ORTHOPAEDICS

Question 1

Ankylosing spondylitis

Answer 1

Chronic inflammatory disorder affecting the axial skeleton
Sacro-ilitis is a usually visible in plain films
Up to 20% of those who are HLA B27 positive will develop the condition
Affected articulations develop bony or fibrous changes
Typical spinal features include loss of the lumbar lordosis and progressive kyphosis of the cervico-thoracic spine

Question 2

Scheuermann’s disease

Answer 2

Epiphysitis of the vertebral joints is the main pathological process
Predominantly affects adolescents
Symptoms include back pain and stiffness
X-ray changes include epiphyseal plate disturbance and anterior wedging
Clinical features include progressive kyphosis (at least 3 vertebrae must be involved)
Minor cases may be managed with physiotherapy and analgesia, more severe cases may require bracing or surgical stabilisation

Question 3

Scoliosis

Answer 3

Consists of curvature of the spine in the coronal plane
Divisible into structural and non structural, the latter being commonest in adolescent females who develop minor postural changes only. Postural scoliosis will typically disappear on manoeuvres such as bending forwards
Structural scoliosis affects > 1 vertebral body and is divisible into idiopathic, congential and neuromuscular in origin. It is not correctable by alterations in posture
Within structural scoliosis, idiopathic is the most common type
Severe, or progressive structural disease is often managed surgically with bilateral rod stabilisation of the spine

Question 4

Spina bifida

Answer 4

Non fusion of the vertebral arches during embryonic development
Three categories; myelomeningocele, spina bifida occulta and meningocele
Myelomeningocele is the most severe type with associated neurological defects that may persist in spite of anatomical closure of the defect
Up to 10% of the population may have spina bifida occulta, in this condition the skin and tissues (but not not bones) may develop over the distal cord. The site may be identifiable by a birth mark or hair patch
The incidence of the condition is reduced by use of folic acid supplements during pregnancy

Question 5

Spondylolysis

Answer 5

Congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affects L4/ L5
May be asymptomatic and affects up to 5% of the population
Spondylolysis is the commonest cause of spondylolisthesis in children
Asymptomatic cases do not require treatment

Question 6

Spondylolisthesis

Answer 6

This occurs when one vertebra is displaced relative to its immediate inferior vertebral body
May occur as a result of stress fracture or spondylolysis
Traumatic cases may show the classic ‘Scotty Dog’ appearance on plain films
Treatment depends upon the extent of deformity and associated neurological symptoms, minor cases may be actively monitored. Individuals with radicular symptoms or signs will usually require spinal decompression and stabilisation

Question 7

FREIBURG DISEASE

Answer 7

Freibergs disease is an anterior metatarsalgia affecting the head of the second metarsal, it typically occurs in the pubertal growth spurt. The initial injury was thought to be due to stress microfractures at the growth plate. The key feature in the history which distinguishes the injury as being stress fracture is the radiology. In Freibergs disease the x-ray changes include; joint space widening, formation of bony spurs, sclerosis and flattening of the metatarsal head.

Question 8

SALTER HARRIS CLASSIFICATION

Answer 8

SALTER

S (Type 1): Straight through the growth plate
A (Type 2): Above - through growth plate and Above involving the metaphysis
L (Type 3): Lower -through growth plate and beLow involving the epiphysis
T (Type 4):Through - Through both metaphysis, epiphysis and growth plate
E (Type 5): Everything - Crush / compression injury
R (Type 5): Ruined

Question 9

TUR syndrome

Answer 9

TUR syndrome occurs when irrigation fluid enters the systemic circulation POST TURP. The triad of features are:

1. Hyponatraemia: dilutional
2. Fluid overload
3. Glycine toxicity

Management involves fluid restriction and the treatment of the complications associated with the hyponatraemia.

Question 10

Chondromalacia patellae

Answer 10

Teenage girls, following an injury to knee e.g. Dislocation patella
Typical history of pain on going downstairs or at rest
Tenderness, quadriceps wasting

Question 11

PSEUDOGOUT

Answer 11

This is a typical presentation of pseudogout. An elevated transferrin saturation may indicate haemochromatosis, a recognised cause of pseudogout.

A high ferritin level is also seen in haemochromatosis but can be raised in a variety of infective and inflammatory processes, including pseudogout, as part of an acute phase response.

Question 12

ADDUCTOR CANAL COMPRESSION SYNDROME

Answer 12

Adductor canal compression syndrome most commonly presents in young males and is an important differential diagnosis in men presenting with symptoms of acute limb ischaemia on exertion. It is caused by compression of the femoral artery by the musculotendinous band from adductor magnus muscle.
The treatment consists of the division of the abnormal band and restoration of the arterial circulation. Popliteal fossa entrapment is the main differential diagnosis, however the pulse disappears when the knee is fully extended.

Question 13

SCAPHOID FRACTURE

Answer 13

Undisplaced fractures of the waist of the scaphoid and most distal pole fractures can be managed in a cast for 6 weeks with high rates of union.
Displaced scaphoid waist fractures (more than 1-2mm) should be viewed as unstable and surgically fixed.
All proximal pole fractures should be fixed surgically.