Orthopaedic Passmedicine Flashcards
1
Q
What is first line for back pain?
A
NSAIDs
2
Q
What investigation should be offered to those with non-specific back pain?
A
MRI - ONLY if results likely to change management (i.e. where malignancy, infection, fracture, cauda equina or AS is suspected)
3
Q
What advice should you give to people with back pain?
A
Encourage self management
Stay physically active
Exercise
4
Q
What patients should be co-prescribed PPIs if they are given NSAIDs?
A
> 45y
5
Q
What are some other treatments of back pain?
A
Exercise programme
Manual therapy - spinal manipulation, mobilisation, massage
Radiofrequency denervation
Epidural injections of LA/steroid for acute severe sciatica
6
Q
What is the only imaging technique that allows you to see soft tissue structures?
A
MRI
7
Q
What is a common cause of lateral knee pain in runners?
A
Iliotibial band syndrome
8
Q
Where is the tenderness in iliotibial band syndrome?
A
2-3cm above lateral joint line
9
Q
What is involved in the management of iliotibial band syndrome?
A
Activity modification, iliotibial band stretches
If not improving –> physio referral
10
Q
What may compartment syndrome follow?
A
Fractures
Ischaemia reperfusion injury in vascular patients
11
Q
What is compartment syndrome?
A
Raised pressure within a closed anatomical space –> compromises tissue perfusion –> necrosis
12
Q
What are the two main fractures that cause compartment syndrome?
A
Supracondylar fractures
Tibial shaft injuries
13
Q
What are the features of compartment syndrome?
A
Pain (esp on movement, even passive, rapidly progressive, non-responsive to analgesics) Paraesthesiae Pallor Arterial pulsation may still be felt Paralysis of muscle group may occur
14
Q
How can you still feel an arterial pulsation in compartment syndrome?
A
Necrosis results due to microvascular compromise SO presence of a pulse does not rule out compartment syndrome
15
Q
How is compartment syndrome diagnosed?
A
Measuring intracompartmental pressure (>20mmHg abnormal, >40mmHg diagnostic)
16
Q
How is compartment syndrome managed?
A
Prompt + extensive
fasciotomies
Debridement of necrotic tissue
17
Q
What complication may occur following fasciotomy?
A
Myoglobulinuria –> renal failure (these pts need aggressive IV fluids)
18
Q
How long does it take for muscle groups to die in compartment syndrome?
A
4-6h
19
Q
What does myoglobuinuria look like?
A
Dark, brown coloured urine that drips positively for blood
20
Q
What are some specific causes for Dupuytren’s contracture?
A
Manual labour Phenytoin treatment Alcoholic liver disease DM Trauma to the hand
21
Q
Who is more at risk of Dupuytren’s contracture?
A
Older male patients
Those with FH
22
Q
What fingers tend to be affected in Dupuytren’s contracture?
A
Ring finger, little finger
23
Q
How is Dupuytren’s contracture managed?
A
Surgery - fasciectomy
24
Q
When should you consider surgery for Dupuytren’s contracture?
A
When unable to straighten out metacarpophalangeal joints and hand cannot be placed flat on table
25
What are the features of a prolapsed disc?
Clear dermatomal leg pain + assoc. neurological deficits
Leg pain usually worse than back
Pain worse when sitting
26
What features are in line with an L3 nerve root compression?
Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
27
What features are in line with an L4 nerve root compression?
Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
+ve femoral stretch tests
28
What features are in line with an L5 nerve root compression?
Sensory loss dorsum of foot
Weakness in foot + big toe dorsiflexion
Reflexes intact
+ve sciatic nerve stretch test
29
What features are in line with an S1 nerve root compression?
Sensory loss posterolateral aspect of leg + lateral aspect of foot
Weakness in plantarflexion of foot
Reduced ankle reflex
+ve sciatic nerve stretch test
30
How is prolapsed disc managed?
Analgesia (anti-neuropathic), physio, exercises
If symptoms persist >4-6w then refer for consideration of MRI
31
What are the Ottawa ankle rules?
X-ray only req. if pain in malleolar zone +
1. inability to wt bear for 4 steps
2. tenderness over distal tibia
3. bone tenderness over distal fibula
32
What is a popular classification system for describing ankle fractures?
Weber
33
What is the Weber classification?
Related to level of fibular fracture
A. below syndesmosis
B. fracture starts at level of tibial plafond + may extend proximally to involve syndesmosis
C. above syndesmosis (incl. syndesmosis)
34
What is a Masionneuve fracture?
Spiral fibular fracture that leads to disruption of the syndesmosis with widening of the ankle joint
35
How is a Masionneuve fracture managed?
Surgery
36
What is the management of ankle fractures?
Prompt reduction to remove pressure on overlying skin + subsequent necrosis
37
What kind of ankle fractures will req. surgery?
Young patients with unstable, high velocity or proximal injuries
38
What does surgery for ankle fractures usually involve?
Compression plate
39
Who tends to get conservative management for ankle fractures?
Elderly, potentially unstable injuries
| as their bone doesn't hold metalwork as well
40
How should stable/minor ankle fractures be managed?
Weight bearing as tolerated in a controlled ankle motion (CAM) boot
41
Define discitis
Infection in the intervertebral disc space
42
What is a complication of discitis?
Sepsis
| Epidural abscess
43
What are the features of discitis?
```
Back pain
General features (pyrexia, rigors, sepsis)
Neurological changes - e.g. changing lower limb neurology if epidural abscess develops
```
44
What is the most common cause of discitis?
Staph aureus
45
Apart from bacteria what else can cause discitis?
Viruses
TB
Aseptic
46
What is the best imaging for discitis?
MRI
CT guided biopsy may be req. to guide antimicrobial treatment
47
How is discitis treated?
6-8w of IV antibiotics
48
How do you decide what antibiotics to give in discitis?
Culture (CT guided biopsy or blood culture)
49
What further investigations might you do in discitis?
Check for endocarditis (e.g. TOE/TTE) - esp. if it due to staph
50
What kind of movements usually result in meniscal tears?
Twisting movements
51
What are the features of meniscal tears?
```
Pain worse on straightening the knee
Knee may give way
Displaced meniscal tears may --> knee locking
Tenderness along joint line
Thessaly's test +ve
```
52
What is Thessaly's test?
Wt bearing at 20 degrees of knee flexion, pt supported by doctor, positive if pain on twisting the knee
53
What is Froment's test used for?
Assess for ulnar nerve palsy
| Tests adductor pollicis muscle function
54
How do you perform Froment's test?
Hold piece of paper between thumb and index finger and pull it away
If ulnar n. palsy unable to hold paper and will flex flexor pollicis longus to compensate (flexion of thumb at IP joint)
55
What is Phalen's test used for?
Assessing for carpal tunnel syndrome
56
Which of Phalen's and Tinel's is more sensitive?
Phalen's
57
How do you perform Phalen's test?
Hold wrist in maximum flexion (reverse prayer sign) for 30-60s + test +ve if there is numbness in median n. distribution
58
What is tinel's test used for?
Assessing for carpal tunnel syndrome
59
How do you perform tinel's test?
Tap median nerve at the wrist
| +ve if tingling/electric like sensations over distribution of median nerve
60
Why is avascular necrosis a risk in displaced hip fractures?
Blood supply to femoral head runs up the neck
61
What are the features of a hip fracture?
Pain
| Shortened and externally rotated leg
62
What are the two different locations hip fractures can occur in?
Intracapsular (sucapital): from edge of femoral head to insertion of capsule at hip joint
Extracapsular: can be trochanteric or subtrochanteric
63
What structure divides subtrochanteric and trochanteric fractures?
The lesser trochanter
64
What system is used to classify hip fractures?
Garden system
65
What is the Garden system?
Type I: Stable fracture with impaction in valgus
Type II: Complete fracture but undisplaced
Type III: Displaced fracture, usually rotated and angulated, but still has boney contact
Type IV: Complete boney disruption
66
What Garden types most commonly lead to bloody supply disruption?
3 and 4
67
How should an undisplaced intracapsular hip fracture be managed?
Internal fixation
| Hemiarthroplasty if unfit
68
How should a displaced intracapsular fracture be managed?
Young + fit (<70) - reduction and internal fixation
Older + reduced mobility - hemiarthroplasty or THR
69
How should extracapsular hip fractures be managed?
Dynamic hip screws
70
How should reverse oblique, transverse of subtrochanteric extracapsular fractures be managed?
Intramedullary device
71
Should a patient with a subtrochanteric femoral fracture fixed with an intramedullary nail weight bear after the operation?
Yes - should weight bear immediately as tolerated
72
What is the motor supply of the femoral nerve?
Knee extension
| Thigh flexion
73
What is the sensory supply of the femoral nerve?
Anterior and medial aspect of thigh and lower leg
74
What is the typical mechanism of injury of the femoral nerve?
Hip/pelvic fractures
| Stab/gunshot wounds
75
What is the motor supply of the obturator nerve?
Adduction of thigh
76
What is the sensory supply of the obturator nerve?
Medial thigh
77
What trauma may injure the obturator nerve?
Anterior hip dislocation
78
What is the motor supply of the lateral cutaneous nerve of the thigh?
None
79
What is the sensory supply of the lateral cutaneous nerve of the thigh?
Lateral + posterior surfaces of the thigh
80
Where is the lateral cutaneous nerve of the thigh likely to get compressed? What results?
```
ASIS
Meralgia paraesthetica (pain, tingling + numbness in the distribution of the lateral cutaneous nerve of the thigh)
```
81
What is the motor supply of the tibial nerve?
Foot plantarflexion and inversion
82
What is the sensory supply of the tibial nerve?
Sole of foot
83
What kind of injuries may lead to damage to the tibial nerve?
Popliteal lacerations
| Posterior knee dislocation
84
What is the motor supply of the common peroneal nerve?
Foot dorsiflexion and eversion
| Extensor hallicus longus
85
What is the sensory supply of the common peroneal nerve?
Dorsum of foot + lower lateral part of leg
86
Where does injury of the common peroneal nerve commonly occur?
Around neck of fibula
| E.g. may happen if a plaster cast is applied too tightly
87
What does injury to the common peroneal nerve lead to?
Foot drop
88
What is the motor supply of the superior gluteal nerve?
Hip abduction
89
What is the sensory supply of the gluteal nerves?
None
90
What may cause damage to the superior gluteal nerve?
Misplaced IM injection
Hip surgery
Pelvic fracture
Posterior hip dislocation
91
What does damage to the superior gluteal nerve lead to?
+ve Trendelenburg sign
92
What is the motor supply of the inferior gluteal nerve?
Hip extension + lateral rotation
93
What does injury to the inferior gluteal nerve lad to?
Difficulty rising from seated position
| Can't jump, climb stairs
94
What are risk factors for congenital hip dislocation?
```
Female gender
Breech presentation
Family history
Firstborn
Oligohydramnios
```
95
What two tests are used to get for DDH?
Barlow
Ortolani
(those at risk have an USS)
96
What is the most sensitive sign of compartment syndrome?
Pain on passive stetch
97
What age do children tend to get transient synovitis?
2-10y
98
What is transient synovitis?
Acute hip pain associated with a viral infection
99
What is the most common cause of hip pain in children?
Transient synovitis
100
What is perthes disease?
Degenerative condition affecting the hips of children
101
What age do children tend to get perthes?
4-8y
102
What causes perthes?
Avascular necrosis of the femoral head
103
In which gender is perthes more common?
Boys
104
What are the features of perthes?
Hip pain - progressive over a few wks
Limp
Stiffness, reduced RoM
105
What findings do you see on X-ray in perthes disease?
Early changes - widening of joint space
| late changes - decreased femoral head size/flattening
106
What age typically do children get SUFE?
10-15y
107
Who is SUFE more common in ?
Obese boys
108
What occurs in SUFE?
Displacement of the femoral head epiphysis posterior-inferiorly
109
In what two ways can SUFE present?
Acutely after trauma
| With chronic, persistent symptoms
110
What are the features of SUFE?
Knee/distal thigh pain
| Loss of internal rotation of leg in flexion
111
What is JIA?
Arthritis occurring in someone who is less than 16y, lasting >3m
112
What is pauciarticular JIA?
4 or less joints affected
| Most common type of JIA
113
What are the features of pauciarticular JIA?
Joint pain + swelling - usually medium sized joints (knees, ankles, elbows)
Limp
ANA +ve (assoc. with anterior uveitis)
114
What is the typical presentation of septic arthritis?
Acute hip pain + systemic upset (pyrexia)
| Inability/severe limitation of affected joint
115
What is another name for frozen shoulder?
Adhesive capsulitis
116
What is adhesive capsulitis associated with?
Diabetics
117
What movement is affected most in adhesive capsulitis?
External rotation
118
What are the features of adhesive capsulitis?
Active + passive movement affected
| Freezing phase, adhesive phase, recovery phase
119
How long do episodes of adhesive capsulitis typically last?
6m-2y
120
How is adhesive capsulitis managed?
NSAIDs, physio, oral corticosteroids, IA corticosteroids
121
Define open fracture
Disruption of the bony cortex associated with a breach in the overlying skin
122
Any wound that is present in the same limb as a fracture should be suspected as representing what?
An open fracture
123
What system is used to classify open fractures?
Gustilo and Anderson system
124
What is the Gustilo and Anderon system?
1. Low energy wound <1cm
2. Greater than 1cm wound with moderate soft tissue damage
3. High energy wound >1cm with extensive soft tissue damage
3A. Adequate soft tissue coverage
3B. Inadequate soft tissue coverage
3C. Associated arterial injury
125
In gustilo T3C injuries what system may be used to predict the need for primary amputation?
Mangled extremity scoring system (MESS)
126
How should open fractures be managed?
1. Ex for assoc. injuries, control of haemorrhage, extent of injury
2. Imaging to establish distal neurovascular status
3. Cover wound with dressing + give antibiotics, take photo of wound
4. Debridement + irrigation
5. Stabilise
127
What does debridement involve?
Removing foreign material and devitalised tissue
128
How many Ls of fluid should be used to irrigate an open fracture wound?
At least 6L saline
129
What is often used to stabilise an open fracture in the first instance?
External fixator
130
Management of an intracapsular fracture, displaced + independently mobile, does not use more than a stick
Total hip replacement
131
Management of an intracapsular fracture, displaced + not independently mobile
Hemiarthroplasty, cement implants preferred
132
Management of a trochanteric fracture
Sliding hip screw
133
Management of a subtrochanteric fracture
Intramedullary nail
134
What is a psoas abscess?
Collection within the psoas muscle
135
What vertebral levels does the psoas muscle lie over?
T12-L5
136
Where does the psoas muscle insert?
Lesser trochanter of femur
137
Psoas abscess can be of primary origin or as what?
A result of spread from local sources, e.g. pyelonephritis, IBD
138
What are complications of psoas abscesses?
Septicaemia + multi organ failure
139
What is the most common organism causing psoas abscess?
Staph or strep
140
What are risk factors for developing a primary psoas abscess?
Immunosupression, e.g. HIV, cancer, DM
IVDA
Prev. surgery
TB
141
What is the pain like in psoas abscess? Is there a fever?
Increases over several days
| May be a fever
142
How can you evidence psoas irritation?
When position of comfort is pt lying on back with slightly flexed knees
143
Apart from pain + fever what other feature may you see in psoas abscess?
Inability to wt bear or pain when moving the hip
144
What investigations should you do for suspected psoas abscess?
Bloods
Septic screen
CT abdomen/MRI
145
What is the gold standard imaging used to identify psoas abscess?
MRI
146
What is the management of psoas abscess?
Antibiotics +/- drainage
| Management of RFs
147
What are buckle fractures?
Incomplete fractures of the shaft of a long bone characterised by bulging of the cortex
148
In who do buckle fractures tend to occur?
5-10yos
149
How are buckle fractures managed?
Usually self-limiting so can be managed with splinting + immobilisation rather than a cast
150
Why do children get buckle fractures instead of proper breaks in their bones?
Their bone is more elastic so axial trauma --> deformity rather than a true fracture
151
What sort of things tend to lead to hip dislocation?
Direct trauma, e.g. road traffic accident/fall from significant height
Large amounts of forces req. to dislocate hip
152
What must you be aware of in hip fractures?
Huge amounts of forces req. to dislocate hip so may be associated with fractures or life-threatening injuries
153
What are the features of hip dislocation?
Extreme pain
| Deformity depending on type
154
What is the most common type of hip dislocation?
Posterior dislocation (90%)
155
What is the appearance of a posterior hip dislocation?
Affected leg shortened, adducted and internally rotated
156
What is the appearance of a anterior hip dislocation?
Affected leg abducted and externally rotated with NO leg shortening
157
What are the three types of hip dislocation?
Posterior
Anterior
Central
158
How do you manage hip dislocations?
ABCDE
Analgesia
Reduction under GA within 4h
159
What is involved in the long term management of hip dislocations?
Physio to strengthen surrounding muscles
160
Why should you reduce a hip fracture within 4h?
To reduce risk of avascular necrosis
161
What are complications of hip fracture?
Sciatic/femoral nerve injury
Avascular necrosis
OA
Recurrent dislocation
162
Why are patients who have had a hip fracture at risk of recurrent dislocation?
Due to damage of supporting ligaments
163
How long does it take for a hip to heal after a traumatic dislocation?
2-3m
164
When is prognosis best after a hip dislocation?
If hip reduced less than 12h post-injury and when there is less damage to the joint
165
What are baker's cysts?
Distensions of the gastrocnemius-semimembranosus bursa
166
What are the two types of baker's cysts?
Primary
| Secondary - underlying condition, e.g. OA
167
Who are primary baker's cysts usually seen in?
Children
168
Where are baker's cysts?
In popliteal fossa
169
What are the feature of ruptured baker's cyst?
Similar to DVT - pain, redness, swelling in calf
| But most are asymptomatic
170
How should you manage baker's cysts in children?
These typically resolve and don't require treatment
171
How should you manage baker's cysts in adults?
Treat underlying cause
172
How do baker's cysts tend to present?
Asymptomatic, fluctuant swelling behind the knee
173
Where is the pain + tenderness in medial epicondylitis?
Medial epicondyle
174
What is medial epicondylitis also known as?
Golfer's elbow
175
What aggravates the pain in golfer's elbow?
Wrist flexion + pronation
176
What other symptoms may you get in golfer's elbow?
Numbness/tingling in 4th + 5th finger due to ulnar nerve involvement
177
What most commonly causes radial tunnel syndrome?
Compression of the posterior interosseous branch of the radial nerve
178
What is thought to cause radial tunnel syndrome?
Overuse
179
What are the features of radial tunnel syndrome?
Similar to lateral epicondylitis but pain is 4-5cm distal to lateral epicondyle
Symptoms worsened by extending elbow + pronating forearm
180
What is cubital tunnel syndrome due to?
Compression of the ulnar nerve
181
What are the features of cubital tunnel syndrome?
Intermittent tingling in 4th + 5th finger
| Worse when elbow resting on firm surface/flexed for extended periods
182
What are later features of cubital tunnel syndrome?
Numbness in 4th and 5th finger with associated weakness
183
What are the features of olecranon bursitis?
Swelling over posterior aspect of elbow
| May be pain, warmth, erythema
184
What kind of injuries tend to lead to AC joint injury?
Collison sports, e.g. rugby
| Fall on outstretched hand
185
How are AC injuries graded?
I-VI
186
How are AC injuries grade I-II managed?
Conservatively - rest + sling
187
What grades of AC injury require surgical intervention?
IV, V, VI
188
How are grade III AC injuries managed?
Depends on individual circumstances
189
What is the stimson maneuver?
Used for reduction of dislocated shoulders
190
What will you see on X-ray in compartment syndrome?
Typically no pathology
191
What sorts of people may get compartment syndrome without having had a fracture?
Those who intensively exercise
| Those with bleeding disorders, e.g. haemophilia
192
Why is subluxation of the radial head more common in young children?
Distal attachment of the annular ligament covering the radial head is weaker in children
193
What are signs of subluxation of the radial head?
Elbow pain, limited supination, extension of the elbow
| Child usually refuses examination
194
How is subluxation of the radial head managed?
Analgesia + passively supination of the elbow joint whilst elbow is flexed to 90 degrees
195
What is lumbar spinal stenosis?
When the central canal is narrowed by a tumour, disc prolapse or degenerative changes
196
How do patients with lumbar spinal stenosis present?
Back pain, neuropathic pain, claudication type symptoms
197
How can you distinguish the claudication from lumbar spinal stenosis from vascular claudication?
Sitting is better than standing
| Easier to walk uphill/ride a bike
198
What is the most common cause of lumbar spinal stenosis?
Degenerative disease
199
Where is degeneration thought to start in lumbar spinal stenosis?
IV disc - biochemical changes, e.g. cell death + loss of proteoglycan + water content --> progressive disc bulging and collapse
--> increased stress on posterior facets which accelerates cartilaginous degeneration, hypertrophy + osteophyte formation, this is associated with thickening + distortion of the ligamentum flavum
200
What things narrow the central canal in lumbar spinal stenosis?
Ventral disc bulging
Osteophyte formation at dorsal facet
Ligamentum flavum hypertrophy
201
What does central canal narrowing mean?
Less space for neurons
202
What nerves are compressed in lumbar spinal stenosis?
Cauda equina nerve roots
203
What is the best imaging to see lumbar spinal stenosis?
MRI
204
How is lumbar spinal stenosis managed?
Laminectomy
205
What are the features of cauda equina syndrome?
Lower back pain
Urinary incontinence/retention
Reduced perianal sensation (saddle anaesthesia)
Decreased anal tone
206
How is cauda equina syndrome investigated?
Urgent MRI lumbar-sacral spine
207
How quickly should someone with suspected cauda equina syndrome be imaged?
ASAP
| Target within 6h
208
What are the complications of cauda equina syndrome?
Incontinence
| Paralysis of lower limbs
209
What is the other name for Charcot joint?
Neuropathic joint
210
What is Charcot joint?
A joint that has become badly disrupted and damaged secondary to a loss of sensation
211
What used to be the commonest cause of Charcot joint?
Syphilis (tabes dorsalis)
212
What is now the commonest cause of Charcot joint?
Diabetic neuropathy
213
What are the features of Charcot joint?
A joint that is a lot less painful that expected given degree of joint disruption
Joint is swollen, red, warm
214
What other neuropathy commonly predisposes to charcot joint?
Alcoholic neuropathy
215
Why do are charcot joints so disrupted and a mess?
It is on a weight bearing joint and individual cannot feel pain from damage so continues to walk on joint and make it worse
216
What are the cardinal features of epidural abscess?
Fever
| Back pain
217
What is De Quervain's tenosynovitis?
Inflammation of the sheath containing the extensor pollicis brevis + abductor pollicis longus tendon
218
Who does De Quervain's tenosynovitis tend to affect?
Women from 30-50ys
219
What are the features of De Quervain's tenosynovitis?
Pain on radial side of wrist
Tenderness of radial styloid
Abduction of thumb against resistance is sore
+ve Finklestein's test
220
How do you carry out Finklestein's test?
Pull thumb whilst in ulnar deviation + longitudinal traction
This causes pain over radial styloid process + along length of EPB + APL
221
How do you manage De Quervain's tenosynovitis?
Analgesia
Steroid injection
Thumb splint
Surgery
222
What muscles are in the anterior compartment of the leg?
Tibialis anterior
Extensor digitorum longus
Peroneus tertius
Extensor hallucis longus
223
What nerve innervates the anterior compartment of the leg?
Deep peroneal nerve
224
What is the action of the tibialis anterior?
Dorsiflexes ankle joint, inverts foot
225
What is the action of extensor digitorum longus?
Extends lateral 4 toes, dorsiflexes ankle joint
226
What is the action of peroneus tertius?
Dorsiflexes ankle, everts foot
227
What is the action of extensor hallucis longus?
Dorsiflexes ankle, extends big toe
228
What are the muscles of the lateral compartment of the leg?
Peroneus longus
| Peroneus brevis
229
What nerve innervates the lateral compartment of the leg?
Superficial peroneal nerve
230
What is the action of the peroneus longus?
Everts foot, assists in plantarflexion
231
What is the action of the peroneus brevis?
Plantaflexes ankle
232
What are the muscles of the superficial posterior compartment of the leg?
Gastrocnemius
| Soleus
233
What nerve innervates the posterior compartment of the leg?
Tibial nerve
234
What is the action of the gastrocnemius?
Plantarflexes foot, flexes knee
235
What is the action of soleus?
Plantarflexor
236
What are the muscles of the deep compartment of the leg?
Flexor digitorum longus
Flexor hallucis longus
Tibialis posterior
237
What is the action of flexor digitorum longus?
Flexes lateral four toes
238
What is the action of flexor hallucis longus?
Flexes great toe
239
What is the action of tibialis posterior?
Plantarflexes, inverts foot
240
What nerve is most likely to be damaged if an individual develops foot drop after a revision of a total hip replacement?
Sciatic
241
What is the most common cause of cauda equina syndrome?
Herniation of an IV disc
242
What are other causes of cauda equina syndrome?
Tumours
Infection (e.g. epidural abscess)
Haematoma
243
Who can be assessed using the FRAX tool?
40-90 year olds with or without a BMD
244
What tools do NICE recommend for assessing risk of fragility fractures?
QFracture, FRAX
245
Who should be assessed for risk of fragility fractures?
```
All women 65+ and all men 75+
Younger pts if they have:
- Had a prev. fragility fracture
- Hx of falls
- Current/frequent recent uses of oral/systemic glucocorticoids
- FH hip fracture
- Other 2ndary causes of osteoporosis
- BMI <18.5
- Smoking
- Alcohol intake >14u/w
```
246
What do FRAX and Qfracture assess?
Risk of fragility fracture in the next ten years
247
Which of QFracture and FRAX are based on UK and which is based on international data?
```
QFracture = UK
FRAX = international
```
248
What factors does FRAX assess?
```
Age
Sex
Wt
Ht
Prev. fracture
Parental fracture
Current smoking
Glucocorticoids
RA
Secondary osteoporosis
Alcohol intake
BMD optional
```
249
What score of FRAX should prompt you to arrange a DEXA scan?
Intermediate
250
What age groups can QFracture be used for?
30-99
251
What things are included in the QFracture risk factors?
```
CV dx
Hx falls
Chronic liver disease
RA
T2DM
TCAs
```
252
In which situations should you go straight to a DEXA scan and miss out FRAX/QFracture?
Before starting medications that may have a rapid adverse effect on BMD
In those <40 who have a major risk factors
253
What major risk factors may make you go straight to giving someone a DEXA scan if they are <40?
Hx of multiple fragility fractures
Major osteoporotic fracture
Current/recent use of high dose oral/system glucocorticoids
254
What treatments may have a rapid adverse effect on BMD?
Sex hormone deprivation for breast cancer/prostate Rx
255
What scores can you get from doing a FRAX without a BMD what scores can you get and what do these mean?
Low risk - reassure + lifestyle advice
Intermediate risk - offer BMD test
High risk - offer bone protection treatment
256
What scores can you get from doing a FRAX with a BMD what scores can you get and what do these mean?
Reassure
Consider treatment
Strongly recommend treatment
257
What kind of results does QFracture produce?
Raw data which then needs interpreted alongside guidelines
258
When should we reassess risk of fragility fracture (i.e. repeat FRAX/QFracture)?
If original risk was in the region of intervention threshold for a proposed treatment and only after a min of 2y or there has been a chance in someone's RFs
259
what group of drugs will worsen compartment syndrome?
Anticoagulants
260
What are the three things that can cause a fracture?
Trauma - excessive force to bone
Stress related
Pathological
261
What is a pathological fracture?
Abnormal bone that fractures during normal use or following minimum trauma
262
What causes stress fractures?
Repetitive low velocity injury
263
What should you ensure to do when examining a fracture site?
Check site + type of injury
Check for assoc. injuries and distal NV deficits
May have to radiograph proximal + distal joints
264
What is an oblique fracture?
Fracture that lies obliquely to long axis of bone
265
What is a comminuted fracture?
>2 fragments
266
What is a segmental fracture?
More than one fracture along a bone
267
What is a transverse fracture?
Perpendicular to long axis of bone
268
What is a spiral fracture?
Severe oblique fracture with rotation along long axis of bone
269
What are the key points about managing fractures?
Immobilise fracture including joint above + below
Monitor NV status
Tetanus prophylaxis
IV antibiotics if open
270
How quickly should open fractures be debrided and lavaged?
6h of injury
271
What are the types of paediatric fractures?
```
Complete fracture
Toddler's fracture
Plastic deformity
Greenstick fracture
Buckle fracture
Growth plate fractures
```
272
What is a complete fracture?
Both sides of cortex are breached
273
What is a toddler's fracture?
Oblique tibial fracture in infants
274
What is a plastic deformity?
Stress on bone resulting in deformity without cortical disruption
275
What is a greenstick fracture?
Unilateral cortical breach only
276
What is a buckle fracture?
Incomplete cortical disruption leading to a periosteal haematoma only
277
What system is used to classify growth plate fractures?
Salter-Harris
278
What is the salter-harris classification?
I - fracture through physis only
II - fracture through physis and metaphysis
III - fracture through physis + epiphysis to include joint
IV - fracture involving physis, metaphysis + epiphysis
V - crush injury involving physis
279
What do SH type 1 fractures look like on X-ray?
Often look normal (same with V)
280
If you get growth plate tenderness but a normal x-ray what is it best to assume it is?
Still safer to assume it is an underlying fracture
281
How do you manage SH type III, IV and V fractures?
Surgery
282
What are type V SH fractures associated with?
Disruption to growth
283
What things may be indicative of NAI?
```
Delayed presentation
Delay in attaining milestones
Lack of concordance with proposed and actual mechanism of injury
Multiple injuries
Sites not commonly exposed to trauma
Child on at risk register
```
284
What causes OI?
Defective osteoid formation due to congenital inability to provide adequate intracellular materials, e.g. osteoid, collagen, dentine
285
OI is due to a failure of ______ maturation in all the connective tissues.
Collagen
286
What might you see on radiology in OI?
Translucent bones, multiple fractures, esp. in long bones
Wormian bones
Trefoil pelvis
287
What is wormian bones?
Irregular patches of ossification
288
What are the types of OI?
I-IV
289
What is type I OI?
Collagen is normal quality but insufficient
290
What is type II OI?
Poor collagen quantity and quality
291
What is type III OI?
Collagen poorly formed but normal quantity
292
What is type IV OI?
Sufficient collagen quantity but poor quality
293
What is osteopetrosis?
Bones are harder and more dense
294
How is osteopetrosis inherited?
AD
295
Who is osteopetrosis most common in?
Young adults
296
What do you see on radiology in osteopetrosis?
Lack of differentiation between cortex and medulla described as marble bone
297
What is talipes quinovarus?
Club foot
| Inverted + plantarflexed foot
298
Where is club foot normally picked up?
On newborn Ex
299
In which gender is club foot more common?
Males
300
What % of cases of club foot are bilateral?
50%
301
What are most cases of clubfoot associated with?
They are idiopathic!
302
What are some associations of club foot?
```
Spina bifida
Cerebral palsy
Edwards syndrome
oligohydramnios
Arthrogryposis
```
303
How is club foot diagnosed?
Clinically
304
How is club foot managed?
Ponseti method mostly
surgery
Night time braces until 4yo
305
What does the Ponseti method involve?
Manipulation and progressive casting starting soon after birth
306
How long does it take the Ponseti method to work usually?
6-10w
307
What is needed in 85% cases of club foot if using the ponseti method to treat it?
Achilles tenotomy
308
What causes the majority of lower back pain?
Non-specific muscular nature
309
What are red flags for lower back pain?
```
age < 20 years or > 50 years
history of previous malignancy
night pain
history of trauma
systemically unwell e.g. weight loss, fever
```
310
What are the features of facet joint lower back pain?
Pain worse in morning + on standing
OE pain over facets
Pain worse on extension of back
311
What are the features of spinal stenosis?
Gradual onset of unilateral/bilateral leg pain +/- back pain, numbness, weakness
Worse on walking, better when sitting
Ex usually normal
312
How does AS tend to present?
Young man with lower back pain and stiffness which is worse in the morning and improves with activity
35% have peripheral arthritis
313
Compression of what nerve causes carpal tunnel syndrome?
Median nerve
314
What is a typical hx of someone with carpal tunnel syndrome?
Pins + needles/pain in thumb, index + middle finger
| Pt shakes hand to obtain relief, classically at night
315
What might you find on Ex of someone with CTS?
Weakness of thumb abduction (APB)
Wasting of thenar eminence
+ve Tinel's + Phalen's sign
316
What are causes of CTS?
```
Idiopathic
Pregnancy
Oedema, e.g. heart failure
Lunate fracture
RA
```
317
What do you see on electrophysiology in CTS?
Motor + sensory: prolongation of the AP
318
What is the treatment of CTS?
Corticosteroid injection
Wrist splints at night
Surgical decompression
319
What does surgical decompression for CTS involve?
Flexor retinaculum division
320
What is a colles' fracture?
1. transverse fracture of radius
2. 1 inch proximal to radio-carpal joint
3. dorsal displacement and agulation
321
What tends to cause a Colles' fracture?
FOOSH
322
What causes a Smith fracture?
Falling backwards onto the palm of an outstretched hand or falling ith wrists flexed
323
What is a Smith's fracture?
Volar angulation of distal radius fragment
324
What is the deformity called in a colle's fracture?
Dinner fork deformity
325
What is the deformity called in a smiths fracture?
Garden spade deformity
326
What is a Bennett;s fracture?
IA fracture of the first carpometacarpal joint
327
What tends to cause a Bennett's fracture?
Impact on flexed metacarpal, caused by fist fights
328
What can you see on X-ray in a Bennett's fracture?
Triangular fragment at ulnar base of metacarpal
329
What is a Monteggia's fracture?
Dislocaton of the proximal radioulnar joint in association with an ulna fracture
330
What causes a Monteggia's fracture?
FOOSH with force pronation
331
Why does Monteggia fractures need prompt diagnosis?
To avoid disability
332
What is a Galeazzi fracture?
Radial shaft fracture with associated dislocation of the distal radioulnar joint
333
What causes a Galeazzi fracture?
Direct blow
334
What is a Pott's fracture?
Bimalleolar ankle fracture
335
What causes a Pott's fracture?
Forced foot eversion
336
What is a Barton's fracture?
Distal radius fractures (colles'/smith's) + assoc. radiocarpal dislocation
337
What causes a Barton's fracture?
Fall onto extended and pronated wrist
338
What is osteomyelitis?
Infection of bone
339
What is the most common cause of osteomyelitis in most pts?
Staph aureus
340
What is the most common cause of osteomyelitis in pts with sickle cell anaemia?
Salmonella spp.
341
What conditions predispose to OM?
```
DM
Sickle cell anaemia
IVDA
Immunosupressed (e.g. meds/HIV)
Alcohol excess
```
342
What is the imaging modality of choice in investigating suspected OM?
MRI
343
What is the management of OM?
IV flucloxacillin for 6w
| Clindamycin if penicillin allergic
344
Where is the most common place for children to get OM and why?
Metaphysis of long bones (as this is highly vascular and OM tends to spread haematongeously)
345
Where is the most common place for adults to get OM?
Epiphysis
346
What analgesics should be recommended for non-specific lower back pain?
Paracetamol, ibruprofen
| Codeine if have CDK
347
What features do you get in a dorsal column lesion?
Loss of vibration + proprioception
| Tabes dorsalis, SACD
348
What features do you get in a spinothalamic lesion?
Loss of pain, sensation and temperature
349
What features do you get in a central cord lesion?
Flaccid paralysis of upper limbs
350
What organism tends to cause OM in IVDAs?
Staph aureus
351
What organism tends to cause OM in those who are immunocompromised?
Funguses
352
What organism tends to cause OM in the thoracic region?
TB
353
What are the features of spinal cord infarction?
Dorsal column signs (loss of proprioception + fine discrimination)
354
What features do uou get in cord compression?
UMN signs
355
What tends to cause brown sequard syndrome?
Hemisection of the cord
356
What features do you get in brown sequard syndrome?
Ipsilateral paralysis
Ipsilateral loss of proprioception + fine discrimination
Contralateral loss of pain + temperature
357
What myotome is responsible for elbow flexion (biceps)?
C5
358
What myotome is responsible for wrist extension?
C6
359
What myotome is responsible for elbow extension (triceps)?
C7
360
What myotome is responsible for long finger flexors?
C8
361
What myotome is responsible for small finger abductors?
T1
362
What myotome is responsible for hip flexors (psoas)?
L1 + L2
363
What myotome is responsible for knee extensors (quadriceps)?
L3
364
What myotome is responsible for ankle dorsiflexors (tibialis anterior)?
L4 + L5
365
What myotome is responsible for toe extensors (hallucis longus)?
L5
366
What myotome is responsible for ankle plantarflexors (gastroc)?
S1
367
What is the anal sphincter innervated by?
S2-4
368
What investigation is required for diagnosis of spinal stenosis?
MRI
369
What is cervical spondylosis?
A very common condition that results from OA
370
How does cervical spondylosis tend to present?
As neck pain although referred pain may mimic headaches
371
What are complications of cervical spondylosis?
Radiculopathy
| Myelopathy
372
Radiculopathy follows a _____ distribution
Dermatomal
373
What are the disorders affecting the Achilles tendon?
Tendinopathy
Partial tear
Complete rupture
374
What are risk factors for achilles tendon disorders?
Quinolone use
| Hypercholesterolaemia (predisposes to tendon xanthomata)
375
What are features of achilles tedinopathy?
Gradual onset posterior heel pain, worse following activity
| Morning pain + stiffness
376
What is the management of achilles tendinopathy?
Analgesia
| Reduction in precipitating activities
377
What are the features of Achilles tendon rupture?
Audible pop in ankle/sudden onset of calf/ankle pain whilst running/playing sport + unable to walk/continue sport after
378
What triad is used to exclude achilles tendon rupture?
Simmonds triad
379
What is Simmonds triad?
Altered angle of dangle
Palpable/visible gap
+ve Thompsons test
380
What is the management of an acute achilles tendon rupture?
Acute referral to ortho specialist
381
What are the features of a respiratory fat embolism?
Early persistent tachycardia
Tachypnoea, dyspnoea, hypoxia 72h following injury
Pyrexia
382
What are the features of a dermatological fat embolism?
Red/brown impalpable petechial rash
| Subconjunctival/oral haemorrhage/petechiae
383
What are the features of a CNS fat embolism?
Confusion + agitation
| Retinal haemorrhages + intra-arterial fat globules on fundoscopy
384
How should you manage a fat embolism?
Prompt fixation of long bone fractures
| DVT prophylaxis General supportive care
385
What is a risk factor for fat embolism?
Recent fracture
386
What is the pathophysiology of Paget's disease?
Focal resportion followed by excessive + chaotic bone deposition
387
Where does Paget's affect the most?
In order@
| Spine, skull, pelvis, femur
388
What blood marker is raised in Paget's?
ALP
389
What do you see on X-ray in Paget's?
Abnormal thickened, sclerotic bone
390
There is a risk of cardiac failure if there is >…% of bony involvement in Paget's?
15
391
What is there a small risk of in Paget's disease?
Sarcomatous change
392
What is the pathophysiology of osteoporosis?
Excessive bone resportion --> demineralised bone
393
What are the symptoms of osteoporosis?
Asymptomatic, just greater risk of fracture
394
How can secondary bone tumours damage bone?
Bone destruction and tumour infiltration can occur
395
What scoring system is used to predict risk of fracture in secondary bone tumours?
Mirel
396
What tends to cause sclerotic secondary bone tumours?
Prostate cancer
397
What tends to cause lytic secondary bone tumours?
Breast
398
How are serum calcium, ALP levels affected by a secondary bone tumour?
Raised
399
How is Paget's disease managed?
Bisphosphonates
400
How is osteoporosis managed?
Bisphosphonates, Ca, Vit D
401
How are secondary bone tumours managed?
Radiotherapy
Prophylactic fixation
Analgesia
402
What kind of injury is an ACL rupture?
Sports injury
403
What mechanism tends to cause an ACL?
High twisting force applied to a bent knee
404
How does ACL rupture tend to present?
Loud pop, pain, RAPID joint swelling (haemoarthrosis)
405
How is ACL rupture managed?
Intense physio
| Surgery
406
What kind of mechanism causes PCL rupture?
Hyperextensive injuries (e.g. knee hitting dashboard)
407
What are signs of PCL rupture?
TIbia lies on back of femur
| Paradoxical anterior draw test
408
What is the mechanism of MCL rupture?
Leg forced into valgus via force outside the leg
409
What are signs of MCL rupture?
Knee unstable when put into valgus
410
What kind of injuries tend to cause meniscal tear?
Rotational sport injuries
411
What are the features of meniscal tear?
Joint locking
Delayed knee swelling
Recurrent episodes of pain + effusion (often following minor trauma) are common
412
What is the typical history of chondromalacia patellae?
Teenage girl following injury to the knee, e.g. patellar dislocation
hx of pain on going downstairs/at rest
Tenderness, quadricep wasting
413
What can cause a dislocated patella?
Trauma -
Direct trauma
Severe contraction of quadriceps with knee stretched in valgus + external rotation
414
What are risk factors for dislocated patella?
Genu valgus
Tibial torsion
High riding patella
415
What type of imaging is required for a patellar dislocation?
Skyline x-ray
416
What kind of fracture is present in %% of dislocated knees?
Osteochondral fracture
417
What are the two types of fractured patella?
Direct blow to patella --> undisplaced fragments
| Avulsion fracture
418
Who do tibial plateau fractures tend to occur in?
Elderly or following significant trauma in the young
419
What is the mechanism that causes a tibial plateau fracture?
Knee forced into valgus/varus, but knee fractures before ligament rupture
420
Varus injury affects the _____ plateau, and valgus injury affects the _____ plateau.
Medial
| Lateral
421
What system is used for classifying tibial plateau fractures?
Schatzker
422
Where does OA most commonly affect?
Knee then hip
423
What are risk factors for OA of the hip?
Increasing age
Female gender
Obesity
DDH
424
What are features of OA hip?
Chronic hx groin ache following exercise + relieved by rest
425
What are red flags that may suggest an alternative diagnosis from hip OA?
Rest pain
Night pain
Morning stiffness >2h
426
What score is used to assess OA hip severity?
Oxford hip score
427
What investigations are required for suspected OA hip?
If typical features - clinical diagnosis can be made
| Otherwise X-ray first line
428
What is the management of hip OA?
Oral analgesia
IA injections
TRH is definitive Rx
429
How do IA injections help in hip OA?
Provide short term benefit
430
What are complications of THR?
VTE
Intraoperative fracture
Nerve injury
431
What are reasons for revising a total hip replacement?
Aseptic loosening (most common cause)
Pain
Dislocation
Infection
432
What is Leriche syndrome?
Atheromatous disease affecting the iliac vessels meaning blood flow to the pelvic viscera is compromised
433
How do patients with Leriche syndrome tend to present?
Buttock + thigh claudication, impotence, atrophy of the musculature of legs
434
What is involved in the diagnostic workup for Leriche syndrome?
Angiography
435
How is Leriche syndrome treated?
Iliac occlusions can sometimes be treated with endovascular angioplasty + stent insertion
Management of RFs (e.g. hypercholesterolaemia, stop smoking)
436
What diseases are encompassed with rotator cuff injury?
```
Subacromial impingement (aka. painful arc syndrome)
Calcific tendonitis
Rottor
```
437
What diseases are encompassed with rotator cuff injury?
Subacromial impingement (aka. painful arc syndrome)
Calcific tendonitis
Rotator cuff tears
Rotator cuff arthropathy
438
What are symptoms of rotator cuff injury?
Shoulder pain worse on abduction
439
What are signs of rotator cuff injuries?
Painful arc of abduction (60-120d) - subacromial impingement
With rotator cuff may be pain in first 60d + weakness/muscle wasting
Tenderness over ant. acromion
440
What can cause a rotator cuff tear?
Trauma
| Chronic impingement
441
How can you differentiate between a rotator cuff tear and impingement?
Get muscle weakness in rotator cuff injury
442
How can you differentiate between a medial meniscal tear and a lateral meniscal tear?
Medial - tenderness over medial joint line and vice versa
443
What is the commonest cause of heel pain in adults?
Plantar fasciitis
444
Where is the pain usually worst in plantar fasciits?
Medial calcaneal tuberosity
445
How do you manage plantar fasciitis?
```
Rest feet where possible
Manage RFs, incl wt loss
Stretching
Where shoes with good arch support + cushioned heels
Insoles/heel pads
```
446
What exacerbates the heel pain seen in planar fasciitis?
Walking on tips of toes
447
Where is the pain in achilles tendonitis?
Calcneal insertion or further up tendon
448
What mechanism of injury tends to cause a scaphoid fracture?
FOOSH
Contact sports, e.g. football
RTA due to pt holding steering wheel
449
What is the blood supply of the scaphoid?
80% from dorsal carpal branch (branch of radial artery) in retrograde manner
450
Interruption of the blood supply to the scaphoid can lead to what?
Avascular necrosis of the head of the scaphoid
451
How do pts with scaphoid fracture tend to present?
Pain along the radial aspect of wrist + base of thumb
| Loss of grip/pincer strength
452
What are signs of scaphoid fracture?
```
Point of maximal tenderness over anatomical snuffbox
Wrist joint effusion (if acute injury)
Pain elicited by telescoping thumb
Tenderness on scaphoid tubercle
Pain on ulna deviation of wrist
```
453
What investigations should be arranged for suspected scaphoid fracture?
X-rays in AP + lateral
| Repeat X-ray in 2w if inconclusive but clinical features strongly suggest scaphoid fracture/scaphoid fracture diagnosed
454
When might a CT be done for scaphoid fracture?
If planning surgery or determining extent of fracture union in follow up
455
What is avascular necrosis?
Death of bone tissue secondary to loss of blood supply --> bone destruction + loss of joint function
456
Where does avascular necrosis tend to affect?
Epiphysis of long bones, e.g. femur
457
What can cause AVN of the hip?
Long term steroid use
Chemotherapy
Alcohol xs
Trauma
458
What are features of AVN of hip?
Initially asymptomatic
| Then pain in affected joint
459
What are early signs of AVN of hip?
Osteopenia + microfractures
| Collapse of articular surface may --> crescent sign
460
What is the investigation of choice in suspected AVN hip?
MRI
461
What is the management of AVN of hip?
Joint replacement may be req.
462
What is an effective method of analgesia for neck of femur fracture?
Iliofascial nerve block is first line
463
What do stress fractures result from?
Repetitive activity + loading of normal bone
464
How are stress fractures managed?
May need immobilisation only if severely painful and presenting at an earlier stage where this may be beneficial
465
What are features of OA of the knee?
Pain may be severe
| Intermittent swelling, crepitus + limitation of movement
466
What kinds of pts tend to get OA of the knee?
>50s, often overwt
467
What is associated with infrapatellar bursitis?
Kneeling
468
What is associated with prepatellar bursitis?
Upright kneeling
469
What test is +ve in ACL rupture?
Draw test
470
What are features of collateral ligament damage?
Tenderness over affected ligament
| Knee effusion may be seen
471
What conditions predispose to a baker's cyst?
Gout
| Arthritis
472
What is Foucher's sign?
Increase in tension of a Baker's cyst on extension of the knee
473
What is a straight leg raise test?
Raise leg while it is straight
| If pain in distribution of sciatic nerve --> +ve
474
How should failed conservative management of plantar fasciitis be managed?
Refer to orthopaedics (cosnider surgery) and physio
475
What causes Duputyren's contracture?
Hyperplasia and then contractures of the palmar aponeurosis
476
What does Duputyren's contracture look like?
Fingers bend towards the palm and cannot be fully extended
477
Is Duputyren's sore?
No not normally
478
Can Duputyren's contracture progress?
It is normally progressive
479
How is CTS formally diagnosed?
Electrophysiological studies
480
What are non-surgical options for the management of CTS?
Splinting
| Bracing
481
What are Osler's nodes?
Deposition of immune complexes
482
What do Osler's nodes present like?
Painful, red, raised lesions on the hands + feet
483
What are Bouchard's nodes?
Hard, bony outgrowths or gelatinous cysts on the proximal IP joints
484
What causes Bouchard's nodes?
OA
| caused by formation of calcific spurs of the articular cartilage
485
How do Heberden's nodes develop?
Chronic swelling of affected joint or sudden onset redness, numbness, loss of manual dexterity
Initial inflammation + pain subsides + pt left will permanent bony outgrowth that often skews the fingertip sideways
486
Where are ganglions usually found?
Back of hand
| Wrist
487
How are ganglions managed?
Usually asymptomatic + disappear after a few months but if troublesome can be excised
488
What are ganglions?
Swellings in association with a tendon sheath (usually near a joint)
489
What fluid are ganglions filled with?
Fluid similar to synovial fluid
490
What are the nerve roots of the musculocutaneous nerve?
C5-7
491
What is the motor supply of the musculocutaneous nerve?
Elbow flexion + supination
492
What is the sensory supply of the musculocutaneous nerve?
Lateral part of forearm
493
What are the nerve roots of the axillary nerve?
C5-6
494
What is the motor supply of the axillary nerve?
Shoulder abduction (deltoid)
495
What is the sensory supply of the axillary nerve?
Regimental badge region
496
What are the nerve roots of the radial nerve?
C5-8
497
What is the motor supply of the radial nerve?
Extension (forearm, wrist, fingers, thumb)
498
What is the sensory supply of the radial nerve?
Small area between dorsal aspect of the 1st and 2nd metacarpals
499
What are the nerve roots of the median nerve?
C6, C8, T1
500
What is the motor supply of the median nerve?
LOAF muscles
501
What is the sensory supply of the median nerve?
Palmar aspect of lateral 3.5 fingers
502
What does the ulnar nerve supply?
Intrinsic hand muscles expect LOAF
| Wrist flexion
503
What is the sensory supply of the ulnar nerve?
Medial 1.5 fingers
504
What is the motor supply of the long thoracic nerve?
C5-7
505
What sort of things may cause damage to the long thoracic nerve?
Blow to ribs
| Complication of mastectomy
506
What sign does damaged long thoracic nerve lead to?
Winging of scapula
507
What sort of thing can lead to damage of the ulnar nerve?
Medial epicondyle fracture
508
What deformity can damage to the ulnar nerve lead to?
Claw hand
509
What fracture can damage the radial nerve?
Humeral midshaft fracture
510
What do you get in radial nerve palsy?
Wrist drop
511
What sort of injuries can cause axillary nerve palsy?
Humeral neck fracture/dislocation
512
What sign do you get in axillary nerve damage?
Flattened deltoid
513
What features do you get if the median nerve is damage at the wrist?
Paralysis of thenar muscles, opponens pollicis
514
What features do you get if the median nerve is damaged at the elbow?
Loss of pronation of forearm and weak wrist flexion
515
What is Erb-Duchenne palsy due to?
Damage to upper trunk of brachial plexus (C5, 6)
516
What commonly causes Erb-Duchenne palsy?
Shoulder dystocia at birth
517
What does Erb-Duchenne palsy look like?
Arm hands by side, and is internally rotated, elbow extended
518
What is Klumpke paralysis due to?
Damage to lower trunk of brachial plexus (C8, T1)
519
What may cause Klumpke paralysis?
Shoulder dystocia, sudden upward jerk of hand
520
What condition is Klumpke paralysis associated with?
Horner's syndrome
521
What are the LOAF muscles?
Lateral two lumbricals
Opponens pollis
Abductor pollis brevis
Flexor pollis brevis
522
What is the bests imaging modality to diagnose a meniscal tear?
MRI
523
How do you investigate a suspected fractured hip?
X-ray
| If occult - MRI
524
What are the clinical features of femoral nerve damage?
Weakness in knee extension, loss of patella reflex, numbness in thigh
525
What are the clinical features of lumbosacral nerve damage?
Weakness in ankle dorsiflexion, numbness of calf and foot
526
What are the features of sciatic nerve damage?
Weakness in knee flexion, foot movements, pain and numbness from gluteal region to ankle
527
What are the features of obturator nerve damage?
Weakness in hip adduction, numbness over medial thigh
528
What are sarcomas?
Malignant tumours of mesenchymal origin
529
What are the two types of sarcomas?
Bone
| Soft tissue
530
What are the bone sarcomas?
Osteosarcoma
Ewings sarcoma
Chondrosarcoma
531
What cells do chondrosarcomas originate from?
Chondrocytes
532
What are types of soft tissue sarcomas?
Liposarcoma
Rhabdomyoarcoma
Leiomyosarcoma
Synovial sarcomas
533
What do liposarcomas originate from?
Adipocytes
534
What do rhabdomyosarcomas originate from?
Striated muscle
535
What do leiomyosarcomas originate from?
Smooth muscle
536
What do synovial sarcomas originate from?
Cell of origin unknown but not synovium
| Lie close to joints
537
What sarcoma can arise in soft tissue and bone?
Malignant fibrous histiocytoma
538
What features of a mass/swelling should raise suspicion for a sarcoma?
Large >5cm soft tissue mass
Deep tissue location/intramuscular location
Rapid growth
Painful lump
539
How should you assess a suspected sarcoma?
MRI, CT, USS
| Biopsy
540
Who typically gets Ewing's sarcoma?
Males
| 10-20y
541
Where is the commonest site for a Ewing's sarcoma?
Femoral diaphysis
542
What is Ewing's sarcoma like histologically?
A small round tumour
543
How is Ewing's sarcoma treated?
Chemo + surgery
544
How does Ewing's sarcoma tend to spread?
Blood borne metastasis is common
545
What is an osteosarcoma?
Mesenchymal cells with osteoblastic differentiation
546
What age tend to get osteosarcomas?
15-30yos
547
How is osteosarcoma usually managed?
Surgery + chemo
548
Where are liposarcomas?
Tend to be deep locations, e.g. retroperitoneum
549
What age groups do liposarcomas tend to affect?
>40s
550
Are liposarcomas aggressive?
Can be well differentiated + slow growing but may undergo de-differentiation + disease progression
551
What is the issue with doing surgery for liposarcomas?
Tumour may have a pseudocapsule that can be misleading as tumour may invade edge of pseudocapsule
552
What type of treatment is liposarcoma usually resistant to?
Radiotherapy
553
What is the most common sarcoma in adults?
Malignant fibrous histiocytoma
554
What are the four major subtypes of malignant fibrous histiocytoma?
Storiform-pleomorphic
Myxoid
Giant cell
Inflammatory
555
How is malignant fibrous histiocytoma usually managed?
Surgery + adjuvant radio
556
How should you manage a young person with an X-ray that could suggest bone sarcoma?
Very urgent referral to a specialist (<48h)
557
What is meralgia paraesthetica?
Paraesthesia/anaesthesia in distribution of the lateral femoral cutaneous nerve
558
What can cause meralgia paraesthetica?
Trapped LFCN
Iatrogenic after surgery
Neuroma
559
What segments does LFCN arise from?
L2/3
560
Where may the LFCN be subject to pressure or repetitive trauma?
Where it passes the ASIS
561
In which condition is meralgia paraesthetica more common?
Diabetes
562
What are RFs for meralgia paraesthetica?
Obesity
Pregnancy
tense ascites
Trauma
Iatrogenic, e.g. pelvic osteotomy, spinal surgery etc.
Various sports, e.g. gymnastics, bodybuilding
563
How does meralgia paraesthetica present?
Burning, tingling, coldness, shooting pain
Numbness
Deep muscle ache
564
What tends to aggravate symptoms in meralgia paraesthetica?
Standing
| relieved by sitting
565
How can you often reproduce the symptoms of meralgia paraesthetica?
Deep palpation just below the ASIS + with extension of the hip
566
What is the motor deficit in meralgia paraesthetica?
There is no motor weakness
567
How is meralgia paraesthetica investigated?
Pelvic compression test v. sensitive
Injection of nerve with LA will abolish pain
US effective for diagnosis + guiding injections
Nerve conduction studies may be useful
568
Should you weight bear immediately after hip fracture surgery?
Yes
569
How do you perform McMurrays test?
Hold knee in one hand, which is placed along the joint line + flexed while the sole of the foot is held in the other hand
Pull knee towards a varus position whilst the other hand rotates the leg internally and extends the knee
If pain or click is felt --> +ve
570
What does +ve McMurray's test indicate?
Meniscal tear
571
What are Kanavel's signs of flexor tendon sheath infection?
Fixed flexion, fusiform swelling, tenderness + pain on passive extension
572
How is infective tenosynovitis managed?
Antibiotics + elevation if caught early
| If not may need surgery
573
Where is the most common place to fracture the humerus?
Surgical neck
574
What kind of humeral fractures carry a risk of avascular necrosis to the humeral head?
Anatomical neck fractures which are displaced bby >1cm
575
What is the commonest pattern of humeral fracture in children?
Greenstick fracture throughsurgical neck
576
How are impacted fractures of the surgical neck of the humerus managed?
Collar + cuff for 3 weeks followed by physio
577
How are more significant displaced fractures of the humerus managed?
May need open reduction and fixation or use of an intramedullary device
578
What are the different types of shoulder dislocation and what is most common?
Glenohumeral dislocation (commonest)
Acromioclavicualr dislocation
Sternoclavicular dislocation
579
What is an acromioclavicular dislocation?
Clavicle loses all attachment with the scapula
580
What kind of glenohumeral dislocation is most common?
Anterior shoulder dislocation
581
What deformities do you see in anterior shoulder dislocation?
External rotation + abduction
582
What is anterior shoulder dislocation associated with?
Greater tuberosity fracture
Bankart lesion
Hill-Sachs defect
583
What three signs do you see on X-ray with a posterior shoulder dislocation?
Rim's sign
Light bulb sig
Trough sign
584
How common are superior shoulder dislocations?
Rare, usually follow major trauma
585
How are shoulder dislocations managed?
Prompt reduction
586
What must you check pre and post-reduction in shoulder dislocations?
Neurovascular status
| X-ray to ensure no fracture has occurred
587
In recurrent anterior dislocation there is usually what kind of lesion? How is this repaired?
Bankart lesion
| Surgically
588
What kind of injury tends to cause an anterior shoulder dislocation?
Fall on arm/shoulder
589
What pulses/nerves should you especially check in anterior shoulder dislocation?
Axillary
590
What kind of things tends to ause posterior shoulder dislocation?
Seizures/electrocution
591
How should you manage suspected scaphoid fracture?
Refer to hospital for urgent ortho/ED review
592
What is Morton's neuroma?
Benign neuroma affecting the intermetatarsal plantar nerve (most commonly in the 3rd intermetatarsophalangeal space)
593
What are the features of a Morton's neuroma?
```
Forefoot pain (third intermetatarsophalangeal space)
Worse on walking
May be shooting/burning pain
May feel like pebble in shoe
May be distal loss of sensation in toes
Mulder's click
```
594
How do you elicit Mulder's click?
One hand squeezes the metatarsals together
| Click may be heard as the neuroma moves between the metatarsal heads
595
How is Morton's neuroma diagnosed?
Usually clinical
| USS may help
596
How is Morton's neuroma managed?
Avoid high heels
Metatarsal pads
Metatarsal dome orthotic
597
When should you refer for Morton's neuroma?
If symptoms persist >3m despite footwear modifications + use of metatarsal pads
598
What are some secondary care options for treating Morton's neuroma?
Corticosteroid injection
| Neurectomy of involved interdigital nerve and neuroma
599
What are red flags for back pain?
```
Thoracic pain
Age <20 or >55 years
Non-mechanical pain
Pain worse when supine
Night pain
Weight loss
Pain associated with systemic illness
Presence of neurological signs
Past medical history of cancer or HIV
Immunosuppression or steroid use
IV drug use
Structural deformity
```
600
What tests should those with red flags for back pain have?
ESR, FBC, Ca, Phosp, ALP, PSA
| X-Ray
601
What kind of X-ray is needed to see the scaphoid?
Ulnar deviation AP
602
What tends to cause a radial head fracture?
FOOSH
603
What will you see OE in radial head fracture?
Tenderness over the head of the radius, impaired movements at the elbow, sharp pain at lateral side of elbow at extremes of rotation
604
What is the ulnar paradox?
Proximal lesions of the ulnar nerve produce a less prominent deformity than distal lesions
605
How should you manage children with an unexplained bone swelling/pain?
Very urgent X-ray to assess for bone sarcoma (<48h)
606
What is the initial imaging modality of choice for suspected Achilles tendon rupture?
USS
607
What is an iliopsoas abscess?
Collection of pus in the iliopsoas compartment
608
What is causes a primary iliopsoas abscess?
Haematogenous spread usually staph aureus
609
What can causes a secondary iliopsoas abscess?
```
Crohn's (commonest cause in this category)
Diverticulitis, colorectal cancer
UTI, GU cancers
Vertebral osteomyelitis
Femoral catheter, lithotripsy
Endocarditis
```
610
What is the difference in prognosis between primary and secondary iliopsoas abscesses?
Primary has a much lower mortality
611
What are the clinical features of iliopsoas abscess?
Fever
Back/flank pain
Limp
Wt loss
612
What position do those with an iliopsoas abscess tend to lie in?
Supine with knee flexed and hip mildly externally rotated
613
What tests can you do to diagnose iliopsoas inflammation?
Put hand above pts ipsilateral knee and ask them to lift thigh against hand --> pain due to contraction of psoas
Lie pt on normal side and hyperextend affected hip --> pain as psoas is stretched
614
What is the gold standard imaging for iliopsoas abscess?
CT
615
How is iliopsoas abscess managed?
Antibx
Percutaneous drainage
Surgery if failure of percutaneous draining or presence of another intra-abdominal pathology req.s surgery
616
What is the medical term for joint replacement?
Arthoplasty
617
What is the most common type of hip replacement?
Cemented hip replacement
618
What pts may not want a cemented hip replacement?
Younger
| More active pts
619
What other option is there for hip replacement?
Hip resurfacing
620
What do pts receive post-hip replacement?
Physio
Course of home exercises
Walking sticks/crutches to use for up to 6w post-hip or knee replacement
621
what basic advice should you give to those who have had a hip replacement to minimise the risk f dislocation?
Avoid flexing hip >90d
Avoid low chairs
Do not cross legs
Sleep on back for first 6w
622
What are complications of joint replacement?
Wound and joint infection
VTE
Dislocation
623
What is given to those undergoing a hip replacement to reduce the risk of VTE?
LMWH for 4w following operation
624
What nerve is most likely to be damaged during a knee arthroplasty?
Common peroneal nerve
625
What is thought to cause trigger finger?
Disparity between the size of the tendons and pulleys through which they pass, i.e. tendons become stuck and cannot pass smoothly through the pulley
626
What things are associated with trigger finger?
Being female
RA
DM
627
In which fingers is trigger finger most common?
Thumb, middle or ring finger
628
What are the features of trigger finger?
Initially stiffness + snapping when extending a flexed digit
| Nodule may be felt at base of affected finger
629
What is the management of trigger finger?
Steroid injections + splinting
| Surgery if this fails
