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
A 67 year old male on the vascular ward is reviewed. They have longstanding poorly controlled type 2 diabetes, obesity, foot ulcers, hypertension and hypercholesterolaemia. They complain of pain in their 3rd toe, where they recently had an ulcer. On examination, there is acute tenderness and crepitus on palpation and spreading erythema. The patient is febrile, other observations are normal.
What is the most likely dx? [1]
Clostridium perfringens is a common cause of gas gangrene (clostridial myonecrosis), characterised by crepitus (due to gas production), acute tenderness, erythema, and systemic signs like fever
Osteogenesis imperfecta is a disorder of type [] collagen
Name some presenting features [3]
Osteogenesis imperfecta is a disorder of type 1 collagen
- Brittle bones manifesting in frequent breaks are a common problem.
- Abnormally coloured sclera
- brittle, translucent teeth are also frequently seen in those with osteogenesis imperfecta
Describe the presentation of a supracondylar fractur of the humerus [1]
Which nerve is damaged? [1]
Ulnar nerve damage:
- Loss of sensation to the palmar aspects of the first and second fingers of the right hand and weakened right wrist flexion
Describe why unimpacted fractures of the femoral shaft are typically associated with shortening of the limb? [1]
The proximal segment of a fractured femur is flexed by the iliopsoas and abducted by the gluteus medius and minimus, while the adductors pull the distal segment medially; contraction of these muscle groups produces shortening of the limb.
Explain exactly what a Boxer’s fracture is [1]
Describe the treatment options depending on the level of fracture [2]
Boxer’s fracture:
- a break in the fifth metacarpal typically caused by punching
Treatment:
Non-operative management typically involves immobilization with a splint or cast
The indications for surgery are:
* Significant rotation or angulation of the affected fingers.
* Articular involvement of the fracture.
* Multiple metacarpal fractures.
* Open fractures.
Which carpal bone is most likely to dislocate? [1]
Scaphoid
Hamate
Capitate
Pisiform
Lunate
How would this present? [3]
Why? [1]
Lunate
- wrist pain and weakness of the thumb and index finger of the hand
- weakness in ability to oppose the thumb
- loss of sensation over the palmar aspect of the lateral fingers of his right hand.
- due to the lunate bone typically dislocates anteriorly into the carpal tunnel and compresses the median nerve, resulting in wrist pain, altered sensation in the lateral finger’s palmar aspect, and weakness in thumb opposition.
NB: the scaphoid is the most likely to fracture, not dislocate
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.
What is the most likely cause? [1]
In ruptured posterior cruciate ligament the tibia lies back on the femur and can be drawn forward during a paradoxical draw test.
Describe what is happening at point F [1]
Juxta-articular osteopenia refers to a reduction in bone mineral density (BMD) that occurs near the joint (juxta-articular means “next to the joint”
A patient reports having ‘a pebble in their shoe’
What is the most likely diagnosis? [1]
Morton’s neuroma
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
Describe exactly what Finklestein’s test is [1]
ulnar deviation of the hand with the thumb fully flexed and fingers wrapped around it
Ptx presents with:
* wrist drop.
* 0/5 power in wrist extension and weakened triceps extension
Where is their nerve lesion? [1]
very high radial nerve injury (at the axilla)
NB: Radial nerve motor function: Innervates triceps brachii and the extensor muscles in the forearm
How does a posterior hip dislocation present [3]
leg is adducted, shortened and internally rotated
Posterior hip dislocation - ISAd :(
Describe the difference in the presentation of a low, high and very high radial nerve injury [3]
Low radial nerve injury:
- difficulty extending fingers (finger drop) but sensation would be intact
High radial nerve injury:
- difficulty extending his wrist (wrist drop) on top of having finger drop
Very high radial nerve injury:
- tricep weakness on top of having wrist and finger drop
How does median nerve injury present? [1]
Where does median nerve injury usually occur? [1]
Median nerve injury usually happen at the wrist:
- not be able to form a complete fist and reduced sensation over the median distribution of the hand.
How does ulnar nerve injury present? [1]
Where does ulnar nerve injury usually occur? [1]
ulnar nerve injury may happen as a result of a fracture at the elbow :
- findings such as claw hand or inability to make a complete fist
- also be reduced sensation over the hypothenar eminence.
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]
Where is the most common site for bone mets? [1]
Thoracic spine
What are the risk factors associated with osteosarcoma? [+]
- Age 10-20
- Paget’s disease
- Radiotherapy
- Rothmund-Thomson syndrome
- Familial retinoblastoma syndrome
- Li-Fraumeni syndrome
- Fibrous dysplasia
What is the Lhermitte phenomenon, and when does it occur? [2]
Painful “electric shock” sensation elicited by neck flexion.
It occurs in cervical spondylotic myelopathy, and may also occur in myelitis (including multiple sclerosis).
Which of the urethral sphincters is under voluntary control and what is its innervation? [2]
External urethral sphincter is under voluntary control through the pudendal nerve (S2-S4).
What is the first line treatment for spasmodic pain in palliative care? [1]
Diazepam
What is the electrolyte derangement commonly found in metastatic bone disease?
Hypercalcaemia
Which carcinomas are most likely to metastasise to bone? [5]
- Breast
- Lung
- Thyroid
- Renal
- Prostate
Describe the position of the humeral head in an anterior dislocated shoulder [1]
The dislocated humeral head usually lies in a subcoracoid position.
What do Hill-Sachs deformity & Bankart lesions specifically refer to? [2]
Hill-Sachs deformity
- Posterolateral humeral head depression fracture, resulting from the impaction with the anterior glenoid rim
Bankart lesions
- Injuries specifically at the anteroinferior aspect of the glenoid labral complex
NB: often seen together
Describe how the shoulder works and why this results in more anterior dislocations than posterior [1]
Most of our use of shoulder involves outward rotation and abduction of shoulder like in throwing position. Almost all the sports, involves that action.
Now in that position, the humeral head is forcing itself anteriorly and its kept inside the joint firm by contraction of rotator cuff muscles and the ligament restraints of glenoid socket.
Whenever, the force of action overpowers the capability of rotator cuff and shoulder ligaments to restrain shoulder, dislocation occurs.
Very few actions need forcing of humeral head in posterior direction. Hence anterior dislocation is much more common than posterior.
The only time posterior dislocation occurs is during epilepsy. In epilepsy, all the muscles contract violently. The stronger anterior subscapularis muscle of rotator cuff overpowers the posterior muscle (infraspinatus) and posterior dislocation occurs.
After dynamic hip screw, what advice do you give regarding weight bearing? [1]
The aim of hip fracture surgery is to allow immediate post-operative weight bearing
As a guide, a QFracture score ≥ []% means a [] should be arranged
As a guide, a QFracture score ≥ 10% means a DEXA scan should be arranged
Medial meniscus vs ACL injury presentations? [2]
Sudden popping sound during athletic activity; knee pain; swelling and instability ACL injury
- also cause rapid haemarthrosis and swelling
. Catching or locking of the knee with an inability to extend fully or bend the joint is seen in a ruptured medial meniscus.
- whilst meniscal tears normally take a while longer (~24hrs) to swell up
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)
What is a ganglion? [1]
A ganglion presents as a ‘cyst’ arising from a joint or tendon sheath. They are most commonly seen around the dorsal aspect of the wrist and are 3 times more common in women.
Herniated disc; reflexes normal = lesion where? [1]
reflexes normal -> L5
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
State risk factors for thoracic outlet syndrome [2]
trauma - heamorrhage or displacement; then subsequent fibrosis
lots of overhead exercise can irritate the area, as can strength training that focuses on the muscles around the thoracic outlet
postural element: as rounding the shoulders makes the outlet relatively small.
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
Describe the pattern of Ewing sarcoma on x-ray [1]
like onion skin (multiple layers of new bone formation due to rapid growt
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
A patient has multiple rib fractures, but x-ray reveals they do not have a flail chest segment.
Morphine has been given, but the patient still has considerable pain.
What is the next stage of management? [1]
Nerve block
A [] fracture is a dislocation of the distal radioulnar joint with an associated fracture of the radius
Monteggia fracture
Colles’ fracture
Smith’s fracture
Galeazzi fracture
Boxer’s fracture
A [] fracture is a dislocation of the distal radioulnar joint with an associated fracture of the radius
Monteggia fracture
Colles’ fracture
Smith’s fracture
Galeazzi fracture
Boxer’s fracture
Monteggia ulna (Manchester United), Galeazzi radius (Galaxy rangers)
A [] fracture is a distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation
Monteggia fracture
Colles’ fracture
Smith’s fracture
Galeazzi fracture
Boxer’s fracture
A [] fracture is a distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation
Monteggia fracture
Colles’ fracture
Smith’s fracture
Galeazzi fracture
Boxer’s fracture
What movement is the classic exam q for ACL [1] and PCL? [1]
The classic question for ACl is a football / rugby / tennis player twisting abruptly.
Classic for PCL is car crash.
[] is an effective and commonly used method of analgesia for patients with a neck of femur fracture
An iliofascial nerve block is an effective and commonly used method of analgesia for patients with a neck of femur fracture
You are performing a newborn examination. Which one of the following best describes the clinical findings of a clubfoot?
Inverted + plantar flexed foot which is not passively correctable
Inverted + dorsiflexed foot + pes planus which is not passively correctable
Inverted + plantar flexed foot + pes planus which is passively correctable
Everted + dorsiflexed foot which is not passively correctable
Inverted + plantar flexed foot which is passively correctable
Inverted + plantar flexed foot which is not passively correctable
Whats a good way of remebering if sensitive/specific helps to rule in / out? [1]
Remember SNOUT and SPIN.
SeNsitive tests are good at ruling things OUT.
SPecific tests are good at ruling things IN.
L3 nerve root compression has sensory loss where? [1]
Sensory loss over anterior thigh
L4 nerve root compression has sensory loss where? [1]
Sensory loss anterior aspect of knee and medial malleolus
L5 nerve root compression causes sensory loss where? [1]
S1 nerve root compression causes sensory loss where? [1]
L5: dorsum of foot; medial aspect of food
S1: Sensory loss posterolateral aspect of leg and lateral aspect of foot
Describe the sensory loss in each of L3-S1 if nerve root becomes compressed [4]
L3: Sensory loss over anterior thigh
L4: Sensory loss anterior aspect of knee and medial malleolus
L5: dorsum of foot; medial aspect of food
S1: Sensory loss posterolateral aspect of leg and lateral aspect of foot
Describe the expected change in muscle movements in L3-S1 nerve root compressions [4]
L3: Weak hip flexion, knee extension and hip adduction
L4: Weak knee extension and hip adduction
L5: Weakness in foot and big toe dorsiflexion
S1: Weakness in plantar flexion of foot
Where would you expect weakness in an L3 slipped disc? [1]
L3: Weak hip flexion, knee extension and hip adduction
Where would you expect weakness in an L4 slipped disc? [1]
L4: Weak knee extension and hip adduction
Where would you expect weakness in an L5 slipped disc? [1]
L5: Weakness in foot and big toe dorsiflexion
Where would you expect weakness in an S1 slipped disc? [1]
S1: Weakness in plantar flexion of foot
ACL rupture comes from what mechanism? [1]
How does it present? [3]
Mechanism: high twisting force applied to a bent knee
- loud crack, pain and RAPID joint swelling (haemoarthrosis)
PCL rupture comes from what mechanism? [1]
How does it present? [3]
Mechanism: hyperextension injuries
- Tibia lies back on the femur
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
Medial meniscus comes from what mechanism? [1]
How does it present? [3]
- Rotational sporting injuries
- Delayed knee swelling
- Joint locking (Patient may develop skills to ‘unlock’ the knee
- Recurrent episodes of pain and effusions are common, often following minor trauma
Describe the difference in speed of swelling between ACL and medial meniscus injury? [1]
ACL: rapid swelling
Medial meniscus: delayed swelling
What are the two types of patella fracture? [2]
i. Direct blow to patella causing undisplaced fragments
ii. Avulsion fracture
What mechanism causes a tibial plateau fracture? [1]
knee forced into valgus or varus, but the knee fractures before the ligaments rupture
Describe the appearance of the following types of cancers on x-ray:
- Ewing’s sarcoma
- Giant cell tumour
- Osteosarcoma
- Ewing’s sarcoma: onion skin
- Giant cell tumour: soap bubble
- Osteosarcoma: sunburst
Bite into a raw onion = ew
thus,
onion skin = ewings
What is the most common post orthopaedic surgery complication? [1]
VTE
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
Name three risk factors for avascular necrosis of the hip [3]
Chronic steroid use
Chronic alcohol consumption
Trauma
Chemotherapy
What investigation is first line for avascular necrosis of the hip? [1]
MRI
- Xray may not show any signs of changes for a couple of months
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
Describe what an iliopsoas abscess is [1]
What is the imaging modality of choice? [1]
Collection of pus in ilopsoas compartment / purulent infectious collection within the psoas muscle
CT is optimum imaging choice
What type of fracture is most likely to cause compartment syndrome in arm [1] and leg [1]
Arm:Supracondylar
Leg: tibial shaft fracture
If have knee pain in children - what are your two main differentials and how can you compare? [2]
Osgood-Schlatter
- pain and swelling BELOW kneecap
Osteochondritis dissecans:
- complete or partial detachment of bone
- piece of bone and the attached cartilage break down and become loose.
How do you immediately manage ankle fractures when there is dislocation? [1]
Immediately perform a closed reduction of the dislocation
- otherwise might get NV compromise
Then can perform ORIF etc
What are the managment plans for the different Garden classifications? [3]
Type 1 & 2: Internal fixation
Type 3 & 4: THR of hemiarthoplasty (if older/frail)
What are the management options for non-intracapsular NOFs? [2]
Stable intracapsular:
- DHS
Reverse oblique; transverse; sub. troch:
- intramedullary nail
Blue sclera x multiple fracutres = ? [1]
Osteogenesis imperfecta
Osteogenesis imperfecta causes what change in eye colour? [1]
Blue sclera
Osteogenesis imperfecta occurs because of a defect in which type of collagen
Type 1
Type 2
Type 3
Type 4
Osteogenesis imperfecta occurs because of a defect in which type of collagen
Type 1
Type 2
Type 3
Type 4
EDS occurs because of a defect in which type of collagen
Type 1
Type 2
Type 3
Type 4
EDS occurs because of a defect in which type of collagen
Type 1
Type 2
Type 3
Type 4
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
What is first and second line treatment for carpal tunnel syndrome? [2]
First:
- Wrist splint / steroids / NSAIDs
Second:
- Surgery
How often do you dose:
- Alendronic acid
- Zolendronic acid
Alendronic acid:
- weekly
Zolendronic acid:
- yearly
Describe the presentation of Marfans [+]
- Upwards lens dislocation
- A. root dilatation
- Mitral valve prolapse
- Hypermobile joints
- Pectus exvatacum
- High arch palate
- Flat feet
What is the pathophysiology of Marfans? [1]
Missense mutation of fibrillin
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
Which Salter-Harris classification causes growth arreset? [1]
Type 5 - causes compression of growth plate
Anti-Scl 70 = ? [1]
Anti-Jo. = ? [1]
Anti-Scl 70 - Diffuse systemic sclerosis
Anti-Jo = Dematomyositis
Posterior hip dislocation causes a risk of damaging which nerve? [1]
What are the nerve roots? [1]
Sciatic nerve; L4 through S3
When do you immediately give a DEXA scan? [2]
> 50 and history of fragility fracture
< 40 and major fracture risk
What sign would indicate scaphoid fracture? [1]
Longitudinal compression of pain
- Hold patients thumb and press towards wrist
Describe the position of Boutonniare position [1]
PIP fixed flexion
DIP fixed extension
Imagine doing up buttons
SCA x osteomyelitis = which organism? [1]
Salmonella
+ve sciatic stretch test indicates nerve damage where? [2]
L5 (wouldn’t be able to dorsiflex )or S1 (wouldn’t be ble to plantar flex and decreased ankle reflex)
+ve femoral test indicates nerve damage where? [2]
L3/4
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
How does a tibial plateua fracture occur? [1]
Knee in varus / valgus but ligaments hold
Cubital nerve compression occurs because of what position? [1]
What nerve impacted? [1]
Continue elbow flexion; compression of ulnar nerve
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
How does carpal tunnel syndrome impact action propogation in sensory and motor axons? [1]
Prolongs both
Damage to tibial nerve causes what changes to lower limb movement? [2]
Inhibits foot dorsiflexion
Inhibits foot inversion
Damage to superficical nerve causes what changes to lower limb movement? [1]
Decreases in foot eversion
Damage to deep nerve causes what changes to lower limb movement? [2]
Foot drop - cant plantar flex
Cant extend toes
Cant foot evert
Describe the different x-ray findings in bone mets for different causes of them [5]
PB KTL
PB:
- Sclerotic (Prostate)
KTL
- Lytic - Lungs
Anterior shoulder dislocation causes which deformities? [2]
Hill-Sachs:
- Posterolateral humeral head depression fracture
Bankart:
- Anteriorinferior glenoid compression fracture
Describe the difference in speed of swelling in ACL vs medial men. injury [1]
ACL: rapid swelling
MM: slower swelling
What are the nerve roots for each reflex need to know? [4]
S1-2: ankle reflex
L3-4: knee reflex
C5-C6: bicep reflex
C6-7: tricep reflex
Wake n shake of wrists = ? [1]
Carpal tunnel syndrome
Where is the most common place for a stress fracture? [1]
2nd metatarsal
Frozen shoulder has which reduced movements? [3]
When is pain typically worse? [1]
Reduced IR, ER and abduction
Pain worse at night
Describe the pathophysiology of osteochondritis dessicans [1]
What are the symptoms? [3]
Joint condition where blood supply to section of bone and cartilage decreases causing seperation of the bone and cartilage from surrounding area
- causes swelling after excercise; joint locking and reduced ROM
What are the different DAS-28 scores and their associated classifications of disease severity in RA? [4]
< 2.6 = Disease remission
2.6 - 3.1 = low severity
3.2 - 5.1 = medium severity
> 5.1 = high severity
What is the exact dosing for CES? [1]
Dexamethasone 8mg BD
Ewing sarcoma - causes which x-ray changes? [1]
Which population is genrally affected? [1]
Where does it effect? [1]
Ewing sarcoma:
- onion skin changes
- severe pain
- long bones
- children and adolescants
Chostrosarcoma - commonly affects which bones [1] and population? [1]
Axial skeleton
Older population
Giant cell tumours:
- what x-ray changes? [1]
- Which population? [1]
Bubble wrap / soap bubble signs
20-40 yr olds
Osteosarcoma:
- xray signs? [1]
- Link with which other cancer? [1]
- Population? [1]
- Sunburst
- Retinoblastoma link
- Children and adolescents
How do you decide on the treatment of intracapsular fractures depending on prior patient mobility? [1]
If could previous mobilise: THR
If not: Hemiarthroplasty (cement > )
What is the number 1 reason for THR needing to be replaced? [1]
Aseptic loosening of joint
Firm and well-circumscribed mass that transilluminates on the dorsal aspect of the wrist → []
Firm and well-circumscribed mass that transilluminates on the dorsal aspect of the wrist → ganglion
NB: While fibromas are usually well-defined and firm, they do not transilluminate
Describe how you would manage ganglion cysts? [2]
Management
* ganglions often disappear spontaneously after several months
* surgical excision is indicated for cysts associated with severe symptoms or neurovascular manifestations
Which of the patient’s prescribed medications is most associated with the development of this condition?
Atorvastatin
Bisoprolol
Metformin
Methotrexate
Phenytoin
Phenytoin:
- Dupuytren’s contracture can be a side effect of phenytoin treatment
Describe the result:
- ‘No laxity on valgus stress test’ [1]
‘No laxity on valgus stress test’ means that the medial collateral ligament is intact and is not injured.
A 10-year-old girl is brought to the Emergency Department after falling from a tree swing. She is complaining of pain in the left forearm. An x-ray is requested:
© Image used on license from Radiopaedia
What type of fracture is seen?
Buckle fracture
Greenstick fracture
Salter-Harris type I
Salter-Harris type II
Salter-Harris type IV
Greenstick fracture:
- Unilateral cortical breach only
A 65-year-old man presents to the emergency department with a painful hand following a fall on an outstretched hand. On examination, there is tenderness in the anatomical snuffbox. The hand is neurovascularly intact. Scaphoid view x-rays of the hand reveal a fracture of the proximal pole of the scaphoid.
What is optimal management for this presentation? [1]
All proximal scaphoid pole fractures require surgical fixation
The most likely diagnosis in a patient who presents with bowel symptoms and an axial pattern of arthritis is []
The most likely diagnosis in a patient who presents with bowel symptoms and an axial pattern of arthritis is enteropathic arthropathy
Segund fracture is associated with which injury
MCL
LCL
ACL
PCL
Meniscus tear
Segund fracture is associated with which injury
ACL
An avulsion fracture from the fibular head is known as the…
arcuate sign
reverse Segond fracture
Segond fracture
Stieda fracture
arcuate sign
- The arcuate sign represents an avulsion fracture of the proximal fibula at the site of insertion of the arcuate ligament complex, and is usually associated with cruciate ligament injury.
If a tibial plateau fracture occurs, what specific injury occurs if the force is varus [1] or valgus [1]
**Varus injury **affects medial plateau and if valgus injury, lateral plateau depressed fracture occurs
Describe the affect of damage to the femoral nerve [3]
Weakness in knee extension, loss of the patella reflex, numbness of the thigh
Describe the affect of damage to the lumbosacral trunk [2]
Weakness in ankle dorsiflexion, numbness of the calf and foot
Describe the affect of damage to the sciactic nerve [3]
Weakness in knee flexion and foot movements, pain and numbness from gluteal region to ankle
Describe the affect of damage to the obturator nerve [2]
Weakness in hip adduction, numbness over the medial thigh
How do you differentiate discitis from psoas abscess? [1]
the main differentiating factor would be the location (flank to back) in psoas abscess
- ‘On examination he appears to be in pain and is lying flat on his back with his knees flexed. He actively resists passive movement from his position of comfort and is unable to weight bear due to pain.’ - This suggests psoas sign positive
In discitis you would expect the pain to be more centred over the spine with possible paraspinal muscle spasms.
- likely to co-present with infective endocarditis
if you see patient is lying on back with knees flexed and unable to move due to pain- think []
if you see patient is lying on back with knees flexed and unable to move due to pain- think psoas abscess
Describe what is meant by Leriche sydnrome [3]
Leriche syndrome
Classically, it is described in male patients as a triad of symptoms:
- Claudication of the buttocks and thighs
- Atrophy of the musculature of the legs
- Impotence (due to paralysis of the L1 nerve)
Describe what is meant by Chondromalacia patellae and how it would present [3]
Chondromalacia patellae is damage to the patella. It is like a softening or wear and tear of the cartilage.
Causes:
- pain around knee
- crepitus
- rarely fluid swelling
NB: aka runners knee or patellofemoral pain syndrome
[] injury is a dislocation of the base of the second metatarsal and the medial cuneiform in the midfoot
Lisfranc’s injury is a dislocation of the base of the second metatarsal and the medial cuneiform in the midfoot
Lisfranc’s injury is a dislocation of the base of the second metatarsal and the medial cuneiform in the midfoot
What is the mechanism for this injury? [1]
The injury usually occurs due to a direct force, such as a sudden rotation of the joint during such as changing direction or a forced plantar flexion.
On examination, there is a tender palpable nodule over her right thumb metacarpophalangeal joint. When asked to flex and extend her thumb, she can easily flex it but her thumb catches on the way to full extension.
What is the most likely diagnosis? [1]
Trigger finger
What is the treatment for this? [1]
Dynamic hip screw
* This presentation is typical of an extracapsular hip fracture. There is pain and an inability to bear weight, along with a shortened and externally rotated leg which all suggest an extracapsular fracture.
* Additionally, bruising around the hip joint more commonly occurs with extracapsular fractures as the bleeding is not contained within the capsule.
* The x-ray shows an intertrochanteric fracture of the left hip, which is a subtype of extracapsular fracture.
* The most appropriate treatment for an intertrochanteric fracture is a dynamic hip screw
Which three factors are used for DEXA scan scores? [3]
DEXA scans: the Z score is adjusted for age, gender and ethnic factors
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 fracture has occured? [1]
Fracture of the radial head
- 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 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 fracture? [1]
Galeazzi fracture
mechanisms:
* FOOSH and thumb fracture = [1]
* Punch and thumb fracture = [1]
FOOSH and thumb fracture = Scaphoid
Punch and thumb fracture = Bennett
What test is being described? [1]
A 43-year-old woman complains of right hip pain. During the examination the patient lies prone and the right hip is extended with a straight leg. Flexing the knee then recreates the pain
This is a femoral nerve stretch test
How does cubital tunnel syndrome present? [3]
Why does this presentation occur? [1]
- Claw hand
- Weakness in abduction and adduction of fingers (lumbricals affected)
- Sensory loss in little fingers
Occurs due to ulnar nerve compression
What is a positive Fromont sign and what does it indicate? [1]
Test
* Ask the patient to hold a piece of paper between their thumb and index finger, and then try to pull the paper away.
Positive result
* The patient flexes their thumb to maintain their grip on the paper. This is because they are using the flexor pollicis longus (FPL) muscle, which is innervated by the median nerve, to compensate for the weakened ulnar nerve.
Describe what is meant by Guyons’ canal syndrome and the pathophysiology [2]
How does it present? [3]
Compression of the ulnar nerve at wrist level (aka ulnar tunnel syndrome)
Presentation:
- Weakness in finger abduction / adduction
- Sensory loss in medial / little finger
- Radial deviation during wrist flexion - due to wrist flexors being spared damage
- +ve Fromont sign
Which tendons are affected in DQT? [2]
APL and EPB
Which Schatzker classification is most associated with ACL injuries? [1]
Type 4 - Medial plateau fracture
Foot pain immediately after period of inactivity or start of walking is most likely to be? [1]
Plantar fasciitis
Where is the location of the pain most likely to be in plantar fasciitis? [1]
Where is the location of the pain most likely to be in fat pad atrophy? [1]
PF: Medial aspect of heel
Fat pad atrophy: Central heel pain
Which anti-hypertensive would be most beneifical for someone suffering from osteoporosis. [1]
Why? [1] What is the MoA? [1]
Thiazide diuretics also increase calcium reabsorption at the distal tubule
- increase bone mineral density and will reduce the patient’s risk of further osteoporotic fractures.
- These act by blocking the thiazide-sensitive Na+/Cl− cotransporter found on the apical membrane of the distal convoluted tubules, inhibiting sodium and chloride reabsorption.
A 7-year-old female is taken to the Emergency Department by her parents after she fell onto her arm when playing in the park. On examination, her arm is painful and very swollen. There is no break in the skin and no neurovascular deficit was detected. X-rays were taken and the child was diagnosed with an unstable displaced supracondylar fracture of the humerus.
What is the most appropriate management for this patient?
Application of a collar and cuff with the arm in flexion
Reduction under anaesthesia and application of a collar and cuff with the arm in flexion.
Reduction under anaesthesia and application of an above elbow plaster of Paris
Reduction under anaesthesia and application of a below elbow plaster of Paris
Reduction under anaesthesia pin fixation and application of a collar and cuff with the arm in flexion
A 56-year-old male presents to his General Practitioner (GP) with pain and swelling of the right elbow. He reports feeling generally unwell for the past few days and recalls knocking his elbow while cycling the week before. On examination, he has a temperature of 37.7 °C, a heart rate of 78 bpm, and a blood pressure of 124/78 mmHg. There is a swelling over the posterior aspect of his right elbow, which is erythematous and warm to the touch.
What is dx [1] and tx [1]?
Oral flucloxacillin and refer for urgent aspiration
- This patient has suspected infected olecranon bursitis, characterised by red, hot olecranon swelling, low-grade fever and feeling generally unwell. Empirical antibiotics should be started before culture results are obtained; however, this patient also requires referral to secondary care for urgent same-day aspiration, making this the most appropriate option.
A patient presents with ?CES from malignancy.
What does of dexamethasone should you prescribe? [1]
What should you consider prescribing alongside? [1]
16mg oral dexamethasone + proton pump inhibitor
What is the name for this sign [1]
What does it indicate? [1]
Fromont sign
Ulnar nerve damage
- e.g. in cubital tunnel syndrome
Describe the presentation of cubital tunnel syndrome [2]
Where in the arm is the nerve that is involved damaged? [1]
Compression of ulnar nerve at medial epicondyle
- weak thumb adduction due to paralysis of adductor pollicus longus
- +ve Fromont sign
A patient has a Boxer’s fracture.
Where exactly is this? [1]
What type of splint would be used if it was a uncommunicated, undisplaced fracture? [1]
5th metacarpal
Gutter splint
Describe the McMurray’s test and what positive signs would be [2]
Testing medial and lateral meniscus damage
- MM: with knee extended, passively externally rotate. If pain indicates MM damage
- LM: with knee extended, passively internally rotate. If pain indicates MM damage
Describe the difference in presentation between CES and mets. causing spinal cord compression [+]
CES: LMN damage - hyporeflexia, foot drop
Spinal cord compression - UMN damage - hyperflexia, Babinski sign
A patient has met. bone cancer. What drug could help? [1]
Zoledronic acid
What drug would you give for complex regional pain syndrome? [1]
Amitriptyline
CMS presents as a mix of UMN and LMN signs. State two possible [p2]
Absent ankle reflex
Upwards plantar repsonse
A patient who has a prosethetic joint presents with ?septic arthritis.
What is the next appriopriate mx? [1]
DON’T ASPIRATE
- refer to orthopaedics as joint aspirate should be done in op. theatre
Erb’s palsy is damage at C5/6.
The classic position of the arm is often described as the “waiter’s tip” position:
This is due to the change in which joints? [3]
The classic position of the arm is often described as the “waiter’s tip” position:
* Adducted and internally rotated arm (due to paralysis of the deltoid and infraspinatus).
* Extended elbow (due to loss of biceps function).
* Pronated forearm (due to loss of supinator muscles).
Erb’s palsy is damage at C5/6.
What would the sensory [2] and motor [4] changes be seen in a patient? [+]
Motor Symptoms:
* Weakness or paralysis of the muscles innervated by the C5 and C6 roots (muscles of the upper arm and shoulder):
* Deltoid (C5) – leading to inability to abduct the arm.
* Biceps (C5/C6) – leading to loss of elbow flexion.
* Brachioradialis (C5/C6) – affecting forearm flexion.
* Infraspinatus (C5) – leading to weakness in external rotation of the shoulder.
Sensory Symptoms:
Numbness or reduced sensation in the areas supplied by the C5 and C6 nerve roots:
* Lateral aspect of the upper arm, forearm, and thumb.
Erb’s palsy presents with which reflexes altered? [2]
Biceps reflex (C5/C6) may be diminished or absent.
Brachioradialis reflex may be reduced or absent.
Osteomyelitis tx [1]
drug, length
IV Flucoxacillin for 4 weeks
