SCRUBS work

Question 1

ligaments of wrist

Answer 1

radial and ulnar collateral ligaments -> limit ulnar and radial deviation

palmar radiocarpal -> limit extension

dorsal radiocarpal -> limit flexion

Intercarpal and carpometacarpal -> intrinsic

Question 2

palmaris brevis

Answer 2

ulnar nerve

protects ulnar artery and nerve

deepens cup of palm

Question 3

wrist frxs

Answer 3

Distal radius/ulna:

• Colles’ frx: hyperexternsion, fall on oustretched hand, dinner fork deformity, distal fragment displaced posteriorly w/ posterior tilt
• Smith’s/Reverse Colles’ frx: hyperflexion, garden spade deformity, distal fragment displaced anteriorly w/ anterior tilt
• scaphoid: fall on outstretched hand, frx across waist of bone, pain in anatomical snuff box, difficult to diagnose on x-ray, treatment: splint and immobilise, risks: avasc. necrosis of prox. segment, non union, surgery may be necessary

Question 4

hand frxs

Answer 4

MC frx: direct axial force/ compressive force, pain and swelling - possible angular/rotational deformity, management: RICE (rest, ice, compression, elevation), analgesics followed by xrays, deformity is reduced, splinting, unstable frx may need to be surgically pinned

-boxer’s frx (pic): frx of 5th MC w/ volar (palm of hand) displacement of MC head, due to striking an object w/ a clenched fist

Question 5

Dupuytren’s contracture

Answer 5

cause: progressive thickening/shortening of palmar fascia, nodules develop in palmar aponeurosis, limiting finger extension, ultimately causing flexion deformity

S&Ss:often develops in 4/5th finger, flexion deformity at MCPJs and Prox. IPJs

management: surgical excision of fibrotic tiss

Question 6

tenosynovitis

Answer 6

pain, swelling, difficulty in movement, spread of infection from 1st and 5th flexor sheaths into the forearm

inflammation of synovial sheath

Question 7

ulnar nerve injury at wrist

Answer 7

causes: compression between pisiform and hamate - handlebar neuropathy, penetrating wound, injury posterior of medial epicondyle

sensory loss: hypoesthesia in med. 1.5 digits

motor loss: weakness of intrinsic muscles ulnar nerve supplies

deformity: prominent ulnar claw
- 4th and 5th MCPs hyperextended (due to unopposed ex. dig.)
- 4th and 5th IPs flexed (unopposed FDS and FDP)
- flat hypothenar eminence
- > however, in ulnar paradox, the ulnar nerve is lacerated further up the arm beyond the point where it innervates the FDP -> the med. 2 digits are extended and look better when in fact the injury is worse

Treatment: padding (gloves), ice, NSAIDs

Question 8

articulations and ligaments of elbow joint

Answer 8

Articulations: ant: head of radius w/ capitulum of humerus, trochlea of humerus w/ trochlear notch of ulnar

post.: olecranon process of ulna w/ olecranon fossa of humerus

Ligaments: 2 radial ligaments, 1 ulnar ligament - anterior, posterior, oblique, annular ligament around head of radius, all stabilise

Question 9

pulled elbow

Answer 9

in children esp girls, eg when pulled up a kerb

weak annular ligament and under development of head of radius, forearm is abducted and med. rotated

subluxation of joint

gentle supination and compression needed and, after a few days, the radius pops back in

Question 10

4 frxs to humerus and nerves damaged

Answer 10

frx to surgical, anatomical neck of humerus, axillary

mid humeral frx, radial

supracondylar frx, median

ulnar nerv is also vulnerable as it lies unprotected behind the medial epicondyle

Question 11

nerve routes passing distal humerus

Answer 11

radial: anterior to lat. epicondyle
median: anterior to med. epicondyle
ulnar: posterior to med. epicondyle

Question 12

medial and lateral epicondylitis

Answer 12

medial/golfer’s elbow: repeated use of flexors, pulls on periosteum of med. epicondyle

lateral/tennis elbow: repetitive use of superficial extensors of forearm, pain radiates down post. apsect of forearm as it can lead ot radial nerve compression

-inflammation of periosteum of lateral epicondyle (ie the epicondylitis)

Question 13

student’s elbow

Answer 13

repeated pressure on and inflammation of olecranon bursa, local anaesthetics, drainage, steroids, surgical excision

Question 14

subtendinous bursitis

Answer 14

not common, deeper bursa, triceps tendon and olecranon involced, can lead to tendon calcification, deeper bursa than one in student’s elbow

Question 15

olecranon frx

Answer 15

fall on elbow, triceps pulls olecranon prximally, surgical intervention - pin, ulnar nerve can be damaged

Question 16

ligaments of shoulder joint

Answer 16

gleno humeral ligaments reinforce anterior aspect of capsule, coracohumeral and coracoacromial strengthen superiorly

Question 17

shoulder dislocation

Answer 17

normally anterior, fall on outstretched hand

Question 18

painful arc syndrome

Answer 18

supraspinatus tendinitis, subacromial bursitis

on ACTIVE abduction, scapulo-humeral rhythm is disturbed

pain is worsened on abduction between ~60-120 degrees, either side of this pain is not there

Question 19

origins and insertions of rotator cuff muscles

Answer 19

Supraspinatus: supraspinous fossa of scapula -> superior facet of greater tubercle of humerus

Infraspinatus: infraspinous fossa of scapula -> middle facet of greater tubercle

Teres minor: middle part of lat. border of scapula -> inferior facet of greater tubercle

Subscapularis: subscapular fossa -> lesser tubercle of humerus

Question 20

whiplash associated disorder/WAD

Answer 20

h.flexion -> h.extension -> sp/train cervical tissues, can occur when going slowly - 10mph, 1-4 seriousness (4 most), cervical spine most at risk from sideways impact (less ligamentous support), cervical lateral x ray - loss of lordosis due to neck muscles spasming, may have a lack of symptoms for a few weeks

Question 21

ligaments of the spine

Answer 21

Anterior Longitudinal ligament: stronger than PLL, gets broader from cervical -> lumbar spine, attaches to periosteum of vert. bodies and does not attach to intervert. discs

Posterior Longitudinal Iigament: weaker than ALL, narrower from cervical -> lumbar spine, serrated margins which attach to the intervert. discs but are free over the vert. bodies, separated from vert. bodies by basivertebral veins

Question 22

differences between vertebral bodies: atlas and axis

Answer 22

atlas/C1: no body or spinous process, large lateral masses w/ widest transverse processes of cervical vertebrae to hold up the cranium

axis/C2: strongest of cervical vert., two large superior articular facets that the atlas can rotate on, dens/odontoid process projuects superiorly, held in place against post. aspect of ant. arch of the atlas by transverse ligament of the atlas

Question 23

differences between cervical, thoracic and lumbar:

Answer 23

cervical: small oval body, large triangular vertebral foramen, transverse process had transverse foramina containing vertebral artery and vein, short and bifid spinous process (C3-6)

Thoracic: heart shaped body w/ 1/2 costal facets for articulation w/ ribs, circular and smaller vertebral foramen than cervical, long and strong transverse process w/ a decreasing length between T1-12, long spinous process that slopes postero-inferiorly

Lumbar: massive kidney shaped body, triangular foramen that is larger than thoracic’s but smaller than cervical’s, long and slender transverse process, short, thick and sturdy spinous process

OVERALL: as you go down the vertebral column, the foramen gets smaller, the body gets bigger

Question 24

kyphosis and lordosis commonly due to

Answer 24

K: OP (anterior wedging of thoracic vertebrae)

L: pregnancy, obesity, or weak abdominal muscles

Question 25

OA (of spine in particular)

Answer 25

degeneration (wear and tear) or articular cartilage and underlying bone, often affects unilateral joints, aggravated by movement, relieved by rest -xray findings: joint space narrowing, subchondral sclerosis, osteophytes, subarticular cysts, bone spurs in spine commonest form of arthritis, risk factors include age, obesity, previous trauma mainly affects knee, hand, hip and pine joints (whereas RA is mainly hands

Question 26

RA (of spine in particular)

Answer 26

autoimmune, systemic inflammatory disease, affects large joint bilaterally, atlanto-axial instability, commonly affects hand joints x ray findings: decreased joint space (like OA), marginal erosions (different to OA), osteopenia (low bone mineral density), joint subluxation, soft tissue swelling in picture the axis and atlas have sublaxed

Question 27

scoliosis

Answer 27

lateral deviation structural causes: fixed, fails to correct, can be due to hemivertebra (vertebra not completely developed on one side, wedge shaped), OP, developmental problems non structural causes: can be due to leg length inequality, weak muscles

Question 28

ankylosing spondylitis

Answer 28

fusion of joints, similar to RA in that it affects 2 joints and gets better after exercise and worse after rest a systemic inflammatory disease most likely in young males, linked w/ UC and chron's (HLA-B27 antigen) when severe it can lead to fusion of facet joints, SI (sacroiliac) joints tiredness, malaise, initial weight loss tests: blood CRP, HLA-B27, MRI

Question 29

herniation of IV discs

Answer 29

nucleus pulposus ruptures through the annulus fibrosis (jam doughnut analogy), most commonly at L5/S1, then L4/5, commonly leads to flexion compression of ventral root -\> motor symptoms classic sciatica symptoms (compression of spinal roots that lead to sciatic nerve), ventral and dorsal horn affected assess the neurological function of limbs (sensory, motor, reflex), SLR (straight leg raise), palpate spine SLR: lie on back, relax leg in hand, raise leg, pain above 30 degrees

Question 30

cauda equina

Answer 30

medical emergency, need urgent decompressive surgergy centro-posterior herniation of IV discs or spinal tumour symptoms: saddle anaesthesia (numbness around genitalia and buttocks), urinary a/o faecal incompetence (due loss of anal tone, though it may just be changing bowel habit), neurological deficit - functional abnormality of a body area due to a decrease in the function of the brain, spinal cord, muscles or nerves (normally bilateral)

Question 31

relationship between spinal nerves and vertebra

Answer 31

there are 7 cervical vertebrae, but 8 cervical nerves -\> the nerves are always located on top of the vertebra nerve C8 lies between vertebrae C7 and T1 after that, the nerve lies underneath its vertebra

Question 32

roles of the ligaments of the hip joint

Answer 32

iliofemoral: ant. and sup., prevents h.extension pubofemoral: ant. and inf., prevents over abduction ischiofemoral: post., weakest and has little function ligament of the head of the femur: from acetabular notch -\> fovea for the ligament of the head of the femur, little function in strengthening joint, but contains the artery to the head of the femur, which supplies the epiphysis especially in children

Question 33

femoral canal

Answer 33

borders: anterosuperiorly inguinal ligament, post. pectineal ligament lying anterior to the superior pubic ramus, med. lacunar ligament, lat. femoral vein canal has space for the femoral vein to dilate during exercise, also contains lymphatic vessels and lymph nodes embedded in areolar tissue

Question 34

mid inguinal point/midpoint of inguinal ligament

Answer 34

midpoint directly between ASIS and pubic symphysis, femoral pulse found here/midpoint along the inguinal ligament length, used for a femoral nerve block (injection of local anaesthetic for pain relief)

Question 35

types of hip frx

Answer 35

subcapital: intracapsular, high up neck, near head, can tear and damage joint capsule and disrupt blood supply cervical: neck, w/in margins of capsule - in either of these, retinacular arteries from medial circumflex artery disrupted -\> blood supply halted -\> avascular necrosis as only artery to head of femur remains - \>commonest in elderly, injured limb appears shorter and laterally rotated (frx large injury -\> lat. rotated, disloc. medium injury -\> med. rotated) pertrochanteric: extracapsular, intertrochanteric region

Question 36

dislocations of hip

Answer 36

acquired: posterio-inferior dislocation - when hip is flexed + adducted + medially rotated - presentation is limb shortening and med. rotation - can cause compression of sciatic nerve leading to paralysis of hamstring muscles and muscles distal to knee, sensory deficits in leg congenital: due to abnormal angle of neck of femur, most common in girls

Question 37

+ve trendelenburg

Answer 37

caused by superior gluteal nerve lesion, frx of greater trochanter (glut med attaches here), dislocation of hip joint abductors maintain a level position when opposite limb is unsupported (in swing phase), results in waddling gait (raising pelvis), steppage gait (lifting foot) or swing-out gait (foot out laterally)

Question 38

possible causes of swelling in popliteal fossa

Answer 38

popliteal aneurysm (pulsatile swelling) baker's cyst (swelling of semimembranosus tendon or herniation of synovial membrane) abscess tumour enlarged lymph nodes

Question 39

unhappy triad

Answer 39

lateral impact during extension medial meniscus, medial collateral and anterior cruciate damaged can tell by performing ant/post draw test, collaterals

Question 40

menisci tears

Answer 40

in young people it can be due to a sporting injury, twist of knee/direct tackle, in the elderly it is weakened w/ age True locking: something physically gets in the way stopping extension eg meniscus, stuck in about 20-30 degrees of flexion, can flex beyond that, but extension is stopped Pseudo locking: pain inhibits knee movement, can be due to inflam arthritis, gout, septic arthritis

Question 41

dislocation of patella

Answer 41

direct blow/sudden twist of knee weakness invastus medialis causes the patella to dislocate laterally w/ a lot of pain and effusion (seeping of fluid into body cavity) more common in women due to an increased q angle (angle between line from ASIS -\> patella and patella -\> tibial tuberosity, in women it should be less than 22 degrees, in men less than 18)

Question 42

pulled hamstring

Answer 42

common in those who run a/o kick hard eg running, jumping, football violent muscular exertion can tear part of the prox. attachments to the ischial tuberosity extremely painful

Question 43

bursa/bursitis of knee

Answer 43

pre-patellar bursa -\> housemaid's knee (caused by one off large injury eg fall onto knee, or many minor injuries commonly from kneeling) subcutaneous infrapatellar bursa -\> clergyman's knee (from kneeling a lot again, esp. on hard surfaces which is what clergymen used to do) suprapatella bursa deep infrapatellar bursa

Question 44

compartment syndrome

Answer 44

raised intra-compartmental pressure -\> intra arterial pressure -\> arterial occlusion -\> ischaemia presentation: 6 Ps: pain, paresthesia, perishing cold, pallor, pulselessness, paralysis

Question 45

roots of sciatic nerve, supply and termination

Answer 45

sacral plexus (anterior and post. divisions of ant. rami of L4-S3) supplies all hamstrings and hamstring portion of adductor magnus -also indirectly lower leg and foot sensory innervation bifurcates into tibial (all hamstrings) and common fibular (short head of biceps femoris)

Question 46

roots of gluteal nerves, supply and termination

Answer 46

Superior: post. L4-S1, glut med, min and TFL, enters sup. to piriformis and goes as far as TFL Inferior: post L5-S2, glut max, divides into several branches at the inf. part of glut. max.

Question 47

pott's frx

Answer 47

mech. forced foot eversion deltoid ligament pulls on med. mall. and causes avulsion talus displaced lat. and post. and causes avulsion of lat. mall., bimalleolar frx

Question 48

varicose veins

Answer 48

long dilated tortuous superficial veins due to incompetent valves at sapheno-femoral/-popliteal or perforator junctions (where perforator veins enter muscles) -venous stasis/stagnation is a cause of this, and can be due to a) incompetent/loose fascia that fails to resist muscle expansion, b) external pressure eg bedding in hospital or a tight cast or c) muscular inactivity eg from a long flight risk factors: prolonged standing, obesity, pregnancy, family history, oral cont. pill surgery can be used

Question 49

medial malleolus relations to vessels

Answer 49

posterior: Tom (tibialis posterior), Dick (FDL) and (post. tibial artery) very/bloody (posterior tibial vein) nervous (tibial nerve) Harry (FHL) anterior: long saphenous vein, saphenous nerve

Question 50

apparent and true limb shortening

Answer 50

Apparent: xiphisternum/xiphoid process or umbilicus-\> med. malleolus -looks at eg fixed joint deformity, pelvic tilt True: from greater trochanter of femur/ or ASIS -\> med. malleolus -looks at actual loss of bone length

Question 51

why does a peripheral nerve lesion -\> skin becoming red -\> dry and scaly?

Answer 51

peripheral contains sensory, efferent and autonomic fibres, loss to SyNS fibres can lead to loss of vasoconstriction to skin -\> vasodilation and redness from increased blood flow to the skin -\> loss of innervation to sweat glands -\> dry then scaly

Question 52

flexor retinaculum attachments

Answer 52

medially: pisiform and hook of hamate laterally: tubercle of scaphoid and med. part of volar surface and ridge of trapezium

Question 53

femoral ring borders and contents

Answer 53

lat. : vert. septum between femoral canal and vein post. : superior ramus of pubis covered by pectineus muscle and fascia med. : lacunar ligament ant. : med. part of inguinal ligament contents: base of the femoral canal