MSK proper Flashcards
Q: What common cause of admission to casualty is facilitated by the Ottawa ankle rules?
A: Ankle fractures.
Q: According to the Ottawa ankle rules, when are x-rays necessary for ankle injuries?
A: If there is pain in the malleolar zone and any one of the following: inability to weight bear for 4 steps, tenderness over the distal tibia, or bone tenderness over the distal fibula.
unless neurovascular compromise - then do closed reduction then do xrays then manage
Q: What classification systems exist for describing ankle fractures?
A: Potts, Weber, and AO systems.
Q: What is the Weber classification related to?
A: The level of the fibular fracture.
Q: Describe a Type A fracture in the Weber classification.
A: Below the syndesmosis.
Q: Describe a Type B fracture in the Weber classification.
A: Starts at the level of the tibial plafond and may extend proximally to involve the syndesmosis.
Q: Describe a Type C fracture in the Weber classification.
A: Above the syndesmosis which may itself be damaged.
Q: What is a Maisonneuve fracture?
A: A spiral fibular fracture that leads to disruption of the syndesmosis with widening of the ankle joint, requiring surgery.
Q: What factors does the management of ankle fractures depend on?
A: Stability of the ankle joint and patient co-morbidities.
Q: Why should all ankle fractures be promptly reduced?
A: To remove pressure on the overlying skin and prevent subsequent necrosis.
Q: What is the typical management for young patients with unstable, high-velocity, or proximal ankle injuries?
A: Surgical repair, often using a compression plate.
Q: Why might elderly patients with potentially unstable ankle injuries fare better with conservative management?
A: Their thin bone does not hold metalwork well.
Q: When is an ankle x-ray required according to the Ottawa Rules?
A: If there is any pain in the malleolar zone and any one of the following findings: bony tenderness at the lateral malleolar zone, bony tenderness at the medial malleolar zone, or inability to walk four weight-bearing steps immediately after the injury and in the emergency department.
Q: What is an ankle sprain?
A: A stretching, partial, or complete tear of a ligament in the ankle.
Q: What is the difference between high and low ankle sprains?
A: High ankle sprains involve the syndesmosis, while low ankle sprains involve the lateral collateral ligaments.
Q: What is the most common mechanism of injury for low ankle sprains?
A: Inversion injury.
Q: Which ligament is most commonly affected in low ankle sprains?
A: The anterior talofibular ligament (ATFL).
Q: How are low ankle sprains classified?
A: Grade I (mild), Grade II (moderate), Grade III (severe).
Q: What are the characteristics of Grade I low ankle sprains?
A: Stretch or micro tear, minimal bruising and swelling, normal pain on weight-bearing.
Q: What are the characteristics of Grade II low ankle sprains?
A: Partial tear, moderate bruising and swelling, minimal pain on weight-bearing.
Q: What are the characteristics of Grade III low ankle sprains?
A: Complete tear, severe bruising and swelling, severe pain on weight-bearing.
Q: What is the investigation method for low ankle sprains?
A: Radiographs according to the Ottawa ankle rules, and MRI if there is persistent pain or to evaluate perineal tendons.
Q: What is the typical treatment for low ankle sprains?
A: Non-operative treatment with RICE (Rest, Ice, Compression, Elevation), possibly a removable orthosis, cast, and/or crutches. MRI and surgical intervention are rare but may be considered if symptoms fail to settle.
Q: What is the mechanism of injury for high ankle sprains?
A: External rotation of the foot causing the talus to push the fibula laterally.
Q: How are high ankle sprains typically diagnosed?
A: Radiographs showing widening of the tibiofibular joint (diastasis) or ankle mortise, and MRI if there is high suspicion of syndesmotic injury.
Q: What is the treatment for high ankle sprains if there is no diastasis?
A: Non-weight-bearing orthosis or cast until pain subsides.
Q: What treatment is needed if there is diastasis or failed non-operative management for high ankle sprains?
A: Operative fixation.
Q: What is avascular necrosis (AVN)?
A: The death of bone tissue secondary to loss of the blood supply, leading to bone destruction and loss of joint function.
Q: Which part of long bones is most commonly affected by avascular necrosis?
A: The epiphysis.
Q: What are common causes of avascular necrosis?
A: Long-term steroid use, chemotherapy, alcohol excess, and trauma.
Q: What are the early findings on a plain x-ray for avascular necrosis?
A: Osteopenia and microfractures may be seen, but x-rays may be normal initially.
Q: What sign on x-ray indicates collapse of the articular surface in avascular necrosis?
A: The crescent sign.
Q: What is the investigation of choice for avascular necrosis?
A: MRI, as it is more sensitive than radionuclide bone scanning.
Q: What may be necessary in the management of avascular necrosis?
A: Joint replacement.
Q: What is a Baker’s cyst?
A: A distension of the gastrocnemius-semimembranosus bursa, not a true cyst.
Q: What are the two types of Baker’s cysts?
A: Primary (no underlying pathology, typically in children) and secondary (associated with underlying conditions like osteoarthritis, typically in adults).
Q: Where do Baker’s cysts present?
A: As swellings in the popliteal fossa behind the knee.
Q: What are the symptoms if a Baker’s cyst ruptures?
A: Pain, redness, and swelling in the calf, similar to deep vein thrombosis. However, most ruptures are asymptomatic.
Q: Which tendon is most commonly ruptured in a biceps tendon injury?
A: The long tendon (90% of cases).
Q: What are common risk factors for biceps tendon rupture?
A: Heavy overhead activities, shoulder overuse or underlying shoulder injuries, smoking, and corticosteroid use (which weakens tendons).
Q: What symptoms are typically reported by patients with a biceps tendon rupture?
A: A sudden ‘pop’ or tear, followed by pain, bruising, and swelling.
Q: What weakness typically follows a biceps tendon rupture?
A: Weakness in the shoulder and elbow, often with difficulty in supination.
Q: What is the initial examination for suspected biceps tendon rupture?
A: Palpate the long head and distal biceps tendon and assess neurovascular function in the upper extremities.
Q: What does the biceps squeeze test assess?
A: If the biceps tendon is intact, squeezing the muscle will cause forearm supination.
Q: What is the first-line investigation for suspected biceps tendon rupture?
A: Musculoskeletal ultrasound performed by a skilled clinician.
Q: What is the investigation of choice for suspected distal biceps tendon rupture?
A: An urgent MRI, as diagnosis based on clinical signs alone is challenging and surgical intervention is usually required.
Q: What is the characteristic feature of Paget’s disease?
A: Focal bone resorption followed by excessive and chaotic bone deposition.
Q: Which bones are most commonly affected by Paget’s disease, in order?
A: Spine, skull, pelvis, and femur.
Q: What is the serum marker typically raised in Paget’s disease?
A: Serum alkaline phosphatase.
Q: What is seen on x-ray in Paget’s disease?
A: Abnormal thickened, sclerotic bone.
Q: What are the risks associated with Paget’s disease?
A: Risk of cardiac failure with >15% bony involvement and a small risk of sarcomatous change.
Q: What is the main treatment for Paget’s disease?
A: Bisphosphonates.
Q: What is the cause of osteoporosis?
A: Excessive bone resorption resulting in demineralised bone.
Q: What are the typical symptoms of osteoporosis?
A: It is usually asymptomatic, but there is an increased risk of pathological fractures.
Q: What serum markers are typically normal in osteoporosis?
A: Alkaline phosphatase and calcium.
Q: What are the main treatments for osteoporosis?
A: Bisphosphonates, calcium, and vitamin D.
Q: What characterizes secondary bone tumors?
A: Bone destruction and tumor infiltration.
Q: What scoring system is used to predict the risk of fracture in secondary bone tumors?
A: Mirel scoring.
Q: What serum markers may be elevated in secondary bone tumors?
A: Serum calcium and alkaline phosphatase.
Q: What are the main treatments for secondary bone tumors?
A: Radiotherapy, prophylactic fixation, and analgesia.
Q: What is a buckle (torus) fracture?
A: An incomplete fracture of the shaft of a long bone characterized by bulging of the cortex.
Q: In which age group are buckle fractures most commonly seen?
A: In children aged 5-10 years.
Q: How are buckle fractures typically managed?
A: They are usually self-limiting and do not require operative intervention, often managed with splinting and immobilization instead of a cast.
Q: Which bone is commonly affected by a buckle fracture in children?
A: The distal radius.
Q: What causes carpal tunnel syndrome?
A: Compression of the median nerve in the carpal tunnel.
Q: What are the common symptoms of carpal tunnel syndrome?
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.
Q: What is a common sign of carpal tunnel syndrome on examination?
A: Weakness of thumb abduction (abductor pollicis brevis) and wasting of the thenar eminence (not hypothenar).
Q: What are the positive signs used in the examination of carpal tunnel syndrome?
A: Tinel’s sign (tapping causes paraesthesia) and Phalen’s sign (flexion of the wrist causes symptoms).
Q: What are some common causes of carpal tunnel syndrome?
A: Idiopathic, pregnancy, oedema (e.g., heart failure), lunate fracture, and rheumatoid arthritis.
Q: What is the recommended first-line treatment for mild to moderate carpal tunnel syndrome?
A: A 6-week trial of conservative treatments, including corticosteroid injections and wrist splints at night (especially useful for transient factors like pregnancy).
Q: What is the treatment for severe carpal tunnel syndrome or if symptoms persist despite conservative management?
A: Surgical decompression (flexor retinaculum division).
Q: What is cauda equina syndrome (CES)?
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.
Q: What is the most common cause of cauda equina syndrome?
A: A central disc prolapse, typically occurring at L4/5 or L5/S1.
Q: What are some other causes of cauda equina syndrome?
A: Tumours (primary or metastatic), infection (e.g., abscess, discitis), trauma, and haematoma.
Q: What are some possible symptoms of cauda equina syndrome?
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).
Q: What is a late sign of cauda equina syndrome that may indicate irreversible damage?
A: Urinary incontinence.
Q: What is a recommended practice in patients with new-onset back pain to help detect cauda equina syndrome?
A: Checking anal tone, although this has poor sensitivity and specificity for CES.
Q: What is the primary investigation for suspected cauda equina syndrome?
A: Urgent MRI.
Q: What is the management for cauda equina syndrome?
A: Surgical decompression.
Q: What is cervical spondylosis?
A: A degenerative condition affecting the cervical spine, particularly the intervertebral discs, vertebral bodies, and facet joints, often referred to as cervical osteoarthritis.
Q: What are common symptoms of cervical spondylosis?
A: Chronic neck pain, radiculopathy (radiating pain, paraesthesia, weakness), myelopathy (spinal cord compression), and occipital headaches.
Q: What is cervical spondylotic myelopathy?
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.
Q: What examination findings are commonly associated with cervical spondylosis?
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).
Q: What imaging is used to diagnose cervical spondylosis?
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).
Q: What is the first-line treatment for cervical spondylosis?
A: Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management.
Q: What is a Charcot joint?
A: A neuropathic joint that becomes disrupted and damaged due to a loss of sensation, most commonly seen in diabetics today.
Q: What are the common features of a Charcot joint?
A: Swelling, redness, warmth in the affected joint, and a less painful presentation than expected.
Q: What complications may arise as a Charcot joint progresses?
A: Joint instability, abnormal movements, increased risk of fractures and dislocations, significant deformities, and secondary complications like skin ulceration and infection.
Q: What is the typical mechanism of injury for a Colles’ fracture?
A: It classically follows a fall onto an outstretched hand (FOOSH).
Q: What is a Colles’ fracture?
A: A distal radius fracture with dorsal displacement of the fragments, often described as a dinner fork-type deformity.
Q: What are the three classical features of a Colles’ fracture?
A: 1) Transverse fracture of the radius, 2) 1 inch proximal to the radio-carpal joint, 3) Dorsal displacement and angulation.
Q: What deformity is associated with a Colles’ fracture?
A: The dinner fork deformity.
Q: What are the early complications of a Colles’ fracture?
A: Median nerve injury (acute carpal tunnel syndrome), compartment syndrome, vascular compromise, malunion, and rupture of the extensor pollicis longus tendon.
Q: What are the late complications of a Colles’ fracture?
A: Osteoarthritis and complex regional pain syndrome.
Q: What is compartment syndrome?
A: Compartment syndrome is a complication where raised pressure within a closed anatomical space compromises tissue perfusion, leading to necrosis.
Q: What are the typical features of compartment syndrome?
A: Pain (especially on movement), excessive use of breakthrough analgesia, parasthesiae, pallor, possible arterial pulsation, and paralysis of the muscle group.
Q: How is compartment syndrome diagnosed?
A: By measuring intracompartmental pressure; pressures over 20mmHg are abnormal, and pressures over 40mmHg are diagnostic.
Q: What is the treatment for compartment syndrome?
A: Prompt and extensive fasciotomy; if muscle groups are necrotic, they may require debridement or amputation.
Q: What potential complication can occur after fasciotomy for compartment syndrome?
A: Myoglobinuria, which may lead to renal failure, necessitating aggressive IV fluid therapy.
Q: How quickly can muscle groups die in compartment syndrome?
A: Muscle groups may die within 4-6 hours if untreated.
Q: What causes cubital tunnel syndrome?
A: Cubital tunnel syndrome is caused by compression of the ulnar nerve as it passes through the cubital tunnel.
Q: What are the clinical features of cubital tunnel syndrome?
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.
Q: What is a common history seen in cubital tunnel syndrome patients?
A: A history of osteoarthritis or prior trauma to the elbow area.
Q: What is the management for cubital tunnel syndrome?
A: Avoid aggravating activities, physiotherapy, steroid injections, and surgery in resistant cases.
Q: What is De Quervain’s tenosynovitis?
A: De Quervain’s tenosynovitis is an inflammation of the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons.
Q: What are the clinical features of De Quervain’s tenosynovitis?
A: Pain on the radial side of the wrist, tenderness over the radial styloid process, and pain with abduction of the thumb against resistance.
Q: What is Finkelstein’s test, and how is it used to diagnose De Quervain’s tenosynovitis?
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.
Q: What is the management for De Quervain’s tenosynovitis?
A: Management includes analgesia, steroid injections, immobilisation with a thumb spica splint, and occasionally surgical treatment.
Q: What is discitis?
A: Discitis is an infection in the intervertebral disc space that can lead to complications like sepsis or an epidural abscess.
Q: What are the general clinical features of discitis?
A: Back pain, pyrexia, rigors, and sepsis.
Q: What neurological features may occur in discitis?
A: Changing lower limb neurology may occur if an epidural abscess develops.
Q: How is discitis diagnosed?
A: MRI is the most sensitive imaging modality, and a CT-guided biopsy may be required to identify the organism and guide treatment.
Q: What is Dupuytren’s contracture?
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.
Q: What are the risk factors for Dupuytren’s contracture?
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.
Q: Which fingers are most commonly affected by Dupuytren’s contracture?
A: The ring finger and little finger are most commonly affected.
Q: When should surgical treatment be considered for Dupuytren’s contracture?
A: Surgical treatment should be considered when the metacarpophalangeal joints cannot be straightened, and the hand cannot be placed flat on a table.
Q: What are the features of lateral epicondylitis (tennis elbow)?
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.
Q: What are the features of medial epicondylitis (golfer’s elbow)?
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.
Q: What is radial tunnel syndrome and its features?
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.
Q: What are the features of cubital tunnel syndrome?
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.
Q: What is olecranon bursitis and its features?
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.
Q: What is a Smith’s fracture and how is it caused?
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.
Q: What is a Bennett’s fracture and how is it caused?
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.
Q: What is a Monteggia’s fracture?
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.
Q: What is a Galeazzi fracture?
A: Galeazzi fracture involves a radial shaft fracture with associated dislocation of the distal radioulnar joint, usually caused by a direct blow.
Q: What is a Pott’s fracture?
A: Pott’s fracture is a bimalleolar ankle fracture caused by forced foot eversion.
Q: What is a Barton’s fracture?
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.
Q: What are the respiratory features of fat embolism?
A: Respiratory features include early persistent tachycardia, tachypnoea, dyspnoea, hypoxia, and pyrexia, typically developing 72 hours following injury.
Q: What are the dermatological features of fat embolism?
A: Dermatological features include a red/brown impalpable petechial rash, seen in 25-50% of cases, along with subconjunctival and oral haemorrhage/petechiae.
Q: What are the CNS features of fat embolism?
A: CNS features include confusion, agitation, retinal haemorrhages, and intra-arterial fat globules observed on fundoscopy.
Q: How is fat embolism diagnosed?
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.
Q: What is the treatment for fat embolism?
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.
Q: What are the three main causes of fractures?
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).
Q: What are the different types of fractures and their descriptions?
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.
Q: What are the Gustilo and Anderson classifications for open fractures?
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.
Q: What are key points in the management of fractures?
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.
Q: What is a ganglion and where is it most commonly seen?
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.
Q: What are the features of a ganglion?
A: A ganglion is a firm, well-circumscribed mass that transilluminates.
Q: How is a ganglion managed?
A: Ganglions often disappear spontaneously after several months. Surgical excision is indicated for cysts associated with severe symptoms or neurovascular manifestations.
Q: What is greater trochanteric pain syndrome also known as?
A: Greater trochanteric pain syndrome is also referred to as trochanteric bursitis.
Q: What are the features of greater trochanteric pain syndrome?
A: Features include pain over the lateral side of the hip/thigh and tenderness on palpation of the greater trochanter.
Q: What are Osler’s nodes?
A: Osler’s nodes are painful, red, raised lesions found on the hands and feet due to the deposition of immune complexes.
Q: What are Bouchard’s nodes?
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.
Q: What are Heberden’s nodes?
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.
Q: What types of hip dislocation exist, and how are they characterized?
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.
Q: What is the management approach for hip dislocation?
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.
Q: What are the complications of hip dislocation?
A: Complications include sciatic or femoral nerve injury, avascular necrosis, osteoarthritis (more common in older patients), and recurrent dislocation due to ligament damage.
Q: What is the prognosis for hip dislocation, and when is it most favorable?
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.
Q: What are the classic signs of a hip fracture?
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.
Q: How are hip fractures classified by location?
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).
Q: What are the types of intracapsular fractures according to the Garden classification system?
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.
Q: What is the management of an undisplaced intracapsular hip fracture?
A: Management includes internal fixation or hemiarthroplasty if the patient is unfit for surgery.
Q: What is the management of a displaced intracapsular hip fracture?
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.
Q: What is the management of extracapsular hip fractures?
Stable intertrochanteric fractures: Managed with a dynamic hip screw.
Reverse oblique, transverse, or subtrochanteric fractures: Managed with an intramedullary device.
Q: What condition is often picked up during newborn examination and is associated with positive Barlow’s and Ortolani’s tests?
A: Developmental dysplasia of the hip.
Q: What is the typical age group for transient synovitis (irritable hip)?
A: 2-10 years.
Q: What is the most common cause of hip pain in children?
A: Transient synovitis (irritable hip), which is associated with viral infections.
Q: What is Perthes disease and what age group does it primarily affect?
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.
Q: What are the features of Perthes disease?
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.
Q: What age group is typically affected by slipped upper femoral epiphysis (SUFE), and which children are at higher risk?
A: SUFE typically affects children aged 10-15 years, especially obese children and boys.
Q: What are the key features of slipped upper femoral epiphysis (SUFE)?
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.
Q: What is juvenile idiopathic arthritis (JIA) and how is it classified?
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
Q: What are the features of pauciarticular juvenile idiopathic arthritis (JIA)?
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.
Q: What is septic arthritis and how does it present?
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.
Q: What is an iliopsoas abscess?
A: An iliopsoas abscess is a collection of pus in the iliopsoas compartment (iliopsoas and iliacus muscles).
Q: What are the primary causes of iliopsoas abscess?
A: Primary iliopsoas abscess is due to haematogenous spread of bacteria, with Staphylococcus aureus being the most common pathogen.
Q: What are the secondary causes of iliopsoas abscess?
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.
Q: What are the clinical features of iliopsoas abscess?
A: Fever, back/flank pain, limp, and weight loss.
Q: What is the clinical examination finding for iliopsoas abscess?
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).
Q: What is the investigation of choice for iliopsoas abscess?
A: CT abdomen is the investigation of choice.
Q: What is the initial management of iliopsoas abscess?
A: Initial management includes antibiotics and percutaneous drainage, which is successful in about 90% of cases.
Q: When is surgery indicated in the management of iliopsoas abscess?
A: Surgery is indicated if percutaneous drainage fails or if there is another intra-abdominal pathology that requires surgery.
Q: What is the unhappy triad in knee injuries?
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).
Q: What is the typical cause of damage to the anterior cruciate ligament (ACL)?
A: ACL damage may result from twisting injuries.
Q: Which tests may be positive for ACL damage?
A: The anterior drawer test and Lachman test may be positive if the ACL is damaged.
Q: What type of injury causes damage to the posterior cruciate ligament (PCL)?
A: PCL damage may occur following dashboard injuries.
Q: What is a common cause of damage to the medial collateral ligament (MCL)?
A: MCL damage is commonly caused by skiing and following valgus stress.
Q: What is a typical sign of damage to the MCL?
A: Damage to the MCL typically causes abnormal passive abduction of the knee.
Q: What causes damage to the menisci?
A: Meniscal damage often results from twisting injuries.
Q: What are common symptoms of meniscal damage?
A: Locking and giving way are common symptoms of meniscal damage.
Q: What are the common presentations of a ruptured ACL?
A: A ruptured ACL often presents with a loud crack, pain, and rapid joint swelling (haemoarthrosis).
Q: How is a ruptured ACL managed?
A: A ruptured ACL is managed with intense physiotherapy or surgery.
Q: Who is most commonly affected by chondromalacia patellae?
A: Chondromalacia patellae commonly affects teenage girls, typically following an injury to the knee (e.g., patellar dislocation).
Q: What is a common history in patients with chondromalacia patellae?
A: Patients often report pain on going downstairs or at rest, along with tenderness and quadriceps wasting.
Q: What is the typical cause of patellar dislocation?
A: Patellar dislocation most commonly occurs through direct trauma or severe contraction of the quadriceps with the knee stretched in valgus and external rotation.
Q: What is the mechanism of tibial plateau fractures?
A: Tibial plateau fractures occur when the knee is forced into valgus or varus, but the knee fractures before the ligaments rupture.
Q: What are the typical features of an ACL injury?
A: Features include knee swelling, instability, and the feeling that the knee will give way.
Q: What is the anterior drawer test used for?
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.
Q: What does an intact ACL prevent during the anterior drawer test?
A: An intact ACL prevents forward translational movement of the tibia.
Q: What is the Lachman’s test?
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.
Q: Why is the Lachman’s test considered more reliable than the anterior drawer test?
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.
Q: What is a common feature of knee pain caused by a meniscal tear?
A: Pain is often worse on straightening the knee.
Q: What symptom may occur with a meniscal tear that affects knee stability?
A: The knee may “give way” due to instability caused by the tear.
Q: What can displaced meniscal tears cause in terms of knee movement?
A: Displaced meniscal tears may cause knee locking.
Q: Where is tenderness typically found in a meniscal tear?
A: Tenderness is usually along the joint line.
Q: What is Thessaly’s test used to assess?
A: Thessaly’s test is used to assess for a meniscal tear.
Q: How is Thessaly’s test performed?
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.
Q: What are common characteristics of osteoarthritis of the knee in older adults?
A: Typically occurs in patients over 50 years, often overweight. Pain may be severe, with intermittent swelling, crepitus, and limited movement.
Q: What is infrapatellar bursitis (Clergyman’s knee) associated with?
A: Infrapatellar bursitis is associated with kneeling.
Q: What is prepatellar bursitis (Housemaid’s knee) associated with?
A: Prepatellar bursitis is associated with more upright kneeling.
Q: What is Leriche syndrome and how is it treated?
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.
Q: What are the red flags for lower back pain?
Age < 20 years or > 50 years
History of previous malignancy
Night pain
History of trauma
Systemically unwell (e.g., weight loss, fever)
thoracic pain
Q: What are common causes of lower back pain that require specific treatment?
Facet joint pain
Spinal stenosis
Ankylosing spondylitis
Peripheral arterial disease
Q: What are the clinical features of facet joint pain in lower back pain?
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
Q: What are the key features of spinal stenosis?
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
Q: What are the symptoms of ankylosing spondylitis in lower back pain?
Typically occurs in young men
Morning stiffness that improves with activity
Peripheral arthritis in 25% of cases (more common in females)
Q: How does peripheral arterial disease manifest in patients with lower back pain?
Pain on walking, relieved by rest
Absent or weak foot pulses
History of smoking or vascular diseases
Q: What is the recommended first-line treatment for non-specific lower back pain according to NICE guidelines?
NSAIDs are the first-line treatment for back pain
Paracetamol monotherapy is not effective
Q: When should MRI be used in non-specific lower back pain?
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
Q: What are the typical features of a prolapsed lumbar disc?
Leg pain is usually worse than back pain
Pain often worsens when sitting
Associated with neurological deficits and clear dermatomal leg pain
Q: What are the features of L3 nerve root compression in prolapsed disc?
Sensory loss over the anterior thigh
Weak hip flexion, knee extension, and hip adduction
Reduced knee reflex
Positive femoral stretch test
Q: What are the features of L4 nerve root compression in prolapsed disc?
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
Q: What are the features of L5 nerve root compression in prolapsed disc?
Sensory loss on the dorsum of the foot
Weakness in foot and big toe dorsiflexion
Reflexes are intact
Positive sciatic nerve stretch test
Q: What are the features of S1 nerve root compression in prolapsed disc?
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
Q: What is the management approach for a prolapsed lumbar disc?
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
Q: What are the motor functions and sensory distribution of the femoral nerve?
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
Q: What are the motor functions and sensory distribution of the obturator nerve?
Motor: Thigh adduction
Sensory: Medial thigh
Typical mechanism of injury: Anterior hip dislocation
Q: What are the motor functions and sensory distribution of the lateral cutaneous nerve of the thigh?
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)
Q: What are the motor functions and sensory distribution of the tibial nerve?
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)
Q: What are the motor functions and sensory distribution of the common peroneal nerve?
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
Q: What are the motor functions and sensory distribution of the superior gluteal nerve?
Motor: Hip abduction
Sensory: None
Typical mechanism of injury: Misplaced intramuscular injection, hip surgery, pelvic fracture, posterior hip dislocation
Result: Positive Trendelenburg sign
Q: What are the motor functions and sensory distribution of the inferior gluteal nerve?
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
Q: What is lumbar spinal stenosis?
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.
Q: What are common symptoms of lumbar spinal stenosis?
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.
Q: What is a key feature that differentiates lumbar spinal stenosis from true claudication?
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.
Q: What are the pathological changes in lumbar spinal stenosis?
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.
Q: How is lumbar spinal stenosis diagnosed?
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.
Q: What is the main treatment for lumbar spinal stenosis?
A: Laminectomy, a surgical procedure to relieve pressure on the nerve roots.
Q: What is medial epicondylitis also known as?
A: Golfer’s elbow.
Q: What are the key features of medial epicondylitis?
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.
Q: What activities or movements aggravate the pain in medial epicondylitis?
A: Wrist flexion and pronation.
Q: Which nerves may be involved in medial epicondylitis, causing additional symptoms?
A: The ulnar nerve, leading to numbness and tingling in the 4th and 5th fingers.
Q: What is meralgia paraesthetica?
A: Meralgia paraesthetica is an entrapment mononeuropathy of the lateral femoral cutaneous nerve (LFCN), causing paraesthesia or anaesthesia in the distribution of the nerve.
Q: What are the typical symptoms of meralgia paraesthetica?
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.
Q: How can meralgia paraesthetica be diagnosed?
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.
Q: What is a metatarsal fracture?
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.
Q: Which metatarsal is most commonly fractured?
A: The proximal 5th metatarsal is the most commonly fractured metatarsal and the most common site of midfoot fractures.
Q: What are the typical symptoms of a metatarsal fracture?
A: Symptoms include pain, bony tenderness, swelling, and an antalgic gait.
Q: What are Jones fractures, and how are they different from pseudo-Jones fractures?
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.
Q: What does Froment’s sign assess for?
A: Froment’s sign is used to assess for ulnar nerve palsy.
Q: How is Froment’s sign tested?
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.
Q: What does Phalen’s test assess for?
A: Phalen’s test is used to assess for carpal tunnel syndrome.
Q: How is Phalen’s test performed?
A: The wrist is held in maximum flexion. The test is positive if there is numbness in the median nerve distribution.
Q: What does Tinel’s sign assess for?
A: Tinel’s sign is used to assess for carpal tunnel syndrome.
Q: How is Tinel’s sign tested?
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.
Q: How are open fractures graded?
A: Open fractures are graded using the Gustilo and Anderson system.
Q: What are the three grades of open fractures in the Gustilo and Anderson system?
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
Q: What are the subgroups of Grade 3 open fractures in the Gustilo and Anderson system?
3A: Adequate soft tissue coverage
3B: Inadequate soft tissue coverage
3C: Associated arterial injury
Q: What system can help predict the need for primary amputation in Type IIIc injuries?
A: The Mangled Extremity Scoring System (MESS) can help predict the need for primary amputation in Type IIIc injuries.
Q: What is the initial management of open fractures?
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.
Q: What is the cornerstone of open fracture management?
A: Early debridement is the cornerstone of the management of open fractures, aimed at removing foreign material and devitalized tissue.
Q: How is the wound typically treated in open fractures?
A: The wound is typically left open after debridement, and the area is irrigated with around 6 liters of saline.
Q: How is the fracture stabilized in open fractures?
A: The fracture is stabilized with an external fixator in most cases.
Q: What causes osteoarthritis of the hand?
A: It results from the loss of cartilage at synovial joints and is often accompanied by the degeneration of underlying bone.
Q: What are some risk factors for osteoarthritis of the hand?
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.
Q: What are the common features of osteoarthritis of the hand?
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.
Q: How long does the stiffness last in osteoarthritis of the hand compared to rheumatoid arthritis?
A: Stiffness lasts only a few minutes in osteoarthritis of the hand, whereas in rheumatoid arthritis, stiffness lasts longer, especially in the morning.
Q: What is the functional impact of osteoarthritis of the hand?
A: Patients usually do not have functional problems. However, severe involvement of the DIPJs can lead to reduced grip strength and disuse atrophy.
Q: What is the primary diagnostic investigation for osteoarthritis of the hand?
A: X-ray is used to identify osteophytes and joint space narrowing. Signs may appear on X-ray before symptoms develop.
Q: What is osteoarthritis of the hip?
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.
Q: What are the risk factors for osteoarthritis of the hip?
Increasing age.
Female gender (twice as common in women).
Obesity.
Developmental dysplasia of the hip.
Q: What are the typical features of osteoarthritis of the hip?
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.
Q: How is the severity of osteoarthritis of the hip assessed?
A: The Oxford Hip Score is widely used to assess the severity of osteoarthritis of the hip.
Q: What investigations are recommended for osteoarthritis of the hip?
If features are typical, a clinical diagnosis can be made.
Plain x-rays are the first-line investigation if diagnosis is uncertain.
Q: What is the management of osteoarthritis of the hip?
Oral analgesia.
Intra-articular injections for short-term benefit.
Total hip replacement remains the definitive treatment.
Q: What are some complications of total hip replacement?
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.
Q: What is joint replacement (arthroplasty) used for in osteoarthritis?
A: Joint replacement is the most effective treatment for osteoarthritis patients who experience significant pain and disability.
Q: What are the common surgical techniques for hip joint replacement?
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
Q: What is involved in the post-operative recovery following joint replacement surgery?
Physiotherapy and home exercises are prescribed.
Walking sticks or crutches are typically used for up to 6 weeks after hip or knee replacement surgery.
Q: What advice is given to patients post-hip replacement to prevent dislocation?
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.
Q: What are the complications of joint replacement surgery?
Wound and joint infection.
Thromboembolism: NICE recommends low-molecular weight heparin for 4 weeks following a hip replacement.
Dislocation.
Q: What is osteochondritis dissecans (OCD)?
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.
Q: What are the typical symptoms of osteochondritis dissecans (OCD)?
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.
Q: What signs are associated with osteochondritis dissecans (OCD)?
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.
Q: What investigations are used for diagnosing osteochondritis dissecans (OCD)?
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.
Q: What is the management strategy for osteochondritis dissecans (OCD)?
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.
Q: What is osteomyelitis?
A: Osteomyelitis is an infection of the bone. It can be subclassified into haematogenous and non-haematogenous osteomyelitis.
Q: What is haematogenous osteomyelitis?
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.
Q: What is non-haematogenous osteomyelitis?
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.
Q: What is the most common cause of osteomyelitis?
A: Staphylococcus aureus is the most common cause, except in patients with sickle cell anaemia, where Salmonella species predominate.
Q: What is the best imaging modality for osteomyelitis?
A: MRI is the imaging modality of choice, with a sensitivity of 90-100%.
Q: What is the typical management for osteomyelitis?
A: The typical treatment is flucloxacillin for 6 weeks. Clindamycin is used if the patient is penicillin-allergic.
Q: What guidelines does NICE recommend for assessing osteoporosis risk?
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.
Q: What are some risk factors for osteoporosis?
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.
Q: How should secondary causes of osteoporosis be managed?
A: Secondary causes should be excluded first, as underlying conditions may also require treatment, such as bone metastases, myeloma, and Paget’s disease.
Q: When should a DEXA scan be offered?
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.
Q: What tools are recommended to assess fragility fracture risk?
A: NICE recommends using clinical prediction tools such as FRAX or QFracture to assess a patient’s 10-year risk of a fracture.
Q: What should be done if the 10-year fracture risk is ≥10%?
A: If the 10-year fracture risk is ≥10%, a DEXA scan should be arranged.
