lower limb pathology

Question 1

neck of femur fracture presentation

Answer 1

• commonly due to falls
• stabbing pain, worse on palpation
• localized pain
• loss of movement
• complication: avascular necrosis of femoral head

Question 2

osteomyelitis of lower limb bones presentation

Answer 2

• gradually worsening pain
• constitutional infective symptoms
• infectious history / risk factors
• confirm diagnosis with x-ray (haziness) and FBC (increased WBC count)

Question 3

osteoarthritis of the lower limb presentation

Answer 3

• on and off pain with no specific timing
• risk factors: increased activity causing microtrauma
• increased pain on motion (suggestive of mechanical/articular cause)

Question 4

sciatica presentation

Answer 4

• radiating pain, tingling, numbness due to compression of spinal nerve
• longer onset
• poor posture is a risk factor
• differential: artherosclerosis

Question 5

meniscus tear presentation

Answer 5

• due to activity or trauma
• initial inflammation and swelling with unresolving pain
• unhappy triad: also includes ACL tear and MCL tear (not included, but bursitis is also common)

Question 6

septic joint arthritis presentation

Answer 6

• risk factor: DM
• short onset (a few days)
• constitutional symptoms
• hallmarks of inflammation present
• pussy, thick and white joint aspirate

Question 7

ligament sprain presentation

Answer 7

• commonly due to trauma
• initially no symptoms (different from fracture - immediate pain)
• gradual onset of pain, inflammation
• common ligament sprains: calcaneofibular ligament, anterior talofibular ligament

Question 8

diabetic foot ulcer presentation

Answer 8

• ulcer on the foot (obviously)
• risk factors: diabetes (obviously), wet foot dressing
• minimal foot pain
• chronic
• can lead to osteomyelitis, treat immediately

Question 9

gout presentation

Answer 9

• painful joint (v pain), most often 1st metatarsalphalangeal joint
• swelling
• abrupt onset
• remission in 2 weeks
• erythema
• podagra
• tophi
• urate crystals (strongly negatively birefringent needle shaped crystals under polarized microscopy)

Question 10

pseudogout presentation

Answer 10

• acute attack
• joint pain
• stiffness at affected joint
• swelling and inflammation at joint
• calcium pyrophosphate crystals (rhomboid-shaped, positively birefringent crystals under polarized microscopy)

Question 11

septic arthritis/gonococcal septic arthritis presentation

Answer 11

• risk factors: joint surgery, unprotected sexual activity
• migratory joint pain
• tenosynovitis
• pustules
• high WBC count in joint aspirate with positive gram stain / culture

Question 12

osteoarthritis presentation

Answer 12

• risk factors: >50yo
• joint pain worsening with activity
• morning stiffness <30min
• crepitus with joint movement
• bony enlargement of affected joints (BUT no palpable warmth, bc not usually inflamed)
• x-ray: joint space narrowing, osteophyte formation, subchondral sclerosis

Question 13

meralgia paresthetica presentation

Answer 13

• numbness and burning sensation on lateral thigh (especially after standing for long periods or wearing tight clothes)
• due to compression of lateral cutaneous nerve

Question 14

referred pain from hip osteoarthritis presentation

Answer 14

• unilateral chronic pain in knee, worsening with activity
• limited hip range of motion, especially in internal rotation

Question 15

L5 radiculopathy presentation

Answer 15

• lower back pain and numbness radiating to unilateral lateral thigh + anterior shin + dorsal foot
• poor foot dorsiflexion and big toe extension
• positive straight leg test
• inability to extort/abduct hip

Question 16

S1 radiculopathy presentation

Answer 16

• lower back pain and numbness radiating to unilateral posterior leg, sole and lateral edge of foot
• poor plantar flexion of foot and diminished Achilles tendon reflex
• positive straight leg test

Question 17

common peroneal (fibular) nerve palsy presentation

Answer 17

• foot drop, weakness in foot eversion
• sensory deficits in dorsum of foot and lateral shin
• STILL CAN extort and abduct hip (unlike L5 radiculopathy)
• caused by prolonged squatting and pressure on lateral aspect of knee

Question 18

poliomyelitis presentation

Answer 18

• risk factors: no polio vaccine, childhood onset
• asymmetric flaccid paralysis with no sensory loss
• constitutional symptoms
• no deep tendon reflexes

Question 19

myasthenia gravis presentation

Answer 19

• fatiguable muscle weakness
• bilateral ptosis
• diplopia
• difficulty speaking
• no sensory deficits, normal reflexes
• test with acetylcholine receptor antibody test (pyridostigmine)

Question 20

peripheral neuropathy presentation

Answer 20

• symmetric sensory loss in glove and stocking distribution
• diminished ankle reflex
• risk factor: diabetes mellitus

Question 21

vitamin B12 deficiency presentation

Answer 21

• peripheral neuropathy with decreased deep tendon reflexes
• preserved muscle strength
• oral ulcers
• risk factors: total gastrectomy, tapeworms, malnutrition

Question 22

femoral artery pseudoaneurysm presentation

Answer 22

• pain and swelling in groin area with a pulsatile mass (can hear a bruit)
• diminished foot pulse on swelling side
• usually due to cardiac catheterization causing blood to leak out of puncture site and form a sac

Question 23

trochanteric bursitis presentation

Answer 23

• lateral hip pain over greater trochanter with gradual onset
• pain worsens when lying on affected side, rising from seated position, crossing legs
• risk factor: middle age
• diagnose with positive Trendelenburg test

Question 24

hallux valgus presentation

Answer 24

• bony prominence and pain at 1st MTPJ
• lateral deviation of toe
• exacerbated pain and swelling by tight footwear

Question 25

Duchenne Muscular Dystrophy presentation

Answer 25

• onset in early childhood
• risk factors: male (X-linked recessive genetic disease), family history
• progressive muscle weakness (Gower’s sign, waddling gait, calf muscle pseudohypertrophy, Trendelenburg positive on both sides of hip)
• due to nonsense/frameshift mutation causing a lack of dystrophin protein

Question 26

myotonic dystrophy presentation

Answer 26

• progressive muscle weakness bilaterally (especially in face)
• myotonia (fine motor difficulties)
• systemic symptoms (sleep disturbances, frontal balding, cataracts, bilateral ptosis)
• risk factor: family history (genetic mutations in C19 DMPK gene and/or C3 CNBP gene) - diagnostic