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MSK Flashcards

1
Q

What happens on clavicular fracture to the fragments?

A

Medial fragment moves superiorly due to unopposed scm action

Lateral fragment moves inferiorly due to limb weight and medially due to unopposed adductor pull

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2
Q

What is the first bone to start ossification? When?

A

Clavicle, 5/6th week

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3
Q

What is the last long bone to finish ossification? When?
Implication
How to overcome it?

A

Clavicle! 35-30 yrs
Potential to misinterpret epiphysis as a fracture
Image both clavicles, should be the same

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4
Q

Commonest site of humerus fracture?

What sort of fracture do they tend to be? Implication?

A

Surgical neck

Impacted - often stable and able to move arm passively

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5
Q

How would the arm be positioned if the greater tubercle was avulsed on the humerus? Why?

A

Medially rotated
Lack of attachment of lateral rotating muscles infraspinatous and teres minor leading to unopposed subscapularis medial rotation

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6
Q

How would a fractured shaft of humerus position post fracture? Why?

A

Proximal portion abducted by unopposed deltoid

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7
Q

How could a midshaft humerus fracture occur?

A

Direct blow

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8
Q

How could a surgical neck humerus fracture occur?

A

FOOSH in elderly with osteoporosis

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9
Q

How does a greater tubercle of humerus avulsion commonly occur?

A

Fall onto acrominion

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10
Q

How could an intercondylar fracture of the humerus occur?

A

Fall onto flexed elbow driving olecranon up

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11
Q

What is a colles fracture?
What position does it end up in? With what signs?
What other fracture commonly accompanies it?

A

Complete transverse fracture of distal 2cm of humerus
Distal fragment displaced dorsally and proximally
Radial styloid becomes proximal to ulna styloid
Dinner fork deformity
Avulsion of the ulna styloid

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12
Q

How does pain from a fractured scaphoid present?

A

Lateral wrist
Worse on dorsiflexion and abduction of hand
Telescoping thumb produces pain

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13
Q

What condition occurs if a scaphoid fracture undergoes avascular necrosis? What may have to occur then?

A

Degenerative joint disease of the wrist - may need fusing

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14
Q

What protective factors do the metacarpals have if fractured?

A

Closely bound so stable

Good blood supply

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15
Q

What is a boxers fracture?

A

Fracture of fifth metacarpal by hitting with the wrong knuckles

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16
Q

How do fractured phalanges usually occur? What type of fracture do they tend to be? Why is this important?

A

Crush injury
Comminuted
Close association with flexor tendons thus needs to be carefully realigned.

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17
Q

Where is the weakest point of the clavicle?

A

The join between the medial and lateral thirds

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18
Q

Define myotome
What does this imply for muscles?
What group of muscles of the upper limb are made from a single myotome?

A

The unilateral embryological muscle mass receiving innervation from a single spinal cord segment or spinal nerve
Most muscles consist of multiple myotomes
The intrinsic muscles of the hand (T1)

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19
Q

Sensation to the upper shoulder is provided by…

A

The supraclavicular nerves C3/C4

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20
Q

Sensation to the lateral arm is provided by?

A

Superior (c5/c6) and inferior (c5/c6) lateral cutaneous nerves of the arm

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21
Q

Nerves that supply sensation to the forearm and origin nerves

A

Lateral cutaneous nerve to the forearm - musculocutanious
Medial cutaneous nerve to the forearm - brachial plexus
Posterior cutaneous nerve to the forearm - radial

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22
Q

Sensation provided by ulnar nerve

A

Medial palm and dorsum with medial 1.5 digits

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23
Q

Sensation provided by median nerve directly

A

Lateral palm and lateral 3.5 digits palmer and tips of dorsal

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24
Q

Sensation provided by radial nerve directly

A

Lateral dorsum of hand and lateral 3.5 fingers except the tips.

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25
Q

How is pec major formed? What do the heads do? How can they be tested?

A

Big sternocostal head - adducts and extends the arm - abduct to 60degrees then adduct against resistance
Smaller clavicular head - flexes the arm - abduct to 90degrees then flex against resistance
Together adduction and medial rotation

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26
Q

Function of serratus anterior?

Test it?

A

Protracts the scapular when reaching anteriorly
Raises the gh joint to reach above 90degrees
Anchors the scapular so when pushing against resistance it doesn’t move backwards
Push against a wall and the stands should be visble/palpable

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27
Q

What is the classification method for growth plate fractures in children?

A

Salter harris

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28
Q

What is a salter harris 1

A

Fracture through the growth plate

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29
Q

What is a salter harris 2

A

Through growth plate and metaphysis

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30
Q

What is a salter harris 3

A

Through growth plate and epiphysis

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31
Q

What is a salter harris 4

A

Through growth plate, metaphysis and epiphysis

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32
Q

What is a salter harris 5

A

Impacted fracture of growth plate

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33
Q

What is the worst salter harris fracture prognostically ?

A

5

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34
Q

What is the commonest salter harris fracture?

A

2

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35
Q

What proportion of childhood fractures involve the growth plate?
What effect can this have?

A

One third

Stunted growth of that limb due to premature closure

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36
Q

Why are salter harris 3 and 4 worse than 1 and 2

A

Damages both zone of proliferation and zone of reserve cartilage

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37
Q

What are the phases of gait?

A

Stance - foot strike to toe off

Swing

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38
Q

What is a gibbous deformity of the spine?

A

One vertebra wedged causing increased forward flexion with sudden angulation and posterior ridge

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39
Q

Define kyphosis and lordosis

A

Curvature of spine in saggital plane with apex:
Kyphosis - posterior
Lordosis - anterior

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40
Q

What should be felt in a spinal exam?

A

Spinous processes
Paraspinal muscles
Sacroiliac joint
Consider feeling for AAA in lumbar pain

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41
Q

What are you feeling for on spinous process palpation?

A

In line
Tender
Prominent - ? Wedge fracture

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42
Q

What special tests can be done in a spine examination?

A

Spurlings sign
Schobers test
Straight leg raise

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43
Q

What is straight leg raise otherwise known as?

Interpret pain at 10degrees 50degrees and 90degrees

A

Lasegues test
10 - nerve root compression not herniated disc
50 - probable disc herniation
90 - normal

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44
Q

How can pain from a straight leg raise be worsened or relieved?

A

Worsen by dorsifexing foot

Relieve by flexing knee

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45
Q

What would ipsolateral (effected side) pain on a contralateral straight leg raise indicate?

A

Severe impingement

Possible high risk of cauda equina

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46
Q

What is spurlings sign?

A

Elicites nerve root irritation in neck
Extend and rotate neck to effected side
Apply downwards pressure

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47
Q

What is schobers test?

A

Assesses spinal flexion
Mark between dimples of venus, 10cm above and 5cm below
Flex and gap should increase from 15 to 20 cm

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48
Q

Red flags for lower back pain

A 
55
Non mechanical
Thoracic pain
Night pain
Systemic symptoms
History of cancer
Drug abuse or steroid use
Widespread neurology 
Traumatic
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49
Q

What bladder problems are associated with cauda equina?

A

Urinary retention

Overflow incontinence

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50
Q

What features of back pain itself would raise concerns about cancer

A

Non mechanical
Worse at night
Progressive in spite of management

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51
Q

Xray features of vertebral cancer

A

Lucency or opacity

Winking owl sign (loss of pedicle)

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52
Q

Best imaging modality for suspected spinal infection

What may be seen?

A

MRI
Fluid in disc and vertebra
Epidural abcess

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53
Q

Xray changes in spinal infection

A 
No change
Disc narrowing
Bony sclerosis
Vertebral collapse 
Paraspinal mass
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54
Q

Which way do discs commonly herniate? Why?

A

Posteriolateral
Not straight posterior due to posterior longitudinal ligament, but backwards as patient flexes forwards pressure forces it back

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55
Q

What occurs as a result of dehydration of the nucleus pulposus?

A

Fibrosis
Narrowed disc space
Osteophyte formation

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56
Q

Why is an acute disc herniation more severe than an equivalent chronic herniation?

A

Inflammatory component in acute herniation with less time to react

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57
Q

What is the term for subluxation of the vertebra? Where dose it occur often?

A

Spondylolisthesis

L5 S1

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58
Q

What is spondylisis?

A

Inflammation of the vertebral joints

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59
Q

What is spondylosis?

A

General wear and tear / dysfunction of the vertebral joints generally related to disc degeneration and osteoarthritis

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60
Q

Management options for cervical radiculopathy

A

Conservative - collar, exercises, traction, rest

Surgical - disc removal and replacement or removal of some lamina

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61
Q

What are the characteristics of pain from spinal arthritis?

A

Worse on standing and following inactivity (eg. On getting up in the morning)
Eased by lying and stooping.

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62
Q

Conservative management options for osteoarthritis of the spine

A

Nsaids
Weight loss
Physical therapy

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63
Q

What is spondylolysis?

What can it cause?

A

Stress fracture of the vertebra arch between superior and inferior facets - risk of spondylolisthesis

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64
Q

Yellow flags in back pain

A

Belief pain is serious pathology or severely disabling
Belief that passive is better than active management
Avoidance of activities
Social or financial problems
Tendancy towards depression

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65
Q

Types of osteoporotic spine fractures

A

Wedge

Burst

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66
Q

Presentation of osteoporotic spine fractures

A 
Central back pain
Loss of height
Kyphosis 
Paravertebral muscle spasm
Neurological complications
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67
Q

What are the sorts of hypertonia?

General causes

A

Spasticity (inc clasp knife) - pyramidal

Rigidity (inc lead pipe and cogwheel) - extrapyramidal

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68
Q

What is the max number of clonus beats to be normal?

A

5

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69
Q

How can muscle power be measured?

A 
MRC scale
0 - no
1 - twitch
2 - no gravity 
3 - against gravity 
4 - mild resistance
5 - strong resistance
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70
Q

Muscles to test myotomes

A 
C5 - elbow flex
C6 - wrist flex
C7 - elbow extend
C8 - finger flex
T1 - finger abduct
L2 - hip flex
L3 - knee extend 
L4 - ankle dorsiflex
L5 - big toe extend
S1 - ankle plantarflex
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71
Q

What reflexs should be done onto the examiners fingers?

A

Biceps

Supinator

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72
Q

What are the neural levels of the core reflexs?

A 
Biceps - c5
Brachialis - c6
Triceps c7
Knee l4
Ankle s1
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73
Q

Which way should babinskis reflex go in normal people?

A

Flex and adduct

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74
Q

How can reflexs be graded?

A 
Increased +++
Normal ++
Reduced +
Needs reinforcement +/-
Absent -
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75
Q

What can be used to reinforce reflexes?

A

Clench teeth

Jendrassik’s manoeuvre

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76
Q

What can finger pointing test show you

A

Coordination
Past pointing
Intention tremor

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77
Q

What test should be preformed on the hands as a special reflex test?

A

Hoffmans

Isolate middle finger and flick distal segment, +ve if others flex

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78
Q

What should be felt on a shoulder exam?

A

Bones, joint and biceptial groove whilst arm is rotated

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79
Q

Basic movements in shoulder exam?

A

Flex
Abduct
Externally rotate with elbows at 90degrees
Internally rotate by dorsum of hand to small of back and raise up spine

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80
Q

How should supraspinatous power be assessed in a shoulder exam?

A

Internally rotate and abduct to 90degrees in plane of scapula
Elevate against resistance
OR
Drop arm test: Fully abduct then lower to 90 and hold

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81
Q

How should the external rotators be tested in a shoulder examination?

A

Elbows flexed from anatomic position and rotate against pressure

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82
Q

How can subscapularis be tested in a shoulder exam?

A

Put dorsum of hand over sacrum

Push posteriorly against resistance

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83
Q

What tests can be used to assess for impingement in the shoulder?

A

Hawkins test

Neers test

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84
Q

What is hawkins test?

A

Flex shoulder to 90, flex elbow to 90, internally rotate forearm across body. Depress hand and elevate elbow forcing internal rotation

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85
Q

What is neers test?

A

Internally rotate and fully flex shoulder

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86
Q

How can the AC joint be tested in a shoulder exam?

A

Cross arm test

Flex to 90 then adduct across body

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87
Q

How can the biceps be tested in a shoulder exam

A

Flex shoulder slightly from anatomical
Flex forearm against resistance
From flexed forearm supinate vs resistance

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88
Q

Test for anterior impingement in shoulder exam?

A

Apprehension test
Flex elbow
Abduct and externally rotate whilst stabilising scapula

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89
Q

Test for posterior instability on shoulder exam?

A

Pt supine
Hold arm at 30 degrees adduction with flexed elbow
Push back

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90
Q

Test for inferior instability on shoulder exam

A

Hold elbow and humeral head and apply downwards traction

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91
Q

What should be checked before assessing shoulders for instability?

A

Beighton score for hypermobility

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92
Q

Causes of shoulder instability?

A

Acute traumatic - dislocation causing weakening
Gradual stretch - repetitive overhead movements
Muscle pattern - unbalanced muscles pulling the head of humorous

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93
Q

What is the common mechanism behind traumatic anterior shoulder dislocation?

A

Excessive external rotation and extension

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94
Q

What effect do traumatic shoulder dislocations have on the physical surrounding structures?

A

Axillary nerve injury
Bankart lesion - glenoid labrum detachment
Hill-sachs lesion - compression fracture of posterior humoural head

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95
Q

What treatment options are available for shoulder instability?

A

Activity avoidance
Nsaids
Physiotherapy
Ligament repair surgery

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96
Q

How can the AC joint dislocate? What ligaments are involved in mild and severe dislocation?

A

Hard fall onto should
Mild results from AC ligament rupture
Severe results from AC and CC rupture

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97
Q

What is the technical name for frozen shoulder? What is it?

A

Adhesive capsulitis

Fibrosis and scarring between joint capsule and rotator cuff, subacromial bursa and deltoid

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98
Q

What causes adhesive capsulitis?

A 
Injury (dislocation, rotator cuff tear, bicepital tendonitis)
DM
Heart disease
Dupuytrons contracture
Stroke
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99
Q

How is adhesive capsulitis subdivided?

A

Phases 1 2 and 3
1 - much pain progressive motion restriction
2 - reducing pain and very bad movement restriction
3 - resolving

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100
Q

What is the prognosis for adhesive capsulitis?

A

Will resolve itself in 2 to 3 years

Will not resolve in diabetic patients

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101
Q

What conservative treatment options exist for adhesive capsulitis?

A

Physiotherapy
NSAIDs
Corticosteroid injection

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102
Q

Surgical treatments for adhesive capsulitis

A

Arthroscopic capsular release

Manipulation under anaesthetic

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103
Q

Causes of rotator cuff tears

A

Acute trauma - FOOSH or lifting heavy weight

Chronic degeneration - repeated overhead motions, loss of blood supply with age

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104
Q

What is rotator cuff tear pain like? Associated with?

A

Worse at night
Weakness
Decreased range of motion

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105
Q

Treatment of rotator cuff injuries

A 
Nsaids
Physio
Steroid injection
Avoid exacerbating activities
Surgical
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106
Q

Complication of rotator cuff injury?

A

Rotator cuff arthropathy due to superior displacement of humoural head rubbing against acromion

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107
Q

Which joint of the shoulder does OA most commonly effect?

A

AC

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108
Q

Where may pain from OA in the AC joint of the shoulder be?

A

Top of shoulder radiating to neck

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109
Q

Surgical options for GH and AC shoulder arthritis

A

Arthroscopy with debridement
GH replacement
AC joint resection (removal of part of the clavicle)

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110
Q

What do the short head of biceps and coracobrachialis form? Significance?

A

Conjoined tendon

Nearly all nerves and vessels medial to it so surgery lateral to it is safe

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111
Q

What should be conducted prior to assessing the shoulder for instability?

A

Examine for hypermobility using a beighton score

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112
Q

What is the term for an upper brachial plexus injury?

Presentation?

A

Erb duchenne palsy

Waiters tip

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113
Q

What is the term for a lower brachial plexus injury

Presentation

A

Klumpke paralysis

Claw hand

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114
Q

Causes of upper brachial plexus injuries?

A

Increased angle between neck and shoulder

Carry heavy backpack

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115
Q

Most common shoulder pathology in young people?

A

Instability

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116
Q

Most common age range for adhesive capsulitis

A

40-60

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117
Q

Most common age range for osteoarthritis of shoulder

A

> 60

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118
Q

What should be looked for on elbow examination?

A 
Normal crap
Bursa
Rheumatoid nodules
Carrying angle 
Hand for ulnar claw
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119
Q

What is carrying angle?

A

The normal valgus position of the forearm in relation to the arm
Up to15degrees in females
Up to10 degrees in males

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120
Q

What should be palpated in an elbow exam

A

Med lat epicondyles and olecranon - straight line in extension, triangle when flexed
Radial head
Biceps tendon

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121
Q

How should angle of pronation and supination be assessed?

A

From a starting point of palms medially

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122
Q

How to assess for tennis elbow?

A

Flex elbow to 90

Extend wrist against resistance

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123
Q

How to assess for golfers elbow

A

Flex elbow to 90 and supinate

Flex wrist against resistance

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124
Q

What neurological test may be performed at the elbow?

A

Tinnels test

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125
Q

What is tennis elbow?

What age range does it tend to present in?

A

Lateral epicondylitis
Inflammation of extensor tendons
40s-50

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126
Q

What is golfers elbow?

A

Medial epicondylitis

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127
Q

Treatment options for m and l epicondylitis

A 
Limit activity 
Brace
Nsaids
Physiotherapy 
Corticosteroids
Surgery to remove damaged tendon
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128
Q

What is the common mechanism of injury for s supracondyler humorous fracture?

A

FOOSH with hyperextended elbow pushes olecranon through weak area of bone remodelling in humorous

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129
Q

What is the grading system for supracondyler fractures of the humorous?

A

Gartland
1 - undisplaced
2 - angulated but in contact
3 - displaced

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130
Q

Complicaitons of supracondylar humorous fracture?

A

Varus deformity due to malunion
Brachial artery damage
Ulnar nerve damage

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131
Q

Why would an olecranon fracture usually require pinning?

A

Traction from triceps pulls fragment away

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132
Q

Why are children at greater risk of medial epicondyle fractures?

A

Weak as not fully ossified

133
Q

What pneumonic can be used to determine the order of ossification around the elbow?

A 
Capitulum
Radial head
Internal epicondyle
Trochlea
Olecranon
External epicondyle
134
Q

What is students elbow?
What is its counterpart?
Causes?

A 
Students = subcutanious olecranon bursitis from repeated pressure and friction
Other = subtendinous olecranon bursitis from repetitive movement
135
Q

What are treatment options for elbow bursitis?

A

Aspiration
Corticosteriods
Nsaids

136
Q

Xray views needed in suspected dislocated shoulder?

A

AP
Scapula Y
Axillary

137
Q

What lumps in the hand occur with OA? Which joints?

A

Heberdens - DIP

Bouchards - PIP

138
Q

What should be checked in suspected metatarsal fracture? How

A

Finger rotation
Check nail angle
Ask to make fist and look for crossing of fingers

139
Q

Where can the scaphoid be palpated?

A

Palmer at base of thumb by tracing flexor carpi radialis
Waist in anatomical snuff box
Radial to listers tubercle on dorsum of hand

140
Q

Where can the lunate be palpated?

A

Ulnar to listers tubercle on dorsum of hand

141
Q

How to palpate triquestrum?

A

Radially deviate wrist and feel at top of ulnar

142
Q

How to palpate pisiform

A

Within flexor carpi ulnaris

143
Q

Where are the trapezium and trapezoid palpated?

A

Base of first and third metacarple

144
Q

Where is the hamate palpated

A

Its hook beyond the triquestrum

145
Q

How would you test the ulnar nerve in the hand?

A

Sensation on palmer little finger
Motor - abduct little fingers against resistance
Test interossei
Froments test - hold paper against resistance between thumb and index finger. If adductor pollicis deficient then thumb will bend

146
Q

How would you test the median nerve in the hand?

A

Sensation on palmer middle finger
Motor - abduct thumb pressing on median eminance
OK sign against resistance

147
Q

What branch of the median nerve is tested when making the ok sign? When is it commonly damaged?

A

Anterior interosseus nerve

Supracondylar fractures

148
Q

Testing the radial nerve in the hand

A

Sensation - dorsal base of thumb

Motor - wrist extensors, finger extensors extensor pollicis all against resistance

149
Q

What tendon is. Especially important to assess in distal radial fractures?

A

Extensor pollicis longus

150
Q

Other than looking, feeling bones and testing nerves and tendons what other tests should be considered in a hand exam?

A

Functional tests

Vasculature (allens test, radial pulse)

151
Q

What are spoon shaped nails called?

Causes?

A

Koilonychia

Iron deficiency anaemia

152
Q

What is separation of the nail from the bed called? Appearence? Causes?

A

Onycholysis
White opacity
Trauma, infection, drugs

153
Q

What deep horizontal grooves in the nail called? Causes?

A

Beau’s lines

Severe illness causing temporary cessation of cell division

154
Q

What is overgrowth of the nail called? Causes?

A

Onychogryphosis

Trauma - acute or chronic (e.g. Shoe rubbing)

155
Q

What are white lines on the nail called?.

Causes

A

Leukonychia
Injury to base of nail
Hypoalbuminaemia (liver disease)

156
Q

What is a colles fracture?

What is often associated with it?

A

Extra articular transverse fracture of the distal 2cm of radius with dorsal displacement and impaction
Avulsed ulnar styloid

157
Q

What occurs so commonly in patients with colles fractures it should be checked for?

A

Osteoporosis

158
Q

What are the other fractures of the distal radius other than a colles?

A

Smiths

Bartons

159
Q

What is a bartons fracture?
Which direction is usual?
Management?

A

An articular fracture of the distal radius
Usually involves volar deformity
Nearly always needs internal fixation

160
Q

What hand positioning would make a scaphoid fracture worse?

A

Dorsiflexion and abduction

161
Q

What treatment may be required in a scaphoid fracture with secondary avascular necrosis (common and medical term)

A

Fusion - arthrodesis

162
Q

What is terry thomas sign?

Complication?

A

Scapholunate ligament injury causing gap to appear between bones
Arthritis

163
Q

Causes of tenosynovitis?

A

Infection
Overuse
Rheumatoid arthritis

164
Q

From which digits can tenosynovitis spread? Where too?

A

1 and 5

To the common flexor sheath, carpal tunnel and anterior forearmg

165
Q

Term for tenosynovitis in APL and EPB tendon sheath?

A

Quervain tenovaginitis

166
Q

How does Quervain tenovaginits present?

A

Pain on medial surface spreading up the forearm and down the thumb
Tenderness on anatomical snuff box

167
Q

Sign that is positive in quervain tenovaginitis?

A

Finkelstein’s sign - grip thumb in closed fist and ulnar deviate to cause pain in snuffbox

168
Q

Risk factors for dupuytrens contracture?

A 
Family 
Male
Northern european
Liver disease
Antiepileptic meds
169
Q

Presentation of dupuytrens contracture?

A

Painless
Flexion of digits, usually 4 and 5
Ridged palmer skin

170
Q

Dupuytrens is associated with?..

A 
Planter fibromatosis (foot)
Peyronie's disease (penis)
171
Q

Treatment options for dupuytrens?

A

Surgical fasciotomy

Collagenase injection

172
Q

Causes of carpal tunnel syndrome?

A 
Idiopathic
Pregnancy
Hypothyroid
Trauma
Tenosynovitis
Amyloidosis 
Infection
Ganglion
173
Q

Muscles effected in carpal tunnel syndrome?

A

Abductor pollicis brevis
Opponens pollicis
Flexor pollicis brevis

174
Q

Treatment options for carpal tunnel syndrome?

A

Treat cause
Night splints
Steroid injection
Carpal tunnel release

175
Q

What is mallet finger?

A

Forced flexion of extended finger avulses extensor tendon leaving dipj in fixed flexion

176
Q

What is trigger finger?

A

Thickening of the a1 pully by the mcpj

Causes finger to lock and release with snapping noise

177
Q

Treatments of trigger finger

A

Steroid injecition

Surgical pulley release

178
Q

Where does osteoarthritis usually effect in the hand?

A 
DIPJs
Then 
1st MCPJ
Then
PIPJs
179
Q

What is a ganglion

Features

A

Leak of fluid from synovial capsule

Smooth mass which changes size

180
Q

Where are ganglions usually found

A

Scapholunate joint

181
Q

What is a ganglion on the dipj callled?

Complication?

A

Digital mucous cyst

Nail deformity

182
Q

What is skiers thumb?

A

Tear to ulnar colateral ligament of 1st mcpj caused by fall onto outstreatched thumb

183
Q

Types of gait to look out for on examination of the hip?

What are they?

A

Antalgic - limited weight baring on painful leg
Trendelenberg - contralateral hip drops on weight baring
Stiff hip gate - lack of full hip extension

184
Q

Special tests to do on hip examination?

A

Trendelenbergs

Thomas test

185
Q

What is thomas test?

A

Hand under lumber spine
Flex knee and hip until spine touches hand
Positive if contralateral leg raises

186
Q

What does a positive thomas test mean?

A

Flexion deformity
If knee extends then rectus femoris tight
If knee flexes then iliopsoas tight

187
Q

Position of leg in fractured neck of femur?

A

Shortened and externally rotated

188
Q

How can neck of femur fractures be classified? What are the different classifications?

A

Garden
Stage 1 - incomplete fracture undisplaced
Stage 2 - complete fracture undisplaced
Stage 3 - complete fracture partially displaced
Stage 4 - complete fracture fully displaced

189
Q

What can be used to assess 30 day mortality of fractured neck of femur?

A

Nottingham hip fracture score

190
Q

What indicates a negative prognosis for mortality of a hip fracture?

A 
Age
Male
Low hb
Low mmts
Institutionalised care
Cormorbidities
Malignancy 
Raised lactate
191
Q

Types of neck of femur fracture?

A

Intracapular

Extracapsular

192
Q

What is the condition called that results from a mismatch between head of the femur and the acetabulum?

A

Femoral acetabular impingement

193
Q

What position worsens femoral acetabular impingement? Why is this an issue particularly in younger people?

A

Hip adduction, flexion and external rotation, a common position in sport

194
Q

Treatment options for femoral acetabular impingement?

A

Activity avoidance
Nsaids
Physiotherapy
Arthrascopic repair and shaving

195
Q

What sign has a high ppv for herniated disc?

A

Crossed straight leg raise

Raise contralateral leg and sciatica worsens ipsolaterally

196
Q

What bedside test should be performed on all patients with acute back pain? Why?

A

Bladder scan

May be urinating but still retaining an amount of urine - retention

197
Q

Condition associated with painful arc?

With high painful arc?

A

Shoulder impingement beneath ac joint

High - ac joint pathology

198
Q

Another term for trochantic bursitis?

A

Greater trochantic pain syndrome

199
Q

Cause of trochantic bursitis?

A 
Overuse
Inflammation
Trauma
Pressure 
Calcium deposition
200
Q

Treatment of trochantic bursitis?

A

Rest
Ice
Nsaids

201
Q

Causes of hip avascular necrosis?

A

Trauma - femoral neck fracture, dislocation, subluxation

Atraumatic - corticosteroids, alcohol abuse, intravascular coagulation, liver disease

202
Q

Presentation of avascular necrosis of the femoral head

A

Groin pain radiating to buttocks and knee
Worse on weight bearing
Limited abduction
Painful passive movement

203
Q

Xray features of femoral head avascular necrosis

A 
Femoral head lucency 
Subchondral sclerosis
Subchondral collapse
Crecent sign, flattening of the head
Joint space narrowing
204
Q

Treatment of avascular necrosis of the femoral head?

A

Remove cause if able
Core decompression with graft insertion
Replacement

205
Q

What tests should be run on a patient with a suspected septic hip?

A

WCC, CRP
USS
Aspiration

206
Q

Presentation of a hip infection

A

Usually children
Severe pain and stiffness
Reluctance to bear weight and limp
Sepsis

207
Q

Which gender is more likely to suffer congenital hip dysplasia?

A

Female

208
Q

Test to identify congenital hip dysplasia? What are they? How to remember?

A 
Barlow test (Barlows push Back)
Adduct hip at 90 flexion whilst pushing posterior on knee feel for pop as hip dislocates
Ortolani manoeuvre (Ortolani move Out)
Abduct hip at 90 flexion whilst pressing on lesser trochanters and feel for a pop as hip relocates
209
Q

Diagnosis of congenital hip dysplasia?

A

USS

Arthrography

210
Q

Treatment options for congenital hip dysplasia?

A

Pavlik harness
Closed reduction and hip spica
Open reduction

211
Q

Long term complications of congenital hip dysplasia

A

Adult arthritis

212
Q

What age range is perthes most common

A

4-8 yrs but can be 2-15 yrs

213
Q

Presentation of perthes

A 
Mild groin pain refers to knee
Reduced range of motion
Inequality in leg length 
Thigh wasting
Limp
214
Q

Xray features of perthes?

A

Flattened femoral head progressing to fragmented femoral head

215
Q

Natural history of perthes?

A

Avascular necrosis of head of femur due to insufficiency of artery oc ligamentum teres
Bone fragments
Bone replaced and reossifies
Bone heals

216
Q

Treatment needed for most perthes patients?

A

Nothing! Watchful waiting

217
Q

If needed treatment options for perthes?

A

Physiotherapy
Activity avoidance
Cast
Surgery

218
Q

Classic age range for slipped femoral epiphysis? Most common gender?

A

Males 10-16
Females 12-14
Most common in males

219
Q

Presentation of slipped femoral epiphysis

A 
Gradual onset
20% bilateral
Hip pain
Limp 
Shortened leg
220
Q

What xray view to see slipped femoral epiphysis?

A

Frog leg

221
Q

Treatment of slipped femoral epiphysis?

A

Surgical pinning

222
Q

What is an issue with using xrays to screen for sinister causes of lower back pain? What are they good for?

A

Xrays wont show malignancy until most of the vertebra is gone
Good for suspected fractures
Good for reassuring patients

223
Q

What blood tests may be of use in a patient presenting with simple back pain?

A

Fbc

Esr

224
Q

Treatment options for simple lower back pain?

A

Paracetamol / NSAIDs
Short course of diazapam
Early mobilisation and return to normal activities
Physiotherapy

225
Q

Usual cause of sciatica

A

Pressure onto the nerve roots L5 to S1 NOT the sciatic nerve!

226
Q

Which nerve root is most commonly effected by prolapsed disc?

A

L5

227
Q

Causes of lumbar nerve root irritation?

A

Prolapsed disc
Venous congestion
Osteophytes

228
Q

How long does sciatia usually take to resolve? Mechanism of healing if caused by disc prolapse?

A

6 weeks

Shrinkage and fibrosis of the disc

229
Q

What presentation of long term herniated disc patient would benefit most from surgery?
Indication for rapid surgery in disc herniation?

A

Patients with long term leg symptoms

Cauda equina, rapidly evolving motor radiculopathy

230
Q

Treatment options for herniated disc if watchful waiting fails?

A

Chemonucleoslysis - enzyme to dissolve disc

Discectomy - pop the disc out

231
Q

How does sciatica present?

A

Pain radiating down back or side of thigh into calf and foot. Worse on movement. Worse on coughing or sneezing as CSF shockwave travels around the nerve.

232
Q

Examination findings of sciatica?

A

Sciatic scoliosis - bending chest to side to reduce pressure on trapped nerve
Straight leg raises positive
Reduced forward flexion
Impaired reflexes and muscle weakness

233
Q

What is spinal stenosis? Pathology? Causes?

A

Stenosis of spinal canal
Causes pressure, decreased blood flow and ischemia
Causes are congenital, idiopathic, spondylosis, spondylolisthesis, pagets disease

234
Q

Signs and Symptoms of spinal stenosis

A

Rapid or insidious onset
Worse on mobilisation relieved by rest
Stooping to increase size of canal (eased on a bike or walking uphill!)

235
Q

What is the term for the syndrome caused by spinal stenosis? What is similar? How can they be differentiated?

A

Neurogenic claudication
Similar to vascular claudication

N - starts proximal and spreads distal, C - opposite
N - worse on walking and standing, C - just walking
N - eases on several minutes sitting, C - eases with seconds of rest
N - stoops, C - normal posture
N - can cycle! C - limited whatever exercise
N - normal skin and pulses, C - pale, hairless and pulseless

236
Q

How would spinal stenosis be diagnosed? Treatment?

A

MRI
Symtomatic treatment
Can consider epidural
Surgical decompression

237
Q

What blood test is most sensitive for spinal infection?

A

Esr

238
Q

If you suspect a spinal infection what needs to be done?

A

MRI
Biopsy!
Culture
Then antibiotics

239
Q

Pathology of TB of the spine? (Potts)

A

Infection on the anterior margin of the body near the disc
Spread to, then destruction of, the disc
Anterior collapse causing angular kyphosis
Abscess formation

240
Q

How can infectious narrowing of the disc space be differentiated from degenerative (spondylosis)

A

Lack of osteophytes

241
Q

Presentation of potts disease?

A 
Back pain
Back stiffness
Kyphosis
Abscess 
Spinal cord compression
242
Q

Treatment of mallet finger

A

Splint the finger for 6-8 weeks

243
Q

Indications. For surgery in rheumatoid arthritis?

A

Tendon repair
Mcp joint arthroplasty (placing in rubber surfaces)
Arthrodesis
Removal of rheumatoid nodules

244
Q

What is the term for the for the line drawn from the asis through the patella to the tibial tuberosity? What should the deviation from the asis patella to the patella tuberosity be?

A

The q angle

Roughly 9-18 degrees in valgus

245
Q

Causes of increased q angle?

A

Genu valgum

External tibial torsion

246
Q

Tests for knee effusion?

A

Patella tap

Medial sweep with lateral push

247
Q

What is the normal range of knee flexion?

A

Young - ankle to bum

Elderly - roughly 110 degrees

248
Q

Additional test for acl injury? How?

A

Lachmans test
Knee at 20 degree flexion
Push thigh down and pull tibia up
If acl rupture then end point will be boggy, if intact will be firm

249
Q

Hand conditions associated with rheumatoid arthritis?

A

Carpal tunnel syndrome
Raynauds
Trigger finger
Tendon rupture

250
Q

Complications of total hip replacement?

A

DVT, PE
Dislocation
Bleeding/nerve damage
Infectoin

251
Q

What proportion of hip replacements will develop infection? What is the treatment? Risk factors?

A

1%
Revision and antibiotics
Diabetes, immunosuppression and immunocompromised state, smoking

252
Q

In an patient with chronic hip pain where is the pain most likely to be located if the problem is with the joint itself? What about if it is a trochanteric bursitis or spinal pain?

A

Joint - groin
Trochantic bursa - greater trochanter
Spine - buttocks

253
Q

If hip pain is generalised how may surgeons isolate the pain to a joint problem prior to committing to a replacement operation? How is this done?

A

Anaesthetic and steroid injection

Performed as a day case under local anaesthetic and xray visualisation

254
Q

Risks of intra articular hip steroid injections?

A

Infections

Steroid induced necrosis

255
Q

When performing a knee examination what other joint should be assessed, especially if no clear knee cause is elicited?

A

Hip

256
Q

Risk factors for hip osteoarthritis

A 
SUFE
Perthes
CHD
Septic arthritis
Trauma
257
Q

In what direction valgus/varus does the knee classically point in osteo and rheumatoid arthritis?

A

OA - varus

RA - valgus

258
Q

When performing a knee examination what is the benefit of doing a straight leg raise?

A

Check the spine

Confirm extensor mechanisms are intact

259
Q

What is knee locking?

A

Inability to fully extend the knee. It can still be flexed!

260
Q

What is the likely cause of a traumatic rapidly developing knee effusion?

A

Bleeding secondary to acl rupture

261
Q

Absolute contraindication to aspiration of a knee effusion?

A

Overlying skin infection

262
Q

What can cause patellofemoral joint problems? Who does it normally effect?

A

Pain in the anterior knee caused by patella malaligment, muscular imbalance or overuse. Degeneration of this joint can occur following fractures or dislocations. Tends to effect the young.

263
Q

What is the pain of patello femoral joint pathology like?

A

Anterior
Worse up and down stairs
Worse on standing from chair

264
Q

Treatment options for patellofemoral joint problems

A

Physiotherapy to strengthen vastus mediallis
Strapping/taping
Activity modification
Realignment surgery

265
Q

What is the typical history of a ACL injury?

A

Twist on fixed foot with knee flexed

Sudden pain and rapid joint swelling

266
Q

Treatment of acl injury?

A

Immidiate - aspiration of blood eases pain

Long term - activity avoidance or reconstruction

267
Q

Prognosis of acl injury?

A

1/3 back to normal
1/3 suffer when playing sport
1/3 have constant pains and sensations of knee giving way

268
Q

Presentation of a meniscal injury

A

Often follows sport or twisting action
Pain on joint line of knee
Rapid or slow swelling
Loss of extension

269
Q

What surgery is performed now on meniscal tears? Why”

A

Repair

Not removal as weight distributes incorrectly and very high risk of arthritis

270
Q

Which way does the patella usually dislocate?

A

Laterally

271
Q

What mechanism may cause a pcl tear?

A

Fall onto tibial tuberoisty with flexed knee

Dashboard impact

272
Q

Causes of knee locking?

A

Free body
Torn menisci
Osteophyte

273
Q

Signs of RA on an xray?

A 
Periarticular erosions
Periarticular osteopneoa
Soft tissue swelling
Joint subluxation
Joint malalignment
274
Q

Four stages of Perthes

A

Bone dies
Bone fragments
Bone reossifies
Bone remodels

275
Q

When would surgery be necessary in perthes?

A

When the head is no longer in the acetabulum

276
Q

What should be looked for on an xray with a suspicion of slipped femoral epiphysis? Which view?

A

Klein’s line
Trace the lateral border of the femoral neck - should pass through the lateral 1/3rd of the head
Frog leg

277
Q

What is a major differential for septic arthritis of the hip in a child?

A

Transient synovitis

278
Q

What does transient synovitis tend to follow?

A

LRTI or gastroenteritis

279
Q

What scoring system can be used to determine risk of septic arthritis vs transient synovitis? Componenets

A 
Kocher criteria
WCC >12
ESR >40
Unable to weightbare 
Fever >38.5
280
Q

What is a scoliosis?

A

Deformity in spine rotation, lateral bending and lordosis

281
Q

Causes of scoliosis?

A

Idiopathic
Congenital
Neuromuscular

282
Q

Neuromuscular causes of scoliosis?

A

Polio
Muscular dystrophy
Cerebral palsy

283
Q

What gait should be looked out for in knee exam? What does it mean?

A

Varus thrust
Lateral bowing of the knee on weightbearing
Knee OA in medial compartment with lax ligament or muscle weakness

284
Q

Causes of sciatica

A 
Herniated disc
Spondylolythesis
Spinal stenosis
Piriformis syndrome
Tumour
285
Q

Antibiotic for use in mrsa patients?

A

Teicoplanin

Vancomycin

286
Q

Open fracture classifcation?

A

Gustilo anderson
1- 10cm, high energy, gross contamination
A - can be closed
B - needs plastics, extensive periosteal stripping
C- neurovascular injury

287
Q

Complications of open fractures

A

Infection
Compartment syndrome
NV injury
Periosteal stripping with non-union

288
Q

Antibiotics for open fracture with allergic and mrsa alternatives

A

Coamoxiclav
Cefuroxime
Teicoplanin

289
Q

What should be done to the wound before dressing an open fracture?

A

Remove gross contaminants

Photograph

290
Q

When shoud an open fracture have surgery?

A

Within 24 hours in daytime!

Unless severe contamination or nv injury

291
Q

Description of a fracture to a senior?

A 
Pattern
Angulation
Rotation
Translation
Shortening
292
Q

Risk factors for osteoporosis

A 
Low peak bone mass
Age
Female
Early menopause or late menarche
Smoking
Steroids
Family history
293
Q

Common fragility fractures in osteoporosis

A

NOF
Colles
Vertebral compression

294
Q

Scoring system for osteoporosis?

A

FRAXS

295
Q

Indications for fractured clavicle surgery

A 
Open
Tenting
Nv compromise 
Involve AC joint
Comminuted 
>2cm overlap
296
Q

Grading for risk of septic arthritis?

A 
Kocher criteria
WBC >12
Inability to weightbare
Fever >38.5
ESR >40
Score of 4 - 99% chance
Score of 1 - 3% chance
297
Q

When would you not asperate a joint in A+E?

A

Replacement! Do it in surgery

298
Q

What is a two stage joint revision?

A

Remove infected prosthesis, wash out, add antibiotic cement

Add new joint 6 weeks later

299
Q

Causes of posterior shoulder disolcation

A

Epilepsy

Electric shock

300
Q

Complications of shoulder dislocation?

A

Hill sachs
Bankart
Axillary nerve
Rotator cuff tear

301
Q

Significance of bankart or hillsachs?

A

Risk of recurrent dislocations

302
Q

In case of a humeral shaft fracture with radial nerve injury when should surgery be considered?

A

> 2 months duration of palsy

If occured post manipulation

303
Q

How should a humeral shaft fracture be treated normally?

A

Hanging cast

304
Q

Types of forearm fractures?

Which typically need surgery?

A

Both bones
Isolated ulnar - fix
Galeazzi - distal radius with disruption of DRUJ - fix
Monteggia - prox ulnar with radial head dislocation - fix ulnar

305
Q

What are the angles at the wrist with regards to the radius and ulnar. Significance?

A

Radial inclination - 22degrees - allows
Radial height - 2mm - allows ulnar deviation
Volar tilt - 11degrees - allows flexion

306
Q

Causes of patellar fracture?

A

Direct blow - comminuted

Stopping a fall by tensing quads - transverse fracture

307
Q

Treatment of a webber A fracture?

A

Boot or below knee cast

308
Q

Types of webber b fracture and treatment

A

Without talar shift or med/pos malleolus fracture - below knee cast
With any of the above - surgery - orif

309
Q

What fractures are associated with a fall onto the heels? Implication?

A

Calcaneum, impacted distal tibia, tibial plateau, pelvic, spine

If one is seen look for the others!

310
Q

What is a common injury of the midfoot? What does it involve?

A

LisFranc injury
Injury to lisfrank ligament between metatarsal and cuneiform
Often associated with fractured metatarsal bases

311
Q

How does a lizfrank injury present?

A

Swollen foot with bruising on the sole

Severe midfoot pain

312
Q

How should a lizfrank injury be checked for if xrays are normal initially?

A

Weightbaring xrays
CT
Look at allignment

313
Q

Problems with screw fixing intracapsular nof fractures.

A

Still risk of avascular necrosis

Needs to be non weightbearing after

314
Q

Causes of compartment syndrome?

A 
Fractures
Crush injuries
Burns
Tight dressings/casts
Bleeding/haemotomas
Extravasation of iv fluid infusion
315
Q

Complications of compartment syndrome

A

Infarction with muscle necrosis, rhabdomyolysis, contracture

316
Q

What defines non union of a fracture?

A

Failure to heal within 9 months

317
Q

What sorts of non-union are there? What causes each?

A

Hypertrophic - splayed ends - inadequate stability

Atrophic - tapered ends - inadequate biological mechanisms

318
Q

How can you aid fracture healing if stability is the problem?

A

Non-weightbearing
More stable cast
Surgical stabilisation
Revision surgery

319
Q

How can you aid fracture healing in a non union break if biological issues are the problem?

A

Stimulate bleeding
Apply bone graft
Ensure adequate nutrition
Stop smoking

320
Q

What should be done before fixing a fracture associated with a tumour or prophylactically fixing a bone with a tumour? What is the big risk?

A

Embolise the tumour to reduce bleeding

Contaminates the entire bone

321
Q

Which bone tumour is most likely to effect more elderly patients?

A

Chondrosarcoma

322
Q

Which two bone tumours usually effect young adults

A

Osteosarcoma

Ewings sarcoma

323
Q

Where does osterosarcoma usually occur?

A

Either side of the knee

324
Q

Where does ewings sarcoma usually occur?

A

Pelvis or femur

325
Q

Where does condrosarcoma usually occur?

A

Scapula
Pelvis
Femur

326
Q

Treatment of a bite injury

A

Coamoxiclav
Clean pack and dress
Xray to exclude foreign body

327
Q

What generic infections should be considered in a patient with a bite injury that act distant to the site of injury

A

Tetanus

Rabies

328
Q

Commonest infection from a dog bite?

A

Pasteurella multocida

329
Q

Msk complication of cushings?

A

Avascular necrosis of femoral head,

Osteoporosis

IPE (17 decks)

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