MSK/orthopaedic

Question 1

Classification system for intracapsular fractures

Answer 1

Gardens

1: incomplete fracture line
2: complete fracture line, non displaced
3: complete fracture line, partial displaced
4: complete fracture line, complete displaced

Question 2

O/E femoral next fracture:

Answer 2

affected leg is shorted, adducted, externally rotated,

inability to weight bear, or straight leg raise, decreased mobility, painful to palpate/rotate

Question 3

Management of extracapsular NOF fractures

Answer 3

Internal fixation with dynamic hip screw

Question 4

Management Intracapsular NOF fractures

Answer 4

Garden 1/2 : screws
Garden 3/4:
<55- screws
>75- hemiarthroplasty
55-75- total hip replacement

Question 5

Classification system for pubic ramus fracture

Answer 5

Young & Burgess - based on vector of disrupting force

Tile- fractures based ons stability of pelvic ring

Question 6

Patella fracture epidemiology

Answer 6

20-50y

M>F

Question 7

Management patella fracture

Answer 7

conservative: if non/minimally displaced and no extensor injury –> brace/cylinder cast
Surgery: if extensor injury, ORIF with tension band wiring, or if more simple case can use screws instead of wires

Question 8

ACL function

Answer 8

Limits anterior translation of the tibia relative to the femur

Question 9

Cause of ACL injury

Answer 9

Sudden deceleration, often athlete twisting and weight bearing

Question 10

ACL tests

Answer 10

Lachman

Anterior drawer test

Question 11

Segond fracture

Answer 11

On xray it shows a bony avulsion of the lateral proximal tibia, it is pathognomic of ACL injury.

Question 12

Medical collateral ligament function

Answer 12

vagus stabiliser

Question 13

medial meniscus features

Answer 13

is less circular than the lateral and is attached to the medial collateral ligament

Question 14

lateral meniscus

Answer 14

more circular

is not attached to the lateral collateral ligament.

Question 15

RF for achilles tendon rupture

Answer 15

Sports that stress the Achilles (e.g., basketball, tennis and track athletics)
Increasing age
Existing Achilles tendinopathy
Family history
Fluoroquinolone antibiotics (e.g., ciprofloxacin and levofloxacin, Rupture can occur spontaneously within 48 hours of starting treatment.)
Systemic steroids

Question 16

Achilles tendon ruptur O/E

Answer 16

When relaxed in a dangled position, the affected ankle will rest in a more dorsiflexed position
Tenderness to the area
A palpable gap in the Achilles tendon (although swelling might hide this)
Weakness of plantar flexion of the ankle (dorsiflexion is unaffected)
Unable to stand on tiptoes on the affected leg alone
Positive Simmonds’ calf squeeze test

Question 17

Simmonds’ calf squeeze test

Answer 17

When squeezing the calf muscle in a leg with an intact Achilles, there will be plantar flexionof the ankle. Squeezing the calf pulls on the Achilles. When the Achilles is ruptured, the connection between the calf and the ankle is lost. Squeezing the calf will not cause plantar flexion of the ankle in a leg with a ruptured Achilles. A lack of plantar flexion is a positiveresult.

Question 18

Management of achilles tendon rupture

Answer 18

RICE, VTE prophylaxis
Non surgical option: specialised boot
Surgical option: reattaching achilles and then boot

Question 19

pilon fracture (plafond)

Answer 19

severe injuries affecting the distal tibia, talus driven into the plafond

Question 20

Classification of lateral malleolus fractures

Answer 20

Danis-Weber
three fracture types (i.e., A, B, C ), defined by the location of the fibular fracture
A - below the tibiotalar joint , below the syndesmosis
B - at the level of the tibiotalar joint ,at the level of the syndesmosis
C - above the tibiotalar joint ( usually the most unstable) , above the level of the syndesmosis,almost always need surgical fixation.
also there is the Lauge-Hansen classification which is more detailed

Question 21

Ottawa ankle rules

Answer 21

Used in diagnostic uncertainty
state plain radiographs must be undertaken if :
Bone tenderness at the posterior edge or tip of the lateral malleolus, OR
the medial malleolus, OR
An inability to bear weight both immediately and in the emergency department for four steps

Question 22

Foot x-ray is only required if there is midfoot zone pain and any out of:

Answer 22

Bone tenderness at base of the fifth metatarsal.
Bone tenderness at navicular bone.
Inability to bear weight both immediately and in emergency department for four steps.

Question 23

ORIF indicated for ankle fractures if

Answer 23

Displaced bimalleolar or trimalleolar fractures
Weber C fractures
Weber B fractures with talar shift indicates disruption of syndesmosis
Open fractures

Question 24

Undisplaced ankle fractures can be treated with

Answer 24

elow knee cast for 6 weeks (or boot for type a )

Question 25

Lisfranc injury

Answer 25

severe injuries to the tarsometatarsal (Lisfranc) joint between the medial cuneiform and the base of the 2nd metatarsal.

Question 26

Lisfranc injury clinical features

Answer 26

severe pain, swelling, in the midfoot difficulty in weight-bearing. The ‘piano key’ sign is prominence of the metatarsal bones, which reduce back down with pressure plantar bruising is highly suggestive of a Lisfranc injury

Question 26

Xray features of Lisfranc injury

Answer 26

(take xray while weight bearing) widening of tarsometatarsal joint ( 1st-2nd) Fleck sign in the same space (Lisfranc segment avulsion)

Question 27

O'Brien's test

Answer 27

superficial pain localized to AC joint is suggestive of AC joint pathology

Question 28

Risk factors bicep tendon rupture

Answer 28

``` previous episodes of biceps tendinopathy steroid use Smoking chronic kidney disease (CKD) use of fluoroquinolone antibiotics. ```

Question 29

Bicep tendon rupture clinical features

Answer 29

sudden onset pain and weakness feeling of a “pop” during the incident. marked swelling and bruising in the antecubital fossa. As the proximal muscle belly retracts (due to loss of counter traction) a bulge may become evident in the arm; this is termed the “reverse Popeye sign” The Hook test is a special test to identify a potential distal tendon rupture:The elbow is actively flexed to 90º and fully supinated, the examiner attempts to ‘hook’ their index finger underneath the lateral edge of the biceps tendon(which cannot be done in a ruptured biceps tendon)

Question 29

classification system of clavicle fracture

Answer 29

Allman classification system, determined by the anatomical location of the fracture along the clavicle. Type I – fracture of the middle third of the clavicle, most common Type II – fractures involving the lateral third of the clavicle Type III- medial ⅓ of clavicle, most serious

Question 30

classification system of olecranon head fracture

Answer 30

Mayo classification and the Schatzker classification

Question 31

Management of olecranon head fractures

Answer 31

Treatment is usually guided by the degree of displacement on imaging. non-operative management is usually indicated for displacement <2mm, with immobilisation in 60-90 degrees elbow flexion Operative management is usually indicated for displacement >2mm

Question 32

Essex-Lopresti fracture

Answer 32

describes a fracture of the radial head with disruption of the distal radio-ulnar joint, and will always require surgical intervention.

Question 33

Sail sign

Answer 33

Elbow effusions on a lateral projection

Question 34

classification system of radial head fractures

Answer 34

Mason classification: Mason Type 1 – Non-displaced or minimally displaced fracture (<2mm). Mason Type 2 – Partial articular fracture with displacement >2mm or angulation. Mason Type 3 – Comminuted fracture and displacement

Question 35

Management of radial head fractures

Answer 35

Mason type 1 injuries – treated non-operatively, with a short period of immobilization with sling (less than 1 week) followed by early mobilisation Mason Type 2 injuries – if no mechanical block then can be treated as per a type 1 Mason type 3- ORIF or adial head excision or replacement

Question 36

boxer's fracture

Answer 36

fracture of the neck of the 4th or 5th metacarpal.

Question 37

injury to flexor digitorum profundus results in

Answer 37

loss of terminal Interphalangeal joint function ( the PIP and MP joints can still be flexed by FDS)

Question 38

Trigger finger

Answer 38

finger or thumb click or lock when in flexion, preventing a return to extension. thought to be caused by inflammation of the long flexor tendons (often from repetitive movements of the fingers). In response to the inflammation, the tendon becomes thickened or develops a nodule – making it difficult for the tendon to pass through the pulleys.

Question 39

De Quervain’s tenosynovitis

Answer 39

type of repetitive strain injury where there is swelling and inflammation of the tendon sheaths in the wrist. results in pain on the radial side of the wrist.

Question 40

types of distal radius fractures

Answer 40

Colles’ fracture (90% of all distal radius fractures) Smith’s fracture Barton’s fracture

Question 41

Colles’ Fracture

Answer 41

extra-articular fracture of the distal radius with dorsal angulation and dorsal displacement, within 2cm of the articular surface. This type of fracture typically occurs as a “fragility fracture” in osteoporotic bone..“dinner fork”

Question 42

Smith’s Fracture

Answer 42

volar angulation of the distal fragment of an extra-articular fracture of the distal radius (the reverse of a Colles fracture), with or without volar displacement. caused by falling backwards and planting the outstretched hand behind the body,

Question 43

Barton’s Fracture

Answer 43

intra-articular fracture of the distal radius with associated dislocation of the radio-carpal joint. A Barton fracture can be described as volar (more common) or dorsal (less common), depending on whether the volar or dorsal rim of the radius is involved.

Question 44

Risk factors distal radius fracture

Answer 44

``` main risk factors for distal radius fractures are related to osteoporosis: Increasing age Female gender Early menopause Smoking or alcohol excess Prolonged steroid use ```

Question 44

diagnosis of a distal radius fracture:

Answer 44

Radial height <11mm Radial inclination <22 degrees Radial (volar) tilt >11 degrees

Question 45

Surgery indicated for distal radius fracture

Answer 45

Significantly displaced or unstable fractures , Any fracture with an intra-articular step of the radiocarpal joint >2mm ORIF with plating, or K-wire fixation.

Question 45

Epidemiology scaphoid fractures

Answer 45

most common in men aged 20-30 years and are high-energy injuries. Approximately 10% have an associated fracture.

Question 46

Xray of scaphoid fractures

Answer 46

not always detected by initial radiographs (especially undisplaced fractures); if there remains sufficient clinical suspicion, patient should have the wrist immobilised in a thumb splint and repeat plain radiographs in 10-14 days .If still negative, however clinical findings are still in keeping with a scaphoid fracture, an MRI scan of the wrist is indicated.

Question 46

risk of scaphoid fracture

Answer 46

avascular necrosis (in around 30% of cases) , which would present with pain and stiffness at the wrist.The more proximal the scaphoid fracture, the higher the risk of AVN.

Question 46

Froment’s sign

Answer 46

test for ulnar nerve palsy – specifically paralysis of the adductor pollicis: The patient is asked to hold a piece of paper between the thumb and index finger, as the paper is pulled away. They should be able to hold the paper there with no difficulty (via adduction of the thumb). A positive test is when the patient is unable to adduct the thumb due to weak adductor pollicis. Instead, they flex the thumb at the interphalangeal joint to try to maintain a hold

Question 47

Carpal tunnel syndrome

Answer 47

Compression of the median nerve within the carpal tunnel

Question 48

Carpal tunnel syndrome can be secondary to

Answer 48

``` Diabetes Pregnancy Hypothyroidism Acromegaly Radial fracture Rheumatoid arthritis ```

Question 49

Clinical presentation Carpal tunnel syndrome

Answer 49

numbness, tingling, and pain in the distribution of the median nerve (first 3 digits) . Symptoms can wake the patient from sleep and are usually worse in the morning. Relieved by skiing /hanging out hand at night here may also be clumsiness in hand movements

Question 50

Tests for carpal tunnel syndrome

Answer 50

Tinel’s sign – tapping the nerve in the carpal tunnel to elicit pain in median nerve distribution. Phalen’s manoeuvre – holding the wrist in flexion for 60 seconds to elicit numbness/pain in median nerve distribution.

Question 51

Management Carpal tunnel syndrome

Answer 51

splint, holding the wrist in extension overnight to relieve symptoms. If this is unsuccessful, corticosteroid injections into the carpal tunnel can be trialled. Surgical decompression of the carpal tunnel may be required in severe cases

Question 52

Erb's palsy

Answer 52

upper roots, involves C5-6 nerve roots "waiter's tip" sign with shoulder adduction, elbow extension, forearm pronation and wrist flexion. It is most typically associated with shoulder dystocia and traumatic childbirth.

Question 53

Klumpke's palsy

Answer 53

lower roots, C8-T1 nerve roots with corresponding dermatomal sensory loss, and weakness of the intrinsic muscles of the hand.

Question 54

Frozen shoulder epidemiology

Answer 54

Most common in adults aged 40-60 | More common in those with diabetes, cardiovascular disease and cancer

Question 55

Clinical presentation Frozen shoulder

Answer 55

Presents with gradual onset pain and stiffness of the shoulder with reduced movement, most notably external rotation Pain worsens initially and persists for weeks-months Stiffness can persist for months-years

Question 56

Lateral epicondylitis or 'tennis elbow'

Answer 56

pain at the site of insertion of the forearm extensors at the lateral epicondyle of the humerus. It typically presents in those over the age of 35 in those who perform repetitive activities involving elbow extension. Symptoms typically resolve with rest.

Question 57

Medial epicondylitis, 'golfer's elbow'

Answer 57

occurs due to tendinopathy of the wrist flexor tendons which attach to the medial epicondyle of the distal humerusmedial elbow pain exacerbated by activity, particularly flexion of the wrist. There may also be weakness of wrist flexion.

Question 58

Rotator cuff tendonitis

Answer 58

Rotator cuff disease tendons of the rotator cuff muscles become inflamed. This may be due to microtrauma or impingement. The tendons may become calcified as a result of repeated inflammation

Question 59

Subacromial impingement

Answer 59

Rotator cuff disease tendons of the rotator cuff muscles become compressed between the humeral head and the acromion. Presents with pain and stiffness, particularly when performing overhead activities.

Question 60

Rotator Cuff Injury

Answer 60

Rotator cuff disease any injury of the four rotator cuff muscles.Typically presents with shoulder pain, reduced range of motion and shoulder weakness.

Question 61

Bankart lesions

Answer 61

are tears to the anterior portion of the labrum. These occur with repeated anterior subluxations or dislocations of the shoulder.

Question 61

key complication of shoulder injury

Answer 61

Axillary nerve damage - particularly anterior dislocation and proximal humeral fractures.

Question 62

Axillary nerve damage symptoms

Answer 62

nerve comes from the C5 and C6nerve roots. Damage causes a loss of sensation in the “regimental badge” area over the lateral deltoid. profound weakness of shoulder abduction due to disruption in the motor supple to deltoid and teres minor. weakness in shoulder flexion, extension and external rotation The extension lag test can be used to evaluate motor deficit. To perform this, elevate patient's arm to near full extension, and ask the patient to maintain the position. The test is positive if the arm drops.

Question 63

Clinical presentation shoulder dislocation

Answer 63

They will hold their arm against the side of their body. The deltoid will appear flattened, the head of the humerus will cause a bulge and be palpable at the front of the shoulder. painful shoulder acutely reduced mobility a feeling of instability Patients will be reluctant to move the affected limb. On examination, there is often an asymmetry with the contralateral side.

Question 64

Hill-Sachs lesions

Answer 64

are compression fractures of the posterolateral part of the head of the humerus. As the shoulder dislocates anteriorly, the posterolateral part of the humeral head impacts with the anterior rim of the glenoid cavity. Part of the humeral head is damaged, making the shoulder less stable and at risk of further dislocations.

Question 65

causes of pathological fractures

Answer 65

Tumours: Primary, Secondary (metastatic, most common) Metabolic: Osteoporosis (most common) Paget's disease Hyperparathyroidism

Question 66

Common peroneal nerve injury

Answer 66

commonly occurs due to injury around the knee. The common peroneal nerve is particularly vulnerable to injury at the neck of the fibula. Injury causes a 'foot drop' (weakness of the dorsiflexion muscles ) due to paralysis of the foot extensors (tibialis anterior, extensor digitorum longus and extensor hallucis longus). Foot inversion may also occur as the common peroneal nerve also innervates the foot evertor muscles.

Question 67

Lateral epicondylitis exacerbated by

Answer 67

wrist extension and supination of the forearm

Question 68

Medial epicondylitis aggravated by

Answer 68

wrist flexion and pronation. Sometimes it is associated with ulnar nerve compression.

Question 69

Cubital tunnel syndrome clinical presentation

Answer 69

Presents with the signs of ulnar nerve compression. Paraesthesia is in the ulnar nerve distribution and is exacerbated when the elbow is flexed for extended periods of time.

Question 70

hand nerves

Answer 70

Finger flexion, Finger and wrist extension, finger abduction/adduction Rock, paper, scissors Median, radial, ulnar (alphabetical)

Question 71

Flail chest:

Answer 71

caused by two or more rib fractures along three or more consecutive ribs, usually anteriorly

Question 72

Fat embolism triad

Answer 72

hypoxaemia, neurological abnormalities (eg confusion ) and petechial rash

Question 73

Broad arm sling

Answer 73

clavicle fracture and shoulder dislocation