashion towards the proximal pole Volar branch supplies the other 20% The scaphoid is at risk of avascular necrosis after fracture because of its ‘retrograde blood supply’ which enters at its distal end, and moves proximally. This means that a fracture to the middle (or ‘waist’) of the scaphoid may interrupt the blood supply to the proximal part of the scaphoid bone rendering it avascular. The more proximal the scaphoid fracture, the higher the risk of AVN

Answer 317

Proximal pole - 25% Waist - 65% Distal pole - 10%

Answer 318

Fall onto an outstretched hand - axial load across a hyperdorsiflexed, pronated and ulnarly deviated wrist

Answer 319

History of trauma Sudden onset wrist pain +/- bruising, swelling Pain and restricted pronation Tenderness in floor of anatomical snuffbox, pain on palpation of scaphoid tubercle, pain on telescoping of thumb

Answer 320

Triangular depression on the lateral aspect of the dorsum of the hand Defined laterally by the abductor pollicis longus and extensor pollicis brevis tendons (the 1st extensor compartment), and medially by the extensor pollicis longus tendon (the 3rd extensor compartment) Contents - radial artery, superficial radial nerve, cephalic vein Floor made of the scaphoid, along with the trapezium (distally) and the radial styloid (proximally)

Answer 321

Distal radial fracture Alternative carpal bone fracture Fracture of the base of the 1st metacarpal Ulnar collateral ligament injury Wrist sprain De Quervains tenosynovitis

Answer 322

Can be difficult to detect, up to 40% missed initially X-ray - scaphoid series (PA, lateral, oblique, PA angled), if negative but still sufficient clinical suspicion should have wrist immobilised and repeat X-ray in 10-14 days If still negative but scaphoid fracture suspected - MRI of wrist

Answer 323

Scapholunate ligament rupture Perilunate dislocation

Answer 324

Non-operative - cast immobilisation Majority of fractures If stable, non-displaced fracture If normal X-ray but suspicion of scaphoid fracture Operative Percutaneous screw fixation - proximal pole fracture displacement >1mm, non-displaced waist fractures ORIF - significantly displaced, associated perilunate dislocation, comminuted, unstable vertical or oblique

Answer 325

Scaphoid non-union (5-10%, higher rates for proximal pole fractures), treatment is with vascularised or non-vascularised bone grafting Avascular necrosis - 13-50%, higher risk with more proximal fractures Malunion Scaphoid non-union advanced collapse - progressive arthritis of wrist due to chronic scaphoid nonunion

Answer 326

Scaphoid fracture visible on only PA and PA + ulnar deviation views

Answer 327

Transverse scaphoid waist fracture

Answer 328

Triquetrum fracture - comminution of the dorsal cortex of the triquetrum Soft tissue swelling over the dorsum of the wrist

Answer 329

Fracture through the hamate

Answer 330

Perilunate dislocation Dorsal dislocation of the capitate

Answer 331

Lateral view Perilunate - capitate not sitting in distal articular 'cup' of lunate, line drawn through radius and lunate does not intersect capitate, lunate in articulation with distal radius, abnormal scapholunate and capitolunate angles, scaphoid fracture present in 60% Lunate - lunate displaced and angulated volarly, 'spilled teacup' appearance, lunate does not articulate with capitate or radius

Answer 332

All require operative management for definitive management May have initial closed reduction and splinting Then open reduction, ligament repair, fixation, possible carpal tunnel release

Answer 333

Median nerve

Answer 334

Head, neck or shaft Neck most commonly fractured Fifth metacarpal most commonly injured

Answer 335

Open fractures - common over dorsal MCP joints Tendon laceration Neurovascular injury Compartment syndrome - multiple fractures/dislocations, crush injuries

Answer 336

Boxer’s Fracture – a fracture of the 5th metacarpal neck, which typically occurs from a clenched fist striking a hard surface (such as a wall); these are typically very stable fractures and can be managed with a period of buddy taping and then full mobilisation Bennett’s Fracture – an intra-articular fracture of the 1st metacarpal base with a palmar and ulnar fragment, usually with some degree of subluxation or dislocation of CMC joint, typically requires reduction and surgical fixation. Rolando Fracture – an intra-articular fracture of the 1st metacarpal base, with a Y or T configuration. This fracture pattern typically requires reduction and surgical fixation.

Answer 337

History of trauma Pain and swelling overlying injuries Reduced ROM at affected joint May have rotational deformity - make a fist, finger rotated internally or externally (no longer pointing towards scaphoid tubercle), may have overlying fingers (scissoring)

Answer 338

X-ray hand - PA, oblique, lateral CT if complex, fracture-dislocations, pre-op planning

Answer 339

Remove jewellery Analgesia Elevate in high-arm sling to reduce swelling Mainly non-operative management - immobilisation with buddy taping, ulnar gutter or volar resting splint, repeat X-ray to assess for displacement Surgical management Indications - rotational deformity, intra-articular involvement, significant volar angulation, significant shortening, unstable fracture pattern Techniques - closed reduction and percutaneous fixing with K-wires, ORIF

Answer 340

Closed reduction then immobilisation - simple dislocations Open reduction - complex dislocations/delayed presentation

Answer 341

Typical mechanism - punching Pain Swelling Ulnar deviation of 5th digit

Answer 342

Reduction closed/open K-wire fixation as usually unstable

Answer 343

4th and 5th MCP joint dislocation

Answer 344

Boxer's fracture Fracture of 4th and 5th metacarpal

Answer 345

Intra-articular fracture of the ring finger middle phalanx

Answer 346

Comminuted fracture of the little finger distal phalanx due to a crush injury Transverse fracture of the ring finger middle phalanx

Answer 347

Boxer's fracture

Answer 348

Bennett's fracture - intra-articular fracture of the 1st metacarpal base, subluxation

Answer 349

Rolando fracture - Y shaped fracture of base of 1st metacarpal

Answer 350

Wrist at 30 degrees of flexion MCP joint at 80-90 degrees of flexion PIP and DIP joints fully extended at 0 degrees

Answer 351

Pain and deformity of affected digit Skin puckering - interposition of soft tissues within joint May have collateral ligament injury - check with lateral stressing while in flexion Hyperextension - incompetency of volar plate May have traction neuropraxia due to stretched of adjacent digital nerves

Answer 352

X-ray - AP, lateral, oblique Views of individual fingers V-sign - dorsal joint widening, indicates subtle subluxation

Answer 353

Non-operative - closed reduction and splinting, if <40% joint involved and stable Operative - closed reduction and percutaneous pinning or ORIF, if >40% of joint involved and unstable

Answer 354

Non-operative - closed reduction +/- splinting, 1st line Operative - open reduction +/- flexor digitorum profundus repair, if two reduction attempts fail Other operative - volar plate arthroplasty, arthodesis, amputation

Answer 355

DIPJ stiffnes Mallet finger deformity - seen with volar dislocations

Answer 356

Shenton's line disrupted Increased density of femoral neck due to overlapping impacted bone Lesser trochanter more prominent than usually due to external rotation of the femur = subcapital intracapsular fracture

Answer 357

Complete fracture of the full diameter of the femoral neck Total displacement of the 2 fracture components Loss of Shenton's line

Answer 358

Intertrochanteric femur fracture Comminution with separation of the lesser trochanter

Answer 359

Subtrochanteric femur fracture

Answer 360

Acetabulum = cup on inferolateral pelvis Deepened by fibocartilaginous collar - acetabular labrum Head of femur = hemisphere, fits into acetabulum Both covered in articular cartilage

Answer 361

Proximally - edge of acetabulum Distally - intertrochanteric line anteriorly, femoral neck posteriorly

Answer 362

Intracapsular Ligament of head of femur - from acetabular fossa to fovea of femur, encloses a branch of the obturator artery (artery to head of femur), minor source of arterial supply to hip Extracapsular Iliofemoral ligament - from anterior inferior iliac spine, bifurcates and inserts into intertrochanteric line of the femur, Y shaped, prevents hyperextension, strongest extracapsular ligament Pubofemoral ligament - from superior pubic rami to intertrochanteric line of femur, triangular, prevents excessive abduction and extension Ischiofemoral - from body of ischium to greater trochanter of femur, spiral orientation, prevents hyperextension and holds femoral head in acetabulum

Answer 363

Complex blood supply including: Branches of profunda femoris artery - medial and lateral femoral circumflex Branches of internal iliac artery - superior and inferior gluteal artery, obturator artery Obturator artery gives off artery of ligamentum teres which travels inside the ligament of the head of the femur to supply the femoral head - significant source of blood supply in children, not sufficient in adults (after growth plate closes, >15) to prevent AVN if other blood supply disrupted Tochanteric anastomosis - circumferential connection involving superior gluteal artery, medial femoral circumflex and lateral femoral circumflex arteries around the femoral neck, supplies the femoral head The supply to the femoral head is retrograde, meaning it moves from distal to proximal. If there is a displaced intracapsular NOF the blood supply will be cut off and the head can undergo avascular necrosis.

Answer 364

Sciatic, femoral and obturator nerves Same as knee - can have referred pain in either joint

Answer 365

Mostly low energy in older patients, e.g. fall Also high energy in younger patients e.g. RTA, fall from height, associated with other significant injuries

Answer 366

NOF = anywhere from subcapital region of the femoral head to 5cm distal to the lesser trochanter Intracapsular - subcapital region of femoral head to basocervical region of femoral neck, immediately proximal to the trochanters Extra-capsular - outside the capsules Inter-trochanteric - between greater and lesser trochanter Sub-trochanteric - from lesser trochanter to 5cm distal

Answer 367

Displaced intra-capsular fractures

Answer 368

Garden classification Grade I - incomplete fracture, valgus impaction (non-displaced) Grade II - complete fracture, non-displaced Grade III - complete fracture, partially displaced (trabeculae at an angle) Grade IV - complete fracture, fully displaced (trabeculae are parallel)

Answer 369

History of trauma, often low-energy Pain - groin, thigh or referred to knee Inability to weight bear Leg shortened, abducted and externally rotated - classically displaced fractures Pain on pin-rolling and axial loading Distal neurovascular deficits rare

Answer 370

Unapposed pull of external rotators (e.g. iliopsoas - attached to lesser trochanter)

Answer 371

Age - >65 in women >75 in men Risk factors for osteoporosis. -menopause, amenorrhoea, smoking, excessive alcohol intake, physical inactivity, steroids History of falls Poor nutrition Low BMI Visual impairment (risk of falls) History of tumours - primary or secondary bone tumours, breast, bowel, prostate, kidney, lung, thyroid tumours

Answer 372

Other fractures e.g. pubic ramus, acetabulum, femoral head, femoral shaft Dislocated hip Femoral head avascular necrosis Slipped capital femoral epiphysis (intermittent pain for months, pain worse on activity) Tendonitis of any muscles of the hip Hip bursitits Osteomyelitis (fever, chills, swelling, redness)

Answer 373

Plain film radiographs - AP, lateral, AP pelvis (assess contralateral hip) Full length femoral X-ray if suspicion of pathological fracture Investigate cause of fall - FBC, U&Es, urine dip, CXR, ECG CT - determine displacement/comminution MRI - if negative X-ray but still clinical suspicion, gold standard for exclusion

Answer 374

A-E - often concurrent injuries Analgesia - paracetamol, opioids, iliofascial/femoral nerve block Avoid NSAIDs - increased risk of second NOF fracture IV access - fluid resuscitations, ?blood transfusion, administration of medications Assess + managed complications e.g. correct anaemia, ?reverse anticoagulation and ?VTE prophylaxis, volume depletion, infection

Answer 375

Intra-capsular: Non-displaced (blood supply to femoral head intact) - internal fixation (cannulated hip screw) Displaced (risk of AVN) - total or hemiarthroplasty (total if well, good mobility pre-injury, indepedent) Extra-capsular: Intertrochanteric/basocervical fracture - dynamic hip screw (sliding screw) or short IM nail Sub-trochanteric - intramedullary nail

Answer 376

Total - replace head of femur and acetabulum Hemiarthroplasty - replace femoral head and neck via femoral component fixed in proximal femur

Answer 377

Lag screw into the neck, a sideplate, and bicortical screws The lag screw is able to slide through the sideplate, allowing for compression with weight bearing and primary healing of the bone

Answer 378

Three parallel screws in an inverted triangle formation, driven into femoral head across fracture to stabilise fracture

Answer 379

The titanium rod is placed through the medullary cavity of the femur for stabilisation

Answer 380

Cannulated hip screws

Answer 381

Dynamic hip screw

Answer 382

Total hip arthroplasty

Answer 383

Hip hemiarthroplasty

Answer 384

Intramedullary nail

Answer 385

Surgical site infection VTE Bleeding Fat embolism Post-operative delirium Nerve/vessel injury Muscle/ligament damage Leg-length discrepancies

Answer 386

Analgesia Rehabilitation - early mobilisation and weight bearing Falls risk assessment Dietetic assessment - avoid protein-caloric malnutrition Axial bone densitometry - assess for osteoporosis, offer anti-resorptive therapy to reduce risk of future fragility fractures Antibiotic prophylaxis Thromboembolism prophylaxis

Answer 387

Patients not fit for surgery Short life expectancy Delayed presentation with signs of healing Immobile patients Patient choice Casts/splints/traction - period X-rays required Poor outcomes - high mortality

Answer 388

30% mortality in 1 year 50% do not return to functional baseline Non-union Femoral head AVN Peri-prosthetic fracture Aseptic prosthetic loosening Dislocation of prosthesis Deep infection/prosthetic joint infection

Answer 389

Both describe loss of bone mineral density - osteopaenia less severe than osteoporosis Increases bone fragility and susceptibility to fragility fractures

Answer 390

Endocrine disease including Diabetes mellitus, Hyperthyroidism, and hyperparathyroidism GI conditions that cause malabsorption such as Crohn's disease, Ulcerative colitis, Coeliac disease, and Chronic pancreatitis CKD Chronic liver disease COPD Menopause Immobility BMI of less than 18.5 kg/m² Age Oral corticosteroids (dependent on the dose and duration of treatment, >7.5mg per day for >3 months significantly increases risk) Smoking. Alcohol (3 or more units daily). Previous fragility fracture (risk increases with increasing number of fractures) Risk is highest for previous hip fractures and lowest for previous vertebral fractures Rheumatological conditions, such as Rheumatoid arthritis, and other inflammatory arthropathies Parental history of hip fracture Drugs - SSRIs, PPIs, anticonvulsants e.g. carbamazepine

Answer 391

A fragility fracture is defined as a fracture following a fall from standing height or less. May occur without fall (e.g. vertebral fracture). An osteoporotic fracture is a fragility fracture occurring as a consequence of osteoporosis. Characteristically occur in the wrist, spine, and hip, but can also occur in the arm, pelvis, ribs, and other bones.

Answer 392

FRAX tool - predicts absolute risk of hip fracture and major osteoporotic fractures (spine, wrist, shoulder) over the next 10 years (QFracture score also used) Should be used in all women >65, men >75 Also used in women 50-64 and men 50-74 with risk factors Younger than 50 if high-dose steroids, previous fragility fracture, untreated premature menopause Low risk <10% risk score Intermediate risk - close to 10% High risk >10%

Answer 393

Dual-energy X-ray absorptiometry (DEXA) Measures bone density at hip and produces Z and T score Z score - number of SDs the patients bone density is below the mean for their age T score - number of SDs below the mean for a healthy young adult T score is used for WHO classification

Answer 394

FRAX outcome without a BMD result will suggest one of three outcomes: Low risk – reassure Intermediate risk – offer DEXA scan and recalculate the risk with the results High risk – offer treatment FRAX outcome with a BMD result will suggest one of two outcomes: Treat - -2.5 or lower Lifestyle advice and reassure

Answer 395

Activity and exercise Maintain a healthy weight Adequate calcium intake Adequate vitamin D Avoiding falls Stop smoking Reduce alcohol consumption

Answer 396

If adequate calcium intake (700mg/day) - Vitamin D only (400 units) If inadequate calcium - 400 or 800 units Vitamin D and 100mg calcium

Answer 397

If T-score 2.5 or less, consider if on high dose steroids Bisphosphonate - alendronate 10mg OD or 70mg once weekly, risedronate 5mg OD or 35mg once weekly Other options - denosumab, strontium ranelate, raloxifene, HRT

Answer 398

Gastrointestinal (most common) — nausea, dyspepsia, mild gastritis, and abdominal pain. More likely in the first month of treatment. Take on an empty stomach sitting upright for 30 minutes before moving or eating. NSAIDs may increase risk. Bone, joint, and/or muscle pain (common) Oesophageal reactions (uncommon) — oesophagitis, oesophageal ulcers, oesophageal strictures, and oesophageal erosions. Osteonecrosis of the jaw (rare) Osteonecrosis of the external auditory canal (very rare). Atypical stress fractures

Answer 399

Low-risk - lifestyle advice, follow-up in 5 years for repeat assessment On bisphosphonates - FRAX and DEXA scan after 3-5 years, treatment holiday considered if BMD improved and no fragility fractures

Answer 400

Two hip bones (innominate/pelvic bones) - ilium, ischium and pubis Sacrum and coccyx Articulations - Two sarcoiliac joints - between ilium and sacrum Sarcoccygeal symphysis - sarcum and coccyx Pubic symphysis - between pubic bodies

Answer 401

Greater sciatic foramen - Divided into suprapiriform and infraspiriform foramen by piriformis muscle Suprapiriform - superior gluteal artery, vein and nerve Infrapiriform - sciatic nerve, pudendal nerve, inferior gluteal artery, vein and nerve, posterior femoral cutaneous nerve, nerve to obturator internus, nerve to quadratus femoris Lesser sciatic foramen Internal pudendal artery, vein and nerve, obturator internus tendon, nerve to obturator internus Obturator foramen - obturator artery, vein and nerve Anterior and posterior sacral foramina - anterior and posterior divisions of the sacral nerves

Answer 402

Low energy - fall from standing height in osteoporotic patient, most commonly pubic ramus fracture High energy - direct or transmitted trauma e.g. RTA, more extensive fractures, can include acetabulum and sacroiliac joint (if involving pelvis ring will usually have fractures in two places) Can be unstable injuries requiring emergency surgery, associated with soft tissue and vascular injury (bladder and urethra at high risk of damage), can result in life-threatening haemorrhage

Answer 403

History of high-energy trauma - usually blunt Pain and inability to weight bear Swelling Deformity Injury to sacral nerve roots - bladder/bowel incontinence, loss of sensation Signs of bleeding - ecchymosis, haematoma formation (perineal, scrotal, labial) Abdominal injuries, urethral injuries (gross haematuria) Open fractures - including internal open fracture into rectum or vaginal vault

Answer 404

Follow ATLS protocol - primary survey to identify life-threatening injuries Hypotension can indicate pelvic fracture with life-threatening haemorrhage - pelvic binder should be applied Imaging - AP, inlet view and outlet view X-rays requires to assess pelvic ring Usually a trauma CT is performed so X-rays not required

Answer 405

Provides skeletal stability which allows for clot formation - prevents ongoing haemorrhage and development of coagulopathy Centered over greater trochanter

Answer 406

Venous injury (80%) - shearing injury of posterior venous plexus, leads to retroperitoneal haemorrhage (can hold up to 8L of blood) Bleeding cancellous bone Arterial injury (less common, 10-20%) - superior gluteal most common

Answer 407

Young and Burgess classification – based on the vector of the disrupting force and the resulting degree of displacement Antero-posterior compression (APC) Lateral compression (LC) Vertical shear (VS) Tile classification - based on the stability of the pelvic ring A-type - rotationally and vertically stable B-type - horizontally unstable but vertically stable C-type - both horizontally and vertically unstable Denis classification - for fractures of the sacrum, describes the line of the fracture in relation to the sacral foramina Type 1 - lateral to the foramina Type 2 - transforaminal Type 3 - medial to the foramina

Answer 408

Antero-posterior compression - pubic symphysis disruption, more severe has disruption of posterior ligamentous structures of the pelvis Lateral compression - pubic ramus fracture --> fracture of iliac blade (creates floating fragment) on side of compression, more severe than have contralateral iliac wing fracture Vertical shear - detachment of sacrum from rest of pelvis, bilateral in more severe

Answer 409

Fracture through superior and inferior pubic rami - obturator ring is incomplete on the right

Answer 410

Step in cortical edge of pelvic ring - acetabular fracture, passes to obturator ring and through inferior pubic ramus

Answer 411

Pubic symphysis and right sacroiliac joint are widened - APC 3

Answer 412

ASIS avulsion fracture - small fragment of bone detached, pulled off by sartorius tendon Normal appearance of unfused iliac crest apophysis - teenager

Answer 413

Loss of smooth arcuate lines Sacral fracture

Answer 414

If haemodynamically unstable may require interventional radiology or trauma laparotomy +/- retroperitoneal packing Indications for operative management - life-threatening haemorrhage, unstable fracture, open fracture, associated urological injury Operative management involves a combination of anterior and posterior stabilisation

Answer 415

Lateral malleolus tip fractured distal to the ankle joint - Weber A

Answer 416

Fracture through distal fibula at level of ankle joint - Weber B

Answer 417

Distal fibula fracture, at level of ankle joint - Weber B

Answer 418

Distal fibula fracture, above level of ankle joint - Weber C Transverse medial malleolus fracture Distal tibiofibular joint also widened

Answer 419

Fractures of both the lateral malleolus (Weber C) and medial malleolus

Answer 420

Trimalleolar fracture - fracture of medial, lateral and posterior malleolus

Answer 421

Subtle widening of the ankle medially indicates instability at the distal tibiofibular joint A Maisonneuve fracture should be suspected and images of the proximal fibula obtained

Answer 422

Pilon fracture - fracture of the distal tibia involving the articular surface of the tibia

Answer 423

Osteochondral fracture of the talar dome

Answer 424

Trimalleolar fracture - lateral malleolus fracture (Weber C), posterior malleolus fracture, medial malleolus fracture The joint is unstable and widened anteriorly and at the distal tibiofibular syndesmosis The talus is displaced posteriorly and laterally along with the medial and lateral malleolus bone fragments

Answer 425

Complete dislocation of the talus from the tibia and fibula Get proximal views of the tibia/fibula - fibula fracture common if widening of tibiofibular joint distally

Answer 426

Complete dislocation of the talus from the tibia and fibula

Answer 427

Bones of leg - tibia, fibula Bones of ankle - talus, calcaneus Tibia and fibula are bound together by tibiofibular ligaments, forms a socket covered in hyaline cartilage = mortise Body of talus fits into mortise

Answer 428

Medial (deltoid) ligament - medial malleolus --> talus, calcaneus, navicular bones (resists over-eversion) Lateral ligament - lateral malleolus --> lateral talus, posterior talus, calcaneus Syndesmosis - anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, intraosseous ligament, intraosseous membrane, inferior transverse ligament

Answer 429

The arterial supply to the ankle joint is derived from the malleolar branches of the anterior tibial, posterior tibial and fibular arteries. Innervation is provided by tibial, superficial fibular and deep fibular nerves.

Answer 430

A fracture of any malleolus (lateral, medial, or posterior), with or without disruption to the syndesmosis

Answer 431

Fracture involving the tibial articular surface of the ankle joint

Answer 432

Anatomically: Isolated lateral malleolar fracture Isolated medial malleolar fracture Bimalleolar fracture (medial + lateral malleolar fracture) Trimalleolar fracture (medial, lateral, posterior malleolar fracture) Weber classification for lateral malleolus fractures Type A = below the syndesmosis Type B = at the level syndesomosis Type C = above the level of the syndesmosis Lauge-Hansen classification - based on ankle position at time of injury and deforming force used

Answer 433

Ankle pain following traumatic injury Inability to weight bear Reduced ROM Associated deformity if fracture dislocation Ecchymosis, fracture blisters, open fracture

Answer 434

Ottowa rules In the presence of any of the below features, plain radiographs must be undertaken: Bone tenderness at the posterior edge or tip of the lateral malleolus, OR Bone tenderness at the posterior edge or tip of the medial malleolus, OR An inability to bear weight both immediately and in the emergency department for four steps They cannot be used in cases if the patient is intoxicated or uncooperative, has other distracting painful injuries, has diminished sensation in their legs, or has gross swelling.

Answer 435

Plain radiograph - AP and lateral (with ankle in full dorsiflexion) CT scan for complex, especially displaced posterior malleolus fragment

Answer 436

Conservative - stable lateral/medial malleolus fracture, posterior with <25% joint involvement or <2mm step, Weber A or B, unfit for surgery Immediate reduction under sedation to realign, below knee back slab Surgical management - displaced bi/trimalleolar, Weber C, Weber B with talar shift, open fracture ORIF

Answer 437

Post-traumatic arthritis ORIF - surgical site infection, DVT or PE, neurovascular injury, non-union, metalwork prominence

Answer 438

Hip dislocation - femoral head lies superior and lateral to the acetabulum

Answer 439

Hip dislocation - total hip replacement Ball of the femoral component is displaced from the cup of the acetabular component

Answer 440

High-energy trauma - RTA, significant fall from height Often associated with other injuries

Answer 441

Posterior dislocation: Accounts for 90% of hip dislocations, mainly due to axial load on femur. The affected leg is shortened, adducted, and internally rotated. Anterior dislocation: The affected leg is usually abducted and externally rotated. No leg shortening. Central dislocation

Answer 442

Acute pain Inability to weight bear Deformity

Answer 443

X-ray - AP CT - determine direction of dislocation, loose bodies and associated fractures (should always be done after reduction)

Answer 444

ABCDE approach Analgesia Closed reduction first line (unless associated femoral neck fracture) If irreducible or delayed presentation - open reduction Reduction should be within 4 hours to prevent avascular necrosis/nerve injury

Answer 445

Sciatic or femoral nerve injury Avascular necrosis Osteoarthritis: more common in older patients. Recurrent dislocation: due to damage of supporting ligaments

Answer 446

High-energy - RTA, crush injury, fall from height Low-energy - athletic injury, walking (typically obese) Hyperextension leads to anterior dislocation Posterior force across proximal tibia leads to posterior dislocations (dashboard injuries)

Answer 447

Vascular injury Nerve injury - common peroneal injury (25%), tibial nerve injury less common Fractures in 60% Soft tissue injuries - patellar tendon rupture, periarticular avulsion, displaced menisci

Answer 448

Anterior (30-50%) - hyperextension injury, usually PCL tear Posterior (30-40%) - axial load on a flexed knee, highest incidence vascular injury (popliteal artery tear) Lateral - varus or valgus force, usually PCL and ACL tear Medial - varus or valgus force, usually disruption of PCL Rotational - usually irreducible

Answer 449

History of trauma Knee pain and instability Deformity of knee 50% spontaneously reduce Swelling, effusions, abrasions, ecchymosis Pulses absent/diminished - vascular injury (may still be vascular injury with normal pulses) Sensory/motor deficit - peroneal or tibial nerve injury

Answer 450

X-ray - pre- and post-reduction AP and lateral CT - fractures MRI - soft tissue injuries, after acute reduction

Answer 451

Emergent closed reduction followed by vascular assessment Immobilisation as definitive management Open reduction - irreducible, posterolateral dislocation, open fracture-dislocation, vascular injury Delayed ligamentous reconstruction/repair if required

Answer 452

Vascular compromise Stiffness - arthrofibrosis Laxity and instability Peroneal nerve injury

Answer 453

Total dislocation of the knee Tibia and fibula rotated

Answer 454

Lateral dislocation of the patella

Answer 455

Patellar fracture - wide separation of the upper and lower poles of the patella

Answer 456

Severe injuries to the tarsometatarsal (Lisfranc) joint between the medial cuneiform and the base of the 2nd metatarsal. They can be either solely ligamentous injuries or involving the bony structures of the midfoot (fracture-dislocation)

Answer 457

Most commonly due to severe torsional or translational forces applied through a plantar flexed foot - usually RTA, athletic injuries Severe midfoot pain Difficulty weight bearing Swelling and tenderness over midfoot Plantar bruising is highly suggestive Tarsometatarsal injuries - features of compartment syndrome Piano key sign - prominence of metatarsal bones - reduce down with pressure

Answer 458

X-ray - AP, oblique, lateral foot view while weight bearing CT scan for pre-op panning of comminuted fracture MRI for ligamentous injury

Answer 459

Widening of the interval between the base of the 1st and 2nd metatarsal Bony fragment (“fleck sign”) in the space between the 1st and 2nd metatarsal, indicates avulsion of the Lisfranc ligament from the base of the second metatarsal Disruption of a line drawn from the medial base of the 2nd metatarsal to the medial side of the middle cuneiform (on AP view) Malalignment of the medial border of the lateral cuneiform and the medial edge of the 3rd metatarsal, or medial border of the cuboid and the medial edge of the 4th metatarsal (on oblique view) Dorsal displacement of the proximal bases of the 1st or 2nd metatarsals (on lateral view)

Answer 460

Hardcastle and Myerson classification can be used to classify Lisfranc injuries: Type A – complete homolateral dislocation Type B1 – partial injury, medial column dislocation Type B2 – partial injury, lateral column dislocation Type C1 – partial divergent dislocation Type C2 – complete divergent dislocation

Answer 461

Significantly displaced - closed reduction in A&E to correct gross deformity and protect soft tissue - gentle traction to midfoot and corrective pressure to metatarsal base, then placed in backslab If no significant diaplcement - manage conservatively with cast immobilisation and non-weight bearing mobilsation for 6-12 weeks Displaced - operative management Temporary external fixation then definitive screw fixation

Answer 462

Post-traumatic arthritis - 25% Midfoot compartment syndrome important

Answer 463

Back pain that arises from the spine, intervertebral disks or surrounding soft tissue Often a specific cause is not identified

Answer 464

Describes bone mineral density as number standard deviations from normal for healthy young adult >-1 is normal <-1 but >-2.5 represents osteopaenia <-2.5 osteoporosis (can be +/- fracture, fracture alone can diagnose osteoporosis)

Answer 465

Often have identifiable injury - bending or lifting Pain and stiffness Few clinical features No red flag symptoms

Answer 466

Muscle or ligament sprain Facet joint dysfunction Sacroiliac joint dysfunction Herniated disc Spondylolisthesis (anterior displacement of a vertebra out of line with the one below) Scoliosis (curved spine) Degenerative changes (arthritis) affecting the discs and facet joints

Answer 467

No investigation required unless another diagnosis suspected Patients with a short history (< 6 weeks) do NOT need routine investigation Prolonged symptoms or patients with RED flags should be investigated – FBC with differential WCC – ESR – LFT’s – Bone profile – Myeloma screen – CRP

Answer 468

Promote patient education Good early symptomatic control using simple analgesia - NSAIDs first line, codeine, benzodiazepines for muscle spasm (only up to 5 days) Early return to normal activities (including work) Self referral to physiotherapists Safety netting advice for red flag symptoms

Answer 469

Herniated disc Spondylolithesis Facet joint hypertrophy Bone spurs Fracture - trauma or pathological Malignancy - usually metastatic Infection - extradural abscesses, osteomyelitis (Pott's disease, Herpes Zoster)

Answer 470

Nucleus pulpous prolapses out via a defect in the degenerative annulus fibrous Compresses the adjacent nerve root or the exiting nerve root, depending on location of disc herniation

Answer 471

95% are L4/5 or L5/S1

Answer 472

Radicular pain - leg pain usually worse than back, dermatomal distribution Pain worse when sitting usually Associated neurological deficit - numbness, tingling, weakness L3 - sensory loss over anterior thigh, weak quadriceps, reduced knee reflex, positive femoral stretch test L4 - sensory loss anterior aspect of knee, weak quadriceps, reduced knee reflex, positive femoral stretch test L5 - sensory loss dorsum of foot, weakness in foot and big toe dorsiflexion, reflexes intact, positive sciatic nerve stretch test S1 - sensory loss posterolateral aspect of leg and lateral aspect of foot, weakness in plantar flexion of foot, reduced ankle reflex, positive sciatic nerve stretch test

Answer 473

Straight leg raising (SLR) * Pain = increased nerve root tension and lack of the normal excursion of the root at the herniation site. Laségue sign - flexion of knee in straight leg raise * Should cause pain in the ipsilateral leg distal to the knee * If contralateral leg pain can be elicited this is thought as a pathognomonic sign of disc herniation (Crossover sign)

Answer 474

MRI Indications: >6 weeks radicular pain failed conservative measures Neurological deficit Bilateral lower limb deficit or peroneal symptoms - urgent referral to on-call orthopaedic service for emergency MRI to rule out CES

Answer 475

Soft tissue injury - neurovascular injury, damage to the soft tissue envelope around the fracture

Answer 476

Reduce Retain - immobilise Rehabilitate

Answer 477

Location - which bone or joints, where in the bone (epiphysis, metaphysis, diaphysis, proximal, middle or distal shaft) Configuration - transverse, oblique, spiral etc. Displacement - undisplaced, angulated, translated, shortened, rotated Stability Open?

Answer 478

Transverse - direct blow Oblique - bending force Spiral - rotational force Comminuted - high energy Segmental - high energy Avulsion - musculo-tendinous pull off Compression - axial force Torus - child, low energy Greenstick - child, bending force

Answer 479

Undisplaced - no loss of fracture position Angulated - describe the angulation of the distal portion of the fracture with respect to the proximal portion Translated - medio-lateral or anteroposterior drift of the fracture, describe in percentages Shortened Rotated - internal or external, usually best assessed clinically

Answer 480

Conservative - casts, slings, splints, traction Surgical - smooth wires, plates and screws, intramedullary nail, external fixation

Answer 481

Smooth wires - minimally invasive, poor stability, quick Intramedullary nail - moderately invasive, very stable, longer procedure Plates and screws - more invasive, very stable, longer procedure External fixation - can be applied quickly in patients who are unstable/have other injuries, minimal soft tissue stripping

Answer 482

Atrophic - failure of biology, smoking, malnutrition, immunocompromised Hypertrophic - failure of immobilisation

Answer 483

Bone graft Bone accelerant Internal fixation

Answer 484

Median nerve

Answer 485

Ulnar nerve

Answer 486

Thumb, index, middle and radial half of ring finger

Answer 487

Flexor pollicis longus, the four flexor digitorum superficialis, the four flexor digitorum profundus as well as the median nerve

Answer 488

Thumb abduction

Answer 489

Flexor carpi ulnaris

Answer 490

Little finger and ulnar half of ring finger

Answer 491

Tibial nerve terminal branches

Answer 492

Inversion/eversion

Answer 493

1st metatarsal joint

Answer 494

Majority non-surgical Physiotherapy Analgesia - simple analgesia and NSAIDs Spasm - benzodiazepines (short course initially) Unless CES and progressive neurological deficit surgery not considered earlier than 6 weeks from onset of symptoms If symptoms >6 weeks - MRI, referral to orthopaedic surgeon

Answer 495

Cauda equina syndrome - faecal incontinence, urinary retention (painless, with secondary overflow incontinence), saddle anaesthesia Infection - immunosuppression, IVDU, fever Fracture or infection - chronic steroid use Fracture - significant trauma, osteoporosis or metabolic disease Malignancy/metastatic disease - >50, history of malignancy, weight loss, night pain

Answer 496

Impaired sensation in dermatomal levels below level of cord compression Pain Bi/uni-lateral weakness Upper motor neurone signs - hypertonia, hyperreflexia (absent reflexes at level of compression), Babinski's sign, clonus Autonomic involvement late stage - bowel incontinence, constipation, urinary retention

Answer 497

Intermittent neurogenic claudication = pain from intermittent compression and/or ischaemia of single or multiple nerve roots within the intervertebral foramen or central spinal canal Symptoms when standing/walking, bending forward relieves symptoms Lower back pain, buttock and leg pain, leg weakness, tingling, numbness Mild symptoms may be only heaviness of legs, severe can have impaired motor function and bowel/bladder dysfunction

Answer 498

Spinal cord compression - UMN signs Cauda equina - LMN signs

Answer 499

Urgent MRI - whole MRI spine within 24 hours of presentation Management High dose oral dexamethasone Urgent oncological assessment for consideration of radiotherapy or surgery

Answer 500

Scoliosis = abnormal lateral curvature of the spine Kyphosis = excessive convex curvature of the spine (forward curvature along the sagittal plane)

Answer 501

Dextroscoliosis - primary curve towards right Levoscoliosis - primary curve towards left

Answer 502

Sideways curvature of the spine/body posture Shoulders/hips uneven Muscular back pain Local ligament pain Impaired pulmonary function - progressive severe scoliosis

Answer 503

Visible deformity of spine - excessive forward curvature Increased forwards posture of head Uneven shoulder height Back pain - worse with movement More severe - chest pain, SOB, loss of sensation, bowel/bladder incontinence

Answer 504

Thoracic scoliosis (dextroscoliosis)

Answer 505

Passes posterior to elbow through ulnar (cubital) tunnel Travels between two heads of the flexor carpi ulnaris and continues into the forearm and hand

Answer 506

Medial wall - medial epicondyle of humerus Lateral wall - olecranon of ulna Floor - elbow joint capsule and medial collateral ligament of elbow Roof - cubital tunnel retinaculum (arcuate ligament of Osbourne)

Answer 507

Froment's sign - paralysis of adductor pollicis Hold paper between thumb and index finger, paper pulled away, cannot hold onto paper without flexing thumb at interphalangeal joint

Answer 508

Prior fracture/dislocation of the elbow Bone spurs/osteoarthritis of elbow Repetitive/prolonged activities with flexed elbow Cubitus varus or valgus deformities Medial epicondylitis Burns Tumours and ganglion cysts Heterotopic ossification

Answer 509

Paresthesias of small finger, ulnar half of ring finger and ulnar dorsal hand Initially intermittent then constant Chronic - weakness and muscle wasting Night symptoms - sleeping with arm in flexion, relieved by hanging arm out of bed/running under water Examination - 4th and 5th digit clawing, ulnar nerve subluxation over medial epicondyle as elbow moves through flexion-extension, sensory deficit in ulnar digits, Froment's sign, Tinel's sign positive over cubital tunnel, elbow flexion for >60 seconds reproduces symptoms

Answer 510

Conservative - avoid aggravating activity, physiotherapy, NSAIDs, night elbow splinting (NOT steroids - risk of injuring nerve) Operative - cubital tunnel decompression surgery

Answer 511

Absolute: Cauda equina syndrome Progressive neurologic deficit Relative: Intractable radicular pain Neurologic deficit that does not improve with conservative measures Recurrent sciatica following successful trial of conservative measures

Answer 512

PR exam - sensation and anal tone Bladder scan pre and post void to assess for bladder emptying If suspicion of CES then urgent MRI Refer to neurosurgeons if MRI not immediately available out of hours for transfer If proven needs emergency surgical decompression

Answer 513

Overuse injuries which cause elbow pain Golfer's elbow = medial epicondylitis (extensor carpi radialis brevis tendon) Tennis elbow = lateral epicondylitis (flexor-pronator tendon) Lateral epicondylitis much more common Lateral epicondylitis - pain and tenderness over lateral epicondyle, worse on resisted wrist extension with elbow extended or supination of forearm with elbow extended Medial epicondylitis - pain and tenderness over medial epicondyle, worse on wrist flexion and pronation, may have ulnar nerve involvement

Answer 514

Non-operative - NSAIDs, physiotherapy, steroid injections, effective in 95% Operative - release and debridement of ECRB origin

Answer 515

Non-operative - NSAIDs, physiotherapy, bracing, steroid injections, effective in 95% Operative - debridement and reattachment of flexor-pronator origin

Answer 516

Swelling, pain, redness and warmth over posterior aspect of elbow. Fever and malaise if infective.

Answer 517

Trauma Prolonged pressure Infection Rheumatoid arthritis Gout

Answer 518

Uric acid level CRP Aseptic needle aspiration of bursa (Gold standard for diagnosis of infection) - urgent gram stain, culture and sensitivity, pathology for crystals

Answer 519

Non-infective - ice, elevation, NSAIDS, treat cause (e.g. gout) Infective - after aspiration start broad-spectrum antibiotics, oral or IV depending on severity Recurrent - ?bursectomy

Answer 520

Bursitis - ROM usually preserved, only mild discomfort unless at extremes of movement Septic arthritis - any movement produces large amounts of pain

Answer 521

Primary osteoarthritis Secondary osteoarthritis Post-traumatic - fracture or dislocation Inflammatory/crystalline arthritis (RA, gout etc.) Osteonecrosis (AVN) Rotator cuff arthropathy - massive RC tear leading to arthritis

Answer 522

Rheumatoid arthritis of the shoulder - large peri-articular erosions around humeral head, erosion of distal clavicle Widening of acromioclavicular joint

Answer 523

Sclerosis of humeral head and glenoid fossa Narrowed joint space Osteophyte lower border of humeral head = shoulder OA

Answer 524

Shoulder pain Reduced ROM - especially external rotation due to anterior capsule contraction Night pain Crepitus

Answer 525

Non-operative - NSAIDs, physiotherapy, steroid injections Operative - joint replacement

Answer 526

Rotator cuff muscles Glenoid labrum Ligaments Biceps tendon

Answer 527

Progressive pain in anterior superior shoulder Pain exacerbated by abduction, relieved by rest Associated with weakness and stiffness Examination Painful arm of abduction between 60-120 degrees Neer impingement test = arm internally rotated and passively flexed, positive if pain in anterolateral shoulder Hawkin's test - shoulder and elbow flexed to 90 degrees, humerus stabilised, passively internally rotate arm, positive if pain in anterolateral shoulder

Answer 528

Can be acute onset with injury or gradual onset Shoulder pain Weakness and pain with movements relating to site of tear e.g. abduction with supraspinatus tear Night pain

Answer 529

Supraspinatous - Jobe's test (empty can test) Infraspinatous - external rotation lag Teres minor - Hornblower sign Subscapularis - lift-off test, Belly-press test

Answer 530

Non-operative - physiotherapy, NSAIDS, steroid injection Operative - rotator cuff repair (young, fit), rotator cuff debridement (elderly irreparable tear), tendon transfer (young, fit, irreparable tear), reverse total shoulde arthroplasty (if massive tear with advanced arthritis)

Answer 531

Diabetes Mellitus Hypothyroidism Rheumatoid Arthritis Acromegaly Wrist fractures Pregnancy Use of heavy vibrating machinery

Answer 532

Nocturnal waking with tingling - relieved by shaking hands/running under water Altered/reduced sensation in the median nerve distribution - thumb, index, middle and half of ring finger Difficulty manipulating small objects Clumsiness - dropping cups/mugs/loose change Reduced power thumb abduction Thenar muscle wasting (late sign) +ve Tinel's sign and Phalen's test

Answer 533

Wrist splints - especially for nocturnal symptoms Steroid injections - especially during pregnancy Carpal tunnel decompression surgery - local anaesthetic with tourniquet, divide flexor retinaculum longitudinally

Answer 534

L – Loss of joint space O – Osteophytes (bone spurs) S – Subarticular sclerosis (increased density of the bone along the joint line) S – Subchondral cysts (fluid-filled holes in the bone)

Answer 535

Heberden’s nodes (in the DIP joints) Bouchard’s nodes (in the PIP joints) Squaring at the base of the thumb at the carpometacarpal joint Weak grip Reduced range of motion

Answer 536

Physiotherapy/exercise Orthoses e.g. splints Topical NSAIDs - diclofenac gel Oral analgesics - NSAIDs Intra-articular steroid injections - used for painful interphalangeal joints Surgery for structural hand abnormalities if other treatments have failed - trapziectomy for thumb base OA, arthodesis/arthroplasty for interphalangeal OA

Answer 537

Constriction and thickening of A1 pulley, nodules on tendon Risk factors: Activities involving prolonged gripping and use of the hand RA Diabetes Female Age

Answer 538

Initially painless clicking/locking/catching when trying to extend finger Most commonly middle or ring finger More than one finger can be involved, may be bilateral Can become painful over time

Answer 539

Trigger finger Extensor tendon subluxation Dupuytren's disease Radial nerve or PIN palsy

Answer 540

Peripheral nerve entrapment (Carpal Tunnel Syndrome and Cubital Tunnel Syndrome) Central nerve entrapment Peripheral Neuropathy

Answer 541

Non-operative - splintage, steroid injections Operative - surgical release/widening of A1 pulley

Answer 542

M>F Family history - autosomal dominant, variable penetrance Caucasian Northern European Diabetes Epilepsy Anti-convulsants Alcohol/liver disease

Answer 543

Fixed flexion deformities of MCP and PIP joints, most commonly ring and little fingers Difficulty with ADLs (can’t put hand in pocket, poke themselves in the eye when washing their face) If young patient then ectopic manifestations are indicative of aggressive disease (= Dupuytren’s diathesis)

Answer 544

Needle aponeurectomy - under LA a hypodermic needle is used to cut the cords Collagenase injections - injection of an enzyme into the cords that digests the collagen and weakens the cord allowing it to be ‘snapped’ by firm extension of finger 24-72hrs later Fasciectomy - surgical excision of the cords Dermofasciectomy - surgical excision of cords and overlying skin then application of a full thickness skin graft

Answer 545

Most commonly hands and feet Dorsal carpal Volar carpal Volar retinacular (tendon sheath) Dorsal DIP joint

Answer 546

Leave alone (many will spontaneously regress) Aspirate (~50-70% successful) Excise (~90% successful)

Answer 547

Level - tip, distal to flexor digitorum superficialis, proximal to FDS, hand, forearm, arm Vascularity and time from injury Bone, tendon and nerve injury - bone loss, nail loss, skin loss

Answer 548

Trim bone if too long Dressing only Terminalisation and primary closure Local advancement/transposition flap

Answer 549

Dependent on extent of amputation: Distal to FDS but proximal to DIPJ - ideal for replant because PIPJ is undamaged and likely to be flexible Proximal to FDS - if a single digit then terminalise rather than replant as PIPJ likely to be very stiff leading to a single stiff extended finger Hand and more proximal - replant

Answer 550

Vascular assessment - capillary refill, pulses, if vascular compromise but potential for replantation/revascularisation then it is a surgical emergency Neurological assessment - assess if there is injury to nerves of hand Tendon assessment - if finger laceration need to differentiate between tendons of FDS (PIP flexion) and FDP (DIP, PIP and MCP flexion)

Answer 551

Local anaesthetic (neurological assessment first) and irrigation Tetanus/IV Abx Dressing and back slab Low threshold for surgical exploration - any suspicion of tendon/nerve injury refer to orthopaedics/plastics

Answer 552

Pain - in groin, thigh, buttock or knee Aggravated by weight bearing and improved with rest Worse at end of day and better in the mornings Stiffness - improves with mobility, with grinding or crunching Antalgic gait Pain on passive movement, reduced ROM Severe - fixed flexion deformity, Trendelenburg gait

Answer 553

Initial management Analgesia - WHO analgesic ladder Weight loss Exercise Smoking cessation Physiotherapy Steroid joint injections Definitive management - total or hemiarthroplasty

Answer 554

Thromboembolic disease Bleeding Dislocation - during extremes of hip flexion, present with clunk, pain and inability to weight bear Infection Nerve injury Loosening of the prosthetic Leg length discrepancy

Answer 555

Trauma - vascular injury to vessels supplying femoral head results in ischaemia Non-traumatic AVN: Intra-vascular coagulation of the intra-osseous microcirculation results in venous thrombosis Subsequent retrograde arterial occlusion, causes intra-osseous hypertension Decreased blood flow to osteocytes in femoral head Disruption of vascular supply/ischaemia causes osteocyte necrosis Process of bone resorption and incomplete repair, loss of structural integrity from demineralisation and trabecular thinning Ultimately causes subchondral bone fracture and femoral head collapse

Answer 556

Traumatic - femoral head/neck fracture, hip dislocation, slipped upper femoral epiphysis Non-traumatic Alcohol abuse Steroids Irradiation Haematological disease e.g. leukaemia, lymphoma, sickle cell Dysbaric disorders e.g. decompression sickness from deep sea diving Hyper-coagulable states e.g. pregnancy Connective tissue disorder e.g. SLE, vasculitis Viral e.g. hepatitis, HIV Idiopathic

Answer 557

Adolescents aged 10-16, during rapid growth Male Some ethnicities higher risk e.g. black Obesity is most significant risk factor - increased forces through physis Presentation can be acute, after injury, subacute (<3 weeks) or chronic and more insidious (>3 weeks) May have limp Groin pain, often referred to thigh or knee Leg externally rotated and shortened Localised tenderness around hip joint Pain on attempts to rotate hip with decreased range of motion, especially internal rotation

Answer 558

Disruption of Shenton's line Steel sign - shadow behind superior femoral neck Widening of physis, reciprocal decrease in height of epiphysis Prominent lesser trochanter due to external rotation of hip joint Klein's line - line drawn along superior edge of the femoral neck fails to intersect the lateral part of the superior femoral epiphysis

Answer 559

AP pelvis, frog-leg lateral Check opposite hip joint as bilateral SUFE not uncommon

Answer 560

Female First born Left hip (60%, due to common intra-uterine position) Breech position in utero or delivery Family history in parent or first degree sibling Other MSK abnormalities e.g. foot deformity Oligohydramnios Large birthweight for gestational age

Answer 561

Abnormal development of the hip joint resulting in dysplasia (shallow underdeveloped acetabulum), possible subluxation of the joint (partial displacement) and potential hip dislocation (complete displacement)

Answer 562

Neonate to <3 months: Asymmetry e.g. extra or deeper thigh creases Positive Ortolani and Barlow tests (palpable hip subluxation on exam), reduced abduction >3 months to 18 months: Asymmetry, leg length discrepancy Limitation in hip abduction >1 year to walking child: Difficulty walking or unusual gait Lumbar lordosis, Trendelenburg gait (abductor weakness), toe-walking (to accommodate for leg length discrepancy) Pelvic obliquity (misalignment) Delayed presentation into childhood and adolescence: Groin, thigh, trochanter hip pain Leg length discrepancy Unexpectedly large ROM

Answer 563

Neonate to <3 - hip joint US >6 months - femoral head begins to ossify so X-rays can be used Delayed presentation - X-ray may show early onset osteoarthritis

Answer 564

Barlow test - attempts to dislocate an articulated femoral head Ortolani test - attempts to relocate a dislocated femoral head

Answer 565

Neonate to <3 months - splintage of joints in abduction and flexion with hips in a reduced position (Pavlik harness) can result in remodelling of acetabulum >3 months to 18 months - closed or open reduction of hip joint under anaesthesia with immobilisation in hip spica cast for minimum of 3 months >1 year to walking child - closed or open reduction under anaestheisa with immobilisation in hip spica cast for minimum 3 months +/- femoral or acetabular osteotomy if significant dysplasia Delayed presentation - femoral or acetabular osteotomy, if OA already started to develop will likely require total hip replacement

Answer 566

Usually elderly men with pre-existing tendinopathy from fall or eccentric loading of tendon - complain of pain in area before rupture (indicates tendinopathy) In younger patient usually direct trauma

Answer 567

Site of rupture typically at insertion of tendon into patella Can be complete or partial Bruising and swelling around quadriceps tendon Tenderness at site of rupture May have palpable defect Unable to extend knee against resistance If complete tendon rupture present may be unable to perform straight leg raise

Answer 568

Affects younger age group than quadricep rupture, commonly male and aged 20 – 40 Infra-patellar pain after sudden quadriceps contraction with knee in flexed position e.g. jumping during sport May have popping sensation

Answer 569

Elevated patella with large haemarthrosis Tenderness at site of rupture May have palpable defect around inferior pole of patella If complete tear will be unable to straight leg raise or maintain extension of knee Reduced ROM at knee joint with difficulty weight bearing

Answer 570

Previous tendon injury Existing tendinopathy Previous corticosteroid injection Steroid use Co-morbidities e.g. SLE, rheumatoid arthritis, chronic renal disease, diabetes Increasing age (for quadricep rupture)

Answer 571

Quadriceps - AP and lateral X-rays of knee will show effusion and possible 'patella baja' (abnormally low lying patella) Patella - AP and lateral X-rays of knee show proximal migration of the patella, 'patella alta'

Answer 572

Quadriceps - open repair followed by protection in extension cast or splint Patella Non-operative (for partial tears with intact extensor mechanism) - immobilisation in full extension with progressive exercise programme Operative (for complete rupture) - open repair of tendon

Answer 573

Traumatic tear - young patients, twisted knee while flexed and weight-bearing, onset of symptoms soon after Degenerative disease - older patients, more minor twisting

Answer 574

Typical mechanism of injury Pain, may localise periarticularly Instability, more notable when flexed Swelling and effusion around knee, develops gradually following injury Localised joint line tenderness on palpation, medial side more commonly injury than lateral ROM limited by swelling and effusion Locking - block to full extension, indicates torn meniscus is becoming trapped between joint Positive McMurray's test

Answer 575

ACL - forced flexion or hyperflexion of the knee, twisting injury or direct blow behind upper tibia, often sporting injury PCL - hyperextension or forced displacement of upper tibia with respect to femur, can occur when falling onto an object, less common than ACL MCL - twisting injury, possible to have pure valgus force but uncommon LCL - varus force, less common than MCL

Answer 576

ACL - haemarthrosis which develops rapidly after injury, generalised tenderness, positive anterior drawer and Lachman's test PCL - haemarthrosis, generalised tenderness, posterior sag MCL - bruising and swelling over medial knee, tenderness over ligament and medial joint, laxity on valgus stress LCL - bruising and swelling over lateral knee, tenderness over ligament and lateral joint, laxity on varus stress

Answer 577

Painful medial prominence, aggravated by walking, weight bearing, wearing narrow-toed shoes Hallux in valgus, pronated position at rest May have inflammation or skin breakdown over prominence at base of hallux Excessive ROM in transverse plane Contracture of extensor hallucis longus with longstanding joint subluxation

Answer 578

Lateral deviation and joint subluxation Measure angle between first metatarsal and first proximal phalanx - diagnosed if angle >15 degrees (mild 15-20, moderate 21-39, severe >40)

Answer 579

Female Connective tissue disorders Hypermobility syndromes Anatomical variants - long first metatarsal bone, malalignment of the first MTP joint, and flat feet

Answer 580

Analgesia Adjusting footwear Orthosis if flat feet Physiotherapy Surgical management - if QOL significant impacted Chevron procedure - osteotomy of first metatarsal, shifted laterally to normal alignment, fixed by pins and screws (mild deformity) Scarf procedure - osteotomy of shaft of first metatarsal, distal portion moved laterally and fixed with screws (moderate to severe) Lapidus procedure - base of first metatarsal and medial cuneiform fused (if tarsometatarsal joint hypermobility) Keller procedure - MTP joint capsule opened, joint surfaces removed, stabilised by suturing surrounding tissues (if MTP arthritis)

Answer 581

Gastrocnemius (originates on the posterior femur) and soleus (originates on the posterior fibula and medial tibia, deep to gastrocnemius) join together to form the Achilles tendon, which inserts on the posterior calcaneus Contraction of these muscles causes plantarflexion of the foot to allow for walking, running and jumping

Answer 582

Pain/aching in heel, worse with activity, stiffness, tenderness, swelling, nodules on palpation Simmonds’ test negative

Answer 583

Sports – ‘weekend warrior’ Increasing age M>F Achilles tendinopathy Steroid injections, systemic steroids Fluoroquinolone antibiotics e.g. ciprofloxacin, levofloxacin

Answer 584

Usually traumatic during a sporting event Can occur with: Sudden forced plantarflexion Violent dorsiflexion in a plantarflexed foot

Answer 585

Symptoms: Suggestive history with pop Sudden onset pain in Achilles/calf Feeling of something hitting them in the back of the leg Difficulty walking, unable to stand on tiptoes Signs: Increased resting ankle dorsiflexion Loss of power on plantar flexion (still possible due to peroneal tendons) Increased passive dorsiflexion Positive Simmonds’ test Palpable ‘step’ or gap in Achilles tendon

Answer 586

Same-day orthopaedics review Immediate management: Analgesia Immobilisation – splinted in plaster in full equinus (toes pointed) Non-weight bearing VTE prophylaxis while immobilised Conservative Boot to immobilise ankle, initially with foot in full plantarflexion, over 6-12 weeks ankle gradually moved to neutral position, higher rate of rerupture than surgery Operative Open end-to-end achilles tendon repair or percutaneous repair After repair, same process of immobilisation in plantarflexion --> neutral position

Answer 587

Adults - frequently rolling ankle/ankle sprains Children - asymptomatic usually Pain across medial longitudinal arch and ankle, can also affect midfoot, heel, knee, hip or back Standing - medial arch dropped, calcaneal valgus Altered gait pattern Contracted Achilles tendon

Answer 588

Pain under first metatarsal Calcaneal varus Plantar fasciitis Ankle arthritis Achilles tendonitis Back pain Tripping Lateral ankle instability and foot pain

Answer 589

Often underlying neurological condition - Charcot-Marie-Tooth idsease, spinal dysraphism, polyneutritis, intraspinal tumours, poliomyelitis, syringomyelia, Friedreich ataxia, cerebral palsy, spinal cord tumours Congenital clubfoot Post-traumatic bone malformation Contracture of plantar fascia Shortening of Achilles tendon

Answer 590

Congenital: Hypermobility syndromes - Ehlers-Danlos syndrome, Down syndrome, Marfan's syndrome Cerebral palsy High BMI Acquired: Diabetes Foot and ankle injury - rupture or dysfunction of posterior tibial tendon Pregnancy

Answer 591

Neuropathy - peripheral neuropathy and loss of proprioceptive sensation Peripheral arterial disease - macro and microvascular ischaemia

Answer 592

Calluses Ulceration Charcot's arthropathy Cellulitis Osteomyelitis Gangrene

Answer 593

Imbalance between bone formation and bone resorption - resorption by osteoclasts takes weeks, formation by osteoblasts takes months Increased activity of osteoclasts and osteoblasts Loss of trabecular bone, both mineralised and collagen components

Answer 594

Qualitative bone disorder secondary to low vitamin D levels that lead to decreased bone mineral content Causes low calcium and phosphate levels - secondary hyperparathyroidism leads to increased reabsorption of bone Causes: Vitamin D deficiency - malabsorption (coeliac, IBD), lack of sunlight, diet CKD Drug induced e.g. anticonvulsants Inherited - hypophosphataemic rickets Liver disease e.g. cirrhosis

Answer 595

Vitamin D dependent: Low UV exposure Low oral intake Low intestinal absorption (cyastic fibrosis, chronic pancreatitis, coeliac disease, gastrectomy) Drugs - anticonvulsants Hepatobiliary disease Rare hereditary forms Alcoholism Tumours Hypophosphataemia Vitamin D independent (decreased mineralisation due to phosphate deficiency): Defects in renal tubular functioning - renal tubular acidosis, Fanconi syndrome Drugs - bisphosphonates, fluoride, excessive use of phosphate-binding antacids Rickets - defective mineralisation during growth in childhood Vitamin D resistant Rickets (hypophosphataemic, X-linked dominant) Vitamin D deficiency Rickets (nutritional) Type I and II Vitamin D dependent (autosomal recessive) Renal osteodystrophy Hyperparathyroidism

Answer 596

Most prominent at large physes - knee, wrist Fraying and widening of metaphysis - cupping Increased physeal width and cortical thinning and bowing Bowing of long bones Rachitis rosary - widening of anterior rib at costal cartilages leads to lines of prominences (like beads) Kyphosis Flattening of skull May have pain at deformities

Answer 597

Low serum calcium Low serum phosphate High serum Alk phos High serum PTH Low Vit D - 25-(OH) and 1,25-(OH) Low urinary calcium

Answer 598

Pain in bones and muscles Proximal muscle weakness - waddling gait Fractures - insufficiency fractures (Looser zones - wide, transverse lucencies with sclerotic borders traversing partway through a bone) Trefoil pelvis - loss of pelvic volume Biconcave vertebral fracture

Answer 599

Vitamin D supplementation - may require loading dose Calcium supplementation if dietary intake insufficient

Answer 600

Localised pain and tenderness Increased focal temperature due to hyperaemia - vasculariy Increased bone size Bowing deformities Kyphosis Decreased ROM Often asymptomatic at time of diagnosis

Answer 601

?Viral aetiology - paramyxovirus + genetic susceptibility Increased uncoordinated osteoclast and osteoblast activity - lytic --> sclerotic Patchy areas of high density (sclerotic) and low density (lytic) bone - enlarged, misshaped bones with structural problems, increased risk of pathological fractures Usually polyosteotic - femur, tibia, pelvis, skull, spine affected commonly

Answer 602

Calcium and phosphate normal Alkaline phosphate raised Urinary hydroxyproline raised

Answer 603

Skull Osteoporosis circumscripta - large, well-defined lytic lesion Cotton wool appearance - mixed lytic and sclerotic Diploic widening - expansion of cancellous bone between innner and outer tables of calvaria Tam O'Shanter sign - skull hanging over facial bones Pelvis Cortical thickening and sclerosis of iliopectineal and ischiopubic lines Acetabular protrusion Enlargement of pubic rami and ischium Long bones Blade of grass/candle flame sign - subchondral area of lucency with advancing tip of V-shaped osteolysis, extending towards diaphysis Lateral curvature of femur Anterior curvature of tibia Spine Picture frame sign - cortical thickening and sclerosis encasing the vertebral margins Squaring - flattening of normal concavity of anterior margin of vertebral body Vertical trabecular thickening

Answer 604

Deafness - cranial nerve entrapment Osteogenic sarcoma Fractures Skull thickening High-output cardiac failure Spinal stenosis and spinal cord compression Hyperparathyroidism

Answer 605

Expectant if symptoms minimal Bisphosphonates first line Calcitonin Arthroplasty/fracture fixation if necessary - likely to bleed excessively

Answer 606

Mechanisms which lead to ischaemic - vascular interruption, intravascular occlusion, intraosseous extravascular compression Reduced subchondral blood supply induces hypxoia, leading to loss of integrity of cell membranes and necrosis of cells Invasion of neutrophils and macrophages Causes subchondral collapse and subsequent joint degeneration

Answer 607

Direct cellular toxicity - chemotherapy, radiotherapy, thermal injury, smoking Intravascular occlusion - coagulation disorders, sickle cell crises Repetitive trauma Steroids - high doses for prolonged periods Alcohol misuse Autoimmune disease e.g. lupus Bisphosphonate use Decompression illness

Answer 608

Sites with retrograde blood supply or low collateral capabilities Femoral head Knee Talus Humeral head Mandible Wrist - lunate, scaphoid

Answer 609

90% are HLA-B27 positive Affected first degree relative Typically presents in young men - affects men and women equally ?

Answer 610

Typically young man in teens - 30s Symptoms develop gradually over >3 months Lower back pain and stiffness and sacroiliac pain Worse with rest, improves with movement Pain worse at night and in the morning - takes at least 30 minutes for stiffness to improve Reduced lateral flexion, reduced forward flexion (Schober's test), reduced chest expansion Systemic associations (As) Achilles tendonitis (+ plantar fasciitis - enthesitis) Anaemia Anterior uveitis Aortitis, aortic regurgitation Apical fibrosis (pulmonary fibrosis) AV node block - heart block + Inflammatory bowel disease Weight loss, fatigue Chest pain Dactylitis Restrictive lung disease

Answer 611

Osteoid osteoma - arises from osteoblasts, tend to be small, most common in long bones (femur, tibia), <25 y/o, X-ray sclerotic margin and radiolucent nidus Osteochondroma - derived from cartilage/bone, most common benign bone tumours, usually males <20 y/o, X-ray catilage-capped ony projection on external surface of bone, metastatic transformation rare Giant cell tumour - tumour of multinucleated giant cells within a fibrous stroma, 20-40 years, usually in epiphysis of long bone, X-ray shows double bubble or soup bubble Enchondroma - cartilage tumour, usually in hands, 20-50, well-defined lucent, central medullary lesion on X-ray Lipoma - tumours of mature fat, 40-60, common in upper back, thighs, buttocks, shoulders, arms. may see radiolucent lesion on X-ray, seen on CT/MRI

Answer 612

Breast Prostate Thyroid Renal Lung

Answer 613

Bone tumours - primary or mets Myeloma Lymphoma

Answer 614

spine pelvis ribs skull long bones

Answer 615

Bone pain Pathological fractures Hypercalcaemia Raised ALP

Answer 616

Osteosarcoma - bone Ewing's sarcoma - marrow Chondrosarcoma - cartilage

Answer 617

Bone pain - worse at night, constant or intermittent, resistant to analgesia Atypical bony or soft tissue swelling/masses Pathological fractures Easy bruising Mobility issues - unexplained limp, joint stiffness, reduced ROM Inflammation and tenderness over bone Systemic symptoms - weight loss, fatigue, night sweats

Answer 618

Osteosarcoma - mostly in teens - 20s (growth spurt), associated with genetic conditions (Li Fraumeni p53 and familial retinoblastoma RB1) arise from metaphysis of distal femur, proximal tibia or proximal humerus Chondrosarcoma - males, 30-50, proximal femur, distal femur, pelvis, scapula Ewing's sarcoma - children, diaphysis of long bones such as femur, tibia and humerus, also flat bones e.g. pelvis

Answer 619

X-ray - malignant poorly defined with blurred borders, involve soft tissue, have cortical destruction MRI - soft tissue involvement Bone biopsy Staging - Enneking staging system (based on surgical grade, local extent and presence or absence of metastases)

Answer 620

Osteosarcoma - medullary and cortical destruction, significant periosteal reactions (Codman's triangle or Sunburst pattern) Ewing's sarcoma - lytic lesion with periosteal reactions, layers of reactive bone leading to 'onion skin' appearance Chondrosarcoma - lytic with calcification, cortical remodelling, endosteal scalloping

Answer 621

Osteosarcoma - aggressive surgical resection, systemic chemotherapy Ewing's sarcoma - neoadjuvant chemo then surgical excision Chondrosarcoma - surgical resection

Answer 622

Blood loss Delirium Nausea Infection Pain AKI Shock Compartment syndrome Thromboembolic disease

Answer 623

History not always possible Screening tool - abbreviated mental test score (AMTS), more detailed e.g. MMSE, ACE-III Clinical examination Confusion screen - FBC, U&Es, LFTs, coag/INR, urinalysis, imaging (CT head, CXR) etc.

Answer 624

Age >65 Multiple co-morbidities Underlying cognitive impairment e.g. dementia Renal/hepatic impairment Male Sensory impairment - hearing, visual Significant injury Sleep disturbance Pain Environmental changes Drugs - illicit, alcohol

Answer 625

WHO pain ladder Step 1 - PRN paracetamol Step 2 - PRN opioid (+ ketamine infusion?) Step 3 - PRN opioid (nurse controlled or PCA) Step 4 - opioid infusion

Answer 626

Female History of motion sickness or previous PONV Non-smoker Post-operative opiates Younger age Use of volatile anaesthetics

Answer 627

A-E assessment if unstable History - symptoms which point to symptoms Examine for signs of resp infection, UTI, IV line infections, wound infections, calf tenderness, specific signs from operation (e.g. peritonism in anastomotic leak) Septic screen - bloods, urinalysis, cultures, imaging Scores - qSOFA (RR >22, altered mental state, SBP <100, >2 points)

Answer 628

Blood loss - intra- or post-operative GI loss - vomiting/diarrhoea Being NBM for prolonged period without adequate replacement Third space losses - sepsis, bowel obstruction, burns Relative hypovolaemia - anaesthetic drugs

Answer 629

Tachypnoea Tachycardia Dizziness Agitation Reduced urine output Hypotension Reduced consciousness level

Answer 630

Class I <750ml, <15% blood loss HR, BP, RR normal Urine output >30ml/hr Class II 750-1500ml, 15-30% blood loss HR 100-120, normal BP, RR 20-30 Urine output 20-30ml/hr Class III 1500-2000ml, 30-40% blood loss HR 120-140, BP low, RR 30-40 Urine output 5-20ml/hr Class IV >2000ml, >40% blood loss HR >140, BP low, RR >40 Urine output <5 ml/hr

Answer 631

A-E assessment Direct pressure to bleeding site if visible Urgent blood transfusion if moderate to severe - if severe bleeding: packed red cells, platelets, FFP May need to re-operate for definitive haemostasis

Answer 632

Virchow's triad: Blood stasis - immobilisation, tourniquet Endothelial injury - surgical disruption, position, manipulation of limb Hypercoagulability - trauma response/blood loss, patient factors e.g. smoking, sepsis, malignancy

Answer 633

DVT - unilateral leg pain and swelling PE - sudden onset dyspnoea, pleuritic chest pain, cough, rarely haemoptysis, tachycardia, tachypnoea, pyrexia, raised JVP, pleural rub/effusion

Answer 634

Increasing age Previous VTE Smoking Pregnancy or recently post-partum Recent surgery (especially abdominal surgery, pelvic surgery, or hip or knee replacements) Prolonged immobility (> 3 days) Hormone replacement therapy or the combined oral contraceptive pill Current active malignancy Obesity Known thrombophilia disorder (e.g. antiphospholipid syndrome or Factor V Leidin)

Answer 635

DVT - calculate Well's score <1 - measure d-dimer to exclude >1 - doppler scan (or contrast venography) Management - DOAC usually (sometimes warfarin or LMWH or both), 3 months in provoked DVT, may require lifelong anticoagulation if persistent risk factor or high risk recurrence

Answer 636

PE Well's score <4 - D-dimer to exclude >4 - CTPA (or V/Q scan if poor renal function) ECG - sinus tachycardia typically seen Management - if stable anticoagulate with DOAC (or LMWH +/- warfarin), if unstable thrombolysis, IVC filter if secondary to recurrent DVTs

Answer 637

Consider in all patients undergoing lower limb surgery Al patients undergoing surgery should have mechanical thromboprophylaxis - anti-embolic stocking, intermittent pneumatic compression (intra-operatively), early mobilisation Pharmacological prophylaxis - aspirin, warfarin, unfractionated heparin (e.g. clexane), DOACs (rivaroxaban, apixaban)

Answer 638

Occurs when fatty tissue enters the systemic circulation Mechanical theory - fatty tissue directly released into vascular circulation due to trauma (long bone fractures are greatest risk) Biochemical theory - inflammatory response to trauma causes release of free fatty acids into the venous system from bone marrow Fat emboli cause severe inflammatory response in local tissues, increases vessel permeability - causes cerebral oedema and ARDS

Answer 639

Young age Long bone fractures Closed fractures Multiple fractures Conservative management for long bone fractures Hip/knee arthroplasty

Answer 640

Following trauma/surgery, within 24-72 hours Worsening shortness of breath Confusion, drowsiness Petechial rash - classically axilla and conjunctiva On examination - tachypnoea, tachycardia, hypoxia Non-specific neurological signs - acute confusion, seizures Low grade pyrexia Gurd's criteria - 2 major or 1 major and 4 minor Major - petechial rash, respiratory insufficiency, cerevbral involvement Minor - tachycardia, pyrexia, retinal changes, jaundice, thrombocytopaenia, anaemia, raised ESR, fat macroglobinaemia

Answer 641

Bloods - FBC, CRP, U&Es, LFTs, clotting screen ABG - type 1 respiratory failure Blood film - fat globules CXR - bilateral diffuse pulmonary infiltrates CTPA - ground-glass changes with global distribution

Answer 642

Largely supportive - mostly require respiratory support (mechanical ventilation) Steroids not shown to be effective in treatment

Answer 643

Fix long bone fractures as early as possible Close monitoring of patients with intramedullary nailing - continuous pulse oximetry

Answer 644

Staph aureus Streptococci Pseudomonas MRSA Salmonella - sickle cell disease

Answer 645

Symptoms of infection e.g. urinary symptoms, cough/SOB, erythematous/discharging wound, peritonism Features of organ dysfunction - hypoxia, oliguria, AKI, thrombocytopaenia, coagulation dysfunction, hypotension, hyperlactaemia (>2), reduced consciousness

Answer 646

Sepsis 6: Measure urine output - catheterise if appropriate Measure lactate (+ other routine bloods) Take blood cultures - prior to Abx Give IV fluids - initial bolus 500-1000ml, ongoing reassessment Give IV antibiotics - empirical then targeted therapy Give oxygen - 15L trauma non-rebreather mask, aim for 94-98% (88-92% in chronic CO2 retainers)

Answer 647

Empirical antibiotics started ASAP after blood cultures and joint aspirate taken Native joint - IV flucloxacillin (IV vancomycin if MRSA or penicillin allergic, + gentamicin if high risk for gram negative) Prosthetic joint - IV vancomycin + IV gentamicin Infected native joint - irrigation and debridement (may need multiple) Prosthetic - washout, revision surgery (acute or staged)

Answer 648

Erythema Warm to touch Tense Thickened Oedematous Bullae - fluid-filled blisters Golden-yellow crust - staph aureus infection Systemic upset - fever, confusion, tachycardia, hypotension, tachypnoea

Answer 649

Eron classification Class I - no signs of systemic toxicity, no uncontrolled co-morbidities Class II - systemically unwell or systemically well but with co-morbidity (e.g. PAD, chronic venous insufficiency, morbid obesity) Class III - significant systemic upset e.g. acute confusion, tachycardia, tachypnoea, hypotension, unstable co-morbidities or limb threatening infection due to vascular compromise Class IV - sepsis syndrome or a severe life-threatening infection e.g. necrotising fasciitis

Answer 650

Mild skin/soft tissue infection - oral flucloxacillin Moderate/severe cellulitis - IV flucloxacillin (IV vancomycin if MRSA/penicillin allergy, IV clindomycin if rapidly progressing)

Answer 651

Type I - polymicrobial, mixture of anaerobes (e.g. bacteroides) and aerobes (e.g. staph aureus), more common, especially in elderly/co-morbid Type II - monomicrobial, primarily caused by strep pyogenes (group A strep, can also be Panton-Valentine leucocidin-positive staph aureus), more common in young patients with history of trauma

Answer 652

May have precipitating event e.g. bite, trauma, surgery Rapid progression Severe pain, out of keeping with clinical signs Haemodynamic instability - fever, tachycardia, hypotension Multi-organ dysfunction Overlying skin can be normal initially, will progress with erythema, oedema, crepitus, vesicles/bullae, obvious skin necrosis Positive finger sweep test

Answer 653

Suspected necrotising fasciitis - urgent debridement/surgical exploration, antibiotics (flucloxacillin, benzxylpenicillin, metronidazole, clindamycin, gentamicin)

Answer 654

Painful Tender Erythematous Initially swelling is firm, then progresses to fluctuant, may then spontaneously drain Local cellulitis Lymphangitis - tracking Regional lymphadenopathy Fever

Answer 655

Incision and drainage if significant pain/swelling - usually under LA, may require GA Antibiotics if signs of systemic infection, cellulitis, immunocompromise

Answer 656

Toddler: Transient synovitis Infection - septic arthritis, osteomyelitis Developmental dysplasia of the hip Trauma - any fracture, sprain etc. Older child: Transient synovitis Infection Trauma Perthes' disease Adolescent Transient synovitis Infection Trauma Slipped upper femoral epiphysis Late Perthes' Overuse syndromes - Osgood Schlatter's disease, Sever's disease Other Neuromusclar - Duchenne's muscular dystrophy, cerebral palsy Bony dysplasia - club foot Discoid meniscus Osteochondritis dissecans Tarsal coalition Arthritides

Answer 657

Trauma - history of injury, X-ray appearance (stress fracture may not be visible initially) Infection - pyrexial, generally unwell, pain on any movement of joint, local warmth/tenderness, raised WCC, CRP/ESR Transient synovitis - age 3-8, similar presentation to infection but less severe, often preceded by viral illness, may be recurrent, bloods usually normal DDH - usually picked up early on routine checks, if missed may present with limp or delayed gait, shortened leg, reduced abduction, painless Perthes' disease - boys > girls, age 4-8 SCFE - usually around puberty, groin or knee pain Osgood-Schlatter's disease - palpable tender lump at tibial tuberosity, anterior knee pain, exacerbated by physical activity Meniscal tear - twisting injury, symptoms of locking or catching Juvenile arthritis - gradual onset, intermittent joint pain and swelling, single joint often affected, general malaise

Answer 658

More buckle and greenstick fractures - bone more fibrous with tough periosteum Epiphyseal growth plate is area of weakness - epiphyseal fractures occur commonly Less severe growth plate fractures (Salter-Harris I-III) do not cause growth disturbance, more severe (Salter-Harris IV) traverses growth plate and cause growth disturbance if not properly reduced Fracture healing occurs faster, difficult to correct position if not done quickly Remodelling ability means less than perfect position can be acceptable (ability decreases with age) Loss of length is made up by overgrowth (as long as <2cm) Produce more callus - often palpable Pathological fractures occur due to bone cysts, osteitis, neoplasm, osteogenesis imperfecta

Answer 659

Salter-Harris classification Salter-Harris I - separation of growth plate without bone involvement (metaphysis or epiphysis), most commonly at distal fibular epiphysis Salter-Harris II - fracture across growth plate, small fragment of metaphysis attached to epiphysis, most commonly at distal radial epiphysis Salter-Harris III - fracture across growth plate with extension across epiphysis, most commonly at distal tibial epiphysis, occasionally in epiphyses of proximal and middle phalanges of fingers Salter-Harris IV - combination of II and III, fracture line traverses epiphysis and part of diaphysis, most commonly in lateral condylar mass of elbow and distal tibial epiphysis Salter-Harris V - crush injury of part of the epiphysis, nothing seen on X-ray, diagnosis only made as result of deformity occurring at growth plate, most common at distal tibial epiphysis but rare

Answer 660

Neurological examination - evaluate for: AIN neuropraxia - unable to flex interphalangeal joint of thumb and distal interphalangeal joint of index finger (can't make OK sign) Median nerve injury - loss of sensation over volar index finger Radial nerve neuropraxia - inability to extend wrist, MCP joints, thumb IUP joint Vascular exam - assess pulse and perfusion

Answer 661

Cavus (high arch) - tight intrinsics, flexor hallucis longus, flexor digitorum longus Adductus of forefoot - tight tibialis posterior Varus - tight tendoachilles, tibialis posterior, tibialis anterior Equinus (limited dorsiflexion) - tight tendoachilles (CAVE)

Answer 662

Most commonly idiopathic. Associations include: Spina bifida Cerebral palsy Edward's syndrome (trisomy 18) Oligohydramnios Arthrogryposis

Answer 663

Conservative (most common) - Ponseti method Manipulation and progressive casting, usually corrected in 6-10 weeks, usually requires Achilles tenotomy Brace at night until 4 years old

Answer 664

Multiple injuries Bruises shaped like hands or identifiable objects Bruises, lacerations or abrasions on non-bony parts of body or face/ears Multiple bruises or clustered bruises Bruises, lacerations or abrasions in a child who cannot mobilise Human bites Thermal injuries in places you would not expect to come into contact with a hot object, in the shape of an object (e.g. cigarette) or sharply delineated (immersion injury) Fractures of different ages on imaging (especially if no record of seeking medical care) Occult rib fractures, spiral fractures, metaphyseal corner fractures Multiple subdural haemorrhages Retinal haemorrhages Delayed presentation

Answer 665

Pigeon toeing (persisting femoral anteversion) - normal variant aged 2-4, due to rotational posture of hips and joint laxity, worsened by sitting in W position, resolves with time Splay feet - opposite to pigeon toed, resolves naturally with time usually Genu varum and valgum - often bow legs from 6 months - 2 years, above 2 years knock knee is more common, often worse in obese children but resolve spontaneously Flat feet - most infants have flat feet, arch reappears when standing on toes and will resolve with age

Answer 666

Equally occurs in men and women, most commonly presents ages 30-50 Mostly peripheral polyarticular disease, asymmetric DIP joint involvement common Axial involvement 5% at presentation Pain, morning stiffness, swelling, tenderness of joints Enthesitis - inflammation at insertion of tendons and ligaments, most commonly Achilles Dactylitis - inflammation of whole digit, fingers or toes Severity of arthritis and skin symptoms usually do not correlate Skin disease - scalp, intergluteal and perianal lesions associated with higher risk of PsA Nail disease - discoloured (yellow/brown), onycholysis, pitting, ridging, subungal keratosis

Answer 667

CVD - hypertension, IHD (mitral valve prolapse, aortic root dilation, aortic regurgitation) Lymphoma/malignancy Depression Uveitis Obesity Osteoporosis NAFLD Renal disease IBD

Answer 668

Rheumatoid has autoantibodies Rheumatoid tends to be more symmetrical whereas PsA is usually asymmetrical Psoriasis has skin and nail involvement DIP and axial involvement in PsA, rare in RA Enthesitis and dactylitis in PsA Bone proliferation occurs in PsA, more bone erosion in RA Genetic susceptibility - HLA-B27 in PsA, HLA-DRB1 in RA

Answer 669

Periostitis - inflammation of periosteum, causes thickened, irregular outline of bone Ankylosis - bones join together Osteolysis - destruction of bone Dactylitis - soft tissue swelling Pencil-in-cup appearance - central erosions of bone beside joints, one bone looks hollow, other is narrow and sits inside the cup

Answer 670

NSAIDs first line for peripheral arthritis, axial disease, dactylitis and enthesitis Topical treatment first line for skin/nail disease Systemic DMARDs (e.g. methotrexate) second line for peripheral arthritis, skin and nail changes Biologics (anti-TNF, IL-12, 23, 17) option for inadequate response to first line for peripheral arthritis, axial disease, dactyltitis, enthesitis, skin and nail disease Intra-articular steroid injections option for peripheral arthritis

Answer 671

Screening test: Psoriasis Epidemiology Screening Tool (PEST) Measurement of response to treatment: Psoriatic arthritis response criteria (PsARC) for disease improvement American College of Rheumatology Response (ACR20) Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) - used for axial disease Dermatology assessment tool: Psoriasis Area and Severity Index (PASI)

Answer 672

Typically young man, teens - 20s (actually affects men and women equally) Gradual onset lower back pain and stiffness Sacroiliac pain (buttocks) Pain and stiffness worse with rest, improves with movement Pain worse at night, may wake from sleep Morning stiffness - >30 minutes Reduced lateral flexion and forward flexion (Schober's test) 95% HLA-B27 positive

Answer 673

Enthesitis - Achilles, planter fasciitis Dactylitis Uveitis Aortitis Heart block Restrictive lung disease Pulmonary fibrosis - apical Chest pain - costosternal joint inflammation Anaemia IBD Peripheral arthritis

Answer 674

Squaring of vertebral bodies Subchondral sclerosis and erosions Small erosions at corners of vertebral bodies with reactive sclerosis - shiny corner sign Syndesmophytes - bone overgrowth where ligaments insert into bone Ossification of ligaments, discs and joints Fusion of facet, sacroiliac, costovertebral joints = 'Bamboo spine'

Answer 675

Sacroiliac joints widen then narrow Subchondral erosions, sclerosis, proliferation of iliac side End-stage - SI joint may be seen as a thin line or not visible

Answer 676

Decreased fat signal, increased fluid signal due to bone oedema adjacent to sacroiliac joints = active sacroiliitis (likely to be normal on X-ray)

Answer 677

NSAIDs first line - manage pain (can try multiple NSAIDs if response not adequate) Steroids - used during flares to control symptoms (oral, IM or joint injections) Biologics - anti-TNF, IL-17 Physiotherapy Bisphosphonates for osteoporosis Surgery occasionally for deformities of spine/other joints - spinal fractures are complication

Answer 678

Peripheral and axial arthritis (including sacroiliitis with or without spondylitis) Extra-articular manifestations - enthesitis, dactylitis, tendonitis, periostitis, osteoporosis, uveitis, erythema nodosum, pyoderma gangrenosum + inflammatory bowel disease

Answer 679

Steroids/DMARDs (including anti-TNF) used to treat IBD often help with symptoms of arthritis Can also use intra-articular steroid injections, NSAIDs (may exacerbate IBD)

Answer 680

Onset after gastroenteritis or sexually transmitted infection (chlamydia most common) - within 4 weeks Typically asymmetrical 1-3 joints affected usually Warm, swollen, painful joint Extra-articular associations - dactylitis, urethritis, conjunctivitis, uveitis, circinate balanitis, keratoderma blenorrhagica HLA-B27 positive

Answer 681

Need to rule out septic arthritis - give antibiotics until this has been done (via joint aspirate, taken before antibiotics started, also send for crystal examination) NSAIDs Steroid injections into affected joint Systemic steroids may be required, especially when multiple joint affected Most resolve within 6 months and don't recur, recurrent cases may require DMARDs or anti-TNF medications

Answer 682

BASDAI – Bath Ankylosing Spondylitis Disease Activity Index BASFI – Bath Ankylosing Spondylitis Functional Index BASMI – Bath Ankylosing Spondylitis Metrology Index (measures spinal mobility) Measure CRP

Answer 683

PRISM: P - pain - SOCRATES R - rashes, skin lesions and nail changes I - immune - systemic sclerosis (CReST), SLE, Sjogren's S - stiffness (RA, AS, SLE, reactive arthritis) M - malignancy - weight loss, night sweats, fatigue, fever, appetite Extra-articular manifestations - uveitis, dry eyes/mouth, interstitial lung disease, urethritis etc.

Answer 684

>50, F>M Bilateral proximal muscle pain and stiffness in neck, shoulder and pelvic girdle for >2 weeks Worse with movement Interferes with sleep Morning stiffness for >45 minutes Systemic symptoms - fever, weight loss, night sweats, malaise, anorexia Strong association with giant cell arteritis - may present with symptoms of GCA (jaw claudication, scalp tenderness, visual changes) CRP/ESR raised Antibodies negative

Answer 685

Steroids - response aids diagnosis Prednisolone 15mg/day, assess response and step down dose (give PPI and bone protection)

Answer 686

Severe unilateral headache around temple/forehead Scalp tenderness Jaw claudication Blurred or double vision Irreversible painless complete sight loss can occur rapidly Systemic symptoms - fatigue, depression, fever, anorexia, night sweats 50% have features of PMR ESR/CRP high Temporal artery biopsy - multi-nucleated giant cells

Answer 687

Immediate initiation of steroids (before confirming diagnosis) - if no visual loss high-dose oral prednisolone, if vision loss IV methylprednisolone given first (+ same day ophthalmology review) PPI and bone protection Taper steroid dose over months Aspirin 75mg daily - decreases vision loss and stroke

Answer 688

Limited cutaneous systemic sclerosis - most common, involves skin or face and skin below elbows and knees (hands and feet) Diffuse cutaneous systemic sclerosis - same areas affected as limited disease + skin on trunk and proximal limbs and internal organs (lungs, kidneys, heart, GI tract)

Answer 689

Limited cutaneous systemic sclerosis - CREST C - calcinosis, deposits of calcium in soft tissues R - Raynaud's, colour change in hands from white --> purple --> pink E - oesophageal dysmotility - dysphagia S - sclerodactyly - thickness and tightness of skin of fingers T - telangiectasia red spots around mouth, nose and sometimes palms Diffuse systemic sclerosis - CREST symptoms + proximal limb and trunk skin involvement GI - oesophagitis, oesophageal strictures, paralytic ileus, constipation, malabsorption Lungs - interstitial fibrosis, pulmonary hypertension Cardiac - pericarditis, heart failure, arrhythmias Kidneys - glomerulosclerosis, intimal hyperplasia

Answer 690

ANA - positive in 90% Anti-SCL 70 - more associated with diffuse Anti-centromere - more associated with limited (RF positive in 30%)

Answer 691

Immunosuppressants slow disease progression - cyclophosphamide Analgesia CCB for Raynaud's (nifedipine) Skin emollients

Answer 692

Symmetrical, proximal muscle weakness Mostly affects shoulder and pelvic girdle Extra-skeletal manifestations - dysphagia, interstitial lung disease, arrhythmias, acute tubular necrosis Elevated creatinine kinase is key diagnostic feature Dermatomyositis - same symptoms with skin involvement Gottron lesions (scaly erythematous patches) on knuckles Photosensitive erythematous rash on back, shoulders and neck Purple rash on face and eyelids (heliotrope) Periorbital oedema Subcutaneous calcinosis Can be a paraneoplastic syndrome

Answer 693

Anti-Jo-1 antibodies - polymyositis (+ dermatomyositis, especially associated with interstitial lung disease) Anti-Mi-2 antibodies - dermatomyositis ANA - dermatomyositis

Answer 694

High-dose steroids - assess response by improvement in muscle strength Methotrexate, azathioprine, mycophenolate used as steroid sparing agents IVIG, plasmapheresis, biologics may be used if inadequate response

Answer 695

Large vessel: Giant cell arthritis Takayasu's arteritis Aortitis Medium vessel: Polyarteritis nodosa Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) Kawasaki disease Small vessel: Henoch-Schonlein purpura Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) Microscopic polyangiitis Granulomatosis with polyangiitis Anti-glomerular basement membrane disease

Answer 696

Purpura Joint and muscle pain Peripheral neuropathy Renal impairment Gastrointestinal disturbance (diarrhoea, abdominal pain and bleeding) Anterior uveitis and scleritis Hypertension Systemic - fatigue, fever, weight loss, anorexia, anaemia

Answer 697

CRP/ESR usually raised Autoantibodies: ANCA positive - most vasculitides p-ANCA (MPO antibodies) - microscopic polyangiitis and Churg-Strauss syndrome c-ANCA (PR3 antibodies) - granulomatosis with polyangiitis Immune complex small vessel vasculitis Henoch-Schonlein purpura - IgA Goodpasture's - anti-GBM

Answer 698

Female Ethnicity - Asian, Hispanic, Black 20s-30s Sunlight exposure Genetic - family history, HLA-DR2/3

Answer 699

Constitutional symptoms - fatigue, fever, mouth ulcers, lymphadenopathy, weight loss Musculoskeletal - arthralgia (non-erosive), myalgia Skin - malar rash, discoid rash, photosensitivity, Raynaud's, livedo reticularis, non-scarring alopecia Cardiovascular - pericarditits, myocarditis Respiratory - pleurisy, fibrosing alveolitis Renal - proteinuria, glomerulonephritis Neuropsychiatric - anxiety and depression, psychosis, seizures

Answer 700

Anaemia Leukopaenia Thrombocytopaenia Raised ESR CRP usually normal unless co-existing infection Immunology ANA raised - high sensitivity Anti-Smith antibodies - high specificity Anti-dsDNA - high specificity, also used to monitor disease activity Antiphospholipid antibodies - secondary to SLE, in 40%, associated with increased risk of VTE

Answer 701

ESR CRP usually normal unless underlying infection Complement (C3/4) - low during active disease (complex formation leads to consumption of complement) Anti-dsDNA used for disease monitoring

Answer 702

First line - NSAIDs, steroids, hydroxychloroquine Sun avoidance and suncream Other immunosuppresants in resistant/severe disease - methotrexate, ciclosporin, azathioprine etc. Biologic therapies - rituximab, belimumab

Answer 703

Dry eyes - grittiness, foreign body, irritation Dry mouth - difficulty swallowing food, dental caries, decreased taste Salivary gland and lacrimal gland enlargement Vaginal dryness Associated conditions - cutaneous vasculitis, arthralgia, interstitial lung disease, dysphagia, nausea, interstitial nephritis, renal tubular acidosis, peripheral neuropathy, fibromyalgia Lymphoma - long term risk

Answer 704

Schirmer test - filter paper under lower eyelid, measure level of moistness after 5 minutes (<10mm significant) Often RF and ANA positive Anti-Ro - positive in 70% Anti-La - positive in 30%

Answer 705

Artificial saliva and tears Pilocarpine - stimulate tears/salivary flow Punctal occlusion Systemic treatment - hydroxychloroquine, methotrexate Biologics - rituximab

Answer 706

Raynaud's Arthralgia Skin inflammation and thickening, hair loss Muscle weakness Oesophageal dysfunction Pulmonary hypertension Interstitial lung disease Rarely - cardiac and renal involvement Lymphadenopathy Splenomegaly

Answer 707

ANA Anti-RNP - specific

Answer 708

Venous/arterial thrombosis - DVT, PE, stroke, MI Recurrent miscarriages Livedo reticularis Thrombocytopaenia Prolonged APTT Pre-eclampsia Pulmonary hypertension

Answer 709

Antiphospholipid antibodies: Lupus anticoagulant Anticardiolipin antibodies Anti-beta-2 glycoprotein I antibodies

Answer 710

Primary thromboprophylaxis - low-dose aspirin Secondary thromboprophylaxis - Initial venous thromboemoblic events - lifelong warfarin with target INR of 2-3 Recurrent VTE - lifelong warfarin (add aspirin), INR 3-4 If pregnant - LMWH + aspirin

Answer 711

RF - rheumatoid arthritis ANA - generally connective tissue disorders Anti-CCP - RA Anti-dsDNA - SLE Anti-Ro - Sjogren's, neonatal lupus Anti-La - Sjogren's Anti-SM - SLE Anti-Jo-1 - polymyositis Anti-centromere - limited cutaneous systemic sclerosis Anti-Scl-70 - diffuse cutaneous systemic sclerosis Anti-RNP - mixed connective tissue disease p-ANCA (MPO) - microscopic polyangiitis and Churg Strauss c-ANCA (PR3) - granulomatosis with polyangiitis

Answer 712

Includes granulomatosis with polyangiitis (Wegner's), eosinophilic granulomatosis with polyangiitis (Churgh-Strauss syndrome) and microscopic polyangiitis Highest incidence in >70s Symptoms: Constitutional - fever, weight loss, fatigue, night sweats, myalgia Upper respiratory tract - epistaxis, crusty nasal secretions, hearing loss, sinusitis, saddle shaped nose due to septum perforation Lower respiratory tract - cough, wheeze, haemopytsis, consolidation on CXR Kidneys - glomerulonephritis Skin - purpuric rash Eye - scleritis Nerve - peripheral neuropathies (wrist/foot drop)

Rheumatology + Orthopaedics Flashcards

(743 cards)