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MRCS part A- Principles of surgery in general > Orthopaedic for the MRCS part A > Flashcards

Orthopaedic for the MRCS part A Flashcards

1
Q

Define ankle fractures

A

A fracture around the tibia-talar joint of any malleolus(lateral,medial,or posterior) with or without disruption to the syndesmosis

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2
Q

What is the location of the ankle fracture?

A

A fracture involving the

(1) Lateral malleolus and/or
(2) Medial malleolus and/or
(3) Posterior malleolus

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3
Q

What is the incidence of ankle fractures?

A

Affect men and women equally
1st/Generally-ankle fractures are common and account for approx.10% of all fractures seen in trauma setting

2nd/Sex:(1)Men-have a higher rate as young adults due to sports and contact injuries
(2)Women-have a higher rate old or menopausal causing fragility type fracture

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4
Q

What is the general incidence of ankle fractures?

A

(1) ankle fractures are common and account for approx.10% of all fractures seen in trauma setting
(2) affect men and women equally

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5
Q

What is the sex incidence of ankle fractures?

A

(1) Men-have a higher rate as young adults due to sports and contact injuries
(2) Women-have a higher rate old or menopausal causing fragility type fracture

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6
Q

What is the incidence of ankle fractures in men?

A

have a higher rate as young adults due to sports and contact injuries

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7
Q

What is the age incidence of ankle fractures?

A

(1) Men-young adults
(2) Women-old or post menopausal

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8
Q

What is the incidence of ankle fractures in women?

A

have a higher rate old or post-menopausal causing fragility type fracture

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9
Q

Why ankle fractures occur in men?

A

Due to sports and contact injuries

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10
Q

What is most common period ankle fractures occur in women?

A

Old or post menopausal

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11
Q

What ankle fractures cause during post menopausal period in women?

A

Fragility type fractures

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12
Q

What are the types of ankle fractures?

A

(1) Tillaux-fracture occurs during the unique closure pattern of the distal tibial physis
(2) Pilon-occurs at the bottom of the tibia(shinbone)which is the tibial plafond,i.e.,tibial articular surface.
- involves the weight-bearing surface of the ankle joint -is a separate injury

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13
Q

Define Tillaux ankle fracture

A

fracture occurs during the unique closure pattern of the distal tibial physis

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14
Q

Define Pilon ankle fracture

A
  • occurs at the bottom of the tibia(shinbone)which is the tibial plafond,i.e.,tibial articular surface
  • involves the weight-bearing surface of the ankle joint -is a saparate injury
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15
Q

Discuss osseos anatomy in relation to ankle fractures

A
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16
Q

Discuss ligamentous anatomy in relation to ankle fractures

A
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17
Q

What is the other name of medial side of the ankle in relation to the ligamentous anatomy as explanation of ankle fracture?

A

Deltoid ligament

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18
Q

What is the division of medial side of the ankle in relation to the ligamentous anatomy as explanation of ankle fracture?

A

Divided into

(1) Superficial portion
(2) Deep portion

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19
Q

What is the function of medial side of the ankle in relation to the ligamentous anatomy as explanation of ankle fracture?

A

Is the primary restraint to valgus tilting of the talus

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20
Q

What are the components of lateral side of the ankle in relation to the ligamentous anatomy as explanation of ankle fracture?

A

The lateral side of the ankle consists from anterior to posterior of:-

(1) Anterior talofibular ligament(ATFL)
(2) Calcaneofibular ligament(CFL)
(3) Posterior talofibular ligament(PTFL)

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21
Q

What is the other name of lateral side of the ankle in relation to the ligamentous anatomy as explanation of ankle fracture?

A

Lateral ligament complex

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22
Q

What is the function of lateral side of the ankle in relation to the ligamentous anatomy as explanation of ankle fracture?

A

All the 3 ligaments on the lateral side of the ankle(ATFL,CFL and PTFL)

(1) resist valgus stress to the ankle
(2) are a restrain to the anterior translation of the talus within the Morris joint

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23
Q

Discuss syndesmosis

A
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24
Q

Define syndesmosis

A

Is a ligament complex between the distal tibia and fibula,holding the two bones together and consists of a very strong fibrous structure

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25
Q

What is the location of the syndesmosis?

A

Between the distal tibia and fibula

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26
Q

What is the function of the syndesmosis?

A

(1) Holds the tibia and fibula together
(2) Stability of the ankle-It is fundamental to the integrity of the ankle joint,and its disruption leads to instability

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27
Q

What does syndesmosis of ankle joint consist of?

A

Mnemonic;A TIP

It consists of(from anterior to posterior)the:-

(1) Anterior-inferior tibiofibular ligament(AITFL)
(2) Transverse tibiofibular ligament(TTFL)
(3) Interosseous membrane
(4) Posterior inferior tibiofibular ligament(PITFL)

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28
Q

Discuss clinical picture of ankle fractures

A
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29
Q

What is the usual presentation of a traumatic ankle fracture?

A
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30
Q

Discuss Ottawa rules

A
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31
Q

Discuss imaging of ankle fracture

A
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32
Q

Discuss XRs for ankle fractures

A
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33
Q

What are the indications of AP-lateral and mortise views in ankle fractures?

A
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34
Q

Define mortise view in imaging of ankle joint

A

20 degrees internal rotation

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35
Q

What are the indications(i.e.,how do we know) of imaging in syndesmosis injury?

A
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36
Q

What kind of imaging is done for syndesmosis injury in ankle fractures?

A

XRs(AP,lateral and mortise view(20 degrees internal rotation))

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37
Q

What should be the position of the ankle joint on imaging and why?

A

Dorsiflexed

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38
Q

What are the indications of stress radiographs in ankle fractures?

A
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39
Q

What is the indication of CT in syndesmosis injury?

A

used for surgical planning

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40
Q

When is appropriate time of doing plain radiographs in ankle fractures?

A
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41
Q

Discuss classification of ankle fractures

A
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42
Q

Discuss anatomical classification of ankle fracture?

A
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43
Q

Discuss Lauge Hansen classification of ankle fractures

A
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44
Q

What are the parts of Lauge-Hansen classification of ankle fractures?

A
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45
Q

What are the types of Lauge-Hansen classification of ankle fractures?

A
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46
Q

What are the indications of Lauge-Hansen classification?

A
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47
Q

What is the classical feature of the Lauge-Hansen classification system?

A

used widely in orthopaedic practice as it is much more detailed than Denise-Weber classification

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48
Q

Discuss Denis-Weber classification of ankle fractures

A
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49
Q

What is the frequency of use of Denise-Weber classification in ankle fractures?

A

Commonly used

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50
Q

What are the indications of Denis-Weber classification of ankle fractures?

A
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51
Q

What are the types of Denis-Weber classification of ankle fractures?

A
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52
Q

plain radiography demonstrating Denise-Weber classification system

A
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53
Q

Compare with a picture between Lauge-Hansen and Denis-Weber classification of ankle fractures

A
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54
Q

Discuss management of ankle fractures

A
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55
Q

What is the initial management of ankle fractures?

A
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56
Q

Discuss general principles of initial management of ankle fractures

A
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57
Q

How do you manage high energy ankle injuries?

A

Management should follow ATLS principles to identify more significant injuries first

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58
Q

How do you manage open ankle injuries?

A

Management should be in line with BOAST 4 principles

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59
Q

How do you manage ankle deformities and dislocation?

A

(1) Reduce obvious deformity with appropriate analgesia or conscious sedation
(2) Radiographs of clearly deformed or dislocated joints are not necessary
(3) Removing the pressure on the surrounding soft tissues from the underlying bony deformity is the priority

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60
Q

Enumerate indications of conservative management of ankle fractures

A
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61
Q

How do you define stability of ankle fracture and what is the treatment of each definition?

A

+often involves (1)stress radiographs (2)a trial of mobilisation (3)repeat radiographs

+defining unstability is a subject of much ongoing research

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62
Q

How do you define stability of ankle fractures?

A

+often involves (1)stress radiographs (2)a trial of mobilisation (3)repeat radiographs

+defining unstability is a subject of much ongoing research

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63
Q

What is the definition and treatment of Weber A ankle fracture ?

A
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64
Q

What is the definition and treatment of Weber B ankle fracture ?

A
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65
Q

What is the definition and treatment of Weber C ankle fracture ?

A
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66
Q

Summerise management of different Weber classifications

A
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67
Q

Discuss some examples for defining stability of ankle fracture to underpin the treatment decision

A
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68
Q

Discuss operative fixation of ankle fractures

A
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69
Q

Discuss operative fixation of ankle fractures

A
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70
Q

Discuss internal fixation of ankle fractures?

A
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71
Q

What is the method of internal fixation of ankle fractures?

A
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72
Q

What is the prerequisite of internal fixation of ankle fractures?

A
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73
Q

Why open reduction and internal fixation(ORIF) is often required for ankle fractures?

A

(1)To achieve stable anatomical reduction of the talus within the the ankle mortise. (2)The type of operative procedure peformed depends on the specific type of ankle fracture sustiand

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74
Q

Enumerate indications of open reduction and internal fixation(ORIF)

A
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75
Q

Discuss external fixation of ankle fractures

A
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76
Q

What is the method of external fixation?

A

External fixation,or with a hind foot nail

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77
Q

What is the prerequisite for external fixation?

A

Where soft tissue or bone quality is poor

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78
Q

Discuss post operative management of ankle fractures

A
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79
Q

What is the duration and reason for casts post operatively in ankle fractures?

A

Duration 6 weeks

Reason (a)6 weeks is an appropriate time period to keep cast on in a conservatively managed patient

(b) ankle fractures generally take 6 weeks to(1)unite enough
(2) prevent secondary displacement

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80
Q

What are the factors that weight bearing post operatively depends on?

A
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81
Q

What is the time taken for a patient with ankle fractures to return to activities and what does it require?

A
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82
Q

What is the differential diagnosis of the ankle fracture?

A
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83
Q

Define ankle sprain?

A

Ligamentous injury

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84
Q

What is the incidence of ankle sprain?

A

Much more common

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85
Q

What is the aetiology of ankle sprain?

A

Inversion injury on a plantarflexed ankle

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86
Q

Discuss classification of ankle sprains

A

(1) High ankle sprains Injuries to the syndesmosis
(2) Low ankle sprains Injuries to the: (1)Anterior inferior talofibular ligament(AITFL) (2)Calcaneofibular ligamnet(CFL)-the commonest (3)Posterior inferior talofibular ligament(PITFL)

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87
Q

Define high ankle sprains

A

Injuries to the syndesmosis

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88
Q

Define low ankle sprains

A

Injuries to the: (1)Anterior inferior talofibular ligament(AITFL) (2)Calcaneofibular ligament(CFL)-the commonest (3)Posterior inferior talofibular ligament(PITFL)

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89
Q

What is the most common ligament to be injured in low ankle sprains?

A

Calcaneofibular ligament(CFL)

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90
Q

Discuss the clinical picture of ankle sprains

A

(1)Significant ankle pain and swelling. (2)No weight bearing (3)Finger tenderness distal to the malleoli over the affected ligament

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91
Q

Discuss investigations of ankle sprain

A

Plain film radiograph +the image of choice +to rule out any bony injury

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92
Q

Discuss management of ankle sprains

A

Conservative(Mnemonic;ICE/A) (1)Early I*** mmobilisation (2)***C***_old compression and ice (3)Elevation (4)A_***nalgesia

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93
Q

Enumerate complications of ankle fractures

A
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94
Q

Discuss Maisonneuve fracture

A

Definition A combination of: (1)High proximal tibia fracture(high Weber C) (2)Unstable ankle injury

Significance (1)It is a high fibula fracture which is above the syndesmsis(high Weber C).Therefore,it may be an ankle fracture. (2)Indicates unsable ankle injury with likely injury to the iterosseous membrane.Consequently,it can be associated with ankle instability

Imaging Plain radiograph shows evidence of syndesmotic widening Management Surgical fixation-to reduce and stabilise the syndesmosis

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95
Q

Define Maisonneuve fracture

A

A combination of: (1)High proximal tibia fracture(high Weber C) (2)Unstable ankle injury

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96
Q

What is the significance of Maisonneuve fracture?

A

(1)It is a high fibula fracture which is above the syndesmsis(high Weber C).Therefore,it may be an ankle fracture. (2)Indicates unsable ankle injury with likely injury to the iterosseous membrane.Consequently,it can be associated with ankle instability

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97
Q

What does a plain radiograph show in Maisonneuve fracture?

A

Plain radiograph shows evidence of syndesmotic widening

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98
Q

What is the management of Maisonneuve fracture?

A

Surgical fixation-to reduce and stabilise the syndesmosis

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99
Q

Define avascular necrosis

A
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100
Q

Enumerate causes of avascular necrosis

A
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101
Q

Explain the clinical picture of avascular necrosis of the bone

A
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102
Q

Discuss in brief imaging of avascular necrosis of the bones

A
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103
Q

Discuss treatment of avascular necrosis of bone

A
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104
Q

What are the other names of Perthes disease?

A

(1)Legg-Calve-Perthes disease. (2)Avascular necrosis of the femoral head

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105
Q

Define Perthes disease

A

Idiopathic avascular necrosis of the femoral epiphysis of the femoral head causing a self limiting disease of the femoral head comprising of: (1)Necrosis. (2)Collapse
(3)Repair and remodelling

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106
Q

Discuss incidence of Perthes disease?

A

(1) In general-approximately 1:10000 (2)Sex-males 4 times greater than females(male to female ratio 4:1)
(3) Age-those who are small for their ge and between the overall age 2-12
- rare < 4 years
- common in average 4-8 years(in some other resources 5-7 years) with a limp. -the younger the age of onset,the better the prognosis

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107
Q

What is the aetiology of Perthes disease?

A

A transient disruption in the blood supply to the femoral head

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108
Q

What is the pathogenesis of Perthes disease?

A
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109
Q

What is the clinical picture of Perthes disease?

A

(1)Limping with hip pain(may be referred to the knee)
(2)Bilateral in 20%
(3)Decreased abduction and internal rotation
Mnemonic;PIRAB=Perthes….Internal rotation….Abduction

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110
Q

What are the symptoms of Perthes disease?

A
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111
Q

What is the chance of Perthes disease being bilateral?

A

10-20%

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112
Q

Describe hip pain of a patient with Perthes disease

A

(1)Onset:starts and worsens over few weeks to months (2)On activity, especially,on internal and external rotation (3)Intermittent + no history of trauma

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113
Q

Describe knee pain in a patient with Perthes disease?

A

(1)Chronic (2)With normal knee examination (3)Lasts for several hours

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114
Q

What are the investigations(diagnosis) of Perthes disease?

A

(1) Plain XRs
(2) Technitium-99 bone scan-shows earliest avascular change
(3) MRI-Indications:a)if normal XRs
b) symptoms persist

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115
Q

Discuss catteral staging of Perthes disease?

A
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116
Q

What is catteral stage 1 in Perthes disease?

A

Clinical and histological features only

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117
Q

What is catteral stage 2 in Perthes disease?

A

(1)Sclerosis with or without cystic changes (2)Preservation of the articular surface

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118
Q

What is catteral stage 3 in Perthes disease?

A

Loss of structural integrity of the femoral head

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119
Q

What is catteral stage 4 in Perthes disease?

A

Loss of acetabular integrity

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120
Q

Discuss the role of plain XRs in diagnosing Perthes disease?

A
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121
Q

What is the disadvantage of plain XRs in a patient with Perthes disease?

A

Early disease can be missed on XRs

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122
Q

What are the early changes that could be seen on plain XRs of a patient?

A
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123
Q

What are the changes that could be seen in more advanced cases of Perthes disease?

A

Fragmentation of the femoral head

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124
Q

What is the role of MRI in diagnosing Perthes disease?

A
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125
Q

What are the indications of MRI in diagnosing Perthes disease?

A

(1)If normal XRs and (2)Symptoms persist

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126
Q

What are the findings that could be seen on MRI of a patient with Perthes disease?

A
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127
Q

What is the role of technitium 99 bone scan in diagnosing Perthes disease?

A

It is an alternative option

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128
Q

What is the management of Perthes disease?

A

(1) Remove pressure from joint to allow normal development
(2) Physiotherapy
(3) Usually self limiting if diagnosed and treated promptly

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129
Q

What is the indication of treatment of perthes disease?

A
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130
Q

What is the main objective of management of Perthes disease?

A

To keep the femoral head within the acetabulum by cast,braces or surgery

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131
Q

What should be done in managing a patient with perthes disease < 6 years?

A

Observation and symptomatic treatment

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132
Q

What should be done in managing a patient with Perthes disease between 6-8 years?

A

Brace or surgical management with moderate results

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133
Q

What should be done in managing a patient with perthes disease > 8 years?

A

Surgical containment:(femoral/pelvic)osteotomy

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134
Q

What should be done in managing a patient with perthes disease and has severe deformities?

A

Operate

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135
Q

What is the prognosis of Perthes disease?

A

Early diagnosis improves outcome

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136
Q

Define ankylosing spondylitis?

A

A type of artheritis in which there is a long term or chronic inflammation of the joints of the spine or the axial skeleton

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137
Q

What are the feature of ankylosing spondylitis?

A
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138
Q

What are the general features of ankylosing spondylitis?

A
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139
Q

What are the clinical features of ankylosing spondylitis?

A
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140
Q

What the other name for the early cases of ankylosing spondylitis?

A

Uncomplicated cases

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141
Q

What are the clinical features of early cases of the ankylosing spondylitis?

A
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142
Q

What the other name for the advanced cases in ankylosing spondylitis?

A

Complicated cases

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143
Q

What are the clinical features of advanced cases of the ankylosing spondylitis?

A
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144
Q

What are the sites affected by ankylosing spondylitis?

A
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145
Q

What are the joints affected by ankylosing spondylitis?

A
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146
Q

Define the typical joints affected by ankylosing spondylitis?

A

Where the spine joins the pelvis

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147
Q

What are the other joints affected by ankylosing spondylitis?

A

e.g.,shoulder

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148
Q

What condition affects the joints in association with ankylosing spondylitis?

A

Psoriatc artheritis

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149
Q

What the sites,other than the joints,that are affected by ankylosing spondylitis?

A

Eyes(acute unilateral anterior uveitis) and bowel(IBD,especially ulcerative colitis in which there is a strong association with HLA B27 in patient with ankylosing spondylitis)problems may also occur

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150
Q

What condition affects the eyes in patients with ankylosing spondylitis?

A

acute unilateral anterior uveitis

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151
Q

What condition affects the bowel in patients with ankylosing spondylitis?

A

inflammatory bowel disease(IBD),especially ulcerative colitis in which there is strong association with HLA B27 in patients with ankylosing spondylitis

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152
Q

What type of inflammatory bowel disease affects patients with ankylosing spondylitis?

A

Ulcerative colitis in which there is a strong association with HLA B27 in patients with ankylosing spondylitis

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153
Q

Comment on the back pain in ankylosing spondylitis

A

(1)The characteristic symptoms of ankylosing spondylitis (2)Often comes and goes(i.e.,on and off)

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154
Q

What is the characteristic symptom of ankylosing spondylitis?

A

Back pain

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155
Q

What is the character of back pain in ankylosing spondylitis?

A

Often comes an goes(i.e.,on and off)

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156
Q

Comment on the joint stiffness in ankylosing spondylitis

A

Worsens over time

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157
Q

What are the typical spinal features of ankylosing spondylitis?

A

Typical spinal features which may be seen in a young patient and are suggestive of ankylosing spondylitis: (1)loss of lumbar lordosis (2)restrictions of spinal movement
(3)progressive spinal deformities (4)progressive kyphosis of the cervico-thoracic spine

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158
Q

Comment on the typical spinal features in ankylosing spondylitis

A

(1)seen in young patients (2)suggestive of ankylosing spondylitis

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159
Q

What is the age incidence of the typical spinal features in ankylosing spondylitis?

A

young patients

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160
Q

What the presence of the typical spinal features of ankylosing spondylitis actually means?

A

Suggestive of ankylosing spondylitis

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161
Q

What are the investigations of ankylosing spondylitis?

A
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162
Q

Name one specific physical test for ankylosing spondylitis

A

Schober test

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163
Q

What are the blood tests for investigating ankylosing spondylitis?

A
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164
Q

Comment on the ESR in ankylosing spondylitis

A

Raised

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165
Q

What is the association of ankylosing spondylitis?

A

HLA B27 in up to 20%

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166
Q

Comment on HLA B27 association in ankylosing spondylitis

A
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167
Q

What is the incidence of HLA B27 association in ankylosing spondylitis

A

20%

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168
Q

What is the other disease associated with HLA DR27 only if the patient is affected by ankylosing spondylitis?

A

Ulcerative colitis

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169
Q

What do the radiographs show in patients with ankylosing spondylitis?

A

the classical bamboo spine appearance

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170
Q

What is the one specific radiographic sign suggestive of ankylosing spondylitis?

A

the classical bamboo spine appearance

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171
Q

What is the treatment of ankylosing spondylitis?

A
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172
Q

What is the treament of the early cases in ankylosing spondylitis?

A
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173
Q

What the symptomatic treatment of ankylosing spondylitis?

A

NSAIDs

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174
Q

Comment on the use of NSAIDs in ankylosing spondylitis?

A

Should be carefully used in patients with IBD who may be taking steroids

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175
Q

What is the treatment of advanced cases of ankylosing spondylitis?

A
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176
Q

What is the indication of spinal decompression in patients with ankylosing spondylitis?

A

For complicated cases with progressive neurological deficit

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177
Q

Draw a diagram to illustrate the difference between early and advanced case in ankylosing spondylitis

A
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178
Q

Define spondylolysis

A

Congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body,usually affects L4/L5

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179
Q

What are the vertebrae affected by spondylolysis?

A

L4/L5

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180
Q

What is the incidence of spondylolysis?

A

Up to 5% of the population

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181
Q

What are the symptoms of spondylolysis?

A

(1) Asymptomatic
(2) Spondylolysis is the commonest cause of spondylolisthesis in children

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182
Q

What is the treatment of spondylolysis?

A

Asymptomatic cases do not require treatment

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183
Q

Define spondylolisthesis

A

This occurs when one vertebra is displaced relative to its immediate inferior vertebral body leading to an abnormal forward slip of one vertebral body on another

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184
Q

What is the incidence of sponylolisthesis?

A

a young atheletic female with a background of spondylolysis and presents with a sudden pain

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185
Q

What is the aetiology of spondylolisthesis?

A

(1) Stress fracture
(2) Spondylolysis-is a risk factor for a young atheletic female with a background of spondylolysis and presents with a sudden pain
(3) Trauma

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186
Q

What are the investigations(diagnosis) of spondylolisthesis?

A

Plain films-traumatic cases show the classic ‘Scotty Dog’ appearance on plain films

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187
Q

What are the factors on which treatment of spondylolisthesis depend on?

A

(1) Extent of deformity
(2) Associated neurological symptoms

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188
Q

What is the treatment of spondylolisthesis?

A

(1) Active observation-Minor cases may be actively monitored
(2) Surgery with spinal decompression and stabilisation-Individuals with radicular symptoms or signs require spinal decompression and stabilisation

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189
Q

What is characteristic feature of observation of a patient with spondylolisthesis?

A

Active observation or monitoring

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190
Q

What is the indication of active observation of a patient with spondylisthesis?

A

Minor cases should be actively monitored

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191
Q

What type of sugery is performed for a patient with spondylolisthesis?

A

Surgical decompression and stibilisation

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192
Q

What is the indication of surgery in spondylolisthesis?

A

Radicular symptoms or signs

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193
Q

What other names for sheuermann’s disease?

A

(1)Juvenile kyphosis (2)Juvenile discogenic disease. (3)Vertebral epiphysitis

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194
Q

Define Scheuermann’s disease

A

Epiphysitis of the vertebral joints

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195
Q

What is the main pathological process in Scheuermann’s disease?

A

Epiphysitis of the vertebral joints

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196
Q

What is the incidence of Scheuermann’s disease?

A

Predominately affects adolescents

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197
Q

What is the clinical picture of Scheuermann’s disease?

A

(1) Back pain
(2) Stiffness
(3) Progressive kyphosis(at least 3 vertebrae must be involved)

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198
Q

What is the imaging in Scheuermann’s disease and what does it show?

A

XRs changes include

(1) Epiphyseal plate
(2) Anterior wedging

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199
Q

What is the management(treatment) of Scheuermann’s disease?

A

(1) Minor cases-managed with physiotherapy and analgesia
(2) More severe cases-require bracing or surgical stabilisation

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200
Q

Define scoliosis

A

Lateral curvature of the spine in the coronal plane

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201
Q

Discuss the types of scoliosis?

A

(I)Structural
+Feature:1)affects more than 1 vertebral body
2)not corrected by alterations in posture
+Types:1)Idiopathic-the most common type
2)Congenital
3)Neuromuscular
+Management:Severe or progressive structural disease is managed surgically with bilateral rod stabilisation of the spine

(II)Non structural(postural)
+Incidence:commonest in adolescent females who develop minor postural changes only
+Feature:typically disappear on manoeuvres such as bending forwards

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202
Q

Discuss structural scoliosis

A

+Feature:1)affects more than 1 vertebral body
2)not corrected by alterations in posture
+Types:1)Idiopathic-the most common type
2)Congenital
3)Neuromuscular
+Management:Severe or progressive structural disease is managed surgically with bilateral rod stabilisation of the spine

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203
Q

What are the features of structural scoliosis?

A

1) affects more than 1 vertebral body
2) not corrected by alterations in posture

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204
Q

What are the types of structural scoliosis?

A

1) Idiopathic-the most common type
2) Congenital
3) Neuromuscular

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205
Q

What is the most common type of structural scoliosis?

A

Idiopathic

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206
Q

What is the management of structural scoliosis?

A

Severe or progressive structural disease is managed surgically with bilateral rod stabilisation of the spine

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207
Q

What is the other name for non structural scoliosis?

A

Postural

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208
Q

Discuss non structural(postural)scoliosis

A

+Incidence:commonest in adolescent females who develop minor postural changes only
+Feature:typically disappear on manoeuvres such as bending forwards

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209
Q

What is the incidence of non structural(postural)scoliosis ?

A

commonest in adolescent females who develop minor postural changes only

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210
Q

What is the feature of non structural(postural)scoliosis?

A

typically disappear on manoeuvres such as bending forwards

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211
Q

Define spina bifida

A

No fusion of the vertebral arches during embryonic development

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212
Q

What are the types of spina bifida?

A

(1) Myelomeningocele
(2) Spina bifida occulta
(3) Meningocele

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213
Q

Discuss myelomeningocele

A

(1) the most severe type of spina bifida
(2) associated with neurological defects that may persist in spite of anatomical closure of the spina bifida defect

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214
Q

Discuss spina bifida occulta

A

+Incidence:up to 10% of population
+C/P:(1)the skin and tissues(but not the bone) develop over the distal cord
(2)the site is identified by a birth mark or hair batch

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215
Q

What is the incidence of spina bifida occulta?

A

up to 10% of population

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216
Q

What are the clinical features of spina bifida occulta?

A

(1) the skin and tissues(but not the bone) develop over the distal cord
(2) the site is identified by a birth mark or hair batch​

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217
Q

What is the treatment of spina bifida?

A

The incidence of spina bifida is reduced by the use of folic acid during pregnancy

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218
Q

Discuss dorsal column lesion

A

+Feature:loss of vibration and proprioception
+e.g:Tabes dorsalis,SACD

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219
Q

Discuss spinothalamic tract lesion

A

Loss of pain,sensation and temperature

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220
Q

Discuss osteomyelitis

A

Aetiology

(1) Staph aureus in IVDU
(2) Fungal infections in immunocompromised

Features

(1) Normally progressive
(2) Normally cervical region affected
(3) Thoracic region affected in TB

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221
Q

What is the aetiology of osteomyelitis?

A

(1) Staph aureus in IVDU
(2) Fungal infections in immunocompromised

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222
Q

What are the features of osteomyelitis?

A

(1) Normally progressive
(2) Normally cervical region affected
(3) Thoracic region affected in TB

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223
Q

What are the features of infarction of spinal cord?

A

Dorsal column signs(loss of proprioception and fine discrimination)

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224
Q

What are the features of cord compression?

A

(1) UMN signs
(2) Haematoma
(3) Fracture
(4) Malignancy

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225
Q

What is the cause of central cord lesion?

A

Usually seen in older patients with cervical spondylolysis

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226
Q

What are the features of central cord lesion?

A

(1)Flaccid paralysis of the upper limbs

(2)Preserved motor and sensory fibres to lower limb(these are located prepherally)

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227
Q

What is the aetiology of anterior cord syndrome?

A

(1) Common after compression fractures
(2) Often damage to anterior spinal artery,so neurological damage is a combination of direct trauma with ischaemic damage

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228
Q

What are the features of anterior cord syndrome?

A

(1) Corticospinal-loss of power
(2) Spinothalamic-pain and temperature

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229
Q

What is the aetiology of posterior cord syndrome?

A

(1) Posterior column affected
(2) Proprioception is affected-ataxia

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230
Q

Define Brown sequard syndrome?

A

Hemisection of the spinal cord

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231
Q

What is the aetiology of Brown sequard syndrome?

A

(1)Stab wound (2)Gun shot. (3)Lateral vertebral fractures

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232
Q

What are the features of Brown sequard syndrome?

A

The following manifestations are because of the spinothalamic tract decussation below the level of the cord transection (1)Ipsilateral paralysis(pyramidal tract lesion)

(2)Ipsilateral loss of proprioception and fine discrimination sense(dorsal columns) (3)Contralateral loss of pain and temperature sensation(spinothalamic tract)

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233
Q

What is the explanation of manifestations of the Brown sequard syndrome?

A

spinothalamic tract decussation below the level of the cord transection

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234
Q

Define cauda equina syndrome?

A

a surgical emergency causing compression of the cauda equina below the connus medullaris

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235
Q

Discuss anatomy of cauda equina

A
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236
Q

Define cauda equina?

A

A bundle of spinal nerves that arise from the distal end of the spinal cord

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237
Q

What is the location of the cauda equina?

A

Inferior to the spinal cord below connus medullaris

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238
Q

What is the course of the cauda equina?

A
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239
Q

What is the distribution of the cauda equina?

A
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240
Q

What forms the cauda equina?

A

Lower motor neurons containing

(1)Motor and sensory impulses to the lower limbs (2)Motor innervation to the anal sphincter (3)Parasympathetic innervation for the bladder

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241
Q

Where does the spinal nerves of the cauda equina run?

A

The spinal nerves run in the subarachnoid space

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242
Q

Where does the cauda equina end?

A

They taper to an end +known as the conus medullaris +approximately at the L1 +nerve roots L1-S5 leave at this region

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243
Q

Where does the cauda equina exit?

A

(1)They pass down the spinal canal as the cauda equina (2)They exit at their respective foramina and their appropriate vertebral level

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244
Q

What is the incidence of the cauda equina syndrome?

A
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245
Q

What is the general incidence of the cauda equina syndrome?

A

Approximately 4 in every 10000 patients presenting with lower back pain are ultimately diagnosed with the cauda equina syndrome

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246
Q

What is the age incidence of auda equina syndrome?

A

Peak age onset=40-50 years of age

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247
Q

What is the peak age of onset of cauda equina syndrome?

A

40-50 years of age

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248
Q

What are the aetiology and pathophysiology of the cauda equina syndrome?

A
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249
Q

What is the most common cause of cauda equina?

A

Disc herniation(or intervertebral disc proplapse)

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250
Q

What is the most common disc herniates in relation to cauda equina syndrome?

A

most commonly occurs between L5/S1 and L4/L5 level

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251
Q

What is the most common trauma causing cauda equina syndrome?

A

vertebral fracture and subluxation

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252
Q

What are the types of neoplasms causing cauda equina syndrome?

A

(1)Primary cord tumours (2)Metastatic(i.e.,extrinsic)cord tumours

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253
Q

What are the most common metastatic neoplasms or cancers causing cauda equina syndrome?

A

The most common cancers that spread to spinal vertebrae (1)Thyroid (2)Breast (3)Lungs 🫁 (4)Renal (5)Prostate

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254
Q

Examples of infection causing cauda equina syndrome

A

Mnemonic;PAD

(1)Potts disease (2)Abscess formation (3)Discitis

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255
Q

Example of a chronic inflammation causing cauda equina syndrome?

A

Ankylosing spondylitis

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256
Q

Example of an iatrogenic cause of cauda equina syndrome

A

Haematoma secondary to spinal anaesthesia

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257
Q

What is the next step to be taken if no obvious cause of cauda equia is evident?

A

If no obvious cause of cauda equina is evident,a thorough history and examination may reveal the aetiology and pathophysiology,such as (mnemonic;LAW)

(1)Living in an area of endemic tuberculosis (2)A sign of metastatic disease (3)Weight loss

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258
Q

Discuss the classification of cauda equina

A
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259
Q

What are the manifestations of the cauda equina syndrome with retention(CESR)?

A

(1)Back pain with (2)Unilateral or bilateral sciatica (3)Lower limb motor weakness (4)Sensory disturbance in the saddle region (5)Loss of anal tone, and (6)Loss of urinary control

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260
Q

What are the manifestations of the incomplete cauda equina syndrome(CESI)?

A

As cauda equina with retention, however only altered urinary sensation (e.g. loss of desire to void, diminished sensation, poor stream, and need to strain); painful retention may precede painless retention in some cases.

Incomplete cauda equina has a greater potential for nuerological recovery

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261
Q

What are the manifestations of the suspected cauda equina syndrome(CESS)?

A

(1)Cases of severe back and leg pains with (2)Variable neurological symptoms and signs, and (3)A suggestion of sphincter disturbance

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262
Q

What is the clinical picture of cauda eqina?

A
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263
Q

Comment on the bladder dysfunction or loss of control on bladder caused by cauda equina syndrome

A
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264
Q

Comment on the bowel dysfunction or incontinence caused by cauda equina syndrome

A

should be investigated during the history taking

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265
Q

Define the saddle area anaesthesia caused by cauda equina syndrome?

A

Perianal or lower limb anaesthesia(the lower sacral dermatomes,termed saddle anaesthesia)

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266
Q

A diagram ilustrating the distribution of the saddle area anaesthesia

A
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267
Q

Comment on the loss of anal tone and urinary retention caused by cauda equina syndrome

A

As part of the examination for suspeced CES,regardless of symptoms,patients will require

(1)PR to check for loss of anal tone (2)Post-void bladder scan to check for urinary retention

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268
Q

Comment on lower limb weakness caused by cauda equina syndrome

A

usually associated with

(1)hyporeflexia (2)paralysis with or without sensory loss

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269
Q

What should be done in the full peripheral neurological examination of a patient with cauda equina syndrome?

A
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270
Q

Comment on radiculopathy as a differential diagnosis for cauda equina syndrome

A

presents with radiating back pain,however there will be no faecal,urinary,or sexual dysfunction in these patients

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271
Q

Comment on cord compression as a differential diagnosis for cauda equina syndrome

A

a surgical emergency with a similar pathophysiology to CES, however is characterised by upper motor neurone signs

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272
Q

Comment on muscloskeletal pain as a differential diagnosis for cauda equina syndrome

A

relating to strain of paraspinal muscles, with severe pain that may lead to limited movement, but no other focal neurological signs

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273
Q

What are the investigations of cauda equina syndrome?

A
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274
Q

Comment on the emergency lumbar-sacral spine MRI for investigation of patients with cauda equina syndrome

A
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275
Q

A diagram illustrating an MRI for cauda equina syndrome

A
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276
Q

What is the indication of further imaging in patients with cauda equina syndrome?

A

may be required dependent on the underlying cause

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277
Q

What is the treatment of cauda equina syndrome?

A
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278
Q

What is the indication of urgent surgical decompression in patients with cauda equina syndrome?

A

Any confirmed case must be sent for surgical decompression wihin 36 hours of first presentation of the symptoms

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279
Q

What is the maximum duration that should be taken for undergoing surgical decompression for a patient with cauda equina syndrome?

A

this intervention should take place as soon as possible, including out of hours (24-36 hrs)

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280
Q

What is the reason for undergoing an early surgerical decompression ,within 24 hrs, for patients with cauda equina syndrome?

A

Indeed, a retrospective study examined the case for early surgery and found that patients who were in theatre within 24 hours from onset of autonomic dysfunction had reduced bladder problems at long-term follow up.

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281
Q

What should be done before undergoing urgent surgical decompression for patients with cauda equina syndrome?

A

(1)An early neurosurgical review for urgent decompression must be initiated, especially for those with incomplete CES as the prognosis is potentially more favourable. (2)The neurosurgical team will discuss plans for surgical decompression, risks and benefits with the patient.

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282
Q

What is the purpose of urgent surgical decompression for patinets with cauda equina syndrome?

A

All acute CES patients will usually be recommended for surgical decompression, aiming to prevent permanent sphincter and lower limb dysfunction

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283
Q

What is the indication of radiotherapy and/or chemotharapy for patients with cauda equina syndrome?

A

In certain rarer situations, such as malignancy, radiotherapy and/or chemotherapy may be used (especially if the patient is not suitable for surgery) after consultation with specialist teams.

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284
Q

What should be done before initiating radiotherapy and/or chemotherapy for patients with cauda equina syndrome?

A

consultation with specialist teams.

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285
Q

Discuss prognosis of cauda equina syndrome

A

The prognosis of cauda equina syndrome is variable depending on both aetiology and the time taken from symptom onset to surgery.

Most cases will be progressive in nature and will cause complete compression on the cauda equina if left untreated. This is important for the management, as incomplete cauda equina syndrome has a greater potential for neurological recovery. Additionally, speed of symptom onset is important, as acute rather than subacute onset has a better prognosis when promptly treated.

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286
Q

What is the location of the lumbar disc herniation?

A

The commonest site for sliped disc

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287
Q

What is the herniating structure in lumbar disc herniation?

A

Nucleus polposus

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288
Q

What is the clinical picture of the lumbar disc herniation?

A
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289
Q

What is the nature of the back pain caused by lumbar disc herniation?

A

(1)sudden (2)radiating to one of the lower limbs

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290
Q

What is the cause of lumbar lordosis in lumbar disc herniation?

A

may occur due to spasm and contraction of prevertebral muscles

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291
Q

What is the effect of lumbar disc herniation on the spinal movements?

A

No effect

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292
Q

What is the sensory effect of lumbar disc prolapse on the lower back and limbs?

A

Numbness on the lower back and limbs

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293
Q

What is the effect of lumbar disc prolapse on the bladder?

A

Inability to pass urine

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294
Q

What is the investigation of lumbar disc herniation?

A

MRI

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295
Q

Why MRI is used to investigate lumbar disc herniation?

A

Diagnostic

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296
Q

What is the treatment of lumbar disc herniation?

A

Depending upon severity of disease

(1)Conservative (2)Surgery

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297
Q

On what factor does the treament of lumbar disc herniation depend?

A

Severity of the disease

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298
Q

Discuss dermatomes

A

1st/C2-C4

(1) C2-occiput and top part of the neck
(2) C3-lower part of the neck to the clavicle
(3) C4-the area just below the clavicle

2nd/C5-T1(situated in the arms)

(1) C5-lateral arm at and above the elbow
(2) C6-forearm and the radial(thumb)side of the hand
(3) C7-middle finger
(4) C8-medial aspect of the hand
(5) T1-medial side of the forearm

3rd/T2-T12(the thoracic covers the axillary and chest regions)

(1) T3-T12-chest and back to the hip girdle
(2) T4-the nipples are situated in the middle of T4
(3) T10-umbilicus
(4) T12-ends just above the hip girdle

4th/L1-L5

(1) L1-the cutaneous dermatome representing the hip and groin area
(2) L2-L3-front part of the thighs
(3) L4-L5-medial and lateral aspects of the lower leg

5th/S1-S5

(1) S1-heel and middle back of leg
(2) S2-back of thighs
(3) S3-medial side of buttocks
(4) S4-S5-perineal region
(5) S5(the lowest dermatome)-skin immediately at and adjacent to the anus

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299
Q

What C2 dermatome covers?

A

occiput and top part of the neck

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300
Q

What C3 dermatome covers?

A

lower part of the neck to the clavicle

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301
Q

What C4 dermatome covers?

A

The area just below the clavicle

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302
Q

What is the location of dermatome C5-T1?

A

Situated in the arms

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303
Q

What dermatome C5 covers?

A

lateral arm at and above the elbow

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304
Q

what dermatome C6 covers?

A

forearm and radial(thumb)side of the hand

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305
Q

what dermatome C7 covers?

A

middle finger

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306
Q

What dermatome C8 covers?

A

medial aspect of the hand

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307
Q

What dermatome T1 covers?

A

medial side of the forearm

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308
Q

What dermatome T2-T12 covers?

A

the thoracic myotomes cover the axillary and chest region

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309
Q

What dermatome T3-T12 covers?

A

chest and back to the hip girdle

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310
Q

What dermatome T4 covers?

A

The nipples are situated in the middle of T4

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311
Q

What dermatome T10 covers?

A

Umbilicus

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312
Q

What dermatome T12 covers?

A

Ends just above the hip girdle

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313
Q

What dermatome L1-L5 called?

A

Cutaneous dermatome

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314
Q

What dermatome L1-L5 covers?

A

Hip girdle and groin area

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315
Q

What dermatome L2-L3 covers?

A

Front of thighs

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316
Q

What dermatome L4-L5 covers?

A

Medial and lateral aspects of the lower leg

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317
Q

What dermatome S1 covers?

A

Heel and middle back of leg

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318
Q

What dermatome S2 covers?

A

Back of thighs

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319
Q

What S3 covers?

A

Medial side of buttocks

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320
Q

What dermatome S4-S5 covers?

A

Perineal region

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321
Q

What myotome S5 called?

A

The lowest dermatome

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322
Q

What myotome S5 covers?

A

Skin immediately at and adjacent to anus

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323
Q

Discuss myotomes

A
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324
Q

What myotome C5 indicated?

A

Elbow flexors/biceps

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325
Q

What myotome C6 indicate?

A

Wrist extensors

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326
Q

What myotome C7 indicates?

A

Elbow extensors/triceps

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327
Q

What myotome C8 indicates?

A

Long finger flexors

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328
Q

What myotome T1 indicates?

A

Small finger abductors

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329
Q

What myotome L1 and L2 indicates?

A

Hip flexors(psoas)

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330
Q

What myotome L3 indicates?

A

Knee extensors(quadriceps)

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331
Q

What myotome L4 and L5 indicates?

A

Ankle dorsiflexors(tibialis anterior)

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332
Q

What myotome L5 indicates?

A

Toe extensors(hallucis longus)

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333
Q

What myotome S1 indicates?

A

Ankle plantar flexors(gastrocnemius)

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334
Q

What the Scottie dog sign refers to?

A
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335
Q

What is the other name of Colles’ fracture?

A

Dinner fork deformity

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336
Q

What is the cause of Colles’ fracture?

A

Fall onto an extended outstretched hand

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337
Q

What is the incidence of distal radius fracture?

A

(1) Common
(2) Elderly females with osteoporosis

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338
Q

What is the usual cause for distal radius fracture?

A

Fall onto an extended outstretched hand

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339
Q

What is the location of the Colles’ fracture?

A

Mnemonic;ED 1

(1) Extra-articular
(2) Distal radius fracture
(3) 1 inch proximal to the radio-carpal joint(wrist joint)

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340
Q

What is the feature of Colles’ fracture?

A

(1) Dorsal angulation and displacement of the fracture fragment
(2) The distal end of the ulna is sometimes involved

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341
Q

What are the factors favouring instability of the distal radius(i.e.,wrist joint)?

A

(1) Dorsal tilt of more than 20 degrees
(2) Comminuted fracture
(3) Injury to ulnar styloid
(4) Intra-articular disruption

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342
Q

Discuss the management of Colles’ fracture

A

I)Conservative
(1)Reduction of the fracture under either a haematoma block or Biers block
(2)Immobilisation in a cast
(3)In the elderly with osteoporosis
II)Surgical fixation for unstable injuries

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343
Q

What is the conservative management of Colles’ fracture?

A

(1) Reduction of the fracture under either a haematoma block or Biers block
(2) Immobilisation in a cast
(3) In the elderly with osteoporosis

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344
Q

What is the other name for Smith fracture?

A

Reverse Colles’ fracture

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345
Q

What is the location of Smith’s fracture?

A

(1) Extra-articular
(2) Distal radius fracture
(3) 1 inch proximal to the radio-carpal joint(wrist joint)

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346
Q

What is the cause of Smith’s fracture?

A

Falling backwards onto the palm of an outstretched hand or falling with wrists flexed

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347
Q

What is the feature of Smith’s fracture?

A

Volar angulation and displacement of distal radius fragment(Garden spade deformity)

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348
Q

What is the deformity produced by Smith’s fracture?

A

Garden spade deformity

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349
Q

Define Garden spade deformity?

A
  • Volar angulation and displacement of distal radius fragment
  • Produced by Smith’s fracture
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350
Q

What is the other name for Barton fracture?

A

Colles’/Smith fracture

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351
Q

What is the cause of Barton fracture?

A

Fall onto extended and pronated wrist

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352
Q

What is the location of Barton fracture?

A

(1) Intra-articular
(2) Distal radius fracture

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353
Q

What is the defining feature of Barton fracture?

A

(1) Dorsal or Volar angulation and displacement of fracture segment
(2) Radio-carpal(wrist joint)dislocation
(3) Involvement of the joint is the defining feature

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354
Q

What are the classical features of Colles’ fracture?

A

(1) Transverse radial fracture
(2) 1 inch proximal to the radio-carpal joint(wrist joint)
(3) Dorsal displacement and angulation

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355
Q

What is the cause of Bennett’s fracture?

A

Impact on flexed metacarpal caused by fist fights

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356
Q

Define Bennett’s fracture

A

Intra-articular fracture of the first carpometacarpal joint

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357
Q

Define Rolando fracture?

A

Comminuted intra-articular fracture of the first carpometacarpal joint

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358
Q

Compare using a picture between Bennett’s and Rolando fracture

A
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359
Q

Define Monteggia’s fracture

A

Dislocation of the proximal radioulnar joint in association with ulnar fracture

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360
Q

What is the cause of Monteggia’s fracture?

A

Fall onto an outstretched hand with forced pronation

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361
Q

What is the management of Monteggia’s fracture?

A

Needs prompt diagnosis to avoid disability

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362
Q

What are the features of Galeazzi fracture?

A

(1) Radial shaft fracture
(2) Distal radioulnar joint dislocation
(3) Direct blow

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363
Q

What are the features of Monteggia’s fracture?

A

(1) Ulna fracture
(2) Proximal radioulnar joint dislocation

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364
Q

Compare between Monteggia’s. and Galeazzi fractures

A
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365
Q

Define Holstein Lewis fracture

A

Fracture of the distal 1/3rd of humerus resulting in entrapment of the radial nerve

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366
Q

What is the management of Holstein Lewis fracture ?

A

I)Conservative
(1)Reduction
(2)Functional brace
II)Open surgery for vascular injury

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367
Q

What is the conservative management of Holstein Lewis fracture?

A

(1) Reduction
(2) Functional brace

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368
Q

What is the indication of surgical treatment of Holstein Lewis fracture?

A

Vascular injury requires open surgery

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369
Q

Define Pott’s fracture

A

Bimalleolar ankle fracture

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370
Q

What is the cause of Pott’s fracture?

A

Forced foot eversion

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371
Q

What is the complications of Holstein Lewis fracture?

A

Radial nerve injury(with temporary concussion of the nerve,90% of injuries recover within 3-4 months)

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372
Q

What causes bony injury or fractures?

A

(1) Trauma(excessive forces applied to bone)
(2) Stress related(repetitive low velocity injury)
(3) Pathological(abnormal bone which fractures during normal use of following minimal tauma)

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373
Q

Define trauma in relation to fracture management

A

Excessive forces applied to the bone

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374
Q

Define stress fracture in relation to fracture management

A

Repetitive low velocity injury

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375
Q

Define pathological fracture in relation to fracture management

A

Abnormal bone which fractures during normal use of following minimal trauma

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376
Q

What are the points to be evaluated or assessed in any fracture?

A

Mnemonic;STAD

(1) Site of injury
(2) Type of injury
(3) Associated injuries
(4) Distal neurovascular deficits

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377
Q

What are the points evaluated or assessed in the XRs of any fracture?

A

Mnemonic;CARP

(1) Changes in length of the bone
(2) Angulation of the distal bone
(3) Rotational effects
(4) Presence of material such as glass

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378
Q

Define types of fractures in general

A
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379
Q

Define oblique fracture

A

Fracture lies obliquely to long axis of bone

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380
Q

Define comminuted fracture

A

>2 fragments

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381
Q

Define segmental fracture

A

> 1 fracture along a bone

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382
Q

Define transverse fracture

A

Perpendicular to long axis of bone

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383
Q

Define spiral fracture

A

Severe oblique fracture with rotation along long axis of bone

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384
Q

Discuss Gustilo and Anderson classification system for open vs closed fractures

A
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385
Q

What Gustilo and Anderson classification system is used for in orthopaedic?

A

(1) To distinguish between open from closed injuries
(2) Mainly to classify open fractures

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386
Q

What is grade 1 Gustilo and Anderson classification system for open vs closed fractures?

A

Low energy wounds<1cm

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387
Q

What low energy wound<1cm represents in Gustilo and Anderson classification system for open vs closed fractures?

A

Grade 1

388
Q

What grade 2 represents in Gustilo and Anderson classification system for open vs closed fractures ?

A

(1) Greater than 1cm wound with
(2) moderate soft tissue damage

389
Q

What grade 3 represents in Gustilo and Anderson classification system for open vs closed fractures?

A

(1) High energy wound >10cm with
(2) Extensive soft tissue damage

390
Q

What do wounds greater than 1 cm with moderate soft tissue damage represents in Gustilo and Anderson classification system for open vs closed fractures?

A

Grade 2

391
Q

Give examples for grade 2 Gustilo and Anderson classification system

A

Mnemonic;FAMSS

(1) Flaps
(2) Avulsion
(3) Minimum to moderate crushing component
(4) Simple transverse fractures
(5) Short oblique fractures with minimum comminution

392
Q

Give examples for grade 1 Gustilo and Anderson classification system for open vs closed fractures

A

(1) Quite clean wounds most likely from inside to outside
(2) Minimum muscle contusion
(3) Simple transverse fracture
(4) Short oblique fracture

393
Q

What grade 3A represents in Gustilo and Anderson classification system for open vs closed fractures?

A

(1) Grade 3(High energy wound >10 cm with extensive soft tissue damage)
(2) Adequate soft tissue or bone coverage

394
Q

Give examples for grade 3A in Gustilo and Anderson classification system for open vs closed fractures

A

(1) Segmental fractures
(2) Gunshot injuries

395
Q

What grade 3B represents in Gustilo and Anderson classification system for open vs closed fractures?

A

(1) Grade 3(High energy wound >10 cm with extensive soft tissue damage)
(2) Inadequate soft tissue or bone coverage

396
Q

Give examples for grade 3B in Gustilo and Anderson classification system for open vs closed fractures

A

(1) Periosteal stripping and bone exposure
(2) Massive contamination

397
Q

What does grade 3B requires in Gustilo and Anderson classification system for open vs closed ?

A

Soft tissue coverage

398
Q

What grade 3C represents in Gustilo and Anderson classification system for open vs closed fractures?

A

Vascular injury requires repair

399
Q

What does grade 3C requires in Gustilo and Anderson classification system for open vs closed fractures?

A

Vascular injury requires repair

400
Q

Mention some key points in management of fractures in general

A
401
Q

What is the management of open fractures?

A
402
Q

When do we usually start antibiotics in open fractures and who is giving them?

A

Started immediately
Usually given by ambulance staff in the UK

403
Q

When and how do we immobilise an open fracture?

A

I)Pre-hospital:initial splinting by ambulance staff
II)On arrival to the hospital
+1st/imaging
+2nd/correction of deformities under sedation in the ED
+3rd/immobilisation in splint or plaster

404
Q

What are the indications of CT trauma series for open fractures?

A

(1) Polytrauma patients
(2) High energy trauma

405
Q

What are the steps of wound dressing in any open fractures?

A

I)Prior to formal debridement
1st/Allow photography
2nd/Remove gross contamination from the wound
3rd/Dress the wound with a saline soaked gauze
4th/Cover the wound with an occlusive film
II)For debridement
+Prerequisite:(1)should be done in theatre
(2)should be performed using fasciotomy lines for wound extension
+Timing:1st/immediately for-(a)highly contaminated wounds(agricultural,aquatic,sewage)
(b)vascular compromise(compartment syndrome or arterial disruption producing ischaemia)
2nd/Within 12hrs of injury for-other solitary high energy open fractures
3rd/Within 24hrs of injury for-all other low energy open fractures
+Method:(1)In most cases the wound is left open
(2)The wound is irrigated by 6 litres of normal saline
(3)Initially the fracture should be stabilised with an external fixator

406
Q

How the wounds of open fractures are dressed prior to debridement?

A

1st/Allow photography
2nd/Remove gross contamination from the wound
3rd/Dress the wound with a saline soaked gauze
4th/Cover the wound with an occlusive film

407
Q

How the wound after debridement of any open fracture is dressed ?

A

+Prerequisite:(1)should be done in theatre
(2)should be performed using fasciotomy lines for wound extension
+Timing:1st/immediately for-(a)highly contaminated wounds(agricultural,aquatic,sewage)
(b)vascular compromise(compartment syndrome or arterial disruption producing ischaemia)
2nd/Within 12hrs of injury for-other solitary high energy open fractures
3rd/Within 24hrs of injury for-all other low energy open fractures

408
Q

What is the indication of definitive internal stabilisation for open fractures?

A

Only be carried out when it can be immediately followed with definitive soft tissue cover

409
Q

Discuss the incidence of neck of femur fracture?

A

(1)the most common reason for admission to an orthopaedic trauma ward in the UK
(2)over 65000 fractures annually in the UK
(3)bimodal age distribution
+young patients-high energy injury(e.g.,RTA,horse riding)associated with
-vertical fracture orientation
​ -femoral shaft fractures
+elderly-predominantly females with osteoporotic fracture,i.e.,fragility fracture,due to low energy injury like fall from
standing height

410
Q

What is bimodal age distribution in neck of femur fracture?

A

+young patients-high energy injury(e.g.,RTA,horse riding)
+elderly-predominantly females with osteoporotic fracture,i.e.,fragility fracture,due to low energy injury like fall from
standing height

411
Q

What is the angle of neck of femur?

A

Normal neck-shaft angle is 130+/-7 degrees,and 10+/-7 degrees of neck anteversion

412
Q

What is the blood supply to the femoral head and neck?

A

+Retinacular branches from the medial and lateral femoral circumflex arteries(branches of profunda femoris)
+These anastomose and pierce the joint capsule at the base of the neck ,mainly posteriorly
+There is a small vascular contribution from the artery of the ligament teres

413
Q

Why should we understand the blood supply to the neck of femur?

A

Understanding the blood supply is fundamental to the decision making process in treating neck of femur(NOF)fractures

414
Q

Define hip/neck of femur fracture

A

A fracture of the proximal femur(proximal to 5cm below the lesser trochanter)

415
Q

What is the mode of injury in hip/neck of femur fractures?

A

+young patients-high energy injury(e.g.,RTA,horse riding)associated with
-vertical fracture orientation
-femoral shaft fractures
+elderly-predominantly females with osteoporotic fracture,i.e.,fragility fracture,due to low energy injury like fall from
standing height

416
Q

What are the types of hip/neck of femur(NOF)fracture?

A

(a)Intracapsular fractures-femoral neck and head blood supply disruption is common with intracapsular NOF fractures and rare
with extracapsular fractures
(b)Extracapsular trochanteric fractures
I)pertrochantric
II)subtrochantric(within 5cm distal to the lesser trochanter)
III)Reverse oblique fractures
IV)Isolated trochanteric avulsion fractures
Result from sudden violent force avulsing the insertion of:(1)gluteus medius from greater trochanter
(2)iliopsoas from lesser trochanter

417
Q

What is the classification systems of hip/neck of femur fracture?

A

(1)Named(there has been a move away from named classification systems towards descriptive classification systems)
+Elderly intracapsular-Garden classification
+Young intracapsular-Pauvels(or Pauwels)classification
+Extracapsular intertrochantric(or pertrochantric)-Evans
+Extracapsular subtrochantric-Russell Taylor
(2)Descriptive

418
Q

Draw classification of hip/neck of femur fracture

A
419
Q

Discuss with pictures the named classification systems of hip/neck of femur(NOF)fractures

A
420
Q

Discuss intracapsular hip/neck of femur fracture

A

Location
Involve the femoral neck between the edge of the femoral head and insertion of the capsule of the hip joint

Incidence
Around 1/2 of all hip fractures are intracapsular

Complications
(1)Disrupt the blood supply to the femoral head,leading to avascular necrosis
(2)Femoral neck and head blood supply disruption is common with intracapsular NOF fractures and rare with extracapsular
fractures

421
Q

What is the location of the intracapsular hip/neck of femur(NOF)fracture

A

Involve the femoral neck between the edge of the femoral head and insertion of the capsule of the hip joint

422
Q

What is the incidence of hip/neck of femur(NOF)fracture?

A

Around 1/2 of all hip/neck of femur(NOF)fractures are intracapsular

423
Q

What are the complications of hip/neck of femur(NOF) fracture?

A

(1)Disrupt the blood supply to the femoral head,leading to avascular necrosis
(2)Femoral neck and head blood supply disruption is common with intracapsular NOF fractures and rare with extracapsular
fractures

424
Q

Discuss extracapsular hip/neck of femur(NOF)trochantric fracture

A

Location
Distal to the insertion of the capsule,involving or between the trochanters

Types
I)Intertrochantric or pertrochantric
II)Subtrochantric(within 5 cm distal to the lesser trochanter)
III)Reverse oblique fractures
IV)Isolated trochanteric avulsion fractures
Result from sudden violent force avulsing the insertion of:(1)gluteus medius from greater trochanter
(2)iliopsoas from lesser trochanter

Complication
femoral neck and head blood supply disruption is common with intracapsular NOF fractures and rare with extracapsular fractures

425
Q

What is the location of the extracapsular trochantric fractures?

A

Distal to the insertion of the capsule,involving or between the trochanters

426
Q

What are the types of extracapsular trochanteric fractures?

A

I)Intertrochantric or pertrochantric
II)Subtrochantric(within 5 cm distal to the lesser trochanter)
III)Reverse oblique fractures
IV)Isolated trochanteric avulsion fractures
Result from sudden violent force avulsing the insertion of:(1)gluteus medius from greater trochanter
(2)iliopsoas from lesser trochanter

427
Q

What is the location of extracapsular subtrochantric fracture?

A

within 5 cm distal to the lesser trochanter

428
Q

What is the cause of isolated trochanteric avulsion fractures?

A

Result from sudden violent force avulsing the insertion of:

(1) gluteus medius from greater trochanter
(2) iliopsoas from lesser trochanter

429
Q

What is the clinical picture of hip/neck of femur fracture?

A

(1)Pain-in the outer upper thigh or in the groin
-pain may be particularly aggravated by flexion and rotation of the leg
-where there is a preceding stress injury or bone pathology(e.g.,metastasis)there may be a preceding history of aching
in the groin or thigh
(2)Inability to bear weight
(3)Inability to straight leg raise
(4)The affected leg may be shortened,abducted and externally rotated(due to the unopposed pull of muscles that act across hip).
(5)With undisplaced fractures,signs are more subtle
(6)There may be no history of injury,especially in an elderly patient with confusion or dementia

430
Q

What are the features of pain caused by hip/neck of femur(NOF)fracture?

A

(1)in the outer upper thigh or in the groin
(2)pain may be particularly aggravated by flexion and rotation of the leg
(3)where there is a preceding stress injury or bone pathology(e.g.,metastasis)there may be a preceding history of aching
in the groin or thigh

431
Q

Discuss imaging in hip/neck of femur(NOF)fracture

A

I)Plain films-(1)AP and cross table lateral plain:are sufficient to diagnose the majority of NOF fractures
(2) Full length femur views:to plan surgery if (a)the fracture extends below the level of lesser trochanter
(b)pathological fracture
II)MRI-if plain films are inconclusive and hip/neck of femur(NOF)fractures are highly suspected
III)CT-done if MRI is not available within 24 hrs or contraindicated(e.g.,pacemaker)
-the majority of fractures can be seen with CT so it is becoming the 1st line in many hospitals

432
Q

Discuss the use of plain films to diagnose hip/neck of femur(NOF)fractures

A

(1) AP and cross table lateral plain:are sufficient to diagnose the majority of NOF fractures
(2) Full length femur views:to plan surgery if (a)the fracture extends below the level of lesser trochanter
(b) pathological fracture

433
Q

What is the indication of full length femur views in the diagnosis of hip/neck of femur(NOF)fracture?

A

to plan surgery if (a)the fracture extends below the level of lesser trochanter
(b)pathological fracture

434
Q

What is the feature of AP and cross table lateral plain films in diagnosis of hip/neck of femur(NOF)fracture?

A

are sufficient to diagnose the majority of NOF fractures

435
Q

What are the indications of MRI in the diagnosis of hip/neck of femur(NOF) fractures?

A

if plain films are inconclusive and hip/neck of femur(NOF)fractures are highly suspected

436
Q

What are the indications of CT in diagnosis of hip/neck of femur(NOF) fractures?

A

(1) done if MRI is not available within 24 hrs or contraindicated(e.g.,pacemaker)
(2) the majority of fractures can be seen with CT so it is becoming the 1st line in many hospitals

437
Q

What is the feature of CT in diagnosis of hip/neck of femur(NOF) fractures?

A

the majority of fractures can be seen with CT so it is becoming the 1st line in many hospitals

438
Q

What is the management of hip/neck of femur(NOF)fractures in general?

A

Method-Treated operatively except if the patient is unlikely to survive anaesthesia
Timing-Best practice tarif(BPT)dictates surgery within 36hrs as delay of more than 48hrs is associated with increased
morbidity and mortality

439
Q

Discuss management of intracapsular and extracapsular hip/neck of femur(NOF)fracture

A
440
Q

Discuss management of intracapsular hip/neck of femur(NOF)fractures

A
441
Q

Discuss management of extracapsular hip/neck of femur(NOF)fractures

A
442
Q

What is the aim of management of intracapsular hip/neck of femur(NOF) fractures in young patients?

A

Aim to preserve bone in young patients(internal fixation)or consider total hip replacement(THR)in displaced fractures with high risk of avascular necrosis(AVN)

443
Q

What is the other name for the tibial collateral ligament?

A

Medial collateral ligament

444
Q

Discuss anatomy of the tibial(medial)collateral ligament

A

Shape

(1) Broad
(2) Flat

Attachment

(1) Upper end-attaches to the medial epicondyle of the femur
(2) Some fibres-project onto the adductor magnus muscle
(3) The deepest fibres-are fused with the medial meniscus

Direction of fibres
The ligament passes downwards,forwards to the medial side of the tibia

445
Q

What is the shape of the tibial(medial)collateral ligament?

A

(1) Broad
(2) Flat

446
Q

What is the attachment of the medial collateral ligament?

A

(1)Upper end-attaches to the medial epicondyle of the femur
(2)Some fibres-project onto the adductor magnus muscle
​(3)The deepest fibres-are fused with the medial meniscus

447
Q

What is the direction of fibres of the tibial(medial)collateral ligament?

A

The ligament passes downwards,forwards to the medial side of the tibia

448
Q

Discuss anatomy of the fibular collateral ligament

A

Shape

(1) Round
(2) Cord like

Attachement

(1) Stands clear of the thin,lateral part of the fibrous capsule
(2) It is enclosed within the fascia lata
(3) It splits the tendon of biceps femoris
(4) On the lateral side of the joint the fibres-are short and weak
- bridge the interval between the femoral and tibial condyles
(5) The popliteus tendon intervenes between the lateral meniscus and the capsule

Direction of fibres

(1) Downwards and backwards
(2) In font of its highest point-It passes from the lateral epicondyle of the femur to the head of the fibula

449
Q

What is the shape of the fibular(lateral)collateral ligament?

A

(1) Round
(2) Cord like

450
Q

What is the attachment of the fibular(lateral)collateral ligament?

A

(1) Stands clear of the thin,lateral part of the fibrous capsule
(2) It is enclosed within the fascia lata
(3) It splits the tendon of biceps femoris
(4) On the lateral side of the joint the fibres-are short and weak
- bridge the interval between the femoral and tibial condyles
(5) The popliteus tendon intervenes between the lateral meniscus and the capsule

451
Q

What is the direction of fibres of the fibular(lateral)collateral ligament?

A

(1) Downwards and backwards
(2) In font of its highest point-It passes from the lateral epicondyle of the femur to the head of the fibula

452
Q

What is the other name for the fibular collateral ligament?

A

Lateral collateral ligament

453
Q

What are the functions of both tibial(medial)and fibular(lateral)collateral ligaments?

A

(1) Prevent disruption of the joint at the sides
(2) They are most tightly stretched in extension
(3) Their direction of fibres prevents rotation of the tibia laterally or the femur medially.Rotation is demonstrated in flexed knee.

454
Q

What is the incidence of collateral ligaments injury?

A

(1) Common
(2) The medial is most commonly affected
(3) Associated injuries to both the tibial plateau or minisci are not uncommon

455
Q

What is the cause of collateral ligaments injury?

A

Significant force to strike the side of the leg such as

(1) Sporting tackle
(2) Motor vehicle accident

456
Q

What are the grading and treatment of collateral ligaments injury?

A
457
Q

Discuss knee injury

A
458
Q

Discuss schatzker classification system for tibial plateau fractures

A
459
Q

What is the cause of ruptured anterior cruciate ligament(ACL)?

A

Sport injury

460
Q

What is the mechanism of ruptured anterior cruciate ligament(ACL)?

A

High twisting force applied to a bent knee(POP sound)

461
Q

What is the clinical picture of ruptured anterior cruciate ligament (ACL)?

A

(1) Loud crack/POP sound
(2) Joint pain
(3) Rapid joint swelling(haemarthrosis)
(4) Poor healing

462
Q

What are the investigations(diagnosis)of anterior cruciate ligament(ACL)?

A

(1) Anterior drawer test
(2) Lachman test

463
Q

What is the management of ruptured anterior cruciate ligament(ACL)

A

Intense physiotherapy or surgery

464
Q

What is the mechanism of ruptured posterior cruciate ligament(PCL)?

A

Hyperextension injuries

465
Q

What is the clinical picture of ruptured posterior cruciate ligament(PCL)?

A

(1) Tibia lies back on the femur
(2) Paradoxical anterior drawer test

466
Q

What are the investigations(diagnosis) of ruptured posterior cruciate ligament(PCL)?

A

Posterior drawer test

467
Q

What is the mechanism of ruptured medial collateral ligament?

A

Leg forced into valgus via force outside the leg

468
Q

What is the clinical picture of ruptured medial collateral ligament?

A

Knee unstable when put into valgus position

469
Q

What is the mechanism of menisceal tear?

A

Rotational sporting injuries

470
Q

What is the clinical picture of menisceal tear?

A

(1) Delayed knee swelling
(2) Joint locking(patient may develop skills to unlock the knee
(3) Recurrent episodes of pain and effusions are common,often following minor trauma

471
Q

What are the investigations(diagnosis)of menisceal tear?

A

McMurray’s test

472
Q

What is the sex incidence of chondromalacia patellae?

A

Teenage girls

473
Q

What is the mechanism chondromalacia patellae?

A

Following an injury to knee e.g.,dislocation patella

474
Q

What is the clinical picture of chondromalacia patellae?

A

(1) Typical of pain ongoing downstairs or at rest
(2) Tenderness,quadriceps wasting

475
Q

What is the mechanism of dislocation of the patella?

A

Most commonly occurs as a traumatic primary event,either through

(1) Direct trauma or
(2) severe contraction of quadriceps with knee stretched in valgus and external rotation

476
Q

What are the risk factors of dislocation of patella?

A

(1) Genu valgum
(2) Tibial torsion
(3) High riding patella

477
Q

What is the clinical picture of dislocation of patella?

A

(1) Osteochondral fracture in 5%
(2) 20% recurrence rate

478
Q

What is the incidence of tibial plateau fracture?

A

Occurs in the elderly or following significant trauma in the young

479
Q

What is the percentage of recurrence rate in dislocation of patella?

A

20%

480
Q

What are the mechanisms of fractured patella?

A

(1) Direct blow to patella causing undisplaced fragments
(2) Avulsion fracture

481
Q

What is the mechanism of tibial plateau fracture?

A

Knee forced into valgus or varus,but the knee fractures before the ligaments rupture

482
Q

What is the clinical picture of tibial plateau fracture?

A

(1) Valgus injury affects lateral plateau causing depressed fracture
(2) Varus injury affects medial plateau
(3) Classified according to Schatzker classification

483
Q

What is the classification of tibial plateau fracture?

A
484
Q

Define open fractures

A

Disruption of bony cortex associated with a breach in overlying skin

485
Q

What is the method of wound debridement in open fractures?

A

(1) In most cases the wound is left open
(2) The wound is irrigated by 6 litres of normal saline
(3) Initially the fracture should be stabilised with an external fixator

486
Q

What system is used in type 3C Gustilo and Anderson classification system for open vs closed fractures?and what is used for?

A

The mangled extremity scoring system(MESS)to predict the need for primary amputation

487
Q

What are the basics of osteomalacia?

A
488
Q

What are the types of osteomalacia?

A
489
Q

What are the features of osteomalacia?

A

I)Rickets:(1)knock-knee

(2) bow leg
(3) features of hypocalcaemia

II)Osteomalacia:(1)bone pain

(2) fractures
(3) muscle tenderness
(4) proximal myopathy

490
Q

What are the investigations(diagnosis)of osteomalacia?

A

(1) Serum calcium-low or normal(high in hypophosphatasia)
(2) Serum phosphate-low or normal
- low or normal Ca++x Pi >30 if albumin normal(high in renal osteodystrophy)
(3) 25(OH)vitamin D:low
(4) Alkaline phosphatase:elevated except in hypophosphatasia
(5) Urinary calcium-normal or low(high in hypophosphatasia
(6) Bone biopsy-tetracycline labels abnormal

491
Q

What is the most important biochemical test for osteomalacia which differentiates it from other disease?

A
492
Q

What is the level of serum calcium in osteomalacia?

A

Low or normal(high in hypophosphatasia)

493
Q

What is the level of serum phosphate in osteomalacia?

A

(1)Low or normal

(2)Low or normal Ca++ x Pi > 30 if albumin normal(high in renal osteodystrophy)

494
Q

What is the level of 25(OH)vitamin D in osteomalacia?

A

Low

495
Q

What is the level alkaline phosphatase in osteomalacia?

A

Elevated except in hypophosphatasia

496
Q

What is the level of urinary calcium in osteomalacia?

A

Low or normal(high in hypophosphatasia)

497
Q

What is the state of bone biopsy in osteomalacia?

A

Tetracycline labels abnormal

498
Q

What is the imaging used to diagnose osteomalacia?and what are findings?

A

XRs
1st/Children:cupped,ragged metaphyseal surfaces
2nd/Adults:appendicular predominance-(1)translucent bands(Looser’s zones or pseudofractures)
(2) complete fractures

499
Q

Enumerate causes of pseudofractures

A

(1) Paget’s disease of bone(rare cause)
(2) Hyperparathyroidism
(3) Renal osteodystrophy
(4) Osteogenesis imperfecta
(5) Fibrous dysplasia
(6) Hypophosphatasia

500
Q

What is the other name of looser zones?

A

Cortical infarctions

501
Q

What is the other name for pseudofractures?

A

Milkman lines or Loozer’s zones

502
Q

Describe pseudofractures

A

Transverse lucencies
I)wide
II)with sclerotic borders:(1)travesing partway through a bone
(2)perpendicular to the involved cortex
(3)associated with osteomalacia

503
Q

Define osteomalacia

A

Bone mass variable,meneralisation decreased

504
Q

What is the age of onset of osteomalacia?

A

Any age

505
Q

What are the clinical picture of osteomalacia?

A

+Symptoms-Generalised bone pain
+Signs-(1)Tenderness at fracture site
(2)Generalised tenderness

506
Q

What are the symptoms of osteomalacia?

A

Generalised bone pain

507
Q

What are the signs of osteomalacia?

A

(1) Tenderness at fracture site
(2) Generalised tenderness

508
Q

What the XRs shows in children with osteomalacia?

A

cupped,ragged metaphyseal surfaces

509
Q

What the XRs shows in adults with osteomalacia?

A

appendicular predominance-(1)translucent bands(Looser’s zones or pseudofractures)
(2) complete fractures

510
Q

What is the treatment of osteomalacia?

A

Calcium with vitamin D tablets

511
Q

Define rickets

A

the childhood form of osteomalacia

512
Q

What is the aetiology of rickets?

A

(1)Vit.D deficiency(dietary or metabolic) causing failure of the osteoid to ossify (2)Intestinal malabsorption (3)Renal disease. (4)Liver disease

513
Q

What are the clinical picture of rickets?

A
514
Q

What is the age affected by rickets?

A

(1)Symptoms start about the age of one (2)The child is small for age. (3)History of failure to thrive

515
Q

What are the bone deformities associated with rickets?

A
516
Q

What is the effect of rickets on the femur and tibia?

A

Bowing of the femur and tibia

517
Q

Define the large head in rickts

A

Bossing of the skull due persistence of suture lines and fontanelles

518
Q

What is the reason for large head in patients with rickets?

A

Because of bossing of the skull due persistence of suture lines and fontanelles

519
Q

Define rickettary rosary

A

Deformity of the chest wall with tickening of the costochondral junction

520
Q

Define Harrison’s sulcus in rickets

A

Transverse sulcus in the chest caused by the pull of the diaphragm

521
Q

What is the effect of rickets on the epiphysis?

A

Enlarged epiphysis

522
Q

What is the effect of rickets on growth?

A

Stunted growth

523
Q

What is the effect of rickets on the teeth?

A

Delayed dentition

524
Q

What are findings that could be found in an X-rays film of a patent with rickets?

A

These findings are most readily apparent in the wrist: widening and cupping of the long bones

525
Q

Define osteoporosis

A

(1) A bony atrophy in which the volume of bone tissue per unit volume of anatomical bone is reduced
(2) Bone mass decreased,mineralisation normal

526
Q

What are the types of osteoporosis?

A

1st classification

(1) Generalised-most common
(2) Localised-following pressure or disuse

2nd classification
(1)Type I-incidence:most common
site:Affects cancellous bone of femoral neck and vertebral body
(2)TypeII-incidence:age related=70years
site-both cancellous and cortical bone mass are deficient

527
Q

What is the pathogenesis of osteoporosis?

A
528
Q

What is the hallmark of osteoporosis?

A

Reduction of the amount of osteoid matrix which is normally mineralised

529
Q

What is the clinical picture of osteoporosis?

A

(1) Commoner in-old age-Generally elderly
- postmenopausal women
(2) Asymptomatic
(3) Increased risk of pathological fracture(hip,wedge fractures of vertebrae,Colles’ fracture)
(4) Pain referrable to fracture site
(5) Tenderness at the fracture site

530
Q

What are the causes of osteoporosis?

A

Mnemonic;CA/IDEA

(1) Calcium deficiency
(2) Alcoholism
(3) Idiopathic inactivity
(4) Disuse
(5) Endocrine abnormality
(6) Age

531
Q

What are the investigations(diagnosis) of osteoporosis?

A

(1) Serum calcium-normal
(2) Serum phosphate-normal Ca+++ x Pi >30
(3) Alkaline phosphatase-normal
(4) Urinary calcium-high or normal
(5) Bone biopsy-Tetracycline labels normal

532
Q

What are the imaging to diagnose osteoporosis?

A

(1) Plain films-only visible when calcium content approximately halved
- axial predominance
- show osteopenia,i.e.,loss of bone density,and cortical thickening,when 30-40% of bone mass has been lost
(2) DEXA scan-standard for evaluation
- shows more subtle changes

533
Q

What is the level of serum calcium in osteoporosis?

A

Normal

534
Q

What is the level of serum phosphate in osteoporosis?

A

Normal Ca+++ x Pi >30

535
Q

What is the level of alkaline phosphatase in osteoporosis?

A

Normal

536
Q

What is the level of urinary calcium in osteoporosis?

A

High or normal

537
Q

What is the result of bone biopsy in osteoporosis?

A

Tetracycline labels normal

538
Q

What is the DDx of osteoporosis?

A

Osteomalacia-it is distinct from osteomalacia in which there is abundant osteoid which is poorly calcified

539
Q

What is the difference between osteoporosis and osteomalacia?

A

Osteoporosis is distinct from osteomalacia in which there is abundant osteoid which is poorly calcified

540
Q

What is the complication of osteoporosis?

A

Pathological fracture(hip,wedge fractures of vertebrae,Colles’ fracture)

541
Q

What is the the treatment of osteoporosis?

A

(1) Bisphosphonate
(2) Non bisphosphinate
(3) Vitamin D and calcium supplements

542
Q

Discuss bisphosphonate

A
543
Q

Discuss the combination of Alendronate,residronate and etidronate for treatment of osteoporosis

A
544
Q

Discuss Alendronate for treatment osteoporosis

A
545
Q

Discuss raloxifene for treatment of osteoporosis?

A
546
Q

Discuss strontium ranelate for treatment of osteoporosis

A
547
Q

Discuss secondary prevention of osteoporosis

A
548
Q

Compare osteomalacia and osteoporosis

A
549
Q

Define paget’s disease of bone?

A
550
Q

What is the incidence of Paget’s disease of bone?

A
551
Q

What is the age incidence of Paget’s disease?

A
552
Q

What is the commonest age for Paget’s disease?

A

50 years of age

553
Q

What is the sex incidence of Paget’s disease?

A
554
Q

What is the aetiology of Paget’s disease?

A

Unknown

555
Q

What is the pathogenesis of Paget’s disease?

A
556
Q

What is the clinical picture of Paget’s disease?

A
557
Q

What are the sites of Paget’s disease?

A
558
Q

What are the symptoms of Paget’s disease?

A
559
Q

What is the investigations of Paget’s disease?

A

(1)Elevated alkaline phosphatase(ALP) (2)Normal calcium,phosphate,and PTH

560
Q

What are the complications of Paget’s disease?

A
561
Q

What are the compressive symptoms of Paget’s disease?

A

(1) Blindeness
(2) Deafness
(3) Cranial nerve entrapment
(4) nerve compression

562
Q

What is the treatment of Paget’s disease of bone?

A
563
Q

Discuss paediatric fractures

A
564
Q

Define complete fracture in paediatric

A

Both sides of cortex are breached

565
Q

Define toddlers fracture in paediatric

A

Oblique tibial fracture in infants

566
Q

Define plastic deformity or bowing fractures in paediatric

A

Stress on bone resulting in deformity without cortical disruption

567
Q

What is the pathogenesis of plastic deformity or bowing fractures?

A

The increased flexibility of paediatric bones makes them more likely to bend rather than break

568
Q

What is the other name for plastic deformity?

A

Bowing fracture

569
Q

Define green stick fracture in paediatric?

A

Unilateral cortical breach only

570
Q

What is the pathogenesis of green stick fractures?

A

Occur when the bone bends and partially breaks but does not extend through the width of the bone,giving it a tented appearance

571
Q

What is the other name for buckle fracture?

A

Torus fracture

572
Q

Define buckle or torus fracture

A

Incomplete cortical disruption resulting in periosteal haematoma only

573
Q

What is the pathogenesis of buckle or torus fracture?

A

The bones of paediatric patients are more porous than mature bone,placing them at greater risk for compression fractures

574
Q

What is the pathogenesis of avulsion type fracture?

A

The tendons and ligaments in paediatric patients are proportionally much stronger than the bones, leading to an increased incidence of avulsion

575
Q

XRs illustrating different types of paediatric fractures

A
576
Q

What is the other name for toddler fracture in paediatric?

A

Childhood accidental spiral tibial fracture

577
Q

What is the cause of toddler fracture?

A

Twisting injury while

(1) tripping
(2) stumbling
(3) falling

578
Q

What are the general features of toddler fracture?

A

(1) Minimally or undisplaced spiral fracture
(2) Usually of the tibia
(3) Typically in toddlers
(4) It is difficult to diagnose provided that symptoms and imaging findings are subtle

579
Q

What is the clinical picture of toddler fracture?

A

Limping child refusing to walk

580
Q

What is the treatment of toddler fracture?

A

Plaster

581
Q

Discuss paediatric growth plate fractures/epiphyseal fractures

A
582
Q

What is Salter Harris classification used for?

A

Fractures involving growth plate and epiphysis in children are classified using Salter Harris classification system

583
Q

What is type 1 salter Harris means for growth plate/epiphyseal fractures?

A

Slip-Transverse fracture through the growth plate/physis only

584
Q

What is type 2 salter Harris means for growth plate/epiphyseal fractures?

A

Above-Fracture through the growth plate/physis to the metaphysis(commonest type)

585
Q

What is the commonest type of Salter Harris classification for growth plate/epiphyseal fractures?

A

Type 2

586
Q

What is type 3 Salter Harris means for growth plate/epiphyseal fractures?

A

Lower-Fracture through the growth plate/physis and epiphysis with metaphysis spared

587
Q

What is type 5 Salter Harris means for growth plate/epiphyseal fractures?

A
588
Q

What is type 4 Salter Harris means for growth plate/epiphyseal fractures?

A

Through everything-Fracture involving the growth plate/physis,metaphysis and epiphysis

589
Q

What is the incidence of proximal humerus fractures?

A

(1) Very common injury
(2) Often in the elderly(3rd most common fragility fracture in the elderly)
(3) Usually through the surgical neck

590
Q

What is the cause of proximal humerus fractures?

A

I)Indirect violence,i.e.,fall on the shoulder,often in the elderly
II)Low energy fall in elderly females
III)High energy trauma in young males

591
Q

What are the types of proximal humerus fractures?

A

I]Anatomical neck fractures:
(a)rare
(b)if displaced >1cm carry a risk of avascular necrosis of the humeral head
II]Surgical neck fractures:
greenstick fracture through surgical humeral neck is the commonest in children
III]Undisplaced
IV]Displaced

592
Q

What is the management of proximal humerus fractures?

A

I]Undisplaced or minimally displaced humerus fractures(vast majority)are treated conservatively by
(a)immobilisation in a polysling with a collar and cuff(for gravitational traction)and
(b)progressive mobilisation followed by physiotherapy.
(c)Pendular exercise can commence at 14 days and active abduction from 4-6 weeks
II]Significantly displaced avulsion of the tuberosities or anatomical neck of humerus fractures-
(1)internal fixation (2)repair of rotator cuff
III]Surgical neck fractures-
(a)impacted:collar and cuff for 3-6weeks followed by physiotherapy
(b)significantly displaced:(1)open reduction and fixation or
(2)use of intramedullary device
IV]Operative management indications
(a)Irreducible fracture dislocation
(b)Large displacement
(c)Young patient
(d)Head splitting(intra-articular fracture)
V]PROFHER trial
(a)has suggested no benefit to operative intervention on patient outcome
(b)it must be applied cautiously as majority of patients were elderly with extraarticular fractures

593
Q

How do you manage Undisplaced proximal humerus fractures?

A

Undisplaced or minimally displaced humerus fractures(vast majority)are treated conservatively by

(a) immobilisation in a polysling with a collar and cuff(for gravitational traction)and
(b) progressive mobilisation followed by physiotherapy.
(c) Pendular exercise can commence at 14 days and active abduction from 4-6 weeks

594
Q

How do you manage anatomical humeral neck fractures?

A

Significantly displaced avulsion of the tuberosities or anatomical neck of humerus fractures-

(1) internal fixation
(2) repair of rotator cuff

595
Q

How do you manage significantly displaced avulsion of proximal humerus tuberosities?

A

(1) internal fixation
(2) repair of the rotator cuff

596
Q

How do you manage surgical neck of humerus fractures?

A

(a) impacted:collar and cuff for 3-6weeks followed by physiotherapy
(b) significantly displaced:(1)open reduction and fixation or
(2) use of intramedullary device

597
Q

How do you manage impacted surgical neck of humerus fractures?

A

collar and cuff for 3-6 weeks followed by physiotherapy

598
Q

How do you manage significantly displaced surgical neck of humerus fractures?

A

(1) open reduction and fixation or
(2) use of intramedullary device

599
Q

What are the complications of proximal humerus fractures?

A

(1) Axillary nerve damage(common)
(2) Axillary vessel damage
(3) Shoulder stiffness
(4) Fracture dislocation of the humeral head

For the above complications detailed neurological assessment is essential for all upper limb injuries

600
Q

What is the incidence of supracondylar fractures?

A

(1) One of the most common types of fractures
(2) Peak incidence in children between ages 5-8 years

601
Q

What are the types and causes of supracondylar humerus fractures?

A

1st/Extension type fracture(95-98%)
+Mechanism-Typically occurs from a fall on outstretched hand with elbow in extension or hyperextension
+Complication-Anterior interosseous nerve injury:causing neuropraxia

2nd/Flexion type fracture(2-5%)
+Mechanism-Typically occurs from a fall onto the flexed elbow
+Complications-Ulnar nerve injury:(a)the most common nerve injury from flexion type
(b)iatrogenic from medial pinning

602
Q

What is the incidence of extension type supracondylar fracture?

A

95-98%

603
Q

What is the mechanism of extension type supracondylar humerus fractures?

A

Typically occurs from a fall on outstretched hand with elbow in extension or hyperextension

604
Q

What are the complications of the extension type supracondylar humeral fractures?

A

Anterior interosseous nerve injury:causing neuropraxia

605
Q

What is the most common nerve affected by supracondylar fracture of the humerus?

A

Anterior interosseous nerve causing neuropraxia

606
Q

What is the most common symptom caused by anterior interosseous nerve in supracondylar humerus fractures?

A

Neuropraxia

607
Q

What is the incidence of flexion type supracondylar humerus fractures?

A

2-5%

608
Q

What is the mechanism of flexion type supracondylar humerus fractures?

A

Typically occurs from a fall onto the flexed elbow

609
Q

What are the complications of flexion type supracondylar humerus fractures?

A

Ulnar nerve injury:(a)the most common nerve injury from flexion type
(b)iatrogenic from medial pinning

610
Q

What is the most common nerve injury from flexion type supracondylar humerus fractures?

A

Ulnar nerve injury

611
Q

What are the most common nerve injuries,in order, from supracondylar humerus fractures?

A

1stly/Anterior interosseos nerve(AIN) injury-from extension type supracondylar humerus fractures causing neuropraxia
2ndly/Radial nerve injury-the second most common neuropraxia after anterior interosseous nerve(AIN)palsy

612
Q

What are the investigations(diagnosis)of supracondylar humerus fractures?

A
613
Q

Why should we examine AP views in supracondylar humerus fractures?

A

For Baumann angle

614
Q

What should be done after doing AP view for a patient with supracondylar humerus fractures?

A

(1) Examine for Baumann angle
(2) We need to compare with contralateral arm

615
Q

Why should we examine lateral views in supracondylar humerus fractures?

A

To see if the anterior humeral line intersects the middle 1/3rd of the capitellar ossification centre

616
Q

What is the use of posterior fat pad displacement in supracondylar humerus fractures?

A

Posterior fat pad displacement is always pathological and can indicate a nondisplaced fracture

617
Q

Discuss Gartland classification for supracondylar humerus fractures?

A
618
Q

Picture illustrating Gartland classification of supracondylar humerus fractures

A
619
Q

What are the complications of supracondylar humerus fractures?

A

1st/Neurovascular structures at risk
I]Anterior interosseous nerve(AIN)injury-most common for extension type supracondylar humerus fractures
-causing neuropraxia
II]Ulnar nerve injury-the most common nerve injury from flexion type supracondylar humerus fractures
-iatrogenic from medial pinning
III]Angulation:(1)Posteromedial angulation-associated with radial nerve injury(the 2nd most common neuropraxia after
AIN injury)
(2)Posterlateral angulation-associated with(a)brachial artery injury
(b)median nerve injury

2nd/Vascular injuries(1%)

620
Q

What is the the 2nd most common neuropraxia in supracondylar humerus fractures?

A

Radial nerve injury neuropraxia after AIN injury or palsy neuropraxia

621
Q

What are the complications of posteromedial angulation in supracondylar humerus fractures?

A

Radial nerve injury(the 2nd most common neuropraxia after AIN palsy)

622
Q

What are the complications of posterolateral angulation in supracondylar humerus fractures?

A

(1) Brachial artery injury
(2) Median nerve injury

623
Q

What is the management of supracondylar humerus fractures?

A
624
Q

What is type I Gartland classification of supracondylar humerus fractures?

A

Nondisplaced(beware of subtle medial comminution)

625
Q

What is the management of type I supracondylar humerus fractures?

A

Treated closed in a long arm cast for 2-3 weeks

626
Q

What is the duration of the cast in type I Gartland classification of supracondylar humerus fractures?

A

2-3weeks

627
Q

What is type II Gartland classification of supracondylar humerus fractures?

A

Displaced,posterior cortex and periosteal hinge intact

628
Q

What is the management of type II Gartland classification of supracondylar humerus fractures?

A
629
Q

What are the criteria for conservative management in type II Gartland classification of supracondylar humerus fractures?

A
630
Q

What is type III Gartland classification of supracondylar humerus fractures?

A

Completely displaced

631
Q

What is the management of type III Gartland classification of supracondylar humerus fractures?

A
632
Q

What is the other name for non accidental injury?

A

(1) Battered child
(2) Child abuse

633
Q

Discuss non accidental injury

A
634
Q

What is the incidence of non accidental injury?

A
635
Q

What is the incidence of repeated child abuse if not diagnosed?

A

30-50% there is a chance to repeat the child abuse if not diagnosed

636
Q

What is mortality rate of child abuse(non accidental injury) if not diagnosed?

A

5-10% chance of death from subsequent abuse

637
Q

What is incidence of fractures in non accidental injury(child abuse)?

A

(1) Children younger than 1 year = 50% chance of fractures
(2) Children younger than 3 years =30% chance of fractures

638
Q

What is incidence of fractures in non accidental injury(child abuse) in children younger than 1 year?

A

50%

639
Q

What is incidence of fractures in non accidental injury(child abuse) in children younger than 3 year?

A

30%

640
Q

What is the most cause of femur fractures in non ambulatory children?

A

Non accidental injuries(child abuse)

641
Q

When to suspect non accidental injury(NAI)?

A
642
Q

What is the other name for osteopetrosis?

A

Marble bone disease

643
Q

Define osteopetrosis

A

Hard and more dense bones

644
Q

What is the genetic predisposition of osteopetrosis?

A

Autosomal recessive condition

645
Q

What is the incidence of osteopetrosis?

A

Commonest in young adults

646
Q

What is the pathogenesis of osteopetrosis?

A

Osteoclast dysfunction results in too much bone density

647
Q

What does imaging show in osteopetrosis?

A

Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone

648
Q

Picture illustrating osteopetrosis

A
649
Q

What are the causes of pathological fracture?

A
650
Q

What are the metastatic tumours causing pathological fracture?

A
651
Q

What are the bone diseases causing pathological fracture?

A
652
Q

What are the local benign conditions causing pathological fracture?

A
653
Q

What are the primary malignant tumours causing pathological fracture?

A
654
Q

Define osteogenesis imperfecta

A

Inherited condition causing increased bone fragility

655
Q

What are the common sites affected by osteogenesis imperfecta?

A
656
Q

Discuss pathogenesis of osteogenesis imperfecta

A
657
Q

What are the subtypes of osteogenesis imperfecta?

A

Type I osteogenesis imperfecta - people with type I
O1 have less collagen than normal. This makes their
bones fragile, but they don’t have bone deformities.
The first break usually happens when a child starts
walking. Fractures typically decrease after puberty.
Type I osteogenesis imperfecta-
babies with type
Il Ol usually are born with many fractures, are very
small, and have severe breathing problems. As a
result, most will not survive.
Type Ill osteogenesis imperfecta
- people with
type Ill O1 usually will be shorter than their peers,
and may have severe bone deformities, breathing
problems (which can be life-threatening), brittle
teeth, a curved spine, ribcage deformities, and other
problems.
Type IV osteogenesis imperfecta - people with
type IV O1 can have mild to serious bone
deformities, short stature, frequent fractures (which
may lessen after puberty), and a curved spine.

658
Q

Discuss type I of osteogenesis imperfecta

A

Type I osteogenesis imperfecta - people with type I
O1 have less collagen than normal. This makes their
bones fragile, but they don’t have bone deformities.
The first break usually happens when a child starts
walking. Fractures typically decrease after puberty.

659
Q

Define type I of osteogenesis imperfecta?

A

The collagen is

(1) normal quality
(2) insufficient quantity

660
Q

What is the specific characteristic of type I osteogenesis imperfecta?

A

Mildest form

661
Q

What is the incidence of type I osteogenesis imperfecta?

A

60% of all cases

662
Q

What is the mechanism of type I osteogenesis imperfecta?

A
663
Q

What is the clinical picture of type I osteogenesis imperfecta?

A
664
Q

What is the cause of blue thin sclera in type I osteogenesis imperfecta?

A

It is an important sign caused by sceleral thinness allowing pigmented coat of the choroid to become visible

665
Q

Discuss fractures in type I osteogenesis imperfecta

A

Can occur any time from the perinatal period onwards:-

(1) In adults:There is(a)a 7x greater incidence of overall fracture rate than normal,with
(b) Reduced vertebral bone mineral content in adults
(2) In children:Fractures may be numerous but rarely lead to deformity

666
Q

Discuss type II osteogenesis imperfecta?

A

Type I osteogenesis imperfecta-
babies with type
Il Ol usually are born with many fractures, are very
small, and have severe breathing problems. As a
result, most will not survive.

667
Q

What is the mechanism of type II osteogenesis imperfecta?

A
668
Q

What is the clinical picture of type II osteogenesis imperfecta?

A
669
Q

Discuss multiple fractures in type II osteogenesis imperfecta

A

Frequently occurring in utero

670
Q

What is the cause of short limbs in type II osteogenesis imperfecta?

A

Due to faulty conversion of normal mineralised cartilage to defective bone matrix

671
Q

What is the clinical picture of type II osteogenesis imperfecta?

A
672
Q

Discuss type III osteogenesis imperfecta

A
673
Q

What is the characteristic feature of type III osteogenesis imperfecta?

A

Lethal form

674
Q

What is the characteristic feature of type III osteogenesis imperfecta?

A

Severely progressive deforming subtype

675
Q

Discuss fractures in type III osteogenesis imperfecta

A

Type Ill osteogenesis imperfecta
- people with
type Ill O1 usually will be shorter than their peers,
and may have severe bone deformities, breathing
problems (which can be life-threatening), brittle
teeth, a curved spine, ribcage deformities, and other
problems.

676
Q

Discuss the progressive deformity occurs in type III osteogenesis imperfecta

A
677
Q

What is the period of occurrence of progressive deformity in type III osteogenesis imperfecta?

A

Occurs during early years and increases with age

678
Q

What are the sites where progressive deformity occurs?

A

(1) Skull
(2) Chest
(3) Spine
(4) Long bones
(5) Pelvis

679
Q

What is the appearance of the face in type III osteogenesis imperfecta?

A

Triangular with

(1) Large vault
(2) Prominent eyes
(3) Small jaw

680
Q

Discuss the inability to walk in type III osteogenesis imperfecta

A

Patients rarely walk,even after multiple surgical procedures

681
Q

What is the reason for extreme short stature of patients with type III osteogenesis imperfecta?

A

Due to repeated childhood fractures

682
Q

Discuss dentinogenesis imperfecta(DI) associated with type III osteogenesis imperfecta

A
683
Q

Define dentinogenesis imperfecta(DI) associated with type III osteogenesis imperfecta

A

Impaired dentition

684
Q

What is the aetiology of dentinogenesis imperfecta associated with type III osteoporosis imperfecta?

A

Secondary to type I collagen defect

685
Q

What is colour of sclera in type III osteogenesis imperfecta according to the age?

A

(1) blue in infancy
(2) normal colour in childhood

686
Q

Descuss type IV osteogenesis imperfecta

A

Type IV osteogenesis imperfecta - people with
type IV O1 can have mild to serious bone
deformities, short stature, frequent fractures (which
may lessen after puberty), and a curved spine.

687
Q

Define type IV osteogenesis imperfecta

A

Sufficient collagen quantity but poor quality

688
Q

What is the characteristic feature of type IV osteogenesis imperfecta?

A

Moderately severe form

689
Q

What is the clinical feature of type IV osteogenesis imperfecta?

A
690
Q

What is the period in which type IV osteogenesis imperfecta will apparent?

A

This may be apparent at birth with

(1) Fractures
(2) Recurrent fractures on walking
(3) Bowing of leg

691
Q

What are the features of the sclera in type IV osteogenesis imperfecta?

A

Normal white colour in childhood with

(1) reduced stature
(2) variable disability

692
Q

What are the complications of type IV osteogenesis imperfecta?

A
693
Q

What is the differential diagnosis of type IV osteogenesis imperfecta?

A
694
Q

How to differentiate between type IV and type I osteogenesis imperfecta?

A

Type IV is differentiated from type I by having white sclera

695
Q

How to differentiate between type IV and type III osteogenesis imperfecta?

A

Type IV is differentiated from type I by having autosomal dominant inheritance

696
Q

What are the findings of radiology in osteogenesis imperfecta?

A
697
Q

Discuss Ehler’s Danlos syndrome

A

Ehlers Danlos:

  • Multiple sub types
  • Abnormality of types 1 and 3 collagen
  • Patients have features of hypermobility.
  • Individuals are prone to joint dislocations and pelvic organ prolapse. -In addition to many other diseases related to connective tissue defects.
698
Q

What is the other name of Osgood Schlatter disease?

A

Runner’s knee

699
Q

What is the genetic predisposition of Osgood Schlatter disease/runner’s knee?

A

Autosomal recessive condition

700
Q

What is the cause of Osgood Schlatter disease/Runner’s knee?

A

Involves traction apophysis of tibial tubercle-due to repeated microtrauma to tibial apophysis

701
Q

What is the incidence of Osgood Schlatter disease/Runner’s knee?

A

(1) Age=10-15 years
(2) Sex=M>F

702
Q

What is the age incidence of Osgood Schlatter disease/Runner’s knee?

A

10-15 years of age

703
Q

What is the clinical picture of Osgood Schlatter disease/Runner’s knee?

A

Symptoms
I)No history of trauma
II)Knee pain after activity

Signs
I)Tenderness-very specific point of tenderness over the tibial tubercle
II)Lump-(1)tender
(2)palpable
(3)over proximal tibia

704
Q

what are the symptoms of Osgood Schlatter disease?

A

I)No history of trauma
II)Knee pain after activity

705
Q

What are the signs of Osgood Schlatter disease?

A

I)Tenderness-very specific point of tenderness over the tibial tubercle
II)Lump-(1)tender
(2)palpable
(3)over proximal tibia

706
Q

What are the investigations of Osgood Schlatter disease?

A

XRs- shows fragmentation of apophysis

707
Q

What is the treatment of Osgood Schlatter disease?

A

(1) Rest
(2) Plaster cast for 6-8 weeks

708
Q

What is the location of pes anserinus bursa?

A

(1) At the medial aspect of the knee
(2) At the level of the joint space
(3) Deep to pes anserinus tendons(SGS-Sartorius,Gracilis,Semiteninosus)

709
Q

Define pes anserinus bursitis

A

Symptomatic inflammation of the pes anserinus bursa

710
Q

What are the clinical picture of pes anserinus bursitis

A

Pain

(1) Site-along the proximal medial tibia
(2) Associated with-swelling
(3) Exacerbated by-particular activities such as ascending and descending stairs

711
Q

What is the treatment of pes anserinus bursitis?

A

Physiotherapy-most cases resolve with physiotherapy

712
Q

What is the other name for gout and pseudogout?

A

Crystal induced arthropathies

713
Q

Define gout

A
714
Q

What is the incidence of gout and pseudogout?

A

Common

715
Q

What is the cause of gout?

A

Monosodium urate monohydrate crystals

716
Q

What is the cause of pseudogout?

A

Pseudogout is a form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate in the synovium

717
Q

What are the risk factors for pseudogout?

A
718
Q

What are the symptoms and signs for gout and pseudogout?

A

I)Podagra (initial) joint manifestation in 50% of gout cases and eventually
involved in 90%; also observed in patients with pseudogout and other conditions II)Gout is a form of inflammatory artheritis charaterised by recurrent attacks of a red,tender,hot and swollen joint.The joint at the base of the big toe(i.e.,1st metatarsophalangeal joint) is most commonly affected but many other joints including those of hands my be affected III)Arthritis in other sites
- In gout:(1)the instep,
(2)ankle,
(3)wrist,
(4)finger joints, and
(5)knee;

  • In gout,the joint is
    (1) swollen
    (2) hot
    (3) tender
    (4) red

(3)shows white chalky patches in the skin through which crystals can often be expressed
-In pseudogout, large joints,eg.,the: (1)knee,
(2)wrist,
(3)elbow, or
(4)ankle
(5)shoulder
IV)Monoarticular involvement
(1)most commonly, though polyarticular acute flares are not rare, and
(2)many different joints may be involved simultaneously or in rapid succession

V)In gout, attacks that begin abruptly and typically reach maximum intensity
within < 8-12 hours;
VI)In pseudogout, attacks resembling those of acute gout or a more insidious onset
that occurs over several days
VII)Without treatment, symptom patterns that change over time; attacks can
(1)become more polyarticular,
(2) involve more proximal and upper-extremity joints,
(3)occur more often, and
(4)last longer
VIII)In some cases, eventual development of chronic polyarticular arthritis that can
resemble rheumatoid arthritis

719
Q

What is the most common site for gout?

A

Podagra

(1) initially in 50% of cases
(2) Eventually in 90% of cases

720
Q

Define Podagra

A

Podagra, which in Greek translates to ‘foot trap’, is gout which affects the joint located between the foot and the big toe, known as the metatarsophalangeal joint.

721
Q

What is the incidence of gout in Podagra?

A

Initially 50%

Eventually 90%

722
Q

What other conditions affecting Podagra other than gout?

A

Pseudogout gout and other conditions

723
Q

Which joints are affected by arthritis in gout?

A

(1) instep,
(2) ankle,
(3) wrist,
(4) finger joints, and
(5) knee

724
Q

Which joints are affected by pseudogout?

A

large joints,eg.,the

(1) knee,
(2) ankle,
(3) wrist, or
(4) elbow
(5) shoulder

725
Q

Does gout and pseudogout have monoarticular or polyarticular involvement?

A

Monoarticular involvement most commonly, though polyarticular acute flares are not rare, and many different joints may be involved simultaneously or in rapid succession

726
Q

What is the time expected for polyarticular involvement of gout and pseudogout to occur?

A

different joints may be involved simultaneously or in rapid succession

727
Q

What is the time expected for attacks of gout and pseudogout to occur?

A

(1)In gout, attacks that begin abruptly and typically reach maximum intensity
within 8-12 hours;
(2)in pseudogout, attacks resembling those of acute gout or a more insidious onset
that occurs over several days

728
Q

What is the time expected for attacks of gout to occur?

A

In gout, attacks that begin abruptly and typically reach maximum intensity within 8-12 hours

729
Q

What is the time expected for attacks of pseudogout to occur?

A

in pseudogout, attacks resembling those of acute gout or a more insidious onset that occurs over several days

730
Q

What happens to patients with gout or pseudogout if left without treatment?

A

Without treatment, symptom patterns that change over time; attacks can (1)become more polyarticular,

(2) involve more proximal and upper-extremity joints,
(3) occur more often, and
(4) last longer

731
Q

What is the complication of gout and pseudogout?

A

Eventual development of chronic polyarticular arthritis that can resemble rheumatoid arthritis

Chronic renal failure in gout

732
Q

What are the investigations(diagnosis) of gout?

A

(1) Elevated uric acid
(2) negative birefringent crystals on synovial fluid examination

733
Q

What are the investigations(diagnosis) of pseudogout?

A

(1)Joint aspiration:weakly positively birefringent rhomboid shaped crystal (2)XRs:Chondrocalcinosis

734
Q

What does the joint aspiration show in pseudogout?

A

weakly positively birefringent rhomboid shaped crystal

735
Q

Compare between gout and pseudogout

A

(1) WBCs 3000-50000 in both gout and psedogout
(2) good response to colchicine in gout and weak in pseudogout
(3) red compensator when parallel is yellow in gout and blue in pseudogout

736
Q

What is the management of gout?

A

1st/Acute gout

(1) NSAID
(2) Colchicine

2nd/Chronic gout or for prophylaxis

Allopurinol

737
Q

What is the management of pseudogout?

A

(1) Aspiration of joint fluid to exclude septic arthritis
(2) NSAID
(3) Steroids-intra-articular or intramuscular or oral as for gout

(4)Weak response to colchicine

738
Q

What is the incidence of scaphoid fractures?

A

(1) The commonest carpal fracture
(2) Incidence of scaphoid fractures in the UK ranges from 12.4-29/100000

739
Q

What is the incidence of scaphoid fractures in the UK?

A

Incidence of scaphoid fractures in the UK ranges from 12.4-29/100000

740
Q

What is the reason that scaphoid fractures risk blood supply causing avascular necrosis?

A

Because surface of scaphoid is covered by articular cartilage with small area available for blood vessels

741
Q

What is the anatomical importance of scaphoid bone?

A

Forms floor of the anatomical snuffbox

742
Q

What is the cause or risk factor for scaphoid fractures?

A

Fall onto outstretched hand

(1) tubercle
(2) waist
(3) proximal 1/3rd

743
Q

What is the imaging that should be done for a suspected scaphoid fractures?

A

1st/A series of 4 radiographs should be done
(1)PA view
(2)Pronated oblique view
(3)Ziter view-a PA view with the wrist in ulnar deviation and beam angulated
at 20 degrees
(4)Lateral view

2nd/Repeat imaging should be done at 10 days

3rd/MRI-should be done in case of diagnostic uncertainty where the 4 scaphoid
view radiographs can not exclude scaphoid fractures if negative

744
Q

Define Ziter view

A

A PA view with

(1) the wrist in ulnar deviation and
(2) beam angulated at 20 degrees

745
Q

What is the sensitivity of scaphoid radiographs in the 1st week?

A

80%

746
Q

What is the period required to do a repeat imaging for a suspected scaphoid fracture?

A

At 10 days

747
Q

What should be done in case of diagnostic uncertainty in scaphoid fractures?

A

MRI

748
Q

What should be done in case of diagnostic uncertainty in scaphoid fractures?

A

4 Scaphoid view radiographs can not exclude scaphoid fractures if negative

749
Q

When the MRI should be done in scaphoid fractures?

A

In cases of diagnostic uncertainty where 4 scaphoid view radiographs can not exclude scaphoid fractures if negative

750
Q

What is the classification of scaphoid fractures?

A

(1) Scaphoid tubercle
(2) Distal pole
(3) Waist
(4) Proximal pole

751
Q

What is the management of scaphoid fractures?

A
752
Q

What are the complications of scaphoid fractures?

A
753
Q

Image shows classification of scaphoid fractures,scaphoid blood supply and scaphoid fixation

A
754
Q

What is the commonest organisms causing septic arthritis?

A

(1) Staph.aureus overall
(2) Neisseria gonorrhoea-in sexually active young adults
(3) Staph.aureus-in paediatric patients

755
Q

What is the commonest organism causing septic arthritis in the sexually active young adults?

A

Neisseria gonorrhoea

756
Q

What is the most common organism causing septic arthritis in paediatric patients?

A

Staph.aureus

757
Q

What are the investigations(diagnosis)of septic arthritis?

A

I)Plain XRs
II)Aspiration:Synovial fluids should be obtained before starting treatment
III)Kocher criteria

758
Q

Define Kocher criteria

A
759
Q

What is the expected ESR according to Kocher criteria for septic arthritis?

A

> 40 mm/hr

760
Q

What is the expected WBC count according to Kocher criteria for septic arthritis?

A

> 12000 mm3

761
Q

What is the prerequisite for Kocher criteria to be diagnostic in septic arthritis?

A

When 4/4 criteria are met,there is a 99% chance that the child has septic arthritis

762
Q

What is the chance of having septic arthritis in a child with 4/4 Kocher criteria?

A

90%

763
Q

What is the treatment of septic arthritis?

A

I)Needle aspiration should be used to decompress the joint
II)Arthroscopic lavage
III)Repeated procedures are necessary in some cases
V)Antibiotics:(1)urgent washout and antibiotics otherwise high risk of joint
destruction.
(2)Antibiotics should be given for 6-12 weeks
(3)IV antibiotics cover gram+ve cocci.BNF currently recommends
flucloxacillin or clindamycin if penicillin allergic
V)Surgical drainage of the affected joint,this should be as soon as possible since
permenant damage to the joint may occur

764
Q

What is the purpose of needle aspiration in septic arthritis?

A

to decompress the joint

765
Q

Discuss the use of antibiotics in the treatment of septic arthritis?

A

(1)Urgent washout and antibiotics otherwise high risk of joint destruction (2)Antibiotics should be given for 6-12 weeks
(3)IV antibiotics cover gram+ve cocci.
BNF currently recommends flucloxacillin or clindamycin if penicillin allergic

766
Q

What is the duration of antibiotics in treatment of septic arthritis?

A

6-12 weeks

767
Q

What is the reason for using antibiotics in septic arthritis?

A

urgent washout and antibiotics otherwise high risk of joint destruction.

768
Q

What is the organism covered by IV antibiotics in septic arthritis?

A

IV antibiotics cover gram+ve cocci.BNF currently recommends flucloxacillin or clindamycin if penicillin allergic

769
Q

What are the antibiotics recommended to treat septic arthritis?

A

IV antibiotics cover gram+ve cocci.BNF currently recommends flucloxacillin or clindamycin if penicillin allergic

770
Q

What is the purpose of surgical treatment in septic arthritis?

A

Surgical drainage of the affected joint,this should be as soon as possible since permenant damage to the joint may occur

771
Q

What are the complications of Perthes disease?

A

(1)Flattening and fragmentation of epiphysis:due to osteonecrosis of proximal femoral epiphysis

(2)AVN….Deformity….Subsequent revascularisation(2-4 years cycles)

772
Q

What does a plain XRs film show in Perthes disease?

A

XRs normal in early stage

773
Q

Define Gage’s sign in Perthes disease

A
774
Q

Discuss the other staging of Perthes disease?(NOT THE CATTERALL STAGING)

A
775
Q

What are the causes of stress fractures?

A

The following may result in small hairline stress fractures

(1) Repetitive activity
(2) Loading of normal bone

776
Q

What is the clinical picture of stress fractures?

A

(1) Painful
(2) Stress fractures are seldom displaced
(3) Surrounding soft tissue injury is unusual
(4) Stress fractures may present late following the injury,in which case callus formation may be identified on radiographs

777
Q

What is the management of stress fractures?

A

(1)Stress fractures may not require formal immobilisation
(2)Injuries associated with severe pain and presenting at an earlier stage may benefit from immobilisation tailored to the site
of injury

778
Q

What are the causes of pathological fractures among children?

A

(1) Osteogenesis imperfecta
(2) Osteopetrosis
(3) Osgood-Schlatter disease/Runner’s knee
(4) Pott’s fracture
(5) Bone cyst
(6) Bone tumour
(7) Non accidental injury(NAI) or child abuse

779
Q

What are the causes of growth plate fractures/epiphyseal fractures?

A

I)Non accidental injury(NAI) or child abuse
II)Pathological fractures
(1)Osteogenesis imperfecta
(2)Osteopetrosis
(3)Osgood-Schlatter disease/Runner’s knee
(4)Pott’s fracture
(5)Bone cyst
(6)Bone tumour

780
Q

What is the other name for transient tenosynovitis?

A

Irritable hip

781
Q

What is the incidence of Transient tenosynovitis(irritable hip)?

A

A common childhood condition affecting children between 3-8 years of age

782
Q

What is the clinical picture of transient synovitis(irritable hip)?

A

(1) History of URTI or other similar viral infections
(2) Fever
(3) Pain-usually in the knee or thigh
(4) Hip pain
(5) Restricted movement in one of the hip joints

783
Q

What are the complications of transient tenosynovitis(irritable hip)?

A

(1) Effusion
(2) Synovitis

784
Q

What are the investigations(diagnosis)of transient tenosynovitis(irritable hip)?

A

Blood tests and radiology are normal

785
Q

What is the treatment of transient tenosynovitis/irritable hip?

A

(1) Self resolving
(2) Analgesics
(3) Rest

786
Q

Define developmental dysplasia of the hip

A

Congenital abnormality of 2 types:

(1) Mild dysplasia acetabulum
(2) Irreducible dislocation

787
Q

What are the types of developmental dysplasia of the hip(DDH)?

A

(1) Mild dysplasia acetabulum
(2) Irreducible dislocation

788
Q

What is the incidence of developmental dysplasia of the hip (DDH)?

A

More common in

(1) Extended breach babies
(2) Females

789
Q

What is the cause or risk factors of developmental dysplasia of the hip (DDH)?

A

Mnemonic;MBC OFF

(1) Multiple pregnancies
(2) Breach position
(3) Certain ethnic groups-native American
(4) Oligohydromnios
(5) Female sex
(6) First born child with prematurity

790
Q

(1) Usually diagnosed in infancy by screening tests
(2) Left hip more affected but may be bilateral
(3) Leg length inequality when disease is unilateral
(4) Slight external rotation
(5) As disease progresses child may limp and then early onset arthritis
(6) Trendelenberg test positive

A
791
Q

What are the clinical tests to confirm developmental dysplasia of the hip(DDH)?

A

1st/Barlow’s test(BAD)

  • *Mnemonic;Barlow….Adduction….Dislocation(BAD)**
    (1) Adduct the hip
    (2) Apply light pressure on the knee directing the force posteriorly trying to dislocate the joint
    (3) If the hip is dislocatable,the test is considered positive

2nd/Ortolani test(ABO)
Mnemonic;Abduction….Ortolani(ABO)
+Purpose:The Ortolani manoeuvre is then used,to confirm that the positive findings(positive Barlow’s test,i.e.,that the hip
actually dislocated)
+Manoeuvre:(1)It is performed by gently abducting the infant’s leg by the examiner’s thumb
(2)Apply anterior pressure on the greater trochanter using the examiner’s index and forefinger
(3)A positive sign is a distinctive ‘clunk’ which can be heard and felt as the femoral head relocates anteriorly into
the acetabulum

792
Q

Discuss Barlow’s test

A

Mnemonic;Barlow….Adduction….Dislocation(BAD)

(1) Adduct the hip
(2) Apply light pressure on the knee directing the force posteriorly trying to dislocate the joint
(3) If the hip is dislocatable,the test is considered positive

793
Q

Discuss Ortolani test

A

Mnemonic;Abduction….Ortolani(ABO)
+Purpose:The Ortolani manoeuvre is then used,to confirm that the positive findings(positive Barlow’s test,i.e.,that the hip
actually dislocated)
+Manoeuvre:(1)It is performed by gently abducting the infant’s leg by the examiner’s thumb
(2)Apply anterior pressure on the greater trochanter using the examiner’s index and forefinger
(3)A positive sign is a distinctive ‘clunk’ which can be heard and felt as the femoral head relocates anteriorly into
​ the acetabulum

794
Q

Picture illustrating Barlow’s and Ortonali test

A
795
Q

What are the investigations(diagnosis) of developmental dysplasia of the hip(DDH)?

A
796
Q

What is the initial findings on plain XRs of developmental dysplasia of the hip(DDH)?

A

(1)Initially no obvious change on plain films but small femoral head
may be present
(2)On plain films shentons line should form a smooth arc

797
Q

What are the findings in ultrasound of developmental dysplasia of the hip(DDH)?

A

(1)The most effective
(2)USS gives best resolution until 3 months of age
(3)In recent years,hip ultrasonography(US)has appeared as an effective tool for the
early diagnosis of developmental dysplasia of the hip(DDH)in the newborns
(4)US Is an effective and noninvasive method without radiation
(5)Due to the high cost of US,there are still some controversial issues to use US as
a screening method

798
Q

What is the most effective method of diagnosing developmental dysplasia of the hip(DDH)?

A

US

799
Q

What is the characteristic feature of US in diagnosing developmental dysplasia of the hip(DDH)?

A

(1) USS gives best resolution until 3 months of age
(2) The most effective method
(3) Effective tool for early diagnosis of developmental dysplasia of the hip

800
Q

What is the treatment of developmental dysplasia of the hip(DDH)?

A
801
Q

What is the treatment of developmental dysplasia of the hip in the age 0-6m?

A

(1) Pelvic harness
(2) Surgery is needed in case of dislocated and irreducible cases

802
Q

What is the treatment of developmental dysplasia of the hip in the age 6m-18m?

A

(1)Close reduction+/-adductor tenotomy
(2)If fail then arthrogram+open reduction with hip spica cast 600 abduction and
900 flexion

803
Q

What is the treatment of developmental dysplasia of the hip in the age 18m-3yrs?

A

OR+/-femoral varus de rotation osteotomy

804
Q

What is the treatment of developmental dysplasia of the hip in the age 3yrs-8yrs?

A

OR+/-Femoral varus de rotation osteotomy+pelvic osteotomy

805
Q

What is the treatment of developmental dysplasia of the hip in the age > 8yrs?

A

THR when system justify surgical intervention

806
Q

What is the general treatment of developmental dysplasia of the hip(DDH)?

A

(1)Splints and harnesses or traction
(2)In later years osteotomy and hip realignment procedures may be needed
(3)In arthritis a joint replacement may be needed.However,this is best deferred if
possible as it will almost certainly require

807
Q

Discuss follow up of developmental dysplasia of the hip(DDH)?

A

At least until walking normally;WHO recommend up to 5 years

808
Q

What is the other name of slipped capital femoral epiphysis(SCFE)?

A

(1) Slipped upper femoral epiphysis(SUFE)
(2) Displaced upper femoral epiphysis

809
Q

What is the incidence of slipped capital femoral epiphysis(SCFE)?

A

Older obese male adolescents

810
Q

Define slipped capital femoral epiphysis(SCFE)?

A

Displaced upper femoral epiphysis(head)from neck

811
Q

Discuss clinical picture of slipped capital femoral epiphysis(SCFE)?

A

(1) Obese(remember,only this clue can guide you to the answer)
(2) Bilateral in 20%
(3) Associated with decreased GH and sex hormones
(4) Pain at the thigh and knee
(5) Knee pain at 2 months prior to hip slipping
(6) Mild shortening of limb
(7) Increased adduction and external rotation
(8) Decreased or limitation of abduction and internal rotation
(9) Chance of AVN increased

812
Q

What does XRs show in slipped capital femoral epiphysis(SCFE)?

A

XRs

813
Q

Picture illustrating slipped capital femoral epiphysis(SCFE)

A
814
Q

Discuss treatment of slipped capital femoral epiphysis(SCFE)

A
815
Q

What is the aim of bed rest and non weight bearing in the treatment of slipped capital femoral epiphysis(SCFE)?

A

To avoid avascular necrosis

816
Q

What is the treatment of minor to moderate cases of slipped capital femoral epiphysis(SCFE)?

A

Cannulated hip screw

817
Q

What is the treatment of severe slippage of slipped capital femoral epiphysis(SCFE)?

A

Percutaneous pinning of the hip

818
Q

What is the treatment if delayed cases of slipped capital femoral epiphysis(SCFE)?

A

Femoral neck osteotomy

819
Q

What is the use of the southwick angle in slipped capital femoral epiphysis(SCFE)?

A

Gives an indication of the articular surface and disease severity

820
Q

What is the other name for talipes equinovarus?

A

Club foot

821
Q

What are the types of talipes equinovarus(club foot)?

A

(1) Equinus of the hindfoot
(2) Adduction and varus of the midfoot
(3) High arch

822
Q

What is the incidence of talipes equinovarus(club foot)?

A

(1) Most cases in developing countries
(2) Incidence in the UK is 1/1000 live births
(3) More common in males

823
Q

What is the sex incidence of talipes equinovarus(club foot)?

A

More common in males

824
Q

What is the cause of talipes equinovarus(club foot)?

A

(1) Strong familial link
(2) Associated with other developmental disorders such as Down syndrome

825
Q

What are the key anatomical deformities of talipes equinovarus(club foot)?

A

(1) Bilateral in 50%
(2) Adducted and inverted calcaneus
(3) Wedge shaped distal calcaneal articular surface
(4) Severe tibio-talar plantar flexion
(5) Medial talar neck inclination
(6) Displacement of the navicular bone(medially)
(7) Wedge shaped head of talus
(8) Displacement of the cuboid(medially)

826
Q

What is the treatment of Talipes equinovarus(club foot)?

A

1st/Conservative(The Ponesti method)
*Advantage:gives comparable results to surgery
*It consists of:(1)Serial casting-to mold the foot into correct shape
(2)Achilles tenotomy-following casting around 90% requires
Achilles tenotomy
(3)Walking braces-done following Achilles tenotomy to maintain
the correction
2nd/Surgical correction
*Indication:reserved for those cases that fail to respond to conservative treatment
*Involves:(1)Multiple tenotomies
(2)Lengthening procedures
(3)Ilizarov frame-in patients who fail to respond surgically and gives
good results

827
Q

What is the conservative management of talipes equinovarus(club foot)?

A

The Ponesti method
*Advantage:gives comparable results to surgery
*It consists of:(1)Serial casting-to mold the foot into correct shape
(2)Achilles tenotomy-following casting around 90% requires
Achilles tenotomy
(3)Walking braces-done following Achilles tenotomy to maintain
the correction

828
Q

What is the advantage of the Ponesti method for treatment of talipes equinovarus(club foot)?

A

gives comparable results to surgery

829
Q

What does Ponseti method,for the treatment of talipes equinovarus(club foot),consists of?

A

Mnemonic;SAW

(1) Serial casting-to mold the foot into correct shape
(2) Achilles tenotomy-following casting around 90% requires Achilles tenotomy (3)Walking braces-done following Achilles tenotomy to maintain the correction

830
Q

What is the surgical treatment of talipes equinovarus(club foot)?

A

*Indication:reserved for those cases that fail to respond to conservative treatment
*Involves:(1)Multiple tenotomies
(2)Lengthening procedures
(3)Ilizarov frame-in patients who fail to respond surgically and gives
good results

831
Q

What is the indication of surgical correction for the treatment of talipes equinovarus(club foot)?

A

reserved for those cases that fail to respond to conservative treatment

832
Q

What does surgical correction involves in the treatment of talipes equinovarus(club foot)?

A

(1) Multiple tenotomies
(2) Lengthening procedures
(3) Ilizarov frame-in patients who fail to respond surgically and gives good results

833
Q

What is the indication of Ilizarov frame reconstruction for treatment of talipes equinovarus(club foot)?

A

in patients who fail to respond surgically and gives good results

834
Q

Picture illustrating types talipes equinovarus(club foot)

A
835
Q

What are the causes of painful shoulder?

A
836
Q

What is most common site for shoulder fracture?

A

Proximal humerus accounting for around 5% of all fractures.

837
Q

What is the incidence of proximal humerus fracture?

A

5 %

838
Q

What are the causes of proximal humerus fracture?

A

The majority of proximal humeral fractures are low energy injuries occurring in elderly patients falling onto an outstretched hand from standing. These injuries occur primarily in the context of an osteoporosis.

They also less commonly occur in younger patients usually the result of a high energy traumatic injury, therefore there are often associated soft tissue or neurovascular injuries.

839
Q

What are the causes of proximal humerus fracture in the elderly?

A

The majority of proximal humeral fractures are low energy injuries occurring in elderly patients falling onto an outstretched hand from standing. These injuries occur primarily in the context of an osteoporosis.

840
Q

What are the causes of proximal humerus fracture in the young patients?

A

They also less commonly occur in younger patients usually the result of a high energy traumatic injury, therefore there are often associated soft tissue or neurovascular injuries.

841
Q

What are the risk factors of proximal humerus fracture?

A

The risk factors for low energy proximal humerus fractures are comparable to other osteoporotic fractures, including female gender, early menopause, prolonged steroid use, recurrent falls, and frailty.

842
Q

What are the clinial picture of proximal humerus fracture?

A

1st/Symptoms (1)pain around the upper arm and shoulder, with (2)restriction of arm movement and (3)an inability to abduct their arm.

2nd/On examination, there is likely to be significant swelling and bruising of the shoulder, which can spread to the chest and down the arm.

Due to the close anatomical relationship with the axillary nerve and the circumflex vessels, is important to check the neurovascular status of the arm; damage to the axillary nerve can result in loss of sensation in the lateral shoulder (“Regimental Badge Area”) and loss of power of the deltoid muscle.

843
Q

What are the symptoms of proximal humerus fracture?

A

(1)pain around the upper arm and shoulder, with (2)restriction of arm movement and (3)an inability to abduct their arm.

844
Q

What are the signs of proximal humerus fracture?

A

On examination, there is likely to be significant swelling and bruising of the shoulder, which can spread to the chest and down the arm.

Due to the close anatomical relationship with the axillary nerve and the circumflex vessels, is important to check the neurovascular status of the arm; damage to the axillary nerve can result in loss of sensation in the lateral shoulder (“Regimental Badge Area”) and loss of power of the deltoid muscle.

845
Q

What are the indications of conservative management of proximal humerus fracture?

A

(1) Minimally displaced fractures
(2) No neurovascular compromise

846
Q

What are the steps of conservative management of proximal humerus fracture?

A

The patient requires immobilisation initially with early mobilisation including (1)pendular exercises at 14 days or 2-4 weeks post injury dependent on fracture pattern. (2)correctly applied polysling that allows their arm to hang; the effect of gravity on the arm will aid the reduction of the fragments of most humeral fractures. (3)Active abduction from 4-6 weeks

847
Q

What are the indications of operative management of proximal humerus fracture?

A

(a) Irreducible fracture dislocation
(b) Large displacement
(c) Young patient
(d) Head splitting(intra-articular fracture) (e)Open fracture. (f)Neurovascularly compromised fracture

848
Q

What are the factors that determine the type of surgery in proximal humerus fracture?

A

(1) Complexity of the fracture
(2) Patient factors

849
Q

What does PROFHER trial suggest in the treatment of proximal humerus fractures?

A

(a) has suggested no benefit to operative intervention on patient outcome
(b) it must be applied cautiously as majority of patients were elderly with extraarticular fractures

850
Q

What is the indication of ORIF and intermedullary nail ,in general,as operative options for the management of proximal humerus fractures?

A

multiple segment injuries

851
Q

Discuss ORIF as an operative option for the management of proximal humerus fractures?

A

(1) Most commonly used
(2) Plate and screw fixation
(3) Can reconstruct complex fractures

852
Q

What is the indication of ORIF as an operative option for the management of proximal humerus fractures?

A

often preferred in a head splitting fracture

853
Q

Discuss indications of intramedullary nail as an operative option for the management of proximal humerus fractures?

A

(1) Suitable for extra-articular configuration,
(2) Predominately if the fracture involves surgical neck+/- greater tuberosity(GT)fractures (3)If the fracture is combined with a humeral shaft fracture

854
Q

Discuss hemiarthroplasty as an operative option for the management of proximal humerus fractures?

A

Used for unreconstructable fractures in the older patient who has good glenoid quality

can be performed in a small number patients who experience complex injuries, or injuries that include splitting of the humeral head and are likely to have significant complications if the fracture is treated using ORIF.

855
Q

Discuss total shoulder arthroplasty as an operative option for the management of proximal humerus fractures?

A

Unconstructable fractures where high functioning shoulder is required(hemiarthroplasty will cause glenoid erosion)

856
Q

Discuss reverse shoulder arthroplasty as an operative option for the management of proximal humerus fractures?

A

Total shoulder arthroplasty that provides better functional outcome than conventional total shoulder replacement

Reverse shoulder arthroplasty (RSA) is an option for low demand patients, or patients who require revision after a failed previous procedure. RSA involves a total shoulder arthroplasty in which the ball and socket portions of the shoulder joint are reversed. Usually conservative management will be attempted before arthroplasty.

857
Q

What is osteology of proximal humerus?

A

*Consists of
I)Articular head
II)Greater tuberosity
III)Metaphysis
IV)Diaphysis
V)Anatomical neck(previous physis):between the articular head and the tuberosities
VI)Surgical neck:between the tuberosities and the metaphysis

*Attachments
I)Greater tuberosity-attaches the following muscles
(1)Supraspinatus
(2)Infraspinatus
(3)Teres minor
II)Lesser tuberosity-attaches the subscapularis

858
Q

What is the vascular supply of humeral head?

A

Anterior and posterior humeral circumflex arteries

859
Q

What are the blood tests for proximal humerus fracture?

A

1st/for any trauma case, urgent bloods, including a coagulation and Group and Save, should be sent.

2nd/Where a pathological cause is suspected, further work-up bloods, such as a 1)serum calcium 2)myeloma screen, may be warranted.

860
Q

What is the imaging of proximal humerus fractures?

A

*Aims

(1) Delineate the fracture pattern
(2) Confirm/exclude the presence of an associated dislocation

*Types of radiographs
I)Plain XRs film radiographs
+Feature:the required initial imaging modality for suspected shoulder fracture +Indication:to visulaise and classify aproximal humeral fracture +Options:1)True anteroposterior(AP)
2)Axillary lateral view and/or 3)Lateral scapular Y view
II)CT
1)better define intra-articular involvement
2)aid preoperative planning 3)if the position of any of the humeral segments is unclear.
III)MRI-is not useful for fracture imaging

861
Q

Discuss classification of the proximal humerus fractures

A

The Neer classification system*
+Frequency:most commonly used

+Uses:used to characterise proximal humeral fractures based on the relationship between 4 main segments of the proximal humerus
+Aims:(1)Describe fractures as 2,3,or 4 depending on the number main fragments (2)Comments on the degree of displacement (3)Description of the fracture-more useful than classification
(4)Humeral alignment
(5)Fracture displacement
(6)Greater tuberosity position-rotator cuff will pull the greater tuberosity(GT)supero-posteriorly,which can cause impingement
problems with malunion
+Details:1st/Fragments
(1)Greater tuberosity
(2)Lesser tuberosity
(3)Articular surface or segment (anatomical neck)
​ (4)Humeral shaft (surgical neck)
2nd/Displacement
(1) > 1 cm or angulation
(2) > 45 degrees

*These segments are considered separate if there is displacement >1cm between segments, or if there is at least 45 degrees of angulation; it categorises injuries into either minimal displacement or two to four part injuries, dependent on the number of separate segments present.

862
Q

What are the aims of proximal humerus fractures classification?

A

(1)Describe fractures as 2,3,or 4 depending on the number main fragments (2)Comments on the degree of displacement (3)Description of the fracture-more useful than classification
(4)Humeral alignment
(5)Fracture displacement
(6)Greater tuberosity position-rotator cuff will pull the greater tuberosity(GT)supero-posteriorly,which can cause impingement
problems with malunion

863
Q

What is the type of classification of proximal humerus fractures?

A

The Neer classification system*
+Frequency:most commonly used

+Uses:used to characterise proximal humeral fractures based on the relationship between 4 main segments of the proximal humerus
+Aims:(1)Describe fractures as 2,3,or 4 depending on the number main fragments (2)Comments on the degree of displacement (3)Description of the fracture-more useful than classification
(4)Humeral alignment
(5)Fracture displacement
(6)Greater tuberosity position-rotator cuff will pull the greater tuberosity(GT)supero-posteriorly,which can cause impingement
problems with malunion
+Details:1st/Fragments
(1)Greater tuberosity
(2)Lesser tuberosity
(3)Articular surface or segment (anatomical neck)
​ (4)Humeral shaft (surgical neck)
2nd/Displacement
(1) > 1 cm or angulation
(2) > 45 degrees

*These segments are considered separate if there is displacement >1cm between segments, or if there is at least 45 degrees of angulation; it categorises injuries into either minimal displacement or two to four part injuries, dependent on the number of separate segments present.

864
Q

What is the frequency of Neer classification?

A

Most commonly used

865
Q

What are the details of Neer classification for proximal humerus fractures?

A

The Neer classification system*
+Frequency:most commonly used

+Uses:used to characterise proximal humeral fractures based on the relationship between 4 main segments of the proximal humerus
+Aims:(1)Describe fractures as 2,3,or 4 depending on the number main fragments (2)Comments on the degree of displacement (3)Description of the fracture-more useful than classification
(4)Humeral alignment
(5)Fracture displacement
(6)Greater tuberosity position-rotator cuff will pull the greater tuberosity(GT)supero-posteriorly,which can cause impingement
problems with malunion
+Details:1st/Fragments
(1)Greater tuberosity
(2)Lesser tuberosity
(3)Articular surface or segment (anatomical neck)
​ (4)Humeral shaft (surgical neck)
2nd/Displacement
(1) > 1 cm or angulation
(2) > 45 degrees

*These segments are considered separate if there is displacement >1cm between segments, or if there is at least 45 degrees of angulation; it categorises injuries into either minimal displacement or two to four part injuries, dependent on the number of separate segments present.

866
Q

What are the complications of proximal humerus fracture

A

(1)reduced range of motion is the most common complication of a proximal humeral fracture , and extensive physiotherapy will be required to regain full function and reduce pain. Rehabilitation time for a proximal humeral fracture is around 1 year and is very dependent on how soon the patient was allowed to mobilise their shoulder.

(2)avascular necrosis of the humeral head following an injury disrupting the blood supply (from the anterior and posterior humeral circumflex arteries). In such cases, a hemiarthroplasty or reverse shoulder arthroplasty may be required.

Damage to the neurovascular supply is thankfully rare, however it remains essential to check the axillary nerve in these injuries.

867
Q

What is the incidence of scapula fractures?

A

Uncommon

868
Q

What is the cause of scapula fracture?

A

High energy trauma

869
Q

What are the sites most commonly involved in scapula fractures?

A

(1) Scapula body(50%)
(2) Spine(50%)
(3) Glenoid fossa
(4) Glenoid neck

870
Q

What should be excluded in scapula fractures?

A

Associated life threatening injury

871
Q

What is imaging done for scapula fractures?

A

I)Plain radiographs
(1)True anteroposterior(AP)
(2)Axillary lateral and/or scapula Y view
II)CT scanning
(1)Define intra-articular involvement,displacement
(2)For three dimensional reconstruction

872
Q

Discuss classification of scapula fractures?

A

Based on the location of the fracture
(1)Coracoid
(2)Acromion
(3)Glenoid neck-Floating shoulder:Beware of ipsilateral glenoid neck and clavicle
where limb is effectively dissociated from
axial skeleton
(4)Glenoid fossa
(5)Scapula body

873
Q

What is the treatment of scapula fractures?

A

I]Conservative-sling immobilisation for 2 weeks followed by early rehabilitation
II]Surgical-(1)Floating shoulder:for fixation
(2)Intra-articular and displaced/angulated glenoid fractures

874
Q

What are the types of dislocation around the shoulder joint?

A

(1) Glenohumeral dislocation
(2) Acromioclavicular joint disruption
(3) Sternoclavicular dislocation

875
Q

What is the incidence of glenohumeral dislocation?

A

Commonly seen in the A&E with an incidence of up to 1.7% in the general population.

876
Q

What is the recurrence rate of glenohumeral dislocation?

A

As high as 80% in teenagers

877
Q

What is the cause of glenohumeral dislocation?

A

Usually a traumatic cause(multi-directional instability in frequent dislocation requires discussion with orthopaedics)

878
Q

Discuss assessment of glenohumeral dislocation

A

(1) Careful history,examination,and documentation of neurovascular status of the limb,in particular the axillary nerve(regimental badge sensation)
(2) This should be reassessed post manipulation
(3) Early radiographs to confirm direction of dislocation

879
Q

What is the initial management of glenohumeral dislocation?

A

(1) Emergent closed reduction under entanox and analgesics,but often requires conscious sedation
(2) Arm should then immobilised in a polysling
(3) XRs to confirm relocation

880
Q

What is the imaging that should be done to diagnose glenohumeral dislocation?

A

(1) True anteroposterior(AP)
(2) Axillary
(3) Lateral and/or scapula Y view-reduced humeral head should lie between acromion and coracoid on lateral/scapula view

881
Q

Discuss types of glenohumeral dislocation

A
882
Q

What is the incidence of anterior glenohumeral dislocation?

A

Most common dislocation(> 90%)

883
Q

What is the cause of anterior glenohumeral dislocation?

A

Usually traumatic anterior force on arm when shoulder is abducted,externally rotated

884
Q

What is the examination of glenohumeral dislocation?

A

(1) Sulcus sign-Loss of shoulder contour
(2) Humeral head can be felt anteriorly

885
Q

What is the reduction technique for the anterior glenohumeral dislocation?

A

(1) Hippocratic
(2) Milch
(3) Stimson
(4) Kocher-not advised due to complication of fracture

886
Q

What is the incidence of posterior glenohumeral dislocation?

A

50% missed in A&E

887
Q

What is the cause of posterior glenohumeral dislocation?

A

50% traumatic,but classically post seizure or electrocution

888
Q

What is the examination of posterior glenohumeral dislocation?

A

(1) Shoulder locked in internal rotation
(2) XRs may show lightbulb appearance

889
Q

What is the reduction technique of posterior glenohumeral dislocation?

A

Gentle lateral traction to adducted arm

890
Q

What is the incidence of inferior glenohumeral dislocation?

A

Rare

891
Q

What is the cause of inferior glenohumeral dislocation?

A

Associated with

(1) pectoral and rotator cuff tears
(2) glenoid fracture

892
Q

What is the examination of inferior glenohumeral dislocation?

A

As for primary injury

893
Q

What is reduction technique of inferior glenohumeral dislocation?

A

Management of primary injury

894
Q

What is incidence of superior glenohumeral dislocation?

A

Rare

895
Q

What is cause of superior glenohumeral dislocation?

A

Associated with acromion/clavicle fracture

896
Q

What is the examination of superior glenohumeral dislocation?

A

As for primary injury

897
Q

What is reduction technique of superior glenohumeral dislocation?

A

Management of primary injury

898
Q

What are the associated injuries with glenohumeral dislocation ?

A
899
Q

Define Bankart lesion

A

+Avulsion of the anterior glenoid labrum with an anterior shoulder dislocation
(reverse Bankart if poster labrum in posterior dislocation)
+Associated with glenohumeral dislocation

900
Q

Discuss Hill Sachs defect

A

*Definition
Chondral impaction on posteriorsuperior humeral head from contact with glenoid labrum
(Reverse Hill Sachs in posterior dislocation)

*Treatment
Can be large enough to lock shoulder,requiring open reduction

901
Q

What are the causes of rotator cuff tear?

A

(1) Chronic subacromial impingement-in older patients
(2) Avulsion injury-in younger patients

902
Q

What is the clinical picture of rotator cuff tear?

A
903
Q

What are the types of rotator cuff disease?

A

(1) Subacromial impingement
(2) Rotator cuff tears
(3) Rotator cuff arthropathy(a rtheritis)

904
Q

Discuss anatomy of rotator cuff

A
905
Q

Discuss action of rotator cuff muscles

A

The rotator cuff is composed of four muscles:

  • Supraspinatus – abduction
  • Infraspinatus – external rotation
  • Teres minor – external rotation
  • Subscapularis – internal rotation
906
Q

What is the incidence of rotator cuff tear?

A

Acute full thickness tear

(1) In general-2.5 per 10000,approximately around 20% f the general population
(2) Age-40-70 years of age

907
Q

Enumerate risk factors of rotator cuff tears?

A

1st/main risk factors for rotator cuff tears are(mnemonic;ROTA) (1)Age, (2)Trauma, (3)Overuse, and (4)Repetitive overhead shoulder motions (e.g. athletes, certain occupations).

2nd/Other risk factors include(mnemonic;OSD) (1)O***_besity (2)Smoking (3)D_***iabetes mellitus.

908
Q

Discuss classification of rotator cuff tear

A

Rotator cuff tears are classified as either

1st/According to duration:(1)acute tears(lasting <3 months) or (2)chronic tears(lasting >3 months) .

2nd/According to thickness of the tear

(1)partial thickness tears or . (2)full thickness tears;Full thickness tears can be further classified into +small (<1cm), +medium (1-3cm), +large (3-5cm), or +massive (>5cm or involves multiple tendons)

909
Q

Discuss pathophysiology of rotator cuff tear

A

1st/Acute tears +commonly occur within tendons with pre-existing degeneration +typically occurring alone following minimal force. However, +acute tears can occur in young individuals subjected to a larger force; these will therefore often occur alongside other injuries in the young.

2nd/Chronic tears +occur in individuals with degenerative microtears to the tendon +most commonly from overuse +seen in greater incidence with increasing age

910
Q

Discuss clinical picture of the rotator cuff tear

A

1st/Symptoms (1)history of trauma with no fracture (2)pain over the lateral aspect of shoulder localised to the acromion (3)inability to initiate abduction or abduct the arm above 90 degrees but the patient can do minimal abduction (4)Tears are more common in the dominant arm.

2nd/On examination. (1)tenderness over the greater tuberosity and subacromial bursa regions. (2)Supraspinatus and infraspinatus atrophy can be seen in massive rotator cuff tears. (3)Specific Tests

There are specific tests that can be performed to help assess for the presence of a rotator cuff tear and elucidate which tendon(s) are affected:

a) Jobe’s test (the “empty can test”, tests supraspinatus) – place the shoulder in 90° abduction and 30° of forward flexion and internally rotate fully (as if you’re ‘emptying a can’), gently push downwards on the arm. +A positive test is present if there is weakness on resistance

b) Gerber’s lift-off test (tests subscapularis) – internally rotate the arm so the dorsal surface of hand rests on lower back, then ask the patient to lift hand away from back against examiner resistance +A positive test is weakness in actively lifting the hand away from back (compare to the contralateral side)

c) Internal rotation lag test(test subscapularis)

d) External rotation lag test(tests for infraspinatus)

e) Posterior cuff test (tests infraspinatus and teres minor) – the arm positioned at patient’s side, with the elbow flexed to 90°, then the patient is instructed to externally rotate their arm against resistance +A positive test is present if there is weakness on resistance

911
Q

What are th specific tests used to diagnose rotator cuff tear

A

(1) Jobe’s test- positive for supraspinatus muscle
(2) Internal rotation lag sign-positive for subscabularis muscle
(3) Gerber’s lift-off test-positive for subscabularis muscle
(4) External rotation lag test-positive for infraspinatus muscle

Absense of these clinical signs make rotator cuff tear less likely

912
Q

What are the investigations of rotator cuff tear?

A

(1) Urgent plain film radiograph +Patients presenting with clinical features of a rotator cuff tear should have an to exclude a fracture. +Whilst most plain film radiographs will be unremarkable, in chronic tears, there may be evidence of reduced acromiohumeral distance or sclerosis and cyst formation the rotator cuff insertion on the greater tuberosity.
(2) Ultrasonograhy. . +Once fracture has been excluded, rotator cuff tears can be assessed through further imaging. +can establish the presence and size of tear.

(3)MRI imaging +can also be used to detect the size, characteristics, and location of the tear.

913
Q

What is the differential diagnosis of rotator cuff tear?

A

(1)shoulder fracture. (2)persistent glenohumeral subluxation (3)brachial plexus injury. (4)radiculopathy.

914
Q

Discuss treatment of rotator cuff tear management?

A

*Prerequisite
When considering repair of a cuff tear the following should be considered when making a surgical plan
(1)age of patient
(2)functional status and activity of the patient
(3)nature of the tear(degenerative vs. acute traumatic)
(4)size and retraction of the tear (5)type of the tear

*Indications 1st/conservative (1)patients who are not limited by pain or loss of function (2)patients with significant co-morbidities (3)patients who are unsuitable for surgery (4)patients who are presenting within 2 weeks since injury (5)mild tears or tears in the elderly 2nd/surgical (1)patients who are presenting within 2 weeks since injury and remained symptomatic despite conservative management (2)Moderate tears
(3)Large or massive or retracted or complex tears

*Details

(1) Mild tears or tears in the elderly-managed conservatively
(2) Moderate tears-repaired arthroscopically allowing for earlier recovery
(3) Large or massive or retracted or complex tears-open repair(occasionally with a tendon transfer).Subacromial decompression is performed at the same time to reduce symptoms and recurrence

915
Q

What are the prerequisite of rotator cuff tear management?

A

When considering repair of a cuff tear the following should be considered when making a surgical plan

(1) age of patient
(2) functional status and activity of the patient
(3) nature of the tear(degenerative vs. acute traumatic)
(4) size and retraction of the tear (5)type of the tear

916
Q

What are the indications of conservative and surgical management for rotator cuff tear?

A

1st/conservative (1)patients who are not limited by pain or loss of function (2)patients with significant co-morbidities (3)patients who are unsuitable for surgery (4)patients who are presenting within 2 weeks since injury (5)mild tears or tears in the elderly 2nd/surgical (1)patients who are presenting within 2 weeks since injury and remained symptomatic despite conservative management (2)Moderate tears
(3)Large or massive or retracted or complex tears

917
Q

What are the indications of conservative management for rotator cuff tear?

A

(1)patients who are not limited by pain or loss of function (2)patients with significant co-morbidities (3)patients who are unsuitable for surgery (4)patients who are presenting within 2 weeks since injury (5)mild tears or tears in the elderly

918
Q

What are the indications of surgical management for rotator cuff tear?

A

(1) patients who are presenting within 2 weeks since injury and remained symptomatic despite conservative management (2)Moderate tears
(3) Large or massive or retracted or complex tears

919
Q

What are the details of rotator cuff tear management?

A

(1) Mild tears or tears in the elderly-managed conservatively
(2) Moderate tears-repaired arthroscopically allowing for earlier recovery
(3) Large or massive or retracted or complex tears-open repair(occasionally with a tendon transfer).Subacromial decompression is performed at the same time to reduce symptoms and recurrence

920
Q

What are the complications of rotator cuff tear?

A

(1)adhesive capsulitis The main complication from the condition is leading to stiffness of the glenohumeral joint.

(2)enlargement of tears Ocurrs within 5 years in 40% of those with age-related tears. Of those whose tears enlarge, 80% will become symptomatic.

921
Q

Discuss prognosis of rotator cuff tear

A

(1)Good prognosis

Prognosis following surgical repair overall tends to be very good

(2)Bad prognosis in those with

(1)large or massive tears. (2)age >65yrs (3)poor compliance with rehabilitation programs (4)current smokers often have worse outcomes.

922
Q

What is the location of the subacromial space?

A

(1) Below the subacromial arch
(2) Above the humeral head and greater tuberosity of the humerus

923
Q

What are the structures that form the subacromial arch?

A

Consists of(lateral to medial)the:

(1)acromion. (2)coracoacromial ligament(anterior to the acromioclavicular joint) (3)coracoid process

924
Q

What are the contents of the subacromial space?

A

Within the subacromal space run the (1)rotator cuff tendons (2)long head of biceps tendon (3)coraco-acromial ligament (4)all surrounded by the subacromial bursa which helps to reduce friction between these structures.

925
Q

What are the other names for subacromial impingement syndrome(SAIS)?

A

1) PAINFUL ARC
2) SUBACROMION TENDINITIS
3) CHRONIC SUPRASPINATUS TENDINITIS

926
Q

Define subacromial impingement syndrome(SAIS)?

A

inflammation and irritation of the rotator cuff tendons as they pass through the subacromial space, resulting in pain, weakness, and reduced range of motion within the shoulder.

927
Q

What are the pathologies that constitute subacromial impingement syndrome(SAIS)

A

SAIS encompasses a range of pathology including

(1)rotator cuff tendinosis (2)subacromial bursitis (3)calcific tendinitis

All these conditions result in an attrition between the coracoacromial arch and the supraspinatus tendon or subacromial bursa.

928
Q

What is the incidence of the subacromial impingement syndrome(SAIS)?

A

It occurs most commonly in patients under 25 years, typically in active individuals or in manual professions, and accounts for around 60% of all shoulder pain presentations, making it the most common pathology of the shoulder.

929
Q

Discuss cause of subacromial impingement

A

The most common cause of shoulder pain which results from

(1) Impingement of the superior cuff on the undersurface of the acromion
(2) Inflammatory bursitis

930
Q

What is the clinical picture of subacromial impingement?

A

I)Symptoms Pain-(1)insidious
(2)in the anterior superior shoulder (3)progressive (4)exacerbated by overhead activities abduction in the affected shoulder (5)relieved by rest (6)associated with weakness and stiffness secondary to the pain. (7)chronic pain in mid abduction(60-120)but no pain in early or late abduction

II)Two common examination signs can be elicited in cases of SAIS (specifically for subacromial impingement):

  • Neers Impingement test – The arm is placed by the patient’s side, fully internally rotated and then passively flexed, and is positive if there is pain in the anterolateral aspect of the shoulder.
  • Hawkins test – The shoulder and elbow are flexed forward to 90 degrees, with the examiner then stablising the humerus and passively internally rotates the arm, and the test is positive if pain is in the anterolateral aspect of the shoulder. III)Bigliani classification-associated with certain types of acromial morphology
931
Q

Define rotator cuff arthropathy

A

Shoulder arthritis in the setting of rotator cuff dysfunction

932
Q

What is the cause of rotator cuff arthropathy?

A

(1)Superior migration due to the loss of rotator cuff function and integrity
(2)Unopposed deltoid pulls the humeral head superiorly
​(3)Associated with massive chronic cuff tears

933
Q

What is the imaging of rotator cuff arthropathy?

A

1st/Plain radiographs
I]AP view of shoulder
(1)superior migration of the humerus with a cuff tear
(2)features of arthritis with arthropathy
(3)other causes of pain,e.g.,calcific tendonitis/fracture
II]Outlet view
Useful for defining the acromial morphology

2nd/USS

(1) Allows dynamic imaging of the cuff
(2) inexpensive
(3) very user dependent

3rd/MRI

(1) Best imaging modality for cuff pathology
(2) Allows imaging of the rest of the shoulder
(3) When intra-articular pathology is suspected can be combined with an arthrogram for improved sensitivity and specificity

934
Q

What plain radiographs show in rotator cuff arthropathy?

A

I]AP view of shoulder
(1)superior migration of the humerus with a cuff tear
(2)features of arthritis with arthropathy
(3)other causes of pain,e.g.,calcific tendonitis/fracture
II]Outlet view
Useful for defining the acromial morphology

935
Q

What AP view of the shoulder on plain radiographs shows in rotator cuff arthropathy?

A

(1) superior migration of the humerus with a cuff tear
(2) features of arthritis with arthropathy
(3) other causes of pain,e.g.,calcific tendonitis/fracture

936
Q

What outlet view on plain radiographs shows in rotator cuff arthropathy?

A

Useful for defining the acromial morphology

937
Q

What USS shows in rotator cuff arthropathy?

A

(1) Allows dynamic imaging of the cuff
(2) inexpensive
(3) very user dependent

938
Q

What MRI shows in rotator cuff arthropathy?

A

(1) Best imaging modality for cuff pathology
(2) Allows imaging of the rest of the shoulder
(3) When intra-articular pathology is suspected can be combined with an arthrogram for improved sensitivity and specificity

939
Q

What is the treatment of subacromial impingement?

A

(1)Physiotherapy
(2)Oral anti-inflammatory medication
(3)Subacromial steroid injection
(3)Arthroscopic subacromial decompression-by shaving away the undersurface of the acromion,more space is created for the
rotator cuff
(4)Cuff integrity can be assessed at time of surgery and can be repaired

940
Q

Define calcific tendonitis

A
941
Q

What is the incidence of calcific tendonitis?

A

More common in women aged 30-60 years

942
Q

What is the pathology of calcific tendonitis?

A

(1) When present in the shoulder,it is associated with subacromial impingement and pain
(2) Associated with diabetes and hypothyroidism

(3)Calcifications are usually loctated within the supraspinatus tendon(80% of cases),followed by the infraspinatus(15% of cases)

943
Q

What are the stages or phases of calcific tendonitis?

A
944
Q

What is the presentation of calcific tendonitis?

A

1st/shoulder pain similar in presentation to subacromial impingement

(1) sudden
(2) acute
(3) severe
(4) present even at rest on alla movements
(5) pain over head activities
(6) a traumatic in nature
(7) aggrevated by elevation of the arm above shoulder or by lying on the shoulder
(8) awaken the patient from sleep

2nd/other complaints

(1) stiffness
(2) snapping
(4) catching
(5) shoulder weakness

945
Q

What is the imaging of calcific tendonitis?

A
946
Q

What is the treatment of calcific tendonitis?

A
947
Q

What is the other name of adhesive capsulitis?

A

Frozen shoulder

948
Q

What is the pathogenesis of adhesive capsulitis(frozen shoulder)?

A

The following points are in order:-

(1) Fibroplastic proliferation of capsular tissue
(2) Soft tissue scarring and contracture
(3) Pain and loss of movement of shoulder joint
(4) Patient present with a painful and decreased arc of motion

949
Q

What are the causes of adhesive capsulitis(Frozen shoulder)?

A

Associated with

(1) Prolonged immobilisation
(2) Previous surgery
(3) Thyroid disorder(AI)
(4) Diabetes

950
Q

What are the stages of adhesive capsulitis(Frozen shoulder)?

A
951
Q

How long does it take for the stages of adhesive capsulitis(Frozen shoulder)to resolve?

A

Up to 2 years

952
Q

What is the imaging of adhesive capsulitis(Frozen shoulder)?

A
953
Q

What is the treatment of adhesive capsulitis(frozen shoulder)?

A
954
Q

What are the causes of glenohumeral arthritis?

A

(1) Osteoarthritis(1ry or 2ry to cuff tear or trauma)
(2) Rheumatoid arthritis(RA)-Majority of those with RA will develop symptoms
(3) As part of a spondyloarthropathy

955
Q

What is the incidence of glenohumeral arthritis?

A

More common in the elderly

956
Q

What is the clinical picture of glenohumeral arthritis?

A

Presents like any other arthritis-pain at night and with movement

957
Q

What is the imaging of glenohumeral arthritis?

A
958
Q

What is the treatment of glenohumeral arthritis?

A
959
Q

What are the causes of painful shoulder?

A
960
Q

Few signs and tests in orthopaedics

A
961
Q

A better flow chart for management of neck of femur fracture by Dr Salah(orthopaedician in Salah course)

A
962
Q

How do you define stability of ankle fracture?

A

p

963
Q

What is the main objective of management of Perthes disease?

A

To keep the femoral head within the acetabulum by cast,

964
Q

What is the incidence of sponylolisthesis?

A

a young atheletic female with a background of spondylolysis and presents with a sudden pain

965
Q

What are the manifestations of acromioclavicular arthritis?

A

shoulder pain (1)over the superior aspect of the shoulder (2)worse with internal rotation which is tested by asking the patient to place his arm behind the back

966
Q

What is the cause of acromioclavicular joint(ACJ)dislocation?

A

Direct injury to the superior aspect of the acromion

967
Q

What are the manifestations of acromioclavicular joint(ACJ)dislocation?

A

(1)loss of shoulder contour (2)prominent clavicle

MRCS part A- Principles of surgery in general (6 decks)

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