Orthopaedics Flashcards

Question

Ix for sciatica

Answer 1

Generally, patients with mechanical/non-specific lower back pain can be diagnosed clinically and do not require further investigations. **X-rays** or **CT scans** can be used to diagnose spinal fractures. An **emergency MRI** scan is required in patients with suspected cauda equina (within hours of the presentation). Investigations for suspected ankylosing spondylitis are: * **Inflammatory markers** (CRP and ESR) * **X-ray** of the spinal and sacrum (may show a fused **“bamboo spine”** in later-stage disease) * **MRI** of the spine (may show **bone marrow oedema** early in the disease)

Answer 2

exclude serious underlying causes like cauda equina, ankylosing spondyltis, spinal injury Patients at low risk of chronic back pain can generally be managed with: * Self-management * Education * Reassurance * Analgesia * Staying active and continuing to mobilise as tolerate Additional options for patients at medium or high risk of developing chronic back pain include: * Physiotherapy * Group exercise * Cognitive behavioural therapy The NICE clinical knowledge summaries advise for analgesia: * NSAIDs (e.g., ibuprofen or naproxen) first-line * Codeine as an alternative * Benzodiazepines (e.g., diazepam) for muscle spasm (short-term only – up to 5 days)

Answer 3

The initial management of sciatica is mostly the same as acute low back pain. The NICE clinical knowledge summaries (updated 2020) state **not** to use medications such as gabapentin, pregabalin, diazepam or oral corticosteroids for sciatica. They state **not** to use opioids for chronic sciatica. They suggest considering a neuropathic medication if symptoms are persisting or worsening at follow up, but not gabapentin or pregabalin, leaving at the main choices of: * Amitriptyline * Duloxetine Specialist management options for chronic sciatica include: * Epidural corticosteroid injections * Local anaesthetic injections * Radiofrequency denervation * Spinal decompression

Answer 4

A **compound fracture** is when the skin is broken and the broken bone is exposed to the air. The broken bone can puncture through the skin. A **stable fracture** refers to when the sections of bone remain in alignment at the fracture. A **pathological fracture** refers to when a bone breaks due to an abnormality within the bone (see below).

Answer 5

* Transverse * Oblique * Spiral * Segmental * Comminuted (breaking into multiple fragments) * Compression fractures (affecting the vertebrae in the spine) * Greenstick * Buckle (torus) * Salter-Harris (growth plate fracture) *

Answer 6

**Greenstick** and **buckle fractures** typically occur in children rather than adults. **Salter-Harris fractures** _only occur in children_ (adults do not have growth plates)

Answer 7

A Colle’s fracture refers to a **transverse fracture** of the **distal radius** near the wrist, causing the distal portion to displace **posteriorly** (upwards), causing a **“dinner fork deformity”**. This is usually the result of a **fall onto an outstretched hand** (FOOSH).

Answer 8

A scaphoid fracture is often caused by a **fall onto an outstretched hand** **FOOSH**. A key sign of a scaphoid fracture is **tenderness in the anatomical snuffbox** (the groove between the tendons when extending the thumb). It is worth noting that the scaphoid has a retrograde blood supply, with blood vessels supplying the bone from only one direction. This means a fracture can cut off the blood supply, resulting in **avascular necrosis and non-union.**

Answer 9

These are the scaphoid bone, the femoral head, the humeral head the talus, navicular and fifth metatarsal in the foot.

Answer 10

Weber classification

Answer 11

he fracture is described in relation to the distal syndesmosis (fibrous join) between the tibia and fibula. This tibiofibular syndesmosis is very important for the stability and function of the ankle joint. If the fracture disrupts the syndesmosis, surgery is more likely to be required in order to regain good stability and function of the joint.

Answer 12

The Weber classification defines fractures of the lateral malleolus as: * **Type A** – below the ankle joint – will leave the syndesmosis intact * **Type B** – at the level of the ankle joint – the syndesmosis will be intact or partially torn * **Type C** – above the ankle joint – the syndesmosis will be disrupted

Answer 13

Pelvic fractures often lead to significant intra-abdominal bleeding, either due to vascular injury or from the cancellous bone of the pelvis. This can lead to shock and death, so needs emergency resuscitation and trauma management.

Answer 14

Pathological fractures occur due to an underlying disease of the bone, such as a tumour, osteoporosis or Paget’s disease of the bone. They may occur with minor trauma or even spontaneously without any history of trauma. Common sites are the **femur and the vertebral bodies.**

Answer 15

Po – **Prostate** R – **Renal** Ta – **Thyroid** B – **Breast** Le – **Lung**

Answer 16

Fragility fractures occur due to weakness in the bone, usually due to osteoporosis. They often occur without the appropriate trauma that is typically required to break a bone. For example, a patient may present with a fractured femur after a minor fal

Answer 17

* Calcium and vitamin D * Bisphosphonates (e.g., alendronic acid)

Answer 18

Bisphosphonates work by interfering with **osteoclasts** and reducing their activity, preventing the reabsorption of bone

Answer 19

* **Reflux** and **oesophageal erosions** (oral bisphosphonates are taken on an empty stomach sitting upright for 30 minutes before moving or eating to prevent this) * Atypical fractures (e.g. atypical femoral fractures) * Osteonecrosis of the jaw * Osteonecrosis of the external auditory canal

Answer 20

Denosumab ## Footnote Denosumab is a monoclonal antibody that works by blocking the activity of osteoclasts. It is an alternative to bisphosphonates where they are contraindicated, not tolerated or not effective.

Answer 21

Two views (two x-rays taken from different angles) are always required, as a single view may miss a fraction. CT scans give a more detailed view of the bones when the x-rays are inconclusive or further information is needed.

Answer 22

* External casts (e.g., plaster cast) * K wires * Intramedullary wires * Intramedullary nails * Screws * Plate and screws

Answer 23

* Closed reduction via manipulation of the limb * Open reduction via surgery

Answer 24

a Colle’s fracture in a young adult)

Answer 25

Possible early complications include: * Damage to local structures (e.g., tendons, muscles, arteries, nerves, skin and lung) * Haemorrhage leading to shock and potentially death * Compartment syndrome * Fat embolism (see below) * Venous thromboembolism (DVTs and PEs) due to immobility Possible longer-term complications include: * Delayed union (slow healing) * Malunion (misaligned healing) * Non-union (failure to heal) * Avascular necrosis (death of the bone) * Infection (osteomyelitis) * Joint instability * Joint stiffness * Contractures (tightening of the soft tissues) * Arthritis * Chronic pain * Complex regional pain syndrome

Answer 26

Fat embolism can occur following the fracture of **long** bones (e.g., **femur**)

Answer 27

Gurd’s major criteria: * Respiratory distress * Petechial rash * Cerebral involvement There is a long list of Gurd’s minor criteria, including: * Jaundice * Thrombocytopenia * Fever * Tachycardia

Answer 28

Fat embolisation can cause a systemic inflammatory response, resulting in **fat embolism syndrome**

Answer 29

Increasing age and osteoporosis are major risk factors for hip fractures. Females are affected more often than males.

Answer 30

* Intra-capsular fractures * Extra-capsular fractures

Answer 31

* Head * Neck * Greater trochanter (lateral) * Lesser trochanter (medial) * Intertrochanteric line * Shaft (body)

Answer 32

The capsule of the hip joint is a strong fibrous structure. It attaches to the rim of the **acetabulum** on the pelvis and the **intertrochanteric line** on the femur. It surrounds the **neck** and **head** of the femur.

Answer 33

The head of the femur has a retrograde blood supply. The **medial and lateral circumflex femoral arteries** join the femoral neck just proximal to the **intertrochanteric line.** Branches of this artery run along the surface of the femoral neck, within the capsule, towards the femoral head. They provide the only blood supply to the femoral head. A fracture of the intra-capsular neck of the femur can damage these blood vessels, removing the blood supply to the femoral head, leading to avascular necrosis.

Answer 34

Intra-capsular fractures involve a break in the femoral neck, within the capsule of the hip joint. This affects the area proximal to the intertrochanteric line.

Answer 35

The **Garden classification** is used for intra-capsular neck of femur fractures: * Grade I – incomplete fracture and **non-displaced** * Grade II – complete fracture and **non-displaced** * Grade III – partial **displacement** (trabeculae are at an angle) * Grade IV – full **displacemen**t (trabeculae are parallel) *

Answer 36

Non-displaced intra-capsular fractures may have an intact blood supply to the femoral head, meaning it may be possible to preserve the femoral health without avascular necrosis occurring. They can be treated with internal fixation (e.g., with screws) to hold the femoral head in place while the fracture heals. Displaced intra-capsular fractures (grade III and IV) disrupt the blood supply to the head of the femur. Therefore, the head of the femur needs to be removed and replaced.

Answer 37

Hemiarthroplasty involves replacing the head of the femur but leaving the acetabulum (socket) in place. Cement is used to hold the stem of the prosthesis in the shaft of the femur. This is generally offered to patients who have limited mobility or significant co-morbidities.

Answer 38

Total hip replacement involves replacing both the head of the femur and the socket. This is generally offered to patients who can walk independently and are fit for surgery.

Answer 39

Intertrochanteric fractures Subtrochanteric fractures

Answer 40

Intertrochanteric fractures occur between the greater and lesser trochanter. These are treated with a dynamic hip screw (AKA sliding hip screw) Subtrochanteric fractures occur distal to the lesser trochanter (although within 5cm). The fracture occurs to the proximal shaft of the femur.

Answer 41

The typical scenario is an older patient (over 60) who has fallen, presenting with: * Pain in the groin or hip, which may radiate to the knee * Not able to weight bear * Shortened, abducted and externally rotated leg

Answer 42

* Anaemia * Electrolyte imbalances * Arrhythmias * Heart failure * Myocardial infarction * Stroke * Urinary or chest infection

Answer 43

**X-rays** - Two views are essential, as a single view can miss the fracture. Anterior-to-posterior (AP) and lateral views are standard. **MRI or CT** scanning may be used where the x-ray is negative, but a fracture is still suspected.

Answer 44

On admission, patients will have: * Appropriate analgesia * Investigations to establish the diagnosis (e.g., x-rays) * Venous thromboembolism risk assessment and prophylaxis (e.g., low molecular weight heparin) * Pre-operative assessment (including bloods and an ECG) to ensure they are fit and optimised for surgery * Orthogeriatrics input

Answer 45

Is a condition caused by damage to the bundle of peripheral nerves protruding from the bottom of the Spinal cord It is similar to sciatica but the herniation is usually larger and more nerves are compressed including those that control the bladder and reproductive organs

Answer 46

* Herniated disc (the most common cause) * Tumours, particularly metastasis * Spondylolisthesis (anterior displacement of a vertebra out of line with the one below) * Abscess (infection) * Trauma

Answer 47

**Loss of sensation in the bladder and rectum (not knowing when they are full)** **Urinary retention or incontinence** **Faecal incontinence** Decrease in sexual function **Saddle anesthesia** (reduced sensation/pins-and-needles in the perianal area) **Bilateral or severe motor weakness in the legs** Reduced anal tone on PR examination **Sciatica (mostly bilateral)**

Answer 48

MRI or CT (preferably MRI?)

Answer 49

Bilateral or severe motor weakness in the legs Reduced anal tone on PR examination

Answer 50

* Sensation to the perineum, bladder and rectum * Motor innervation to the lower limbs and the anal and urethral sphincters * Parasympathetic innervation of the bladder and rectum

Answer 51

When a metastatic lesion compresses the spinal cord (before the end of the spinal cord and the start of the cauda equina), this is called metastatic spinal cord compression (MSCC). This is different to cauda equina, which specifically refers to compression of the cauda equina. MSCC is an oncological emergency and requires rapid imaging and management. There are specialist MSCC coordinators who should be involved early to coordinate the imaging and treatment of patients with MSCC.

Answer 52

Spinal stenosis refers to the narrowing of part of the spinal canal, resulting in compression of the spinal cord or nerve roots. This usually affects the cervical or lumbar spine. This section focuses on lumbar spinal stenosis, which is the most common type.

Answer 53

Spinal stenosis is more likely to occur in patients **older than 60 years**, relating to degenerative changes in the spine.

Answer 54

* **Central stenosis** – narrowing of the **central spinal canal** * **Lateral stenosis** – narrowing of the **nerve root canals** * **Foramina stenosis** – narrowing of the **intervertebral foramina**

Answer 55

* Congenital spinal stenosis * Degenerative changes, including facet joint changes, disc disease and bone spurs * Herniated discs * Thickening of the ligamenta flava or posterior longitudinal ligament * Spinal fractures * Spondylolisthesis (anterior displacement of a vertebra out of line with the one below) * Tumours

Answer 56

**Intermittent neurogenic claudication** is a key presenting feature of lumbar spinal stenosis with **central stenosis.** It is sometimes referred to as **pseudoclaudication**. Typical symptoms are: * Lower back pain * Buttock and leg pain * Leg weakness

Answer 57

Lateral stenosis and **foramina** stenosis in the lumbar spine tends to cause symptoms of **sciatica.**

Answer 58

The term radiculopathy refers to compression of the nerve roots as they exit the spinal cord and spinal column, leading to motor and sensory symptoms.

Answer 59

The exam question might specify that the peripheral pulses or the ankle-brachial pressure index (ABPI) are normal, in which case the diagnosis is more likely to be spinal stenosis. Additionally, patients with spinal stenosis are more likely to struggle with back pain, whereas back pain is not a feature of peripheral arterial disease.

Answer 60

MRI is the primary imaging investigation for diagnosing spinal stenosis. Investigations to exclude peripheral arterial disease (e.g., ankle-brachial pressure index and CT angiogram) may be appropriate where symptoms of intermittent claudication are present.

Answer 61

* Exercise and weight loss (if appropriate) * Analgesia * Physiotherapy * Decompression surgery where conservative treatment fails (with variable results)

Answer 62

Laminectomy refers to the removal of part or all of the lamina from the affected vertebra. The laminae are the bony parts that form the posterior part of the vertebral foramen (forming the spinal canal) and attaches to the spinous process.

Answer 63

Osteomyelitis refers to inflammation in a bone and bone marrow, usually caused by bacterial infection.

Answer 64

Haematogenous osteomyelitis refers to when a pathogen is carried through the blood and seeded in the bone. This is the most common mode of infection. Alternatively, osteomyelitis can occur due to direct contamination of the bone, for example, at a fracture site or during an orthopaedic operation.

Answer 65

Staphylococcus aureus causes most cases of osteomyelitis.

Answer 66

The key risk factors for developing osteomyelitis are: * Open fractures * Orthopaedic operations, particularly with prosthetic joints * Diabetes, particularly with diabetic foot ulcers * Peripheral arterial disease * IV drug use * Immunosuppression

Answer 67

The typical presentation of osteomyelitis is with: * Fever * Pain and tenderness * Erythema * Swelling

Answer 68

**X-rays** often do not show any changes, particularly in early disease. They cannot be used to exclude osteomyelitis. The potential signs of osteomyelitis on an x-ray are: * Periosteal reaction (changes to the surface of the bone) * Localised osteopenia (thinning of the bone) * Destruction of areas of the bone **MRI scans** are the best imaging investigation for establishing a diagnosis. **Blood tests** will show raised inflammatory markers (e.g., WBC, CRP and ESR). **Blood cultures** may be positive for the causative organism. **Bone cultures** can be performed to establish the causative organism and the antibiotic sensitivities.

Answer 69

Management involves a combination of: * Surgical debridement of the infected bone and tissues * Antibiotic therapy Prolonged courses of antibiotics are required to treat osteomyelitis. The BNF page on osteomyelitis recommends for acute osteomyelitis: * 6 weeks of flucloxacillin, possibly with rifampicin or fusidic acid added for the first 2 weeks Alternatives to flucloxacillin are: * Clindamycin in penicillin allergy * Vancomycin or teicoplanin when treating MRSA

Answer 70

Compartment syndrome is where the pressure within a fascial compartment is abnormally elevated, cutting off the blood flow to the contents of that compartment.

Answer 71

Fascial compartments involve muscles, nerves and blood vessels surrounded by fascia. Fascia is a sheet of strong, fibrous connective tissue that encases the contents of the compartment. It is not able to stretch or expand.

Answer 72

P – Pain “disproportionate” to the underlying injury, worsened by passive stretching of the muscles P – Paresthesia P – Pale P – Pressure (high) P – Paralysis (a late and worrying feature)

Answer 73

Bone fractures Crush injuries 5Ps **Note that pulseless is not a feature, differentiating it from acute limb ischaemia. The pulses may remain intact depending on which compartment is affected.**

Answer 74

Needle manometry Emergency fasciotomy

Answer 75

Carpal tunnel syndrome is caused by compression of the medial nerve as it travels through the carpal tunnel in the wrist, causing pain and numbness in the median nerve distribution on the hand.

Answer 76

transverse carpal ligament

Answer 77

* **Swelling** of the contents (e.g., swelling of the tendon sheaths due to repetitive strain) * **Narrowing** of the tunnel

Answer 78

* Thumb * Index and middle finger * The lateral half of ring finger

Answer 79

* Abductor pollicis brevis (thumb abduction) * Opponens pollicis (thumb opposition – reaching across the palm to touch the tips of the fingers) * Flexor pollicis brevis (thumb flexion)

Answer 80

* Repetitive strain * Obesity * Perimenopause * Rheumatoid arthritis * Diabetes * Acromegaly * Hypothyroidism

Answer 81

* Thumb * Index and middle finger * The lateral half of ring finger * Sensory symptoms include: * Numbness * Paraesthesia (pins and needles or tingling) * Burning sensation * Pain Motor symptoms of carpal tunnel syndrome affect the thenar muscles, with: * Weakness of thumb movements * Weakness of grip strength * Difficulty with fine movements involving the thumb * Wasting of the thenar muscles (muscle atrophy)

Answer 82

Phalen’s test Tinnel’s test

Answer 83

Phalen’s test involves fully flexing the wrist and holding it in this position. Often this is done by asking the patient to put the backs of their hands together in front of them with the wrists bent inwards at 90 degrees. The test is positive when this position triggers the sensory symptoms of carpal tunnel, with **numbness and paraesthesia** in the median nerve distribution.

Answer 84

Tinnel’s test involves tapping the wrist at the location where the median nerve travels through the carpal tunnel. This is in the middle, at the point where the wrist meets the hand. The test is positive when this position triggers the sensory symptoms of carpal tunnel, with **numbness and paraesthesia** in the median nerve distribution.

Answer 85

* Do symptoms wake you at night? * Do you have trick movements (e.g., shaking the hand) to improve symptoms? * Is your little finger affected? (Answering yes scores negatively, making carpal tunnel syndrome less likely)

Answer 86

Nerve conduction studies are the primary investigation for establishing the diagnosis. A small electrical current is applied by an electrode (nerve stimulator) to the median nerve on one side of the carpal tunnel. Recording electrodes over the median nerve on the other side of the carpal tunnel record the electrical current that reaches them. This demonstrates how well signals are passing through the carpal tunnel along the median nerve.

Answer 87

Management options for carpal tunnel syndrome are: * Rest and altered activities * Wrist splints that maintain a neutral position of the wrist can be worn at night (for a minimum of 4 weeks) * Steroid injections * Surgery Carpal tunnel syndrome surgery is usually performed as a day case procedure under **local anaesthetic**. It can be performed by **open** (with a vertical incision at the wrist) or **endoscopic** (keyhole) surgery. The **flexor retinaculum** (AKA transverse carpal ligament) is cut to release the pressure on the median nerve.

Answer 88

adhesive capsulitis

Answer 89

Frozen shoulder is also called adhesive capsulitis. It is a relatively common cause of shoulder pain and stiffness. The loss of range of motion and function in the shoulder joint can significantly impair activities.

Answer 90

The glenohumeral joint is the ball and socket joint in the shoulder. The glenohumeral joint is surrounded by connective tissue that forms the joint capsule. In adhesive capsulitis**, inflammation and fibrosis** in the joint capsule lead to **adhesions** (scar tissue). The adhesions bind the capsule and cause it to tighten around the joint, restrict movement in the joint.

Answer 91

There is a typical course of symptoms, with three phases: * **Painful phase** – shoulder pain is often the first symptom and may be worse at night * **Stiff phase** – shoulder stiffness develops and affects both active and passive movement (external rotation is the most affected) – the pain settles during this phase * **Thawing phase** – there is a gradual improvement in stiffness and a return to normal

Answer 92

* Supraspinatus tendinopathy * Acromioclavicular joint arthritis * Glenohumeral joint arthritis * Septic arthritis * Inflammatory arthritis * Malignancy (e.g., osteosarcoma or bony metastasis)

Answer 93

* Shoulder dislocation * Fractures (e.g., proximal humerus, clavicle or rarely the scapula) * Rotator cuff tear

Answer 94

Adhesive capsulitis is a clinical diagnosis based on the history and examination and excluding other causes of shoulder pain and stiffness. Imaging investigations are not usually required. X-rays are usually normal. However, they are helpful for diagnosing osteoarthritis as a differential. Ultrasound, CT or MRI scans can show a thickened joint capsule.

Answer 95

Non-surgical options for improving symptoms and speeding up recovery are: * Continue using the arm but don’t exacerbate the pain * Analgesia (e.g., NSAIDs) * Physiotherapy * Intra-articular steroid injections * Hydrodilation (injecting fluid into the joint to stretch the capsule) Surgery may be used in particularly resistant or severe cases. The options are: * Manipulation under anaesthesia – forcefully stretching the capsule to improve the range of motion * Arthroscopy – keyhole surgery on the shoulder to cut the adhesions and release the shoulder

Answer 96

Rotator cuff tears refer to injury to the tendons of the rotator cuff muscles. The tendon may be partially or fully torn. Tears of the rotator cuff can occur due to an acute injury (e.g., a fall onto an outstretched hand) or degenerative changes with age. They may be related to overhead activities, such as playing tennis or overhead construction work.

Answer 97

Rotator cuff tears may present either with an acute onset of symptoms after an acute injury, or with a gradual onset of symptoms. Patients typically present with: * Shoulder pain * Weakness and pain with specific movements relating to the site of the tear (e.g., abduction with a supraspinatus tear) Patients may find it difficult to get comfortable at night due to pain in the shoulder, disrupting sleep.

Answer 98

X-rays will not show soft tissue injuries such as rotator cuff tears. They may be helpful for excluding bony pathology, such as osteoarthritis. Ultrasound or MRI scans can diagnose a rotator cuff tear.

Answer 99

Non-surgical options are: * Rest and adapted activities * Analgesia (e.g., NSAIDs) * Physiotherapy here are many options for surgical management, depending on individual factors. The main option is arthroscopic rotator cuff repair, where the tendon is reattached to the bone during an arthroscopy (keyhole surgery).

Answer 100

Shoulder dislocation is where the ball of the shoulder (head of the humerus) comes entirely out of the socket (glenoid cavity of the scapula).

Answer 101

Subluxation refers to a partial dislocation of the shoulder. The ball does not come fully out of the socket and naturally pops back into place shortly afterwards

Answer 102

electric shocks and seizures. Exam questions might challenge you to distinguish between anterior and posterior dislocations. The answer is almost certainly an anterior dislocation unless the patient has had a seizure or an electric shock.

Answer 103

**Bankart lesions** **Hill-Sachs lesions** **Axillary nerve damage** is a key complication. The axillary nerve comes from the C5 and C6 nerve roots. Damage causes a loss of sensation in the “regimental badge” area over the lateral deltoid. It also leads to motor weakness in the deltoid and teres minor muscles. Fractures Rotator cuff tears

Answer 104

Axillary nerve damage?

Answer 105

* Humeral head * Greater tuberosity of the humerus * Acromion of the scapula * Clavicle

Answer 106

The apprehension test is a special test to assess for shoulder instability, specifically in the anterior direction. It is likely to be positive after previous anterior dislocation or subluxation of the shoulder. This may be performed after recovery from any acute injuries. The patient lies supine. The shoulder is abducted to 90 degrees, and the elbow is flexed to 90 degrees. The shoulder is then slowly externally rotated in this position while watching the patient. As the arm approaches 90 degrees of external rotation, patients with shoulder instability will become anxious and apprehensive, worried that the shoulder will dislocate. There is no pain associated with the movement, only apprehension.

Answer 107

X-rays Magnetic resonance arthrography is an MRI scan Arthroscopy

Answer 108

* Analgesia, muscle relaxants and sedation as appropriate * Gas and air (e.g., Entonox) may be used, which contains a mixture of 50% nitrous oxide and 50% oxygen * A broad arm sling can be applied to support the arm * Closed reduction of the shoulder (after excluding fractures) * Dislocations associated with a fracture may require surgery * Post-reduction x-rays * Immobilisation for a period after relocation of the shoulder

Answer 109

There is a high risk of **recurrent dislocations,** particularly in younger patients. **Physiotherapy** is recommended to improve the function of the shoulder and reduce the risk of further dislocations. **Shoulder stabilisation surgery** may be required to improve stability and prevent further dislocations. This may be an arthroscopic or an open procedure. Underlying structural problems are corrected, such as: * Repairing Bankart lesions * Tightening the shoulder capsule * Bone graft using bone from the coracoid process to correct a bony injury to the glenoid rim (Latarjet procedure) * Correcting Hill-Sachs lesions (Remplissage procedure)

Answer 110

McMurray’s test involves the patient lying supine. The examiner takes the leg and flexes the knee. While internally rotating the tibia (by turning the foot inwards) and applying varus pressure to the knee (applying outward pressure to the inside of the knee), carefully extend the knee. Pain or restriction indicates lateral meniscal damage. Repeating the flexed to extended movement with external rotation of the tibia and valgus (inward) pressure on the knee tests for medial meniscal damage.

Answer 111

The Apley grind test involves the patient lying prone and flexing the knee to 90 degrees with the thigh flat on the couch. Downward pressure is applied through the leg into the knee, and the tibia is internally and externally rotated at the same time. Pain indicates a positive result, suggesting meniscal damage. The pain is localised to the area of damage (e.g., medial or lateral meniscus).

Answer 112

Bone fractures are worth considering as a differential diagnosis in patients presenting with acute knee injuries. The Ottawa knee rules can be used to determine whether a patient requires an x-ray of the knee after an acute knee injury to look for a fracture. The Ottawa knee rules state that a patient requires a knee x-ray if any of the following are present: * Age 55 or above * Patella tenderness (with no tenderness elsewhere) * Fibular head tenderness * Cannot flex the knee to 90 degrees * Cannot weight bear (cannot take 4 steps – limping steps still count)

Answer 113

MRI scan Arthroscopy

Answer 114

Conservative management of most acute soft tissue injuries, including meniscal tears, is with the RICE mnemonic: R – Rest I – Ice C – Compression E – Elevation **NSAIDs** are usually used first-line for analgesia in MSK injuries. **Physiotherapy** can be used for rehabilitation after the initial pain and swelling have settled. **Surgery** may be required. This involves arthroscopy (keyhole surgery) of the knee joint. The main options are: * Repair of the meniscus if possible * Resection of the affected portion of the meniscus (this often results in osteoarthritis)

Answer 115

* Age over 50 (cancer) * Weight loss (cancer) * Bilateral neurological motor or sensory symptoms (cauda equina) * Saddle anaesthesia (cauda equina) * Urinary retention or incontinence (cauda equina) * Faecal incontinence (cauda equina) * History of cancer with potential metastasis (cauda equina or spinal metastases) * Fever (spinal infection) * IV drug use (spinal infection)