Orthopaedics

Question 1

Describe lateral epicondylitis

Answer 1

Lateral epicondylitis: worse on resisted wrist extension/supination whilst elbow extended

also pain and tenderness localised to the lateral epicondyle

Typically house painting or playing tennis (‘tennis elbow’)

Question 2

Describe causes of hip pain

Answer 2

• osteoarthritis
• inflammatory arthritis
• referred lumbar spine pain (positive femoral nerve stretch test)
• greater trochanteric pain (trochanteric bursitis)
• avascular necrosis
• pubic symphysis dysfunction (common in pregnancy)
• transient idiopathic osteoporosis (uncommon, pregnancy)

Question 3

Describe osteomyelitis and its management

Answer 3

Osteomyelitis describes an infection of the bone

Classification

• haematogenous osteomyelitis
  > vertebral osteomyelitis is the most common form of haematogenous osteomyelitis in adults
  > risk factors: sickle cell anaemia, IVDU, immunosuppression, infective endocarditis
• non-haematogenous osteomyelitis:
  > contiguous spread of infection from adjacent soft tissues to the bone or from direct injury/trauma to bone
  > risk factors: diabetic foot ulcers/pressure sores, diabetes mellitus, peripheral arterial disease

Microbiology
- Staph. aureus is the most common cause except in sickle-cell anaemia where Salmonella species are most common

Investigations: MRI

Management
> flucloxacillin for 6 weeks
> clindamycin if penicillin-allergic

Question 4

Describe the pathophysiology and clinical features of compartment syndrome

Answer 4

can occur following fractures (or following ischaemia reperfusion injury in vascular patients)

characterised by raised pressure within a closed anatomical space
> raised pressure will eventually compromise tissue perfusion resulting in necrosis

> 2 main fractures carrying this complication: supracondylar fractures and tibial shaft injuries.

Features
> Pain, especially on movement (even passive)
> excessive use of breakthrough analgesia
> Paraesthesia
> Pallor
> Arterial pulsation may still be felt as the necrosis occurs as a result of microvascular compromise
> Paralysis of the muscle group may occur

Question 5

describe the diagnosis and management of compartment syndrome

Answer 5

Diagnosis
> measurement of intracompartmental pressure via needle manometry
> Pressures >20mmHg are abnormal and >40mmHg is diagnostic
> no pathology on x-ray

Treatment: cut dressings down to skin

> prompt and extensive fasciotomies releasing all compartments

> Myoglobinuria may occur following fasciotomy leading to renal failure - aggressive IV fluids

> Where muscle groups are necrotic at fasciotomy - debridement +/- amputation

Death of muscle groups may occur within 4-6 hours

Question 6

Describe the following knee problems:

• Infrapatellar bursitis
• Prepatellar bursitis

Answer 6

Infrapatellar bursitis- Clergyman’s knee
> Associated with kneeling

Prepatellar bursitis - housemaid’s knee
> Associated with more upright kneeling

Question 7

Describe features and causes of cauda equina syndrome

Answer 7

Clinical features
> Urinary retention, bladder distension
> Reduced/absent anal tone, faecal incontinence
> Bilateral sciatica
> bilateral motor weakness in legs
> Saddle anaesthesia
> loss of perianal sensation (S2-S4)

causes
- disc prolapse in lumbosacral canal

investigations
- pre and post-voiding bladder scan (retention/incomplete bladder emptying)
- emergency MRI whole spine (within 4 hours)

Management
> Neurosurgery referral - decompression laminectomy within 24h

> Metastatic cancer: IV dexamethasone, radiotherapy

Complications
- urinary dysfunction requiring catheterisation
- sexual dysfunction
- chronic pain
- leg weakness

Question 8

Describe the clinical features and causes carpal tunnel syndrome

Answer 8

caused by compression of median nerve in the carpal tunnel

History
> pain/pins and needles in thumb, index, middle finger
> unusually the symptoms may ‘ascend’ proximally
> patient shakes hand to obtain relief, classically at night

Examination
> weakness of thumb abduction (abductor pollicis brevis)
> wasting of thenar eminence
> Tinel’s sign: tapping causes paraesthesia
> Phalen’s sign: flexion of wrist causes symptoms

Causes
- idiopathic
- pregnancy
- oedema e.g. heart failure
- lunate fracture
- rheumatoid arthritis
- acromegaly
- hypothyroidism
- diabetes
- chronic renal failure

Question 9

describe the diagnosis and management of carpal tunnel syndrome

Answer 9

Electrophysiology: motor + sensory: prolongation of the action potential

Treatment
- 6-week trial of conservative treatments mild-moderate

> wrist splints at night: particularly useful if transient factors present e.g. pregnancy
+/- corticosteroid injection

if severe symptoms or persistent:
> surgical decompression (flexor retinaculum division)

Question 10

Describe sciatica

Answer 10

Causes
> Prolapsed lumbar disc

Clinical features
> Clear dermatomal leg pain associated with neurological deficits
> Leg pain worse than back pain
> Pain worse when sitting

Management
> analgesia, physiotherapy, exercises
> if symptoms persist >4-6 weeks, refer for MRI

Question 11

Describe the presentation of scaphoid fractures

Answer 11

wrist fracture, typically due to fall onto an outstretched hand (FOOSH).

Presentation
> Pain along radial aspect of wrist at the base of the thumb
> Loss of grip / pinch strength

Signs:
- maximal tenderness over anatomical snuffbox
- pain elicited by telescoping of the thumb (pain on longitudinal compression)
- tenderness of the scaphoid tubercle (volar aspect of the wrist)
- pain on ulnar deviation of the wrist

Investigations
- Plain film radiographs
- CT scan if ongoing clinical suspicion
- MRI is definite investigation

Question 12

describe complications and management of scaphoid fractures

Answer 12

Management
- Immobilisation with a Futuro splint or standard below-elbow backslab
- referral to orthopaedics
> undisplaced fractures of the scaphoid waist - cast for 6-8 weeks

> displaced scaphoid waist fractures
- surgical fixation
proximal scaphoid pole fractures
- surgical fixation

Complications
non-union → pain and early osteoarthritis
avascular necrosis
> most of the blood supply is derived from the dorsal carpal branch (branch of the radial artery), in a retrograde manner. Interruption of the blood supply risks avascular necrosis

Question 13

What’s the normal position of the wrist joint?

Answer 13

10 degrees of volar angulation

Question 14

describe open fracture management

Answer 14

ATLS approach
- inspect and photograph wound
- cover wound with saline soaked swab
- early antibiotics - IV cefuroxime, consider tetanus

Investigations - X-ray for diagnosis

management
- temporary stabilisation
> thomas splint - femur
> backslab - tibia

• definitive debridement and stabilisation in theatre

Question 15

describe the classification of open fractures

Answer 15

Gustilo Anderson Classification

Type I
- skin wound <1cm
- clean
- simple fracture pattern

Type II
- laceration >1cm but <10cm
- moderate soft tissue damage
- adequate bone coverage

Type III
- laceration >10cm with extensive soft tissue damage

> IIIA: adequate soft tissue cover of bone but segmental / severely comminuted wounds
IIIB: extensive soft tissue injury with periosteal stripping and bone exposure; major wound contamination
IIIC: open fracture with arterial injury requiring repair

Question 16

describe causes and features of septic arthritis

Answer 16

most common organism overall is Staphylococcus aureus

young adults who are sexually active - Neisseria gonorrhoeae is the most common organism (disseminated gonococcal infection)

causes
- bacteraemia - haematogenous spread
- direct innoculation (trauma / surgery)
- contiguous spread (adjacent osteomyelitis)

Features
> acute, swollen joint
> restricted movement
> examination findings: warm to touch/fluctuant
> fever

Question 17

describe investigations and management of septic arthritis

Answer 17

Investigations
- synovial fluid sampling: joint aspiration

> before Abx unless extreme
fluid often cloudy if septic
send fluid for gram stain, culture and crystal analysis
aspirate prosthetic joints in theatre

• blood cultures + bloods
• joint imaging (X-ray)

Management
- intravenous antibiotics: flucloxacillin or clindamycin if penicillin allergic for 4-6 weeks

• needle aspiration should be used to decompress the joint
• arthroscopic lavage may be required

can get irreversible joint damage due to release of proteolytic enzymes within 8 hours

Question 18

describe investigations, management and complications of cauda equina syndrome

Answer 18

investigations
- pre and post-voiding bladder scan (retention/incomplete bladder emptying)
- emergency MRI whole spine (within 4 hours)

Management
> Neurosurgery referral - decompression laminectomy within 24h

> Metastatic cancer: IV dexamethasone, radiotherapy

Complications
- urinary dysfunction requiring catheterisation
- sexual dysfunction
- chronic pain
- persistent leg weakness / altered sensation

Question 19

describe the contents of the carpal tunnel

Answer 19

tendons:
- flexor digitorum profundus (4)
- flexor digitorum superficialis (4)
- flexor pollicis longus (1)

nerve:
- median nerve

Question 20

Describe the following eponymous fractures
- Colles’
- Bennett’s
- Pott’s
- Smith’s
- Monteggia’s
- Galeazzi
- Barton’s

Answer 20

• Colles’ - dinner fork deformity
  FOOSH resulting in transverse fracture of radius 1 inch proximal to radiocarpal joint with dorsal displacement and angulation
• Bennett’s - intra-articular fracture of first CMC joint from fist fight, triangular fragment at ulnar base of metacarpal on X-ray
• Pott’s - bimalleolar ankle fracture on forced foot eversion
• Smith’s: (reverse Colles’) volar angulation of distal radius fragment, caused by falling backwards onto palm of outstretched hand
• Monteggia’s: dislocation of proximal radioulnar joint due to ulna fracture due to FOOSH with forced pronation
• Galeazzi: radial shaft fracture with dislocation of distal radioulnar joint (direct blow)
• Barton’s - distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation (fall onto extended and pronated wrist)

Question 21

Describe the classification of ankle injuries and their management

Answer 21

Weber classification of ankle fractures

• type A: below level of ankle joint
  > syndesmosis intact
  > usually stable
  > remain weight-bearing as tolerated in CAM boot for 6 weeks
• type B: at the level of ankle joint
  > syndesmosis intact or torn
  > medial malleolus may be fractured
  > deltoid ligament may be torn
  > variable stability
• type C: above ankle joint
  > syndesmosis disrupted
  > medial malleolus fracture and deltoid ligament rupture
  > open reduction and external fixation (ORIF)

Maisonneuve fracture: spiral fibular fracture that leads to disruption of the syndesmosis with widening of the ankle joint
> surgery is required

Management
> prompt reduction of ankle fractures (before X-ray if neurovascular compromise)
> young patients with unstable/high velocity/proximal injuries - surgical repair with compression plate
> elderly patients - conservative management

Question 22

List the Ottawa ankle rules

Answer 22

Ottawa ankle rules (to determine need for X-rays): if pain in malleolar zone and
> inability to weight bear for 4 steps
> tenderness over distal tibia
> bone tenderness over distal fibula

Question 23

describe scheuermann’s disease

Answer 23

epiphysitis of the vertebral joints

predominantly affects adolescents

symptoms: back pain, stiffness

X-ray changes
- epiphyseal plate disturbance
- anterior wedging

clinical features
- progressive kyphosis

management
- physiotherapy
- analgesia
- severe cases may require bracing, surgical stabilisation

Question 24

describe a ganglion cyst

Answer 24

cyst arising from a joint or tendon sheath

most commonly seen on dorsal aspect of wrist

features
- firm and well-circumscribed mass that transilluminates

management
- often disappear spontaneously within months
- surgical excision is indicated if severe symptoms or neurovascular manifestations

Question 25

list late radiological features of avascular necrosis

Answer 25

- crescent sign: subchondral collapse - osteochondral fracture - flattening of femoral head - joint space narrowing

Question 26

describe the following tumours - osteoma - giant cell tumour - chondrosarcoma

Answer 26

osteoma - benign overgrowth of bone, typically on the skull - associated with Gardner's syndrome (variant of familial adenomatous polyposis) giant cell tumour - tumour of multinucleated giant cells within fibrous stroma - peak incidence: 20-40 years - usually in epiphyses of long bones - X-ray: double bubble or soap bubble appearance chondrosarcoma - malignant tumour of cartilage - most commonly affects axial skeleton - more common in middle age

Question 27

Describe hip fractures and their management

Answer 27

Features > pain > shortened and externally rotated leg Classification > intracapsular (subcapital) > extracapsular: these can either be trochanteric or subtrochanteric Garden classification system also used to classify NOF fractures Management - Intracapsular hip fracture > Undisplaced: internal fixation, or hemiarthroplasty if unfit. > displaced: replacement arthroplasty (total hip replacement or hemiarthroplasty) >> sciatic nerve damage associated with THR - Extracapsular hip fracture > stable intertrochanteric fractures: dynamic hip screw > reverse oblique, transverse or subtrochanteric fractures: intramedullary device

Question 28

List red flags in back pain

Answer 28

Age <18 or >50 Immunosuppression Waking from pain night sweats, fever, weight loss recent trauma progressive neurological deficit worst at night or at rest thoracic back pain bladder or bowel dysfunction history of malignancy

Question 29

Describe cubital tunnel syndrome

Answer 29

due to compression of the ulnar nerve as it passes through the cubital tunnel > ulnar nerve travels between two heads of FCU in cubital tunnel retinaculum clinical features - tingling and numbness of the 4th and 5th fingers - weakness of finger abduction - hypothenar wasting - pain worse on leaning on the affected elbow - +ve Tinel's at elbow - history of OA / prior trauma investigations: clinical diagnosis but nerve conduction studies may be used management - avoid aggravating factors - physio - soft elbow splints - surgery in resistant cases

Question 30

Describe necrotising fasciitis and its management

Answer 30

classification: - type 1: mixed anaerobes and aerobes (often occurs post-surgery in diabetics) - most common - type 2: Streptococcus pyogenes Risk factors > skin factors: recent trauma, burns or soft tissue infections > diabetes mellitus > intravenous drug use > immunosuppression The most commonly affected site is the perineum (Fournier's gangrene). Features > acute onset > pain, swelling, erythema at the affected site > rapidly worsening cellulitis with pain out of keeping with physical features > extremely tender over infected tissue with hypoaesthesia to light touch > skin necrosis and crepitus/gas gangrene are late signs > fever and tachycardia may be absent or occur late in the presentation Management > urgent surgical referral debridement > intravenous antibiotics Prognosis - average mortality of 20%

Question 31

describe shoulder dislocation

Answer 31

humeral head dislodges from glenoid cavity of scapula anterior dislocation: FOOSH posterior dislocation: seizures, electric shock inferior dislocation management: reduction - if recent reduction e.g. Kocher reduction may be attempted without analgesia/sedation - some patients may require analgesia or sedation to relax rotator cuff muscles

Question 32

describe achilles tendinopathy

Answer 32

risk factors > quinolone use e.g. ciprofloxacin > hypercholesterolaemia (xanthomata) achilles tendinitis - gradual onset of posterior heel pain that is worse following activity - morning pain and stiffness management - rest, ice, analgesia - reduction in precipitating activities - calf muscle eccentric exercises achilles tendon rupture - audible pop in the ankle while playing a sport or running - sudden onset significant pain in the calf or ankle - inability to walk or continue the sport simmond's - abnormal angle of declination - greater dorsiflexion than uninjured side - palpate for gap in tendon - squeeze muscles to check integrity of tendon imaging: US first-line acute referral to orthopaedics if rupture management: > RICE immediately > non-surgical: immobilisation > surgical: reattachment

Question 33

describe achondroplasia

Answer 33

AD disorder caused by mutation in FGFR-3 this results in abnormal cartilage - short limbs (rhizomelia) with shortened fingers (brachydactyly) - large head with frontal bossing and narrow foramen magnum - midface hypoplasia with flattened nasal bridge - trident hand deformity - lumbar lordosis mostly a sporadic mutation, risk factor is increasing parental age

Question 34

describe subacromial impingement

Answer 34

first stage of rotator cuff disease, most common cause of shoulder pain clinical features - pain exacerbated by overhead activities and lifting objects away from body - night pain - painful arc of abduction between 60-120 degrees - tenderness over anterior acromion - X-ray may show calcification of supraspinatus tendon management - physiotherapy - NSAIDs - subacromial injections - surgery

Question 35

describe spondylolysis and spondylolisthesis

Answer 35

spondylolysis - congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affects L4/5 - commonest cause of spondylolisthesis in children spondylolisthesis - one vertebra is displaced relative to its immediate inferior vertebral body - may occur as a result of stress fracture or spondylolysis - treatment > active monitoring > individuals with radicular symptoms or signs will require spinal decompression and stabilisation

Question 36

describe metatarsal fractures

Answer 36

the 5th metatarsal is the most commonly fractured metatarsal and is the most common site of midfoot > proximal avulsion fractures (pseudo-Jones fractures): most common type >> associated with lateral ankle sprain and often follows inversion injuries of the ankle > jones fractures >> transverse fracture at the metaphyseal-diaphyseal junction metatarsal stress fractures - occurs in otherwise healthy athletes - most common site is 2nd metatarsal shaft > features: pain and bony tenderness, swelling, antalgic gait investigations: stress fractures may appear normal on X-ray but sometimes there is a periosteal reaction 2-3 weeks later > isotope scan or MRI if inconclusive

Question 37

describe Sweet's syndrome

Answer 37

aka acute febrile neutrophilic dermatosis features - fever - painful inflamed or blistered skin rash - mucosal lesions - joint pain - headache associations: HLA B54 - IBD - RA / lupus - URTI - immunodeficiency treatment - systemic steroids

Question 38

describe acetabular labral tear and femoroacetabular impingement (FAI)

Answer 38

labral tears may occur as a result of trauma or degenerative change features - acute history / contact sport - hip/groin pain - snapping sensation - patient able to weight bear with pain on external rotation - locking sensation FAI - chronic condition predisposing to acetabular tear

Question 39

describe de Quervain's tenosynovitis

Answer 39

common condition in which sheath containing extensor pollicis brevis and abductor pollicis longus tendons is inflamed typically affects females 30-50 years old features - pain on radial side of wrist - tenderness over radial styloid process - abduction of thumb against resistance is painful - Finkelstein's test: examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction > if positive will cause pain over radial styloid process and along tendons management - analgesia - steroid injection - immobilisation with a thumb splint (spica) - surgery

Question 40

describe plantar fasciitis

Answer 40

inflammation of plantar fascia most common cause of heel pain in adults clinical features - gradual onset heel pain - pain is worse around medial calcaneal tuberosity - exacerbated by walking on tip toes management - rest, ice, analgesia - wear shoes with good arch support and cushioned heels - insoles / heel pads - physio - steroid injections

Question 41

describe superficial radial neuritis (Wartenberg's syndrome)

Answer 41

entrapment of the superficial branch of the radial nerve features - pain over distal radial forearm - paraesthesia over dorsal radial aspect of hand - symptoms at rest regardless of thumb and wrist position (as opposed to De Quervain's tenosynovitis)

Question 42

list causes of a dupuytren's contracture

Answer 42

- alcoholic liver disease - phenytoin treatment > also causes peripheral neuropathy - diabetes - manual labour - trauma to the hand

Question 43

describe hip dislocation

Answer 43

mostly caused by trauma or falls from height Posterior hip dislocation - most common - associated with internally rotated, adducted and shortened limb - can result in sciatic nerve injury > reduced sensation in posterior leg and foot > impaired ability to dorsiflex foot Anterior hip dislocation - rare - associated with externally rotated and abducted limb with no leg shortening Management - analgesia - reduction under GA within 4h complications - sciatic or femoral nerve injury - avascular necrosis - osteoarthritis - recurrent dislocation

Question 44

describe the management of suspected scaphoid fracture with unconclusive imaging

Answer 44

wrist splint further imaging + clinical review in 7-10 days

Question 45

describe an osteochondroma

Answer 45

benign tumour, aka exostosis - most common benign bone tumour - more in males, usually <20 years - cartilage-capped bony projection on the external surface of a bone

Question 46

describe multiple myeloma

Answer 46

most common primary bone malignancy pathophysiology: > neoplastic proliferation of plasma cells which manifest as skeletal lesions > neoplastic plasma cells produce immunoglobulins commonly age >40 clinical features - back pain - bone pain - pathological fracture - systemic features myeloma screen - IgG, IgA, IgM - heavy chains - urine sample for Bence Jones protein (light chain) solitary lesion - plasmacytoma treatment - radiotherapy / chemotherapy - stem cell transplantation - bisphosphonates - prophylatic fixation

Question 47

list primary tumours that metastasise to bones

Answer 47

- lung - lytic - breast - sclerotic - thyroid - lytic - renal - lytic - prostate - sclerotic / lytic

Question 48

describe the clinical features of bone tumours

Answer 48

- pain (night pain) - swelling - systemic features: unexplained weight loss, night sweats, fatigue - pathological fracture - nerve compression - history of malignancy

Question 49

describe a unicameral bone cyst

Answer 49

aka simple cyst benign non-neoplastic, most common in young adults commonly in metaphysis of long bones (60% humerus) often present with pathological fracture treatment - nil if asymptomatic - fractures - usually heal normally - bone curettage and graft sometimes required

Question 50

describe osteosarcoma

Answer 50

most common primary malignant bone tumour bimodal distribution - children and young adults - older adults (malignant conversion of Paget's disease) X-ray: Codman triangle (from periosteal elevation) and sunburst pattern metaphyseal region of long bones affected - distal femur, proximal tibia most common symptoms - pain - fever - mass - pathological fracture management - chemotherapy - surgical resection

Question 51

describe Ewing's sarcoma

Answer 51

small round blue cell tumour commonly affects pelvis and long bones - most common in males 10-20 years - associated with t(11;22) X-ray features: > lytic lesion with lamellated / onion type periosteal reaction > affects diaphysis of long bones treatment - chemotherapy (risk of developing AML/myelodysplasia later) - radiotherapy - curative resection

Question 52

list Kanavel's signs

Answer 52

signs of pyogenic flexor tenosynovitis - pain to palpation of flexor tendon sheath - uniform swelling along entire finger - held in passive flexion - pain with passive extension

Question 53

describe quadriceps tendon rupture

Answer 53

can occur with foot planted and knee bent or direct trauma clinical features - pain - tenderness at site of rupture - palpable defect in quad tendon Knee X-ray: patella baja treatment - knee immobilisation in brace - surgical repair

Question 54

describe proximal humerus fracture

Answer 54

due to fall onto outstretched hand in elderly or high energy trauma in young patients clinical features - pain and swelling - decreased motion complications: axillary nerve or artery injury management - sling immobilisation - surgical repair

Question 55

describe a Lisfranc injury

Answer 55

tarsometatarsal fracture dislocation traumatic disruption between the articulation of the medial cuneiform and base of the 2nd metatarsal management - surgery: ORIF. arthrodesis

Question 56

describe a fat embolism

Answer 56

can occur following fracture of long bones e.g. femur fat globules released into circulation and can lodge in pulmonary arteries diagnosed with Gurd's criteria - respiratory distress - petechial rash - cerebral involvement - jaundice - thrombocytopaenia - fever - tachycardia operate early to reduce risk of fat embolism syndrome

Question 57

describe spinal stenosis

Answer 57

3 types - central stenosis - lateral stenosis - foramina stenosis causes - congenital - degenerative - herniated disc - malignancy - fracture clinical features - gradual onset - symptoms absent at rest but appear when standing/walking - lower back pain - buttock and leg pain (intermittent neurogenic claudication) - leg weakness - improvement walking uphill or bending forwards investigations - MRI scanning management - exercise and weight loss - analgesia - physiotherapy - decompression surgery: laminectomy

Question 58

describe meralgia paraesthetica

Answer 58

burning sensation over anterolateral thigh due to compression of lateral femoral cutaneous nerve of thigh clinical features - burning - numbness - pins and needles - cold sensation - localised hair loss aggravated by walking / standing up and improved sitting down can be caused by sudden weight gain extension of hip worsens symptoms management - conservative: rest, looser clothing - medical: paracetamol, NSAIDs, neuropathic medications e.g. amitriptyline - surgical: decompression

Question 59

describe trochanteric bursitis

Answer 59

clinical features - aching/burning pain over outer hip (greater trochanteric pain syndrome) - pain worse with activity, after sitting for a prolonged period of time and trying to sit cross-legged - tenderness over greater trochanter but no swelling positive Trendelenburg management - rest, ice, analgesia - steroid injections

Question 60

describe a meniscal tear

Answer 60

May be caused by twisting of the knee > Locking and giving-way are common feature > rotational sporting injury accompanied by pop sound or sensation clinical features - pain, swelling, stiffness - reduced ROM - tender joint line management - RICE - analgesia - surgery: arthroscopy

Question 61

describe an ACL tear

Answer 61

Anterior cruciate ligament tear > May be caused by twisting of the knee - pivot shift mechanism clinical features - popping noise - rapid onset of knee effusion with pain and swelling (haemarthrosis) - instability or giving way - positive anterior draw test / Lachman test investigations: MRI, arthroscopy management - NSAIDs - physiotherapy - arthroscopic reconstruction

Question 62

describe Osgood-Schlatter disease

Answer 62

inflammation at tibial tuberosity at insertion of patellar ligament commonly ages 10-15, males usually unilateral but can be bilateral clinical features - visible or palpable hard and tender lump - pain anterior knee - pain exacerbated by physical activity, kneeling and extension of knee management - rest, ice - NSAIDs - hard non-tender lump present permanently after complication - complete avulsion fracture

Question 63

describe a Baker's cyst

Answer 63

non-tender lump in popliteal fossa causes - meniscal tear - knee injuries - OA, inflammatory arthritis clinical features - pain, swelling, fullness/pressure - Foucher's sign: increase in tension of the Baker's cyst on extension of the knee investigations: USS, MRI management - no treatment if asymptomatic - physiotherapy, analgesia - US-guided aspiration - steroid injections - surgery

Question 64

describe fat pad atrophy

Answer 64

atrophy of fat pad protecting calcaneus atrophy can occur from age, repetitive strain from running, jumping or steroid injections for plantar fasciitis clinical features - similar to plantar fasciitis - pain and tenderness over plantar aspect of heel - symptoms worse with activities, especially barefoot investigations - ultrasound management - comfortable shoes, custom insoles - weight loss if appropriate

Question 65

describe Morton's neuroma

Answer 65

dysfunction of nerve usually between 3rd and 4th metatarsals clinical features - pain at front of foot at location of lesion - sensation of lump in shoe - burning, numbness or pins and needles in distal toes - exacerbated by high heels/narrow shoes investigations - deep pressure applied to intermetatarsal space causes pain - metatarsal squeeze - Mulder's sign: painful click when manipulating metatarsal heads - US/MRI management - adapting activities, insoles, weight loss - analgesia, steroid injections - radiofrequency ablation, surgery

Question 66

describe paediatric fracture classification for fractures affecting the epiphyseal plate

Answer 66

Salter-Harris classification (SALTR) Grade I - straight across epiphyseal plate > X-ray often normal Grade II - above the physis > fracture through physis and metaphysis Grade III - lower than the physis > fracture through physis and epiphysis Grade IV - through the physis > fracture through metaphysis, physis and epiphysis Grade V - rammed (crushed) > crush injury involving the physis, X-ray may appear normal > growth disruption

Question 67

describe types of paediatric fractures

Answer 67

- Complete fracture > both sides of the cortex are breached - Salter Harris fracture > fracture affecting epiphyseal plate - Toddler's fracture > oblique tibial fracture in infants - plastic deformity > stress on bone resulting in deformity without cortical disruption - greenstick fracture > unilateral cortical breach only - buckle "torus" fracture > incomplete cortical disruption resulting in periosteal haematoma only

Question 68

list causes of pathological fracture in children

Answer 68

osteogenesis imperfecta - radiology shows translucent bones, multiple fractures (especially long bones), wormian bones (irregular patches of ossification), trefoil pelvis osteopetrosis - bones become harder and more dense - AR condition - radiology: lack of differentiation between cortex and medulla described as marble bone

Question 69

describe Simmonds triad

Answer 69

- calf squeeze test - observation of the angle of declination - palpation of the tendon

Question 70

describe acromioclavicular joint dislocation

Answer 70

normally occurs secondary to direct injury to superior aspect of acromion clinical features - loss of shoulder contour - prominent clavicle Rockwood classification management - physio - reconstruction or ORIF with hook plate

Question 71

describe glenohumeral dislocation

Answer 71

types - anterior dislocation > associated with axillary nerve injury > flattened deltoid, head of humerus palpable at front of shoulder - posterior dislocation > uncommon > usually due to seizures or electric shock > lightbulb sign on X-ray X-ray features - Hill Sachs lesion management - shoulder reduction +/- analgesia/sedation

Question 72

describe iliotibial band syndrome

Answer 72

non-traumatic overuse injury often seen in runners, cyclists clinical features - pain/tenderness on palpation of lateral knee - pain elicited when heel strikes floor - pain may radiate to outer thigh/calf - swelling outer knee management - rest, ice, analgesia, physio

Question 73

describe bunions

Answer 73

aka hallux valgus bony lump created by deformity at MTP joint at base of hallux investigations - weight bearing X-ray management - conservative: wide, comfortable shoes and analgesia, bunion pads - surgery

Question 74

describe the clinical features of a dupuytren contracture

Answer 74

palmar fascia becomes thickened and tight and develops nodules clinical features - hard nodules on palm - skin thickening and pitting - finger pulled into flexion - impossible to fully extend finger - ring finger most likely to be affected investigations - table top test: hand cannot rest completely flat on a table management - conservative - surgical: needle fasciotomy, limited fasciectomy, dermofasciectomy

Question 75

describe trigger finger

Answer 75

aka stenosing tenosynovitis most commonly affects first annular (A1) pulley at the MCP joint clinical features > painful tender finger around MCP joint on the palm side of the hand > finger does not move smoothly > gets stuck in flexed position > popping/clicking sound upon extension symptoms are worse in the morning and improve during the day management - rest and analgesia - splinting - steroid injections - surgery

Question 76

describe olecranon bursitis

Answer 76

aka student's elbow usually young/middle-aged man with an elbow that is swollen, warm, tender and fluctuant management - rest, ice, compression, analgesia - aspiration of fluid - steroid injections

Question 77

describe Marfan's syndrome

Answer 77

AD connective tissue disorder caused by defect in fibrillin-1 (FBN1 gene) Features - tall stature with long arms - high-arched palate - arachnodactyly - pectus excavatum - pes planus - scoliosis of > 20 degrees heart: - dilation of the aortic sinuses > aortic aneurysm, aortic dissection, aortic regurgitation - mitral valve prolapse lungs: repeated pneumothoraces eyes: - upwards lens dislocation (superotemporal ectopia lentis) - blue sclera - myopia - dural ectasia life expectancy: 40-50 years

Question 78

describe the clinical features of damage to the following nerves: - femoral nerve - obturator nerve - lumbosacral trunk - sciatic nerve

Answer 78

- femoral nerve > Weakness in knee extension, loss of the patella reflex, numbness of the thigh - obturator nerve > Weakness in hip adduction, numbness over the medial thigh - lumbosacral trunk > Weakness in ankle dorsiflexion, numbness of the calf and foot - sciatic nerve > Weakness in knee flexion and foot movements, pain and numbness from gluteal region to ankle Most nerve injuries recover within six to eight weeks, but occasionally nerve damage can be permanent.

Question 79

describe a PCL tear

Answer 79

Mechanism - anterior force applied to the proximal tibia (e.g. knee hitting dashboard during car accident) - hyperextension injury examination - posterior sag sign - tibia lies back on femur - paradoxical anterior drawer test

Question 80

describe collateral ligament tears

Answer 80

medial collateral ligament - mechanism: leg forced into valgus via force outside the leg >Tenderness over the affected ligament > Knee effusion may be seen

Question 81

describe patellar dislocation

Answer 81

mechanism - traumatic primary event: direct trauma or severe contraction of quadriceps with knee stretched in valgus and external rotation risk factors: genu valgum, tibial torsion and high riding patella Skyline x-ray views of patella > osteochondral fracture may be present associated injuries - popliteal artery - common peroneal nerve injury: foot drop gait (loss of dorsiflexion) 20% recurrence rate

Question 82

describe a patellar fracture

Answer 82

2 types: i. Direct blow to patella causing undisplaced fragments ii. Avulsion fracture features - swelling, bruising - palpable gap - if straight leg raise possible, extensor mechanism is intact investigations: knee X-ray AP & lateral management - undisplaced with intact extensor mechanism: non-operative in hinged knee brace for 6 weeks - displaced/loss of extensor mechanism: surgical management with screws/wires

Question 83

describe rib fractures

Answer 83

clinical features - severe sharp chest wall pain - pain more severe with deep breaths/coughing - crackles on auscultation if underlying lung injury / hypoventilation pneumonia long-term investigations - CT chest complication - pneumothorax, flail chest management > analgesia: morphine, nerve blocks > surgical fixation if >12 weeks with failed healing

Question 84

describe a tibial plateau fracture

Answer 84

Occur in the elderly (or following significant trauma in young) Mechanism: knee forced into valgus or varus, but the knee fractures before the ligaments rupture Varus injury affects medial plateau and if valgus injury, lateral plateau depressed fracture occurs Classified using the Schatzker system

Question 85

describe chondromalacia patellae

Answer 85

Teenage girls, following an injury to knee e.g. Dislocation patella featurs - pain on going downstairs or at rest - grinding sensation / clicking - quadriceps wasting/ weakness

Question 86

describe flail chest

Answer 86

multiple rib fractures with 2 or more rib fractures along 3 or more consecutive ribs flail segment moves paradoxically during respiration and impairs ventilation associated with pulmonary contusion treatment - invasive ventilation, surgical fixation

Question 87

describe Salter Harris fracture classification

Answer 87

SALTR S - straight across physis A - above the physis > growth plate and metaphysis L - lower than the physis > growth plate and epiphysis T - through the physis > through all 3 layeres R - right through > crush injury of growth plate

Question 88

describe osteogenesis imperfecta

Answer 88

defective osteoid formation associated features - hypermobility - blue/grey sclera - triangular face, short stature, dental problems - deafness - bone deformities: bowed legs, scoliosis - joint and bone pain management - bisphosphonates, vitamin D

Question 89

describe osteopetrosis

Answer 89

bones become harder and more dense AR condition radiology - marble bone > lack of differentiation between cortex and medulla

Question 90

describe biceps tendon rupture

Answer 90

mechanism - sudden excessive eccentric contraction of biceps brachii clinical features - sudden pop or tear at shoulder (proximal tendon) or at antecubital fossa (distal tendon) - pain, bruising, swelling - popeye deformity in the middle of the upper arm - hook test biceps squeeze test: causes forearm supination if intact investigations - ultrasound, MRI treatment - conservative: physio - surgical repair

Question 91

describe - Hill Sachs lesions - Bankart lesions

Answer 91

Hill Sachs defect > posterolateral humeral head depression fracture due to anterior dislocation Bankart lesion > injuries of anteroinferior glenoid labral complex > common complication of anterior shoulder dislocation

Question 92

describe a perilunate dislocation

Answer 92

mechanism: wrist extended with ulnar deviation Mayfield classification treatment - urgent reduction + fixation with K wires + ligament reconstruction +/- carpal tunnel release

Question 93

describe extensor tendon subluxation

Answer 93

weakness of sagittal bands that hold extensor tendon centrally over MCP joint causes - traumatic - chronic - commoner in RA clinical features - tendon subluxes on flexion - flicks back in extension or finger has to be straightened manually management - acute: splint with MCPJ extended for 6 weeks - surgical repair/reconstruction if failed conservative or chronic

Question 94

describe a radial / posterior interosseous nerve palsy

Answer 94

causes - trauma - RA of elbow - compression neuropathy clinical presentation - weakness of active extension of wrist/fingers and thumb - wrist drop - normal passive movement management - if laceration - repair nerve - synovitis - treat inflammation - compression neuropathy - surgical decompression

Question 95

describe thumb CMC OA and STT OA

Answer 95

thumb carpometacarpal osteoarthritis > pain and stiffness > pain on wringing/removing stiff lids > +ve Grind test scapho-trapezio-trapezoid OA also causes radial pain management - non-operative: analgesia, splintage, steroid injection - surgical: excise (trapeziectomy), fuse, replace

Question 96

describe hallux rigidus

Answer 96

1st MTPJ osteoarthritis clinical features - pain, stiffness - prominent bump management - non-operative: accommodative footwear, rocker sole, orthotics - operative: cheilectomy, fusion

Question 97

describe adhesive capsulitis (frozen shoulder)

Answer 97

- common in middle age and diabetics clinical features (typically develop over days) - painful, stiff movement - limited active and passive movement in all directions - loss of external rotation and abduction phases: painful freezing phase, adhesive phase, thawing phase clinical diagnosis management - NSAIDs - physiotherapy - oral or intra-articular corticosteroids

Question 98

what is the most common reason total hip replacements need to be replaced?

Answer 98

aseptic loosening of the hip replacement

Question 99

describe calcific tendonitis

Answer 99

calcification and tendon degeneration near the rotator cuff insertion diagnosis - X-ray > calcium deposits overlying the rotator cuff insertion treatment - NSAIDs - physiotherapy - steroid injections - US-guided needle lavage

Question 100

describe rotator cuff tears

Answer 100

causes: traumatic injuries in young patients as well as degenerative disease in the elderly patient clinical features - pain of insidious onset with pain worse on overhead activities - pain in deltoid region - night pain - acute pain and weakness with with traumatic tear - loss of active ROM with normal passive ROM gold standard investigation - MRI management - NSAIDs - physiotherapy - subacromial corticosteroid injections - surgery

Question 101

describe rotator cuff arthropathy

Answer 101

rotator cuff tear leading to abnormal glenohumeral wear and subsequent superior migration of the humeral head clinical features diagnosis - shoulder X-ray showing glenohumeral arthritis with a decreased acromiohumeral interval treatment - minimally symptomatic: > activity modification > subacromial steroid injections > physical therapy shoulder arthroplasty if progressive pain and deterioration of shoulder function

Question 102

list complications of distal radius fracture

Answer 102

- median nerve injury - compartment syndrome - vascular compromise - malunion - rupture of extensor pollicis longus tendon late: OA, complex regional pain syndrome

Question 103

describe osteochondritis dissecans

Answer 103

fragment of bone in the knee becomes detached due to a lack of blood supply most common in young adults who are active / participate in sports features - knee pain - intermittent swelling - locking of joint

Question 104

describe Sever's disease

Answer 104

aka calcaneal apophysitis type of growing pain Calcaneus grows faster than leg muscles / tendons - leads to tight Achilles tendon and calf > in active children, calcaneus is pulled hard by the Achilles tendon, leading to tiny cracks -> pain, swelling and tenderness of heel Usually age 8-14, settles by age 15 Management: analgesia, keep as active as pain allows, ice, stretching exercises

Question 105

describe superior gluteal nerve damage

Answer 105

clinical features - lateral pelvic tilt - trendelenburg gait - reduced hip abduction - positive Trendelenburg's test investigations: MRI complication of hemiarthroplasty management - supportive: walking stick on contralateral side - if associated with arthroplasty, usually recovery within 2y

Question 106

describe radial tunnel syndrome

Answer 106

due to compression of the radial nerve within radial tunnel near elbow presents similarly to lateral epicondylitis but pain is typically distal to epicondyle pain worse on elbow extension / forearm pronation may also have numbness/tingling in dorsum of hand or fingers due to compression of radial nerve

Question 107

describe ankle sprains

Answer 107

inversion injury: anterior talofibular ligament eversion injury: deltoid ligament