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Flashcards in T&O IV Deck (17):

The metabolic response to trauma causes which of the following?
(Please select 1 option)
Decreased anti-diuretic hormone
Decreased glucagon secretion
Decreased growth hormone
Decreased insulin secretion
Decreased urine osmolality

Decreased insulin secretion

The metabolic response to trauma is mediated by both endocrine and paracrine factors.

In the neurohumoral response the pituitary-adrenal axis and the sympathetic nervous system are important.

Local released cytokines (for example, tumour necrosis factor-alpha, interleukins) are important in modulating the response.

Increased growth hormone and glucagon contribute to the hyperglycaemia seen following surgery and trauma.

In the pancreas, glucagon is released and insulin secretion is diminished.

Hypovolaemia results in increased antidiuretic hormone (ADH) production and an increase in urine osmolality.


A 16-year-old male has had a splenectomy following traumatic splenic rupture in a road traffic accident.
Which one of the following haematological features may be present on the blood film six months later?
(Please select 1 option)
Fragmented cells
Howell-Jolly bodies

Howell jowell Bodies

The spleen removes intracytoplasmic inclusions such as Howell-Jolly bodies, Heinz bodies and siderotic granules. All of these are increased after splenectomy.

Senescent cells are removed by the spleen and when it is absent

The red cells are flatter and thinner than normal
Target cells and spherocytes are increased and
Osmotic fragility is decreased.
There are also depressed levels of IgM, properidin and tuftsin (which promotes phagocytosis).


Which of the following is true concerning osteomyelitis complicating diabetic foot ulcers?
(Please select 1 option)
A diagnosis of osteomyelitis should be considered if bone is visible at the ulcer base
A skin biopsy is indicated to make a definitive diagnosis
Haematogenous spread is the most common source
Less than 2% of patients with a diabetic foot ulcer develop osteomyelitis
Surgical debridement and intravenous antibiotics are usually the first line of management

A diagnosis of osteomyelitis should be considered if bone is visible at the ulcer base

Osteomyelitis is a common complication seen in patients with diabetic foot ulcers and can affect up to 15% of patients.

Haematogenous spread is not the most common source and a contiguous spread from adjacent soft tissues is the most common cause.

The diagnosis should be considered if bone is visible or palpable in the ulcer base. Bone biopsy for culture and sensitivity is a very useful investigation in making a confirmatory diagnosis of osteomyelitis.

Surgical debridment is indicated only if there is associated extensive soft tissue contamination with slough or necrotic tissue.

Long term oral antibiotics (with good bone penetration such as fusidic acid or clarithromycin) is usually sufficient to treat osteomyelitis associated with diabetic foot ulcers.


Which of the following is correct regarding calcific tendonitis of the shoulder?
(Please select 1 option)
External rotation of the shoulder is possible
Is usually caused by direct injury to the shoulder joint
Leads to calcium deposits within the infraspinatus tendon
Pain is usually felt over the posterior aspect of the shoulder
Usually causes insidious pain with an onset over many weeks

External rotation of the shoulder is possible

Calcific tendonitis is a common disorder of unknown aetiology which results in an acutely painful shoulder joint.

In the majority of patients there is no history of trauma. The deposition of calcium within the supraspinatus tendon (seen radiologically) may be part of a degenerative process.

Clinical features of this condition include sudden onset of pain with no apparent precipitating cause.

On examination the shoulder is tender antero-laterally with some restriction of both active and passive movements.

External rotation of the shoulder is however possible thus distinguishing it from frozen shoulder.


Which of the following is true regarding rupture of the Achilles tendon?
(Please select 1 option)
After surgical correction, the ankle in kept in equines position
Is associated with haematoma in the deep posterior compartment of the leg
Is caused by sudden relaxation of the gastrocnemius and soleus muscles
Is common in young active athletes
Results in the loss of dorsiflexion of the ankle

After surgical correction, the ankle in kept in equines position

Rupture of the Achilles tendon is more common in patients over the age of 40. This is probably because the tendon is degenerate.

The rupture usually occurs when the patient is involved in unaccustomed activities such as running or jumping (active athletes have a good muscle tone).

Sudden contraction of the gastrocnemius and soleus muscles is resisted by the body weight leading to rupture of the tendon. Soon after the tear, a gap can be felt about 5 cms above the insertion of the tendon but there is no haematoma in the lower leg (calf).

The patient is unable to tiptoe and plantar flexion of the ankle is weak or lost leading to a positive Simmond's test (reduced plantar flexion of the ankle on squeezing the calf muscle).

The management is either conservative (using plaster casts) or surgical (approximation and suturing the cut ends). Following surgery, the ankle and the foot are immobilised in a below-knee plaster cast in equines position for six to eight weeks. This is to avoid any strain on the sutured tendon.


Which of the following are true of Crush syndrome?
(Please select 1 option)
Is also referred to as traumatic squeeze
Sensory and motor function is preserved in the compressed limbs
Serum creatinine, potassium and phosphate are elevated
The serum calcium level is usually elevated
The urine is clear

Serum creatinine, potassium and phosphate are elevated

'Crush syndrome' may also be referred to as traumatic rhabdomyolysis. The sustained crushing of a significant muscle mass causes impaired perfusion and therefore ischaemia of the muscle.

Damaged muscle cells release myoglobin (an assay should be used to confirm its presence) and potassium, causing hyperkalaemia. Myoglobin can induce renal failure, therefore making intravenous fluid resuscitation critical.

Alkalisation of urine with sodium bicarbonate reduces tubular precipitation of myoglobin and may be used in treatment.

Other toxic metabolites released from damaged muscle cells may affect the myocardium leading to a reduced cardiac output and shock.

The diagnostic criteria for crush syndrome are:

Crushing injury to a large mass of skeletal muscle
There are sensory and motor disturbances in the compressed limbs, which subsequently become tense and swollen
Myoglobinuria and/or haematuria
Peak creatine kinase (CK) >1000 U/l.
Renal problems are common with one of the following characteristics:

Oliguria (urine output


Which of the following is true of carpal tunnel syndrome?
(Please select 1 option)
Is most symptomatic in the morning
Results in a positive Phalen's test
Results in loss of sensation over the lateral aspect of the palm
Results in tingling and pain in the ring and little fingers
Results in wasting of the hypothenar eminence

Results in a positive Phalen's test

Carpal tunnel syndrome is more common after repetitive actions and is the most common cause of hand pain at night. It is due to compression of the median nerve as it passes under the flexor retinaculum. When the pain is at its worst the patient characteristically flicks or shakes the wrist to bring about relief.

Clinical features are of median nerve distribution - wasting of the thenar eminence and decreased sensation over the palm (note: lateral palmar sensation is spared as it is supplied by the palmar cutaneous branch of the median nerve which does not pass through the tunnel).

Phalen's test (holding the wrist hyperflexed for one to two minutes) reproduces the symptoms.

This is more reliable than Tinel's test - tapping over the tunnel to produce paraesthesia over the area of median nerve distribution in the palm.


Which of the following is true of fracture of the scaphoid bone?
(Please select 1 option)
Is commonly complicated by avascular necrosis of the distal pole
Is the most common fracture of the carpal bones
Is usually diagnostic on plain x ray of the wrist (scaphoid views)
Resulting in non-union; can be treated effectively in a plaster of Paris cast for 12 weeks
Results in osteoarthritis soon after injury

Is the most common fracture of the carpal bones

The scaphoid is the most frequently fractured of the carpal bones, accounting for approximately 80% of all carpal bone fractures. This fracture which is notoriously easy to miss results from a fall on the hand (usually outstretched).

The classical signs of scaphoid fracture are

Pain on wrist movements
Tenderness on direct pressure 2 cm distal to Lister's tubercle of the radius (in the anatomical snuff box) and on proximal pressure on the extended thumb or index finger.
Initial x rays rarely pick up the fracture. If x rays are negative and scaphoid fracture a strong possibility, treatment in a plaster cast for two weeks followed by repeat x ray is recommended, by which time the fracture may be visible. If the x ray is still inconclusive, a bone scan is a good investigation.

Non-union varies from 20-50% depending on the fracture pattern. In such instances, a bone graft or Herbert screw fixation is indicated.

The major blood supply (nutrient artery) enters the scaphoid from the distal pole; therefore avascular necrosis of the proximal fragment is a serious complication.

Degeneration of the wrist and early osteoarthritis are recognised complications of scaphoid fractures.


Which of the following is true regarding the shoulder joint?
(Please select 1 option)
Capsule includes the origin (attachment) of the long head of biceps muscle
Capsule is taut inferiorly
Is only partially reliant on soft tissues structures for stability
Is supplied by the accessory nerve
Synovial cavity does not communicate with the subscapular bursa

Capsule includes the origin (attachment) of the long head of biceps muscle

The shoulder joint (gleno-humeral joint) is a ball and socket joint (synovial type). It is totally reliant on soft tissue structures for both static and dynamic stability.

The capsule is attached around the glenoid cavity and extends on to the base of the coracoid process superiorly to include the biceps attachment (long head). The capsule of the joint is lax inferiorly allowing wide abduction of the joint.

The two major bursae of the shoulder joint are: subacromial (superiorly) and subscapular (anteriorly).The subacromial bursa does not normally communicate with the synovial cavity while the subscapular bursa communicates with the synovial cavity. The joint is supplied by the axillary and suprascapular nerves.


Which of the following is a radiographic feature of osteoarthritis?
(Please select 1 option)
Increase in joint space
Osteophytes causing lipping at joint margins
Patchy changes in bone density
Soft-tissue swelling
Subchondral lysis

Osteophytes causing lipping at joint margins

In osteoarthritis, radiographs show:

An asymmetrical narrowing of the joint space
Subchondral sclerosis
Joint deformity.
Soft tissue swelling is a feature of rheumatoid arthritis.

Patchy changes in bone density are seen in Paget's disease of the bone, for example, sclerotic 'white' vertebrae.


Which of the following is true of Perthes' disease?
(Please select 1 option)
Has an incidence of 20% of in obese children
Is commonly seen in the 15-20 age group
Is bilateral in 10% of cases
Results in displacement through the growth plate with the epiphysis slipping down and back
Results in normal x ray appearance

Is bilateral in 10% of cases

Perthe's disease is avascular necrosis of the femoral head, and affects those aged 3-11 years (commonest 4-7 years).

It is bilateral in 10% with a Male to Female ratio of 4:1.

Patients (children) present with pain in hip or knees, and with a limp. All movements of the hip are restricted.

It is not associated with obesity; obesity is a feature in patients with slipped upper femoral epiphysis.

Early x rays show widening of the joint space; later there is decrease in the size of the nuclear femoral head with patchy density. Normal x ray is a feature of 'irritable hip' (also called transient synovitis).

The important differential diagnoses for this condition are:

slipped upper femoral epiphysis
irritable hip, and
tubercular arthritis


Which of the following is correct regarding rheumatoid arthritis?
(Please select 1 option)
Causes ulnar deviation at the wrist joint
Commonly results in dorsal subluxation of the metacarpo-phalangeal (MCP) joints
Is associated with hepatomegaly
Leads to subcutaneous nodules on the flexor aspect of the limbs
Predominantly affects the synovium rather than the bone

Predominantly affects the synovium rather than the bone This is the correct answerThis is the correct answer
Rheumatoid arthritis (RA) causes volar subluxation of the MCP joints. RA is essentially a disease of the synovium with late bone changes; synovial hypertrophy is frequent and generally clinically obvious. Subcutaneous nodules are common on the extensor aspect of the limbs.

In RA there is radial deviation of the wrist and ulnar deviation of the MCP joints.

Splenomegaly associated with RA is called Felty's syndrome.

The other associations/complications include:

Normochromic and normocytic anaemia
Instability of the atlanto-axial joint.


Dupuytren's contractures:
(Please select 1 option)
results from contracture of the palmaris longus muscle
is a recognised complication of ischemia of the hypothenar muscles
can result in an "intrinsic plus appearance"
symptoms can be improved by the release of the flexor digitorum profundus tendon
in severe deformity, the flexor tendons are always involved

can result in an "intrinsic plus appearance"

Dupuytren's contracture results from contracture of the palmar aponeurosis.

The tendon sheaths may be involved but never the flexor tendons themselves. Since there is no tendon involvement release of either the flexor digitorum profundus or the flexor digitorum superficialis does not help in the improvement of the symptoms (contractures).

Dupuytren's disease can cause contracture of the intrinsic muscles of the hand, could lead to flexion of the MCP joints and extension of the PIP joints - the so-called "intrinsic plus appearance".


Which one of the following signs suggests a significant injury in a patient involved in a high speed road traffic collision?
(Please select 1 option)
High riding prostate
Periumbilical discolouration (Cullen's sign)
Plain abdominal x ray showing a 'gasless abdomen'
Positive Murphy's sign
Tingling or hyperactive bowel sounds

High riding prostate

Tingling or hyperactive bowel sounds is a sign of intestinal (bowel) obstruction; in visceral injury, bowel sounds are usually absent.

Murphy's sign is not indicative of injury to a viscus; it is a sign elicited in acute cholecystitis.

High riding prostate is a sign of injury to the bladder neck and is seen with pelvic fractures.

Periumbilical discolouration is a sign commonly seen in acute pancreatitis; discolouration of the flanks [Grey Turner's sign] occurs with visceral injury.

Gasless abdomen is a classical feature of acute small bowel ischaemia.

In abdominal injury causing perforation of a hollow viscus, there is free air in the abdominal cavity, commonly under the diaphragm.


Which one of the following is true of the Salter-Harris classification for bone injuries in children?
(Please select 1 option)
Accounts for

In Salter-Harris type V, there is compression of the epiphysis leading to growth arrest

This classification is for fractures through the growth plate or the epiphysis (in Salter-Harris types II and IV the metaphyseal fragment is also involved but the diaphysis is never affected).

Salter-Harris types I and II do not involve the germinal layer and therefore growth disturbance is uncommon.

Salter-Harris types II and I are the commonest forms of epiphyseal injuries.

In Salter-Harris types III and IV the germinal layer is breached and growth disturbance is likely, although its incidence could be minimised by precise reduction of the fracture.

Although not originally described, Salter-Harris type V fracture is recognised as a crushing injury of the epiphysis following which growth arrest is common.

This fracture is often diagnosed retrospectively, when disturbance of physeal growth is apparent as a limb deformity.

Because of the weakness of the growth plate these injuries are relatively common accounting for approximately one-third of all fractures in children.


Regarding acute septic arthritis, which one of the following is untrue?
(Please select 1 option)
All joint movements are restricted
If untreated in the early stages, bony ankylosis and permanent deformity can occur
Intravenous antibiotics are usually effective in treating this condition
Staphylococci and Haemophilus influenzae are the commonest causative organisms
The infection usually starts in the synovial membrane and then leads to progressive destructive of the articular cartilage

Intravenous antibiotics are usually effective in treating this condition

Acute septic arthritis occurs either from direct infection from a wound, an injection into a joint or an operative procedure on the joint (for example, arthroscopy). They can also be infected by spread from acute osteomyelitis or through the bloodstream (haematogenous).

The joint is the site of maximum tenderness; it may be swollen and the overlying skin may be red and tender. All the joint movements are severely restricted.

The infection usually starts in the synovial membrane, and seropurulent exudates develop in the synovial fluid.

The articular cartilage is progressively destroyed and vascular damage may lead to death of the epiphyseal bone. At this stage infection may spread to the diaphysis or into the overlying tissues to form an abscess which may eventually drain onto the skin through one or more sinuses.

The differential diagnoses of this condition include:

Acute osteomyelitis
Traumatic synovitis
Acute rheumatic fever
Rheumatoid arthritis
Gout, and
The white cell count and erythrocyte sedimentation rate are usually raised.

The treatment is by joint aspiration supplemented by antibiotics and analgesia. Formal open drainage may also be required.

The final result may be resolution, but secondary osteoarthritis and avascular bone necrosis are common sequelae.

Bony ankylosis and permanent deformity develop when the articular destruction is severe.


Which one of the following regarding developmental (congenital) dislocation of the hip is untrue?
(Please select 1 option)
If identified at birth, conservative treatment is usually effective
Instability of the hip occurs in less than 1 in 20,000 live births
It is a recognised complication of breech presentation
It is characterised by an anterior 'lump' sign
One of the possible causes of this condition is subclinical neuromuscular abnormality

Instability of the hip occurs in less than 1 in 20,000 live births

Congenital dislocation of the hip (CDH), now termed developmental dysplasia, is of uncertain aetiology and occurs in some 5 cases per 1000 live births.

In many instances there is a strong family history and predominance in females, although this is less marked in late presentations. Breech presentation, caesarean section and being the first-born child are other recognised factors.

The causes of hip instability are thought to be capsular laxity, acetabular anteversion and possibly subclinical neuromuscular abnormality.

The diagnostic sign is elicited at birth by separating the infant's flexed thighs and noting the 'jump' or 'thud' as the femoral head slips back into the socket in the mid range of abduction.

Once the child starts to walk the restricted hip movement causes gait abnormalities, the limb appears shortened with pelvic asymmetry and there is an anterior groin 'lump' sign. The limb may be extremely rotated and abduction is limited.

Splintage with the hips 90 degrees abducted and 90 degrees flexed produces a successful outcome in about 98% of the cases if the instability is identified at birth.