ORTHO bro

Question 1

Ac joint degenerative disease

Answer 1

a very common occurance, by 3rd decade of life usually.

pain particularly on overhead or cross body activities.

occurs due to large axial loads on a small surface area.

Ix: imaging with x-rays, or palpation

Rx: activity modification, nsaids.
steroid injection
surgery- remove only 8-10 mm as any more risks loosing ligamentous stability.

Question 2

AC joint seperation

Answer 2

quite common, 9% of all shoulder injuries.- a fall onto adducted arm.

Rf: male, athletes.

S+S: pain, noticable seperation, history consistent, pain on adduction

Ix: imaging- x-ray Ap B/L.
+ axuillary lateral view + zanca view.

Classification:
1- no instability- reducable Rx with sling

2- AC torn, CC sprained, horizonal instability-inc CC distance <25% of contralateral– RX with sling.

3- AC + CC torn. inc CC dist 25-100% contralateral. - controversial management.
3A has only vertical instability
3B has both horiz and vert.

4- AC + CC Torn- skin tenting, posterior fullness. - lateral clav dinsplaced into trap posteriorly on axillary XR. – surgery.

5- Ac +CC torn- shoulder droop, not imp with shrug. CC dist > 100% contralat. – surg

6- inferior dislocation- surg

Question 3

achilles tendon rupture

Answer 3

sudden dorsiflexion of a plantarflexed foot- I.e stepping backwards

clinical diagnosis- dangle angle, thompsons test, weakness.

MRI can confirm + plan surgical management.

Rf: male, 30-40, weekend warrior, steroid injections, fluroquinolones.

S+S: pop, weakness, difficulty walking.

Rx: mix of casting + bracing or surgery to re-approximate the ends.- similar outcomes.

if ends done approximate- hen ? surgical management.

Question 4

role of nsaids and corticosteroids in achilles tendinopathy

Answer 4

nsaids in acute phase only, not for long term use

no corticosteroids

Question 5

ACL tear

Answer 5

half of all knee injuries

Rf: female, previous concussion, landing in risky position.

non contact pivoting injury, assoc with lateral meniscus tears (54% of time) medial in chroinc cases.

2 bundles- AM- ightest in flexion,
PL- tightest in extension

S+S: pop, immediate swelling,

Ix: lachmans most sensitive, pivot shift,
confirm with MRI scan

Rx: can be conservative
or
reconstruction-

repair - in younger/ avulsion patients.

Question 6

adhesive capsulitis

Answer 6

painful, restrictive shoulder condition. fibrosing pathology. usually lasts 18-24 months.

Rf: women, 40-70. recent trauma to shoulder. DM, Thyroid

S+S: pain, worse in bed and disturbs sleep.
stiffness- capsular pattern

Ix: diagnosis of exclusion- X-rays +/- ultrasound may help.

Rx:
heat pack, physio, analgesia.
2’ -steroid early if no progress with physio.
3’ - MUA, Hydrodilatation, arthroscopic release.

pain and stiffness for 3 months–> refferal.

Question 7

ankle fracture

Answer 7

generally following trauma.
most commonly lat mal.
but can be medial +/- posterior also.

inability to wt bear/ ottowa ankle rules helpful

Ix: plain x-ray.

Rx: non-displaced, anatomically reduced- conservative- cast 6/52

if open- debride wound, saline irrigation
internal fixation once wound clean.

if talar shift, irreducable, webber C, - ORIF.

Question 8

distal biceps tendon rupture

Answer 8

excessive eccentric contraction- avulses bicep off its radial tuberosity.

occurs in dominant hand in men in their 40s.

Rf: steds (both types) smoking,

S+S: acute, pop sound, weakness + pain in supination. reverse popeye sign,

Ix: Hook test, MRI- will help beetween partial/ full.

Rx: low demand + willing to ccept functional loss- non-op

op otherwise- done within a few weeks of injury.

Question 9

biceps tendinopathy

Answer 9

painful, swollen, and structurally weaker tendon that is at risk of rupture

Rf: young, active,

S+S: pain worse on stressing tendon, tenderness on palp,

Ix: speeds test
clinical diagnosis- aided by uss.

Rx: analgesia, physio
uss guided injections

3’- arthroscopic tenodesis, tenectomy.

Question 10

clavicle fracture

Answer 10

fall onto lateral shoulder +/- adducted arm.

most common fracture of childhood- 10% of all fractures.

middle 1/3 # in 70% of cases, lateral in 28%, v rare medial.

Rf: male, sports, young, cycling, older + falling.

S+S: pain, trauma, setp, tenderness on palp,

Ix: perform a complete neurovasc exam.
X-rays- AP + 45 deg cephalic tilt.

Rx
- non displaced- sling with less than 90 deg motion

displaced- fix-

absolut indications for surg- neurvasc compromise, open, tenting, angulation/ displacement.

shortening of 1.5cm or more, or 15% of contralateral side. floating shoulder, poly trauma, seziure disorder.

Question 11

compartment syndrome

Answer 11

where the ossiofascial compartment of the leg reaches pressure that causes occlusion of the vessels. – causing hypoaemia and damage

S+S: severe foot ankle and leg pain, worsens with time and movement of the foot.
- pain out of proportion with current sitch

common following trauma/ crush injuries.

common in the young.

Ix: compartment pressure measurement- within 5cm of #.

Rx: generally emergency fasciotomy of all 4 compartments. - anterior lateral and posteriomedial incisions- 15-18 in length.

Question 12

distal radius fracture

Answer 12

most common orthopaedic injury- nearly 20% of all fractures.

FOOSH

50% intra-articular

RF: osteoperosis- DEXA reccomended for all women with one.

S+S: swelling, pain, deformity.

Ix: X-rays, AP, lateral, oblique.

Rx: non-op if- less than 5mm radial shortening
dorsal angulation of less than 5’

ORIF- if intra articular step >2mm.

Question 13

dupuytrens contracture

Answer 13

benign proliferative disorder

painless nodule progressing to diseased cords.

2:1 male- female ratio. 5-7th decades of life.
northern europeans most at risk.

autosomal dominant with variable penetrance.

ring > small> middle > index.

cytokine-mediated transformation of normal fibroblasts into abnormal myofibroblasts, turning normal fascial bands into pathological cords

generally painless, restricts ROM.

Ix: clinical diagnosis
Rx: watch + wait
hand therapy + injection
needle aponeurotomy

partial/ full palmary fasciectomy if severe

Question 14

elbow dislocation

Answer 14

most often posteriorlateral dislocations.

10-20 year old active people.

axial load, supination force + valgus posteriolateral.

progression of lig injury lateral to medial.

simple- if no assoc #.
complex- if # e.g terrible triad (coronoid + radial head)

Ix: x-ray.

Rx: simple- closed reduction and immobilisation splint at least 90’ for 10 days.

complex- ORIF- LCL repair, fix #s.

Question 15

flexor tendon injury zones

Answer 15

1- fdp
2fdp and fds
3- palm
4 - carpal tunnel
5- after wrist

Question 16

extensor tendon injury zones

Answer 16

odd is on a joint
1- dip or later
2- middle phalanx
3- pip
4- prox phalanx
5- mcp
6- back of hand
7- wrist.

Question 17

hip fracture- discuss frequency, classification, subclassificaiton of the classification and some treatment (but most covered next card)

Answer 17

65000 each year in the uk

30% one year mortality.

intra capsular- up to just proximal of the trochanters

extra-capsular. - 2 types
sub troch- lesser trochanter to 5cm more distal

inter-troch- as it says.

predominant blood supply- medial circumflex.-

displaced intracapsular fractures disrupt the blood supply- even if fixed. ——- need arthroplasty.

garden classification 1-4
1-2 non displaced (1 not fully through)
3-4 displaced- 3 partial 4 fully.

Question 18

hip fracture S+S, Ix, Rx.

Answer 18

S+S: trauma, shortened + externally rotated.

pain in the groin thigh or knee

Ix: plain film x-ray
if long lie- CK.

Rx: - displaced subcapital- him hemi/ full if they are good craic

intertroch- DHS

non displaced intra-capsular- cannulated hip screws. (or consider THR if good craic)

sub troch- IM fem nail.

Question 19

humeral fracture- shaft

Answer 19

bimodal- in young due to trauma

in old due to frailty.

sig risk of radial nerve damage.

S+S: pain and deformity after trauma.
reduced sensation over dorsal 1st webspace. , weakness in wrist extension

Ix: check neurovasc status
X-ray - AP and Lateral.

Rx: realign limb + brace. (<20 angulation, <30 deg var/val, <3cm shortening)

ORIF if big deformity
IM if pathological

Question 20

humeral head/ neck fracture

Answer 20

FOOSH injury, fragility fracture.

due to close relation to axillary nerve and circumflex art - need neurovas status of arm assessed.

Ix: plain film X-ray

classification-
greater tuberosity
lesser tuberosity

anatomical neck (articular segment)
humeral shaft (surgical neck)

Rx: nearly always non surg- immobilisation in collar + cuff 2-4 weeks.

surg if displaced, open or neurovasc comprimise.

Question 21

liz franc injury

Answer 21

severe injury to the tarsometatarsal joint
medial cuneiform and base of 2nd metatarsal.

can be ligamentous or bony also.

severe torsional or teanslational force through plantarflexed foot.

piano key sign- bones go down and back up with pressure.

Ix: plain film AP, Oblique, lateral foot.

Rx: non displaced- cast/immobilisation + NWB mvt.

displacement- op- ex fix if big swelling going on
screw fixation if not too much swelling. #

arthritis is significant risk, midfoot compartment syndrome also frequent.

Question 22

MCL injury

Answer 22

most commonly injured knee lig.

Pop with slower swelling over hours. pain common.

inc laxity on valgus test.

grade 3 is lax in both extension and 30 deg flex,
grade 2 only lax in 30 deg.

Ix: gold standard MRI

Rx: gd 2-3 - brace

surgery if distal avulsion alongside.

Question 23

meniscal tears

Answer 23

injury occurs through trauma or degeneration.

S+S: tearing feeling in knee, slow swelling. can lock.
joint tenderness

Ix: MRI gold standard

Rx: large or persistantly symptomatic - surg

in outer 1/3 suture repair
inner 1/3- trim (poor vasc)

sig risk for 2’ osteoarthritis.

Question 24

metacarpal/ phalangeal fractures- types of + ix rx etc.

Answer 24

boxers- classic
bennets - thumb displacement - intra articular

rolando- intra atricular 1st metacarpal - in Y or T shape (similar to bennets)

Ix: X-ray then build up to CT.

Rx: REMOVE jewlery
if simple- buddy strap for 3-4 weeks. re-xray at 1 weeks to asssess for displacement.

if rotational deformity, intraarticular involvement, angulation, shortening or unstable—– fix.

K wire or ORIF 2 choices.

Question 25

metatarsal stress fractures

Answer 25

most commonly 2nd or 3rd

sudden inc in duration or intensity of activity.

generally low risk stress fractures.

Ix: x-ray, MRI gold standard

Rx: analgesia and rest mostly

high risk of non union in neck of 2nd #s, but in stress its ok.

Question 26

mortons neuroma

Answer 26

compression neuropathy of common digital plantar nerve

mostly in 3rd intermetatarsal space.
occ in 2nd
rarely elsewhere

benign fibrotic thickening of the nerve due to constant irritation

RF: high arch feet, tight/ ill fitting shoes, heavy impact on feet.

avg age 50-55. 4:1 women : men

S+S: pain in forefoot, lump feeling, tingle, pain on squeezing.

Ix: clinical with x-ray and bloods to rule out # or gout etc.

Question 27

olecranon bursitis

Answer 27

either septic or aseptic

commonly found in young/ middle aged men.

people with repetitive trauma

generally only painful if infected- or in full flexion of elbow when the bursa is compressed.

Ix: clinically- if not infectious don’t aspirate

aspirate if concern about septic.

Rx: RICE, activity modification. can aspirate for symptoms relief. refer after 2 months if still bothering

if septic- aspirate- treat empirically

fluclox (500 mg four times daily)
2’-

Clarithromycin (500 mg twice daily) may be used if the person is allergic to penicillin. Erythromycin (500 mg four times daily) is the preferred macrolide in pregnancy and breastfeeding.

Question 28

olecranon fracture

Answer 28

common

often causes disruption of the extensor mechanism

mean age- 57 years.

direct blow- cominuted #
FOOSH- transverse / oblique #.

many classification systems.

Ix: plain film

Rx: non displaced with intact extensor mechs- immobilise 45-90 degrees - 1 week. early rom.

surgery if above criteria not met. many options.

Question 29

pathological fracture

Answer 29

500x more likely to be as a result of a met than a primary sarcoma.

lung, breast, thyroid, renal, and prostate- most frequently met to bone.

Ix: when detected- comprehensive work up if primary unkwown.

PSA CEA etc

x-ray - high aggression indicated by lesion diameter > 5 cm, cortical interruption, periosteal reaction, and associated pathologic fracture.

Rx: there are criteria to meet for prophylactic fixation (50% of diameter, 2.5cm in size, lesser trochanter, pain after radiotherapy)

healing rates for metastasis from multiple myeloma, renal, breast, and lung carcinoma are 67%, 44%, 37%, and 0%, respectively

if renal met- excise widely where possible.

Question 30

plantar fasciitis- one good fact but not the whole thing

Answer 30

assoc with seronegative arthritidies

Question 31

pubic ramus fracture

Answer 31

needs at least 3 x - rays to assess whole ring

AP
inlet view
outlet view

generally don’t operate

fragility fracture

6-8 weeks to solidify but FWB through the rehab, manage pain as needed.

Question 32

radial head fracture

Answer 32

most common elbow fracture

mean age 45. 85% occur before 60.

FOOSH- elbow extension and forearm pronation

Type I
Nondisplaced or minimally displaced (<2mm), no mechanical block to rotation
Type II
Displaced >2mm or angulated, possible mechanical block to forearm rotation
Type III
Comminuted and displaced, mechanical block to motion
Type IV
Radial head fracture with associated elbow dislocation

S+S: pain, possible blocks to elbow ROM (inc pro/sup)

Ix: x-ray
ct for surg workup

RX: type 1-2 with no block.
immobilise for 3-7 days then light rom

2 with block-3-4 ORIF if feasible.

if more than 3 bits- replace radial head, or if continued non union.

Question 33

scaphoid fracture

Answer 33

blood supply by dorsal carpal branch of radial artery

80% is supplied by retrograde flow.

snuffbox tenderness / tubercle tenderness is important
scaphoid compression (axial thumb) is pretty sensitive and specific.

Ix: 5 view scaphoid imaging

repeat in 14-21 days if no # seen but high suspicion.

or mri

Rx: cast immobilisation 21 at least- non displaced- if <1mm pretty high union rate

perc screw fixation - pole #, displacement >1mm, waist #.

ORIF if pretty mad looking x-rays.

Question 34

scoliosis

Answer 34

most common is adolescent idiopathic

affects 10-18 year old girls most commonly
(10-1 female-male for big curves >30’) equal ratio for smol ones.

multifactoral causes predominantly unknown.

Rf: FH

Ix: standing PA, lateral. Cobb angle (>10’ is scolisosis)

Rx: Cobb angle <25 deg. - nonop
Cobb angle 25-45- bracing.
cobb angle 45+ - surgery- posterior spinal fusion.

Question 35

septic arthritis

Answer 35

inflammation 2’ to infection

monoarticular usually.

staph aureus is common causitive organism.

more common in kids than adults.

Rf: kid or over 80, DM, RA, recet surg, prosthesis, prev injection, skin infections, hiv, sex,

S+S: acute monoarticular joint pain, fever, sepsis, swelling, inflammation.

Ix: synovial culture
Rx: antimicrobial therapy- Fluclox 4-6/52.

clincamycin if allergic.

if large collection- drainage and washout.

Question 36

shoulder dislocation

Answer 36

contact sports in young, falls in the old.

associated with bankart lesion
hill-sachs lesion
axillary nerve injury

mostly are anterior dislications, 2-4% are posterior

S+S: arm often abducted and externally rotated.

Ix: X-ray AP and axillary lateral/ Y views

Rx: reduce and sling
if recurrent - bankeart repair –> laterjet

Question 37

spondylosis/ spondylolisthesis

Answer 37

due to pars fracture insificciency- one vertebra slips foreward relative to the other one

causes: degenerative, isthmic, traumatic, dysplastic, or pathologic.

Ix: AP/ lateral flexion and extension.
graded: based on quaters of slippage.

Rx: grade 1- nothing
grade 2- probably nothing

after that no real defined terms for how to do the operations.

Question 38

spinal chord injury- types, how are they graded + treatment.

Answer 38

primary- irreversable arising from direct damage

2’- as a result of changes prod by primary.

most common cause- car crash.

Graded using ASIA score- A worse, E best.
Image with MRI

Rx:
maintain BP above 90 systolic,
consider need for intubation
catheterise if retaining

Question 39

trigger finger

Answer 39

A1 pulley mechanical impingement

progressive pain, clicking, triggering, tenderness

Rf: diabetic, female, over 50,

increaced type 3 collagen

associated with carpal tunnel 60% of the time.

Grading
1- pain
2- some locking but goes away on onw
3- locking requing manual release
4- locked

Ix: clinical diagnosis

Rx: splinting, activity modification, nsaids

steroid treatment

Operative- perc release of A1 tendon.

Question 40

ulner nerve entrapment

Answer 40

gen occurs in cubital tunner in elbow or in guyons canal

ulnar is medial chord of brachial plexus.

men 2:1 women at elbow.

Ix: x-rays to rule out any ossious/ ossification cause.

Rx: NSAIDs, pad the nerve, splints at night.

atrophy + weakness = release of ligaments, medial epicondylectomy.

Question 41

ganglion cysts

Answer 41

mucin filled synovial cysts
can occur spont or at site of injury.

most common hand mass

dorsal 70%.
volar carpal 20%
volar retinacular 10%

usually asymptomatic.
Ix: firm well circumscribed transilluminating mass- clinical

Rx: usually leave alone
closed rupture (bible) - high reocurrence
aspiration- 2’ line usually. avoid on volar due to radial artery.

operative- resection- recurrent