MSK proper Flashcards

Question

Q: How are high ankle sprains typically diagnosed?

Answer 1

A: Radiographs showing widening of the tibiofibular joint (diastasis) or ankle mortise, and MRI if there is high suspicion of syndesmotic injury.

Answer 2

A: Non-weight-bearing orthosis or cast until pain subsides.

Answer 3

A: Operative fixation.

Answer 4

A: The death of bone tissue secondary to loss of the blood supply, leading to bone destruction and loss of joint function.

Answer 5

A: The epiphysis.

Answer 6

A: Long-term steroid use, chemotherapy, alcohol excess, and trauma.

Answer 7

A: Osteopenia and microfractures may be seen, but x-rays may be normal initially.

Answer 8

A: The crescent sign.

Answer 9

A: MRI, as it is more sensitive than radionuclide bone scanning.

Answer 10

A: Joint replacement.

Answer 11

A: A distension of the gastrocnemius-semimembranosus bursa, not a true cyst.

Answer 12

A: Primary (no underlying pathology, typically in children) and secondary (associated with underlying conditions like osteoarthritis, typically in adults).

Answer 13

A: As swellings in the popliteal fossa behind the knee.

Answer 14

A: Pain, redness, and swelling in the calf, similar to deep vein thrombosis. However, most ruptures are asymptomatic.

Answer 15

A: The long tendon (90% of cases).

Answer 16

A: Heavy overhead activities, shoulder overuse or underlying shoulder injuries, smoking, and corticosteroid use (which weakens tendons).

Answer 17

A: A sudden 'pop' or tear, followed by pain, bruising, and swelling.

Answer 18

A: Weakness in the shoulder and elbow, often with difficulty in supination.

Answer 19

A: Palpate the long head and distal biceps tendon and assess neurovascular function in the upper extremities.

Answer 20

A: If the biceps tendon is intact, squeezing the muscle will cause forearm supination.

Answer 21

A: Musculoskeletal ultrasound performed by a skilled clinician.

Answer 22

A: An urgent MRI, as diagnosis based on clinical signs alone is challenging and surgical intervention is usually required.

Answer 23

A: Focal bone resorption followed by excessive and chaotic bone deposition.

Answer 24

A: Spine, skull, pelvis, and femur.

Answer 25

A: Serum alkaline phosphatase.

Answer 26

A: Abnormal thickened, sclerotic bone.

Answer 27

A: Risk of cardiac failure with >15% bony involvement and a small risk of sarcomatous change.

Answer 28

A: Bisphosphonates.

Answer 29

A: Excessive bone resorption resulting in demineralised bone.

Answer 30

A: It is usually asymptomatic, but there is an increased risk of pathological fractures.

Answer 31

A: Alkaline phosphatase and calcium.

Answer 32

A: Bisphosphonates, calcium, and vitamin D.

Answer 33

A: Bone destruction and tumor infiltration.

Answer 34

A: Mirel scoring.

Answer 35

A: Serum calcium and alkaline phosphatase.

Answer 36

A: Radiotherapy, prophylactic fixation, and analgesia.

Answer 37

A: An incomplete fracture of the shaft of a long bone characterized by bulging of the cortex.

Answer 38

A: In children aged 5-10 years.

Answer 39

A: They are usually self-limiting and do not require operative intervention, often managed with splinting and immobilization instead of a cast.

Answer 40

A: The distal radius.

Answer 41

A: Compression of the median nerve in the carpal tunnel.

Answer 42

A: Pain/pins and needles in the thumb, index, and middle fingers, with symptoms sometimes ascending proximally. The patient may shake their hand to relieve symptoms, classically at night.

Answer 43

A: Weakness of thumb abduction (abductor pollicis brevis) and wasting of the thenar eminence (not hypothenar).

Answer 44

A: Tinel's sign (tapping causes paraesthesia) and Phalen's sign (flexion of the wrist causes symptoms).

Answer 45

A: Idiopathic, pregnancy, oedema (e.g., heart failure), lunate fracture, and rheumatoid arthritis.

Answer 46

A: A 6-week trial of conservative treatments, including corticosteroid injections and wrist splints at night (especially useful for transient factors like pregnancy).

Answer 47

A: Surgical decompression (flexor retinaculum division).

Answer 48

A: A rare but serious condition in which the lumbosacral nerve roots below the spinal cord are compressed, potentially leading to permanent nerve damage if untreated.

Answer 49

A: A central disc prolapse, typically occurring at L4/5 or L5/S1.

Answer 50

A: Tumours (primary or metastatic), infection (e.g., abscess, discitis), trauma, and haematoma.

Answer 51

A: Low back pain, bilateral sciatica, reduced sensation/pins-and-needles in the perianal area, decreased anal tone, and urinary dysfunction (e.g., incontinence, reduced bladder awareness).

Answer 52

A: Urinary incontinence.

Answer 53

A: Checking anal tone, although this has poor sensitivity and specificity for CES.

Answer 54

A: Urgent MRI.

Answer 55

A: Surgical decompression.

Answer 56

A: A degenerative condition affecting the cervical spine, particularly the intervertebral discs, vertebral bodies, and facet joints, often referred to as cervical osteoarthritis.

Answer 57

A: Chronic neck pain, radiculopathy (radiating pain, paraesthesia, weakness), myelopathy (spinal cord compression), and occipital headaches.

Answer 58

A: A severe manifestation of cervical spondylosis caused by spinal cord compression, leading to symptoms like clumsiness, gait disturbance, limb weakness, and possibly bowel or bladder dysfunction.

Answer 59

A: Reduced neck range of motion, tenderness over the cervical spine, and signs of radiculopathy or myelopathy (e.g., positive Spurling's test, hyperreflexia, or gait instability).

Answer 60

A: X-rays (for disc space narrowing, osteophytes, facet joint arthropathy), MRI (gold standard for evaluating soft tissue structures), and electrophysiological studies (for differentiating radiculopathy).

Answer 61

A: Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management.

Answer 62

A: A neuropathic joint that becomes disrupted and damaged due to a loss of sensation, most commonly seen in diabetics today.

Answer 63

A: Swelling, redness, warmth in the affected joint, and a less painful presentation than expected.

Answer 64

A: Joint instability, abnormal movements, increased risk of fractures and dislocations, significant deformities, and secondary complications like skin ulceration and infection.

Answer 65

A: It classically follows a fall onto an outstretched hand (FOOSH).

Answer 66

A: A distal radius fracture with dorsal displacement of the fragments, often described as a dinner fork-type deformity.

Answer 67

A: 1) Transverse fracture of the radius, 2) 1 inch proximal to the radio-carpal joint, 3) Dorsal displacement and angulation.

Answer 68

A: The dinner fork deformity.

Answer 69

A: Median nerve injury (acute carpal tunnel syndrome), compartment syndrome, vascular compromise, malunion, and rupture of the extensor pollicis longus tendon.

Answer 70

A: Osteoarthritis and complex regional pain syndrome.

Answer 71

A: Compartment syndrome is a complication where raised pressure within a closed anatomical space compromises tissue perfusion, leading to necrosis.

Answer 72

A: Pain (especially on movement), excessive use of breakthrough analgesia, parasthesiae, pallor, possible arterial pulsation, and paralysis of the muscle group.

Answer 73

A: By measuring intracompartmental pressure; pressures over 20mmHg are abnormal, and pressures over 40mmHg are diagnostic.

Answer 74

A: Prompt and extensive fasciotomy; if muscle groups are necrotic, they may require debridement or amputation.

Answer 75

A: Myoglobinuria, which may lead to renal failure, necessitating aggressive IV fluid therapy.

Answer 76

A: Muscle groups may die within 4-6 hours if untreated.

Answer 77

A: Cubital tunnel syndrome is caused by compression of the ulnar nerve as it passes through the cubital tunnel.

Answer 78

A: Tingling and numbness in the 4th and 5th fingers, starting intermittently and becoming constant, weakness, muscle wasting, and pain that worsens with leaning on the affected elbow.

Answer 79

A: A history of osteoarthritis or prior trauma to the elbow area.

Answer 80

A: Avoid aggravating activities, physiotherapy, steroid injections, and surgery in resistant cases.

Answer 81

A: De Quervain's tenosynovitis is an inflammation of the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons.

Answer 82

A: Pain on the radial side of the wrist, tenderness over the radial styloid process, and pain with abduction of the thumb against resistance.

Answer 83

A: Finkelstein's test involves pulling the patient's thumb in ulnar deviation and longitudinal traction, causing pain over the radial styloid process and along the tendons of extensor pollicis brevis and abductor pollicis longus in De Quervain's tenosynovitis.

Answer 84

A: Management includes analgesia, steroid injections, immobilisation with a thumb spica splint, and occasionally surgical treatment.

Answer 85

A: Discitis is an infection in the intervertebral disc space that can lead to complications like sepsis or an epidural abscess.

Answer 86

A: Back pain, pyrexia, rigors, and sepsis.

Answer 87

A: Changing lower limb neurology may occur if an epidural abscess develops.

Answer 88

A: MRI is the most sensitive imaging modality, and a CT-guided biopsy may be required to identify the organism and guide treatment.

Answer 89

A: Dupuytren's contracture is a condition where the fingers, especially the ring and little fingers, are affected by progressive contracture of the connective tissue in the palm.

Answer 90

A: It is more common in older males, and about 60-70% of cases have a positive family history. Specific causes include manual labor, phenytoin treatment, alcoholic liver disease, diabetes mellitus, and trauma to the hand.

Answer 91

A: The ring finger and little finger are most commonly affected.

Answer 92

A: Surgical treatment should be considered when the metacarpophalangeal joints cannot be straightened, and the hand cannot be placed flat on a table.

Answer 93

A: Lateral epicondylitis presents with pain and tenderness localized to the lateral epicondyle, worsened by resisted wrist extension with the elbow extended or forearm supination with the elbow extended. Episodes typically last 6 months to 2 years, with acute pain for 6-12 weeks.

Answer 94

A: Medial epicondylitis presents with pain and tenderness localized to the medial epicondyle, aggravated by wrist flexion and pronation. Symptoms may be accompanied by numbness or tingling in the 4th and 5th fingers due to ulnar nerve involvement.

Answer 95

A: Radial tunnel syndrome is caused by compression of the posterior interosseous branch of the radial nerve, often due to overuse. Symptoms are similar to lateral epicondylitis, but the pain is typically around 4-5 cm distal to the lateral epicondyle and worsens with elbow extension and forearm pronation.

Answer 96

A: Cubital tunnel syndrome is due to compression of the ulnar nerve. Early symptoms include intermittent tingling in the 4th and 5th fingers, worsening when the elbow is resting on a firm surface or flexed for extended periods. Later, there is numbness in the 4th and 5th fingers with associated weakness.

Answer 97

A: Olecranon bursitis presents as swelling over the posterior aspect of the elbow, with associated pain, warmth, and erythema. It typically affects middle-aged male patients.

Answer 98

A: Smith's fracture (reverse Colles' fracture) involves volar angulation of the distal radius fragment, resulting in a "garden spade deformity." It is caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed.

Answer 99

A: Bennett's fracture is an intra-articular fracture of the first carpometacarpal joint, typically caused by impact on the flexed metacarpal, such as in fist fights. X-rays show a triangular fragment at the ulnar base of the metacarpal.

Answer 100

A: Monteggia's fracture involves a dislocation of the proximal radioulnar joint in association with an ulna fracture, typically caused by a fall on an outstretched hand with forced pronation. Prompt diagnosis is crucial to avoid disability.

Answer 101

A: Galeazzi fracture involves a radial shaft fracture with associated dislocation of the distal radioulnar joint, usually caused by a direct blow.

Answer 102

A: Pott's fracture is a bimalleolar ankle fracture caused by forced foot eversion.

Answer 103

A: Barton's fracture is a distal radius fracture (Colles' or Smith's) with associated radiocarpal dislocation, typically caused by a fall onto an extended and pronated wrist.

Answer 104

A: Respiratory features include early persistent tachycardia, tachypnoea, dyspnoea, hypoxia, and pyrexia, typically developing 72 hours following injury.

Answer 105

A: Dermatological features include a red/brown impalpable petechial rash, seen in 25-50% of cases, along with subconjunctival and oral haemorrhage/petechiae.

Answer 106

A: CNS features include confusion, agitation, retinal haemorrhages, and intra-arterial fat globules observed on fundoscopy.

Answer 107

A: Diagnosis may be challenging as imaging can be normal. Fat emboli tend to lodge distally, so CTPA may not show vascular occlusion, but a ground glass appearance may be seen at the periphery.

Answer 108

A: Treatment includes prompt fixation of long bone fractures, DVT prophylaxis, and general supportive care. There is some debate regarding the benefit versus risk of medullary reaming in femoral shaft or tibial fractures.

Answer 109

A: Fractures may arise from trauma (excessive forces applied to bone), stress-related injury (repetitive low-velocity injury), or pathological causes (abnormal bone that fractures under minimal trauma).

Answer 110

Oblique fracture: Fracture lies obliquely to the long axis of the bone. Comminuted fracture: More than two fragments. Segmental fracture: More than one fracture along a bone. Transverse fracture: Perpendicular to the long axis of the bone. Spiral fracture: Severe oblique fracture with rotation along the long axis of the bone.

Answer 111

Grade 1: Low-energy wound <1 cm. Grade 2: Wound >1 cm with moderate soft tissue damage. Grade 3: High-energy wound >1 cm with extensive soft tissue damage. 3A: Adequate soft tissue coverage. 3B: Inadequate soft tissue coverage. 3C: Associated arterial injury.

Answer 112

Immobilise the fracture including the proximal and distal joints. Carefully monitor and document neurovascular status. Manage infection with tetanus prophylaxis and IV broad-spectrum antibiotics for open injuries. Thoroughly debride open fractures and avoid internal fixation devices or use with caution. Open fractures should be debrided and lavaged within 6 hours of injury.

Answer 113

A: A ganglion is a cyst arising from a joint or tendon sheath, most commonly seen on the dorsal aspect of the wrist. It is three times more common in women.

Answer 114

A: A ganglion is a firm, well-circumscribed mass that transilluminates.

Answer 115

A: Ganglions often disappear spontaneously after several months. Surgical excision is indicated for cysts associated with severe symptoms or neurovascular manifestations.

Answer 116

A: Greater trochanteric pain syndrome is also referred to as trochanteric bursitis.

Answer 117

A: Features include pain over the lateral side of the hip/thigh and tenderness on palpation of the greater trochanter.

Answer 118

A: Osler's nodes are painful, red, raised lesions found on the hands and feet due to the deposition of immune complexes.

Answer 119

A: Bouchard's nodes are hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints, a sign of osteoarthritis, caused by calcific spurs of articular cartilage.

Answer 120

A: Heberden's nodes are bony outgrowths that develop in middle age, typically after chronic swelling or inflammation of the affected joints, often causing deformity of the fingertip.

Answer 121

Posterior dislocation (90% of cases): The affected leg is shortened, adducted, and internally rotated. Anterior dislocation: The affected leg is abducted and externally rotated, with no leg shortening. Central dislocation.

Answer 122

A: The management includes the ABCDE approach, analgesia, and reduction under general anaesthetic within 4 hours to reduce the risk of avascular necrosis. Long-term management includes physiotherapy.

Answer 123

A: Complications include sciatic or femoral nerve injury, avascular necrosis, osteoarthritis (more common in older patients), and recurrent dislocation due to ligament damage.

Answer 124

A: The prognosis is best when the hip is reduced within 12 hours post-injury and when there is less damage to the joint. Healing typically takes 2 to 3 months.

Answer 125

A: The classic signs of a hip fracture are pain, a shortened and externally rotated leg. Patients with non-displaced or incomplete fractures may still be able to weight bear.

Answer 126

Intracapsular (subcapital): From the edge of the femoral head to the insertion of the capsule of the hip joint. Extracapsular: Can be trochanteric or subtrochanteric (lesser trochanter is the dividing line).

Answer 127

Type I: Stable fracture with impaction in valgus. Type II: Complete fracture but undisplaced. Type III: Displaced fracture with rotation and angulation, still has bony contact. Type IV: Complete bony disruption. Blood supply disruption is most common in Types III and IV.

Answer 128

A: Management includes internal fixation or hemiarthroplasty if the patient is unfit for surgery.

Answer 129

A: NICE recommends replacement arthroplasty (total hip replacement or hemiarthroplasty) for all patients with displaced intracapsular hip fractures. Total hip replacement is favored over hemiarthroplasty if the patient is able to walk independently, is cognitively intact, and is medically fit for the procedure.

Answer 130

Stable intertrochanteric fractures: Managed with a dynamic hip screw. Reverse oblique, transverse, or subtrochanteric fractures: Managed with an intramedullary device.

Answer 131

A: Developmental dysplasia of the hip.

Answer 132

A: 2-10 years.

Answer 133

A: Transient synovitis (irritable hip), which is associated with viral infections.

Answer 134

A: Perthes disease is a degenerative condition affecting the hip joints of children, typically between the ages of 4-8 years, caused by avascular necrosis of the femoral head.

Answer 135

A: Hip pain developing progressively over a few weeks, limp, stiffness, reduced range of hip movement, and changes seen on X-ray, such as widening of joint space and later decreased femoral head size or flattening.

Answer 136

A: SUFE typically affects children aged 10-15 years, especially obese children and boys.

Answer 137

A: Knee or distal thigh pain, loss of internal rotation of the leg in flexion, and displacement of the femoral head epiphysis postero-inferiorly. A bilateral slip occurs in 20% of cases.

Answer 138

A: JIA is arthritis occurring in children under 16 years old that lasts for more than three months. Pauciarticular JIA refers to cases with 4 or fewer joints affected, accounting for around 60% of JIA cases. Salmon pink Rash

Answer 139

A: Joint pain and swelling, usually in medium-sized joints like the knees, ankles, or elbows, limp, and potentially positive ANA associated with anterior uveitis.

Answer 140

A: Septic arthritis is characterized by acute hip pain associated with systemic upset, such as pyrexia, and inability or severe limitation of the affected joint.

Answer 141

A: An iliopsoas abscess is a collection of pus in the iliopsoas compartment (iliopsoas and iliacus muscles).

Answer 142

A: Primary iliopsoas abscess is due to haematogenous spread of bacteria, with Staphylococcus aureus being the most common pathogen.

Answer 143

A: Secondary causes include Crohn's disease (most common), diverticulitis, colorectal cancer, UTI, GU cancers, vertebral osteomyelitis, femoral catheter, lithotripsy, endocarditis, and intravenous drug use.

Answer 144

A: Fever, back/flank pain, limp, and weight loss.

Answer 145

A: The patient is in the supine position with the knee flexed and hip mildly externally rotated. Specific tests include asking the patient to lift the thigh against your hand (causing pain) and hyperextending the affected hip (which causes pain).

Answer 146

A: CT abdomen is the investigation of choice.

Answer 147

A: Initial management includes antibiotics and percutaneous drainage, which is successful in about 90% of cases.

Answer 148

A: Surgery is indicated if percutaneous drainage fails or if there is another intra-abdominal pathology that requires surgery.

Answer 149

A: The unhappy triad consists of damage to the anterior cruciate ligament (ACL), medial collateral ligament (MCL), and meniscus (classically the medial meniscus, but recent evidence shows the lateral meniscus is more commonly injured).

Answer 150

A: ACL damage may result from twisting injuries.

Answer 151

A: The anterior drawer test and Lachman test may be positive if the ACL is damaged.

Answer 152

A: PCL damage may occur following dashboard injuries.

Answer 153

A: MCL damage is commonly caused by skiing and following valgus stress.

Answer 154

A: Damage to the MCL typically causes abnormal passive abduction of the knee.

Answer 155

A: Meniscal damage often results from twisting injuries.

Answer 156

A: Locking and giving way are common symptoms of meniscal damage.

Answer 157

A: A ruptured ACL often presents with a loud crack, pain, and rapid joint swelling (haemoarthrosis).

Answer 158

A: A ruptured ACL is managed with intense physiotherapy or surgery.

Answer 159

A: Chondromalacia patellae commonly affects teenage girls, typically following an injury to the knee (e.g., patellar dislocation).

Answer 160

A: Patients often report pain on going downstairs or at rest, along with tenderness and quadriceps wasting.

Answer 161

A: Patellar dislocation most commonly occurs through direct trauma or severe contraction of the quadriceps with the knee stretched in valgus and external rotation.

Answer 162

A: Tibial plateau fractures occur when the knee is forced into valgus or varus, but the knee fractures before the ligaments rupture.

Answer 163

A: Features include knee swelling, instability, and the feeling that the knee will give way.

Answer 164

A: The anterior drawer test is used to assess the integrity of the ACL by evaluating anterior motion of the tibia in comparison to the femur.

Answer 165

A: An intact ACL prevents forward translational movement of the tibia.

Answer 166

A: The Lachman's test is a variant of the anterior drawer test, performed with the knee at 20-30 degrees, to evaluate anterior translation of the tibia in relation to the femur.

Answer 167

A: The Lachman's test is considered more reliable because it is less dependent on patient relaxation and is more sensitive in detecting ACL injuries.

Answer 168

A: Pain is often worse on straightening the knee.

Answer 169

A: The knee may "give way" due to instability caused by the tear.

Answer 170

A: Displaced meniscal tears may cause knee locking.

Answer 171

A: Tenderness is usually along the joint line.

Answer 172

A: Thessaly's test is used to assess for a meniscal tear.

Answer 173

A: The patient is weight-bearing at 20 degrees of knee flexion and supported by the examiner. The test is positive if there is pain on twisting the knee.

Answer 174

A: Typically occurs in patients over 50 years, often overweight. Pain may be severe, with intermittent swelling, crepitus, and limited movement.

Answer 175

A: Infrapatellar bursitis is associated with kneeling.

Answer 176

A: Prepatellar bursitis is associated with more upright kneeling.

Answer 177

A: Leriche syndrome is a form of atheromatous disease involving the iliac vessels, leading to compromised blood flow to the pelvic viscera. It typically presents with buttock claudication and impotence. Diagnosis includes angiography, and iliac occlusions are treated with endovascular angioplasty and stent insertion.

Answer 178

Age < 20 years or > 50 years History of previous malignancy Night pain History of trauma Systemically unwell (e.g., weight loss, fever) thoracic pain

Answer 179

Facet joint pain Spinal stenosis Ankylosing spondylitis Peripheral arterial disease

Answer 180

Pain may be acute or chronic Pain is worse in the morning and on standing Pain is aggravated by back extension Tenderness over the facet joints on examination

Answer 181

Gradual onset of pain Unilateral or bilateral leg pain, numbness, and weakness, which worsens with walking and is relieved by sitting down or leaning forward MRI is required for diagnosis

Answer 182

Typically occurs in young men Morning stiffness that improves with activity Peripheral arthritis in 25% of cases (more common in females)

Answer 183

Pain on walking, relieved by rest Absent or weak foot pulses History of smoking or vascular diseases

Answer 184

NSAIDs are the first-line treatment for back pain Paracetamol monotherapy is not effective

Answer 185

MRI should only be offered if it is likely to change management or if malignancy, infection, fracture, cauda equina syndrome, or ankylosing spondylitis is suspected

Answer 186

Leg pain is usually worse than back pain Pain often worsens when sitting Associated with neurological deficits and clear dermatomal leg pain

Answer 187

Sensory loss over the anterior thigh Weak hip flexion, knee extension, and hip adduction Reduced knee reflex Positive femoral stretch test

Answer 188

Sensory loss on the anterior aspect of the knee and medial malleolus Weak knee extension and hip adduction Reduced knee reflex Positive femoral stretch test

Answer 189

Sensory loss on the dorsum of the foot Weakness in foot and big toe dorsiflexion Reflexes are intact Positive sciatic nerve stretch test

Answer 190

Sensory loss on the posterolateral aspect of the leg and lateral aspect of the foot Weakness in plantar flexion of the foot Reduced ankle reflex Positive sciatic nerve stretch test

Answer 191

Similar to musculoskeletal lower back pain: analgesia, physiotherapy, and exercises First-line treatment: NSAIDs + proton pump inhibitors If symptoms persist after 4-6 weeks, consider referral for MRI

Answer 192

Motor: Knee extension, thigh flexion Sensory: Anterior and medial aspect of the thigh and lower leg Typical mechanisms of injury: Hip and pelvic fractures, stab/gunshot wounds

Answer 193

Motor: Thigh adduction Sensory: Medial thigh Typical mechanism of injury: Anterior hip dislocation

Answer 194

Motor: None Sensory: Lateral and posterior surfaces of the thigh Typical mechanism of injury: Compression of the nerve near the ASIS → meralgia paraesthetica (pain, tingling, numbness)

Answer 195

Motor: Foot plantarflexion and inversion Sensory: Sole of the foot Typical mechanism of injury: Popliteal lacerations, posterior knee dislocation (rare injury due to nerve protection)

Answer 196

Motor: Foot dorsiflexion and eversion, Extensor hallucis longus Sensory: Dorsum of the foot and the lower lateral part of the leg Typical mechanism of injury: Injury at the neck of the fibula, tightly applied lower limb plaster cast Result: Foot drop

Answer 197

Motor: Hip abduction Sensory: None Typical mechanism of injury: Misplaced intramuscular injection, hip surgery, pelvic fracture, posterior hip dislocation Result: Positive Trendelenburg sign

Answer 198

Motor: Hip extension and lateral rotation Sensory: None Typical mechanism of injury: Generally injured with the sciatic nerve Result: Difficulty rising from a seated position, inability to jump, and climb stairs

Answer 199

A: It is a condition where the central canal of the spine narrows due to tumor, disk prolapse, or degenerative changes, leading to compression of the nerve roots of the cauda equina.

Answer 200

A: Patients may present with a combination of back pain, neuropathic pain, and symptoms resembling claudication. Sitting is often better than standing, and walking uphill may be easier than walking downhill.

Answer 201

A: The positional nature of the pain. Patients with lumbar spinal stenosis often feel relief when sitting, and walking uphill may be easier than walking downhill.

Answer 202

A: Degeneration of the intervertebral disk, hypertrophy of posterior facet joints, osteophyte formation, and thickening of the ligamentum flavum, leading to narrowing of the spinal canal and compression of nerve roots.

Answer 203

A: MRI is the best modality for demonstrating canal narrowing. Historically, the bicycle test was used to differentiate it from true vascular claudication, as vascular claudicants could not complete the test.

Answer 204

A: Laminectomy, a surgical procedure to relieve pressure on the nerve roots.

Answer 205

A: Golfer's elbow.

Answer 206

A: Pain and tenderness localized to the medial epicondyle, aggravated by wrist flexion and pronation, and possible numbness/tingling in the 4th and 5th fingers due to ulnar nerve involvement.

Answer 207

A: Wrist flexion and pronation.

Answer 208

A: The ulnar nerve, leading to numbness and tingling in the 4th and 5th fingers.

Answer 209

A: Meralgia paraesthetica is an entrapment mononeuropathy of the lateral femoral cutaneous nerve (LFCN), causing paraesthesia or anaesthesia in the distribution of the nerve.

Answer 210

A: Burning, tingling, coldness, shooting pain, numbness, or deep muscle ache in the upper lateral aspect of the thigh, aggravated by standing and relieved by sitting.

Answer 211

A: Diagnosis can often be made with the pelvic compression test, which is highly sensitive. Local anaesthetic injection into the nerve and ultrasound-guided therapy are also effective.

Answer 212

A: A metatarsal fracture is a break in one or more of the metatarsal bones in the foot, often caused by direct trauma, crush injuries, or repeated mechanical stress.

Answer 213

A: The proximal 5th metatarsal is the most commonly fractured metatarsal and the most common site of midfoot fractures.

Answer 214

A: Symptoms include pain, bony tenderness, swelling, and an antalgic gait.

Answer 215

A: Jones fractures are transverse fractures at the metaphyseal-diaphyseal junction of the 5th metatarsal, whereas pseudo-Jones fractures are avulsion fractures at the proximal tuberosity, often associated with lateral ankle sprains.

Answer 216

A: Froment's sign is used to assess for ulnar nerve palsy.

Answer 217

A: The patient holds a piece of paper between their thumb and index finger, and the object is pulled away. If there is ulnar nerve palsy, the patient will be unable to hold the paper and will flex the thumb at the interphalangeal joint due to compensation by the flexor pollicis longus.

Answer 218

A: Phalen's test is used to assess for carpal tunnel syndrome.

Answer 219

A: The wrist is held in maximum flexion. The test is positive if there is numbness in the median nerve distribution.

Answer 220

A: Tinel's sign is used to assess for carpal tunnel syndrome.

Answer 221

A: The median nerve is tapped at the wrist, and the test is positive if there is tingling or electric-like sensations over the distribution of the median nerve.

Answer 222

A: Open fractures are graded using the Gustilo and Anderson system.

Answer 223

Grade 1: Low energy wound <1cm Grade 2: Wound >1cm with moderate soft tissue damage Grade 3: High energy wound >1cm with extensive soft tissue damage

Answer 224

3A: Adequate soft tissue coverage 3B: Inadequate soft tissue coverage 3C: Associated arterial injury

Answer 225

A: The Mangled Extremity Scoring System (MESS) can help predict the need for primary amputation in Type IIIc injuries.

Answer 226

A: Initial management should focus on careful patient examination, control of hemorrhage, assessment of associated injuries, and establishment of distal neurovascular status. The wound should be covered with a dressing, and antibiotics should be administered.

Answer 227

A: Early debridement is the cornerstone of the management of open fractures, aimed at removing foreign material and devitalized tissue.

Answer 228

A: The wound is typically left open after debridement, and the area is irrigated with around 6 liters of saline.

Answer 229

A: The fracture is stabilized with an external fixator in most cases.

Answer 230

A: It results from the loss of cartilage at synovial joints and is often accompanied by the degeneration of underlying bone.

Answer 231

Previous trauma to a joint increases the risk. Obesity. Hypermobility of a joint increases the risk. Occupations like cotton workers and farmers are more susceptible. Osteoporosis reduces the risk.

Answer 232

Usually bilateral, with one joint affected at a time. Commonly affects carpometacarpal joints (CMC) and distal interphalangeal joints (DIPJ). Episodic joint pain, provoked by movement and relieved by rest. Stiffness, worse after long periods of inactivity (e.g. morning stiffness). Painless nodes: Heberden's nodes at the DIP joints. Bouchard's nodes at the PIP joints. Squaring of the thumbs due to deformity of the carpometacarpal joint.

Answer 233

A: Stiffness lasts only a few minutes in osteoarthritis of the hand, whereas in rheumatoid arthritis, stiffness lasts longer, especially in the morning.

Answer 234

A: Patients usually do not have functional problems. However, severe involvement of the DIPJs can lead to reduced grip strength and disuse atrophy.

Answer 235

A: X-ray is used to identify osteophytes and joint space narrowing. Signs may appear on X-ray before symptoms develop.

Answer 236

A: Osteoarthritis (OA) of the hip is the second most common presentation of OA after the knee and accounts for significant morbidity. Total hip replacement is a common operation for this condition.

Answer 237

Increasing age. Female gender (twice as common in women). Obesity. Developmental dysplasia of the hip.

Answer 238

Chronic history of groin ache following exercise, relieved by rest. Red flag features suggesting an alternative cause include: Rest pain. Night pain. Morning stiffness lasting more than 2 hours.

Answer 239

A: The Oxford Hip Score is widely used to assess the severity of osteoarthritis of the hip.

Answer 240

If features are typical, a clinical diagnosis can be made. Plain x-rays are the first-line investigation if diagnosis is uncertain.

Answer 241

Oral analgesia. Intra-articular injections for short-term benefit. Total hip replacement remains the definitive treatment.

Answer 242

Perioperative complications: Venous thromboembolism. Intraoperative fracture. Nerve injury. Surgical site infection. Leg length discrepancy. Posterior dislocation: Can occur during extremes of hip flexion, with acute pain, inability to weight bear, and internal rotation with shortening of the affected leg. Aseptic loosening: The most common reason for revision. Prosthetic joint infection.

Answer 243

A: Joint replacement is the most effective treatment for osteoarthritis patients who experience significant pain and disability.

Answer 244

Cemented hip replacement: A metal femoral component is cemented into the femoral shaft, with a cemented acetabular polyethylene cup. Uncemented hip replacement: Becoming more popular, especially in younger, active patients. It is more expensive than cemented replacements. Hip resurfacing: A metal cap is placed over the femoral head, often used in younger patients. It preserves the femoral neck for future surgery options

Answer 245

Physiotherapy and home exercises are prescribed. Walking sticks or crutches are typically used for up to 6 weeks after hip or knee replacement surgery.

Answer 246

Avoid flexing the hip more than 90 degrees. Avoid low chairs. Do not cross your legs. Sleep on your back for the first 6 weeks.

Answer 247

Wound and joint infection. Thromboembolism: NICE recommends low-molecular weight heparin for 4 weeks following a hip replacement. Dislocation.

Answer 248

A: OCD is a pathological process affecting the subchondral bone, often in the knee joint, with secondary effects on the joint cartilage, including pain, oedema, free bodies, and mechanical dysfunctions. It generally affects children and young adults.

Answer 249

Knee pain and swelling, typically after exercise. Knee catching, locking, and/or giving way. Severe symptoms are associated with the presence of loose bodies. A painful 'clunk' when flexing or extending the knee, indicating involvement of the lateral femoral condyle.

Answer 250

Joint effusion. Tenderness on palpation of the articular cartilage of the medial femoral condyle, when the knee is flexed. Wilson's sign: Pain at around 30° flexion with internal rotation of the tibia, relieved by external rotation of the tibia.

Answer 251

X-ray (anteroposterior, lateral, and tunnel views) may show the subchondral crescent sign or loose bodies. MRI is used to evaluate cartilage, visualize loose bodies, and assess the stability of the lesion.

Answer 252

A: Early diagnosis is important. Due to subtle early-stage signs, there should be a low threshold for imaging and/or seeking an orthopaedic opinion.

Answer 253

A: Osteomyelitis is an infection of the bone. It can be subclassified into haematogenous and non-haematogenous osteomyelitis.

Answer 254

A: Haematogenous osteomyelitis results from bacteraemia, is usually monomicrobial, and is the most common form in children. Vertebral osteomyelitis is the most common form in adults. Risk factors include sickle cell anaemia, intravenous drug use, immunosuppression, and infective endocarditis.

Answer 255

A: Non-haematogenous osteomyelitis results from the contiguous spread of infection from adjacent soft tissues or from direct trauma to the bone. It is often polymicrobial and is the most common form in adults. Risk factors include diabetic foot ulcers, pressure sores, diabetes mellitus, and peripheral arterial disease.

Answer 256

A: Staphylococcus aureus is the most common cause, except in patients with sickle cell anaemia, where Salmonella species predominate.

Answer 257

A: MRI is the imaging modality of choice, with a sensitivity of 90-100%.

Answer 258

A: The typical treatment is flucloxacillin for 6 weeks. Clindamycin is used if the patient is penicillin-allergic.

Answer 259

A: NICE guidelines recommend assessing all women aged ≥65 and all men aged ≥75. Younger patients should be assessed if they have risk factors such as a previous fragility fracture, use of glucocorticoids, history of falls, family history of hip fracture, or other secondary osteoporosis causes.

Answer 260

A: Risk factors include previous fragility fracture, use of oral/systemic glucocorticoids, history of falls, family history of hip fracture, secondary causes such as hypogonadism, endocrine conditions (e.g., diabetes, hyperthyroidism), malabsorption conditions, rheumatoid arthritis, low BMI, smoking, and excessive alcohol intake.

Answer 261

A: Secondary causes should be excluded first, as underlying conditions may also require treatment, such as bone metastases, myeloma, and Paget's disease.

Answer 262

A: A DEXA scan should be offered for patients >50 with a fragility fracture, <40 with major risk factors, or before starting treatments that may impact bone density, such as sex hormone deprivation for breast/prostate cancer.

Answer 263

A: NICE recommends using clinical prediction tools such as FRAX or QFracture to assess a patient's 10-year risk of a fracture.

Answer 264

A: If the 10-year fracture risk is ≥10%, a DEXA scan should be arranged.

Answer 265

A: FRAX results give a colour-coded risk: green (low), orange (moderate), and red (high). Patients in the orange and red zones should have a DEXA scan if not already done to refine their 10-year risk.

Answer 266

A: Risk should be reassessed if the original risk was near the intervention threshold (after 2 years) or when there is a change in the patient's risk factors.

Answer 267

A: Osteoporosis is a condition where bone mineral density decreases, increasing the likelihood of fragility fractures, which occur due to mechanical forces that would not usually cause a fracture.

Answer 268

A: The spine (vertebra) is one of the most common sites for osteoporotic fractures.

Answer 269

A: Osteoporotic vertebral fractures are common but difficult to quantify as not all patients present to clinicians, and fractures may not always be visible on X-ray.

Answer 270

A: Major risk factors include advancing age, history of fragility fractures, prolonged glucocorticoid use, history of falls, family history of hip fracture, secondary osteoporosis causes (e.g., Cushing's disease), low BMI, tobacco smoking, and excessive alcohol intake.

Answer 271

A: They may be asymptomatic, cause acute back pain, breathing difficulties due to organ compression, and gastrointestinal issues. A history of fall or trauma is often absent.

Answer 272

A: Signs include loss of height, kyphosis (spinal curvature), and localized tenderness over the spinous processes at the fracture site.

Answer 273

A: X-ray of the spine is the first investigation and may show wedging of the vertebra or old fractures.

Answer 274

A: CT spine provides a detailed view of the bone structure, and MRI spine helps differentiate osteoporotic fractures from those caused by other pathologies, such as tumors.

Answer 275

A: A complete fracture is where both sides of the bone cortex are breached.

Answer 276

A: A toddler's fracture is an oblique tibial fracture in infants.

Answer 277

A: A plastic deformity occurs when stress on the bone results in deformity without cortical disruption.

Answer 278

A: A greenstick fracture is a unilateral cortical breach only, often occurring in children.

Answer 279

A: A buckle (torus) fracture is an incomplete cortical disruption that results in a periosteal haematoma.

Answer 280

A: The Salter-Harris system is used to classify growth plate fractures in children.

Answer 281

A: A Type I Salter-Harris fracture involves a fracture through the physis only, often appearing normal on an X-ray.

Answer 282

A: A Type II Salter-Harris fracture involves a fracture through the physis and metaphysis.

Answer 283

A: A Type III Salter-Harris fracture involves a fracture through the physis and epiphysis, extending to include the joint.

Answer 284

A: A Type IV Salter-Harris fracture involves a fracture through the physis, metaphysis, and epiphysis

Answer 285

A: A Type V Salter-Harris fracture is a crush injury involving the physis and may appear normal on an X-ray.

Answer 286

A: Growth plate tenderness should be assumed to indicate an underlying fracture, even if the X-ray appears normal.

Answer 287

A: Types III, IV, and V fractures usually require surgery.

Answer 288

A: Pathological fractures occur due to genetic conditions such as osteogenesis imperfecta or osteopetrosis.

Answer 289

A: Osteogenesis imperfecta is a genetic condition causing defective osteoid formation due to inadequate production of substances like osteoid, collagen, and dentine, leading to fragile bones.

Answer 290

A: Osteopetrosis is a condition where bones become harder and denser, typically seen in young adults, with radiological features of "marble bone" due to lack of differentiation between cortex and medulla.

Answer 291

A: Patella fractures can be caused by direct injury (from a blow or trauma) or indirect injury (from forceful quadriceps contraction against a blocked knee extension).

Answer 292

A: A direct patella injury typically occurs from a fall or dashboard injury causing an undisplaced crack or comminuted fracture, often without affecting the extensor mechanism.

Answer 293

A: An indirect patella injury occurs when the quadriceps forcefully contracts against a blocked knee extension, often leading to a transverse patella fracture and possible extensor mechanism disruption.

Answer 294

A: Clinical features include swelling, bruising, localized pain and tenderness around the knee, and a palpable gap in the patella. Extensor mechanism function is assessed by the patient's ability to straight leg raise.

Answer 295

A: Plain X-rays with at least two views (AP and lateral) are typically sufficient for diagnosing patella fractures. Skyline views may be used if the diagnosis is unclear but can be uncomfortable to obtain.

Answer 296

A: Undisplaced fractures, especially vertical fractures with an intact extensor mechanism, are managed non-operatively in a hinged knee brace for 6 weeks, with full weight-bearing allowed.

Answer 297

A: Operative management is indicated for displaced fractures or those with extensor mechanism disruption. Treatment options include tension band wire, inter-fragmentary screws, or cerclage wires, followed by a hinged knee brace for 4-6 weeks.

Answer 298

A: Plantar fasciitis is the most common cause of heel pain in adults.

Answer 299

A: The pain is usually worse around the medial calcaneal tuberosity.

Answer 300

A: Management includes resting the feet, wearing shoes with good arch support and cushioned heels, and using insoles and heel pads.

Answer 301

A: Risk factors include polytrauma, osteoporosis, steroid use, chronic obstructive pulmonary disease, and cancer metastases (prostate cancer in men, breast cancer in women).

Answer 302

A: Severe, sharp chest wall pain, which worsens with deep breaths or coughing.

Answer 303

A: Pneumothorax, lung injury, flail chest, and reduced oxygen saturation due to pain-induced reduced ventilation.

Answer 304

A: Flail chest occurs with multiple rib fractures along three or more consecutive ribs, leading to paradoxical movement of the rib segment, which impairs lung ventilation and may cause serious lung injury.

Answer 305

A: A CT scan of the chest is the best diagnostic test, while chest X-rays may show fractures but are less informative for soft tissue injuries.

Answer 306

A: Most are managed conservatively with good analgesia, and nerve blocks may be considered if pain is not controlled. Surgical fixation may be considered if fractures fail to heal after 12 weeks of conservative management.

Answer 307

A: Flail chest segments should be urgently discussed with cardiothoracic surgery due to their potential to impair ventilation and cause significant lung trauma.

Answer 308

A: Shoulder pain, particularly worsening with abduction.

Answer 309

A: Tenderness over the anterior acromion.

Answer 310

A: Sarcomas are a diverse group of malignant tumours originating from mesenchymal tissue, accounting for about 1% of adult cancers and 15% of paediatric cancers.

Answer 311

A: Sarcomas are classified into bone sarcomas (e.g., osteosarcoma, chondrosarcoma, Ewing's sarcoma) and soft tissue sarcomas (e.g., liposarcoma, rhabdomyosarcoma, synovial sarcoma, fibrosarcoma, angiosarcoma, leiomyosarcoma).

Answer 312

A: Symptoms include pain, swelling or a palpable mass, impaired function, pathologic fractures (in bone sarcomas), and systemic symptoms like fatigue, weight loss, and fever.

Answer 313

A: X-rays, CT scans, MRI, and PET scans are used to localize the tumour, assess its size, and evaluate metastatic spread.

Answer 314

A: A biopsy (via FNA, core needle, or incisional biopsy) is used to obtain a tissue sample for histopathological analysis to confirm the diagnosis and grade the tumour.

Answer 315

A: Surgery, aimed at complete resection with negative margins to reduce local recurrence risk. Limb-sparing surgery may be performed, or amputation may be necessary for advanced tumours.

Answer 316

A: Radiation therapy can be used preoperatively (neoadjuvant) to shrink the tumour or postoperatively (adjuvant) to minimize recurrence. Intraoperative radiation therapy (IORT) may also be used.

Answer 317

A: A scaphoid fracture is a wrist fracture, often caused by falling onto an outstretched hand (FOOSH), resulting in axial compression of the scaphoid with wrist hyperextension and radial deviation.

Answer 318

A: The scaphoid's blood supply comes primarily from the dorsal carpal branch of the radial artery, in a retrograde manner. Disruption of this blood flow, especially in proximal fractures, can lead to avascular necrosis.

Answer 319

A: Patients present with pain along the radial aspect of the wrist, at the base of the thumb, and loss of grip or pinch strength.

Answer 320

A: 1. Point of maximal tenderness over the anatomical snuffbox (sensitive but not specific) 2. Wrist joint effusion 3. Pain on telescoping of the thumb (longitudinal compression) 4. Tenderness of the scaphoid tubercle on the volar aspect 5. Pain on ulnar deviation of the wrist

Answer 321

A: Plain film radiographs (AP, lateral views), 'scaphoid views' (PA, oblique, Ziter view), and CT scans. MRI is the most definitive investigation for confirmation, especially when radiographs are inconclusive.

Answer 322

A: Immobilization with a Futuro splint or standard below-elbow backslab, referral to orthopaedics, and follow-up imaging 7-10 days later if radiographs are inconclusive.

Answer 323

A: Undisplaced scaphoid waist fractures are managed with a cast for 6-8 weeks, with union achieved in over 95% of cases. If you cant see it on xray and there is suspicion, cast and repeat xray in 2 weeks

Answer 324

A: Displaced scaphoid waist fractures require surgical fixation.

Answer 325

A: Proximal scaphoid pole fractures require surgical fixation.

Answer 326

A: Complications include non-union (leading to pain and early osteoarthritis) and avascular necrosis.

Answer 327

A: Over 95% of shoulder dislocations are anterior.

Answer 328

A: Adhesive capsulitis, or frozen shoulder, is common in middle-aged individuals and diabetics, characterized by painful, stiff movement and limited range of motion in all directions, particularly loss of external rotation and abduction in about 50% of patients.

Answer 329

A: Supraspinatus tendonitis, also known as subacromial impingement or painful arc, is a rotator cuff injury. It causes a painful arc of abduction between 60 and 120 degrees, with tenderness over the anterior acromion.

Answer 330

A: A dorsal column lesion causes loss of vibration and proprioception. Conditions associated include tabes dorsalis and subacute combined degeneration (SACD).

Answer 331

A: A spinothalamic tract lesion causes loss of pain sensation and temperature.

Answer 332

A: A central cord lesion leads to flaccid paralysis of the upper limbs.

Answer 333

A: Osteomyelitis is typically progressive. It is associated with Staphylococcus aureus in intravenous drug users (IVDU), primarily affecting the cervical region, and fungal infections in immunocompromised patients. Tuberculosis (TB) commonly affects the thoracic region.

Answer 334

A: Spinal cord infarction presents with dorsal column signs, including loss of proprioception and fine discrimination.

Answer 335

A: Cord compression leads to upper motor neuron (UMN) signs, which can be caused by malignancy, haematoma, or fracture.

Answer 336

A: Brown-Séquard syndrome is caused by hemisection of the spinal cord, resulting in ipsilateral paralysis and loss of proprioception and fine discrimination, and contralateral loss of pain and temperature sensation.

Answer 337

A: Stress fractures are small hairline fractures caused by repetitive activity and loading of normal bone. They are often not displaced, and surrounding soft tissue injury is uncommon. They may present late, with callus formation visible on radiographs. Early-stage injuries with severe pain may require immobilisation tailored to the site of injury.

Answer 338

A: Talipes equinovarus, or club foot, describes an inverted (inward turning) and plantar flexed foot.

Answer 339

A: Talipes equinovarus is usually diagnosed on the newborn exam and the deformity is not passively correctable; imaging is not normally needed.

Answer 340

A: Conditions associated with talipes equinovarus include spina bifida, cerebral palsy, Edward's syndrome (trisomy 18), oligohydramnios, and arthrogryposis.

Answer 341

A: Most cases of talipes equinovarus are idiopathic.

Answer 342

A: The Ponseti method consists of manipulation and progressive casting which starts soon after birth, usually correcting the deformity after 6-10 weeks. An Achilles tenotomy is required in around 85% of cases.

Answer 343

A: An Achilles tenotomy is required in around 85% of cases and can usually be done under local anaesthetic.

Answer 344

A: Trigger finger is a condition associated with abnormal flexion of the digits, caused by a disparity between the size of the tendon and the pulleys through which they pass.

Answer 345

A: The thumb, middle, and ring fingers are more commonly affected.

Answer 346

A: Initially, there is stiffness and snapping ('trigger') when extending a flexed digit, and a nodule may be felt at the base of the affected finger.

Answer 347

A: Steroid injection is successful in the majority of patients, and a finger splint may be applied afterwards. Surgery is reserved for patients who have not responded to steroid injections.

Answer 348

A: Elbow flexion (supplies biceps brachii) and supination.

Answer 349

A: Lateral part of the forearm.

Answer 350

A: Isolated injury is rare - usually injured as part of brachial plexus injury.

Answer 351

A: Shoulder abduction (deltoid muscle).

Answer 352

A: Inferior region of the deltoid muscle.

Answer 353

A: Extension (forearm, wrist, fingers, thumb).

Answer 354

A: Small area between the dorsal aspect of the 1st and 2nd metacarpals.

Answer 355

A: LOAF* muscles. Features depend on the site of the lesion: wrist - paralysis of thenar muscles, opponens pollicis; elbow - loss of pronation of forearm and weak wrist flexion.

Answer 356

A: Palmar aspect of lateral 3½ fingers.

Answer 357

A: Intrinsic hand muscles except LOAF* and wrist flexion.

Answer 358

A: Medial 1½ fingers.

Answer 359

A: Due to damage of the upper trunk of the brachial plexus (C5, C6). May be secondary to shoulder dystocia during birth. The arm hangs by the side and is internally rotated, elbow extended.

Answer 360

A: Due to damage of the lower trunk of the brachial plexus (C8, T1). May be secondary to shoulder dystocia during birth or caused by a sudden upward jerk of the hand. Associated with Horner's syndrome.

Answer 361

A: Small-vessel vasculitides, including granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome), and microscopic polyangiitis.

Answer 362

A: Urinalysis for haematuria and proteinuria, blood tests (urea and creatinine, full blood count, CRP), ANCA testing, and chest x-ray.

Answer 363

A: Serine proteinase 3 (PR3).

Answer 364

A: Myeloperoxidase (MPO).

Answer 365

A: Granulomatosis with polyangiitis (90%).

Answer 366

A: Eosinophilic granulomatosis with polyangiitis (50%), microscopic polyangiitis (75%), ulcerative colitis (70%), primary sclerosing cholangitis (70%), anti-GBM disease (25%), and Crohn's disease (20%).

Answer 367

A: HLA-B27.

Answer 368

A: A young man aged 20-30 years old presenting with lower back pain and stiffness of insidious onset.

Answer 369

A: It is usually worse in the morning and improves with exercise.

Answer 370

A: Pain that improves on getting up.

Answer 371

A: To assess reduced forward flexion of the spine.

Answer 372

A: The distance between two lines (drawn 10 cm above and 5 cm below the back dimples) should increase by more than 5 cm when the patient bends forward.

Answer 373

A: Reduced lateral flexion, reduced forward flexion, and reduced chest expansion.

Answer 374

A: Apical fibrosis, anterior uveitis, aortic regurgitation, Achilles tendonitis, AV node block, amyloidosis, and cauda equina syndrome.

Answer 375

A: ESR and CRP.

Answer 376

A: Plain x-ray of the sacroiliac joints.

Answer 377

A: Early: normal x-rays, later: sacroiliitis (subchondral erosions, sclerosis), squaring of lumbar vertebrae, 'bamboo spine', syndesmophytes.

Answer 378

A: Obtain an MRI to look for early inflammation involving sacroiliac joints (bone marrow oedema).

Answer 379

A: A restrictive defect due to pulmonary fibrosis, kyphosis, and ankylosis of the costovertebral joints.

Answer 380

A: Regular exercise, NSAIDs, and physiotherapy.

Answer 381

A: Anti-TNF therapy.

Answer 382

A: An acquired disorder characterized by a predisposition to both venous and arterial thromboses, recurrent fetal loss, and thrombocytopenia.

Answer 383

A: Systemic lupus erythematosus (SLE), where around 30% of patients with SLE have positive antiphospholipid antibodies.

Answer 384

A: Venous/arterial thrombosis, recurrent miscarriages, livedo reticularis, pre-eclampsia, and pulmonary hypertension.

Answer 385

A: Anticardiolipin antibodies, anti-beta2 glycoprotein I (anti-beta2GPI) antibodies, and lupus anticoagulant.

Answer 386

A: Thrombocytopenia and prolonged APTT.

Answer 387

A: Low-dose aspirin.

Answer 388

A: Lifelong warfarin with a target INR of 2-3.

Answer 389

A: Lifelong warfarin; if events occurred while taking warfarin, consider adding low-dose aspirin and increase target INR to 3-4.

Answer 390

A: Lifelong warfarin with a target INR of 2-3.

Answer 391

A: It is caused by autoantibodies against aminoacyl-tRNA synthetase enzymes, with the most common autoantibody being anti-Jo-1.

Answer 392

A: Myositis, characterized by muscle weakness, especially in proximal muscles.

Answer 393

A: Difficulty performing activities like climbing stairs or lifting objects, along with elevated muscle enzymes such as creatine kinase (CK).

Answer 394

A: Interstitial Lung Disease (ILD), which can cause chronic dry cough, shortness of breath, and reduced exercise tolerance.

Answer 395

A: High-resolution CT scans are typically used for diagnosis.

Answer 396

A: Mechanic's hands, which are hyperkeratotic, thickened, and cracked skin on the sides of the fingers and palms.

Answer 397

A: Arthritis, fever, fatigue, weight loss, and malaise.

Answer 398

A: Immunosuppressive therapy, including corticosteroids and other immunomodulatory drugs, to control inflammation and prevent progression. Additional treatments may be required for significant lung involvement, such as antifibrotic agents and supplemental oxygen.

Answer 399

A: Mercaptopurine, a purine analogue that inhibits purine synthesis.

Answer 400

A: To identify individuals prone to azathioprine toxicity.

Answer 401

A: Bone marrow depression, nausea/vomiting, pancreatitis, and increased risk of non-melanoma skin cancer.

Answer 402

A: A full blood count.

Answer 403

A: Interaction with allopurinol, requiring lower doses of azathioprine.

Answer 404

A: Oral ulcers, genital ulcers, and anterior uveitis.

Answer 405

A: HLA B51.

Answer 406

A: Thrombophlebitis, deep vein thrombosis, arthritis, neurological involvement (e.g., aseptic meningitis), gastrointestinal symptoms (e.g., abdominal pain, diarrhea, colitis), and erythema nodosum.

Answer 407

A: No, the diagnosis is based on clinical findings.

Answer 408

A: Bisphosphonates inhibit osteoclasts by reducing recruitment and promoting apoptosis, decreasing bone demineralisation.

Answer 409

A: Bisphosphonates are used in the prevention and treatment of osteoporosis, hypercalcaemia, Paget's disease, and pain from bone metastases.

Answer 410

A: Oesophageal reactions (oesophagitis, oesophageal ulcers), osteonecrosis of the jaw, increased risk of atypical stress fractures (especially with alendronate), acute phase response (fever, myalgia, arthralgia), and hypocalcaemia.

Answer 411

A: Hypocalcaemia and vitamin D deficiency should be corrected before initiating bisphosphonates.

Answer 412

A: Calcium: Normal, Phosphate: Normal, ALP: Normal, PTH: Normal.

Answer 413

A: Calcium: Decreased, Phosphate: Decreased, ALP: Increased, PTH: Increased.

Answer 414

A: Calcium: Increased, Phosphate: Decreased, ALP: Increased, PTH: Increased.

Answer 415

A: Calcium: Decreased, Phosphate: Increased, ALP: Increased, PTH: Increased.

Answer 416

A: Calcium: Normal, Phosphate: Normal, ALP: Increased, PTH: Normal.

Answer 417

A: Calcium: Normal, Phosphate: Normal, ALP: Normal, PTH: Normal.

Answer 418

A: Osteoma is a benign overgrowth of bone, typically occurring on the skull, and is associated with Gardner's syndrome (a variant of familial adenomatous polyposis, FAP).

Answer 419

A: Osteochondroma is the most common benign bone tumor, typically occurring in males under 20 years old. It is a cartilage-capped bony projection on the external surface of a bone.

Answer 420

A: Giant cell tumor is a tumor of multinucleated giant cells within a fibrous stroma, most commonly occurring in the epiphyses of long bones, with a peak incidence between 20-40 years. X-ray shows a "double bubble" or "soap bubble" appearance.

Answer 421

A: Osteosarcoma is the most common primary malignant bone tumor, seen mainly in children and adolescents. It occurs in the metaphyseal region of long bones. X-ray shows Codman triangle and "sunburst" pattern. Mutation of the Rb gene significantly increases the risk, and it is associated with retinoblastoma, Paget's disease, and radiotherapy.

Answer 422

A: Ewing's sarcoma is a small round blue cell tumor seen mainly in children and adolescents. It most frequently affects the pelvis and long bones, causing severe pain. X-ray shows an "onion skin" appearance. It is associated with t(11;22) translocation.

Answer 423

A: Chondrosarcoma is a malignant tumor of cartilage that commonly affects the axial skeleton, more common in middle age.

Answer 424

A: Dactylitis refers to the inflammation of a digit (finger or toe).

Answer 425

A: Common causes of dactylitis include spondyloarthritis (e.g. Psoriatic arthritis, reactive arthritis), sickle-cell disease, and rare causes like tuberculosis, sarcoidosis, and syphilis.

Answer 426

A: Denosumab is given as a subcutaneous injection of 60mg every 6 months for osteoporosis.

Answer 427

A: Denosumab is a human monoclonal antibody used to treat osteoporosis by inhibiting RANKL, preventing the development of osteoclasts.

Answer 428

A: Oral bisphosphonates (e.g., alendronate) are first-line, and denosumab is considered if bisphosphonates are not tolerated or in cases with specific criteria met.

Answer 429

A: Dermatomyositis is an inflammatory disorder causing symmetrical, proximal muscle weakness and characteristic skin lesions. It may be idiopathic or associated with connective tissue disorders or underlying malignancy.

Answer 430

A: Dermatomyositis is associated with ovarian, breast, and lung cancer in 20-25% of cases, more commonly in older patients.

Answer 431

A: Characteristic skin features include a photosensitive macular rash over the back and shoulders, heliotrope rash in the periorbital region, Gottron's papules on the extensor surfaces of fingers, and 'mechanic's hands' with dry, scaly skin and cracks.

Answer 432

A: Gottron's papules are roughened red papules that appear over the extensor surfaces of the fingers in dermatomyositis.

Answer 433

A: Nail fold capillary dilatation is one of the skin manifestations observed in dermatomyositis.

Answer 434

A: Systemic features include proximal muscle weakness, Raynaud's phenomenon, respiratory muscle weakness, interstitial lung disease, and dysphagia or dysphonia.

Answer 435

A: Investigations include ANA testing (positive in about 80% of cases) and testing for anti-synthetase antibodies (e.g., anti-Jo-1, anti-SRP, anti-Mi-2).

Answer 436

A: Discoid lupus erythematosus is a benign, autoimmune disorder commonly seen in younger females, characterized by erythematous, raised, sometimes scaly rashes. It very rarely progresses to systemic lupus erythematosus.

Answer 437

A: Features include an erythematous, raised rash, often photosensitive, primarily affecting the face, neck, ears, and scalp. Lesions heal with atrophy, scarring (which may cause scarring alopecia), and pigmentation.

Answer 438

A: Treatment includes topical steroid creams as first-line, with oral antimalarials (e.g., hydroxychloroquine) as second-line. Patients should also avoid sun exposure.

Answer 439

A: Drug-induced lupus is a condition where lupus-like symptoms occur due to medication use, but not all features of systemic lupus erythematosus (SLE) are present, particularly renal and nervous system involvement. It usually resolves once the drug is discontinued.

Answer 440

A: Features include arthralgia, myalgia, skin involvement (e.g., malar rash), and pulmonary involvement (e.g., pleurisy). ANA is positive in 100% of cases, but dsDNA is negative. Anti-histone antibodies are found in 80-90% of cases, and anti-Ro, anti-Smith antibodies may be positive in around 5%.

Answer 441

A: The most common causes include procainamide and hydralazine.

Answer 442

A: Ehlers-Danlos syndrome is an autosomal dominant connective tissue disorder that primarily affects type III collagen, leading to increased tissue elasticity, joint hypermobility, and skin that is more elastic than normal.

Answer 443

A: Features include elastic, fragile skin, joint hypermobility (leading to recurrent joint dislocations), easy bruising, and a range of cardiovascular and neurological complications.

Answer 444

A: Complications include aortic regurgitation, mitral valve prolapse, aortic dissection, subarachnoid hemorrhage, and angioid retinal streaks.

Answer 445

A: Gout is a form of inflammatory arthritis characterized by episodes of pain, swelling, and erythema. Acute episodes typically develop rapidly and reach maximal intensity within 12 hours. Symptoms often resolve between flares.

Answer 446

A: Around 70% of first presentations affect the 1st metatarsophalangeal (MTP) joint, historically called podagra. Other commonly affected joints include the ankle, wrist, and knee.

Answer 447

A: Investigations include measuring uric acid levels and synovial fluid analysis. A uric acid level ≥ 360 µmol/L supports a diagnosis. Synovial fluid analysis shows needle-shaped, negatively birefringent monosodium urate crystals under polarised light.

Answer 448

A: Radiological features include joint effusion, well-defined 'punched-out' erosions with sclerotic margins, relative preservation of joint space, eccentric erosions, and no periarticular osteopenia. Soft tissue tophi may also be seen.

Answer 449

A: Gout is caused by microcrystal synovitis due to the deposition of monosodium urate monohydrate in the synovium, typically caused by chronic hyperuricaemia (uric acid > 450 µmol/l).

Answer 450

A: NSAIDs or colchicine are first-line treatments. NSAID doses should be maximized for 1-2 days after symptoms settle. Gastroprotection (e.g., proton pump inhibitors) may be indicated.

Answer 451

A: The main side effect of colchicine is diarrhoea.

Answer 452

A: Oral steroids (e.g., prednisolone 15mg/day) may be used if NSAIDs and colchicine are contraindicated.

Answer 453

A: ULT is recommended after the first attack if there are >= 2 attacks in 12 months, tophi, renal disease, uric acid renal stones, or if the patient is on cytotoxics or diuretics.

Answer 454

A: It is traditionally delayed until 2 weeks after an acute attack to avoid precipitating further attacks, but the British Society of Rheumatology now supports starting ULT once inflammation has settled.

Answer 455

A: Allopurinol is first-line, typically started at 100 mg once daily with dose titration to achieve a serum uric acid level of < 360 µmol/L.

Answer 456

A: Colchicine cover should be considered when starting allopurinol. NSAIDs can be used if colchicine cannot be tolerated, potentially for up to 6 months.

Answer 457

A: Lesch-Nyhan syndrome is a genetic disorder caused by hypoxanthine-guanine phosphoribosyl transferase (HGPRTase) deficiency. It is X-linked recessive, affecting boys, and leads to gout, renal failure, neurological deficits, learning difficulties, and self-mutilation.

Answer 458

A: Haemochromatosis.

Answer 459

A: Behcet's disease.

Answer 460

A: HLA-B27 is associated with ankylosing spondylitis, reactive arthritis, acute anterior uveitis, and psoriatic arthritis.

Answer 461

A: Coeliac disease.

Answer 462

A: HLA-DR2 is associated with narcolepsy and Goodpasture's syndrome.

Answer 463

A: HLA-DR3 is associated with dermatitis herpetiformis, Sjogren's syndrome, and primary biliary cirrhosis.

Answer 464

A: HLA-DR4 is associated with type 1 diabetes mellitus (especially DRB104:01 and DRB104:04) and rheumatoid arthritis.

Answer 465

A: Hydroxychloroquine is used in the management of rheumatoid arthritis and systemic/discoid lupus erythematosus.

Answer 466

A: The main adverse effect of hydroxychloroquine is bull's eye retinopathy, which can lead to severe and permanent visual loss.

Answer 467

A: The 4 types are Type I (Anaphylactic), Type II (Cell bound), Type III (Immune complex), and Type IV (Delayed hypersensitivity).

Answer 468

A: In Type I hypersensitivity, an antigen reacts with IgE bound to mast cells.

Answer 469

A: Examples include anaphylaxis, asthma, eczema, and hay fever.

Answer 470

A: In Type II hypersensitivity, IgG or IgM binds to an antigen on the cell surface.

Answer 471

A: Examples include autoimmune haemolytic anaemia, ITP, Goodpasture's syndrome, pernicious anaemia, acute haemolytic transfusion reactions, rheumatic fever, and pemphigus vulgaris/bullous pemphigoid.

Answer 472

A: In Type III hypersensitivity, free antigen and antibody (IgG, IgA) combine to form immune complexes.

Answer 473

A: Examples include serum sickness, systemic lupus erythematosus, post-streptococcal glomerulonephritis, and extrinsic allergic alveolitis (acute phase).

Answer 474

A: Type IV hypersensitivity is T-cell mediated.

Answer 475

A: Examples include tuberculosis/tuberculin skin reaction, graft-versus-host disease, allergic contact dermatitis, scabies, extrinsic allergic alveolitis (chronic phase), multiple sclerosis, and Guillain-Barré syndrome.

Answer 476

A: Langerhans cell histiocytosis is a rare disorder characterized by the proliferation of Langerhans cells, which are specialized dendritic cells that present antigens to T lymphocytes. It can affect multiple organs, including bones, skin, lungs, and the endocrine system.

Answer 477

A: Common features include bone pain (typically in the skull or proximal femur), cutaneous nodules, pituitary involvement (leading to diabetes insipidus), pulmonary involvement (dyspnoea, cough, chest pain), recurrent otitis media/mastoiditis, and tennis racket-shaped Birbeck granules on electron microscopy.

Answer 478

A: Marfan's syndrome is an autosomal dominant connective tissue disorder caused by a defect in the FBN1 gene on chromosome 15, which codes for the protein fibrillin-1. It affects about 1 in 3,000 people.

Answer 479

A: Common features include tall stature with arm span to height ratio > 1.05, high-arched palate, arachnodactyly, pectus excavatum, pes planus, scoliosis > 20 degrees, and cardiovascular, ocular, and skeletal manifestations.

Answer 480

A: Cardiovascular issues include dilation of the aortic sinuses (seen in 90% of patients), which can lead to aortic aneurysm, aortic dissection, and aortic regurgitation. Mitral valve prolapse is also present in 75% of cases.

Answer 481

A: McArdle's disease is an autosomal recessive type V glycogen storage disease caused by myophosphorylase deficiency, leading to decreased muscle glycogenolysis.

Answer 482

A: Features include muscle pain and stiffness following exercise, muscle cramps, rhabdomyolysis, myoglobinuria, and low lactate levels during exercise.

Answer 483

A: Methotrexate is used in the treatment of inflammatory arthritis (especially rheumatoid arthritis), psoriasis, and some chemotherapy regimens like acute lymphoblastic leukaemia.

Answer 484

A: Common adverse effects include mucositis, myelosuppression, pneumonitis, pulmonary fibrosis, and liver fibrosis.

Answer 485

A: Methotrexate requires regular monitoring of FBC, U&E, and LFTs. FBC, renal, and LFTs should be monitored weekly until therapy stabilizes, then every 2-3 months thereafter. Folate (5mg weekly) should be co-prescribed, taken more than 24 hours after the methotrexate dose.

Answer 486

A: Methotrexate should not be prescribed concurrently with trimethoprim or co-trimoxazole due to increased risk of marrow aplasia. High-dose aspirin can increase the risk of methotrexate toxicity by reducing excretion.

Answer 487

A: The treatment of choice for methotrexate toxicity is folinic acid.

Answer 488

A: Myopathies typically present with symmetrical muscle weakness (proximal > distal), with common problems such as difficulty rising from a chair or getting out of a bath. Sensation and reflexes are usually normal, and fasciculations are absent.

Answer 489

Inflammatory: polymyositis Inherited: Duchenne/Becker muscular dystrophy, myotonic dystrophy Endocrine: Cushing's syndrome, thyrotoxicosis Alcohol-related myopathy

Answer 490

A: In osteoarthritis, the typical affected joints include large weight-bearing joints (hip, knee) and the carpometacarpal joint, along with DIP and PIP joints.

Answer 491

A: In rheumatoid arthritis, the typical affected joints include MCP and PIP joints.

Answer 492

A: Osteoarthritis typically presents with pain following use, improving with rest, unilateral symptoms, and no systemic upset.

Answer 493

A: Rheumatoid arthritis typically presents with morning stiffness, improving with use, bilateral symptoms, and systemic upset.

Answer 494

A: X-ray findings in osteoarthritis include loss of joint space, subchondral sclerosis, subchondral cysts, and osteophytes forming at joint margins.

Answer 495

A: X-ray findings in rheumatoid arthritis include loss of joint space, juxta-articular osteoporosis, periarticular erosions, and subluxation.

Answer 496

A: Topical NSAIDs are first-line analgesics, particularly beneficial for patients with OA of the knee or hand.

Answer 497

A: Oral NSAIDs are second-line treatment for osteoarthritis.

Answer 498

A: A proton pump inhibitor should be co-prescribed with oral NSAIDs to protect the stomach.

Answer 499

A: Intra-articular steroid injections may be tried, but they provide only short-term relief (2-10 weeks).

Answer 500

A: If conservative methods fail, refer the patient for consideration of joint replacement.

Answer 501

A: LOSS stands for Loss of joint space, Osteophytes, Subchondral sclerosis, and Subchondral cysts.

Answer 502

A: Osteogenesis Imperfecta is caused by an abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides.

Answer 503

A: Osteogenesis Imperfecta is inherited in an autosomal dominant pattern.

Answer 504

A: Common features include fractures following minor trauma, blue sclera, deafness secondary to otosclerosis, and dental imperfections.

Answer 505

A: Adjusted calcium, phosphate, parathyroid hormone, and ALP levels are usually normal in Osteogenesis Imperfecta.

Answer 506

A: Osteomalacia describes softening of the bones secondary to low vitamin D levels, leading to decreased bone mineral content.

Answer 507

A: Main causes include vitamin D deficiency, malabsorption, lack of sunlight, chronic kidney disease, drug-induced (e.g. anticonvulsants), inherited (e.g. hypophosphatemic rickets), liver disease (e.g. cirrhosis), and coeliac disease.

Answer 508

A: Common features include bone pain, bone/muscle tenderness, fractures (especially femoral neck), and proximal myopathy (which may lead to a waddling gait).

Answer 509

A: Investigations show low vitamin D levels, low calcium and phosphate (in about 30% of patients), and raised alkaline phosphatase (in 95-100% of patients). X-rays may show translucent bands (Looser's zones or pseudofractures).

Answer 510

A: Treatment includes vitamin D supplementation (often with a loading dose), and calcium supplementation if dietary calcium is inadequate.

Answer 511

A: Patients ≥ 75 years old who have had a fragility fracture are presumed to have underlying osteoporosis and should be started on first-line therapy (oral bisphosphonate) without the need for a DEXA scan.

Answer 512

A: The 2014 NOGG guidelines suggest treatment should start in all women over 50 years old who have had a fragility fracture, although BMD measurement may sometimes be appropriate, particularly in younger postmenopausal women.

Answer 513

A: For patients under 75 years old, a DEXA scan should be arranged. The results can be entered into a FRAX assessment (along with the history of fracture) to determine ongoing fracture risk.

Answer 514

History of glucocorticoid use Rheumatoid arthritis Alcohol excess History of parental hip fracture Low body mass index Current smoking

Answer 515

SSRIs Antiepileptics Proton pump inhibitors Glitazones Long-term heparin therapy Aromatase inhibitors (e.g., anastrozole)

Answer 516

History and physical examination Blood cell count, sedimentation rate or C-reactive protein, serum calcium, albumin, creatinine, phosphate, alkaline phosphatase, and liver transaminases Thyroid function tests Bone densitometry (DXA) Lateral radiographs of lumbar and thoracic spine/DXA-based vertebral imaging Protein immunoelectrophoresis, urinary Bence-Jones proteins 25OHD, PTH, serum testosterone, SHBG, FSH, LH (in men), serum prolactin 24-hour urinary cortisol/dexamethasone suppression test Endomysial and/or tissue transglutaminase antibodies (for coeliac disease) Isotope bone scan, markers of bone turnover, urinary calcium excretion

Answer 517

Full blood count Urea and electrolytes Liver function tests Bone profile CRP Thyroid function tests

Answer 518

A: The T score is based on the bone mass of a young reference population and indicates how much a person's bone mass deviates from the average for a young, healthy person.

Answer 519

A: A T score of -1.0 means the bone mass is one standard deviation below that of the young reference population.

Answer 520

> -1.0 = Normal -1.0 to -2.5 = Osteopaenia < -2.5 = Osteoporosis

Answer 521

A: The T score compares bone mass to a young reference population, while the Z score adjusts for age, gender, and ethnic factors.

Answer 522

A: Bone protection should be started immediately in patients who are likely to take glucocorticoids for at least 3 months, rather than waiting until 3 months have passed.

Answer 523

A: 1. Patients over 65 years or those who have had a fragility fracture should be offered bone protection. 2. Patients under 65 years should have a bone density scan to determine management.

Answer 524

Greater than 0: Reassure Between 0 and -1.5: Repeat bone density scan in 1-3 years Less than -1.5: Offer bone protection

Answer 525

A: The first-line treatment is alendronate. Patients should also be calcium and vitamin D replete.

Answer 526

A: Oral bisphosphonates (e.g., alendronate, risedronate)

Answer 527

A: If starting ≥7.5 mg/day prednisolone or equivalent for 3 months or more, start bone protective treatment immediately with oral bisphosphonates (e.g., alendronate, risedronate), without waiting for a DEXA scan.

Answer 528

A: Start treatment immediately with oral bisphosphonates (e.g., alendronate, risedronate) along with general osteoporosis management.

Answer 529

A: Gastrointestinal discomfort, oesophagitis, hypocalcaemia, and rare but serious risks like atypical femoral fractures and osteonecrosis of the jaw.

Answer 530

A: Paget's disease is a disorder of increased, but uncontrolled, bone turnover, primarily affecting osteoclasts. It results in excessive osteoclastic resorption followed by increased osteoblastic activity.

Answer 531

A: The skull, spine/pelvis, and long bones of the lower extremities are most commonly affected.

Answer 532

A: Only 5% of patients are symptomatic. The typical presentation includes bone pain (e.g., pelvis, lumbar spine, femur) and an isolated raised alkaline phosphatase (ALP). Untreated features include bowing of the tibia and bossing of the skull.

Answer 533

Bloods: Raised alkaline phosphatase (ALP), normal calcium and phosphate (hypercalcaemia may occur with immobilisation) X-rays: Osteolysis in early disease, mixed lytic/sclerotic lesions later, thickened skull vault Bone scintigraphy: Increased uptake at sites of active bone lesions Other markers of bone turnover include PINP, CTx, NTx, hydroxyproline.

Answer 534

A: Treatment is indicated for bone pain, skull or long bone deformity, fractures, and periarticular Paget's disease. First-line treatments include bisphosphonates (oral risedronate or IV zoledronate), with calcitonin being used less frequently.

Answer 535

Deafness (due to cranial nerve entrapment) Bone sarcoma (1% if affected for >10 years) Fractures Skull thickening High-output cardiac failure

Answer 536

A: Polyarteritis nodosa (PAN) is a vasculitis that affects medium-sized arteries, causing necrotizing inflammation leading to aneurysm formation.

Answer 537

Fever, malaise, arthralgia Weight loss Hypertension Mononeuritis multiplex, sensorimotor polyneuropathy Testicular pain Livedo reticularis Haematuria, renal failure

Answer 538

A: Hepatitis B serology is positive in about 30% of patients with polyarteritis nodosa.

Answer 539

A: Angiography may show beading and microaneurysms in the intrarenal and intrahepatic vessels. Similar changes may be seen in the arteries of the intestines, with a lack of normal arterial structures.

Answer 540

A: Polyarthritis refers to the inflammation of five or more joints simultaneously, typically within the first six weeks of symptom onset.

Answer 541

Patients with polyarthritis typically present with pain, swelling, and stiffness in multiple joints. The joint involvement may be symmetrical (e.g., rheumatoid arthritis) or asymmetrical (e.g., psoriatic arthritis). Systemic symptoms such as fever, weight loss, and fatigue may also be present, reflecting the underlying inflammatory process.

Answer 542

Inflammatory arthritis (e.g., rheumatoid arthritis, psoriatic arthritis, SLE) Seronegative spondyloarthropathies Infective causes (e.g., viral infections like EBV, HIV, hepatitis, mumps, rubella, tuberculosis, disseminated gonococcal infection) Pseudogout Henoch-Schonlein purpura Sarcoidosis

Answer 543

A: Polymyalgia rheumatica (PMR) is a relatively common condition seen in older people, characterized by muscle stiffness and raised inflammatory markers. The exact cause is unclear, and while it is closely related to temporal arteritis, it does not appear to be a vasculitic process.

Answer 544

Age: Typically seen in patients > 60 years old Onset: Usually rapid (< 1 month) Symptoms: Aching, morning stiffness in proximal limb muscles Weakness is not a symptom of PMR Mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats

Answer 545

Raised inflammatory markers, especially ESR > 40 mm/hr Creatine kinase (CK) and EMG are typically normal

Answer 546

First-line treatment is prednisolone, typically starting at 15mg/od Patients usually show a dramatic response to steroids. Failure to respond should prompt consideration of an alternative diagnosis.

Answer 547

A: Polymyositis is an inflammatory disorder causing symmetrical, proximal muscle weakness, thought to be a T-cell mediated cytotoxic process directed against muscle fibers. It may be idiopathic or associated with connective tissue disorders and is associated with malignancy.

Answer 548

A: Dermatomyositis is a variant of polymyositis where skin manifestations are prominent, such as a heliotrope rash (purple rash) on the cheeks and eyelids.

Answer 549

Proximal muscle weakness (often with tenderness) Raynaud's phenomenon Respiratory muscle weakness Interstitial lung disease (e.g. fibrosing alveolitis, organising pneumonia) seen in ~20% of patients, indicating a poor prognosis Dysphagia and dysphonia

Answer 550

Elevated creatine kinase Other muscle enzymes (LDH, aldolase, AST, ALT) are elevated in 85-95% of patients EMG Muscle biopsy Anti-synthetase antibodies, especially anti-Jo-1 antibodies, which are associated with lung involvement, Raynaud's, and fever

Answer 551

High-dose corticosteroids tapered as symptoms improve Azathioprine may be used as a steroid-sparing agent

Answer 552

A: Pseudogout is a form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate crystals in the synovium. It is also known as acute calcium pyrophosphate crystal deposition disease.

Answer 553

Knee, wrist, and shoulder joints most commonly affected Joint aspiration shows weakly-positively birefringent, rhomboid-shaped crystals X-ray shows chondrocalcinosis, with linear calcifications of the meniscus and articular cartilage in the knee

Answer 554

Aspiration of joint fluid to exclude septic arthritis NSAIDs or intra-articular, intra-muscular, or oral steroids as for gout

Answer 555

A: Psoriatic arthropathy is an inflammatory arthritis associated with psoriasis and is classed as one of the seronegative spondyloarthropathies. It often precedes the development of skin lesions and correlates poorly with cutaneous psoriasis.

Answer 556

Symmetric polyarthritis (30-40% of cases, similar to rheumatoid arthritis) Asymmetrical oligoarthritis (typically affects hands and feet, 20-30% of cases) Sacroiliitis DIP joint disease (10%) Arthritis mutilans (severe deformity of fingers/hands, 'telescoping fingers') uveitis SIDE (sacroiliitis, iritis, dactylitis, enthesitis)

Answer 557

Psoriatic skin lesions Periarticular disease: Enthesitis (e.g. Achilles tendonitis, plantar fasciitis) Tenosynovitis (typically of flexor tendons of the hands) Dactylitis (diffuse swelling of fingers or toes) Nail changes: pitting, onycholysis

Answer 558

Coexistence of erosive changes and new bone formation Periostitis 'Pencil-in-cup' appearance

Answer 559

Managed by a rheumatologist Mild peripheral arthritis/axial disease: NSAIDs Moderate/severe disease: Methotrexate, monoclonal antibodies like ustekinumab (IL-12, IL-23) and secukinumab (IL-17), apremilast (PDE4 inhibitor) Psoriatic arthritis has a better prognosis than rheumatoid arthritis (RA).

Answer 560

Connective tissue disorders: Scleroderma (most common) Rheumatoid arthritis Systemic lupus erythematosus (SLE) Leukaemia Type I cryoglobulinaemia, cold agglutinins Vibrating tools use Drugs: oral contraceptive pill, ergot Cervical rib

Answer 561

Onset after 40 years Unilateral symptoms Rashes Presence of autoantibodies Features suggesting rheumatoid arthritis or SLE (e.g., arthritis, recurrent miscarriages) Digital ulcers, calcinosis Rarely: chilblains

Answer 562

Referral to secondary care for suspected secondary Raynaud's phenomenon First-line treatment: Calcium channel blockers (e.g., nifedipine) IV prostacyclin (epoprostenol) infusions may have lasting effects for weeks/months.

Answer 563

A: Reactive arthritis is an arthritis that develops following an infection where the organism cannot be recovered from the joint. It is part of the HLA-B27 associated seronegative spondyloarthropathies.

Answer 564

"Can't see, pee or climb a tree": See: Conjunctivitis Pee: Urethritis Climb a tree: Arthritis, typically affecting large joints (e.g., knees, ankles).

Answer 565

Symptomatic treatment with analgesia, NSAIDs, and intra-articular steroids. Sulfasalazine and methotrexate may be used for persistent disease. Symptoms rarely last more than 12 months.

Answer 566

Asymmetrical oligoarthritis (typically in the lower limbs) Dactylitis Symptoms of urethritis Conjunctivitis (seen in 10-30% of patients) Anterior uveitis Circinate balanitis (painless vesicles on the coronal margin of the prepuce) Keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)

Answer 567

A: Reactive arthritis typically develops within 4 weeks of the initial infection. Symptoms generally last 4-6 months, with around 25% of patients having recurrent episodes and 10% developing chronic disease.

Answer 568

A: Keratoderma blenorrhagica refers to waxy yellow/brown papules found on the palms and soles of patients with reactive arthritis.

Answer 569

Pulmonary fibrosis Pleural effusion Pulmonary nodules Bronchiolitis obliterans Methotrexate pneumonitis Pleurisy

Answer 570

Have at least 1 joint with definite clinical synovitis Have synovitis not better explained by another disease

Answer 571

A: Rheumatoid factor (RF) is recommended as the first-line antibody test for patients with suspected rheumatoid arthritis.

Answer 572

A: Anti-CCP is an antibody that may be detectable up to 10 years before RA. It plays a key role in the diagnosis and allows early detection of patients suitable for aggressive anti-TNF therapy. It has a sensitivity of around 70% and a specificity of 90-95%.

Answer 573

A: NICE recommends testing for anti-cyclic citrullinated peptide antibody (anti-CCP) in rheumatoid factor negative patients.

Answer 574

A: NICE recommends performing x-rays of the hands and feet for all patients with suspected rheumatoid arthritis.

Answer 575

A: The initial therapy for RA includes DMARD monotherapy (disease-modifying antirheumatic drugs) +/- a short-course of bridging prednisolone.

Answer 576

A: Monitoring of FBC (full blood count) and LFTs (liver function tests) is essential due to the risk of myelosuppression and liver cirrhosis. Other side effects include pneumonitis.

Answer 577

A: NICE recommends using a combination of CRP (C-reactive protein) and disease activity (using a composite score such as DAS28) to assess response to treatment.

Answer 578

A: Flares of RA are often managed with corticosteroids (oral or intramuscular).

Answer 579

A: TNF-inhibitors are indicated for patients with inadequate response to at least two DMARDs, including methotrexate.

Answer 580

A: Rituximab is an anti-CD20 monoclonal antibody that depletes B-cells. It is administered as two 1g intravenous infusions two weeks apart. Infusion reactions are common.

Answer 581

A: Rheumatoid arthritis typically presents with swollen, painful joints in the hands and feet, stiffness worse in the morning, and gradual worsening with larger joints becoming involved. The presentation usually develops insidiously over a few months.

Answer 582

A: A positive 'squeeze test' in rheumatoid arthritis (discomfort on squeezing across the metacarpal or metatarsal joints) indicates inflammation in the joints.

Answer 583

A: Swan neck and boutonniere deformities are late features of rheumatoid arthritis and are unlikely to be present in a recently diagnosed patient.

Answer 584

A: Poor prognostic features in rheumatoid arthritis include rheumatoid factor positivity, anti-CCP antibodies, poor functional status at presentation, early erosions on X-ray (e.g. after < 2 years), extra-articular features (e.g. nodules), HLA DR4 positivity, and insidious onset.

Answer 585

A: Early X-ray findings in rheumatoid arthritis include loss of joint space, juxta-articular osteoporosis, soft-tissue swelling, periarticular erosions, and subluxation.

Answer 586

Staph aureus

Answer 587

A: The most common cause of septic arthritis in sexually active young adults is Neisseria gonorrhoeae (disseminated gonococcal infection).

Answer 588

A: The most common location for septic arthritis in adults is the knee.

Answer 589

A: Typical features of septic arthritis include acute, swollen joint, restricted movement (80% of patients), warm to touch/fluctuant joint, and fever (present in the majority of patients).

Answer 590

A: Synovial fluid sampling is obligatory in septic arthritis and should be done prior to antibiotic administration if possible.

Answer 591

A: Intravenous antibiotics covering Gram-positive cocci are indicated, such as flucloxacillin or clindamycin if penicillin allergic.

Answer 592

A: Antibiotic treatment for septic arthritis is typically given for 4-6 weeks, with a switch to oral antibiotics after 2 weeks.

Answer 593

A: Management options for septic arthritis include intravenous antibiotics, needle aspiration to decompress the joint, and arthroscopic lavage if necessary.

Answer 594

A: Seronegative spondyloarthropathies are associated with HLA-B27 and are rheumatoid factor negative.

Answer 595

A: Seronegative spondyloarthropathies typically present with peripheral arthritis, which is usually asymmetrical.

Answer 596

A: A characteristic feature is sacroiliitis, which is inflammation of the sacroiliac joints.

Answer 597

A: The types of spondyloarthropathies include ankylosing spondylitis, psoriatic arthritis, reactive arthritis, and enteropathic arthritis (associated with IBD).

Answer 598

A: Sjogren's syndrome is an autoimmune disorder affecting exocrine glands, resulting in dry mucosal surfaces. It can be primary or secondary to other autoimmune diseases like rheumatoid arthritis.

Answer 599

A: Sjogren's syndrome is associated with a 40-60 fold increase in the risk of lymphoid malignancy.

Answer 600

A: Common features include dry eyes (keratoconjunctivitis sicca), dry mouth, vaginal dryness, arthralgia, Raynaud's phenomenon, myalgia, sensory polyneuropathy, recurrent episodes of parotitis, and renal tubular acidosis.

Answer 601

A: Rheumatoid factor (RF) is positive in nearly 50% of patients, ANA in 70%, anti-Ro (SSA) in 70%, and anti-La (SSB) in 30% of patients with primary Sjogren's syndrome.

Answer 602

A: Treatment includes artificial saliva and tears, and pilocarpine may be used to stimulate saliva production.

Answer 603

A: Common features include arthralgia, elevated serum ferritin, a salmon-pink maculopapular rash, pyrexia (rises late afternoon/evening), lymphadenopathy, and negative rheumatoid factor (RF) and anti-nuclear antibody (ANA).

Answer 604

A: Fever in Still's disease typically rises in the late afternoon/early evening and is often associated with worsening joint symptoms and the rash.

Answer 605

A: NSAIDs are used first-line to manage fever, joint pain, and serositis. They should be trialled for at least a week before considering steroids.

Answer 606

A: Sulfasalazine is a disease-modifying anti-rheumatic drug (DMARD) used in the management of inflammatory arthritis, especially rheumatoid arthritis, and inflammatory bowel disease.

Answer 607

A: Sulfasalazine should be used with caution in patients with G6PD deficiency and those with an allergy to aspirin or sulphonamides (due to cross-sensitivity).

Answer 608

A: Adverse effects include oligospermia, Stevens-Johnson syndrome, pneumonitis / lung fibrosis, myelosuppression, Heinz body anaemia, megaloblastic anaemia, and staining of tears (which can stain contact lenses).

Answer 609

A: Fatigue, fever, mouth ulcers, and lymphadenopathy.

Answer 610

A: Malar (butterfly) rash (spares nasolabial folds), discoid rash (scaly, erythematous, well-demarcated rash in sun-exposed areas), photosensitivity, Raynaud's phenomenon, livedo reticularis, and non-scarring alopecia.

Answer 611

A: Arthralgia and non-erosive arthritis.

Answer 612

A: Pericarditis (most common cardiac manifestation) and myocarditis.

Answer 613

A: Pleurisy and fibrosing alveolitis.

Answer 614

A: Proteinuria and glomerulonephritis (with diffuse proliferative glomerulonephritis being the most common type).

Answer 615

A: Anxiety and depression, psychosis, and seizures.

Answer 616

99% of patients are ANA positive, which is a useful rule-out test, but it has low specificity. 20% are rheumatoid factor positive.

Answer 617

A: Anti-dsDNA is highly specific (>99%) for SLE but has lower sensitivity (70%).

Answer 618

A: Anti-Smith is highly specific (>99%) but has low sensitivity (30%).

Answer 619

A: Anti-U1 RNP, SS-A (anti-Ro), and SS-B (anti-La).

Answer 620

ESR is commonly used. During active disease, CRP may be normal, and a raised CRP may indicate an underlying infection. Complement levels (C3, C4) are low during active disease due to consumption by immune complexes. Anti-dsDNA titres can be used for disease monitoring (but not present in all patients).

Answer 621

A: NSAIDs and sun-block are essential for basic management.

Answer 622

A: Hydroxychloroquine is the treatment of choice for SLE.

Answer 623

A: Systemic sclerosis is characterized by hardened, sclerotic skin and other connective tissues.

Answer 624

A: CREST syndrome is a subtype of limited cutaneous systemic sclerosis characterized by Calcinosis, Raynaud's phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasia.

Answer 625

A: In limited cutaneous systemic sclerosis, scleroderma predominantly affects the face and distal limbs, and it is associated with anti-centromere antibodies.

Answer 626

A: In diffuse cutaneous systemic sclerosis, scleroderma predominantly affects the trunk and proximal limbs, and it is associated with anti-scl-70 antibodies.

Answer 627

A: Key features include headache (85%), jaw claudication (65%), vision problems (amaurosis fugax, vision loss), tender, palpable temporal artery, and features of Polymyalgia Rheumatica (PMR) in around 50% of patients.

Answer 628

A: Diagnosis is supported by raised inflammatory markers (ESR > 50 mm/hr, CRP), temporal artery biopsy (showing skip lesions), and normal creatine kinase/EMG.

Answer 629

A: High-dose glucocorticoids (e.g., prednisolone) should be given urgently as soon as Temporal Arteritis is suspected. If visual loss is evolving, IV methylprednisolone is usually given before starting oral steroids.

Answer 630

A: Urgent ophthalmology review is necessary because visual damage can be irreversible if not treated promptly.

Answer 631

C1, 2 - Look at your shoe- Neck flexion/extension C3 - A fallen tree - Neck lateral flexion C4 - I'm not sure - Shoulder elevation C5 - Arms out wide - Shoulder flexion, abduction, & lateral rotation C6, 7, 8 - Close the gate - Shoulder extension, adduction & medial rotation C5, 6 - Pick up sticks - Elbow flexion C7, 8 - Lay them straight - Elbow extension C5, 6 - Flick my wrists - Forearm supination C7, 8 - The time is late - Forearm pronation C6, 7 - Fly up to heaven - Wrist flexion & extension C7 - Paper - Finger extension C8 - Rock - Finger flexion (though some sources say C7, 8 does both finger extension and flexion) T1 - Scissors - Finger abduction & adduction (T1-12 - Supplies chest wall and abdominal muscles) (L1 - Contributes to hip flexion & adduction) Kicking a ball: L2, 3 - Lift my knee - Hip flexion L3, 4 - Kick the door - Knee extension (& knee-jerk reaction) L4, 5 - Foot points to the sky - Ankle dorsiflexion Bringing foot back to the floor: L4, 5 - Extend my thigh - Hip extension L5, S1, (S2) - Kick my bum (Run to poo) - Knee flexion S1, 2 - Stand on my shoes - Ankle plantarflexion (& ankle jerk) (Babinski plantar reflex/extensor response in UMN lesion is L5, S1, S2) L2, 3, 4 - Modestly close the door - Hip adduction & internal/medial rotation L4 - S2 - The opposite is true - Hip abduction & external/lateral rotation [ SUPPLIES ] C3, 4, 5 - Keeps the diaphragm alive â→ Innervates the diaphragm S2, 3, 4 - Keeps s*** off the floor â→ Innervates bowel, bladder, sex organs, anal sphincter, pelvic muscles. (& anal wink reflex)

Answer 632

pain on passive stretch

Answer 633

achilles rupture

Answer 634

A: Achilles tendon disorders.

Answer 635

A: Gradual onset of posterior heel pain that worsens following activity, and morning pain and stiffness.

Answer 636

A: Supportive management, including simple analgesia, reduction in precipitating activities, and calf muscle eccentric exercises (self-directed or physiotherapy-guided).

Answer 637

A: Ultrasound.

Answer 638

A: An acute referral to an orthopaedic specialist should be made.

Answer 639

GRIMUS helps to remember which forearm bone is fractured and whether the distal ('inferior') or proximal ('superior') part of the bone is involved * G: Galeazzi - R: radius - I: inferior * M: Monteggia - U: ulna - S: superior

Answer 640

sciatic nerve, L4-S1

Answer 641

repeat xray 7-10 days later. MRI to check for avascular necrosis

Answer 642

hemiarthroplasty rather than total hip replacement

Answer 643

supracondylar fractures and tibial shaft injuries

Answer 644

sitting down and leaning forward

Answer 645

Refer to surgeon

Answer 646

tenderness 2-3cm above the lateral joint line lateral knee pain occurs in runners

Answer 647

most common upper limb injury in children under the age of 6 elbow pain and limited supination and extension of the elbow

Answer 648

analgesia and passively supination of the elbow joint whilst the elbow is flexed to 90 degrees

Answer 649

nerve blocks

Answer 650

- Surgical emergency - Caused by human and animal bites (metacarpal strikes a tooth) - Kanavel's signs: fusiform swelling, tenderness over flexor sheath, semiflexed posture, pain on passive extension - I.V antibiotics with elevation - Mx Surgical debridement Can lead to fibrosis and contractures which can be very disabling

Answer 651

scaphoid pole fracture - surgical fixation

Answer 652

Pain along the radial aspect of the wrist, at the base of the thumb Loss of grip / pinch strength Pain on longitudinal compression of the thumb

Answer 653

painful arc syndrome this is typically between 60 and 120 degrees. With rotator cuff tears the pain may be in the first 60 degrees

Answer 654

Weber A: cast/boot and weight bear as tolerated Weber B: cast/boot and weight bear as tolerated but if talar shift, ORIF Weber C (unstable): ORIF Follow-up in 6-8 weeks

Answer 655

discomfort upon hip extension

Answer 656

reassess after 5 years

Answer 657

Oral bisphosphonates should be swallowed with plenty of water while sitting or standing on an empty stomach at least 30 minutes before breakfast (or another oral medication); the patient should stand or sit upright for at least 30 minutes after taking

Answer 658

Testosterone blood tests are important when suspecting osteoporosis in a man. Hypogonadism is a common cause of osteoporosis in men.

Answer 659

polymyositis

Answer 660

polymyositis has raised CK

Answer 661

chest xray for TB as biologics can cause reactivation

Answer 662

high WBC count, predominantly PMNs. Appearance is typically yellow and cloudy with absence of crystals. 'Sterile synovial fluid'

Answer 663

urgent referral - link to malignancy

Answer 664

RA + splenomegaly + low white cell count

Answer 665

pyrazinamide and ethambutol

Answer 666

anti histone

Answer 667

haemochromatosis

Answer 668

Only ESR, high CRP suggests infection

Answer 669

fluoroquinolones eg ciprofloxacin

Answer 670

sarcoidosis - lupus pernio (PURPLE rash)

Answer 671

lupus pernio - sarcoidosis

Answer 672

CT to check for malignancy

Answer 673

immediately

Answer 674

rest, nsaids, physio

Answer 675

anterior ischemic optic neuropathy - Fundoscopy typically shows a swollen pale disc and blurred margins

Answer 676

anterior groin

Answer 677

Weber A -> 99% of times CAM boots as ankle is fine. Weber B -> need radiograph (mortis view) to assess syndesmosis + mortis for ankle stability. It there is instability as ligaments are affect -> surgery. If not, then CAM boot. Weber C -> 99% of times fracture will involve syndesmosis -> ankle instability -> required surgery (ORIF)

Answer 678

folic acid to prevent bone marrow suppression

Answer 679

posterior dislocation

Answer 680

Ulnar injury at wrist : marked claw Ulnar injury at elbow : less claw but get worse before getting better

Answer 681

Beighton Score

Answer 682

2-4 weeks after episode

Answer 683

Iliofascial nerve block or spinal anaesthesia during surgery

Answer 684

numbness and pain over the lateral skin of the left/right thigh

Answer 685

causes neutropaenia due to Autoimmune destruction of neutrophils

Answer 686

medial circumflex femoral

Answer 687

subacute combined degeneration of the spinal cord