Orthopaedics 1

Question 1

Achilles Tendon Disorders

1. What are the risk factors for tendon disorders?
2. Achilles tendinopathy
   a) What clinical features are seen?
   b) How is it managed?
3. Achilles Tendon Rupture
   a) What will be in the history?
   b) What is seen on examination?
   c) What investigation is done?

Answer 1

1. • quinolone use (e.g. ciprofloxacin)
   • hypercholesterolaemia (predisposes to tendon xanthomata)
2. a)
   - gradual onset posterior heel pain worst following activity
   - morning pain and stiffness

b)
- analgesia
- reduction in precipitating activities
- eccentric calf muscle exercises

3.

a)
- audible pop in ankle
- sudden onset severe pain
- inability to continue activity

b) Simmond’s triad
- palpate for gap in tendon
- patient prone with feet of end of bed: achilles rupture will show foot more dorsiflexed
- calf squeeze - in rupture foot will remain in neutral position

c) US

Question 2

1. What clinical features are seen in adhesive capsulitis?

2. How long does it typically last?

Answer 2

1. • external rotation > internal rotation + abduction
   • active + passive motion effected
   • typically pain phase, stiffness phase, recovery phase
2. 6 months - 2 years

Question 3

Ankle Fracture

1. When is an ankle XR required?
2. Regarding fibular fracture, what is meant by Weber
   a) Type A
   b) Type B
   c) Type C
3. How should ankle fracture be managed?
4. What fracture could cause widening of the ankle joint?

Answer 3

1. Pain in the malleolar zone with 1 of the following:
   - inability to walk 4 weight bearing steps
   - bony tenderness in lateral malleolus or in lowest 6cm of fibula
   - bony tenderness in medial malleolus or in lower 6cm of tibia
2. a) below tibiofibular syndemosis
   b) fracture at level of tibular plafond extending proximally
   c) fracture above syndemosis

(Type B and C can have syndemosis damage)

3. • promptly reduce fracture to remove pressure on overlying skin to prevent necrosis
   • high energy forces in young (e.g. spiral fracture) then surgical
   • otherwise below knee plaster cast for 6 weeks

generally: surgery if young, conservative if old
4. maisonneuve fracture - spiral fracture of fibula resulting in disruption to tibiofibular syndemosis causing the widened ankle

Question 4

Ankle Sprain

1. Low ankle sprain (>90%)
   a) What is the most common injury?
   b) What clinical features will be seen?
   c) What should be done if symptoms fail to settle?
2. High ankle sprain
   a) What is often the mechanism of injury?
   b) What clinical feature is seen?
   c) What is seen on investigation?

Answer 4

1. a) anterior talofibular ligament
   b)
   - pain, swelling and tenderness over effected tendons +/- bruising

often can weight bear unless severe

c) MRI

2. a) external rotation of foot causing talus to push fibula laterally thus cause tibiofibular syndemosis injury

b)
- pain when tibia and fibula squeezed at level of mid calf (Hopkin’s squeeze test)
- weight bearing noticeably more painful in comparison to low ankle sprains

c) widened of tibiofibular joint on XR
- MRI if XR normal but remain suspicious

Question 5

Avascular Necrosis

1.

a) What is it?
b) Where is it most common?

2. What can cause it?
3. a) What clinical features can be seen?
   b) What can be seen on investigation?

Answer 5

1. a) death of bone tissue secondary to loss of blood supply
   b) epiphysis (rounded edge of long bones) e.g. femur - hip
2. • alcohol excess
   • long term steroid use
   • chemotherapy
   • trauma
3. a) asymptomatic initially the pain
   b) XR could see:
   - normal
   - osteopenia
   - microfractures
   - collapse of articular surface causing crescent sign

MRI is gold standard

Question 6

Baker’s cyst

1. What are they?
2. How can they present in rupture?

Answer 6

1. distension of the gastrocnemius-semimembranous bursa

2. red, swollen, painful leg (I.e. similar to DVT)

Question 7

Biceps rupture

1. Where is it most likely to occur?
2. What are the risk factors?
3. What is the mechanism of injury for
   a) proximal long tendon ruptures
   b) distal tendon ruptures
4. What clinical features can be seen?
5. What investigations can be done?

Answer 7

1. proximal long tendon rupture (90%) - often older patients
2. • corticosteroids
   • smoking
   • heavy overhead activities
   • shoulder overuse / injury stressing the biceps tendon
3. a) when the biceps are lengthened and contracted and a load is applied
   b) when a flexed elbow is suddenly and forcefully extended whilst the biceps muscle is contracted already

4.

• sudden pop followed by pain bruising and swelling
• weakness in shoulder and elbow
• “popeye” deformity

5. • biceps squeeze test (normally would cause supination of forearm)
   • US

Question 8

Pagets Disease

1. What is it?
2. Where is affected in what order?
3. What is seen on investigation?
4. How is it treated?
5. What can the complications be?

Answer 8

1. focal bone resorption followed by chaotic bone deposition
3. spine
4. skull
5. pelvis
6. femur
7. bloods: raised ALP with other parameters normal
   XR: abnormally thickened, sclerotic bone
   +/- bowing of tibia, bossing of skull
8. bisphosphonates
9. • cranial nerve entrapment (often deafness)
   • heart failure
   • sarcomatous change (aggressive malignancy)

Question 9

Osteoporosis

1. What is seen on bloods?
2. How is it treated?

Answer 9

1. normal
2. • calcium
   • vitamin D
   • bisphosphonates

Question 10

Secondary bone tumours

1. What CAN (not will) be seen on bloods?
2. How can it be managed?

Answer 10

1. raised ALP and calcium
2. • radiotherapy
   • prophylactic fixation
   • analgesia

Question 11

Buckle fracture

1. What is it?
2. Who do they occur in?
3. How are they treated?

Answer 11

1. incomplete fractures of the long bones causing bulging of the cortex on XR

NOTE: useful to look at XR on passmed

2. children aged 5-10
3. cast / splint
   - > surgery not required

Question 12

Carpal Tunnel Syndrome

1. What is it?
2. What is seen on examination?
3. What can cause it?
4. What is seen on investigation?
5. How is it managed?

Answer 12

1. compression of the median nerve in the carpal tunnel
2. • weakness of thumb abduction
   • wasting of thenar eminence (bulge at bottom of thumb)
   • Tinel’s sign: tapping over carpal tunnel causes parathesiae
   • Phalen’s sign: flexion of wrist exacerbates symptoms
3. • pregnancy
   • oedema
   • rheumatoid arthritis
   • lunate fracture
4. electrophysiology shows prolongation of motor and sensory action potentials
5. mild-moderate: try steroid injection or splint while sleeping

severe / resistant - surgery: flexor retinaculum division

Question 13

Cauda Equina Syndrome

1. What can cause it?
2. What clinical features can be seen?
3. What investigation is done?
4. How is it managed?

Answer 13

1. 
most common: disc prolapse L4/5 or L5/S1
- tumours (primary or metastatic)
- trauma
- infection: abscess, discitis 
- haematoma 

2. presents in variety of ways, features can include:
   - back pain
   - reduced anal tone
   - reduced sensation / parathesiae in perianal area
   - urinary dysfunction (no urge to void, reduced awareness of bladder filling, incontinence late sign and could indicate irreversible damage)
   - bilateral sciatica (50%)
3. urgent MRI
4. surgical decompression

Question 14

Cervical Spondylosis

1. What is it?
2. What can cause it?
3. How can it present?
4. What complications can be seen?

Answer 14

1. degeneration of discs of cervical spine
2. OA
3. neck pain
   +/- referred pain mimicking headaches
4. • myelopathy: compression of spinal cord
   • radiculopathy: compression of nerve root from spinal cord

Question 15

Charcot Joint (AKA neuropathic joint)

1. What is it?
2. What clinical features are seen?
3. Who can it be seen in?

Answer 15

1. a joint which has become badly disrupted / deformed secondary to loss of sensation

I.e. simply cannot feel pain so do not stop that movement or stop wearing those shoes

2. • warm, red swollen joint
   • significantly less painful than one would assume with the joint disruption
3. • diabetics
   • syphilis