Ortho / Rheum Flashcards
Which STI is most likely to lead to reactive arthritis?
- chlamydia
- gonorrhoea
Chlamydia
Which STI is most likely to lead to septic arthritis?
- chlamydia
- gonorrhoea
Gonorrhoea
Can’t see, pee or climb a tree makes you think of what condition
Reactive arthritis
inability to dorsiflex the foot after a blow to the knee
Which nerve is likely to be injured?
Common peroneal nerve
Foot drop.
Which nerve is likely to be injured?
Common peroneal nerve
Which nerve supplies the serratus anterior?
Long thoracic nerve
Which cranial nerves are present in the cerebellopontine angle?
V, VII, VIII
60 year old woman walks with a drop foot and a high stepping gait shortly after a hip replacement. Which nerve is responsible for this?
- femoral
- sciatic
Sciatic nerve
A broad based unstable gait with veering to the right side.
Cerebellar disease
34 year old woman falls to the ground after hearing some bad news suggests a vasovagal syncope. True or false>
True
First line DMARD in RA?
Methotrexate
How is disease activity in RA measured?
DAS 28 score
- score > 5.1 then eligible for biologic therapy
DMARDs are useful in ankylosing spondylitis. True or false?
False
- not useful in spinal disease
RA is usually symmetrical. True or false?
True
Psoriatic arthritis is usually symmetrical / asymmetrical ?
Asymmetrical
Reactive arthritis mainly affects large / small joints?
Large joints
- commonly the knee
- presents few weeks after illness
In SLE there is low complement / raised complement?
Low complement
How does systemic sclerosis come around?
Excess collagen deposition in the skin
Which medication is used to manage raynauds phenomenon?
CCB
Anti phospholipid syndrome
- prolonged PT / APTT
APTT
Lupus anticoagulant +ve
Anticardiolipin +ve makes you think
Anti phospholipid syndrome
Patients who are found to have positive antibodies for anti-phospholipid syndrome but who have never had had an episode of thrombosis do not require anti-coagulation. True or false?
True
Gout - synovial fluid sample shows
Needle shaped monosodium urate crystals
Negative bifringence
Polymyalgia rheumatica - use high dose / low dose steroids?
Low dose steroids (15mg)
Constant headache, visual disturbances, jaw claudication and scalp tenderness suggests
GCA
Typical biopsy findings include mononuclear infiltration or granulomatous inflammation, usually with multinucleated giant cells.
This suggests which condition
GCA
Which dose of steroids should you use for GCA?
40-60mg
What does this suggest?
symmetrical, proximal muscle weakness in the upper and lower extremities. This is often insidious in onset and is commonly noticed as difficulty with particular activities e.g. climbing stairs
Anti-Jo-1 +ve
Polymyositis
What does this suggest?
symmetrical, proximal muscle weakness in the upper and lower extremities. This is often insidious in onset and is commonly noticed as difficulty with particular activities e.g. climbing stairs
+ heliotrope rash
+ gottrons papules on fingers
Dermatomyositis
Name 2 large cell vasculitis
GCA
Takayasu arteritis
Takayasu arteritis commonly affects young / old woman?
Young (2nd / 3rd decade of life)
Mainstay of treatment for takayasu arteritis
40-60mg prednisolone
nose bleeds, deafness, recurrent sinusitis and nasal crusting (over time there can be collapse of the nose). Respiratory symptoms such as haemoptysis and cavitating lesions on x-ray are frequently seen. What does this suggest? - EGPA - GPA - MPA
GPA
late onset asthma, rhinitis and a raised peripheral blood eosinophil count. Neurological symptoms such as mono neuritis multiplex are common. What does this suggest? - EGPA - GPA - MPA
EGPA
Child
URTI few weeks ago
Now has vasculitis type non blanching rash. purpuric rash over the buttocks and lower limbs, abdominal pain and vomiting and joint pain.
What is likely diagnosis?
HSP
- IgA mediated
What is the management of HSP
Usually self limiting
Which of these autoantibodies is most specific for SLE?
a. Anti-Scl-70
b. Anti-nuclear antibody
c. Anti-Ro antibody
d. Anti-DNA binding antibody
e. Anti-smooth muscle antibody
d. Anti-DSDNA
Which of these tests is the initial investigation of choice for detecting renal involvement in vasculitis?
a. Urea
b. Glomerular filtration rate (GFR)
c. Urinalysis
d. Creatinine
e. Renal ultrasound scan
c. urinalysis
If allopurinol cant be tolerated, which drug is used instead?
Febuxostat
Pain, weakness, wasting - is this a joint problem or is this a muscle problem?
Muscle problem
what duration is prolonged early morning stiffness?
over 1 hour
Inflammatory conditions have had a shorter/longer duration of onset?
Shorter
DIP joint involvement - think which type of arthritis?
OA
won’t be RA
Base of thumb involved - which type of arthritis?
Osteoarthritis
‘squaring of the thumb’
Why are the DIP joints not involved in rheumatoid arthritis?
Only a little amount of synovial fluid in DIP joints
Over 50, acute onset pain in shoulder girdle and hip girdle.
Polymyalgia rheumatica
Whats the most common organism to cause reactive arthritis?
Campylobacter
also chlamydia if STI
Which medications can precipitate gout?
Thiazide like diuretics
Which medications can precipitate gout?
Thiazide like diuretics
Have you ever been to the eye clinic as an emergency. Why is this important in rheumatology?
Uveitis - think about seronegative arthropathies
Butterfly malar rash is made worse by
Sun
- it is photosensitive
takes a while to go away
Raynauds that develops later on in life. What disease does this suggest?
Systemic sclerosis
Bilateral carpal tunnel syndrome. What should you be wary of?
Rheumatioid arthritis
50 year old woman develops raynauds and dysphagia?
Systemic sclerosis
low trauma fractures and family history of osteoporosis. What is the best investigation?
bone density scan
Bilateral hilar lymphadenopathy
erythema nodosum
fever
This is the triad of
Sarcoidosis
Approach to acute monoarthritis. What investigations must you do?
Joint aspirate
Blood tests: FBC, CRP, blood cultures, serum uric acid
X-rays
Patient with gout like symtoms but normal serum uric acid levels. What should you do>
Treat for gout and re-check serum uric acid levels in a few weeks
Where are heberdens nodes?
What condition is this seen in?
DIP joints
OA
Onycholisis and nail pitting and dactylitis is common in which condition?
Psoriatic arthritis
Age between 20 and 40. Lasting longer than 12 weeks. Worse in the morning ,improving with exercise. Buttock pain Relief with NSAIDs Night time awakening. These patients get investigated for?
Ankylosing spondylitis
Should you always x-ray both hands and feet in ?RA even if the patient doesn’t have any problems with the feet? or just do hands?
Do both Hands and feet x-ray
First line DMARD in Rheumatoid arthritis
methotrexate
How long do DMARDs take to work roughly?
What are used in the interm?
3 months
Steroids are used in the interim as DMARDs take months to work
What can methotrexate do in the lungs?
Pulmonary pneumonitis
How is methotrexate given in the treatment of rheumatoid arthritis?
It is given as a weekly dose followed by folic acid at least 24 hours later.
Hydroxychloroquine is never used on its own. True or false?
True
What is the first line treatment in gout?
NSAIDs
- can use colchicine if NSAIDs don’t work but this carries risk of diarrhoea
What is the management of compartment syndrome?
Emergency fasciotomy
Management of hypertrophic non union fracture
Plate and screws to stabilise
What are the 3 x-ray views for assessing c-spine fracture
AP
Lateral
Peg open mouth
When thinking of pelvic fractures, what analogy do you think of?
Polomint
- if break in one place there is most likely going to be another break elsewhere
‘open book pelvic fracture’. how does this occur and what is the management
Occurs due to anterior-posterior compression injury whereby the pubic symphisus is disrupted
Tx:
Initial reduction -> pelvic binder -> external fixation
shortening of the affected limb, leg flops into external rotation, can’t straight leg raise
this makes you think
NOF fracture
What is the main complication of NOF fracture to be aware of?
avascular necrosis
Which carries more risk for AVN:
- intracapsular NOF fracture
- extracapsular NOF fracture
Intracapsular NOF fracture
- in the capsule so risk of disrupting blood supply to femoral head
Management of intracapsular NOF fracture
Hip replacement
- total
- partial
Management of extracapsular (intertrochanteric) NOF fracture
Internal fixation
- hip screw
- IM nail
Management of extracapsular (subtrochanteric) NOF fracture
Thomas splint + analgesia -> IM nail
Which nerve is most likely to be damaged in humeral shaft fracture?
Radial nerve
Wrist drop
Loss of sensation in first dorsal web space
This suggests injury to which nerve?
Radial nerve
Define colles fracture
Extra-articular fracture of the distal radius
Which nerve is at risk of damage in a colles fracture
median nerve
Smiths fracture has volar/dorsal displacement
Volar displacement
- occurs after falling onto flexed wrist
Pain in the anatomical snuff box following FOOSH may indiacte?
Scaphoid fracture
What is the major complication to be aware of for scaphoid fracture?
Avascular necrosis
Management of stable ankle fracture
Moonboot / cast for 6 weeks
Management of unstable ankle fracture
Open reduction + internal fixation
Monteggia fracture is fracture of the radius / ulna?
Fracture of ULNA with dislocation of the radial head
Galeazzi fracture-dislocations is fracture of the radius / ulna?
Fracture of the RADIUS with dislocation of the ulna
Supracondylar fractures of the elbow risks damage to which nerve?
Median nerve damage
In general, how are femoral shaft fractures managed in children over 6?
IM nail
Displaced subcapital / transcervical (intracapsular) NOF fracture in frail elderly patient. What is the management
Unipolar hemiarthroplasty
- keep the acetabulum
- replace the femoral head
Displaced subcapital / transcervical (intracapsular) NOF fracture in younger fitter patient. What is the management
Total hip replacement
In child: Force to one side of bone may cause break in only one cortex and the other cortex bends. What is this?
Greenstick fracture
What is the salter harris classification used for?
Classifying fractures in children
Which fat pad sign is always abnormal
- anterior
- posterior
Posterior
Which fracture type is most suspicious of NAI ?
Spiral
Suspect NAI from x-ray images. Which investigation is done next?
Skeletal survey
In what way can pelvic fractures result in massive blood loss ?
arterial bleeding (internal iliac artery & branches), venous bleeding (pelvic venous plexus)
If you describe the angulation of a lower limb fracture as “varus” this means the distal fragment points towards / away from the midline?
Distal fragment points towards the midline
Early local complications of fractures
Compartment syndrome
Vascular injury
Nerve compression
What is the treatment of acute reactive arthritis?
Ibuprofen
Malignancy and raised CK makes you think
Polymyositis
WHat is the medical name for a pulled elbow?
Nursemaids elbow
Osteoporosis is typically associated with normal blood test values. True or false?
True
NICE recommend performing x-rays of the hands and feet of all patients with suspected rheumatoid arthritis. True or false?
True
oral ulcers, genital ulcers and anterior uveitis triad makes you think
Bechets syndrome
presents in childhood fractures following minor trauma blue sclera deafness secondary to otosclerosis dental imperfections
osteogenesis imperfecta
Child
Long bone (diaphysis) lesion
onion skin’ appearance on X-ray
What does this make you think>
Ewing’s sarcoma
what is the most appropriate initial investigation to confirm a diagnosis of ankylosing spondylitis?
x-ray of pelvis
What is the 1st line management for ankylosing spondylitis?
Exercise + NSAIDs
Which condition has Raised CK?
- polymyalgia rheumatica
- polymyositis
Polymyositis
The cardinal clinical signs of ________ are (1) increased pain on passive stretching of the involved muscle, and (2) severe pain outwith the anticipated severity in the clinical context
compartment syndrome
Anterior dislocation of the shoulder is associated with which nerve palsy
Axillary nerve palsy
Posterior dislocation of the hip is associated with which nerve injury?
Sciatic nerve injury
What is the most common causative organism of septic arthritis in adults?
Staph aureus
Any joint suspected of septic arthritis should be aspirated under aseptic technique before antibiotics are given. True or false?
True
What is the most common type of shoulder dislocation?
a. Anterior
b. Posterior
c. Lateral
d. Inferior
A. Anterior
Anterior dislocation of the shoulder could damage which nerve?
Axillary nerve
How are extra-capsular hip fractures often treated?
a. Hemiarthroplasty or Total Hip Replacement
b. Dynamic hip screw
c. Open reduction, internal fixation
Dynamic hip screw
patients who cannot straight leg raise after a fall. What do you suspect?
Quadriceps tendon rupture
the majority of minimally displaced proximal humerus fractures are managed in what way?
Collar and cuff
Name 3 drugs which can precipitate gout?
Thiazide diuretics / loop diuretics
Chemotherapy drugs
What is the mainstay of treatment of gout?
NSAIDs and COX-2 inhibitors
What is the mechanism of action of allopurinol,febuxostat?
Xanthine oxidase inhibitors
Which patients with gout should be offered preventative medication: More than X attacks per year
2
Why should uric acid lowering therapy should not be started while the patient has an acute episode of gout?
any sudden changes in uric acid levels can
precipitate further attacks of gout or prevent the acute episode from settling down
Women rarely get gout before the menopause. Why is this?
Oestrogen promotes excretion of uric acid
You suspect SLE in a patient and auto-antibody tests are carried out which confirm the diagnosis. Which other investigations are now required?
Urinalysis - SLE is associated with glomerulonephritis
CXR - to exclude interstitial lung disease
Active SLE disease is associated with poor maternal and fetal outcomes. True or false?
True
- patients should be asked not to get pregnant
until their disease has been quiescent for at least 6 months
Central cord syndrome - more likely to have paralysis of the UPPER/LOWER limbs. Why?
Upper limbs
Corticospinal tract for upper limbs lies more centrally within the spinal cord
loss of motor function (corticospinal tracts) as well as loss of coarse touch, pain and temperature sensation (lateral spinothalamic tract) whilst proprioception, vibration sense and light touch are preserved (dorsal columns). A - anterior cord syndrome B - posterior cord syndrome C - central cord syndrome D - brown sequard syndrome
A - anterior cord syndrome
Ipsilateral paralysis and loss of dorsal column sensation occurs with contralateral loss of pain, temperature and coarse touch sensation. A - anterior cord syndrome B - posterior cord syndrome C - central cord syndrome D - brown sequard syndrome
D - brown sequard syndrome
Which is more common
anterior or posterior shoulder dislocation?
Anterior shoulder dislocation
The risk of recurrent shoulder dislocation is predicted by the age of the patient at the time of initial dislocation. The younger/older you are, the more likely you are to have recurrent dislocations?
The younger you are
How are recurrent shoulder dislocations managed surgically?
Bankart repair
Anterior shoulder dislocations usually occur if the arm is internally/externally rotated?
Externally rotated
Light bulb sign on x-ray think
Posterior shoulder dislocation
Typical management of a diaphyseal fracture of both bones of the forearm in adults
ORIF with plate and screws
In a colles fracture there is often an associated injury of ?
The ulnar syloid
What is A specific late local complication of Colles fractures
rupture of the extensor pollicus longus tendon
Smiths fractures are usually stable / unstable?
What is the management?
Usually unstable
Management: ORIF using plate and screws
If a scaphoid fracture is suspected clinically but the x‐ray fails to demonstrate a fracture, what do you do?
Splint the wrist - and further clinical assessment +/‐ further x‐ray is arranged around two weeks after the injury
Typical management of a scaphoid fracutre?
Plaster cast for 6-12 weeks
pain, a drooped DIPJ of the affected finger and inability to extend at the DIPJ - what does this describe?
How do you treat it?
Mallet finger
Treat: splint for at least 4 weeks
Long term bisphospinate use for osteoporosis can cause which strange complication?
Stress fracture ( commonly seen in femoral shaft)
Osteosarcoma is most common in adults/children. It usually affects which region of long bones?
Children
Metaphyseal region
Pain is elicited during wrist flexion and pronation
- tennis elbow
- golfers elbow
Golfers elbow
Tennis elbow
- medial epicondylitis
- lateral epicondylitis
Tennis elbow - lateral epicondylitis
- pain elicited during wrist extension and supination
Which is more likely to present with pain and weakness?
- polymyalgia rheumatica
- polymyositis
Polymyositis
Name 4 side effects of using steroids
Cataracts
Thin skin
Osteoporosis
weight gain
What should you co-prescribe along with steroids in a post-menopausal woman with Polymyalgia rheumatica (+GCA)
Refer for Dexa scan
Start bisphosphinates
Mainstay of treatment for ankylosing spondylitis
NSAIDs and physiotherapy exercises
If in spite of trying 2 NSAIDS for ank spon for a period of 4 WEEKS EACH but not working, what do you do?
Introduce biologic agents
- anti-TNF agents
Treatment of distal femur fracture
these fractures are usually fixed with a plate and screws as the fracture position is difficult to maintain in a cast
Patellar dislocations are usually medial/lateral?
Lateral
Common complication of intra-articular fractures
Post-traumatic osteoarthritis
Which nerve causes foot drop
Injury to the common peroneal nerve
Ankle injuries are most often inversion. True or false?
True
In the foot, what is a common site for a stress fracture?
2nd metatarsal
Be suspicious of which condition if you have a patient
with prolonged ENT symptoms not responding to
conventional treatment. Sinusitis, nasal crusting and
blockage, epistaxis, collapse of nasal cartilage due to
necrosis causing a saddle nose deformity can all
occur.
GPA
The presence of red cell casts in the urine indicates
Glomerulonephritis
What is the screening test for small vessel vasculitis?
ANCA
cANCA or pANCA in GPA?
cANCA
cANCA or pANCA in IBD?
pANCA
What is the treatment of vasculitis?
Immunosuppression with steroids and steroid sparing agents (methotrexate)
Pneumocystis jirovecii prophylaxis with
Which antibiotic? in patients getting cyclophosphamide
Co-trimoxazole
Name 5 early local complications of joint replacement
Infection Dislocation / instability Nerve injury Bleeding DVT
Which nerve entrapment causes cubital tunnel syndrome?
Ulnar nerve at elbow
What is a sequestrum?
Dead fragment of bone
An acute osteomyelitis in the absence of recent surgery usually occurs in children/adults ?
Children
What is the most common causative organism for osteomyelitis?
Staph aureus
For mechanical back pain, bed rest is advised. True or false?
False
L3/4 prolapse > causes L? root entrapment > pain down to
L4 root entrapment medial ankle (L4), loss of quadriceps power, reduced knee jerk
pain down dorsum of foot, reduced power Extensor Hallucis Longus and tibialis anterior - this suggests - L4 - L5 - S1 entrapment?
L5 entrapment
pain to sole of foot, reduced power planarflexion, reduced ankle jerks - this suggests - L4 - L5 - S1 entrapment?
S1 entrapment
What nerve roots does sciatica typically affect?
L4, L5, S1
Urgent imaging investigation for ?cauda equinae syndrome?
MRI scan
Cervical myelopathy has UMN signs. True or false?
True
atlanto‐axial subluxation can occur in which rheumatology condition?
Rheumatoid arthritis
Which 3 muscles attach to the greater tuberosity of the shoulder joint
supraspinatous
infraspinatous
teres minor
Which rotator cuff muscle is responsible for external roatation
Infraspinatous + teres minor
Which rotator cuff muscle is responsible for initiation of abduction ?
Supraspinatous
Which rotator cuff muscel is responsible for internal rotation?
Subscapularis
In impingement syndrome, which muscle is most likely to be affected?
Supraspinatous
First line management of impingement syndrome
NSAIDs
Analgesia
Physiotherapy
Subacromial Intraarticular steroid injection (up to 3)
What is the principal clinical sign of frozen shoulder?
loss of external rotation
Which surgery is done if there are recurrent shoulder dislocations / instability ?
Bankart repair
Which nerve passes through the carpal tunnel ?
Median nerve
On examination there may be demonstrable loss of sensation and/or muscle wasting of the thenar eminence - this makes you think
Carpal tunnel syndrome (median nerve compression)
Movement of the finger produces a clicking sensation, as this nodule catches on and then passes underneath the pulley. This sensation may be painful and the finger may lock in a flexed position as the nodule passes under the pulley but can’t go back though on extension. The patient may have to forcibly manipulate the finger to regain extension, usually with pain. Any finger can be affected but the middle and ring are those most commonly affected.
- trigger finger
- dupetrynes contracture
Trigger finger
WHat is the most likely management of trigger finger
Intra-articular steroid injections
The 1st carpo‐metacarpal joint (trapziometacarpal joint) at the base of the thumb metacarpal is commonly affected by OA/RA
OA
What is the most common soft tissue swelling of the hand?
Ganglion cyst
pain and tenderness in the region of the greater trochanter with pain on resisted abduction.
this makes you think
Trochanteric bursitis
The MCL in the knee resists valgus/varus force?
Valgus
twisting force on a loaded knee (eg turning at football, squatting). The patient localizes pain to the medial (majority) or lateral joint line and an effusion develops by the following day - this suggests which type of injury
Meniscal tear
turning the upper body laterally on a planted foot (leading to internal rotation force on the tibia), often at football, rugby, skiing or another high impact sport. A “pop” is usually felt or heard and the patient usually develops a haemarthrosis (an effusion due to bleeding in the joint) - what injury does this suggest
ACL rupture
burning pain and tingling radiating into the affected toes. Women are four times more commonly affected and the wearing of high heels has been implicated as a cause. The third interspace nerve is most commonly involved followed by the second. Clinical examination may reveal loss of sensation in the affected web space. - what is the likely pathology?
Morton’s neuroma
hyperextension at the MTPJ with hyperflexion at the PIPJ and DIP
- claw toe
- hammer toe
Claw toe
What degree of fixed flexion deformity in dupetryns is required at the MCPJs for a patient to fail the Hueston Table Top Test?
a. >50 degrees
b. >10 degrees
c. >70 degrees
d. >30 degree
D - over 30 degrees
The thickest hyaline cartilage in the body is found on the articular surface of which bone?
a. Talar dome
b. Patella
c. Femoral head
d. Radial head
e. Tibial plateau
Patella
Adhesive capsulitis is a disorder characterized by progressive pain and stiffness of the shoulder in patients between 40 and 60, resolving after around 18‐24 months. Patients will initially complain of pain, which will subside (after around 2‐9 months) as stiffness increases (for around 4‐12 months) and then the stiffness gradually “thaws” out over time, usually with good recovery of shoulder motion.
The principle clinical sign on examination is restriction of shoulder movement in which direction?
a. Flexion
b. Abduction
c. Internal rotation
d. External rotation
External rotation
A varus malalignment of the knee will predispose the patient to early osteoarthritis of which compartment of the knee?
medial
lateral
Medial
Hip and knee joint arthroplasty is a common elective orthopaedic operation. From the list below, choose the chief indication for performing this operation. Please select only one answer:
To increase strength at the joint
To improve function
To improve range of movement at the joint (reduce stiffness)
Pain
Pain
multiple fragility fractures of childhood, short stature with multiple deformities, blue sclerae and loss of hearing. What is the likely diagnosis?
Osteogenesis imperfecta
What is the medical name for short stature?
Skeletal dysplasia
Which disorder does this suggest
- marfans
- ehlers danlos
- down syndrome
Marfans syndrome
How do you confirm the diagnosis of duchenes muscular dystrophy?
raised serum creatinine phosphokinase and abnormalities on muscle biopsy
More at risk of getting compartment syndome with
- high energy open fracture
- closed fracture
High energy open fracture (surprisingly)
If someone has potential compartment syndrome, what would the symptoms be and how would you assess?
Pain pain pain pain pain
pain around the fracture site
tense when you palpate
assess pain on passive stretch of the affected compartment
- flex big toe for posterior compartment
- extend big toe for anterior compartment
What is the key management of compartment syndrome
fasciotomy
Sensation: First dorsal web space in back of hand . Which nerve is responsible
Radial nerve
Motor: which nerve is responsible for abduction and adduction of the fingers?
Ulnar nerve
Motor: which nerve is responsible for making a fist?
Median nerve
Sensation: first dorsal web space in foot. Which nerve is responsible?
Deep peroneal nerve
Treatment of choice for extracapsular hip fracture
Dynamic hip screw
Child with bone pain worse at night, fever, swelling. What is this typical of?
Osteosarcoma
Which typical type of bone is osteosarcoma most common in
Long bone
What is cervical spondylosis? Slipping of cervical vertebrae Crushing of cervical vertebrae Degenerative osteoarthritis of the neck Degenerative rheumatoid arthritis of the neck The same as ankylosing spondylitis
Degenerative osteoarthritis of the neck
A 65-year-old woman patient presents with gross irreversible retinopathy. Which of the following DMARDs is most likely to be responsible? Methotrexate Gold Anti-TNF therapy Prednisolone Hydroxychloroquine
Hydroxychloroquine
Which nerve supplies the posterior compartment of the leg?
Tibial nerve
Which nerve supplies the posterior compartment of the thigh?
sciatic nerve
80-year-old man presents with pathological fracture. On X-ray there is thickened, brittle and mis-shaped bones, including pelvis and femur. There is excessive osteoclast reabsorption and increased osteoblast activity. Bone scans show increased uptake in the area. Blood tests show normal calcium, normal phosphate, normal PTH and increased ALP. Diagnosis? A – Osteoporosis B - Paget’s Disease C - Osteoarthritis D - Bony Mets E – Osteomalacia
Padgets
- everything normal but Raised ALP
A 19 year old male is playing football when another player’s boot collides with the outside of his leg. There is pain and about 4 hours later there is stiffness, bruising and swelling. The pain is felt on the medial aspect of the knee. On examination, there is abnormal passive abduction of the knee. What is the most likely diagnosis? A – MCL B – LCL C – ACL D – PCL E – meniscus
MCL
Patient has a positive Steinman’s test – pain is worse on internal rotation, better on external rotation A – ACL tear B – PCL tear C - Lateral meniscal tear D – Medial meniscal tear E – Lateral collateral tear
Lateral meniscal tear
Pain is worse on internal rotation that means the outside (lateral) ligament is more stretched to allow the leg to move inwards
