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Musculoskeletal > MBChB > Flashcards

MBChB Flashcards

1
Q

Seropositive arthritis

A 
Lupus
Rheumatoid arthritis
Scleroderma
Vasculitis
Sjogrens
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2
Q

Seronegative Arthritis

A

Ankylosing Spondylitis
Psoriatic Arthritis
Reactive arthritis
Inflammatory bowel disease arthritis

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3
Q

Most common form of arthritis?

A

Osteoarthritis

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4
Q

Second degree causes of OA

A 
Congenital dislocation of the hip
Perthes
SUFE
Previous intra‐articular fracture
Extra‐articular fracture with malunion
Osteochondral / hyaline cartilage injury
Crystal arthropathy
Inflammatory arthritis (can give rise to mixed pattern arthritis)
Meniscal tears
Genu Varum or Valgum
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5
Q

What is perthes?

A

A disease where the top of the thigh bone in the hip softens and breaks down

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6
Q

SUFE

A

Slipped upper femoral epiphyses

the growth plate is weak and the ball slips down and backwards

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7
Q

Radiographical findings of osteoarthritis?

A

L (loss of joint space)
O (osteophytes)
S (sclerosis)
S (subchondral cysts)

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8
Q

Diagnosis of rheumatoid arthritis

A

Clinical presentation, radiographic findings and serological analysis
The ACR/EULAR Rheumatoid Arthritis Criteria scoring system assists in the diagnosis.

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9
Q

Which internal organs can be affected in rheumatoid arthritis?

A

Rheumatoid Lung

Ischaemic heart disease

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10
Q

Operations performed for rheumatoid arthritis

A 
Synovectomy
Joint replacement
Joint excision
Tendon transfers
Arthrodesis (fusion)
Cervical spine stabilisation
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11
Q

Synovectomy

A

Removes inflamed synovium

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12
Q

Most likely places to get joint involvement in SLE?

A

Hands and knees

Avascular necrosis can also occur in the hip and knee

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13
Q

How would you treat tendon ruptures and severe symptomatic joint damage in SLE?

A

Surgery

but remember that they try to treat everything with drugs primarily

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14
Q

Which gender is more commonly affected in ankylosing spondylitis?

A

Males 3:1
chronic inflammatory disease of the spine and sacro‐iliac joints which leads to eventual fusion of the intervertebral joints and SI joints
May often develop knee and hip arthritis aswell

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15
Q

Conditions associated with ankylosing spondylitis

A

aortitis, pulmonary fibrosis and amyloidosis

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16
Q

Xrays show bony spurs from the vertebral bodies known as syndesmophytes which can bridge the intervertebral disc resulting in fusion producing a “bamboo spine”

A

Ankylosing Spondylitis

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17
Q

Treatment for ankylosing spondylitis

A

Treatment consists of physiotherapy, exercise, simple analgesia and DMARDs for more aggressive disease

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18
Q

onycholysis

A

Lifting of the nail from the nail bed

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19
Q

In psoriatic arthritis, some patients have a predilection for arthritis in which joints?

A

DIP

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20
Q

In psoriatic arthritis, 5% of patients with DIP arthritis develop a more aggressive and destructive form of this. What is this condition called?

A

Arthritis Mutilans

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21
Q

Enteropathic arthritis

A

Enteropathic arthritis refers to an inflammatory arthritis involving the spine and peripheral joints occurring in patients with inflammatory bowel disease (Crohn’s disease and Ulcerative Colitis), coeliac disease, patients with extensive bowel resections and patients with a reactive arthritis from bacterial or parasitic infection of the GI tract (Shigella, Salmonella, Yersinia, Campylobacter, Cryptosporidium, Giardia and others)

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22
Q

Treatment for Enteropathic Arthritis

A

10‐20% of IBD sufferers will experience spine or joint problems. Treatment includes treating the underlying condition (corticosteroids, antibiotics) and DMARDs can help. Any peripheral arthritis is usually self‐limiting and orthopaedic surgery is not required but steroid injection can help.

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23
Q

Some patients have a triad of symptoms of urethritis, uveitis and arthritis known as Reiter’s syndrome

A

Reactive Arthritis

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24
Q

What is gout usually due to?

A

Gout is a crystal arthropathy caused by deposition of urate crystals within a joint which is usually due to high serum uric acid levels (hyperuricaemia)

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25
Q

Gouty tophi

A

Painless white accumulations of uric acid can occur in the soft tissues and erupt through the skin

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26
Q

What can chronic gout result in?

A

Destructive erosive arthritis

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27
Q

How to diagnose gout

A

A definitive diagnosis can be made by analysing a sample of synovial fluid with polarised microscopy (the fluid is also analysed with Gram stain and culture to exclude infection). Uric acid crystals are needle shaped and display negative birefringence (change from yellow to blue when lined across the direction of polarization).

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28
Q

Treatment for Gout

A

Treatment for acute attacks includes NSAIDs, corticosteroids, opioid analgesics and colchicine for patients who cannot tolerate NSAIDs (though it can have GI side effects and interfere with other medications). For sufferers of recurrent attacks or those with joint destruction or tophi, allopurinol or probenecid can prevent attacks but they should not be started until an acute attack has settles as theoretically they could potentiate an acute attack.

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29
Q

What is Chondrocalcinosis

A

The term chondrocalcinosis is used when calcium pyrophosphate deposition occurs in cartilage and other soft tissues in the absence of acute inflammation

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30
Q

Treatment of Pseudogout

A

Treatment of acute attacks includes NSAIDs, corticosteroids (systemic and intra‐articular) and occasionally colchicine. There are no medications used as prophylaxis to prevent recurrence.

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31
Q

Where does gout tend to affect?

A

Knee, wrist and ankle

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32
Q

What can pseudogout coexist with?

A

Pseudogout can coexist with hyperparathyroidism, hypothyroidism, renal osteodystrophy, haemochromatosis and Wilson’s disease. It can also occur in some cases of OA however chronic CPPD can also result in osteoarthritic change

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33
Q

Which bacteria can infect osteocytes intracellularly and make osteomyelitis very hard to get rid of?

A

Staph. aureus

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34
Q

In which age group would you usually see an acute osteomyelitis in the absence of surgery?

A

Children

Also seen in immunocompromised

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35
Q

Brodie’s Abscess

A

Children can develop a subacute osteomyelitis with a more insidious onset where the bones react by walling off the abscess with a thin rim of sclerotic bone. This is known as a Brodie’s abscess

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36
Q

Where does chronic osteomyelitis tend to occur in adults?

A

Chronic osteomyelitis tends to be in the axial skeleton (spine or pelvis) with haematogenous spread from pulmonary or urinary infections, or from infection from the intervertebral discs.
Chronic OM in adults/children can be peripheral from previous open fracture or internal fixation

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37
Q

What might suppress chronic osteomyelitis?

A

Antibiotics

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38
Q

What well known historical disease could cause osteomyelitis?

A

Tuberculosis (particularly in spine from haematogenous spread from the primary lung infection)

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39
Q

Where might you see osteomyelitis occurring if you’ve had TB?

A

Spine

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40
Q

In which patients might you see an osteomyelitis caused by salmonella?

A

Sickle cell anaemia patients

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41
Q

Which groups of people are particularly susceptible to osteomyelitis of the SPINE?

A

Diabetics, intravenous drug users and other immunocompromised patients

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42
Q

What can be used to determine extent of infection in osteomyelitis?

A

MRI

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43
Q

Organism which usually causes osteomyelitis?

A

Staph aureus but atypical in immunocompromised

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44
Q

Which heart condition should you check for in osteomyelitis

A

Endocarditis should be considered (look for clubbing, splinter haemorrhages, murmur, consider ECHO

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45
Q

Indications for surgery in osteomyelitis

A

Indications for surgery include inability to obtain cultures by needle biopsy, no response to antibiotic therapy, progressive vertebral collapse and progressive neurological deficit. Surgery involves debridement, stabilization and fusion of adjacent vertebrae.

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46
Q

Doughy Swelling?

A

Synovitis

You would see this in rheumatoid arthritis ;)

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47
Q

Synovectomy?

A

Surgery to remove inflamed synovium

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48
Q

Predominant feature of inflammatory arthritis?

A

Synovium inflammation

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49
Q

Which non-articular diseases would suggest spondyloarthritis?

A

psoriasis, iritis, inflammatory bowel disease, non-specific urethritis, recent dysentery

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50
Q

Anticyclic citrullinated peptide antibodies

A

Marker for erosive disease in RA

ESR and CRP raised in RA. You may also see normochromic normoctytic anaemia

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51
Q

Complications of Rheumatoid Arthritis

A 
Bakers cysts (joint rupture)
Ruptured tendons
Joint infection
Spinal cord compression
AMYLOIDOSIS
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52
Q

Most common cause of secondary AA amyloidosis?

A

Rheumatoid Arthritis

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53
Q

Which procedure can excise all metatarsal heads in end stage rheumatoid foot?

A

Excision arthroplasty

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54
Q

What is arthrodesis gold standard for?

A

1st MTPJ OA

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55
Q

Which surgical procedure was originally used for TB hip and young OA hip?

A

Arthrodesis say whuuuut

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56
Q

Name a way in which you could fix malunion following a fracture?

A

Osteotomy

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57
Q

What is gold standard for hallux valgus?

A

Osteotomy

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58
Q

What is osteotomy?

A

Surgical realignment of bone

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59
Q

Antibodies in RA?

A

Antibodies to the Fc fragment of IgG (rheumatoid factor)

Antibodies to citrullinated cyclic peptide

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60
Q

Allele associated with RA?

A

HLA-DR4

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61
Q

Which type of RA is smoking an environmental risk factor for?

A

Seropositive RA

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62
Q

What drives the overproduction of TNF-a in RA?

A

The interaction between macrophages, B & T lymphocytes

interleukin 6 is also involved in RA

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63
Q

How does the pannus of inflamed synovium damage the underlying cartilage?

A

Blocks normal route for nutrition and it is also damaged through the direct effects of cytokines on the chondrocytes

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64
Q

Histological appearance of RA synovium?

A

Hypertrophy of the tissues with infiltration by lymphocytes and plasma cells

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65
Q

What is a useful predictor of prognosis of RA?

A 
Rheumatoid factor
(persistently high titre in early disease implies more persistently active synovitis, more joint damage and a greater disability eventually)
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66
Q

Carpal tunnel syndrome

A

Carpal tunnel syndrome (CTS) is a median entrapment neuropathy that causes paresthesia, pain, numbness, and other symptoms in the distribution of the median nerve due to its compression at the wrist in the carpal tunnel
(10% of people with RA could present with this)

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67
Q

When is pain and stiffness worse in RA?

A

In the morning

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68
Q

Complications of RA

A 
Ruptured tendons,
Ruptured joints (Baker's cysts)
Joint Infection
Spinal cord compression (atlantoaxial or upper cervical spine)
Amyloidosis (rare)
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69
Q

What cells might you see in septic arthritis?

A

Neutrophil leucocytosis

abnormally high number of neutrophils

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70
Q

Finger deformities in RA?

A

Ulnar deviation
Boutonniere deformity
Swan-neck deformity

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71
Q

Foot deformities in RA?

A
  • Foot becomes broader and hammer-toe deformity develops
  • Exposure of metatarsal heads to pressure by forward migration of the protective fibrofatty pad causes pain
  • Ulcers&calluses may develop under the metatarsal heads and over the dorsum of the toes
  • flat medial arch and loss of flexibility
  • ankle often assumes a valgus position
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72
Q

Soft tissue non-articular manifestations of RA

A 
Rheumatoid nodules
(typically elbow, finger joints and achilles tendon)
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73
Q

Non-articuar manifestations of rheumatoid arthritis

A 
Scleritis
Atlantoaxial subluxation rarely causing spinal compresison
Pleural effusion
Fibrosing alveolitis
Caplans syndrome
Small airways disease
Nodules
Anaemia
Carpal tunnel syndrome
Nail fold lesions of vasculitis
Splenomegaly
Leg ulcers
Ankle oedema
Amyloidosis
Tendon sheath swelling
Bursitis/nodules
Pericarditis
Lymphadenopathy
Sjogrens syndrome (dry eyes, dry mouth)
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74
Q

Poorly controlled RA with a persistently raised CRP and high cholesterol is a risk factor for premature what? (<3)

A

Premature coronary artery and cerebrovascular atherosclerosis

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75
Q

Most common cause of secondary osteoporosis?

A

Corticosteroids

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76
Q

Can sulfasalazine be used during pregnancy?

A

Yes

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77
Q

What must you monitor for when on steroids?

A

Hypertension and diabetes

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78
Q

Side effects when using sulfasalazine?

A

Leucopania
Thrombocytopenia
Nausea
Skin rashes and mouth ulcers

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79
Q

“Gold standard” drug in RA

A

Methotrexate

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80
Q

If nausea/poor absorption limit the efficacy of methotrexate, how might you administer it?

A

Subcutaneously

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81
Q

What could you give in combination with methotrextae to minimise side effects?

A

Oral folic acid

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82
Q

Side effects of leflunamide?

A 
Diarrhoea
(leflunamide works in some patients who have failed to respond to methotrexate)
Neutropenia and thrombocytopenia
Alopecia
Hypertension
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83
Q

Leflunamide and pregnancy?

A

Should avoid in pregnancy due to long half life

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84
Q

Anti-TNF is usually given in combo with..?

A

Methotrexate

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85
Q

List 5 anti-TNFs

A 
Adalimumab
Etanercept (s/c)
Infliximab (IV)
Certolizumab
Golimumab (s/c) for severe RA
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86
Q

Side effects of methotrexate?

A

Nausea, mouth ulcers, diarrhoea
Neutropaenia and/or thrombocytopenia
Renal impaitment
Pulmonary fibrosis

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87
Q

Etanercept side effects?

A

Injection site reactions

Infections e.g. TB and septicemia

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88
Q

Adalimumab side effects?

A

Hypersensitivity reactions
Heart failure
Demyelination and autoimmune syndromes
Reversible lupus-like syndromes

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89
Q

Rituximab side effects?

A 
Hypo/hypertension
Skin rash
Nausea
Pruritis
Back pain
Rare: toxic epidermal necrolysis
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90
Q

Side effects of Tocilizumab?

A

Headache, skin eruption, stomatitis, fever, anaphylactic reactions

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91
Q

RA drugs to avoid in pregnancy?

A

Leflunamide, methotrexate, Gold, CYCLOPHOSPHAMIDE, penicillamine (women must not conceive when on leflunamide or methotrexate)

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92
Q

When can oral NSAIDS and selective COX-2 inhibitors be used during pregnancy?

A

Oral NSAIDS and selective COX-2 inhibitors can be used after implantation up until the 3rd trimester

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93
Q

Can corticosteroids be used during pregnancy?

A

Yes, they can be used to control disease flares (the main maternal risks are hypertension, glucose intolerance and osteoporosis)

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94
Q

Which DMARDS can be used during pregnancy?

A

Sulfasalazine, hydroxychloroquine, aziathioprine, cyclosporin A
These can be used if required to control inflammation

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95
Q

Drugs that can induce SLE

A 
Hydralazine
Procainamide
Penicillamine
Isoniazid
(SLE is mild though, kidneys and CNS are not affected)
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96
Q

What kind of light can trigger flares of SLE?

A

Ultrviolet

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97
Q

Pathology of SLE

A

SLE of the skin is characterised by deposition of complement and IgG antibodies and influx of neutrophils and lymphocytes

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98
Q

Most common clinical feature of SLE?

A

Joint problems

Patients often present with similar features to RA

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99
Q

Hypocalcaemia Symptoms

A 
Parasthesia
Muscle cramps
Irritability
Fatigue
Seizures
Brittle nails
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100
Q

What is a psuedofracture?

A

A dignostic form of osteomalacia
A condition seen in the radiograph of a bone as a thickening of the periosteum and formation of new bone over what looks like an incomplete fracture.

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101
Q

Hypercalcemia Symptoms

A

fatigue, depression, bone pain, myalgia, nausea, thirst, polyuria, renal stones, osteoporosis

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102
Q

Test for Carpal Tunnel

A

Tinel’s Test: tapping nerve in carpal tunnel

Phalen’s Test: holding wrist in flexion position

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103
Q

Treatment for carpal tunnel syndrome?

A

Splint wrist in dorsiflexion overnight. This should resolve in a couple of weeks. If this doesn’t then you can try a corticosteroid injection (avoid the nerve!!)

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104
Q

Carpal tunnel symptoms

A 
numbness
altered sensation
dysaesthesia 
clumsiness
night awakening
pain
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105
Q

Investigations for Carpal Tunnel

A 
Nerve conduction studies
PV
X-ray
T4
blood glucose
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106
Q

Results (carpal tunnel) Free distribution, ulnar or radial?

A

Ulnar

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107
Q

Indications for Carpal Tunnel Syndrome decompression

A

Failed conservative treatment
Constant numbness
Weakness

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108
Q

What is the surgical treatment for carpal tunnel syndrome?

A

Standard open carpal tunnel release
Arthroscopic
endoscopic carpal tunnel release
mini-open carpal tunnel release

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109
Q

Which gender does cubital tunnel syndrome affect more?

A

Men

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110
Q

Symptoms of Cubital Tunnel Syndrome

A

Symptoms include numbness, tingling and/or pain in arm/hand/fingers
Symptoms often felt during the night or during the day when you’ve had your elbow bent for long periods of time
May have noticed clumsiness/weaker grip when using hand

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111
Q

Which fingers are likely to tingle in cubital tunnel syndrome?

A

Ring and little fingers :) aw little

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112
Q

Test shown in lecture slide that you could use when assessing cubital tunnel syndrome?

A

Trying to get patient to hold paper between fingers

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113
Q

Froment’s Sign?

A

(thumb super bent when you try to get them to pinch stuff, because with ulnar nerve palsy, the patient will experience difficulty maintaining a hold and will compensate by flexing the FPL (flexor pollicis longus) of the thumb to maintain grip pressure causing a pinching effect.
Clinically, this compensation manifests as flexion of the IP joint of the thumb (rather than extension, as would occur with correct use of the adductor pollicis).
The compensation of the affected hand results in a weak pinch grip with the tips of the thumb and index finger, therefore, with the thumb in obvious flexion )

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114
Q

Treatment for Cubital Tunnel Syndrome

A 
Splint
Neurolysis
Anterior transposition
subcutaneous
submuscular
intra-muscular
medial epicondylectomy
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115
Q

Causes of mechanical back pain

A

Causes implicated include obesity, poor posture, poor lifting technique, lack of physical activity, depression, degenerative disc prolapse, facet joint OA and spondylosis. Spondylosis is where the intervertebral discs lose water content with age resulting in less cushioning and increased pressure on the facet joints leading to secondary OA.

116
Q

Explain disc degeneration and prolapse

A

The spinal disc tends to lose its water content during compressive loading – this is replaced during rest periods (when we are non weight-bearing) by absorbing tissue fluid from the adjacent vertebrae. In addition, as we age, the disc becomes less hydrated and loses its elasticity - ageing of the disc occurs early and can often be seen in the late teens or early twenties.

Everyday neck movements can squeeze a brittle disc, which forces the gel-like nucleus against the sides of the disc’s fibrous outer wall, the pulp material extrudes into the spinal nerve root or spinal canal causing a herniated or prolapsed disc – similarly this can occur due to a traumatic injury.

117
Q

What is instability?

A

excessive motion caused by a degenerate disc, diagnosed typically on MRI

118
Q

What type of motor neurone signs are reflexes?

A

Lower motor neurone

119
Q

Commonest site for sciatica/lumbar radiculopathy

A

The commonest site for this to occur in the spine is the lower lumbar spine with the L4, L5 and S1 nerve roots contributing to the sciatic nerve and pain radiating to the part of the sensory distribution of the sciatic nerve (hence the term “sciatica”).

120
Q

Prolapse in lumbar spine and resulting signs

A

L3/4 prolapse > L4 root entrapment > pain down to medial ankle (L4), loss of quadriceps power, reduced knee jerk
L4/5 prolapse > L5 root entrapment > pain down dorsum of foot, reduced power Extensor Hallucis Longus and tibialis anterior
L5/S1 prolapse > S1 root entrapment > pain to sole of foot, reduced power planarflexion, reduced ankle jerks

121
Q

Treating an open fracture

A

ABx, tetanus, early debridement and operative stabilisation

122
Q

Treating compartment syndrome

A

fasciotomy & operative stabilisation

123
Q

Vascular injury # treatment

A

reduction, stabilisation and reassess circulation. May need revscularisation procedure

124
Q

Pilon fracture

A

Inter-articular fracture of the distal tibia

125
Q

Distal tibia fractures associated injuries

A

Spine, pelvis, calcaneus

126
Q

Distal tibia fracture is a surgical emergency, how could you fix it?

A

Urgent bridging,
External fixation
(allows soft tissues to settle)
-Limited internal fixation
-CT scan to determine personality of fracture
-Internal fixation once soft tissues settle

127
Q

Colles Fracture

A

A Colles’ fracture, also raikar’s fracture, is a fracture of the distal radius in the forearm with dorsal (posterior) and radial displacement of the wrist and hand

128
Q

Galeazzi fracture dislocation

A

If the radius is fractured in isolation, suspect a dislocation of the DRUJ

129
Q

Monteggia fracture dislocation

A

If the ulna is fractured in isolation, suspect a dislocation of the radial head

130
Q

What is polytrauma?

A

> 1 fracture (long bones +/- pelvis)

131
Q

Causes/associations of patella dislocation

A

Hypermobility
Under-developed (hypoplastic) lateral femoral condyle
Increased Q-angle
Genu valgum
Increased femoral neck anteversion
Lateral quads insertions or weak vastus medialis

132
Q

Treatment for repeat Patella dislocations

A

Surgery
(Lateral release / medial reefing
Patella tendon realignment)

133
Q

Medial Reefing

A

A surgical procedure to tighten the tissues on the medial aspect of the patella

134
Q

Lateral Release? (Patella dislocation treatment)

A

Loosening the tissues on the lateral side of the patella

135
Q

What should you be aware of in patella dislocation spontaneous relocation?

A

Lateral collateral ligament injury and peroneal nerve injury

136
Q

Nerve that could be damaged in knee dislocation?

A

Peroneal nerve

137
Q

Associated fractures of hip dislocation

A

Posterior acetabular wall

Femoral #’s

138
Q

Hip dislocation presentation

A

Flexed, internally rotated and adducted knee

139
Q

Nerve that could be damaged in hip dislocation

A

Sciatic nerve

140
Q

Hip Dislocation Complications

A

Sciatic nerve palsy
Avascular necrosis of the femoral head
Secondary osteoarthritis of hip
Myositis ossificans

141
Q

What may cause an olecranon fracture?

A

Usually an avulsion fracture from triceps contraction

142
Q

If you dislocate your elbow, which bone might you fracture?

A

The head of the radius

143
Q

What is a nightstick fracture?

A

Isolated fracture of the Ulna

144
Q

How might you fix a colles fracture?

A

K-wiring

145
Q

Complications of Distal Radial Fracture

A

Median nerve compression, EPL rupture, CRPS, loss grip strength

146
Q

Distal Radius Fractures: how would you fix a comminuted intra-articular fracture with small fragments?

A

External fixation +/- K-wires

147
Q

How would you fix a Smith’s fracture?

A

ORIF

148
Q

When might you consider looking for endocarditis in septi arthritis?

A

When you have multiple bones/joints affected by septic arthritis (septic emboli)

149
Q

Who might get E.coli septic arthritis?

A

The elderly, IV drug users and seriously ill

150
Q

Organisms which can cause a “low grade” infection in surgical implants (i.e. not the most common organism but the one that is most likely to be picked up later than should be)

A

Staph epidermidis

151
Q

Useful blood tests for bone and joint infection?

A

CRP and Plasma viscosity

Occasionally useful: blood cultures, white cell count, ESR

152
Q

Most common causative organism in osteomyelitis?

A

Staph aureus

haemophilus in children

153
Q

What antibiotics does our lecturer use for cellulitis?

A

He uses Flucloxacillin and benzylpenicillin

154
Q

In cellulitis, what is crepitis a sign of?

A

Crepitus is a sign of infection most commonly observed with anaerobic organisms

155
Q

Which cells produce granulation tissue in secondary cone healing?

A

Fibroblasts

156
Q

Which cells form cartilage?

A

Chondroblasts

157
Q

Which cells lay down bone matrix (collagen type 1)

A

Osteoblasts

158
Q

Which process produces immature woven bone?

A

Calcium mineralisation

159
Q

By what week is the soft callus usually formed?

A

2-3 weeks

160
Q

How long does it take the hard callus to appear?

A

6-12 weeks

161
Q

Why can smoking impair healing of a fracture?

A

It causes vasospasm (bones need good blood supply for nutrients, oxygen and stem cells etc)

162
Q

Aside from smoking, what else can impair fracture healing?

A

Chronic ill health

Malnutrition

163
Q

When do oblique fractures occur?

A

Obliques fractures occur with a shearing force (e.g. fall from a height, deceleration)

164
Q

Why do oblique fractures have a slight advantage?

A

You can fix these with an interfragmentary screw.

Remember also, oblique fractures tend to shorten and may angulate

165
Q

Why are spiral fractures most unstable?

A

They can rotate, may also angulate

166
Q

Why do spiral fractures occur?

A

Spiral fractures occur due to torsional forces

167
Q

Are segmental fractures stable or unstable?

A

Segmental fractures are very unstable and require stablisation with long rods or plates

168
Q

Clinical signs of a fracture

A

Localised bony tenderness (not mild diffuse tenderness)
Swelling
Deformity
Crepitus (from bone ends grating with an unstable fracture)

169
Q

Guidelines used for ankle injury?

A

Ottowa guidelines

170
Q

Investigation for mandibular fracture?

A

Tomogram

171
Q

Which fractures can an oblique x-ray be good for?

A
  • Scaphoid
  • Acetabulum
  • Tibial plateau
172
Q

When are technetium bone scans useful?

A

Technetium bone scans can be useful to detect stress fractures (e.g. hip, femur, tibia, fibula, 2nd metatarsal) as these may fail to show up on x-ray until hard callus begins to appear

173
Q

Analgesia usually given for long bone fracture?

A

IV morphine

174
Q

Initial management of long bone fracture

A

S (splintage/immobilisation)
I (investigation e.g. x-ray)
A (analgesia)

175
Q

Another name for temporary plaster slab

A

Backslag

176
Q

When might you consider reducing fracture before waiting for x-rays?

A

If a fracture is grossly displaced, if there is an obvious fracture dislocation (e.g. of the ankle) or if there is a risk of skin damage
(x-ray will still be seen on x-ray post-reduction)

177
Q

Anaesthetic that can be used for reducing an unstable fracture

A

GA
Spinal
Peripheral nerve block
Bier’s block

178
Q

When is a Bier block indicated?

A

For fractures of the forearm, wrist and hand (not appropriate for elbow)

179
Q

Early complications of fractures

A

Compartment syndrome
Vascular injury with ischaemia
Nerve compression or injury
Skin necrosis

180
Q

Early systemic complications of fractures

A 
Hypovolaemia
Fat embolism
Shock
ARDS
Acute renal faiure
Systemic Inflammatory Response Syndrome
Multi-organ Dysfunction Syndrome
Death
181
Q

Volkmann’s Ischaemic Contracture

A

Volkmann’s ischaemic contracture, is a permanent flexion contracture of the hand at the wrist, resulting in a claw-like deformity of the hand and fingers

182
Q

The main late systemic complication of a fracture

A

Pulmonary embolism

deep vein thrombosis is a late LOCAL complication of a fracture

183
Q

Why does secondary ischaemia occur in compartment syndrome?

A

Rising pressure compresses the venous system which results in congestion within the muscle. This means that oxygenated arterial blood cannot supply the congested muscle

184
Q

What characterises muscle ischaemia in compartment syndrome?

A

Severe pain
Pressure rises can also compress nerves resulting in parasthesia and sensory loss.
THE CARDINAL CLINICAL SIGNS ARE (1) INCREASED PAIN ON PASSIVE STRETCHING OF THE INVOLVED MUSCLE AND (2) SEVERE PAIN OUTWITH THE ANTICIPATED SEVERITY IN THE CLINICAL CONTEXT
(loss of pulses is a feature of end stage ischaemia)

185
Q

What happens if ischaemic muscle is left untreated?

A

If left untreated ischaemic muscle will necrose resulting in fibrotic contracture known as Volkmann’s ischaemic contracture and poor function

186
Q

What artery is at risk if a child sustains an elbow fracture?

A

Brachial artery injury

187
Q

Which artery can be affected in shoulder trauma

A

Axillary artery

188
Q

Which fracture may be associated with life threatening haemorrhage from arterial or venous bleeding?

A

Pelvic fractures

189
Q

How might you localise the site of arterial occlusion?

A

Urgent angiography

190
Q

How could you control ongoing haemorrhage from arterial injury in the pelvis?

A

Ongoing haemorrhage from arterial injury in the pelvis can be controlled by angiographic embolization performed by interventional radiologists

191
Q

Where does the triceps insert at the elbow and what elbow movement does it produce?

A

The triceps is responsible for elbow extension and inserts at the olecranon process

192
Q

Where do the brachialis and biceps insert and which elbow movement do they produce?

A

Brachialis inserts at the coronoid process and biceps inserts at the BICIPITAL TUBEROSITY of the radius. They produce flexion at the elbow. (the biceps also produces supination along with the supinator muscles)

193
Q

Painful and tender lateral epicondyle with resisted middle finger and wrist extension?

A

Lateral epicondylitis (tennis elbow)

194
Q

Which nerve could be damaged in a total hip replacement?

A

The sciatic nerve

195
Q

Causes of avascular necrosis of the hip?

A

AVN of the hip may be primary/idiopathic

-It can also be secondary to alcohol abuse, steroids, hyperlipidemia or thrombophilia

196
Q

Why would queen victoria get AVN of the hip?

A

She was fat (hyperlipidemia)

She had thrombophili

197
Q

Patchy sclerosis of the weight bearing area with lytic lesions underneath formed by granulation tissue of an attempted repair

A

AVN

198
Q

Hanging rope sign on x-ray?

A

AVN

199
Q

Pain and tenderness in the region of the greater trochanter with pain on restricted abduction

A

Trochanteric bursits/gluteal cuff syndrome

200
Q

What is complete knee dislocation?

A

When you rupture all 4 of the ligaments in your knee

201
Q

In an obese patient, you may not be able to feel the palpable gap in an extensor mechanism, what could you do?

A

Do an ultrasound to determine the extent of the injury

202
Q

Which way does the patella dislocate?

A

It dislocates laterally

203
Q

When can patellar dislocation occur?

A

After a sudden blow to the knee or after a sudden turn

204
Q

Risk factors for patella dislocation

A
  • Ligamentous laxity
  • Female gender
  • Shallow trochlear groove
  • Genu valgum
  • Femoral neck anteversion
  • High riding patella
205
Q

When would you see a haemarthrosis?

A

Following dislocation of the patella

206
Q

The word that is associated with bunions but I always forget?

A

Hallux valgus

207
Q

Hallux valgus?

A

Medial deviation of the 1st metatarsal and lateral deviation of the toe itself

208
Q

Mulder’s click test?

A

Squeezing the forefoot to produce a click (will happen if mortons neuroma is present)
-Ultrasound may be used for diagnosis

209
Q

Can you use steroid and local anaesthetic injections in mortons neuroma?

A

Yes you can

210
Q

Where do metatarsal fractures most commonly occur?

A

The 2nd metatarsal followed by the 3rd

Mortons neuroma most commonly occurs in the 3rd interspace nerve, and then the 2nd

211
Q

Pain “like being kicked in the back of the leg”

A

Achilles tendon rupture

212
Q

Gottron’s sign

A
  • Erythematous, scaly eruption over the MCPs and interphalngeal joints
  • Seen in dermatomyositis
213
Q

Diagnosis of polymyositis- history

A

Muscle weakness in symmetrical proximal muscles
May also have muscle pain
Weight loss, breathlessness, FEVER, RAYNAUDS PHENOMENON, polyarthritis
Other medical problems: DM, thyroid
Medications: steroids, statins
Family history
Social history: alcohol, illicit drugs

214
Q

How to diagnose polymyositis?

A

MUSCLE BIOPSY IS THE DEFINITIVE TEST
Raised CK
(check electrolytes, calcium, PTH, TSH to exclude other causes)
Inflammatory markers
ANA, Anti-Jo-1
Electromyography (EMG): increased fibrillations, abnormal motor potentials, complex repetitive discharges

215
Q

Electromyography in polymyositis?

A

Increased fibrillations, abnormal motor potentials, complex repetitive discharges

216
Q

What would you find in a muscle biopsy in polymyositis?

A

Perivascular inflammation and muscle necrosis

217
Q

Polymyositis MRI?

A

Muscle inflammation, oedema, fibrosis and calcification

218
Q

Treatment for polymyositis/dermatomyositis?

A 
Glucocorticoids
Azathioprine
Methotrexate
Ciclosporin
IV immunoglobulin
219
Q

Drugs that can cause polymyositis?

A

Statins, steroids

220
Q

Differences between polymyositis and inclusion myositis?

A

-CK lower in inclusion myositis than polymyositis
-Inclusion bodies in biopsy of inclusion myositis (perivascular inflammation and muscle necrosis in polymyositis)
-Inclusion body myositis responds poorly to therapy
-Weakness symmetrical in polymyositis, asymetrical in inclusion myositis
AGE AGE AGE (polymyositis >18 years, dermatomyositis child/adult, Inclusion myositis OVER 50!!!)

221
Q

What is polymyalgia rheumatica associated with?

A

Temporal arteritis

Giant cell arteritis

222
Q

Clinical findings of fibromyalgia

A

Tender 11/18 points
No other abnormality of musculoskeletal system
-No diagnostic tests

223
Q

Perimysial inflammation?

A

Dermatomyositis

224
Q

Endomysial inflammation?

A

Polymyositis

225
Q

Endomysial inflammation and CD8+ cells?

A

Polymyositis

226
Q

Perimysial inflammation and CD4 cells?

A

Polymyositis

227
Q

Why does intoeing occur?

A

Anteversion of femoral head –> internal torsion of tibia –> metatarsus adductus

228
Q

How can you check internal tibial torsion?

A

Thigh foot angle

229
Q

Bow legs, photographs or x-rays?

A

Photographs!

230
Q

What causes bow legs?

A

<2 years, fine

More than two years, think about internal tibial torsion

231
Q

When should you refer for bow legs?

A
  • asymmetry
  • painful
  • height <2SD
232
Q

When do you refer for knock knees?

A

If the intermalleolar distance is greater than 8cm at 11 years old

233
Q

Do insoles help knock knees?

A

No

234
Q

An adolescent girl presents with anterior knee pain and localised patellar tenderness. It is worse when she squats or goes down stairs. What investigations would you like to carry out?

A

X-ray, check its not her hips!

Give physio.

235
Q

How do you fix curly toes?

A

With tenotomy (after 6 years old because fairly normal until then)

236
Q

When can a baby sit unsupported?

A

10 months

237
Q

Congenital vertical talus

A

Rocker bottom feet

238
Q

Rocker bottom feet

A

Congenital vertical talus

239
Q

NF diagnosis

A 
-6 or more cafe au lait spots (pigmented birth marks) 
>5mm pre puberty
>15 post puberty
-2 or more NF or 1 PNF
-axillary/groin freckling
-osteoporosis/osteomalacia/skeletal dysplasia
-kyphoscoliosis, sphenoid dysplasia
-pseudoarthrosis
-1st degree relative
-known genetic mutation 17q11.2
240
Q

Classifying skeletal dysplasias

A

The Wynne-Davies classification
(epiphyseal/metaphyseal/diaphyseal, bone density, spinal involvement, storage disease, fibrous disorder, dysplasia with a tumour like appearance)

241
Q

FGF3 gene mutations?

A

Achondroplasia

242
Q 
Frontal bossing
Midface hypoplasia
Rhizomelic disproportion
Genu varum
Trident hand
Normal intelligence
Motor delay
A

Achondroplasia

243
Q

Which part of the brain is damaged in cerebral palsy?

A

The encephalon

244
Q

What is the leading cause of childhood disability?

A

Cerebral palsy

245
Q

Drug treatment for spasticity (BBB)

A

Benzodiazepines
Botox
Baclofen
Surgery = rhizotomy

246
Q

Features of upper motor neurone syndrome?

A
  • Hyper-reflexia
  • Clonus
  • Co-contraction
  • Spasticity
247
Q

Management of cerebral palsy (grade I-III)

people who can walk

A
  • orthothotics
  • botox
  • physio
  • surgery
248
Q

Management of tip-toe walking

A 
Usually idiopathic 
Common before 3 years
Physio/observation
Splinting/casting
Botox
Surgery
249
Q

Spinal claudication

A
  • Age 50+
  • M:F 2:1
  • Limited walking capacity (i.e can’t walk very far)
  • Stoop/lean forward/sit to relieve symptoms
  • “heavy or tired” legs
250
Q
  • Age 50+
  • M:F 2:1
  • Limited walking capacity (i.e can’t walk very far)
  • Stoop/lean forward/sit to relieve symptoms
  • “heavy or tired” lefgs
A

Spinal claudication

251
Q

How do you relieve spinal claudication?

A

-flexing

remember in comparison to claudication, going uphill and cycling are not that bad

252
Q

Spinal stenosis/claudication on x-ray

A

Hypertrophic spine with narrowing of the interpedicular space and obliteration of the neural foramena

253
Q

Investigation for spinal claudication?

A

X-ray

254
Q

Deep seated low central back pain that gets worse as the day goes on

  • Typically worse on coughing
  • made worse by flexing
  • worse with activity
A

Discogenic back pain

255
Q
  • Pain in the back (may radiate to buttocks and legs)
  • Stiff in the morning, loosening up routine
  • Restless –> difficulty sitting, standing, driving
  • Worse with extension
  • BETTER WITH ACTIVITY
A

Facet arthropathy

256
Q

Facet Arthropathy

A
  • Stiff in the mornings
  • Loosening up routine
  • Restless (difficulty sitting, standing, driving)
  • WORSE WITH EXTENSION, relieved by activity
  • Often radiates to buttocks and legs
257
Q

Worse with extension, better with activity

A

Facet arthropathy

258
Q

Worse with flexion

A

Discogenic back pain

259
Q

Relieved by flexion

A

Spinal claudication/stenosis

260
Q

Feels like ‘walking on marbles’

A

Metatarsalgia

261
Q

Which fracture can be associated with an ankle fracture?

A

Twisting of the ankle or foot can be associated with an avulsion fracture of the base of the 5th metatarsal

262
Q

Deltoid ligament?

A

Medial side of the ankle.

Attaches the medial malleolus to multiple tarsal bones

263
Q

The ligament complex on the lateral side of the foot?

A

The talofibular ligament complex

264
Q

The dorsalis pedis pulse?

A

Lateral to the flexor hallucis longus

265
Q

The posterior tibialis pulse?

A

Distal and posterior to the medial maleolus

266
Q

Nerve supply to the foot?

A

Superficial peroneal nerve and deep peroneal nerve

267
Q

Where does the deep peroneal nerve supply?

A

The gap between the big toes and he toe next to it

268
Q

What is the tendo-Achilles and what does it do?

A

Tendinous extension of the gastrocnemius and soleus

-Plantar flexes the foot

269
Q

De Quervain’s tenosynovitis affects which tendon sheaths?

A

Abductor pollicis longus

Extensor pollicis brevis

270
Q

Give an example of when de Quervain’s tenosynovitis might hurt?

A

When you turn your wrist, make a fist, grasp anything etc etc

271
Q

Which fracture causes pain in the snuffbox?

A

A scaphoid fracture

272
Q

Ligaments of the elbow?

A

Medial and lateral collateral ligaments

273
Q

Bursa at the elbow?

A

Olecranon bursa

274
Q

The humero-ulna joint

A

Flexion/extension of the elbow

275
Q

Radio-capitellar joint

A

Pronation/supination

276
Q

Pain at insertion of the extensor muscles of the forearm?

A

Lateral epicondylitis

277
Q

Pain at insertion of the common flexor origin?

A

Medial epicondylitis

278
Q

Which elbow problem is associated with muscle wasting/weakness, sensory loss and provocation tests?

A

Cubital tunnel syndrome

279
Q

What does the FDS flex?

A

The PIPJ

280
Q

What does the FDP flex?

A

The DIPJ

281
Q

If you see a high arched foot what should you be thinking of?

A

You should be thinking of neurological conditions e.g. cerebral palsy, spina bifida, stroke, muscular dystrophy, Charcot-Marie tooth disease

282
Q

What could a flat foot mean?

A

RA

Posterior tibialis dysfunction

283
Q

Where can you use cartilage regeneration techniques?

A

Knee and ankle

284
Q

When can excision arthroplasty be used?

A
  • 1st CMC (trapeziectomy) for OA in hand
  • 1st MTPJ OA & hallux valgus in frail, elderly patients (Keller’s procedure)
  • Can excise all metatarsal heads for end stage rheumatoid foot
285
Q

What is Keller’s procedure?

A

Excision of the 1st MTPJ / hallux valgus

-often used for frail, elderly patients with OA

Musculoskeletal (44 decks)

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