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Phase II > MSK > Flashcards

MSK Flashcards

1
Q

De Quarvains patho

A

Thickening of tunnel in which APL and EPB travel through

Pregnancy known aetiology, hormones?

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2
Q

Symptoms of de quarvain’s tenosynovitis syndrome

A

Pain on using thumb felt at side of wrist
Swelling
Stiffness
Trigger or catch

pain on the radial side of the wrist
tenderness over the radial styloid process abduction of the thumb against resistance is painful
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3
Q

Test for de quarvains tenosynovitis

A

Finkelstein’s test: with the thumb is flexed across the palm of the hand, pain is reproduced by movement of the wrist into flexion and ulnar deviation

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4
Q

Treatment of de quarvain’s

A 
NSAIDS
	Rest and Splint
Steroid injection (thinning of skin at injection site
Tendon release
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5
Q

What is froments signs and why positive

A
  • Froment’s sign
  • Pinc paper
  • Normally Adductor pollicis (flat and holds) with lumbricles (unless median)
  • If not then Flexor policis longus and flexor digitorum profundus
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6
Q

What is retropulsion and why?

A

Extensor pollicis longus spontaneous break.

Old ladies

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7
Q

Important assessment in RA in hand?

A

Look at tendons

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8
Q

Causes of swan neck defromity

A

Swelling/ inflammation of volar plate due to synovitis/ effusions, causes hyperextension at PIP

	OR Traumatic from volar plate injury from hyperextension of digit e.g. basketball
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9
Q

Causes of boutonniere deformity

A

Extention DIP
Flexion POP
Rupture of central slip over PIP joint so loss of extension of PIP (flexed), Extensor tendon slips down causing extension of DIP
ED splits into 3 at MCP joint

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10
Q

Treatment boutonniere deformity

A

Spliont 6 weeks, encourage movement

Repair and relocate band

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11
Q

UMN vs LMN

A

UMN

LMN

Reflexes

Increased (loss of

Absent

Tone

Increased/Spastic paralysis

Flaccid

Atrophy

None

Atrophy

Fasciculations

Absent

Present possibly

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12
Q

What is Hoffman reflex?

A
  • Flick middle finger

* Positive = UMNL amd flexion of terminal phalax of thumb

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13
Q

How to assess motor of upper limb

A
  • C5 -> Elbow flexion
  • C6 -> Wrist extension
  • C7 -> Elbow extension
  • C8 -> like a cat
  • T1 -> finger abduction
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14
Q

upper limb neuro sensory

A
  • Sensory – light and pin prick
  • C4 -> Top of deltoid
  • C5 -> anterior cubital fossa, lateral side, just proximal on bicep
  • C6 -> Thumb dorsal aspect
  • C7 -> Middle finger dorsal aspect
  • C8 -> Little finger dorsal aspect
  • T1 -> anterior cubital fossa, medial side, just proximal to elbow
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15
Q

upper limb neuro motor

A
  • Make easy for patient (active movements then put in full extension as easier)
  • Stabilise patient – always hold appropriate joint
  • C5 -> Elbow flexion
  • C6 -> Wrist flexion
  • C7 -> Elbow extension
  • C8 -> like a cat
  • T1 -> finger abduction
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16
Q

Upperlimb reflexes

A
  • C5,6 – Biceps tendon (pick up sticks) anjd brachioradalis
  • C7,8 – Triceps tendon (lay them straight)
  • Hoffman
  • Flick middle finger
  • Positive = UMNL amd flexion of terminal phalax of thumb
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17
Q

Lower limb sensory

A
  • L1 = lateral to gonad on anterior thigh
  • L2 = halfway to knee anterior medial thigh
  • L3 – Medial knee
  • L4 – Medial malleuolus
  • L5 – Just distal to dorsalis pedis
  • S1 – Lateral posterior heel
  • S2 – Posterior knee
  • L1 = lateral to gonad on anterior thigh
  • L2 = halfway to knee anterior medial thigh
  • L3 – Medial knee
  • L4 – Medial malleuolus
  • L5 – Just distal to dorsalis pedis
  • S1 – Lateral posterior heel
  • S2 – Posterior knee
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18
Q

Lower limb motor

A
  • L2 – hip flexion
  • March like soldier
  • L3 – Knee extension
  • Squat
  • L4 – Ankle dorsi flexion
  • Walk on heel
  • L5 – Toe dorsiflexion
  • Walk on heel barefoot
  • S1 – plantarflexion ankle
  • Walk on tip toes
  • Anything wrong then examine on couch
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19
Q

Lower limb reflexes

A
  • S1/2 – ankle jerk (buckle my shoe)

* L3/4 – bicep brachii (kick the door)

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20
Q

MRC power scale

A

0 No muscle contraction is seen or identified with palpatio; paralysis
1 Can’t produce joint motion even without gravity but seen or felt
2 Muscle can move joint across full range of motion if force of gravity eliminated
3 Full range against gravity but not resistnace
4 Full range of motion against moderate resistance
5 Full ROM aginst full resistance of examiner

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21
Q

Where does the spinal cord end

A

L1/2

Anterior horn cells

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22
Q

HOw many nerves may a disc herniation knock out

A

2 or more if central (Williams diagnram)

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23
Q

hallux rigidus patho and cause

A

Unknown
Assoc
Trauma

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24
Q

Hallux rigidus presentation

A

Lump

Pain

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25
Q

Hallux rigidus treatment

A 
Foot orthotics, shoe modification
	NSAIDS
	Steroid injection
	PT
	Surgery 
		Osteotomy
		Arthodesis - fusion better for men
		Arthroplasty (surgical reconstruction)
			Excision
Interposition (something between joint)
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26
Q

Hallux valgus pathophysiology/ RFs

A 
RF
		Female 
		Middle aged
	Why?
		Genetic element
		Shoes contribute - high heels
		Space between 1 and 2 MCP 
		Splaying
		Tendon maintains line - extensor hallucis longus
Deviates and rotates toes
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27
Q

Hallux valgus Symptoms

A 
1MCP swelling, diavtion and rotation
		Hammer toe (2nd forced down)
			Hyperextension of DIP, flexion of DIP
		Overriding 1st toe
Callouses
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28
Q

Hallux valgus treatment

A 
Treatment
		Change shoe/ orthotics
		NSAIDs
		Do not operate for cosmetic reasons only if pain, second toe or ulceration
		Metatarsal osteotomy
			5% worse
			Hypersensitivity
Stiffness
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29
Q

Pes planus pathophysiology

A 
RF
		Female 
Middle age
	Pathophys
Weakness/ rupture of tib post
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30
Q

Pes planus history

A 
Progressive deformity
		History of trauma
		Pain behind MM
		Also impingement of lateral side and pain
Pain starts medial and moves lateral
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31
Q

Pes planus signs

A

Weakness/rupture of tibialis posterior tendon
Test tibialis posterior by plantar flexing foot & inverting
Inability to invert = weakness of tibialis posterior
Too many toes (valgus - look at heel from behind)
Heels fail to turn to varus on tiptoes

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32
Q

Treatment pes planus

A

Insoles- medial arch support
PT
Surgery
Reconstruction if foot flexible
Planovalgus (triple fusion)/ athrodesis
No flexibility - cant walk on angle but pain free

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33
Q

Pes planus xray

A

Loss of straight line of talus with tarsal and metatarsal (Meary’s angle)

Calcaneal pitch decreased - normally 20deg

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34
Q

Treatment of ankle arthritis

A 
o	Analgesia
o	Modify activity
o	Limit movement
o	Surgical
	Osteotomy
	Arthrodesis (fusion) - good for pain but not movement)
	Arthroplasty
•	Excision (removing the joint)
•	Interposition (tissue insertion between joint surfaces) 
•	Replacement
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35
Q

Causes of pes cavus

A
  • Bilateral pes cavus in a young person  Charcot-Marie-Tooth disease
  • Unilateral pes cavus  neurological
  • High arch due to overactive tibialis posterior
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36
Q

Features of pes cavus

A

o Curling of 1st MTPJ

o Heel varus at rest

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37
Q

What is Morton’s neuroma and symptoms

A

• Benign neuroma affecting the intermetatarsal plantar nerve
o Commonly in the 3rd inter-metatarsophalangeal space
• Features
o Forefoot pain – 3rd inter-MTP space
o Worse on walking

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38
Q

Diagnosis of morton’s neuroma

A

• Clinical diagnosis

o USS may help

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39
Q

Management of morton’s neuroma

A

• Management
o Avoid high-heels
o Metatarsal pad- splays two affected metatarsals/ orthotics
o Steroid injection/neurectomy of nerve & neuroma

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40
Q

Describe Weber classification of ankle

A

• Type A
o Fracture of the medial malleolus distal to the malleolus distal to the syndesmosis
 Below level of ankle joint
 Tib-fib syndesmosis intact
 Deltoid ligament intact (not always
 Medial malleolus often fractured
 Usually stable  open reduction & external fixation not needed, just do a cast
• Type B
o Fracture of fibula at level of syndesmosis
 Syndesmosis intact or only partially torn
 Medial malleolus may be fractured, or deltoid ligament torn
 Variable stability
• Type C
o Fracture of the fibula proximal to the syndesmosis
 Syndesmosis disrupted with widening of distal tib-fib articulation
 Medial malleolus fractured or deltoid ligament injury
 Unstable  requires open reduction, internal fixation

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41
Q

Describe full course, branches and innervation of the common fib

A 
Common fib L4-S2
	Arises from Sciatic nerve at apex of pop fossa
	Travels lateral to fibula neck- 2 cutaneous branches just before neck so spared in fracture
		Sural nerve
			Medial leg down to just below MM
		Lat sural nerve
			Lateral knee, lower thigh and leg
	Slits into deep and superficial
	superficial
		lat compartment
		Fib long and brev
		After lat continues travelling round to innervate lower antlat leg and dorsum of foot (not between toes 1 and 2)
	Deep
		Tib ant
		Extensor digitorum
		Extensor hallucis longus
		Fib terrt - MT5
Between toes 1 and 2 dorsum
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42
Q

Describe full course, branches and innvervation of tib

A 
Tib nerve L4-S3
	From pop fossa 
	Suferficial post comparment of leg
		gastroc and soleus and plantaris
		 Tib post, flex digitorum, flex hallucis, Popliteus
	Gives off sural
		Posterio lateral leg
	Post and inf to MM (tarsal tunnel)
	Terminates by dividing:
		Medial calcaneal
		Medial plantar
Lateral plantar
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43
Q

Shoulder history key symptoms

A 
•	Pain (SQITARS)
o	Onset – spontaneous, injury & mechanism
o	Site – localised (AC joint), diffuse (cervical pain)
o	Night pain
o	Activity related
o	VAS
o	Analgesia
o	Referred 
•	Stiffness (reduced ROM) (e.g. Frozen shoulder, arthritis)
o	Loss of active movement
o	Passive restriction
o	Overhead activities 
o	Diabetes 
•	Weakness
o	Pain
o	Cuff tear
o	Nerve palsy – axillary, long thoracic 
•	Instability
o	Caused by muscle imbalance, ligament laxity
o	Activities producing instability
o	Trauma
o	Arm ‘feeling dead’, ‘popping out’
o	Voluntary – doesn’t need treatment 
•	Swelling
o	Subdeltoid bursitis
o	ACJ dislocation
o	Malunion clavicle
o	ACJ OA – osteophytes
o	Infection
o	Cuff tear arthropathy 
o	Dislocated head
o	Fractures 
•	Neuropathy
o	Pressure on the plexus
o	Radiation from the neck
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44
Q

Spine red flags

A 
x	Age, weight loss, fever, widespread neurology
	History of cancer, infection
	Steroids / Drug abise
>55 <17
Non-mechanical pain
Thoracic pain
Night pain
Trauma history
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45
Q

Good questions if RTA

A

o Seatbelt/airbags/headrest?

o Anyone ejected or killed?

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46
Q

How to present a ortho xray

A

• BLT LARD
o Bone, Location of bone, Type of fracture
o Lengthening, Angulation (radial inclination), Rotation, Displacement

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47
Q

Cauda equina symptoms

A 
o	Bilateral/unilateral sciatica
o	Perianal/peri-genital numbness
o	Painless retention of urine
o	Urinary/faecal overflow incontinence (LMN sign) 
o	Loss of sexual function
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48
Q

Cauda equina pathogenesis and prognosis

A

• Commonly an extradural compression (disc compression)  leading to ischaemic insult
• Progressive neuro-deficit  permanent loss of sphincter control + motor paralysis + sensory loss of legs
o Prognosis better with decompression before sphincter paralysis
o Once paralysis develops recovery uncertain & likely to be incomplete

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49
Q

Cauda equina investigation

A

DRE

  • Sensation - blunt and sharp
  • squeeze
  • cough

Percuss bladder

MRI

Bladder scan (post void residue)

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50
Q

Cauda equina management

A

Urgent decompression

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51
Q

Tumour/ mets to back investigations

A

T2 MRI - better for bodies/ bone marrow

Xray - winking owl sign (loss of pedical between vertebrae and transverse process)

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52
Q

Management of back mets

A

o MRI – whole spine
o Staging/diagnostic CT CAP
o FBC, U&E, serum calcium, clotting screen
o Myeloma screen, other tumour markers
• Treatment
o Dexamethasone 16mg/day - decrease oedema around corn/ stop compression
o Keep patient supine if spine unstable
o Surgery indicated for
 Stabilising spine
 Decompress spinal cord to prevent paralysis
 Severe pain from mechanical instability

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53
Q

Infection of spine name and path

A

infective spondylodiscitis
Inflam or vertebral disc and vertebrae (spares arch)

Worldwide - TB
UK - staph aureus

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54
Q

Complications of infective spondylodiscitis

A

o Vertebral collapse
o Progressive angular kyphosis - bony destruction
o Extradural & paravertebral abscess

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55
Q

Management of infective spondyldiscitis

A 
o	Diagnosis often delayed (avg. 12 weeks)
o	Establish microbial diagnosis
	Blood culture/sputum specimen
o	Antibiotics
	6-12 weeks in non-TB
	6-12 months in TB
o	Surgery indicated in
	Paralysis from spinal cord/cauda equina compression
	Drainage of paravertebral abscess
	Mechanical instability
•	Progressive deformity
•	Severe pain on loading

Always stabalise/ decompress

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56
Q

Cervical spondlytotic myelopathy pathology

A

• Progressive damage to the cervical spinal cord due to
o Central stenosis – arthritic change in spinal cord, narrowing of pinal canal, pinch cancal or cauda equina
 caused by wear & tear

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57
Q

Symptoms of cervical spondylotic myelopathy

A

o Sensory/motor loss with incoordination e.g. holding fork, but and leg weakness
o Loss of dexterity & poor balance
o Bowl/ bladder symptoms and sexual disfunction
o Progressive in over 90% of patients over a 5-yr period
o UMN signs
o LMNS at level of spinal cord compression
o Pain upper neck

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58
Q

neurogenic claudication pathophysiology

A

lumbar spinal stenosis  impingement, ischaemia of lumbosacral nerve roots secondary to compression

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59
Q

Neurogenic claudication symptoms

A

Back pain worse supine/ standing e.g. relieved sitting
Better when spine is flexed e.g. walking uphill
Improves with movement
Variable distance (vasc is fixed)
Relieved in minutes (unlike vasc which is seconds)
Proximal to distal
Assoc with numbness and parasthesian

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60
Q

Neurogenic claudication treatment

A 
NSAID
PT
Steroid
Weight reduction
Surgical decompression
Interspinous distraction procedure e.g. insert device
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61
Q

Neurogenic claudication exam

A

Flexed posture
Loss of lumbar lordosis
Check peripheral pulses

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62
Q

Sciatica presentation

A

• Sudden onset (usually)
• Specific localised pain down to foot
o L3/4 – L4 root (anterior thigh to knee, shin)
o L4/5 – L5 root (lateral calf, medial/dorsal foot)
o L5/S1 – S1 root (posterior calf, lateral/plantar foot)
• Often associated with pins & needles
• Cough-impulse pain  rise in intradural pressure

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63
Q

Sciatica patho

A

 Spondylolithesi, spinal stenosis, spondylolisthesis, piriformis syndrome

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64
Q

What is Spondylolisthesis

A

Slippage of one vertebrae compared to another

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65
Q

Sciatica treatment

A

o 80% resolve in 3 months
o Short period of bedrest (2-3 days)
o Staying active & mobile within limits
o Analgesics – NSAIDs, codeine-based opiates
o Neuromodulating drugs – gabapentin, pregabalin
o If unresolving,
 Epidural/nerve root block with LA
 Lumbar discectomy successful in 90% patients in relieving neuropathic leg pain

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66
Q

PAget’s cause/ path

A

• Disturbance of both osteoblast and osteoclast activity
o Excess breakdown & formation of bone, followed by disorganised bone remodelling
o Frequently affects pelvis, spine, skull & proximal long bones
• Pathogenesis – 4 stages
o Osteoclastic activity
 Increased rate of bone resorption in localised areas
 Localised osteolysis seen radiologically
o Mixed osteoclastic-osteoblastic activity
 Compensatory increase in bone formation by osteoblasts
o Osteoblastic activity
 Accelerated deposition of lamellar bone in a disorganised fashion
• Chaotic picture of trabecular bone (‘mosaic’ pattern)
o Malignant degeneration
 Resorbed bone is replaced
 Marrow spaces filled with excess hyper-vascular fibrous connective tissue
• Causes
o Viral
o Genetic

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67
Q

Paget’s symptoms

A 
o	First is raised ALP 
o	Bone pain/back pain
	Localised pain/tenderness 
o	Bone weakening  
o	Misshapen bones
o	Fractures
o	Arthritis in joints near affected bones
o	Increased temp due to hyperaemia
o	Kyphosis/ Bowing deformity
o	Decreased ROM
o	Spine/ pelvis/ skull/ proximal long bones
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68
Q

Xray signs

A 
o	Spine
	Cortical thickening &amp; sclerosis 
	Squaring of vertebrae 
o	Skull
	Cotton wool appearance
	More b
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69
Q

Paget’s disease treatmetn

A

Bisphosphonates

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70
Q

Acute disc herniation pain exaccerbated by?

A

Cough

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71
Q

Acute disc herniation prog?

A

8/10 spontaneous resolution with time

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72
Q

Diff between mech and inflam back pain

A

Inflammatory back pain (IBP) is typically improved with activity and not relieved by rest,
as opposed to mechanical pain which is worse with activity and is relieved by rest. IBP
can wake the patient in the early hours of the morning and sacroilieitis can radiate to the
thigh, but these features are much less specific. Morning stiffness is specific for
inflammatory back pain but not persistent daytime stiffness. IBP can occur at any age
although mechanical pain is less common in young people.

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73
Q

Commonest conditions of shoulder at different ages

A
  • 10-30  Instability (dislocation), fractures
  • 40-60  Impingement, adhesive capsulitis, inflammatory arthropathy
  • 60-80  degenerative cuff tear, OA, cuff arthropathy
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74
Q

Treatment of shoulder OA

A

o NSAIDs

o Shoulder replacement if rotator cuff is intact

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75
Q

Adhesive caps what and stages

A

 Probs sleeping/ depression, RF chronic disease
 3 stages
 1 – ‘freezing’ stage. Slow onset of pain, ROM loss. 6 weeks  9 months.
 2 – ‘frozen’ stage. Slow improvement in pain but stiffness remains. 4  9 months
 3 – ‘thawing’ stage. Shoulder ROM slowly returns to normal. 526 months – doesn’t become normal in DM

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76
Q

Stabalising factors in shoulder

A
  • Labrum
  • Ligaments (sup. Mid. Inf. Glenohumeral ligaments)
  • Capsule
  • Muscles
  • Negative pressure
  • Contact
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77
Q

Adhesive caps treatment

A

 Stage 1 – NSAIDs, painkillers, and steroid injections in the joint
 Stage 2 – MUA/distension arthrogram (hydrodialtion)/leave alone
 Stage 3 – leave alone
 Physio may worsen condition

78
Q

Impingement/ tendonitis symp and treat

A 
	Activity modification
	Pain killers
	Steroid + LA injection (only 1/3 improve) max. of 3, 6 weeks apart
	Physiotherapy may help 
	Subacromial decompression
79
Q

Rotator cuff injury examination and treatment

A

o Examination
 Muscle wasting/weakness, crepitus
 Reduced active movement, normal passive ROM
o Treatment
 Rotator cuff repair – arthroscopic, open
 Physiotherapy

80
Q

Os Acromiale

A

o Failure of fusion of the acromion process

o Asympmatic but can cause subacromial impingement syndrome

81
Q

Anterior shoulder dislcation

A 
o	Bankart lesion
	Injury to anterior glenoid labrum
o	Hill-Sachs lesions
	Humeral head compression fracture – hits posterior glen
o	Treatment
	Neutral/external rotation splint
	Surgery
•	Arthroscopic stabilisation
•	Open Bankart repair
82
Q

Tennis elbow treatment

A 
	Rest, NSAIDs
	Physiotherapy
	Splint
	Steroid injection
	Surgery
83
Q

Elbow young people

A 
•	Young
o	Pulled elbow (radial head subluxation) [annular ligament]
o	Fractures
	Supracondylar
	Humerus
	Epicondyles 
	Radial neck
o	Infection
84
Q

Elbow older people

A 
•	Older
o	Lateral epicondylitis (micro-tear at origin of ECRB)
o	Medial epicondylitis (micro-trauma of flexor pronator mass)
o	OA
	Elbow locking due to loose bodies 
o	Fractures
	Radial head
	Olecranon 
	Distal humerus
o	Nerve entrapment
	Ulnar nerve
	Posterior interosseous nerve (deep branch of radial nerve, supplies most extensors in forearm. Trapped at angle of Frohse part of the supinator. Finger drop and radial wrist deviation on extension.
	Median nerve
85
Q

Elbow symptoms

A
  • Pain
  • Swelling
  • Stiffness
  • Locking
  • Neurological
  • Instability
86
Q

When to treat elbow fractures?

A

treat fractures if the anterior humeral line or radiocapitellar line are no longer intact.

87
Q

What is a Monteggia fracture/

A

o Proximal 1/3 ulna fracture with dislocation of the proximal radial head.
o Needs re-alignment with surgery

88
Q

Calcific tendonitis path and symptoms

A 
Path
		Hydroxyapatite (CaPo4) in any tendon )often rotator cuff
		Assoc with adhesive capsulitis
	Symp/ sign
		Pain on abduction 
		Pain on lying on shoudler
		May wake person from sleep
		Stiffness
		Weakness
		Can present acute on chronic
	Cause
Unknown
89
Q

Calcific tendinitis diag/ treatment

A 
Spontaneous improvemetn
		NSAID
		Steroid
		Physio
		ECSW therapy
		Surgery
High success to remove deposits
90
Q

What is Personage-Turner syndrome RF and symptoms

A

x

91
Q

Personage-Turner syndrome treatment and prognosis

A

x

92
Q

Septic arthirtis RFs and Symptoms

A 
Advancing age
		RA
		Bactaraemia
		Immunocompromised
		Prosthetic joins
		Intra-articular injections
	Symptoms
		Severe pain on any movement
		Swelling
		Erythematous
		Temp
		Pos bloods
		Irreversible joint damage after 48hrs of onset 
		May lead to osteonecrosis
93
Q

Septic arthritis treatment and investigation

A 
Investigation
		XR
			Adjunct if cant aspirate
			Often normal
			Effusion - 
			Juxta artic osteoporosis (hyperaemia)
			Cartilage destruction in acute phase
		Blood
			Infection
			Cultures
			Ues - abx
		Aspirate - purulent fluid
			Gram stain and culture
	T
		Abx
			Often IV 2 weeks or improgvement
			Oral for 4 weeks
			Fluclox or 2nd/3rd gen cephalosporin cerfuroxime
Aspirated to dryness, may need multiple
94
Q

Trochanteric bursitis all

A

Greater trochanteric pain syndrome • Causes/ DDX
o Bursitis (GTPS), tendinitis, degeneration, referred back pain
• Usually localised postero-superior tenderness – walkin gor lying
• Trendelenburg test
• Cray, US, MRI may show tears or swlling but often useless
• Treatment
o Heat/cold
o NSAIDs
o Physiotherapy
o Injection
o Surgery
• Examine in lateral

95
Q

Femoro-acetabular impingement

A

• Pincer
o Abnormally shaped acetabulum – over the top
• Cam
o Abnormally shaped femoral head – blocks
• Mixed
• Precursor to OA

96
Q

AVN hip

A

• Gradual progression
• Cartilage gets nutrition from the synovial fluid so remains intact as the bone degenerates
• Causes
o Alcohol, steroids, transplant, liver disease, trauma, age 30-50
• Investigations
o X-ray & MRI to diagnose & stage
• Treatment
o Decompression
o Arthroplasty

97
Q

Hip infection

A 
•	Common in children (septic arthritis) 
o	Differentiate from irritable hip/transient synovitis, growing pains
•	Destroys cartilaginous hip 
•	Symptoms
o	Severe pain
o	Fever
o	Systemic sepsis
o	Very stiff
o	Unable to weight bear
•	Investigations
o	XR – normal
o	USS – fluid in hip
o	CRP, WBC raised 
o	Aspiration of joint 
•	Treatment
o	Urgent decompression/washout
98
Q

DDH

A

• Presentation
o Femur not covered by acetabulum so risk of dislocation
o Neonate (<6wks)
 Breach birth
 Family history
o Starting to walk
 Painless limping infant
 Leg length discrepancy
 Reduced ROM
• Barlow + Ortolani tests
o Barlow  adduction + knee pressure (posterior force) – feel fro popping out
o Ortolani  abduction + anterior pressure on greater trochanter. Confirm barlow , relocates hip after barlow
• Investigations
o <6wks – USS (femoral head has not ossified)
o XR otherwise
• Treatment
o Braces
o Surgery – put femoral head into acetabulum. Casting
o Neonates have a better outcome

99
Q

Perthes disease

A 
•	AVN in a growing child
o	4-9 yrs old
•	Signs/symptoms
o	Hip, knee or groin pain exacerbated by movement 
o	ROM reduced
o	Limp 
•	XR changes
o	Widening of the joint space
o	Decreased femoral head size/flattening 
•	Treatment
o	Self-limiting – will revascularize 
o	Avoid weight-bearing on the affected side
	Crutches for 2 years 
	No activity
100
Q

Slipped upper femoral epiphysis (SUFE)

A 
•	9-14 yr old children
o	Commoner in obese boys
•	Symptoms/signs
o	Gradual onset
o	Pain – groin, thigh, knee 
o	Limp
o	Unable to weight bear (serious sign)
o	Loss of internal rotation
o	Hip may be fixed in external rotation
o	Bilateral common
•	Treatment
o	External in-situ pinning
o	Open reduction &amp; pinning
101
Q

Describe cause of petellofemoral pain syndrome and ddx

A 
DDX chondromalacia patella, patellar tendonitis
	Problem with PF joint
		Trauma 
		Overuse
		Anatomical/ biomech abnormaliy
e.g. runners, cyclers (runners knee)
102
Q

Examination of arthritic knee

A

get fluid in knee - sweep or patella tap positive
Limited in movmenet
Flexion deformity
Limitation of flexion 10-90 for e.g.
May be bowed
Lateral thrust (sway to outside with weight)

103
Q

Petellofemoral pain syndrome symptoms and treatment/

A 
Signs and symptoms
		Predominantly in front of knee
		Downstairs/downhill
		Feeling of downhill
		Pain when knee flexed
		Pseudolock due to grating of patellofemoral knee
		Sweliing
		Crepitus and irritability
		Rule out other knee
	Physiotherapy (80% improve), injection, PFJ replacent, TKR
104
Q

Meniscal tear

A 
•	History
o	Twisting or hyperflexion injury or degenerative knee. Twisting turning cutting
•	Signs/symptoms
o	Locking, swelling
o	Joint line tenderness (precise) 
•	Examination
o	MRI
•	Treatment
o	Arthroscopy – repair or excision

Swelling >24-48 hours then meniscal as less blood supply to meniscus/ <24 then ACL

105
Q

ACL rupture

A 
•	History
o	Planted foot injury, body takes force causing twisting (or valgus force to knee
•	Signs/symptoms
o	Acute swelling, cannot continue
o	Giving way, lack of trust in knee
•	Examination
o	Lachman test, pivot shift test
o	MRI
•	Treatment
o	Physiotherapy
o	ACL reconstruction
106
Q

Osteochondritis dissecans

A 
•	Cracks in the articular cartilage and underlying subchondral bone. Bone underneath dies and gets crushed but cartilage ok
•	History 
o	Teenage – middle aged
o	Pain in the knee
o	Swelling, occasional locking
•	Investigations
o	XR, MRI
•	Treatment
Immobilisation
o	Arthroscopic stabilisation excision
107
Q

Cause lipohaemarthosis

A

Lateral tibial plateau fracture

108
Q

Would you ever do internal fixation for NOF?

A

Youung, need lots of replacments anyway

If non-displaced then less risk of AVN

109
Q

What is the Nottingham hip fracture score?

A

o Age, sex, AMTS, Hb on admission, Residence, comorbidities, active malignancy in last 20 yrs

110
Q

Describe numbers in the wirst e.g. angles and length

A
  • Distal radius sits 2mm more distally than the ulna.
  • Radial inclination is at 22O from medial to lateral.
  • Radial volar tilted at 11O
111
Q

Flexor carpi ulnaris is where?

A

o Pisiform

 Next to FCU

112
Q

Describe salter Harris classification

A

type I
slipped
5-7%
fracture plane passes all the way through the growth plate, not involving bone
cannot occur if the growth plate is fused cit
good prognosis
type II
above
~75% (by far the most common)
fracture passes across most of the growth plate and up through the metaphysis
good prognosis
type III
lower
7-10%
fracture plane passes some distance along the growth plate and down through the epiphysis
poorer prognosis as the proliferative and reserve zones are interrupted
type IV
through or transverse or together
intra-articular
10%
fracture plane passes directly through the metaphysis, growth plate and down through the epiphysis
poor prognosis as the proliferative and reserve zones are interrupted
type V
ruined or rammed
uncommon <1%
crushing type injury does not displace the growth plate but damages it by direct compression
worst prognosis - plate is crushed

Injuries of Types III, IV and V will usually require surgery. Type V injuries are often associated with disruption to growth.

113
Q

Diff between intretrochanteric crest and ridge?

A

Intratrochanteric ridge on posteroor shows as line not intratrichanteric line

114
Q

Other artery that may be dominant to NOF

A

Inferior gluteal artery also be dominant

115
Q

What determines hip replacement over hemi

A

Activity, walk with more than stick? co morbidities

116
Q

Conserve treatment for NOF

A

6-8 weeks of discomfort
Walking aid but can walk
Patients may not want to stay in hospital for 6 weeks

117
Q

Conserve treatment for NOF

A

6-8 weeks of discomfort
Walking aid but can walk
Patients may not want to stay in hospital for 6 weeks

118
Q

Investigations into cancer

A

• Urine dip
o Blood, protein, infection
• FBC
o FBC (anaemia), WBC (raised), platelets (raised in 1o blood cancer)
• U&E/glucose
o Kidney function
• Bone profile/LFT (check for liver mets)
o Serum calcium (hypercalcaemia), ALP, ALT, bilirubin
• TFT
• PSA
• ECG
• Blood cultures
• Myeloma screen – serum electrophoresis
• X-ray

Local CT/MR
Staging CT scan
PET?
Radioisotope bone scan - gamma - mets throughout skeleton
Myeloma no contrast in bladder
119
Q

DDX cancer and history?

A 
•	Prostate
o	Stream (dribbling, hesitancy)
o	Nocturia
o	Haematuria
o	Prostate cancer commonly show sclerotic lesions on XR
•	Renal
o	Lethargy (anaemia)
•	Lung (bronchus)
o	Smoking history 
•	Thyroid
o	Can be asymptomatic 
o	Nodules 
o	New onset AF
o	Hyper/hypothyroid symptoms 
•	Breast
120
Q

Commonest primary cancer

A
  • Most common primary bone tumour is myeloma (40%)

* XR more commonly shows osteolytic lesions

121
Q

Describe a bone cancer on xray

A 
	Area shown
	Bone
	Part of the bone (epi/meta/diaphysis)
	Primary appearance
	Zone of transition 
	Periosteal reaction
	Soft tissue involvement
122
Q

Complications of a long bone pathological fracture, prevention?

A
  • Blood loss
  • Pulmonary embolus
  • Fracture non-union
  • Implant failure
  • Slow functional recovery
  • All risks reduced with prophylactic fixation
123
Q

Treatment aims with mets

A
  • Pain control
  • Prevent and treat fractures
  • Maintain & improve function
  • Treat the tumour
124
Q

Types of primary bone tumours and location

A 
Osteosarcoma
•	Affects younger population (20s) mainly but elderly as well. 
•	Distal femur and proximaln tibia
•	Assoc with Pagets disease
Chondrosarcoma 
	Axial skeleton in older patients e.g. vertebrae, pelvis, ribs
Lymphoma 
Ewing sarcoma
•	Younger population
Myeloma
 alcohol, obesity, fx, 
cause kidney probs from abs
spine and ribs
localised pain = fracture
Treatable but incurable
125
Q

Describe the Gustillo and Anderson grading of fractures

A

o Grade 1
 Puncture from within out
 Skin wound less than 1cm
 No comminution (splintering)
 No periosteal stripping
 Minimal soft tissue injury
o Grade II
 Skin wound greater than 1cm but less than 10cm
 Minimal periosteal stripping
 Minimal comminution
 Minimal soft tissue injury
o Grade III (bad)
 Any high energy injury (greater than fall from standing, walking)
 Any injury with contamination (farmyard, open water)
 Skin wound greater than 10cm
 Periosteal stripping
 Comminution present
• III A – wound can be covered from existing tissue (opposable & closable wound)
• III B – requires soft tissue cover, local or distant flap - 30-35 weeks off work
• III C – vascular injury
• Infection, amputation & fracture healing correlates with grade of injury

126
Q

How to assess open fracture

A 
•	Pulses
•	Nerve function
o	Motor
o	Sensory
•	Soft tissue integrity
•	Contamination
•	Compartment syndrome
•	X-ray
127
Q

How to treat an open fracture

A

• IV access
o Bloods – FBC, U&E, glucose, Group & Save, INR
o Analgesia & anti-emetics
 Morphine 10mg, Cyclizine or metoclopramide
o IV antibiotics + tetanus prophylaxis within 3 hrs of injury
 Co-amoxiclav 1.2g TDS IV
o Fluids
• Control bleeding/remove debris
o Wash/ irrigate (not NICE guidance) obvious contam (not hours), remove leaves/ manure
o Direct pressure. Do not blindly clamp tourniquet
• Tetanus status?
• Take photograph
• Dressing
o Soaked In saline
• Stabilise
o Re-align, splint (plaster back slab)
• Repeat neurovascular exam
• Xray
• Refer to orthopaedic surgeon +/- plastic surgeon
• Anaesthatist
• Confirm NBM & document
• Hand over & admit onto ward
o Write instructions and prescriptions

128
Q

When to operate on open fracture?

A

Within 24hrs or 12hrs G3 but ASAP if IIIc or dirty

129
Q

Compartment syndrome pathophys

A

• Raised pressure within an enclosed fascial space leading to metabolite build up
• Pathogenesis
o Compartment syndrome has a swelling haematoma = increased compartment pressure
o Occludes veins (due to lower pressure) resulting in an outflow problem
o Arterial pressure maintained (so pulses present)
 Eventually, arterial pressure shut off  acute ischaemia

130
Q

acute signs of compartment syndrome

A

o Pain
o Swollen tense compartment
o Paraesthesia, hypoesthesia
o Passive stretch causes compartment pain
o Pulse still present (pulseless = late sign)

131
Q

Diagnosis of compartment syndrome

A

o Clinical
o Compartment pressure monitoring
 >40mmHg
 Pressure differential 30 mmHg below diastolic blood pressure

132
Q

Management of compartment syndrome

A 
o	Get rid of backslab/ extrinsic compression
o	Immediate surgical decompression
	Dermatofasciotomy
	2 cuts for 4 compartments
o	Debridement of necrotic tissue
o	Skeletal stabilisation
o	Treatment of underlying cause
133
Q

Non-union of bones DDX

A

(SPLINT)
o Soft tissue interposition
o Position of reduction (too much traction, immobilisation, movement)
o Location (e.g. lower 1/3 of tibia slow to heal)
o Infection
o Nutritional (damaged vessel)
o Tumour

134
Q

What is clubfoot

A

Talipes equinovarus

•	Common condition
•	Foot inverted + plantar flexed not correctable
•	Affects every level of the foot
o	Ankle, subtalar joint, mid-talar joint
•	Treatment
o	Commence soon after birth 
o	Ponseti treatment
	Plaster foot into correct shape
135
Q

What is Chronic regional pain syndrome

A

• Stages: 1- acute, II-dystrophic, III-atrophic/ contractures

136
Q

WHat is hyperalgesia/ Allodynia

A 
•	Central sensitisation disorder
o	Hyperalgesia/allodynia
	Hyperalgesia – won’t let you touch it
	Allodynia – won’t let you move
•	Pain catastrophisation 
o	High sensitivity to pain 
•	Yellow flags  attitudes, beliefs, compensation, diagnosis, emotions, family, work (school)
137
Q

What is Leriche syndrome?

A
  1. Claudication of the buttocks and thighs
  2. Atrophy of the musculature of the legs
  3. Impotence (due to paralysis of the L1 nerve)

therosclerotic occlusive disease involving the abdominal aorta and/or both of the iliac arteries

138
Q

What is a ganglion?

A

A ganglion presents as a ‘cyst’ arising from a joint or tendon sheath. They are most commonly seen around the back of the wrist and are 3 times more common in women

Ganglions often disappear spontaneously after several months

139
Q

What i sMEralgia parasthetica

A

compression of lateral cutaneous nerve of thigh due to the sudden weight gain.
typically burning sensation over antero-lateral aspect of thigh

140
Q

Osteogenesis imperfecta

A

Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine.
Failure of maturation of collagen in all the connective tissues.
Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.

141
Q

Why do hip replacements need to be revised?

A

Aseptic loosening

142
Q

What is a Charcot joint

A

The x-ray shows extensive bone remodeling / fragmentation involving the midfoot. In combination with the presence of a swollen, red, warm joint in a patient with a history of poorly controlled diabetes is highly suggestive of a Charcot’s joint.

143
Q

Osteomyelitis presdisposing feaetures

A

x

144
Q

Osteomyelitis presentation

A

x

145
Q

Osteomyelitis organism, investigation and treatment

A

x

146
Q

investigations in pre assessment clinic

A

o FBC, G&S, HbA1c, U&Es + glucose, ECG, CXR, MRSA screen, urine dip + culture, X-ray of joint

147
Q

What to do if low Hb on pre assessment?

A 
•	History
o	GI symptoms (+/- OGD, flex sig)
o	GU symptoms
•	Investigations
o	Haematinics
	B12, folate, transferrin
•	Rapid access anaemia clinic 
•	Postpone surgery
148
Q

High glucose at pre assessment?

A
  • Do not operate on undiagnosed diabetics
  • Blood glucose control should be optimised
  • Refer to diabetes team if Hba1C >8.5%
149
Q

Risks of hip surgery?

A
  • DVT risk 13-16%, PE risk 0.3%
  • Operation failure
  • Death (less than 1 in 100)
  • Bleeding + blood transfusion (10-15% chance, depends on entry Hb)
  • Infection 1%
  • Damage to nerve & vessels
  • Dislocation
150
Q

What medication to prescribe at pre op?

A 
•	Existing medications
•	Antibiotics – ‘at induction’ in anaesthetic room
o	Co-amoxiclav (augmentin) 1.2g
	3 times  induction, 8 hrs post op, 16 hrs post op
o	If penicillin, teicoplanin 400mg &amp; gentamicin   1 time at induction
•	Anticoagulants – Dalteparin (given 6pm following surgery in elective orthopaedic surgery)
o	Early mobilisation
o	Compression stockings
o	LMWH or dabigatran(?)
•	Analgesia 
o	Paracetamol 1g QDS
o	Opiates (watch for constipation, resp. depression)
•	Laxatives
o	Fybogel or similar bulking agent first
o	Senna or similar stimulant next
•	Antiemetics 
o	Cyclizine
o	Metoclopramide 
o	Ondansetron – more anasthetics use
•	TED stockings
151
Q

SubTrochanteric fracture and mobility not an issue?

A

Intramedullary nail

152
Q

Talk about psoas abcess

A 
Staph aureus or strep.
Immuno suppressed or IVDU
Fever and severe pain
Pain with straight legs
Abx +/- drainage
153
Q

Who should be assessed for osteoporosis?

A

They advise that all women aged >= 65 years and all men aged >= 75 years should be assessed. Younger patients should be assessed in the presence of risk factors, such as:
previous fragility fracture
current use or frequent recent use of oral or systemic glucocorticoid
history of falls
family history of hip fracture
other causes of secondary osteoporosis
low body mass index (BMI) (less than 18.5 kg/m²)
smoking
alcohol intake of more than 14 units per week for women and more than 21 units per week for men.

154
Q

What is a Galeazzi fracture

A 
aleazzi fractures occur after a fall on the hand with a rotational force superimposed on it. On examination, there is bruising, swelling and tenderness over the lower end of the forearm. X- Rays reveal a displaced fracture of the radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint.
Get shorting of radius so ulnar protudes
G: Galeazzi
R: radius
I: inferior (distal)
M: Monteggia
U: ulna
S: superior (proximal)
155
Q

What is a Monteggia fracture

A

Dislocation of the proximal radioulnar joint in association with an ulna fracture
Fall on outstretched hand with forced pronation
Needs prompt diagnosis to avoid disability
G: Galeazzi
R: radius
I: inferior (distal)
M: Monteggia
U: ulna
S: superior (proximal)

156
Q

What is a Barton’s fracture?

A

Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation
Fall onto extended and pronated wrist

157
Q

Describe chondromalacia patellae

A

Often young, sudden onset or older more arthritis picture.

Pain going up/ down stairs

158
Q

Tetanus symptoms

A 
Muscle spasms (jaw_
Fever
Sweating
Headache
10% mortality
159
Q

Tetanus bacteria

A

Clostridium tetani - soil, saliva, dust, manure

160
Q

Treatment of tetanus

A

Tetanus immunoglobulin
Tetnus booster vaccine (if needed)
IV metronidazole
IV or oral diazepam

161
Q

What is radicular pain?

A

Along a dermatome

162
Q

Yellow flags back pain

A

attitudes, beliefs, compensation, diagnosis, emotions, family, work (school)

163
Q

How to test FCU, and FCR

A

Stabalise elbow and flex wrist with deviation

164
Q

What are you looking for in joint aspirate

A

WBC, lactate, culture, crystal studies

165
Q

How to assess a bite wound

A

Signs of infection? Rubor, tumour, dolor, discharge, cellultits, lymphadenopathy, fever
MoA?
Tetnus status
Risk of BBV
Xray if clenched fist or crush injuries for fracture/ foreign body.
Photograph and record description

166
Q

Managing human bite

A 
Bleed wound if recent
Irrigate with warm runnning water
Analgesia
Abx under 72 hrs - coamox or Metronidazole and macrolide for 7 days
Tetanus prophylaxis

Close if no infection risk <6hours old

167
Q

Managing a cat/ dogo bite

A 
Bleed wound if recent
Irrigate with warm runnning water
Analgesia
Abx under 48hrs for cats, bits to hand, foot, face or involving joints, tendon, lig or fractures or immunocompromised - coamox or Metronidazole and macrolide for 7 days
Tetanus prophylaxis

Close if no infection risk <6hours old
Think about teh rabies

168
Q

Protiens which stimulate bone healing

A

Bone morphogenetic proteins

Work just as well as bone graft from iliac crest

169
Q

Time to union in a tibial fracture

A

(shaft)

  • low energy frx: 10-13 weeks;
    - high energy frx: 13-20 weeks;
    - open frx: 16-26 weeks
    - type 3B & 3C open frx requires 30 to 50 weeks for sonsolidation;
170
Q

What is a myelopathy? vs radiculopathy?

A

Neurological deficit related to the spinal cord. MOst commonly CSM but can be acute. INflammatory = myelitis

vs pinched spinal nerve most commonly cervical

171
Q

Initial management of lower back pain and sciatica

A

Reassurance
Benign nature of condition
Return to work where applicable, physical activity and exercise.

Consider manual therapy
Oral NSAIDs
Consdier CBT for Lower back pain

Radiofrequency denervation
non-surgical treatment has not worked for them and
the main source of pain is thought to come from structures supplied by the medial branch nerve and
they have moderate or severe levels of localised back pain (rated as 5 or more on a visual analogue scale, or equivalent) at the time of referral.

Surgical
- spinal cord stimulation

172
Q

MoA Co amox

A

Amoxicillin - inhibits B lactamase/ cell wall synthesis

173
Q

MoA Teicoplanin

A

Glycopeptide (vacomycin), inhibits cell wall synthesis

Gram pos

174
Q

MoA Gentamicin

A

Aminoglycoside (also Streptomycin) - stops protein synthesis. Gram neg

175
Q

Abx porphylaxis for MSK and penicillin allergic

A

Co amox IV, at induction, 8, 16hrs post op

If allergic - ticoplanin and gentimicin once only

176
Q

Metronidazole MoA

A

Nucleic acid synthesis

177
Q

Why check calcium in metastatic bone diseasE?

A

treatment
hydration (volume expansion)
loop diuretics
bisphosphonates

178
Q

Greater tuberosity fracture management

A

Closed reduction if ant dislocation

If not then treat

179
Q

Xray findings of posterior dislocation

A

Shoulder - Posterior dislocation - AP
The glenohumeral joint is widened (arrowheads) and the humeral head has taken on a more rounded ‘light bulb’ shape
These are typical appearances of a posterior glenohumeral dislocation

internal rotation

180
Q

Surgery in anterior shoulder dislocation

A

Anterior shoulder dislocations are usually managed with closed reduction and a period of immobilisation (e.g. 6 weeks) to allow adequate capsular healing, although whether this significantly changes the likelihood of recurrent dislocation is not certain 4. The key to successful healing and normal eventual function is a structured course of physical therapy aimed at reducing muscle wasting and maintaining mobility. The emphasis, especially early on, is on isometric exercises, which the glenohumeral joint remains immobilised 4.

Surgical repair is not required for dislocation per se, but rather to treat complications and associated injuries which include:

shoulder instability due to damage to the inferior glenohumeral ligament (IGHL)
Hill-Sachs lesion
Bankart lesion or other anterior glenolabral injuries
damage to the axillary artery, or brachial plexus
intraarticular loose body

181
Q

How do you know if its a supracondylar fracture?

A

anterior fat pad sign (sail sign): the anterior fat pad is elevated by a joint effusion and appears as a lucent triangle on the lateral projection
posterior fat pad sign
anterior humeral line should intersect the middle third of the capitellum in most children 2 although, in children under 4, the anterior humeral line may pass through the anterior third without injury

182
Q

Complication of supracondylar

A

malunion: resulting in cubitus varus (varus deformity of the elbow, also known as gunstock deformity)

183
Q

Commonest fracture in aldults of elbow?

A

Radial head fracture - Fat pads - Lateral

184
Q

What is a Greenstick fracture

A

A greenstick injury comprises a bend in the bone on one side and a visible break in the bone cortex on the other side

185
Q

Scaphoid injury but no fracture?

A

Treat as fracture

MRI may show

186
Q

What is mallet finger?

A

A ‘mallet finger’ may result from a tendon tear (not visible with X-ray) or an avulsion fracture
The X-ray is taken to see if an avulsion fracture is present - as in this case

Dorsal

187
Q

What if two ossification centres of petalle?

A

Bipartite - superior andf lateral ostly

188
Q

Avulsion fracture in knee?

A

From ACL

189
Q

What is a Maisonneuve injury?

A

Proximal fibula fracture with associated fracutre or lig injury of medial ankle

190
Q

What does a tibial stress fracture look like?

A

White lump

191
Q

What is a Lisfranc injury?

A

Gap between MTs - disruption of Lisfranc lig

Phase II (18 decks)

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