Questions (Orthopaedics) Flashcards
Describe what is meant by autonomic dysreflexia [1]
What are typical symptoms? [3]
Autonomic dysreflexia is caused by excessive sympathetic activity in the absence of parasympathetic supply in a high spinal lesion.:
- It rarely occurs in lesions below the level of T6
- Hypertension, sweating, and flushing are typical symptoms
How would you differentiate between supraspinatous muscle and nerve injury? [2]
Pain:
* Damage to the supraspinatus muscle itself would be painful
* painless nature suggests damage to the suprascapular nerve, which supplies the supra- and infraspinatus.
Describe a common MCQ stem for damage to suprascapular nerve [1]
Moreover, the mechanism of injury is suggestive – the shoulder straps of a rucksack (likely to be used during a hiking holiday) on the root of the neck likely caused prolonged pressure on the suprascapular nerve, with secondary neuropraxia
Normal x-ray
What would you like to do with the aspirated synovial fluid? For ?SA
Send for gram staining, cultures and sensitivity and crystal analysis
Urgent pH analysis
Discard it safely
Needs urgent gram staining only
Send for gram staining, cultures and sensitivity and crystal analysis
It is important to urgently rule out an infective cause, especially septic arthritis. Gram staining can be done fairly quickly; cultures and sensitivity may take a little longer. To check the synovial fluid for crystal is important if gout or Pseudogout is suspected.
How would you manage septic arthritis?
Prolonged oral antibiotics
Joint replacement
Vigorous Intravenous antibiotics and analgesia
Intravenous antibiotics and surgical washout of affected joint
- Analgesia and NSAIDs and provide pain relief and decrease inflammation
- Underlying cause will need to be treated with intravenous antibiotics initially followed by a prolonged course of oral antibiotics
- Needs a surgical washout of the joint to prevent destruction of the joint
?Gout
Synovial fluid is E is from Mr Jones’ knee.
Normal = A
Inflammatory, e.g. rheumatoid arthritis = C
Non-Inflammatory, e.g. Osteoarthritis = B
Hemorrhagic = F
Septic = D
Results from Mr Jones’ synovial fluid demonstrated presence of crystals. How they are best analysed?
Microscopic analysis under polarizing light
Periodic acid–Schiff (PAS) stain
Ziehl-Neelsen staining
Congo red staining
Results from Mr Jones’ synovial fluid demonstrated presence of crystals. How they are best analysed?
Microscopic analysis under polarizing light
Periodic acid–Schiff (PAS) stain
Ziehl-Neelsen staining
Congo red staining
Why do you need to consider metabolic syndrome when thinking about gout? [1]
Metabolic syndrome is important to consider as patient with hyperuricaemia are at risk of cardiovascular disease, especially as Mr Jones has hypertension and family history of heart disease.
What is the normal serum urate level?
Upper limit of 230 μmol/L in males and 160 μmol/L in females
Upper limit of 360 μmol/L in males and 460 μmol/L in females
Upper limit of 380 μmol/L in males and 260 μmol/L in females
Upper limit of 430 μmol/L in males and 360 μmol/L in females
Upper limit of urate is 430 μmol/L in males and 360 μmol/L in females
How should an asymptomatic patient with a high serum urate be managed?
Do nothing as it may be incidental
Start them on allopurinol
Wait for them to develop symptoms
Address risk factors and modify lifestyle
Address risk factors and modify lifestyle
Vertebral fractures at T4 or above suggest []
Vertebral fractures at T4 or above suggest cancer rather than osteoporosis.
How can you tell if there is a rotator cuff injury? [1]
How do you distinguish this from a rotator cuff tear? [1]
Rotator cuff (impingement) syndrome because there is a painful arc when the arm is passively abducted.
However, the drop arm test indicates that there is a complete rotator cuff tear, rather than tendinitis
- A patient may be able to lower the arm slowly to 90 degrees because this uses mostly the deltoid muscle but, below 90 degrees, the arm will drop to the side.
A positive McMurray test and pain on the lateral aspect of the knee joint, a [] tear is likely.
positive McMurray test and pain on the lateral aspect of the knee joint, a lateral meniscal tear is likely.
Which of the following is true about acute osteomyelitis in children?
Spread from local cellulitis is the most common
Intravenous (IV) drug usage is an important risk factor
Salmonella species are the most common causative organism
The most common site is metaphyses of the femur
Bone scans can pick up abnormalities while X-rays cannot
#45410
The most common site is metaphyses of the femur
Patients often complain of pain in scaphoid fractures when pressure is applied to the anatomical snuffbox. Specialised scaphoid views (a scaphoid series) are recommended to ensure the bone is well visualised. This entails four views, as opposed to the normal two views for imaging of the wrist.
A radiologist examined the films and observed a single fracture of the carpal bone that articulates with most of the base of the third metacarpal bone.
Which of the following bones was most likely fractured?
Trapezium
Pisiform
Hamate
Triquetrum
Capitate
#45950
Capitate
Which of the following is the most common finding in patients with a Salter–Harris fracture?
A crush fracture
Growth plate sparing
Transverse fracture through the growth plate
A greenstick fracture
Fracture through the metaphysis sparing the epiphysis
Fracture through the metaphysis sparing the epiphysis
Which of these statements is true?
The humerus is most likely to lie posterior to the scapula
The regimental badge area over the left upper arm may be numb
The injury is likely to require operative intervention
A post-reduction X-ray is not usually performed
Associated rotator cuff injuries are rare
There may be associated neurological deficit in the area supplied by the axillary nerve, as this is most commonly damaged in anterior shoulder dislocations. Therefore, further tests or examination may be performed to rule these out.
m. An X-ray shows a fracture of the surgical neck of the humerus. You believe the fracture may have caused a nerve injury.
Which of the following describes the nerve roots of the affected nerve?
C5 and 6
C5, 6, 7, 8 and T1
C8 and T1
C5, 6 and 7
C5, 6, 7 and 8
C5 and 6
C5-6: axillary nerve
C5-7: musculocutaneous nerve
C5-T1: median and radial nerve
C8-T1: ulnar nerve
Lhermitte phenomenon secondary to cervical spondylosis.
How would this present? [1]
When shock-like pain occurs on neck flexion, it is called the Lhermitte phenomenon. It is due to cervical cord compression by osteophytes or midline disc herniation. It may also occur in multiple sclerosis
This patient presents with neurological deficits suggestive of conus medullaris syndrome. The level of cord compression is confirmed by MRI, which shows collection at the level of []
This patient presents with neurological deficits suggestive of conus medullaris syndrome. The level of cord compression is confirmed by MRI, which shows collection at the level of L1/L2.
After a game of squash, a 32-year-old female complains of pain at the lateral aspect of her right elbow, which radiates down the back of the forearm. She is diagnosed as having tennis elbow, epicondylitis of the lateral epicondyle of the humerus.
Which one of the following muscles has an attachment at this site?
Coracobrachialis
Extensor digitorum
Flexor carpi radialis
Pronator teres
Triceps
#33137
Extensor digitorum
A 40-year-old male falls and injures his thumb while skiing. On examination, there is significant pain and laxity of the thumb on valgus stress and weakness of the pinch grasp.
What is the dx? [1]
Ulnar collateral ligament tear
- ‘Skier’s thumb’ refers to an acute injury where the ulnar collateral ligament (UCL) of the thumb’s metacarpophalangeal (MCP) joint is partially or completely torn.
- Patients experience pain on the ulnar side of the MCP joint and may report weakness in grasping or pinching.
- his injury is commonly seen in skiers who fall with an abducted thumb against a ski pole or the ground
- The thumb appears hyperextended and laterally deviated with swelling and bruising.
Saturday night palsy occurs due to compression of the [] nerve.
How does it present? [2]
Saturday night palsy occurs due to compression of the radial nerve to the prolonged pressure applied on the mid-arm
- Paralysis or weakness of the hand and finger extensors
Which clinical test can you perform to help aid dx of de Quervian’s tenosynovitis [1]
Finkelsteins test
[] formation is a typical feature of steroid-induced osteoporosis on x-ray
exuberant callus formation is a typical feature of steroid-induced osteoporosis.
An ACL injurt can be ID by which test? [1]
Lachmann’s test
Rotational knee injury is most likely to cause which type of injury? [1]
Which signs upon examination that would indicate this injury? [3]
A meniscal tear:
- The notable symptom is knee locking.
- McMurray’s test is performed during examination, involving external and internal rotation of the flexed knee followed by forced extension
- Pain or an audible pop indicates pathology in the medial or lateral meniscus
An X-ray of the right arm demonstrates a mid-humeral shaft fracture
Which of the following conditions is this patient most likely to suffer?
Atrophy of the deltoid muscle
Inability to flex the wrist
Loss of sensation to the right fifth finger
Compartment syndrome
Loss of sensation to the dorsum of the right hand
Loss of sensation to the dorsum of the right hand:
- Mid-humeral shaft fractures raise suspicions of radial nerve damage, as the radial nerve traverses the radial groove.
What is an occult fracture? [1]
Which of the following is the gold-standard investigation for a suspected occult fracture?
Dual-energy X-ray absorptiometry (DEXA) scan
Hip ultrasound scan
Magnetic resonance imaging (MRI) scan
Positron-emission tomography (PET) scan
X-ray hip lateral view
#48508
An occult fracture is a fracture that is not apparent on initial imaging, usually X-ray
Magnetic resonance imaging (MRI) scan
How can you distinguish scaphoid and lunate from their shape? [1]
lunate is found in the proximal row of the carpal bones of the wrist and is distinguished by the rest due to its crescent shape
Supracondylar humeral fractures are most likely to damage the [] nerve.
Median nerve
Give the cause of a positive Trendeleburg’s gait
Weakness or dysfunction of gluteus medius
A rupture of the tendon of the long head of the biceps brachii is diagnosed.
To which of the following bony points does this tendon normally attach?
Coracoid process of the scapula
Greater tuberosity of the humerus
Lesser tuberosity of the humerus
Infraglenoid tubercle of the scapula
Supraglenoid tubercle of the scapula
Supraglenoid tubercle of the scapula
Which artery that supplies the femoral head, if compromised, will lead to avascular necrosis? [1]
Medial femoral circumflex artery
- the lateral is typically not associated with NOF
anterior shoulder dislocations causes which change in upper arm sensation? [1]
Why? [1]
The regimental badge area over the left upper arm may be numb:
- There may be associated neurological deficit in the area supplied by the axillary nerve, as this is most commonly damaged in anterior shoulder dislocations.
Weakness and loss of bulk in which muscle group occurs because of carpal tunnel? [1]
Thenar muscles
Ptx is 92.
Treatment? [1]
Dynamic hip screw
- extracapsular fracture
What clinical sign will the patient most likely have? [1]
External rotation of the left leg:
- The radiograph demonstrates a left intertrochanteric fracture, manifesting clinically as hip pain, external rotation and shortening of the affected leg
What classification criteria is used to grade intracapsular NOF fractures? [1]
Garden
What classification criteria is used to grade tibial plateau fractures? [1]
schatzker
What is the name for this type of fracture? [1]
Mallet Finger is a finger deformity caused by disruption of the terminal extensor tendon distal to DIP joint
- usually caused by a traumatic impaction blow (i.e. sudden forced flexion) to the tip of the finger in the extended position.
is the
How would you treat this patient? [1]
** left intertrochanteric fracture**:
- open reduction and internal fixation (ORIF)
A 35-year-old male falls while skiing. He has weakness of pincer grip and pain and laxity on the valgus stress test of his thumb.
What is the most likely injury?
Scaphoid fracture
Extensor pollicis longus strain
Ulnar collateral ligament of the thumb injury
De Quervain’s tenosynovitis
Bennett’s fracture
Ulnar collateral ligament of the thumb injury
- abduction force is exerted on the thumb in a fall.
NB: ulnar collateral ligament (UCL) of the thumb injury aka ‘skiers/gamekeeper’s thumb’
How does ulnar collateral ligament of thumb injury present? [2]
Patients typically describe weak pincer grip and reduced range of movement of the thumb at the metacarpophalangeal joints (MCPJ).
Which is the most common Salter-Harris fracture? [1]
Describe this fracture [1]
Salter–Harris type II fracture:
- fracture through the metaphysis sparing the epiphysis
Which nerve runs around the surgical neck of the humerus?
Median nerve
Anterior branch of the axillary nerve
Lateral cutaneous nerve
Posterior interosseous nerve
Radial nerve
Anterior branch of the axillary nerve
A young teenager attends the fracture clinic for a review of a fracture to his tibia and fibula. He has removed his plaster of Paris cast, and it is noted that he cannot dorsiflex his foot.
Which nerve has been damaged?
Tibial nerve
Obturator nerve
Sural nerve
Common peroneal nerve
Femoral nerve
Common peroneal nerve:
- emerges and divides into the superficial and deep peroneal nerves. The latter innervates the tibialis anterior, the main dorsiflexor of the foot.
Foot drop occurs because of which nerve being damaged? [1]
Common peroneal nerve injury
X-ray of the hip demonstrates an uncomplicated, intertrochanteric fracture.
What is the most appropriate management of this patient?
Total arthroplasty
Dynamic hip screw
Hemi-arthroplasty
CT to further characterise the fracture
MRI to further characterise the fracture
X-ray of the hip demonstrates an uncomplicated, intertrochanteric fracture.
What is the most appropriate management of this patient?
Dynamic hip screw
Common peroneal nerve injury presents as [3]
foot drop, weakness in foot eversion, and numbness over the dorsum of the foot
PC: Pain in forearm; hot and sweaty; shiny skin
PMH: Carpal tunnel syndrome surgery two months ago
Dx? [1]
Complex regional pain syndrome
[] and [] of the shoulder are highly suggestive of frozen shoulder
**Pain at night and on both active and passive movement **of the shoulder are highly suggestive of frozen shoulder
Cervical fracture x unable to support own airway.
What is the best method to maintain airway? [1]
Jaw thrust
A patient presents with symptoms of spinal cord compression.
What is the immediate management plan? [3]
Dexamethasone 16mg, urgent neurosurgical referral, MRI whole spine
lower back pain, radicular pain affecting both lower limbs and Neurogenic claudication = ? [1]
Spinal Stenosis
When does carpal tunnel often present worse? [1]
Why? [1]
Often worse at night
- people sleep weird angles; also lower BP
What is a key differential for spinal stenosis? [1]
How would you differentiate between them? [1]
Explain the differences in cause of presentation [1]
Peripheral vascular diseaes:
Both present with intermittent claudification
But spinal stenosis:
- neurogenic claudication caused by increased metabolic demands of compressed nerve roots that have become ischemic due to stenosis
PVD:
- vascular claudication, or pain in the legs while walking, is caused by insufficient blood flow
What are the red flags for lower back pain? [5]
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
NB: thoracic back pain is also a red flag
Compartment syndrome is most commonly associated with [] and [] fractures
Compartment syndrome is most commonly associated with supracondylar and tibial shaft fractures
A ptx fractures their ribs; severe pain; normal analgesia isn’t working.
What is the next appropriate step in managing the patient? [1]
Nerve blocks may be considered if a rib fracture is not controlled by normal analgesia
the combination of severe lower back pain, fever, and malaise x tenderness over lumbar spine = ? [1]
discitis
What is Meralgia parasthetica? [1]
What can it be caused by? [1]
Meralgia parasthetica: is an entrapment mononeuropathy of the LFCN - lateral femoral cutaneous nerve
Meralgia parasthetica can be caused by sudden weight gain
It most commonly originates from the L2/3 segments.
Knee locking and giving-way are common features of [] lesions
Knee locking and giving-way are common features of meniscal lesions
Dx of osteomyelitis; what part of the bone is most commonly affected in children?
Metaphysis
Diaphysis
Epiphysis
Periosteum
Medullary cavity
Metaphysis
- highly vascularised
Osteomyelitis most commonly affects which part of the bone in:
- adults [1]
- children [1]
Adult: epiphysis
Children: metaphysis
Describe this fracture [1]
Buckle, or torus, fractures are incomplete fractures of the shaft of a long bone that is characterised by bulging of the cortex
NB: Buckle is lower down than a salter harris
[] is the initial imaging modality of choice for suspected Achilles tendon rupture
Ultrasound is the initial imaging modality of choice for suspected Achilles tendon rupture
What is the Thompson test and how do you interpret it? [2]
The calf squeeze test, also known as the Thompson test:
* A positive result (i.e., no movement of the foot) indicates a likely rupture of the Achilles tendon.
* A negative result (i.e., normal plantarflexion of the foot) does not definitively rule out an Achilles tendon rupture.
What is the difference between Osgood-Schlatter to Osteochondritis dissecans? [1]
Osteochondritis dissecans (OCD) is a pathological process affecting the subchondral bone (most often in the knee joint) with secondary effects on the joint cartilage, including pain, oedema, free bodies and mechanical dysfunction
Osgood-Schlatter disease is an apophysitis of the tibial tuberosity that causes anterior knee pain during adolescence and is usually self-limiting.
- It is thought to occur as a result of repetitive strain from the patella tendon at its insertion on the ossification centre (apophysis) of the tibial tuberosity.
Desribe the difference in presentation between OCD and Osgood-Schlatter [1]
Osteochondritis dissecans typically presents with knee pain after exercise, locking and ‘clunking’
Osgood-Schlatter disease may cause similar symptoms in children and adolescents but the pain is usually localized to the tendinous insertion with overlying tibial tuberosity tenderness and swelling.
Dx? [1]
Left subcapital fracture
- This diagnosis is based on the presence of a fracture line through the neck of the femur, just below the head, which is characteristic of a subcapital hip fracture.
A patient presents after a fall, and an x-ray demonstrates lateral talar shift and a fibular neck fracture. What is the eponymous name of this injury?
* Bosworth fracture
* Duverney fracture
* Maisonneuve fracture
* Segond fracture
* Tillaux fracture
- Maisonneuve fracture
What mechanism of injury would cause a Maisonneuve fracture? [1]
The mechanism for this injury is forceful pronation and external rotation of the ankle.
X-ray features consistent with a [] fracture include an intra-articular fracture of the base of the first metacarpal bone
The mechanism for this injury is forced abduction of the thumb.
Bennet fracature
[type of fracture] would appear as an ulnar shaft fracture with dislocation of the radial head at the elbow
Monteggia fracture
What is a raised fat pad sign? [1]
If the anterior fat pad is raised away from the humerus, or if a posterior fat pad is visible between triceps and the posterior humerus, then this indicates a joint effusion:
- n the setting of trauma this is due to haemarthrosis (blood in the joint) secondary to a bone fracture. This is often the only X-ray sign of a bone injury.
Describe this fracture [2]
Describe the position of the humeral head in an anterior dislocated shoulder [1]
The dislocated humeral head usually lies in a subcoracoid position.
Describe the difference in mechanism of injury for medial meniscus injury and ACL injury x [2]
MM: loaded twist
ACL: valgus force (blow to outside –> inside of the knee)
Describe what is meant by thoracic outlet syndrome [1] and what the common presentation is like [3]
neurovascular disorder that can be caused by compression of the brachial plexus (neurogenic) or of the subclavian vessels (vascular):
- Neurogenic presentation is by far the most common (>95% of cases): neck and should pain; numbing and tingling; muscle wasting
- Trapezius pain combined with sensory symptoms that are often exacerbated by overhead activities is a typical presentation of neurogenic thoracic outlet syndrome
What is Spurling’s sign and what pathology does it indicate? [2]
diagnosis of cervical radiculopathy
Which form of cancer typically shows a sunburst appearance on x-ray of a bone? [1]
Osteosarcoma
Which form of cancer typically shows a moth-eaten pattern of bone destruction? [1]
Chondrosarcoma
This patient has an associated nail damage.
What is the name of the fracture?
Mallet
Seymour
Tuft
Barton’s
This patient has an associated nail damage.
What is the name of the fracture?
Mallet
Seymour
Tuft
Barton’s
Mallet
Seymour
Tuft
Barton’s
Mallet
Seymour
Tuft
Barton’s
What Garden stage is this fracture? [1]
Why? [1]
3 - complete; moderately displaced
Where would you expect weakness in an L3 slipped disc? [1]
L3: Weak hip flexion, knee extension and hip adduction
MCL rupture comes from what mechanism? [1]
How does it present? [3]
Mechanism: leg forced into valgus via force outside the leg
* Knee unstable when put into valgus position
What does the red arrow show? [1]
Lipohaemarthrosis is seen when fat and blood from the bone marrow goes into the joint and it is usually seen in long bone fractures with intra-articular involvement. The fact that this patient just sustained an intra-articular fracture makes this finding even more likely.
Which pathology would a “Rocker bottom foot’ refer to? [1]
Charcot joint
- when the bones in the middle of your foot break down and collapse and lose the arch
Describe how a Charcot joint would present? [3]
Warm; Swollen; Red; Pain
Usually localised unilateral swelling
May initially look like an infection but as time goes on will continue to form Rocker foot
How does the shape of the shoulder change when acromioclavicular joint dislocation occurs? [2]
Superior aspect of clavicle: more prominent
Get loss of shoulder contour
What type of fracture is most likely to cause compartment syndrome in arm [1] and leg [1]
Arm:Supracondylar
Leg: tibial shaft fracture
Blue sclera x multiple fracutres = ? [1]
Osteogenesis imperfecta
A fracture over the hypothenar eminence would most likely impact which bone? [1]
How would you test for this? [2]
Hamate bone
Tests
tenderness over the hook of hamate
* most common finding (80% sensitivity)
**hook of hamate pull test **
- hand held in ulnar deviation as patient flexes DIP joints of the ulnar 2 digits against resistance
Describe the presentation of Marfans [+]
- Upwards lens dislocation
- A. root dilatation
- Mitral valve prolapse
- Hypermobile joints
- Pectus exvatacum
- High arch palate
- Flat feet
Describe a method of remembering the different types of Salter-Harris fractures [5]
Type 1: S - Straight through
Type 2: A - Above
Type 3: - L Lower
Type 4: - T Transverse
Type 5: - R Rammed
Thurstan-Hollan segment refers to which Salter-Harris Classification? [1]
Type 2
Describe what is meant by myositis ossificans [1]
Describr an important ddx and how you would differentiate? [1]
Heterotrophic ossification in large muscles usually precipitated by prior trauma 2-6 weeks ago
- Mimics sarcoma; distinguish with biopsy
Describe the mechanism and features of ACL injury [3]
Pop; acute and quick swelling; pain
Sudden twisting; planting and turning movement
Describe the mechanism and features of PCL injury [1]
How do the bones reposition themselves afterwards? [1]
Hyperextending leg
* Tibia lies on femur
Describe the mechanism of MCL injury [1]
Leg forced into valgus position via force from outside of leg
When do you get pain in cubital nerve compression? [1]
Where do you get sensory nerve disturbance? [1]
Pain at medial flexion
Sensory disturbance at 4th and 5th digit and hypothenar eminence
The crescant sign refers to what pathology? [1]
the crescent sign is a finding on conventional radiographs that is associated with avascular necrosis
