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1
Q

What is skiers thumb?

A

Formerly gamekeepers thumb

Injury to base of thumb resulting in damage/rupture of ulnar collateral ligament

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2
Q

What is the management for skiers thumb?

A

Complete tear - surgical repair

Partial rupture - immobilisation in thumb spica

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3
Q

Which is the most common skeletal neoplasm?

A

Osteochondroma

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4
Q

When do osteochondromas most commonly occur?

A

First two decades of life

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5
Q

Where are osteochondromas most commonly found?

A

Long bones

Especially distal femur, proximal tibia

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6
Q

What are Brown tumours?

A

Osteolytic lesions due to hyperparathyroidism

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7
Q

What are possible complications of a supracondylar fracture?

A

Vascular
Nerve injury
Compartment syndrome
Malunion

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8
Q

What is the initial management of a displaced supracondylar fracture in which there is vascular compromise?

A

Analgesia
Emergency reduction of fracture into good anatomical position with percutaneous pinning
If blood flow not restored, surgical exploration of brachial artery - sutures/vein graft

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9
Q

What is the Milch classification for lateral condyle fractures?

A

Milch 1: fracture line lateral to capitello-trochlear groove, relationship between humerus and forearm intact, elbow stable
Milch 2: fracture passes through capitello-trochlear groove, elbow is unstable

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10
Q

What is the Gartland classification of supracondylar fractures?

A

Type 1: non displaced
Type 2: extended but not completely translated with some cortical contact
Type 3: circumferential break in cortex with displacement of fracture fragments

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11
Q

What are causes for immediate onset of knee swelling after trauma?

A 
Haemarthrosis:
ACL/PCL rupture
Patella dislocation
Ostechondral
Medial meniscal tear 
Hoffas syndrome 
Bleeding diathesis
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12
Q

What are key features of a meniscal injury?

A

Deceased range of movement
Joint line tenderness
Effusion
Typical history

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13
Q

What are the cardinal signs of suppurative flexor tenosynovitis?

A

Flexed posture
Fusiform swelling
Pain on passive extension
Flexor sheath tenderness

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14
Q

What characterises complex regional pain syndrome?

A 
Localised or diffuse pain
Swelling 
Trophic changes
Vasomotor disturbance 
Allodynia
Hyperhydrosis
Nail or hair growth changes 
Tremor
Spasm
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15
Q

What is a Bennetts fracture?

A

Intra articular fracture of the base of the first metacarpal

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16
Q

What is a galeazzis fracture?

A

Radial shaft with dislocation of distal radioulnar joint

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17
Q

What is a colles fracture?

A

Distal radial fracture with dorsal displacement of distal fragment

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18
Q

What type of joint is the frontal coronal suture?

A

Fibrous

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19
Q

What is the only pivot joint in the body?

A

Dens of axis and atlas

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20
Q

What type of joint is between trapezium and first metacarpal?

A

Saddle

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21
Q

What type of joint is a saddle joint?

A

Can move in a range of directions by gliding over one another

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22
Q

What type of joint is found between shafts of radius and ulna?

A

Syndesmosis

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23
Q

What are some systemic causes of avascular necrosis?

A 
Sickle cell disease
Scleroderma
SLE
Infective endocarditis
Alcoholism
Extensive burns
Radiation
Diabetes mellitus
Steroid therapy
Cushings disease
Gaucher's disease
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24
Q

What are some local causes which predispose to avascular necrosis?

A

RA
Trauma
Severe OA
Psoriatic arthropathy

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25
How does transient synovitis of the hip present?
Child less than 5 Discomfort, limited range of movement and a limp following an URTI Mild symptoms, self resolving
26
Who is generally affected by a slipped capital femoral epiphysis?
Overweight boys approaching puberty
27
What are symptoms of a slipped capital femoral epiphysis?
Pain Limping Restriction of medial rotation, abduction and flexion
28
What is perthes disease?
Avascular necrosis of the femoral head
29
A 65 year old woman presents to ED with inability to extend the MCP joints of her right hand and wrist drop. She tripped over and fell and injured her arm. She also has altered sensation over the region of the anatomical snuffbox. The triceps reflex is absent. What has happened?
Injury to the radial nerve at the level of the mid shaft of the humerus
30
Why does ulnar nerve damage result in a claw?
Action of unopposed long flexors
31
Why is pinching difficult with ulnar nerve damage?
Paralysis of adductor pollicis and first palmar interossei
32
What is froments sign?
Flexion of the thumb due to unopposed action of flexor pollicis longus particularly demonstrated when asked to grasp a card between thumb and index finger
33
From which cell does a Ewings tumour arise?
Mesenchymal cell | Long bone
34
How does ewings tumour present?
Pyrexia Pain Elevated ESR Usually pelvis
35
What is the classical appearance of a Ewings tumour?
Lamellated series of periosteal reactions showing an onion skin appearance Codmans triangle appearance due to elevated periosteum
36
What are causes of charcots arthropathy?
``` Diabetes mellitus Tabes dorsalis Cauda equina Leprosy Syringomyelia ```
37
What is the treatment for mallet finger?
Splinting the affected finger to the adjacent one for 6 weeks
38
What causes mortons metatarsalgia?
``` Increased pressure on the metatarsal heads due to: Intense training or activity High arch Foot deformities Excess weight Poorly fitting shoes High heels Stress fractures Morton's neuroma ```
39
What can cause osteomalacia?
``` Vitamin D deficiency due to: Malabsorption Renal disease (familial hypophosphataemic rickets) Chronic renal failure Anticonvulsant therapy ```
40
What are Loosers zones?
Wide transverse lucencies traversing part way through a bone usually at right angles to the involved cortex Associated with osteomalacia and rickets Type of pseudofracture
41
How does osteomalacia often present?
Bone pain and proximal myopathy
42
What can malunion of a Colles fracture result in?
Deformity Limited movement Delayed rupture of extensor tendon due to attrition by rough dorsal aspect of fracture line Carpal tunnel syndrome Stiffness of fingers and wrist Sudecks atrophy (complex regional pain syndrome)
43
What is sudecks atrophy?
Complex regional pain syndrome Severe pain in hand and wrist Swelling and circulatory disturbance in hand with oedema Painful stiffness of all joints of hands
44
What blood results would you expect in Ankylosing spondylitis?
Serum calcium normal Alkaline phosphatase normal ESR elevated
45
What are the Ottawa ankle rules?
X-rays are only necessary if there is pain in the malleolar zone and: 1. Inability to weight bear for 4 steps 2. Tenderness over the distal tibia (6cm) 3. Bone tenderness over the distal fibula (6cm)
46
What is the Weber classification for fibular fractures?
Type A is below the syndesmosis Type B fractures start at the level of the tibial plafond and may extend proximally to involve the syndesmosis Type C is above the syndesmosis which may itself be damaged
47
What is a Maisonneuve fracture ?
Spiral fibular fracture that leads to disruption of the syndesmosis with widening of the ankle joint, surgery is required
48
What structure is damaged in a child with pulled elbow/nursemaids elbow?
Subluxation of radial head leading to damage to the annular ligament
49
Which part of the bone is affected by osteosarcoma?
Metaphyses of long bones
50
Where are osteosarcomas most commonly seen?
Knee and proximal humerus
51
What disease state predisposes to osteosarcoma formation?
Paget's disease
52
How do osteosarcomas usually present?
Bone pain and palpable lump
53
What does an X-ray show in osteosarcoma?
Periosteal elevation (codmans triangle) and sunburst appearance due to soft tissue involvement
54
What route of metastatic spread occurs with osteosarcoma?
Haematogenous
55
What are symptoms of a medial meniscus tear?
Pain along joint line or through whole knee Inability to extend knee fully Locking Swelling
56
What is the gold standard investigation for excluding a septic joint?
Joint aspiration
57
What are some causes of pathological fractures?
Neoplasia Osteomalacia Osteomyelitis
58
At what time frame is a clinical review required with a scaphoid fracture if there is concern despite apparently normal initial films?
7-10 days
59
What biochemical changes are suggestive of Paget's disease?
Alkaline phosphatase raised | Urinary hydroxyproline raised
60
What are some complications of Paget's disease?
Pain Deformity Sarcomatous change
61
What is Milchs technique?
For reduction of anterior shoulder dislocation External rotation and abduction of shoulder so arm is in overhead position Direct pressure placed over humeral head to force it back into glenoid fossa
62
What is the kocher method?
For reduction of anterior shoulder dislocation | Traction to elbow with external rotation of humerus and adducting the elbow toward the chest
63
What are complications of kocher method for reduction of anterior shoulder dislocation?
Neurovascular complications | Proximal humerus fractures
64
What is Barlow's manoeuvre?
Test for developmental dysplasia of the hips Place index finger on lateral aspect of femur and thumb on knee Apply posterior force Dislocatable hip will click posteriorly as the hip comes out of the acetabulum
65
What are symptoms of a scaphoid fracture?
Deep dull pain in radial side of wrist made worse by gripping Swelling Bruising Fullness of anatomical snuffbox - effusion
66
What is routine management of a scaphoid fracture?
Plastering | Bring patient back to fracture clinic in two weeks for scaphoid X-ray
67
A 75 year old female presents with weakness, fatigue and pelvic pains. On examination she has a proximal myopathy. An X-ray reveals pseudofractures in the pelvis. What is the diagnosis?
Osteomalacia - vitamin d deficiency
68
What is the difference between osteochondroma and osteosarcoma?
Osteochondroma is benign | Osteosarcoma is malignant
69
Why is a Pagets leg likely to feel warm to touch?
Increased blood flow through the bone
70
What muscles form the rotator cuff?
Teres minor Supraspinatus Infraspinatus Subscapularis
71
What factors maintain the integrity of the shoulder joint?
Glenohumeral joint capsule Cartilagenous glenoid labrum Muscles of the rotator cuff
72
What is the most common type of shoulder dislocation?
Anterior
73
Which nerve is most commonly injured due to shoulder dislocation?
Axillary
74
A 46 year old man presents after penetrating injuries to his arm and forearm. He is unable to extend his fingers. There is no sensory disturbance and there is no vascular injury. Which nerve has been damaged?
Posterior interosseous Supplies all extensor muscles except brachioradialis, extensor carpi radialis brevis and longus. It has no cutaneous branch
75
When is Simmonds test positive?
Achilles tendon is ruptured
76
What is Simmonds test?
Test for achilles tendon rupture | Reduced plantar flexion of ankle on squeezing calf muscle
77
How is Achilles tendon rupture usually treated?
``` Rest Ice Elevation Physiotherapy Surgery ```
78
What is often the cause of gastrocnemius and soleus tears?
Sudden unaccustomed exercise
79
What are risk factors for DVT?
``` Hospitalisation Immobility Increasing age Pregnancy Oral contraceptive pill Surgery - orthopaedic or pelvic Malignancy Hx of DVT and thrombophilia ```
80
What are clinical features of DVT?
``` Redness Swelling Pain Calf tenderness Dilated superficial veins Low grade pyrexia ```
81
When is a DVT most likely to occur post operatively?
After 7- 10 days
82
What is usually the cause of an acute swelling in the knee joint after trauma if there is no evidence of fracture?
Damage to cruciate ligaments or menisci
83
If there is a joint effusion with severe pain, what can be done to relieve the acute symptoms?
Aspiration of the knee joint under local anaesthetic
84
What is speeds test and what is it used to diagnose?
Elbow extended, forearm supinated and humerus elevated to 60 degrees. Examiner resists humeral forward flexion Biceps tendonitis. Positive test if pain located to bicipital groove
85
What are some causes of a positive trendelenburg test?
Gluteal paralysis or weakness Pain in hip causing gluteal inhibition Coxa vara Congenital dislocation of the hip
86
What is the contents of the carpal tunnel?
Median nerve Four flexor digitorum profundus tendons Four flexor digitorum superficialis tendons Flexor pollicis longus
87
What is Popeye sign a feature of?
Rupture of long head of biceps
88
Where does the long head of biceps originate?
Supraglenoid tubercle
89
Why does rupture of the long head of biceps usually occur?
At bony attachment due to inflammation from impingement in subacromial region
90
What type of dislocation classically shows a light bulb appearance on X-ray?
Posterior shoulder dislocation
91
A 49 year old female has developed insidious pain, weakness and loss of movement in her shoulder. The pain is exacerbated by abduction. What is the diagnosis?
Impingement syndrome
92
What is impingement syndrome?
Irritation of the tendons of the rotator cuff as they pass through the subacrcomial space usually by osteoarthritic spurs
93
What are some causes of avascular necrosis?
``` HTN Sickle cell disease Caisson disease Radiation induced arteritis Corticosteroid therapy Connective tissue disease Alcohol abuse Marrow storage disease (gauchers) Dyslipoproteinaemia ```
94
What is the major difference between synovial fluid and other body fluids derived from plasma?
High content of hyaluronic acid (mucin)
95
How does slipped upper femoral epiphysis present?
``` Obese adolescent boys with positive family history Externally rotated hip Antalgic gait Decreased internal rotation Thigh atrophy depending on chronicity Hip, thigh and knee pain ```
96
What are the classical signs of scaphoid fracture?
Swelling Pain on wrist movement Tenderness on direct palpation 2cm distal to listers tubercle of the radius (in anatomical snuffbox) and on proximal pressure on extended thumb or index finger
97
What is the treatment for suspected scaphoid fracture which is not proven on X-ray?
Plaster cast for 2 weeks Repeat X-ray If still inconclusive, bone scan
98
What is done to manage non union of a scaphoid fracture?
Bone graft | Herbert screw fixation
99
What is severs disease?
Pain in one or both heels upon walking or standing caused by a disturbance or interruption to the growth plates at the back of the calcaneous Affects children age 8-13 Extreme pain when placing heel on ground, alleviated when walking on tip toes
100
What is Klippel Feil syndrome?
Congenital fusion of any of the cervical vertebrae | Caused by failure in normal segmentation or division of cervical vertebrae during early weeks of foetal development
101
What are signs of Klippel feil syndrome on examination?
Short neck Low hairline at back of head Restricted mobility of upper spine
102
Which abnormalities are associated with Klippel Feil syndrome?
``` Scoliosis Spina bifida Anomalies of kidneys and ribs Cleft palate Respiratory problems Heart malformations ```
103
A 40 year old lady presents to clinic complaining of an 18 month hx of dorsoradial wrist pain. She is a keen tennis player. On examination she has tenderness localised to the dorsoradial aspect of the wrist and passive motion of the thumb causes crepitus in the same region. Finkelstein's test is positive. What is the likely diagnosis?
De Quervains tenosynovitis
104
What is a frax assessment tool?
``` Assess individuals 10 year risk of fracture Age Sex Weight Height Previous fracture Parent fractured hip Smoker Glucocorticoids RA Secondary osteoporosis Alcohol 3 or more units/day Femoral neck BMD ```
105
What are risk factors for osteoporosis development?
``` Glucocorticoid use RA Alcohol excess History of parental hip fracture Low body mass index Current smoker Sedentary lifestyle Premature menopause ```
106
What form of tumour generates a soap bubble appearance on X-ray of the knee?
Osteoclastoma
107
What conditions can cause Charcots arthropathy?
Diabetes Mellitus Syringomyelia Syphilis
108
What is the medical name for bunions?
Hallux valgus deformity sometimes with bursa
109
What does a low calcium and phosphate combined with raised alkaline phosphate suggest?
Osteomalacia
110
What are different types of osteomalacia?
``` Vitamin D deficiency: malabsorption, lack of sunlight, diet Renal failure Drug induced: anticonvulsants Vitamin D resistant: inherited Liver disease ```
111
What are features of osteomalacia?
Bone pain Fractures Muscle tenderness Proximal myopathy
112
What are features of rickets?
Knock knee Bow leg Features of hypocalcaemia
113
How do you investigate osteomalacia?
Low calcium, phosphate, vitamin D Raised alkaline phosphatase X-ray: children - cupped ragged metaphyseal surfaces. Adults - translucent bands (loosers zones/pseudofractures)
114
How are simple undisplaced fractures of the small toes?
Analgesia Padded buddy strapping Elevation
115
What is the Weber classification for ankle fractures?
Describes level of fibular fracture in relation to syndesmosis Gives idea of stability of fracture. C is least stable A: below syndesmosis B: at the level of syndesmosis C: above level of syndesmosis
116
What is a Potts fracture?
Medial malleolus avulsion fracture after inverting ankle
117
What is Tietzes syndrome?
Benign condition of unknown aetiology Non specific inflammation and swelling of one or more costal cartilages Local tenderness on palpation of the lump
118
What is Severs disease?
Pain in one or both heels upon walking or standing caused by disturbance or interruption to growth plates at back of calcaneus Usually affects children aged 8-13
119
What is chondromalacia patellae?
Softening of the cartilage of the patella Common in teenage girls Anterior knee pain on walking up and down stairs and rising from prolonged sitting Usually responds to physio
120
What is osgood schlatter disease?
Seen in sporty teenagers Pain, tenderness and swelling over the tibial tubercle Tibial apophysitis
121
What is osteochondritis dissecans?
Pain after exercise | Intermittent swelling and locking
122
What is patellar tendonitis?
More common in athletic teenage boys Chronic anterior knee pain worsens after running Tender below the patella on examination
123
Which conditions are associated with trigger finger?
Rheumatoid arthritis | Diabetes mellitus
124
What is the management of trigger finger?
Steroid injection Finger splint Surgery if no response
125
Which movement of the shoulder is mainly affected in adhesive capsulitis?
External rotation
126
What is Fouchers sign?
Increase in tension of bakers cyst on extension of knee
127
What is a bakers cyst?
Swelling behind the knee filled with synovial fluid commonly if underlying problem like OA Can mimic DVT if it ruptures
128
What are features of adhesive capsulitis?
External rotation affected more than internal rotation or abduction Active and passive movements affected Painful freezing phase, adhesive phase and recovery phase Typically lasts between 6 months and 2 years
129
What is kochers criteria?
``` For likelihood of septic arthritis Non weight bearing ESR over 40 Fever over 38.5 WCC over 12 If all 4, 99% chance septic arthritis ```
130
What is a jersey finger?
Traumatic avulsion of the flexor digitorum profundus from its insertion into the distal phalanx
131
What is a mallet finger?
Injury to extensor tendon at its insertion into distal phalanx
132
What is a Seymour fracture?
Fracture of distal phalanx associated with a nail bed injury
133
What is a lisfranc injury?
Injury of foot whereby one or more metatarsal bones are displaced from tarsus when excessive kinetic energy is placed to the midfoot
134
What is hallux rigidus?
Degenerative arthritis causing bone spurs at the metatarsophalangeal joint of the hallux making the big toe painful and stiff
135
What is a jones fracture?
Fracture in mid diaphyseal junction of fifth metatarsal of the foot
136
What are the stages of frozen shoulder?
Freezing stage: pain/stiffness Frozen stage: persistent stiffness Thawing stage: improved mobility
137
Which movement is particularly affected in frozen shoulder?
External rotation
138
What is the most common complication of fracture of the clavicle?
Malunion - angulation, shortening, poor appearance
139
What are 3 main complications of a colles fracture?
Malunion Stiffness of fingers and wrist Sudecks atrophy
140
What is sudecks atrophy?
Severe pain in hand and wrist, swelling, circulatory disturbance in hand with oedema Resulting in painful stiffness of all joints of hands
141
What is a lisfranc injury?
Injury of the foot whereby one or more metatarsal bones are displaced from the tarsus seen when excessive kinetic energy is directly or indirectly placed on the mid foot such as in a traffic collision
142
What is a jones fracture?
Fracture in meta diaphyseal junction of 5th metatarsal of foot
143
What is Parsonage Turner syndrome?
Brachial neuritis | Peripheral nerve disorder causing severe pain which can complicate viral illness
144
What are the most common causative organisms in osteomyelitis?
Staphylococcus Haemophilus influenzae Salmonella
145
What are serious side effects of bisphosphonates?
Osteonecrosis of the jaw Atypical fracture Oesophagitis
146
What are causes of spinal stenosis?
``` Ligamentum flavum hypertrophy Osteophytes Disc prolapse Degenerative disc disease Facet joint degeneration Osteoporotic fracture OA RA Spondylolisthesis Tumour ```
147
What are the Ottawa foot rules?
Foot X-ray required if pain in mid foot and: Bone tenderness at navicular bone Bone tenderness at base of 5th metatarsal Inability to weight bear immediately and in the emergency department
148
What are the Ottawa ankle rules?
Ankle X-ray required only if pain in malleolar zone and any findings: Boney tenderness at lateral malleolus to 6cm posterior fibula Boney tenderness at medial malleolus to 6cm posterior tibia Inability to walk four weight bearing steps immediately after the injury and in ED
149
What are the Ottawa knee rules?
``` X-ray indicated if: Over 55 Tenderness at head of fibular Isolated patella tenderness Inability to flex knee to 90 Inability to walk 4 steps immediately after and in ED ```
150
What is vertebroplasty?
Cement injected percutaneously in order to fix a fractured vertebra Usually osteoporotic wedge fracture
151
Which conditions pre dispose to osteomyelitis?
``` Diabetes Mellitus Sickle cell anaemia IV drug user Immunosuppression Alcohol excess ```
152
Within what time frame after an elective total hip replacement should low molecular weight heparin be commenced?
6-12 hours after surgery
153
What is a galeazzi fracture?
Displaced fracture of radius and prominent ulnar head due to dislocation of inferior radio ulnar joint
154
What is a hill Sachs lesion?
Posterolateral humeral head compression fracture secondary to anterior shoulder dislocation as the humeral head comes to rest against anteroinferior part of glenoid
155
What is osteitis fibrosa cystica?
Advanced bony changes seen in patients with primary or secondary hyperparathyroidism Increased osteoclastic activity with bone resorption and peritrabecular fibrosis
156
What is a brown tumour on X-ray?
Osteitis fibrosa cystica | Manifestation of hyperparathyroidism
157
What are the 4 components of describing bone displacement?
Bone Length Angulation Rotation Translation
158
What are the 4 Rs of fracture management?
Resuscitation: ABCDE approach Reduction: Correct any displacement of fracture, either open (in operating theatre) or closed (manipulating two ends of the bone back into position non-operatively) Restriction: Keep two ends of bone aligned correctly so they can heal, either non-operatively e.g. traction, braces, backslab, slings or operatively e.g. internal fixation, or external fixation (usually for open fractures) Rehabilitation: Physiotherapy and occupational therapy to help return to baseline
159
What exam findings might you expect to find with an anterior shoulder dislocation?
``` Squaring of shoulder Pain Immobility External rotation Abduction Anterior displacement ```
160
What is the management for anterior shoulder dislocation?
Resuscitation Axillary Nerve C5/C6 testing before and after reduction Restriction in broad arm sling Rehabilitation
161
What are the different types of anterior shoulder dislocation?
Sub-coracoid: Most common, humeral head is anterior to glenoid fossa and inferior to coracoid process Sub-glenoid: 2nd most common, humeral head is inferior to glenoid fossa and coracoid process
162
What is a bankart lesion?
Injury of anterior glenoid labrum secondary to anterior dislocation which can lead to recurrent dislocations and pain
163
What is a hill Sachs lesion?
Fracture indentation of the posterolateral humeral head secondary to anterior dislocation of the shoulder
164
What are causes of posterior shoulder dislocation?
electrocution or seizure
165
What is diagnosed with a light bulb sign?
Posterior Dislocations are diagnosed with the light bulb sign on a Y view shoulder X-ray
166
What is the classification system for AC joint dislocation?
Rockwood
167
What exam findings may you expect with AC joint dislocation?
Positive Scarf Test (Active shoulder cross adduction)
168
What is the management for AC joint dislocation?
``` Broad arm sling and early mobilization (rockwood I-II) Surgical repair (rockwood III+) ```
169
What is the salter Harris classification of fractures?
For paediatric fractures, classify them based on their relation to the growth plate (physis) Type 1: transverse through physis Type 2: through physis and metaphysis, sparing epiphysis Type 3: through physis and epiphysis, sparing metaphysis Type 4: through all elements of bone Type 5: compression of growth plate
170
Which is the most common type of salter Harris fracture?
Type 2
171
Which classification system is used for supracondylar fractures?
Gartland Type 1: hairline crack Type 2: displaced anterior wall, intact posterior hinge Type 3: complete displacement, both anterior and posterior
172
What is a Barton's fracture?
Intraarticular distal radius fracture
173
What should be done if clinical suspicion of scaphoid fracture but it is not visible on X-ray?
Scaphoid series +/- clenched fist view | Repeat in 7-10 days or CT/MRI
174
Which part of the scaphoid is most susceptible to AVN when fractured?
More proximal the #, the higher the risk of AVN and non-union (30-50%)
175
What is the terry thomas sign with a scaphoid fracture?
Widening of the scapholunate interval due to associated injury of the scapholunate ligament
176
What is a monteggia fracture?
Proximal 1/3 ulna fracture with proximal radial head-humeral capitulum joint dislocation
177
What is a galleazi fracture?
Distal 1/3 radial fracture with distal radio-ulnar joint dislocation
178
What is shentons line?
Imaginary curved line drawn along inferior border superior pubic ramus and inferomedial neck of femur Should be smooth If disrupted - NOF fracture
179
What is the garden classification of NOF fractures?
Garden 1: incomplete impacted Garden 2: complete fracture, undisplaced Garden 3: displaced, capsule intact Garden 4: displaced
180
What are the 4 signs of OA on knee X-ray?
Loss of joint space (medial more common –causes varus deformity) Osteophytes Subchondral sclerosis Subchondral cysts
181
What are the Ottawa ankle rules?
In A+E – Xray ankle if: bony tenderness along distal 6cm of posterior edge of tibia or fibula Or, bony tenderness in either malleolar tip, Or, inability to weight bear 4 steps
182
What is the Weber classification of ankle fractures?
Level of fibular fracture relative to syndesmosis Weber A: below syndesmosis Weber B: level with syndesmosis Weber C: above level of syndesmosis
183
What are signs of ligamentous instability in an ankle fracture?
Talar shift, talar tilt, distal tibiofibular interval
184
What are the 3 views of ankle X-rays that should be taken?
AP Mortise Lateral
185
What are the different Weber B ankle fractures?
Webers B1: Usually Spiral May involve medial malleolus fracture as well (B2, bimalleolar fracture) If involves posterolateral tibia (B3, trimalleolar fracture)
186
What is a maissoneuvre fracture?
A type of weber C ankle fracture Spiral proximal fibula fracture and unstable ankle injury (distal tibiofibular syndesmosis and/or deltoid ligament disruption, or fracture of the medial malleolus)
187
What is a Potts fracture?
Dislocation of the ankle joint seen by talar shift Fracture of the fibular 6-7cm above the lateral malleolus (Webers C) Rupture of distal tibiofibular ligaments/distal syndesmosis, or, medial malleolar fracture
188
Which is the most common primary bone malignancy in children?
Osteosarcoma
189
Where do osteosarcomas occur?
metaphyses of long bones | Most common sites are around knee (75%) or proximal humerus
190
Where does osteosarcoma mainly metastasise to?
Lungs
191
What is Ewing's sarcoma?
Primitive neuroectodermal tumour thought to arise from mesenchymal stem cells
192
How does Ewing's sarcoma present?
Mass or swelling, most commonly in long bones of arms and legs, pelvis or chest but also in the skull and flat bones of trunk
193
What does an X-ray of a Ewing's sarcoma show?
Bone destruction with overlying onion-skin layers of periosteal bone formation
194
What are the most common primaries that metastasise to bone in childhood?
Wilm’s tumour | Neuroblastoma
195
What is non specific back pain?
NO red flags and not in high risk group
196
What are nice guidelines for management of non specific back pain?
``` Paracetamol Weak opioids NSAIDs +/- PPI Low dose tricyclic antidepressant eg amityptyline Short-term use only strong opioids Graded exercise programme Manual therapy Acupuncture for up to 12 weeks duration ```
197
What is the modified New York criteria for diagnosis of Ankylosing spondylitis?
Clinical criteria: Low back pain, for more than 3 months, improved by exercise, not relieved by rest. Limitation of lumbar spine motion in both sagittal and frontal planes. Limitation of chest expansion relative to normal values for age and sex Radiological criterion: sacroiliitis on X-ray Definite AS is diagnosed if radiological criterion is present plus at least one clinical criterion and probable AS if 3 clinical criteria present, or if radiological criterion is present but no clinical criteria are present
198
What initial investigations should be done for Ankylosing spondylitis?
``` X-ray sacro-iliac joints MRI SI joints in early disease FBC CRP HLA B27 ```
199
What are presenting features of myeloma?
``` Bone destruction Bone marrow failure Hyperviscosity symptoms Hypercalcaemia Renal impairment ```
200
What are indications for a spinal MRI?
Routine referral for MRI spine is indicated after 6-12 weeks of genuine radiculopathy with no improvement on conservative therapy Urgent referral is for patients with acute and severe radiculopathy or low back pain within high risk group (<20 or >55 years, osteoporosis, alcoholism, HIV, drug abuse, steroid therapy, adolescent athletic injury, malignancy (suspected or diagnosed). Red flag signs or symptoms
201
What are absolute contraindications to MRI?
``` Pacemaker or cardiac defibrillator Cochlear implant Neurostimulator Orbital or spinal metallic foreign body Untested intracranial aneurysm clips Infusion pumps Implanted drug infusion ports ```
202
What are symptoms of lateral disc protrusion?
Pain in buttock, and down the back of the thigh and the leg aggravated by coughing, sneezing and straining, is more intense that any associated backache Numbness or tingling in the distribution of the affected root
203
What are clinical findings of an L4 deficit?
Quadriceps wasting and weakness Impaired knee jerk Sensory impairment over medial calf
204
What are clinical findings of an L5 deficit?
Wasting and weakness of dorsiflexors of foot (with some degree of foot drop), extensor digitorum longus and extensor hallucis longus Wasting of extensor digitorum brevis Sensory impairment over lateral calf and dorsum of foot
205
What are clinical findings of an S1 deficit?
Sensory impairment over outer aspect of the foot Impaired ankle jerk Possible wasting and weakness of the plantar flexors, but may remain strong due to S2 supply
206
What is the management of a prolapsed disc?
90% of acute sciatica attacks improve with conservative management Indication for surgical treatment: altered bladder and bowel function, progressive neurological deficits such as motor weakness or sensory deficit in lower extremities, Consider in patients with radicular pain that persists after an adequate course of conservative management
207
What are causes of osteoporosis?
``` Endocrine Metabolic Smoking Alcohol excess Malabsorption eg IBD Immobility Iatrogenic – medication; especially corticosteroids Genetic – family history ```
208
What are risk factors for osteoporosis?
Previous fragility fracture Current use or frequent past use of oral glucocorticoids History of falls Family history of hip fracture Other secondary causes of osteoporosis Low body mass index (BMI) (less than 18.5 kg/m2) Smoking more than 10 cigarettes per day Alcohol intake of more than 4 units per day
209
What are presenting symptoms of cauda equina?
Leg weakness bilateral Sensory disturbance perineal – saddle anaesthesia Urinary and faecal disturbance, progressing to incontinence
210
What are clinical indicators of pathology in a child with back pain?
``` Age under four years Symptoms persisting for more than four weeks Interference with function Systemic features (fever, weight loss) Worsening pain Neurological features Recent onset of scoliosis Stiffness ```
211
What are risks of bisphosphonates?
Inflamed gastric / oesophageal mucosa GI upset Osteonecrosis of the jaw Atypical femoral fractures
212
In which patients should caution be used with bisphosphonates?
Previous gastric surgery Active dyspepsia / peptic ulcer disease Abnormalities of oesophagus High doses, recent dental surgery, cancer patients
213
What symptoms should patients on methotrexate report?
``` Neutropenia: streptococcal sore throat Bruising Mouth ulcers Shortness of breath Cough Fever Nausea Vomiting Dark urine Abdominal discomfort Stomatitis ```
214
What are problems with NSAIDs?
Dypepsia, smaller risk of ulcerating disease, GI bleed CVS risk: double risk of heart failure and acute LVF AND increased risk thrombotic event (MI) Renal: afferent arteriole dilation reduces renal perfusion pressure –causing AKI. Rare cases of RTA Preterm labour and miscarriage Worsened asthma
215
What are side effects of corticosteroids?
``` Diabetogenic Hypertension Cataracts Osteoporosis HPA suppression: growth suppression in childhood, menstrual irregularity Cushingoid features: weight gain, Deranged electrolytes, calcium, triglycerides Dyspepsia ```
216
What classification system is used for open fractures?
Gustilo and Anderson system
217
What are risk factors for septic arthritis?
``` Intra articular injections RA Diabetes Immunosuppression Penetrating injury Infections elsewhere e.g. Gonococcal ```
218
Which bug causes septic arthritis in patients with joint replacement?
Staphylococcus epidermis
219
Where does supraspinatus attach onto the humerus?
Greater tubercle
220
What classification system is used for open fractures?
Gustilo and Anderson
221
What is the termination of the spinal cord called?
Conus medullaris
222
Where does the spinal cord terminate in adults and neonates?
Adults: L3/4 Neonates: L4/5
223
What are conservative management steps for fractures?
Splinting Cast Traction Do nothing
224
When does external fixation get done?
Soft tissue damage | Open fracture
225
Who is eligible for THR after fractured NOF?
Can walk a mile, no frame
226
What are the 3 important principles of fracture management?
Reduce Immobilise/fix Rehabilitate
227
What are the 4 different fracture deformities?
Displacement Angulation Rotation Shortening
228
What is the most common salter Harris fracture?
Type 2
229
Which tumours metastasise to bone?
``` Lung Breast Thyroid Kidney Prostate ```
230
What X-ray view is important in a SUFE?
Frog leg lateral
231
What is the blood supply to the femoral head?
Ligamentum teres artery from obturator (degenerates over time) Medial circumflex from deep femoral - retinacular arteries Lateral circumflex

Phase 3 (23 decks)

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