18- Orthopedics MSQs Only Flashcards
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A 4 year old boy falls and sustains a fracture to the growth plate of his right wrist. Which of the following systems is used to classify the injury?
Salter - Harris system
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The mnemonic ‘SALTR’ can be used to help remember the first five types.
This mnemonic requires the reader to imagine the bones as long bones, with the epiphyses at the base.
I ‘S’ = Slip (separated or straight across). Fracture of the cartilage of the physis (growth plate)
II ‘A’ = Above. The fracture lies above the physis, or Away from the joint.
III ‘L’ = Lower. The fracture is below the physis in the epiphysis.
IV ‘TE’ = Through Everything. The fracture is through the metaphysis, physis, and epiphysis.
V ‘R’ = Rammed (crushed). The physis has been crushed
The Salter - Harris system is most commonly used. The radiological signs in Type 1 and 5 injuries may be identical. Which is unfortunate as type 5 injuries do not do well (and may be missed!). One of our users has helpfully supplied a mnemonic for remembering the types (see above).
2 of 94
An 86 year old retired pharmacist is admitted to Emergency Department following a fall. She complains of right hip pain. She is known to have hypertension and is currently on bendrofluazide. She lives alone and mobilises with a Zimmer frame. Her right leg is shortened and externally rotated. A hip x-ray confirms a displaced intracapsular fracture. What is the best management option?
Hemiarthroplasty
Hemiarthroplasty is offered to older, less mobile individuals compared to fracture reduction and fixation in younger patients.
7 of 94
A 63 year nurse falls on an extended and pronated wrist. An x-ray shows a distal radial fracture with radiocarpal dislocation. Which type of fracture is most likely?
Barton’s
Barton’s fractures tend to have intra-articular involvement and dislocation may sometimes be present.
3 of 94
A 65-year-old Asian female presents with an extracapsular neck of femur fracture. Investigations show:
Calcium 2.07 mmol/l (2.20-2.60 mmol/l)
Phosphate 0.66 mmol/l (0.8-1.40 mmol/l)
ALP 256 IU/l (44-147 IU/l)
What is the most likely diagnosis?
Osteomalacia
Osteomalacia
low: calcium, phosphate
raised: alkaline phosphatase
The low calcium and phosphate combined with the raised alkaline phosphatase point towards osteomalacia.
4 of 94
A tall 18 year old male athlete is admitted to the emergency room after being hit in the knee by a hockey stick. On examination, his knee is tense and swollen. X-ray shows no fractures. What is the diagnosis?
Dislocated patella
A patella dislocation is a common cause of haemarthrosis and many will spontaneously reduce when the leg is straightened. In the chronic setting physiotherapy is used to strengthen the quadriceps muscles.
5 of 94
Which of the following statements relating to avascular necrosis is false?
When associated with fracture may occur despite the radiological evidence of fracture union.
Pain and stiffness will typically precede radiological evidence of the condition.
Drilling of affected bony fragments may be used to facilitate angiogenesis where arthroplasty is not warranted.
The earliest detectable radiological evidence is a radiolucency of the affected area coupled with subchondral collapse.(Right)
It is less likely when prompt anatomical alignment of fracture fragments is achieved.
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Avascular necrosis- radiological changes occur late.
Radiolucency and subchondral collapse are late changes. The earliest evidence on plain films is the affected area appearing as being more radio-opaque due to hyperaemia and resorption of the neighboring area. It may be diagnosed earlier using bone scans and MRI.
6 of 94
A 54-year-old man presents to the Emergency Department with a 2 day history of a swollen, painful left knee. You aspirate the joint to avoid admission to the orthopaedic wards. Aspirated joint fluid shows calcium pyrophosphate crystals. Which of the following blood tests is most useful in revealing an underlying cause?
Transferrin saturation
This is a typical presentation of pseudogout. An elevated transferrin saturation may indicate haemochromatosis, a recognised cause of pseudogout.
A high ferritin level is also seen in haemochromatosis but can be raised in a variety of infective and inflammatory processes, including pseudogout, as part of an acute phase response.
8 of 94
A 34 year old man presents with localised spinal pain over 2 months which is worsened on movement. He is known to be an IVDU. He has no history suggestive of tuberculosis. The pain is now excruciating at rest and not improving with analgesia. He has a temperature of 39 C. What is the most likely diagnosis?
Osteomyelitis
In an IVDU with back pain and pyrexia have a high suspicion for osteomylelitis. The most likely organism is staph aureus and the cervical spine is the most common region affected. TB tends to affect the thoracic spine and in other causes of osteomyelitis the lumbar spine is affected.
9 of 94
A 74 year old lady falls and injures her left arm. Following assessment she is found to have an impacted fracture affecting the surgical neck of the humerus. What is the most appropriate course of action?
Apply a collar and cuff system for three weeks and then commence physiotherapy
Impacted fractures of the surgical neck are stable injuries and usually heal without complication. It is rare to need to resort to surgery. Its important to start physiotherapy early.
10 of 94
A 34 year old woman is a passenger in a car during an accident. Her knee hits the dashboard. On examination, the tibia looks posterior compared to the non injured knee. Which structure has been injured?
Posterior cruciate ligament
In ruptured posterior cruciate ligament the tibia lies back on the femur and can be drawn forward during a paradoxical draw test.
11 of 94
A 25 year old ski instructor who falls off a ski lift and sustains a spiral fracture of the mid shaft of the tibia. Attempts to achieve satisfactory position in plaster have failed. Overlying tissues are healthy. What is the most appropriate course of action?
Intramedullary nail
This would be a good case for intramedullary nailing. Open reduction and internal fixation would strip off otherwise healthy tissues and hence is unsuitable. In some units the injury may be managed with an Ilizarov frame device but the majority would treat with IM nailing.
13 of 94
An otherwise fit 74 year old man presents with pain in the right hip following minimal trauma. On examination, his leg is shortened and externally rotated. Plain films demonstrate a displaced intracapsular fracture of the femoral neck. What is the best course of action?
Total hip replacement
In otherwise fit patients aged over 70, the best long term functional outcomes are obtained with total hip arthroplasty.
12 of 94
the list below, which is not a cause of avascular necrosis?
Steroids
Sickle cell disease
Radiotherapy
Myeloma(Right)
Caisson disease
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Causes of avascular necrosis
P ancreatitis
L upus
A lcohol
S teroids
T rauma
I diopathic, infection
C aisson disease, collagen vascular disease
R adiation, rheumatoid arthritis
A myloid
G aucher disease
S ickle cell disease
Steroid containing therapy for myeloma may induce avascular necrosis, however the disease itself does not cause it. Caisson disease as may occur in deep sea divers is a recognised cause.
15 of 94
Which of the following is not a typical feature of talipes equinovarus?
Adducted and inverted calcaneus
Medial displacement of the navicular bone
It is nearly always unilateral (Right)
Wedge shaped head of talus
Severe Tibio-talar plantar flexion
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It is bilateral in 50% of cases.
16 of 94
A 1 year-old is brought to the Emergency Department with a history of failure to thrive. On examination, the child is small for age and has a large head. X-ray shows a cupped appearance of the epiphysis of the wrist. What is the most likely cause?
Rickets
Rickets is the childhood form of osteomalacia. It is due to the failure of the osteoid to ossify due to vitamin D deficiency. Symptoms start about the age of one. The child is small for age and there is a history of failure to thrive. Bony deformities include bowing of the femur and tibia, a large head, deformity of the chest wall with thickening of the costochondral junction (rickettary rosary), and a transverse sulcus in the chest caused by the pull of the diaphragm (Harrison’s sulcus). X- Rays show widening and cupping of the epiphysis of the long bones, most readily apparent in the wrist.
14 of 94
An obese 12 year old boy presents with knee pain. On examination, he has pain on internal rotation of the hip. His knee is clinically normal. What is the most appropriate investigation?
Hip X-ray
The main differential diagnosis in a boy over 10 years old is of slipped upper femoral epiphysis. Knee pain is a common presenting feature. An anteroposterior pelvic x-ray may miss a minor slip, therefore request a hip film.
17 of 94
A 4 year boy presents with an abnormal gait. He has a history of recent viral illness. His WCC is 11 and ESR is 30. What is the most likely cause?
Transient synovitis
Viral illnesses can be associated with transient synovitis. The WCC should ideally be > 12 and the ESR > 40 to suggest septic arthritis.
18 of 94
A 45 year old man has been admitted after being knocked off his bicycle. His ankle is grossly deformed with bilateral malleolar tenderness with severe ankle swelling and tenting of the medial soft tissues. What is the most appropriate initial management?
Immediate reduction and application of backslab
This is an unstable ankle injury that is likely to require surgical fixation. The immediate management of a displaced ankle fracture is to reduce the fracture to prevent soft tissues compromise and help reduce swelling. This can be performed before an x-ray is obtained if performing the x-ray will significantly delay reduction.
19 of 94
An athletic 15 year old boy presents with knee pain of 3 weeks duration. It is worst during activity and settles with rest. On examination, there is tenderness overlying the tibial tuberosity and an associated swelling at this site. What is the diagnosis?
Osgood Schlatters disease
Athletic boys and girls may develop this condition in their teenage years. It is caused by multiple micro fractures at the point of insertion of the tendon into the tibial tuberosity. Most cases settle with physiotherapy and rest.
20 of 94
Which of the following fractures names best accounts for the injury seen in a 14 year old boy who jumps off a 10 foot wall and lands on both feet and whose imaging shows a bimalleolar fracture of the right ankle?
Pott’s
21 of 94
A 60 year old male is admitted to the emergency room with a fall. He lives with his wife and still works as a restaurant manager. He has a past history of benign prostatic hyperplasia and is currently taking tamsulosin. He is otherwise fit and healthy. On examination, there is right hip tenderness on movement in all directions. A hip x-ray confirms an intertrochanteric fracture. What is the best management option?
Dynamic hip screw
The blood supply to the femoral head may be intact and the fracture should heal with compression type devices such as gamma nails or dynamic hip screws. The latter device being the most commonly performed therapeutic intervention.
22 of 94
A 30 year old man is admitted overnight, following a road traffic accident. He has an open tibial fracture with a 20 cm wound and extensive periosteal stripping. He is neurovascularly intact; IV antibiotics and wound dressing have been administered in the emergency department. What is the most appropriate course of action?
Combined skeletal and soft tissue reconstruction on a scheduled operating list
This patient has a Gustillo-Anderson Grade 3B open fracture. He will require definitive skeletal and soft tissue reconstruction, which should be performed on a combined ortho-plastic scheduled operating list, as per the BOA/BAPRAS guidelines. The surgery does not have to be performed out of scheduled hours unless there is marine/ sewage contamination, vascular compromise or it is a polytrauma.
Whilst it is reasonable to apply an external fixator prior to definitive skeletal and soft tissue reconstruction, this should be converted to internal fixation within 72 hours.
23 of 94
A 19 year old sportswoman presents with knee pain which is worse on walking down the stairs and when sitting still. On examination, there is wasting of the quadriceps and pseudolocking of the knee. What is the diagnosis?
Chondromalacia patellae
A teenage girl with knee pain on walking down the stairs is characteristic for chondromalacia patellae (anterior knee pain). Most cases are managed with physiotherapy.
24 of 94
A 26 year old man presents to the emergency department with a swelling over his left elbow after a fall on an outstretched hand. On examination, he has tenderness over the proximal part of his forearm, and has severely restricted supination and pronation movements. What is the most likely injury?
Fracture of the radial head
Fracture of the radial head is common in young adults. It is usually caused by a fall on the outstretched hand. On examination, there is marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination).
25 of 94
An obese 12 year old boy is referred with pain in the left knee and hip. On examination, he has an antaglic gait and limitation of internal rotation. His knee has normal range of passive and active movement. What is the most likely diagnosis?
Slipped upper femoral epiphysis
Slipped upper femoral epiphysis is commonest in obese adolescent males. The x-ray will show displacement of the femoral epiphysis inferolaterally. Treatment is usually with rest and non weight bearing crutches.
26 of 94
A 5 month baby boy presents with swelling of his right arm and is found to have a spiral fracture of the humerus. He had been in the care of his mother’s boyfriend who reported that he had nearly dropped him that day when reaching for his bottle and had inadvertently pulled on his arm to save him. He was immediately taken to the Emergency Department. What is the most likely issue?
Accidental fracture
The mechanism fits with the fracture pattern and the presentation is not delayed.
27 of 94
A 74 year old male is admitted to the Emergency Department with a fall. He is known to have rheumatoid arthritis and is on methotrexate and paracetamol. He lives alone in a bungalow and enjoys playing golf. He is independent with his ADLs. He complains of left groin pain, therefore has a hip x-ray which confirms a displaced intracapsular fracture. What is the best course of action?
Total hip replacement
This patient has pre-existing joint disease, good level of activity and a relatively high life expectancy, therefore THR is preferable to hemiarthroplasty.
28 of 94
A 42 year old skier falls and impacts his hand on his ski pole. On examination, he is tender in the anatomical snuffbox and on bimanual palpation. X-rays with scaphoid views show no evidence of fracture. What is the most appropriate course of action?
Application of futura splint and fracture clinic review
A fracture may still be present and should be immobilised until repeat imaging can be performed. If clinical suspicion persists then subsequent imaging should be with MRI scanning or CT if MRI is contra-indicated.
32 of 94
An 80 year old woman has a hip fracture. Her calcium is normal. She has never been given a diagnosis of osteoporosis. Apart from treating the hip fracture what additional intervention should be considered?
Vitamin D, calcium supplements and bisphosphonates
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The patient has a frailty fracture and by definition therefore will have osteoporosis and should therefore commence treatment, a DEXA scan will not change this decision.
The osteoporosis guidelines state if a postmenopausal woman has a fracture she should be put on bisphosphonates (there is no need for a DEXA scan).
29 of 94
A 78 year old man complains of a long history of shoulder pain and more recently weakness. On examination, active attempts at abduction are impaired. Passive movements are normal. What is the most likely diagnosis?
Rotator cuff tear
Rotator cuff tears are common in elderly people and may occur following minor trauma or as a result of long standing impingement. Tears greater than 2cm should generally be repaired surgically. The length of the history in this scenario is suggestive of a tear complicating impingement.
30 of 94
A toddler aged 3 years presents to the Emergency Department with swelling of his leg and is found to have a spiral fracture of the tibia. His mother reports that he had tripped and fallen the previous day but she had not noticed any sign of injury at the time. She is a single parent with little family support. The child is not on the child protection register. What is the most likely underlying problem?
Non accidental injury
Delayed presentation is unusual and should raise concern. In addition, spiral fractures are usually the result of rotational injury which is not compatible with the mechanism proposed by the parent.
31 of 94
A 50 year old female slips on wet floor injuring her ankle. On examination, she has tenderness over the lateral and medial malleolus. X-rays (stress views) demonstrate an undisplaced fracture of the distal fibula at the level of the syndesmosis and a congruent ankle mortise. What is the most appropriate management?
Application of below knee plaster cast
This is a Weber B fracture and therefore potentially unstable. Medial malleolar tenderness indicates deltoid ligament injury. As the fracture is currently undisplaced and the ankle mortice is congruent, the injury can be initially managed conservatively in a below knee plaster but the patient should be monitored in the outpatient clinic for fracture displacement in the first few weeks.
33 of 94
A 30 year old man presents with severe pain in the left hip it has been present on and off for many years. He was born at 39 weeks gestation by emergency caesarean section after a long obstructed breech delivery. He was slow to walk and as a child was noted to have an antalgic gait. He was a frequent attender at the primary care centre and the pains dismissed as growing pains. X-rays show almost complete destruction of the femoral head and a narrow acetabulum. What is the most likely underlying disease process?
Developmental dysplasia of the hip
Developmental dysplasia of the hip. Usually diagnosed by Barlow and Ortolani tests in early childhood. Most Breech deliveries are also routinely subjected to USS of the hip joint. At this young age an arthrodesis may be preferable to hip replacement.
35 of 94
A 38 year old window cleaner falls from his ladder. He lands on his left arm and notices an obvious injury. An x-ray and clinical examination demonstrate that he has a fracture of the proximal ulna and associated radial dislocation. What eponymous name is used to describe this injury?
Monteggia’s
This constellation of injuries is referred to as a Monteggia’s fracture.
34 of 94
A 40 year old woman is admitted after being knocked off her bike. She has an open fracture of her tibia, with a 10 cm wound. No peripheral pulses are palpable. Intravenous antibiotics have been administered in the emergency department and the wound has been dressed. What is the best course of action?
Immediate vascuIar shunting, followed by temporary skeletal stabilisation and vascular reconstruction
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This patient has a Gustillo-Anderson Grade 3C open fracture with vascular injury. Vascular impairment requires immediate surgery and restoration of circulation, ideally within 3-4 hours. This should follow the sequence of shunting, temporary skeletal stabilisation and then vascular reconstruction as per BOA / BAPRAS guidelines. Revascularisation using vascular shunts should be performed before skeletal fixation.
36 of 94
A 6 year old boy presents with pain in the hip it is present on activity and has been worsening over the past few weeks. There is no history of trauma. He was born by normal vaginal delivery at 38 weeks gestation On examination he has an antalgic gait and limitation of active and passive movement of the hip joint in all directions. C-reactive protein is mildly elevated at 10 but the white cell count is normal. What is the most likely diagnosis?
Perthes disease
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Early plain x-ray changes in Perthes Disease:
Widening of the joint space.
Sub chondral linear lucency.
This is a typical presentation for Perthes disease. X-ray may show flattening of the femoral head or fragmentation in more advanced cases.
37 of 94
Which of the following is not typically seen in patients with a femoral neck fracture?
Malunion(Right)
Non union
Avascular necrosis
Shortening
External rotation
……………………………………………….
Malunion would be unusual with a femoral neck fracture. Because it is a weight bearing joint, if the fracture is not united then it does not heal at all. It is for this reason that most femoral neck fractures are fixed. Avascular necrosis is a well recognised complication and a total hip replacement or hemiarthroplasty is usually considered in the elderly.
