Diseases

Question 1

What are the two classifications of arthritis?

Answer 1

• inflammatory

- non inflammatory

Question 2

What are the four classifications of inflammatory arthritis?

Answer 2

• seropositive
• seronegative
• infectious
• crystal induced

Question 3

What is inflammatory arthritis?

Answer 3

• clearly defined group of conditions where there is joint or tendon inflammation
• associated with abnormal blood results and imaging
• rapidly destructive if untreated
• may affect other systems
• symmetrical
• involves smaller joints of the hands and feet
• any joint with synovium is affected

Question 4

How does inflammatory arthritis present?

Answer 4

• pain and stiffness in small joints, usually hands and feet
• reduction in grip strength
• rapid onset
• swelling of affected joints
• usually symmetrical

Question 5

Describe the pathogenesis of inflammatory arthritis

Answer 5

• potential triggers include infections and cigarette smoking
• severity and course depend on genetic factors and presence of auto-antibodies
• main structure involved is the synovium
• synovium lines synovial joint capsules and tendon sheaths
• makes direct contact with synovial fluid which acts as a lubricant
• synovial joints include hand joints, wrists, elbows, shoulders, knees, hips, ankles and feet

Question 6

What is key to the early development of rheumatoid arthritis?

Answer 6

Citrullination of proteins and development of autoantibodies

Question 7

Describe the diagnosis of rheumatoid arthritis

Answer 7

• history and clinical examination
• inflammatory markers (CRP, ESR / plasma viscosity)
• autoantibodies
• imaging

Question 8

Describe the clinical features of rheumatoid arthritis

Answer 8

• prolonged morning stiffness (>30 mins)
• involvement of small joints of hands and feet (PIPs / MCPs and MTPs)
• symmetric distribution
• positive compression tests of metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints

Question 9

Describe the autoantibodies of rheumatoid arthritis

Answer 9

• rheumatoid factors; sensitivity 50-80%, specificity 70-80%
• anti- CCP antibodies; sensitivity 60-70%, specificity 90-99%

Question 10

Describe anti-CCP

Answer 10

• can be present for several years prior to articular symptoms
• correlated with disease activity
• more likely to be associated with erosive damage
• associated with current or previous smoking history
• anti-CCP remains positive despite treatment
• low sensitivity; absence does not exclude disease
• higher the titre, the worse the prognosis

Question 11

Describe x ray imaging in rheumatoid disease

Answer 11

Early disease;

• normal
• soft tissue swelling
• periarticular osteopenia

Late disease;

• erosions
• subluxation

Question 12

Describe ultrasound imaging in rheumatoid disease

Answer 12

• increased sensitivity for synovitis in early disease
• consistently superior to clinical examination
• can detect more MCP erosions than plain x-ay in early RA
• useful in making treatment changes

Question 13

Which auto-antibody is most specific for RA?

Answer 13

Anti-CCP antibody

Question 14

Name some complications of rheumatoid arthritis

Answer 14

• increased cardiovascular risk

- osteopenia / osteoperosis

Question 15

Name the key factors in management of rheumatoid arthritis

Answer 15

• early recognition and diagnosis
• early treatment with DMARDs
• importance of tight control with target remission or low disease activity
• patient education
• multidisciplinary team involvement

Question 16

Name the DMARDs

Answer 16

• methotrexate
• sulfasalazine
• leflunomide
• hydroxychloroquine
• combination therapy with MTX, SASP and HCQ
• steroids

Question 17

Describe the side effects of DMARDs

Answer 17

• bone marrow suppression
• infection
• liver function derangement
• pneumonitis
• nausea

Question 18

Describe methotrexate

Answer 18

• first choice DMARD in most patients
• can be given orally or subcutaneously
• often used in combination
• teratogenic; must be stopped in females at least 3 months before conception
• need regular blood monitoring

Question 19

How would you asses disease activity in rheumatoid arthritis?

Answer 19

• DAS28 score
• > 2.6 = remission
• > 5.1 = active disease

Question 20

Describe the biologics used in rheumatoid arthritis

Answer 20

• anti TNF agent = infliximab, entanercept, adalimumab, certolizumab, golimumab
• t cell receptor blocker; abatacept
• b cell depletor; rituximab
• IL-6 blocker; tocilizumab
• JAK inhibitor; tofacitinib, baricitinib

Question 21

Who gets biologic treatment in rheumatoid arthritis?

Answer 21

• tried 2 DMARDs

- DAS 28 score still >5.1

Question 22

Describe the adverse effects of the biologics

Answer 22

• risk of infection (especially TB)
• question over risk of malignancy
• contraindicated in certain situations eg pulmonary fibrosis, heart failure

Question 23

Describe osteoarthritis

Answer 23

• a chronic disease characterised by cartilage loss and accompanying periarticular change
• commonly referred to as ‘wear and tear’
• one of the most common causes of chronic disability in adults due to pain and altered joint function that result from characteristic pathologic changes in the joint tissues
• 8.5 million people in the UK are affected by joint pain that may be related to OA
• knees, hands and hips are the most commonly affected joints
• altered joint function by characteristic changes
• any synovial joint can be affected

Question 24

Describe the pathophysiology of osteoarthritis

Answer 24

• metabolically active dynamic process that involves all joint tissues; cartilage, bone, synovium / capsule, ligaments and muscle
• key pathological changes include the localised loss of hyaline cartilage and remodelling of adjacent bone with new bone formation (osteophyte) at joint margins
• combination of tissue loss and new tissue synthesis indicated that it is a repair process of synovial joints
• a variety of joint traumas may trigger the need to repair
• defined as a common complex disorder with multiple risk factors
• a slow but efficient repair process - structurally disordered but functional joint repair

Question 25

What are the two types of osteoarthritis?

Answer 25

- localised | - generalised

Question 26

Localised OA can affect what?

Answer 26

- hips - knees - finger interphalangeal joints - facet joint of the lower cervical and lower lumbar spines

Question 27

Generalised OA can affect what?

Answer 27

- defined as OA at either the spinal or hand joints and in at least 2 other joint regions - subset involving DIP joints, thumb bases (1st CMC and trapezoscaphoid joints), first MTP joint, lower lumbar and cervical facet joints, knees, hips - the clinical marker is the presence of multiple heberdens nodes

Question 28

Describe the clinical presentation of OA

Answer 28

- extremely variable - pain worse with joint use - morning stiffness lasting less than 30 minutes - inactivity gelling - instability - poor grip in thumb OA

Question 29

Describe the examination features of OA

Answer 29

- joint line tenderness - most appreciate in the knee joint - crepitus - cartilage worn out so bones rub against each other - bony swelling - deformity - limitation of motion

Question 30

There is usually sparing of what joints in OA?

Answer 30

MCP joints

Question 31

Describe the features of knee OA

Answer 31

- osteophytes, effusions, crepitus and restriction of movement - genu varus and valgus deformities - bakers cysts; bulging of synovial tissue to the back of the knee

Question 32

Pain in the lateral aspects of the hip or buttocks is most likely radiated from where?

Answer 32

The back

Question 33

Where could pain from the hip be felt?

Answer 33

- pain may be felt in groin or radiating to knee - pain felt in hip may be radiating from the lower back - hip movements restricted

Question 34

Where could pain from the spine be felt?

Answer 34

- cervical; pain and restriction of movement, occipital headaches may occur - osteophytes may impinge on nerve roots - lumbar; osteophytes can cause spinal stenosis if they encroach on the spinal canal

Question 35

Describe diagnosis of OA

Answer 35

- clinical based on signs and symptoms - no specific laboratory tests - radiological imaging - plain xrays - MRI scans - ultrasound scans

Question 36

Describe x ray findings of OA

Answer 36

- marginal osteophytes - joint space narrowing - subchondral sclerosis - subchondral cysts

Question 37

Describe management of OA

Answer 37

- education - lifestyle management - physiotherapy - occupational therapy - analgesia - local intra-articular steroid injections, work especially well in the knee, only if there is evidence of active osteoarthritis - avoid opiates as it is chronic condition and can be addictive

Question 38

Describe surgical management of OA

Answer 38

- joint replacement; a select group of patients - arthroscopic surgery to remove loose bodies etc - trapezectomy; last resort

Question 39

What are crystal arthropathies?

Answer 39

- a diverse group of disorders characterised by the deposition of various minerals in joints and soft tissues, leading to inflammation - gout monosodium urate crystals - pseudogout calcium pyrophosphate crystal deposition - hydroxyapatite basic calcium phosphate deposition - end result is the same; intense inflammatory reaction

Question 40

What is gout?

Answer 40

Defined as a potentially disabling and erosive inflammatory arthritis caused by the deposition of monosodium urate crystals into joints and soft tissues

Question 41

Describe increased urate production

Answer 41

- inherited enzyme defects - myeoloproliferative / lymphoproliferative disorders; fast turnover - psoriasis; fast turnover - haemolytic disorders - alcohol (beer, spirits) - high dietary purine intake (red meat, seafood, corn syrup) most common cause

Question 42

Describe reduce urarte excretion

Answer 42

- chronic renal impairment - volume depletion eg heart failure - hypothyroidism - diuretics - cytotoxic eg cyclosporin

Question 43

What are gouty tophi?

Answer 43

Aggregates of uric acid crystals

Question 44

Chronic tophaceous gout

Answer 44

- chronic joint inflammation - often diuretic associated - high serum uric acid - tophi - may get acute attacks

Question 45

Describe investigations for gout

Answer 45

- serum uric acid (may be normal during acute attack) - raised inflammatory markers - polarised microscopy of synovial fluid - renal impairment (may be cause or effect) - x rays - you must aspirate joint; red hot and swollen and acute so need to exclude septic arthritis

Question 46

Describe the treatment of acute attacks of gout

Answer 46

- NSAIDs - colchicine; reduce inflammation, reduced microtubules, many side effects - steroids - takes about 48 hours to resolve

Question 47

Describe prophylactic treatment of gout

Answer 47

- xanthine oxidase inhibitors; allopurinol, febuxostat - uricosuric drugs; sulfinpyrazone, probenecid, benxbromarone - il-1 inhibitors; canakinumab

Question 48

Why do you always start prophylactic therapy alongside NSAIDs or colchicine?

Answer 48

Starting prophylactic treatment can cause a flare up. Any sudden rise or fall in uric acid will cause gout symptoms

Question 49

Describe indications for prophylactic therapy

Answer 49

- two or more attacks of gout in a year in spite of lifestyle modifications - presence of gouty tophi or signs of chronic gouty arthritis - uric acid calculi; kidney stones, needs long term treatment - chronic renal impairment - heart failure where unable to stop diuretics - chemotherapy patients who develop gout

Question 50

Describe calcium pyrophosphate deposition disease

Answer 50

- commoner in elderly - chondrocalcinosis increases with age - related to osteoarthritis - affects fibrocartilage; knees, wrists, ankles - calcification of cartilage, inflammatory reaction - acute attacks are due to calcium pyrophosphate crystals (pseudogout) - marked raise in inflammatory markers

Question 51

Describe calcium pyrophosphate crystals

Answer 51

- envelope shaped | - mildly positively birefringent on polarising microscopy

Question 52

Describe associations with calcium pyrophosphate crystals

Answer 52

- hyperparathyroidism - familial hypocalciuric hypercalcaemia - haemochromatosis - haemosiderosis - hypophosphatasia - hypomagnesemia - hypothyroidism - gout - neuropathic joints - aging - amyloidosis - trauma

Question 53

Describe treatment with CPPD

Answer 53

- NSAIDs - colchicine - steroids; if intolerant of NSAIDs - rehydration - no prophylaxis, degenerative condition - symptomatic treatment

Question 54

Describe hydroxyapatite

Answer 54

- milwaukee shoulder - hydroxyapatite crystal deposition in or around the joint - release of collagenases, serine proteinases and IL-1 - acute and rapid deterioration - females, 50-60 years - much rarer - destructive arthritis in the shoulders

Question 55

Describe the treatment of hydroxyapatite

Answer 55

- NSAIDs - intra-articular steroid injection - physiotherapy - partial or total arthroplasty - surgery is there is a lot of damage

Question 56

Describe soft tissue rheumatism

Answer 56

- general term to describe pain that is caused by inflammation / damage to ligaments, tendons, muscles or nerve near a joint rather than either the bone or cartilage - pain should be confined to a specific site eg shoulder, wrist etc - more generalised soft tissue pain; consider fibromyalgia - general term used to describe pain around the joint but not the bone or cartilage - usually in one site - if it is widespread consider chronic pain syndrome such as fibromyalgia

Question 57

Describe some shoulder problems

Answer 57

- commonest area for soft tissue pain - adhesive capsulitis - rotator cuff tendinosis - calcific tendonitis - impingement - partial rotator cuff tears - full rotator cuff tears - adhesive capsulitis; frozen shoulder

Question 58

Describe investigations and treatment of soft tissue

Answer 58

- usually unnecessary - xray; calcific tendonitis - MRI if fails to settle - identify precipitating factors - pain controls - rest and ice compressions - PT; always first line - steroid injections - surgery

Question 59

Describe joint hypermobility syndrome

Answer 59

- females > males - general or local - rare genetic syndromes eg marfans, ehlers danlos syndrome - usually presents in childhood or 3rd decade - diseases of connective tissues - pain arises from the hypermobile joints but not in all patients

Question 60

Describe symptoms and signs in joint hypermobility syndrome

Answer 60

- joint pains especially after exercise / physical work - joint stiffness - foot and ankle pain - neck and backache - frequent sprains and dislocations - thin stretchy skin

Question 61

Describe the modified beighton score

Answer 61

- >10 degrees hyperextension of the elbows - passively touch the forearm with the thumb, while flexing the wrist - passive extension of the fingers or a 90 degree or more extension of the fifth finger - knees hyperextensions > 10 degrees - touching the floor with the palms of the hands when reaching down without bending knees - hypermobility if > 4/ 9 criteria met

Question 62

Describe treatment of hypermobility

Answer 62

- patient education - physiotherapy - analgesia as required - surgery is not recommended

Question 63

What are connective tissue diseases?

Answer 63

- conditions associated with spontaneous overactivity of the immune system - specific auto-antibodies are present - they evolve over months to years sometimes leading to organ failure and death

Question 64

Name some examples of connective tissue diseases

Answer 64

- systemic lupus erythematosus - sjogrens syndromes - systemic sclerosis - dermatomyositis / polymyositis - anti-phospholipid syndrome

Question 65

What is SLE?

Answer 65

- systemic autoimmune condition that can affect almost any part of the body - immune system attacks cells and tissue resulting in inflammation and tissue damage - immune complexes form and precipitate causing further immune response

Question 66

Who gets SLE?

Answer 66

- prevalence around 20:100,000 - female to male ratio 9:1 commonly presenting in childbearing years - commoner and more severe in those afro-caribbean, hispanic american, asian and chinese ethnicity - commoner in smokers, less common in men but when present is usually severe

Question 67

Describe the pathogenesis of SLE

Answer 67

- essentially in patients who have a genetic predisposition and who are exposed to precipitating factors, the immune system to loose its normal regulation mechanisms - apoptosis becomes deregulated and ineffective which means the apoptotic cells are removed less quickly and efficiently which results in cell contents circulating longer than normal which then results in the immune system recognising the cell contents as antigens so begins generating an immune response against these - auto-antibodies are generated, over time these antibodies begin to attack cell contents - this process generates chronic inflammation and damage over time - antigens and auto-antibodies from immune complexes which can be deposited in areas commonly in basement membrane of the kidneys

Question 68

What is an important complication of SLE?

Answer 68

Glomerular nephritis, dipstick the urine

Question 69

Describe the cutaneous features of SLE

Answer 69

- subacute cutaneous or discoid lupus - acute cutaneous lupus - non scarring alopecia - oral ulceration - lupus rashes is often photosensitive, precipitated by UV light exposure

Question 70

Describe the neurological presentations of SLE

Answer 70

- delirium - psychosis - seizure - headache - cranial nerve disorder

Question 71

Name haematological complications of SLE

Answer 71

- leukopenia - thrombocytopenia - haemolytic anaemia - lymphadenopathy

Question 72

Name renal complications of SLE

Answer 72

- proteinuria >0.5 g in 24 hours - biopsy proven nephritis - red cell casts - looking for evidence of blood or protein present in the urine

Question 73

Describe ANA

Answer 73

- anti-nuclear antibody - positive in titre of 1:80 in almost all SLE patients - titres of less than 1:160 are present in up to 20% of the healthy population - positive in a lot of other diseases, not diagnostic

Question 74

Describe dsDNA

Answer 74

- anti-double stranded DNA antibody - present in 60% of lupus patients - specific for SLE - titre correlates with disease activity - associated with lupus nephritis - much more specific, rarely falsely positive - negative doesn't rule out lupus, just need other clear indications

Question 75

Describe APLS

Answer 75

- antiphospholipid antibodies - lupus anticoagulant - anti-cardiolipin antibodies - anti-beta2glycoprotein antibodies - associated with venous and arterial thrombosis and recurrent miscarriage - livedo reticularis - associated with lupus but can also be a primary condition

Question 76

Describe anti-Ro antibody

Answer 76

- can be associated with neonatal lupus and congenital heart block

Question 77

Describe anti Sm antibody

Answer 77

- highly specific for lupus

Question 78

What antibody is most specific for lupus?

Answer 78

anti-double stranded DNA antibody

Question 79

What is the management for all patients with SLE?

Answer 79

- sun protection measures - hydroxychloroquine - minimise steroid use - monitor disease activity using SLEDAI score

Question 80

Describe the symptoms of sjogrens

Answer 80

- dry eyes, gritty feeling - dry mouth - dry throat - vaginal dryness - bilateral parotid gland enlargement - joint pains - fatigue - unexplained increase in dental caries

Question 81

Who generally gets sjogrens?

Answer 81

Generally middle aged women

Question 82

Describe the immunology of sjogrens

Answer 82

- anti ro - anti la - may also have raised IgG (if tested) and raised plasma viscosity / ESR

Question 83

What is systemic sclerosis / scleroderma

Answer 83

- systemic sclerosis is a multisystem autoimmune disease characterised by vasculopathy, autoimmunity and fibrosis - classic symptoms of raynauds, skin thickening, difficulty swallowing, FGORD, telangiectasia, calcinosis +/- SOB

Question 84

What is diffuse cutaneous systemic sclerosis?

Answer 84

- skin involvement on extremities above and below elbows and knees (plus face and trunk)

Question 85

What is limited cutaneous systemic sclerosis?

Answer 85

- skin involvement on extremities and only below elbows and knees (plus face)

Question 86

Describe the usual timing of problems in patients with systemic sclerosis (diffuse cutaneous variant)

Answer 86

- raynauds, digital ischaemia - joint contractures - skeletal myopathy - interstitial lung disease - myocardial involvement - renal crisis

Question 87

Describe the usual timing of problems in patients with systemic sclerosis (limited cutaneous variant)

Answer 87

- raynauds, digital ischaemia - oesophageal disease - pulmonary hypertension - malabsorption

Question 88

Describe the facial changes in systemic sclerosis

Answer 88

- small mouth with 'puckering' - beaked nose - thickened / tight skin; lack of wrinkles - telangiectasia

Question 89

Describe systemic sclerosis related GI complications

Answer 89

- difficulty swallowing; dysphagia - GORD - gastric antral vascular ectasia - small intestinal bacterial overgrowth - malabsorption - fluctuating bowel habit - faecal incontinence

Question 90

Describe cardio / respiratory complications of systemic sclerosis

Answer 90

- interstitial lung disease - pulmonary arterial hypertension - myocardial disease

Question 91

Describe renal complications of systemic sclerosis

Answer 91

- scleroderma renal crisis | - non specific progressive renal dysfunction

Question 92

What is raynauds phenomenon?

Answer 92

Classically triphasic - blanching; white - acrocyanosis (purple / blue) - reactive hyperaemia (redness)

Question 93

Describe treatment of vasculopathy / raynauds

Answer 93

- CCB; nifedipine usually first line treatment - others; fluoxetine, ARBs, nitrates - PDE-5 inhibitor; sildenafil - prostacyclin infusion; iloprost - endothelin receptor antagonist; bosentan in order of primary raynauds to recurrent digital ulcers

Question 94

Describe the five groups of pulmonary hypertension

Answer 94

1. pulmonary arterial hypertension 2. PH due to left heart disease 3. PH due to lung disease and or hypoxaemia 4. PH due to chronic thromboembolism 5. OH with unclear multifactorial mechanisms

Question 95

Describe symptoms of pulmonary hypertension

Answer 95

- predominantly shortness of breath on exertion - increased risk with; telangiectasia, anti centromere antibody, increased duration of disease - it is essential to screen for PH yearly

Question 96

Describe systemic sclerosis and pulmonary hypertension

Answer 96

- true pulmonary arterial hypertension - probably a vasculopathy - treatment (aimed at slowing progression); PDE5 inhibitors, ERA, eproprostenol infusions, oxygen - progressive complication ultimately leading to right heart failure

Question 97

Describe signs and symptoms of pulmonary fibrosis

Answer 97

- progressive SOB - usually associated with a cough - bilateral crackles on chest examination - pulmonary function tests (must be done yearly) - restrictive pattern, reduced FVC, reduced transfer factor - hardening of lung tissue, less pliable and more inefficient

Question 98

Describe treatment of pulmonary fibrosis

Answer 98

- mycophenolate mofetil (immunosuppression) - rarely cyclophosphamide (for aggressive disease) - rituximab as a second line agent - nintedanim (antifibrotic) - lung transplant is a theoretic but rare transplant

Question 99

Describe systemic sclerosis and renal disease

Answer 99

- renal crisis - associated with anti RNA polymerase 3 antibody - usually early in disease (presenting feature) - high dose of steroids puts people at risk - uncontrolled hypertension with proteinuria and rapidly worsening renal function - treated by ACE inhibitors (sometimes need dialysis) - incidence much less as we use less steroids now

Question 100

Describe skin fibrosis treatments

Answer 100

- methotrexate | - mycophenolate

Question 101

Define spondyloarthropathy

Answer 101

A family of inflammatory arthritides characterised by involvement of both the spine and joints, principally genetically predisposed (HLA B27 positive) individuals

Question 102

Describe HLA B27

Answer 102

- associated with ankylosing spondylitis, reactive arthritis, crohns disease, uveitis - background prevalence varies depending on geographical location - not a useful screening or diagnostic test unless patients also have symptoms

Question 103

Name the subgroups of spondyloarthritis disease subgroups

Answer 103

- ankylosing spondylitis - psoriatic arthritis - reactive arthritis - enteropathic arthritis

Question 104

Describe mechanical back pain

Answer 104

- worsened by activity | - typically worse at end of day, better with rest

Question 105

Describe inflammatory back pain

Answer 105

- worse with rest | - better with activity, significant early morning stiffness (>30 minutes)

Question 106

Describe the shared rheumatological features of the spondyloarthropathies

Answer 106

- sacroiliac and spinal involvement - enthesitis; inflammation at insertion of tendons into bones eg achilles tendinitis, plantar fasciitis - inflammatory arthritis; oligoarticular, asymmetric, predominantly lower limb - dactylitis; inflammation of entire digit

Question 107

Describe the shared extra-articular features of spondyloarthropathies

Answer 107

- ocular inflammation (anterior uveitis, conjunctivitis) - mucocutaneous lesions - rare aortic incompetence or heart block - no rheumatoid nodules - heart features are rare

Question 108

What is ankylosing spondylitis?

Answer 108

- chronic systemic inflammatory disorder that primarily affects the spine - late adolescence or early adulthood - more common in men 3-5:1

Question 109

Describe the modified new york criteria for diagnosis of ankylosing spondylitis 1992

Answer 109

1. limited lumbar motion 2. lower back pain for 3 months; improved with exercise, not relieved by rest 3. reduced chest expansion 4. bilateral, grade 2 to 4 , sacroilitis on x ray 5. unilateral, grade 3 to 4, sacroilitis on x ray - radiological changes are later so this criteria doesnt pick up patients with early disease

Question 110

Describe the ASAS classification criteria for axial spondyloarthritis (SpA)

Answer 110

- in patients with > 3months back pain and age of onset <45 years - sacroiliitis on imaging and > 1 spa feature OR - HLA B27 positive and >2 other spa features

Question 111

Describe spa features

Answer 111

- inflammatory back pain - arthritis - enthesitis (heel) - uveitis - dactylitis - psoriasis - crohns / colitis - good response to NSAIDs - Fhx - HLA B27 - elevated CRP

Question 112

Describe the clinical features of ankylosing spondylitis

Answer 112

- back pain (neck, thoracic, lumbar, sacroiliac) - enthesitis - peripheral arthritis (shoulders, hips) - extra-articular features; anterior uveitis, cardiovascular involvement, pulmonary involvement, asymptomatic enteric mucosal inflammation, neurological involvement, amyloidosis

Question 113

Describe the 'A' disease of ankylosing spondylitis

Answer 113

- axial arthritis - anterior uveitis - aortic regurgitation - apical fibrosis - amyloidosis / IgA nephropathy - achilles tendinitis - plantar fasciitis

Question 114

How does the spine change with ankylosing spondylitis?

Answer 114

- syndesmophytes (fusion of the vertebrae) | - loss of lumbar lordosis

Question 115

Describe diagnosis of ankylosing spondylitis

Answer 115

- history - examination; tragus / occiput to wall, chest expansion, modified schober test - bloods; inflammatory parameters (ESR, CRP, PV), HLA B27 - xrays; sacroiliitis, syndesmophytes, bamboo spine

Question 116

Describe the occiput to wall test

Answer 116

- patient stands with their back, buttocks and heels against the wall - then tries to put head / neck against the wall, restricted in most patients with disease

Question 117

Describe the schober test

Answer 117

- a measure of lumbar sacral fusion | - patient tries to touch toes without bending the knees, restricted in SA

Question 118

Describe the imaging of ankylosing spondylitis

Answer 118

- xrays; usually show changes after a long period of time | - eg sacroiliac sclerosis / vertebral fusion / erosions

Question 119

Describe the ankylosing spondylitis spine

Answer 119

- bone density; normal in early disease, reduced in late disease - shiny corners - flowing syndesmophytes - fusion (bamboo spine)

Question 120

Describe the spine of osteoarthritis

Answer 120

- normal bone density - reduced joint space - subchondral sclerosis - subchondral cyst formation - osteophyte formation associated with neural foraminal narrowing

Question 121

What is psoriatic arthritis?

Answer 121

Inflammatory arthritis associated with psoriasis, but 10-15% of patients can have PsA without psoriasis

Question 122

Describe the clinical subgroups of psoriatic arthritis

Answer 122

1 confined to distal interphalangeal joints (DIP) hands / feet 2. symmetric polyarthritis (similar to RA) 3. spondylitis (spine involvement) with or without peripheral joint involvement 4. asymmetric oligoarthritis with dactylitis 5. arthritis mutilans

Question 123

Describe the clinical features of psoriatic arthritis

Answer 123

- nail involvement (pitting, onycholysis) - dactylitis - enthesitis; achilles tendinitis, plantar fasciitis - extra articular features (eye disease)

Question 124

Describe the diagnosis of psoriatic arthritis

Answer 124

- history - examination - bloods; inflammatory parameters, negative RF - xrays; marginal erosions and whiskering, pencil in cup deformity, osteolysis, enthesitis

Question 125

What is reactive arthritis?

Answer 125

- infection induced systemic illness characterised primarily by an inflammatory synovitis from which viable microorgansism cannot be cultured - symptoms 1-4 weeks after infection - most common infections; urogenital eg chlamydia, enterogenic eg salmonella, shigella, yersinia - young adults (20-40) - equal sex distribution - HLA B27 positive

Question 126

Describe reiters syndrome

Answer 126

- a form of reactive arthritis | - triad; urethritis, conjunctivitis / uveitis / iritis, arthritis

Question 127

Describe clinical features of reactive arthritis

Answer 127

- general symptoms (fever, fatigue, malaise) - asymmetrical monoarthritis or oligoarthritis - enthesitis - mucocutaneous lesions; keratoderma blenorrhagica, circinate balanitis, painless oral ulcers, hyperkeratotic nails - ocular lesions (unilateral or bilateral), conjunctivitis, iritis - visceral manifestations; mild renal disease, carditis

Question 128

Describe diagnosis of reactive arthritis

Answer 128

- history - examination - bloods; inflammatory parameters, FBC, U and Es, HLA B27 - cultures - joint fluid analysis - x ray of affected joints - ophthalmology opinion

Question 129

Describe enteropathic arthritis

Answer 129

- associated with inflammatory bowel disease eg crohns, ulcerative colitis, patients with inflammatory bowel disease - patients present with arthritis in several joint, especially the knees, ankles, elbows and wrists, and sometimes in the spine, hip or shoulders - 20% of patients with crohns will have sacroiliitis - worsening of symptoms during flare-ups of inflammatory bowel disease

Question 130

Describe the clinical symptoms of enteropathic arthritis

Answer 130

- GI; loose, watery stool with mucous and blood - weight loss, low grade fever - eye involvement (uveitis) - skin involvement (pyoderma gangrenosum) - enthesitis (achilles tendonitis, plantar fasciitis, lateral epicondylitis) - oral; apthous ulcers

Question 131

Describe investigations for enteropathic arthritis

Answer 131

- upper and lower GI endoscopy with biopsy showing ulceration / colitis - joint aspirate; no organisms or crystals - raised inflammatory markers; CRP, PV - x ray / MRI showing sacroiliitis - USS showing synovitis / tenosynovitis

Question 132

Describe pharmacological management of spondyloarthropathies

Answer 132

- NSAIDs - corticosteroids / joint injections - topical steroid eyedrops - disease modifying drugs (methotrexate, sulfasalazine, leflunomide) - anti TNF in severe disease unresponsive to NSAIDs and methotrexate (infliximab, etanercept, adalimumab, golimumab, certolizumab) - secukinumab (anti-IL17) only for PsA and AS

Question 133

Describe non-pharmacological management of spondyloarthropathies

Answer 133

- physio - occupational therapy - orthotics, chiropodist

Question 134

Inflammatory myopathies are characterised by what?

Answer 134

Characterised by weakness

Question 135

Polymyalgia rheumatic are characterised by what?

Answer 135

By pain and stiffness

Question 136

Fibromyalgia is characterised by what?

Answer 136

By pain and fatigue

Question 137

How do muscle diseases present?

Answer 137

- muscle pain (myalgia) - muscle weakness / tiredness - stiffness - abnormal blood tests - other organ features

Question 138

What is myopathy?

Answer 138

- a disease of the muscle in which the muscle fibres do not function properly - this results in muscular weakness - means muscle disease

Question 139

Describe polymyositis and dermatomyositis

Answer 139

- idiopathic inflammatory myopathies - autoimmune - prevalence 1/100,000 - female:male 2:1 - peak incidence ages 40-50 years - increased incidence of malignancy

Question 140

Describe the clinical features of polymyositis and dermatomyositis

Answer 140

- muscle weakness - insidious onset, worsening over months - usually symmetrical, proximal muscles - often specific problems eg difficulty brushing hair, climbing stairs - myalgia in 25-50% (usually mild) - grottons sign - heliotrope rash - shawl sign

Question 141

Describe other organ involvement of polymyositis and dermatomyositis

Answer 141

- lung; ILD, respiratory muscle weakness - oesophageal; dysphagia - cardiac; myocarditis - other; fever, weight loss, raynauds phenomenon, inflammatory arthritis

Question 142

Describe the malignancy risk in polymyositis and dermatomyositis

Answer 142

- 15% incidence in dermatomyositis - 9% polymyositis - ovarian, breast, stomach, lung, bladder and colon cancers - risk greater in men over 45 years

Question 143

Describe the examination of polymyositis and dermatomyositis

Answer 143

- confrontational testing; direct testing of power - isotonic testing; 30 second sit to stand test - wasting of muscles

Question 144

Describe investigations of polymyositis and dermatomyositis

Answer 144

Blood test - muscle enzymes eg CK - inflammatory markers - electrolytes, calcium, PTH, TSH - autoantibodies; ANA, anti-jo-1, myositis specific antibodies - electromyography (EMG)l increased fibrillations, abnormal motor potentials, complex repetitive discharges

Question 145

Describe diagnosis of polymyositis and dermatomyositis

Answer 145

- muscle biopsy; definitive test. perivascular inflammation and muscle necrosis - MRI; muscle inflammation, oedema, fibrosis and calcification - scarring or atrophy of muscle

Question 146

Describe treatment of polymyositis and dermatomyositis

Answer 146

- corticosteroids | - immunosuppression; azathioprine, methotrexate, ciclosporin, IV immunoglobulin, rituximab

Question 147

What is the main symptoms in inflammatory myositis?

Answer 147

Muscle weakness

Question 148

What is the most definitive diagnostic test for polymyositis?

Answer 148

Muscle biopsy

Question 149

What is polymyalgia rheumatica?

Answer 149

- occurs almost exclusively in those over 50 years - prevalence of approx 1% - incidence higher in nothern regions - associated with temporal arteritis / giant cell arteritis (15%)

Question 150

Describe the clinical manifestations of polymyalgia rheumatica

Answer 150

- ache in shoulder and hip girdle - morning stiffness - usually symmetrical - fatigue, anorexia, weight loss and fever may occur - reduced movement of shoulders, neck and hips - muscle strength is normal - usually progressive over a couple of weeks to very debilitating symptoms like struggling to get out of bed in the morning

Question 151

Describe temporal arteritis / giant cell arteritis

Answer 151

- granulomatous arteritis of large vessels - features; headache, scalp tenderness, jaw claudication, visual loss (amaurosis fugax), tender, enlarged, non-pulsatile temporal arteries - form of large vasculitis affecting arteries - dark curtain descending over one eye; can lead to permanent vision loss

Question 152

Describe diagnosis of temporal arteritis

Answer 152

- raised ESR, plasma viscosity, CRP - temporal artery biopsy - temporal artery USS

Question 153

Describe treatment of temporal arteritis

Answer 153

- rapid and dramatic response to low dose steroids - steroid dose; PMR; start at prednisolone 15mg daily, GCA; start at prednisolone 40-60mg daily - gradual reduction in steroid dose over 18 months to 2 years

Question 154

What is fibromyalgia?

Answer 154

- common cause of chronic musculoskeletal pain - not associated with inflammation - commonest cause of musculoskeletal pain in women - 22-50 years - prevalence of 2-5% - commoner in women - may begin after emotional or physical trauma

Question 155

Describe symptoms of fibromyalgia

Answer 155

- chronic headaches - sleep disorders - dizziness - cognitive impairment - memory impairment - anxiety - depression - myofascial pain - fatigue - twitches - morning stiffness - problems urinating - vision problems - joint dysfunction - pain - weight gain - cold symptoms - multiple chemical sensitivity - chest pain - nausea - dysmenorrhoea

Question 156

Describe the ACR proposed diagnostic criteria for fibromyalgia (2010)

Answer 156

- fibromyalgia can be diagnosed if; - patient experiences widespread pain and associated symptoms - symptoms have been present at same level for >3 months - no other condition otherwise explains the pain

Question 157

Described associated symptoms of fibromyalgia

Answer 157

- unrefreshed sleep - cognitive symptoms - fatigue - other somatic symptoms

Question 158

Describe a treatment of fibromyalgia

Answer 158

- patient education - multi disciplinary response - graded exercise programme - cognitive behavioural therapy - complementary medicine eg acupuncture - anti depressants eg tricyclics, SSRIs - analgesia - gabapentin and pregabalin

Question 159

What is vasculitis?

Answer 159

- vasculitis is inflammation of blood vessels; arteries, arterioles, veins, venules or capillaries - it can often lead to inflammation, ischaemia and or necrosis of tissue - clinical manifestations are diverse and depend on the size and depend on the size and location of the involved vessels and the degree of the organ dysfunction and inflammation

Question 160

Describe the aetiology of vasculitis

Answer 160

- may be primary or secondary - primary vasculitis results from an inflammatory response that targets the vessel walls and has no known cause - secondary vasculitis may be triggered by an infection, a drug or a toxin or may occur as part of another inflammatory disorder or cancer

Question 161

Describe the clinical features of vasculitis

Answer 161

- the presentation of vasculitis depends largely on which vessel it affects - systemic symptoms such as fever, malaise, weight loss and fatigue are common to all vasculitides

Question 162

Name the classifications of vasculitis

Answer 162

- medium vessel vasculitis; polyarteritis nodosa, kawasaki disease - ANCA associated small vessel vasculitis - large vessel vasculitis; takayasu arteritis, giant cell arteritis - immune complex small vessel vasculitis

Question 163

Describe large vessel vasculitis

Answer 163

- main causes of large vessel vasculitis are takayasu arteritis (TA) and giant cell arteritis (GCA) - granulomatous infiltration of the walls of the large vessels - two main conditions; TA and GCA

Question 164

Describe takayasus arteritis

Answer 164

- TA under 40 years old commoner in females - more prevalent in asian populations - claudication - bruit, with the most common location being the carotid artery - blood pressure difference of extremities; pulseless disease - angiogram - mainly the arm; so the pain in the arm a common complaint - inflammation of vessel, less blood supply so when exercised there is pain

Question 165

Describe giant cell arteritis

Answer 165

- GCA over 50 years - typically causes temporal arteritis; unilateral acute temporal headache, scalp tenderness, temporary visual disturbances / blindness and or jaw claudication - temporal arteries may be prominent with reduced pulsation - strong association with polymyalgia rheumatica - more common in late 60s and later - pulse can be absent

Question 166

Describe investigations of giant cell arteritis

Answer 166

- ESR or plasma viscosity and CRP raised - temporal artery biopsy (skip lesion can occur so biopsy may be negative) - ultrasound - PET CT or CT angiogram - biopsy is GOLD STANDARD

Question 167

Describe the management of large vessel vasculitis

Answer 167

- start 40-60mg prednisolone - steroid sparing agents may be considered eg leflunamide, methotrexate - tocilizumab - not beyond 2 years

Question 168

What is granulomatosis with polyangiitis (GPA)?

Answer 168

- commoner in those of nothern european descent - male to female ratio 1.5:1 - typically aged 35-55 years - incidence 10/million - prevalence 250/million - constitutional symptoms and arthralgia are common

Question 169

Describe ENT features of GPA

Answer 169

- sinusitis - nasal crusting - epitaxis - mouth ulcers - sensorineural deafness - otitis media and deafness - saddle nose due to cartilage damage from ischaemia - sub glottic inflammation

Question 170

Describe ocular features of GPA

Answer 170

- conjunctivitis - episcleritis - uveitis - optic nerve vasculitis - retinal artery occlusion - proptosis

Question 171

Describe respiratory features of GPA

Answer 171

- cough - haemoptysis - pulmonary infiltrates - diffuse alveolar haemorrhage - cavitating nodules on CXR

Question 172

Describe cutaneous features of GPA

Answer 172

- palpable purpura | - cutaneous ulcers

Question 173

Describe renal features of GPA

Answer 173

- necrotising glomerulonephritis

Question 174

Describe nervous system features of GPA

Answer 174

- mononeuritis multiplex - sensorimotor polyneuropathy - cranial nerve palsies

Question 175

What is henoch-schonlein purpura (HSP)?

Answer 175

- HSP is an acute immunoglobulin A (IgA) mediated disorder - generalised vasculitis involving the small vessels of the skin, the GI tract, the kidneys, the joints and rarely, the lungs and the CNS - approx 75% of cases occur in children ages 2-11 years, rare in infants

Question 176

Describe the presentation of HSP

Answer 176

- purpuric rash typically over buttocks and lower limbs - colicky abdominal pain - bloody diarrhoea - joint pain +/- swelling - renal involvement (50%)

Question 177

Describe investigations for vasculitis

Answer 177

- urine dipstick - FBC, liver and renal profile, inflammatory markers - ANCA and specific antibodies, connective tissue disease screen, compliment levels - imaging investigations chest x ray and or CT scan - nerve conduction tests - tissue biopsy

Question 178

Describe the management of HSP

Answer 178

- usually self limiting - symptoms tend to resolve within 8 weeks - relapses may occur for months to years - essential to perform urinalysis to screen for renal involvement

Question 179

Describe simple backache

Answer 179

- presents age 20-55 - lumbosacral region, buttocks and thighs - pain mechanical in natures; varies with time and activity - patient well - prognosis good; 90% better in 6 weeks - most common back pain

Question 180

Describe nerve root pain

Answer 180

- unilateral leg pain> back pain - pain radiates to foot or toes - numbness and paraesthesia in same distribution - nerve irritation signs - motor, sensory or reflex changes in one nerve root - prognosis reasonable; 50% recover from acute attack in 6 weeks - can have no back pain at all - can go to upper parts of the leg, depends on nerve root

Question 181

Name some serious spinal pathology

Answer 181

- emergency; cauda equina syndrome, recent onset flaccid foot - urgent; tumours, spinal infection, inflammatory, deformity

Question 182

Name red flags for serious spinal pathology

Answer 182

- age <20 and > 55 - violent trauma - constant, progressive non-mechanical pain - severe night pain - thoracic pain - cancer - systemic steroids, premature menopause, DMARDs - TB/IV drug abuse / HIV - systemically unwell - unexplained eight loss - widespread neurological changes - structural deformity

Question 183

Describe cauda equina syndrome

Answer 183

- saddle anaesthesia (anus, perineum or genitals) - difficulty with micturition - loss of anal sphincter tone or faecal incontinence - widespread or progressive motor weakness in the legs or gait disturbance - unilateral leg pain that progresses to bilateral leg pain - or can have back pain only numbness about buttocks, altered feeling with toilet paper, loss of sensation when passing urine, leaking urine or recently using incontinence pads, not knowing whether bladder is empty or full, no control over bowel movements, a change in ability to achieve erection or ejaculation or a change in sexual organs during or after sexual intercourse

Question 184

Describe inflammatory disorders and back ache

Answer 184

- gradual onset - marked morning stiffness - persisting limitation of spinal movement in all directions - peripheral joint involvement - iritis, skin rashes, colitis, urethral discharge - family history

Question 185

Describe the subjective history of back pain

Answer 185

- site / nature of symptoms - history of presenting condition - past medical history - drug history - social history - diagnostic triage

Question 186

Describe objective examination of back pain

Answer 186

- willingness to move / ease of movement - posture - spinal movement - motor power / sensation / reflexes - nerve stretch; femoral, sciatic - neurological examination if symptoms below the buttock

Question 187

Describe management of back pain

Answer 187

- diagnosis / prognosis - advice - drugs - referral; physio, x ray / MRI, surgical opinion, pain management

Question 188

Describe pharmacological treatment of back pain

Answer 188

- NSAIDs first line then weak opiates with or without paracetamol - nerve root pain; gabapentin, pregabalin, amitriptyline (also helps with sleep) - topical treatments; capsaicin cream, menthol in aqueous solution

Question 189

Describe advice given to patients with nerve root pain

Answer 189

- keep moving - try to stay at work - restrict rather than avoid activity - exercises can help but are direction specific - weight control - ergonomic advice

Question 190

Describe exercises to suggest to patients where bending aggravates the pain

Answer 190

- those who complain of pain when sitting, driving, putting socks on etc - spend more time standing - short walks regular basis - stand and put hands at hip pockets and bend backwards, keep knees and hips straight - feels more comfortable to lean backwards, repeat movement 20-30 times - pain should start to be abolished from furthest away from the spine first - lie face down on bed or floor and straightening elbows and lifting up chest, legs still on floor

Question 191

Describe exercises for patients in which bending relieves pain

Answer 191

- fine when sitting, worse with standing - ask them to lie on back with knees bent, feet resting on bed, draw knees one at a time towards the shoulders 10-2 movements then both knees towards shoulders 10-20 movements - can sit towards edge of chair and try to touch toes or lift knees one at a time towards shoulders, not easy to do - NHS inform

Question 192

What do patients present with to their gp for back ache?

Answer 192

- pain; localised, lumbar - referred pain eg sciatica - stiffness - loss of sleep - loss of function; walking, lifting, carrying, hence affects ability to work

Question 193

Describe the history / enquiry for back pain

Answer 193

- SOCRATES for pain; type, radiates / localised - loss of function; subjective - trauma; recent / past - previous surgery - symptoms suggesting other pathology eg urinary tract, GI, resp, systemic illness (virus, TB etc)

Question 194

Describe the physical examination for back pain

Answer 194

- look; how the patient walks in and out, deformity - feel; spinal tenderness, paravertebral muscles, get the patient to show you where - move; flexion, extension, lateral flexion, SLR, tone, power, reflexes, sensation in legs if indicated

Question 195

When would a MRI be indicated for back pain?

Answer 195

- only if red flags or if considering surgery (non resolving sciatica, spinal stenosis)

Question 196

Name causes for back pain

Answer 196

- mechanical / non specific; >90% - tumour / metastases - 0.7% - ankylosing spondylitis - 0.3% - infection - 0.01%

Question 197

Name the yellow flags for back pain

Answer 197

- low mood - high levels of pain / disability - belief that activity is harmful - low educational level - obesity - problem with claim / compensation - job dissatisfaction - light duties not available at work - lots of lifting at work

Question 198

Describe GP management of back pain

Answer 198

- explanation - reassurance - encourage to mobilise - cultivate positive mental attitude - analgesia; paracetamol, opiates - NSAIDs short term - muscle relaxants eg diazepam, short term - physio - osteopathy and chiropractic - referral

Question 199

Describe referred leg pain

Answer 199

- dull / knawing - buttock / thigh - rarely below knee - ill defined sensory symptoms

Question 200

Describe leg pain - root

Answer 200

- sharp / shooting / electric - invariably below the knee to foot and ankle - anatomical sensory / motor symptoms - sciatica

Question 201

Describe neurological symptoms of the leg

Answer 201

- paraesthesia - numbness - weakness

Question 202

Describe neurological symptoms of the bowel /bladder

Answer 202

- loss of motor or sensory function - not constipation - not urinary frequency

Question 203

Name bowel / urinary symptoms of cauda equina syndrome

Answer 203

- incontinence - loss of control - awareness - perineal / saddle anaesthesia - bilateral / unilateral / no leg symptoms

Question 204

Name causes of referred back pain

Answer 204

- peptic ulcer disease - gall bladder - pancreatic - renal - uterine / ovarian - colonic

Question 205

Describe overt pain behaviour

Answer 205

- guarding - bracing - rubbing - grimacing - sighing

Question 206

Describe behavioural responses (waddell)

Answer 206

- superficial / non anatomical tenderness - simulation; axial loading / rotation - distraction - SLR etc - over reaction to examination - regional; sensory disturbance, giving way

Question 207

A technetium scan shows what?

Answer 207

It reflects osteoblast activity

Question 208

Describe acute osteomyelitis

Answer 208

- mostly post traumatic / open = inoculation - then children or immunosuppressed - haematogenous - staph aureus - haemophilus in children

Question 209

Name the ligaments of the knee

Answer 209

- lateral collateral ligament - medial collateral ligament - ACL - PCL

Question 210

What kinds of fibres do the menisci have?

Answer 210

- longitudinal fibres | - radial fibres

Question 211

Who usually gets meniscal tears?

Answer 211

- usually sporting injury in younger patients - or getting up from squatting position in younger patients - can get atraumatic spontaneous degenerate tears in older patients (middle aged onwards)

Question 212

What percentage of ACL rupture have a meniscal tear?

Answer 212

50%

Question 213

Describe the pain of meniscal tears

Answer 213

- pain and tenderness localised to the joint line

Question 214

What is more common - medial meniscal tears or lateral meniscal tears?

Answer 214

- medial meniscal tears are approximately 9-10 times more common

Question 215

Describe tests and investigations for meniscal tears

Answer 215

- +ve meniscal provocation tests (unreliable) | - investigate with MRI is suspected

Question 216

Name the patterns of tear for meniscal tears

Answer 216

- longitudinal tear - bucket handle tear - radial tear - parrot beak tear

Question 217

Describe the healing potential for meniscal tears

Answer 217

- limited healing potential - only peripheral 1/3 has blood supply - radial tears wont heal - pain from initial injury may settle

Question 218

When would arthroscopic meniscal repair be considered for meniscal tears?

Answer 218

- acute traumatic peripheral meniscal tears in younger patients

Question 219

When would arthroscopic meniscectomy be considered for meniscal tears?

Answer 219

- for irreparable tears with recurrent pain, effusion or mechanical symptoms (catching, clicking, locking) which fails to settle

Question 220

Acute locked knee signifies displaced what?

Answer 220

Bucket handle meniscal tear

Question 221

Describe bucket handle meniscal tears

Answer 221

- patient will have 15 degrees springy block to extension - urgent surgery required to unlock knee - may be repairable if picked up early - if knee remains locked, may develop FFD - if irreparable needs partial meniscectomy to unlock knee and prevent further damage

Question 222

Describe degenerate meniscal tears

Answer 222

- common (20% over 50, many asymptomatic) - meniscus weakens with age and can tear spontaneously - probably represents 1st stage of OA - pain from 2nd degree effects - bone marrow oedema, synovitis - inflammation from initial onset may settle - injection may help - increasing evidence that arthroscopic meniscectomy ineffective - only for unstable tear with mechanical symptoms, not for pain only

Question 223

The MCL resists what stress?

Answer 223

Valgus

Question 224

The LCL resists what stress?

Answer 224

Varus

Question 225

The ACL resists what stress?

Answer 225

- anterior subluxation of the tibia and internal rotation of the tibia in extension

Question 226

The PCL resists what stress?

Answer 226

Posterior subluxation of the tibia ie anterior hyperextension of the knee

Question 227

Describe grade 1 knee ligament injuries

Answer 227

- sprain | - tear some fibres but macroscopic

Question 228

Describe grade 2 knee ligament injuries

Answer 228

- partial tear | - some fascicles disrupted

Question 229

Describe grade 3 knee ligament injuries

Answer 229

- complete tear

Question 230

MCL rupture may lead to what instability?

Answer 230

Valgus instability

Question 231

ACL rupture may lead to what instability?

Answer 231

Rotatory instability

Question 232

PCL rupture may lead to what instability?

Answer 232

Recurrent hyperextension or instability descending stairs

Question 233

An MCL tear can tear which attachments?

Answer 233

- femoral attachment (most common) - tibial attachment - midsubstance

Question 234

Describe MCL injury treatment

Answer 234

- MCL usually heals well even if complete tear - brace, early motion, physio - pain can take a few to several months to settle - rarely requires surgery - reconstruction with tendon graft

Question 235

What is the classic history of ACL rupture?

Answer 235

- usually sports injury - football, rugby, skiing | - classic history of 'pop' haemarthrosis and giving way on turning

Question 236

Describe the treatment and outcomes for ACL rupture

Answer 236

- ACL injuries can stabilise with time and physio - 1/3 compensate and are able to function - 1/3 can avoid instability by avoiding certain activities - 1/3 do not compensate have frequent instability or cant get back to high impact sport

Question 237

Describe the role of surgery in ACL rupture

Answer 237

- rotatory instability not responding to physio - protect meniscal repair - professional athletes / very keen on high impact sport - as part of multiligament reconstruction - does not treat pain - does not prevent arthritis - risk vs benefit of surgery - RCT - no difference in functional outcomes conservative vs reconstruction

Question 238

Describe the outcomes of ACL reconstruction surgery

Answer 238

- 3/12 to 1 year rehab - some neve get back to full sport - 85-90% professional footballers RTP - 45-50% amateurs RTP - around 20% failure rate - graft donor site morbidity - stiffness - infection 1% - those that do return to sport may not get back to prior level and may only last a few years - most have radiographic evidence of arthritis within 10 years

Question 239

Describe LCL injury

Answer 239

- relatively uncommon - varus and hyperextension - LCL doesnt heal and can cause varus and rotatory instability - high incidence common peroneal nerve palsy - often occurs in combination with PCL or ACL injury - complete rupture needs urgent repair if early (within 2-3 weeks) - later > reconstruction (hamstring or other tendon)

Question 240

Describe PCL rupture

Answer 240

- direct blow to anterior tibia, (dashboard / motorbike) or hyperextension injury - popliteal knee pain and bruising - isolated PCL rupture rare (usually with other injury) - most isolated cases dont require reconstruction - instability > recurrent hyperextension or feeling unstable when going down stairs - if part of multi-ligament knee injury, usually need reconstruction

Question 241

Describe knee dislocations

Answer 241

- serious high energy with high incidence complications - popliteal artery injury (tear, intimal tear and thrombosis) - nerve injury common peroneal nerve - compartment syndrome - emergency reduction, recheck neurovascular status - any concerns with vascular status > vascular surgery review, may need revascularisation - may need ex fix for temporary stabilisation - multi-ligament reconstruction later

Question 242

Describe patellar dislocation

Answer 242

- rapid turn or direct blow - increased incidence in females, adolescents, ligamentous laxity, valgus knee, torsional abnormalities - 10% > recurrent dislocation - can cause chondral or osteochondral injury - some may benefit from surgical stabilisation - MPFL reconstruction

Question 243

The patella is always dislocated in which direction?

Answer 243

Laterally

Question 244

Describe patellofemoral pain syndrome

Answer 244

- aka idiopathic adolescent anterior knee pain, chondromalacia patellae - may be due to muscle imbalance (including gluteal weakness), tightness of lateral tissues, bony malalignment (valgus, internal rotation), flat feet - some cases have obvious patellar maltracking - physio for vast majority - many get better - can do invasive bony surgery for the most severe cases but results are unpredictable

Question 245

Describe extensor mechanism rupture

Answer 245

- fall onto flexed knee with quads contraction > rupture quads or patellar tendon - previous tendonitis - steroids - chronic renal failure, ciprofloxacin - unable to straight leg raise - palpable gap - US or MRI if in doubt - require urgent surgical repair

Question 246

Describe osteochondral injuries

Answer 246

- a highly controversial area - should only be used for small localised areas of damage with persistent pain - various surgical techniques, results unpredictable - does not work for more general / widespread changes of OA or multiple defects

Question 247

What is osteochondritis dissecans?

Answer 247

- an area of the surface of the knee loses its blood supply and cartilage +/- bone can fragment off - most common in adolescence, some asymptomatic - can heal or resolve spontaneously - can cause pain, recurrent effusions, limping

Question 248

Describe treatment in osteochondritis dissecans

Answer 248

- indications for surgery controversial - if detaching on MRI can pin in place - if detached can fix or remove - may consider cartilage regeneration for persistent pain - can only fix is the child is still growing, otherwise needs removed

Question 249

Describe bone bruising / bone marrow oedema

Answer 249

- only appreciated after advent of MRI - impaction of articular surface leads to microscopic fracture of trabecular bone with bleeding and inflammation - a major source of pain after meniscal tear, ligament injury - a major source of pain after meniscal tear, ligament injury - will settle with time; typically 3 months but can take over a year - no treatments known to speed its resolution - hyaline cartilage may deteriorate over time > chondral defect

Question 250

Describe loose bodies with knee soft tissue problems

Answer 250

- trauma, OCD and joint degeneration can cause a fragment of cartilage +/- bone to detach causing a loose body in the joint - they can grow over time getting nutrition from synovial fluid and may cause painful locking or catching - some can stick to synovium or fat pad > no longer 'loose' - they are commonly over-diagnosed with an opacification identified on xray

Question 251

Describe the treatment of loose bodies

Answer 251

- arthroscopic removal can help troublesome symptoms

Question 252

What is a fabella?

Answer 252

An accessory ossicle (usually) in the lateral head of gastrocnemius commonly misdiagnosed as a loose body

Question 253

Describe bakers cyst and bursitis

Answer 253

- common swellings around the knee | - risk of wound problems and recurrence is removed > leave alone

Question 254

Getting up from squatting, sudden sharp pain medial joint line, effusion, recurrent medial pain and catching +/- locking is the classic history for what?

Answer 254

Meniscal tears

Question 255

Name the bone forming MSK tumours

Answer 255

- osteoma - osteoid osteoma - osteoblastoma - osteosarcoma

Question 256

Name the cartilage forming MSK tumours

Answer 256

- chondroma (enchondroma) - osteochondroma - chondrosarcoma

Question 257

Name other MSK tumours (non bone forming and non cartilage forming)

Answer 257

- ewings sarcoma | - giant cell tumours

Question 258

What is the commonest cancer affecting the bone?

Answer 258

Metastatic (secondary) bone cancer

Question 259

What is the commonest primary cancer affecting the bones?

Answer 259

Multiple myeloma

Question 260

What is the commonest primary bone tumour?

Answer 260

Osteosarcoma

Question 261

Ewings sarcoma is characterised by what?

Answer 261

Loss of bone / lysis

Question 262

Name the commonest cancers for secondary spread to bone

Answer 262

- breast - lung - thyroid - kidney (renal) - prostate

Question 263

Bone tumours account for what percentage of childhood cancers?

Answer 263

10%

Question 264

Name risk factors for primary bone cancer

Answer 264

- vast majority are idiopathic - previous radiotherapy - predisposing conditions; pagets, fibrous dysplasia, multiple endochondroma - genetic; li fraumeni (p53) / familial retinoblastoma

Question 265

Describe the presenting features of primary bone cancer

Answer 265

- persistent, increasing pain - usually not associated with movement - worse at night - swelling and erythema over joint - palpable mass - pathological fracture - pain does not respond well to simple analgesia

Question 266

Describe diagnosis and staging of primary bone cancer

Answer 266

- plain radiographs (AP and lateral including joint above and below) - CT - MRI - bone scan - differential; osteomyelitis / multiple myeloma / metabolic bone disease (eg renal osteodystrophy) / pathological fracture

Question 267

Describe the treatment of primary bone cancer

Answer 267

- neoadjuvant - chemo/ radiation / hormone - surgery; reconstruction / amputation - adjuvant - chemo / radiotherapy

Question 268

Describe osteosarcoma

Answer 268

- most common primary sarcoma of bone - affects children / young adults, 2nd peak in elderly (pagets) - usually around distal femur / proximal tibia - 10-20% present with pulmonary metastases - 75% long term survival - treatment; chemotherapy and limb salvage - 10-30 years old - usually metaphysis - areas of increased whiteness

Question 269

Describe ewings sarcoma

Answer 269

- young people 5-25 years of age - 2nd commonest malignant bone tumour in children - usually found in diaphysis of long bones, again distal femur / prox tibia - 5 year survival; 70% localised / 30% metastatic disease - treatment chemotherapy with limb salvage +/- adjuvant radiation

Question 270

Describe chondrosarcoma

Answer 270

- malignancy of chondrocytes - majority arise de novo - few arise from benign lesions (endochondroma and osteochondroma 1%) - older patients 40-75 yrs - commonest in pelvis, proximal and distal femur - may be slow growing / aggressive - this correlates with survival - lytic or blastic lesion with reactive cortical thickening - cartilage forming

Question 271

Describe osteoid osteoma

Answer 271

- painful, benign tumour of long bones - young people aged 5-25 years - central nodule of woven bone with osteoblastic rim - pain worse at night, relieved by aspirin - usually resolve spontaneously - can treat with rapid radiofrequency

Question 272

Describe osteochondroma

Answer 272

- most common benign bone tumour - benign lesion formed from abnormal cartilage - solitary or multiple (hereditary multiple exostoses, HME) - common in adolescents / young adults - can be caused by trauma - <1% progress to chondrosarcoma (pelvic lesions) - forms bone and cartilage - pedunculated and large lesions - can be excised if there is pain or irritation of nerve - management is usually monitoring for malignant change in patients with multiple lesions

Question 273

Describe enchondroma

Answer 273

- benign intramedullary cartilage lesion - 2nd most common benign bone tumour - commonest in 20-50 year olds - usually asymptomatic, usually presents as incidental finding - conservative treatment, curettage and bone grafting if symptomatic - incredibly common

Question 274

Name the 5 commonest sites for bone metastases

Answer 274

- vertebra - pelvis - ribs - femur - skull

Question 275

Describe the xray appearance of bone metastases

Answer 275

- lesion not visible on xray until >50% cortex destroyed | - lytic (loss of bone) / mixed / sclerotic (gain of bone)

Question 276

Describe radiographic features of bone tumours

Answer 276

- location / nature - neocortex - look at periosteum - cortical involvement - destruction of cortical bone is a sinister feature - zone of transition; how long it takes to move from abnormal to normal bone - matrix; chondroid appearance, popcorn appearance

Question 277

What percentage of routine xrays show a degree of OA of the hips?

Answer 277

30%

Question 278

Describe management for hip pain

Answer 278

- education - weight reduction - home adaptations (occ therapy) - walking stick - analgesia - NSAIDs - physio - complementary medicines - mobility allowance, disability badge for car

Question 279

Name some common causes of hip pain

Answer 279

- osteoarthritis - rheumatoid arthritis - fracture - referred from back - malignancy

Question 280

How do patients usually present with knee pain to their GP?

Answer 280

- pain; anterior, often localised - stiffness - swelling / lump - giving way - deformity - loss of sleep - loss of function; eg trouble walking, cant kneel

Question 281

Describe primary care management of knee pain

Answer 281

- explanation - keep mobile - support - NSAID - short term - analgesia - physio - referral

Question 282

Name some common knee problems in primary care

Answer 282

- ligament strain often medial collateral - bursitis - osgood schlatters - osteoarthritis (patello - femoral > knee)

Question 283

Name the components of lateral and hindfoot anatomy

Answer 283

- distal fibula and fibula shaft - ankle lateral gutter and syndesmosis - lateral wall calcaneus - peronei - CFL and ATFL - sural nerve

Question 284

Name the components of medial and hindfoot topography

Answer 284

- medial malleolus - anteromedial tibiotalar joint - deltoid ligament - PTT, FDL, FHL - posterior tibial artery

Question 285

Name the components of the posterior ankle and hindfoot

Answer 285

- achilles tendon - calcaneal insertion - retrocalcaneal space - peroneal tendons - FHL

Question 286

Name the components of the anterior ankle topography

Answer 286

- anterior ankle joint - superficial peroneal nerve - tibialis anterior - EHL - EDL - saphenous nerve

Question 287

Name the components of plantar topography

Answer 287

- heel pad - 5th metatarsal base - plantar fascia - metatarsal heads - tibial posterior insertion

Question 288

Describe the exposure and look section of foot and ankle examination

Answer 288

- shoes and socks off, exposed to knee - general; age of patient, obvious rheumatoid disease, walking aids - shoes; raises, insoles, uneven wear - view front and behind; atrophy, skin, hair, swelling, erythema, nails

Question 289

Describe the phases of gait

Answer 289

- 1st rocker; heel strike to flat foot - 2nd rocker; mid stance - 3rd rocker; heel rise

Question 290

What do you 'move' during a foot and ankle examination?

Answer 290

- ankle joint - subtalar joint - talonavicular and CC joints - forefoot; 1st MTPJs, PJs

Question 291

What muscle would be tested for power during a foot and ankle exam?

Answer 291

- tibialis posterior - tibialis anterior - peroneus longus - peroneus brevis - EHL, FHL - EDL, FDL

Question 292

What motion is tibialis posterior responsible for?

Answer 292

- inverts the foot and locks cc during motion

Question 293

What motion is tibialis anterior responsible for?

Answer 293

- important ankle dorsiflexor, particularly during foot clearance

Question 294

What motion is peroneus longus responsible for?

Answer 294

Plantar flexion of the big toe

Question 295

What motion is peroneus brevis responsible for?

Answer 295

Evertor of the foot, foot clearance important

Question 296

What motion is extensor hallucis longus and flexor hallucis longus responsible for?

Answer 296

Big toe function extension flexion

Question 297

What motion is extensor digitorum longus and flexor digitorum longus responsible for?

Answer 297

Lesser toe extension flexion

Question 298

What nerves are tested for for sensation and vascular status in the foot and ankle examination?

Answer 298

- saphenous - sural - deep peroneal - superficial peroneal - tibial - medial and lateral plantar - DP and posterior tibial arteries

Question 299

Name the special tests of the foot and ankle examination

Answer 299

- simmonds test (thompsons); TA rupture (palpable gap and foot declination) - anterior draw; ankle stability - 1st MTPJ grind test; MTPJ OA - mulders click; mortons neuroma - ottawa ankle and foot rules

Question 300

What is hallux valgus?

Answer 300

- deformity of the first toe - lateral deviation results in bunion - associated with pathology in the lesser toes - less than 8 degrees is a normal hallux valgus, larger than that it would be considered pathological

Question 301

Describe the incidence of hallux valgus

Answer 301

- increases with age (16% of over 60s) - usually bilateral - 3F > 1M - adolescent subgroup

Question 302

Describe the aetiology of hallux valgus

Answer 302

- some familial (? joint laxity, bony alignment) - shoes? - hypermobility - rheumatoid, pes planus - splayed forefoot associated with loss of muscle tone and age

Question 303

Describe the presentation of hallux valgus

Answer 303

- unable to wear closed shoes; dorsomedial eminence > bursa and or nerve damage - joint pain; osteoarthritis - transfer metatarsalgia; defunctioned 1st ray- symptoms will worsen with time - falls risk /balance, poorly functioning 1st ray > defunctioned 1st ray - cosmesis; unrealistic expectations

Question 304

Describe the conservative management of hallux valgus

Answer 304

- limited benefit; cochrane database review 2000, no benefit vs no treatment - analgesia - orthotics / splints/ toes spacers / bunion pads - low heel, wide, soft, well fitting shoes - physiotherapy for tight gastrocnemius - reassurance

Question 305

Describe the operative management of hallux valgus

Answer 305

- indications; failure of non-op, pain, lesser toe deformities, lifestyle limitation, overlapping, ulceration, functional limitation - many oseotomies - aim to realign the hallux and decrease the HV angle - correct any lesser toe deformities at same time (soft tissue releases, osteotomies, fusions)

Question 306

Describe claw, hammer and mallet toes

Answer 306

- acquired imbalance between flexors and extensors, tight shoes, poor balance - stiff / flexible? - toe props, appropriate footwear - surgery can include tenotomies (division of tendons), tendon transfer, fusions (PIP) or amputation

Question 307

What is mortons neuroma?

Answer 307

- benign fibrotic thickening of a plantar digital nerve due to irritation - degenerative process rather than neoplastic

Question 308

Describe the prevalence of mortons neuroma

Answer 308

- 1/3 population will be affected by the condition - mean age of 45-50 years - obesity - prevalence 8-10 times > in women

Question 309

Describe the presentation of mortons neuroma

Answer 309

- heels - constrictive toe box - characterised by a painful forefoot, commonly 3-4 IS - burning, tingling / numbness - 'wrinkle sock' sensation - +/- sensory deficit - pain on palpation - exacerbated by footwear - relieved by removal of shoe, massaging foot and changing footwear

Question 310

Describe examination / tests for motons neuroma

Answer 310

- tender IS, + mulders sign - radiographic (AP/LAT/ oblique WB) to rule out MSK pathology - eg stress fracture, metatarsal phalangeal joint pathology, exostosis, foreign body or nodules - diagnostic ultrasound recommended; poor specificity < 6mm in diameter, risk of false +ve

Question 311

Describe patient direct / first line treatment options for mortons neuroma

Answer 311

- weight loss if appropriate - stretching of calf muscles may help forefoot pain by reducing force on the met heads - RICE - footwear advice - activity modification and management advice - metatarsal padding

Question 312

Describe second line intervention (12-24 weeks) for mortons neuroma

Answer 312

- biomechanical assessment and orthosis

Question 313

Describe third line intervention for mortons neuroma

Answer 313

- corticosteroid injection | - ultrasound guided

Question 314

Describe surgical options for mortons neuroma

Answer 314

- symptoms persistent after footwear modification and metatarsal pads / metatarsal dome unsuccessful after 2-3 months - inadequate response to corticosteroid injection

Question 315

Describe pes planus

Answer 315

- flat feet - normal variant - 20% of population - familial - associated ligamentous laxity - developmental are common, do not often cause problems and require no treatment - flexible flat feet form an arch when patient tip toes - no indication for orthotics in children

Question 316

What is tibialis posterior dysfunction?

Answer 316

- most common cause of acquired flat foot deformity in adult - up to 10% of elderly women - usually present for years prior to diagnosis - multiple medical consultations - often missed

Question 317

Describe the presentation of tibialis posterior dysfunction

Answer 317

- pain and or swelling posterior to medial malleolus - very specific - change in foot shape - diminished walking ability / balance - dislike of uneven surfaces - more noticeable hallux valgus - lateral wall 'impingement' pain - midfoot and ankle pain (end stage of the condition)

Question 318

Describe the aetiology of tibialis posterior dysfunction

Answer 318

- obese middle aged female - increases with age - hypertension - diabetes - steroid injection - seronegative arthropathies - idiopathic tendonosis

Question 319

Describe the examination findings of TPD

Answer 319

- type 1; swelling, tenderness, slightly weak muscle power - type 2; planovalgus, midfoot abduction, passively correctable - 'too many toes' cannot single heel raise - type 3 and 4; fixity and mortise signs

Question 320

Describe the treatment options for TPD

Answer 320

- physiotherapy - insole to support medial longitudinal arch - no steroid injections - orthoses to accommodate foot shape - bespoke footwear - surgery

Question 321

Describe pes cavus

Answer 321

- idiopathic commonest - variety of other causes (mostly neurological; HSMN, CP, polio, spina bifida, club foot) - often clawing of toes - surgery is required may be complex (soft tissues, releases, tendon transfers, calcaneal osteotomy, arthrodesis)

Question 322

Describe symptoms and examination for plantar fasciitis

Answer 322

- start up pain after rest - can be worse after exercise - fullness or swelling plantarmedial aspect of heel - tenderness over plantar aspect of heel and or plantarmedial aspect of heel - tinels test positive for baxters nerve

Question 323

Name causes of plantar fasciitis

Answer 323

- physical overload; excessive exercise weight - seronegative arthropathy - diabetes - abnormal foot shape; planovalgus or cavovarus - improper footwear - 'heel spurs'

Question 324

Describe treatments of plantar fasciitis

Answer 324

- NSAIDs - night splints - taping - heel cups or medial arch supports - physiotherapy; eccentric exercise programme - steroid injection - ECSWL; not supported by NICE guidlines - surgery; 50% success, better if acute onset - usually self limiting over 18-24 months - self management

Question 325

Describe achilles tendonopathy

Answer 325

- repetitive microtrauma, failure of collagen repair with loss of fibre alignment / structure - hypovascular region 2-6cm proximal to insertion implicated; over training, some drugs (cipro, steroids), CTDs - pain, morning stiffness, eases with heat / walking - can be midsubstance or distal

Question 326

Describe diagnosis of achilles tendonopathy

Answer 326

- clinical - USS - MR

Question 327

Describe management of achilles tendonopathy

Answer 327

- activity modifications / analgesia - NSAIDs - shockwave therapy - orthotics - physio - surgery

Question 328

What is TA rupture?

Answer 328

- usually over 40s - sudden deceleration with resisted calf contraction - patients often think somebody has hit them

Question 329

Describe the symptoms of TA rupture

Answer 329

- unable to weight bear - weak plantar flexion - palpable painful gap - positive calf squeeze (simmonds) test

Question 330

Describe the management of TA rupture

Answer 330

- controversial - operative - non operative - both involve an extended recovery / cast time - functional outcome normally good

Question 331

Describe the injury mechanism of ankle instability

Answer 331

- initial contact on a plantarflexed inverted foot - excessive supination of the rearfoot about an externally rotated leg - ATFL (the weakest ligament) injured first - CFL has 2-3.5 higher load to failure than ATFL - PTFL rarely torn

Question 332

Describe the grading of ankle sprains

Answer 332

- grade 1; microscopic tear (stretch) - grade 2; partial tear - grade 3; complete rupture - acute; chronic >6/12 - recurrent sprains or giving way, persisting for more than six months

Question 333

Describe ankle instability management

Answer 333

- most patients have an element of functional instability - physio first - arthroscopy for pain (75% will not need reconstruction) - proceed with reconstruction if needed - brostrom is the gold standard

Question 334

Describe 1st line treatment of ankle arthritis

Answer 334

- Pt directed advice - weight loss - PRICE - footwear advice - analgesia; NSAIDs - activity modification

Question 335

Describe 2nd line treatment of ankle arthritis

Answer 335

- biomechanical assessment and foot orthosis | - footwear adaptations; brace / rocker bottom / AFO

Question 336

Describe symptoms and imaging of hallux rigidus

Answer 336

- painful 1st MTP joint - stiffness - pain increases with activity / aggravated by shoes - dorsal exotosis - interphalangeal joint (IPJ) hyperextension - imaging; WB AP/LAT + oblique

Question 337

Describe 1st line treatment of hallux rigidus

Answer 337

- Pt directed advice - weight loss - PRICE - footwear advice - analgesia; NSAIDs - activity modification

Question 338

Describe 2nd line treatment of hallux rigidus

Answer 338

- biomechanical assessment and foot orthosis | - footwear adaptations; rigid sole / rocker bottom

Question 339

Describe surgical intervention of hallux rigidus

Answer 339

- fusion | - replacement

Question 340

What are the classifications of ankle fractures?

Answer 340

- weber A - weber B - weber C - lauge hansen

Question 341

Describe pilon fractures

Answer 341

- high energy - significant soft tissue problems - ? open - often other injuries - damage to joint may lead to OA - risk of infection - non-union - amputation

Question 342

Describe metatarsal fractures

Answer 342

- 5th metatarsal fractures - very common - inversion injury 1. avulsion by peroneus brevis tendon (heal predictably in moonboot, do well) 2. jones fracture, poor blood supply, 25% risk non-union 3. proximal shaft (common site for stress fracture)

Question 343

Describe lisfranc fractures

Answer 343

- tarsometatarsal fracture dislocation - the fracture may be subtle and the dislocation difficult to appreciate - often have other injuries - high energy - require fixation - risk OA

Question 344

Describe calcaenus fractures

Answer 344

- fall from height - look for other injuries especially spinal - often intra-articular - significant swelling - risk compartment syndrome - management is controversial - high risk infection / wound breakdown with surgery - benefit not proven

Question 345

Describe talus fractures

Answer 345

- forced dorsioflexion / rapid deceleration - talus has reversed blood supply - risk of AVN and OA

Question 346

What is femoroacetabular impingement syndrome (FAI)?

Answer 346

- altered morphology of femoral neck and or acetabular - causes abutment of the femoral neck on the edge of the acetabulum during movement - usually flexion, adduction and internal rotation

Question 347

Describe CAM type impingement (FAI)

Answer 347

- femoral deformity - usually young athletic males - asymmetric femoral head with decreased head; neck ratio - can be related to previous SUFE

Question 348

Describe pincer type impingement (FAI)

Answer 348

- acetabular deformity - usually seen in females - acetabular overhang

Question 349

What do both pincer type and CAM type impingement cause?

Answer 349

- damage to the labrum and tears - damage to cartilage - osteoarthritis in later life

Question 350

Describe the patient presentation of FAI

Answer 350

- activity related pain in the groin, particularly in flexion and rotation - difficult sitting - C sign positive - FADIR provocation test positive

Question 351

Describe the diagnosis of FAI

Answer 351

- radiographs - CT - MRI (better for visualising damage to the labrum and bony oedema)

Question 352

Describe management of FAI

Answer 352

- observation in asymptomatic patients - arthroscopic or open surgery to remove CAM / debride labral tears - peri-articular osteotomy / debride labral tears in pincer impingement - arthroplasty older patients with secondary OA

Question 353

What is avascular necrosis?

Answer 353

- failure of the blood supply to the femoral head

Question 354

Describe the pathophysiology of avascular necrosis

Answer 354

- idiopathic AVN: - coagulation of the intraosseous microcirculation - venous thrombosis causes retrograde arterial occlusion - intraosseous hypertension - decreased blood flow to femoral head - necrosis of the femoral head - chondral fracture and collapse - AVN associated with trauma; - due to injury of femoral head blood supply (medial femoral circumflex)

Question 355

Describe the aetiology of avascular necrosis

Answer 355

- males over females - typical age is 35-50 - bilateral disease 80% of cases

Question 356

Describe risk factors for avascular necrosis

Answer 356

- irradiation - trauma - hematologic diseases (leukaemia, lymphoma), sickle cell or hypercoaguable states - dysbaric disroders - alcoholism - steroid use - although most cases are idiopathic

Question 357

Describe the patient presentation for avascular necrosis

Answer 357

- insidious onset of groin pain - exacerbated by stairs or impact - examination is usually normal unless disease has advanced collapse / OA

Question 358

Describe the diagnosis of avascular necrosis

Answer 358

- radiographs (often normal in early disease) | - MRI scans is most sensitive / specific

Question 359

Describe management of avascular necrosis

Answer 359

- biphosphonates - core decompression +/- bone grafting - curettage and bone grafting - vascularised fibular bone graft - rotational osteotomy - total hip replacement

Question 360

What is idiopathic transient osteonecrosis of the hip (ITOH)?

Answer 360

Local hyperaemia and impaired venous return with marrow oedema and increased intramedullary pressure

Question 361

Describe the patient presentation of ITOH

Answer 361

- progressive groin pain over several weeks - difficulty weight bearing - usually unilateral

Question 362

Describe the epidemiology of ITOH

Answer 362

- males > females | - 2 groups; middle aged men and pregnant women in third trimester

Question 363

Describe the diagnosis of ITOH

Answer 363

- elevated ESR - radiographs; osteopenia of the head and neck, thinning of the cortices, preserved joint space - MRI (gold standard) - bone scan - diagnosis of exclusion

Question 364

Describe the management of ITOH

Answer 364

- self limiting condition that resolves in 6-9 months - analgesia - protected weight bearing to avoid stress fracture

Question 365

What is trochanteric bursitis?

Answer 365

- repetitive trauma caused by iliotibial band tracking over trochanteric bursa - causes inflammation of the bursa

Question 366

Describe the aetiology of trochanteric bursitis

Answer 366

- female patients | - young runners and older patients (may be linked to gluteal cuff syndrome)

Question 367

Describe the patient presentation of trochanteric bursitis

Answer 367

- pain on the lateral aspect of the hip | - pain on palpation of greater trochanter

Question 368

Describe the diagnosis of trochanteric bursitis

Answer 368

- clinical diagnosis - radiographs usually unremarkable - visible on MRI but not usually needed

Question 369

Describe the management of trochanteric bursitis

Answer 369

- analgesia - NSAIDs - physiotherapy - steroid injection - no proven benefit from surgery

Question 370

What is osteoarthritis?

Answer 370

- degenerative disease of synovial joints that causes progressive loss of articular changes - inflammatory changes in the capsule lead to thickening and tightness

Question 371

Describe the aetiology of osteoarthritis

Answer 371

- females > males - typically in older age - genetic element - pre-existing hip disease

Question 372

Describe the patient presentation of osteoarthritis

Answer 372

- groin pain - worse on activity - pain at night - start up pain - stiff on testing ROM

Question 373

Describe assessment / diagnosis of osteoarthritis

Answer 373

- level of symptoms and impact on quality of life - medical co-morbidities - social history - radiographs

Question 374

What are the radiographic signs of OA?

Answer 374

- joint space narrowing - subchondral sclerosis - osteophytes - cyst formation

Question 375

Describe the management of osteoarthritis

Answer 375

- analgesia - weight loss - walking aids - physiotherapy if weakness is identified - ? steroid injections - total hip arthroplasty; a very successful procedure

Question 376

What is the main indication for total hip arthroplasty?

Answer 376

Pain

Question 377

Describe the benefits and risks of total hip arthroplasty

Answer 377

Benefits; pain relief and secondary improvement in function Risks; - scar - bleeding - neurovascular injury - fracture - clotting (DVT, PE, CVA) - infection - dislocation - leg length discrepancy - loosening - ongoing symptoms

Question 378

Name prostheses choices for total hip arthroplasty

Answer 378

- cemented - uncemented - hybrid

Question 379

Name bearing choices for total hip arthroplasty

Answer 379

- metal on poly - ceramic on poly - ceramic on ceramic

Question 380

Describe the basic science of hyaline cartilage

Answer 380

- covers the surface of bone in synovial joints - decreases friction and distributes load - comprised of water, collagen, proteoglycans and chondrocytes - chondrocytes produce and regulate the extracellular matrix - no blood vessels; nutrition from synovial fluid and subchondral bone, healing / repair poor - proteoglycans highly hydrophilic > act like balloons to give compressive strength - collagen fibres give tensile strength

Question 381

Why does osteoarthritis happen?

Answer 381

- all joints deteriorate (degenerate) with age - some get easier - lifestyle - obesity - heavy physical workload - sports and hobbies - genetic influences; can run in families - previous injury eg ACL rupture, fracture, chondral - (degenerate) meniscal tear - malalignment; genu varum or valgum - many cases we dont know why

Question 382

How does osteoarthritis affect people?

Answer 382

- variable spectrum of pain and disability - pain - stiffness - weakness of surrounding muscles - feelings of instability - loss of confidence in the joint - can have good spells and bad spells (flare ups) - many have advanced OA on xray yet little or no pain - some have mild OA but severe pain

Question 383

Describe the conservative management of osteoarthritis

Answer 383

- analgesics, NSAIDs - weight loss - physiotherapy - activity modification - steroid injection for flare up; can give up to 3 per year, can damage knee further and accelerate OA

Question 384

Who gets knee replacement?

Answer 384

- only for older, medically fit, appropriate patient with end stage arthritis and severe pain refractory to conservative management - constant severe pain - sleep disturbance - pain limiting function / walking distance - frequent bad 'flare ups' of pain - improvement in function is less predictable, around 2/3 improve

Question 385

Describe the limitations of total knee replacement

Answer 385

- they dont act like a normal knee - they dont last for ever - they often dont improve stiffness - younger patients have higher dissatisfaction and early failure - frequent heavy work or sport may cause damage and loosening - 20% have unexplained moderate or severe pain - predictors; young, obesity, psychologic distress, chronic pain, less severe OA - when they loosen or become infected they are big trouble

Question 386

Describe the predictors of a poor outcome of total knee replacement

Answer 386

- young age - obesity - chronic pain syndrome - depression and anxiety - very active lifestyle

Question 387

Who is the ideal knee replacement patient?

Answer 387

- older patient where replacement will last for good; over 60 as a guide - severe end stage arthritis - not morbidly obese - no chronic pain syndrome - no major risk factors for infection - no major medical problems or previous blood clots

Question 388

How long are total knee replacements designed to last?

Answer 388

15-20 years in older, low demand patients if put in well

Question 389

Name the potential complications of total knee replacements

Answer 389

- deep infection 1-2% - pain - stiffness - instability - early failure / loosening - medical complications, blood clots

Question 390

What are the problems with revision knee replacement?

Answer 390

- much bigger surgery, more blood loss, higher risk of complications - revision knee replacements do not work as well as first time nor last as long - once a revision fails; risk of fusion or amputation - re-doing the surgery for unexplained pain doesnt work - younger patients more likely to 'outlive' their knee replacement

Question 391

Name alternatives to total knee replacement

Answer 391

- unicompartmental knee replacement | - osteotomy

Question 392

Describe osteotomy as an alternative to total knee replacement

Answer 392

- surgical realignment of joint to redistribute forces - less predictable results than TKR; 60-70% satisfaction, takes around a year to benefit, duration of benefit varies - it doesnt remove the damaged joint - many surgeons dont believe its a good op - only for very active patients who would damage / loosen a knee replacement

Question 393

Describe a mucous cyst

Answer 393

- outpouching of synovial fluid from DIPJ OA - typical appearance - may be painful - may fluctuate / discharge - may deform nail, cause ridge - Mx - may be left alone - excision (often needs advancement / rotation flap) - affects women more than men - raised swelling - on radial or ulnar side of the midline - large can cause deformity of the nail or ridges - cyst itself is rarely painful

Question 394

Describe ganglions

Answer 394

- outpouching of synovial cavity; therefore more common over synovial joints eg wrist - filled with synovial fluid - fluctuate / trans illuminate - usually painless, but may feel tight - usually resolve with time - more common than mucous cysts - fluid can be thick or gelatinous; can be hard to aspirate - standard assessment if to feel a lesions that is fluctuant and not attached to skin - ganglion may feel tight

Question 395

Describe management of ganglion cysts

Answer 395

- benign neglect - 'family bible' - aspiration - excision

Question 396

Describe trigger finger

Answer 396

- tendons run within flexor tendon sheath - any swelling on tendon leads to irritation; more swelling, tendon gets caught on edge on A1 pullet - pain over A1 pulley (MC head) - sticking of finger (usually in flexion) - may need other hand to extend - may not be able to extend at all

Question 397

Describe examination for trigger finger

Answer 397

- demonstrate triggering - tender over A1 pulley - feel nodule pass beneath pulley - NB; distinguish from dupuytrens - examination usually clear - tenderness over finger

Question 398

Describe conservative and surgical management of trigger finger management

Answer 398

Conservative; - often resolves spontaneously - splint to prevent flexion - occasionally refer to hand physiotherapy tendon sheath injection; - steroid + LA, ultrasound guidance - often curative - may be repeated up to 2x surgery; - under GA or LA - divide A1 pulley (no others)

Question 399

What are the LOAF muscles?

Answer 399

- lumbricals 1 and 2 - opponens pollicis - abductor pollicis brevis - flexor pollicis brevis

Question 400

What does the median nerve supply?

Answer 400

- motor to LOAF muscles | - sensory to palmar aspect of hand, thumb, index, middle and radial half of ring finger

Question 401

Describe the history of carpal tunnel syndrome

Answer 401

- often sensory involvement to radial 3 1/2 fingers - often worse at night; relieved by shaking the hand - palmar sensation often spared - often idiopathic - female to male 5-8:1 - identifiable causes include; DM, pregnancy, hypoT4, fluid overload, acromegaly, rh arthritis

Question 402

Describe examination of carpal tunnel syndrome

Answer 402

- examination of LOAF muscles (APB) - phalens test (1 min) - tinels test - nerve conduction studies - kamath and atothard carpal tunnel questionnaire

Question 403

Describe the management of carpal tunnel syndrome

Answer 403

- splintage; over night, metal bar over the flexor surface - diagnostic steroid injection - surgery

Question 404

What is dequervains synovitis?

Answer 404

Inflammation of tendon sheaths in the first extensor compartment

Question 405

Describe the symptoms of dequervains

Answer 405

- spontaneous - painful - swollen / red - finkelsteins test

Question 406

Describe management of dequervains

Answer 406

- NSAIDs - splint - rest - steroid injection - surgery; decompression

Question 407

Describe dupuytrens contracture

Answer 407

- painless, gradual progression | - usually starts as palmar pit / nodule

Question 408

Describe causes of dupuytrens

Answer 408

- ?genetics - DM - alcohol / cirrhosis - smoking - epilepsy / anti-epileptic medication - ?trauma

Question 409

Describe examination of dupuytrens

Answer 409

- feel cords - MCP / PIP joint involvement, measure angles - table top test

Question 410

Describe conservative treatment for dupuytrens disease

Answer 410

- stretches | - activity modificayion

Question 411

Describe surgical management for dupuytrens disease

Answer 411

- segmental fasciectomy - fasciectomy - dermofasciectomy - amputation

Question 412

Name some newer treatments for dupuytens disease

Answer 412

- collagenase injection | - percutaneous needle fasciotomy

Question 413

Describe paronychia

Answer 413

- infection within nail fold - often in children - risks; nail biting - may result in pus collection - management; elevated, antibiotics, incise and drain collection - oral mucosa becomes involved in the nail fold tissues - for recurrent cases; nail plate may need removed and through debridement may be required

Question 414

Describe flexor tendon sheath infection

Answer 414

- rare, but important; surgical emergency - infection within sheath, tacking up palm + arm - extremely painful - limited extension (including passive), due to pain - kanavels cardinal signs - management; wash out tendon sheath, A1 and A5 pulleys - can be from direct penetrating trauma or can be haematogenous spread from a separate infection

Question 415

What are kanavels cardinal signs? (flexor tendon sheath infection)

Answer 415

- affected finger held in fixed flexion - fusiform swelling over finger - painful to percuss over sheath - painful on passive extension

Question 416

Describe the different types of nail and nailbed injuries

Answer 416

``` Type 1; soft tissue only Type 2; soft tissue and nail Type 3; soft tissue and nail and bone Type 4; proximal 1/3 of phalanx Type 5; proximal to DIPjt ```

Question 417

Describe the treatment for type 1 and 2 nailbed injuries

Answer 417

Dressing only

Question 418

Describe the treatment for level 3 nailbed injuries

Answer 418

Repair nail bed + stabilise bone

Question 419

Describe the treatment for level 4 nailbed injuries

Answer 419

Repair nail bed + stabilise bone. As above unless <5mm of nail bed > ablate If tip not available, terminalise or V-Y flap

Question 420

Describe boxers fractures

Answer 420

- minimal displacement - no rotation - more distal Treatment; 'buddy strap', early mobilisation

Question 421

Describe examination for mallet finger

Answer 421

- resisted finger extension | - tenderness / bruising

Question 422

Describe management for mallet finger

Answer 422

- mallet splint for 6/52 - occ fix large displaced avulsion fragment - wire - dermatotenodesis in chronic cases

Question 423

Describe PIPJ dislocation

Answer 423

- common injury - vital to be treated acutely; pull to reduce, buddy strap - delayed presentation a disaster - many reduced on the sports pitch

Question 424

Described delayed presentation of PIPJ dislocations

Answer 424

- impossible to reduce - may require fusion - degeneration of the articular surface

Question 425

What is a bennets fracture?

Answer 425

A fracture of the base of the thumb

Question 426

Describe the principles of mutilating injuries

Answer 426

- preserve amputated parts on ice - early debridement - establish stable bony support - establish vascularity - repair all tissues; nerves, tendons - establish skin cover; grafts/ flaps - prevent / treat infection - aggressive mobilisation

Question 427

What is the standard treatment for burns?

Answer 427

- respiratory - infection - dehydration - pain relief

Question 428

Describe specific hand burns treatment

Answer 428

- excise damaged skin and perform split skin grafts early - aggressive mobilisation to prevent finger stiffness - escharotomy

Question 429

What is eschar?

Answer 429

- thick, leathery, inelastic skin which can form alter burns - may require surgical release to allow movement

Question 430

What is the function of a tendon?

Answer 430

To link muscle which is the motor unit to bone to enable joint function

Question 431

What is the predominant cell in tendons?

Answer 431

The fibroblast - responsible for the production and maintenance of collagen and other proteins which confer the flexibility and tensile strength of tendons

Question 432

What is the blood supply to tendons?

Answer 432

- perimyseum - the periosteal insertion of the tendon - paratendon

Question 433

Describe the aetiology of tendinopathy

Answer 433

- intrinsic; age, gender, obesity, predisposing diseases eg Rh A, anatomical factors - extrinsic; trauma / injury, repetitive injury, drugs (steroids, antibiotics), sports related factors

Question 434

Describe tendonosis

Answer 434

- histologic degeneration of collagen and extracellular matrix - likely due to matrix metalloproteinases (MMPs); increase with age and repetitive strain - can be present and not painful - unclear why painful in some and not others - usually occurs at areas od poor blood supply

Question 435

Describe the principles of management of tendonosis

Answer 435

- conservative; rest, physio (eccentric strengthening), - analgesics; anti-inflammatories - injections; rotator cuff, tennis elbow, NOT achilles tendon or extensor knee mechanism - splinting; achilles tendon

Question 436

Why would you not inject into achilles tendon or knee extensor mechanism?

Answer 436

Due to the risk of rupture

Question 437

Describe the surgical principles of management of tendonosis

Answer 437

- debridement; removal of diseased tissue - decompression; supraspinatus tendonitis and subacromial decompression - synovectomy; helps to prevent rupture, extensor tendons of wrist (rheumatoid arthritis), tibialis posterior - tendon transfer; tibialis posterior, extensor pollicis longus

Question 438

Describe controversial treatments for tendonosis

Answer 438

- ultrasound - platelet rich plasma (PRP) - steroid injection; toxic to tenocytes evidence that physio as effective as injection in tennis elbow and shoulder impingement - surgery

Question 439

Name examples of upper limb problems

Answer 439

- rotator cuff - biceps brachii rupture - tennis elbow - golfers elbow - de quervains tenosynovitis - rheumatoid extensor tendon rupture - EPL rupture - trigger finger

Question 440

Describe the aetiology of rotator cuff pathology

Answer 440

- athletes (throwing events) | - manual workers (painters)

Question 441

Describe the clinical findings of rotator cuff pathology

Answer 441

- achy pain down arm - difficulty sleeping on affected side, reaching overhead and on lifting - painful arc +/- weakness - positive impingement tests

Question 442

Describe the management of rotator cuff pathology

Answer 442

- conservative; physio, inject | - surgical; subacromial decompression

Question 443

Name the muscles of the rotator cuff

Answer 443

- supraspinatus - infraspinatus - subscapularis - teres minor

Question 444

What rotator cuff muscle is most involved in pathology

Answer 444

Supraspinatus

Question 445

Describe biceps tendinopathy

Answer 445

- can be proximal or distal - overuse, instability, impingement or trauma - pain anterior shoulder radiating to elbow; aggravated by shoulder flexion, forearm pronation and elbow flexion, snapping with shoulder movements if subluxation - Dx; clinical exam, USS - Mx; conservative vs surgical

Question 446

Clinical signs of a biceps tendon rupture include what?

Answer 446

- a popeye sign | - extensive bruising

Question 447

Describe lateral epicondylitis (tennis elbow)

Answer 447

- predominantly unilateral but 10-20% bilateral - characterised by pain and tenderness over the lateral epicondyle at the attachment of the forearm muscles - pain is worse when stretching the muscles eg opening a jar - mills test is positive - diagnosis is predominantly clinical but USS and MRI maybe required where the diagnosis is uncertain and NCS should be carried out if there are any nerve symptoms - management of tennis elbow is the same as golfers elbow; rest, physio, injection of LA and steroids, orthotics and surgical release for refractory cases

Question 448

Describe medial epicondylitis (golfers elbow)

Answer 448

- medial elbow pain; origin of the wrist flexors - repetitive stress - worse upon grasping eg opening a jar - self limiting condition - avoid injection; ulnar nerve - surgical release last resort

Question 449

Describe de quervains tenosynovitis

Answer 449

- first extensor compartment; APL, EPB - pain over radial styloid process - typically presents as a repetitive strain injury with pain over the radial styloid process at the wrist - most common between 30 and 50, associated with pregnancy

Question 450

What is a diagnostic test for de quervains tenosynovitis ?

Answer 450

Finkelsteins test; patient makes a fist over the thumb and the hand is ulnar deviated to reproduce pain

Question 451

Describe management for de quervains tenosynovitis

Answer 451

- splint - rest - physio - analgesics - inject - surgical decompression

Question 452

Describe RA and extensor tendon rupture

Answer 452

- autoimmune attack on synovium > tendon degeneration > rupture - weakness wrist extension or dropped finger - cant repair disease tendon > tendon transfer - synovectomy can prevent

Question 453

Describe EPL rupture

Answer 453

- can occur with RA or after colles fracture - substantial loss of function - requires tendon transfer (EIP)

Question 454

Describe traction apophysitis

Answer 454

- at tibial tubercle - osgood schlatters disease - insertion of patellar tendon into tibial tuberosity - adolescent active boys - leaves prominent bony lump - can also happen at patella and achilles

Question 455

Describe achilles tendon rupture

Answer 455

- common, middle ages - tends to occur after a sudden force such as forceful push off the foot eg while running, jumping etc - commoner in pateitns with rheumatoid arthritis, those on steroids and patients with tendonitis

Question 456

Describe the clinical findings of achilles tendon rupture

Answer 456

- bruising - a palpable gap - patients being unable to tip to stand and a positive simmonds test

Question 457

Describe clinical examination of achilles tendon rupture

Answer 457

- clinical examination usually confirms the diagnosis but USS and MRI can be used where the diagnosis is uncertain or where there is re-rupture of the tendon or a large gap is suspected

Question 458

Describe management of achilles tendon rupture

Answer 458

- conservative or by surgical repair - rehabilitation and early range of movement are better following surgical repair and may decrease the re-rupture rate - plaster vs repair - equinus cast with serial casts to bring foot back up to neutral position

Question 459

Describe common shoulder pathologies in terms of age

Answer 459

- 20-30s; instability - 30s-40s; impingement - 40s-50s; frozen shoulder - 50s-60s; cuff tear - >60; arthritis

Question 460

Name extrinsic muscles of the shoulder

Answer 460

- deltoid - trapezium - pectoralis major - latissimus dorsi

Question 461

Describe the shoulder range of movement

Answer 461

- forward flexion - extension - abduction - external rotation - internal rotation

Question 462

Describe the aetiology of shoulder instability

Answer 462

- teenage to 30s - young - sporty - mostly traumatic

Question 463

Describe anterior vs posterior shoulder instability

Answer 463

Anterior dislocation; - common 95% - traumatic - sports Posterior dislocation; - infrequent 5% - epileptic fit - electrocution

Question 464

Describe the presentation of shoulder instability

Answer 464

- acute in trauma clinic; emergency department reduction, painful, in sling - chronic in shoulder clinic; atraumatic laxity / subluxations, not painful, no support

Question 465

Describe history and examination of shoulder instability presentation

Answer 465

- history; traumatic event, mechanism of injury, ease of dislocation, frequency, general laxity - examination; abnormal shoulder contour, muscle wasting, tenderness, muscle spasm, good ROM, scapular winging / dyskinesia, RC strength, apprehension, relocation, general laxity

Question 466

Describe anterior shoulder dislocation in the emergency department

Answer 466

- analgesia IV - O2 - sedation IV - reduction by manipulation; kocher method, hippocratic method, stimson method

Question 467

Describe post reduction treatment for should dislocation / instability

Answer 467

- 2-3 weeks sling - analgesia - gradual early mobilisation - physiotherapy

Question 468

Describe investigations for instability

Answer 468

- radiographs; AP shoulder and garth views (apical oblique) | - MRI arthrogram

Question 469

Describe associated injuries for shoulder instability

Answer 469

- labral lesion (bankart) - fracture humeral head (hill sachs) - fracture of glenoid (bony bankart) - rotator cuff tear (older patients >40)

Question 470

Describe general treatment for shoulder instability

Answer 470

- all nonoperative - physiotherapy; RC and core strengthening, scapula stabilising - the younger the patient, the higher the risk of recurrent dislocation - arthroscopic / open stabilisation - repair of bankart lesion

Question 471

Describe the rehab for shoulder instability

Answer 471

- 6 week sling - 8-10 weeks no driving - 12 weeks no heavy lifting - return to sports; 12 weeks non contract, 6 months contact

Question 472

What is impingement syndrome?

Answer 472

Pain originating from the sub-acromial space

Question 473

Describe intrinsic and extrinsic causes of impingement syndrome

Answer 473

Intrinsic; - tendon vascularity - watershed area - tendon degeneration - cuff dysfunction Extrinsic; - external 'pressure' - type of acromion - coraco-acromial ligament - clavicular spur / osteophyte

Question 474

Describe impingement syndrome and Neers classification

Answer 474

1. inflammation, oedema and haemorrhage <25 yo 2. fibrosis and tendonitis bursa / cuff 25-40yo 3. partial / full thickness tears and degeneration RC >40 yo

Question 475

Describe investigations for impingement

Answer 475

- radiographs; AP shoulder and garth views (apical oblique) or outlet view - USS or MRI depending on shoulder mobility

Question 476

Describe non-surgical treatment for impingement

Answer 476

- rest; activity modification - pain relief - physiotherapy exercises - cortico-steroid injections in subacromial space - minimum 6 months non-operative treatment

Question 477

Describe surgical treatment for impingement

Answer 477

- arthroscopic / open subacromial decompression - subacromial / subdeltoid bursectomy - acromioplasty - release of CA ligament - release of calcific deposits - excision infraclavicular spur

Question 478

Describe rehab for impingement

Answer 478

- painful - sling 1-2 weeks - early PT and ROM exercises - RC strengthening

Question 479

Describe cuff tear presentation

Answer 479

- age 50-60s - grey hair = cuff tear - acute traumatic - chronic attrition - weakness - pain

Question 480

Describe investigation for cuff tears

Answer 480

- radiographs - USS, if good ROM - MRI, if very stiff

Question 481

Describe cuff tear treatment

Answer 481

- rest - analgesia - sling Chronic - physiotherapy; anterior deltoid strengthening - steroid injections - wait and see approach - arthroscopic or open repair of RC

Question 482

Describe rehab for cuff repair

Answer 482

- sling 6 weeks - no driving 8-10 weeks - 12 weeks no heavy lifting - prolonged physiotherapy - prolonged recovery 6-9 months - 20-40% re-tear rate at 1 year

Question 483

Describe frozen shoulder presentation

Answer 483

- 40-50s - more females 1:2 - not uncommonly bilateral (often not simultaneous) - gradual severe pain - association with diabetes, lipid and endocrine disease and dupuytrens

Question 484

Describe the pathology for frozen shoulder

Answer 484

- contracture and thickening of coraco-humeral ligament, rotator interval (SSp-SSc), axillary fold (IGHL) - decrease in joint volume - NOT adhesion

Question 485

Describe non operative treatments for frozen shoulder

Answer 485

- gentle movements - analgesia - physiotherapy - glenohumeral steroid injections - fluoroscopic distension

Question 486

Describe operative treatments for frozen shoulder

Answer 486

- manipulation under anaesthetic (abduction, adduction, external, internal rotation) - arthroscopic capsular release (arthrolysis)

Question 487

Describe rehab for post release frozen shoulder

Answer 487

- short period in sling - excellent pain control - aggressive physiotherapy - 'the armpit test'

Question 488

Describe glenohumeral osteoarthritis presentation

Answer 488

- over 60s - uncommon location - osteoarthritis, rheumatoid arthritis and post traumatic arthritis - gradual onset - intermittent exacerbations

Question 489

Describe the history for glenohumeral osteoarthritis

Answer 489

- gradual onset - pain at rest and night - stiffness - intermittent exacerbations - functional difficulties

Question 490

Describe examination findings for glenohumeral osteoarthritis

Answer 490

- asymmetry - wasting - limitation external rotation - global restriction in movement - pain throughout ROM

Question 491

Describe radiographic findings for glenohumeral osteoarthritis

Answer 491

- joint space narrowing - subchondral sclerosis - subchondral cysts - osteophyte formation

Question 492

Describe non-operative management for glenohumeral osteoarthritis

Answer 492

- analgesia - physiotherapy - GH steroid injection

Question 493

Describe operative management for glenohumeral osteoarthritis

Answer 493

- shoulder replacemen (arthroplasty) - resurfacing - total shoulder arthroplasty - reverse polarity shoulder arthroplasty

Question 494

Describe post shoulder arthroplasty rehab

Answer 494

- sling 6 weeks - good perioperative pain relief - physiotherapy - driving 8-10 weeks - heavy lifting 12 weeks

Question 495

Describe the aetiology of carpal tunnel syndrome

Answer 495

- >30s - common (up to 10%) - female - pregnancy / hormonal fluctuations - hypothyroidism - diabetes - obesity - rheumatoid arthritis

Question 496

Describe carpal tunnel anatomy

Answer 496

- scaphoid tubercle and trapezium radial - hook of hamate and pisiform ulnar - transverse carpal ligament superficial - bony carpus deep - 9 flexor tendons - 1 nerve (median)

Question 497

Name the early, late and functional carpal tunnel symptoms

Answer 497

Early - pins and needles - pain - clumsiness Late - numbness - weakness Functional - early morning wakening - driving - phone use - reading

Question 498

Name carpal tunnel signs

Answer 498

- thenar atrophy - altered sensation - weakness APB - durkins test; compression - tinnels test; tapping - phalens test; volar flexion

Question 499

Describe carpal tunnel investigations

Answer 499

- carpal tunnel questionnaire (hamath and stothard) | - nerve conduction studies (MCS) and electromyogram (EMG)

Question 500

Describe carpal tunnel syndrome treatment

Answer 500

Mild / moderate - splintage - physiotherapy - steroid injection Severe - carpal tunnel decompression

Question 501

Describe the aims of decompression surgery

Answer 501

1. prevent progression | 2. reduce symptoms

Question 502

Describe carpal decompression surgery

Answer 502

- day surgery - local anaesthetic - division transverse carpal ligament - anatomical variations

Question 503

Describe carpal decompression rehab

Answer 503

- 2 days reduce dressings - 5 days keep dry - 10 days for sutures - 6 weeks return pincher grip - 12 weeks grip strength

Question 504

Describe cubital tunnel syndrome aetiology

Answer 504

- >30 - 2nd most common - more males - post traumatic causes - direct pressure (cysts, other tumours) - arthritis

Question 505

Describe ulnar nerve anatomy

Answer 505

- intramuscular septum at arcade of struthers - cubital tunnel - roof; FCU fascia and osbornes ligament - floor; MCL and joint capsule - walls; medial epicondyle and olecranon

Question 506

Describe the early, late and functional cubital tunnel symptoms

Answer 506

Early - ulnar pins and needles - pain - clumsiness Late - numbness - weakness Functional - night - leaning

Question 507

Describe cubital tunnel signs

Answer 507

- hypothenar and interosseous atrophy - clawing of ring and small finger - altered sensation - weakness Abd Dig minimi - weakness of grasp and pinch - wartenbergs sign; abducted small finger

Question 508

Describe cubital tunnel tests

Answer 508

- tinnels test; tapping - modified phalens test; elbow flexion test - froments test; thumb flexion during key grip - FPL by AIN

Question 509

Describe cubital tunnel syndrome treatment

Answer 509

Mild/ moderate - elbow splintage - physiotherapy, nerve gliding - NSAIDs Severe - ulnar nerve decompression

Question 510

Describe ulnar nerve decompression

Answer 510

- day surgery - local, regional general anaesthetic - release nerve from arcade struthers to the heads of FCU

Question 511

Describe ulnar nerve decompression rehab

Answer 511

- 2 days reduce dressings - 5 days keep dry - 10 days for sutures - early return function is successful (80-90%)

Question 512

Name symptoms of arthritis

Answer 512

- pain - swelling - stiffness - deformity - loss of function

Question 513

Name some causes of arthritis

Answer 513

- degenerate (OA) - inflammatory (RA, psoriasis, gout) - post traumatic - septic

Question 514

Name the basic treatment principles for arthritis

Answer 514

- nothing - rest/ analgesia / splintage - steroid injections - replace - fuse - excise

Question 515

Describe arthritis of the sternoclavicular joint

Answer 515

- rare - swelling / pain at SCjt - Mx; physio, injection, excision (rare)

Question 516

Describe arthritis of the acromioclavicular joint

Answer 516

- very common - often overlaps with impingement - may be due to trauma - Mx; injection, excision

Question 517

Describe arthritis of the glenohumeral joint

Answer 517

- less common than hip / knee - may be due to; cuff tear, instability, previous surgery, idiopathic - pain - crepitus (grinding) - loss of movement, especially external rotation

Question 518

Name some complications of shoulder replacement

Answer 518

- infection - instability - stiffness - nerve damage - loosening; 90% at 10 years vs 98% of for hips, much fewer, so specialist operation (hip and knee are much more common)

Question 519

Describe cuff tear arthropathy

Answer 519

- rotator cuff centres humeral head on glenoid - if torn, deltoid pulls head upwards - abnormal forces on gleaned leads to OA - anatomic shoulder replacement will fail

Question 520

Describe reverse polarity shoulder replacement

Answer 520

- reverse ball socket - increases lever arm of deltoid - lengthens deltoid - resurfaces joint - prevents upward migration

Question 521

Describe radiocapitellar OA

Answer 521

- radial head is only secondary stabiliser (so not vital) - excise - replace

Question 522

Describe elbow replacements

Answer 522

- limited life span - no good for young / active - limit to 5kg / 1kg repeatedly

Question 523

Describe the characteristic features of osteoarthritis

Answer 523

- monoarticular - localised - osteophytes / sclerosis - early if space narrowing - base of thumb - PIP + DIPjts

Question 524

Describe the characteristic features of rheumatoid

Answer 524

- polyarticular - systemic - erosions - later joint space narrowing - synovitis - tendon rupture - MCPjt - carpus

Question 525

Name some examples of rheumatoid surgery

Answer 525

- synovectomy - tendon realignment - replacement - fusion - a la carte - NB rheumatoid patients are often low demand

Question 526

Describe base of thumb OA

Answer 526

- #2 site in the body - very common - trade off of opposable thumbs - results in subluxation of CMCjt - pain especially in pinch

Question 527

Describe swan neck deformity

Answer 527

- volar plate of PIP jt becomes attenuated | - small ligaments and lumbrical tendons fall more dorsal to joint centre

Question 528

Describe boutonniere

Answer 528

- button hole - extensor hood of PIPjt becomes attenuated - slips of extensor tendon move from dorsal to volar to centre of rotation; results in flexion of PIPjt, middle phalangeal head 'buttonholes' through extensor hood - lateral slips of extensor tendon stretched around PIPjt; become taut, results in hyperextensions of DIP jt

Question 529

Name important history points for swellings

Answer 529

- when did it appear, gradually or suddenly - any history or trauma - is it painful - is the size increasing, staying the same or doe that fluctuate - is the patient unwell in any way (systemic symptoms) - do they have or have they had any other similar swellings - what functional problems does it cause

Question 530

Name important examination features for swellings

Answer 530

- site - size - shape - generalised (ill defined) or discreet (well defined) - consistency; is it fluctuant - surface texture - mobile or fixed; to both skin and underlying structures - temperature - is it transluminable - skin changes - local lymphadenopathy

Question 531

Name history features for infections

Answer 531

- systemic upset - pyrexia - trauma (break in skin) - association with medical co-morbidities

Question 532

Name examination features of infections

Answer 532

- calor - dolor - rubor - tumor

Question 533

What is cellulitis?

Answer 533

- inflammation and infection of the soft tissues | - a generalised swelling rather than a discreet lump

Question 534

Describe the presentation of cellulitis

Answer 534

- pain - swelling - erythema - spectrum; minor problem; septic

Question 535

Names organisms associated with cellulitis

Answer 535

- beta haemolytic streps | - staphylococci

Question 536

Describe management of cellulitis

Answer 536

- rest - elevation - analgesia - splint - antibiotics; oral vs IV - penicillin NOT SURGERY

Question 537

What is an absess?

Answer 537

Discreet collection of pus

Question 538

Describe the presentation of abscesses

Answer 538

- defined and fluctuant swelling - erythema, pain - history of trauma (eg bite, IVDU) - spectrum; minor problem -septic

Question 539

Describe management of abscesses

Answer 539

- surgical incision and drainage - 'if theres pus let it out' - rest - elevation - analgesia - splint - antibiotics

Question 540

Describe septic arthritis

Answer 540

- bacterial infection of a joint; traumatic (joint penetration), haematogenous spread - not a common phenomenon but a clinically important diagnosis - an orthopaedic emergency - irreversible damage to hyaline articular cartilage - common organisms; staph aureus, step, e coli

Question 541

Describe the presentation of septic arthritis

Answer 541

- acute monoarthropathy - decreased ROM +/- swelling - systemic upset - raised WCC + inflammatory markers

Question 542

Describe management of septic arthritis

Answer 542

- urgent orthopaedic review - aspiration; M, C & S - urgent open / arthroscopic washout and debridement

Question 543

What are ganglia?

Answer 543

- outpouching of the synovium lining of joints and filled with synovial fluid

Question 544

Describe the appearance of ganglia

Answer 544

- discreet, round swellings - non tender - <10mm, several cms - skin mobile, fixed to underlying structures - wrists, feet, knees

Question 545

Describe the management of ganglia

Answer 545

- based upon symptoms / function impairment - nothing - not aspiration - percutaneous rupture - surgical excision

Question 546

What are bakers cysts?

Answer 546

Special mention to this cyst and ganglion of the popliteal fossa

Question 547

Describe presentation and management of bakers cysts

Answer 547

Presentation; - can appear as general fullness of the popliteal fossa - soft and nontender - associated with OA - painful rupture Management; - non operative

Question 548

What is bursitis?

Answer 548

- inflammation of the synovium lined sacs that protect bony prominences and joints - can become secondarily infected and form an abscess

Question 549

Describe the management of bursitis

Answer 549

- NSAIDs / analgesia - antibiotics - incision and drainage (secondary infection) - v rarely excision (chronic cases)

Question 550

Describe gout

Answer 550

- an inflammatory arthritis most commonly affecting the great toe but can affect other joints, especially the knee - elevated serum urate causes a deposition of uric acid crystals in joints - episodes of inflammation result in acute attacks - will cause chronic progressive joint damage - associations; purine rich food, alocohol, dairy

Question 551

Describe the presentation of gout

Answer 551

- severe pain - red - hot - swollen joint - sometimes mistaken for septic arthritis

Question 552

Describe the diagnosis of gout

Answer 552

- clinical features | - aspirate; negatively birefringent monosodium urate crystals

Question 553

Describe the treatment of gout

Answer 553

- NSAIDs - steroids - allopurinol

Question 554

What are rheumatoid nodules?

Answer 554

Appear around joints in rheumatoid patients, again, associated with repetitive trauma

Question 555

Describe the presentation of rheumatoid nodules

Answer 555

- chronic - more severely affected RA patients - rheumatoid factor +ve

Question 556

Describe the management of rheumatoid nodules

Answer 556

- do not respond to DMARDs - excision if problematic (scar vs nodule) - recurrence high

Question 557

Describe bouchards nodes

Answer 557

- these are bony swellings of the interphalangeal joints in hands - caused by bony spurs due to chronic trauma - proximal IPJ - less common - OR or RA

Question 558

Describe heberdens nodes

Answer 558

- bony swellings of interphalangeal joints in hands - caused by bony spurs due to chronic trauma - distal IPJ - more common - OA

Question 559

Describe dupuytrens disease

Answer 559

- progressive disease resulting in digital flexion contractures - excessive myofibroblast proliferation and altered collagen matrix composition lead to thickened and contracted palmar fascia - bands are primarily collagen type 3 - avascular process involving O2 free radicals - it is not a disease of the flexor tendons

Question 560

Describe the pathophysiology of dupuytrens disease

Answer 560

- genetic predisposition; autosomal dominant with variable penetration, common in northern europe, men > women - alcohol, diabetes and trauma - multiple protein expression enzymes up-regulated and down-regulated

Question 561

Describe management of dupuytrens disease

Answer 561

- depedent on functional impediment - needle fasciotomy (single band) - collaginase injection (mild deformity) - limited fasciectomy (removal of the bands) - dermofasciectomy + graft (removal of the band, adherent / contracted skin and covering graft) - it can recur

Question 562

Name the 2 types of giant cell tumour of the tendon sheath

Answer 562

- localised (common) | - diffuse (uncommon; associated with PVNS)

Question 563

Describe the presentation of giant cell tumours of the tendon sheath

Answer 563

- firm - discreet swelling, usually on volar aspect of digits - can occur in toes - may or may not be tender

Question 564

Describe management of giant cell tumour of the tendon sheath

Answer 564

- leave alone if no functional issue | - surgical excision; usually marginal excision, ie not complete as adherent to tendon sheath, incidence of recurrence

Question 565

Describe presentation of lipoma

Answer 565

- benign neoplastic proliferation of fat, subcutaneous - can be discreet or less well defined - slow growing and painless / non tender - can be large (several cms) - characteristic consistency - no overlying skin changes

Question 566

Describe the management of lipoma

Answer 566

- based on symptoms - can be left alone - surgical excision if causing symptoms - balance of removal vs scarring - s shaped incision - langers lines

Question 567

Describe osteochondroma

Answer 567

- a benign lesion derived from aberrant cartilage from the perichondral ring that may take the form of; solitary osteochondroma, multiple hereditary exostosis - commonly occuring near the knee; distal femur / proximal tibia - usually occurs in adolescence - cartilage capped ossified pedicle - small potential for malignant change - in multiple hereditary exostosis there are multiple tumours; higher chance of malignancy

Question 568

Describe the presentation of otseochondroma

Answer 568

- painless, hard lump | - symptoms with activity (pain from tendons; numbness from nerve compression)

Question 569

Describe the management of osteochondroma

Answer 569

- close observation | - surgical excision

Question 570

Describe ewings sarcoma

Answer 570

- malignant primary bone tumour of the endothelial cells in the marrow - 2nd most common malignant bone tumour - worst prognosis - most common age 10-20 years

Question 571

Describe presentation of ewings sarcoma

Answer 571

- the great mimic; hot, swollen, tender joint or limb with raised inflammatory markers - can mimic infection - be suspicious; ask about night pain and duration of symptoms, investigate early

Question 572

Describe management of ewings sarcoma

Answer 572

- poor prognosis - surgical excision problematic - becuase its the tumour of the bone marrow - prosthesis and function after surgery - often radio and chemo sensitive

Question 573

Describe sebaceous cysts (epidermoid / pilar)

Answer 573

- strictly speaking that is a dermatological condition | - originated at hair follicles and fill with caseous material (keratin)

Question 574

Describe the presentation of sebaceous cysts

Answer 574

- slow growing - painless - mobile discreet swellings - can become infected

Question 575

Describe management of sebaceous cysts

Answer 575

Excision is required

Question 576

Describe history of myositis ossificans

Answer 576

- abnormal calcification of a muscle haematoma - trauma - initial soft swelling - hardness develops over several weeks

Question 577

Describe imaging and management of myositis ossificans

Answer 577

- XRs and MRI (peripheral mineralisation) - observation - intervene only if symptoms demand - must wait until maturity of ossification, otherwise risk of recurrence (6-12 months)

Question 578

Describe the epidemiology of hip fractures

Answer 578

- more than 6000 per year in scotland - 92% patients older than 60 years - 73% female - young adults; high energy trauma, different treatment ethos

Question 579

Describe the risk factors for hip fractures

Answer 579

- risk doubles every 10 years after age 50 - osteoporosis - smoking - malnutrition - excess alcohol - neurological impairment - impaired vision - low BMI - falls risk - bone health

Question 580

Name the features of surgical anatomy of the femur

Answer 580

- femoral head - femoral neck - greater trochanter - lesser trochanter - fovea

Question 581

What does intra-articular fracture mean?

Answer 581

A fracture into and through the articular surface

Question 582

What does extra-articular fracture mean?

Answer 582

Does not involve the articular surface of the joint

Question 583

Describe the blood supply to the femoral head

Answer 583

- intramedullary artery of shaft of femur - medial and lateral circumflex branches of profunds femoris - artery of ligamentun teres

Question 584

What type of fractures have a high risk of AVN?

Answer 584

Intracapsular

Question 585

Name types of intracapsular fractures

Answer 585

- undisplaced | - displaced

Question 586

Name types of proximal femoral fracture

Answer 586

Extracapsular - basicervical - intertrochanteric - subtrochanteric

Question 587

Describe the physical examination for hip fractures

Answer 587

- unable to weight bear / pain - cognitive impairment? delirium or dementia? - missed injuries - fluid status / dehydration - examination of limb; neurology, vascular status, may be shortened and externally rotated

Question 588

Describe investigations for hip fractures

Answer 588

- ECG - bloods - xrays; pelvis and lateral hip, CXR; if pre-existing lung disease, if in doubt; MRI

Question 589

What is shentons line?

Answer 589

- formed by the medial edge of the femoral neck and the inferior edge of the superior pubic ramus - loss of contour of shentons line is a sign of a fractures neck of femur

Question 590

Describe management of high function intracapsular hip fractures

Answer 590

- displaced >THR | - undisplaced >CHS

Question 591

Describe management of low function intracapsular hip fractures

Answer 591

- hemiarthroplasty

Question 592

Describe management of intertrochanteric extracapsular hip fractures

Answer 592

- DHS screw

Question 593

Describe subtrochanteric extracapsular hip fractures

Answer 593

- IM nail

Question 594

Describe complications of hip fractures

Answer 594

- loss of function - infection - medical risk; DVT / PE / MI / CVA - dislocation - periprosthetic fracture Intracapsular; - non union 20% - AVN 6-20% Extracapsular; - malunion - non union

Question 595

Describe examination findings for injured limbs and basic fracture management

Answer 595

- signs of fracture - crepitus, bruising, swelling, bony tenderness - neurovasular status - does injury match mechanism and pattern - NAI - open or closed - state of soft tissues - distracting injuries - vascular; pulses, cap refill, colour and warmth

Question 596

Which area tests solely the median nerve?

Answer 596

Index finger tip

Question 597

Which area tests solely the ulnar nerve?

Answer 597

Little finger tip, palmar surface

Question 598

Which area tests solely the radial nerve?

Answer 598

First dorsal web space

Question 599

What nerves are tested in a lower limb neurological screen?

Answer 599

- SPN - DPN - tibial nerve - branches on sole of foot

Question 600

Describe initial management of injured limbs and basic fractures

Answer 600

- analgesia - imaging - splintage (many types) - open fractures, compartment syndrome - traction

Question 601

Describe assessment of open fractures

Answer 601

- ABCD - exposure; fracture - direct pressure if bleeding - reduce dislocation - remove macroscopic debris - photograph and cover - stabilise - neurovascular status before and after reduction - AP and lateral xrays

Question 602

Describe initial treatment of open fractures

Answer 602

- antibiotics; within 3 hours - IV co-amoxiclav - co-trimoxazole and metronidazole if penicillin allergic - until wound closure (max 72 hours) - tetanus

Question 603

What is compartment syndrome?

Answer 603

- muscle compartment pressure > perfusion pressure - ischaemia and lactic acidosis - necrosis and muscle / nerve / vessel death - results from interstitial pressure increases in closed osseofascial compartments - causes microvascular compromise - commonly anterior and deep posterior compartments of leg and volar compartment of forearm - significant muscle damage at compartment pressures >30-40mmh or within 10-30 of diastolic

Question 604

Describe the pathophysiology of compartment syndrome

Answer 604

- increased tissue pressure > capillary collapse - decreased blood flow > oedema, pressure increased further - > venous occlusion (with arterial patency) - > rapidly increased pressure, no venous drainage - > arterial occlusion, ischaemia and necrosis

Question 605

Who gets compartment syndrome?

Answer 605

- patient risk factors; male gender, high muscle bulk - injury risk factors; high energy trauma - crush injury / chronic pressure eg unconscious patient - open fractures - burns (circumferential) - ++ tissue swelling eg extravasation of IV/ bleeding / post ischaemic swelling - tight bandages / casts can contribute

Question 606

Where does compartment syndrome occur?

Answer 606

- anywhere skeletal muscle surrounded by fascia | - common sites on the body; calf, forearm / hand, foot, thigh / buttock

Question 607

Describe the clinical signs and symptoms of compartment syndrome

Answer 607

- disproportionate pain - pain on passive stretch of muscles in involved compartment - paraesthesiae - do not delay - immediate release all dressings / cast to skin - do not elevate, phone senior help, theatre - pain, paraesthesia, pallor, pulselessness

Question 608

Describe definitive management of injured limbs and basic fractures

Answer 608

- goals; restore joint surfaces, restore alignment, length and rotation - intra/ extra articular - open or closed reduction - stabilisation of fractures;; cast, K wires, internal fixation with plates and screws, internal fixation with intramedullary nails, external fixation

Question 609

Define a dislocation

Answer 609

Complete loss of joint contact

Question 610

Define a subluxation

Answer 610

Partial loss of contact between bones

Question 611

Describe examination for dislocations

Answer 611

- inspection; deformity - palpation; vascular supply, neurology - must be examined and documented before invention - vascular; capillary refill, feel for warmth, feel for pulses - neurology; move toes up and down against your fingers, assessing sensation etc

Question 612

Describe the mechanism and incidence of shoulder dislocations

Answer 612

- fall, traction injury | - common in young adults

Question 613

Describe the directions of shoulder dislocations

Answer 613

- anterior; common - posterior - inferior; rare

Question 614

Name the most common shoulder dislocation

Answer 614

Anterior

Question 615

Describe anterior shoulder dislocations

Answer 615

- fall with shoulder in external rotation - humeral head anterior to the glenoid - needs regimental badge area sensory assessment - axillary nerve - top of the finger or cotton wool, compare both sides sensation - arm held in abduction - needs prompt neurovascular assessment and reduction

Question 616

Describe posterior shoulder dislocations

Answer 616

- fall with shoulder in internal rotation - direct blow to anterior shoulder - humeral head posterior to the glenoid - light bulb sign

Question 617

Describe management of shoulder dislocations

Answer 617

- closed reduction under sedation - open reduction - stabilisation and rehabilitation - reduction methods; hippocratic, in line traction - recurrent instability risk; related to age, risk of recurrence decreases with age - put into a broad armed sling and then physio, to prevent recurrent dislocation and stiffness

Question 618

Describe mechanism and incidence of elbow dislocations

Answer 618

- fall onto outstretched hand | - incidence

Question 619

Describe the directions of elbow dislocations

Answer 619

- posterior - anterior - medial / lateral Small risk of; - radial head - coronoid process fracture

Question 620

Describe management of elbow dislocations

Answer 620

- closed reduction under sedation - open reduction rarely required - 2 weeks in sling and rehab - reduction methods; traction in extensions +/- pressure over olecranon - recurrent instability risk; low - children may be put into a light cast

Question 621

Describe mechanism and direction of interphalangeal joint (IPJS) dislocations

Answer 621

- hyperextension injury; direct axial blow | - almost always posterior

Question 622

Describe the possible pitfalls of IPJS dislocations

Answer 622

- head of phalanx button-holes through volar plate | - recurrent instability due to associated fracture

Question 623

Describe management of IPJS dislocations

Answer 623

- closed reduction under digital or metacarpal block - open reduction rarely required - 2 weeks in neighbour strapping - volar slab in edinburgh position if unstable ++ - reduction methods; in line traction and corrective pressure - generally under general anaesthetic

Question 624

Describe a ring block

Answer 624

- general anaesthetic around the web spaces of the hand

Question 625

Describe the mechanism and incidence of patella dislocation

Answer 625

- sudden quads contraction with a flexing knee | - most common in teenagers, girls >> boys

Question 626

What direction does the patella usually dislocate?

Answer 626

'Always' lateral

Question 627

What type of bone is the patella bone?

Answer 627

Sesamoid

Question 628

What is the most common structure to damaged in patella dislocations?

Answer 628

MPFL

Question 629

Describe associations and causes of patella dislocations

Answer 629

- hypermobility - under-developed (hypoplastic) lateral femoral condyle - increased q angle, genu valgum, increased femoral neck anteversion - lateral quads insertions or weak vastus medialis

Question 630

Describe the presentation of patella dislocation

Answer 630

- clear history of patella dislocating laterally | - often self relocating

Question 631

Describe the examination of patella dislocation

Answer 631

- pain medially (from torn medial retinaculum) - effusion (haemarthrosis ) - patella apprehension test + ve

Question 632

Describe management of patella dislocation

Answer 632

- reduce with knee extension - radiographs - aspiration - brace - physiotherapy - repeat dislocations; surgery, lateral release / medial reefing, patella tendon realignment - rarely aspirate; only if very swollen and is causing intractable pain (Rare)

Question 633

Describe mechanism and incidence of knee dislocations

Answer 633

- high velocity injuries - low velocity injuries - most common in teenagers, girls >> boys

Question 634

Describe assessment of knee dislocations

Answer 634

- vascular injuries; popliteal artery / vein injury, may not be obvious (intimal tear or thrombosis) - normal exam = observe in hospital - clinical concern = arteriogram / MRI - nerve injuries; peroneal nerve - ligamentous stability; examination (under anaesthetic)

Question 635

What indicates peroneal nerve injury?

Answer 635

Foot drop or cant move toes

Question 636

Describe urgent management for knee dislocations

Answer 636

- reduction under sedation - may requires theatre reduction if condyle button holed through capsule - stabilise in splint or extrernal fixation

Question 637

Name investigations for knee dislocations

Answer 637

- plain radiographs - associated fractures - MRI

Question 638

Describe early and definitive knee dislocations

Answer 638

Early; - vascular repair (6hr window) - nerve repair Definitive; - sequential ligamentous repair

Question 639

Describe compliations of knee dislocations

Answer 639

- arthrofibrosis and stiffness - ligament laxity - nerve or arterial injury

Question 640

Describe the mechanism for hip dislocations

Answer 640

- high velocity; RTA dashboard injury | - fall from height

Question 641

Describe the direction and associated fractures of hip dislocations

Answer 641

- most commonly posterior - posterior acetabular wall - femoral fractures

Question 642

Describe presentation of hip fractures

Answer 642

- flexed, internally rotated and adducted knee

Question 643

Describe early management of hip fractures

Answer 643

- neurovascular assessment (part sciatic nerve) - radiographs (changes can be subtle) - urgent reduction - stabilise in tractions if required - further imaging (CT)

Question 644

Describe definitive management of hip fractures

Answer 644

- fixation of associated pelvic fractures | - fixation of other injuries in poly trauma patients

Question 645

Describe complications for hip fractures

Answer 645

- sciatic nerve palsy - avascular necrosis of the femoral head - secondary osteoarthritis of hip

Question 646

Describe the epidemiology of hip fractures

Answer 646

- 25% of children injured every year - 60% boys, 40% girls - 80% upper limb - 20% lower limb - 0.7% open - 15% physeal

Question 647

What are physeal injruies?

Answer 647

Injuries to the growth plate

Question 648

What history features concerning NAI ?

Answer 648

- history that does not match the nature or the severity of the injury - vague parental accounts or accounts that change during the interview; inconsistency - accusations that the child injured him / herself intentionally - delay in seeking help - child dressed inappropriately for the situation

Question 649

Describe features that concerning NAI

Answer 649

- any obvious or suspected fractures in a child under <2yr - injuries in various stages of healing, especially burns and bruises - more injuries than usually seen in children of the same age - injuries scattered on many areas of the body - increased intracranial pressure in an infant - suspected intra-abdominal trauma in a young child - any injury that does not fit the description of the cause given

Question 650

The thumbs up sign tests which nerve?

Answer 650

Radial nerve, the extensor

Question 651

The starfish sign tests which nerve?

Answer 651

Abduct your fingers, ulnar nerve, intrinsic muscles

Question 652

The okay sign tests which nerve?

Answer 652

Median nerve

Question 653

What does an arthrogram shows what?

Answer 653

The surface of the joint

Question 654

What displaces fractures?

Answer 654

- initial force on impact | - muscle action and gravity

Question 655

Gallows traction is used in which ages?

Answer 655

3 months to around 3 years

Question 656

Describe gallows traction

Answer 656

- child lies and the legs are suspended with weights - applies a longitudinal pull or traction - put into it for a couple of days then a spica

Question 657

What ages would a thomas splint traction be used?

Answer 657

- 4 or 5 or older, better tolerated - traction through adhesive elastic tapes - temporary basis

Question 658

Describe flexible nailing

Answer 658

- increasingly used for long bones (femur, tibia, humerus, radius and ulna) AVD; - predictable position rapid healing - early joint mobilisation and weight bearing DISADV; - infection risk - risk of anaesthesia

Question 659

What support to slings provide?

Answer 659

- weight of the arm is at the back of the neck - no traction onto the upper limb - useful in clavicle fractures, shoulder dislocations

Question 660

What support do cuffs allow?

Answer 660

- allowing the weight of the arm to reduce so there is traction - useful in proximal humeral fractures

Question 661

How many types of salter harris fracture are there and what are they?

Answer 661

- salter harris fractures are fractures of the physis | - there are 5 types