orthopaedics

Question 1

ix for achilles tendon rupture

Answer 1

ultrasound

quinolones risk factor for injury

Question 2

adhesive capsulitis

Answer 2

Features typically develop over days
external rotation is affected more than internal rotation or abduction
both active and passive movement are affected
patients typically have a painful freezing phase, an adhesive phase and a recovery phase
bilateral in up to 20% of patients
the episode typically lasts between 6 months and 2 years
associated with DMT2

Question 3

meralgia paraesthetica

Answer 3

burning anterolateral thigh

lateral cutaneous nerve of thigh compression

Question 4

salter harris classification

Answer 4

I Fracture through the physis only (x-ray often normal)
II Fracture through the physis and metaphysis
III Fracture through the physis and epiphyisis to include the joint
IV Fracture involving the physis, metaphysis and epiphysis
V Crush injury involving the physis (x-ray may resemble type I, and appear normal)

Question 5

Kanavel’s signs of flexor tendon sheath infection

Answer 5

fixed flexion, fusiform swelling, tenderness and pain on passive extension

Question 6

frax score for dexa

Answer 6

A FRAX score of 10% or greater warrants a DEXA scan

Question 7

radiculopathies and sciatica

Answer 7

L4 radiculopathy would cause reduced knee jerk, whilst S1 would affect the ankle jerk.

L5 radiculopathy presents with weakness of hip abduction and foot drop, as seen in this patient. It is typically due to a slipped disc compressing the nerve root. It presents with a positive SLR test and as L5 does not provide any reflex loop, reflexes remain intact.

Sciatic neuropathy which is commonly confused with this would cause a loss of the ankle jerk and plantar response and loss of knee flexion and power below the knee

Question 8

acromioclavicular joint management

Answer 8

Grade I and II injuries are very common and are typically managed conservatively including resting the joint using a sling.

Grade IV, V and VI are rare and require surgical intervention.

Question 9

types of shoulder dislocation

Answer 9

Posterior shoulder dislocation is more likely associated with seizures and electric shock. It presents with unilateral shoulder deformity.

Anterior shoulder dislocation is associated with a fall onto an outstretched hand (FOOSH). It presents with unilateral shoulder deformity.

Question 10

Finkelstein test positive

Answer 10

De Quervain’s tenosynovitis as she is Finkelstein test positive ie. she has pain over her radial styloid on forced abduction/flexion of the thumb.

Question 11

mx of #nof

Answer 11

Intracapsular fracture, displaced Independently mobile, does not use more than a stick Total hip replacement

Intracapsular fracture, displaced Not independently mobile Hemiarthroplasty, cemented implants preferred

Trochanteric fracture Mobility not a factor Sliding hip screw

Subtrochanteric fracture Mobility not a factor Intramedullary nail

Question 12

Monteggia fracture and Galeazzi

Answer 12

a fracture of the proximal ulna in association with a dislocation of the proximal head of the radius. It is most commonly seen in children aged between 4 and 10 years.

A Galeazzi (4) fracture is a fracture of the distal radius with an associated dislocation of the distal radioulnar joint.

A method to remember the difference between the two of these is by combining the name of the fracture with the bone that is broken:

Monteggia ulna (Manchester United), Galeazzi radius (Galaxy rangers)

Question 13

herbedens
vs
bouchards

Answer 13

DIPs

PIPs
both seen in OA

Question 14

fat embolism fx

Answer 14

Respiratory
Early persistent tachycardia
Tachypnoea, dyspnoea, hypoxia usually 72 hours following injury
Pyrexia
Dermatological
Red/ brown impalpable petechial rash (usually only in 25-50%)
Subconjunctival and oral haemorrhage/ petechiae
CNS
Confusion and agitation
Retinal haemorrhages and intra-arterial fat globules on fundoscopy

Question 15

red flags for back pain

Answer 15

Thoracic pain
Age <20 or >55 years
Non-mechanical pain
Pain worse when supine
Night pain
Weight loss
Pain associated with systemic illness
Presence of neurological signs
Past medical history of cancer or HIV
Immunosuppression or steroid use
IV drug use
Structural deformity

Question 16

l3 radiculopathy

Answer 16

Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test

Question 17

l4

Answer 17

Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test

Question 18

l5

Answer 18

Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test

Question 19

s1

Answer 19

Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test

Question 20

causes of AVN of hip

Answer 20

long-term steroid use
chemotherapy
alcohol excess
trauma

Question 21

mx of plantar fasciitis

Answer 21

Initially, plantar fasciitis should be managed conservatively with rest and the management of any precipitating factors, including weight loss. Stretching exercises are also recommended as first line therapy in combination with rest. These exercises should be conducted three times per day and are aimed at the plantar fascia and the Achilles tendon.

Orthotics and NSAIDs are appropriate in the management of plantar fasciitis, however should not be called upon before the measures listed in the paragraph above. Additionally, the patient has asthma

Question 22

Femoral nerve

Answer 22

m:Knee extension, thigh flexion
s:Anterior and medial aspect of the thigh and lower leg Hip and pelvic fractures
Stab/gunshot wounds

Question 23

Obturator nerve

Answer 23

Thigh adduction Medial thigh Anterior hip dislocation

Question 24

Lateral cutaneous nerve of the thigh

Answer 24

None Lateral and posterior surfaces of the thigh Compression of the nerve near the ASIS → meralgia paraesthetica, a condition characterised by pain, tingling and numbness in the distribution of the lateral cutaneous nerve

Question 25

Tibial nerve

Answer 25

Foot plantarflexion and inversion Sole of foot Not commonly injured as deep and well protected.
Popliteral lacerations, posterior knee dislocation

Question 26

Common peroneal nerve

Answer 26

Foot dorsiflexion and eversion
Extensor hallucis longus Dorsum of the foot and the lower lateral part of the leg Injury often occurs at the neck of the fibula
Tightly applied lower limb plaster cast

Injury causes foot drop

Question 27

Superior gluteal nerve

Answer 27

Hip abduction None Misplaced intramuscular injection
Hip surgery
Pelvic fracture
Posterior hip dislocation

Injury results in a positive Trendelenburg sign

Question 28

Inferior gluteal nerve

Answer 28

Hip extension and lateral rotation None Generally injured in association with the sciatic nerve

Injury results in difficulty rising from seated position. Can’t jump, can’t climb stairs

Question 29

leriche syndrome

Answer 29

1. Claudication of the buttocks and thighs
2. Atrophy of the musculature of the legs
3. Impotence (due to paralysis of the L1 nerve)

Leriche syndrome, is atherosclerotic occlusive disease involving the abdominal aorta and/or both of the iliac arteries. Management involves correcting underlying risk factors such as hypercholesterolaemia and stopping smoking. Investigation is usually with angiography.

Question 30

charcot joint fx

Answer 30

A Charcot joint is also commonly referred to as a neuropathic joint. It describes a joint which has become badly disrupted and damaged secondary to a loss of sensation. In years gone by they were most commonly caused by neuropathy secondary to syphilis (tabes dorsalis) but are now most commonly seen in diabetics.

Features
Charcot joints are typically a lost less painful than would be expected given the degree of joint disruption due to the sensory neuropathy. However, 75% of patients report some degree of pain
the joint is typically swollen, red and warm

Question 31

weber classification

Answer 31

Related to the level of the fibular fracture.
Type A is below the syndesmosis -CAM boot
Type B fractures start at the level of the tibial plafond and may extend proximally to involve the syndesmosis- cast
Type C is above the syndesmosis which may itself be damaged- surgery

Question 32

mx of ankle fracture

Answer 32

All ankle fractures should be promptly reduced to remove pressure on the overlying skin and subsequent necrosis
Young patients, with unstable, high velocity or proximal injuries will usually require surgical repair. Often using a compression plate.
Elderly patients, even with potentially unstable injuries usually fare better with attempts at conservative management as their thin bone does not hold metalwork well.

Question 33

open fracture mx

Answer 33

1) IV antibiotics
2) Neurovascular status
3) immediate surgery - if vascular impaired
4) urgent surgery - if wound heavily contaminated
5) plastic + ortho team involved
6) debridement
7) cover wound
8) splint leg
9) vacuum foam dressing or antibiotic bead pouch
10) definite skeletal stabilisation

Question 34

most common cause of osteomyelitis in sickle cell

Answer 34

salmonella

Question 35

parsonage turner syndrome

Answer 35

This is a peripheral neuropathy that may complicate viral illnesses and usually resolves spontaneously.

Question 36

anterior shoulder dislocation
nerve
radiolgical sign
fx

Answer 36

axillary nerve (shoulder badge anaesthesia)
hill-sachs defect
External rotation and abduction
35-40% recurrent (it is the commonest disorder)
Associated with greater tuberosity fracture, Bankart lesion, Hill-Sachs defect

Question 37

iliotibial band syndrome

Answer 37

Iliotibial band syndrome is a common cause of lateral knee pain in runners, occurring in around 1 in 10 people who run regularly.

Features
tenderness 2-3cm above the lateral joint line

Management
activity modification and iliotibial band stretches
if not improving then physiotherapy referral

Question 38

Chondromalacia patellae

Answer 38

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 39

Dislocation of the patella

Answer 39

Most commonly occurs as a traumatic primary event, either through direct trauma or through severe contraction of quadriceps with knee stretched in valgus and external rotation
Genu valgum, tibial torsion and high riding patella are risk factors
Skyline x-ray views of patella are required, although displaced patella may be clinically obvious
An osteochondral fracture is present in 5%
The condition has a 20% recurrence rate

Question 40

Thessaly’s test

Answer 40

weight bearing at 20 degrees of knee flexion, patient supported by doctor, postive if pain on twisting knee

Question 41

Menisceal tear

Answer 41

Rotational sporting injuries
Delayed knee swelling
Joint locking (Patient may develop skills to ‘unlock’ the knee
Recurrent episodes of pain and effusions are common, often following minor trauma