Ortho III

Question 1

What is plantar fasciitis

Answer 1

inflammation of the plantar fascia.

The plantar fascia is thick connective tissue. It attaches to the calcaneus at the heel, travels along the sole of the foot and branches out to connect to the flexor tendons of the toes.

Question 2

Presentation of plantar fasciitis

Answer 2

gradual onset of pain on the plantar aspect of the heel. This is worse with pressure, particularly when walking or standing for prolonged periods. There is tenderness to palpation of this area.

Question 3

Mx of plantar fasciitis

Answer 3

Rest
Ice
Analgesia (e.g., NSAIDs)
Physiotherapy
Steroid injections (can be very painful and rarely cause rupture of the plantar fascia or fat pad atrophy)

Surgery rarely

Question 4

What is fat pad atrophy

Answer 4

affects the fat pad over the heel of the foot (under the calcaneus). The fat pad protects the heel from impact.

Question 5

Why does atrophy atrophy occur

Answer 5

can occur with age or inflammation from repetitive impacts, such as jumping activities, running, walking, and obesity. Local steroid injections (used to treat plantar fasciitis) can cause fat pad atrophy.

Question 6

Presentation of fat pad atrophy

Answer 6

similar to plantar fasciitis, with pain and tenderness over the plantar aspect of the heel. Symptoms are worse with activities, particularly when barefoot on hard surfaces.

Question 7

Mx of fat pad atrophy

Answer 7

Management involves comfortable shoes, custom insoles, adapting activities (e.g., avoiding high heels) and weight loss if appropriate.

Question 8

What is Morton’s neuroma

Answer 8

dysfunction of a nerve in the intermetatarsal space (between the toes) towards the top of the foot. The abnormal nerve is usually located between the third and fourth metatarsal. It is caused by irritation of the nerve relating to the biomechanics of the foot.

Question 9

Presentation of Morton’s neuroma

Answer 9

Pain at the front of the foot at the location of the lesion
The sensation of a lump in the shoe
Burning, numbness or “pins and needles” felt in the distal toes

High-heels or narrow shoes may exacerbate it

Question 10

Mx of Morton’s neuroma

Answer 10

Deep pressure applied to the affected intermetatarsal space on the dorsal foot causes pain
Metatarsal squeeze test
Mulder’s sign

Question 11

Mx of Morton’s neuroma

Answer 11

Adapting activities (e.g., avoiding high heels)
Analgesia (NSAIDs if suitable)
Insoles
Weight loss if appropriate
Steroid injections
Radiofrequency ablation
Surgery (e.g., excision of the neuroma)

Question 12

What is a hallux valves deformity

Answer 12

Bunions

bony lump created by a deformity at the metatarsophalangeal joint (MTP) at the base of the big toe. The first metatarsal becomes angled medially, the big toe (hallux) become angled laterally (towards the other toes), and the MTP joint becomes inflamed and enlarged

Question 13

Mx of bunions

Answer 13

Conservative management is with wide, comfortable shoes and analgesia. Patients can use bunion pads to protect the bunion from friction inside their shoes.

Surgery is the definitive treatment.

Question 14

Most common type of spinal stenosis

Answer 14

Lumbar spinal stenosis

Question 15

Causes of spinal stenosis

Answer 15

Congenital spinal stenosis
Degenerative changes, including facet joint changes, disc disease and bone spurs
Herniated discs
Spinal fractures
Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
Tumours

Question 16

Presentation of spinal stenosis

Answer 16

Intermittent neurogenic claudication
Lower back pain
Buttock and leg pain
Leg weakness

Cauda equina syndrome in severe compression

Question 17

Diagnosis and ix - spinal stenosis

Answer 17

MRI

Investigations to exclude peripheral arterial disease (e.g., ankle-brachial pressure index and CT angiogram) may be appropriate where symptoms of intermittent claudication are present.

Question 18

Mx of spinal stenosis

Answer 18

Exercise and weight loss (if appropriate)
Analgesia
Physiotherapy
Decompression surgery where conservative treatment fails (with variable results)

Laminectomy

Question 19

Presentation of trochanteric bursitis

Answer 19

Trendelenburg test
Resisted abduction of the hip
Resisted internal rotation of the hip
Resisted external rotation of the hip

Question 20

What does the trendelenburg test involve

Answer 20

The Trendelenburg test involves asking the patient to stand one-legged on the affected leg. Normally, the other side of the pelvis should remain level or tilt upwards slightly. A positive Trendelenburg test is when the other side of the pelvis drops down, suggesting weakness in the affected hip.

Question 21

Mx of trochanteric bursitis

Answer 21

Rest
Ice
Analgesia (e.g., ibuprofen or naproxen)
Physiotherapy
Steroid injections

Question 22

What are baker’s cysts associated with

Answer 22

Degnerative changes in knee
Meniscal tears (an important underlying cause)
Osteoarthritis
Knee injuries
Inflammatory arthritis (e.g., rheumatoid arthritis)

Question 23

Presentation of baker’s cyst

Answer 23

Pain or discomfort 
Fullness
Pressure
A palpable lump or swelling
Restricted range of motion in the knee (with larger cysts)

Question 24

What can a ruptured baker’s cyst lead to

Answer 24

Compartment syndrome

Question 25

Mx of symptomatic baker’s cyst

Answer 25

Modified activity to avoid exacerbating symptoms
Analgesia (e.g., NSAIDs)
Physiotherapy
Ultrasound-guided aspiration 
Steroid injections

Surgical mx - arthroscopy

Question 26

Presentation of meniscal tears

Answer 26

Pain
Swelling
Stiffness
Restricted range of motion
Locking of the knee
Instability or the knee “giving way”

Question 27

Special tests for meniscal tears

Answer 27

McMurray’s test and Apley grind test

Question 28

Ottawa knee rules for x-ray

Answer 28

Age 55 or above
Patella tenderness (with no tenderness elsewhere)
Fibular head tenderness
Cannot flex the knee to 90 degrees
Cannot weight bear (cannot take 4 steps – limping steps still count)

Question 29

IX for meniscal tears

Answer 29

MRI scan

Arthroscopy

Question 30

Mx of meniscal tears

Answer 30

RICE

NSAIDs
physiotherapy
Surgery