Orthopaedics Flashcards

Question

Cervical myelopathy

Answer 1

LMN signs AT level of lesion UMN signs below level of lesion

Answer 2

Massive central lumbar disc protrusion at L4/5

Answer 3

90% at L4/L5 or L5/S1 levels Posterolateral disc protrusion will affect the traversing root, e.g. an L4/5 disc protrusion will affect the L5 nerve root. Far-lateral disc protrusion (extraforaminal) will affect the exiting nerve root, e.g. a far-lateral L5/S1 disc protrusion will affect the L5 nerve root

Answer 4

Classic symptoms: back, buttock, thigh and calf pain LIGAMENTUM FLAVUM Provoked by walking and extended posture Relieved by flexed posture Symptoms progress in up to one-third of untreated patients

Answer 5

Unilateral or bilateral defect in the pars interarticularis without vertebral slippage Incidence in athletic population 15–47% May be completely asymptomatic/incidental finding on radiograph Difficult to image, but MRI proving more useful Conservative treatment: activity modification, antilordotic brace Surgical treatment: direct repair preserving motion or spinal fusion if associated disc degeneration

Answer 6

Forward slippage of the vertebral body caused by a break in in the continuity of pars interarticularis Wiltse classification of spondylolisthesis identifies the CAUSE = 6 types Meyerding classification grades severity = 4 grades Low grade slip I - II --> fusion-in-situ High grade slips III - IV--> decompression and fusion

Answer 7

Breast 21% Lung 14%

Answer 8

Osteoid osteoma Osteoblastoma Chondroma Chondroblastoma Chondromyoixod fibroma Giant cell tumous Haemangioma Lymphangioma Lipoma Benign tumours tend to occur in the posterior elements

Answer 9

Aggressive osteoblastoma Haemangiopericytoma Haemangioendothelioma Chordoma

Answer 10

Osteosarcoma Chondrosarcoma Ewing’s sarcoma Neuroectodermal tumours Malignant lymphoma Myeloma Angiosarcoma Fibrosarcoma Liposarcoma Malignant tumours tend to involve the entire vertebral column

Answer 11

Benign tumours arising from the nerve sheath Three types: -Cutaneous -Spinal -Plexiform 90% of cases they present as solitary lesions, Multiple = patients with neurofibromatosis type 1 (NF1), -autosomal dominant

Answer 12

Referred to as peripheral neurofibromatosis or von Recklinghausen disease 1 in 3000 Diagnosis of NF1 (2 or more of the following): -At least 6 cafe au lait spots >5mm pre-puberty -At least 6 cafe au lait spots >15mm post-puberty -Two or more neurofibromas (any type) -Presence of plexiform neurofibroma -Multiple freckles in the axillary or inguinal regions, -Distinctive bone abnormality involving the eye socket or arm/leg bones -Optic glioma in the brain -Two or more Lisch nodules in the eye, -Parent, sibling or child with NF1

Answer 13

Central 1 in 40,000 Schwannomas on both 8th cranial (vestibular) nerves Parent, sibling or child with NF2 plus: -One vestibular schwannoma in a person less than 30 years of age -Any two of the following: meningioma, glioma, schwannoma, juvenile cataracts

Answer 14

Surgical emergency Majority of cases occur within the thoracic spine. Without treatment --> neurological deficit including paralysis may develop.

Answer 15

AAS with a PADI of 14 mm or less AAS with at least 5 mm of basilar invagination Subaxial subluxation with a sagittal canal diameter of 14 mm or less (PADI= posterior atlantodental interval)

Answer 16

= Scoliosis

Answer 17

Cause disruption to lug development After 8 years, late onset scoliosis, the alveoli are developed Early onset may cause cor pulmonale and RHF

Answer 18

Idiopathic curves of less than 25° are monitored with clinical and radiographic examination In growing children (premenarchal) with curves between 20° and 29°, a brace may be indicated. Bracing is used to prevent curve progression Curves beyond 45° are not amenable to brace treatment. Surgery in the form of corrective instrumentation and spinal fusion is indicated for curve progression beyond 40°, truncal imbalance and unacceptable cosmesis. During surgery, continuous spinal cord monitoring is used in the form of somatosensory evoked potentials (SSEP), motor-evoked potentials (MEP) and free-run and stimulated electromyographic (EMG) activity to minimise the risk of neurological damage. The risk of neurological injury is 0.4% (1 in 250).

Answer 19

Occurs due to gamekeepers thumb Aponeurosis of ABductor pollicis longus interposed between the ruptured ulnar collateral ligament (UCL) of the thumb and its site of insertion at the base of the proximal phalanx No longer in contact with its insertion site, the UCL cannot spontaneously heal Mx: surgicalk attachment

Answer 20

Wedging og T7 - T10 vertebrae Apical pain and lower back pain --> attempts by lumbar musculature to compensate for the thoracic hyperkyphosis Mx Physiotherapy Bracing in skeletally immature Surgical: -Pain (apical or low back pain produced by compensatory hyperlordosis) -Progressive deformity greater than 70°, -Unacceptable cosmesis and neurological and/or cardiopulmonary compromise Anterior release followed by posterior correction and fusion. Posterior chevron osteotomies carried out at the time of posterior instrumentation may prevent the need for the initial anterior release

Answer 21

An abnormal bony or cartilaginous spur projecting across the middle of the vertebral canal --> dividing the dural tube and spinal cord in two Between 50% and 70% of patients are seen to have a skin naevus, dimple or hairy patch when the spine is examined

Answer 22

Providing no neural comprimise Bed rest Analgesia If painful --> Kyphoplasty -->Vertebroplasty

Answer 23

Abnormal descent of the scapular from its embryonic mid-cervical position High, small, rotated scapular that remains attached to the cervical spine by a: -bony bar, or -fibrous band, or -omovertebral body

Answer 24

Congenital abnormality involving fusion of at least two cervical vertebrae --> short neck and reduced mobility, causes apparent low hair-line

Answer 25

Diabetes Cardiovascular disease Thyroid disease Female gender Age

Answer 26

Acute pain with restricted movement around the shoulder due to subacromial calcific deposits BUT external rotation possible Tx: Corticosteroid injections Barbotage: aspiration and flushing Surgical decompression if persistent

Answer 27

Osteoporosis Destruction of articular cartilage Synovial proliferation Pannus formation

Answer 28

Tends to be proximal tendon rupture in elderly patients due to abrasion under the anterior acromion --> bulge appears in arm -->sometimes pain of biceps tendonitis is relived by rupture In elderly it doesn't alter function --> conservative management

Answer 29

Traumatic Atraumatic Habitual

Answer 30

Traumatic -Surgery Atraumatic -Surgery Habitual -Not for surgery

Answer 31

Detachment of the anteroinferior labrum

Answer 32

Damage to the humeral head Cortical depression on posterolateral humeral head

Answer 33

Repair of labrum Tightening of anterior capsule +/- graft of Hill-Sachs

Answer 34

Forced internal rotation -Electrocution -Seizure -Restraint

Answer 35

Radial head excision Elbow arthroplasty

Answer 36

Within the cubital tunnel (behind medial epicondyle) Junction of arcade of Struthers Medial intermuscular septum as nerve passes into posterior compartment of distal humerus Between heads of flexor carpi ulnaris

Answer 37

Weakness of adductor pollicis = ulnar nerve palsy

Answer 38

Hand splinting position to prevent collateral ligament shortening and deformity during times of immobiliation = Wrist extension =MCP flexion =IPJ extension

Answer 39

= Gamekeepers thumb Chronic overuse --> stretching of ulnar collateral ligament of thumb Skier's thumb = forceful abduction causing acute tear Surgical Mx: pollicis abbductor tendon slips between two ends and prevents healing

Answer 40

Triangular fibrocartilage complex: -Ulnocarpal ligaments -Extensor carpi ulnaris tendon -Meniscus-like structure between distal ulna and carpus Stabilises distal radio-ulnar joint Injury --> ulna wrist pain and instability Mx: arthroscopic / open repair Debridement if chronic damage

Answer 41

Abscess of specialised fibrous septae in finger pulp Can cause DIP osteomyelitis Mx: I&D

Answer 42

Nail bed infection Incision, drainage and Abx +/- partial removal of nail to allow drainage

Answer 43

Kanavel's cardinal signs -held in flexion -swelling over tendon and digit -tender -pain on passive extension Mx: tendon sheath irrigation and IV Abx Untreated: adhesions, necrosis, +/- proximal spread

Answer 44

Boutonniere Swan-neck Flexor tendon synovitis Radial deviation of wrist + prominent ulnar head Flexion, subluxation and ulnar deviation of MCPs

Answer 45

Autosomal dominant Palmar nodules Skin puckering Cords Flexion contractures Garrods knuckle pads over dorsal of PIPs Associated with: Smoking Trauma Epilepsy AIDS Hypothyroidism Alcohol liver cirrhosis Mx: when patient can't put hand flat on table OR Flexion develops in the PIP joint --> surgery Z-plasties Digital nerves at-risk Proceed to amputation if finger restricting useful movements

Answer 46

Tendon size mismatch between flexor tendon sheath pulley A1 and size of flexor tendon --> locking / snapping of finger --> pain Mx: Corticosteroid injection Proceed to pulley release In thumb in children --> resolved spontaneosuly

Answer 47

Tenosynovitis of abductor pollicis longus and extensor pollicis brevis within first dorsal extensor compartment 1st EC Associated: Female patients during pregnancy (New mother's wrist) Inflammatory arthritis Test: Finkelstein's

Answer 48

Majority idiopathic BUT... Diabetes Thyroid disease Alcoholism Amyloidosis Inflammatory arthritis Pregnancy Obesity

Answer 49

Phalen's test: flexion of wrist Tinnel's test: tap on carpal tunnel Durkin's test: press on carpal tunnel

Answer 50

Night splinting of wrist in extension Surgical decompression -Transverse carpal ligament

Answer 51

Ulnar nerve compression in Guyon's tunnel Tingling and numbness in little and ring finger Hypothenar wasting Dorsal branches don't pass through so dorsal sensation intact Causes: Ganglion Ulnar artery aneurysm Hook of hamate fracture

Answer 52

Idiopathic avascular necrosis of the lunate

Answer 53

Idiopathic avascular necrosis of the scaphoid

Answer 54

Retinacular branches of medial circumflex femoral artery Small contribution from ligament teres

Answer 55

Avascular of the femoral head can be idiopathic (Perthe's) or secondary --> collapse of femoral head -->secondary osteoarthritis Causes: -Sickle cell disease -Haemoglobinopathies -Hypercoaguable states (protein C and S deficiency) -Caisson disease (the bends in divers) -Hyperlipidaemia -SLE -Gaucher's disease -Antiphospholipid syndrome -Radiotherapy -Chemotherapy -HIV -Steroids -Chronic liver disease -Alcoholism

Answer 56

Men aged 35-45 Bilateral in >50% Asymptomatic initially Ache in groin Limp Limitation of movement

Answer 57

Initially normal, request an MRI Early: sclerosis Crescent sign --> subchondral bone resorption Flattening --> femoral collapse Graded I - IV

Answer 58

Pre-collapsed stage --> surgical decompression using core decompression +/- inserting vascular bone graft Collapsed --> femoral osteotomy to shift WB or replacement

Answer 59

Trauma Avascular necrosis / Perthe's Slipped capital femoral epiphysis Dysplasia Inflammatory arthtropathy = Rheumatoid Developmental dysplasia of hip Septic arthritis Femeroaectabular impingement

Answer 60

Along the fibres of gluteus maximus, dividing short external rotators of the hip sciatic nerve at risk

Answer 61

=Hardinge Parts of the gluteus medius and minimus are reflected off the greater trochanter superior gluteal at risk

Answer 62

Three times more common than lateral meniscus tears Outer third of the meniscus is vascular and so tears can be repaired with the prospect of healing

Answer 63

Two bundles Anteromedial bundle: tight in flexion Posterolateral bundle: tight in extension

Answer 64

Two bundles: Anterolateral bundle: tight in flexion Posteromedial bundle: tight in extension

Answer 65

Disruption to the cornerstone second metatarsal 2nd metatarsal is recessive in relation to 1st and 3rd --> Loss of transverse arch and flat foot

Answer 66

Gastrocnemius Soleus Plantaris

Answer 67

Tibialis posterior Flexor digotorium longus Flexor hallucis longus

Answer 68

Peroneus longus Peroneus brevis

Answer 69

Tibialis anterior Extensor digitorum longus Extensor hallucis longus Peroneus tertius

Answer 70

Pain in the second or third web space Compression of common digital nerve between third and fourth metatarsal --> pain Usually secondary to other foot deformities

Answer 71

Avascular necrosis of epiphysis of metatarsal --> re-shaping osteotomy

Answer 72

Immediate off-loading and casting to correct deformity

Answer 73

= solitary mass of myeloma

Answer 74

Osteogenic tumours Two peaks: Adolescence Second in elderly patients with Paget's disease or post radiotherapy treatment

Answer 75

= Ewing's sarcoma

Answer 76

Maffuci syndrome -Enchondromatosis and soft tissue angiomas Ollier disease -Enchondromatosis Familial retinoblastoma syndrome

Answer 77

Nonhereditary sporadic disorder where intraosseous benign cartilaginous tumors (enchondroma) develop close to growth plate cartilage

Answer 78

Maffucci syndrome is a sporadic disease characterized by the presence of multiple enchondromas associated with multiple cavernous hemangioma and phlebolith.

Answer 79

Hereditary multiple exocytoses Polyostotic Paget's Radiation osteitis

Answer 80

Osteomyelitis Osteonecrosis Fibrous dysplasia Osteogenesis imperfecta Osteoblastoma Chondroblastoma

Answer 81

Retroperitoneal veins with no valves that allow haematgenous mets to the spine + proximal long bones

Answer 82

Pancreatic metastasis

Answer 83

Bening bone-forming lesion -Usually occur in children and adolescents Small but very painful Pain occurs at night Responds to NSAIDs Commonly in proximal femur, and cause a dense cortical reaction in the centre of which is a nidus

Answer 84

Larger version of osteoid osteoma - still benign >2cm More aggressive counterpart of osteoid osteoma that more typically occurs in the spine.

Answer 85

Malignant bone-forming tumour Most common site: distal femur Classification: -Sclerotic -Chondroblastic -Telangiectatic Usually intraosseous

Answer 86

Osteoid osteoma – small, painful; produce dense cortical reaction Osteoblastoma – larger and more aggressive than osteoid osteoma Osteosarcoma – malignant; commonest in lower femur and upper tibia

Answer 87

Benign cartilage-capped bony projection Continuity between cortex of bone and frowth - characteristic finding Bony projection always grows away from the joint towards the diaphyseal region of the bone. Osteochondromas can be pedunculated with a stalk or sessile (without a stalk) Usually solitary, but some patients have multiple osteochondromas (hereditary multiple exostoses, autosomal dominant inheritance) Cause compressive symptoms: nerve impingement, vascular pseudoaneurysm, fracture and infarction

Answer 88

Autosomal dominant

Answer 89

Benign cartilagenous neoplasm Within the intramedullary cavity of bone 50% are in the hands and feet: enchondromas are the most common bone tumours in the hand. A Pain, swelling or pathological fracture, many are asymptomatic Patchy calcification, expansion and scalloping can be visible on radiographs Ollier disease is a developmental condition characterised by multiple enchondromas Maffucci syndrome, multiple enchondromas are associated with multiple angiomas Malignant transformation to chondrosarcoma can occur in approximately 20% of patients with Ollier disease and is almost inevitable in patients with Maffucci syndrome.

Answer 90

Enchondroma

Answer 91

Benign cartilage-producing tumour Occurs in EPIPHYSES of bones in CHILDREN Commonly knee Presents: severe pain and knee effusion Radiograph often missed lytic lesion in centre of epiphyses -Isotope bone scan can help identify the lesion

Answer 92

Malignant tumour with cartilagenous differentiation Low- grade --> aggressive Pain + welling Many arise from enchondromas or osteochondromas Clear cell chondrosarcoma is a rare form of chondrosarcoma that occurs in the epiphysis

Answer 93

Osteochondroma – cartilage capped; grows away from physis Enchondroma – inside bone; commonest in hands and feet Chondroblastoma – in epiphyses of adolescents Chondrosarcoma – of varying malignancy

Answer 94

Eosinophilic granuloma is a rare neoplasm of Langerhans cells Unifocal (eosinophilic granuloma) Multifocal (Hand–Schuller–Christian disease) Disseminated (Letterer–Siwe disease). --> Skull and the diaphyses of long bone In the spine it can present with collapse, known as vertebra plana Radiographs can appear aggressive and similar to Ewing’s sarcoma -often expansion and a ground glass appearance, sometimes with cystic change

Answer 95

Malignant round cell sarcoma T11:22 Arises diaphysis long bone or pelvis Painful mass and may have systemic symptoms including fever, anaemia and increased erythrocyte sedimentation rate (ESR) Radiologically the bone appears moth-eaten and may show an ‘onion-skin’ periosteal reaction

Answer 96

Simple bone cyst – proximal long bones of children Aneurysmal bone cyst – more aggressive, expanding Giant cell tumour – found in epiphyses around the knee Fibrous dysplasia – may be multiple; long bones, ribs and skull Ewing’s – round cell sarcoma; patients may have fever and anaemia

Answer 97

Staging primary bone cancers If breached cortex = 2B

Answer 98

Staging for malignant sodt tissue tumours Based on tumour differentiation, mitotic count and tumour necrosis,

Answer 99

an osteoid osteoma

Answer 100

Painful Increasing in size More than 5 cm in diameter

Answer 101

Only biopsy once staging is completed Biopsy should be performed at the institution undertaking the main surgery Imaging-guided biopsy is more reliable he biopsy track must be excised at definitive surgery Jamshidi needles for bone, Trucut needles for soft tissues

Answer 102

Used in treatment of osteoid osteoma Many recgress spontaneously

Answer 103

Pre-op chemotherapy used for: -Osteosarcoma -Ewing's sarcoma

Answer 104

Chondrosarcomas

Answer 105

Used to predict risk of pathological fracture Larger, more painful, lytic lesions carry a higher risk Lower limb higher risk vs upper limb

Answer 106

Complete excision with biopsy tract Not senitive to chemotherapy Pre-op and post-op radiotherapy can be useful but can impair wound healing

Answer 107

Pathological feature of osteomyelitis in which new bone is constructed around dead bone forming many sinuses

Answer 108

Can only be undertaken if the prosthesis is well-fixed The surrounding infected soft tissue and bone must be fully excised and modular components exchanged This cannot be achieved by arthroscopic surgery Good soft tissue cover is essential. Following debridement, the patient is treated with long-term antibiotics (frequently 6 weeks of intravenous therapy followed by 6 months or more of oral antibiotics). Prolonged infection-free intervals will be achieved in 80% of patients but success with this strategy may be lower in infections caused by Staphylococcus aureus.

Answer 109

Thorough excision is undertaken and all cement and loose foreign material is removed. An antibiotic-impregnated spacer may be implanted (which may be articulating) This is a temporary measure and cannot withstand full weight bearing. The patient is treated with oral or intravenous antibiotics, most commonly for 6 weeks. New prosthesis is implanted after the course of antibiotics has been completed. Rerevision surgery for infection has a higher failure rate than a first revision, and so early referral to a specialist centre should be considered.

Answer 110

Removal and reimplantation are undertaken in the same operating session. Healthy soft tissues around the new implant are essential to prevent reinfection. Some centres consider single-stage revisions when less florid signs of infection are present (i.e. absence of collections or sinus tracts), or for frail patients for whom the risk of a second operation is higher. There are no adequate trial data comparing outcomes with the two-stage approach.

Answer 111

Vertebral column Children: long bones

Answer 112

Classification for chronic osteomyelitis Four stages of infection Stage 1: medullary -just cancellous bone -ream bone and pack with Abx pellets Stage 2: superficial -Only the cortical bone is involved and this requires excision. - follows skin ulceration and there may be large skin defects which require complete excision and local or free muscle flaps Stage 3: localised -limited area of dead cortical bone with medullary infection. -staged reconstruction after excisio n Stage 4: diffuse -Involves the entire circumference of the bone and surrounding soft tissue -All infected non-unions are Stage 4. -Resection must be segmental and stabilisation in an external fixator will be required. Reconstruction will involve the introduction of new bone and healthy soft tissue -Ilizarov method, which uses distraction osteogenesis to fill bone defects Three host groups A- C A, no active concurrent disease B, compromised host C,severe comorbidity preventing surgery

Answer 113

Stage 1: medullary Stage 2: superficial Stage 3: localised Stage 4: diffuse

Answer 114

Usually occur within 2 motnhs of fertilisation The upper limb bud forms on the lateral wall of the embryo 4 weeks after fertilisation, followed promptly by the lower limb bud AER controls proximal to distal differentiation and interdigital necrosis ZPA directs posterior to anterior differentiation Wnt influences dorsal to ventral differentiation

Answer 115

Compressibe forces inhibit growth Tensile forces stimulate growth

Answer 116

Bone deposition and resorption depend on the stresses applied

Answer 117

Guides mesordermal proliferation in the progress zone in proximal --> distal direction Controls digit formation

Answer 118

Mesodermal zone of polarising activity directs anteroposterior limb development via the sonic hedgehog protein

Answer 119

Ectodermal driven wingless- type (Wnt) signalling centre develops dorsoventral axis configuration and limb alignment.

Answer 120

Femur/hip: Persistent femoral neck anteversion Tibia: Internal tibial torsion Foot: Metatarsus adductus

Answer 121

Internal tibial torsion is assessed by the thigh–foot angle Commonly associated with physiological tibia vara in infants Spontaneous correction can be expected by age 4, as the tibia also rotates as it grows.

Answer 122

Children’s legs are often bowed until age 2 years and then knock-kneed until age 6 or 7 years Neuromuscular pathology must be excluded in toe walkers, particularly when the onset is late Intoeing or extoeing may be caused by excessive femoral or tibial torsion or foot deformity Flexible, pain-free flat feet do not need treatment

Answer 123

Flexible vs rigid Flexible: On tiptoe the arch is restored and the heel corrects into varus; subtalar joint movements are full and pain free Rigid: On tiptoe the arch fails to return and the heel remains in valgus; subtalar joint movements are restricted and often painful =inflammation or a tarsal coalition (calcaneonavicular bar)

Answer 124

Gain in function mutation in fibroblast growth factor receptor 3 (FGFR3) Short arm chromosome 4 Autosomal dominant Disproportionate short stature where the limbs are shorter than the trunk Radiograph features: -Splaying metaphysis -Over-long fibula -Slight bowing -Horzontal acetabulum -Square pelvic wings Underdevelopment of the foramen magnum and spinal stenosis can cause neurological difficulties

Answer 125

Precoious puverty Cafe-au-lait spots Fibrous dysplasia

Answer 126

Fibrous dysplasia

Answer 127

DDH defines the spectrum of hip instability, ranging from the hip that is in joint but has a shallow (dysplastic) acetabulum 'pushed out’ (Barlow positive) to the dislocated hip Irreducible (Ortolani negative).

Answer 128

Many hips that are unstable in the first few days/weeks of life do not need treatment as they improve spontaneously Up to age 4–6 months, a harness or splint is effective treatment In older babies, closed reduction is often possible and preferable to an open reduction For failed closed treatment, open surgical reduction is required

Answer 129

Kienbock’s disease Lunate Perthe's: Hip Panner’s disease Capitellum of the humerus Freiberg’s disease Metatarsal head – usually the second Köhler’s disease Navicular

Answer 130

Hilton’s law, which states that a joint is supplied by the same nerves as the muscles that move the joint,

Answer 131

Mostly commonly affects medial epicondyle of distal femur Osteochondral fragment becomes partially or totally separated If partial: rest and conservative managment Complete or mechanical symptoms: fixation or removal of loose bodies

Answer 132

Traction apophysitis of patellar tendon insertion Pain, tenderness and swelling at the tibial tubercle, exacerbated by exercise, are diagnostic Radiographs are unnecessary if bilateral, if unilateral ?maliganncy so imaging required Mx: relative rest and analgesia, and the condition resolves once the apophysis has fused

Answer 133

Congenital failure of formation of the lateral ‘column’ of the lower leg

Answer 134

Disordered growth in the posteromedial proximal tibial physis Presents with porgressive and severe tibia vera + intoeing Surgical management necessary

Answer 135

Rare condition presents clinically with an anterolateral bow of the tibia with or without a fracture.

Answer 136

Rare condition presents clinically with an anterolateral bow of the tibia with or without a fracture 50% are associated with neurofibromatosis

Answer 137

Osteochondritis dissecans – better prognosis in children than adults Discoid meniscus – usually lateral, may require surgery Anterior knee pain – treatment almost always conservative Fibular hemimelia – associated with abnormalities from the foot proximally (foot worse than hip), the tibial bow has an anteromedial apex Blount’s disease – clinically, a sharp proximal tibial angulation Congenital pseudarthrosis of the tibia – the tibial bow has an anterolateral apex Posteromedial apex tibial bow – largely physiological, the bow improves with time but the limb may be short

Answer 138

Deformed in three planes -Hindfoot is in equinus and varus -Midfoot cavus and -Forefoot lies adducted and apparently supinated, although actually pronated relative to the hindfoot. M > F 50% bilateral Most cases are idiopathic but neuromuscular causes include spina bifida and arthrogryposis Scoring systems (Pirani/Dimeglio), are used to assess the severity

Answer 139

Associated with VACTERL syndrome -abnormal vertebrae, anus, cardiovascular system, trachea, oesophagus, renal system and limb buds - short radius -deformed ulna - +/- an absent thumb Mx: balance of conservative measures, including physiotherapy and splinting, and judicious surgery to centralise and stabilise the hand and wrist on the single bone forearm

Answer 140

Presents with a fixed forearm position in childhood

Answer 141

Usually posterolateral vs traditional traumatic anterior

Answer 142

Usually caused by moulding but may present with fixed sternocleidomastoid contracture or with a palpable ‘tumour’ within the muscle. There is a strong correlation with DDH Most cases resolve with stretching Persistent cases develop facial asymmetry and require surgical release of the sternocleidomastoid at one or both ends.

Answer 143

Fever > 38.5 Non-weight bearing ESR >40 WCC >12 0: 2% 1: 9.5% 2: 35% 3: 72.8% 4: 93%

Answer 144

= Non-accidental injury

Answer 145

Issues with bone mineralisation low Ca low vit D low Phos, high ALP

Answer 146

Issues with bone remodelling bloods all normal tx: Alendronic acid Bisphosphonates Raloxifene (SERM, + at bone and - at breast) Strontium Ranelate

Answer 147

sartorius, gracilis, and semitendinosus muscles

Answer 148

pain walking up and donw stairs over the proximal medial tibia

Answer 149

Impacted fractures of the surgical neck are usually managed with a collar and cuff for 3 weeks followed by physiotherapy.

Answer 150

Most commonly used. Plate and screw fixation. Can reconstruct complex fractures.

Answer 151

Suitable for extra-articular configuration, predominantly surgical neck +/- GT fractures.

Answer 152

Used for un-reconstructable fractures in the older patient who has good glenoid quality.

Answer 153

Unconstructable fractures where high functioning shoulder is required (hemiarthroplasty will cause glenoid erosion)

Answer 154

Subacromial impingemenet

Answer 155

Hemisection of the spinal cord Ipsilateral paralysis Ipsilateral loss of proprioception and fine discrimination Contralateral loss of pain and temperature