Orthopedics Flashcards
A 30 year old man presents with severe pain in the left hip it has been present on and off for many years. He was born at 39 weeks gestation by emergency caesarean section after a long obstructed breech delivery. He was slow to walk and as a child was noted to have an antalgic gait. He was a frequent attender at the primary care centre and the pains dismissed as growing pains. X-rays show almost complete destruction of the femoral head and a narrow acetabulum. What is the most likely underlying disease process?
Developmental dysplasia of the hip Slipped upper femoral epiphysis Extra capsular fracture of the femoral neck Rheumatoid arthritis Perthes disease
Developmental dysplasia of the hip. Usually diagnosed by Barlow and Ortolani tests in early childhood. Most Breech deliveries are also routinely subjected to USS of the hip joint. At this young age an arthrodesis may be preferable to hip replacement.
An 80 year old woman has a hip fracture. Her calcium is normal. She has never been given a diagnosis of osteoporosis. Apart from treating the hip fracture what additional intervention should be considered?
Vitamin D and calcium supplements alone Vitamin D, calcium supplements and bisphosphonates Vitamin D alone Calcium supplements alone DEXA scan
Vitamin D, calcium supplements and bisphosphonates
The osteoporosis guidelines state if a postmenopausal woman has a fracture she should be put on bisphosphonates (there is no need for a DEXA scan).
A 50 year old female slips on wet floor injuring her ankle. On examination, she has tenderness over the lateral and medial malleolus. X-rays (stress views) demonstrate an undisplaced fracture of the distal fibula at the level of the syndesmosis and a congruent ankle mortise. What is the most appropriate management?
Application of full leg cast Surgical fixation Application of below knee plaster cast Application of external fixator Bed rest, splinting and traction
This is a Weber B fracture and therefore potentially unstable. Medial malleolar tenderness indicates deltoid ligament injury. As the fracture is currently undisplaced and the ankle mortice is congruent, the injury can be initially managed conservatively in a below knee plaster but the patient should be monitored in the outpatient clinic for fracture displacement in the first few weeks.
A 78 year old man complains of a long history of shoulder pain and more recently weakness. On examination, active attempts at abduction are impaired. Passive movements are normal. What is the most likely diagnosis?
Rotator cuff tear Osteoarthritis Metastatic malignancy Adhesive capsulitis Calcific tendonitis
Rotator cuff tears are common in elderly people and may occur following minor trauma or as a result of long standing impingement. Tears greater than 2cm should generally be repaired surgically. The length of the history in this scenario is suggestive of a tear complicating impingement.
A toddler aged 3 years presents to the Emergency Department with swelling of his leg and is found to have a spiral fracture of the tibia. His mother reports that he had tripped and fallen the previous day but she had not noticed any sign of injury at the time. She is a single parent with little family support. The child is not on the child protection register. What is the most likely underlying problem?
Metabolic bone disease of prematurity Non accidental injury Hypophosphataemic rickets Osteogenesis imperfecta Rickets
Non accidental injury
Delayed presentation is unusual and should raise concern. In addition, spiral fractures are usually the result of rotational injury which is not compatible with the mechanism proposed by the parent.
A 24 year old man sustains a distal radius fracture during a game of rugby. Imaging shows a comminuted fracture with involvement of the articular surface. What is the most appropriate definitive management?
Open reduction and internal fixation Reduction under anaesthesia and place in plaster cast Reduction under haematoma block and place into plaster cast Place onto skeletal traction system Apply a futura splint and review in fracture clinic
Open reduction and internal fixation
Meticulous anatomical alignment of the fracture segments is crucial to avoid the development of osteoarthritis and risk of malunion.
A 15 year old boy is brought to the clinic by his mother who is concerned that he has a mark overlying his lower spine. On examination, the boy has a patch of hair overlying his lower lumbar spine and a birth mark at the same location. Lower limb neurological examination is normal. What is the most likely cause?
Spina bifida occulta Meningomyelocele Spondylolisthesis Scheuermanns disease Myelocele
Spina bifida occulta is a common condition and may affect up to 10% of the population. The more severe types of spina bifida have more characteristic skin changes. Occasionally the unwary surgeon is persuaded to operate on these cutaneous changes and we would advocate performing an MRI scan prior to any such surgical procedure in this region.
An 82 year old female presents to the emergency room after tripping on a step. She complains of shoulder pain. On examination there is pain on initiating shoulder abduction. What is the most likely diagnosis?
Glenohumeral dislocation Fracture of the anatomical neck of the humerus Sternoclavicular dislocation Supraspinatus tear Infraspinatus tear
A supraspinatus tear is the most common of rotator cuff tears. It occurs as a result of degeneration and is rare in younger adults.
A 35 year old mechanic is hit by a fork lift truck. He sustains a Gustilo and Anderson type IIIA fracture of the shaft of the left femur. What is the most appropriate course of action?
Amputation Debridement and external fixation Open reduction and fixation Debridement and placement of intramedullary nail Debridement and placement of long leg plaster cast
As there is no associated vascular injury the patient may be suitable for debridement of the area and external fixation. If debridement leaves a tissue defect then plastic surgical repair will be needed at a later stage. With open fractures, its best not to place intramedullary metalwork as this may become infected
A 42 year old skier falls and impacts his hand on his ski pole. On examination, he is tender in the anatomical snuffbox and on bimanual palpation. X-rays with scaphoid views show no evidence of fracture. What is the most appropriate course of action?
Admission and surgical debridement Application of tubigrip bandage and fracture clinic review Application of futura splint and fracture clinic review Admission for open reduction and fixation Discharge with reassurance
Application of futura splint and fracture clinic review
A fracture may still be present and should be immobilised until repeat imaging can be performed. If clinical suspicion persists then subsequent imaging should be with MRI scanning or CT if MRI is contra-indicated.
A 30 year old man injures his ankle playing football. On examination, he has tenderness over both medial and lateral malleoli. X-ray demonstrates a bimalleolar fracture with a displaced distal fibula fracture, at the level of the syndesmosis and fracture of the medial malleolus with talar shift. The ankle has been provisionally reduced and splinted in the emergency department. What is the most appropriate management?
Application of external fixation device Application of compression dressing and physiotherapy Application of ankle boot Surgical fixation Below knee amputation
This is an unstable fracture pattern with a Weber B fracture of the distal fibula and a fracture of the medial malleolus. Talar shift indicates loss of ankle mortice congruity. This injury should therefore be treated with surgical fixation.
A 74 year old male is admitted to the Emergency Department with a fall. He is known to have rheumatoid arthritis and is on methotrexate and paracetamol. He lives alone in a bungalow and enjoys playing golf. He is independent with his ADLs. He complains of left groin pain, therefore has a hip x-ray which confirms a displaced intracapsular fracture. What is the best course of action?
Cemented hemiarthroplasty Uncemented hemiarthroplasty Total hip replacement Dynamic hip screw Intramedullary nail
This patient has pre-existing joint disease, good level of activity and a relatively high life expectancy, therefore THR is preferable to hemiarthroplasty.
An obese 12 year old boy is referred with pain in the left knee and hip. On examination, he has an antaglic gait and limitation of internal rotation. His knee has normal range of passive and active movement. What is the most likely diagnosis?
Septic arthritis Developmental dysplasia of the hip Perthes disease Osteoarthritis of the hip Slipped upper femoral epiphysis
Slipped upper femoral epiphysis is commonest in obese adolescent males. The x-ray will show displacement of the femoral epiphysis inferolaterally. Treatment is usually with rest and non weight bearing crutches.
A 5 month baby boy presents with swelling of his right arm and is found to have a spiral fracture of the humerus. He had been in the care of his mother’s boyfriend who reported that he had nearly dropped him that day when reaching for his bottle and had inadvertently pulled on his arm to save him. He was immediately taken to the Emergency Department. What is the most likely issue?
Non accidental injury Accidental fracture Malignant bone disease Osteoporosis Osteogenesis imperfecta
Accidental fracture
The mechanism fits with the fracture pattern and the presentation is not delayed
A 26 year old man presents to the emergency department with a swelling over his left elbow after a fall on an outstretched hand. On examination, he has tenderness over the proximal part of his forearm, and has severely restricted supination and pronation movements. What is the most likely injury?
Fracture of the olecranon Fracture of the radial head Galeazzi fracture Fracture of the shaft of the radius and ulnar Fracture of the coronoid process
Fracture of the radial head is common in young adults. It is usually caused by a fall on the outstretched hand. On examination, there is marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination).
A 19 year old sportswoman presents with knee pain which is worse on walking down the stairs and when sitting still. On examination, there is wasting of the quadriceps and pseudolocking of the knee. What is the diagnosis?
Osteoarthritis Quadriceps tendon rupture Undisplaced fracture patella Chondromalacia patellae Osgood Schlatters disease
A teenage girl with knee pain on walking down the stairs is characteristic for chondromalacia patellae (anterior knee pain). Most cases are managed with physiotherapy.
A 58 year old man presents to the plastics team with severe burns to his hands. He is not distressed by the burns. He has bilateral charcot joints. On examination; there is loss of pain and temperature sensation of the upper limbs. What is the most likely diagnosis?
Potts disease of the spine Tabes dorsalis Transverse myelitis Syringomyelia Subacute degeneration of the cord
This patient has syringomyelia which selectively affects the spinotholamic tracts. Syringomyelia is a disorder in which a cystic cavity forms within the spinal cord. The commonest variant is the Arnold- Chiari malformation in which the cavity connects with a congenital malformation affecting the cerebellum. Acquired forms of the condition may occur as a result of previous meningitis, surgery or tumours. Many neurological manifestations have been reported, although the classical variety spares the dorsal columns and medial lemniscus and affecting only the spinothalamic tract with loss of pain and temperature sensation. The bilateral distribution of this patients symptoms would therefore favor syringomyelia over SCID or Brown Sequard syndrome. Osteomyelitis would tend to present with back pain and fever in addition to any neurological signs. Epidural haematoma large enough to produce neurological impairment will usually have motor symptoms in addition to any selective sensory loss, and the history is usually shorter.
A 32 year old man falls from scaffolding and sustains an injury to his forearm. Clinical examination and x-ray shows that he has sustained a radial fracture with dislocation of the distal radio-ulna joint. What eponymous name is used to describe this injury?
Galeazzi Monteggia's Smith's Colles' Barton's
Galeazzi fracture
Radial shaft fracture with associated dislocation of the distal radioulnar joint
Direct blow
A 24 year old man is brought to the emergency department having suffered a crush injury to his forearm. Assessment demonstrates that the arm is tender, red and swollen. There is clinical evidence of an ulnar fracture and the patient cannot move their fingers. Which is the most appropriate course of action?
Application of an external fixation device Closed reduction Debridement Discharge and review in fracture clinic Fasciotomy
The combination of a crush injury, limb swelling and inability to move digits should raise suspicion of a compartment syndrome that will require a fasciotomy. Paralysis is a very late sign.
A 5 year old boy presents with a painful limp. The symptoms have been present for 8 weeks. Two hip x-rays have been performed and appear normal. What is the best course of action?
Arrange a hip USS Arrange a hip CT scan Arrange a hip MRI Arrange a further hip X-ray Discharge and reassure
Perthes disease should be suspected in boys over 4 years old presenting with a limp. Early disease can be missed on x-ray. An MRI will often demonstrate areas of hypoperfusion and subtle changes that allow for earlier diagnosis. A bone scan is an alternative option.
An 8 year old boy presents with symptoms of right knee pain. The pain has been present on most occasions for the past three months and the pain typically lasts for several hours at a time. On examination; he walks with an antalgic gait and has apparent right leg shortening. What is the most likely diagnosis?
Perthes Disease Osteosarcoma of the femur Osteoarthritis of the hip Transient synovitis of the hip Torn medial meniscus
Perthes Disease
There are many causes of the irritable hip in the 10-14 year age group. Many of these may cause both hip pain or knee pain. Transient synovitis of the hip the commonest disorder but does not typically last for 3 months. An osteosarcoma would not usually present with apparent limb shortening unless pathological fracture had occurred. A slipped upper femoral epiphysis can cause a similar presentation although it typically presents later and with different patient characteristics.
A 30 year old man is admitted overnight, following a road traffic accident. He has an open tibial fracture with a 20 cm wound and extensive periosteal stripping. He is neurovascularly intact; IV antibiotics and wound dressing have been administered in the emergency department. What is the most appropriate course of action?
Immediate skeletal stabilisation and application of negative pressure dressing Skeletal fixation followed by vascular reconstruction Immediate vascuIar shunting, followed by temporary skeletal stabilisation and vascular reconstruction Combined skeletal and soft tissue reconstruction on a scheduled operating list Fasciotomy with four compartment decompression
This patient has a Gustillo-Anderson Grade 3B open fracture. He will require definitive skeletal and soft tissue reconstruction, which should be performed on a combined ortho-plastic scheduled operating list, as per the BOA/BAPRAS guidelines. The surgery does not have to be performed out of scheduled hours unless there is marine/ sewage contamination, vascular compromise or it is a polytrauma.
Whilst it is reasonable to apply an external fixator prior to definitive skeletal and soft tissue reconstruction, this should be converted to internal fixation within 72 hours.
Which of the following types of growth plate fractures may have similar radiological appearances?
Salter Harris types 1 and 5 Salter Harris types 4 and 5 Salter Harris types 3 and 5 Salter Harris types 1 and 2 Salter Harris types 1 and 3
Salter Harris injury types 1 and 5 (transverse fracture through growth plate Vs. Compression fracture) may mimic each other radiologically. Type 5 injuries have the worst outcomes. Radiological signs of type 5 injuries are subtle and may include narrowing of the growth plate.
A 60 year old male is admitted to the emergency room with a fall. He lives with his wife and still works as a restaurant manager. He has a past history of benign prostatic hyperplasia and is currently taking tamsulosin. He is otherwise fit and healthy. On examination, there is right hip tenderness on movement in all directions. A hip x-ray confirms an intertrochanteric fracture. What is the best management option?
Cemented hemiarthroplasty Total hip replacement Dynamic hip screw Percutaneous pinning Leg traction
The blood supply to the femoral head may be intact and the fracture should heal with compression type devices such as gamma nails or dynamic hip screws. The latter device being the most commonly performed therapeutic intervention.
Which of the following fractures names best accounts for the injury seen in a 14 year old boy who jumps off a 10 foot wall and lands on both feet and whose imaging shows a bimalleolar fracture of the right ankle?
Pott's Barton's Galeazzi Colles' Bennett's
Pott’s fracture
Bimalleolar ankle fracture
Forced foot eversion
A 22 year old rugby player falls onto an outstretched hand and sustains a fracture of the distal radius. The x-ray shows a dorsally angulated comminuted fracture. What is the most appropriate management?
Reduce under haematoma block and place in plaster Admit for open reduction and internal fixation Reduce using Biers block and place into plaster cast Discharge home with arm sling and review in fracture clinic Discharge home with futura splint and fracture clinic appointment
Admit for open reduction and internal fixation
Unlike an osteoporotic fracture in an elderly lady this is a high velocity injury and will require surgical fixation.
An athletic 15 year old boy presents with knee pain of 3 weeks duration. It is worst during activity and settles with rest. On examination, there is tenderness overlying the tibial tuberosity and an associated swelling at this site. What is the diagnosis?
Chondromalacia patellae Avulsion fracture of the tibial tubercle Osgood Schlatters disease Quadriceps tendon rupture Undisplaced fracture patella
Osgood Schlatters disease
Athletic boys and girls may develop this condition in their teenage years. It is caused by multiple micro fractures at the point of insertion of the tendon into the tibial tuberosity. Most cases settle with physiotherapy and rest.
A 23 year old rugby player falls directly onto his shoulder. There is pain and swelling of the shoulder joint. The clavicle is prominent and there appears to be a step deformity. What is the most likely diagnosis?
Acromioclavicular joint dislocation Glenohumeral dislocation Sternoclavicular dislocation Supraspinatus tear Infra spinatus tear
Acromioclavicular joint (ACJ) dislocation normally occurs secondary to direct injury to the superior aspect of the acromion. Loss of shoulder contour and prominent clavicle are key features. Note; rotator cuff tears rarely occur in the second decade.
A 4 year boy presents with an abnormal gait. He has a history of recent viral illness. His WCC is 11 and ESR is 30. What is the most likely cause?
Perthes disease Transient synovitis Septic arthritis Slipped upper femoral epiphysis Osteomyelitis
Viral illnesses can be associated with transient synovitis. The WCC should ideally be > 12 and the ESR > 40 to suggest septic arthritis.
An 8 year old boy falls onto an outstretched hand and is brought to the emergency department. He is examined by a doctor and a bony injury is cleared clinically. He re-presents a week later with pain in his hand. What is the most likely underlying injury?
Fracture of the distal radius Fracture of the scaphoid Dislocation of the lunate Rupture of flexor pollicis longus tendon Bennett's fracture
Scaphoid fractures in children are rare, will usually involve the distal pole and are easily missed. The initial clinical examination (and sometimes x-rays) may be normal and repeated clinical examination and imaging is advised for this reason. Whilst the other injuries may be sustained from a fall onto an outstretched hand they are less likely to be overlooked on clinical examination. In the case of a Bennetts fracture, the injury mechanism is less compatible with this type of injury.
A 45 year old man has been admitted after being knocked off his bicycle. His ankle is grossly deformed with bilateral malleolar tenderness with severe ankle swelling and tenting of the medial soft tissues. What is the most appropriate initial management?
Application of compression dressing and physiotherapy Application of external fixation device Immediate reduction and application of backslab Surgical fixation Application of full leg plaster cast
This is an unstable ankle injury that is likely to require surgical fixation. The immediate management of a displaced ankle fracture is to reduce the fracture to prevent soft tissues compromise and help reduce swelling. This can be performed before an x-ray is obtained if performing the x-ray will significantly delay reduction.
A 1 year-old is brought to the Emergency Department with a history of failure to thrive. On examination, the child is small for age and has a large head. X-ray shows a cupped appearance of the epiphysis of the wrist. What is the most likely cause?
Osteoporosis Ehlers Danlos Marfans Rickets Non accidental injury
Rickets is the childhood form of osteomalacia. It is due to the failure of the osteoid to ossify due to vitamin D deficiency. Symptoms start about the age of one. The child is small for age and there is a history of failure to thrive. Bony deformities include bowing of the femur and tibia, a large head, deformity of the chest wall with thickening of the costochondral junction (rickettary rosary), and a transverse sulcus in the chest caused by the pull of the diaphragm (Harrison’s sulcus). X- Rays show widening and cupping of the epiphysis of the long bones, most readily apparent in the wrist.
A 40 year old marine injures his ankle on an assault course. On examination he has a severely swollen ankle, as well as tenderness over the medial malleolus and proximal fibula. X-rays demonstrate a medial malleolar fracture, spiral fracture of the proximal fibula and widening of the syndesmosis. What is the most appropriate definitive management?
Surgical fixation Application of ankle boot Application of lower leg plaster cast Application of external fixation device Below knee amputation
This is a Maisonneuve fracture of the proximal fibula. It indicates an unstable ankle injury with likely injury to the interosseous membrane. In the setting of radiographic evidence of syndesmotic widening, this requires surgical fixation to reduce and stabilise the syndesmosis.
Which of the following is not a typical feature of talipes equinovarus?
Adducted and inverted calcaneus Medial displacement of the navicular bone It is nearly always unilateral Wedge shaped head of talus Severe Tibio-talar plantar flexion
It is bilateral in 50% of cases.
Which of the following statements relating to menisceal tears is false?
The medial meniscus is most often affected True locking of the knee joint may occur Most established tears will heal with conservative management In the chronic setting there is typically little to find on examination if the knee is not locked An arthroscopic approach may be used to treat most lesions
Menisci have no nerve or blood supply and thus heal poorly. Established tears with associated symptoms are best managed by arthroscopic menisectomy.
An obese 12 year old boy presents with knee pain. On examination, he has pain on internal rotation of the hip. His knee is clinically normal. What is the most appropriate investigation?
USS hip CT scan of the hip Radinucleotide scan Hip X-ray Anteroposterior pelvic x-ray
The main differential diagnosis in a boy over 10 years old is of slipped upper femoral epiphysis. Knee pain is a common presenting feature. An anteroposterior pelvic x-ray may miss a minor slip, therefore request a hip film.
A 12 year-old boy who is small for his age presents to the clinic with poor muscular development and hyper-mobile fingers. His x-rays show multiple fractures of the long bones and irregular patches of ossification. What is the most likely diagnosis?
Osteogenesis imperfecta Osteoporosis Scurvy Osteopetrosis Osteomalacia
Osteogenesis imperfecta is caused by defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine. There is a failure of maturation of collagen in all the connective tissues. Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.
An otherwise fit 74 year old man presents with pain in the right hip following minimal trauma. On examination, his leg is shortened and externally rotated. Plain films demonstrate a displaced intracapsular fracture of the femoral neck. What is the best course of action?
Uncemented hemi arthroplasty Dynamic hip screw Total hip replacement Intra medullary nail Percutaneous pins
In otherwise fit patients aged over 70, the best long term functional outcomes are obtained with total hip arthroplasty.
Of the list below, which is not a cause of avascular necrosis?
Steroids Sickle cell disease Radiotherapy Myeloma Caisson disease
Steroid containing therapy for myeloma may induce avascular necrosis, however the disease itself does not cause it. Caisson disease as may occur in deep sea divers is a recognised cause.
A 34 year old woman is a passenger in a car during an accident. Her knee hits the dashboard. On examination, the tibia looks posterior compared to the non injured knee. Which structure has been injured?
Anterior cruciate ligament Posterior cruciate ligament Medial collateral ligament Lateral collateral ligament Patella tendon
In ruptured posterior cruciate ligament the tibia lies back on the femur and can be drawn forward during a paradoxical draw test.
A 32 year old man presents with a painful swelling over the volar aspect of his hand after receiving a hard blow to his palm. On examination, he experiences pain on moving the wrist and on longitudinal compression of the thumb. What is the most likely injury?
Bennets fracture Scaphoid fracture 5th metacarpal fracture Ganglion Bursitis
Scaphoid fractures usually occur as a result of direct hard blow to the palm or following a fall on the out-stretched hand. The main physical signs are swelling and tenderness in the anatomical snuff box, and pain on wrist movements and on longitudinal compression of the thumb
Which of the following is the first radiological change likely to be apparent in a plain radiograph of a 12 year old presenting with suspected Perthes disease
Multiple bone cysts Sclerosis of the femoral head Loss of bone density Joint space narrowing Collapse of the femoral head
In Catterall stage I disease there may be no radiological abnormality at all. In Stage II disease there may be sclerosis of the femoral head.
Indication for treatment (aide memoire):Half a dozen, half a head
Those aged greater than 6 years with >50% involvement of the femoral head should almost always be treated.
A 25 year old ski instructor who falls off a ski lift and sustains a spiral fracture of the mid shaft of the tibia. Attempts to achieve satisfactory position in plaster have failed. Overlying tissues are healthy. What is the most appropriate course of action?
Amputation Open reduction and fixation using a long plate Intramedullary nail Skeletal traction Long limb casting
This would be a good case for intramedullary nailing. Open reduction and internal fixation would strip off otherwise healthy tissues and hence is unsuitable. In some units the injury may be managed with an Ilizarov frame device but the majority would treat with IM nailing.
A 20 year old woman sustains a Holstein-Lewis fracture. Which nerve is at risk?
Ulnar Radial Median Musculocutaneous Axillary
Since the distal humerus is affected, the radial is at risk.
A 74 year old lady falls and injures her left arm. Following assessment she is found to have an impacted fracture affecting the surgical neck of the humerus. What is the most appropriate course of action?
Reduce the fracture and apply a plate to stabilize the fragments Perform a hemiarthroplasty Apply a collar and cuff system for three weeks and then commence physiotherapy Apply an upper limb cast for 8 weeks Apply an external fixator system
Impacted fractures of the surgical neck are stable injuries and usually heal without complication. It is rare to need to resort to surgery. Its important to start physiotherapy early.
A footballer is sustains a knee injury in a match and is being assessed in the outpatient department. On examination, he has a positive valgus stress test and minimal joint effusion. What is the most likely underlying injury?
Injury to the lateral collateral ligament Injury to the medial collateral ligament Injury to the anterior cruciate ligament Injury to the posterior cruciate ligament Injury to the patellar tendon
A knee injury in the footballer with a positive valgus stress test is usually associated with MCL injury.
A 63 year old lady undergoes an axillary clearance for breast cancer. She makes steady progress. However, 8 weeks post operatively she still suffers from severe shoulder pain. On examination, she has reduced active movements in all planes and loss of passive external rotation. What is the most likely cause?
Metastatic cancer Adhesive capsulitis Rotator cuff tear Osteoarthritis Rheumatoid disease
Adhesive capsulitis
Frozen shoulder is more likely. Metastatic cancer can cause pain. However, passive movements are normally unaffected.
Frozen shoulder passes through an initial painful stage followed by a period of joint stiffness. With physiotherapy the problem will usually resolve although it may take up to 2 years to do so.
A 63 year nurse falls on an extended and pronated wrist. An x-ray shows a distal radial fracture with radiocarpal dislocation. Which type of fracture is most likely?
Bennett's Barton's Pott's Smith's Monteggia's
Barton’s fractures tend to have intra-articular involvement and dislocation may sometimes be present.
A 34 year old man presents with localised spinal pain over 2 months which is worsened on movement. He is known to be an IVDU. He has no history suggestive of tuberculosis. The pain is now excruciating at rest and not improving with analgesia. He has a temperature of 39 oC. What is the most likely diagnosis?
Transverse myelitis Osteomyelitis Potts disease of the spine Epidural haematoma Brown-Sequard syndrome
In an IVDU with back pain and pyrexia have a high suspicion for osteomylelitis. The most likely organism is staph aureus and the cervical spine is the most common region affected. TB tends to affect the thoracic spine and in other causes of osteomyelitis the lumbar spine is affected.
A 19 year old female is involved in an athletics event. She has just completed the high jump when she suddenly develops severe back pain and weakness affecting both her legs. On examination, she has a prominent sacrum and her lower back is painful. What is the most likely underlying cause?
Structural scoliosis Ankylosing spondylitis Scheuermanns disease Spondylolisthesis Spondylolysis
Young athletic females are the group most frequently affected by spondylolythesis who have a background of spondylolysis. Whilst the latter condition is a risk factor for spondylolythesis the former condition is most likely in a young athletic female who presents with sudden pain.
A 72 year old lady stumbles and falls. On examination, she is tender in the left groin and unable to weight bear. Attempts at internal rotation produce severe pain. Plain films of the hip show no obvious fracture. What is the best course of action?
MRI scan Bone scintigraphy Conservative management Hip arthrodesis Total hip replacement
In those patients who present with a suspected hip fracture, but normal plain films, the most accurate investigation is an MRI or CT scan.
A 54-year-old man presents to the Emergency Department with a 2 day history of a swollen, painful left knee. You aspirate the joint to avoid admission to the orthopaedic wards. Aspirated joint fluid shows calcium pyrophosphate crystals. Which of the following blood tests is most useful in revealing an underlying cause?
Transferrin saturation ACTH ANA Serum ferritin LDH
This is a typical presentation of pseudogout. An elevated transferrin saturation may indicate haemochromatosis, a recognised cause of pseudogout.
A high ferritin level is also seen in haemochromatosis but can be raised in a variety of infective and inflammatory processes, including pseudogout, as part of an acute phase response.
A tall 18 year old male athlete is admitted to the emergency room after being hit in the knee by a hockey stick. On examination, his knee is tense and swollen. X-ray shows no fractures. What is the diagnosis?
Dislocated patella Quadriceps tendon rupture Patella fracture Chondromalacia patellae
A patella dislocation is a common cause of haemarthrosis and many will spontaneously reduce when the leg is straightened. In the chronic setting physiotherapy is used to strengthen the quadriceps muscles.
A 19 year old soldier has just returned from a prolonged marching exercise and presents with a sudden onset, severe pain, in the forefoot. Clinical examination reveals tenderness along the second metatarsal. Plain x-rays are taken of the area, these demonstrate callus surrounding the shaft of the second metatarsal. What is the most likely diagnosis?
Stress fracture Mortons neuroma Osteochondroma Acute osteomyelitis Freiberg's disease
A short history of pain together with clinical examination and radiological signs affecting the second metatarsal favour a stress fracture. The fact that callus is present suggests that immobilisation is unlikely to be beneficial. Freibergs disease is an anterior metatarsalgia affecting the head of the second metarsal, it typically occurs in the pubertal growth spurt. The initial injury was thought to be due to stress microfractures at the growth plate. The key feature in the history which distinguishes the injury as being stress fracture is the radiology. In Freibergs disease the x-ray changes include; joint space widening, formation of bony spurs, sclerosis and flattening of the metatarsal head.
A 65-year-old Asian female presents with an extracapsular neck of femur fracture. Investigations show:
Calcium 2.07 mmol/l (2.20-2.60 mmol/l)
Phosphate 0.66 mmol/l (0.8-1.40 mmol/l)
ALP 256 IU/l (44-147 IU/l)
What is the most likely diagnosis?
Bone tuberculosis Hypoparathyroidism Myeloma Osteomalacia Paget's disease
Osteomalacia
low: calcium, phosphate
raised: alkaline phosphatase
A 78-year-old woman is discharged following a fractured neck of femur. On review, she is making good progress but consideration is given to secondary prevention of further fractures. Unfortunately the orthogeriatricians are all on annual leave and the consultant has asked you to arrange suitable management. Which is the best option?
Alendronate Alendronate, calcium and vitamin D supplementation Strontium Arrange a DEXA scan Hormone replacement therapy
A bisphosphonate, calcium and vitamin D supplementation should be given to all patients aged over 75 years after having a fracture. A DEXA scan is only needed of the patient is aged below 75 years. Hormone replacement therapy has been shown to reduce vertebral and non vertebral fractures, however the risks of cardiovascular disease and breast malignancy make this a less favourable option.
Which of the following statements relating to avascular necrosis is false?
When associated with fracture may occur despite the radiological evidence of fracture union. Pain and stiffness will typically precede radiological evidence of the condition. Drilling of affected bony fragments may be used to facilitate angiogenesis where arthroplasty is not warranted. The earliest detectable radiological evidence is a radiolucency of the affected area coupled with subchondral collapse. It is less likely when prompt anatomical alignment of fracture fragments is achieved.
Radiolucency and subchondral collapse are late changes. The earliest evidence on plain films is the affected area appearing as being more radio-opaque due to hyperaemia and resorption of the neighboring area. It may be diagnosed earlier using bone scans and MRI.
A 28 year old man falls onto an outstretched hand. On examination, there is tenderness of the anatomical snuffbox. However, forearm and hand x-rays are normal. What is the most appropriate course of action?
Discharge with reassurance Place in arm sling and discharge Place in futura splint and review in fracture clinic Admit for surgical exploration Apply an external fixation device
This could well be a scaphoid fracture and should be temporarily immobilised pending further review. A futura splint will immobilise better than an arm sling for this problem.
A 6 year old boy presents with groin pain. He is known to be disruptive in class. He reports that he is bullied for being short. On examination, he has an antalgic gait and pain on internal rotation of the right hip. What is the most likely diagnosis?
Perthes disease Transient synovitis Slipped upper femoral epiphysis Developmental dysplasia of the hip Septic arthritis
This child is short, has hyperactivity (disruptive behaviour) and is within the age range for Perthes disease. Hyperactivity and short stature are associated with Perthes disease.
An 86 year old retired pharmacist is admitted to Emergency Department following a fall. She complains of right hip pain. She is known to have hypertension and is currently on bendrofluazide. She lives alone and mobilises with a Zimmer frame. Her right leg is shortened and externally rotated. A hip x-ray confirms a displaced intracapsular fracture. What is the best management option?
Dynamic hip screw Gamma nail Total hip replacement Hemiarthroplasty Percutaneous pinning
Hemiarthroplasty is offered to older, less mobile individuals compared to fracture reduction and fixation in younger patients.
Which type of fracture is seen when a 22 year old drunk man is involved in a fight and injures his thumb when he punches his opponent?
Barton's Bennett's Galeazzi Colles' Smith's
Bennett’s fracture
Intra-articular fracture of the first carpometacarpal joint
Impact on flexed metacarpal, caused by fist fights
X-ray: triangular fragment at ulnar base of metacarpal
A 4 year old boy falls and sustains a fracture to the growth plate of his right wrist. Which of the following systems is used to classify the injury?
Salter - Harris system Weber system Gustilo - Anderson system Garden system None of the above
The Salter - Harris system is most commonly used. The radiological signs in Type 1 and 5 injuries may be identical. Which is unfortunate as type 5 injuries do not do well (and may be missed!). One of our users has helpfully supplied a mnemonic for remembering the types
A 43 year old man falls over landing on his left hand. Although there was anatomical snuffbox tenderness no x-rays either at the time or subsequently have shown evidence of scaphoid fracture. He has been immobilised in a futura splint for two weeks and is now asymptomatic. What is the most appropriate course of action?
Application of tubigrip bandage and fracture clinic review Admission and surgical debridement Application of futura splint and fracture clinic review Application of below elbow cast for 6 weeks Discharge with reassurance
This patient is at extremely low risk of having sustained a scaphoid injury and may be discharged.
A 28 year old professional footballer is admitted to the emergency department. During a tackle his leg is twisted with his knee flexed. He hears a loud crack and his knee rapidly becomes swollen. Which of the following structures is the main site of injury?
Anterior cruciate ligament Posterior cruciate ligament Meniscus Medial collateral ligament Lateral collateral ligament
This is common in footballers as the football boot studs stick to the ground and high twisting force is applied to a flexed knee. Rapid joint swelling also supports the diagnosis.
A 10 year old boy is referred to the orthopaedic clinic with symptoms of right knee pain. He has suffered pain for the past 3 months and the pain typically lasts for several hours. On examination he walks with an antalgic gait and has apparent right leg shortening. The right knee is normal but the right hip reveals pain on internal and external rotation. Imaging shows flattening of the femoral head. Which of the following is the most likely underlying diagnosis?
Osteogenesis imperfecta Child abuse Osteosarcoma Osteopetrosis Perthes disease
This is a typical description of Perthes disease. Management involves keeping the femoral head in the acetabulum by braces, casts or surgery.
Which of the following is least likely to impair bone fracture healing?
Radiotherapy Osteoporosis Administration of non steroidal anti inflammatory drugs Preservation of periosteum Presence of osteomyelitic sequestra
Periosteal preservation helps fractures to heal.
An obese 14 year old boy presents with difficulty running and mild knee and hip pain. There is no antecedent history of trauma. On examination, internal rotation is restricted but the knee is normal with full range of passive movement possible and no evidence of effusions. Both the C-reactive protein and white cell count are normal. What is the most likely cause?
Perthes disease Slipped upper femoral epiphysis Non accidental injury Septic arthritis Osteoarthritis
Slipped upper femoral epiphysis is the commonest adolescent hip disorder. It occurs most commonly in obese males. It may often present as knee pain which is usually referred from the ipsilateral hip. The knee itself is normal. The hip often limits internal rotation. The diagnosis is easily missed. X-rays will show displacement of the femoral epiphysis and the degree of its displacement may be calculated using the Southwick angle. Treatment is directed at preventing further slippage which may result in avascular necrosis of the femoral head.
A 64 year old man is involved in a motor vehicle accident and is found to have a fracture affecting the anatomical neck of his humerus which is displaced. What is the most appropriate management?
Place a collar and cuff for 3 weeks and then commence physiotherapy Hemiarthroplasty Place in a collar and cuff for 6 weeks and then commence physiotherapy Reduce the fracture and place in an arm sling with repeat imaging at 14 days Reduction under anaesthesia and place in collar and cuff system for 6 weeks
These injuries are at significant risk of avscular necrosis and consideration of surgery is important. A hemi arthroplasty may be needed.
A 70 year old man undergoes a revision total hip replacement. 10 days post operatively the hip dislocates and pus is discharging from the wound. He is systemically unwell with a temperature of 38.5 and WCC 19. What is the most appropriate course of action?
Lay open wound and apply a VAC dressing Hindquater amputation Revision arthroplasty Removal of metalwork and bone grafting Removal of metalwork and implantation of local antibiotics
Removal of metal work implantation of gentamicin beads and delayed revision is the mainstay of managing this complication.
A 15 year-old boy presents to the out-patient clinic with tiredness, recurrent throat and chest infections, and gradual loss of vision. Multiple x-rays show brittle bones with no differentiation between the cortex and the medulla. What is the most likely diagnosis?
Rickets Osteomalacia Osteopetrosis Ehlers Danlos type III Osteogenesis imperfecta
Osteopetrosis is an autosomal recessive condition. It is commonest in young adults. They may present with symptoms of anaemia or thrombocytopaenia due to decreased marrow space. Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone. These bones are very dense and brittle.
A 73 year old lady presents with pain in her left hip. She was walking around the house when she tripped over a rug and fell over. Apart from temporal arteritis which is well controlled with prednisolone she is otherwise well. On examination, her leg is shorted and externally rotated. Her serum alkaline phosphatase and calcium are normal. What is the likely underlying disease process?
Pagets disease Metastatic renal cancer Osteoporosis Osteopetrosis Osteoclastoma
The combination of age, female gender and steroids coupled with hip pain on minor trauma are strongly suggestive of osteoporosis complicated by pathological fracture.
A 72 year old retired teacher is admitted to A&E with a fall and hip pain. He is normally fit and well. He lives with his son in a detached, 2 storey house. A hip x-ray and femur views confirm a sub trochanteric fracture. What is the best course of action?
Insertion of intra medullary nail Total hip replacement Uncemented hemiarthroplasty Percutaneous pinning Hip arthrodesis
Intramedullary devices are normally recommended for reverse oblique, transverse subtrochanteric fractures.
In paediatric orthopaedic surgery, which of the following does not fulfill the Kocher criteria for septic arthritis?
ESR > 40mm/h Positive blood culture Fever White cell count > 12, 000 Non weight bearing on the affected side
Kocher’s ‘WIFE’ is:
WCC >12 Inability to weight bear Fever ESR >40 = >90 chance of septic arthritis
The Kocher criteria do not consider blood culture results.
A 28 year old man falls on the back of his hand. On x-ray, he has a fractured distal radius demonstrating volar displacement of the fracture. What eponymous term is used to describe this?
Barton's Colles' Smith's Pott's Galeazzi
This is a Smith fracture (reverse Colles’ fracture); unlike a Colles’ this is a high velocity injury and may require surgical correction. Note that Colles’ fractures are usually dorsally displaced.
A 28 year old man complains of pain and weakness in the shoulder. He has recently been unwell with glandular fever from which he is fully recovered. On examination there is some evidence of muscle wasting and a degree of winging of the scapula. Power during active movements is impaired. What is the most likely cause?
Parsonage-Turner syndrome Adhesive capsulitis Rotator cuff tear Osteoarthritis Calcific tendonitis
Parsonage-Turner syndrome
This is a peripheral neuropathy that may complicate viral illnesses and usually resolves spontaneously.
A baby is delivered in the breech position. Barlows and Ortolani tests are normal. What is the most appropriate course of action?
Reassure and discharge the patient Reassess the patient at 3 years Arrange a hip USS Arrange a hip X-ray Arrange a hip CT scan
Arrange a hip USS
This child is at risk of developmental dysplasia of the hip (up to 20% will have DDH), so should have the hip joints scanned to exclude this.
An infant is admitted with symptoms and signs of respiratory infection and is found to have several posterior rib fractures on chest radiograph. He was born prematurely at 37 weeks’ gestation and was observed overnight on the special care baby unit for tachypnoea which settled by the following day. On assessment, it is also apparent that his head circumference has increased at an excessive rate and has crossed 3 centiles since birth. What is the most likely underlying issue?
Accidental fracture Pagets disease Myeloproliferative disorder Non accidental injury Osteomalacia
Posterior rib fractures are extremely unusual in neonates. The change in head size may be accounted for by hydrocephalus which may occur as a sequelae from head injury.
A 22 year man is shot in the back, in the lumbar region. He has increased tone and hyper-reflexia of his right leg. He cannot feel his left leg. What is the most likely explanation?
Epidural haematoma Osteomyelitis Transverse myelitis Brown-Sequard syndrome Tabes dorsalis
Brown -Sequard syndrome is caused by hemisection of the spinal cord. It may result from stab injuries or lateral vertebral fractures. It results in ipsilateral paralysis (pyramidal tract) , and also loss of proprioception and fine discrimination (dorsal columns). Pain and temperature sensation are lost on the contra-lateral side. This is because the fibres of the spinothalamic tract have decussated below the level of the cord transection.
A 19 year old female presents to the clinic with progressive pain in her neck and back. The condition has been progressively worsening over the past 6 months. She has not presented previously because she was an inpatient with a disease flare of ulcerative colitis. On examination, she has a stiff back with limited spinal extension on bending forwards. What is the most likely explanation for this process?
Spondylolysis Spondylolisthesis Functional scoliosis Scheuermanns disease Ankylosing spondylitis
Ankylosing spondylitis is associated with HLA B27, there is a strong association with ulcerative colitis in such individuals. The clinical findings are usually of a kyphosis affecting the cervical and thoracic spine. Considerable symptomatic benefit may be obtained using non steroidal anti inflammatory drugs. These should be used carefully in patients with inflammatory bowel disease who may be taking steroids.
A 50 year old man is admitted after falling from scaffolding. He has an open fracture of his tibia with a 15 cm wound. He is neurovascularly intact. What is the best initial course of action?
Intravenous antibiotics, photography and application of saline soaked gauze with impermeable dressing Thorough wound debridement in the emergency department Combined skeletal and soft tissue reconstruction on a scheduled operating list Application of external fixator and conversion to internal fixation after two weeks Immediate skeletal stabilisation and application of negative pressure dressing
The initial management of open fractures should include administration of intravenous antibiotics, photography of wound and application of a sterile soaked gauze and impermeable film. The wound should only be handled to remove gross contamination. The patient is then likely to require definitive skeletal and soft tissue reconstruction.
A 65 year old type 2 diabetic with poor glycaemic control is admitted with forefoot cellulitis. X-ray of the foot shows some evidence of osteomyelitis of the 2nd ray but overlying skin is healthy. What is the best treatment initially?
Intravenous antibiotics Below knee amputation Transfemoral amputation Midfoot amputation Ray amputation
It is worth attempting to try and resolve this situation with antibiotics at first presentation. A primary amputation will not heal well and may result in progressive surgery.
With which of the conditions listed below is a Hill- Sachs lesions classically associated?
Fracture of the surgical neck of the humerus Glenohumeral dislocation Supraspinatus tear Acromioclavicular dislocation Sternoclavicular dislocation
A Hill-Sachs lesion occurs when the cartilage surface of the humerus is in contact with the rim of the glenoid. About 50% of anterior glenohumeral dislocations are associated with this lesion.
A 20 year old woman trips over a step, injuring her ankle. Examination reveals tenderness over the lateral malleolus and an x-ray demonstrates an undisplaced fracture distal to the syndesmosis. What is the best course of action?
Application of ankle boot Surgical fixation Application of full leg plaster cast Application of external fixator Application of Ilizarov frame
This is a Weber A fracture. It is a stable ankle injury and can therefore be managed conservatively. Whilst this patient could also be treated in a below knee plaster, most clinicians would nowadays treat this injury in an ankle boot. Patients should be advised to mobilise in the ankle boot, as pain allows, and can wean themselves out of the boot as the symptoms improve
A 56 year old lady presents with a painful swelling over the lower end of the forearm following a fall. Imaging reveals a distal radial fracture with disruption of the distal radio-ulnar joint. What is the most likely fracture?
Fracture of the distal humerus Fracture of the shaft of the radius and ulnar Fracture of the coronoid process Galeazzi fracture Fracture of the radial head
Galeazzi fractures occur after a fall on the hand with a rotational force superimposed on it. On examination, there is bruising, swelling and tenderness over the lower end of the forearm. X- Rays reveal a displaced fracture of the radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint.
A 10 year old boy undergoes a delayed open reduction and fixation of a significantly displaced supracondylar fracture. On the ward he complains of significant forearm pain and paraesthesia of the hand. Radial pulse is normal. What is the most appropriate course of action?
Fasciotomy Arrange a CT angiogram Provide stronger analgesia Arrange repeat limb x-rays Arrange a forearm duplex scan
The delay is the significant factor here. These injuries often have neurovascular compromise and inactivity now places him at risk of developing complications. In compartment syndrome the loss of arterial pulsation occurs late.
A builder falls from scaffolding and lands on his left hand he suffers a severe laceration to his palm. An x-ray shows evidence of scaphoid fracture that is minimally displaced. What is the most appropriate course of action?
Application of futura splint Discharge with reassurance Admission and surgical debridement Application of below elbow cast and review in 6 weeks Application of tubigrip bandage and fracture clinic review
This is technically an open fracture and should be debrided prior to attempted fixation (which should occur soon after).
A 5 year old boy is playing in a tree when he falls and lands on his right forearm. He is brought to the emergency department by his parents. On examination he has bony tenderness and bruising. An X-ray is taken and shows unilateral cortical disruption and development of periosteal haematoma. What is the most likely diagnosis?
Buckle fracture Greenstick fracture Toddlers fracture Complete fracture None of the above
Greenstick fractures are common childhood injuries. Unilateral cortical disruption is the main radiological feature, since involvement of both cortices makes the injury a complete fracture. Buckle fractures will show periosteal haematoma formation only.
Which of the following is not typically seen in patients with a femoral neck fracture?
Malunion Non union Avascular necrosis Shortening External rotation
Malunion would be unusual with a femoral neck fracture. Because it is a weight bearing joint, if the fracture is not united then it does not heal at all. It is for this reason that most femoral neck fractures are fixed. Avascular necrosis is a well recognised complication and a total hip replacement or hemiarthroplasty is usually considered in the elderly.
A 6 year old boy presents with pain in the hip it is present on activity and has been worsening over the past few weeks. There is no history of trauma. He was born by normal vaginal delivery at 38 weeks gestation On examination he has an antalgic gait and limitation of active and passive movement of the hip joint in all directions. C-reactive protein is mildly elevated at 10 but the white cell count is normal. What is the most likely diagnosis?
Perthes disease Septic arthritis Slipped upper femoral epiphysis Developmental dysplasia of the hip Osteoarthritis
This is a typical presentation for Perthes disease. X-ray may show flattening of the femoral head or fragmentation in more advanced cases.
A 38 year old window cleaner falls from his ladder. He lands on his left arm and notices an obvious injury. An x-ray and clinical examination demonstrate that he has a fracture of the proximal ulna and associated radial dislocation. What eponymous name is used to describe this injury?
Galeazzi Smith's Bennett's Pott's Monteggia's
This constellation of injuries is referred to as a Monteggia’s fracture.
A 40 year old woman is admitted after being knocked off her bike. She has an open fracture of her tibia, with a 10 cm wound. No peripheral pulses are palpable. Intravenous antibiotics have been administered in the emergency department and the wound has been dressed. What is the best course of action?
Immediate skeletal stabilisation and application of negative pressure dressing Intravenous antibiotics, photography and application of saline soaked gauze with impermeable dressing Skeletal fixation followed by vascular reconstruction Immediate amputation Immediate vascuIar shunting, followed by temporary skeletal stabilisation and vascular reconstruction
This patient has a Gustillo-Anderson Grade 3C open fracture with vascular injury. Vascular impairment requires immediate surgery and restoration of circulation, ideally within 3-4 hours. This should follow the sequence of shunting, temporary skeletal stabilisation and then vascular reconstruction as per BOA / BAPRAS guidelines. Revascularisation using vascular shunts should be performed before skeletal fixation.
