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Flashcards in T&O II Deck (39):
1

A 22-year-old male presents with a one day history of pain and swelling of the right knee which developed after he injured his right knee in a tackle whilst playing football three days earlier.
Originally he presented to the emergency department with an area of tenderness 2-3 cm above the joint line on the medial aspect. He has increased valgus deformity on examination.

Medial collateral ligament
The young footballer presents with a typical history of collateral ligament injury with valgus deformity, delayed swelling and tenderness above the joint. Tenderness over the joint line suggests meniscal injury.

2

A 24-year-old female basketball player complained of hearing a popping sound after landing and twisting her foot during a practice game. She was in immediate pain and her knee gave way when she tried to walk.

ACL
The anterior cruciate ligament prevents backward displacement of the femur on the tibial plateau and limits extension of the lateral condyle of the femur.

3

A 42-year-old male is admitted after a road traffic accident, where he hit his knee on the steering column, producing an immediate haemarthrosis.
An x ray showed no bony injury, but he has since had problems walking downstairs.

Posterior cruciate ligament
The posterior cruciate ligament is involved in retaining the femur in position preventing it from sliding over the tibial plateau. The history of problems walking downstairs suggests posterior cruciate injury.

Immediate haemarthrosis is indicative of cruciate ligament rupture or fracture.

4

During an orthopaedic examination of the hip you carry out the following examination:
The patient stands directly in front of you.
You place your hands on their anterior superior iliac spines.
You then ask them to lift their good leg off the floor so that their weight is on the bad leg that is being examined.
You note which way the pelvis tilts.
What is the name of this test?
(Please select 1 option)
Lachmann test
Macintosh test
McMurray test
Thomas test
Trendelenberg test

Trendelenberg test This is the correct answerThis is the correct answer
This is Trendelenberg's test.

In a normal Trendelenberg test, when the patient stands on one leg, the abductors (gluteus medius and minimus) of the supporting leg would pull on the pelvis.

This means that the pelvis tilts and the opposite side of the pelvis rises.

A positive Trendelenberg's test occurs when the opposite side of the pelvis falls.

Causes of a positive Trendelenberg test include:

Gluteal paralysis or weakness
Pain in the hip causing gluteal inhibition
Coxa vara and
Congenital dislocation of the hip.
A Thomas test is also used in the hip examination as a test of hip extension.

Lachmann's, Macintosh's and McMurray's tests are used in the clinical examination of the knee.

5

During the anteriolateral (Hardinge) approach to the hip joint, after division of tensor fascia lata, which muscle is encountered before the hip joint is seen?
(Please select 1 option)
Gemellus
Gluteus maximus
Gluteus medius
Gluteus minimus
Sartorius

Gluteus medius

The three commonest approaches to the hip joint are the

Anterior
Anterolateral (Hardinge) and
Posterior
approaches.

In the Hardinge approach a skin incision is made from the greater trochanter. Tensor fascia lata is divided before gluteus medius is seen. Gluteus medius is then divided to reach the capsule.

In the posterior approach after skin and tensor fascia lata are divided the short external rotators are divided. There is an increased risk of dislocation with this approach.

6

A 27-year-old man attends the fracture clinic. He suffered an anterior dislocation of his shoulder whilst playing rugby three days before. This has been successfully manipulated back into joint in the emergency department. Since then his arm has been in a broad arm sling.
When you examine him in the fracture clinic he is unable to abduct his shoulder and there is a numb patch over the lateral side of his arm.
Which nerve has been affected?
(Please select 1 option)
Axillary nerve
Musculocutaneous nerve
Nerve to subscapularis
Radial nerve
Upper cord of brachial plexus

Axillary nerve

Common mechanisms of axillary nerve injury are

Following anterior dislocation of the shoulder
Proximal fracture of the humerus or
Injury during intramuscular injections into the deltoid muscle.
Injury to the axillary nerve will lead to paralsysis of the deltoid muscle which means that shoulder abduction will be virtually absent. There is also loss of sensation over an area of the upper limb which is also known as the 'regimental badge' area.

The deltoid muscle arises from the lateral third of the clavicle, the acromion and the spine of the scapula. It attaches into the deltoid tuberosity of the humerus.

7

A 23-year-old hairdresser presents with a history suggestive of subarachnoid haemorrhage on the emergency medical intake.
A CT scan is carried out and this is normal. To exclude a bleed, a lumbar puncture is carried out by the medical registrar.
After piercing the interspinous ligament with the spinal needle which of the following is the next structure to be passed through (next deepest structure)?
(Please select 1 option)
Arachnoid mater
Dura mater
Ligamentum flavum
Spinal cord
Supraspinous ligament

Ligamentum flavum

The landmarks for a lumbar puncture are the iliac crests.

The vertebra in the line with these is the fourth lumbar vertebra. The spinal cord ends at L1 level.

The different structures which a spinal needle would pass through are (most superficial to most deep)

Skin
Fascia
Supraspinous ligament
Interspinous ligament
Ligamentum flavum
Areolar tissue
Dura
Arachnoid mater.

8

A 64-year-old lady is undergoing a right total hip replacement.
The surgeon's preferred approach to the hip joint is the lateral approach. To reach the hip joint, he splits the tensor fascia lata, and then gluteus medius and minimus. During this approach, the nerve supply to the tensor fascia lata and gluteus medius is at risk.
What nerve innervates this muscle?
(Please select 1 option)
Femoral nerve
Lateral femoral cutaneous nerve of the thigh
Posterior branch of obturator nerve
Sciatic nerve
Superior gluteal nerve

Superior gluteal nerve This is the correct answerThis is the correct answer
The superior gluteal nerve arises from the ventral rami of L4- S1. It leaves the pelvis through the greater sciatic foramen. It supplies the gluteus medius, gluteus minimus and tensor fascia lata muscles.

There are several different approaches to the hip and different nerves may be damaged depending on which approach is used.

The posterior approach to the hip joint involves an incision through the deep fascia and gluteus maximus and then division of the external rotators. The sciatic nerve is in danger with this approach.

The anterior approach involves the planes between tensor fascia lata and sartorius and then rectus femoris and gluteus medius. The lateral femoral cutaneous nerve of the thigh is in danger with this approach.

9

A 71-year-old lady has a total hip replacement and post operatively develops a Trendelenburg gait.
From the list below which structure is likely to have been damaged?
(Please select 1 option)
Femoral nerve
Obturator nerve
Psoas muscle
Sciatic nerve
Superior gluteal nerve

Superior gluteal nerve This is the correct answerThis is the correct answer
A Trendelenburg gait is caused by weakness of the hip abductors.

A superior gluteal nerve injury would paralyse the gluteus medius causing a Trendelenburg gait.

The femoral nerve supplies the anterior thigh muscles.

The obturator nerve supplies the hip adductors.

Injury to the psoas muscle would cause weakness of hip flexion.

The sciatic nerve supplies the hamstrings and other hip extensors.

10

A 23-year-old keen rugby player fractures his ankle whilst playing rugby and is then placed in a below knee plaster of Paris for six weeks.
After removal of the plaster he is noted to have quadriceps weakness of the affected limb.
What is the likely explanation for the quadriceps weakness?
(Please select 1 option)
Agenesis
Aplasia
Atrophy
Hyperplasia
Hypertrophy

Atrophy

Atrophy is defined as degeneration of an organ or tissue from its fully formed state.

Agenesis is complete failure of an organ or tissue to develop.

Aplasia is failure of an organ or tissue to attain its proper size.

Hyperplasia is an increase in the size of an organ or tissue because of an increase in the number of cells.

Hypertrophy is an increase in the size of an organ or tissue because of an increase in the size of its cells.

11

A 57-year-old male presents to the emergency department a few months after injuring his upper limb.
On examination the following are observed
Wasting of the interossei on the dorsum of the affected hand
Extension of the metocarpophalyngeal joints and
Marked flexion of the proximal and distal interphalyngeal joints.
There is no radial deviation.
Which of the following is the most likely mechanism of injury?
(Please select 1 option)
A laceration at the elbow
A laceration at the wrist
Fall from height and catching a ledge
Supracondylar fracture
Wrist fracture causing carpal tunnel syndrome

laceration in wrist

The description is of a true claw hand caused by injury to the ulnar nerve.

The injury is likely to be at the level of the wrist rather than the elbow as we are told the proximal and distal IP joints are flexed - due to flexor digitorum profundus being intact and there is no radial deviation.

You may expect radial deviation if the ulnar nerve is injured at the level of the elbow due to paralysis of flexor carpi ulnaris, which is also supplied by the ulnar nerve.

A fall from height and catching a ledge would typically cause a brachial plexus injury.

A supracondylar fracture can be complicated by ulnar nerve injury but this would cause signs of injury at the elbow.

Wrist fracture causing carpal tunnel syndrome would lead to signs of median nerve injury.

12

This film was taken on a 30-year-old male who originally presented to the orthopaedic surgeons six weeks ago with a fracture of the right tibia.

Following treatment he now complains of pain in the ankle.
Which of the following options is the likely diagnosis?
(Please select 1 option)
Avascular necrosis
Fractured talus
Fractured tibia
Osteoarthritis
Reflex sympathetic dystrophy

AVN

There is avascular necrosis of the talus.

This is a complication of the initial fracture causing ischaemia of the talus. There is a sub-cortical fissure (lucency) related to the dome of the talus.

13

A 53-year-old pedestrian is brought to the Emergency department after he was hit on a crossing by a car travelling at about 30 mph. He has numerous bruises and lacerations over his left chest wall.
On examination he appears pale and anxious. His blood pressure is 90/64 mmHg, heart rate is 116/min, respiratory rate is 20/min and his jugular venous pressure is elevated. Trachea is central and breath sounds are normal bilaterally but the heart sounds are muffled. A chest radiograph shows fractured 4th, 5th and 6th ribs on the left side and an enlarged cardiac silhouette.
What is the most likely diagnosis?
(Please select 1 option)
Cardiac tamponade
Diaphragmatic rupture
Ruptured thoracic aorta
Tension pneumothorax
Traumatic haemothorax

Cardiac tamponade

Direct penetrating injury to the heart is the mostly likely aetiology for a cardiac tamponade although blunt injuries to the heart may also lead to this condition by injuring the pericardial vessels.

Likewise, high velocity injuries to the great vessels (for example, thoracic aorta) could result in pooling of blood in the pericardium leading to tamponade.

Apart from trauma it can occur following lung or breast carcinomas, myocardial infarctions, dissecting thoracic aneurysm and bacterial, viral or tuberculous pericarditis.

Cardiac tamponade can be difficult to detect clinically, especially in a trauma setting. The classic (and diagnostic) signs include:

A fall in blood pressure
Rising jugular venous pulse and
Muffled heart sounds (Beck's triad).
Pulsus paradoxus may also be an associated finding (normally, there is a physiological decrease in systolic blood pressure during spontaneous inspiration. When this change exceeds 10 mmHg, it is termed pulsus paradoxus.).

In addition, the jugular venous pulse may paradoxically rise with inspiration (Kussmaul's sign).

Chest radiograph may reveal a globular heart, a convex or straight left heart border, and a right cardiophrenic angle of

14

A 29-year-old motorcyclist is brought to the emergency department after he was involved in a high speed road traffic accident on the motorway. He was thrown off his bike onto the road.
On examination, severe bruising is noticed over his left antero-lateral chest wall. There is decreased air entry over the left lower lobe of lung and bowel sounds are heard in the chest. A chest x ray reveals fracture of the lower four ribs on the left side and a raised left dome of the diaphragm.
From the options below choose the one which you think is the most likely diagnosis in this patient.
(Please select 1 option)
Cardiac tamponade
Diaphragmatic rupture
Left basal pneumonia
Tension pneumothorax
Traumatic haemothorax

Diaphragmatic rupture

This patient is most likely to have a ruptured diaphragm. Direct penetrating injury to the thoraco-abdominal region is a common cause for diaphragmatic rupture. The injury could be at any level between the fourth and the tenth inter-costal space, depending on the patient's respiratory pattern.

The other causes include rib fractures and a sudden increase in thoraco-abdominal pressure, as may occur when a patient with a closed glottis is hit in the abdomen.

The diaphragmatic rupture may present with signs and symptoms of cardiac and pulmonary compromise. The patient may or may not be haemodynamically compromised. Diaphragmatic rupture may be difficult to detect clinically, and thus may result in significant morbidity or sometimes mortality. Rupture may be seen on plain chest radiograph especially with the abnormal location of the naso-gastric tube; the accuracy of this method, however, is modest.

The differential diagnoses for a raised left hemidiaphragm, both clinically and in plain radiography, includes

Phrenic nerve palsy
Atelectasis
Diaphragmatic hernia
Distended abdominal viscera.
Conventional CT scan is not very accurate. Helical CT scan and multi-section CT scan identify most injuries in the trauma setting; they are thus the investigations of choice.

MR scanning, although very sensitive and specific, is not feasible in most trauma situations. However, they remain a useful tool to in stable patients to make a more accurate diagnosis and to delineate precisely the extent of anatomical damage.

An exploratory laparotomy or laparoscopy may be necessary to confirm or rule out the diagnosis of diaphragmatic rupture.

Diaphragmatic injury, secondary to high-impact trauma such as RTAs, is associated with a high proportion of associated injuries to the pelvis, thorax and abdomen, and to other visceral organs such as the lung, heart, spleen and liver. Thus a high index of suspicion should be maintained in patients with diaphragmatic injury, and injury to other anatomical structures and organs should be identified and treated.

15

A 7-year-old female presents with an angulated left elbow following a fall from a swing.
Examination reveals a cold left hand with no brachial, radial or ulnar pulses palpable. A plain radiograph of the elbow reveals a displaced left humeral supracondylar fracture.
Which of the following is the most appropriate initial management?
(Please select 1 option)
Backslab plaster and review in fracture clinic
Heparinisation
Manipulation of the fracture under anaesthetic
Open reduction and internal fixation of the fracture
Surgical exploration of the left brachial artery

Manipulation of the fracture under anaesthetic

Supracondylar fractures frequently result in complications, for example,

Vascular
Nerve injury
Compartment syndrome
Malunion.
Arterial injury occurs in 5% of fractures and results from the brachial artery becoming kinked over the anterior prominence of the proximal fragment or from laceration. The distal circulation should be checked carefully and recorded in the patient's notes.

Initial management includes analgesia and an emergency reduction of the fracture into a good anatomical position. This usually results in an unkinking of the brachial artery and restoration of the distal blood flow.

If blood flow is not restored a surgical exploration of the brachial artery should be performed by a vascular surgeon.

Lacerations of the artery are either repaired primarily (with sutures) or with a vein graft.

16

A 19-year-old male presents with a single stab wound to the right side of his abdomen following a fight in a nightclub.
On examination he has a pulse of 120 bpm and a blood pressure of 80/40 mmHg. Abdominal examination reveals generalised tenderness. There are no other obvious injuries.
Which of the following is the most appropriate management for this patient?
(Please select 1 option)
Abdominal ultrasound scan
Abdominal CT scan
Diagnostic peritoneal lavage
Laparoscopy
Laparotomy

Laparotomy This is the correct answerThis is the correct answer
Rapid detection and early intervention can dramatically affect the outcome of patients with intra-abdominal injuries.

A haemodynamically unstable patient with obvious intra-abdominal injury requires immediate laparotomy to control the source of bleeding. Fluid resuscitation (preferably with blood) should be initiated, although this should not be allowed to delay the operative intervention.

Haemodynamically stable patients with abdominal injury require investigation as the ability to detect intra-abdominal injury clinically is limited. In the trauma situation, chest radiographs are usually performed in the supine position and have a limited value in detecting free intra-abdominal air.

Other special diagnostic studies include diagnostic peritoneal lavage (a cannula is introduced via the umbilicus, saline introduced and allowed to drain to identify blood in the peritoneal cavity), however this modality has now been superseded by the improvements in ultrasound and CT.

Both ultrasound and CT have high sensitivities in picking up intra-abdominal bleeding but may miss bowel injuries.

Laparoscopy is useful if ultrasound and CT are equivocal but the patient fails to improve.

If the patient becomes unstable a laparotomy is mandatory.

17

A 33-year-old motorcyclist is brought to the emergency department following a high speed road traffic accident.
On examination his pulse rate is 110/min, blood pressure is 100/74 mmHg and his GCS is 15. There is swelling and tenderness over his left lower leg, x ray of which reveals a closed but comminuted fracture of his left tibia.
Whilst he is being transferred to the orthopaedic ward he complains of severe unremitting pain in his left lower leg and numbness in his left foot. The dorsalis pedis and posterior tibial pulsations are palpable. The pain in his foot is made worse by passive dorsiflexion of the ankle.
Which of the following is the most likely cause for this patient's signs and symptoms?
(Please select 1 option)
Common peroneal nerve palsy
Compartment syndrome
Deep venous thrombosis
Ruptured Achilles tendon
Torn calf muscles (gastrocnemius and soleus)

Compartment syndrome

Compartment syndrome is defined as an increase in the interstitial fluid pressure within an osseofascial compartment of sufficient magnitude to cause a compromise of the microcirculation leading to necrosis of the affected nerve(s) and muscle(s).

It is a devastating early complication seen after fractures and crush injury, commonly in the lower limb. It can also be caused by deep thermal burns, electrical injuries, restricting tourniquets, venom from snake bites and fluid extravasation (for example, intravenous regional anaesthesia).

Early in its development the peripheral pulses are normal as are colour of the affected part (demonstrated by examining the digits of the affected limb), temperature and capillary refill since it is the microvasculature which is initially affected. Loss of peripheral pulses is usually a late and often sinister sign.

The patient may complain of unremitting pain that is not relieved even by high doses of opioid analgesics. Severe pain in response to passive stretch of the ischaemic muscles is by far the most dramatic and reliable clinical sign of compartment syndrome.

Sensory loss (distal paraesthesia) occurs before motor loss since the thin cutaneous nerve fibres are more susceptible to ischaemia than the motor fibres.

With progression of the condition the limb becomes tense and swollen, and if left untreated, the muscle weakness progresses to paralysis and irreversible myoneural necrosis within six to eight hours, even with compartment pressures in the range of 30-35 mmHg (taken in conjunction with the patient's diastolic blood pressure; see below).

The areas of muscle may also infarct giving rise to:

rhabdomyolysis
hyperkalaemia
hyperphosphataemia
high uric acid levels, and
metabolic acidosis.
Classically, the compartment pressures are measured using a slit catheter device. The normal resting pressure within the compartment tissues is estimated to be about 3-4 mmHg.

Compartment pressures in excess of 30-35 mmHg in a normally perfused patient suggested the need for open compartment fasciotomy. Recent evidence, however, suggests that fasciotomy should be undertaken if the difference between the diastolic pressure and the measured compartment pressure is less than 30 mmHg. Hence if the patient is in hypovolaemic shock, as frequently happens in trauma victims, even a modestly increased compartment pressure warrants fasciotomy.

Compartment syndrome can also affect the upper limb, commonly the forearm. In compartment syndromes affecting the anterior forearm the greatest neurologic damage is to the median nerve as it is located in the centre of the muscle mass to be infarcted, whereas the ulnar nerve lies along the periphery of the compartment and is thus subject to less ischaemia and damage.

18

A 23-year-old man is brought to the Emergency department with a gunshot injury to his right upper thigh.
On examination, the wound lies about 4 cm below the inguinal ligament. The vascular status of the limb is normal. Local neurological examination reveals numbness over the anterior thigh and medial aspect of his leg. Although he is able to flex the hip, he is unable to extend the knee on the affected side. The knee jerk is diminished but the ankle jerk is preserved.
Which of the following nerves is most likely to be affected in this patient?
(Please select 1 option)
Common peroneal nerve
Femoral nerve
Lateral cutaneous nerve of thigh
Pudendal nerve
Saphenous nerve

Femoral nerve

The femoral nerve arises from the lumbar plexus (L2-4).

It exits the pelvis by passing beneath the medial inguinal ligament to enter the femoral triangle, after penetrating the psoas muscle.

In the femoral triangle, it lies just lateral to the femoral artery and vein.

It may be injured by the following:

Gunshot wounds
Direct penetrating wounds
Traction during surgery
Catheterisation of the femoral artery
Massive haematoma within the thigh
Nerve injury secondary to femoral nerve block
Psoas abscess
Fractured pelvis
Dislocation of the hip
Apart from trauma, it may be affected in patients with diabetes mellitus (diabetic neuropathy) and lumbar spondylosis.

The femoral nerve innervates the iliopsoas, which helps in flexion of the hip, and the quadriceps, which help in extension of the knee.

The motor branch to the iliopsoas originates in the pelvis proximal to the inguinal ligament and injury at or above this level leads to loss of hip flexion.

The sensory branch of the femoral nerve, the saphenous nerve, innervates the skin over the medial aspect of the thigh and the anterior and medial aspects of the calf. Hence femoral nerve injury results in numbness over the medial aspect of the thigh and the antero-medial aspect of the leg.

Motor loss includes weakness of the quadriceps muscle and decreased patellar reflex (knee jerk) (the ankle jerk is preserved since it is innervated by the tibial nerve [S1-S2]). In longstanding, sub-acute injuries, the patient finds that the knee gives way on walking and has difficulty climbing stairs.

19

An 18-year-old rugby player is brought to the emergency department with a painful right shoulder sustained when he fell awkwardly during a tackle.
On examination there is fullness in the deltopectoral groove and lowering of the anterior axillary fold. The acromion process appears to be prominent. His arm is slightly abducted and externally rotated.
What is the most likely diagnosis?
(Please select 1 option)
Acromioclavicular joint subluxation
Anterior dislocation of the shoulder
Fracture of the acromion process
Fracture of the greater tuberosity of the humerus
Posterior dislocation of the shoulder

Anterior shoulder dislocation

Anterior (subcoracoid) dislocation is the commonest type of shoulder dislocation (this is in contrast to the hip, where posterior dislocation is the most common). The usual mechanism of injury is a fall onto the outstretched arm when the arm is abducted and externally rotated. It can also result from various sporting injuries, commonly basketball and rugby.

Pain is severe and the patient is unwilling to attempt movements of the shoulder.

A swelling may be noticed in the deltopectoral groove (displaced head) with an undue prominence of the acromion process. The arm is held in slight abduction and external rotation. There may be flattening and loss of contour of the shoulder just below the acromion process and lowering of the anterior axillary fold.

If the axillary nerve is damaged patients may present with loss of sensation over the upper, outer aspect of the arm (regimental badge area).

Posterior dislocation of the shoulder, although uncommon, may occur as a result of direct blow to the shoulder joint causing the humeral head to be displaced from the glenoid cavity.

It may result from violent trauma such as an electric shock or an epileptic convulsion. The arm is usually held (or fixed) in internal rotation (note: external rotation in anterior dislocation), which cannot be rotated outwards even as far as the neutral position.

The normal shoulder contour is lost and the anterior aspect of the shoulder appears flat (in contrast to fullness in anterior dislocation).

20

A 2-year-old male child is brought to the Emergency department by his mother.
He has been unable to bear weight since a fall from a chair this morning. He is tender over the mid-tibia but there is no obvious limb deformity.
What is the x ray most likely to reveal?
(Please select 1 option)
Angulated fracture
Compound fracture
Epiphyseal fracture
No fracture likely
Spiral fracture

Spiral fracture This is the correct answerThis is the correct answer
This child has most likely a spiral fracture as he is tender in the mid tibia, and there is no obvious deformity.

The injury is commonly caused by a twisting movement along the long axis of the bone which would have been caused by the fall.

21

Which of the following investigations is most likely to detect the earliest changes of Perthes' disease?
(Please select 1 option)
CT
MRI
Nuclear scan
Plain x ray

MRI

Legg-Calvé-Perthes' disease is the name given to idiopathic osteonecrosis of the capital femoral epiphysis of the femoral head.

Plain x rays of the hip are extremely useful in establishing the diagnosis. MRI and contrast MRI in the early stages, will give far more detail of necrosis, revascularisation and healing than plain x rays. A nuclear scan will provide less detail and exposes the child to radiation although a technetium 99 bone scan is helpful in delineating the extent of avascular changes before they are evident on plain radiographs.

22

An 85-year-old patient presents with recurrent falls and a fracture of the distal ulna.
Which of the following statements are correct?
(Please select 1 option)
Bone fractures attributable to vitamin D deficiency are due to bone density
Low Vitamin D levels are not associated with muscle weakness
Vitamin D deficiency in the elderly is rare
Vitamin D replacement reduces the incidence of fractures in the elderly
The toxic levels of Vitamin D occur at approximately twice the therapeutic dose

Vitamin D replacement reduces the incidence of fractures in the elderly

Vitamin D deficiency in the elderly is more common than often thought, especially in the housebound and those in residential and nursing homes, with an overall frequency of 17% in women aged 85 and over.

Reduced levels of 25(OH)D lead to elevated parathyroid hormone , which results in increased mobilization of calcium from the bone and therefore decreased mineralisation. Vitamin D deficiency is also associated with muscle weakness, as well as osteomalacia, and the risk of fracture among elderly people with vitamin D deficiency are increased by falls secondary to muscle weakness.

Vitamin D replacement (800 IU daily) with calcium, has been shown to reduce falls and fractures by 47% compared with controls who received calcium only.

The correct dose of vitamin D replacement should be 800 IU. Lowest doses at which adverse events have been observed with Vitamin D replacement are 200nmol/L, which equates to a daily dose of 40,000 IU.

23

A 76-year-old woman has had Paget's disease of bone for at least 15 years. She develops a destructive mass in the bony pelvis and a diagnosis of primary tumour is considered.
What is the most likely primary tumour?
(Please select 1 option)
Chondrosarcoma
Exostosis
Multiple myeloma
Osteoma
Osteosarcoma

Osteosarcoma This is the correct answerThis is the correct answer
Paget's disease of bone usually occurs in later life.

In Paget's disease the continual repair process of bone is disturbed and ends at the stage of vascular osteoid bone. Bones are very weak.

Osteogenic sarcoma complicates 5% of cases.

24

A 14-year-old boy is seen after being bitten by a boxer dog.
The wound is cleansed, he is given tetanus toxoid and penicillin.
A week later the boy represented with an erythematous, inflamed and purulent wound. Culture of the wound reveals Gram negative rods.
What is the most likely organism?
(Please select 1 option)
Brucella canis
Clostridium tetani
Escherichia coli
Pasteurella multocida
Toxocara canis

Pasteurella multocida

Pasteurella multocida is a Gram negative rod found in the oral cavity dogs and cats. It frequently causes wound infection following bites. Most cases are in children.

Brucella canis is a Gram negative rod that causes an undulating illness associated with malaise and is associated with lymphadenopathy and heaptosplenomegaly. This is not the pattern of disease associated with tetanus.

Toxocara is associated with visceral larva migrans and is associated with ingestion of eggs in young children.

25

A 14-year-old boy is presents with chronic leg pain and is diagnosed with an osteosarcoma.
Which of the following is true of osteosarcoma?
(Please select 1 option)
Affects the epiphyses of long bones
Are most commonly seen around the knee and in the proximal humerus
Is exclusively a disease of adolescence and early adult life
Typically metastasise to brain
x Ray shows a typical punched out lesion

Are most commonly seen around the knee and in the proximal humerus

Osteosarcomas affect the metaphyses of long bones. They are most commonly seen around the knee and in the proximal humerus.

They often occur in young adults but are also seen in the elderly in association with Paget's disease. They usually present as bone pain and a palpable lump.

x Ray shows periosteal elevation (Codman's triangle) and a 'sunburst' appearance due to soft tissue involvement. Early haematogenous spread occurs and the 5-year survival rate is approximately 50%.

26

Which of the following is true of fractures in children?
(Please select 1 option)
Angulation and displacement of fractures are poorly tolerated
Bone is generally more brittle
Healing is usually prolonged
Stiffness of adjacent joints is common following fracture immobilisation
The periosteum is thicker and more highly developed

The periosteum is thicker and more highly developed This is the correct answerThis is the correct answer
Fractures in children usually heal quicker than similar fractures in adults. The bone is more elastic.

Due to the remodelling potential of paediatric fractures angulation and displacement, if not excessive, are usually well tolerated.

Immobilisation of fractures is also well tolerated in general. The periosteum in children is thick and can often be used as an aid to hold reduction.

27

Which of the following is true concerning scaphoid fractures?
(Please select 1 option)
Anteriorposterior and lateral radiographs reveal most fractures
Rarely occur in young adults
Should be treated by bone grafting and internal fixation even if undisplaced
When complicated by avascular necrosis the proximal pole is usually affected
Wrist fractures are uncommon

When complicated by avascular necrosis the proximal pole is usually affected

Scaphoid fractures are common in young adult males and occur as a result of a fall on an outstretched hand.

If complicated by avascular necrosis the proximal pole is usually affected due to the distal to proximal direction of the scaphoid blood supply.

Undisplaced fractures can be treated in a plaster.

Wrist fractures are common.

Initial radiographs usually involve four views of the scaphoid due to difficulties in visualising fractures.

28

A 35-year-old male is struck on the lateral aspect of his right knee by the bumper of a car travelling at low velocity.
On examination he is unable to dorsiflex the ankle, evert the foot and extend the toes. There is loss of sensation of the dorsum of the foot.
He is most likely to have damaged which structure?
(Please select 1 option)
Common peroneal nerve
Deep peroneal nerve
Saphenous nerve
Sural nerve
Tibial nerve

The common peroneal nerve supplies the muscles of the peroneal and anterior compartment of the leg and sensation to the dorsum of the foot.

The deep peroneal nerve is a division of the common peroneal nerve and supplies only the muscles of the anterior compartment of the leg.

29

During the posterior approach to the hip which of the following muscles is not normally divided to expose the joint capsule?
(Please select 1 option)
Inferior gemellus
Obturator externus
Obturator internus
Piriformis
Superior gemellus

Obturator externus

During the posterior approach to the hip the short external rotators of the hip are divided to expose the capsule (that is, piriformis, obturator internus and the gemelli).

30

Which of the following is not within the carpal tunnel?
(Please select 1 option)
Abductor pollicis longus
Flexor digitorum profundus
Flexor digitorum superficialis
Flexor pollicis longus
Median nerve

Abductor pollicis longus

The contents of the carpal tunnel are

The median nerve
The four flexor digitorum profundus tendons
The four flexor digitorum superficialis tendons
Flexor polllicis longus
and their synovium.

The abductor pollicis longus lies with extensor pollicis brevis in the most radial (first) dorsal wrist compartment.

31

Your crash bleep alerts you to a road traffic accident victim who has just arrived in the Emergency department.
In the casualty is an 18-year-old male who is brought in by the paramedics following a RTA.
He is opening his eyes to painful stimuli, his speech is inappropriate, and he is extending his limbs to pain.
What is his Glasgow coma score?
(Please select 1 option)
4
6
7
8
10

7

The Glasgow coma score is a validated system for assessing a patient's state of consciousness.

The score runs from 3-15 and takes into account

Best motor response
Best verbal response and
Eye opening.
The motor response is scored 1-6 from

None
Extension to pain
Abnormal flexion to pain
Flexes to pain
Localises to pain
Obeys commands.
The verbal response is rated 1-5 from

No response
Incomprehensible
Inappropriate
Confused
Alert and orientated.
The eye opening is scored 1-4 from

No eye opening
To pain
To voice
Spontaneous.
This patient, scoring 7 is comatose, a coma being defined as a GCS of 8 or less.

32

A 33-year-old professional ice hockey player presents to his general practitioner with a 10 day history of weakness in his right arm.
He gives a history of sustaining an injury to the right arm during a game of ice hockey when he was hit directly across the back of the arm by the opponent's stick. He states that he felt a tearing sensation and severe pain in his arm immediately after the injury.
On examination he is unable to extend his arm. A palpable gap is felt at the posterior compartment of the arm just above the olecranon process.
Which of the following is the likely diagnosis?
(Please select 1 option)
Fracture of the shaft of humerus
Injury to median nerve
Injury to musculocutaneous nerve
Tear of biceps tendon
Tear of triceps tendon

Tear of triceps tendon This is the correct answerThis is the correct answer
The signs and symptoms in this patient are suggestive of a tear of the triceps tendon.

The most common method of injury to the triceps tendon is from fall on the outstretched hand with the elbow in mid flexion, with or without a concomitant direct blow to the posterior aspect of the elbow or arm.

The pathognomonic features of triceps tendon rupture are inability or weakness of extension of the elbow and a palpable gap in the substance of the muscle. Depending on the duration of the injury, bruising, ecchymosis, and localised tenderness may be present.

Further imaging studies may be necessary to help to define the exact extent of the injury.

33

A 35-year-old gentleman who is a keen sportsman presents to his general practitioner.
He complains of pain on the lateral side of his elbow radiating to the forearm. On examination he is tender in this area.
What is the most likely diagnosis?
(Please select 1 option)
De Quervain’s tenosynovitis
Golfer’s elbow
Olecrannon bursitis
Rheumatoid arthritis
Tennis elbow

Tennis elbow This is the correct answerThis is the correct answer
The presentation is that of 'tennis elbow' (lateral epicondylitis).

It is thought to be due to the overuse of the extensor carpi radialis brevis.

Medial epicondylitis is known as 'golfer's elbow'.

Olecrannon bursitis is due to inflammation of the olecrannon bursae.

34

A 10-year-old girl presents with back pain. A spinal x ray shows collapsed lumbar vertebrae at L3 and L4 and generalised osteopaenia. She has a history of three previous limb fractures after relatively trivial falls. She is otherwise healthy and well-grown for her age.

Osteogenesis imperfecta
Collapsed vertebra and osteopaenia are uncommon in children. Coupled with low trauma fractures and no dysmorphism, type 1 osteogenesis imperfecta is likely.

35

A 15-month-girl is in foster care following child protection procedures when she presented with a spiral fracture at the age of 11 months.
Her mother is single, poorly supported and had been suffering from postnatal depression at the time. There had been no explanation offered for the original injury.
She now presents with a greenstick fracture of the femur following a trivial fall in the care of the experienced foster-mother who has been known to social services for many years. The girl is just walking independently. Skull x ray shows several Wormian bones.

Osteogenesis imperfecta
Wormian bones are indicative of osteogenesis imperfecta. This condition is an important differential of non-accidental injury (NAI).

36

An 11-month-old girl is brought to the emergency department refusing to move her left arm. An x ray demonstrates a spiral fracture of the humerus. The mother says that 30 minutes previously she lifted her daughter out of the bath and lost grip of her right hand, and her body momentarily twisted round her left arm.

Accidental fracture

There is no delay in presentation and the mechanism of injury fit the description of the episode.

37

Chvostek’s sign

Trunk of facial nerve

Chvostek's sign (tapping over facial nerve produces facial muscle twitching) occurs due to hypocalcaemia.

Hypocalcaemia also produces symptoms of

Tetany
Depression
Peri-oral paraesthesia
Carpo-pedal spasm (Trousseau's sign)
Neuromuscular excitability.
Causes include

Thyroid or parathyroid surgery
Chronic renal failure
Osteomalacea
Over hydration
Pancreatitis
Hypoparathyroidism.

38

Drooping of the side of the mouth following surgery to the ipsilateral submandibular gland.

Marginal branch of the facial nerve

The orbicularis oris is supplied by the buccal and marginal branches of the facial nerve. The marginal branch is prone to injury when approaching the submadibular glands.

39

Unable to wrinkle the ipsilateral forehead muscle following a displaced fracture to the zygomatic arch.

Temporal branch of the facial nerve

The temporal branches of the facial nerve emerge from the upper border of the parotid gland, cross the zygomatic arch and supply motor nerves to the auricularis anterior and the superior part of frontalis.

The supraorbital nerve and supratrochlear nerve are branches of the ophthalmic nerve and provide only a sensory supply to the forehead.