Orthopedics

Question 1

What are the different classifications of fractures?

Answer 1

• Closed or Open
• Transverse, oblique, spiral, comminuted, displaced, angulated, impacted rotated, distracted, Intra-articular
• Pathological, stress

Question 2

How do you treat a closed fracture?

Answer 2

Reduction, immobilisation, protect until the fracture has consolidated, rehabilitation of the muscles and joints of the affected limb.

Question 3

What is a Type One Open Fracture?

Answer 3

Type 1: Puncture of overlying skin or mucous membrane by a bony spike from within.

Question 4

What is a Type Two Open Fracture?

Answer 4

Type 2: Lacerations less than 1cm overlying the fracture

Question 5

What is a Type Three Open fracture?

Answer 5

Type 3: Laceration >1cm overlying fracture

Question 6

What is a Type 3a Open fracture?

Answer 6

Type 3a open fracture: raising of the soft tissue flap around the fracture.

Question 7

What is a Type 3b open fracture?

Answer 7

Type 3B: absolute skin loss around a fracture

Question 8

What is a Type 3c fracture?

Answer 8

Deep and highly contaminated wound such as after a farm injury, gun shot injury, and fractures associated with neurovascular injury.

Question 9

What is delayed union? What are its causes?

Answer 9

Delayed union is when a fracture has not united in a period of time that is at least 25% longer than the expected average time for fracture union at that site. Causes of delayed union include inadequate immobilisation, infection, avascular necrosis of the bone, and soft tissue interposition between fracture ends. Delayed union is assessed radiographically.

Question 10

What is non union and what are its causes?

Answer 10

Non union is said to have occurred when there is no evidence of union that can be seen on sequential x-rays over a six month period of time. Non-union is associated clinically with movement or pain at the fracture site. If there is copious amounts of callus formation but without bridging of the fracture a state of hypertrophic non-union is said to exist and requires rigid internal fixation for cure. If there is no evidence of callus formation, then a state of hypotrophic non-union is said to exist and bone grafting and internal fixation is required for treatment.

Question 11

What is malunion?

Answer 11

Malunion occurs when the fracture unites with a loss of anatomical alignment. Mal-union by shortening may be acceptable but angulation and rotation of the bone following union may not be acceptable and may interfere with normal function.

Question 12

What are the typical features of a prolapsed disc?

Answer 12

A prolapsed disc produces clear dermatomal leg pain associated with neural deficits. The leg pain is often worse than the back pain, and the pain is worse upon sitting. Positive straight leg raise. Don’t order imaging as it doesn’t change treatment. Treat with analgesia, physiotherapy, and excercises.

Question 13

What are the presenting features of chondromalacia patellae?

Answer 13

Chondromalacia patellae is a softening of the patella cartilage. It typically occurs in teenage girls. Chondromalacia patellae presents with pain that worsens on walking up and down stairs and upon sitting for long periods of time. Chondromalacia patellae responds well to physiotherapy.

Question 14

What are the presenting features of Osgood-Schlatter disease?

Answer 14

Osgood-Schlatter disease (tibial apophysitis) is seen in sporty teenagers and is caused by overuse.. It presents with pain, tenderness, and swelling in the tibial tubercle. Treat conservatively with activity moderation. Use plain x rays to rule out other causes if other lesions of the proximal tibia if pain is unilateral and/or severe and persistent.

Question 15

What is osteochondritis dissecans?

Answer 15

Osteochondritis dissecans is an acquired potentially reversible idiopathic lesion of subchondral bone resulting in delamination and sequestration with or without articular cartilage involvement and instability. It mainly involves the knee, ankle, and radiocapitellar joint of the elbow. Presents with pain after exercise, intermittent swelling and locking.

Question 16

What are the presenting features of patellar subluxation?

Answer 16

Patellar subluxation presents with medial knee pain due to lateral subluxation of the patella. The knee may give way.

Question 17

What are the red flags for lower back pain?

Answer 17

Red flags for lower back pain
•age < 20 years or > 50 years
•history of previous malignancy
•night pain
•history of trauma
•systemically unwell e.g. weight loss, fever

Question 18

What are the typical features of spinal stenosis?

Answer 18

Usually gradual onset
Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as ‘aching’, ‘crawling’.
Relieved by sitting down, leaning forwards and crouching down
Clinical examination is often normal
Requires MRI to confirm diagnosis

Question 19

What are the typical features of facet joint pain?

Answer 19

May be acute or chronic
Lower back pain worse in the morning and on standing
On examination there may be pain over the facets. The pain is typically worse on extension of the back.

Question 20

What are the typical feature of lateral epicondylitis?

Answer 20

ain and tenderness localised to the lateral epicondyle
•pain worse on wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended
•episodes typically last between 6 months and 2 years. Patients tend to have acute pain for 6-12 weeks

Question 21

What is trigger finger?

Answer 21

Trigger finger is a common condition associated with abnormal flexion of the digits. It is thought to be caused by a disparity between the size of the tendon and pulleys through which they pass. In simple terms the tendon becomes ‘stuck’ and cannot pass smoothly through the pulley. It is more common in women than men, and is associated with diabetes and RA. A nodule may be felt at the base of the finger, associated with difficulting extending a flexed digit. Manage with steroid injections, splint, or surgery,

Question 22

What is talipes equinovarus?

Answer 22

Talipes equinovarus, or club foot, describes an inverted (inward turning) and plantar flexed foot. It is usually diagnosed on the newborn exam. Manage with the Ponseti method.

Question 23

Describe the origin, and ennervations of the ulnar nerve.

Answer 23

•arises from medial cord of brachial plexus (C8, T1)
•sensory to medial 1 1/2 fingers (palmar and dorsal aspects)
- Finger abduction, thumb adduction, wasting of hypothenar eminence and intrinsic lumbricals”
-Can produce ‘claw hand’ - hyperextension of the metacarpophalangeal joints and flexion at the distal and proximal interphalangeal joints of the 4th and 5th digits

Question 24

What is the typical presentation of medial epicondylitis?

Answer 24

• pain and tenderness localised to the medial epicondyle
• pain is aggravated by wrist flexion and pronation
• symptoms may be accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement

Question 25

What is the typical presentation of olecranon bursitis?

Answer 25

Swelling over the posterior aspect of the elbow. There may be associated pain, warmth and erythema. It typically affects middle-aged male patients.

Question 26

What is cubital tunnel syndrome?

Answer 26

Due to the compression of the ulnar nerve.
•initially intermittent tingling in the 4th and 5th finger
•may be worse when the elbow is resting on a firm surface or flexed for extended periods
•later numbness in the 4th and 5th finger with associated weakness

Question 27

What are the symptoms of radial tunnel syndrome?

Answer 27

Most commonly due to compression of the posterior interosseous branch of the radial nerve. It is thought to be a result of overuse.•symptoms are similar to lateral epicondylitis making it difficult to diagnose
•however, the pain tends to be around 4-5 cm distal to the lateral epicondyle
•symptoms may be worsened by extending the elbow and pronating the forearm

Question 28

What are the rotator cuff muscles?

Answer 28

Supraspinatus, Infraspinatus, teres minor, Subscapularis

Question 29

What are the presenting features of supraspinatus tendonitis?

Answer 29

Shoulder pain worse on movement (particularly quick movement), no precipitating injury, pain at night when lying on the shoulder, painful passive abduction between 60-120 degrees (supraspinatus abducts shoulders before deltoids).

Question 30

What is Morton’s neuroma?

Answer 30

Morton’s neuroma is a benign neuroma affecting the intermetatarsal plantar nerve, most commonly in the third inter-metatarsophalangeal space. The female to male ratio is around 4:1. Pain is worse on walking, described as shooting/burning, may feel as though there is a pebble in their shoe, there may be a loss of sensation in the distal toes. Confirm diagnosis with ‘Mulder’s click’ and ultrasound. Avoid high heels, use metatarsal pads, treat with corticosteroid injections or neurectomy of the involved interdigital nerve and neuroma.

Question 31

What are the two divisions of the sciatic nerve?

Answer 31

The sciatic nerve divides into the tibial and common peroneal nerves.

Question 32

What are the features of a common peroneal nerve lesion?

Answer 32

• Foot Drop
• Weakness of foot dorsiflexion
• Weakness over extensor hallicus longus
• sensory loss over the dorsum of the foot and the lower lateral part of the leg
• wasting of the anterior tibial and peroneal muscles.

Question 33

What is the most common organism involved in osteomyelitis?

Answer 33

Staphylococcus aureus is the most commonly involved organism in osteomyelitis. Other organisms include pneumococcus, streptococcus, heamophilus influenza, and gram negative mycobacteria.

Question 34

In chronic osteomyelitis there is the presence of a sequestrum, involucrum, and a cloaca. To what do these terms refer to?

Answer 34

Sequestrum: necrotic bone
Involucrum: new bone that surrounds the sequestrum
Cloaca: communication from the intramedullary abscess through the skin to form a sinus which may discharge pus and necrotic debris.

Question 35

What is rickets?

Answer 35

Rickets is an uncommon condition of the immature skeleton characterised by poor mineralisation of osteoid. It is caused by a dietary lack of calcium and vitamin D or a lack of exposure to sunlight. Associated with malnourishment, or malabsortion syndromes. Presents with joint tenderness, swelling, and deformity. Typically involves the tibia and ribs.

Question 36

What are Looser’s zones?

Answer 36

Looser’s zones are areas of radiological areas of bone loss assocated with osteomalacia.