Acetabular labral tear; ACL injury; Bicep tears; Meniscal tears

Question 1

Describe where the acetabulam & acetabulam labrum is and their function [2]

Answer 1

The acetabular labrum is a cartilaginous ring which encompasses the acetabulum, deepening the socket and subsequently increasing the stability of the hip joint.

Question 2

Describe what happens in an acetabular labral tear [1]

Answer 2

results from damage to the cartilage that makes the acetabular labrum, most commonly occurring on the anterior aspect

Question 3

What are the cardinal features of acetabular labral tears? [3]

Answer 3

The cardinal clinical features of acetabular labral tears are hip pain, locking and instability:
- Pain is felt in the groin/hip region: specifically in the anterior hip or groin region.
- Clicking, locking, catching and giving way of the hip

Question 4

The two main diagnostic investigations for acetabular labral tears are [2]?

Answer 4

MR-arthrogram
* An MRI scan combined with injecting contrast direct into the hip joint.

Diagnostic laparoscopy
* The gold standard definitive investigation.

Question 5

Describe the treatment for acetabular labral tears [3]

Answer 5

Physiotherapy:

Medical management:
- NSAIDs
- Intra-articular steroid and local anaesthetic injections

Surgery:
- Hip arthroscopy is the surgical management of choice for acetabular labral tears: debridement or repair

Question 6

Describe the role of the ACL in the knee

Answer 6

Key stabilising structure within the knee joint:
- preventing excessive anterior translation and rotational movement of the tibia relative to the femur

Question 7

Draw the ligaments of the knee [5]

Answer 7

Question 8

What caueses an ACL injury? [1]

Answer 8

ACL injuries typically occur due to a sudden change in direction, deceleration, or landing from a jump with an extended, twisted, or hyperextended knee

The majority of ACL injuries occur without contact and result from a sudden change of direction twisting the flexed knee.

NB Understanding the pathophysiology of an ACL injury begins with recognising its biomechanical role in the knee. The ACL is subjected to high tensile forces during activities involving sudden deceleration, changes in direction, or landing from a jump. When these forces exceed the ligament’s load-bearing capacity, an ACL tear can occur.

Question 9

Desribe the clinical presentation of an ACL injury [3]

Answer 9

Acute onset of pain
- severe and local to knee joint
- hear a pop at time of injury

Swelling

Instability:
- knee ‘gives way’

Question 10

50% of ACL tears will also have a [] tear, with the [] the more commonly affected

Answer 10

50% of ACL tears will also have a meniscal tear, with the medial meniscus the more commonly affected

Question 11

Describe which clinical tests you can perform to test an ACL injury [2]

Answer 11

Anterior drawer test:
- Increased anterior translation, along with a soft or absent endpoint, suggests an ACL injury

Lachman test:
- patient is positioned supine with the knee flexed to 20-30 degrees
- The examiner stabilizes the femur with one hand and grasps the proximal tibia with the other hand
- The tibia is then pulled anteriorly while stabilizing the femur
- Increased anterior translation and a soft or absent endpoint compared to the contralateral side indicate an ACL injury.

NB: The Lachman test is considered more sensitive and specific than the anterior drawer test for detecting ACL injuries

Question 12

[] is the gold standard for diagnosing ACL injuries

Answer 12

Magnetic resonance imaging (MRI) is the gold standard for diagnosing ACL injuries

Question 13

How would you differentiate ACL to meniscal injury:
- based off the history [1]
- based off the symptoms [1]
- clinical test [1]

Answer 13

meniscal tears are typically associated with a twisting injury or direct impact to the knee while it’s flexed and weight-bearing.

Meniscal injuries classically have a ‘locking’ of the knee joint

A positive McMurray’s test - characterised by pain or a palpable click during flexion and rotation of the knee - is suggestive of a meniscal tear.

https://litfl.com/mcmurray-test/ for video

Question 14

How do you differentiate ACL injury to patellar dislocation? [1]

Answer 14

patients with patellar dislocation typically report a visible deformity or ‘shifting’ of the kneecap which is not seen in ACL injuries.

Question 15

Surgical management for ACL injury? [1]

Answer 15

ACL reconstruction: Autograft (using the patient’s own tissue) or allograft (using donor tissue) is used to replace the torn ACL.

ACL repair: In select cases, such as proximal avulsion tears with preserved tissue quality, primary ACL repair may be performed.

Question 16

The biceps muscle has 2 tendons at its origin; the long tendon which attaches to the [] and the short tendon which attaches to the [] process.

It inserts distally via another tendon onto the [] tuberosity.

A biceps tendon rupture is when one of these tendons separates from its attachment site or is torn across it’s full width

Answer 16

The biceps muscle has 2 tendons at its origin; the long tendon which attaches to the glenoid and the short tendon which attaches to the coracoid process.

It inserts distally via another tendon onto the radial tuberosity

Question 17

Bicep tendon rupture most commonly occurs in which tendon? [1]

Answer 17

This most frequently occurs at the long tendon (90%), but rarely can occur in the distal tendon (10%).

Question 18

Describe the deformity seen in a bicep rupture [1]

Answer 18

Popeye’ deformity; this is when the muscle bulk results in a bulge in the middle of the upper arm.

Question 19

[] by a skilled clinician and should always be the first investigation for suspected biceps tendon rupture

For suspected distal biceps tendon rupture, an urgent [] should be performed as a diagnosis on clinical signs alone is challenging, and this usually requires surgical intervention.

Answer 19

Musculoskeletal ultrasound by a skilled clinician and should always be the first investigation for suspected biceps tendon rupture

For suspected distal biceps tendon rupture, an urgent MRI should be performed as a diagnosis on clinical signs alone is challenging, and this usually requires surgical intervention.

Question 20

An iliopsoas abscess describes a collection of pus in iliopsoas compartment (iliopsoas and iliacus).

What is the most likely causative agent? [1]

Answer 20

Staphylococcus aureus: most common

Question 21

What is the gold standard for testing for an iliopsoas abscess? [1]

Answer 21

CT is the gold standard.

Question 22

Describe what is meant by meralgia paraesthetica [1]

Answer 22

syndrome of paraesthesia or anaesthesia in the distribution of the lateral femoral cutaneous nerve (LFCN).
- compression of this nerve anywhere along its course can lead to the development of meralgia paraesthetica.

Question 23

The [] test is highly sensitive, and often, meralgia paraesthetica can be diagnosed based on this test alone.

Describe this test [1]

Answer 23

The pelvic compression test is highly sensitive, and often, meralgia paraesthetica can be diagnosed based on this test alone

deep palpation just below the ASIS:
- causes pain; numbness; coldness or burning

Question 24

Tx for meralgia parasethetica? [1]

Answer 24

Injection of the nerve with local anaesthetic will abolish the pain. Using ultrasound is effective both for diagnosis and guiding injection therapy in meralgia paraesthetica

Question 25

The menisci are nourished primarily by the blood supply from the [] arteries.

Describe how the vascularity of the menisci changes and why this is clinically relevant [3]

Answer 25

The menisci are nourished primarily by the blood supply from the geniculate arteries

The vascular supply decreases from the periphery to the inner third, creating three distinct zones: the red-red, red-white, and white-white zones. The red-red zone has the best healing potential, while the white-white zone has a limited ability to heal due to avascularity.

Question 26

Describe the surgical repairs used for meniscal injuries [3]
State when they are indicated [3]

Answer 26

Meniscal repair:
- Indicated for tears in the vascular red-red or red-white zones, with a higher likelihood of healing. Repair techniques include inside-out, outside-in, and all-inside methods

Partial meniscectomy:
- Indicated for tears that are not amenable to repair, such as those in the avascular white-white zone or complex degenerative tears.
- The goal is to remove the unstable, non-viable tissue while preserving as much healthy meniscus as possible.

Meniscal transplantation:
- Indicated in select cases where the patient has undergone a previous total or subtotal meniscectomy and experiences persistent pain or functional impairment.
- The procedure involves transplanting a cadaveric meniscus to replace the missing or non-functional meniscus.

Question 27

What would indicate someone has an osteoporotic vertebral fracture? [3]

Answer 27

• Loss of height: vertebral osteoporotic fractures of lead to compression of the spinal vertebrae hence a reduction in overall length of the spine and thus the patient becomes shorter
• Kyphosis (curvature of the spine)
• Localised tenderness on palpation of spinous processes at the fracture site

Question 28

Which investigations would you perform for an osteoporotic vertebral fracture? [2]

Answer 28

X-ray of the spine:
- This should be the first investigation ordered and may show wedging of the vertebra due to compression of the bone. An X-ray of the spine may also show old fractures (which can have a sclerotic appearance)

dual-energy X-ray absorptiometry (DEXA) scan should be considered

Question 29

Which is the specific artery that supplies the meniscus? [1]

Answer 29

Middle genicular artery

Question 30

What is the pathognomonic fracture associated with ACL tears? [1]

Answer 30

Segund fracture - this is an avulsion fracture of the proximal lateral tibia.

Question 31

What is the most sensitive test for cruciate ligament rupture? [1]

Answer 31

Lachmans test

Question 32

How do you treat an undisplaced and displaced patella fractures? [1]

Answer 32

Undisplaced fractures, particularly vertical fractures with an intact extensor mechanism can be managed non-operatively in a hinged knee brace for 6 weeks and patients allowed to fully weight bear.

Displaced fractures and those with loss of extensor mechanisms should be considered for operative management with either tension band wire, inter-fragmentary screws or cerclage wires. Again, patients are placed in a hinged knee brace for 4 to 6 weeks and allowed to fully weight bear.