Orthopedics Flashcards
What is golfers elbow?
Typically aggravated by?
Medial epicondylitis
Typically aggravated by wrist flexion and pronation
Treatment of septic arthritis?
Fluclox
4-6 weeks
Screening tool for osteoporosis?
FRAX
–> if higher than 10% –> DEXA
DEXA diagnosis of Osteoporosis?
If either hip or lumbar spine have a T score of < -2.5 then treatment is recommended.
Osteoporosis bloods?
Normal
Why do we review pts for such a long time / regularly post hip replacements?
retrograde blood supply
What injury gives a positive Finkelstein’s test?
de Quervain’s tenosynovitis
Pain and sometimes swelling at the radial styloid, extending toward the base of the thumb.
De Quervain’s occurs due to inflammation of the
- abductor pollicis longus (APL)
- extensor pollicis brevis (EPB) tendons.
What is osteomalacia?
Osteomalacia is the softening of bones due to a deficiency of Vitamin D. When it occurs in children, it is referred to as rickets.
What is the pathophysiology of osteomalacia?
A deficiency in Vitamin D leads to a decrease in bone mineral density (BMD), resulting in soft bones.
What are the causes of osteomalacia?
Causes include Vitamin D deficiency (due to malabsorption like coeliac disease, poor diet, or poor sunlight exposure)
chronic kidney disease (CKD)
liver disease
drug-induced causes (e.g., anti-epileptics).
What are the clinical features of osteomalacia?
- Clinical features include bony pain, bone/muscle tenderness
- proximal myopathy (symmetrical weakness of arm and upper/lower limb muscles)
- waddling gait
- fractures, especially of the femur
What investigations are done for osteomalacia?
Investigations include blood tests showing a decrease in Vitamin D, calcium, and phosphate levels, and an increase in alkaline phosphatase (ALP). X-rays may show translucent bands in bones.
What is the management of osteomalacia?
The management involves Vitamin D supplementation, typically using a loading dose regimen.
What is Raynaud’s disease?
Raynaud’s disease is excessive vasoconstriction of digital arteries and arterioles due to cold or stress. It is the primary form of Raynaud’s.
What is Raynaud’s phenomenon?
Raynaud’s phenomenon is the secondary form of Raynaud’s, which occurs in association with other conditions such as SLE, rheumatoid arthritis (RA), systemic sclerosis, or use of vibrating tools.
What are the stages of Raynaud’s?
The stages are: 1) Cold exposure → whitening of fingers, 2) Blood vessel reaction → purple/blue fingers, 3) Blood flow restored → erythema.
Who is most likely to present with Raynaud’s?
Raynaud’s typically presents in young women (up to 40 years old) and is usually bilateral.
When should you screen for underlying rheumatic disease in a pt presenting with raynauds?
If Raynaud’s is unilateral, occurs in older patients (40+), or is accompanied by rashes, it is important to screen for underlying rheumatic diseases.
What is the management of Raynaud’s disease?
The management includes calcium channel blockers (CCBs), such as nifedipine.
Referral to a rheumatologist is needed if secondary Raynaud’s is suspected.
What is fibromyalgia?
Fibromyalgia is a syndrome characterized by widespread pain with tenderness at specific points.
What is the pathophysiology of fibromyalgia?
The pathophysiology of fibromyalgia is unknown.
What are the risk factors for fibromyalgia?
Risk factors include being a woman and being between the ages of 30 and 50.
What are the clinical features of fibromyalgia?
The clinical features include chronic pain at multiple, specific tender points (may also be widespread), headaches, cognitive impairment (brain fog), and sleep issues.
What are the differential diagnoses for fibromyalgia?
Differential diagnoses include rheumatoid arthritis (RA), chronic fatigue, lupus, and hypothyroidism.
How is fibromyalgia diagnosed?
Diagnosis is clinical, aiming to rule out other conditions. CRP and ESR are normal, and there is no evidence of neurological disease.
Diagnosis is supported by tenderness in 11+ out of 18 specific points.
What is the management of fibromyalgia?
Management involves explaining and reassuring the patient, aerobic exercise, cognitive behavioral therapy (CBT), and medications for neuropathic pain.
What is osteomyelitis?
Osteomyelitis is an infection of the bone, most commonly occurring in the lower limb or vertebrae.
What are the types of osteomyelitis?
There are two types:
haematogenous (spread from bacteria in the blood, common in children)
non-haematogenous (spread from adjacent infected soft tissue or bone, or direct trauma, common in adults).
What bacteria cause osteomyelitis?
The most common bacteria is Staphylococcus aureus
In sickle cell disease, Salmonella is more common.
What is the investigation of choice for osteomyelitis?
The investigation of choice is MRI, which shows hyperintense bright bone.
What is the management of osteomyelitis?
The management involves flucloxacillin for 6 weeks or clindamycin if the patient is allergic to flucloxacillin.
What is osteoporosis?
Osteoporosis is a disorder characterized by a reduction in bone mineral density (BMD) leading to non-traumatic fractures. Any patient suffering a fragility fracture should be assessed for osteoporosis.
What is the pathophysiology of osteoporosis?
Osteoporosis involves increased bone loss without bone growth.
What are the T score classifications of bone density?
- Osteopenia: T score -1 to -2.5
- Osteoporosisis > 2.5
- Osteoporosis: T score < -2.5
What are the risk factors for osteoporosis?
- Post-menopausal women
- Drugs: steroids, PPIs, SSRIs
- Alcohol, smoking
- Low BMI
- Family history
- RA, CKD, hyperthyroid
- Testosterone deficiency in men
What are the clinical features of osteoporosis?
- Pathological fractures (fragility fractures):
- Vertebral fractures: Sudden back pain on rest/bending
- NOF (neck of femur): Hip pain, inability to bear weight, short, externally rotated leg
- Distal radial (Colles): Wrist pain from FOOSH (fall on outstretched hand)
What are the differential diagnoses for osteoporosis?
- Paget’s disease: Older male with bone pain, ↑ ALP (treated with bisphosphonates)
- Osteomalacia: Bone pain, muscle tenderness, proximal muscle weakness, ALP ↑, ↓ Ca and phosphate (treated with vitamin D)
- Multiple myeloma: Hypercalcaemia, renal failure, and pathological fractures in older patients (especially low back)
What are the investigations for osteoporosis?
- Bloods: LFTs, Bone profile (normal ALP, calcium, phosphate, PTH)
- U&E, TFTs, Testosterone (to rule out secondary osteoporosis)
- DEXA scan: Measures bone mineral density (BMD), provides a T score (< -2.5 for osteoporosis) and Z score (adjusted to age, gender, ethnicity)
- FRAX score: Calculates the probability of a pathological fracture in the next 10 years
How is osteoporosis managed?
Bispohosphonates
- Patients on long-term steroids: Consider anticipatory bone protection
- Post-menopausal women or men >50: If starting corticosteroids >7.5mg/day for 3+ months, begin treatment (no need for scan)
- Women 65+, Men 75+: QFracture or FRAX score, DEXA scan if appropriate
- After hip fragility fracture: >75yo or postmenopausal women (even <75yo) with vertebral fractures should receive treatment without a scan; others need a DEXA scan
What lifestyle modifications are recommended for osteoporosis?
- Regular exercise
- Ensure adequate vitamin D and calcium intake (correct deficiencies before starting bisphosphonates)
- Stop smoking and alcohol
What pharmacological treatments are used for osteoporosis?
- 1st line: Alendronic acid
- 2nd line: If GI issues, use other bisphosphonates like risedronate or etidronate
- 3rd line: If bisphosphonates are not tolerated, use strontium ranelate, raloxifene, or denosumab (with strict criteria)
What should be done after 5 years of treatment for osteoporosis?
Reassess the patient’s risk for osteoporosis after 5 years.
What is the definition of lower back pain?
Pain in the lumbosacral lower back region.
lower back pain DD?
Mechanical back pain
Sciatica
Cauda Equina Syndrome, Malignancy-related pain
Spinal fracture
Spinal stenosis
Spinal infection
Ankylosing spondylitis.
What are the features of mechanical back pain?
Non-specific lower back pain exacerbated by movement, without signs of infection, inflammation, or malignancy.
What is the typical presentation of sciatica?
Back pain radiating unilaterally down the leg in a dermatomal pattern, often worse when sitting.
What is radiculopathy?
Weakness, sensory loss, and reflex loss due to significant nerve impingement.
What are the red flag symptoms in back pain?
Thoracic back pain, night pain, history of malignancy, systemic symptoms (weight loss, fever, night sweats), age <20 or >50, trauma, cauda equina features.
What are the features of spinal stenosis?
Pain, numbness, and weakness worse on walking, relieved by leaning forward or walking uphill.
there is always a postural element
What are the features of spinal infection?
Associated systemic upset, including fever.
What are the features of malignancy-related back pain?
Pain worse at night, waking from sleep, and associated constitutional symptoms.
What are the features of cauda equina syndrome?
Bilateral leg pain, saddle anaesthesia, urinary retention, bowel dysfunction, reduced anal tone.
What are the key investigations for back pain?
MRI if symptoms persist or red flags are present. Sciatic nerve stretch tests (Lasegue’s test, femoral stretch test) for nerve root involvement.
What are the nerve roots affected in radiculopathy and their features?
L3: Anterior thigh sensory loss, weak hip flexion/knee extension, ↓ knee reflex.
L4: Anterior knee + medial malleolus sensory loss, weak knee extension, ↓ knee reflex.
L5: Foot dorsum sensory loss, weak hip abduction/foot dorsiflexion (foot drop), reflex intact.
S1: Posterolateral leg + lateral foot sensory loss, weak plantar flexion, ↓ ankle reflex.
What is the first-line management for lower back pain?
Exercise and physiotherapy.
What is the first-line pharmacological management for lower back pain?
NSAIDs (+ PPI if >45 years old).
What additional treatment is used for radiculopathy?
Neuropathic pain medications (amitriptyline, duloxetine, pregabalin, gabapentin).
What is cauda equina syndrome?
Compression of lumbosacral nerve roots of the cauda equina.
What is the most common cause of cauda equina syndrome?
Prolapsed intervertebral disc (often L4/L5 or L5/S1).
What are other possible causes of cauda equina syndrome?
Malignancy, infection, trauma.
What is the classic presenting symptom of cauda equina syndrome?
Bilateral sciatica (lower back pain radiating down both legs).
What sensory symptoms are seen in cauda equina syndrome?
Reduced/abnormal sensation in the perianal/genital region (saddle anaesthesia).
What urinary symptoms occur in cauda equina syndrome?
Urinary retention (most common) or incontinence.
What bowel symptom is seen in cauda equina syndrome?
Faecal incontinence.
What clinical sign is found on rectal examination in cauda equina syndrome?
Reduced anal tone.
What is the key investigation for suspected cauda equina syndrome?
Urgent MRI spine.
What other examination is essential in suspected cauda equina syndrome?
Digital rectal examination (DRE).
What is the management of cauda equina syndrome?
Urgent surgical decompression.
What is spinal stenosis?
Narrowing of the central spinal canal, usually lumbar, due to tumour, disc prolapse, or degenerative changes.
How does spinal stenosis typically present?
Back pain, often with radiation down the legs, worsened by standing and relieved by sitting, leaning forward, or walking uphill. May have neuropathic pain (burning/shooting).
What is the first-line investigation for spinal stenosis?
MRI.
What is the management of spinal stenosis?
Laminectomy.
What is Frozen Shoulder?
Adhesive Capsulitis, characterized by a global reduction in shoulder movement through a painful phase, followed by a stiff/frozen phase and gradual recovery.
What are the risk factors for Frozen Shoulder?
Diabetes (DM), middle-aged females.
What are the features of Frozen Shoulder?
Restricted ROM (both passively and actively), with external rotation being most affected, followed by internal rotation and abduction. Starts with pain, followed by stiffness.
How is Frozen Shoulder diagnosed?
Clinical diagnosis.
What is the management for Frozen Shoulder?
NSAIDs and physiotherapy.
What is a Rotator Cuff Injury?
Injury to one of the rotator cuff muscles (supraspinatus, infraspinatus, teres minor, subscapularis). Includes subacromial impingement syndrome, muscle tears/strains, and ACJ injury.
What is the most common type of Rotator Cuff Injury?
Subacromial impingement syndrome, where muscle tendons are impinged causing pain.
What are the key features of Rotator Cuff Injury?
Tenderness over the acromion, weakness on muscle testing (indicating a tear), pain on shoulder abduction (low arc pain 60-120 degrees), and pain on abduction (in impingement).
What is the management for Rotator Cuff Injury?
Referral, NSAIDs, and possibly steroid injection depending on the injury.
What is the most common type of shoulder dislocation?
Anterior dislocation (95%).
What causes posterior shoulder dislocation?
Posterior dislocations are commonly caused by seizures.
How is shoulder dislocation treated?
Reduction of the shoulder with or without analgesia.
What is Olecranon Bursitis?
Swelling over the posterior elbow with erythema/warmth, potentially associated with inflammatory conditions (e.g., RA).
What are the clinical features of Medial Epicondylitis?
Pain and tenderness over the medial epicondyle, with pain on resisted wrist flexion and pronation.
What is Medial Epicondylitis commonly known as?
Golfer’s elbow.
What are the clinical features of Lateral Epicondylitis?
Pain and tenderness over the lateral epicondyle, with pain on resisted wrist extension and supination.
What is Lateral Epicondylitis commonly known as?
Tennis elbow.
What is the management for Epicondylitis?
Rest (avoid the activity causing pain), analgesia, and physiotherapy.
What is Carpal Tunnel Syndrome?
Compression of the median nerve at the wrist, often caused by RA, idiopathic reasons, or lunate fracture.
What are the features of Carpal Tunnel Syndrome?
Pain and pins and needles in the first 3 fingers (thumb, index, and middle), often worse at night; relief by shaking the hand.
What signs are associated with Carpal Tunnel Syndrome on examination?
- Weakness of thumb abduction/opposition
- Thenar eminence wasting
- Tinnel’s sign (tapping wrist → paraesthesia)
- Phalen’s sign (pain/paraesthesia on wrist flexion).
How is Carpal Tunnel Syndrome diagnosed?
Diagnosis is confirmed with EMG showing prolongation.
What is the initial management for Carpal Tunnel Syndrome?
Conservative management for 6 weeks: steroid injections and wrist splints.
What is the surgical management for Carpal Tunnel Syndrome?
Surgical decompression of the flexor retinaculum.
What is Cubital Tunnel Syndrome?
Compression of the ulnar nerve, often caused by OA or trauma.
What are the features of Cubital Tunnel Syndrome?
Pain and paraesthesia in the 4th and 5th fingers, worsened by elbow leaning.
What signs are associated with Cubital Tunnel Syndrome on examination?
Weakness of little finger abduction, Froment’s sign (thumb flexion when holding paper).
What is the management for Cubital Tunnel Syndrome?
Similar to Carpal Tunnel Syndrome: conservative management with rest, analgesia, and potentially surgery.
What is De Quervain’s Tenosynovitis?
Inflammation of the tendon sheath holding the thumb muscles.
What are the features of De Quervain’s Tenosynovitis?
Pain over the radial wrist, tenderness of the radial styloid process, and painful resisted thumb abduction.
What is the management for De Quervain’s Tenosynovitis?
Similar to Carpal Tunnel and Cubital Tunnel Syndrome: conservative management with rest, analgesia, and possibly surgery.
What are the basic principles of fracture management (4Rs)?
- Resuscitation and Initial Care: Analgesia and assessment (including NV status), XR, MRI/CT if occult.
- Reduction: Urgent reduction of displaced fractures if neurovascular status is compromised.
- Restriction: Immobilisation using a sling, cast, splint, or fixation.
- Rehabilitation: Post-fracture rehab to restore function.
How should open fractures be managed?
- IV Antibiotics: Administer as soon as possible.
- Tetanus Prophylaxis: Administer if necessary.
- Debridement & Lavage: Perform urgently in theatre to clean the wound.
- External Fixation: Always use external fixation to avoid infection risk associated with internal fixation.
What are the characteristics and management of a Colles’ Fracture?
Description: Transverse distal radial fracture with dorsal displacement (caused by FOOSH).
Complication: Median nerve injury.
Management: Closed reduction or ORIF if unstable.
What are the characteristics and management of a Smith Fracture?
Description: Distal radial fracture with volar displacement (typically caused by falling on a flexed wrist).
Management: ORIF if unstable.
Which metatarsal is most commonly fractured and how should it be managed?
Most common: 5th metatarsal, often after foot inversion.
Management: Immobilisation.
How do stress fractures of the metatarsal present, and which metatarsal is most commonly affected?
Presentation: Pain and tenderness, often without trauma.
Most commonly affected: 2nd metatarsal shaft.
What are common causes of pathological fractures?
Metastasis (breast, lung, thyroid, renal, prostate)
Bone diseases (osteoporosis, Paget’s)
Primary bone tumours:
- Osteosarcoma: Sun-burst pattern.
- Ewing’s Sarcoma: Onion skin pattern.
What are the types of humerus fractures and their complications?
Neck Fracture: Risk of axillary nerve injury.
Midshaft Fracture: Risk of radial nerve injury.
What is a tibial plateau fracture and its management?
Cause: High-energy trauma, often seen in elderly patients.
Management: ORIF (Open Reduction and Internal Fixation).
What is a Bennett’s fracture and its common cause?
Description: Fracture at the base of the thumb metacarpal.
Common cause: Fist fights.
What is a Monteggia’s fracture and its management?
Description: Proximal ulnar fracture with radial head dislocation.
Management: Surgical ORIF.
What is a Galeazzi fracture and how is it managed?
Description: Distal radial shaft fracture with distal radioulnar joint dislocation (prominent ulnar head dislocation).
Management: Surgical ORIF.
What is a Barton’s fracture?
Description: Distal radial fracture (Colles or Smith type) with associated radiocarpal dislocation.
What is a radial head fracture and how should it be managed?
Cause: Common in young adults, usually from a FOOSH injury.
Management: Displaced fractures require ORIF; undisplaced fractures can be immobilised.
What is a Pott’s fracture and its cause?
Description: Bimalleolar fracture, typically caused by foot eversion.
What is the definition of a hip fracture?
Most commonly seen in older osteoporotic women.
What are the classifications of Garden’s Hip Fracture?
- I - Undisplaced, and not complete
- II - Undisplaced but complete
- III - Complete, with partial displacement
- IV - Complete with full displacement
What are the clinical features of a hip fracture?
PC:
-Pain
-Shortened and externally rotated leg
How is a hip fracture diagnosed?
Ix:
-XR Pelvis
-If Occult - MRI
What is the management for an intracapsular undisplaced hip fracture?
Undisplaced: Internal fixation (if very unfit, consider hemiarthroplasty)
What is the management for a displaced intracapsular hip fracture?
- If fit & well, and able to mobilise → THR (Total Hip Replacement)
- Else → Hemiarthroplasty
What is the management for an extracapsular hip fracture?
- Intertrochanteric → DHS (Dynamic Hip Screw)
- Subtrochanteric → IM (Intermedullary Device)
What is the Garden classification for a displaced, complete, and fully displaced hip fracture?
IV - Complete with full displacement
What type of surgical fixation is used for subtrochanteric fractures?
IM (Intermedullary Device)
What is the definition of a scaphoid fracture?
A scaphoid fracture is a fracture of the small scaphoid carpal in the hand, often occurring after a fall on an outstretched hand (FOOSH).
What is a potential complication of a scaphoid fracture?
The fracture may compromise the radial artery, leading to avascular necrosis of the scaphoid.
What are the clinical features (PC) of a scaphoid fracture?
Pain around the radial wrist and base of the thumb, pain on ulnar deviation, and wrist effusion.
What are the physical examination findings (O/E) for a scaphoid fracture?
Pain in the anatomical snuff box and pain on longitudinal compression of the thumb.
What is the diagnostic test of choice for scaphoid fractures?
An X-ray is commonly used, although it may be inconclusive in the acute phase. MRI is the best option but is rarely used in the UK.
What should be done if a scaphoid fracture is suspected but not confirmed on X-ray?
A futuro splint should be applied, and the patient should be reviewed in 7-10 days for repeat X-rays and orthopaedic review.
What is the management for a confirmed scaphoid fracture?
- Undisplaced fracture: Cast for 6-8 weeks.
- Displaced or proximal pole fracture: Surgical fixation.
What is the definition of compartment syndrome?
A post-fracture complication where blood pools inside a closed anatomical space, increasing pressure and leading to neurovascular compression and necrosis, commonly in the anterior compartment.
What is the pathophysiology of compartment syndrome?
Increased pressure leads to compression of blood vessels, resulting in ischemia and eventual tissue necrosis.
What are the risk factors for compartment syndrome?
Supracondylar humeral fractures, tibial shaft fractures.
What are the clinical features of compartment syndrome?
PC: Pain, especially on movement (even passive movement), parasthesia (numbness, pins and needles), pallor, paralysis.
What are the physical examination findings for compartment syndrome?
May include absence of pulse in the affected limb.
What is the diagnostic test for compartment syndrome?
Intracompartmental pressure > 40 mmHg (anything over 20 mmHg is abnormal).
What is the management for compartment syndrome?
Urgent fasciotomy and IV fluids.
What is the difference between RA and OA pain?
RA → pain/stiffness worse in the morning, improves with use, inflammatory markers ↑.
OA → pain/stiffness worse with exercise, improves with rest, age/obesity/previous injury seen.
What is referred lumbar pain and how is it tested?
Referred lumbar pain is pain radiating from the lumbar spine. Sciatic/femoral stretch test is positive.
What are the signs of a hip fracture?
Hip fracture → shortened and externally rotated leg, unable to weight bear.
What is the most common type of hip dislocation?
Posterior hip dislocation (90%): leg is shortened, internally rotated, and adducted.
Anterior dislocation: leg is abducted, externally rotated, and not shortened.
How is hip dislocation treated?
Reduction under GA within 4 hours.
What complications can arise from a hip dislocation?
Sciatic nerve injury → foot drop and loss of dorsal foot sensation.
Femoral nerve injury → loss of anteromedial thigh sensation.
Other complications: avascular necrosis, OA, recurrent dislocations.
What is Greater Trochanteric Pain Syndrome?
Trochanteric bursitis caused by repeated movement of the ITB, leading to inflammation.
Common in older women. Symptoms include pain on the lateral hip/thigh and tenderness over the greater trochanter.
What is avascular necrosis?
Avascular necrosis is ischemic bone tissue death.
Caused by traumatic events (e.g., hip dislocation, hip fracture), steroid use, chemotherapy, or alcohol excess.
Symptoms include pain around the hip.
How is avascular necrosis diagnosed?
XR: initially normal, later shows flattening of the femoral head and subchondral crescent sign. MRI is first-line imaging.
How is avascular necrosis treated?
Treatment includes Hemiarthroplasty or Total Hip Replacement (THR).
What is Meralgia Paraesthetica?
Meralgia Paraesthetica is caused by compression of the lateral cutaneous nerve.
It presents as pain and burning/tingling over the upper lateral thigh, worse on standing.
What is the first-line imaging for knee injuries?
MRI is first-line for knee injuries.
What is the triad of injuries in the knee?
The triad often includes ACL tear, MCL tear, and meniscal tear.
How is ACL injury typically caused?
ACL injuries are often caused by non-contact twisting/landing injuries, lateral blows to the knee, or skiing.
What are the key features of an ACL injury?
Sudden pop/crack, instant knee swelling, knee instability (feeling like the knee “gives way”), and pain.
What tests are used to assess ACL injury?
The anterior draw test or Lachman’s test are used to assess for ACL injuries.
How is a meniscal tear caused?
A meniscal tear is typically caused by a twisting knee injury.
What are the features of a meniscal tear?
Symptoms include knee locking, knee instability (feeling like the knee “gives way”), and pain, particularly during knee extension.
What physical examination finding is suggestive of meniscal tear?
Joint line tenderness is a key physical exam finding for a meniscal tear.
How is MCL injury caused?
An MCL injury is caused by a valgus (inward) stress on the knee, resulting in abnormal passive abduction.
How is PCL injury caused?
PCL injury often results from a dashboard injury. It is diagnosed with posterior sag and posterior draw test.
What bones make up the ankle joint?
The ankle joint is composed of the distal tibia and fibula, which articulate with the talus bone.
What is the syndesmosis in the ankle?
The syndesmosis in the ankle includes ligaments such as the anterior inferior tibiofibular ligament (AITFL).
What is a low-ankle injury, and how is it managed?
A low-ankle injury (90% of cases) involves AITFL injury, usually caused by inversion, with pain and swelling. Management: Rest + removable boot.
What is a high-ankle injury, and how is it managed?
A high-ankle injury is caused by external rotation and presents with painful weight-bearing.
Management: Rest + removable boot if no separation, surgical fixation if tibia/fibula are separated.
When should an X-ray be ordered for an ankle injury?
An X-ray should be ordered for suspected fractures if there is pain in the malleolar area and any of the following: tenderness over medial/lateral malleolus or inability to walk 4 weight-bearing steps.
What medication is common risk factors for Achilles tendon problems?
Quinolone use (e.g., ciprofloxacin) is a significant risk factor for Achilles tendon problems.
What are the features of Achilles tendinopathy?
Achilles tendinopathy presents as posterior heel pain and stiffness, especially worse following activity.
How is Achilles tendinopathy treated?
Treatment for Achilles tendinopathy includes NSAIDs, rest, and physiotherapy.
What are the features of an Achilles tendon rupture?
Features of a ruptured Achilles tendon include a pop heard in the ankle, severe calf pain, inability to weight bear, and a positive Simmonds test.
What is the Simmonds test, and what does a positive result indicate?
The Simmonds test involves squeezing the calf, and a positive result indicates inability to move the foot due to Achilles tendon rupture.
How is an Achilles tendon rupture diagnosed?
An ultrasound (USS) is used to diagnose an Achilles tendon rupture.
How is an Achilles tendon rupture treated?
Treatment for Achilles tendon rupture typically involves surgical fixation.
which metatarsal is most likely to stess fracture?
2
acronym for remembering the salter harris classification?
SALTR
I: Slipped (either side of the growth plate slipping past each other)
II: Above growth plate
III: Lower than growth plate
IV: Through (fracture through both above and below the growth plate)
V: Rammed (a crush injury)
imaging for achilles tendon rupture?
Calf US
Sensory loss to
-Thigh
-Knee/Medial leg
-Dorsum of foot
-Lateral foot
Are which nerve roots?
Thigh → L3
Knee/Medial leg → L4
Dorsum of foot → L5
Lateral foot → S1
Weak movement at this joint is which nerve root?
Knee extension
Dorsiflexion (foot drop)
Plantarflexion (pushing off ground)
Knee extension → L3, L4
Dorsiflexion (foot drop) → L5
Plantarflexion (pushing off ground) → S1
✅ Knee jerk gone? Think
✅ Foot drop? Think
✅ Lost ankle reflex?
✅ Sciatica-type pain?
✅ Knee jerk gone? Think L3/L4
✅ Foot drop? Think L5
✅ Lost ankle reflex? Think S1
✅ Sciatica-type pain? L5/S1 likely
If lower limb reflexes are intact which nerve root is question reffering too?
L5
Who should you not prescribe Sulfasalazine too?
-G6PD deficiency
-allergy to aspirin or sulphonamides (cross-sensitivity)
How do you test for anti-phospholipid syndrome?
one of the following x2 positive tests 12 weeks apart
1️⃣ Lupus Anticoagulant (LA) – Prolonged clotting tests (e.g., prolonged APTT, not corrected by mixing studies)
2️⃣ Anti-Cardiolipin Antibodies (aCL) – IgG or IgM (moderate-high titres)
3️⃣ Anti-Beta-2 Glycoprotein I Antibodies – IgG or IgM
Question where you think it might be Felty’s syndrome but normal white cell?
are they on immunosuppression
In stem of q - swollen, red and crepitus
What is the crepitus indicating?
gas gangrene - likely due clostridial myonecrosis
Deep vs common peroneal nerve?
where the lack of sensation is
Deep - sensation to the first web space of the foot
Common dorsum of the foot
Pain on the radial side of the wrist/tenderness over the radial styloid process ?
De Quervain’s tenosynovitis
Colles’ fracture is?
Dorsally Displaced Distal radius → Dinner fork Deformity
Who can you start on bisphosponates without a DEXA?
A postmenopausal woman, or a man age ≥50 has a symptomatic osteoporotic vertebral fracture
If starting someone on allopurinol what might you consider prescribing aswell?
NSAIDs or Colchine
is Hyperuricemia a RF for psuedogout?
NO this is a trick question
pseudogout is though
key features of psoas abscess?
✅ Triad: Fever + Back Pain + Psoas Sign (pain with hip extension)
✅ Pain radiating to thigh/groin, relieved by hip flexion & external rotation
✅ Common risk factors: IV drug use, endocarditis, recent infection (e.g., skin, UTI)
✅ Tenderness over L1-L3 (psoas muscle origin)
✅ Systemic signs: Fever, tachycardia
Think psoas abscess in what pt?
any febrile patient with back pain & hip pain relieved by flexion!
Which complement levels are usually low during active SLE disease
(C3, C4)
Which structures are affected in De Quervain’s Tenosynovitis?
Inflammation of the tendon sheaths of:
📌 Abductor Pollicis Longus (APL)
📌 Extensor Pollicis Brevis (EPB)
how to differentiate between osteoporosis and osteomalacia?
porosis - normal cells and mineralisation (less density)
malacia - lack of mineralization
osteoarthrtis is uni or bilateral?
unilateral
-reduced rom
-crepitus
-functional adl
PC knee OA?
worse on inclined walking
joint line tendrness
fixed flexed deformity
shoulder OA PC?
acromioclavicular - pain on joitn line
reduced rom
difference form frozen shoulder - oa seen on xr
hip OA PC?
more common in women with DDH
is physio first line for people with OA?
no
weigt loss and exercise
medial vs lateral epicondylitis
medial - golfer - men
-wrist flexion and pronation
-men flex and promote
lateral - tennis - ladies
-wrist extension and supination
women support and extend
bilateral dr quervains tenosynovitis ?
new born parents repetitively lifting babies
damage to axillary nerve causes?
flattened deltoid
damage to MSK nerve causes?
this is rare in isolation
damage to radial nerve causes
wrist drop
damage to long thoracic nerve causes?
winged scapula
damage to ulnar nerve causes
cupital tunnel
and claw hand
older man with back pain remember to consider
myeloma
young male smoker with cramping pain?
buergers
how long after should you prescribe allopurinol after a gout attack?
2 weeks
What might stop a fracture healing?
meds - steroids
smoking
diabetes
infection
impact of age on herniation vs stenosis?
Disc herniations more common in pts under 50
Spinal stenosis more common in pts over 60
leg shortened, internally rotated, slightly flexed and adducted
Posterior hip dislocation
leg abducted and externally rotated. No shortening.
Anterior hip dislocation
osteoporosis in a man?
check testosterone
