MSK Flashcards
1
Q
What is a garden class I fracture?
A
Incomplete/impacted, valgus angulation of distal component
2
Q
What is a garden class II fracture?
A
Complete fracture, undisplaced
3
Q
What is a garden class III fracture?
A
Complete, partially displaced fracture
4
Q
What is a garden class IV fracture?
A
Complete, totally displaced
5
Q
What is the Weber classification used for?
A
Fibula fractures
6
Q
What is a Weber class A fracture?
A
Distal to the ankle syndesmosis
7
Q
What is a weber class B fracture?
A
At the level of the ankle syndesmosis
8
Q
What is a weber class C fracture?
A
Proximal to the ankle syndesmosis
9
Q
What is the Gustilo classification used for?
A
Open fractures
10
Q
What is a Gustilo I fracture?
A
Low energy fracture
Small clean wound
11
Q
What is a Gustilo II fracture?
A
Moderate energy, clean wound >1cm
Mild-moderate comminution
12
Q
What is a Gustilo III fracture?
A
High energy
Extensive skin damage
Neurovascular damage and wound contamination
13
Q
What is the Salter-Harris classification?
A
Physeal (growth plate) fractures
14
Q
What is a Salter-Harris class I fracture?
A
Complete physeal fracture
15
Q
What is a salter-Harris class II fracture?
A
Complete physeal fracture + chip of metaphysis
16
Q
What is a salter-Harris III fracture?
A
Physeal fracture extending through epiphysis
17
Q
What is a salter-Harris class IV fracture?
A
Physeal and epiphyseal and metaphyseal fractures
18
Q
What is a salter-Harris class V fracture?
A
Compression fracture of growth plate
19
Q
What do the increasing numbers in salter-Harris classification mean?
A
Increasing risk of growth arrest
20
Q
What is the most common type of salter-Harris fracture?
A
II
21
Q
What is the garden classification used for?
A
Intracapsular hip fractures
22
Q
What is the common order for all MSK examinations?
A
Look
Feel
Move
Special tests
23
Q
What do you look for from behind in a spinal examination?
A
Asymmetry - head, shoulders, pelvis
Scoliosis
Muscle wasting
Scars
24
Q
What do you look for from the side in a spinal examination?
A
Kyphosis
Lordosis
25
What does asking a patient to walk on tip toes test?
S1
26
What does asking a patient to walk on their heels test?
L5
27
What do you feel for when palpating the spine?
Spinous processes
Paraspinal muscles
Start at occipital protuberance and move down to SI joints
28
What level is the iliac crest at?
L4
29
What level is the PSIS at?
S2
30
What movements of the cervical spine should you test?
Flexion/extension
Rotation
Lateral flexion
31
What movement of the thoracic spine should you test?
Rotation - hold pelvis still from behind and ask patient to turn to face you
32
What movements of the lumbar spine should you test?
Flexion/extension
| Lateral flexion
33
What is the Schrober test?
Testing lumbar flexion
34
What are the 4 special tests for sciatica?
Straight leg raise
Save's test - dorsiflex ankle, produces pain below knee (at full SLR)
Relax knee - pain goes away
Borg's test - push in upper popliteal fossa
35
What is Spurling's sign?
Laterally flex neck to side of pain
| +ve = pain down arm
36
How do patients with spinal stenosis walk?
Flex forward
| Widens gaps in spine to reduce pain
37
What are the components of a peripheral nerve examination?
```
Inspection
Tone
Power
Reflexes
Sensation
Coordination
```
38
What does 0 on the ASIA chart mean?
Total paralysis
39
What does 1 on the ASIA chart mean?
Palpable or visible contraction
40
What does 2 on the ASIA chart mean?
Active movement, full ROM when gravity is eliminated
41
What does 3 on the ASIA chart mean?
Full ROM against gravity
42
What does 4 on the ASIA chart mean?
Full ROM against moderate resistance in a specific muscle position
43
What does 5 on the ASIA chart mean?
Full ROM against full resistance expected from an otherwise unimpaired person
44
How do you test the C5 myotome?
Elbow flexion
45
How do you test the C6 myotome?
Wrist extension
46
How do you test the C7 myotome?
Elbow extension
47
How do you test the C8 myotome?
Finger flexion
48
How do you test the T1 myotome?
Finger abduction
49
How do you test the L2 myotome?
Hip flexion
50
L3 myotome?
Knee extension
51
L4 myotome?
Ankle dorsiflexion
52
L5 myotome?
Extensor hallucis longus (big toe extension)
53
S1 myotome?
Ankle plantarflexion
54
What is the supply to the Biceps reflex?
C5
55
What is the supply to the brachioradialis/supinator reflex?
C6
56
What is the supply to the triceps reflex?
C7
57
What if Hoffman's sign?
UMN sign
Click your finger with theirs in-between
Positive if the clasp their fingers
Analogous to clonus in lower limb
58
What is the nerve supply to the patella reflex?
L4
59
What is the nerve supply to the ankle reflex?
S1
60
What is babinski's sign?
Stroke along metatarsal V then across to the big toe
| First movement of big toe must be extension, followed by fanning of the other toes = UMN sign
61
How do you test for clonus?
Relax ankle by rolling it then sudden and sustained dorsiflexion
3-4 beats is normal, more than 5 is not - UMN sign
62
What dermatome do you test in the middle finger?
C7
63
Where is the L1 dermatome?
Groins
64
Where is the L2 dermatome?
Hands in pockets
65
Where is the L3 dermatome?
Knee
66
Where is the L4 dermatome?
Inside calf
67
Where is the L5 dermatome?
Outside calf
68
Where is the S1 dermatome?
Lateral foot and sole
69
What are the red flag symptoms for back pain?
```
Age outside 18-55
Non-mechanical pain
Night pain
Thoracic pain
Systemic features: weight loss, night sweats
History of malignancy, infection or trauma
Steroid/drug abuse
Widespread neurology
```
70
Define widespread neurology
Neurological symptoms that can't be explained by a single nerve root defect
71
What is cauda equina syndrome?
Compression, trauma, spinal stenosis or other damage to the cauda equina
I.e. The spinal cord after its termination at L2
72
What are the features of cauda equina syndrome?
Bilateral sciatica + perianal numbness (saddle anaesthesia)
| Complete cauda equina = detrusor involvement - painless retention leading to incontinence
73
What is the treatment for cauda equina syndrome?
Surgical decompression within 48 hrs of sphincter dysfunction for good prognosis
74
What part of the vertebral body is commonly affected by tumours?
Pedicle
75
What colour is water on T2-weighted MRI?
White
76
What are the most common cancers found in the spine?
Mets
| Lung, breast, kidney, prostate, thyroid
77
What primary tumour may appear in the spine?
Myeloma
78
What infections may be present in the spine?
Spondylo-discitis
Epidural abscess
Paravertebral abscess
TB
79
What are the features of neurological claudication?
```
Proximal to distal
Variable distance
Sit to relieve (jelly legs)
Relieved in minutes
Associated pins and needles, numbness and weakness
```
80
What are the features of vascular claudication?
Distal to proximal
Fixed distance
Stand to relieve
Relieved in seconds
81
What is the management for spinal stenosis?
Physio
Pain relief
Injections
Surgical decompression
82
What is the conservative/medical management of sciatica?
```
Short period of bed-rest
Analgesics
Muscle relaxant eg diazepam
Neuromodulating agents eg gabapentin
Physio once pain is under control
```
83
What surgery may be offered for sciatica?
Mini discectomy
| Micro discectomy
84
What are the features of mechanical pain?
Varies with activity and time
| Relieved by rest
85
What is the management of mechanical back pain?
Conservative with core stabilisation
Bed rest is bad
Aim for return to function ASAP
Simple analgesics and physio
86
What is referred pain?
Irritation of end place supplies felt in the whole area that the nerve supplies
87
What is the distinguishing feature of sciatica?
Must go below the knees
| If it doesn't, it is referred pain not sciatica
88
In the shoulder, if passive movement is greater than active, what does this suggest?
Nerve or tendon injury
89
What are the common shoulder problems in the 10-30 age group?
Instability
| Muscle packing problem
90
What are the common shoulder problems in the 40-60 age group?
Impingement
Adhesive capsulitis (frozen shoulder)
Inflammatory Arthropathy
91
What are the common shoulder problems in 60-80 year olds?
Degenerative cuff tear
Osteoarthritis
Cuff arthropathy
92
What are the 4 articulations at the shoulder?
Glenohumeral
Sternoclavicular
Acromioclavicular
Scapulothoracic
93
What is the function of the glenoid labrum?
Increases depth of joint
| Increases stability
94
What is the conjoined tendon?
Coracobrachialis + short head of biceps
95
What is the main surgical approach to the shoulder?
Deltopectoral
96
What are the stabilising factors of the shoulder joint?
```
Labrum
Ligaments
Capsule
Muscles
Negative pressure
Contact
```
97
What is true singing of the scapula?
Long thoracic nerve damage
98
What is the most common cause of winged scapula?
Muscle imbalance
99
What is Popeye's sign?
Rupture or adhesionary tear of biceps tendon
100
What nerve may be damaged in a posterior shoulder dislocation?
Axillary
101
How do you palpate the shoulder?
Use 2 fingers
One side at a time
Only palpate the affected shoulder but still look and move both
102
How do you feel the head of humerus?
Rotate shoulder internally and externally to feel the head moving in the sulcus
103
What movements do you test at the shoulder?
Forward elevation
Rotation: external and internal
Abduction: with palms facing up
104
How do you test internal rotation at the shoulder?
Put hands behind back, how high can their thumb reach? Should be mid-thoracic spine for full ROM
105
How do you test external rotation of the shoulder?
Lock elbows at side
106
What condition is suggested if both active and passive movements are restricted at the shoulder?
Frozen shoulder
| Arthritis
107
Through what degrees of shoulder abduction is painful arc syndrome?
40-120
108
How do you test rotator cuff function?
Supraspinatous: abduction
Infraspinatous & teres minor: resist pressure when in full external rotation
Subscapularis: empty beer can
109
What is the Scarff test?
Put arm across neck
| Pain = acromioclavicular joint pain
110
What are the causes of impingement at the shoulder?
Bursitis
Tendonitis (eg calcific)
Inflammation
Tear
111
What scoring system is used for hypermobility?
Beighton score
| Ligamentous laxity
112
How do you finish a shoulder examination?
Neurological examination
| Examination of cervical spine
113
What is the main clinical feature of a frozen shoulder?
114
How is a frozen shoulder managed?
1- NSAIDs, steroid injections
2- MUA, distension, arthrogram
3- leave it alone
Physio may make it worse
115
How do you manage shoulder impingement?
Physio
Steroid injections
USS/MRI to check for cuff tear
Su acromegaly decompression
116
How are steroid injections used in impingement syndrome?
Maximum 3
Each 6 weeks apart
Only give 2nd if the first gives sustained benefit
117
What is a Bankart lesion?
Shoulder dislocation causing tear of the glenoid labrum in the anteroinferior portion
Provides an area for the humeral head to dislocate into
118
What is a Hill-Sack's lesion?
Impaction causes fracture of posterior humeral head
119
What are the common conditions of the elbow in children?
Pulled elbow
Fractures: supracondylar, epicondyles, radial neck
Infection
120
What are the common elbow conditions in older people?
Lateral epicondylitis
Medial epicondylitis
Osteoarthritis
Fractures: radial head, Olecranon, distal humerus
Nerve entrapment: ulnar, palmar interosseous, median
121
What do you look for in all MSK examinations?
```
MRS SAD
Muscle wasting
Rash
Scars
Swelling
Asymmetry
Deformity
```
122
Which deformity of elbow alignment is a functional problem?
Valgus - can stretch the ulnar nerve, causing palsy
123
What is 3-point relation at the elbow?
Olecranon, medial and lateral epicondyles make an isosceles triangle when bent, and a straight line when extended
124
What movements do you test at the elbow?
Flexion/extension
| Supination/pronation, with elbows bent at side
125
What are the special tests at the elbow?
Golfer's elbow: flex wrist against resistance, palpate for tenderness
Tennis elbow: extend wrist against resistance, palpate lateral epicondyle for tenderness
Instability: test collateral ligaments
126
What is the most common elbow dislocation?
Posterolateral
127
What are the causes of a stiff elbow?
OA
| RA
128
What is the volar surface of the hand?
Palmar surface
129
What is the relation of the MCPJ of the thumb and those of the other fingers?
Thumb MCPJ is at 90degrees to others
130
What is the normal resting posture of the hand?
Cascade: little finger is the most flexed at rest
131
What does a single palmar crease signify?
Simian crease
| Seen in down's and other congenital syndromes
132
What are Heberden's nodes?
Swelling and deformity of distal IPJs
| Classic of OA
133
What are the signs of RA in the hands?
Symmetrical swelling
| Ulnar deviation of proximal finger joints
134
What are Dupuytren's?
Contracture of fibrous bands in palmar fascia
135
What are the borders of the anatomical snuffbox?
Radial side: extensor pollicis brevis
| Ulnar side: extensor pollicis longus + extensor digitorum
136
What does tenderness in the anatomical snuffbox suggest?
Scaphoid injury
137
What does tenderness at the tip of the radial styled process suggest?
deQuervain's disease
| = tenovaginitis of combined sheath of EPB and AbPL
138
What movements do you test in the hand?
Wrist flexion/extension
Ulnar/radial deviation
Pronation/supination
139
How do you test thumb movements?
Hold patient's hand flat on the table dorsal surface down
1. Stretch to the side (extension)
2. Point to the ceiling (abduction)
3. Pinch my finger (adduction)
4. Touch your little finger (opposition)
140
How do you test flexor digitorum profundus?
Hold proximal IPJ extended and ask patient to bend finger
141
How do you test flexor digitorum superficialis?
Inactivate profundus by holding other fingers in extension and ask patient to flex finger to be tested
142
What are the differences in the tendons of FDS and FDP?
FDS has 4 separate muscle bellies
| FDP has 1 belly then splits into 4 tendons
143
What is the Tonodesis test?
Flex wrist - fingers extend
| Extend wrist - fingers flex
144
How do you test extensor digitorum/indicis?
Make fist and stretch out relevant finger
145
What is Allen's test?
Compress both ulnar and radial arteries, get patient to make fist and clench
Open hand out and release first radial artery: how quickly does it go from white to red? Then repeat releasing ulnar first
146
How do you test interosseous muscle function?
Spread fingers and push little fingers against each other
| If one is weaker, that hand's fingers will collapse
147
What is Froment's sign?
Grip card between thumb and index finger
If adductor pollicis is weak, the affected thumb will be flexed to bring FPL into action
Also tests ulnar nerve function
148
What is Tennell's test?
Tap halfway between borders of wrist to stimulate median nerve
Causes tingling/shooting in median distribution
149
What are nerve symptoms?
```
Tingling
Weakness
Numbness
Pain
Muscle wasting
Loss of dexterity
```
150
How do you test nerve function in children following fracture?
Thumbs up = radial
Make O = anterior interosseous
Cross fingers = ulnar
151
What is Phalen's test?
Flex wrist
| Causing pain within 1 min = carpal tunnel
152
What are the causes of carpal tunnel syndrome?
```
Idiopathic
Hypothyroidism
Pregnancy
Wrist fracture
Work-related
```
153
What is the first part of the nerve affected when it is compressed?
Myelin, leading to decreased conduction velocity
154
Where are the majority of ulnar nerve compressions?
Cubical tunnel (elbow)
155
What digits are affected by ulnar nerve compression?
Ulnar 1.5 fingers
156
What muscles are affected by ulnar nerve compression?
Intrinsic muscles of hand
Adductor pollicis
FDP
157
What fracture can cause radial nerve damage?
Humeral shaft
| Most commonly lower third of humerus
158
Where do you check sensory supply of the radial nerve?
1st dorsal webspace
159
What is the motor supply of the radial nerve?
Wrist extensors
Finger extensors
Extensor pollicis longus
160
What are the risk factors for Dupuytren's contractures?
Family history
Alcoholism
Diabetes
Hand trauma
161
What is the threshold for intervention in Dupuytren's?
When they can't get their hand flat on the table
162
What is trigger finger?
Pulley that holds tendon against bone becomes thickened
| Means the tendon gets stuck and doesn't move smoothly
163
What is DeQuervain's tenosynovitis?
Radial sided wrist pain
| Swelling and tenderness over styloid
164
How do you test for flexor tendon injury?
Cascade
Tenodesis test
Squeeze test
FDS and FDP tests
165
What is tenosynovitis?
Chronic inflammation of a tendinous sheath
166
How many extensor compartments are there in the wrist?
6
167
What is the contents of the 1st extensor compartment of the wrist?
Abductor pollicis longus
| Extensor pollicis brevis
168
What joints in the hand are commonly affected by osteoarthritis?
DIPJ
| MCPJ
169
What are Bouchard's nodes?
Swelling over PIPJs
170
What are the differentials for a lump in the hand?
Endochondroma
Giant cell tumour
Malignant tumour
Cystic eg ganglion
171
What type of scaphoid fracture takes longest to heal and why?
Tail
| It is furthest from he blood supply (which is distal to proximal)
172
What does an enlarged gap between carpal bones suggest?
Ligament rupture
173
What is SNAC?
Scaphoid non-Union advanced collapse
174
What is the main risk with scaphoid fractures?
Avacular necrosis due to disruption of the blood supply
175
How are finger fractures stabilised?
Buddy strapping
Splintage
Internal fixation
176
What are the risk factors for hand infections?
```
Peripheral vascular disease
Diabetes
Immunocompromised
Innocuous injury eg gardening
Smoking
IVDU
```
177
What are the feature of a flexor sheath infection?
Confines to digit affected
Tender on volar aspect
EMERGENCY
178
What is pollicisation?
Turning a finger into thumb
| May also use a big toe to make a thumb
179
What is excision arthroplasty?
Removal of arthritic parts of the joint
180
What is interposition?
Autograft
| In the thumb, take part of flexor carpi radialis and use it as a sling to wrap around the joint
181
Why do patients with arthritis get stiffness when starting walking after rest?
Normally cartilage creates a fluid film when you get up from a period of inactivity
Bone on bone in arthritis initially, as fluid takes longer to build up due to less cartilage being there
182
What are the red flag symptoms for the hip?
Severe night pain
Inability to weight bear on limb
History of malignancy
Rapid deterioration of symptoms
183
How do you do Trendelenburg's test?
You're testing the leg they're standing on
Sit down and hold their pelvis, tell them to hold your elbows
If positive, you feel the pelvis drop and they push on your elbow (when they are stood on the bad leg)
184
How do you position the patient to feel the hip joint?
Patient laid on side with knees to chest
185
What bony prominences should you feel for in a hip examination?
```
ASIS
PSIS
Greater Trochanter
Pubic Tubercle
Ischial Tuberosity
```
186
What area is commonly tender in an arthritic hip?
Anterior groin
187
Other than bony prominences, what else do you feel for in a hip examination?
Pulses
| Leg length - thumbs behind each medial malleolus
188
What movements should you test at the hip?
Flexion then...External and internal rotation
Ab and adduction
External and internal rotation with leg in extension
189
What movement at the hip is most sensitive to arthritis?
Internal rotation
190
What special tests do you do at the hip?
Leg length - pulses at the same time
Thomas' test (fixed flexion deformity)
Trendelenburg
191
What does the leg look like when the hip is fractured?
Externally rotated and shortened
192
What are the features in a history that suggest OA?
Other joint involvement
Gradual onset, progressing over a long time
Pain, stiffness, loss of function
Family history
193
What is GTPS?
Greater Trochanteric Pain Syndrome
Eg Trochanteric bursitis
Terrible pain there all the time, can't sleep on affected side
194
What is FAI?
Femoroacetabular impingement
Pre-arthritic hip, due to tearing of labrum
Common in sportsmen
195
How do you test for FAI?
Flexion + adduction + internal rotation
196
What are the causes of avascular necrosis of the head of femur?
```
Alcohol
Steroid
Transplant
Liver disease
Trauma
```
197
What does the head of femur look like in avascular necrosis?
White and sclerotic
198
What are the signs of hip infection?
Severe pain and systemic sepsis
Common in children
Very stiff and unable to weight bear
199
How do you manage hip infection?
USS shows fluid in hip
| Urgent referral - needs decompression and cleaning early
200
What is SUFE?
Slipped Upper Femoral Epiphysis
201
When a lytic lesion has no clear edges, what does this suggest?
Aggressive tumour
| No osteoblast activity
202
What are the risk factors for #NOF?
```
Caucasian
Female
70+ years
Osteoporosis, osteomalacia
Diabetes, stroke, alcoholism, chronic debilitating disease
Muscle weakness, poor balance
```
203
What is the Garden classification of #NOF?
1. Incomplete impacted fracture
2. Complete undisplaced
3. Complete with moderate displacement
4. Severely displaced
204
What is the blood supply to the head of femur?
Intramedullary vessels in femoral neck
Ascending branches of medial and lateral circumflex femoral arteries
Vessels of ligamentum teres - insufficient in adults
205
What is the potential complication of displaced #NOF and why?
Avascular necrosis of femoral head
| Tearing of ascending branches of medial and lateral circumflex arteries (found in capsule)
206
How are elderly patients managed post-op hip fractures?
Early mobilisation
| To prevent pulmonary complications and bed sores
207
How are hip fractures managed in young people?
Reduce fracture and check with X-Ray
If satisfactory, fix with screws
Impacted fractures can be fixed as they lie
208
What is hemiarthroplasty?
Only femoral part of hip joint replaced
209
What are the indications for THR in hip fractures?
Acetabular damage
| Metastatic or Paget's disease
210
What are the advantages of hemiarthroplasty vs THR in hip fractures?
Shorter operating time
Less blood loss
Lower infection rate
211
What are the three types of proximal femur fracture?
Transcervical (neck of femur)
Intertrochanteric
Subtrochanteric
212
How are intertrochanteric fractures managed?
Internal fixation - dynamic hip screw
213
How do Subtrochanteric fractures compare to NOF fractures?
Blood loss greater in Subtrochanteric
214
How are Subtrochanteric fractures managed?
Open reduction + internal fixation with intramedullary nails and locking screws into femoral head
215
What is a common complication of Subtrochanteric fractures?
Malunion
216
What are the common presenting complaints with the knee?
```
Pain
Stiffness
Loss of function
Locking
Giving way
Swelling
Trauma
```
217
What is locking of the knee?
Can't be flexed
218
What does the knee giving way going down stairs suggest?
PFJ problem
219
What does the knee giving way on twisting/locking suggest?
Meniscus problem
| Osteoarthritis
220
What pain may be referred to the knee and why?
Hip
| Femoral nerve innervation
221
What is an antacid gait?
Hopping onto the good leg as soon as possible
| To avoid pain
222
What is a varus thrust?
Knee buckles to the side as it weight-bears
223
What bony landmarks should you feel for in the knee?
```
Femur
Tibia
Patella
Joint line
All done in 90degree flexion
```
224
What is the sweep test?
Testing for effusion in the knee
| Sweep fluid from medial side, then push back
225
What special tests do you do for the knee?
```
Sweep test
Collaterals
Anterior/posterior drawer
Lachman's
Straight leg raise
```
226
How do you do anterior/posterior drawer tests?
Fix foot by sitting on it
| Fingers either side of tibial tuberosity and rock back/forwards
227
What is Lachman's test?
For ACL
Pull tibia back/forward on femur
One hand on each bone at 30degrees
228
What is the straight leg raise test for?
Shows extensor mechanism is intact
229
What knee conditions are common in adolescents?
```
Trauma/sporting injury eg meniscus, ACL, patella dislocation
PFJ pain
Osteochondritis dissecans
Inflammatory arthritis
Tumour
Infection
```
230
What knee conditions are common in elderly patients?
```
Osteoarthritis
Trauma
Crystal deposition
Infection
Secondary tumour
```
231
What are the red flag symptoms for the knee?
```
Inability to weight bear
Worsening pain
Acutely very stiff knee
Fever
Night pain
History of malignancy
```
232
What are the functions of the menisci?
Improve articulate congruency and stability
Control rolling and gliding of knee
Distribute load during weight bearing
233
Which meniscus is more liable to tearing and why?
Medial - less mobile than lateral meniscus
234
What types of meniscal tear are there?
Bucket-handle
Anterior horn
Posterior horn
Horizontal tear
235
What types of meniscal tear have worse healing?
Tears closer to the centre of the joint
| This area is avascular
236
What is the common presenting complaint of a meniscal tear?
Severe pain
Knee locked in flexion
Young patient following twisting injury to the knee
237
What is the imaging of choice for meniscal tears?
MRI
| White line through meniscus = tear
238
What is osteochondritis dissecans?
Small fragment of avascular bone and overlying cartilage separates from femoral condyle
Later appears as a loose body in the joint
Intermittent pain and swelling
239
What are the causes of loose bodies in the knee?
```
Injury - chip of bone or cartilage
Osteochondritis dissecans
Osteoarthritis
Charcot's disease
Synovial chondromatosis
```
240
What factors pre-dispose to OA of the knee?
Torn meniscus
Injury to articular surface
Ligament instability
Pre-existing deformity
241
Where does cartilage breakdown most commonly start in the knee?
Area of greatest weight-bearing...medial compartment
242
What may you observe in an osteoarthritic knee?
Swelling
Varus deformity
Quadriceps wasting
243
What are the signs of OA on X-ray?
Loss of joint space
Subchondral sclerosis
Osteophytes
Sunchondral cysts
244
What is the conservative management of osteoarthritis?
Analgesia
Apply warmth
Physio (quads)
Reduce joint load by sticks or weight loss
245
What are the indications for knee surgery in OA?
Persistent, unresponsive pain
| Progressive deformity and instability
246
What happens in knee arthroscopy for OA?
Trim meniscal fragments/osteophytes and washout
| Temporary relief, useful if reconstructive surgery is contraindicated
247
When is realignment osteotomy used for OA?
Medial compartment disease in young people
248
What are the sources of anterior knee pain?
Referred pain from the hip
Patellofemoral disorders
Knee joint disorders
Periarticular disorders
249
What is Osgood-Schlatter's disease?
Tibial tubercle apophysitis
250
What patellofemoral disorders can cause anterior knee pain?
Patellar instability
Patellofemoral overload
Osteochondral injury
PFJ arthritis
251
What is suggested by the feeling of the knee wanting to give way, or actually doing so, during weight-bearing activity?
Chronic ligamentous instability
252
What are the types of tibiofemoral instability?
```
Sideways tilt (varus or valgus)
Excessive glide (forwards or backwards)
Unstable rotation
```
253
What are the indications for surgery in chronic ligamentous instability?
Intolerable giving way
Unacceptably reduced function
Associated internal injury eg torn meniscus
Symptomatic ligament injuries in adolescents
254
What is Sinding-Larsen-Johansson syndrome?
Patellar tendinitis due to patellar ligament strain or partial rupture
Common in adolescent athletes
Repeated episodes of pain and local tenderness
255
What is the function of the medial foot?
Stability and rigidity
256
What is the function of the lateral foot?
Flexibility
257
What is the function of the plantar fascia?
Helps support arch
| Attaches skin to underlying tissue
258
What is suggested by acute pain around the 1st MTPJ?
Gout
259
What is metatarsalgia?
Diffuse ache across the forefoot
260
Where is the subtalar gap?
In front of the lateral malleolus
261
What is the nerve supply to the majority of the dorsum of the foot?
Superficial peroneal nerve
262
What is the sensory supply to the lateral foot?
Sural nerve
263
What should you look for when examining the foot?
Shoes
Whole leg: hip and knee
From front: alignment
Swelling, callosities, ulcers, vascularity
From behind: alignment, swelling, callosities, muscle bulk
Side: arches
Sole: plantar ulcer and callosities
264
How many toes should you see from behind the foot?
2
| More indicates a flat foot - too many toes sign
265
What does walking on the outside of the feet test?
Tibialis posterior function
266
What does deep pain and tenderness under the medial arch suggest?
Plantar fasciitis
267
What movements should you test at the ankle?
```
Dorsiflexion
Plantarflexion
Inversion
Eversion
Flexion and extension of toes
```
268
What is the normal range of dorsiflexion at the ankle?
15 degrees
269
What is the normal range of plantarflexion at the ankle?
40 degrees
270
How do you test tibialis posterior function?
Point toes and push foot inwards while I resist
| Tendon should stand out clearly behind medial malleolus
271
What is Thomson's test?
Squeeze calf and foot automatically plantarflexes
| Doesn't happen if Achilles has ruptured
272
What happens to the heels when you stand on tiptoes?
Swing into valgus
| Action of tibialis posterior
273
How do you complete a foot and ankle examination?
Vascularity - pulses
| Neuro: sensation and proprioception
274
What is hallux valgus?
Bunion
275
What happens in bunion surgery?
Metatarsal osteotomy - break and move metatarsal and put in screws/staples
276
What is hallux rigidus?
Arthritis of 1st metatarsophalangeal joint
277
What are the surgical options for hallux rigidus?
Osteotomy
Arthrodesis
Arthroplasty: excision/interposition/replacement
278
What is planovalgus?
Flat foot
279
What is the treatment of planovalgus?
Medial arch support
Physio
Can reconstruct tib post tendon
280
What are the features of ankle arthritis?
Pain anteriorly over ankle
| Stiffness
281
How do you treat ankle arthritis?
Limit movement eg braces
Total ankle replacement
Osteotomy, arthrodesis, arthroplasty
282
In what order are ankle ligaments commonly damaged?
Anterior talofibular
Calcaneofibular
Posterior talofibular
283
What proportion of ankle sprains are associated with a fracture?
15%
284
When is an X-ray indicated with ankle sprain?
Pain around the malleolus
Inability to weight bear/take 4 steps
Bone tenderness around base of metatarsal V
285
How do you remember the structures passing anterior to the medial malleolus?
All Hospitals Are Not Very Dirty Places
286
What else is commonly injured in ankle fractures?
Ligaments - invisible part of the injury
287
What ankle fractures require internal fixation?
Displaced fractures and fracture-dislocations
288
What are the complications of ankle fractures?
Joint stiffness
Complex regional pain syndrome
Osteoarthritis
289
What is a Pilon fracture?
Tibial plafond fracture
| Severe axial compression of ankle joint eg fall from height
290
What is commonly associated with calcaneal fractures?
Spine, pelvis or hip injuries
291
What are the common causes of metatarsal fractures?
Direct blow
Severe twisting
Repetitive stress
292
What is the composition of bone extracellular matrix?
35% organic material: type I collagen, proteoglycans, glycosaminoglycans, lipids
65% inorganic material: hydroxyapatite
293
What are cutting cones?
In bone formation
| Osteoclasts remove bone at the front of the cone, osteoblasts follow behind producing new bone
294
What is intramembranous ossification?
Preosteoblasts differentiate into osteoblasts which produce bone
This increases bone width
295
What is endochondral ossification?
Pre-existing cartilage template is replaced by bone to increase bone length
Due to osteoblast activity
296
Define fracture
Break in the structural continuity of bone
297
What are the local complications of fracture?
Local oedema
Inflammatory reactions
Neurovascular impairment
298
What is an open fracture?
Breach in skin or body cavity
299
What is primary bone healing?
Minimal granulation tissue and no callus
Cutting cones form and cross the fracture site
Osteoclasts clear damaged bone and osteoblasts produce new bone
Happens if defect/gap is small
300
What are the stages of secondary bone healing?
Haematoma formation
Fibrocartilaginous callus formation
Bony callus formation
Bone remodelling
301
How does a haematoma form over a fracture site?
Fracture causes rupture of vessels
Damaged tissue and platelets release cytokines, vasomodulatory substances and growth factors
Causes clot to form
302
What is Wolff's law?
Bone can remodel and adapt to the loads placed on it
303
What are BMPs?
Bone Morphogenic Proteins
I.e. Cytokines, metabolites
Induce formation of bone and cartilage
304
How does PTH affect bones?
Stimulates osteoclasts
305
What factors interrupt bone healing?
Movement of bony fragments
Soft tissue lying in between bony fragments
Misalignment
Infection
Bone disease
Surrounding soft tissue injury - damages blood supply
306
What patient factors interrupt fracture healing?
```
Poor general health
Malnutrition
Drug therapy
Age
Smoking
Diabetes
```
307
How does diabetes affect fracture healing?
Defective collagen production
308
How does smoking affect fracture healing?
Reduces osteoblast activity
| Nicotine constricts vessels, reducing blood flow to fracture site
309
What local patient factors affect fracture healing?
Blood supply
Soft tissue damage
Bone loss - need bone contact for Union
310
What are the stages of fracture management?
Diagnosis
Reduction
Stabilisation
Rehabilitation
311
What forms the physical examination of a fracture?
Deformity - open or closed?
| Neurovascular status distal to fracture
312
How do you describe displacement of a fracture?
Distal fragment relative to proximal fragment
313
What is fracture translation?
% displacement
314
What is anatomical reduction of a fracture?
To restore perfect bony anatomy and morphology
| Required with joint fractures
315
What is functional reduction of a fracture?
To restore relationship between proximal and distal bone fragments
Length, alignment and rotation restored
Needed for metaphyseal and diaphyseal fractures
316
What is indirect reduction?
Closed reduction - lower infection risk
317
What are the indications for open reduction?
Failure of closed reduction
Large articular fragments
Avulsion fractures
Associated injuries eg arterial damage
318
What are the aims of fracture stabilisation?
Prevent fragment displacement
Alleviate pain
Allow soft tissue healing
Allow movement of unaffected joints
319
What are the different methods used for fracture stabilisation?
```
Sustained traction
Cast splintage
Functional bracing
Internal fixation
External fixation
```
320
What are the risks associated with cast splintage?
Cast too tight - constricts blood supply causing diffuse pain
Pressure sores
Stuff joints
Loose cast
321
What is functional bracing?
Segments of cast over bones, leaving joints exposed
| Segments connected by hinges
322
How may ultrasound be used in fracture healing?
Exogen ultrasound bone healing system
Treat non-union fractures of long bones
Stimulates production of growth factors and proteins to increase removal of old bone and production of new bone
323
What are the indications for internal fixation?
```
Can't be reduced with other techniques
Prone to displacement after reduction
Poor or slow fracture Union suspected
Pathological fractures
Multiple fractures
Patients with nursing difficulties
```
324
What are the potential complications of internal fixation?
Inaction
Non-Union
Implant failure eg metal fatigue
Re-fracture if implants removed too soon
325
What is external fixation?
Bone fixed above and below fracture site
| Screws, pins and tension wires connected together by rigid bars or attached to a frame
326
What are the complications of external fixation?
Soft tissue damage
Over-distraction
Pin-track infection
327
What are the aims of early movement and weight-bearing following fracture?
Prevent oedema
Restore joint movement
Restore muscle power
Introduce patient back to normal activity
328
How does exercise help fracture healing?
Stimulates blood flow
Prevents soft tissue adhesions
Promotes fracture healing
329
What antibiotics do you give immediately once an open fracture has been diagnosed?
Co-amoxiclav or Cefuroxime
| Clindamycin if penicillin allergic
330
How do you inspect an open fracture?
```
Clean or dirty
Gross contamination
Site and size
Tidy or ragged damage
Establish communication of wound with fracture
Condition of soft tissues
Neurovascular status
```
331
What are the steps in managing an open fracture in A&E?
```
ATLS assessment
Tetanus prophylaxis + Antibiotics
Inspect wound
Photograph
Revise splint from paramedics
X-ray or CT
Remove gross contamination and photograph again
Refer to ortho, plastics or vascular and transfer
```
332
When is amputation indicated for open fractures?
```
Uncontrollable haemorrhage
Incomplete traumatic amputation
4-6h of ischaemia
Segmental muscle loss of 2 compartments
Bone loss greater than 1/3 of the tibia
```
333
What are the causes of pathological fractures?
Tumour: primary or secondary
Infection
Metabolic disease: osteoporosis, osteogenesis imperfecta
334
What are the red flag symptoms for children?
Bone tenderness to palpation
Joint swelling
Muscle weakness
Fall in height or weight growth curve
335
What 5 cancers commonly metastasise to bone?
```
Kidney
Prostate
Thyroid
Breast
Lung
```
336
What are the red flag symptoms for soft tissue lumps?
>5cm
Deep to deep fascia
Painful
Enlarging
337
What investigations should you do if pathological fracture is suspected?
```
X-ray whole bone
CXR
PSA
Bence-Jones protein in urine (myeloma)
Isotope bone scan
CT chest
MRI lesion
```
338
What are the treatment options for pathological fractures?
Intramedullary nail
Cement augmentation
Replacement
Consider excision if tumour is primary and prognosis good
339
What are the three most common types of primary bone tumour?
Osteosarcoma
Chondrosarcoma
Ewing's sarcoma
340
Where do osteosarcomas commonly present?
Distal femur or proximal tibia
| Young adult
341
How do malignant bone tumours present?
```
Mass - 80%
Discomfort/pain - 40%
Fracture
Mets
Systemic symptoms
```
342
How do soft tissue sarcomas present?
Large mass
Deep to deep fascia
Rapidly growing
Calcification within mass on radiograph
343
What are the urgent complications of a fracture?
```
Vascular injury
Local visceral injury
Compartment syndrome
Haemarthrosis
Nerve injury
Infection
Gas gangrene
```
344
What are the late complications of fracture?
```
Malunion
Non-Union
Avascular necrosis
Muscle contracture
Joint instability
Regional pain syndrome
Osteoarthritis
```
345
What vessel is commonly injured in 1st rib fracture?
Subclavian artery
346
What vessel is commonly affected in shoulder dislocation?
Axillary artery
347
What vessel is commonly damaged in humeral supracondylar fracture?
Brachial artery
348
What vessel is commonly affected in knee dislocation?
Popliteal artery
349
What nerve may be damaged in a humeral shaft fracture?
Radial
350
What nerves may be damaged in humeral supracondylar fracture?
Radial
| Median
351
What nerve may be damaged in elbow dislocation?
Ulnar
352
What nerve may be damaged in a monteggia fracture?
Posterior interosseous
353
What nerve may be damaged in hip dislocation?
Sciatic
354
What nerve may be damaged in knee dislocation?
Peroneal
355
How may wrist fractures affect nerves?
Sometimes cause nerve compression
| Median or ulnar nerve
356
Define compartment syndrome
Raised pressure within an enclosed fascial space
| Leading to localised tissue ischaemia
357
What vessels are affected first in compartment syndrome?
Veins
358
What are the causes of acute compartment syndrome?
```
Fracture (70%)
Crush syndrome
Bleeding disorder / anticoagulants
Soft tissue injury without fracture
Reperfusion injury
Infection
Iatrogenic eg osteotomy, reduction
```
359
Where is compartment syndrome most common?
Lower limb
| Mainly due to tibial fractures
360
What are the clinical features of compartment syndrome?
Pain: excessive or progressive, not relieved by analgesia
Tense, swollen compartment
Paraesthesiae
Pulses rarely absent
361
What test can tell you which compartment is involved in compartment syndrome?
Passive stretch test
| Pain
362
How do you manage acute compartment syndrome?
Split circumferential dressings to skin
Single dose opiate
Reassessment
May need compartment pressure monitoring
363
Who should have compartment pressure monitoring?
```
Unconscious
Difficult to assess
Multiple injuries
Associated nerve injury
Young men
```
364
What are the compartments of the lower leg?
Anterior
Lateral
Deep posterior
Superficial posterior
365
How is fasciotomy of the lower leg performed?
2 incisions:
| Medial and anterolateral
366
What are the three compartments of the thigh?
Anterior
Medial
Posterior
367
What are the three compartments of the forearm?
Palmar (flexor)
Dorsal (extensor)
Radial
368
How is compartment syndrome managed post-op fasciotomy?
```
Leave wounds open
Loose absorbent dressings
Gentle elevation
Fluid balance and analgesia
Re-inspection + debridement + delayed closure @ 2-5d
```
369
What are the complications of compartment syndrome?
```
Muscle necrosis
Joint stiffness
Nerve fibrosis
Delayed fracture union
Significant functional impairment
```
370
What type of deformity is common following tibial fracture?
Ischaemic contractures
371
How do microorganisms reach bones and joints?
Bloodstream
| Direct invasion from skin puncture, operation or open fracture
372
What can microbial invasion in bones and joints lead to?
Pyogenic osteomyelitis
Arthritis
Granulomatous reaction (chronic)
373
Why does bone infection lead to necrosis more rapidly than soft tissue infection?
It is a rigid compartment so
| More susceptible to cell death from pressure build-up in acute inflammation
374
What factors increase susceptibility to infection of bone?
Local factors: trauma, poor circulation, chronic bone or joint disease and presence of foreign bodies
Systemic factors: malnutrition, general illness, diabetes, RA, steroid treatment
Very young or very old age
375
What is the pathophysiology of acute pyogenic infection?
Pus formation = concentration of defunct leucocytes, dead bacteria and tissue debris
Often localised to form an abscess
376
What are the principles of treatment for pyogenic bone infection?
```
Analgesia and supportive measures
Rest affected area
Antibiotic or chemotherapy treatment
Evacuate pus and necrotic tissue
Stabilise bone if fractured
Maintain soft tissue and skin cover
```
377
What organism is the most common cause of acute osteomyelitis?
Staph aureus
378
Why does acute osteomyelitis lead to bone necrosis?
Rising intraosseus pressure
Vascular stasis
Compromise of blood supply to bone
379
Where do children commonly get acute osteomyelitis?
Organisms settle in metaphysis of long bones
| Commonly distal femur or proximal tibia
380
How does acute osteomyelitis present?
Most commonly children under 4
Severe pain, malaise and fever
May be history of preceding skin lesion, injury or sore throat
Holding limb still, acutely tender over nearby joint, pseudoparalysis
381
Where is the commonest site of acute osteomyelitis in adults?
Spine
382
What are the differential diagnoses for acute osteomyelitis?
Cellulitis
| Sickle cell crisis
383
What are the complications of acute osteomyelitis?
Spread to joints or other bones
Pathological fracture
Growth disturbance
Persistent infection
384
What is subacute haematogenous osteomyelitis?
Osteomyelitis in a relatively mild form
| Due to less virulent organisms or a more resistant patient
385
What is a Brodie's abscess?
Small oval cavity surrounded by sclerotic bone
| Classic of subacute haematogenous osteomyelitis
386
What is the commonest cause of osteomyelitis in adults?
Post-traumatic (open fractures)
387
How does chronic osteomyelitis present?
Following acute bone infection
| Recurrent episodes of pain, redness, tenderness at affected site
388
What organism commonly causes septic arthritis?
Staph aureus
389
How do organisms get into a joint to cause septic arthritis?
Penetrating wound
Eruption of adjacent bone abscess
Blood spread from distant site
390
What joints are most commonly affected by septic arthritis?
Hip in children
| Knee in adults
391
What does X-ray show in septic arthritis?
Soft tissue swelling
Widening of joint space due to effusion
Periarticular osteoporosis
392
How do you investigate septic arthritis?
Joint aspiration and send for microbiology
393
What are the differential diagnoses for an acute swollen joint?
```
Septic arthritis
Osteomyelitis
Acute haemarthrosis
Transient synovitis
Gout or pseudogout
```
394
What are the complications of septic arthritis?
Dislocation
Epiphyseal destruction
Growth disturbance
Ankylosis
395
What is the management of septic arthritis?
Antibiotics
Splintage
Drainage
396
What is NAI?
Non-accidental injury
397
What is the cause of 90% of fractures before age 1?
Non-accidental injury
398
What are Greenstick fractures?
One side of the periosteum stays intact when the bone is bent, so the fracture is not full thickness
Because periosteum is very thick in children
399
Give a cause of a physeal fracture
Knee hyper extension injury
400
What is the apophysis?
Centre of ossification where a tendon is inserting
401
In what order to the ossification centres develop at the elbow?
```
CRITOL
Capitulum
Radial head
Internal (medial) condyle
Trochlea
Olecranon
Lateral epicondyle
```
402
What are the differential diagnoses for a limping child?
```
Infection
Developmental Dysplasia of the hip
Perthes' disease
SUFE (adolescent)
Club foot
```
403
How does hip infection present in children?
Unable to weight bear
Raised WCC and CRP
Fever over 38.5
404
What are the risk factors for developmental dysplasia of the hip?
Female
Family history
Breach presentation at birth
405
How do you test for developmental dysplasia of the hip?
Ortolani test: reduces dislocation
| Abduct and lift, feel it clunking back into place
406
How do you treat developmental dysplasia of the hip?
Frame to abduct and flex hip
407
What is Perthes' disease?
Avascular necrosis of the hip
Cause of loss of blood supply unknown
Causes deformity of the head of femur and predisposes to OA
Commonly presents in 4-8y, but can be other ages
408
What is SUFE?
Slipped Upper Femoral Epiphysis
| Neck of femur slipping and externally rotating can cause avascular necrosis, impingement or secondary OA
409
What is the incidence of club foot?
1 in 1000
410
How is club foot managed?
Slowly manipulating feet using plaster casts
| Minor surgery may be required later on if the problem recurs
411
How does foot alignment change during development?
Infant: geno varum
2-3y: geno valgum
7y: adult alignment (coronal)
