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MSK > Orthopaedic Passmedicine > Flashcards

Orthopaedic Passmedicine Flashcards

1
Q

What is first line for back pain?

A

NSAIDs

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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)

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3
Q

What advice should you give to people with back pain?

A

Encourage self management
Stay physically active
Exercise

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4
Q

What patients should be co-prescribed PPIs if they are given NSAIDs?

A

> 45y

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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

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6
Q

What is the only imaging technique that allows you to see soft tissue structures?

A

MRI

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7
Q

What is a common cause of lateral knee pain in runners?

A

Iliotibial band syndrome

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8
Q

Where is the tenderness in iliotibial band syndrome?

A

2-3cm above lateral joint line

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9
Q

What is involved in the management of iliotibial band syndrome?

A

Activity modification, iliotibial band stretches

If not improving –> physio referral

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10
Q

What may compartment syndrome follow?

A

Fractures

Ischaemia reperfusion injury in vascular patients

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11
Q

What is compartment syndrome?

A

Raised pressure within a closed anatomical space –> compromises tissue perfusion –> necrosis

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12
Q

What are the two main fractures that cause compartment syndrome?

A

Supracondylar fractures

Tibial shaft injuries

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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
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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

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15
Q

How is compartment syndrome diagnosed?

A

Measuring intracompartmental pressure (>20mmHg abnormal, >40mmHg diagnostic)

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16
Q

How is compartment syndrome managed?

A

Prompt + extensive
fasciotomies
Debridement of necrotic tissue

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17
Q

What complication may occur following fasciotomy?

A

Myoglobulinuria –> renal failure (these pts need aggressive IV fluids)

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18
Q

How long does it take for muscle groups to die in compartment syndrome?

A

4-6h

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19
Q

What does myoglobuinuria look like?

A

Dark, brown coloured urine that drips positively for blood

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20
Q

What are some specific causes for Dupuytren’s contracture?

A 
Manual labour
Phenytoin treatment
Alcoholic liver disease
DM
Trauma to the hand
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21
Q

Who is more at risk of Dupuytren’s contracture?

A

Older male patients

Those with FH

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22
Q

What fingers tend to be affected in Dupuytren’s contracture?

A

Ring finger, little finger

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23
Q

How is Dupuytren’s contracture managed?

A

Surgery - fasciectomy

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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

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25
Q

What are the features of a prolapsed disc?

A

Clear dermatomal leg pain + assoc. neurological deficits
Leg pain usually worse than back
Pain worse when sitting

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26
Q

What features are in line with an L3 nerve root compression?

A

Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test

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27
Q

What features are in line with an L4 nerve root compression?

A

Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
+ve femoral stretch tests

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28
Q

What features are in line with an L5 nerve root compression?

A

Sensory loss dorsum of foot
Weakness in foot + big toe dorsiflexion
Reflexes intact
+ve sciatic nerve stretch test

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29
Q

What features are in line with an S1 nerve root compression?

A

Sensory loss posterolateral aspect of leg + lateral aspect of foot
Weakness in plantarflexion of foot
Reduced ankle reflex
+ve sciatic nerve stretch test

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30
Q

How is prolapsed disc managed?

A

Analgesia (anti-neuropathic), physio, exercises

If symptoms persist >4-6w then refer for consideration of MRI

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31
Q

What are the Ottawa ankle rules?

A

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
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32
Q

What is a popular classification system for describing ankle fractures?

A

Weber

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33
Q

What is the Weber classification?

A

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)

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34
Q

What is a Masionneuve fracture?

A

Spiral fibular fracture that leads to disruption of the syndesmosis with widening of the ankle joint

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35
Q

How is a Masionneuve fracture managed?

A

Surgery

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36
Q

What is the management of ankle fractures?

A

Prompt reduction to remove pressure on overlying skin + subsequent necrosis

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37
Q

What kind of ankle fractures will req. surgery?

A

Young patients with unstable, high velocity or proximal injuries

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38
Q

What does surgery for ankle fractures usually involve?

A

Compression plate

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39
Q

Who tends to get conservative management for ankle fractures?

A

Elderly, potentially unstable injuries

as their bone doesn’t hold metalwork as well

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40
Q

How should stable/minor ankle fractures be managed?

A

Weight bearing as tolerated in a controlled ankle motion (CAM) boot

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41
Q

Define discitis

A

Infection in the intervertebral disc space

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42
Q

What is a complication of discitis?

A

Sepsis

Epidural abscess

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43
Q

What are the features of discitis?

A 
Back pain 
General features (pyrexia, rigors, sepsis)
Neurological changes - e.g. changing lower limb neurology if epidural abscess develops
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44
Q

What is the most common cause of discitis?

A

Staph aureus

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45
Q

Apart from bacteria what else can cause discitis?

A

Viruses
TB
Aseptic

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46
Q

What is the best imaging for discitis?

A

MRI

CT guided biopsy may be req. to guide antimicrobial treatment

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47
Q

How is discitis treated?

A

6-8w of IV antibiotics

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48
Q

How do you decide what antibiotics to give in discitis?

A

Culture (CT guided biopsy or blood culture)

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49
Q

What further investigations might you do in discitis?

A

Check for endocarditis (e.g. TOE/TTE) - esp. if it due to staph

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50
Q

What kind of movements usually result in meniscal tears?

A

Twisting movements

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51
Q

What are the features of meniscal tears?

A 
Pain worse on straightening the knee 
Knee may give way 
Displaced meniscal tears may --> knee locking
Tenderness along joint line 
Thessaly's test +ve
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52
Q

What is Thessaly’s test?

A

Wt bearing at 20 degrees of knee flexion, pt supported by doctor, positive if pain on twisting the knee

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53
Q

What is Froment’s test used for?

A

Assess for ulnar nerve palsy

Tests adductor pollicis muscle function

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54
Q

How do you perform Froment’s test?

A

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)

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55
Q

What is Phalen’s test used for?

A

Assessing for carpal tunnel syndrome

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56
Q

Which of Phalen’s and Tinel’s is more sensitive?

A

Phalen’s

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57
Q

How do you perform Phalen’s test?

A

Hold wrist in maximum flexion (reverse prayer sign) for 30-60s + test +ve if there is numbness in median n. distribution

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58
Q

What is tinel’s test used for?

A

Assessing for carpal tunnel syndrome

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59
Q

How do you perform tinel’s test?

A

Tap median nerve at the wrist

+ve if tingling/electric like sensations over distribution of median nerve

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60
Q

Why is avascular necrosis a risk in displaced hip fractures?

A

Blood supply to femoral head runs up the neck

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61
Q

What are the features of a hip fracture?

A

Pain

Shortened and externally rotated leg

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62
Q

What are the two different locations hip fractures can occur in?

A

Intracapsular (sucapital): from edge of femoral head to insertion of capsule at hip joint
Extracapsular: can be trochanteric or subtrochanteric

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63
Q

What structure divides subtrochanteric and trochanteric fractures?

A

The lesser trochanter

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64
Q

What system is used to classify hip fractures?

A

Garden system

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65
Q

What is the Garden system?

A

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

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66
Q

What Garden types most commonly lead to bloody supply disruption?

A

3 and 4

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67
Q

How should an undisplaced intracapsular hip fracture be managed?

A

Internal fixation

Hemiarthroplasty if unfit

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68
Q

How should a displaced intracapsular fracture be managed?

A

Young + fit (<70) - reduction and internal fixation

Older + reduced mobility - hemiarthroplasty or THR

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69
Q

How should extracapsular hip fractures be managed?

A

Dynamic hip screws

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70
Q

How should reverse oblique, transverse of subtrochanteric extracapsular fractures be managed?

A

Intramedullary device

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71
Q

Should a patient with a subtrochanteric femoral fracture fixed with an intramedullary nail weight bear after the operation?

A

Yes - should weight bear immediately as tolerated

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72
Q

What is the motor supply of the femoral nerve?

A

Knee extension

Thigh flexion

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73
Q

What is the sensory supply of the femoral nerve?

A

Anterior and medial aspect of thigh and lower leg

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74
Q

What is the typical mechanism of injury of the femoral nerve?

A

Hip/pelvic fractures

Stab/gunshot wounds

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75
Q

What is the motor supply of the obturator nerve?

A

Adduction of thigh

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76
Q

What is the sensory supply of the obturator nerve?

A

Medial thigh

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77
Q

What trauma may injure the obturator nerve?

A

Anterior hip dislocation

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78
Q

What is the motor supply of the lateral cutaneous nerve of the thigh?

A

None

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79
Q

What is the sensory supply of the lateral cutaneous nerve of the thigh?

A

Lateral + posterior surfaces of the thigh

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80
Q

Where is the lateral cutaneous nerve of the thigh likely to get compressed? What results?

A 
ASIS
Meralgia paraesthetica (pain, tingling + numbness in the distribution of the lateral cutaneous nerve of the thigh)
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81
Q

What is the motor supply of the tibial nerve?

A

Foot plantarflexion and inversion

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82
Q

What is the sensory supply of the tibial nerve?

A

Sole of foot

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83
Q

What kind of injuries may lead to damage to the tibial nerve?

A

Popliteal lacerations

Posterior knee dislocation

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84
Q

What is the motor supply of the common peroneal nerve?

A

Foot dorsiflexion and eversion

Extensor hallicus longus

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85
Q

What is the sensory supply of the common peroneal nerve?

A

Dorsum of foot + lower lateral part of leg

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86
Q

Where does injury of the common peroneal nerve commonly occur?

A

Around neck of fibula

E.g. may happen if a plaster cast is applied too tightly

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87
Q

What does injury to the common peroneal nerve lead to?

A

Foot drop

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88
Q

What is the motor supply of the superior gluteal nerve?

A

Hip abduction

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89
Q

What is the sensory supply of the gluteal nerves?

A

None

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90
Q

What may cause damage to the superior gluteal nerve?

A

Misplaced IM injection
Hip surgery
Pelvic fracture
Posterior hip dislocation

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91
Q

What does damage to the superior gluteal nerve lead to?

A

+ve Trendelenburg sign

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92
Q

What is the motor supply of the inferior gluteal nerve?

A

Hip extension + lateral rotation

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93
Q

What does injury to the inferior gluteal nerve lad to?

A

Difficulty rising from seated position

Can’t jump, climb stairs

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94
Q

What are risk factors for congenital hip dislocation?

A 
Female gender
Breech presentation
Family history
Firstborn
Oligohydramnios
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95
Q

What two tests are used to get for DDH?

A

Barlow
Ortolani

(those at risk have an USS)

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96
Q

What is the most sensitive sign of compartment syndrome?

A

Pain on passive stetch

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97
Q

What age do children tend to get transient synovitis?

A

2-10y

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98
Q

What is transient synovitis?

A

Acute hip pain associated with a viral infection

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99
Q

What is the most common cause of hip pain in children?

A

Transient synovitis

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100
Q

What is perthes disease?

A

Degenerative condition affecting the hips of children

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101
Q

What age do children tend to get perthes?

A

4-8y

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102
Q

What causes perthes?

A

Avascular necrosis of the femoral head

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103
Q

In which gender is perthes more common?

A

Boys

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104
Q

What are the features of perthes?

A

Hip pain - progressive over a few wks
Limp
Stiffness, reduced RoM

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105
Q

What findings do you see on X-ray in perthes disease?

A

Early changes - widening of joint space

late changes - decreased femoral head size/flattening

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106
Q

What age typically do children get SUFE?

A

10-15y

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107
Q

Who is SUFE more common in ?

A

Obese boys

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108
Q

What occurs in SUFE?

A

Displacement of the femoral head epiphysis posterior-inferiorly

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109
Q

In what two ways can SUFE present?

A

Acutely after trauma

With chronic, persistent symptoms

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110
Q

What are the features of SUFE?

A

Knee/distal thigh pain

Loss of internal rotation of leg in flexion

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111
Q

What is JIA?

A

Arthritis occurring in someone who is less than 16y, lasting >3m

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112
Q

What is pauciarticular JIA?

A

4 or less joints affected

Most common type of JIA

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113
Q

What are the features of pauciarticular JIA?

A

Joint pain + swelling - usually medium sized joints (knees, ankles, elbows)
Limp
ANA +ve (assoc. with anterior uveitis)

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114
Q

What is the typical presentation of septic arthritis?

A

Acute hip pain + systemic upset (pyrexia)

Inability/severe limitation of affected joint

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115
Q

What is another name for frozen shoulder?

A

Adhesive capsulitis

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116
Q

What is adhesive capsulitis associated with?

A

Diabetics

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117
Q

What movement is affected most in adhesive capsulitis?

A

External rotation

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118
Q

What are the features of adhesive capsulitis?

A

Active + passive movement affected

Freezing phase, adhesive phase, recovery phase

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119
Q

How long do episodes of adhesive capsulitis typically last?

A

6m-2y

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120
Q

How is adhesive capsulitis managed?

A

NSAIDs, physio, oral corticosteroids, IA corticosteroids

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121
Q

Define open fracture

A

Disruption of the bony cortex associated with a breach in the overlying skin

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122
Q

Any wound that is present in the same limb as a fracture should be suspected as representing what?

A

An open fracture

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123
Q

What system is used to classify open fractures?

A

Gustilo and Anderson system

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124
Q

What is the Gustilo and Anderon system?

A
  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
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125
Q

In gustilo T3C injuries what system may be used to predict the need for primary amputation?

A

Mangled extremity scoring system (MESS)

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126
Q

How should open fractures be managed?

A
  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
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127
Q

What does debridement involve?

A

Removing foreign material and devitalised tissue

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128
Q

How many Ls of fluid should be used to irrigate an open fracture wound?

A

At least 6L saline

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129
Q

What is often used to stabilise an open fracture in the first instance?

A

External fixator

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130
Q

Management of an intracapsular fracture, displaced + independently mobile, does not use more than a stick

A

Total hip replacement

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131
Q

Management of an intracapsular fracture, displaced + not independently mobile

A

Hemiarthroplasty, cement implants preferred

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132
Q

Management of a trochanteric fracture

A

Sliding hip screw

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133
Q

Management of a subtrochanteric fracture

A

Intramedullary nail

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134
Q

What is a psoas abscess?

A

Collection within the psoas muscle

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135
Q

What vertebral levels does the psoas muscle lie over?

A

T12-L5

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136
Q

Where does the psoas muscle insert?

A

Lesser trochanter of femur

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137
Q

Psoas abscess can be of primary origin or as what?

A

A result of spread from local sources, e.g. pyelonephritis, IBD

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138
Q

What are complications of psoas abscesses?

A

Septicaemia + multi organ failure

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139
Q

What is the most common organism causing psoas abscess?

A

Staph or strep

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140
Q

What are risk factors for developing a primary psoas abscess?

A

Immunosupression, e.g. HIV, cancer, DM
IVDA
Prev. surgery
TB

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141
Q

What is the pain like in psoas abscess? Is there a fever?

A

Increases over several days

May be a fever

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142
Q

How can you evidence psoas irritation?

A

When position of comfort is pt lying on back with slightly flexed knees

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143
Q

Apart from pain + fever what other feature may you see in psoas abscess?

A

Inability to wt bear or pain when moving the hip

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144
Q

What investigations should you do for suspected psoas abscess?

A

Bloods
Septic screen
CT abdomen/MRI

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145
Q

What is the gold standard imaging used to identify psoas abscess?

A

MRI

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146
Q

What is the management of psoas abscess?

A

Antibiotics +/- drainage

Management of RFs

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147
Q

What are buckle fractures?

A

Incomplete fractures of the shaft of a long bone characterised by bulging of the cortex

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148
Q

In who do buckle fractures tend to occur?

A

5-10yos

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149
Q

How are buckle fractures managed?

A

Usually self-limiting so can be managed with splinting + immobilisation rather than a cast

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150
Q

Why do children get buckle fractures instead of proper breaks in their bones?

A

Their bone is more elastic so axial trauma –> deformity rather than a true fracture

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151
Q

What sort of things tend to lead to hip dislocation?

A

Direct trauma, e.g. road traffic accident/fall from significant height

Large amounts of forces req. to dislocate hip

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152
Q

What must you be aware of in hip fractures?

A

Huge amounts of forces req. to dislocate hip so may be associated with fractures or life-threatening injuries

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153
Q

What are the features of hip dislocation?

A

Extreme pain

Deformity depending on type

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154
Q

What is the most common type of hip dislocation?

A

Posterior dislocation (90%)

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155
Q

What is the appearance of a posterior hip dislocation?

A

Affected leg shortened, adducted and internally rotated

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156
Q

What is the appearance of a anterior hip dislocation?

A

Affected leg abducted and externally rotated with NO leg shortening

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157
Q

What are the three types of hip dislocation?

A

Posterior
Anterior
Central

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158
Q

How do you manage hip dislocations?

A

ABCDE
Analgesia
Reduction under GA within 4h

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159
Q

What is involved in the long term management of hip dislocations?

A

Physio to strengthen surrounding muscles

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160
Q

Why should you reduce a hip fracture within 4h?

A

To reduce risk of avascular necrosis

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161
Q

What are complications of hip fracture?

A

Sciatic/femoral nerve injury
Avascular necrosis
OA
Recurrent dislocation

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162
Q

Why are patients who have had a hip fracture at risk of recurrent dislocation?

A

Due to damage of supporting ligaments

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163
Q

How long does it take for a hip to heal after a traumatic dislocation?

A

2-3m

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164
Q

When is prognosis best after a hip dislocation?

A

If hip reduced less than 12h post-injury and when there is less damage to the joint

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165
Q

What are baker’s cysts?

A

Distensions of the gastrocnemius-semimembranosus bursa

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166
Q

What are the two types of baker’s cysts?

A

Primary

Secondary - underlying condition, e.g. OA

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167
Q

Who are primary baker’s cysts usually seen in?

A

Children

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168
Q

Where are baker’s cysts?

A

In popliteal fossa

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169
Q

What are the feature of ruptured baker’s cyst?

A

Similar to DVT - pain, redness, swelling in calf

But most are asymptomatic

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170
Q

How should you manage baker’s cysts in children?

A

These typically resolve and don’t require treatment

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171
Q

How should you manage baker’s cysts in adults?

A

Treat underlying cause

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172
Q

How do baker’s cysts tend to present?

A

Asymptomatic, fluctuant swelling behind the knee

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173
Q

Where is the pain + tenderness in medial epicondylitis?

A

Medial epicondyle

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174
Q

What is medial epicondylitis also known as?

A

Golfer’s elbow

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175
Q

What aggravates the pain in golfer’s elbow?

A

Wrist flexion + pronation

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176
Q

What other symptoms may you get in golfer’s elbow?

A

Numbness/tingling in 4th + 5th finger due to ulnar nerve involvement

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177
Q

What most commonly causes radial tunnel syndrome?

A

Compression of the posterior interosseous branch of the radial nerve

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178
Q

What is thought to cause radial tunnel syndrome?

A

Overuse

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179
Q

What are the features of radial tunnel syndrome?

A

Similar to lateral epicondylitis but pain is 4-5cm distal to lateral epicondyle
Symptoms worsened by extending elbow + pronating forearm

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180
Q

What is cubital tunnel syndrome due to?

A

Compression of the ulnar nerve

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181
Q

What are the features of cubital tunnel syndrome?

A

Intermittent tingling in 4th + 5th finger

Worse when elbow resting on firm surface/flexed for extended periods

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182
Q

What are later features of cubital tunnel syndrome?

A

Numbness in 4th and 5th finger with associated weakness

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183
Q

What are the features of olecranon bursitis?

A

Swelling over posterior aspect of elbow

May be pain, warmth, erythema

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184
Q

What kind of injuries tend to lead to AC joint injury?

A

Collison sports, e.g. rugby

Fall on outstretched hand

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185
Q

How are AC injuries graded?

A

I-VI

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186
Q

How are AC injuries grade I-II managed?

A

Conservatively - rest + sling

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187
Q

What grades of AC injury require surgical intervention?

A

IV, V, VI

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188
Q

How are grade III AC injuries managed?

A

Depends on individual circumstances

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189
Q

What is the stimson maneuver?

A

Used for reduction of dislocated shoulders

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190
Q

What will you see on X-ray in compartment syndrome?

A

Typically no pathology

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191
Q

What sorts of people may get compartment syndrome without having had a fracture?

A

Those who intensively exercise

Those with bleeding disorders, e.g. haemophilia

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192
Q

Why is subluxation of the radial head more common in young children?

A

Distal attachment of the annular ligament covering the radial head is weaker in children

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193
Q

What are signs of subluxation of the radial head?

A

Elbow pain, limited supination, extension of the elbow

Child usually refuses examination

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194
Q

How is subluxation of the radial head managed?

A

Analgesia + passively supination of the elbow joint whilst elbow is flexed to 90 degrees

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195
Q

What is lumbar spinal stenosis?

A

When the central canal is narrowed by a tumour, disc prolapse or degenerative changes

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196
Q

How do patients with lumbar spinal stenosis present?

A

Back pain, neuropathic pain, claudication type symptoms

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197
Q

How can you distinguish the claudication from lumbar spinal stenosis from vascular claudication?

A

Sitting is better than standing

Easier to walk uphill/ride a bike

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198
Q

What is the most common cause of lumbar spinal stenosis?

A

Degenerative disease

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199
Q

Where is degeneration thought to start in lumbar spinal stenosis?

A

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

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200
Q

What things narrow the central canal in lumbar spinal stenosis?

A

Ventral disc bulging
Osteophyte formation at dorsal facet
Ligamentum flavum hypertrophy

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201
Q

What does central canal narrowing mean?

A

Less space for neurons

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202
Q

What nerves are compressed in lumbar spinal stenosis?

A

Cauda equina nerve roots

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203
Q

What is the best imaging to see lumbar spinal stenosis?

A

MRI

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204
Q

How is lumbar spinal stenosis managed?

A

Laminectomy

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205
Q

What are the features of cauda equina syndrome?

A

Lower back pain
Urinary incontinence/retention
Reduced perianal sensation (saddle anaesthesia)
Decreased anal tone

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206
Q

How is cauda equina syndrome investigated?

A

Urgent MRI lumbar-sacral spine

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207
Q

How quickly should someone with suspected cauda equina syndrome be imaged?

A

ASAP

Target within 6h

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208
Q

What are the complications of cauda equina syndrome?

A

Incontinence

Paralysis of lower limbs

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209
Q

What is the other name for Charcot joint?

A

Neuropathic joint

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210
Q

What is Charcot joint?

A

A joint that has become badly disrupted and damaged secondary to a loss of sensation

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211
Q

What used to be the commonest cause of Charcot joint?

A

Syphilis (tabes dorsalis)

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212
Q

What is now the commonest cause of Charcot joint?

A

Diabetic neuropathy

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213
Q

What are the features of Charcot joint?

A

A joint that is a lot less painful that expected given degree of joint disruption
Joint is swollen, red, warm

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214
Q

What other neuropathy commonly predisposes to charcot joint?

A

Alcoholic neuropathy

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215
Q

Why do are charcot joints so disrupted and a mess?

A

It is on a weight bearing joint and individual cannot feel pain from damage so continues to walk on joint and make it worse

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216
Q

What are the cardinal features of epidural abscess?

A

Fever

Back pain

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217
Q

What is De Quervain’s tenosynovitis?

A

Inflammation of the sheath containing the extensor pollicis brevis + abductor pollicis longus tendon

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218
Q

Who does De Quervain’s tenosynovitis tend to affect?

A

Women from 30-50ys

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219
Q

What are the features of De Quervain’s tenosynovitis?

A

Pain on radial side of wrist
Tenderness of radial styloid
Abduction of thumb against resistance is sore
+ve Finklestein’s test

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220
Q

How do you carry out Finklestein’s test?

A

Pull thumb whilst in ulnar deviation + longitudinal traction
This causes pain over radial styloid process + along length of EPB + APL

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221
Q

How do you manage De Quervain’s tenosynovitis?

A

Analgesia
Steroid injection
Thumb splint
Surgery

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222
Q

What muscles are in the anterior compartment of the leg?

A

Tibialis anterior
Extensor digitorum longus
Peroneus tertius
Extensor hallucis longus

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223
Q

What nerve innervates the anterior compartment of the leg?

A

Deep peroneal nerve

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224
Q

What is the action of the tibialis anterior?

A

Dorsiflexes ankle joint, inverts foot

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225
Q

What is the action of extensor digitorum longus?

A

Extends lateral 4 toes, dorsiflexes ankle joint

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226
Q

What is the action of peroneus tertius?

A

Dorsiflexes ankle, everts foot

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227
Q

What is the action of extensor hallucis longus?

A

Dorsiflexes ankle, extends big toe

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228
Q

What are the muscles of the lateral compartment of the leg?

A

Peroneus longus

Peroneus brevis

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229
Q

What nerve innervates the lateral compartment of the leg?

A

Superficial peroneal nerve

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230
Q

What is the action of the peroneus longus?

A

Everts foot, assists in plantarflexion

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231
Q

What is the action of the peroneus brevis?

A

Plantaflexes ankle

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232
Q

What are the muscles of the superficial posterior compartment of the leg?

A

Gastrocnemius

Soleus

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233
Q

What nerve innervates the posterior compartment of the leg?

A

Tibial nerve

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234
Q

What is the action of the gastrocnemius?

A

Plantarflexes foot, flexes knee

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235
Q

What is the action of soleus?

A

Plantarflexor

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236
Q

What are the muscles of the deep compartment of the leg?

A

Flexor digitorum longus
Flexor hallucis longus
Tibialis posterior

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237
Q

What is the action of flexor digitorum longus?

A

Flexes lateral four toes

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238
Q

What is the action of flexor hallucis longus?

A

Flexes great toe

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239
Q

What is the action of tibialis posterior?

A

Plantarflexes, inverts foot

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240
Q

What nerve is most likely to be damaged if an individual develops foot drop after a revision of a total hip replacement?

A

Sciatic

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241
Q

What is the most common cause of cauda equina syndrome?

A

Herniation of an IV disc

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242
Q

What are other causes of cauda equina syndrome?

A

Tumours
Infection (e.g. epidural abscess)
Haematoma

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243
Q

Who can be assessed using the FRAX tool?

A

40-90 year olds with or without a BMD

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244
Q

What tools do NICE recommend for assessing risk of fragility fractures?

A

QFracture, FRAX

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245
Q

Who should be assessed for risk of fragility fractures?

A 
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
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246
Q

What do FRAX and Qfracture assess?

A

Risk of fragility fracture in the next ten years

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247
Q

Which of QFracture and FRAX are based on UK and which is based on international data?

A 
QFracture = UK
FRAX = international
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248
Q

What factors does FRAX assess?

A 
Age
Sex
Wt
Ht
Prev. fracture
Parental fracture
Current smoking
Glucocorticoids
RA
Secondary osteoporosis
Alcohol intake 
BMD optional
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249
Q

What score of FRAX should prompt you to arrange a DEXA scan?

A

Intermediate

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250
Q

What age groups can QFracture be used for?

A

30-99

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251
Q

What things are included in the QFracture risk factors?

A 
CV dx
Hx falls
Chronic liver disease
RA
T2DM
TCAs
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252
Q

In which situations should you go straight to a DEXA scan and miss out FRAX/QFracture?

A

Before starting medications that may have a rapid adverse effect on BMD
In those <40 who have a major risk factors

253
Q

What major risk factors may make you go straight to giving someone a DEXA scan if they are <40?

A

Hx of multiple fragility fractures
Major osteoporotic fracture
Current/recent use of high dose oral/system glucocorticoids

254
Q

What treatments may have a rapid adverse effect on BMD?

A

Sex hormone deprivation for breast cancer/prostate Rx

255
Q

What scores can you get from doing a FRAX without a BMD what scores can you get and what do these mean?

A

Low risk - reassure + lifestyle advice
Intermediate risk - offer BMD test
High risk - offer bone protection treatment

256
Q

What scores can you get from doing a FRAX with a BMD what scores can you get and what do these mean?

A

Reassure
Consider treatment
Strongly recommend treatment

257
Q

What kind of results does QFracture produce?

A

Raw data which then needs interpreted alongside guidelines

258
Q

When should we reassess risk of fragility fracture (i.e. repeat FRAX/QFracture)?

A

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
Q

what group of drugs will worsen compartment syndrome?

A

Anticoagulants

260
Q

What are the three things that can cause a fracture?

A

Trauma - excessive force to bone
Stress related
Pathological

261
Q

What is a pathological fracture?

A

Abnormal bone that fractures during normal use or following minimum trauma

262
Q

What causes stress fractures?

A

Repetitive low velocity injury

263
Q

What should you ensure to do when examining a fracture site?

A

Check site + type of injury
Check for assoc. injuries and distal NV deficits
May have to radiograph proximal + distal joints

264
Q

What is an oblique fracture?

A

Fracture that lies obliquely to long axis of bone

265
Q

What is a comminuted fracture?

A

> 2 fragments

266
Q

What is a segmental fracture?

A

More than one fracture along a bone

267
Q

What is a transverse fracture?

A

Perpendicular to long axis of bone

268
Q

What is a spiral fracture?

A

Severe oblique fracture with rotation along long axis of bone

269
Q

What are the key points about managing fractures?

A

Immobilise fracture including joint above + below
Monitor NV status
Tetanus prophylaxis
IV antibiotics if open

270
Q

How quickly should open fractures be debrided and lavaged?

A

6h of injury

271
Q

What are the types of paediatric fractures?

A 
Complete fracture
Toddler's fracture
Plastic deformity
Greenstick fracture
Buckle fracture 
Growth plate fractures
272
Q

What is a complete fracture?

A

Both sides of cortex are breached

273
Q

What is a toddler’s fracture?

A

Oblique tibial fracture in infants

274
Q

What is a plastic deformity?

A

Stress on bone resulting in deformity without cortical disruption

275
Q

What is a greenstick fracture?

A

Unilateral cortical breach only

276
Q

What is a buckle fracture?

A

Incomplete cortical disruption leading to a periosteal haematoma only

277
Q

What system is used to classify growth plate fractures?

A

Salter-Harris

278
Q

What is the salter-harris classification?

A

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
Q

What do SH type 1 fractures look like on X-ray?

A

Often look normal (same with V)

280
Q

If you get growth plate tenderness but a normal x-ray what is it best to assume it is?

A

Still safer to assume it is an underlying fracture

281
Q

How do you manage SH type III, IV and V fractures?

A

Surgery

282
Q

What are type V SH fractures associated with?

A

Disruption to growth

283
Q

What things may be indicative of NAI?

A 
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
Q

What causes OI?

A

Defective osteoid formation due to congenital inability to provide adequate intracellular materials, e.g. osteoid, collagen, dentine

285
Q

OI is due to a failure of ______ maturation in all the connective tissues.

A

Collagen

286
Q

What might you see on radiology in OI?

A

Translucent bones, multiple fractures, esp. in long bones
Wormian bones
Trefoil pelvis

287
Q

What is wormian bones?

A

Irregular patches of ossification

288
Q

What are the types of OI?

A

I-IV

289
Q

What is type I OI?

A

Collagen is normal quality but insufficient

290
Q

What is type II OI?

A

Poor collagen quantity and quality

291
Q

What is type III OI?

A

Collagen poorly formed but normal quantity

292
Q

What is type IV OI?

A

Sufficient collagen quantity but poor quality

293
Q

What is osteopetrosis?

A

Bones are harder and more dense

294
Q

How is osteopetrosis inherited?

A

AD

295
Q

Who is osteopetrosis most common in?

A

Young adults

296
Q

What do you see on radiology in osteopetrosis?

A

Lack of differentiation between cortex and medulla described as marble bone

297
Q

What is talipes quinovarus?

A

Club foot

Inverted + plantarflexed foot

298
Q

Where is club foot normally picked up?

A

On newborn Ex

299
Q

In which gender is club foot more common?

A

Males

300
Q

What % of cases of club foot are bilateral?

A

50%

301
Q

What are most cases of clubfoot associated with?

A

They are idiopathic!

302
Q

What are some associations of club foot?

A 
Spina bifida
Cerebral palsy 
Edwards syndrome
oligohydramnios
Arthrogryposis
303
Q

How is club foot diagnosed?

A

Clinically

304
Q

How is club foot managed?

A

Ponseti method mostly
surgery
Night time braces until 4yo

305
Q

What does the Ponseti method involve?

A

Manipulation and progressive casting starting soon after birth

306
Q

How long does it take the Ponseti method to work usually?

A

6-10w

307
Q

What is needed in 85% cases of club foot if using the ponseti method to treat it?

A

Achilles tenotomy

308
Q

What causes the majority of lower back pain?

A

Non-specific muscular nature

309
Q

What are red flags for lower back pain?

A 
age < 20 years or > 50 years
history of previous malignancy
night pain
history of trauma
systemically unwell e.g. weight loss, fever
310
Q

What are the features of facet joint lower back pain?

A

Pain worse in morning + on standing
OE pain over facets
Pain worse on extension of back

311
Q

What are the features of spinal stenosis?

A

Gradual onset of unilateral/bilateral leg pain +/- back pain, numbness, weakness
Worse on walking, better when sitting
Ex usually normal

312
Q

How does AS tend to present?

A

Young man with lower back pain and stiffness which is worse in the morning and improves with activity
35% have peripheral arthritis

313
Q

Compression of what nerve causes carpal tunnel syndrome?

A

Median nerve

314
Q

What is a typical hx of someone with carpal tunnel syndrome?

A

Pins + needles/pain in thumb, index + middle finger

Pt shakes hand to obtain relief, classically at night

315
Q

What might you find on Ex of someone with CTS?

A

Weakness of thumb abduction (APB)
Wasting of thenar eminence
+ve Tinel’s + Phalen’s sign

316
Q

What are causes of CTS?

A 
Idiopathic
Pregnancy
Oedema, e.g. heart failure
Lunate fracture
RA
317
Q

What do you see on electrophysiology in CTS?

A

Motor + sensory: prolongation of the AP

318
Q

What is the treatment of CTS?

A

Corticosteroid injection
Wrist splints at night
Surgical decompression

319
Q

What does surgical decompression for CTS involve?

A

Flexor retinaculum division

320
Q

What is a colles’ fracture?

A
  1. transverse fracture of radius
  2. 1 inch proximal to radio-carpal joint
  3. dorsal displacement and agulation
321
Q

What tends to cause a Colles’ fracture?

A

FOOSH

322
Q

What causes a Smith fracture?

A

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

323
Q

What is a Smith’s fracture?

A

Volar angulation of distal radius fragment

324
Q

What is the deformity called in a colle’s fracture?

A

Dinner fork deformity

325
Q

What is the deformity called in a smiths fracture?

A

Garden spade deformity

326
Q

What is a Bennett;s fracture?

A

IA fracture of the first carpometacarpal joint

327
Q

What tends to cause a Bennett’s fracture?

A

Impact on flexed metacarpal, caused by fist fights

328
Q

What can you see on X-ray in a Bennett’s fracture?

A

Triangular fragment at ulnar base of metacarpal

329
Q

What is a Monteggia’s fracture?

A

Dislocaton of the proximal radioulnar joint in association with an ulna fracture

330
Q

What causes a Monteggia’s fracture?

A

FOOSH with force pronation

331
Q

Why does Monteggia fractures need prompt diagnosis?

A

To avoid disability

332
Q

What is a Galeazzi fracture?

A

Radial shaft fracture with associated dislocation of the distal radioulnar joint

333
Q

What causes a Galeazzi fracture?

A

Direct blow

334
Q

What is a Pott’s fracture?

A

Bimalleolar ankle fracture

335
Q

What causes a Pott’s fracture?

A

Forced foot eversion

336
Q

What is a Barton’s fracture?

A

Distal radius fractures (colles’/smith’s) + assoc. radiocarpal dislocation

337
Q

What causes a Barton’s fracture?

A

Fall onto extended and pronated wrist

338
Q

What is osteomyelitis?

A

Infection of bone

339
Q

What is the most common cause of osteomyelitis in most pts?

A

Staph aureus

340
Q

What is the most common cause of osteomyelitis in pts with sickle cell anaemia?

A

Salmonella spp.

341
Q

What conditions predispose to OM?

A 
DM
Sickle cell anaemia
IVDA
Immunosupressed (e.g. meds/HIV)
Alcohol excess
342
Q

What is the imaging modality of choice in investigating suspected OM?

A

MRI

343
Q

What is the management of OM?

A

IV flucloxacillin for 6w

Clindamycin if penicillin allergic

344
Q

Where is the most common place for children to get OM and why?

A

Metaphysis of long bones (as this is highly vascular and OM tends to spread haematongeously)

345
Q

Where is the most common place for adults to get OM?

A

Epiphysis

346
Q

What analgesics should be recommended for non-specific lower back pain?

A

Paracetamol, ibruprofen

Codeine if have CDK

347
Q

What features do you get in a dorsal column lesion?

A

Loss of vibration + proprioception

Tabes dorsalis, SACD

348
Q

What features do you get in a spinothalamic lesion?

A

Loss of pain, sensation and temperature

349
Q

What features do you get in a central cord lesion?

A

Flaccid paralysis of upper limbs

350
Q

What organism tends to cause OM in IVDAs?

A

Staph aureus

351
Q

What organism tends to cause OM in those who are immunocompromised?

A

Funguses

352
Q

What organism tends to cause OM in the thoracic region?

A

TB

353
Q

What are the features of spinal cord infarction?

A

Dorsal column signs (loss of proprioception + fine discrimination)

354
Q

What features do uou get in cord compression?

A

UMN signs

355
Q

What tends to cause brown sequard syndrome?

A

Hemisection of the cord

356
Q

What features do you get in brown sequard syndrome?

A

Ipsilateral paralysis
Ipsilateral loss of proprioception + fine discrimination
Contralateral loss of pain + temperature

357
Q

What myotome is responsible for elbow flexion (biceps)?

A

C5

358
Q

What myotome is responsible for wrist extension?

A

C6

359
Q

What myotome is responsible for elbow extension (triceps)?

A

C7

360
Q

What myotome is responsible for long finger flexors?

A

C8

361
Q

What myotome is responsible for small finger abductors?

A

T1

362
Q

What myotome is responsible for hip flexors (psoas)?

A

L1 + L2

363
Q

What myotome is responsible for knee extensors (quadriceps)?

A

L3

364
Q

What myotome is responsible for ankle dorsiflexors (tibialis anterior)?

A

L4 + L5

365
Q

What myotome is responsible for toe extensors (hallucis longus)?

A

L5

366
Q

What myotome is responsible for ankle plantarflexors (gastroc)?

A

S1

367
Q

What is the anal sphincter innervated by?

A

S2-4

368
Q

What investigation is required for diagnosis of spinal stenosis?

A

MRI

369
Q

What is cervical spondylosis?

A

A very common condition that results from OA

370
Q

How does cervical spondylosis tend to present?

A

As neck pain although referred pain may mimic headaches

371
Q

What are complications of cervical spondylosis?

A

Radiculopathy

Myelopathy

372
Q

Radiculopathy follows a _____ distribution

A

Dermatomal

373
Q

What are the disorders affecting the Achilles tendon?

A

Tendinopathy
Partial tear
Complete rupture

374
Q

What are risk factors for achilles tendon disorders?

A

Quinolone use

Hypercholesterolaemia (predisposes to tendon xanthomata)

375
Q

What are features of achilles tedinopathy?

A

Gradual onset posterior heel pain, worse following activity

Morning pain + stiffness

376
Q

What is the management of achilles tendinopathy?

A

Analgesia

Reduction in precipitating activities

377
Q

What are the features of Achilles tendon rupture?

A

Audible pop in ankle/sudden onset of calf/ankle pain whilst running/playing sport + unable to walk/continue sport after

378
Q

What triad is used to exclude achilles tendon rupture?

A

Simmonds triad

379
Q

What is Simmonds triad?

A

Altered angle of dangle
Palpable/visible gap
+ve Thompsons test

380
Q

What is the management of an acute achilles tendon rupture?

A

Acute referral to ortho specialist

381
Q

What are the features of a respiratory fat embolism?

A

Early persistent tachycardia
Tachypnoea, dyspnoea, hypoxia 72h following injury
Pyrexia

382
Q

What are the features of a dermatological fat embolism?

A

Red/brown impalpable petechial rash

Subconjunctival/oral haemorrhage/petechiae

383
Q

What are the features of a CNS fat embolism?

A

Confusion + agitation

Retinal haemorrhages + intra-arterial fat globules on fundoscopy

384
Q

How should you manage a fat embolism?

A

Prompt fixation of long bone fractures

DVT prophylaxis General supportive care

385
Q

What is a risk factor for fat embolism?

A

Recent fracture

386
Q

What is the pathophysiology of Paget’s disease?

A

Focal resportion followed by excessive + chaotic bone deposition

387
Q

Where does Paget’s affect the most?

A

In order@

Spine, skull, pelvis, femur

388
Q

What blood marker is raised in Paget’s?

A

ALP

389
Q

What do you see on X-ray in Paget’s?

A

Abnormal thickened, sclerotic bone

390
Q

There is a risk of cardiac failure if there is >…% of bony involvement in Paget’s?

A

15

391
Q

What is there a small risk of in Paget’s disease?

A

Sarcomatous change

392
Q

What is the pathophysiology of osteoporosis?

A

Excessive bone resportion –> demineralised bone

393
Q

What are the symptoms of osteoporosis?

A

Asymptomatic, just greater risk of fracture

394
Q

How can secondary bone tumours damage bone?

A

Bone destruction and tumour infiltration can occur

395
Q

What scoring system is used to predict risk of fracture in secondary bone tumours?

A

Mirel

396
Q

What tends to cause sclerotic secondary bone tumours?

A

Prostate cancer

397
Q

What tends to cause lytic secondary bone tumours?

A

Breast

398
Q

How are serum calcium, ALP levels affected by a secondary bone tumour?

A

Raised

399
Q

How is Paget’s disease managed?

A

Bisphosphonates

400
Q

How is osteoporosis managed?

A

Bisphosphonates, Ca, Vit D

401
Q

How are secondary bone tumours managed?

A

Radiotherapy
Prophylactic fixation
Analgesia

402
Q

What kind of injury is an ACL rupture?

A

Sports injury

403
Q

What mechanism tends to cause an ACL?

A

High twisting force applied to a bent knee

404
Q

How does ACL rupture tend to present?

A

Loud pop, pain, RAPID joint swelling (haemoarthrosis)

405
Q

How is ACL rupture managed?

A

Intense physio

Surgery

406
Q

What kind of mechanism causes PCL rupture?

A

Hyperextensive injuries (e.g. knee hitting dashboard)

407
Q

What are signs of PCL rupture?

A

TIbia lies on back of femur

Paradoxical anterior draw test

408
Q

What is the mechanism of MCL rupture?

A

Leg forced into valgus via force outside the leg

409
Q

What are signs of MCL rupture?

A

Knee unstable when put into valgus

410
Q

What kind of injuries tend to cause meniscal tear?

A

Rotational sport injuries

411
Q

What are the features of meniscal tear?

A

Joint locking
Delayed knee swelling
Recurrent episodes of pain + effusion (often following minor trauma) are common

412
Q

What is the typical history of chondromalacia patellae?

A

Teenage girl following injury to the knee, e.g. patellar dislocation
hx of pain on going downstairs/at rest
Tenderness, quadricep wasting

413
Q

What can cause a dislocated patella?

A

Trauma -
Direct trauma
Severe contraction of quadriceps with knee stretched in valgus + external rotation

414
Q

What are risk factors for dislocated patella?

A

Genu valgus
Tibial torsion
High riding patella

415
Q

What type of imaging is required for a patellar dislocation?

A

Skyline x-ray

416
Q

What kind of fracture is present in %% of dislocated knees?

A

Osteochondral fracture

417
Q

What are the two types of fractured patella?

A

Direct blow to patella –> undisplaced fragments

Avulsion fracture

418
Q

Who do tibial plateau fractures tend to occur in?

A

Elderly or following significant trauma in the young

419
Q

What is the mechanism that causes a tibial plateau fracture?

A

Knee forced into valgus/varus, but knee fractures before ligament rupture

420
Q

Varus injury affects the _____ plateau, and valgus injury affects the _____ plateau.

A

Medial

Lateral

421
Q

What system is used for classifying tibial plateau fractures?

A

Schatzker

422
Q

Where does OA most commonly affect?

A

Knee then hip

423
Q

What are risk factors for OA of the hip?

A

Increasing age
Female gender
Obesity
DDH

424
Q

What are features of OA hip?

A

Chronic hx groin ache following exercise + relieved by rest

425
Q

What are red flags that may suggest an alternative diagnosis from hip OA?

A

Rest pain
Night pain
Morning stiffness >2h

426
Q

What score is used to assess OA hip severity?

A

Oxford hip score

427
Q

What investigations are required for suspected OA hip?

A

If typical features - clinical diagnosis can be made

Otherwise X-ray first line

428
Q

What is the management of hip OA?

A

Oral analgesia
IA injections
TRH is definitive Rx

429
Q

How do IA injections help in hip OA?

A

Provide short term benefit

430
Q

What are complications of THR?

A

VTE
Intraoperative fracture
Nerve injury

431
Q

What are reasons for revising a total hip replacement?

A

Aseptic loosening (most common cause)
Pain
Dislocation
Infection

432
Q

What is Leriche syndrome?

A

Atheromatous disease affecting the iliac vessels meaning blood flow to the pelvic viscera is compromised

433
Q

How do patients with Leriche syndrome tend to present?

A

Buttock + thigh claudication, impotence, atrophy of the musculature of legs

434
Q

What is involved in the diagnostic workup for Leriche syndrome?

A

Angiography

435
Q

How is Leriche syndrome treated?

A

Iliac occlusions can sometimes be treated with endovascular angioplasty + stent insertion
Management of RFs (e.g. hypercholesterolaemia, stop smoking)

436
Q

What diseases are encompassed with rotator cuff injury?

A 
Subacromial impingement (aka. painful arc syndrome) 
Calcific tendonitis
Rottor
437
Q

What diseases are encompassed with rotator cuff injury?

A

Subacromial impingement (aka. painful arc syndrome)
Calcific tendonitis
Rotator cuff tears
Rotator cuff arthropathy

438
Q

What are symptoms of rotator cuff injury?

A

Shoulder pain worse on abduction

439
Q

What are signs of rotator cuff injuries?

A

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
Q

What can cause a rotator cuff tear?

A

Trauma

Chronic impingement

441
Q

How can you differentiate between a rotator cuff tear and impingement?

A

Get muscle weakness in rotator cuff injury

442
Q

How can you differentiate between a medial meniscal tear and a lateral meniscal tear?

A

Medial - tenderness over medial joint line and vice versa

443
Q

What is the commonest cause of heel pain in adults?

A

Plantar fasciitis

444
Q

Where is the pain usually worst in plantar fasciits?

A

Medial calcaneal tuberosity

445
Q

How do you manage plantar fasciitis?

A 
Rest feet where possible
Manage RFs, incl wt loss 
Stretching 
Where shoes with good arch support + cushioned heels
Insoles/heel pads
446
Q

What exacerbates the heel pain seen in planar fasciitis?

A

Walking on tips of toes

447
Q

Where is the pain in achilles tendonitis?

A

Calcneal insertion or further up tendon

448
Q

What mechanism of injury tends to cause a scaphoid fracture?

A

FOOSH
Contact sports, e.g. football
RTA due to pt holding steering wheel

449
Q

What is the blood supply of the scaphoid?

A

80% from dorsal carpal branch (branch of radial artery) in retrograde manner

450
Q

Interruption of the blood supply to the scaphoid can lead to what?

A

Avascular necrosis of the head of the scaphoid

451
Q

How do pts with scaphoid fracture tend to present?

A

Pain along the radial aspect of wrist + base of thumb

Loss of grip/pincer strength

452
Q

What are signs of scaphoid fracture?

A 
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
Q

What investigations should be arranged for suspected scaphoid fracture?

A

X-rays in AP + lateral

Repeat X-ray in 2w if inconclusive but clinical features strongly suggest scaphoid fracture/scaphoid fracture diagnosed

454
Q

When might a CT be done for scaphoid fracture?

A

If planning surgery or determining extent of fracture union in follow up

455
Q

What is avascular necrosis?

A

Death of bone tissue secondary to loss of blood supply –> bone destruction + loss of joint function

456
Q

Where does avascular necrosis tend to affect?

A

Epiphysis of long bones, e.g. femur

457
Q

What can cause AVN of the hip?

A

Long term steroid use
Chemotherapy
Alcohol xs
Trauma

458
Q

What are features of AVN of hip?

A

Initially asymptomatic

Then pain in affected joint

459
Q

What are early signs of AVN of hip?

A

Osteopenia + microfractures

Collapse of articular surface may –> crescent sign

460
Q

What is the investigation of choice in suspected AVN hip?

A

MRI

461
Q

What is the management of AVN of hip?

A

Joint replacement may be req.

462
Q

What is an effective method of analgesia for neck of femur fracture?

A

Iliofascial nerve block is first line

463
Q

What do stress fractures result from?

A

Repetitive activity + loading of normal bone

464
Q

How are stress fractures managed?

A

May need immobilisation only if severely painful and presenting at an earlier stage where this may be beneficial

465
Q

What are features of OA of the knee?

A

Pain may be severe

Intermittent swelling, crepitus + limitation of movement

466
Q

What kinds of pts tend to get OA of the knee?

A

> 50s, often overwt

467
Q

What is associated with infrapatellar bursitis?

A

Kneeling

468
Q

What is associated with prepatellar bursitis?

A

Upright kneeling

469
Q

What test is +ve in ACL rupture?

A

Draw test

470
Q

What are features of collateral ligament damage?

A

Tenderness over affected ligament

Knee effusion may be seen

471
Q

What conditions predispose to a baker’s cyst?

A

Gout

Arthritis

472
Q

What is Foucher’s sign?

A

Increase in tension of a Baker’s cyst on extension of the knee

473
Q

What is a straight leg raise test?

A

Raise leg while it is straight

If pain in distribution of sciatic nerve –> +ve

474
Q

How should failed conservative management of plantar fasciitis be managed?

A

Refer to orthopaedics (cosnider surgery) and physio

475
Q

What causes Duputyren’s contracture?

A

Hyperplasia and then contractures of the palmar aponeurosis

476
Q

What does Duputyren’s contracture look like?

A

Fingers bend towards the palm and cannot be fully extended

477
Q

Is Duputyren’s sore?

A

No not normally

478
Q

Can Duputyren’s contracture progress?

A

It is normally progressive

479
Q

How is CTS formally diagnosed?

A

Electrophysiological studies

480
Q

What are non-surgical options for the management of CTS?

A

Splinting

Bracing

481
Q

What are Osler’s nodes?

A

Deposition of immune complexes

482
Q

What do Osler’s nodes present like?

A

Painful, red, raised lesions on the hands + feet

483
Q

What are Bouchard’s nodes?

A

Hard, bony outgrowths or gelatinous cysts on the proximal IP joints

484
Q

What causes Bouchard’s nodes?

A

OA

caused by formation of calcific spurs of the articular cartilage

485
Q

How do Heberden’s nodes develop?

A

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
Q

Where are ganglions usually found?

A

Back of hand

Wrist

487
Q

How are ganglions managed?

A

Usually asymptomatic + disappear after a few months but if troublesome can be excised

488
Q

What are ganglions?

A

Swellings in association with a tendon sheath (usually near a joint)

489
Q

What fluid are ganglions filled with?

A

Fluid similar to synovial fluid

490
Q

What are the nerve roots of the musculocutaneous nerve?

A

C5-7

491
Q

What is the motor supply of the musculocutaneous nerve?

A

Elbow flexion + supination

492
Q

What is the sensory supply of the musculocutaneous nerve?

A

Lateral part of forearm

493
Q

What are the nerve roots of the axillary nerve?

A

C5-6

494
Q

What is the motor supply of the axillary nerve?

A

Shoulder abduction (deltoid)

495
Q

What is the sensory supply of the axillary nerve?

A

Regimental badge region

496
Q

What are the nerve roots of the radial nerve?

A

C5-8

497
Q

What is the motor supply of the radial nerve?

A

Extension (forearm, wrist, fingers, thumb)

498
Q

What is the sensory supply of the radial nerve?

A

Small area between dorsal aspect of the 1st and 2nd metacarpals

499
Q

What are the nerve roots of the median nerve?

A

C6, C8, T1

500
Q

What is the motor supply of the median nerve?

A

LOAF muscles

501
Q

What is the sensory supply of the median nerve?

A

Palmar aspect of lateral 3.5 fingers

502
Q

What does the ulnar nerve supply?

A

Intrinsic hand muscles expect LOAF

Wrist flexion

503
Q

What is the sensory supply of the ulnar nerve?

A

Medial 1.5 fingers

504
Q

What is the motor supply of the long thoracic nerve?

A

C5-7

505
Q

What sort of things may cause damage to the long thoracic nerve?

A

Blow to ribs

Complication of mastectomy

506
Q

What sign does damaged long thoracic nerve lead to?

A

Winging of scapula

507
Q

What sort of thing can lead to damage of the ulnar nerve?

A

Medial epicondyle fracture

508
Q

What deformity can damage to the ulnar nerve lead to?

A

Claw hand

509
Q

What fracture can damage the radial nerve?

A

Humeral midshaft fracture

510
Q

What do you get in radial nerve palsy?

A

Wrist drop

511
Q

What sort of injuries can cause axillary nerve palsy?

A

Humeral neck fracture/dislocation

512
Q

What sign do you get in axillary nerve damage?

A

Flattened deltoid

513
Q

What features do you get if the median nerve is damage at the wrist?

A

Paralysis of thenar muscles, opponens pollicis

514
Q

What features do you get if the median nerve is damaged at the elbow?

A

Loss of pronation of forearm and weak wrist flexion

515
Q

What is Erb-Duchenne palsy due to?

A

Damage to upper trunk of brachial plexus (C5, 6)

516
Q

What commonly causes Erb-Duchenne palsy?

A

Shoulder dystocia at birth

517
Q

What does Erb-Duchenne palsy look like?

A

Arm hands by side, and is internally rotated, elbow extended

518
Q

What is Klumpke paralysis due to?

A

Damage to lower trunk of brachial plexus (C8, T1)

519
Q

What may cause Klumpke paralysis?

A

Shoulder dystocia, sudden upward jerk of hand

520
Q

What condition is Klumpke paralysis associated with?

A

Horner’s syndrome

521
Q

What are the LOAF muscles?

A

Lateral two lumbricals
Opponens pollis
Abductor pollis brevis
Flexor pollis brevis

522
Q

What is the bests imaging modality to diagnose a meniscal tear?

A

MRI

523
Q

How do you investigate a suspected fractured hip?

A

X-ray

If occult - MRI

524
Q

What are the clinical features of femoral nerve damage?

A

Weakness in knee extension, loss of patella reflex, numbness in thigh

525
Q

What are the clinical features of lumbosacral nerve damage?

A

Weakness in ankle dorsiflexion, numbness of calf and foot

526
Q

What are the features of sciatic nerve damage?

A

Weakness in knee flexion, foot movements, pain and numbness from gluteal region to ankle

527
Q

What are the features of obturator nerve damage?

A

Weakness in hip adduction, numbness over medial thigh

528
Q

What are sarcomas?

A

Malignant tumours of mesenchymal origin

529
Q

What are the two types of sarcomas?

A

Bone

Soft tissue

530
Q

What are the bone sarcomas?

A

Osteosarcoma
Ewings sarcoma
Chondrosarcoma

531
Q

What cells do chondrosarcomas originate from?

A

Chondrocytes

532
Q

What are types of soft tissue sarcomas?

A

Liposarcoma
Rhabdomyoarcoma
Leiomyosarcoma
Synovial sarcomas

533
Q

What do liposarcomas originate from?

A

Adipocytes

534
Q

What do rhabdomyosarcomas originate from?

A

Striated muscle

535
Q

What do leiomyosarcomas originate from?

A

Smooth muscle

536
Q

What do synovial sarcomas originate from?

A

Cell of origin unknown but not synovium

Lie close to joints

537
Q

What sarcoma can arise in soft tissue and bone?

A

Malignant fibrous histiocytoma

538
Q

What features of a mass/swelling should raise suspicion for a sarcoma?

A

Large >5cm soft tissue mass
Deep tissue location/intramuscular location
Rapid growth
Painful lump

539
Q

How should you assess a suspected sarcoma?

A

MRI, CT, USS

Biopsy

540
Q

Who typically gets Ewing’s sarcoma?

A

Males

10-20y

541
Q

Where is the commonest site for a Ewing’s sarcoma?

A

Femoral diaphysis

542
Q

What is Ewing’s sarcoma like histologically?

A

A small round tumour

543
Q

How is Ewing’s sarcoma treated?

A

Chemo + surgery

544
Q

How does Ewing’s sarcoma tend to spread?

A

Blood borne metastasis is common

545
Q

What is an osteosarcoma?

A

Mesenchymal cells with osteoblastic differentiation

546
Q

What age tend to get osteosarcomas?

A

15-30yos

547
Q

How is osteosarcoma usually managed?

A

Surgery + chemo

548
Q

Where are liposarcomas?

A

Tend to be deep locations, e.g. retroperitoneum

549
Q

What age groups do liposarcomas tend to affect?

A

> 40s

550
Q

Are liposarcomas aggressive?

A

Can be well differentiated + slow growing but may undergo de-differentiation + disease progression

551
Q

What is the issue with doing surgery for liposarcomas?

A

Tumour may have a pseudocapsule that can be misleading as tumour may invade edge of pseudocapsule

552
Q

What type of treatment is liposarcoma usually resistant to?

A

Radiotherapy

553
Q

What is the most common sarcoma in adults?

A

Malignant fibrous histiocytoma

554
Q

What are the four major subtypes of malignant fibrous histiocytoma?

A

Storiform-pleomorphic
Myxoid
Giant cell
Inflammatory

555
Q

How is malignant fibrous histiocytoma usually managed?

A

Surgery + adjuvant radio

556
Q

How should you manage a young person with an X-ray that could suggest bone sarcoma?

A

Very urgent referral to a specialist (<48h)

557
Q

What is meralgia paraesthetica?

A

Paraesthesia/anaesthesia in distribution of the lateral femoral cutaneous nerve

558
Q

What can cause meralgia paraesthetica?

A

Trapped LFCN
Iatrogenic after surgery
Neuroma

559
Q

What segments does LFCN arise from?

A

L2/3

560
Q

Where may the LFCN be subject to pressure or repetitive trauma?

A

Where it passes the ASIS

561
Q

In which condition is meralgia paraesthetica more common?

A

Diabetes

562
Q

What are RFs for meralgia paraesthetica?

A

Obesity
Pregnancy
tense ascites
Trauma
Iatrogenic, e.g. pelvic osteotomy, spinal surgery etc.
Various sports, e.g. gymnastics, bodybuilding

563
Q

How does meralgia paraesthetica present?

A

Burning, tingling, coldness, shooting pain
Numbness
Deep muscle ache

564
Q

What tends to aggravate symptoms in meralgia paraesthetica?

A

Standing

relieved by sitting

565
Q

How can you often reproduce the symptoms of meralgia paraesthetica?

A

Deep palpation just below the ASIS + with extension of the hip

566
Q

What is the motor deficit in meralgia paraesthetica?

A

There is no motor weakness

567
Q

How is meralgia paraesthetica investigated?

A

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
Q

Should you weight bear immediately after hip fracture surgery?

A

Yes

569
Q

How do you perform McMurrays test?

A

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
Q

What does +ve McMurray’s test indicate?

A

Meniscal tear

571
Q

What are Kanavel’s signs of flexor tendon sheath infection?

A

Fixed flexion, fusiform swelling, tenderness + pain on passive extension

572
Q

How is infective tenosynovitis managed?

A

Antibiotics + elevation if caught early

If not may need surgery

573
Q

Where is the most common place to fracture the humerus?

A

Surgical neck

574
Q

What kind of humeral fractures carry a risk of avascular necrosis to the humeral head?

A

Anatomical neck fractures which are displaced bby >1cm

575
Q

What is the commonest pattern of humeral fracture in children?

A

Greenstick fracture throughsurgical neck

576
Q

How are impacted fractures of the surgical neck of the humerus managed?

A

Collar + cuff for 3 weeks followed by physio

577
Q

How are more significant displaced fractures of the humerus managed?

A

May need open reduction and fixation or use of an intramedullary device

578
Q

What are the different types of shoulder dislocation and what is most common?

A

Glenohumeral dislocation (commonest)
Acromioclavicualr dislocation
Sternoclavicular dislocation

579
Q

What is an acromioclavicular dislocation?

A

Clavicle loses all attachment with the scapula

580
Q

What kind of glenohumeral dislocation is most common?

A

Anterior shoulder dislocation

581
Q

What deformities do you see in anterior shoulder dislocation?

A

External rotation + abduction

582
Q

What is anterior shoulder dislocation associated with?

A

Greater tuberosity fracture
Bankart lesion
Hill-Sachs defect

583
Q

What three signs do you see on X-ray with a posterior shoulder dislocation?

A

Rim’s sign
Light bulb sig
Trough sign

584
Q

How common are superior shoulder dislocations?

A

Rare, usually follow major trauma

585
Q

How are shoulder dislocations managed?

A

Prompt reduction

586
Q

What must you check pre and post-reduction in shoulder dislocations?

A

Neurovascular status

X-ray to ensure no fracture has occurred

587
Q

In recurrent anterior dislocation there is usually what kind of lesion? How is this repaired?

A

Bankart lesion

Surgically

588
Q

What kind of injury tends to cause an anterior shoulder dislocation?

A

Fall on arm/shoulder

589
Q

What pulses/nerves should you especially check in anterior shoulder dislocation?

A

Axillary

590
Q

What kind of things tends to ause posterior shoulder dislocation?

A

Seizures/electrocution

591
Q

How should you manage suspected scaphoid fracture?

A

Refer to hospital for urgent ortho/ED review

592
Q

What is Morton’s neuroma?

A

Benign neuroma affecting the intermetatarsal plantar nerve (most commonly in the 3rd intermetatarsophalangeal space)

593
Q

What are the features of a Morton’s neuroma?

A 
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
Q

How do you elicit Mulder’s click?

A

One hand squeezes the metatarsals together

Click may be heard as the neuroma moves between the metatarsal heads

595
Q

How is Morton’s neuroma diagnosed?

A

Usually clinical

USS may help

596
Q

How is Morton’s neuroma managed?

A

Avoid high heels
Metatarsal pads
Metatarsal dome orthotic

597
Q

When should you refer for Morton’s neuroma?

A

If symptoms persist >3m despite footwear modifications + use of metatarsal pads

598
Q

What are some secondary care options for treating Morton’s neuroma?

A

Corticosteroid injection

Neurectomy of involved interdigital nerve and neuroma

599
Q

What are red flags for back pain?

A 
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
Q

What tests should those with red flags for back pain have?

A

ESR, FBC, Ca, Phosp, ALP, PSA

X-Ray

601
Q

What kind of X-ray is needed to see the scaphoid?

A

Ulnar deviation AP

602
Q

What tends to cause a radial head fracture?

A

FOOSH

603
Q

What will you see OE in radial head fracture?

A

Tenderness over the head of the radius, impaired movements at the elbow, sharp pain at lateral side of elbow at extremes of rotation

604
Q

What is the ulnar paradox?

A

Proximal lesions of the ulnar nerve produce a less prominent deformity than distal lesions

605
Q

How should you manage children with an unexplained bone swelling/pain?

A

Very urgent X-ray to assess for bone sarcoma (<48h)

606
Q

What is the initial imaging modality of choice for suspected Achilles tendon rupture?

A

USS

607
Q

What is an iliopsoas abscess?

A

Collection of pus in the iliopsoas compartment

608
Q

What is causes a primary iliopsoas abscess?

A

Haematogenous spread usually staph aureus

609
Q

What can causes a secondary iliopsoas abscess?

A 
Crohn's (commonest cause in this category)
Diverticulitis, colorectal cancer
UTI, GU cancers
Vertebral osteomyelitis
Femoral catheter, lithotripsy
Endocarditis
610
Q

What is the difference in prognosis between primary and secondary iliopsoas abscesses?

A

Primary has a much lower mortality

611
Q

What are the clinical features of iliopsoas abscess?

A

Fever
Back/flank pain
Limp
Wt loss

612
Q

What position do those with an iliopsoas abscess tend to lie in?

A

Supine with knee flexed and hip mildly externally rotated

613
Q

What tests can you do to diagnose iliopsoas inflammation?

A

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
Q

What is the gold standard imaging for iliopsoas abscess?

A

CT

615
Q

How is iliopsoas abscess managed?

A

Antibx
Percutaneous drainage
Surgery if failure of percutaneous draining or presence of another intra-abdominal pathology req.s surgery

616
Q

What is the medical term for joint replacement?

A

Arthoplasty

617
Q

What is the most common type of hip replacement?

A

Cemented hip replacement

618
Q

What pts may not want a cemented hip replacement?

A

Younger

More active pts

619
Q

What other option is there for hip replacement?

A

Hip resurfacing

620
Q

What do pts receive post-hip replacement?

A

Physio
Course of home exercises
Walking sticks/crutches to use for up to 6w post-hip or knee replacement

621
Q

what basic advice should you give to those who have had a hip replacement to minimise the risk f dislocation?

A

Avoid flexing hip >90d
Avoid low chairs
Do not cross legs
Sleep on back for first 6w

622
Q

What are complications of joint replacement?

A

Wound and joint infection
VTE
Dislocation

623
Q

What is given to those undergoing a hip replacement to reduce the risk of VTE?

A

LMWH for 4w following operation

624
Q

What nerve is most likely to be damaged during a knee arthroplasty?

A

Common peroneal nerve

625
Q

What is thought to cause trigger finger?

A

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
Q

What things are associated with trigger finger?

A

Being female
RA
DM

627
Q

In which fingers is trigger finger most common?

A

Thumb, middle or ring finger

628
Q

What are the features of trigger finger?

A

Initially stiffness + snapping when extending a flexed digit

Nodule may be felt at base of affected finger

629
Q

What is the management of trigger finger?

A

Steroid injections + splinting

Surgery if this fails

MSK (27 decks)

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