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Musculoskeletal system > Clinical > Flashcards

Clinical Flashcards

1
Q

What fraction of the general population consults a GP about a musculoskeletal problem each year?

A

1 in 5

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2
Q

What type of shoulder/elbow problems typically present clinically for a patient in their teens/20s?

A

Fractures and instability

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3
Q

What type of shoulder/elbow problems typically present clinically for a patient in their 30s/40s?

A

Rotator cuff injuries and capsultitis

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4
Q

What type of shoulder/elbow problems typically present clinically for a patient in their 50s/60s?

A

Impingement and AC joint problems

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5
Q

What type of shoulder/elbow problems typically present clinically for a patient in their 70s onwards?

A

Degenerative rotator cuff and joint problems

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6
Q

What is the general causes of upper limb fractures?

A
  • Young high energy injuries

- Elderly osteoporotic injuries

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7
Q

What does upper limb fracture management depend on?

A

Fracture configuration and patient biology

Surgery vs non-surgical methods

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8
Q

What is the most common type of traumatic shoulder dislocation?

A

Anterior (90%)

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9
Q

What treatments are available for traumatic shoulder dislocation?

A

Manipulation
Immobilisation
Physiotherapy
Surgery

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10
Q

What occurs in subacromial impingement?

A

Pain and dysfunction from any pathology that decreases the volume of the subacromial space or increases the size of its contents

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11
Q

What treatments are available for subacromial impingement?

A
  • Subacromial steroid injection
  • Physiotherpay
  • Arthroscopic subacromial decompression
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12
Q

What is another name for frozen shoulder?

A

Adhesive capsulitis

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13
Q

How is frozen shoulder diagnosed?

A

Clinical diagnoses based on findings

A normal radiograph would be seen

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14
Q

What is a treatment for early presentation of frozen shoulder?

A

Hydrodilatation

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15
Q

What is a treatment for late presentation of frozen shoulder?

A

Surgery

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16
Q

What is the natural timecourse of frozen shouder?

A

Pain>Stiffness»‘Thawing’

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17
Q

What are two types of causes of rotator cuff tear injuries?

A

Traumatic

Degenerative

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18
Q

What is the treatment for acute rotator cuff tears?

A

Early surgery

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19
Q

What is the treatment for chronic degenerative rotator cuff tears?

A

Surgery if symptomatic

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20
Q

What does treatment for rotator cuff tear depend on?

A

Size, Time, Age

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21
Q

What is an option for massive irreparable rotator cuff tears?

A

Superior Capsular Reconstruction

uses cadaveric skin graft to reconstruct capsule

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22
Q

What are some causes of shoulder arthritis?

A

Osteoarthritis
Inflammatory arthritis
Post-traumatic arthritis

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23
Q

What surgical option may exist for severe shoulder arthritis?

A

Shoulder replacement using custom made implants

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24
Q

What tends to cause elbow problems in younger patients?

A

Fractures and dislocations

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25
Q

What tends to cause elbow problems in middle age patients?

A

Tendinopathies

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26
Q

What tends to cause elbow problems in elderly patients?

A

Degenerative disease

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27
Q

When may cubital tunnel syndrome present in patients?

A

Any age

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28
Q

List the GALS Screening Questions for MSK History in systematic enquiry?

A
  • Do you have any pain or stiffness in your muscles, joints or back?
  • Can you dress yourself completely without any difficulty?
  • Can you walk up and down stairs without any difficulty?
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29
Q

What are common orthopaedic symptoms when something FEELS wrong?

A

Pain, Dysaesthesiae, Weakness

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30
Q

What are common orthopaedic symptoms when something MOVES wrong?

A

Stiffness, Reduced RoM (eg locking), limp, instability/collapsing, crepitus

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31
Q

What are common orthopaedic symptoms when something LOOKS wrong?

A

Swelling, Deformity, Wasting, Shortening, Discolouration (Redness, pallor, bruising), wounds

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32
Q

What are the cardinal presenting orthopaedic symptoms?

A 
Pain
Stiffness
Swelling
Deformity
Discolouration
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33
Q

What questions may be asked in history of a typical day in MSK history?

A 
Wake at normal time or woken by pain?
How are they first thing in the morning? Is this when pain/swelling/stiffness is worst?
How long does it take to get going? Do they have to do exercises?
Dressing etc?
Walking distance on flat?
Driving?
Shopping?
Work, Hobbies?
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34
Q

What are some red flags from history taking that may suggest serious pathology?

A
  • Severe and worsening pain
  • Night pain disturbing sleep
  • Non-mechanical pain
  • General malaise, febrile, rigors
  • Unexplained weight loss, anorexia, night sweats
  • Past history of malignant disease
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35
Q

What is in the GALS Screening system for musculoskeletal examination?

A

Gait
Arms
Legs
Spine

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36
Q

What angle are the joints at in anatomical position?

A

0 degrees

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37
Q

In hand and forearm, what terms should be used as an alternative to lateral and medial?

A

Radial and ulnar

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38
Q

In hand and forearm, what terms should be used as an alternative to posterior and anterior?

A

Dorsal and volar (palmar)

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39
Q

What is the system used in local musculoskeletal examination?

A

Look
Feel
Move
X-Ray

(If possible, look at available xrays first - don’t move fresh fracture!)

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40
Q

What should be considered in Look?

A 
Posture - of patient, limb
Relevant negatives and obvious positives
Gait - limp?
Skin - scars, wounds etc
Colour - redness, bruising, pallor, vascular markings
Swelling
Wasting (In lower limb, look at proximal muscles to joint problem)
Deformity
Limb lengths - real and apparent
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41
Q

How are real limb lengths measured?

A

FRom ASIS/greater trochanter/tibial tuberosity to medial malleolus

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42
Q

How are apparent limb lengths measured?

A

Xiphisternum or umbilicus to medial malleolus

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43
Q

What should be considered in Feel?

A

Skin - temp, sweating, cap refill
Tenderness (Localised, diffuse)
Swelling
Deformity

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44
Q

What should be considered in Move?

A

Active movements
Passive movements
Special tests - abnormal movement, joint laxity, tests
Range, rate, rhythm
RoM’s - degrees or % vs normal side, comparisons
Accompanied by pain, crepitus, stiffness
Rhythm/smoothness, laxity/hypermobility, tenodess,
Muscle tone
Power/strength
Joint laxity/hypermobility

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45
Q

What else needs to be considered in MSK examination?

A
  • Must examine joints above and below, and examine spine for any limb symptoms
  • +Neurovascular examination of whole limb
  • Consider other relevant systematic examination - chest, abdomen, neuro

Record findings - xray?
Re-examine and compare

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46
Q

What sort of presentation may be seen with C5/6 Brachial Plexus Damage?

A

Erb-Duchenne paralysis (Porter’s tip)

Caused by downward traction eg fall on side of neck

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47
Q

What sort of presentation may be seen with T1 Brachial Plexus Damage?

A

Klumpke’s paralysis (hand ‘clawed’)

Caused by upward traction eg breech delivery

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48
Q

What presentation may be seen with motor deficit of the axillary nerve?

A

Loss of shoulder abduction

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49
Q

What presentation may be seen with sensory deficit of the axillary nerve?

A

Sensory loss in ‘badge’ area

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50
Q

What is saturday night palsy’?

A

Pressure on posterior cord of brachial plexus, resulting in damage to axillary nerve/radial nerve.

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51
Q

What presentation may be seen with motor deficit of the radial nerve?

A

Wrist drop (Extensor damage)

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52
Q

What presentation may be seen with sensory deficit of the radial nerve?

A

Sensory loss in 1st web space dorsally

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53
Q

What can median nerve damage arise as a complication of?

A

Carpal tunnel syndrome

Wrist lacerations

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54
Q

What presentation may be seen with motor deficit of the median nerve?

A

Thenar wasting (Monkey hand), Pointing finger

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55
Q

What presentation may be seen with sensory deficit of the medial nerve?

A

Sensory loss of volar aspect of thumb

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56
Q

What can ulnar nerve damage arise as a complication of?

A

Fractures of humeral condyles

Wrist lacerations

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57
Q

What presentation may be seen with motor deficit of the ulnar nerve?

A

Claw hand, Hypothenar and 1st dorsal interossus wasting

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58
Q

What presentation may be seen with sensory deficit of the ulnar nerve?

A

Sensory loss of little finger

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59
Q

What condition does compression of lateral femoral cutaneous nerve cause?

A

Meralgia Paraesthetica

It is sensory to lateral aspect of thigh

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60
Q

What presentation may be seen with motor deficit of the common fibular nerve?

A

Foot drop

Slapping gait

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61
Q

What is the most commonly injured nerve in the lower limb?

A

Common fibular nerve

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62
Q

What test may be used to investigate ulnar nerve palsy?

A

Froment’s Test

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63
Q

What clinical conditions may result in axillary nerve damage?

A

Shoulder dislocation

Fractured surgical neck of humerus

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64
Q

Weakness of what muscle may cause winging of scapula?

A

Serratus anterior

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65
Q

What are some mechanisms for achilles tendon rupture?

A
  • Pushing off with weight bearing foreforr whilst extending knee (sprint starts, jumping)
  • Unexpected dorsiflexion of ankle
  • Violent dorsiflexion os plantarflexed foot
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66
Q

What are some examples of nerve compression?

A

Carpal tunnel syndrome
Sciatica
Morton’s neuroma

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67
Q

List some clinical features in nerve injury?

A

Sensory - dysaethesiae (anaesthetic, hypo/hyperaesthetic, paraesthetic)

Motor - paresis/paralysis/wasting
dry skin

Reflexes - diminished/absent

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68
Q

What clinical sign may be used to monitor nerve recovery?

A

Tinel’s sign

Also via nerve conduction studies

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69
Q

What methods may be used in nerve repair?

A

Direct repair

Nerve grafting

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70
Q

When should surgery ideally be performed for clean and sharp nerve injuries?

A

Immediately within 3 days

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71
Q

When should surgery ideally be performed for blunt/contusive nerve injuries?

A

Within 3 weeks

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72
Q

When should surgery ideally be performed for closed nerve injuries?

A

Within 3 months

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73
Q

In what three directions can the shoulder dislocate?

A

Anterior
Posterior
Inferior

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74
Q

What are some common crystal deposition diseases?

A

Gout (Monosodium urate)

Pseudogout (Calcium pyrophosphate dihydrate (CPPD))

Calcific periarthritis/tendonitis (Basic calcium phosphate hydroxy-apatite (BCP))

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75
Q

In gout, what it a tophi?

A

Massive accumulation of uric acid

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76
Q

Degradation of what molecule makes up the majority of urate production in the body?

A

Purine metabolism

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77
Q

How does gout arise in the majority of people with gout?

A

Reduced efficiency of renal urate clearance

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78
Q

How does HPGRT deficiency lead to gout?

A

HPGRT normally recycles purine bases - deficiency leads to build up

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79
Q

List some connective tissue multi-system autoimmune diseases?

A 
Systemic Lupus Erythematosus (SLE)
Scleroderma
Sjogren's syndrome
Auto-immune myositis
Mixed connective tissue disease
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80
Q

List some systemic vasculitis autoimmune diseases?

A

Giant cell arteritis
Granulomatosis polyangitis (Wegeners)
Microscopic polyangiitis
Eosoniphilic granulomatosis polyangiitis (Churg-Strauss)

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81
Q

What are some mimics to systemic autoimmune diseases?

A

Drugs - cocaine, minocyline, PTU
Infection - HIV, endocarditic, Hepatitis, TB
Malignancy - lymphoma

Cardiac myxoma
Cholesterol emboli
Scurvy

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82
Q

What is used for diagnosis of systemic autoimmune diseases?

A 
Cardinal clinical features: History & Exam
Immunology
Imaging
Tissue
Exclusion of differential diagnosis
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83
Q

List some type of large vessel vasculitis?

A

Takayasu Arteritis

Giant Cell Arteritis

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84
Q

List some type of medium vessel vasculitis?

A

Polyartertis Nodosa

Kawasaki Disease

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85
Q

List some type of small vessel vasculitis?

A

ANCA-Associated Vasculitis

  • Microscopic Polyangiitis
  • Granulomatosis with polyangiitis
  • Eosoniphilic Granulomatosis with Polyangitis

Immune Complex SSV

  • Anti-GBM Disease
  • Cryoglobulinemic Vasculitis
  • IgA Vaculitis (Henoch-Schonlein)
  • Hypocomplementemic Urticarial Vasculitis (Anti-C1q Vasculitis)
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86
Q

In what conditions is a positive ANA test not helpful?

A

Rheumatoid Arhritis (30-40% +)
MS (25%)
Infection (Varies)
Normal (30%!)

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87
Q

In children’s orthopaedics, what hip problems tend to present around 0-5yrs?

A 
'Normal variant'
Trauma
Transient synovitis
Osteomyelitis
Septic arthritis
DDH (Developental dysplasia of hip)
JIA
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88
Q

In children’s orthopaedics, what hip problems tend to present around 5-10yrs?

A 
Trauma
Transient synovitis
Osteomyelitis
Septic arthritis
Legg-Calve-Perthes disease
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89
Q

In children’s orthopaedics, what hip problems tend to present around 10-15yrs?

A 
Trauma
Osteomyelitis
Septic arthritis
SUFE
Chondromalacia
Neoplasm
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90
Q

What may excessive anterior displacement in a Drawer test suggest?

A

Injury of the ACL ligament

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91
Q

What may excessive posterior displacement in a Drawer test suggest?

A

Injury of the PCL ligament

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92
Q

What is the normal angle of the neck shaft of the hip joint?

A

~130degrees

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93
Q

What is the normal angle of femoral anteversion of the hip joint?

A

15 degrees

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94
Q

What is the normal angle of acetabular anteversion of the hip joint?

A

20 degrees

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95
Q

What can be some clinical signs of hip pathology?

A 
-C sign
Exacerbating Factors
Worse Weight Bearing
Difficulty tying shoe laces
Site of pain - Trochancteric, buttock, groin, referred
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96
Q

What is shenton’s line?

A

Shenton’s line is formed by the medial edge of the femoral neck and the inferior edge of the superior pubic ramus.

Loss of contour is a sign of neck of femur fracture

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97
Q

What is the clinical management of extra-capsular hip fracture?

A

Always fix

The blood supply is intact

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98
Q

What is the clinical management of intra-capsular hip fracture?

A

Management based on age of patient, and displacement.
Blood supply compromised

Undisplaced - Fix
Displaced and Young - Fix
Displaced and old - replace (either hemiarthroplasty or THR)

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99
Q

What is the normal ROM for the knee joint?

A

5-130 degrees

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100
Q

What are some common knee injuries?

A 
Meniscal tears
Ligament injuries
OCD lesions
Loose bodies
Fractures
Quads/patellar tendon ruptures
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101
Q

What are some presentations of ACL injury?

A 
Knee buckles during pivot
Unable to play on
Immediate haemarthrosis
Recurrent instability
X-ray - Haemarthrosis, segond fracture
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102
Q

What is the hip Q angle in males?

A

14 degrees

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103
Q

What is the hip Q angle in females?

A

17 degrees

104
Q

What does genu varum deformity refer to?

A

Bow legs

105
Q

What does genu valgum deformity refer to?

A

Knock knees

106
Q

What type of invasive imaging can be used at the knee joint?

A

Arthroscopy

107
Q

What meniscii of the knee is more commonly damaged?

A

Medial menisci

108
Q

How may a meniscal tear present?

A
  • “Pop” or crack, delayed swelling
  • Locked knee - soft, painful block to full extension (displaced “bucket handle” tear)
  • Tender on affected side, sometimes feel click
109
Q

What is the definition of a limp?

A

Abnormal gait commonly due to pain, weakness or deformity

Shorter stance phase on the affected limb

110
Q

List some common causes of limp in a child?

A 
Toxic synovitis
Septic arthritis
Trauma
Osteomyelitis
Viral syndrome
Perthes disease
Fracture
JRA etc
111
Q

Where is the most common source of origin of limp in children?

A

Hip

112
Q

What questions should be asked in history of a limping child?

A

Duration and progression of limp?
Recent trauma and mechanism?
Associated pain and its characteristics?
Accompanying weakness?
Time of day when limp is worse?
Can the child walk or bear weight?
Has the limp interfered with normal activities?
Presence of systemic symptoms like fever, weight loss?
Medical history, —birth history, immunisation history, nutritional history, and developmental history
Drug history, allergies
Family history

113
Q

What may be revealed in examination of an antalgic gait?

A

Tenderness

Reduced range of motion

114
Q

List some common examples of antalgic gait?

A 
Trauma
Toddler's fracture
Overuse syndrome
Infection
Inflammations
115
Q

What may be revealed in examination of an abductor lurch gait?

A

Trendelenburg sign

116
Q

List some common examples of abductor lurch gait?

A

Hip dysplasia

Cerebral palsy

117
Q

What may be revealed in examination of an equinus gait?

A

Heel-cord contraction

Neurological exam needed

118
Q

List some common examples of equinus gait?

A

Cerebral palsy
Idiopathic toe walker
Clubfoot

119
Q

What may be revealed in examination of an circumduction gait?

A

Assess limb lengths
Neurological exam
Check range of motion

120
Q

List some common examples of circumduction gait?

A

Painful foot

Leg length inequality

121
Q

What should take place in the examination of a limping child?

A

Look –
Check sole of foot for foreign bodies !
Deformity? Erythema? Swelling? Effusion?
limitation of active ROM, asymmetry.
Assess shoes for unusual wear on the soles, asymmetry, point of initial foot strike, and also assess the fit.
In older children look for scoliosis, midline dimples, and hairy patches, which could indicate spinal pathology.
Assess gait with the child barefoot.
Assess thigh or calf circumference for asymmetry
Leg length assessment

Feel & Move– Spine, Hip, Knee, Ankle, Foot
Neurological assessment

122
Q

What are some potential infection/inflammatory causes of limp in a child?

A

Septic arthritis
Osteomyelitis
Transient synovitis

123
Q

What history may suggest infective/inflammation cause of acute limping in a child?

A 
Limp (age dependent)
Pain
General malaise/ loss of appetite/ listless
Temperature
Recent URTI/ ear infections
Trauma
Pseudoparalysis
Listen to the parent, they are usually right
124
Q

What are differential diagnoses to infection/inflammation causing limping in a child?

A

Transient synovitis
Osteomyelitis
Septic arthritis

Soemthing else

  • Sarcoma
  • Myositis
  • Osteoid osteoma
  • Abscess
  • Inflammatory arthropathy
125
Q

What initial investigations may you do to investigate infection/inflammation causing limp in a child?

A

Temperature
Xray
USS
Bloods - WCC, CRP, ESR, CK, Cultures

126
Q

What features in a limping child may raise concern of neoplasm?

A 
Night pain
Often incidental trauma
Strops doing sport/going out
Sweats and fatigue
Abnormal blood results - low Hb, atypical blood film, atypical platelets
Get a paediatrician/oncology opinion
127
Q

What is the most common cause of death in children?

A

Trauma

128
Q

What are some risk factors for children’s fractures?

A

Boys>Girls (60%)
Age - increased physeal injury w age
Previous fracture
Metabolic bone disease

129
Q

List some reasons children’s fractures often heal quickly

A

Metabolically active periosteum
Cellular bone
Plastic

-Therefore do not over immobilise/treat!

130
Q

What are some principles surrounding children’s fractures?

A
  • Often simple, incomplete and heal quickly,
  • Remodel well in plane of joint movement
  • Thick periosteal hinge is helpful
  • Fractures involving physes can result in progressive deformity (Deformity - elbow, Arrest - knee, ankle, Overgrowth - femur)
131
Q

What type of forearm fractures can arise from low energy impact?

A
  • Buckle

- Greenstick

132
Q

What type of forearm fractures can arise from high energy impact?

A

Open, displaced, soft tissue injury

133
Q

What would be taken into account on assessment of a children’s fracture?

A

History - mechanism
Deformity
Soft tissue - Whole limb, wounds, sensation, motor function, vascular status

Document findings, and repeat post-intervention

134
Q

List some complications from children’s fractures of the forearm

A

Compartment syndrome (Eg Volkmann’s fracture)
-Nonunion (5%)
-Refracture (5%)
Radioulnar synostosis (Abnormal connection)
PIN injury
Superficial radial nerve injury
DRUJ/Radiocapitellar problems

135
Q

List some differential diagnosis for knee trauma?

A 
Infection
Inflammatory arthopathy
Neoplasm
Apophysitis
Hip
Foot
Sickle, Haemophilia
'Anterior knee pain'
136
Q

What type of bony injuries may affect the knee?

A 
Physeal/Metaphyseal
Tibial spine
Tibial tubercle
Patellar fracture
Sleeve fracture
Patellar dislocation
Referred
137
Q

What may be required for physeal arrest?

A 
Monitoring - Harris lines, angulation and length
Resect Bar
Complete epiphysiodesis
Contralateral epiphysiodesis
Corrective osteotomy
138
Q

List some warning signs of non accidental injuries in children?

A 
Incongruent hx
Bruising – pattern
Burns
Multiple fractures, multiple stages of healing
Metaphyseal #, Humeral shaft #
Rib #
Non-ambulant #
139
Q

What is used in a undisplaced patellar fracture?

A

Cylinder cast

140
Q

What is used in a displaced patellar fracture?

A

Open reduction internal fixation (ORIF)

141
Q

List some risk factors for patella dislocation

A 
Laxity 
Poor vastus Medialis 
Q angle
Femoral anterversion
Tibial external rotation
Patella alta
142
Q

What is used in patellar dislocation management?

A 
Cast 2 wks
Repair medial ligament
Mobilise
Lateral release
VM exercises
143
Q

What is the name of the set of rules used to determine if ankle xrays are required?

A

Ottawa rules

144
Q

What are some pitfalls in ankle fracture assessment?

A

Missed fractures
Normal variation
Persistent displacement

145
Q

What are some management techniques fro ankle fractures

A

Pop
MUA (Mobilisation under anaesthetic)
Reduction and interfrag screw
Open reduction internal fixation (ORIF)

146
Q

What is the commonest ankle fracture?

A

SH2 (Salter Harris type 2)

147
Q

When do transitional ankle fractures take place?

A

Around the age of growth plate closing (13-14)

148
Q

Name some transitional ankle fractures

A

Tillaux

Triplane

149
Q

Name some types of overuse injuries in children

A

Osgood-Schlatter’s Disease

Sever’s Disease

150
Q

What is a sarcoma?

A

Malignant tumour arising from connective tissue

151
Q

List some bone forming tumours

A

Benign - Osteoid osteoma, osteoblastoma

Malignant - Osteosarcoma

152
Q

List some cartilage forming tumours

A

Benign - Enchondroma, osteochonroma

Malignant - Chondrosarcoma

153
Q

List some fibrous tissue tumours

A

Benign - Fibroma

Malignant - Fibrosarcoma, malignant fibrous histiocytoma (MFH)

154
Q

List some vascular tissue tumours

A

Benign - Haemangioma, Aneurysmal bone cyst

Malignant - Angiosarcoma

155
Q

List some adipose tissue tumours

A

Benign - Lipoma

Malignant - Liposarcoma

156
Q

List some marrow tissue tumours

A

Benign - Ewing’s sarcoma, lymphoma, myeloma

157
Q

What are the characteristics of Giant Cell tumours (GCT)?

A

Benign, Locally destructive, and can rarely metastasise

158
Q

What should happen to all patients with a soft tissue tumour suspected of malignancy?

A

Referred to a specialist tumour centre

159
Q

What are potentially suspicious signs of soft tissue tumours?

A

Deep tumours of any size
Subcutaenous tumours >5cm
Rapid growth, hard, craggy, non-tender
Recurrence after previous excision

160
Q

What is a bony tumour in someone over the age of 50 likely to be?

A

Bony metastases - much more common than malignant skeletal tumour

161
Q

What is the most common primary malignant bone tumour in a younger patient?

A

Osteosarcoma

162
Q

What is the most common primary malignant bone tumour in a older patient?

A

Myeloma

163
Q

What would be described in the history of bony/soft tissue tumour?

A

Pain
Mass
Abnormal Xrays - incidental
Bone tumours - pain

164
Q

What would be looked at in the examination of a bony tumour?

A 
General health
Measurements of mass
Location
Shape
Consistency
Mobility
Tenderness
Local temperature
Neuro-vascular deficits
165
Q

What are some cardinal features of malignant primary bone tumours?

A 
Increasing pain
Unexplained pain
Deep-seated boring nature
Night pain
Difficulty weight-bearing
Deep swelling
166
Q

What are the most common bone sites for metastatic bone disease?

A

Vertebrae>Proximal femur>Pelvis>Ribs>Sternum>Skull

167
Q

What are the most common primary cancers to metastasise to bone?

A 
Lung 
Breast
Prostate
Kidney
Thyroid
GI tract
Melanoma
168
Q

What can be used to prevent pathological fracture in bone/soft tissue cancers?

A

Early chemo/DXT
Prophylactic internal fixation
Use of bone cement
Embolisation before surgery
Aim for early painless weight bearing and mobilisation
Treat non weight bearing fractures conservatively

169
Q

What risk assessment may be used for pathological fracture?

A

Mirel’s Scoring System

170
Q

In soft tissue tumours, what increases the likelihood of sarcoma?

A

If over 5cm (80% of sarcoma >5cm)

171
Q

What type of tarsal coalitions may take place in the foot?

A

Talocalcaneal
Calcaneonavicular
Other

Results in stiff hindfeet

172
Q

What may lead to ankle arthritis?

A

Commonly post-traumatic

Consider haemochromatosis if no trauma and under 50

173
Q

What are differences between ankle arthritis and hip arthritis?

A

Ankle arthritis starts earlier and is harder to treat

174
Q

What examinations are used in the assessment of achilles tendon?

A

Silvferskiold test
Lunge test
Thompson’s or Simmonds’
Matle’s (Angle of Dangle)

175
Q

What types of conditions lead to cavovarus feet?

A

Neurological
Congenital - Club foot, idiopahtic familial
Post-traumatic

176
Q

What muscle weakness can lead to clawing of toes?

A

Weakness of intrinsic muscles

177
Q

What can lead to the ‘plunger effect’ by proximal phalanges?

A

Plantarflexion of MTs

‘Overaction’ of Peroneus longus

178
Q

What muscle weakness can lead to hindfoot varus?

A

Weakness of peroneus brevis

179
Q

What muscle weakness can lead to equinus?

A

Weakness of tibilais anterior

180
Q

What can lead to adduction of forefoot?

A

Overpull of tibilais posterior

181
Q

What can clawing of toes and plantarflexion of metatarsals manifest as clinically?

A

Plantar callosities and shoe problems

182
Q

What can weakness of peronenus brevis/hindfoot varus result in clinically?

A

Ankle instability

183
Q

What can weakness of tibilais anterior/equinus result in clinically?

A

Altered gait

184
Q

What can overpull of tibilais posterior/adduction of forefoot result in clinically?

A

Stress fractures of lateral metatarsals

185
Q

What questions needs to be asked during investigation of feet deformity?

A 
Progressive?
Family history?
Muscle pain/weakness?
Elevated creatinine kinase?
Altered sensation?

Undiagnosed - requires neurology opinion.

186
Q

What is the Coleman Block Test used for?

A

Differentiates between forefoot driven hindfoot varus and hindfoot driven varus

187
Q

What are the general treatment options for common foot and ankle problems?

A 
Non operative management
-Analgesia
-Shoe wear modification
-Activity modification
-Weight loss
-Physiotherapy
-Orthotics including insoles and bracing
Operative management (If non-op management fails)
188
Q

What pathological grouping exist for foot and ankle problems?

A 
Vascular (ischaemic)
Infective
Traumatic
Autoimmune
Metabolic (endocrine /drugs)
Inflammatory
Inherited (congenital)
Neurological
Neoplastic
Degenerative
Idiopathic
189
Q

List some common forefoot problems?

A 
Hallux valgus
Hallux rigidus
Lesser toe deformities
Morton’s neuroma
Metatarsalgia
Rheumatoid Forefoot
190
Q

List some causes of metatarsalgia

A

Synovitis, bursitis, arthritis, neuralgia, neuromata, Freiberg’s disease
Tight gastrocnemius

191
Q

List some treatments for rheumatoid forefoot?

A

Non-operative - shoewear/orthotics/activity
Operative
-Current gold standard - 1st MTPJ arthrodesis
-2-5th toe excision arthroplasty

192
Q

List some hindfoot problems?

A 
Achilles tendonitis/tendinosis
Plantar fasciitis
Ankle OA
Tibilalis posterior dysfunction
Cavovarus foot
193
Q

What is the clinical significance of intracapsular neck of femur fracture?

A

Blood supply is disrupted

194
Q

What is the clinical significance of extracapsular neck of femur fracture?

A

Blood supply maintained

195
Q

In a knee injury, what does early swelling suggest?

A

Haemarthrosis

196
Q

What may be indications for surgery for knee problems?

A 
Failure of conservative Rx
Demands of work
Demands of sport
Problems with daily activities
Prevention of further joint injury
Prevention of falls
197
Q

What factors affect intensity of force in injury?

A
  • Mass of object
  • Velocity
  • Area on which force acts
198
Q

What can excessive mechanical force cause?

A

Compression
Traction
Torsion
Tanegital (shearing)

199
Q

What defines a contusion?

A

Burst blood vessels in the skin

Eg bruise

200
Q

What defines an abrasion?

A

Scraping of skin surface

Eg graze, scratch

201
Q

What defines an laceration?

A

Tear/split of skin due to crushing

202
Q

What factors affect prominence of bruising?

A 
Skin pigmentation
Depth and location
Fat - more subcut fat, easily bruise
Age
Resilient areas
Coagulative disorders - thrombocytopenia, von willebrand's disease, haemophilia, liver disease (alcoholics), bone marrow disease
203
Q

What is the definition of an incised wound?

A

Superficial sharp force injury caused by slashing motion

Longer on skin surface than it is deep

204
Q

What is the definition of an stab wound?

A

Penetrating injury resulting from thrusting motion

Wound depth greater than length on the surface

205
Q

What type of signs can be seen as a result of blunt force injury?

A

Contusions
Abrasions
Lacerations

206
Q

What type of signs can be seen as a result of sharp force injury?

A

Incised wounds

Stab wounds

207
Q

What type of injuries may be suggestive of passive defense type injuries?

A

Slices backs of hands, forearms etc

208
Q

What type of injuries may be suggestive of active defense type injuries?

A

Slices incised wounds on palmer aspects of hands and web spaces between fingers

209
Q

What type of injuries may suggest self-inflicted injury?

A

Commonly sharp force
Site of election - usually wrists/forearms, chest and abdomen
Parallel, multiple and tentative incisions

210
Q

What factors do the consequences of injury depend on?

A
  • Type of mechanical insult
  • Nature of target tissue
  • Forces involved
  • Number of impacts
211
Q

What types of bleeding over the brain may present after a head injury?

A

Subarachnoid
Subdural
Extradural

212
Q

What causes traumatic subarachnoid haemorrhage?

A

Rapid rotational movement of head - single punch to jaw/upper part of neck/sudden unexpected twisting movement

213
Q

What is the result of traumatic subarachnoid haemorrhage?

A

Traumatic rupture of vessels at base of brain

Immediately unconscious and in cardiac arrest

214
Q

What is the result of diffuse axonal injury?

A

Immediate and prolonged coma with no apparent mass lesion or metabolic abnormality

215
Q

What can be suggestive of post mortem injury?

A

Lack of vital reaction
Parchmentation
Animal predation
Insect predation

216
Q

What is involved in primary survery of trauma patients?

A

ABC - detect and treat immediate threats to life

Uses a team approach

217
Q

What is involved in secondary survey of trauma patients?

A

Identification of all injuries and more detailed history

218
Q

What is involved in ABC approach?

A 
Airway with C-spine control
Breathing with O2
Circ. with haemorrhage control
Disability
Expose and environment

Catastrophic haemorrhage control in CABC for battlefield ATLS

219
Q

What is involved in airway assessment in trauma?

A
  • Noise assessment (Speech, gurging, stridor)

- Visual assessment (Swelling/deformity)

220
Q

What is involved in airway management in trauma?

A
  • Airway manouvres
  • Suction
  • Adjuncts (OPA etc)
  • Advanced procedures
221
Q

When may you assume C-spine injury in trauma?

A
  • Dangerous mechanism
  • Reduced conscious level
  • Injury above clavicles
  • Neurological signs
222
Q

What is involved in breathing assessment in trauma?

A

Expose the chest

  • Look - Visible injuries, RR, Effort/expansion
  • Feel - Palpate, Percuss
  • Listen - Auscultate
223
Q

What is involved in circulation assessment in trauma?

A

HR, Cap Refill, BP, Palpable pulses, Pulse pressure narrows, Urine output, Confusion

Blood tests - HB, Lactate

Imaging - US, CT

224
Q

Where are 5 sites for blood loss in trauma?

A 
Floor
Chest
Abdomen
Pelvis
Long bones
225
Q

What can be used as an alternative to IV in trauma patients if access is difficult?

A

IO access (Intraosseus)

226
Q

What can be used in trauma to monitor volume replacement?

A

Vital signs
Urine output
Lactate

227
Q

What is the lethal triad to prevent in trauma circulation?

A

Coagulopathy
Acidosis
Hypothermia

228
Q

What is used in disability assessment in trauma patients?

A

-Neurological examination
(AVPU, GCS, Pupils, Tone/reflexes, Log roll)

-Glucose (DEFG!)

229
Q

What bedside tests could be considered in trauma patients?

A
  • ECG
  • Arterial blood gas
  • Urine dipstick
230
Q

What is the definition of a dislocation?

A

Complete joint disruption

231
Q

What is the definition of a subluxation?

A

Partial dislocation - not fully out of joint

232
Q

How is diagnosis made of dislocation?

A

Clinical and radiological diagnosis

233
Q

What is the appearance of an anterior shoulder dislocation?

A

Shoulder is squared off

234
Q

What is the appearance of an posterior elbow dislocation?

A

Olecranon is prominent

235
Q

What is the definition of an open fracture?

A

Direct communication between external environment and the fracture

(Not always break the skin - pelvic fracture can penetrate rectum etc)

236
Q

What is a type 3 open fracure in gustilo classification?

A

Extensive soft-tissue damage, complex fracture pattern, wound >10cm

237
Q

What is a type 1 open fracure in gustilo classification?

A

<1cm wound, low energy, clean

238
Q

What is contemporary management of open fracture?

A

MD standardised Approach

Referral to specialist centres if lack expertise

239
Q

List some indications for emergency urgent surgery in open fracture?

A 
Polytraumatised patient
Marine/farmyard environment
Gross contamination
Neurovascular compromise
Compartment syndrome
240
Q

List some indications for amputation in open fracture?

A

Dual consultant decision
Insensate limb/foot
Irretrievable soft tissue or bony damage
Other life threatening injuries

241
Q

What are the characteristics of complete spinal cord injury?

A
  • No motor or sensory function distal to lesion
  • No anal squeeze
  • No sacral sensation
  • ASIA Grade A
  • No chance of recovery
242
Q

What is tetraplegia?

A
  • Partial/total loss of use of all four limbs
  • Loss of motor/sensory function in cervical segments of the spinal cord
  • Respiratory failure due to loss of diaphragm innervation
  • Spasticity (^Tone)
243
Q

What is paraplegia?

A
  • Partial or total loss of use of the lower limbs
  • Impairment or loss of motor/sensory function in thoracic, lumbar or sacral segments of the spinal cord
  • Arm function soared
  • Possible impairment of function in trunk
244
Q

List some partial cord syndromes

A

Central cord syndrome
Anterior cord syndrome
Brown-Sequard syndrome

245
Q

What are the characteristics of central cord lesion?

A

Older patients (arthritic neck)/Hyperextension injuries

  • Centrally cervical tracts more involved
  • Weakness of arms > legs
  • Perianal sensation + lower extremity power preserved
246
Q

What are the characteristics of anterior cord syndrome?

A
  • Hyperflexion injury
  • Anterior compression fracture
  • Damaged anterior spinal artery
  • Fine touch and proprioception preserved
  • Profound weakness
247
Q

What are the characteristics of brown-sequard syndrome?

A

Hemi-section of cord

  • Penetrating injuries
  • Paralysis on affected side (corticospinal)
  • Loss of proprioception and fine discrimination (dorsal columns)
  • Pain and temperature loss on opposite side below the lesion (spinothalamic tract)
248
Q

What is the management of SCI patients?

A
  • Prevention of secondary insult

- ABCD/ATLS

249
Q

What are signs of spinal shock in SCI?

A

Not circulatory in nature!

  • Transient depression of cord function below level of energy
  • Flaccid paralysis
  • Areflexia
  • Last several hours to days after injury
250
Q

What are signs of neurogenic shock in SCI?

A

Circulatory in nature

  • Hypotension
  • Bradycardia
  • Hypothermia
  • Injuries above T6
  • Secondary to disruption of sympathetic outflow
251
Q

What is the preferred method of surgical fixation in SCI?

A

Pedicle screw fixation

252
Q

What is the long term management of SCI?

A

Spinal cord injury unit - intermediate term

  • Physio
  • Occupational therapy
  • Psychological support
  • Urological/Sexual counselling
253
Q

What is the management of spinal nerve root pain?

A
  • Most will settle in 3 months
  • Physio
  • Strong analgesia
  • Referral after 12 weeks
  • Imaging -MRI
254
Q

What are some potential spinal disc problems?

A
  • Bulge
  • Protrusion
  • Extrusion
  • Sequestration
255
Q

What signs may be observed in Cervical/lumbar spondylosis (OA)?

A

If severe can compress whole cord causing myelopathy

-UMN signs in limbs (increased tone, brisk reflexes etc)

256
Q

What are some characteristics of spinal claudication?

A
  • Usually bilateral
  • Sensory dysaesthesiae
  • Possible weakness (drop foot - tripping)
  • Takes several minutes to ease after stop walking
  • Worse walking down hills - spinal cord becomes smaller in extension
257
Q

What is the treatment for spinal stenosis?

A

Non-operative

  • Nerve root injection (for lateral/foraminal stenosis)
  • Epidural injection
  • Surgery

Musculoskeletal system (5 decks)

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