Clinical Conditions Flashcards
1
Q
How does a patient with medial elbow tendinopathy present?
A
Aching pain over the medial elbow, often associated with the acceleration phase of throwing. Pain is produced on resisted flexion or pronation of the wrist.
Ulnar nerve symptoms are present in up to 20% of cases die to the proximity of the ulnar nerve to the medial epicondyle.
2
Q
What is psoriatic arthropathy?
A
Arthritis developed as a result of psoriasis. This is an asymmetrical oligoarthritis,
3
Q
How does a patient with a pulled elbow present?
A
Reduced movement of the elbow, pain over the lateral aspect of the proximal forearm. Parents often say that their child is “not using their arm.”
4
Q
If the radial nerve gets injured in the spinal groove of the humerus, what is the likely distribution of sensory impairment?
A
The parasthesia is in the distribution of the superficial branch of the radial nerve. (Thumb and two fingers (not tips) and back of hand)
The posterior cutaneous nerve of the arm branches above the spiral groove so it unaffected.
The posterior cutaneous nerve of the forearm branches in the spiral groove so is also usually unaffected.
5
Q
What is marginal osteophytosis?
A
This is when the nucleus pulpous dehydrates with age so leads to a decrease in the height of the disc. It also leads to alterations of the load stresses on the joint. Osteophytes therefore develop adjacent to the end plates of the disc.
6
Q
What is hallux rigidus?
A
Osteoarthritis of the 1st MTPJ resulting in stiffness. It can also be caused by gout and previous septic arthritis.
7
Q
How does an elbow dislocation usually occur?
A
It usually occurs when a young child falls onto an outstretched hand with the elbow partially flexed. This is because, in this position, it is more reliant upon ligaments.
8
Q
What joints in the hand are most commonly affected by osteoarthritis?
A
1st CMC joint (between trapezium and 1st metacarpal).
More common in women.
9
Q
How are most clavicle fractures treated?
A
Conservatively using a shoulder sling
10
Q
What is sciatica?
A
This is the name given to pain caused by irritation or compression of one or more of the nerve roots that contribute to the sciatic nerve (L4, L5, S1, S2).
11
Q
What is Osgood-Schlatter disease?
A
This is inflammation of the patellar ligament at the tibial tuberosity.
12
Q
How do patients with Osgood-Schlatter’s disease present?
A
Localised pain and swelling.
Patients complain of intense knee pain during running, jumping, squatting, ascending and descending stairs and during kneeling.
13
Q
Why do most young children appear to be flat footed?
A
Their arches have not developed fully and there is also a large amount of subcutaneous adipose tissue in the sole of the foot (the medial fat pad). It is only of the deformity persists into adolescence or after recurs during or after adolescence. that it is considered abnormal.
14
Q
What population develop rheumatoid nodules?
A
Sufferers of RA who are smokers and have more joint disease. They are also prone to other extra-articular manifestations of RA including vasculitis and lung disease.
15
Q
What shoulder joint does osteoarthritis most commonly affect?
A
Acromioclavicular joint (not glenohumeral)
16
Q
What could cause sciatica?
A
Marginal osteophytosis
slipped disc
17
Q
What three ways can pathogens reach the bones and tissues of the spine?
A
Haematogenous (most common)
Direct inoculation during spinal procedures (e.g. lumbar puncture, epidural or spinal anaesthesia)
Spread from adjacent soft tissue infection.
18
Q
If a prolapsed intervertebral disc causes a patient to compress the L5 nerve root, what actions and sensory regions will be compromised?
A
Weakness of dorsiflexion of great toe
Parasthesia of L5 dermatome (lateral leg and dorsum of foot)
19
Q
What are the most common places to be affected by Duputren’s contracture?
A
Ring and little finger. But 1st webspace and thumb can also be involved.
20
Q
What is the most common mechanism of injury of the odontoid process of the axis?
A
An elderly patient with osteoporosis falling forward and impacting their forehead on the pavement. This hyperextension injury of the cervical spine can result in a fracture of the odontoid peg.
Alternatively, they can be caused by a blow to the back of the head resulting in a hyeprflexion injury e.g. falling against a wall when balance is compromised.
21
Q
How does a patient with a posterior shoulder dislocation present?
A
Arm internally rotated and adducted.
They demonstrate flattening / squaring of the shoulder with a prominent coracoid process.
The arm cannot be externally rotated into the anatomical position.
22
Q
What is the mechanism if injury of a Jefferson’s fracture?
A
Axial loading.
e.g. diving into shallow water, impacting the head against the roof of a vehicle, falling from playground equipment.
23
Q
90% of hip dislocations go in which direction?
A
Posterior. The affected limb will be in a position of flexion, adduction and internal rotation.
24
Q
How does an upper brachial plexus injury usually occur?
A
An excessive increase in the angle between the neck and the shoulder:
Trauma
Birth of a baby if the shoulders become impacted in the pelvis and excessive traction is applied to the babies neck.
25
What are the symptoms of myelopathy?
Global muscle weakness. gait dysfunction, loss of balance and/or loss of bowel and bladder control. They arise due to compression and dysfunction of the ascending and descending tracts within the spinal cord.
26
What is gouty tophi?
Nodular masses of monosodium urate crystals deposited in the soft tissues.
They are a late complication of hyperuricaemia and develop in over 50% of patients with untreated gout.
They are usually painless.
27
What are the short term consequences of compartment syndrome?
Increase in intracompartmental pressure
Decreased perfusion of muscle
Ischaemic muscle releases mediators which further increase capillary permeability and exacerbate the rise in pressure.
If severe, rhabdomyolysis (muscle necrosis) and acute kidney injury can occur.
28
In what population are supracondylar fractures most common?
5-7 year old boys.
| 90% of supracondylar fractures occur in children under 10
29
What is a Swan neck deformity?
This the PIPJ hyperextends and MCPJ and DIPJ are flexed. It is thought to resemble the neck of a swan. (opposite to Boutonniere)
The tissue on the solar (palmar) aspect of PIPJ becomes lax (synovitis).
At DIPJ - rupture or elongation of insertion of extensor digitorum into base of proximal phalanx. This causes a mallet deformity.
30
What is it called when the nucleus pulposus herniates posteriolaterally?
Paracentral prolapse.
| It occurs in 96% of cases of prolapse.
31
How could the superficial peroneal nerve be damaged?
Fractures of the proximal fibula or penetrating injury to the lateral leg.
Ankle arthroscopy or during a lateral approach to surgery on the ankle joint.
32
How does a patient with Heberden's nodes present?
Start - chronic swelling or sudden pain, swelling and loss of manual dexterity.
Then - cystic swelling containing gelatinous hyaluronic acid on dorsolateral DIPJ.
Initial inflammation and pain subside and patient is left with an osteophyte
33
How do ankle sprains occur?
They usually occur through excessive stress on the ligaments of the ankle. e.g. through excessive external rotation, inversion or eversion of the foot caused by an external force.
When the foot is moved past its range of motion, the excess stress puts a strain on the ligaments. If the strain is great enough to the ligaments pass the yield point, then the ligament becomes damaged or sprained.
34
What is the only 'cure' for osteoarthritis of the hip?
A Total Hip Replacement.
| This operation replaces the damaged surfaces with implants and helps to relieve pain and restore mobility.
35
What is a Smith fracture?
Fractures of the distal radius with solar (palmar) angulation of the distal fracture fragment(s).
36
What is a peg fracture?
This is a fracture of the odontoid process.
37
How do you treat an intracapsular #NOF?
Surgical replacement of the femoral head. This is due to the high risk of avascular necrosis - especially in displaced fractures.
38
In what part of the clavicle do most fractures occur?
80% of the fractures occur in the middle third of the clavicle
39
What is the pain distribution of S1 sciatica?
Posterior thigh, posterior calf, heel, sole of foot
40
What parts of the scaphoid are most commonly fractured?
Waist of scaphoid (70-80%)
Proximal pole (20%)
Distal pole / scaphoid tubercle (10%)
41
If you paralyse the median nerve at the elbow (e.g. with a supracondylar fracture), what actions will no longer be possible or be weak?
```
Flexion of the wrist
Pronation
Flexion of the thumb
Opposition
Palmar abduction
Flexion of index and middle finger. (Hand of Benediction)
```
Also sensory loss in whole region supplied by the median nerve.
42
What causes the ACL to tear?
The ACL is usually torn as a result of a quick deceleration, hyperextension or rotational injury that does not involve contact with another individual. This injury often occurs with a sudden change of direction.
It can also be torn by the application of a large force to the back of the knee with the joint partly flexed.
43
How does a patent with septic arthritis present?
Symptoms of triad:
-Fever
-Pain
-Reduced range of motion
Symtoms evolve over few weeks-days. The fever is low grade with riggers present sometimes.
Joint examined for erythema (redness), swelling, warmth tenderness, limitations of active and passive range of movement.
44
What is the most common cause sciatic nerve entrapment in piriformis syndrome?
Spasm of the piriformis muscle, usually due to overuse or direct trauma.
But, anatomical variations between nerve and muscle can also lead to nerve compression and piriformis syndrome.
45
What muscle waste in long standing carpal tunnel syndrome?
Thenar muscles.
46
Where exactly does medial elbow tendinopathy most commonly occur?
In the interface between the pronator trees and the flexor carpi radialis origins,
47
Where does gouty trophi most commonly occur?
Fingers and ears.
| But, can also occur in the olecranon bursa and the subcutaneous tissues of the elbow.
48
How do patients with a femoral shaft fracture present?
The patient will have a tense, swollen thigh.
The blood loss in closed femoral shaft fractures is 1000-1500ml and the patient may have hypovolaemic shock. The blood loss in an open femoral fracture may be double this amount.
49
What is the ulnar paradox?
The ulnar claw is less pronounced if you have a low ulnar nerve injury compared to one at the elbow.
This is because FDP is paralysed so there is no flexion at the DIPJs of the ring and little finger so the ulnar claw will only consist of hyperextension a the MCPJs and flexion at the PIPJs.
50
How would a patient paralyse the ulnar nerve at the elbow?
Medial epicondyle fracture or compression in the cubital tunnel.
51
What are the main complications of supracondylar fractures?
Malunion - causes cubitus varus (gunstock deformity)
Nerve damage - Ulnar (most common), medial or radial.
Ischaemic contracture
52
How can an injury to the median nerve at the wrist occur?
Penetrating injury
| Compression of the carpal tunnel
53
How does cervical spondylosis lead to myelopathy?
If the degenerative process leads to narrowing of the spinal canal, this may instead put pressure on the spinal cord.
This is less common than radiculopathy.
54
What causes cervical myelopathy?
Caused by degenerative stenosis of the spinal canal caused by spondylosis (degenerative arthritis).
Or, congenital stenosis of the spinal canal (which is often asymptomatic until adulthood when age-related secondary degeneration starts to occur),
cervical disc herniation,
spondytolosthesis (anterior slippage of a vertebral body on the vertebra below),
trauma,
tumour and
RA affecting the cervical spine.
55
What is the usual mechanism of injury of a patella dislocation?
Internal rotation of the femur on a planted foot whilst flexing the knee (e.g. in a sudden change of direction in sports)
56
Why can whiplash lead to injury to the cervical cord?
The cervical spine is highly mobile and ligaments and capsule of the joints are weak and loose. Hence, there may be significant movement of the vertebrae (e.g. subluxation or dislocation)at the time of impact, with return to the normal anatomical position afterwards.
57
What is cervical spondylosis?
A chronic degenerative osteoarthritis affecting the intervertebral joints in the cervical spine.
58
What is Horner's syndrome?
Damage to the sympathetic trunk leading to miosis (decreased pupil size), partial ptosis (drooping eyelid) and anyhydrosis (decreased sweating on the affected side of the face)
59
What is a frozen shoulder>
This is adhesive capsulitis. This is a painful and disabling disorder in which the capsule of the glenohumeral joint becomes inflamed and stiff, greatly restricting movement and causing chronic pain.
60
What causes femoral shaft fractures in the elderly?
In the elderly with osteoporotic bones or in patients with metastases or other bone lesions (cysts), femoral shaft fractures can occur following a low velocity injury such as falling over from the standing position.
61
In what direction do patella dislocations most commonly occur?
Laterally.
62
How does a patient with carpal tunnel syndrome present?
Paraesthesia in median nerve distribution.
Symptoms worse at night (wrist in flexion so make carpal tunnel even smaller), this often wakes the patient up.
As gets worse, daily activities such as driving and brushing hair can aggravate paraesthesia.
63
Explain ischamic contracture than can be caused by a distal supracondylar fracture of the humerus.
The brachial artery is occasionally damaged or occluded by a displaced fracture. If the reflex spasm of the collateral circulation around the elbow also occurs then there will be ischaemia of the muscles in the anterior compartment of the forearm.
This results in oedema and compartment syndrome which makes the ischaemia worse because it stops the arterial inflow.
If untreated, the muscle bellies will undergo infarction.
During the repair phase, dead muscle tissue becomes replaced by scar tissue through fibrosis, the fibrotic tissue contracts (Myofibroblast activity) eventually resulting in a flexion contracture known as Volkmann's ischaemic contracture.
64
What is the classic presentation of a patient with cervical myelopathy?
loss of balance with poor coordination, decreased dexterity, weakness, numbness and in severe cases, paralysis,
Pain is a symptom in many patients, but it may be absent which can lead to a delay in diagnosis.
65
How will a patient with a dislocated shoulder present?
The patients shoulder will be visibly deformed and there may be swelling and / or bruising around the shoulder. Movements of the shoulder will be severely restricted.
66
What rotator cuff tendon is most frequently torn?
Supraspinatus tendon where it passes beneath the coracoaromial arch, tearing at the site of its insertion into the greater tubercle of the humerus.
67
If you paralyse the median nerve at the elbow (e.g. with a supracondylar fracture), what muscles will be paralysed?
```
Pronator teres
Flexor carpi Radialis
Palmaris Longus
Flexor digitorum
And allotter muscles supplied by median nerve in the forearm and hand.
```
68
When is the saphenous vein vulnerable to injury?
During its subcutaneous course int he medial leg.
Saphenous vein cutdown (for emergency venous access) or orthopaedic surgery to the distal tibia or medial malleolus can damage the nerve.
69
Other than age related degeneration, what are some other risk factors for rotator cuff tears?
Lifting
Repetitive overhead activity
Sports that involve repeated overhead motion eg. swimming, volleyball, tennis..)
70
What does the hyeprflexion-hyperextension injury of whiplash lead to?
It leads to tearing of cervical muscles and ligaments. Secondary oedema, haemorrhage and inflammation may occur. The muscles respond to injury by contraction (spasm) with surrounding muscles being recruited in an attempt to splint the injured muscle.
71
How does a patient with osteoarthritis in the hand present?
Pain at the base of their thumb.
Worse when moving and relieved by rest.
Stiffness increases after rest (e.g. morning)
Some swelling around base of thumb
72
What is the pathology of cervical spondylosis?
Age-related disc degeneration followed by marginal osteophytosis (osteophyte formation adjacent to the end plates of the intervertebral disc).
73
What direction does the nucleus pulpous commonly herniate?
Posteriolaterally (lateral to the posterior longitudinal ligament). This causes compression of a spinal nerve root within the intervertebral foramen.
74
What is a Colles' fracture?
An extra-articular fracture of the distal radial metaphysis, with dorsal angulation and impaction.
75
What is the mechanism of injury of a tibial plateau fracture?
A varus or valgus load (abnormal medial or lateral flexion load) to the knee, with or without an accompanying axial load (top to bottom load).
76
What causes cervical spondylotic myelopathy?
Degenerative changes which develop with age, including ligamentous flavum hypertrophy or buckling, facet joint hypertrophy, disc protrusion and osteophyte formation.
77
What is the most common type of knee injury?
Meniscal injuries
78
What are the long term consequences of compartment syndrome?
Rhabdomyolysis can result in acute kidney injury which may become chronic.
The necrotic muscle may also undergo fibrosis leading to Volkmann's ischaemic contracture.
79
If a patient damages the superficial peroneal nerve, what will be absent?
Loss of active eversion of the midfoot
| Loss of sensation over distal anterolateral leg and dorsum of the foot, excluding first webspace.
80
What is the most common cause of a patella dislocation?
Trauma. Often a twisting injury or a direct blow to the knee.
81
What can cause an oblique fracture of the medial malleolus?
AN injury that results in adduction or inversion of the foot can push the medial malleolus off the tibia (an oblique fracture) and pull on the lateral structures, leading to ruptured lateral ligaments or a transverse fracture of the lateral malleolus.
82
What is a Jefferson's fracture?
A Jefferson's fracture is a fracture of the anterior and posterior arches of the C1 vertebrae (atlas).
83
What is the mechanism of injury of the cervical intervertebral disc prolapse?
A tear develops in the annulus fibrosus of the disc, and the nucleus pulposus protrudes from the disc, when the impingement onto adjacent nerve root or the spinal cord.
84
What are the three common causes of swelling around the elbow?
Olecranon bursitis
Rheumatoid nodules
Gouty trophi
85
What is the most common form of impingement syndrome? What are the symptoms of this?
Impingement of the supraspinatus tendon under the acromion, during abduction of the shoulder.
This creates a painful arc of abduction, especially between 60 and 120 degrees of abduction. E.g. pain when reaching up to brush hair or living a food can from an overhead shelf.
86
What are some complications of gouty trophi?
```
Pain
Soft tissue damage
Deformity
Joint destruction
Nerve compression
```
87
What is septic arthritis?
This is the invasion of joint space my miscro-organisms, usually bacteria (but occasionally viruses, mycobacteria and fungi). It differs from reactive arthritis which is a sterile inflammatory process that can result from an extra-articular infection e.g. gastroenteritis.
88
What are the symptoms of radiculopathy?
Dermatomal sensory symptoms (parasthesia, pain) and myotomal motor weakness.
89
In what population does osteoarthritis most commonly occur?
It more commonly occurs in men than women (4:1) and is most common in manual workers and athletes who engage in sports that involve throwing.
90
What is the most common mechanism of a supracondylar fracture?
Falling from a moderate height onto an outstretched hand with the elbow hyperextended. e.g. child falling off monkey bars.
91
How does a patient with pre-patellar bursitis present?
Knee pain and swelling. Also some erythema overlying the inflamed bursa. The patent will find it difficult to walk due to the pain, and will not be able to kneel on the affected side.
92
How does a patient with a meniscal injury present?
Intermittent pain, localised to the joint line, alongside reports of the knee clicking, catching, locking or a sensation of giving way.
Swelling usually occurs as a delayed symptom or not at all as the menisci are largely avascular.
93
What is Dupuytren's contracture?
It is a common condition in which there is localised thickening and contracture of the palmar aponeurosis leading to a flexion deformity of the adjacent fingers.
94
In what circumstances does OA of the ankle joint usually occur?
70%-80% of cases -a joint that has previously suffered trauma (e.g. fracture of severe sprain). This is known as post-traumatic arthritis.
12% cases 0 underlying medical condition e.g. RA
10% - no underlying precipitating cause. Known as primary ankle arthritis.
95
When will an X-ray show a schaphoid fracture?
Not always immediately.
Repeat x-ray 10-14 days later
If still not shown use CT or MRI
Delayed diagnosis is common
96
What does varus mean?
Medial angulation of the distal segment.
97
What is Osgood-Schlatter's disease?
OSD is inflammation of the patellar ligament at its insertion into the tibial tuberosity.
98
When is calcific supraspinatus tendonitis most painful?
During the stage when they are resorbed by phagocytes. In this stage, they appear macroscopically like toothpaste and often appear cloudy on X-Rays.
99
What is the most common joint affected by septic arthritis?
Knee joint (50% of cases)
100
What factors can predispose to a patella dislocation?
Weakness of the quadriceps muscle, especially vests medals obliquus.
Shallow patella groove (in the femur).
Patellofemoral joint hypermobility or maltracking.
101
What is the most common cause of rotator cuff tears?
Age-related degeneration.
With are the blood supply to the rotator cuff tendons decreases, imparting the bodies ability to repair minor injuries.
This is the degenerative-mocrotrauma model.
102
How does a patient with common fibular nerve injury present?
Foot drop - paralysis of tibias anterior and long extensors of the toes
Inversion of the anke - paralysis of peroneus longs and brevis
Loss of sensation on lateral side of leg and dorsally not
103
What are the root values of the common peroneal nerve?
L4-S2
104
What is cervical myelopathy?
This is a condition caused by narrowing of the spinal nerve (vertebral) canal leading to cord dysfunction due to compression of the cord.
105
How do clavicle fractures occur?
From falls onto the affected shoulder or onto the outstretched hand.
106
What can cause an oblique fracture of the lateral malleolus?
An injury that results in either eversion or external rotation of the foot can push the lateral malleolus - potentially leading to an oblique fracture.
107
How does supra patellar bursitis present?
This is an extension of the synovial cavity of the knee joint. A knee effusion therefore often presents with swelling in the supra patellar pouch.
108
What percentage of people with diabetes suffer from foot diseases?
15% This includes, infection, ulceration or destruction of the tissue of the foot. Also loss of sensation due to peripheral neuropathy, ischaemia due to peripheral arterial disease or a combination of these may lead to foot ulcers and other complications.
109
What are the most common causes of deep peroneal mononeuropathy?
```
Motor neurone disease
Diabetes
Ischaemia
Vasculitis
Injured during total knee displacement
```
110
If the sciatic nerve were completely transected (divided) in the buttock, what effect would this have on the movement and sensation of the lower limb?
Movements of the hip normal
Hamstrings paralysed but patient could still extend the hip though strong action go gluteus maximus.
Knee extension unaffected
Active knee flexion would be absent as almost all are supplied by the sciatic nerve
Dorsiflexion and plantar flexion of the ankle and inversion and eversion of the mid foot would be paralysed as would all movements of the toes.
111
What are the risk factors for septic arthritis?
```
Extremes of age
Diabetes Mellitus
Rheumatoid Arthritis
Immunosuppression
IV drug use
Prosthetic joints due to operation contamination.
```
112
Where does the lateral cutaneous nerve of the thigh originate from?
Lumbar plexus - dorsal divisions L2,L3.
It emerges from the lateral border of posts major on the posterior abdominal wall and travels across the iliac fossa, on the surface if the iliacus muscle, it piece the lateral aspect of the inguinal ligament.
113
Why does a pulled elbow commonly occur in young children?
Because as children age, the annular ligament strengthens.
114
How does a patient with Duputren's contracture present?
Thickening or nodule in their palm - painful or painless.
Later, myofibroblasts within the nodule contract leading to the formation of tight bands called 'cords' on the palmar fascia.
The overlying skin is tightly adherent to palmar aponeurosis and becomes involves int he disease, which also progresses to the proximal fascia and skin of the fingers.
The fingers become stuck in a flexed position and cannot be passively straightened.
115
What is piriformis syndrome?
Sciatica like symptoms that do not originate fro compression of the spinal nerve roots, but instead are due to compression of the sciatic nerve by piriformis muscle.
116
Does a Jefferson's fracture cause neurological symptoms?
No, the fracture bursts open like a polo. This 'bursting open' reduces the likely hood of impingement on the spinal cord. This fracture therefore typically causes pain but no neurological symptoms.
117
What artery may become involved if there is severe displacement of a distal femoral fracture?
Popliteal artery
118
What is the unhappy triad?
This is an injury to the anterior cruciate ligament, medial collateral ligament and medial meniscus.
119
How does a lower brachial plexus injury usually occur?
This usually occurs due to forced hyperextension ir hyperabduction such as when someone falls from a height and grasps a tree branch on the way down.
It can also occur if a babies arm is delivered first and traction is applied.
120
How does cervical spondylosis lead to radiculopathy?
Narrowing of the intervertebral foramina can put pressure in the spinal nerves leading to radiculopathy
121
What can cause injury to the common fibular nerve?
Prolonged bed rest
Pressure from a tight plaster cast
Poorly placed stirrups in the operating theatre
Fracture of the neck of the fibula. (Most commonly injured when it wraps around the head of the fibula)
122
What collateral ligament is more common injured?
Medial collateral ligament.
123
What does subluxation mean?
Partial disruption of a joint with some remaining but abnormal position of the articular surfaces.
124
What is student's elbow?
Olecranon bursitis
125
What injuries are associated with inferior shoulder dislocations?
Damage to nerves
Rotator cuff tears
Injury to blood vessels
126
When does a posterior shoulder dislocation occur?
They occur when there is a violent muscle contraction due to an epileptic seizure, electrocution or a lightning strike; when there is a blow to the anterior shoulder or when the arm is flexed across the body and pushed posteriorly.
127
In what direction will the proximal bone fragment go in a femoral shaft fracture?
The proximal fragment is abducted due to the pull of gluteus medius and minimus on the greater trochanter, and flexed due to the action of iliopsoas on the lesser trochanter.
128
What will happen to the position of the arm and clavicular fragments in a displaced mid-clavicular fracture (fracture at the mid-point of the clavicle)?
The sternocleiodomastoid muscle elevates the medial segment
Because the trapezius muscle is unable to hold the lateral segment up,
and also because of the weight of the upper limb, the shoulder drops
The arm is pulled medially by pectoralis major (adduction).
129
What is Erb's Palsy?
Injury to the superior nerve roots of the brachial plexus. It leads to the arm being in a waiters tip position.
130
What causes femoral shaft fractures in children and young adults?
High velocity trauma - falls from a height, road traffic collisions.
Child abuse should also be considered in young children.
131
How is the sciatic nerve in the buttock most commonly damaged?
Stab wounds
| Misplaced intramuscular injections
132
When do you loose peripheral pulses in compartment syndrome?
When the compartment pressure exceeds the systolic arterial pressure. This will also lead to increased capillary refills time.
133
What is a pulled elbow?
Subluxation of the radial head.
134
How does a patient with psoriatic arthritis present?
The patient presents with fusiform (sausage shaped) swelling of the digits (dactylitis). The affected joints stiffen and if can progress to widespread joint destruction known as arthritis mutilans.
135
How does spread of infection into the spinal canal lead to neurological damage?
- Septic thrombosis leading to ischaemia
- Compression of neural elements by abscess / inflammatory tissue
- Direct invasion of neural elements by inflammatory tissue
- Mechanical collapse of bone leading to instability, particularly in chronic infections.
136
What is a tibial plateau fracture?
This is a fracture affecting the articulating surfaces of the knee joint. They can be unicondylar ir bicondylar. Fractures affecting the lateral tibial coney are most common.
137
Other than recurrent dislocations, what are the other common complications of shoulder dislocations?
Axillary artery damage
Axillary nerve damage (10-40% of shoulder dislocations). This is because the axillary nerve wraps around the head of the humerus.
Fractures (in 25% of shoulder dislocations)
Rotator cuff muscle tears
138
What are the most common sites for 'slipped disc'?
L4/5 and L5/S1 due to the mechanical loading at these joints.
139
What causes calcific supraspinatus tendonitis?
Multifactorial -many theories on its causation.
1) Regional hypoxia leads to tenocytes being transformed into chondrocytes and laying down cartilage in the tendon. Calcium deposits are then formed through a process like endochondrial ossification.
2) Ectopic bone formation from metaplasia od mesenchymal stem cells normally present in tendons into osteogenic cells.
140
In what direction do most elbow dislocations occur?
90% of elbow dislocations are posterior.
The distal end of the humerus is driven through the joint capsule anteriorly.
The ulnar collateral ligament is usually torn and there can also be an associated fracture and/or ulnar nerve involvement .
141
What type of #NOF is more dangerous? Why?
Intracapsular fractures are more dangerous as they are more likely to disrupt theMedial Femoral Circumflex Artery. Due to the inability of the artery to the ligament of the head of the femur to sustain the metabolic demand of the femoral head, there is a high risk of avascular necrosis of the bone.
This risk is further increased if the fracture os displaced.
142
What is the blood supply to the scaphoid? What does this mean clinically?
Mainly retrograde - Avascular necrosis.
143
What is tennis elbow?
Lateral elbow tendinopathy
144
Where does the common fibular nerve commonly injury?
When it winds around the neck of the fibula
145
What are the red flag symptoms of cauda equina syndrome?
```
Bilateral sciatica
Perianal numbness (saddle anaesthesia)
Painless retention of urine
Urinary / faecal incontinence
Erectile dysfunction
```
146
What is a hip dislocation?
This is when the the head of the femur is displaced out of the cup-shaped acetabulum of the pelvis.
147
What is the most common clinical presentation of rotator cuff tears?
Anterolateral shoulder pain, often radiating down the arm.
May occur with activity but can also be present at rest.
They also experience pain in their shoulder when they lean on their elbow and push downwards and then they reach forward (flex the shoulder).
Pain restricted moments above horizontal position may be present and also weakness of shoulder abduction.
148
What is cubital tunnel syndrome?
This is when the ulnar nerve gets compressed as it passes beneath the tendinous arch of of the flexor carpi ulnaris to enter the cubital tunnel.
149
In relation to piriformis, where does the sciatic nerve most commonly emerge?
Im 90% of people, the sciatic nerve emerges from the pelvis into the posterior thigh INFERIOR to piriformis,
150
What are Heberden's nodes?
A classic sign of osteoarthritis afffecting the DIPJ of fingers.
More common in middle age women and run in families.
151
What are the two types of claw toe?
Flexible - Joints remain mobile so can be straightened manually
Rigid - fixed deformity
152
How does a patient with a scaphoid fracture present?
Pain in the anatomical snuffbox - worse if moving the wrist.
Passive range of motion reduced slightly
Swelling around radial and posterior wrist.
153
What is the degenerative-microtrauma model?
This supposes that age-related tendon damage, compounded by chronic micro trauma, results in partial tendon tears that then develop into full rotator cuff tears.
Imflammatory cells are recruited and oxidative stress leads to tenocyte (tendon cell) apopotosis, leading to further degeneration, thus a vicious cycle is created.
154
Why is sensation to the palm spared in carpal tunnel syndrome?
As palmar cutaneous branch of median nerve branches proximal to the carpal tunnel and passes superficially into the palm.
155
Why can flat feet develop in adulthood?
Injury
Prolonged stress
Part of the normal ageing process
Tibialis Posterior dysfunction - as main role of this muscle is to support the medial arch of the foot.
156
What is a Hangman's fracture?
This is a fracture of axis (C2) vertebra through the pars interarticularis (the region between the superior and inferior articular process).
157
Why does a pulled elbow occur most commonly in pronation?
Because the annular ligament is taut in supination but more relaxed in pronation so it is easier for subluxation to occur.
158
What does compression of the ulnar nerve in the cubital tunnel result in?
Parasthesia in the cutaneous territory of the ulnar nerve.
| Also sometimes weakness in muscles supplied by the ulnar nerve.
159
What are patients with a patella fracture unable to do?
The patient will be unable to perform a straight leg raise i.e. to lift the leg off the bed by flexing at the hip and keeping the knee extended.
160
If a patient paralyses the median nerve at the wrist, what muscles will be paralysed?
LOAF
Lumbricals to index and middle finger
Opponens pollicis
Abductor pollicis previs
Flexor pollicis brevis (superficial head)
161
If a prolapsed intervertebral disc causes a patient to compress the S1 nerve root, what actions and sensory regions will be compromised?
Weakness of ankle plantar flexion (no tiptoe)
Parasthesia of S1 dermatome (lateral border of foot, sole of foot and heel)
Ankle reflex diminished or absent.
162
What is pes planus?
Flat foot. This implies that the medial arch of the foot has collapsed so that the medial border of the foot almost touches the ground.
163
How does a patient with ulnar tunnel syndrome present?
Parasthesia in the ring and little fingers, progressing to weakness of the intrinsic muscles of the hand supplied by the ulnar nerve.
164
If a patient paralyses the ulnar nerve at the wrist, why are the MCPJs of the ring and little finger hyperextended and the IPJs flexed?
3rd and 4th lumbricals paralysed and they usually flex digits at MCPJ and extent digits at IPJ via the dorsal extensor expansion.
MCPJs are hyperextended due to unopposed extension from extensor digitorum.
PIPJs ans DIPJs are flexed due to unopposed flexion of FDS and FDP respectively. Extensor digitorum cannot extend IP joints as their energy is dissipated in hyperextending the MCPJs.
165
In an anterior inferior dislocation of the humerus, what position can the humeral head end up in?
The head of the humerus usually dislocated anterioinferiorly but often displaces in the anterior direction (subcoracoid -60%) due to the pull of the muscles and disruption of the anterior capsule and ligaments.
Alternatively, the head of the humerus may lie anterior-inferior to the glenoid (subglenoid - 30%).
Both are types of anterior dislocation and the arm is help is external rotation and slight abduction.
166
What is neurogenic claudication?
This is a symptom rather than a diagnosis. The patient reports pain and / or pins and needles in the legs on prolonged standing and on walking, radiating in a sciatica distribution.
167
What is gout?
An inflammatory condition resulting from defective purine metabolism leading to an increased production of uric acid.
As uric acid conc. in blood increases, supra saturation and precipitation occurs, forming crystals of monosodium urate in synovial cavity of joints, tendons and surrounding tissues.
These urate crystals trigger an immune response leading to acute inflammation.
168
What pathological changes occur in tendons during ageing that increase the risk of tendon rupture?
Decreased capillary density and decreased arterial perfusion
Increased stiffness due to decreased elastin, decreased proteoglycans, decreased water content of the tendon and increased cross linking of collagen.
Decreased collagen turnover / synthesis and decreased ability to repair damaged collagen
Calcium deposition
169
In what population does Duputren's most commonly occur?
40-60 yr olds
Males
Northern European origin
70% have family history - it is autosomal dominant. (The rest are sporadic).
170
How do patella fractures present?
On examination, there is often a palpable defect in the patella and the joint will be swollen due to blood (haemarthrosis).
171
What is a Bankart lesion?
When the force of the humeral head popping out of the socket causes a part of the glenoid labrum to be torn off.
This is also known as a labral tear.
172
Where does psoriasis traditionally occur?
```
Elbows
Knees
Scalp
Lower Back
But can be anywhere
```
173
What causes neurogenic claudication?
Compression of the spinal nerves as they emerge from the lumbrosacral spinal cord.
It is an age related phenomenon where a combination of disc bulging, facet joint and ligament flavum hypertrophy (from osteoarthritis) compresses the nerve roots.
This leads to venous engorgement of the nerve roots on exercise, leading to reduced arterial inflow and transient ischaemia.
The ischaemia of the affected nerve(s) results in pain and/or parasthesia.
174
What symptoms do patients with lower cervical myelopathy present with?
Spasticity, loss of proprioception in the legs.
Patients say that their legs 'feel heavy' and experience reduced exercise tolerance.
They typically have gait disturbances and experience multiple falls.
175
Why is osteoarthritis of the elbow uncommon?
Because the joint surfaces are well matched and there are strong stable ligaments, This means the elbow can tolerate large forces without becoming unstable so there is less wear and tear with age.
176
What causes hallux valgus?
The exact cause of hallux valgus is poorly understood but involves abnormal biomechanics in over pronated foot.
Also occur secondary to trauma, arthritic/ metabolic conditions e.g. gout, RA, psoriatic arthritis and CT disorders that involve ligamentous laxity.
High-heeled or tight fitting shoes do not cause hallux valgus. But, can make it worse.
177
What are the signs and symptoms of Achilles tendonitis?
Pain and stiffness along the Achilles tendon in the morning
Pain in the tendon or at the back of the heel that worsens with activity
Severe pain 24 hours after exercising
Thickening of the tendon
Swelling that is present all of the time but worsens during activity
A palpable bone spur (in insertional tendonitis)
178
What are some risk factors for osteoarthritis?
```
Obesity
Previous injury affecting a joint
Occupational factors
Genetics
Age
Female sex
Sedentary lifestyle
```
179
If a patient paralyses the ulnar nerve at the wrist, how will they present?
A low ulnar claw.
The little and ring fingers are hyperextended at the MCPJs and flexed at both PIPJs and DIPJs.
They will also have loss of sensation in the palmar aspect of the ulnar 1.5 digits over the distal phalanges only.
180
If injured, what collateral ligament has a higher change of causing knee instability? Why?
Lateral collateral ligament. This is because the medial tibial plateau forms a deeper and more stable socket for the femoral condyle than the lateral tibial plateau/
181
What is the difference between hammer toe ad mallet toe?
This is a deformity which the toe is flexed at the PIPJ whereas a mallet toe is flexed at the DIPJ.
182
What is the most common pathogen to cause septic arthritis?
Staphylococcus aureus
183
What causes an anterior elbow dislocation?
A direct blow to the posterior aspect of a flexed elbow.
| Olecranon is commonly seen with this due to the degree of force required to dislocate the joint.
184
How does a patient present with tennis elbow?
Pain over the lateral epicondyle during extension of the wrist, especially if this is against resistance.
185
What are the risk factors for OA of the ankle?
Joint stress (ballet dancers, footballers)
Age
Obesity
Family history
186
What is the most common mechanism on injury for sprained ankle?
An inversion injury affecting a plantarflexed and weightbearing foot. In this injury, the anterior talofibular ligament is most at risk of sprain.
187
What are the symptoms of osteoarthritis of the hip?
Joint stiffness
Pain in the hip, gluteal and groin regions radiating to the knee (via obturator nerve)
Mechanical pain
Reduced mobility
188
What is the most common cause of thoracic cord compression?
Vertebral fractures
| Tumours
189
What is calcific supraspinatus tendonitis?
This is characterised by the presence of macroscopic deposits of hydroxyapatite in the tendon of supraspinatus.
190
What are bunions also known as?
Hallux Valgus
191
How does a Colles' fracture occur?
FOOSH with pronated forearm and wrist in dorsiflexion.
The energy is transmitted from the carpus to the distal radius in a dorsal direction and along the long axis of the radius.
The fracture is therefore dorsally angulated and impacted.
192
How do you treat cauda equina syndrome?
Causa equina syndrome has to be treated by surgical decompression within 48 hours of the onset of sphincter symptoms, otherwise the prognosis is poor. E.g. neuropathic pain, impotence, self-catheterisation, incontinence, power limb parasthesia.
193
What are some common causes of meralgia parasthetica?
Obesity
Pregnancy
Tight clothing
Wearing a tool belt
194
How do you treat cubital tunnel syndrome?
Decompress the ulnar nerve that is compressed - this means you surgically release it and transpose it anterior to the medial epicondyle.
195
What do you do if compartment syndrome is suspected?
If compartment syndrome is suspected, surgical decompression (fasciotomy) should be performed of all the affected compartments.
196
What factors contribute to an increased risk of ankle sprains?
- Weak muscles / tendons that cross the ankle joint, especially perineal (fibularis) muscles
- Weak or lax ankle ligaments - this can be hereditary or due to overstitching of ligaments as a result of repetitive ankle sprains.
- Inadequate joint proprioception (sense of joint position)
- Slow neuromuscular response to an off-balance position
- Running on uneven surfaces
- Shoes with inadequate heel support
- Wearing high heeled shoes - due to the weak position of the ankle joint with an elevated heel, and a small base of support.
197
What are the possible complications of a Colles' fracture?
Malunion - dinner fork deformity
Median nerve palsy and post traumatic carpal tunnel syndrome
Secondary osteoarthritis
Tear of extensor policies longs tendon
198
What are the risk factors for mechanical back pain?
Overweight
Poor Posture
Sedentary Lifestyle with deconditioning of the paraspinal muscles
Poorly designed seating
Incorrect manual handling (bending and lifting) techniques
199
What are the characteristics of mechanical back pain?
Pain when the spine is loaded that worsens with exercise and is relieved by rest.
Intermitted and often triggered by innocuous activity.
200
What are rheumatoid nodules?
They are extraarticular manifestations of rheumatoid arthritis. They affect 20% of patients with RA.
201
What are tibial plateau fractures often associated with?
They can be associated with meniscal tears and anterior cruciate ligament (ACL) injuries.
202
What should you do if septic arthritis is suspected?
Aspiration of the joint should be carried out immediately and the aspirate should be sent for urgent microscopy, culture and sensitivities.
It carries high morbidity.
203
If the radial nerve gets injured in the spinal groove of the humerus, will the patient still be bale to actively extend their elbow?
Yes! Extension of the elbow will either be normal or middle compromised.
The nerve supply to the three heads of triceps us given off prior to the radial nerve entering the spinal groove.
Anconeus is paralysed but this only has a minor role in elbow extension.
204
What is impingement syndrome?
This is when the tendons of the rotator cuff muscles impinge on the dorado-acromial arch, leading to irritation and inflammation,
205
What causes olecranon bursitis?
Repeated minor trauma (leaning with elbows on a desk for hours), in which case the contents will be serous fluid.
206
What population usually suffer from intracapsular fracture?
The elderly, especially post-menopausal women with oseoporotic bones. They often occur after a minor fall/
207
In what population does Osgood-Schlatter's disease most commonly occur?
It most commonly occurs in teenagers who play sport (running and jumping).
208
What are the symptoms of osteoarthritis?
A deep aching joint pain, exacerbated by use
Reduced range of motion and crepitus (grinding)
Stiffness during rest (morning stiffness usually lasting under an hour)
209
What is the most common cause of a collateral ligament injury?
This is most commonly a sporting injury. Particularly in direct contact sports such as football. They usually rest from a direct blow to one side of the knee.
210
What is clergyman's knee?
Infrapatellar bursitis.
211
What can cause Trendelenburg sign?
Superior Gluteal Nerve Injury
Fracture of the greater trochanter
Dislocation of the hip joint
212
How does a patient with a radial head and neck fracture present?
Pain in the lateral aspect of the proximal forearm and loss of range of movement. Modest swelling is comparison to supracondylar fractures.
213
What joints are most commonly affected by psoriatic arthritis?
DIPJs. 80% of patients also have nail lesions (pitting and oncholysis)
214
Which bursae of the knee are most commonly inflamed?
Prepatella bursa
Infraparella bursa
Pes anserinus bursa
Suprapatella bursa
215
In a patient with femoral nerve injury, what will be absent?
Wasting and weakness of quads, sartorius, iliacus and pectineus.
Hip flexion compromised
Active extension of knee lost
Knee jerk reflex absent
Parasthesia of anteromedial thigh and medial leg, sometimes down medial border of foot.
216
How does a Smith fracture occur?
Fall nto flexed wrist or a direct blow to the back of the wrist.
217
What does valgus mean?
Lateral angulation of the distal segment. (vaLgus = Lateral)
218
What is claw toe?
This is when the MTPJs are hyperextended and the PIPJ are flexed. Sometimes the DIPJs are also flexed so that they curl under the foot.
219
How does a pulled elbow occur?
When longitudinal traction is applied to the arm with forearm pronated (e.g. tugging an uncooperative child).
The longitudinal traction on the radial head tears the distal attachment of the anular ligament where it is loosely attached to the neck of the radius.
The radial head is the displaced distally through the torn ligament.
220
What does hallux valgus involve?
- Medial deviation of the first metatarsal
- Lateral deviation and/or rotation of the hallux
- Prominence of the first metatarsal head, with or without overlying callus.
221
Where abouts in the gluteal region do you do an intramuscular injection?
Upper outer quadrant. This is to ensure you avoid the sciatic nerve.
222
What population usually suffer from extracapsular fractures?
These tend to affect the young and middle-aged population and are usually the result of significant traumatic force.
223
What is a #NOF?
A fractures neck of femur (#NOF) is defined as a fracture of the proximal femur, up to 5cm below the greater trochanter. It is common but serious.
224
What makes neurogenic claudication better?
It is classically relieved by rest (most effective), a change in position and by flexion of the waist.
Movements that involve flexion of the waist, such as cycling, pushing a trolley and climbing stairs are well tolerated.
225
Why does shortening and internal rotation of the limb occur after posterior dislocation of the hip?
The femoral head is pushed backwards over the posterior margin of the acetabulum and comes to lie on the lateral surface of the ilium.
The head of the femur is then pulled upwards by the strong extensors (Gluteus maximus and hamstrings) and adductors of the hip, causing limb shortening.
The anterior parts of gluteus medium and minimus pull on the posteriorly-displaced greater trochanter and cause the femur to rotate internally.
226
What is ulnar tunnel syndrome?
This is when the ulnar nerve gets compressed when passing through Guyon's canal - radial (lateral) to the pisiform bone over the solar surface of the flexor retinaculum.
227
What is the Hand of Benediction?
When a patient with a high median nerve injury makes a fist, the middle, index and thumb will not flex.
This is not present and rest.
228
Whats Klumpke's palsy?
This is an injury to the lower roots of the brachial plexus, It presents with a claw hand deformity.
229
What is Meralgia paraesthetica?
Compression of the lateral cutaneous nerve of the thigh as it pierces of inguinal or the fascia lata in the thigh.
230
In what population in achilles tendon rupture most common?
More common after middle age (males) and in those with pre-existing tendonitis.
It most commonly occurs when they are playing recreational sports that require bursts of jumping, pivoting and running e.g. tennis, badminton and football.
231
What is the pattern of pain in adhesive capsulitis?
The pain is constant, worse at night and exacerbated by movement and cold weather.
232
What is suprapatellar bursitis a sign of?
This is usually a sign of a significant pathology in the knee joint. E.g. osteoarthritis, rheumatoid arthritis, infection, gout, pseudo gout and repetitive microtrauma to the joint.
233
What is whiplash?
forceful hyperextension-hyperflexion injury of the cervical spine
234
How does the unhappy triad occur?
This results from a strong force applied to the lateral aspect of the knee. The medial meniscus is firmly adherent to the medial collateral ligament, which is why it is also injured.
235
What is carpal tunnel syndrome?
Compression of the median nerve as it passed through the carpal tunnel.
It is the most common site of nerve entrapment in the body.
236
What symptoms do patients with upper cervical myelopathy present with?
Loss of manual dexterity with difficulties writing and non-specific alterations in arm weakness and sensation,
Also dysdiadochonkinesia - impaired ability to perform rapid, alternating movement.
237
What is Volkmann's Ischaemic contracture?
A permanent, painful and disabling contracture of the affected muscle groups.
238
What population are Colles' fractures most common?
Patients with osteoporosis and in post-menopausal women.
| If younger people suffer a Colles' fracture then they have usually been involved in high impact trauma e.g. skiing.
239
What is the role of the clavicle?
It acts as a strut to brace the shoulder from the trunk
Transmits force from the upper limb to the axial skeleton
Protection to the brachial plexus, subclavian vessels and the apex of the lung
240
What is olecranon bursitis?
This is inflammation on the olecranon bursa, situated between the skin and the olecranon process of the ulna.
241
What are the X-Ray features of rheumatoid arthritis?
Joint space narrowing
Periarticular osteopenia
Juxta-articular (also called marginal) bony erosions
Subluxation and gross deformity
242
What does acute haemoarthrosis in a meniscal tear indicate?
This is rare and indicates a tear in the peripheral vascular aspect of the meniscus or an associated injury to the anterior cruciate ligament.
A chronic effusion can occur due to synovitis.
243
What are the clinical signs of compartment syndrome?
Severe pain in the limb which is excessive for the degree go injury, increasing and not relieved by analgesia. This pain is classically exacerbated by passive stretch of the muscles.
244
What does injury to the superior gluteal nerve lead to? Why?
It leads to weakness abducting the thigh at the hip because it supplies the hip abductors: Gluteus medium and gluteus minimus.
This causes the Trendelenburg sign.
245
In what population does a pulled (nursemaids) elbow most commonly occur?
Children ages 2-5
246
What is Boutonniere deformity?
MCPJ and DIPJ are hyperextended and PIPJ is flexed. (Opposite to Swan neck).
PIP inflammation leads to lengthening or rupture of central slip of extensor digitorum at its insertion onto base of middle phalanx on dorsal surface of finger.
The lateral bands slip down the sides of the fingers so they are on the palmar surface of PIPJ - they act as flexors instead of extensors of PIP as well as hyperextending DIPJ.
247
Why is the hip shortened, abducted and externally rotated in a displaced #NOF?
Shortening - Strong muscles of the thigh (Flexors, Adductors and Extensors) pull the distal fragments of the femur upwards.
Iliopsoas now acts as an external rotator of the femur because of the fractured neck. This is because the fracture allows the shaft of the femur to move independently of the hip joint.
Gluteus medius and minimus (strong abductors that attach to greater trochanter) abduct the female distal to the fracture site.
248
In what direction do most shoulder dislocations occur?
90-95% of shoulder dislocations are anterior (the head of the humerus lies anteriorly to the glenoid fossa).
249
What are the causes of cauda equina syndrome?
```
Prolapsed intervertebral disc
Tumours
Spinal infection / abscess
Spinal stenosis
Vertebral fracture
Spinal haemorrhage
Late-stage ankylosing spondylitis
```
250
Are most rotator cuff tears acute or chronic? Why?
Most are chronic
| They are the result of extended use in combination with other factors such as poor biomechanics or muscular imbalance.
251
What is pre-patella bursitis also known as?
Housemaids knee. There is usually a history of repetitive trauma such as may occur during scrubbing the floor.
252
How does a patient with RA of the hands present?
Pain and swelling of PIPJs and MCPJs of the fingers
Erythemia (redness) overlying the joints (inflammation)
Stiffness - worse in the mornings or inactivity
Carpal tunnel syndrome
Fatigue and flu-like symptoms
253
How do young people get a distal femoral fracture?
A high-energy sporting injury. There is often significant displacement of the fracture fragments.
254
Why does claw toe occur?
Claw toe results from a muscles imbalance which cases the ligaments and tendons to become unnaturally tight.
This is usually due to neurological damage and may be secondary to conditions such as cerebral palsy, stroke, diabetes, alcohol dependence, trauma, inflammation and RA.
255
What is L'Hermitte's phenomenon?
This is the sensation of intermittent electric shocks in the limbs that is exacerbated by neck flexion. It is classically associated with cervical myelopathy,
256
In what direction will the distal fragment go in a femoral shaft fracture?
The distal segment is adducted into a virus deformity (towards the midline) due to the action the adductor muscles (adductor magnus, gracilis) and extended due to the pull of gastrocnemius on the posterior femur.
257
What are the symptoms of #NOF?
Reduced mobility / sudden inability to bear weight on the limb
Pain which may be help in the hip, groin and/or knee.
258
What joints are particularly affected by rheumatoid arthritis?
MCPJs and PIPJs of the hands, the feet and the cervical spine.
259
If a prolapsed intervertebral disc causes a patient to compress the L4 nerve root, what actions and sensory regions will be compromised?
Weakness of ankle dorsiflexion
Parasthesia of L4 dermatome (medial leg and ankle)
Diminished patella tendon reflex
260
What are the four stages of disc herniation?
1. Disc degeneration - chemical changes associated with ageing cause discs to dehydrate and bulge.
2. Prolapse - Protrusion of the nucleus pulpous occurs with slight impingement into the spinal canal. The nucleus pulpous is still contained within a rim of annulus fibrosus.
3. Extrusion - The nucleus pulpous breaks through the annulus fibrosus but is still contained within the disc space.
4. Sequestration - The nucleus pulposus separates from the main body of the disc and enters the spinal canal.
261
What are the root vales of the tibial nerve?
L4-S3
262
What kind of pain is experienced in sciatica?
Pain is typically experienced in the back and buttock and radiates to the dermatome supplied by the affected nerve root.
263
What population does non-insertional tendonitis most commonly affect?
Younger, active people
264
How many bursae are in the knee?
11
265
How can you classify #NOFs?
Intracapsular (further classified into subcapital and transcervical)
Extracapsular (intertrochanteric and subtrochaneric)
266
What is Volkmann's ischaemic contracture?
The wrist is typically flexed
The fingers are extended at the MCPJs and flexed at IPJs
The forearm is pronated
The elbow is flexed
267
What is the most common cause of a meniscal injury?
Sudden twisting of the weight baring knee
268
How do the elderly get a distal femoral fracture?
This is seen in elderly patients with osteoporotic bone and the usual mechanism is a fall from standing.
269
What are the symptoms of calcific supraspinatus tendonitis?
Acute or chronic pain, often aggravated by abducting or flexing the arm above the level of the shoulder, or by lying on the shoulder.
Mechanical symptoms may also occur leading to stiffness, a snapping sensation, catching or reduced range of movement of the shoulder.
270
In severe sprain of the ankle, why is it not uncommon to find that the patient has an avulsion fracture of the fifth metatarsal tuberosity?
Peroneus (fibularis) brevis tendon is attacked to the tuberosity of the 5th metatarsal.
271
What causes impingement syndrome?
Anything that narrows the space between the head of the humerus and the dorado-acromial arch further. e.g. thickening of the coracoacromial ligament, inflammation of the supraspinatus tendon, subacromial osteophytes.
272
How are the arches of the foot maintained?
They are maintained by the shape the interlocking bones, the ligaments of the foot, intrinsic muscles of the foot and the pull of the long tendons of extrinsic muscles (i.e. muscles in the anterolateral and posterior compartments of the leg).
273
Who is particularly prone to tennis elbow?
Tennis players, painters, plumbers, carpenters due to the repetitive nature of their activity at the wrist and elbow.
274
If a patient paralyses the ulnar nerve at the wrist, what muscles will be paralysed?
Hypothenar eminence muscles
Adductor pollicis
Deep head of flexor pollicis brevis
Interossei
Lumbricals to the ring and little finger
Palmaris brevis
Palmar digital branches to the ulnar 1.5 digits,
275
What population does insertional tendonitis most commonly affect?
Any age, even in patient who are inactive.
| BUT, most common follows years of overuse e.g. long distance runners.
276
In what population is hallux valgus most common?
Middle-aged females.
277
What toe do the Hammer and Mallet toe deformities most commonly occur?
Second toe
278
How will a patient with a collateral ligament injury present?
Immediately after the injury, the patient will experience pain and swelling of the knee. As the initial pain and stiffness subside, the knee joint may feel unstable and the patient may complain of it giving way or not supporting their body weight.
279
What is the most common complication of shoulder dislocation?
Recurrent dislocations due to damage to the stabilising tissues surrounding the shoulder.
280
What are the four signs of osteoarthritis on an X-Ray?
Reduced joint space
Subchondral sclerosis
Bone cysts
Osteophytes
281
What tests can be used to detect anterior and posterior cruciate ligament injuries?
Anterior and posterior draw tests.
| Lachmans tests can also be used to detect ACL injuries.
282
What is Charcot arthropathy?
This involves the progressive destruction of the bones, joints and soft tissues most commonly in the ankle and foot.
A combination of neuropathy, abnormal loading of the foot, related micro trauma, and metabolic abnormalities of bone lead to inflammation, causing osteolysis, fractures, dislocation and deformities.
As a result of neuropathy, the patient has reduced ability to feel touch, temperature and pain. They may continue to walk making the injury worse.
283
What are the consequences of bacteria invasion in joints?
Damage to articular cartilage - by pathogenic properties or hosts immune response
Neutrophils stimulate synthesis of cytokines and other inflammatory products, resulting in the hydrolysis of collagen and proteoglycans.
284
What are the risk factors for carpal tunnel syndrome?
```
Obesity
Repetitive wrist work
Pregnancy
Rheumatoid arthritis
Hypothyroidism
```
285
What is seen on examination of a patient with a meniscal tear?
The patient usually has joint tenderness and restricted motion due to pain or swelling.
A mechanical block motion or locking can occur with a displaced tear.
286
How does a patient with meralgia parenthetic present?
Burning or stinging sensation over the distribution of the nerve over the anterolateral aspect of the thigh.
Aggrevated by walking or standing and relieved by lying down with he hip flexed.
Tenderness on palpation of the trapped nerve
Reduced sensation in lateral cutaneous distribution
Sometimes positive Tinel's sign
287
What are the signs and symptoms of achilles tendon rupture?
A sudden and severe pain at the back of the ankle or in the calk
The sound of a loud pop or snap
A palpable (and sometimes visible) gap or depression in the tendon
Initial pain and swelling followed by bruising
Inability to stand on tip toe or to push-off whilst walking
288
What is osteoarthritis?
This is the most common disease affecting synovial joints.
It is a degenerative disorder arising from the breakdown of articular hyaline cartilage.
It is also also defined as as a clinical syndrome comprising of joint pain, accompanied by functional limitations and reduced Quality of Life.
289
What injuries are commonly associated with posterior shoulder dislocation?
Fractures
Rotator cuff tears
Hill-Sachs lesion
290
What diseases increases the risk of Dupuytren's contracture?
```
Type 1 diabetes
Liver disease
Smoking
Hypercholestrolaemia
HIV
Heart disease
Hypo or Hyper thyroidism
```
291
What are the symptoms of thoracic cord compression?
Pain at the site of the lesion (thoracic spine), spastic paralysis of all the muscles in the legs, parasthesia in the dermatomes distal to the site of cord compression and loss of sphincter control.
292
What are the types of spondylolisthesis?
Congenital or dysplastic: congenital instability of the facet joints
Isthmic: A defect in the pars interarticularis
Degenerative: result from facet joint arthritis and joint remodelling (older)
Traumatic: Acute fracture in the neural arch, other than the pars interarticularis
Pathological: Infection or malignancy
293
What is a Hill-Sachs lesion?
This is when the posterior aspect of the humeral head becomes jammed against the lip of the glenoid fossa posteriorly causing a dent in the posterolateral humeral head
294
What causes Hammer toe and Mallet toe?
Ill-fitting shoes
Pressure on the second toe from adjacent hallux valgus.
This is because if a tight shoe causes a toe to stay in a flexed position for too long, the muscles contract and shorten. This makes it harder to straighten the toe. Over time, the muscles cannot straighten the toe, even when the shoes are not being worn.
295
How can you look at a odontoid process fracture?
Using an 'open mouth' AP X-Ray or an MRI of the cervical spine.
296
Where does the superior gluteal nerve originate form?
Sacral plexus from the dorsal divisions of L4,L5,S1. It leaves the pelvis via the greater sciatic foramen above piriformis, accompanied by the superior gluteal artery and vein.
297
If a patent damages the tibial nerve in the popliteal fossa, what will be absent?
Paralysis of gastrocnemius and soles so no active plantar flexion (no tip toes)
Loss of active flexion of the toe
Inversion of the mid foot will be compromised
Loss of sensation of sole of foot
Foot adopts a new calcaneovalgus posture because of unopposed dorsiflexion and eversion.
298
What is noticeable on examination of a #NOF?
The affected leg is shortened, abducted and externally rotated.
There is exacerbation of pain on palpitation of the greater trochanter and on rotation of the hip.
299
What are the symptoms of piriformis syndrome?
A due ache in the buttock
Typical sciatic pain in the thigh, leg and foot
Pain when walking up the stairs or inclines
Increased pain after prolonged sitting
Reduced range of motion of the hip joint
300
How does the first episode of anterior dislocation usually occur?
When the arm is abducted and externally rotated (hand behind head) and an unexpected small further injury forces the arm a little further posteriorly, pushing the shoulder into an extreme position, such that the humeral head dislocated,
Alternatively, a direct blow to the posterior shoulder can occur.
301
What is the Trendelenburg sign?
This is when, when a person is asked to stand on their injured limb, the pelvis on the unsupported side descends.
302
Where do rheumatoid nodules most commonly occur?
Exposed regions that are subject to minor trauma.
Elbow
Fingers
Forearms
Back of the heel
303
What is Osgood-Schalatter disease also known as?
Apophysitis of the tibial tubercle.
304
In what situations does a clavicle fracture require surgery?
Complete displacement
Severe displacement causing tenting of the skin, with the risk of puncture
Open fractures
Neurovascular compromise
Fractures with interposed muscle
Floating shoulder: clavicle fracture with ipsilateral fracture of glenoid neck
305
What is a syndesmosis?
A syndesmosis is a slightly movable fibrous joint in which bones such as the tibia and fibula are joined together by connective tissue.
306
Why is infrapatellar bursitis known as clergyman's knee?
This is because is is usually occurs due to repeated micro trauma caused by activities involving kneeling. Clergyman's knee reflect the more upright position of kneeling that generally triggers this condition.
307
What is the pain distribution in L4 sciatica?
Anterior leg, anterior knee, medial leg
308
What can carpal tunnel syndrome result in?
Ischaemia
Focal demyelination
Decrease in axonal calibre
Eventually axon loss
309
What are the mechanisms of injury of achilles tendon rupture?
Making a forceful push-off with an extended knee (e.g. during jumping)
A fall with the foot outstretched in front and the ankle dorsiflexed, forcibly overstitching the tendon.
Falling from a height, or abruptly stepping into a hole off kerb.
310
What is a Heberden's node at the PIPJ called?
Bouchard's node
311
When is a traumatic hip dislocation most common?
An acute traumatic hip dislocation is a severe injury commonly seen in 16-40yr olds involved in high speed road traffic collisions. -Dislocation os caused by the impact of the knee hitting the dashboard.
312
What is the pain distribution in L5 sciatica?
Lateral thigh, lateral calf, dorsum of foot
313
If a patient paralyses the ulnar nerve at the elbow, other than the hand muscles, what other muscles are paralysed?
Flexor carpi ulnaris
Ulnar half of flexor digitorum profundus
Loss of sensation in dorsal and palmar cutaneous branches - sensation lost throughout the ulnar nerve distribution in the hand.
314
What are the symptoms of osteoarthritis of knee?
Knee pain, stiffness and swelling.
Loss of cartilage leads to friction as bone rubs during movement. This increased friction can be felt as CREPITUS.
An effusion may develop and the swelling further limits joint movement.
Some patients with knee OA feel their knee going way or buckling, especially when going down stairs.
315
What are the risk factors for adhesive capsulitis (Frozen shoulder)?
```
Female gender
Epilepsy with tonic seizures
Diabetes
Trauma to shoulder
CT disease
Thyroid disease
Cardiovascular disease
Chronic lung disease
Breast cancer
Polymyalgia rheumatica
Parkinson's disease
```
Long periods of inactivity can also make it worse.
316
How does a Hangman's fracture occur?
Forcible hyperextension of the head on the neck; traditionally by hanging and more recently in road traffic collisions.
317
How does osteoarthritis occur? (its pathology)
1. Hyaline cartilage becomes swollen due to increased proteoglycan synthesis by chondrocytes.
2. The level of proteoglycans falls causing the cartilage to soften and lose elasticity. Flaking and fibrillation develop along the normally smooth articular surface.
3. Over time, the cartilage becomes eroded down to the subchondral bone, resulting in loss of joint space.
4. Eburnation occurs. This is when the changes in the cartilage alter the distribution of biomechanics forces and trigger further active changes in the tissues. The subchondral bone responds with vascular invasion and increased cellularity, becoming thickened and dense at areas of pressure. This manifests as subchondral sclerosis on X-rays.
5. Sunchondral bone may also undergo cystic regeneration and form subchondral cysts.
6. At areas along the articular margin, osseous metaplasia of CT occurs, leading to irregular outgrowth of new bone (osteophytes).
318
What are common mechanisms of a PCL injury?
A 'dashboard injury'. This is when the knee is flexed and a large force is applied to the upper tibia, displacing it posteriorly. This is seen in road traffic collisions when the upper shin collides with the dashboard.
PCL can also be torn in football when the player falls on a flexed knee with their ankle plantarflexed. The tibia hits the ground first and is displaced posteriorly, snapping the PCL. A tackle with the know flexed can also cause this injury.
319
What is spondylolisthesis?
It is anterior displacement of the vertebra above on the vertebrae below.
320
What causes peg fracture (fracture of the odontoid process of axis)?
This is either caused by flexion or extension injuries.
321
How does a patient with a feel peroneal injury present?
Foot drop
Inability to actively extend toes
Small patch of numbness of 1st dorsal webspace
322
What are the most common organisms to cause infection in the spine?
```
Staph aureus (50%)
E. coli and other Gram negative bacilli (30%)
```
After invasive spinal procedures, negative staphylococci (Staph epidermis) becomes more frequent (up to 30%).
Infections with more unusual organisms (Pseudomonas, Candida) may be seen in injecting drug users.
323
What is golfers elbow?
Medial elbow tendinopathy, This is 10 times less common than lateral elbow tendinopathy,
324
How does an inferior shoulder dislocation occur?
Forceful traction on the arm when it is fully extended over the head, as may occur when grasping an object above the head to break a fall i.e. hyperabduction injury.
325
What are the treatments for a frozen shoulder?
Physiotherapy
Analgesia
Anti-inflammatory medication
Sometimes manipulation under anaesthesia which breaks up scar tissue and helps to restore movements. Intense post-operative physiotherapy helps to maintain movement that has been gained.
326
If an L4/5 paracentral disc herniation occurs, what nerve root is most frequently compressed? Why?
The L5 root is most frequently compressed as the L4 root emerges above the level of the L4/5 disc. This is known as the transversing nerve root.
327
What are the two types of achilles tendonitis?
Non-insertional tendonitis - within the tendon itself
| Insertional tendonitis - at the point of insertion into the calcaneum.
328
What causes flat feet?
Excessive stretching of the spring ligament (plantar calcaneonavicular ligament) and plantar aponeurosis.
Stretching of the ligaments results in the taller head being displaced inferiomedially flattening the medial longitudinal arch and producing some lateral deviation of the foot.
329
What could cause secondary osteoarthritis?
```
Trauma
DDH (congenital hip dislocation)
Infection
Inflammatory arthritis
Metabolic disorders affecting the joints
Haematological disorders
Endocrine abnormalities
```
330
What are the symptoms of hallux rigidus?
```
Pain in the MTPJ on walking and on attempted dorsiflexion of the toe.
In severe cases, the pain may be present at rest.
Patients compensate by walking on the outside of their foot.
The range of dorsiflexion of the toe becomes severely limited due to the arthritis, although plantarflexion is usual retained.
Dorsal bunion (Osteophyte) may develop on top of the joint and lead to rubbing on shoes.
```
331
If the radial nerve gets injured in the spinal groove of the humerus, in what position will the patients wrist and fingers be if the wrist is pronated? Why?
The wrist and fingers will be flexed.
As brachioradialis and all extensor muscles of the wrist and fingers are paralysed.
This is called a "Wrist Drop"
332
What is the pre-patella bursa?
This is a superficial bursa with a thin synovial lining, located between the skin and the patella. It does not communicate with the joint space and usually contains a minimal amount of fluid. Inflammation of this
333
In what age group does cervical disc prolapse and compression most commonly occur?
30-50 year olds
334
If a patient paralyses the median nerve at the wrist, how do they present?
Ape hand deformity.
| The thenar eminence is flattened, and the thumb is adducted and externally (laterally) rotated.
335
Where is the infrapatellar bursa?
The infrapatellar bursa consists of two bursae, one of which sits superficially between the patella tendon (below the kneecap) and the skin and the second referred to as the deep infrapatellar bursa is sandwiched between the patella tendon and tibia bone (shin).
Bursitis most commonly affects the superficial infrapatellar bursa.
336
What are the symptoms of Osgood-Schlatter disease?
It is characterised by a painful bump just below the knee that is worse with activity and better with rest.
337
How does a patella fracture commonly occur?
They are caused either by a direct impact injury (e.g. knee against dashboard) or by indirect eccentric contraction.
338
What is the classical mechanism of whiplash?
A patients car being struck from behind leading to an acceleration-deceleration injury:
- At time of impact, vehicle suddenly accelerates forward. About 100ms later, the patients trunk and shoulders follow, induced by a similar acceleration of the car seat.
- The patient's head with no force acting on it, remains static in space. The result is forced extension of the neck, as the shoulders travel anteriorly under the head. With this extension, the inertia of the head is overcome, and the head accelerates forward.
- The neck then acts as a level to increase forward acceleration of the head, forcing the neck into flexion.
339
What is sequestration?
This is when an extruded segment of nucleus pulposus separates from the main body of the disc and enters the spinal canal where it is ultimately reabsorbed over a period of weeks, with resolution symptoms.
340
What is an ankle sprain?
This refers to a partial or complete tear of one or more ligaments of the ankle joint.
341
Where does the femoral nerve originate from?
L2,L3.L4 in the lumbar plexus. It enters the femoral triangle by passing beneath the inguinal ligament, immediately lateral to the femoral artery.
342
What is the result of malunion of a Smith fracture?
Garden spade deformity - Residual volar displacement of the distal radius.
This deformity can also narrow and distort the carpal tunnel and result in carpal tunnel syndrome.
343
If you paralyse the median nerve at the elbow (e.g. with a supracondylar fracture), what position will the forearm be in?
The forearm will be supinated due to unopposed action of supinator (radial nerve) and biceps brachi (musculocutaneous) .
