MSK Written Exam Qs

Question 1

Why can the ACL, MCL and medial meniscus all be damaged within the one injury?

Answer 1

(From MSK Week 1 Lab manual)

Work together to provide rotary and valgus stability of the knee joint, act as secondary restraints to each other (i.e. ACL primary for rotary & anterior translation, MCL primary for valgus). ACL secondary for valgus, MCL secondary for rotary & anterior translation. Medial meniscus attached to MCL, so tensile force can be transferred to each other.

Question 2

A patient present with a laceration on the palmer surface of the proximal phalange of their index finger.

Describe the clinical active movement test(s) that could be used to determine if tendons of either FDS or FDP have also been severed?

Describe two potential complications following a surgical repair of a severed FDS and FDP tendon within the fingers.

Answer 2

(From MSK Anatomy lab manual Week 2)

Clinical tests active movement tests FDS and FDP: FDS: F PIPJ 2^nd finger, FDP: F PIPJ 2^nd finger tendon

Potential complications:

• (i) rupture of repair – weak until tendon remodels, t*
• (ii) tendons adhere to each other (i.e. need to glide relative to each other for ROM*

Question 3

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Question 4

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Question 5

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Question 6

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Ans not provided on formative - please edit this card to write answer

Question 7

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Question 8

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Question 9

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Question 10

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Question 11

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Question 12

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Question 13

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Question 14

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Question 15

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Question 16

Describe the clinical anatomy of an avulsion fracture and why they commonly occur in adolescents.

Answer 16

• Clinical Anatomy: small chunk of bone attached to a tendon or ligament is pulled away from the main part of the bone
• Commonly occur in adolescents: due to the growth plate where bone growth happens that may be weaker than other areas of the bone (as it’s a cartilage). where ligaments/tendons connect near growth plates they may be more likely to fracture the bone when a child/adolescent suffers injury.

Question 17

1. Fractures to the neck of femur are a common orthopaedic presentation.

Explain why they can occur with a relatively low energy injury in frail older female patient (refer to the type of bone in the neck of the femur in your answer)

Answer 17

• NOF = cancellous bone = spongy bone = mesh of trabeculae = less strong than compact bone (Haversian System)
• frail older female = post-menopausal (osteoporosis/osteopenia), possible vit D deficiency, gait disturbances, proximal muscle atrophy, other co-morbidities
• both point 1+2 combined allowed #NOF to occur even with low energy

Question 18

Why can the blood flow to the head of the femur be affected by a displaced intracapsular fracture of the neck of the femur.

Answer 18

• Femoral neck + head is intracapsular
• blood supply to neck + head of femur = retrograde (distal to proximal through medial circumflex femoral artery)
• the greater the displacement of intracapsular #, the higher the risk of vascular compromise due to decreased femoral head perfusion → avascular necrosis (hence why #NOF pt requires hip replacement/arthroplasty to mitigate this)

Question 19

Describe the common clinical presentation of the limb (position of the lower limb) in an elderly patient with a fractured neck of femur.

Answer 19

• shortened limb (on ipsilateral side) + externally rotated /abducted
• s/s = pain, inability to raise leg straight up, pt cannot weight bear, bruising + swelling

Question 20

Describe the effect that congenital hip dysplasia (deformation or misalignment of the bones at the joint, e.g. shallow acetabulum, that occurs with Developmental Dysplasia Hip (DDH)) has on the stability of the hip joint?

Answer 20

• congenital hip dysplasia = “ball & socket” of the hip joint doesnt form properly (shallow)
• causes instability of the hip joint, allowing it to pop in & out on normal movement → hip dislocation, early arthritis (dmg to labrum & cartilage), incomplete maturation & development of the bone+joint (due to uneven weight distribution when walking etc)

Question 21

Describe the anatomical basis (joint angle, movement, direction of applied force and positive test result) of Barlow’s test, which is used to assess hip joint stability of a newborn)?

Answer 21

• Stability hip joint: unstable. hip is popping in & out/clicking
• Barlow’s test: joint angle, movement and direction of applied force:
  
  • joint angle - 10-20degrees adduction (narrow angle)
  • movement - downwards (causes adduction which narrows joint angle)
  • direction of applied force - towards the pt/bed - posteriorly.
• Positive test:What is a positive Barlow test?

Barlow’s Test: If the hip is unstable, the femoral head will slip out of the acetabulum, producing the palpable sensation of the hip dislocating. If the hip is dislocatable, then Barlow’s test is positive.

Barlow test should be done by gently adducting the hip while palpating for the head falling out the back of the acetabulum

• Surface anatomy findings:
  
  • length of legs are not the same
  • hip/legs movements are not symmetrical
  • skin folds under butt do not line up
  • the child has a limp when walking

Question 22

Describe the anatomical basis (joint angle, movement, direction of applied force and positive test result) of Orthalani’s test, which is used to assess hip joint stability of a newborn)?

Answer 22

The test is performed by placing the baby in a supine position with flexed hips at 90 degrees. The examiner’s index and long fingers of the examiner are kept laterally on the greater trochanter of the child and position the thumb medially near the groin crease.

Stabilize the child’s pelvis by holding the contralateral hip and using the opposite hand to gently abduct the hip being tested whilst exerting an upward force simultaneously through the greater trochanter on the lateral side.

The perception of a palpable clunk indicates a positive Ortolani test and along with this also represents the reduction of a dislocated hip into the acetabulum

• Stability hip joint:
• Orthalani’s test: joint angle, movement and direction of applied force:
  
  • joint angle - wide
  • movement - abducting the hip
  • direction of applied force - upwards
• Positive test:What is a positive Orthalani’s test?

femoral head reduces to acetabulum

A positive Ortolani’s sign indicates a hip that is dislocated but reducible.

Question 23

Describe four possible complications that can occur with a dislocation of the knee joint (tibiofemoral joint).

Answer 23

• common peroneal nerve injury -> neuro compromise:
  
  • sensory → sensation loss in the parts distal to the injury (numbness, tingling, pain, etc in the corresponding dermatome)
  • motor → muscle weakness/atrophy in the corresponding myotome
• patellar tendon rupture - inability to flex/extend knee
• popliteal artery injury -> vascular compromise to the distal limb. Acute limb ischaemia. 6PS - pain, pallor, paresthesia, paralysis, pulselessness, polar/perishingly cold.
• ligament tear/rupture: MCL, LCL, ACL, PCL → positive drawers test + appley/thessaly, joint instability (if not fixed), abrupt hematoma formation

Question 24

List 4 clinical signs, 2 risk factors and 2 clinical functional tests for osteoarthritis of the knee joint.

Answer 24

clinical signs:

• Asymmetrical, unilateral, more in larger joints than smaller joints
• joint instability
• loss of flexibility
• morning stiffness < 30 minutes
• pain with movement
• crepitus

risk factors:

• modifiable
  
  • obesity
  • smoking
  • physical inactivity
  • metabolic → hyperCa/hyperPhos
• non modifiable:
  
  • previous sport injury
  • elite athlete (past/current)
  • old age
  • traumatic damage/injury (MVA/falls etc)
  • bone deformity (genu valgum/valrus, hip dysplasia)
  • genetics (Ehler Danlos)

2 clinical functional tests:

• gait + walk (check for unsteady gait, posture, bone abnormality)
• sit + stand test
• 40m fast paced walk test
• 6 minutes walk test
• timed up & go test
• stair climb test

XRAY finding (ROSS):

• R - reduction in joint space
• O - osteoporosis
• S - subchondral cyst
• S - subchondral sclerosis (thickening)

Question 25

Why can the ACL, MCL and medial meniscus all be damaged within the one injury?

Answer 25

• unhappy triad
• ACL (rotational + anterior stability) + MCL (valgus stability) + medial meniscus (attached to MCL)
  
  • all three ligaments work together to provide stability of knee joint
  • they act as secondary restraints to each other
  • they allow tensile force to be transferred to each other (hence allow knee mobility)
  • Excess force from one injury can exhausted all primary and secondary force capacity of all
• they all can be damaged within one injury because they’re all interconnected to each other → injury of one will implicate on the other structures

Question 26

Describe the mechanism of injury of a meniscal tear and two clinical tests used to test for knee joint effusion.

Answer 26

mechanism of injury: twisting the knee while the foot is planted on the ground. This can happen when making a sudden turn or change of direction or landing from a jump (poor pivot technique as in netball players)

two clinical tests for joint effusion:

• patellar tap
• wipe and stroke
• push on suprapatellar bursa

bonus question - Two tests for meniscus injury:

• Apley’s grind test
• Thessaley test

Question 27

Why does effusion in the knee joint enter the suprapatellar bursa?

a. Mechanism of injury
b. Knee joint effusion tests
c. Knee joint effusion enter the suprapatellar bursa

Answer 27

a. Mechanism of injury:

Bursitis is typically caused by an irritation of a bursa sac secondary to overuse and repetitively stressing joints or causing friction. Traumatic events, infections and disease, may also cause this condition.

b. Knee Joint effusion tests: patellar tap and fluid displacement test (wipe and stroke)
c. Knee joint effusion enter the suprapatellar bursa:

Suprapatellar bursa communicates with the knee joint (synovial cavity) → if you have knee effusion → increase in volume within the synovial cavity → increase pressure inside the bursa (and synovial cavity) → bursitis

Question 28

Describe the blood supply of the menisci. Compare the healing capacity of meniscal tears in the central region compared to the peripheral region. Describe the long-term consequences on the knee joint of a meniscal tear or removal of part of a meniscus.

Answer 28

1. Blood supply and healing capacity: relatively avascular - only the external part of the menisci get blood supply from medial, lateral, middle geniculate arteries (branches of popliteal artery)
2. Long-term consequences: OA, knee joint instability, soft tissue damage, unsteady gait, subsequent loss/reduction of mobility

Question 29

Dislocation of the patellofemoral joint is a relatively common injury in the active adolescent population.

Describe the structures commonly injured (note patella dislocates laterally).

Describe the anatomical variations that can increase the risk of recurrent dislocations.

Answer 29

Structures commonly injured:

1. medial retinaculum - vastus medialis
2. lateral retinaculum - vastus lateralis

Recurrent dislocations: Patella Alta (high patella → in young people where patella sits higher than lateral condyle ridge → causing recurrent dislocation)

Question 30

What is Erbs and Klumpkes palsy (aetiology and presentation)?

Answer 30

Question 31

Describe the muscles of the rotator cuff and the special tests you would use to assess each muscle?

Answer 31

Question 32

Overview of Erb’s, Klumpke’s, Thoracic Outlet Syndrome and Winged Scapula

Answer 32

Question 33

Differentiate between the classic clinical presentations of osteoarthritis and rheumatoid arthritis.

Answer 33

Question 34

Answer 34

Question 35

Explain Clonus

Answer 35

Clonus is a set of involuntary and rhythmic muscular contractions and relaxations. Clonus is a sign of certain neurological conditions, particularly associated with upper motor neuron lesions involving descending motor pathways, and in many cases is accompanied by spasticity (another form of hyperexcitability).

Question 36

Achilles Tendinopathy/rupture mechanism and clinical signs

Answer 36

Question 37

Calf muscle strain - mechanism and clinical test

Answer 37

Question 38

50-year-old female, accountant. Gradual onset of pins and needles in right hand in palmar surface of thumb and index finger

Which peripheral nerve may be most likely associated with this clinically based on the given history and clinical presentation? (1)

Describe origin, anatomical pathway in arm and forearm and wrist + sensory and motor innervation (5)

Answer 38

Median nerve affected

• origin – median cord of brachial plexus (C5-T1)
• pathway:
  
  • median cord of the brachial plexus → comes down through axilla → runs deep to biceps along brachial artery → cubital fossa → midline forearm → motor innervation to superior & deep forearm compartment (except to medial ½ FDP, FCU) → through carpal tunnel → innervates thenar muscles & lumbricals of index+middle fingers
• sensory: thenar eminence, 3.5 fingers on palmar surface & dorsum of distal phalange
• motor: wrist flexors except medial half FDP + FCU, thenar eminence & lumbricals of index + middle fingers

Question 39

Clinical pathology name involving compression of the nerve in region of wrist joint, two muscle groups - likely affected, clinical tests for diagnosis? (4)

Answer 39

• CTS
  
  • thenar muscles
  • first 2 lumbricals
• phalens
  
  • 90deg flexion of the wrist in reverse prayer position with both dorsum part of the palm touching each other
  • elicit compression of flexor retinaculum → produces the CTS symptoms
• tinnels
• tap on the region of the flexor retinaculum

Question 40

50-year-old female, accountant. Gradual onset of pins and needles in right hand in palmar surface of thumb and index finger

What specific spinal roots could be causing a radiculopathy in this distribution? Describe differences in sensory and motor deficit if radiculopathy vs peripheral nerve compression and clinical tests to differentiate radiculopathy vs compression (8)

Answer 40

• spinal roots → C5-T1 → radiculopathy
• sensory vs motor deficit
  
  • spinal (radiculopathy)
    
    • sensory - clear margin in pain/sensory alteration alongside C6 dermatome → lateral forearm & thumb + index finger)
    • motor - reduction in motor function along C6 region → the whole arm muscles except muscles innervated by ulna nerve

Musculocutaneous (C5-C7) - biceps brachii, coracobrachialis, brachioradialis

axillary (C5-C6) - deltoid & teres minor

Median (C5-T1) - forearm flexors except ½ medial FDP + FCU

Radial (C5-T1) - triceps, extensors

• peripheral nerve compression
  
  • sensory -> lateral 3.5 fingers
  • motor -> wrist/forearm flexors except medial half of FDP and FCU, thenar muscles, lateral 2 lumbricals.
• clinical test to differentiate radiculopathy vs compression

clinical test: PNS exam to the arm to differentiate spinal and peripheral looking for:

• definitive margin of motor & sensory deficit
• mapping of the symptoms along the limb

what are assessed:

T - tone → atrophy/hypertrophy/normal tone

P - power → 0-5 (0=paralysis, 5=normal power)

R - reflex → absence/presence

S - sensation → map the dermatome (indicating radiculopathy) or cutaneous sensory nerve region (indicating peripheral nerve damage)

General differences between peripheral nerve lesions vs. radiculopathies

• motor: peripheral nerve compression -> complete paralysis of muscle.
  
  • radiculopathy -> just weakness of muscles
  • In case of peripheral nerve lesion, there is complete absence of innervation to the muscles, whereas in radiculopathy, other spinal nerves still supply the respective muscles as a back-up (therefore manifested as weakness, not paralysis)
• sensory:
  
  • radiculopathy -> Pain will be sharp, burning pain with clear margins in the specific part of the innervated dermatome eg. C6 radiculopathy -> sharp pain along the lateral forearm + thumb + index finger.
  • Peripheral nerve injury -> the sensory pain will be in the sensory innervated region of the peripheral nerve, for example, in a median nerve injury, the lateral 3.5 fingers will experience pins and needles, loss of sensation.

⇒ In conclusion, based on the available data above we assume the patient has a peripheral nerve lesion involving the median nerve; known as carpal tunnel syndrome.

Question 41

4 characteristics to differentiate chronic pain from acute pain? (2)

Answer 41

• acute
  
  • immediate onset, duration of minutes/hours/days/weeks
  • due to immediate/direct injury or insult to the tissue (AMI/trauma/sprain)
  • specific known cause
  • readily responsive to analgesia
  • will resolve once cause is fixed/treated
• chronic
  
  • prolonged duration -> weeks/months/years/lifelong
  • often unclear cause
  • diffuse in nature
  • resistant/unresponsive to analgesia (will require weak-stronger opioid)
  • reliant on opioid in order to carry on with ADLs & maintain QOL
  • potentially psychosomatic (previous trauma/PTSD/transferrance etc)