MSK

Question 1

What are the common presenting complaints in MSK health?

Answer 1

• Pain
• Arthralgia - Joint pain
• Myalgia - Muscle pain
• Pain in soft tissues
• Joint stiffness
• Joint swelling

Question 2

What are the differentials to be considered if a patient has shoulder pathology (Pain/Stiffness etc)?

Answer 2

• Impingment (Supraspinatus tendonitis)
• Rotator cuff tear
• Adhesive capsulitis
• OA
• Dislocation/Instability

Question 3

What are the differentials to be considered if a patient has Hip pathology (Pain/Stiffness etc)?

Answer 3

• OA
• Inflammatory arthritis
• Trochanteric bursitis
• # NOF

Question 4

What are the differentials to be considered if a patient has knee pathology (Pain/Stiffness etc)?

Answer 4

• ACL Tear
• PCL tear
• Meniscal tear
• Collateral ligaments tear
• OA
• Pre-patellar bursitis
• Septic Arthritis

Question 5

What are the differentials to be considered if a patient has Spine pathology (Pain/Stiffness etc)?

Answer 5

• OA
• Facet joint deterioration
• Ankylosing spondylitis
• Sciatica
• Cauda Equina
• Spinal cord compression

Question 6

What are the differentials to be considered if a patient has Lower back pathology (Pain/Stiffness etc)?

Answer 6

• MSK pain (Paravertebral muscles)
• Lumbar spondylosis
• Lumbar OA
• Lumbar disc prolapse
• Spinal #
• Discitis
• AS
• Bone lesion/Mets
• PID
• AAA

Question 7

What are the differentials to be considered if a patient has joint pain/stiffness/swelling?

Answer 7

• RA
• Gout
• Psoriatic arthritis
• OA
• Septic arthritis
• Trauma

Question 8

What MSK conditions are common in children?

Answer 8

• Transient synovitis - Knee/Hip/Any joint
• Perthes/SUFE/DDH - Hip
• Osgood-Schlatters/Patellar tendonitis - Knee

Question 9

You are asked to assess an acutely unwell patient with any pathology, how would you approach this assesment?

Answer 9

[Airway]

• Any signs of airway obstruction, foreign bodyFacial/mandibular/laryngeal fracture
• Protect C spine
• If patient talking -> airway likely fine
  
  • Nasopharyngeal airway -> Conscious patient
  • Oropharyngeal airway -> Unconscious patient GCS <8
• Give High flow O2 at high rate - 15L Rebreather

[Breathing]

• Evaluate breathing
• Look/listen/feel for signs of respiratory distress
• Count RR in breaths/min
• Assess rhythm/depth of breaths
• Assess position of trachea
• Equal chest expansion on observation & palpation
• Note chest deformity
• Record SpO2
• Percuss & Auscultate chest

[Circulation]

• Assess cardiac status & control haemorrhage if present
• Assess blood loss
  
  • Pallor & temperature (peripheral circulation)
  • Pulse & CRT <2s
• Level of consciousness
• BP
• If bleeding
  
  • 2 large bore cannula
  • Crossmatch blood & Baseline bloods - FBC/U&E
  • IV fluid - Ringers Lactate
  • Apply pressure to stem bleeding
  • Note: If patient not responding to fluid resus - consider internal bleeding (Abdomen/pelvis)
• Auscultate the heart
  
  • HS present? Any extra?
  • Valve areas
• Urinary catheter to assess fluid loss

[Disability]

• GCS score/AVPU
• Pupils - PEARL
• Assess for spinal cord injury
• blood glucose

[Exposure]

• Fully expose the patient to examine for signs of trauma
• Ensure to prevent hypothermia

Secondary survey

• Head to toe exam
• Hx taking - SAMPLES
  
  • S - signs & symptoms
  • A - Allergies
  • M - Medications
  • P - Past medical Hx
  • L - Last meal & drink
  • E - Events leading up to present illness/injury
  • S - Social Hx

Question 10

A patient presents with joint swelling and pain, you aspirate the synovial fluid and find the following results. What do they suggest?

• Colour -> Colourless
• Clarity - Transparent/translucent
• Viscosity -> Normal
• WBC -> <200 cells/mm3
• Neutrophils -> <25% of total WCC
• Gram stain -> Negative
• Crystals -> Negative

Answer 10

Normal

Question 11

A patient presents with joint swelling and pain, you aspirate the synovial fluid and find the following results. What do they suggest?

• Colour ->Yellow/Green
• Clarity -> Cloudy/Opaque
• Viscosity -> Decreased
• WBC -> >50,000/mm3
• Neutrophils -> 75%
• Gram stain -> Positive
• Crystals -> Negative

Answer 11

Septic Arthritis

Question 12

A patient presents with joint swelling and pain, you aspirate the synovial fluid and find the following results. What do they suggest?

• Colour ->Straw like/yellow
• Clarity -> Translucent
• Viscosity -> Increase
• WBC -> <2000/mm3
• Neutrophils -> <25%
• Gram stain -> Negative
• Crystals -> Negative

Answer 12

Non-inflammatory pathology

Question 13

A patient presents with joint swelling and pain, you aspirate the synovial fluid and find the following results. What do they suggest?

• Colour ->Yellow
• Clarity -> Cloudy
• Viscosity -> Decreased
• WBC -> 2000-50,000/mm3
• Neutrophils -> 50%
• Gram stain -> Negative
• Crystals -> Positive or Negative

Answer 13

Inflammatory Pathology

• Positive crystals = Gout
• Negative crystals = Pseudogout

Question 14

A patient presents with joint swelling and pain, you aspirate the synovial fluid and find the following results. What do they suggest?

• Colour ->Red/xanthochromic
• Clarity -> Bloody
• Viscosity -> Variable (Increased/Decreased)
• WBC -> 200-20,000/mm3
• Neutrophils -> 50-75%
• Gram stain -> Negative
• Crystals -> Negative

Answer 14

Haemarthrosis

Question 15

You are given a patients x-ray result to interpret. How would you do this?

Answer 15

[Patient details]

• Patient ID - Name & DOB & Date of x-ray
• Image orientation
• Adequacy - Correct projection/Area of interest included
• Should be more than one view - AP/Lateral/Frog leg (Hip)
• Joint above & Joint below should be shown
• Due to the potential for additional injuries - Fracture/dislocation
• Is bone and soft tissue easily seen & differentiated
• Assess if the patient is rotated

[Assess image]

• Alignment
• Bones
• Cortex - Should be smooth, continuous line
• Density
• Trabecular pattern - Disruptions Lucent/Sclerotic lines
  
  • Lucent (Black) lines -> Displaced fracture
  • Sclerotic (White) lines -> Overlapping fracture
• Is patient skeletally mature (Fused epiphyses/growth plates)
• Cartilage & Joints Assess for degeneration - LOSS
  
  • Loss of joint space
  • Osteophytes
  • Subchondral cysts
  • Sclerosis (Subchondral)
• Inflammatory changes
  
  • Periarticular osteoporosis
  • Soft tissue swelling
  • Bony erosions
• Soft tissue
• Artefacts

[Describe fracture]

• Site of fracture
  
  • Which bone
  • Which part of the bone
  • Proximal/Middle/Distal 1/3 OR Intra-articular
• Examine entire cortex for any breaks
• Type of fracture
  
  • Simple (Skin intact)/Open (Skin not intact)
  • Transverse (Perpendicular to long axis of bone)
  • Oblique (Angled <90 deg to long axis of bone)
  • Spiral (Curving around bone)
  • Greenstick (Break in one cortex, other cortex remains intact)
  • Vertical (Parallel to long axis of bone)
• Is it single or comminuted (>2 fragments of bone)
• Is it displaced or not?If displaced, in what direction? (relationship of distal fragment to the proximal fragment)
  
  • Non-displaced
  • Anterior/Posterior/medial/lateral displacement
• Impacted (Bone fragments driven into each other)
• Is it angulated?
  
  • Movement of distal fragment relative to proximal bones in deg
• Is the bone of normal consistency or not?
  
  • Osteopenia -> Most of bone is dark (Radiolucent) and cortex is thin
• Radiolucency around joint -> Inflammation/infected joint
  
  • Focal lucent areas -> Bone lesion
  • Sclerotic (Radio-opaque) -> Sclerotic bone metastases
• Is there any shortening of the bone?

[Present exam]

• Wash hands & Thank patient
• “This is patient x who is a x year old Male/Female with the following findings”
• I would take a full Hx from the patient & Examine the joint
• Consider differentials
• Investigations
  
  • Observations
  • Bloods
  • Imaging
• Management

Question 16

What are the different types of #?

Answer 16

• Simple (Skin intact)/Open (Skin not intact)
• Transverse (Perpendicular to long axis of bone)
• Oblique (Angled <90 deg to long axis of bone)
• Spiral (Curving around bone)
• Greenstick (Break in one cortex, other cortex remains intact)
• Vertical (Parallel to long axis of bone)

Question 17

What is the difference between Subluxation and Dislocation?

Answer 17

Subluxation -> Normal anatomy of the join is disrupted - remains contact between articular surfaces of the joint

Dislocation -> Complete disruption of the joint with no contact b/w joint surfaces

Question 18

What would be the findings on x-ray in a joint with OA?

Answer 18

LOSS

• Loss of joint space
• Osteophytes
• Subchondral sclerosis
• Subchondral cysts

Question 19

What would be the findings on x-ray in a joint with RA or any other inflammatory arthritis?

Answer 19

LESP

• Loss of joint space
• Erosions of bone
• Soft tissue swelling
• Periarticular Osteoporosis

Question 20

What would be the findings on x-ray in a patient with Gout?

Answer 20

• Overhanging edges
• Usually 1st MTP joint
• Erosions

Question 21

What is meant by the following terms:

Varus

Valgus

Answer 21

Varus – Distal part to the joint described points TOWARDS the midline

Valgus

Question 22

What is the growth plate/Physis?

What is the biggest worry with a growth plate injury in children?

Answer 22

Physis = Area of cartilage which proliferates and the leading edge calcifies to form new bone

Can lead to cessation of growth & limb shortening

Question 23

What is the structure of bone?

Answer 23

• Epiphysis (Superior)
• Physis (Growth plate)
• Metaphysis
• Diaphysis (Shaft)

Question 24

What is SUFE?

Answer 24

• Slipped upper femoral epiphyses - Caused by instability of the proximal femoral physis which then allows the cap of the femoral head epiphysis to slip
• Usually a-traumatic or due to minor injury

Question 25

What causes SUFE?

Answer 25

Weakness in the growth plate caused by:

• Stress on the growth plate due to obesity
• Endocrine disorders - Pan-hypopituitarism/Hypothyroidism/Renal Osteodystrophy
• Period of rapid grwoth in adolescence

Question 26

How is SUFE classified?

Answer 26

• Stable - Patient can walk & Osteonecrosis is rare (Most common)
• Unstable - Pt unable to walk + 50% risk of osteonecrosis

Question 27

What is the epidemiology of SUFE?

Answer 27

• Most commonly affects the hip
• Common in teenage boys & girls
• Risk factors - Obesity/Local trauma/Endocrine dysfunction

Question 28

What is the classic presentation of SUFE?

Answer 28

• Pain/discomfort in Hip/Referred pain to knee
  
  • Accentuated by activity
  • If acute - <3wks of onset
  • If acute on chronic - Months of pain with sudden pain
• Reduced hip movement - Internal rotation + Abduction due to pain
• Leg length discrepancy
• Trendelenberg gait

Question 29

A patient presents with the following Hx, what are your differentials?

A 13-year-old boy presents with hip, groin, thigh, and medial knee pain. He is overweight and recently experienced an adolescent growth spurt. On physical examination, the affected leg is externally rotated and there is limited range of motion in the hip joint. He is unable to bear weight on the affected leg.

Answer 29

• SUFE
• Hip #
• Perthes disease
• Osteomyelitis
• Septic arthritis
• Acute transient synovitis

Question 30

You suspect the following patient has SUFE, what investigations do you order?

A 13-year-old boy presents with hip, groin, thigh, and medial knee pain. He is overweight and recently experienced an adolescent growth spurt. On physical examination, the affected leg is externally rotated and there is limited range of motion in the hip joint. He is unable to bear weight on the affected leg.

Answer 30

• AP + Frog leg x-ray of Hip
  
  • Widening of epiphyseal line/Displacement of femoral head
  • Normal klein line
• U&E - Normal. May have increased Cr if Renal Osteodystrophy
• TFTs - Normal. May have Increased TSH if Hypothyroidism

Question 31

How is SUFE managed?

Answer 31

• Limit mobility - No movement or rotation of leg
• Analgesia - Paracetamol/Ibuprofen
• If unstable
  
  • Open reduction + Internal fixation w/screws

Question 32

What are the complications of SUFE?

Answer 32

• Chondrolysis - Degeneration of artciular cartilage
• AVN of epiphysis

Question 33

What is classified as a Hip #?

Answer 33

Any # distal to the femoral head + Proximal to 5cm below lesser trochanter

Usually caused by falls from standing height in elderly pts, or high energy trauma in younger pts.

Question 34

What are:

Osteopenia

Osteoporosis

Answer 34

Osteopenia – Decreased BMD due to increased osteoclast activity, and decreased osteoblast activity

• BMD T score of -1 to -2.5

Osteoporosis – Decreased BMD, and deterioration of bone due to increased osteoclast activity, and decreased osteoblast activity

• BMD T score of <-2.5

Question 35

How are hip fractures classified?

Answer 35

Intracapsular – Within the hip capsule (Femoral neck to femoral head)

• Can disrupt the blood supply to the femoral head leading to AVN

Extracapsular – After the line b/w the greater and lesser trochanter (Trochanteric or Subtrochanteric)

• Less likely to disrupt femoral head blood supply

Question 36

What causes Hip #?

Answer 36

• Increasing age >65yrs
• Osteoporosis
• Osteomalacia
• Trauma
• Post menopausal female
• Falls

Question 37

What is Osteomalacia?

Answer 37

Softening of bone due to decreased vitamin D

Question 38

How are intercapusular hip # classified?

Answer 38

Garden classification

• Garden 1 – Undisplaced + Incomplete
• Garden 2 – Undisplaced + Complete (# from superior - inferior cortex)
• Garden 3 – Slightly Displaced + Complete (# from superior - inferior cortex)
• Garden 4 – Completely displaced + Complete (# from superior - inferior cortex)

Question 39

What are the classic symptoms/signs of a hip #?

Answer 39

• Pain in upper thigh or groin, may radiate to the knee
• Inability to weight bear
• Hx of previous injury/trauma
• If pathological # - Hx of previous aching pain
• Increased pain on flexion/rotation of leg
• Shortened/Adducted/Externally rotated leg

Question 40

A patient presents with the following Hx, what is the most likely diagnosis and what are the differentials?

A 72-year-old woman presents with a history of a fall from standing height and an inability to bear weight afterwards. She complains of pain in her right hip. There were no preceding syncopal episodes and no loss of consciousness or chest pain. Physical examination reveals a woman looking her stated age in some distress; cardiac and pulmonary examinatory is non-contributory. Her right hip is painful and sore to palpation with some ecchymoses over the greater trochanter. There are no breaks in the skin, and the right leg is shortened and externally rotated. The pelvis is stable clinically, and there is no pain along the spine and no deformity along the femoral shaft, knee, or tibia. The distal neurovascular status is intact.

Answer 40

• Hip #
• Acetabular #
• Septic arthritis
• Pubic rami #

Question 41

You suspect a patient has suffered a fractured hip, what investigations should be carried out?

Answer 41

• ABCDE assesment
• AP + Lateral x-ray of Hip
  
  • Disruption of trabeculae, inferior±superior cortex #
  • Shentons line broken
• If no # on x-ray but still suspecting a fracture - MRI/CT
• FBC
• Crossmatch blood
• U&E
• Glucose
• ECG

Question 42

How would you manage a Hip #?

Answer 42

Classify the # - Intracapsular v Extracapsular

• Intracapsular:
  
  • Determine garden classification
  • Surgery within 24hrs of admission
    
    • Garden 1 + 2 – Internal fixation w/screws
      
      • If unfit – Arthroplasty
    • Garden 3 + 4 – Replacement of femoral head w/Hemi-arthroplasty or Total hip replacement (If co-morbidities)
• Extracapsular:
  
  • Surgical fixation unless C/I
  • Internal fixation - DHSS/Hip arthroplasty

Question 43

What are the complications of Hip #?

Answer 43

• High mortality rate
• Infection
• Haemorrhage
• AVN
• Delayed union/Malunion
• MI/PE/DVT

Question 44

What is the blood supply to the proximal femur?

Answer 44

• Medial femoral circumflex artery
• Lateral femoral circumflex artery
• Ligamentum teres artery

Question 45

What is Spondylolisthesis?

Answer 45

Spondylolisthesis – Movement of one vertebrae relative to others in Ant./Post. due to instability

Stress # and sliding of vertebrae

Question 46

What is Sponylolysis?

Answer 46

• Spondylolysis – Bony defect (Stress #) in pars interarticularis of vertebral arch
  
  • Can be unilateral/bilateral
  • Commonly affects L5 – causing back pain

Question 47

What is Spondylosis?

Answer 47

• Spondylosis – Degenerative OA changes in the spine
  
  • Due to degeneration of IV discs, leading to narrow IV space
  • Osteophyte formation may lead to pressure on nerve roots – Motor and sensory disturbance

Question 48

What is Spondylitis?

Answer 48

Inflammation of the vertebrae

Question 49

What are the causes/risk factors for spondylolisthesis?

Answer 49

• Female gender
• Young age
• Presence of spina bifida
• Positive FHx
• High impact sport

Question 50

What symptoms/signs do people with degenerative spondylolisthesis present with?

Answer 50

• Aching pain with insidious onset
• Low back pain & posterior thighs
• Neurogenic claudication (Due to spinal stenosis)
  
  • Pain made worse by walking
  • Pain relieved by sitting in forward flexion/lying down
• Chronic & progressive symptoms

Question 51

What are the symptoms/signs of spondylolysis?

Answer 51

• Asymptomatic
• May be symptomatic:
  
  • Low back pain - provoked by lumbar extension
  • Paraspinal spasm
  • Tight hamstrings

Question 52

You suspect a patient may have spondylolithesis, what investigations should be done?

Answer 52

• FBC – Normal. Assess for infection/myeloma
• Ca+ levels – Normal. Assess for hyper/hypocalcaemia
• x-ray – Lateral + AP
• MRI

Question 53

How is Spondylolisthesis managed?

Answer 53

Pain relief – Paracetamol/NSAIDs/Codeine

If stable:

• Bed rest for 2-3 days
• Sleep on side w/pillow b/w knees
• Activity modification to prevent further injury
• Physiotherapy

If unstable:

• Surgery – Fuse affected vertebrae + Discectomy

Question 54

What is Spinal cord compression?

Answer 54

• Neurosurgical emergency
• Spinal cord is compressed due to trauma/tumour/prolapsed IV disc/Infection
  
  • Most common cause is malignancy

Question 55

What are the common malignancies that can cause Spinal cord compression?

Answer 55

• Breast
• Prostate
• Lung
• Bone tumour

Question 56

What are the red flags which may indicate spinal cord compression?

Answer 56

• T or C spine pain
• Severe unremitting or progressive spine pain
• Spinal pain aggravated by straining – Coughing/Sneezing/Passing stool
• Nocturnal spinal pain preventing sleep
• Localised spinal tenderness
• Limb weakness
• Loss of sexual/Bladder/bowel function

Question 57

A patient presents with the following Hx, what is the most likely diagnosis? What are the differential diagnoses?

A 25-year-old man presents to the emergency department after an automobile accident. He was ejected from the vehicle. He complains of numbness in both lower extremities and cannot move his legs. There is no pinprick sensation below the umbilicus except for an anal wink, and there is no rectal tone. The bulbocavernosus reflex is weakly present. Power in the lower extremities is graded at 1/5.

Answer 57

• Spinal cord compression
• Transverse myelitis
• GBS
• MS
• Diabetic neuropathy

Question 58

A patient presents with the following Hx, what is the most likely diagnosis? What are the differential diagnoses?

A 40-year-old woman presents with back pain and difficulty with her gait. She has a long history of smoking and has had some haemoptysis recently. Her examination reveals diminished pinprick sensation from the nipple line caudally, power in the lower extremities of 4/5, absent joint position sense in the lower extremities, and diminished vibratory sense. Anal sphincter tone is intact.

Answer 58

• Spinal cord compression
• Transverse myelitis
• GBS
• MS
• Diabetic neuropathy

Question 59

A patient presents with the following Hx suggestive of spinal cord compression. How should this be investigated?

A 40-year-old woman presents with back pain and difficulty with her gait. She has a long history of smoking and has had some haemoptysis recently. Her examination reveals diminished pinprick sensation from the nipple line caudally, power in the lower extremities of 4/5, absent joint position sense in the lower extremities, and diminished vibratory sense. Anal sphincter tone is intact.

Answer 59

• FBC – Check for infection
• U&E
• MRI Whole spine – Assess for level of compression
  
  • Within 24hrs

Question 60

A patient presents with symptoms suggestive of spinal cord compression, how is this managed?

Answer 60

• Nurse patient lying flat in neutral alignment
• Dexamethasone IV
• Insert catheter to manage bladder dysfunction
• Pain control
  
  • Analgesia
  • Palliative radiotherapy - if malignant cause
• May require spinal orthoses/vertebroplasty/kyphoplasty

Question 61

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 38-year-old man with no significant history of back pain developed acute lower back pain when lifting boxes 2 weeks ago. The pain is aching in nature, located in the left lumbar area, and associated with spasms. He describes previous similar episodes several years ago, which resolved without seeing a doctor. He denies any leg pain or weakness. He also denies fevers, chills, weight loss, and recent infections. Over-the-counter ibuprofen has helped somewhat, but he has taken it only twice a day for the past 3 days because he does not want to become dependent on painkillers. On examination, there is decreased lumbar flexion and extension secondary to pain, but a neurological examination is unremarkable.

Answer 61

• MSK Back pain
• IV disc prolapse
• Vertebral #
• CES
• Spinal metastases
• Osteomyelitis

Question 62

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 48-year-old insurance salesman presents with a 25-year history of back pain. He developed severe back pain while stacking shelves at the local supermarket at age 23. The pain resolved after 10 days of bed-rest, followed by 3 months of physiotherapy. He has had multiple episodes of back pain occurring at increasing regularity over the years and, in the past 10 years, has changed his occupation to salesperson. Currently, he has back pain measuring 8 out of 10 on a visual analogue scale and bilateral leg pain. The back pain is exacerbated by flexion, and the leg pain is reproduced by a straight leg raise of 70 degrees. He has numbness of both feet in the L5 dermatome; motor and reflexes are normal.

Answer 62

• IV disc prolapse
• MSK Back pain
• Vertebral #
• CES
• Spinal metastases
• Osteomyelitis

Question 63

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 68-year-old man presents with increasing back pain. The pain started when he was in his 30s and has progressed over time. He now also reports heaviness in both his legs when he walks 2 blocks. He retired from his job as a teacher 3 years ago, and now spends a large proportion of his time gardening. He can sit for a only few minutes, and then has great difficulty in getting up. He has no other medical conditions. On examination, his spinal range of motion is very disturbed. He stands with a forward stoop. He can stand on his toes and heels and has a normal neurological examination. A straight leg raise causes no pain or restriction.

Answer 63

• IV disc prolapse
• MSK Back pain
• Vertebral #
• CES
• Spinal metastases
• Osteomyelitis

Question 64

A patient presents with back pain, what are the red flags that need to be ruled out?

Answer 64

Cauda Equina Syndrome:

• Saddle anaesthesia/parasthesia
• Recent onset of bladder dysfunction/faecal incontinence
• Perineal/perianal sensory loss
• Severe/progressive neurological deficit in LL

Spinal #

• Sudden onset of severe central pain in spine, relieved by lying down
• Major trauma - RTA/Fall from height
• Minor trauma - strenuous lifting if patient has osteoporosis
• Structural deformity of spine
• Point tenderness over vertebral body

Cancer

• Pain that remains on lying down
• Aching night time pain that disturbs sleep
• Thoracic pain - consider thoracic aortic aneurysm
• Hx of cancer
• Unexplained weight loss

Infection (Discitis/osteomyelitis)

• Fever/Chills
• Unexplained weight loss
• Recent infection - UTI
• IVDU
• Immune suppression
• Point tenderness over vertebral body

Question 65

What are the Waddell signs?

Answer 65

Signs which suggest that the patient is exaggerating their level of pain etc.

• Superficial tenderness
• Stimulation manoeuvres that are painful - e.g. axial loading of head/passively rotating shoulders/pelvis
• No pain on distraction
• Overreaction - disproportionate response to examination

Question 66

A patient presents with the following Hx, suggestive of back pain. What investigations would you order?

How would you manage this patient?

Answer 66

If simple back pain - No investigations

• Spine exam
• Neurological exam

If serious pathology likely e.g. red flags present

• X-ray -> Considering # or cancer
• CT scan -> Considering stress #/spondylolisthesis
• FBC -> Rule out cancer/infection/inflammation
• ESR -> Rule out cancer/infection/inflammation
• CRP -> Rule out cancer/infection/inflammation
• Urinalysis -> Rule out infection
• LFTs – ALP raised if metastatic disease/pagets disease of bone

[Management]

Conservative

• Keep patient active
• Give analgesia to facilitate increased activity if required
• Paracetamol
• NSAIDs - Ibuprofen/Naproxen
  
  • Codeine/Tramadol
• If rest is suggested - only 48hrs
• Physiotherapy

Medical

• Consider epidural corticosteroid injections - reduce nerve pain
• If acute spasm -> Diazepam
• TENS machine
• Trancutaneous Electrical Nerve Stimulation
• Lumbar discectomy - if severe nerve compression or persistent symptoms despite conservative management

Question 67

What is Cauda Equina syndrome?

Answer 67

Where the cauda equina (Below L1) - nerve roots are compressed.

Medical EMERGENCY

Caused by:

• Herniation of Lumbar IV disc - most commonly L4/5 or L5/S1
• Tumours - Metastases/lymphoma/spinal tumour
• Trauma
• Infection
• Congenital - Congenital spinal stenosis/kyphoscoliosis/spina bifida
• Spondylolisthesis
• AS

Question 68

Who Classically gets Cauda Equina?

What are the symptoms/signs?

Answer 68

• Not very common

Symptoms/Signs:

• Low back pain ± pain in unilateral/bilateral LL
• Sudden onset of + Rapidly progressing:
• Bladder ± bowel dysfunction
• Urinary retention
• Decreased bladder/urethral sensation
• Faecal incontinence/Constipation
• Reduced sensation in the saddle (Perineal) area
• Sexual dysfunction
• LMN Neurological signs

Question 69

A patient presents with symptoms suggestive of Cauda Equina. How would you investigate this?

How would you manage this?

Answer 69

Investigations:

• Neurological examination
• DRE - Assess anal tone
• Urgent MRI spine

Management:

• Immediate referral to neurosurgery
• Spinal decompression
• Immobilise spine if due to trauma

Question 70

What complications can arise from Cauda Equina?

Answer 70

• Paralysis
• Sensory abnormalities
• Bladder/Bowel dysfunction
• Sexual dysfunction

Question 71

What are the possible problems with the spinal disc?

Answer 71

• Disc herniation – Prolapsed IV disc
  
  • Common in younger pts <40yrs
• Degenerative disc disease
  
  • Common in older pts >40yrs
• Discitis

Question 72

What is a Prolapsed IV disc?

What causes it?

Answer 72

• Herniation of the nucleus pulposis in the IV disc, leads to:
• Irritation of adjacent nerve root
• Compression of adjacent nerve root e.g. Sciatica

Caused by:

• Trauma
• Secondary to degenerative disc changes

Question 73

What are the classic symptoms/signs of compression of a nerve due to disc herniation?

Answer 73

Sciatica:

• Pain + tingling + numbness - due to nerve root entrapment in lumbosacral spine
• Usually caused by herniated IV disc
• Most commonly L5/S1 level
• Unilateral leg pain which radiates below knee to foot/toes
• More severe than back pain
• Numbness/parasthesia/weakness ± loss of tendon reflexes
• Positive straight leg raise
• Relieved on lying down
• Exacerbated by long walks and prolonged sitting

Question 74

What is Discitis?

Answer 74

• Pus forming infection of the spine, leads to inflammation of the vertebral disc space
• Usually associated with infection, may have concurrent osteomyelitis (Spondylodiscitis)
• Usually due to haematogenous spread of infection
• Commonly caused by Staph aureus

Question 75

Who commonly gets discitis? What are the symptoms/signs?

Answer 75

• Males > Females
• Pts >50yrs
• IVDU
• DM
• Immunosuppression

Symptoms/Signs:

• Low back pain – Pain worse on movement
• Insidious onset - neck/back pain
• Localised tenderness
• Mobility restricted
• Fever
• Weight loss
• May have neurological deficit

Question 76

A patient presents with a Hx suggestive of discitis, what investigations should be ordered?

How should it be managed?

Answer 76

Investigations:

• ESR - Raised
• CRP - Raised
• FBC - may be normal, or raised WCC
• Blood cultures/sputum/urine culture - look for source of infection
• X-ray of spine
  
  • Disc narrowing
  • End plate irregularities
  • Annulus calcification
• MRI is most sensitive and specific

Management:

• CT guided or open biopsy of infected disc space area - allow for histology & culture
• Surgical debridement
• ABx
  
  • Based on local guidelines, adjusted based on culture results
  • May be required for 6-8 weeks
• 2 weeks of bed rest - immobilisation by brace
• Analgesia
  
  • Paracetamol/NSAIDs
  • Codeine/Tramadol

Question 77

How is an Open fracture managed?

Answer 77

Treatment is an emergency!

Manage with:

• Adequate fluid/blood replacement
• Analgesia
• Splinting
• ABx & Tetanus prophylaxis
• IV Co-amoxiclav
• Avoid handling wound unless to remove gross contaminants or obtain photographic evidence then to seal from environment

Surgery only if:

• Gross contamination
• Compartment syndrome risk
• Devascularised limb
• Patient has multiple injuries
• Debridement by orthopaedic & plastic surgeons (Remove non-viable tissue and stabilise #)

Question 78

You are asked to explain weak/moderate opioids (Tramadol/Codeine/Dihydrocodeine) to a patient, how would you go about doing this?

Answer 78

Layout:

• Check what the patient knows
• Brief history
• Do they know what the drug is?
• Indication & Action of the drug
• Side effects
• How to take it
• Monitoring requirements

[Indication & Action of the drug]

Indication:

• Mild to moderate pain - such as post-op pain
• 2nd line for pain relief (WHO ladder)

Action:

• Codeine + Dihydrocodeine -> Very weak opioids Metabolised by liver to produce small amounts of morphine (From codeine) or Dihydromorphine (From Dihydrocodeine)
  
  • Metabolites are stronger agonists of Mu opioid receptors
  • Work by activating Mu opioid receptors in the CNS
• Activation -> Leads to reduced neuronal excitability & pain transmission. In medulla
  
  • Blunt response to hypoxia & hypercapnia -> Reduced respiratory drive and breathlessness
  • Also relieve pain and breathlessness and associated anxiety - reducing SNS activity (Fight or flight)
  • Reduce cardiac work and O2 demand -> relieving symptoms in MI/Pulmonary oedema
• Tramadol -> Moderate opioid

[Side effects]

• Nausea
• Constipation
• Dizziness
• Drowsiness
• Neurological & Respiratory depression - In overdose

Note: Tramadol may cause less constipation & respiratory depression

• Codeine & Dihydrocodeine - Never to be given via IV -> Cause Severe reaction similar to anaphylaxis

Complications & CI

Caution in:

• Significant respiratory disease
• Reduce doses in renal/hepatic impairment/Elderly
• Tramadol lowers seizure threshold

Avoid in:

• Epilepsy

[How to take it]

• Orally as regular or PRN
• Consider need for laxative if regular - Senna (Stimulant laxative) to mitigate constipation
• Can be added to paracetamol -> Co-codamol/Co-dyramol
• Dose should be taken at regular intervals
• Can be taken with or without food

[Monitoring requirements]

Information:

• Constipation is very common - may require pre-emptive laxative use (Senna) along with hydration
• Patient should NOT drive or operate heavy machinery if drowsy/confused
• Review:
  
  • Acute pain - every 1hr
  • Assess for SE - respiratory depression
• Chronic pain - Few weeks
• Assess need to step up or step down pain relief or referral for specialist

Question 79

You are asked to explain strong opioids (Morphine/Oxycodone) to a patient, how would you go about doing this?

Answer 79

Layout:

• Check what the patient knows
• Brief history
• Do they know what the drug is?
• Indication & Action of the drug
• Side effects
• How to take it
• Monitoring requirements

[Indication & Action of the drug]

Indication:

• Rapid relief of acute severe pain - post op pain/MI associated pain
• Relief of chronic pain - when all other pain ladder drugs have been used
• Relief of breathlessness in end of life care
• Relief of breathlessness and anxiety due to acute pulmonary oedema

Action:

• Naturally occurring (Morphine) and synthetic (Oxycodone) opiates
• Work by activating Mu opioid receptors in the CNS
• Activation -> Leads to reduced neuronal excitability & pain transmission
• In medulla
• Blunt response to hypoxia & hypercapnia -> Reduced respiratory drive and breathlessness
• Also relieve pain and breathlessness and associated anxiety - reducing SNS activity (Fight or flight)
• Reduce cardiac work and O2 demand -> relieving symptoms in MI/Pulmonary oedema

[Side effects]

• Respiratory depression
• Reduce respitaroy drive
• Euphoria
• Detachment
• Neurological depression
  
  • Activate chemoreceptor trigger zone -> Nausea & Vomiting
  • Pupil constriction - stimulation of Erdinger-Westphal nucleus
• In large intestine
  
  • Activation of Mu receptors -> Smooth muscle tone + Reduced motility = Constipation
• In skin
  
  • Histamine release -> Itching + Urticaria + Vasodilation + Sweating
• Continued use can lead to tolerance - dependence
  
  • Dependence is apparent as patient has withdrawal reaction on stopping

Complications & CI

Caution - reduce dose in:

• Hepatic failure
• Renal impairment
• Elderly

Avoid in:

• Respiratory failure except in palliative situation
• Biliary colic -> Can cause spasm of sphincter of Oddi - Worsen pain

[How to take it]

• Acute severe pain -> IV for rapid effect
• If severe pain generally -> IM/SC
• Chronic pain -> Orally Immediate release/Modified release
• Immediate release -> Oromorph
• Modified release -> MST every 12hrs

May require breakthrough analgesia

• 1/6 of total daily regular dose, immediate release (Oromorph)

Information:

• Nausea usually settles - but may need anti-emetic -> Metoclopramide
• Constipation is very common - may require pre-emptive laxative use (Senna) along with hydration
• Patient should NOT drive or operate heavy machinery if drowsy/confused

[Monitoring requirements]

• Prescribe with BRAND NAME
• Review:Acute pain - every 1hr
• Assess for SE - respiratory depression
• Chronic pain - Few weeks
• Assess need to step up or step down pain relief or referral for specialist

Question 80

What are the signs of opioid excess/overdose?

How is this managed?

Answer 80

Signs:

• Loss of consciousness
• Pinpoint pupils
• Respiratory depression

Management:

• Naloxone prescription STAT
• Stop any opioids on prescription chart
• Prescribe paracetamol as baseline analgesia, until effects of overdose are gone

Question 81

What are the following wrist #’s?

Colles #

Smiths #

Answer 81

Colles #

• Distal radius
• Dorsal displacement of fragments

Smiths #

• Distal radius
• Volar displacement of fragments

Question 82

What are the Carpal bones called?

Answer 82

Some Lovers Try Positions That They Cant Handle

Proximal row

• (Lateral) Scaphoid - Lunate - Triquetrium - Pisiform (Medial)

Distal row

• (Lateral) Trapezium - Trapezoid - Capitate - Hamate (Medial)

Question 83

What are the classical symptoms/signs of a # anywhere in the body?

Answer 83

• Fall/Trauma preceeding the #
• Osteoporosis Hx
• Pain
• Difficulty weight bearing
• May have open wound
• May have loss of function
• Tenderness over site
• Deformity over site

Question 84

How would you investigate a patient presenting with a #?

How would you manage it?

Answer 84

Investigations:

• Examination of the joint
• Plain x ray of affected joint/bone (Joint above + below)

Management:

• ABCDE Assesment
• Check for neurovascular compromise
• Provide analgesia:
  
  • Paracetamol/Cocodamol/Morphine
• Temporary splinting - Immobilise the joint
• Open/Closed reduction
• F/UP in # clinic

Question 85

What is the significance of a scaphoid #?

Answer 85

• Most common carpal bone #
• Can be displaced or non-displaced
• Vulnerable blood supply - so increased risk of AVN + Non union

Question 86

What is a Galezzi #?

What is a Monteggia #?

Answer 86

Galezzi:

• # of the distal 1/3 of the radius
• Subluxation/dislocation of distal radio-ulnar joint

Monteggia:

• # of proximal 1/3 of Ulna
• Dislocation of radial head

Question 87

What is Septic Arthritis?

Answer 87

Infection producing inflammation in a native/prosthetic joint(s)

• Can be acute/chronic

Either caused by:

• Direct innoculation
• Haematogenous spread

Most commonly caused by Staph Aureus/Group B Strep/Gonococcus (Sexually active)

Question 88

Who classically gets Septic Arthritis?

What are the symptoms/signs?

Answer 88

Epidemiology:

• Common in pts who are immunosuppressed/elderly
• Can occur in pts with prosthetics
• DM/IVDU/Prior joint damage

Symptoms/Signs:

• Single swollen joint with pain on movement
• Fever/Rigors
• Swollen + Red + Hot joint
• Antalgic gait
• Unwilling to weight bear
• Tenderness in joint
• Effusion

Question 89

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 55-year-old woman presents with a 1-week history of pain and swelling in her left wrist. She was diagnosed with rheumatoid arthritis at the age of 36 years but the rest of her joints are currently asymptomatic. Her rheumatoid arthritis is well controlled on her current medication. On examination her left wrist is found to be hot, swollen, tender, and highly restricted in its range of movement. There is no sign of inflammation in any of her other joints. She has a temperature of 37.5˚C (99.5˚F).

Answer 89

• Septic Arthritis
• RA/OA
• Gout
• Reactive arthritis
• Lyme disease
• Cellulitis

Question 90

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 25-year-old man who is a known intravenous drug abuser presents with a 5-day history of pain and swelling in his right leg. On examination there are multiple sites of intravenous puncture. His right leg is swollen from the knee downwards. There is a large effusion on the right knee together with significant cellulitic changes of the overlying skin.

Answer 90

• Septic Arthritis
• RA/OA
• Gout
• Reactive arthritis
• Lyme disease
• Cellulitis

Question 91

A patient presents with the following Hx suggestive of Septic arthritis, how would you investigate and manage this case?

A 25-year-old man who is a known intravenous drug abuser presents with a 5-day history of pain and swelling in his right leg. On examination there are multiple sites of intravenous puncture. His right leg is swollen from the knee downwards. There is a large effusion on the right knee together with significant cellulitic changes of the overlying skin.

Answer 91

Investigations:

• FBC – Increased WCC
• CRP + ESR – Elevated
• Blood culture – Exclude systemic sepsis
• Synovial fluid analysis + Culture – WCC + Gram stain
• X-ray of joint

Management:

• Surgical drainage + Lavage of joint (Aspiration)
• High dose IV ABx:
  
  • IV Flucloxacillin/Clindamycin (If allergic)
  • 2-3 weeks then switch to oral for 2-4 weeks
• If MRSA + then Vancomycin/Teicoplanin

Question 92

What is osteomyelitis?

Answer 92

Infection of the bone marrow, that can spread to the cortex + periosteum via the Haversian canals

• Leads to inflammatory destruction of bone + necrosis

Can be spread via:

• Haematogenous – Spread via blood from remote source, common in children
• Direct contiguous – From surgical procedure/trauma

Typically caused by Staph Aureus/Haemophilus Influenzae/Streptococcus/E.Coli

Question 93

Who typically gets Osteomyelitis?

What are the classic symptoms/signs?

Answer 93

Epidemiology:

• Patients with DM/PAD
• Everyone (Children + Adults)
• Patients with trauma/previous joint surgery or prosthetic device
• IVDU

Symptoms/Signs:

• Fever
• Painful + Immobile limb
• Made worse by movement
• May also have Septic arthritis
• Swelling + Tenderness
• Erythema + Increased temperature
• Localised oedema
• Hx of accidental/surgical trauma (Dental procedures also)
• May have had DM/PAD ulcer

Question 94

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 40-year-old man who suffered an open tibial fracture in a motor vehicle accident 6 months ago presents with swelling and pain in his lower leg.

Answer 94

• Osteomyelitis
• Cellulitis
• Gout
• Acute sickle cell crisis
• Trauma

Question 95

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 5-year-old boy fell off his bicycle 2 weeks ago and has stopped walking and complains of non-specific pain in his leg. His mother reports that he apparently has had flu, with fever and chills.

Answer 95

• Osteomyelitis
• Cellulitis
• Gout
• Acute sickle cell crisis
• Trauma

Question 96

You are presented with the following Hx, what investigations would you do? What are the differentials?

A 5-year-old boy fell off his bicycle 2 weeks ago and has stopped walking and complains of non-specific pain in his leg. His mother reports that he apparently has had flu, with fever and chills.

Answer 96

Investigations:

• FBC – Increased WCC
• CRP/ESR – Increased
• Blood culture – May be positive
• Bone culture – Positive
• Culture of expressed pus – Positive
• X-ray:
  
  • Patchy osteopenia
  • Signs of bone destruction

Management:

• Surgical debridement
• Analgesia
• ABx therapy for 4-6 weeks – Flucloxacillin/Clindamycin (Allergic)
  
  • May require Fucidin/Rifampicin
  • If MRSA – Vancomycin/Teicoplanin
• If chronic infection/Prosthesis – Contact Infectious diseases

Question 97

What is Potts disease?

Answer 97

• Vertebral Osteomyelitis from haematogenous spread of TB
• Leads to damage to neighbouring verebrae – Vertebral collapse + Abscess formation

Pus can track to adjacent structures causing:

• Night sweats
• Malaise
• Fever

Question 98

What is Osteoporosis?

Answer 98

Progressive systemic skeletal disease with:

• Decreased bone mass
• Microarchitectural deterioration of bone tissue
• Bone = Increasingly fragile, increased risk of fragility #

Question 99

What is the normal process of bone remodelling?

Answer 99

• Osteocytes submit signals to Osteoclasts + Osteoblasts – Bone remodelling

Osteoclasts:

• Resorb bone matric – Apoptosis – Signal osteoblasts

Osteoblasts:

• Synthesise bone matrix – mineralisation

Cytokines regulate the process

• Ca+ Metabolism – PTH + Vitamin D + Calcitonin + Oestrogen
• Osteoclast function – RANK + RANK Ligand + OPG
• RANK L expressed by osteoblasts, RANK Receptors expressed by osteoclasts
• OPG inhibits RANK Ligand (Lost in postmenopausal women)

Question 100

Who classically gets osteoporosis?

What are the symptoms/signs?

Answer 100

• Women > Men
• Increased bone loss in older age + Post menopause
• Corticosteroid use/Low BMI
• Smoking

Symptoms/Signs:

• Asymptomatic
• May have bone #

Question 101

How is bone density measured?

Answer 101

Using DEXA scan

T score – In relation to young health population

Z - Score – Age based Normal

• Normal = T score > -1
• Osteopenia = T score -1 to -2.5
• Osteoporosis = T score < -2.5

Question 102

A patient presents with the following Hx suggestive of osteoporosis, how would you investigate? How would you manage them?

A 70-year-old man, 6 months after renal transplantation and on corticosteroid treatment, presents with severe back pain. X-ray evaluation of the thoracic and lumbar spine discloses evidence of multiple vertebral compression fractures.

Answer 102

Investigations:

• Assess # risk, then DEXA if high risk
• X-ray – Detect #
• LFTs + Albumin – Normal.
• Serum ca+ – Normal
• U&E – Normal
• Phosphate – Normal
• Vitamin D – Normal.
• Serum PTH – Normal.
• TFTs – Normal

Management:

• Reduce polypharmacy
• If postmenopausal w/o fragility #:
  
  • Bisphosphonates - Alendronate/Risendronate
  • Denosumab - 2nd line. Note risk of Osteonecrosis of jaw
• Post-menopausal women with fragility #:
  
  • Alendronate
  • Ca+ & Vit D supplementation
• Men + Pre-menopausal women:
  
  • Alendronate
  • HRT for pre-menopausal women

Question 103

How do you assess a patients # risk, if they may have Osteoporosis?

Answer 103

Q Fracture score

If pt is:

• Low risk – No treatment or BMD measurement
• Medium risk – Arrange DEXA for BMD + Recalculate Q fracture score
• High risk – Treat + BMD Not essential

Question 104

What is Osteoarthritis?

Answer 104

Destablised bone remodelling, leading to increased bone breakdown + decreased bone formation

• Most common form of arthritis
• Usually affects knees/hips/small joints of hands

Characterised by:

• Loss of cartilage
• Remodelling of adjacent bone
• Associated inflammation

Can be:

• Primary – Idiopathic, no preceeding injury
• Secondary – Antecendent to insult to the joint

Question 105

Who classically gets OA?

What are the symptoms/signs of OA?

Answer 105

• Female > Male
• FHx of OA
• Congenital deformities – DDH
• Patients with joint trauma/arthropathy
• Age related >50yrs
• Obesity

Symptoms/Signs:

• Activity related joint pain
• Joint stiffness <30mins in morning
• Pain exacerbated by exercise/use - Relieved by rest
• Decreased joint function - ROM restriction
• Joint swelling/synovitis (Increased Temp + Effusion)
• Bony swelling + Deformity (Osteophyte formation)

Question 106

A patient presents with the followng Hx, What is the most likely diagnosis? What are the differentials?

A 60-year-old woman presents complaining of bilateral knee pain on most days of the past few months. The pain was gradual in onset. The pain is over the anterior aspect of the knee and gets worse with walking and going up and down stairs. She complains of stiffness in the morning that lasts for a few minutes and a buckling sensation at times in the right knee. On examination, there is a small effusion, diffuse crepitus, and limited flexion of both knees. Joint tenderness is more prominent over the medial joint line bilaterally. She has a steady but slow gait, slightly favouring the right side.

Answer 106

• Osteoarthritis
• Bursitis
• Referred pain
• Gout
• RA
• Septic arthritis

Question 107

A patient presents with the followng Hx, What is the most likely diagnosis? What are the differentials?

A 55-year-old woman has been complaining of pain and swelling in several fingers of both hands for the past 2 months. She describes morning stiffness lasting for 30 minutes. Her mother tells her that she had a similar condition at the same age. She denies any other joint pain or swelling. On examination, she has tenderness, slight erythema, and swelling in one PIP joint and two DIP joints in each hand. She has squaring at the base of her right thumb (the first carpometacarpal joint). There is no swelling or tenderness in her MCP joints.

Answer 107

• Osteoarthritis
• Bursitis
• Referred pain
• Gout
• RA
• Septic arthritis

Question 108

A patient presents with the following Hx suggestive of OA, How would you investigate this? How would you manage it?

A 55-year-old woman has been complaining of pain and swelling in several fingers of both hands for the past 2 months. She describes morning stiffness lasting for 30 minutes. Her mother tells her that she had a similar condition at the same age. She denies any other joint pain or swelling. On examination, she has tenderness, slight erythema, and swelling in one PIP joint and two DIP joints in each hand. She has squaring at the base of her right thumb (the first carpometacarpal joint). There is no swelling or tenderness in her MCP joints.

Answer 108

Investigations:

• Clinical diagnosis if:
  
  • Pt >45yrs
  • Activity related joint pain
  • Morning joint stiffness <30mins
• x-ray - confirm diagnosis:
  
  • Loss of joint space
  • Osteophytes
  • Subchondral sclerosis
  • Subchondral cysts
• BMI - Normal/Elevated
• FBC – Normal
• U&E + Creatinine – Normal
• LFTs – Normal
• Joint aspiration if effusion – Normal
• CRP + ESR – Normal
• RF + Anti CCP – Negative

Management:

• Assess QoL with the symptoms
• Patient education
• Weight loss advice
• Exercise + Physiotherapy
• Walking aids if required

Medical management:

• Paracetamol ± NSAIDs (Topical/Oral)
• Topical capsacin
• PPI for gastric protection – Omeprazole
• Intrarticular injections of steroid (Methylprednisolone)

Surgery:

• Arthroscopic lavage + Debridement
• Joint replacement surgery

Question 109

You are asked to explain one Bisphosphonate (Alendronic acid/Pamidronate/Zolendronic Acid) to a patient, how would you do this?

Answer 109

Layout:

• Check what the patient knows
• Brief history
• Do they know what the drug is?
• Indication & Action of the drug
• Side effects
• How to take it
• Monitoring requirements

[Indication & Action]

Indications

• Used as 1st line drug treatment for patients at risk of osteoporotic fragility #
• Pamidronate + Zolendronic acid used for treatment of severe hypercalcaemia of malignancy after IV rehydration
• Patients with myeloma and breast cancer with bone mets - reduce the risk of pathological #/cord compression/need for radiotherapy/surgery
• Used as 1st line treatment for metabolically active Pagets disease - reduce bone turnover and pain

Action

• Aim: Help strengthen bones to prevent # and/or lower Ca+ levels in the blood
• Inhibit action of osteoclasts - responsible for bone resorption
• Similar structure to pyrophosphate (Naturally occurring) - so are readily incorporated into bone
• As bone is resorbed - bisphosponates accumulate in osteoclasts
  
  • Inhibit activity
  • Promote apoptosis
• Reduction of bone loss + improvement of bone mass

[How to take it]

• Take once a week
  
  • Note: They bind Ca+ so their absorption is reduced if taken with Calcium salts (Milk), and antacids and iron salts
• Poorly absorbed orally
• Enhance absorption by - Must take tablets whole at least 30mins before breakfast or other medications + Take with plenty of water
  
  • Remain upright for 30mins after taking to reduce oesophageal irritation
• Long term

[Important SE]

• Oesophagitis when taken orally
• Hypo-phosphataemia
• Osteonecrosis of the jaw (Rare, but serious)
• Ensure good dental care
• Atypical femoral # (Rare)

Complications/Contraindications

Avoid in:

• Severe renal impairment
• Hypocalcaemia
• Upper GI disorders
• Pregnancy

Caution in:

• Due to risk of osteonecrosis
• Smokers
• Major dental disease

[Monitoring requirements]

• Patient should see dentist before starting treatment
• Osteoporosis
• Check and replace Ca+ and Vit D before treatment
• Monitor efficacy with DEXA every 1-2yrs

Monitor for SE:

• Oesophagitis
• Osteonecrosis of the jaw
• Ca+ levels in serum
• Phosphate levels in serum

Question 110

What are the 3 joints of the shoulder?

Which is most commonly dislocated?

Answer 110

• Sternoclavicular joint
• Acromioclavicular joint
• Glenohumeral joint – Most commonly dislocated

Question 111

Which muscles make up the rotator cuff?

Answer 111

SITS

• Supraspinatus
• Infraspinatus
• Teres Minor
• Subscapularis

Joint together to form the rotator cuff tendon

Question 112

What are the causes of shoulder pain?

Answer 112

Rotator cuff disorders

• Rotator cuff tear
• Impingement (Subacromial bursitis/tendonitis)

Glenohumeral disorder

• Frozen shoulder (Adhesive capsulitis)
• Arthritis

ACJ disorders

Biceps tenonditis

Shoulder instability – Dislocation/Subluxation

PMR

Question 113

Which muscle in the rotator cuff is most prone to tearing?

Which is the most common shoulder pathology?

Answer 113

Supraspinatus

Subacromial impingement

Question 114

If a patient presents with shoulder pain, how should they be investigated and managed?

Answer 114

Investigations:

• Shoulder exam
• Full Hx
• USS - if muscle pathology
• x-ray if considering dislocation/arthritis

Management:

• Physiotherapy
• Modification of activities
• Analgesia:
  
  • Paracetamol - Codeine
  • NSAID
• Subacromial steroid injection if limited function b/c of pain

Question 115

What is Shoulder dislocation?

What are the symptoms/signs?

Investigations

Management

Answer 115

Loss of congruity b/w head of humerus and glenoid fossa

• Anterior most common, Posterior - rare - can be due to seizures/electrocution

Symptoms/Signs:

• Pain
• Decreased range of movement
• Prominent humeral head
• Head in abducted + externally rotated

Investigations:

• x-ray – AP + Lateral

Management:

• Closed reduction
• Sling immobilisation
• Analgesia

Question 116

What are the complications that can occur with an anterior dislocation of the shoulder?

Answer 116

• Axillary nerve + Artery damage
• Damage to brachial plexus
• Increased risk of recurrence

Question 117

What is a rotator cuff tear?

Symptoms/Signs?

Investigations

Management

Answer 117

Tear to the rotator cuff muscles (SITS)

• Caused by – Trauma/Degeneration/Weight lifting

Symptoms/Signs:

• Partial tear – Painful arc syndrome
• Complete tear – Limited shoulder abduction
• Pain
• Shoulder tenderness on palpation
• Weakness

Investigations:

• Shoulder exam
• x-ray
• MRI

Management:

• Rest + Physiotherapy
• Analgesia
• Arthroscopy ± repair

Question 118

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A right-handed 65-year-old man presents after painting a room in his house. He complains of pain in his right shoulder, which worsens with overhead lifting, and some night pain since the onset of symptoms. He has no past history of shoulder problems and no other medical conditions. He has no neurological symptoms and does not complain of weakness.

Answer 118

• Rotator cuff tear
• Rotator cuff impingement
• Subacromial bursitis
• Humeral #
• Bicep tendonitis

Question 119

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 57-year-old woman who is typically sedentary presents complaining of shoulder pain after a trip and fall onto her outstretched hand. She has no prior history of shoulder injuries. She has pain on the lateral aspect of her shoulder and weakness with external rotation and forward elevation.

Answer 119

• Rotator cuff tear
• Rotator cuff impingement
• Subacromial bursitis
• Humeral #
• Bicep tendonitis
• PMR

Question 120

What is Adhesive capsulitis?

Who gets it?

Symptoms/signs

Investigations

Management

Answer 120

Chronic fibrosing condition – Insidious + Progressive

• Glenohumeral disorder - thickening & contraction of the glenohumeral capsule
• Restriction of active + passive shoulder ROM
• Self limiting - resolves in 2 yrs

Who gets it:

• Common >40yrs
• Women > Men
• Pts with DM/Thyroid disease

Symptoms/Signs:

• Stiffness in shoulder joint
• Pain
• Restriction in Active + Passive ROM
• Impaired external rotation
• Tenderness

Investigations:

• Clinical diagnosis
• x-ray – Normal

Management:

• Analgesia – Paracetamol + NSAIDs
• Maintain activity levels
• Physiotherapy with joint mobilisation
• Corticosteroid injections

Question 121

What is Trochanteric Bursitis?

Answer 121

Pain in the greater trochanter (Hip), due to stresses at muscle insertions on greater trochanter – leading to inflammation

• Painful bursa due to friction b/w trochanter and iliotibial band over it

Who gets it:

• Women > Men
• Runners
• OA of the hips/back/knees
• Degenerative disc disease of L spine
• Obesity

Symptoms/Signs:

• Pain - Aching/burning
• Tenderness over greater trochanter
• Pain worse on lying on affected side
• Snapping sound
• Antalgic gait
• Pain on resisted abduction + external rotation

Investigations:

• Clinical diagnosis:
  
  • Tenderness on palpation of greater trochanter
  • Pain on abduction + external rotation

Management:

• Rest + decrease activity
• Self limiting (2-3 months)
• Apply ice pack for 10-20 mins
• NSAIDs for pain + inflammation
• Weight loss
• Physiotherapy

Surgery:

• Bursectomy/Release of iliotibial band

Question 122

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 50-year-old woman with diabetes presents with a 2-month history of insidious onset right shoulder pain. She denies a history of shoulder trauma. She has no history of neck pain, arm/hand weakness, or numbness or paraesthesias of the arms/hands. She complains of shoulder pain at extremes of range of motion and has difficulty sleeping on the affected side. She has noticed increasing difficulty with activities of daily living, including brushing her hair, as well as putting on or taking off her blouse and brassiere. Her examination shows a marked decrease in both active and passive range of motion of the right shoulder; with forward flexion (FF) to 75°, abduction (ABD) to 75°, external rotation (ER) to 15°, and internal rotation (IR) to the iliac crest with pain at extremes of motion. Rotator cuff strength is normal.

Answer 122

• Adhesive capsulitis
• Glenohumeral dislocation
• Rotator cuff tear
• Rotator cuff impingement
• Biceps tendonitis

Question 123

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 65-year-old man presents for follow-up 6 months after a mild acromioclavicular sprain that occurred after falling directly onto the left shoulder. He was treated with sling immobilisation for 2 weeks. His acromioclavicular joint pain has completely resolved, but he now complains of shoulder stiffness. He is a construction worker and has noticed difficulty reaching overhead to perform his job over the past several months. Examination shows that he has no tenderness to palpation of the acromioclavicular joint, and has a negative cross arm adduction test. He is severely limited in his range of motion, with FF to 100°, ABD to 80°, ER to 10°, and IR to the iliac crest.

Answer 123

• Adhesive capsulitis
• Glenohumeral dislocation
• Rotator cuff tear
• Rotator cuff impingement
• Biceps tendonitis

Question 124

What is the growth plate?

What is the major issue with growth plate injury?

Answer 124

• Area of cartilage which proliferates/enlarges with the leading edge calcifying to form new bone in children
• Can lead to cessation of growth + Limb shortening

Question 125

What are the following Salter Harris #s?

Type 1

Type 2

Type 3

Type 4

Type 5

Answer 125

• Type 1 – # through the growth plate (Across)
• Type 2 – # through growth plate + metaphysis but not the epiphysis. Most common type
• Type 3 # – # through the growth plate leading to separation of epiphysis + growth plate from the metaphysis
• Type 4 – # through growth plate + metaphysis + epiphysis
• Type 5 – Compression # through growth plate. Poor prognosis

Question 126

What is Osgood schlatter disease?

Answer 126

Inflammation of the patellar ligament at the tibial tuberosity

Self limiting condition, typically during childhood

Question 127

Who classically gets Osgood Schlatters?

What are the symptoms/signs?

Answer 127

• Active children (Multiple avulsion # of tibial tuberosity)
• During growth spurts (Strength of Quadriceps > ability of tibial tuberosity to resist force)
• Boys > Girls
• Common in teenagers

Symptoms/Signs:

• Gradual onset pain + Swelling below knee
• Relieved by rest
• Worse by activities
• Tenderness/Swelling at tibial tuberosity
• Pain on knee extension
• Localised warmth
• Prominent tibial tubercle

Question 128

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 13-year-old male basketball player presents with several months of insidious onset of unilateral anterior knee pain, worse during practice and games and alleviated by rest, ice, and anti-inflammatory medicines. Physical examination demonstrates prominence of the tibial tubercle, with mild swelling and tenderness to palpation over the tubercle. Resisted knee extension causes pain

Answer 128

• Osgood Schlatters disease
• Bone tumour
• Septic arthritis/JIA
• Hip pathology – Perthes/SUFE/Transient synovitis
• Knee injury

Question 129

You are presented with a patient with the following Hx suggestive of Osgood Schlatters, How would you investigate? How do you manage it?

A 13-year-old male basketball player presents with several months of insidious onset of unilateral anterior knee pain, worse during practice and games and alleviated by rest, ice, and anti-inflammatory medicines. Physical examination demonstrates prominence of the tibial tubercle, with mild swelling and tenderness to palpation over the tubercle.

Answer 129

Investigations:

• Clinical diagnosis
• x-ray:
  
  • Irregular apophysis + seperation of tibial tuberosity

Management:

• Conservative treatment
• Rest from painful activity
• ICE
• Physiotherapy
• Paracetamol/Ibuprofen

Question 130

What is Perthes disease?

Answer 130

Childhood condition with disruption of blood flow to the head of the femur, leading to avascular necrosis of the femoral head

Not caused by trauma

Question 131

Who classically gets Perthes disease?

What are the symptoms/signs?

Answer 131

• Boys > Girls
• Age 4-7yrs
• White children

Symptoms/Signs:

• Pain in hip or referred to knee
• Can be bilateral/asymmetrical
• No Hx of trauma
• Short stature
• Antalgic gait
• Hip effusion due to synovitis
• All hip movements are limited

Question 132

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 5-year-old Caucasian boy is brought in to the orthopaedic clinic by his mother with complaints of a limp favouring the right side with no associated pain. This painless limp had started insidiously 3 weeks earlier and was first noticed by the school physical education teacher. The mother notes that it has recently been getting worse. He is one of 3 siblings and lives with his single mother. The other siblings include an elder sister (from his mother’s earlier marriage) and a younger brother. His mother’s current partner is a heavy smoker. His mother recalls that 1 year earlier he came from school and complained of right knee pain. This was initially overlooked for a few days, but when it persisted he was taken to the general practitioner who reassured his mother but did not arrange follow-up. The symptoms had recurred the following month when he was taken to the emergency department and blood tests and x-rays were reportedly normal.

Answer 132

• Perthes disease
• Septic arthritis
• Transient synovitis
• Hypothyroidism – Bilateral
• Sickle cell disease – Bilateral

Question 133

A patient with the following Hx suggestive of Perthes presents, what investigations do they require & how would you manage them?

A 5-year-old Caucasian boy is brought in to the orthopaedic clinic by his mother with complaints of a limp favouring the right side with no associated pain. This painless limp had started insidiously 3 weeks earlier and was first noticed by the school physical education teacher. The mother notes that it has recently been getting worse. He is one of 3 siblings and lives with his single mother. The other siblings include an elder sister (from his mother’s earlier marriage) and a younger brother. His mother’s current partner is a heavy smoker. His mother recalls that 1 year earlier he came from school and complained of right knee pain. This was initially overlooked for a few days, but when it persisted he was taken to the general practitioner who reassured his mother but did not arrange follow-up. The symptoms had recurred the following month when he was taken to the emergency department and blood tests and x-rays were reportedly normal.

Answer 133

Investigations:

• FBC – Normal
• CRP – Normal/Reactive so Increased
• ESR – Normal
• x-ray – Frog lateral + AP
  
  • May be normal
  • Widening of joint space
  • Collapse + deformity of femoral head w/new bone formation
  • Subchondral #

Management:

• Aim to maintain shape of femoral head + prevent secondary arthritis
• May not require treatment
• Acute pain – Paracetamol ± NSAIDs
• Physiotherapy – Muscle strengthening + stretching

Surgery:

• If Age >6yrs + >50% risk of femoral head necrosis
• Proximal varus osteotomy
• Arthrodesis at skeletal maturity

Question 134

What is Developmental Dysplasia of the Hip?

Answer 134

• Abnormality of the hip joint where the socket does not fully cover the ball, leading to increased risk of joint dislocation.
• Congenital DDH – Hip dysplasia at birth or early in life

Question 135

Who typically gets DDH?

What are the symptoms/signs?

Answer 135

• Newbowns/Young babies
• L hip is more likely to be affected
• Common if swaddled
• FHx of DDH
• Breech vaginal delivery/Breech position
• Oligohydraminos
• Girls > Boys

Symptoms/Signs:

• Asymmetrical gluteal/thigh skin folds
• Leg length discrepancy
• Barlow + Ortlani – Positive
• Unilateral limitation + asymmetry of hip abduction
• Unilateral femoral shortening
• Waddling gait

Question 136

A patient presents with the following Hx suggestive of DDH, how would you investigate and manage?

A baby girl is seen for a routine examination at 2 weeks of age. She was born at term with no pregnancy or delivery complications. A screening examination of the hips, using the provocative tests of Barlow and Ortolani, reveals laxity of the left hip joint. A characteristic ‘clunk’ is felt as the femoral head shifts out of the acetabulum with pressure applied directly posteriorly in the adducted hip, as well as when it shifts back into the acetabulum with the hip abducted and anterior pressure applied.

Answer 136

Investigations:

• Dynamic USS – Assess hip stability + Acetabular development
• Pelvic x-ray if older:
  
  • Once femoral head ossification has occured

Management:

• Usually stabilise spontenously at 2-6 weeks
• If unstable/dislocatable – treatment:
  
  • Bracing if <6mo with Pavlik harness
  • If brace fails/>6 mo:
  • Closed reduction of hip (Surgically)
  • • 3-4 months plaster cast/abduction brace

Question 137

What is Transient synovitis?

What are the symptoms/signs?

How is it investigated?

How is it managed?

Answer 137

Inflammation of a joint, that commonly affects young people

• Self limiting
• Due to secondary temporary inflammation due to viral URTI
• Most common cause of hip pain + limb in children

Symptoms/Signs:

• Limited ROM
• Pain on movement
• Fever
• Tenderness on palpation
• Antalgic gait

Investigations:

• FBC – Normal or increased WCC
• ESR – Normal or Increased
• CRP – Normal or increased
• x-ray:
  
  • Normal

Management:

• Activity restriction
• Paracetamol
• NSAIDs – Ibuprofen/Naproxen

Question 138

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 3-year-old boy is seen in the accident and emergency department at 2 a.m. because he is crying. He is otherwise healthy. Earlier in the day he was playing, but his mother noted that he may have had a limp. He has no fever and otherwise feels well. On physical examination, slight movement of his hip is tolerated but excess motion causes him to cry. His full blood count and erythrocyte sedimentation rate are normal.

Answer 138

• Transient synovitis
• Septic Arthritis
• Osteomyelitis
• Perthes disease
• JIA

Question 139

What is Hallux valgus deformity?

Answer 139

• Lateral deviation of the great toe (Valgus deformity of 1st MTP)
  
  • AKA Bunion
• Can present with pain in the hallux MTP joint on walking

Question 140

What is Plantar fasciitis?

Answer 140

Acute/chronic pain in the inferior heel at the attachment of the plantar fascia to the medial calcaneal tubercle

• Overuse injury

Diagnosis – Reproduction of pain by asking pt to stand on toes or passive dorsiflexion of toes

Manage – Rest + Physio + NSAIDs and Paracetamol

Question 141

What is Carpal Tunnel syndrome?

Answer 141

Compression of the median nerve as it travels through the carpal tunnel

Symptoms/Signs:

• Pain
• Numbness
• Paraesthesia in dristribution of median nerve (Thumb + Index + Middle finger)
• Worse at night causes wakening – Hanging it off the bed to ease pain
• May have weakness
• Positive Phalens + Tinnels test

Management:

• Observation
• Splints
• Steroid injections
• Surgery - release the carpal tunnel

Question 142

You are asked to perform a GALS Examination, how would you go about doing this?

Answer 142

[Introduction]

• Wash hands & Introduce self
• Ask Patient name & DOB & Age
• Today I am going to be examining your walking, your arms, legs, and spine as part of a screening exam to assess your bones and muscular system. is that ok?
• I will need you to undress to your underwear and wear a robe, the examiner will act as a chaperone for both of us – is that ok?
• Do you have any pain at the moment? Would you like some painkillers?

[Screening Questions]

• Do you have any pain in your muscles/joints/back?
• Do you have any difficulty dressing yourself?
• Do you have any difficulty walking up and down the stairs?

[General Inspection]

• Look at surrounding area for:
  
  • Walking aids
  • Specialist shoes
• Assess patient for signs:
  
  • Pain
  • Body habitus
  • Systemic illness

[Inspection]

Can you please stand in the neutral position in front of me with your palms facing forward, assess:

• Examine shoes for abnormal signs of wear
• Overall alignment & willingness to weight bear
• Limb alignment
• Bulk & symmetry of
• Shoulder
• Gluteal muscles
• Quadriceps
• Calf muscles (Gastrocnemius & Soleus)
• Alignment of the spine (From behind/sides)
• Equal level of iliac crests
• Ability to fully extend elbows & knees
• Popliteal swelling
• Excessively high or low foot arch profile
• Skin changes - Rash/Erythema/Psoriatic plaques

[Assess gait]

Ask patient to walk from A to B, assess:

• Symmetry
• Smoothness
• Normal heel strike & toe off
• Ability to turn quickly
• Gait
• Antalgic gait
• Trendelenberg gait
• Foot drop
• Toe walking

[Assess spine]

Ask patient to remain standing

Inspection:

• Normal Lordosis/kyphosis
• C & L -> Lordosis
• T & S -> Kyphosis
• Any scoliosis
• C spine

Movements:

• Lateral flexion -> Can you please move your ear to your shoulder, repeat on other side
• Flexion -> Can you put your chin to your chest
• Extension -> Can you put your head back as far as possible
• Rotation -> Can you look over your shoulder, repeat on other side
• L Spine Flexion -> Place 2 fingers on L vertebrae, ask patient to bend forward and touch your toes
  
  • Fingers should move apart

[Arms]

Are you happy to remain standing or would you like to take a seat for me to examine your arms?

• Shoulder & elbow Can you put your hands behind your head?Assess shoulder abduction & external rotation & elbow flexion
  
  • Restrictive movement -> Elbow/shoulder pathology
  • Excessive movement -> Hypermobility
• Hands Assess for:
  
  • Swelling/deformity
  • Nails for psoriasis
  • Loss of muscle bulk - Thenar & Hypothenar eminence
• Can you hold your hands in front of you, palms facing down, fingers outstretched
  
  • Assess Forward flexion of shoulder & Elbow extension & wrist extension & small joints of fingers extension
  • Can you turn your hands over (Supination) Assess Wrist & elbow supination
• Ask the patient to make a fist
  
  • Assess flexion of small joints of fingers & hand function
• Ask patient to squeeze my fingers to assess grip strength - compare R + L
• Ask patient to touch each finger to their thumb (Opposition/precision grip)
  
  • Assess coordination of small joints - Fingers & thumb & manual dexterity
• Squeeze each MCP joint on R+L hand, ask patient to splay out hand - squeeze both ends of MCP joints
  
  • Assess tenderness & symmetry of joint

[Legs]

Ask patient to lie down on the bed, check if any pain/comfortable

• Assess the knee Flexion -> Hold the knee with one hand on the patella to feel for crepitus
  
  • Flex the knee to bend to approx 130 deg
  • Assess for crepitus & asymmetry b/w R + L knee
• Extension -> Extend the knee back to the original position & further to determine if restricted movement/hypermobile
• Patellar tap test
  
  • Milk the suprapatellar pouch from the thigh down to the knee. Hold at the patella
  • Push the patella down - Feel for tap of the patella due to Medium/Large effusion

Assess the hip

• Flex the hip & knee -> Ask the patient to bring their hip towards their chin
  
  • Assess passive internal rotation of the hip Move foot OUTSIDE away from the other leg
  • Note asymmetry & range of movement on R + L

Assess feet Assess

• Swelling/Erythema
  
  • Deformity
  • Callus
• Im going to be squeezing the small joints in your foot let me know if its tender Squeeze MTP joints all together

[Present exam]

• Wash hands & Thank patient
• “This is patient x who is a x year old Male/Female with the following findings”
• I would take a full Hx from the patient & Examine any joints which were problematic during the GALS exam
• Consider differentials
• Investigations
  
  • Observations
  • Bloods
  • Imaging
• Management

Question 143

You are asked to perform an Examination of a patients spine, how would you go about doing this?

Answer 143

[Introduction]

• Wash hands & Introduce self
• Ask Patient name & DOB & Age
• Today I am going to be doing an examination on your spine today, as I believe you have had some issues. Is that what you were expecting?
• So the examination will involve me having a look at you from the end of the bed/then closer at your spine/I will feel the spine/ and move it around and ask you to do some movements also
  
  • Does that all sound ok?
• I will need you to remove your clothing down to your underwear for me so that I can see your whole spine, the examiner will act as a chaperone for both of us – is that ok?
  
  • Do you have any pain at the moment? Would you like some painkillers?

[General Inspection]

• Can you tell me where on your back is sore? Do you have any trouble walking?
• To examiner: I will be assessing the whole spine, I will start by doing a general inspection
  
  • Assess the surrounding are
  • Walking aids
  • Specialist shoes
  • Back brace etc
• Look at patient from end of the bed
  
  • Signs of pain
  • Body habitus
  • Systemically unwell

[Close inspection/Look]

I will need to have a look at what you look like when you are walking so can you walk up and down from me.

Assess gait:

• Antalgic
• Foot drop
• Trendelenberg
• Stiff hip

Next I would like to have a look more closely at your spine - Facing me/L/R/Facing the wall

• Overall alignment
• Willingness to weight bear
• Scars
• Spinal surgery
• Deformity
• Normal Lordosis/Kyphosis
• Scoliosis
• Any swellings/erythema
• Any skin changes - colour/bruising
• Muscle wasting
• Paraspinal muscles
• Gluteal muscles

[Feel]

Im just going to briefly feel your back and the structures there, let me know if you have any tenderness/if its too much I will stop

Palpate the bones

• C spine
• T spine
• L spine
• Sacrum
  
  • Assess for any increased prominence & tenderness
• Palpate sacro-iliac joints for tenderness
• Palpate muscles/soft tissues
• Trapezius muscle
• Interscapular muscles
• Paraspinal muscles

[Move]

C spine

• Lateral flexion -> Can you please move your ear to your shoulder, repeat on other side
  
  • Make sure its ear to shoulder not shoulder to the ear
• Flexion -> Can you put your chin to your chest
• Extension -> Can you put your head back as far as possible
• Rotation -> Can you look over your shoulder, repeat on other side
  
  • Any pain? Any difficulty?

T spine

• Rotation -> Can you twist your body to your R, I will hold your hip so that you don’t move it
• Next I need you to do the same with your other side so twist your body to your L as far as you can
• Any pain? Any difficulty?

L Spine

• Flexion -> Place 2 fingers on L vertebrae, ask patient to bend forward and touch your toes
  
  • Fingers should move apart
  • Any pain? Any difficulty?
• Extension -> Can you lean back as far as possible please, I will stand behind you to catch you if you are unsteady
• Look to see if the movement is from the spine or the hips
• Lateral flexion -> I need you to slide your L hand down you L leg so I can see how far you can go
• Can you do the same on the R side

[Special tests]

Schober’s test

• Patient standing with back facing me
  
  • Find centre point of lumbosacral region (Above PSIS - Dimple of venus)
• Mark area/put finger to mark it
  
  • Measure 10cm above this - Mark it with pen or use finger
  • Measure 5cm below the centre point - Mark it with pen or use finger
• Ask patient to bend forward to touch their toes Measure increase in distance between the 2 marks
  
  • >5cm = normal
  • <5cm = Reduced range of flexion

Straight leg raise

• Can you please lie flat on your back on the bed
• Can you keep your leg straight and relaxed
• Let me raise your leg from the bed
• Raise leg to 90 deg to assess for pain
• Positive = pain in lower back/buttocks at 30-70 deg -> Disc herniation/tight hamstrings/sciatic nerve entrapment
• Assesses L4/5 and S1 nerve compression

Femoral stretch test

• Can you turn on your front and lie on the couch please
• Flex knee to 90 deg
• Extend hip by raising it off the bed Positive -> Pain in lower back/buttocks/legs = disc herniation at femoral nerve roots
• Assess L2/3/4 nerve compression

Note: Waddells signs:

• Superficial non-anatomical tenderness
• overreaction
• Pain on axial loading of skull/Pain on passive rotation of shoulder or pelvis
• Non-dermatomal pattern of sensory loss

[Complete examination]

To complete the examination I would:

• Examine the Joint Below -> Hip
  
  • Internal rotation of Hip

I would assess the Neurovascular status of the shoulder joint

• Power – All LL myotomes
  
  • L2/3 Quadriceps
  • L3/4 Knee flexion
  • L4/5 Toe dorsiflexion
  • L5 Great toe dorsiflexion
  • S1 Plantarflexion
  • L5/S1 Knee extension
  • L4/L5 Hip extension
• Sensation – All LL dermatomes
  
  • L2 Antero-medial thigh
  • L3 Medial knee
  • L4 Medial malleolus
  • L5 1st web space
  • S1 Lateral calcaneus
  • S2 Popliteal fossa
• Reflexes
  
  • Knee
  • Ankle
• Vascular
  
  • Dorsalis pedis
  • Posterior tibial

[Present examination]

• Wash hands & Thank patient
• “This is patient x who is a x year old Male/Female with the following findings”
• I would take a full Hx from the patient & Examine the joint below (Hip)
• Consider differentials
• Investigations
  
  • Observations
  • Bloods
  • Imaging
• Management

Question 144

You are asked to perform an Examination of a patients shoulder, how would you go about doing this?

Answer 144

[Introduction]

• Wash hands & Introduce self
• Ask Patient name & DOB & Age
• Today I am going to be doing an examination on your shoulder, as I believe you have had some issues. Is that what you were expecting?
• So the examination will involve me having a look at you from the end of the bed/then closer at your shoulder/I will feel the shoulder joint/ and move it around and ask you to do some movements also
  
  • Does that all sound ok?
• I will need you to take your top off so that I can see your whole shoulder, the examiner will act as a chaperone for both of us – is that ok?
  
  • Do you have any pain at the moment? Would you like some painkillers?

[General inspection]

• Which shoulder is sore? Where is the pain?
• Are you right/left handed?
• To examiner: Would you like me to examine both shoulder joints or is one sufficient with the time allowed?
  
  • Look at the surrounding area around the patient
  • Any discarded slings?
• Look at the patient
  
  • Could you stand up for me?
  • Any signs of pain?
  • Are they systemically unwell?
  • Body habitus

[Close inspection]

• Look at the shoulder for:
  
  • Overall alignment
  • Symmetry of the shoulder girdle
  • Obvious signs of trauma
  • Scoliosis
  • Deformity
  • Any steps in the clavicle
  • Any Dislocation?
• Can you put your arms out against the wall, and push against the wall
  
  • Any winging of the scapula (From behind) -> Due to Long thoracic nerve injury
• Any scars?
  
  • From Arthroscopy
  • Any Shoulder surgery?
• Muscle wasting
  
  • Trapezius muscle
  • Deltoid
  • Triceps
  • Biceps
  • Supraspinatus
  • Infraspinatus
• Any swellings?
  
  • Inflammation/Bursitis
• Skin changes
  
  • Bruising – Ecchymosis
  • Erythema
• Check the axilla – Disease here can present as shoulder symptoms
  
  • Check for scars – Axillary clearance etc

[Feel]

Temperature

• Using back of hands – feel temperature around the joint
• Feel from Clavicle – Deltoid – Trapezius – Scapula
  
  • Compare both sides
• If Warm -> Inflammatory process

Structures

• SCJ – Clavicle – ACJ – Acromion – Coracoid process – Borders of the scapula – Supraspinatus – Infraspinatus – Deltoid muscle - Greater tubercle of humerus – Biceps tendon
• Assess for swelling/Tenderness

[Movement]

Function

• Can you put your hands behind your head (External rotation & abduction)
• Can you put your hands behind your back (Internal rotation)
• Can you put your R/L hand across your shoulder like you are putting on a scarf – Repeat for other hand

Flexion

• Can you stand with your palms facing me - Can you raise your arms above your head
  
  • Any pain on movement?
• Record range of movement – as angle
  
  • Normal 150-180 deg

Extension

• Can you stand with your palms facing me – Can you move your arms behind you to try and touch the wall behind?
  
  • Any pain on movement?
• Record range of movement – as angle
  
  • Normal 40deg

Abduction

• Can you put your arms by your sides + Palms facing forwards + Thumbs upwards
• Raise your arms slowly out to the sides until they are above your head
  
  • Any pain on movement?
• Record range of movement – as angle
  
  • Normal 180deg
  • Any Low arc pain – 80-90 deg = Supraspinatus impingement
  • Any High arc pain - >120 deg = Suggestive of ACJ injury/pathology

Adduction

• Can you bring your arms across your body to cross your hands to opposite sides
  
  • Any pain on movement?
• Record range of movement – as angle
  
  • Normal 30-40 deg

External rotation

• Can you put your arms by your sides + elbows flexed to 90deg + Fixed to your side (Tuck it into your hip)
  
  • Can you rotate your arm OUT
• Record range of movement – as angle
  
  • Normal 80-90 deg
  • Loss of external rotation -> Frozen shoulder

Internal rotation

• Can you put your hand behind your back as far as you can
• Record range of movement

Note: if range of movement is restricted or there is pain – Repeat movement passively

[Special tests]

Rotator cuff – SITS (Supraspinatus/Infraspinatus/Teres Minor/Subscapularis

Supraspinatus – Abduction of humerus

• Empty can test – Can you put your arms out at about 70deg + Point your thumb downwards
• I’m going to push your forearms down – stop me from pushing it down

Infraspinatus & Teres Minor – External rotation of humerus

• Can you put your arms by your sides + elbows flexed to 90deg + Fixed to your side (Tuck it into your hip)
• Can you rotate your arm OUT – Stop me from pushing it back IN

Subscapularis – Internal Rotation

• Gerbers lift off test – Can you put your hand behind your back as far as you can
• Don’t let me push your hand into your back
• Weakness in resistance -> Tear in the specific muscle

Impignement testing

Hawkins-Kennedy

• Can you move your upper arm out straight (Abduct shoulder to 90deg) + Bend your elbow so your hand is in front of you (Flexed to 90deg) + Palm facing down
• Hold and support proximal wrist and elbow – stop me from rotating your arm down towards your body
  
  • Note: Pain -> Supraspinatus impingement

Scarf test

• Can you touch your opposite shoulder with your R/L hand
• Apply pressure on the elbow

[Complete examination]

To complete the examination I would:

• Examine the joint above -> C Spine & Joint Below -> Elbow
  
  • C-Spine – Flexion + Extension + Rotation + Lateral flexion
• I would assess the Neurovascular status of the shoulder joint
  
  • Power – Deltoid -> Axillary nerve
  • Sensation – Regimental Badge area -> Axillary nerve
  • Vascular – Radial pulse

[Present exam]

• Wash hands & Thank patient
• “This is patient x who is a x year old Male/Female with the following findings”
• I would take a full Hx from the patient & Examine the joint above (C-spine) and below (Elbow)
• Consider differentials
• Investigations
  
  • Observations
  • Bloods
  • Imaging
• Management

Question 145

You are asked to perform an Examination of a patients elbow, how would you go about doing this?

Answer 145

[Introduction]

Wash hands & Introduce self

• Ask Patient name & DOB & Age
• Today I am going to be doing an examination on your elbow, as I believe you have had some issues. Is that what you were expecting?
• So the examination will involve me having a look at you from the end of the bed/then closer at your elbow/I will feel the elbow joint/ and move it around and ask you to do some movements also
  
  • Does that all sound ok?
• I will need you to remove your top or just move it so I can see the whole shoulder, the examiner will act as a chaperone for both of us – is that ok?
  
  • Do you have any pain at the moment? Would you like some painkillers?

[General Inspection] - Sitting

• Can you tell me which elbow is sore? Where on the elbow is painful?
• Are you Right/Left handed?
• To examiner - Ideally I would examine both elbows, but due to the time constraints I will only examine one, is that ok?
• Assess the surrounding area:
  
  • Discarded slings
  • Casts
  • Painkillers
• Look at the patient from the end of the bed:
  
  • Body habitus
  • Signs of pain
  • Are they systemically unwell? -> The patient looks well at rest

[Close inspection/Look]

Inspect from the front to the back

• Overall alignment
• Symmetry of the joint
  
  • Normal -> 10deg flexion at elbow when standing
• Scars
  
  • Scar at medial epicondyle -> Ulnar nerve surgery
  • Olecranon scar
  • Arthroscopy scar
• Any obvious deformity
  
  • Dislocation
  • Swelling
  • Effusion/Olecranon bursitis
• Fixed flexion deformity
  
  • Cubitus valgus deformity (>15 deg)-> Due to lateral epicondyle trauma
  • Cubitus varus deformity (<5 deg) -> Due to medial epicondyle trauma
• Assess for muscle wasting
  
  • Forearm - Flexors/Extensors
  • Upper arm - Biceps/Triceps etc
• Skin changes
  
  • Thickening
  • Nodules -> Sign of RA
  • Psoriatic plaques -> Sign of Psoriatic arthritis
  • Erythema/Ecchymosis

[Feel]

Assess temperature in the joint

• Around the joint line/Medial aspect/Lateral aspect/Anterior/Posterior

Assess the structures of the joint

• Flex patients elbow at 90deg, Can you relax your arm and let me feel around the joint

Assess:

• Medial/Lateral epicondyles
• Effusion behind radial head
• Radial head + Radio-capitellar joint
• Biceps tendon - within ante-cubital fossa
• Olecranon process
• Ulnar nerve - behind medial epicondyle

[Move]

Assess Function

• Can you put your hands behind your head?
• Can you put your hands to your mouth?

Flexion

• Can you bring your hands to touch your shoulders?
• Record range of motion in deg
  
  • Normal -> 0-145 degs

Extension

• Can you put your arms out straight to your sides?
• Record range of motion in deg
• Assess for hyperextension
  
  • Normal -> 0 deg

Pronation

• Can you keep your arms to your sides, stick it in your hip/bend your elbows to 90deg/Fix them into your side
• Can you rotate your arm so your palm is facing down?
• Record range of motion in deg
  
  • Normal -> 0-85 deg

Supination

• Can you keep your arms to your sides, stick it in your hip/bend your elbows to 90deg/ Fix them to your side
• Can you rotate your arm so your palm is facing UP?
• Record range of motion in deg
  
  • Normal -> 0-90 deg

Repeat all movements passively

• Flexion/Extension/Pronation/Supination
• Place hand over the joint to feel for crepitus

[Special tests]

Medial epicondylitis - Golfers elbow

• Patient has a problem with resisted wrist flexion
• Can you put your arm straight out in front of you/Elbow extended /Supinated - Palm UP
• Let me take hold of your forearm
• Palpate medial epicondyle with one hand/Hold pts wrist with other hand
• Can you make a fist? and move it towards your body?
• I’m going to try and push your wrist down, try and stop me (Resisted flexion)
  
  • Pain over medial epicondyle -> Positive test for Epicondylitis
  • Note: Medial epicondyle is the attachment for all the forearm Flexors

Lateral epicondylitis - Tennis elbow

• Problem with resisted wrist extension
• Can you put your arm straight out in front of you/Elbow extended /Pronation - Palm DOWN
• Let me take hold of your forearm
• Palpate lateral epicondyle with one hand/Hold pts wrist with other hand
• Can you make a fist? and move it away from your body?
• Im going to try and push your wrist UP, try and stop me (Resisted extension)
  
  • Pain over Lateral epicondyle -> Positive test for epicondylitis
  • Note: Lateral epicondyle is the attachment for all the forearm Extensors

[Complete examination]

• I would examine the joint above (Shoulder) & Below (Wrist)
  
  • Hands behind head
• I would assess the neuromuscular state of the limb Power
  
  • Ulnar nerve - Scissors
  • Median nerve - Stone
  • Anterior Osseous branch of medial - OK
  • Radial nerve - Wrist extension - Paper
• Sensation
  
  • Ulnar nerve -> Lateral aspect of little finger
  • Median nerve -> Lateral aspect of index finger
  • Radial nerve -> Dorsal 1st interosseous space
• Vascular function
  
  • Radial/Ulnar pulse

[Present examination]

• Thank patient & Wash hands
• “This is patient x who is a x year old Male/Female with the following findings”
• I would take a full Hx + examine any other relevant joints and systems
• I would consider the differentials
• I would order relevant investigations
  
  • Observations
  • Bloods
  • Imaging
• I would initiate management of the most likely differential

Question 146

You are asked to perform an Examination of a patients Hand & Wrist, how would you go about doing this?

Answer 146

[Introduction]

• Wash hands & Introduce self
• Ask Patient name & DOB & Age
• Today I am going to be doing an examination on your hand & wrist, as I believe you have had some issues. Is that what you were expecting?
• So the examination will involve me having a look at you from the end of the bed/then closer at your hand & wrist/I will feel the hand & wrist joint/ and move it around and ask you to do some movements also
  
  • Does that all sound ok?
• I will need you to remove your top or just move it so I can see the up to your elbow, the examiner will act as a chaperone for both of us – is that ok?
  
  • Do you have any pain at the moment? Would you like some painkillers?
• You can remain seated for this exam with a pillow under your hand

[General Inspection]

• Can you tell me which hand is sore? Where on the hand is painful?
  
  • Are you Right/Left handed?
• To examiner - Ideally I would examine both hands, but due to the time constraints I will only examine one, is that ok?
• Assess the surrounding area:
  
  • Discarded slings/splints
  • Painkillers
• Look at the patient from the end of the bed:
  
  • Body habitus
  • Signs of pain
  • Are they systemically unwell? -> The patient looks well at rest

[Close inspection/Look]

Start by looking at the dorsum of the hand

• Hand posture
  
  • Any abnormal posture - Contracture/ulnar deviation
• Nail changes
  
  • Nailfold vasculitis -> RA/Small vessel vasculitis
  • Nail pitting/Onycholysis -> Psoriasis/Psoriatic Arthritis
• Skin changes
  
  • Thinning/bruising -> Steroid use/inflammatory arthritis
  • Psoriatic plaques -> Psoriatic arthritis
  • Erythema -> Cellulitis/Septic arthritis
  • Pallor of nail beds - CRT <2s -> PVD/Anaemia
• Scars
  
  • Previous hand surgery
• Swelling
  
  • Comparing R & L hands
• Muscle wasting
  
  • 1st dorsal interossei -> secondary to chronic joint pathology/LMN lesion e.g. carpal tunnel syndrome
• Deformities
  
  • Herbedens nodes - DIPJ -> OA sign
  • Bouchards nodes - PIPJ -> OA sign
  • Boggy swelling -> Synovitis/RA/Trama
  • Cystic swelling -> Ganglion
  • Swan neck deformity -> RA
    
    • DIPJ Flexion + PIPJ Hyperextension
  • Boutonnieres deformity -> RA
    
    • PIPJ Flexion + DIPJ Hyperextension
  • Z thumb -> RA
    
    • Hyperextension of IPJ + Fixed flexion + Subluxation of MCPJ
  • Ulnar deviation
    
    • MP joints deviate towards little finger (Ulna)
  • Mallet - DIP fixed flexion

Assess the palmar surface of the hand

• Hand posture
  
  • Asymmetry
  • Dupytrens contracture
• Scars/Swelling
  
  • Scars from previous surgery
• Compare R + L for swelling
• Skin colour
  
  • Palmar erythema -> RA
• Hypothenar eminence
• Deformity
  
  • Gouty tophi
  • Dupytrens contracture
  • Rheumatoid nodules
• Assess the wrist Deformity
  
  • Subluxation
  • Deviation
  • Swelling
  • RA Nodules
  • Ganglion
• Scars
  
  • Carpal tunnel release surgery
  • Scaphoid surgery
• Assess the elbow Psoriatic rashes/lesions
  
  • If YES - Ask patient, do you have any other lesions anywhere on your body?
• To examiner: I would also examine the ears/neck/scalp for plaques/tophi
  
  • Note: Tophi most likely at the ears

[Feel]

Temperature

• Move distal to proximal & compare both sides
• Increased warmth -> Septic arthritis/inflammatory arthritis

Pulses

• Radial pulse
• Ulnar pulse

Muscle bulk

• Thenar eminence (Median nerve)
• Hypothenar eminence (Ulnar nerve)

Palmar thickening

• Palpate palms for palpmar thickening -> Dupytrens contracture

Nerve sensation

• Ulnar nerve -> Lateral little finger
• Median nerve -> Lateral index finger
• Radial nerve -> 1st dorsal web space

Joint assessment MCP squeeze

• Squeeze each MCPJ and look at patient for signs of pain
• If tender -> Inflammatory arthritis

Bimanual palpation of ALL joints - thumb & index finger at sides & top

• MCPJ/PIPJ/DIPJ/CMCJ of thumb
• Anatomical snuffbox - get patient to abduct thumb
• Tenderness -> Scaphoid fracture

Palpate wrist joint - irregularity/tenderness

• Ulnar border
• Radial styloid process
• Ulnar head

[Move]

Assess function

• Can you squeeze my fingers -> Grip strength
• Can you touch your thumb to all your fingers on that hand -> Opposition
• Are you able to do up your buttons/pick up a coin from a flat surface -> Fine motor

Fingers

• Flexion -> Can you make a fist
• Extension -> Open your fist and straighten your fingers out
• Abduction -> Can you spread your fingers wide apart
• Adduction -> Bring your fingers back together

Thumb

• Abduction -> Can you move you thumb OUT to form an L
• Adduction -> Can you move it back towards your index
• Flexion -> Can you bring your thumb into your palm? Extension - And back out
• Opposition -> Can you touch each finger with your thumb

Wrist

• Extension -> Put your palms together and push them together - Prayer sign
• Flexion -> Put the backs of your hands together and push them together - Reverse prayer
• Pronation/Supination -> Can you turn your wrist so your dorsum faces up/Palm

[Special tests]

Tinnels test

• Tap over the carpal tunnel with finger
• Ask patient to report any sensation
• Positive -> Tingling in thumb & radial 2.5 fingers -> Median nerve irritation & compression (Carpal tunnel syndrome)

Phalens test

• Ask patient to hold wrists in reverse prayer sign
• Hold it there for 60s
• Tell me if you feel any change to your sensation
• Positive -> Patient should report change to sensation -> Carpal tunnel syndrome symptoms - Burning/tingling/numb sensation in thumb/index/middle/ring fingers

Froments test

• Ask patient to hold paper b/w flat of thumb and index finger
• Attempt to pull the paper out
• Positive -> Patient needs pinch grip to hold the paper

[Complete examination]

• I would examine the joint above (Elbow)
• I would assess the neuromuscular status of the joint

Motor

• Radial nerve -> Resisted wrist extension - don’t let me push your hand down
• Ulnar nerve -> Resisted little finger abduction - don’t let me push your little finger in
• Median nerve -> Resisted thumb opposition - thumb to little finger, don’t let me pull them apart

Sensation

• Ulnar nerve -> Lateral little finger
• Median nerve -> Lateral index finger
• Radial nerve -> 1st dorsal web space

Pulses

• Capillary refill time
• Radial/Ulnar pulse

[Present examination]

• Thank patient & Wash hands
• “This is patient x who is a x year old Male/Female with the following findings”
• I would take a full Hx + examine any other relevant joints and systems
• I would consider the differentials
• I would order relevant investigations
  
  • Observations
  • Bloods
  • Imaging
• I would initiate management of the most likely differential

Question 147

You are asked to perform an Examination of a patients Knee, how would you go about doing this?

Answer 147

[Introduction]

• Wash hands & Introduce self
• Ask Patient name & DOB & Age
• Today I am going to be doing an examination on your knee, as I believe you have had some issues. Is that what you were expecting?
• So the examination will involve me having a look at you from the end of the bed/then closer at your knee/I will feel the knee joint/ and move it around and ask you to do some movements also
  
  • Does that all sound ok?
• I will need you to remove your clothing from your bottom half or wear shorts so I can see the whole knee, the examiner will act as a chaperone for both of us – is that ok?
  
  • Do you have any pain at the moment? Would you like some painkillers?

[General Inspection]

• For the examination, I will need you standing up - can you do that?
  
  • Can you tell me which knee is sore? Where exactly is the pain?
• To examiner: I would ordinarily examine both knees however due to the time constraints I will examine the knee that is affected, are you happy with that?
• Assess the surrounding area:
  
  • Walking aids
  • Specialist shoes
  • Assess the patients shoes
  • Insole
  • Signs of uneven wear
    
    • Normal wear -> Heel & 1st Metatarsal
• Look at the patient and assess
  
  • Signs of pain
  • Body habitus
  • Are they systemically unwell?

[Close inspection/Look]

Gait

• For the next part of the examination, I will need to have a look at you walking. Can you walk the wall A to wall B.
• Assess gait looking for:
  
  • Normal gait - Stance & Swing phase
  • Antalgic gait -> Decreased flexion of the knee, due to pain
  • Thrusting gait -> Knee gives way as patient is walking
  • Foot drop -> High stepping gait, due to Common Peroneal nerve injury

Inspect the joint closely - Anterior/Lateral/Posterior/LateralSymmetry

• Are the knees symmetrical?
• Any Valgus/Varus deformity
• Suggestive or OA/Rickets (Varus) & OA/RA (Valgus)
• Look at feet & ankles for symmetry
  
  • Alignment of knees
• Signs of Hyper-extension from the side
• Is the patient willing to weight bear?

Muscle wasting

• Quadriceps (Anterior)
• Gastrocnemius/Hamstrings (Posterior)

Swellings

• Effusion -> Look for loss of medial knee dimple
• Bakers cyst/Popliteal artery aneurysm (Posterior)
  
  • Note if it is pulsatile -> Popliteal aneurysm

Bursitis/Inflammation

Fixed flexion deformity - (Lateral)

• Sign of OA/Other knee pathology

Scars

• Arthroscopy
• Knee replacement -> Large Anterior crossing the joint

Skin changes

• Erythema
• Brusing
• Nodules

[Feel]

Temperature

• Assess the temperature along the patella/medial/Lateral/Posterior joint line
• Increased temp -> Inflammation
• Decreased temp -> Vascular compromise

Measure the thigh circumference

• 10cm above the patella
• Compare both sides

Patellar tap test

• Milk the suprapatellar pouch from the thigh down to the knee. Hold at the patella
• Push the patella down - Feel for tap of the patella due to Medium/Large effusion

Sweep/Bulge test

• Sweep fluid UP from the medial/Lateral aspect of the patella x2 - then sweep down on the opposite side
• Look for bulge on opposite side -> Sign of small effusion

Assess the structures of the knee

• Can you please bend your knee, bringing your heel to your bottom (90 deg flexion)
• Asses for:Local tenderness along the joint line (Anterior/Lateral/Posterior/Medial)
  
  • Lateral/Medial joint line tenderness -> OA/Meniscal tear
  • Patella tendon
  • Insertion of patellar tendon (Tibial tuberosity)
  • Quadriceps tendon
  • Margins of the Patella
  • Medial/Lateral collateral ligaments
  • Hamstring tenderness (Posterior)
  • Swellings behind knee
  • Bakers cyst -> Non pulsatile
  • Popliteal aneurysm -> Pulsatile

Feeling for:

• Tenderness
• Bony abnormality (Osteophyte)

[Move]

Function

• Can I ask you to squat down
• Do you have any pain or weakness?

Flexion

• Active - Can you bring your heel to your bottom - Assess range of motion
• Passive - If you don’t mind i’m going to move your heel closer to your bottom, let me know if you feel any pain
• Feel for crepitus & Look for pain
  
  • Normal - 140 deg

Extension

• Can you straighten your knee onto the bed, and then push the back of your knee into the bed
• Hyper-extension
• Can you please relax your leg and let me raise it off the bed, Raise leg by ankle/foot
  
  • Normal extension - <10 deg
  • Hyper-extension - >10 deg -> Joint Hypermobility syndrome

Straight leg raise

• Can you keep your leg straight and let me raise your heel of the bed
• To identify if Patellar tendon is intact (Extensor)

[Special tests]

Cruciate ligaments (ACL/PCL)Assess for posterior sag (PCL tear)

• Ask pt to flex knee to 90 deg with feet flat on bed - can you bring your heel to your bottom
• Look at the knee to see if there is a plateau before the tibia, caused by posterior sag
• This could mean the pt has a false positive ACL drawer test

ACL drawer test

• Ask pt to flex knee to 90 deg with feet flat on bed - can you bring your heel to your bottom
• I am going to sit on your feet just to fix it to the bed, is that ok?
• Hold the leg below the knee & thumbs on the proximal tibia
• Can you relax your leg for me, I’m going to pull your leg quite forcefully. Let me know if you have any pain
• Pull tibia AWAY From patient
  
  • Normal - Little movement & firm end-point
  • If Lax - see/feel the tibia moving forward -> ACL tear

PCL drawer test

• I’m just going to do the same thing as before but this time push your shin towards you, again let me know if you feel any pain
• Push tibia TOWARDS patient
  
  • Normal - Little movement & firm end-point
  • If lax - see/feel the tibia moving backwards -> PCL tear

McMurrays test - Meniscal tear

• Grasp sole of foot with one hand & on top of the knee with the other hand (Thumb feeling down one joint line & Index feeling down another)
• Flex the knee and hip to 90deg
  
  • Slowly straighten the knee with the foot in external rotation - Lateral meniscus
• Flex the knee again and hip to 90deg
  
  • Slowly straighten the knee with the foot in internal rotation - Medial meniscus
• Feel over the knee for a click/grinding & Look at the patient for signs of pain/discomfort

Collateral ligaments (LCL/MCL)

• Hold the knee with one hand & the ankle with the other
  
  • Flex the knee to 30deg
• For the MCL - Apply INWARD force on Knee + OUTWARD force on the ankle
• For the LCL - Apply OUTWARD force on knee + INWARD force on ankle
  
  • Tear in ligament -> pain or lack of firm end-point in movement

Patellar apprehension test

• Can you keep your legs straight
• Apply lateral force to patella & Start to flex the knee
• Watch patients face -> Apprehension on face and doesn’t allow to move (Positive)
  
  • Apprehension -> Previous patellar dislocation

[Complete examination]

• To complete the examination, I would assess the joint above (Hip) and the joint below (Ankle)
  
  • Internal rotation of Hip in flexion
• I would also assess the neuromuscular function of the knee
• Power
  
  • Extension of the toes -> Common peroneal nerve
  • Plantarflexion of the foot -> Tibial nerve
• Sensation
  
  • Dorsum of the foot -> Common peroneal nerve
  • Sole of the foot -> Tibial nerve
• Vascular
  
  • Posterior tibial pulse
  • Dorsalis pedis pulse
  • Capillary refill time at hallux

[Present examination]

• Thank patient & Wash hands
• “This is patient x who is a x year old Male/Female with the following findings”
• I would take a full Hx + examine any other relevant joints and systems
• I would consider the differentials
• I would order relevant investigations
  
  • Observations
  • Bloods
  • Imaging
• I would initiate management of the most likely differential

Question 148

You are asked to perform an Examination of a patients Hip, how would you go about doing this?

Answer 148

[Introduction]

• Wash hands & Introduce self
• Ask Patient name & DOB & Age
• Today I am going to be doing an examination on your hip, as I believe you have had some issues. Is that what you were expecting?
• So the examination will involve me having a look at you from the end of the bed/then closer at your hip/I will feel the hip joint/ and move it around and ask you to do some movements also
  
  • Does that all sound ok?
• I will need you to remove your clothing from your bottom half so I can see the whole hip, the examiner will act as a chaperone for both of us – is that ok?
  
  • Do you have any pain at the moment? Would you like some painkillers?
• I’ll need you standing initially for the examination, then on the couch later

[General Inspection]

• Can you tell me which hip is sore? Where exactly is the pain?
• To examiner: I would ordinarily examine both hip however due to the time constraints I will examine the hip that is affected, are you happy with that?
• Assess the surrounding area:
  
  • Walking aids
  • Specialist shoes
  • Assess the patients shoes
  • Insole
  • Signs of uneven wear
    
    • Normal wear -> Heel & 1st Metatarsal
• Look at the patient and assess
  
  • Signs of pain
  • Body habitus
  • Are they systemically unwell?

[Close inspection/Look]

Gait

• For the next part of the examination, I will need to have a look at you walking. Can you walk the wall A to wall B.
• Assess gait looking for:
  
  • Normal gait - Stance & Swing phase
  • Antalgic gait
  • Stiff hip
  • Trendelenberg gait
  • Foot drop -> High stepping gait, due to Common Peroneal nerve injury

Trendelenberg test

• Stand in front of patient with hands on iliac crest & patient hands on my forearms
• Can you please stand on the abnormal leg? with other knee raised
  
  • Normal -> Pelvis on raised knee side rises up
  • Positive pathology -> Pelvis on raised knee side drops down
• Caused by pain that inhibits muscles/muscle wasting/nerve damage

Inspection whilst standing - Anterior/Left/Right/Posterior

• Symmetry of the hip
  
  • Alignment
  • Willingness to weight bear
• Deformity
  
  • Increased Lumbar lordosis
  • Scoliosis
• Hip rotation
• Knee flexion
• Scars
  
  • Arthroscopy
  • Hip replacement
• Muscle wasting
  
  • Quadriceps
  • Gluteal muscles
• Swelling
  
  • Effusion
  • Inflammation
  • Bursitis
• Skin changes
  
  • Erythema
  • Bruising

[Feel] – Supine position

• Temperature - using back of hands
• Palpation
  
  • Greater trochanter
  • ASIS

[Move]

• Ask patient to do a range of movements

Flexion

• Active - bring your knee to your chest
• Passive - Push the hip further after active movement

Rotation

• Passive - With your knees still towards your chest, im going to move it in different directions, tell me if you feel any pain at all

Internal rotation - Rotate leg OUT (Hip rotates IN)

External rotation - Rotate leg IN (Hip rotates OUT)

Abduction & Adduction Fix pelvis over iliac crest & Hold leg out at an angle

• Abduction - Move leg OUT Feel for pelvis tilt at the iliac crest
• Adduction - Move leg IN over other leg, feel for pelvis tilt

Extension

• Can you please roll over on your front fro me
• Can you lift your leg off the bed for me, assist (Passive)

Straight leg raise

• Can you keep your knee straight and lift your leg off the bed
• Assess spine

[Special tests]

Leg length - Ask patient to lie on front, bring ankles together

• Check if medial malleoli meet -> Unlikely leg length discrepancy
• Measure Apparent leg length
  
  • Umbilicus -> Medial malleolus
  • Repeat on other leg
  • Discrepancy -> Pelvic deformity (Pelvic tilt)
• Measure True leg length
  
  • ASIS -> Medial malleolus
  • Repeat on other leg
  • Discrepancy -> Bone deformity

Thomas test

• With patient supine, with legs hanging over the end of the bed
• Place hand under L spine
• Ask patient to flex non-painful or affected knee to their chest
• Lumbar lordosis should be eliminated to 0 deg
  
  • If FFD -> Abnormal, thigh raised off bed
    
    • Caused by FFD (Tightening/shortening of hip flexors) - OA
  • If normal -> Abnormal Thigh stays on bed

[Complete examination]

• To complete the examination, I would assess the joint above (spine) and the joint below (knee)
  
  • Straight leg raise (Spine)
• I would also assess the neuromuscular function of the knee
• Power
  
  • Quadriceps -> Femoral nerve
  • Toe extension -> Common peroneal nerve
  • Plantar flexion of foot -> Tibial nerve
• Sensation
  
  • Anteromedial thigh -> Femoral nerve
  • Dorsum of the foot -> Common peroneal nerve
  • Sole of the foot -> Tibial nerve
• Vascular
  
  • Posterior tibial pulse
  • Dorsalis pedis pulse

[Present examination]

• Thank patient & Wash hands
• “This is patient x who is a x year old Male/Female with the following findings”
• I would take a full Hx + examine any other relevant joints and systems
• I would consider the differentials
• I would order relevant investigations
  
  • Observations
  • Bloods
  • Imaging
• I would initiate management of the most likely differential

Question 149

You are asked to perform an Examination of a patients Ankle & Foot, how would you go about doing this?

Answer 149

[Introduction]

• Wash hands & Introduce self
• Ask Patient name & DOB & Age
• Today I am going to be doing an examination on your ankle & foot, as I believe you have had some issues. Is that what you were expecting?
• So the examination will involve me having a look at you from the end of the bed/then closer at your ankle & foot/I will feel the ankle & foot joint/ and move it around and ask you to do some movements also
  
  • Does that all sound ok?
• I will need you to remove your clothing and wear shorts so I can see the whole of your foot and ankle, and your knee the examiner will act as a chaperone for both of us – is that ok?
  
  • Do you have any pain at the moment? Would you like some painkillers?
• I’ll need you standing initially for the examination, then on the couch later

[General Inspection]

• Can you tell me which ankle & foot is sore? Where exactly is the pain?
• To examiner: I would ordinarily examine both ankles however due to the time constraints I will examine the ankle that is affected, are you happy with that?
• Assess the surrounding area:
  
  • Walking aids
  • Specialist shoes
  • Assess the patients shoes
  • Insole
  • Signs of uneven wear
    
    • Normal wear -> Heel & 1st Metatarsal
• Look at the patient and assess
  
  • Signs of pain
  • Body habitus
  • Are they systemically unwell?

[Close inspection/Look]

Gait

• For the next part of the examination, I will need to have a look at you walking. Can you walk the wall A to wall B.
• Assess gait looking for:
  
  • Normal gait - Stance & Swing phase
  • Antalgic gait
  • Stiff ankle -> Decreased dorsiflexion of ankle
  • Trendelenberg gait
  • Foot drop -> High stepping gait, due to Common Peroneal nerve injury

Assess function (Looking at ankle from behind and in front)

• Can you walk on your tip toes, I will be around to support you
  
  • Can you walk on your heels

Inspection of foot and ankle Front

• Symmetry of feet & ankles
• Toe alignment
  
  • May have Hallux valgus of big toe
  • Bunions - at 1st MTP joint
• Deformity
  
  • Claw toe - Toes bend down like claw
  • Mallet toes - End joint only, mallet appearance at end
  • Hammer toe - Toe bent at middle joint -> Curling of distal toe. Most common in 2nd toe
• Scars
  
  • Previous injury
  • Surgery
• Swelling/Erythema
  
  • Inflammatory arthritis/Septic arthritis/Cellulitis/injury
• Calluses (Skin thickening)
• Foot/Gait deformity or poorly fitting shoes
  
  • Normal at 1st MTP/Heel
• Willingness to weight bear
• Look b/w toast for ulcer/calluses
  
  • Look underneath foot at sole for ulcers/calluses
• Side Foot arches
  
  • Pes planus -> Flat feet Ask patient to stand on tip toes
    
    • If supple -> Correction of pes planus
    • If rigid -> No correction
  • Pes Cavus -> High arched feet
• Back/Behind Heel alignment
• Valgus/varus deformity
• Achilles tendon
  
  • Deformity
  • Swelling -> Achilles tendonitis
  • Discontinuity
• Erythema

[Feel]

Temperature

• Forefoot
• Midfoot
• Ankle

Palpate structures

• Anterior ankle joint line
• Distal fibula (Lateral)
• Calcaneus
• Medial malleoli
• Lateral malleoli
• Subtalar joint
• Midtarsal joint
• MTP joint squeeze

Bimunual palpation of ALL toes Assess for

• Tenderness
• Swelling
• Irregularity

Palpate the achilles tendon

• Position patient kneeling on a chair with feet handing off
• Palpate gastrocnemius muscle + Achilles tendon
  
  • Note:
  • Focal tenderness/swelling -> Achillies tendonitis
  • Apparent gaps in tendon -> Rupture of achilles tendon

[Move]

• Foot plantar flexion -> Push your feet down like you are pushing a pedal
  
  • 0-50 deg
• Foot dorsiflexion -> Point your foot towards your head
  
  • 0-20
• Toe flexion -> Curl up your toes
• Toe extension -> Point your toes up towards your head
• Ankle/Foot inversion -> Stabilise above ankle, move your foot inside (Medial)
• 0-35 deg
• Ankle/foot eversion -> stabilise above ankle, move your foot outside (Lateral)
• 0-15 deg
• Big toe - stabilise mid foot with hand - eliminate ankle movement
  
  • Dorsiflexion -> move your big to up towards your head
  • Plantarflexion -> Move your big toe down to the floor without using the other toes
  • Passive movement - feel for crepitus Mid-tarsal joint
• Stabilise ankle w/L hand, grasp forefoot with R hand
  
  • Apply twisting motion between hands
• Sub-talar joint
  
  • Stabilise foot above ankle joint with L hand grasping heel w/R hand
  • Invert/Evert the foot

[Special tests]

Simmonds test

• Ask patient to kneel on a chair or lie on bed with foot handing over the edge
• Squeeze the calf muscle/gastrocnemius
  
  • Normal -> Plantarflexion of foot
  • Positive -> Absence of plantar flexion of foot - Rupture of achilles tendon

[Complete examination]

• To complete the examination, I would assess the joint above (knee)
  
  • Flexion
  • Extension
• I would also assess the neuromuscular function of the ankle & foot
• Power
  
  • Toe extension -> Common peroneal nerve
  • Plantar flexion of foot -> Tibial nerve
• Sensation
  
  • Dorsum of the foot -> Common peroneal nerve
  • Sole of the foot -> Tibial nerve
• Reflex
  
  • Ankle jerk reflex
• Vascular
  
  • Posterior tibial pulse
  • Dorsalis pedis pulse

[Present examination]

• Thank patient & Wash hands
• “This is patient x who is a x year old Male/Female with the following findings”
• I would take a full Hx + examine any other relevant joints and systems
• I would consider the differentials
• I would order relevant investigations
  
  • Observations
  • Bloods
  • Imaging
• I would initiate management of the most likely differential

Question 150

What is an Antalgic gait?

Trendelenburg gait

Circumduction gait

Spastic gait

Toe walking

High stepping gait

Answer 150

Antalgic gait

• Limp/non weight bearing
• b/c of pain
• Can be due to:
  
  • Trauma e.g. fracture
  • Problems with appendix
  • Hernia
  • Testicular pathology

Trendelenburg gait

• Due to gluteal muscle weakness (Abductors)
  
  • Weight bearing on ipsilateral side -> Pelvis drop on contralateral side
• Note: Normal is for contralateral side to rise
• If bilateral disease -> Waddling gait
• Caused Hip joint disease
  
  • Perthes/SUFE/DDH/JIA
  • Muscle disease
  • DMD/Metabolic muscle disease
  • Neurological conditions
  • Spina bifida/Cerebral palsy

Circumduction gait

• “Peg leg” - Due to excessive hip abduction
  
  • Legs swing forward -> semi-circular movement of the leg
• Caused by:
  
  • Restricted joint movement
  • JIA/Post trauma
  • Leg length discrepancy
  • Hemiplegic cerebral palsy

Spastic gait

• Flexion at hip + knees
  
  • Feet (Ankles) extended & internal rotation
  • Adduction of knees
• Usually flexion of UL
• Caused by:
  
  • UMNL
  • Cerebral palsy/Stroke

Toe walking

• Walking on tip toes w/lack of heel contact
• Caused by:
  
  • Normal variant (If they can walk on heels on request)
  • UMNL
  • Cerebral palsy
  • DMD
  • ASD

High stepping gait

• Toes point down with foot hanging
• Unable to dorsiflex foot
• Caused by:
  
  • Damage to deep peroneal nerve

Question 151

What is comparment syndrome?

Answer 151

Increased pressure within a closed anatomical space, compromising circulation and function of tissues in that space

• Can lead to damage to muscles + nerves
• Acute – Emergency
• Chronic – usually due to acvitity, stops at rest

Commonly affects:

• Anterior/Deep posterior compartment of the leg
• Volar compartment of the forearm

Question 152

What is found in the following forearm compartments?

Ventral

Dorsal

Answer 152

Ventral:

• Median nerve
• Ulnar nerve
• Radial artery
• Ulnar artery

Dorsal

• Posterior interosseous nerve

Question 153

What are the causes of acute compartment syndrome?

Answer 153

• Fracture
• Crush injury
• Prolonged limb compression
• Burns
• Infection

Question 154

What are the symptoms/signs of acute compartment syndrome?

Answer 154

• Within 48hrs of injury
• Loss of muscle function – may have muscle necrosis
• Pain on passive stretching of muscles in the affected compartment
• Disproportionate pain to severity of injury
• Pressure in compartment
• Parasthesia
• Pulselessness
• Pallor
• Paralysis
• Cool to touch
• Loss of capillary refill

Question 155

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 51-year-old man presents to the trauma centre complaining of significant right lower extremity pain after a motor vehicle collision. After careful evaluation he is found to have a pulseless right foot with posterior knee dislocation. On physical examination his extremity is swollen with tight compartments below the knee. Passive range of motion of the foot elicits calf pain out of proportion to examination.

Answer 155

• Acute compartment syndrome
• DVT
• Infection
• Acute ischaemia
• Osteomyelitis

Question 156

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 35-year-old competitive runner presents with exercise-induced pain and a feeling of tightness that begins after about 20 to 30 minutes of running. The pain usually resolves within 15 to 30 minutes of ceasing exercise. Physical examination reveals tenderness over the musculature of the anterior compartment of the lower leg.

Answer 156

• Acute compartment syndrome
• DVT
• Infection
• Acute ischaemia
• Osteomyelitis

Question 157

A patient presents with the following Hx, suggestive of acute compartment syndrome. What investigations are required + management?

Answer 157

Investigations:

• Clinical diagnosis
• Compartment pressure measurment – Differential pressure within 30mmHg of DBP
• MRI - if unsure
• Serum CK – Increased if muscle necrosis
• Urine myoglobin – Increased if muscle necrosis

Management:

• Prompt diagnosis + Early surgery
• Urgent decompression + Prevent severe ischaemia
• Open fasciotomy + Wound left open
• Debridement of muscle necrosis
• Morphine for pain
• If absence of muscle function in neurologically intact limb – Amputation

Question 158

What are the complications of fractures?

Acute v Delayed

Answer 158

Acute:

• Neurovascular damage
• Soft tissue damage
• Blood loss
• Local tissue contamination/infection
• Fracture blisters
• Compartment syndrome

Delayed:

• Delayed union
• Malnunion – # Doesnt heal in normal alignment
• Non-union – Doesnt heal at all
• Osteomyelitis
• AVN
• Loss of function

Question 159

What is the normal process of fracture healing?

Answer 159

• Inflammation with swelling lasting 2-3 wks
• Soft callus formation
• Hard callus formation
• Bone remodelling

Question 160

What does the following x-ray show?

Answer 160

Osteo arthritis in both R + L knees

• Loss of joint space
• Osteophytes
• Subchondral sclerosis
• Subchondral cysts

Question 161

What does the following x-ray show?

Answer 161

Inflammatory Arthritis (e.g. RA)

• Bone erosions
• Ulnar deviation
• Soft tissue swelling
• Joint space narrowing
• Osteopenia

Question 162

What does the following x-ray show?

Answer 162

Gout

• Punched out erosions
• Podagra
• Joint effusion
• No periarticular osteopenia

Question 163

What does the following x-ray show?

Answer 163

Pathological fracture

• Low BMD – Cortical thickness different to normal bone
• Fracture through well defined lesion

Question 164

What does the following x-ray show?

Answer 164

Fractured neck of femur

• Garden 2
• Shentons line disrupted

Question 165

What does the following x-ray show?

Answer 165

SUFE on the L hip (Right side of image)

Question 166

What does the following x-ray show?

Answer 166

Extracapsular hip fracture

Question 167

What does the following x-ray show?

Answer 167

Garden 4 - NOF fracture

Question 168

What does the following x-ray show?

Answer 168

Bilateral Perthes disease

Question 169

What do the following show?

Answer 169

Pes Cavus

Normal arch

Pes Planus

Question 170

What do the following show?

Answer 170

Mallet toe

Hammer toe

Claw toe

Question 171

What are the following fractures?

Answer 171

Tansverse

Linear

Oblique non-displaced

Oblique displaced

Spiral

Greenstick

Communinuted