MSK Flashcards

Question

Presentation of a hip fracture

Answer 1

Shortened and externally rotated | Pain

Answer 2

- Resuscitate: dehydration, hypothermia - Analgesia - Assess NV status of limb - Imaging: AP and lateral films

Answer 3

1. Incomplete #, undisplaced 2. Complete #, undisplaced 3. Complete #, partially displaced 4. Complete #, completely displaced

Answer 4

 Intracapsular: subcapital, transcervical, basicervical |  Extracapsular: Intertrochanteric, subtrochanteric

Answer 5

1. Intramedullary vessels in femoral neck - Interrupted by # 2. Ascending branches of medial (Major contributor) and lateral circumflex femoral arteries, which travel in the capsular retinaculum. - Can be torn if # is displaced 3. Vessels of the ligamentum teres - Insufficient in adults.

Answer 6

```  AVN of fem head in displaced #s (30%)  Non / mal-union (10-30%)  Infection  OA  Intracapsular haematoma (garden 3&4) ```

Answer 7

``` Intracapsular  1,2: ORIF (cancellous/transcervical screws) - hemi if unfit  3,4: <55: ORIF c¯ screws. - arthroplasty if AVN 55-75: total hip replacement >75: hemiarthroplasty ``` Extracapsular  ORIF - dynamic hip screw

Answer 8

Nottingham hip fracture score - Age - SEx - Hb - Residence - Co-morbidities - Malignancy - additionally high venous lactate is a predictor of early death

Answer 9

 Fall onto an outstretched hand  Most common in elderly females c¯ osteoporosis  Dinner fork deformity

Answer 10

 Extra-articular transverse # of dist. radius (w/i 1.5” of radio-carpal joint)  Dorsal displacement and angulation of distal fragment - Normally 11° volar tilt - ↓ radial height (<11mm) - ↓ radial inclination (<22°)  ± avulsion of ulna styloid  ± impaction

Answer 11

- Examine for NV injury (median N and radial A) - displacement → reduction  RA/ GA.  Disimpact and correct angulation.  Position: ulnar deviation + some wrist flexion  Apply dorsal backslab: provide 3-point pressure - Re X-Ray – satisfactory position?  No: ortho review and consider MUA ± K wires  Yes: home c¯ # clinic f/up w/i 48hrs for completion of POP - 6 wks in POP + physio - If comminuted, intra-articular or re-displaces:  Surgical fixation c¯ ex-fix, Kirschner-wires or ORIF and plates.

Answer 12

```  Median N. injury  Frozen shoulder / adhesive capsulitis  Tendon rupture: esp. EPL  Carpal tunnel syn.  Mal- /non-union  Sudek’s atrophy / CRPS ```

Answer 13

Oblique intra-articular # involving the dorsal aspect of | distal radius and dislocation of radio-carpal joint

Answer 14

Buckle - 2 weeks plaster, 2 weeks reduced activity | Greenstick - closed reduction and arm immobilisation f r6 weeks

Answer 15

 FOOSH  Pain in anatomical snuffbox  Pain on telescoping the thumb

Answer 16

 Sscaphoid x-ray view  initially treat even if hx suggestive - If initial x-ray is negative, pt. returns to # clinic after 10 days for re-xray (as localised decalcification)  Place wrist in scaphoid plaster (beer glass position)  # visible → plaster for 6 wks  No visible # but clinically tender → plaster for 2 wks  # not visible and not clinically tender → no plaster

Answer 17

AVN of the scaphoid as blood supply runs distal to proximal.  → stiffness and pain at the wrist

Answer 18

Monteggia  # of proximal 3rd of ulna shaft  Anterior dislocation of radial head at capitellum  May → palsy of deep branch of radial nerve → weak finger extension but no sensory loss

Answer 19

Galleazzi  # of radial shaft between mid and distal 3rds  Dislocation of distal radio-ulna joint

Answer 20

Unstable fractures  Adults: ORIF  Children: MUA + above elbow plaster ``` Fractures of forearm should be plastered in most stable position:  Proximal #: supination  Distal #: pronation  Mid-shaft #: neutral ```

Answer 21

Humeral head dislocates antero-inferiorly | - direct trauma/ falling on hand

Answer 22

Bankart Lesion  Damage to anteroinferior glenoid labrum. Hill-Sachs Lesion  Cortical depression in the posterolateral part of the humeral head following impaction against the glenoid rim during ant dislocation.

Answer 23

 Shoulder contour lost: appears square  Bulge in infraclavicular fossa: humeral head  Arm supported in opposite hand  Severe pain

Answer 24

 Assess for neurovascular deficit: esp. axillary N. - Sensation over regimental badge before and after reduction  X-ray: AP and transcapular view  Reduction under sedation  Rest arm in a sling for 3-4wks  Physio

Answer 25

 Recurrent dislocation - 90% of pts. <20yrs with traumatic dislocation  Axillary N. injury

Answer 26

Entrapment of supraspinatus tendon and subacromial bursa between acromion and grater tuberosity of humerus → subacromial bursitis and/or supraspinatous tendonitis

Answer 27

 Painful arc: 60-120O |  Weakness and ↓ ROM

Answer 28

 Plain radiographs: may see bony spurs  US  MRI arthrogram ``` Rx  Rest  Physiotherapy  NSAIDs +/- Subacromial bursa steroid ± LA injection ``` Surgery - Arthroscopic acromioplasty

Answer 29

 Impingement  Supraspinatous tear or partial tear  Adhesive capsulitis - joint OA

Answer 30

``` Progressive ↓ active and passive ROM  ↓ ext. rotation <30O  ↓ abduction <90O Shoulder pain, esp. @ night (can’t lie on affected side) - assoc DM ```

Answer 31

Conservative: rest, physio Medical  NSAIDs  Subacromial bursa steroid ± LA injection

Answer 32

Partial tears → painful arc ```  Shoulder tip pain  Full range of passive movement  Inability to abduct the arm  Active abduction possible following passive abduction to 90° ``` Supraspinatous --> Lowering the arm beneath 30° → sudden drop Subscapularis - weak int rotation Infraspinatous - pain on resisted ext rotation Rx - open/ arthroscopic repair

Answer 33

 Common in children after FOOSH  Elbow very swollen and held semi-flexed.  Sharp edge of proximal humerus may injure brachial artery which lies anterior to it.

Answer 34

Extension (Commonest type)  Distal fragment displaces posteriorly Gartland further classified extension type:  Type 1: non-displaced  Type 2: angulated - intact posterior cortex  Type 3: displaced - no cortical contact Flexion  Distal fragment displaces anteriorly

Answer 35

Ensure there is no NV damage  If radial pulse absent or damage to brachial artery suspected, take urgently to theatre for reduction ± on-table angiogram.  Median nerve is also vulnerable  Restore the anatomy - No displacement → flex the arm as fully as possible and apply a collar and cuff for 3wks – triceps acts as sling to stabilise fragments. - Displacement → MUA + fixation with K-wires + collar and cuff with arm flexed for 3wks.

Answer 36

NV injury  Brachial A;  Radial and median N (esp. ant interosseous branch of med- Supplies deep forearm flexors (FPL, lateral half of FDP and PQ)) Compartment syndrome  Monitor closely first 24h  Pain on passive extension of the fingers early sign.  Mx: try extension of the elbow, surgical Rx may be needed.  Volkmann’s ischaemic contracture can result → fibrosis of flexors → claw hand. Gunstock Deformity  Valgus, varus and rotational deformities in the coronal plane do not remodel and → cubitus varus

Answer 37

 Resus and Mx life-threatening injuries first. - X-Match  Tibial #: 2 units  Femoral #: 4 units - Assess NV status: esp. distal pulses  If open - Abx and ATT then Take to theatre urgently for debridement, washout and stabilisation ``` Fixation methods  Intramedullary nail  Ex-fix  Plates and screws  MUA c¯ fixed traction for 3-4mo ```

Answer 38

```  Hypovolaemic shock  Neurovascular - SFA: swelling and check pulses - Sciatic nerve  Compartment syndrome  Respiratory complications - Fat embolism - ARDS - Pneumonia ```

Answer 39

Ottowa Ankle Rules  X-ray ankle if pain in malleolar zone + in any of:  Tenderness along distal 6cm of posterior tib / fib including posterior tip of the malleoli.  Inability to bear weight both immediately and in ED ``` Weber Classification  Relation of fibula # to joint line  A: below joint line  B: at joint line  C: above joint line ```

Answer 40

Weber A  Boot or below-knee POP 6 wk Non-displaced Weber B/C  Below-knee POP 6-8 wk Displaced Weber B/C  Closed reduction and POP if anatomical reduction achieved  ORIF if closed reduction fails (and crutch 6-12 wk)

Answer 41

Simmonds triad - abnormal angle of declination - feel for gap - calf squeeze

Answer 42

Typically twisting inversion injury - Strains anterior talofibular part of lateral collateral ligament

Answer 43

Pain and tenderness in lateral thigh due to repeated movements of IT band

Answer 44

 Entrapment of lat. cutaneous nerve of thigh between ASIS and inguinal ligament  Pain ± paraesthesia on the antero lateral thigh  No motor deficit  ↑ risk c¯ obesity: compression by belts, underwear  Relieved by sitting down  Can occasionally be damaged in lap hernia repair

Answer 45

 ACL  MCL  Medial Meniscus

Answer 46

 Immediate = haemarthrosis = # or torn cruciates |  Overnight = effusion = meniscus or other lgt

Answer 47

 Joint line = meniscal |  Med/lateral margins = collateral lgts.

Answer 48

meniscal tear → mechanical obstruction

Answer 49

``` 1°: spontaneous bleeding  Coagulopathy: warfarin, haemophilia 2°: trauma  ACL injury: 80%  Patella dislocation: 10%  Meniscal injury: 10%  Outer third where its vascularised  Osteophyte # ```

Answer 50

 Full examination of acutely swollen knee after injury is difficult.  Take x-ray to ensure no #s - Fluid level indicates a lipohaemarthrosis and indicates either a # or torn cruciate.  If no # → RICE + later re-examination for pathology  If meniscal or cruciate injury suspected → MRI

Answer 51

Conservative  Rest  Physio to strengthen quads and hamstrings  Not enough stability for many sports Surgical  Gold-standard is autograft repair - Usually semitendinosus ± gracilis  Tendon threaded through heads of tibia and femur and held using screws.

Answer 52

 Idiopathic condition in which bony centres of children/adolescents become temporarily softened due to osteonecrosis.  Pressure → deformation  Bone hardens in new, deformed position

Answer 53

Initially: ↑ density / sclerosis |  Then: patchy appearance

Answer 54

Osgood-Shlatter’s  Tibial tuberosity apophysitis + patellar tendonitis  Children 10-14yrs, M>F=3:1  Assoc. c¯ physical activity  Symptoms: pain below knee, esp c¯ quads contraction  X-ray: tuberosity enlargement ± fragmentation  Rx: rest, consider POP ``` Sever’s Disease  Calcaneal apophysitis  8-13yrs  Symptoms: pain behind heal + limping  Rx: physio and temporary cushioned heel support ```

Answer 55

 Piece of bone and overlying cartilage dissects off into joint space (AVN of subchondral bone)  Commonly knee (med. fem. condyle), also elbow, hip and ankle.  Young adult / adolescent  Symptoms: pain, swelling, locking, ↓ ROM, crepitus  X-ray: loose bodies, lucent crater  Mx: arthroscopic removal of loose body

Answer 56

```  # or dislocation  SCD, thalassaemia  SLE  Gaucher’s  Drugs: steroids, NSAIDs ```

Answer 57

```  Developmental dysplasia of the hip  Transient synovitis  Septic arthritis  Perthes’  Slipped Capital Femoral Epiphyses  JIA / Still’s Disease ```

Answer 58

 FH  Breach presentation  Oligohydramnios

Answer 59

Congenital hip joint deformity in which the femoral head is or can be completely / partially displaced.  Screening  Asymmetric skin folds  Limp / abnormal gait

Answer 60

``` Ix - US -+ve Barlow and Ortolani's Mx: maintain abduction  Pavlik harness (birth)  Plaster hip spica (>2m)  Open reduction: derotation varus osteotomy (>6m) ```

Answer 61

 2-12yrs  Sudden onset hip pain / limp  Often following or with viral infection  Not systemically unwell

Answer 62

Ix  PMN and ESR/CRP are normal  -ve blood cultures  May need joint aspiration and culture Mx  Rest and analgesia  Settles over 2-3d

Answer 63

 Osteochondritis of the femoral head 2O to AVN.  4-10yrs  M>F=5:1 Presentation  Insidious onset  Hip pain initially, then painless 10-20% bilateral

Answer 64

``` Ix  X-rays normal initially  ↑ density of femoral head - Becomes fragmented and irregular - Flattening and sclerosis  Bone scan is useful ``` ``` Mx  Detected early and < half femoral head affected - Bed rest and traction  More severe - Maintain hip in abduction c¯ plaster - Femoral or pelvic osteotomy ```

Answer 65

```  Postero-inferior displacement of femoral head epiphysis  10-15yrs  Two main groups - Fat and sexually underdeveloped - Tall and thin ``` ``` Presentation  Slip may be acute, chronic or acute-on-chronic Acute  Groin pain  Shortened, externally rotated leg  All movements painful and limited abduction  20% bilateral Confirm on X-Ray ```

Answer 66

 Acute: reduce and pin epiphysis  Chronic: in situ pinning - Epiphyseal reduction risks AVN

Answer 67

 Chondrolysis: breakdown of articular cartilage  AVN  OA  Subtrochanteric # (pinned too low)

Answer 68

- OA | - premature fusion of growth plates

Answer 69

```  Staph. aureus  Strep  E. coli  Pseudomonas  Salmonella (in SCD) ```

Answer 70

```  Vascular disease  Trauma  SCD  Immunosuppression (e.g. DM)  Children - Rich blood supply to growth plate ```

Answer 71

 Pain, tenderness, erythema, warmth, ↓ROM  Effusion in neighbouring joints  Signs of systemic infection

Answer 72

 ↑ESR/CRP, ↑WCC  +ve blood cultures in 60% ``` X-ray:  Changes take 10-14d  Haziness + ↓ bone density  Sub-periosteal reaction  Sequestrum and involucrum  MRI is sensitive and specific ```

Answer 73

 IV Abx: Flucloxacylin until MCS known  Drain abscess and remove sequestra  Analgesia  Elevate Limb

Answer 74

- Brodies abscess - infection can partly be overcome by natural defences - confined in abscess lined by cortical bone - Chronic osteomyelitis (adults) - pus spreads under periosteum and dies. Perisoteum forms new bone around abscess. Need to eradicate dead bone and give abx

Answer 75

- osteochondroma (often knee) - cartilage capped by bony outgrowth - chondroma - osteoid osteoma (lytic lesions and central nidus with sclerotic limb) - osteoblastoma - osteoclastoma (soap bubble appearance

Answer 76

- Chrondrosarcoma (lytic lesion, fluffy calcification) - Osteosarcoma (commonest) - periosteal elevation (sunburst appearance) - Ewings (lytic tumour, onion-skin)

Answer 77

- thyroid - breast - lung - kidney - prostate

Answer 78

- oestomyelitis - osteoporosis - osteogenesis imperfecta - Paget's - Malignancy

Answer 79

High (C5/6): Erb’s Palsy  Abductors and external rotators paralysed  Waiter’s tip position  Loss of sensation in C5/6 dermatomes Low (C8/T1): Klumpke’s  Paralysis of small hand muscles  Claw hand  Loss of sensation in C8/T1 dermatomes

Answer 80

Low Lesions: posterior interosseous nerve  Site: # around elbow or forearm  E.g. # head of radius  Loss of extension of CMC joints (finger drop)  No sensory loss High Lesions  Site: # shaft of humerus where N. is in radial groove.  Wrist drop  Loss of sensation to dorsum of thumb root (snuff box)  Triceps functions normally Very High Lesions  Site: axilla – e.g. crutches or Sat night palsy  Paralysis of triceps and wrist drop

Answer 81

 Elbow: cubital tunnel  Wrist: in Guyon’s Canal Effects  Intrinsic hand muscle paralysis → claw hand  Ulnar paradox: lesion at elbow has less clawing as FDP is paralysed, decreasing flexion of 4th/5th digits.  Weakness of finger ad/abduction (interossei)  Sensory loss over little finger Tests  Can’t cross fingers for luck  flexion of thumb IPJ when trying to hold paper held between thumb & finger.  Indicates weak adductor policis.

Answer 82

Injury Above the Antecubital Fossa  Can’t flex index finger IPJs (e.g. on clasping hands)  Can’t flex terminal thumb phalanx (FPL)  Loss of sensation in median distribution Injury at the Wrist  Typically affects abductor pollicis brevis CTS

Answer 83

```  Carpal tunnel formed by flexor retinaculum and carpal bones.  Contains  4 tendons of FDS  4 tendons of FDP  1 tendon of FPL  Median N. ``` Median N. supplies LLOAF (aBductor pollicis brevis)  Palmer cutaneous branch travels superficial to flexor retinaculum → spares sensation over thenar area.

Answer 84

Progressive, painless fibrotic thickening of palmar fascia. ```  M>F  Middle age / elderly  Skin puckering and tethering  Fixed flexion contracture of ring and little fingers  Often bilateral and symmetrical  MCP and IP joint flexion ```

Answer 85

``` Associations: BAD FIBERS  Bent penis: Peyronies (3%)  AIDS  DM  FH: AD  Idiopathic: commonest  Booze: ALD  Epilepsy and epilepsy meds (phenytoin)  Reidel’s thyroiditis and other fibromatoses  Ledderhose disease  Smoking ```

Answer 86

``` Mx  Conservative: e.g. physio / exercises  Fasciectomy - when hand can’t be placed flat on table. - Z-shaped scars: prevent contracture - Can damage ulnar nerve - Usually recurs ``` Differential  Skin contracture: old laceration or burn  Tendon fibrosis, trigger finger  Ulnar N. palsy

Answer 87

 Tendon nodule which catches on proximal side of tendon sheath → triggering on forced extension → Fixed flexion deformity  Usually ring and middle fingers  Assoc. c¯ RA Rx: steroid injection (high recurrence) or surgery

Answer 88

- Sheath containing EPB and APL inflammed - pain on radial side of wrist and tenderness over radial styloid process - abd thumb agaisnt resistance painful Mx - analgesia, steroif injection, splint, surgery

Answer 89

``` infection of tendon sheath (s.aurues) kanavel's sings - tenderness along tendon sheath - finger held in flexion - fusiform swelling - pain with passive extension ``` Mx - incisional drainage/ Abx

Answer 90

Softening of cartilage of patella - young women - patellar aching after prolonged sitting/climbing stairs - pain on patellofemoral compression. Clarke's test No abnormality on X-Ray Rx - vastus medialis strengthening

Answer 91

 Popliteal swelling arising between the medial head of gastrocnemius and semimembranosus muscle  Herniation from joint synovium  Usually 2O to OA Rupture: acute calf pain and swelling  DVT differential

Answer 92

- Human - s.aureus/ streptococcus | - dog/cat - pasteurella multocida

Answer 93

- remove any foreign bodies - encourage to bleed - irrigate - swab - splint - elevate - abx- 7d co-amox - tetanus prophylaxis - close is <6h and no signs of infection

Answer 94

- abscess - cellulitis - joint infection - septicaemia - tenosynovitis