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Surgery - Orthopaedics (too much to learn for me) Flashcards

1
Q

In the major haemorrhage protocol, what baseline bloods should be taken pre-transfusion?

A

FBC
Group and save
Clotting
Clauss fibrinogen assay (measures function of fibrinogen)

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2
Q

In which major haemorrhage scenarios can tranexamic acid be given, and how should it be prescribed?

A

If trauma within 3 hours

Dose is 1g bolus over 10 mins followed by 1g infusion over 8 hours

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3
Q

When examining a joint, what 3 things should you assess for?

A

Pain
Effusion
Temperature

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4
Q

What are the 3 main tests to do when examining any joint?

A

Look
Feel
Move

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5
Q

Describe the tests for each muscle of the rotator cuff

A

Supraspinatus tendon: Empty can test
Infraspinatus: External rotation against resistance
Teres minor: Hornblower test
Subscapularis: Internal rotation against resistance

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6
Q

What 2 special tests can be doe on examination for carpel tunnel syndrome? Describe them

A

Tinel’s test: tap along nerve from index finger down through wrist towards antecubital fossa, is positive if tingling or paraesthesia down median nerve as is tapped

Phalen’s test: put hands in like a downwars pray position with backs of hands together, positive if tingling/ paraesthesia in distribution of median nerve

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7
Q

What does the Trendelenburg test assess?

A

Abductor (gluteus medius and minimus) abnormality

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8
Q

What is a positive trendelenburg test?

A

Dip in hip when lifting GOOD side leg

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9
Q

How do you perform Thomas’ test, and what does it assess?

A

Ask pt to lie down, and to bring their knee up to their chest to ‘hug’ it
Positive test = other leg lifts off bed
Tests for fixed flexion deformities eg iliopsoas tightness, ACL tear, osteoarthritis…

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10
Q

How can you identify if leg shortening is tibial or femoral in nature?

A

Galeazzi test
Get pt to lie down, flex hips to 45 degrees and knees to 90 degrees
Test is positive when knees are a different heights
If lower knee displaced towards foot = shortened tibia, if displaced towards body = shortened femur

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11
Q

What can you do on examination to test for Achilles tendon rupture?

A

Simmond’s test

Calf squeeze –> foot movement

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12
Q

What can you do on examination to test for Morton’s neuroma?

A

Mulden’s test

Clasp metatarsals and poke plantar side of foot - positive test will be pain/ tingling

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13
Q

After an orthopaedic examination in PACES, what can you say you would like to do to finish your examination?

A

Assess neurovascular status
Assess joints above and below
Test the contralateral joint

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14
Q

What % of bone matrix is organic vs inorganic?

A

40% osteoid (organic matrix)

60% inorganic

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15
Q

What is osteoid matrix made up of?

A

Protein mix secreted by osteoblasts

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16
Q

Recall the 2 subtypes of lamellar bone

A

Cortical (compact)

Trabecular (cancellous)

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17
Q

What is woven bone?

A

Disorganised bone that forms the embryonic skeleton and fracture callus

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18
Q

What are the 2 types of bone formation?

A
  1. Intramembranous ossification - direct ossification of mesenchymal bone models formed during embryonic development (skull bones, mandible and clavicle for example)
  2. Endochondral ossification - mesenchyme –> cartilage –> bone: most bones ossify this way
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19
Q

What are the 4 stages of fracture healing and how long does each one last?

A
  1. Reactive: first 48 hours
    Reparative phase = 2 days - 2 weeks
  2. Proliferation (reparative phase part 1)
  3. Consolidation (reparative phase part 2)
  4. Remodelling = 1 week - 7 years
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20
Q

Describe the reactive phase of fracture healing

A

Bleeding into the fracture site –> haematoma

Inflammation –> cytokine release –> recruitment of leukocytes and fibroblasts –> granulation tissue

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21
Q

Describe the reparative phase of fracture healing

A

Proliferation of osteoblasts/ fibroblasts –> cartilage and woven bone forms –> callus formation
Consolidation = endochondrial ossification of woven bone to turn it into lamellar bone

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22
Q

Recall the approx healing time for different types of fracture

A

Closed/ paediatric/ metaphyseal/ upper limb = 3 weeks

Open/ adult/ diaphyseal/ lower limb = 6 weeks

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23
Q

Recall some examples of traumatic, stress and pathological fracture

A

Traumatic: direct (assault with metal bar), Indirect (fall on outstretched hand, clavicle #), avulsion
Stress: Foot fracture in marathon runners (particularly 2nd metatarsal)
Pathological: local (tumours), general (osteoporosis, Cushing’s, Paget’s)

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24
Q

What is an avulsion fracture?

A

When small chunk of bone attached to a tendon/ligament gets pulled away from the main part of the bone. Common in young athletes

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25
Q

What radiographs do you need to image a fracture properly?

A

Orthogonal radiographs (at right angles) –> request AP and lateral films

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26
Q

What is an open vs closed fracture?

A

Open breaks the skin, closed doesn’t

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27
Q

What is an extraarticular fracture?

A

One that doesn’t cross the surface of a joint

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28
Q

What is fracture angulation?

A

Where the normal axis of the bone has been altered such that the distal portion of the bone points off in a different direction

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29
Q

What is fracture translation?

A

Movement of the fractured bones away from each other

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30
Q

What are the 4 elements of fracture ‘deformity’ you might comment on?

A

Translation (‘translocation’)
Angulation
Rotation
Impaction

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31
Q

What are the ‘four Rs of fracture management?

A

Resuscitation
Reduction
Restriction
Rehabilitation

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32
Q

Recall the principles of resuscitation in fracture management

A
  1. ATLS - Trauma assessed in primary survey (C spine, chest, pelvis) with secondary survey addressing #
  2. Assess neurovascular status and look for dislocations
  3. Stabilise BEFORE imaging
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33
Q

Recall the ‘6 As’ of managing open fractures

A

Analgesia

Assess: NV status, soft tissues, photograph

Alignment: align # and splint

Anti-sepsis: wound swab, copious irrigation, cover with betadine-soaked dressing

Anti-tetanus: check status (booster lasts 10 years)

Antibiotics: flucloxacillin 500mg IV/IM, benzylpenicillin 600mg IV/IM)

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34
Q

What system can be used to classify open fractures?

A

Gustilo classification

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35
Q

Differentiate the 3 types of fracture in the Gustilo classification in terms of size

A

Type 1: <1cm
Type 2: 1-10cm
Type 3: >10cm

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36
Q

Which of the Gustilo classifications of fracture might involve periosteal stripping?

A

Type 3

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37
Q

If a fracture has been exposed to salt/fresh water, what extra antibiotic coverage will be needed and why?

A

Ciprofloxacin for pseudomonas exposure

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38
Q

Recall the principles of reduction in fracture management

A
  • Displaced fractures should be reduced unless no effect on outcome (eg ribs)
  • Aim for anatomical reduction (especially if articular surfaces involved)
  • Alignment is more important than opposition
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39
Q

What are the principles of restriction in fracture management

A

Based on Wolff’s law
Tissue formed at fracture site depends on strain it experiences
Fixation –> less strain –> bone formation
Also
Fixation –> less pain –> increased stability –> ability to fx

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40
Q

What is the difference between internal and external fixation?

A

Internal: Physically reconnecting bones with screw/plates etc
External: Fragments held in place by pins/ wires connected to an external frame

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41
Q

For open soft tissue injuries, which sort of fixation is best?

A

External

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42
Q

When describing the possible complications of fracture management, under what sub-headings can you classify them? Name some complications under each subheading

A

Anaesthetic - anaphylaxis, damage to teeth, aspiration

Intra-operative - bleeding, damage to local structures (eg neurovascular injury), treatment failure

Early post-operative - compartment syndrome, infection (surgical site, UTI, bed sores), VTE, ABx colitis

Late post-operative - scarring, fx loss, neuropathy, pain, myositis ossificans

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43
Q

What is myositis ossificans?

A

A condition where bone tissue forms inside muscle or other soft tissue after an injury at sites of haematoma formation

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44
Q

Recall 3 possible neurological complications of fracture surgery

A

Neuropraxia (axon preserved, conduction interrupted)
Axonotomesis (Wallerian degeneration of axon, interruption of axon)
Neurotmesis (axon transected - requires surgery)

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45
Q

What is Wallerian degenration?

A

An active process of retrograde degeneration of the distal end of an axon that is a result of a nerve lesion

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46
Q

Describe how compartment syndrome develops

A

Oedema from fracture –> increased pressure –> decreased venous drainage –> increased pressure –> ischaemia

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47
Q

What are the signs and symptoms of compartment syndrome?

A

Pain on passive stretching

Warmth, erythema, swelling, weak pulses, increased CRT

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48
Q

Recall 2 fracture sites that are most associated with compartment syndrome

A

Suprachondylar fractures

Tibial shaft fractures

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49
Q

How should compartment syndrome be managed?

A

Elevate limb, remove all bandages/ splint etc – fasciotomy

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50
Q

Recall the ‘5 Is’ that may cause non-union

A 
Ischaemia (poor blood supply/ AVN) 
Interfragmentory strain 
Intercurrent disease (eg malignancy) 
Infection 
Interposition of tissue between fragments
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51
Q

Into what 2 types can non-union fractures be classified?

A

Hypertrophic (bone end rounded, dense + sclerotic)

Atrophic (osteopaenic bone)

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52
Q

What is Pelligrini-Stieda disease?

A

A form of myositis ossificans where the superior MCL attachment on knee calcifies following trauma

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53
Q

How should myositis ossificans be managed?

A

Excision

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54
Q

What are the previous names for the 3 different types of complex regional pain syndrome?

A

Type 1 = Reflex Sympathetic Dystrophy/ Sudek’s atrophy
Type 2 = Causalgia (persistent pain following injury to a nerve)
Type 3 = Type NOS

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55
Q

Recall 2 criteria that can be used to diagnose complex regional pain syndrome

A

Budapest criteria

IASP criteria

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56
Q

What are the signs and symptoms of complex regional pain syndrome?

A

Affects a NEIGHBOURING area to the area affected by trauma
Hyperalgesia
Allodynia
Vasomotor disturbance (may be hot + sweaty or cold + cyanosed)
Swollen, atrophic and shiny skin
Hyperreflexia/ contractures/ dystonia

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57
Q

Recall some medical and surgical options for managing complex regional pain syndrome

A

Medical: amitriptyline + gabapentin
Surgical: regional nerve block

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58
Q

Recall the signs and symptoms of fat embolism

A

Looks like a PE but with neurological signs
Onset of dyspnoea, hypoxia and tachypnoea within 24 hours of multiple fractures
CNS signs: confusion, agitation, retinal haemorrhage
Dermatological: 25-50% develop a petechial rash

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59
Q

How should fat embolism be managed?

A

DVT prophylaxis

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60
Q

What is the Salter-Harris classification used for, and what are the criteria?

A 
It's used to classify the degree of disruption to the growth plate caused by a fracture
SALT-C
Straight across
Above
Lower 
Through 
CRUSH 
Type 1-5 = increasing risk of growth plate injury
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61
Q

What are the Ottawa rules used for?

A

To decide if an x ray is needed

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62
Q

Recall the 4 criteria of the Ottawa knee rule

A
  • Over 55 years old
  • Isolated patellar tenderness
  • Cannot flex to 90 degrees
  • Inability to weight bear both immediately and in A&E for >4 steps
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63
Q

Recall the Ottawa ankle rule (much more complicated than knee!)

A

LMN FUN
Malleolar zone pain +
- Lateral malleolus posterior edge tenderness
- Medial malleolus posterior edge tenderness
- No weight bearing - both immediately and for 4 steps in A&E

Mid foot zone +

  • Fifth metatarsal base pain
  • Unable to weight bear immediately or for 4 steps in A&E
  • Navicular tenderness
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64
Q

Recall the risk factors for #NOF

A 
SHATTERED
Steroids
Hyperthyroidism/hyperparathyroidism
Alcohol/ smoking
Thin (BMI<22)
Testosterone LOW
Erosive bone disease (eg RhA, MM) 
Renal failure
Early menopause
Dietary calcium low, DM
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65
Q

What is the key examination finding in #NOF?

A

Leg is shortened with external rotation

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66
Q

What is the most common form of intracapsular #NOF?

A

Sub-capital NOF#

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67
Q

What is the most common form of extracapsular #NOF?

A

Intertrochanteric NOF#

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68
Q

If someone’s leg is shortened and internally rotated, what is this indicative of?

A

Posterior dislocation of the hip

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69
Q

What are the 3 types of intracapsular NOF#?

A

Subcapital
Transcervical
Basicervical

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70
Q

What are the 3 types of extracapsular NOF#?

A

Intertrochanteric
Subtrochanteric
Reverse oblique

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71
Q

What is the best analgesia for a #NOF?

A

Iliofascial nerve block

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72
Q

What is the surgical management of intertrochanteric #NOF?

A

Dynamic hip screw

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73
Q

How should extracapsular NOF# be managed?

A

ORIF (although intertrochanteric # can be managed with a DHS)

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74
Q

How can the degree of displacement of an intracapsular NOF# be classified?

A

Using Garden classification (grades I-IV)

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75
Q

How should intracapsular NOF# be managed?

A

Garden 1 + 2 = ORIF with cancellous or cannulated screws
Garden 3 + 4 =
- <55 years: ORIF with cancellous or cannulated screws
- 55 - 75 years: total hip replacement
- >75 years: hemiarthroplasty

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76
Q

What is the difference between a total hip replacement and a hemiarthroplasty?

A 
THR = replaces femoral head and acetabulum
Hemiarthroplasty = replaces femoral head
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77
Q

What is the 1 year mortality for NOF#?

A

30%

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78
Q

What type of NOF# is most likely to be complicated by osteonecrosis and why?

A

Transcervical fracture

Retinacular artery is disrupted from medial circumflex femoral artery

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79
Q

What are the signs and symptoms of osteonecrosis of the hip?

A

Anterior hip pain on climbing the stairs

Insidious onset

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80
Q

What imaging needs to be requested in suspected osteonecrosis of the hip?

A

XR (AP, frog-lateral, contralateral)
MRI (double density appearance)
Bone scan

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81
Q

How can osteonecrosis of the hip be medically managed?

A

Bisphosphonates

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82
Q

Recall some surgical options for managing osteonecrosis of the hip

A 
Core-decompression 
Rotational osteotomy
Free-fibula transfer
Total hip resurfacing/ replacement 
Hip arthrodesis
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83
Q

What is the ‘modified Kerboul angle’ used to determine?

A

Risk of femoral head collapse in osteonecrosis of the hip

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84
Q

How should femoral shaft fractures be managed?

A

Immediately: traction
1st line: intramedullary nailing
2nd line: ORIF

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85
Q

Recall 4 options for managing humeral fracture and the general indications for each one

A

Collar & cuff: 2 parts, minimally displaced, high surgical risk
ORIF: >2 parts but not highly comminuted
Arthroplasty: large displacement of humeral head and high risk of non-union
Reverse arthroplasty - irreprable rotator cuff/ previous unsuccessful replacement

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86
Q

What is the most common type of paediatric elbow fracture?

A

Suprachondylar humeral #

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87
Q

How will a suprachondylar humeral # appear on examination?

A

Elbow swollen and hand semi-flexed

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88
Q

What is the difference between the extension and flexion types of suprachondylar humeral #?

A 
Extension = distal fragment displaces posteriorly (most common) 
Flexion = distal fragment displaces anteriorly
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89
Q

What is the most likely artery to be severed by a suprachondylar humeral #?

A

Brachial artery (by sharp edge of proximal humerus)

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90
Q

What is the most likely nerve to be damaged by a suprachondylar humeral #?

A

Median nerve

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91
Q

Recall the principles of reducing a suprachondylar humeral # if it is undisplaced vs if it is displaced

A

Undisplaced: Collar and cuff with fully flexed arm
Displaced: Manipulation under anaesthetic + K-wire fixation THEN collar and cuff for 3 weeks with fully flexed arm

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92
Q

What is the most common early sign of compartment syndrome following a suprachondylar humeral #?

A

Pain on passive extension of fingers

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93
Q

What is the aetiology of subluxation of the humeral head?

A

In children the distal attachement of the annular ligament covering the radial head is weaker so is at higher risk of subluxation

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94
Q

What are the signs and symptoms of subluxation of the humeral head?

A

Elbow pain and limited supination and extension of the elbow

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95
Q

How should subluxation of the humeral head be managed?

A

Analgesia

Passively supinate elbow joint whilst elbow flexed

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96
Q

What is the ‘dinner fork’ deformity associated with?

A

Colle’s #

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97
Q

What is Colle’s #?

A

Posterior displacement and angulation of the distal radius fragment

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98
Q

What is Smith’s #?

A

Anterior displacement and angulation of the distal radius fragment

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99
Q

What is the typical history of Colle’s vs Smith’s #?

A

Colle’s = fall on an extended wrist

Smith’s fall on a flexed wrist

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100
Q

What are the Barton’s and Reverse Barton’s fractures?

A

Both are oblique intra-articular #s with dislocation at the radio-carpal joint
Barton’s: Dorsal (posterior)
Reverse Barton’s: Volar (anterior)

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101
Q

A Monteggia # is a type of fracture of which bone?

A

Ulnar

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102
Q

A Galeazzi # is a type of fracture of which bone?

A

Radius

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103
Q

Describe how the location of a radius/ulnar fracture guides how the cast should be applied

A

Proximal #: supination
Mid-shaft #: neutral
Distal #: pronation

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104
Q

How are intraarticular fractures of the radius/ulnar managed?

A

ORIF

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105
Q

How are extraarticular fractures of the radius/ulnar managed?

A

MUA + k wire

If unsuitable for k wire –> ORIF

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106
Q

Recall 5 signs of scaphoid fracture

A 
[1] Pain in the anatomical snuffbox
[2] Wrist joint effusion 
[3] Pain on telescoping thumb
[4] Tenderness on scaphoid tubercle 
[5] Pain on ulnar deviation of wrist
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107
Q

Why are scaphoid fractures particularly vulnerable to avascular necrosis?

A

Retrograde blood supply

80% is from the dorsal carpal branch of the radial artery

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108
Q

What is the use of CT in tibial plateau #?

A

To assess whether non-operative management can be used

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109
Q

What is the most common long bone fracture?

A

Tibial

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110
Q

Which bone articulates with the tibia and fibula at the ankle joint?

A

Talus

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111
Q

What is Pott’s fracture?

A

Bimalleolar #

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112
Q

What is a Cotton’s fracture?

A

Trimalleolar #

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113
Q

What is a pilon fracture?

A

A fracture of the distal tibia involving the articular surfaces

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114
Q

What classification system is used to assess the extent of syndesmotic ligament damage at the tibiotalar joint?

A

Weber

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115
Q

Name 2 techniques that can be used to repair syndesmotic tears at the ankle

A

Syndesmotic screws

Tightrope technique

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116
Q

What is a Lisfranc injury?

A

An injury of the foot in which one or more of the metatarsal bones are displaced from the tarsus

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117
Q

Recall some signs and symptoms of Lisfranc injury

A

Medial plantar bruising
Unable to weight bear
Gross midfoot swelling with severe pain

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118
Q

What is the most common metatarsal to be fractured in children vs adults?

A

Children: 1st
Adults: 5th

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119
Q

Into which 3 categories can pelvic fractures be places?

A
  1. Lateral compression (hit from side)
  2. AP compression (Dashboard injury)
  3. Vertical shear (falling from height)
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120
Q

Recall 3 signs/symptoms of fractured patella

A
  1. Palpable patellar defect
  2. Significant haemarthrosis
  3. Loss of straight leg raise
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121
Q

What 3 x ray views are recommended to image a patellar fracture?

A

AP
Lateral
Skyline (inferior-superior)

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122
Q

How should patellar # be managed if the # is comminuted and ORIF is not possible?

A

Partial patellectomy, or total patellectomy if no salvage potential

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123
Q

How is ORIF performed for patellar fractures?

A

Tension Band Wiring
Cerclage wiring
Screw fixation

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124
Q

What is compartment syndrome?

A

Raised pressure in closed space –> compromised tissue perfusion

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125
Q

What are the main signs and symptoms of compartment syndrome?

A

Excessive use of breakthrough analgesia due to significant pain

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126
Q

Why might arterial pulses still be palpable in compartment syndrome?

A

Necrosis occurs as a result of microvascular compromise

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127
Q

How can a manometer be used to help diagnose compartment syndrome?

A

Can use to measure intracompartmental pressure (ICP)
Normal pressure = 0-10mmHg
Delta pressure <30mmHg = compartment syndrome
Absolute pressure >30mmHg = compartment syndrome

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128
Q

What is the ‘delta pressure’ of a compartment?

A

Diastolic pressure - measured intracompartmental pressure

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129
Q

Recall some non-operative options for managing compartment syndrome

A
  • Fluid resuscitation to ensure normotension (as hypoperfusion accelerates tissue injury)
  • Remove circumferential bandages and casts
  • Maintain limb at level of heart
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130
Q

How can compartment syndrome be managed operatively?

A

Fasciotomy

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131
Q

Which tendon is impinged in ‘subacromial impingement’?

A

Supraspinatus tendon

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132
Q

What is Hawkin’s test used to diagnose, and how is it performed?

A

For shoulder impingement
90 degrees shoulder and elbow flexion
Passive internal rotation of the arm –> pain

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133
Q

Recall some differentials for subacromial impingement

A

Adhesive capsulitis
Supraspinatus tear
Osteoarthritis/ Rheumatoid/ Septic arthritis
Gout/ Pseudogout

134
Q

Which x ray views are needed to investigate the aetiology of a subacromial impingement?

A

True AP
30 degrees caudal tilt (subacromial spurring)
Supraspinatus outlet (acromial morphology)

135
Q

Recall some management options for subacromial impingement under the headings of ‘conservative’, ‘medical’ and ‘surgical’

A

Conservative: rest, phyisio
Medical: NSAIDs, subacromial bursa steroid
Surgical: athroscopic acromioplasty

136
Q

Describe the aetiology of subcoracoid impingement

A

Narrowing at the coracohumeral interval impinges the ligaments of:

  • Subscapularis
  • Long head of biceps
  • Middle glenohumeral ligament
137
Q

What are the signs and symptoms of subcoracoid impingement?

A

Pain at the anterior shoulder when arm held adducted/ extended
Maximal pain at 120 degrees flexion + internal rotation

138
Q

What are the 3 stages of calcific tendonitis of the shoulder?

A
  1. Pre-calcific (pain-free fibrocartilaginous metaplasia of tendon)
  2. Calcific (phases of varying levels of pain)
  3. Post-calcific
139
Q

What imaging is useful in calcific tendonitis of the shoulder?

A

XR (shows deposits on AP)

US (shows extend of calcification and targets therapy)

140
Q

Recall some non-operative and operative options for managing calcific tendonitis of the shoulder

A

Non-operative: analgesia, physio, extra-corporeal shockwave therapy, US-guided injections
Operative: Surgical decompression

141
Q

What are the 4 muscles of the rotator cuff?

A

Supraspinatus
Infraspinatus
Subscapularis
Teres minor

142
Q

Recall 4 risk factors for a rotator cuff tear

A

Age >60
Smoking
Family history
Hypercholesterolaemia

143
Q

Recall some possible causes of a rotator cuff tear

A

Chronic degeneration
Chronic impingement
Acute avulsion injury

144
Q

How can you differentiate between a partial and complete rotator cuff tear?

A

Partial –> painful arc

Complete –> shoulder tip pain, FULL RANGE of passive movement but with inability to abduct arm. Active abduction IS possible following passive abduction to 90 degrees. ‘Drop arm’ sign (lowering arm beneath 90 degrees abduction –> sudden drop)

145
Q

Recall some operative options for managing rotator cuff tears

A

Shoulder arthroscopy (to debride rotator cuff and subacromial decompression)
Rotator cuff repair (can be open or laparoscopic)
Tendon transfer
Reverse total shoulder arthroplasty

146
Q

What is the aetiology of rotator cuff arthropathy?

A

Rotator cuff tear –> loss of joint congruence –> abnormal glenohumeral wear –> specific degeneration

147
Q

Describe the signs and symptoms of rotator cuff arthropathy

A

Night pain with weakness and stiffness
Supra/infraspinatus atrophy
Limited ROM +/- crepitus and inability to abduct

148
Q

Recall which muscles are involved in each stage of arm abduction

A

0-15 degrees = supraspinatus
15-90 degrees = deltoid
>90 degrees = serratus anterior + trapezius

149
Q

In which direction does the humeral head migrate in rotator cuff arthropathy?

A

Superiorly

150
Q

What test can be used to test teres minor and how is it performed?

A

Hornblower’s test
Shoulder in 90 degrees abduction and elbow in full flexion
Positive test = pain/ inability to maintain

151
Q

What is adhesive capsulitis?

A

Condition characterised by loss of active AND passive movement with no clear cause

152
Q

Recall the stages of adhesive capsulitis

A

Stage 1: Freezing - gradual onset of diffuse pain
Stage 2: Frozen - decreased ROM
Stage 3: Thawing - gradual return of ROM

153
Q

What is the main associated condition with adhesive capsulitis?

A

Diabetes

154
Q

What score is used to assess hypermobility syndrome?

A

Beighton score

155
Q

What % of shoulder dislocations are anterior vs posterior vs inferior?

A

Anterior: 90%
Posterior: 6%
Inferior: 2-4%

156
Q

Which direction of shoulder dislocation is associated with seizures?

A

Posterior

157
Q

How does acromioclavicular joint dislocation appear on examination?

A

‘Step’ deformity and prominent clavicle

158
Q

What are the signs of glemohumeral dislocation on examination?

A

Shoulder contour lost (‘square shoulder’)

Bulging infraclavicular fossa

159
Q

What must you assess before manipulating a glenohumeral dislocation?

A

Neurovascular status - especially axillary nerve in chevron area

160
Q

What is the management of glenohumeral dislocation?

A

Reduction with sedation
Rest in sling for 3-4 weeks
Physio

161
Q

What is a Hill Sachs defect?

A

Damage to humeral head following shoulder dislocation

162
Q

Where do the short and long tendons of the biceps attach?

A

Long tendon: glenoid

Short tendon: coracoid process

163
Q

Which tendon of the biceps is much more likely t get ruptured?

A

Long

164
Q

What is a ‘popeye deformity’?

A

Caused by proximal biceps tendon rupture - muscle bulk results in a bulge in the middle of the upper arm

165
Q

How can you test for biceps tendon rupture on examination?

A

Biceps squeeze test –> supination if tendon is intact

166
Q

What is the best form of imaging for initial assessment of a proximal biceps tendon rupture?

A

USS

167
Q

What is the best form of imaging for initial assessment of a distal biceps tendon rupture?

A

MRI - it’s a difficult clinical diagnosis and requires surgery

168
Q

What are the 2 forms of traumatic anterior shoulder instability?

A

TUBS - Traumatic Unilateral dislocations with a Bankart lesion - often requires Surgery
AMBRI (“born loose”) = atraumatic Multidirectional Bilateral shoulder dislocation is treated with Rehabilitation, but may require Inferior capsular shift

169
Q

What are the colloquial names for lateral vs medial epicondylitis?

A 
Lateral = tennis
Medial = golfer's
170
Q

What is the aetiology of lateral epicondylitis?

A

Microtear at origin of ERB +/- ERCL and ECU from repetitive wrist extension/ forearm pronation

171
Q

What is the aetiology of lateral epicondylitis?

A

Microtear at insertion of flexor-pronators from repetitive wrist activity

172
Q

Which movements will worsen pain in lateral vs medial epicondylitis?

A

Lateral: worse on wrist extension
Medial: worse on wrist flexion

173
Q

What is the best form of imaging to investigate epicondylitis?

A

USS

174
Q

Is there a better success rate for conservative management of lateral or medial epicondylitis?

A

Lateral (95%)

175
Q

What is the main symptom of olecranon bursitis?

A

Swelling over posterior aspect of elbow

176
Q

Which nerve is compressed in radial tunnel syndrome, and what symptoms does this nerve compression produce?

A

Posterior interosseous branch of radial nerve
Symptoms very similar to lateral epicondylitis (pain in lateral epicondyle, worse on wrist extension, decreases grip strength)

177
Q

Recall 6 associations with carpal tunnel syndrome

A

People who play DA HARP
Diabetes
Acromegaly

Hypothyroidism
Amyloidosis
Rheumatoid arthritis
Pregnancy

178
Q

Which nerve is entrapped in carpal tunnel?

A

Median

179
Q

Which digits get paraesthesia in carpal tunnel syndrome?

A

1st, 2nd and medial half of 3rd

180
Q

What is the best investigative test for carpal tunnel syndrome?

A

EMG

181
Q

Which muscles are supplied by the median nerve (and are weakened in carpal tunnel syndrome)?

A

Lateral 2 lumbricals
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis

182
Q

How can carpal tunnel be managed conservatively?

A

Wrist splints at night

183
Q

How can carpal tunnel be managed if conservative management is unsuccessful?

A

Corticosteroid injection –> surgical decompression

184
Q

What are the contents of the carpal tunnel?

A

Median nerve

FPL, FCR, FDP and FDS tendons

185
Q

What is cubital tunnel syndrome?

A

Ulnar nerve entrapment at elbow

186
Q

What is Guyon canal syndrome?

A

Ulnar nerve entrapment at wrist

187
Q

Recall some risk factors for both Cubital Tunnel Syndrome and Guyon Canal Syndrome

A

Cubital tunnel: cycling, ganglion cyst pressure

Guyon canal: leaning on elbow

188
Q

What are the signs and symptoms of ulnar nerve entrapment?

A

Pins and needles in 4th and 5th digit

Claw hand

189
Q

How should suspected ulnar nerve entrapment be investigated?

A

Nerve conduction studies

190
Q

Recall some conservative and surgical options for managing ulnar nerve entrapment

A

Conservative: wrist splints at night
Surgical: Corticosteroid injection –> surgical decompression

191
Q

What is the aetiology of De Quervain’s Tenosynovitis?

A

Sheath containing extensor pollicis brevis + abductor pollicis longus tendons becomes inflamed

192
Q

Recall some signs and symptoms of De Quervain’s Tenosynovitis

A

Tenderness over radial styloid and radial side of wrist

Abduction of thumb is painful

193
Q

What is Finkelstein’s test used to investigate and how is it performed?

A

Used to investigate De Quervain’s Tenosynovitis

Examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction –> pain in the radial styloid and along the length of EPB and APL

194
Q

How can De Quervain’s Tenosynovitis be managed?

A

Analgesia + activity modification

Steroid injections + thumb splint –> surgery (if conservative measures have failed after 6 months)

195
Q

What is Dupuytren’s contracture?

A

Progressive, painless and fibrotic thickening of the palmar fascia

196
Q

What is the aetiology of Dupuytren’s contracture?

A

Fibroblasts replaced by myofibroblasts which produce a contractile element

197
Q

Recall the associations of Dupuytren’s contracture

A

BAD FIBRES

Bent penis (Peyronie’s)
AIDS
Diabetes mellitus

Family history 
Idiopathic (most common) 
Booze (ALD) 
Riedel's thyroiditis
Epilepsy and anti-epileptics
Smoking
198
Q

Recall some options for managing Dupuytren’s contracture

A
  1. Percutaneous needle fasciotomy
  2. Collagenase injection followed by MUA 24 hours later
  3. Partial fasciectomy (if hand can’t be placed flat on table)
199
Q

What is a trigger finger?

A

Tendon nodule which catches on proximal side of tendon sheath –> triggering on forced extension

200
Q

How can a trigger finger be managed?

A 
Steroid injection (high recurrence) 
Surgical release of 1st pulley
201
Q

What is a ganglion?

A

Smooth, multilocular cystic swellings

202
Q

What is the aetiology of ganglions?

A

Mucoid degeneration of joint capsule / sheath which may communicate with joint capsules/ tendons

203
Q

What are the signs and symptoms of ganglion?

A

Subdermal swellings, fixed to deeper structures + limits planes of movement +/- pain on nerve pressure symptoms

204
Q

How should ganglions be managed?

A

50% disappear spontaneously
Aspiration +/- steroid and hyaluronidase injection
Surgical excision

205
Q

If someone has the symptom of knee locking, what are the differentials?

A

Obstructive causes:

  • Meniscal/ cruciate tear
  • Osteochondritis dissecans
  • Osteophytes
206
Q

What is the O’Donoghue Unhappy Triad?

A

Describes 3 soft tissue injuries that commonly occur together following a lateral blow to the knee on a fixed foot (eg football/ rugby)

  • Ruptured ACL
  • Ruptured MCL
  • Damaged medial meniscus
207
Q

Describe the typical presentation of ACL rupture

A

Rotational sports injury
Loud crack with pain
Rapid swelling due to haemarthrosis

208
Q

Recall 2 signs of PCL rupture

A
  1. Tibial lies posterior to femur

2. Paradoxical anterior draw test

209
Q

What is the key sign of MCL rupture

A

Knee unstable in valgus stress test

210
Q

What are the signs and symptoms of a torn meniscus in the knee?

A
  • DELAYED knee swelling (immediate more likely to be ACL rupture)
  • Joint locking
  • Recurrent pain/ effusions
  • McMurray’s test positive
211
Q

What cause of knee pain typically affects teenage girls?

A

Chondromalacia patellae

212
Q

What classification system is used for tibial plateau fractures?

A

Schatzker system

213
Q

Why would a visible fluid level in the knee (lipohaemarthrosis) on X ray lead you to perform an MRI?

A

It is either a # or a cruciate ligament tear

214
Q

How should an isolated cruciate ligament tear be managed?

A

Specialised quadriceps physiotherapy

215
Q

If a cruciate ligament tear is paediatric or concurrent, how can it be managed?

A

Reconstruction

Gold standard is an autograft repair

216
Q

What is the best conservative management for a medial/ lateral cruciate ligament tear?

A

Hinged knee brace

217
Q

What is the most obvious sign on examination of a medial/ lateral cruciate ligament tear

A

Extreme valgus/ varus

218
Q

What movement produces the most pain in a meniscal tear?

A

When loading knee in flexion (going downstairs)

219
Q

What imaging should be done for a meniscal tear?

A

XR to exclude # followed by MRI

220
Q

How can meniscal tears be managed?

A

Arthroscopic debridement or repair (depends on site)

221
Q

How does site of meniscal tear affect nanagement?

A

Lateral 1/3 tears might be able to be managed conservatively as they have a very rich blood supply
Medial tears 2/3 tears may need a meniscectomy as poor supply of blood

222
Q

What is Osgood-Schlatter’s disease?

A

Tibial tuberosty apophysitis and patellar tendonitis

223
Q

Can Osgood-Schlatter’s disease be bilateral?

A

Yes, it is in 25-50%

224
Q

How is Osgood-Schlatter’s disease diagnosed?

A

Clinical diagnosis + XR

225
Q

What would an X ray show in Osgood-Schlatter’s disease?

A

Fragmentation of tibial tubercle and overlying soft tissue swelling

226
Q

What are the signs and symptoms of osgood schlatter’s?

A

Knee pain after exercise with gradual onset
Localised tenderness and swelling over the tibial tuberosity
Hamstring tightness

227
Q

How should Osgood-Schlatter’s disease be managed?

A

Analgesia, ice packs

Reassure –> should resolve at end of growth spurt

228
Q

What is meralgia paraesthetica?

A

Syndrome of paraesthesia/ anaesthesia in distribution of the lateral femoral cutaneous nerve

229
Q

What is the aetiology of meralgia paraesthetica?

A

As the lateral femoral cutaneous nerve curves medioinferiorly around the ASIS it may be subject to repetitive trauma –> compression leads to symptoms

230
Q

In what age group does meralgia paraesthetica typically develop?

A

30-40y

231
Q

What are the signs and symptoms of meralgia paraesthetica?

A

Upper lateral thigh burning, tingling, coldness or shooting pain
NO MOTOR WEAKNESS
Symptoms usuallya ggravated by standing and relieved by sitting

232
Q

How can you reproduce symptoms of meralgia paraesthetica on examination?

A

Deep palpation beneath ASIS

233
Q

What is the main symptom of chondromalacia patellae?

A

Patellar aching after prolonged sitting or climing stairs

234
Q

How can you investigate for chondromalacia patellae?

A

Clarke’s test

Pain on patellofemoral compression

235
Q

What would be seen on XR in chondromalacia patellae?

A

Normal film

236
Q

How can symptoms of chondromalacia patellae be improved?

A

Vastus medialis strengthening

237
Q

What is a ‘Baker’s cyst’?

A

Popliteal extensions of the gastrocnemius-semimembranosus bursa (not a true ‘cyst’)

238
Q

If Baker’s cysts are secondary, what are they likely to be secondary to?

A

Osteoarthritis

239
Q

What are the signs and symptoms of Baker’s cysts?

A

Swelling in popliteal fossa

240
Q

What is the cause of bipartite patella?

A

Congenital failure of patella to fuse

241
Q

What are the 3 classifications of bipartite patella, and which is most common?

A

Type 1: inferior pole
Type 2: lateral margin
Type 3: superloateral (most common)

242
Q

What are the 3 elements of the ankle syndesmosis?

A
  1. Anterior inferior tibiofibular ligament
  2. Posterior inferior tibiofibular ligament
  3. Interosseous ligament and membrane
243
Q

What is the mainstay of management for low ankle sprain?

A

RICE (rest, ice, compression, elevation)

244
Q

What is the most common type of low ankle sprain?

A

Inversion injury affecting the ATFL

245
Q

How can high ankle sprains be managed?

A

If there is diastasis (separation of fibula and tibia) –> surgical fixation
OR
No diastasis –> non weight-bearing orthosis

246
Q

Which prescription drug is highly associated with achilles tendon rupture?

A

Quinolones (eg ciprofloxacin)

247
Q

What is Simmond’s triad?

A

100% sensitive in combination for picking up an Achilles’ tendon rupture

  • Thomas test does not elicit plantarflexion
  • Angle of declination (greater dorsiflexion of injured foot)
  • Gap in tendon path
248
Q

Which type of imaging is diagnostic of Achiles tendon rupture?

A

USS

249
Q

What are the signs and symptoms of Morton’s neuroma?

A

‘Walking on a marble’
Shooting pain in the ball of the foot
Numb toes

250
Q

Where is the most common site of Morton’s neuroma?

A

Between 3rd and 4th tarsal bones

251
Q

What form of imaging can confirm a diagnosis of Morton’s neuroma?

A

USS

252
Q

What is the management of Morton’s neuroma?

A

Orthotics –> steroid injections –> surgical resection

253
Q

What is plantar fasciitis?

A

Inflammation of the plantar aponeurosis

254
Q

What would make plantar fasciitis better or worse?

A

Exercise makes it better

Inactivity makes it worse

255
Q

What test on examination can be used to identify plantar fasciitis?

A

Windlass test

256
Q

What is the management for plantar fasciitis?

A 
Orthotics 
Physiotherapy 
Analgesia 
Steroid injection 
Refer to orthopaedics
257
Q

What is the proper name for a bunion?

A

Halux valgus

258
Q

How can bunions be manages conservatively?

A

Bunion pads

Plastic wedge between great and 2nd toes

259
Q

What surgery can be used to fix bunions?

A

Metatarsal osteotomy

260
Q

What are the signs and symptoms of charcot foot?

A 
Deformity 
Debris 
Density change
Destruction 
Dislocation
261
Q

What are the signs and symptoms of cervical spondylosis?

A

Neck pain and headaches

262
Q

What are the signs and symptoms of lumbar spine stenosis?

A 
Back pain that is worse when standing 
Leaning forward relieves it 
Neuropathic pain 
Neurogenic claudication 
Preserved distal pulses
263
Q

What is the most common pathogen implicated in discitis?

A

Staph aureus

264
Q

What is the most common pathogen implicated in iliopsoas abscess?

A

Staph aureus

265
Q

What is the difference between the investigation of choice for discitis vs iliopsoas abscess?

A

Discitis: MRI (if S aureus –> echo)

Iliopsoas abscess: CT

266
Q

What is the difference between the management of choice for discitis vs iliopsoas abscess?

A

Discitis: IV Abx

Iliopsoas abscess: Abx and percutaneous drain

267
Q

What is Brown-Sequard syndrome?

A

Hemisected spinal cord

268
Q

What are the signs and symptoms of Brown-Sequard syndrome?

A

Ipsilateral paralysis
Ipsilateral loss of proprioception & fine touch
Contralateral loss of pain & temperature

269
Q

A prolapsed disc at which levels could cause quadriceps weakness?

A

L3 and L4

270
Q

What are the 1st and 2nd line pain management for non-specific lower back pain?

A

1st line: NSAID and PPI

2nd line: codeine + paracetamol

271
Q

What is the management of developmental dysplasia of the hip in a child <6 months old?

A

Pavlik harness for 6 months

272
Q

What is Perthes’ disease?

A

Avascular necrosis of the proximal femoral epiphysis from interruption of supply –> revascularisation and reossification over 18-36 months

273
Q

What test can you perform on examination to test for Perthes?

A

Roll test

Roll affected hip internally and externally –> guarding or spasm

274
Q

Recall the management protocol for Perthes disease

A

If <6 years: analgesia, traction, crutches, physio to improve ROM

If >6 years: pelvic/ femoral osteotomy

275
Q

What is SCFE?

A

Slipped Capital Femoral Epiphysis

Displaced of epiphysis of femoral head postero-inferiorly

276
Q

What are the 2 main key examination findings in SCFE?

A

Loss of internal rotation of a flexed hip

Trendelenburg gait positive

277
Q

How is SCFE managed?

A

Percutaneous internal fixation at growth plate

278
Q

Recall some 5 prescription drug classes that can predispose to osteoporosis

A 
Steroids
SSRIs
PPIs
Glitazones
Anti-epileptics
279
Q

Which prognostic scoring systems are useful in osteoporosis?

A

FRAX
QFracture
Estimate a patient’s 10 year risk of developing a fragility fracture

280
Q

When assessing osteoporosis risk, what would count as ‘long term steroids’?

A

> 7.5mg/day for >3months

281
Q

Recall the treatment indications for bisphosphonates

A
  • Fragility fracture + age >75

- Fragility fracture + T score 65y and on/ about to start longterm steroids

282
Q

When should you give immediate bisphosophonates to patients who are on or about to start longterm steroids?

A
  • If they are over 65

- If under 65 then do a DEXA - give bisphosphonates if

283
Q

What treatments should you give alongside bisphosphonates?

A

Always vitamin D

Calcium supplements IF low levels

284
Q

What are some contrainidications to bisphosphonates?

A

eGFR <30
Severe GORD
Recurrent gastric ulcer

285
Q

Recall the instructions for administration of PO bisphosphonates

A

Take on empty stomach in the morning
Full glass of water
Stay upright for 30 minutes

286
Q

If PO bisphosphonates are not tolerated, what alternative is there?

A

Annual IV zoledronate

287
Q

What is the 2nd line for bisphosphonates if they are not contra-indicated?

A

SC denosumab

288
Q

Recall some abnormalities that might be seen in the hands in osteoarthritis?

A

Heberden’s nodes (DIPJ)

Bouchard’s nodes (PIPJ)

289
Q

WHat are the 4 indications of osteoarthritis on X ray?

A

Loss of joint space
Osteophytes
Subchondral sclerosis
Subchindral cysts

290
Q

Recall some options for managing osteoarthritis

A

Wt loss
Physiotherapy
1st line: PO paracetamol w/ topical NSAID
2nd line: PO NSAIDs + PPI or weak opioids or capsaicin cream
3rd line: intra-articular corticosteroids
Surgical: joint replacement

291
Q

What is the most likely (i) vascular and (ii) nerve injury caused by a knee replacement?

A

Vascular: superficial femoral artery
Nerve: common peroneal

292
Q

Recall some immediate, early and late complications of T knee replacements

A

Immediate: vascular/ nerve injury
Early: DVT, prosthesis infection
Late: Loosening, instability from los ACL

293
Q

Recal some possible complications of anterolateral vs posterior approaches for THR

A

Anterolateral: superior gluteal nerve injury –> Trendelenburg gait
Posterior: sciatic nerve injury –> foot drop

294
Q

What is osteochondritis?

A

Idiopathic condition in which bony centres of paediatric bones become temporarily softened due to osteonecrosis

295
Q

What would be seen on X ray in osteochondritis?

A

Increased density/ sclerosis –> patchy appearance

296
Q

Which variation of osteochondritis affects the vertebral ring epiphyses?

A

Scheuermann’s disease

297
Q

Which variation of osteochondritis affects the navicular bone in toddlers?

A

Kohler’s disease

298
Q

Which variation of osteochondritis affects the lunate bone in adults?

A

Kienbochs disease

299
Q

Which variation of osteochondritis affects the 2nd and 3rd metatarsals at puberty?

A

Friedberg’s disease

300
Q

Which variation of osteochondritis affects the capitulum of the humerus?

A

Panner’s disease

301
Q

What is the aetiology of osteochondritis dissecans?

A

Reduced blood flow –> cracks in articular cartilage and subchondral bone –> AVN –> fragmentation of bone and cartilage with free movement of fragments –> activity-related joint pain

302
Q

What is the management for osteochondritis dissecans?

A

Arthroscopic removal

303
Q

What is necrotising fasciitis?

A

Life-threatening infection that spreads across soft-tissue planes

304
Q

What is pre-patellar bursitis?

A

It’s an infection of the potential space in front of the patella

305
Q

What should you ask about in the history if you are querying pre-patellar bursitis?

A

History of kneeling (eg builders)

306
Q

How should pre-patelllar bursitis be managed?

A

Analgesia, compression, aspiration

307
Q

Recall the risk factors for septic arthritis, and split them into modifiable and non-modifiable

A

Modifiable:
crystal arthropathies
Non-modifiable:
Age >90, rheumatoid arthritis, chronic renal failure, prosthetic joints

308
Q

What investigations should be done to investigate septic arthritis?

A

XR
USS and MC&S joint aspirate
Bloods
Blood cultures

309
Q

How should septic arthritis be managed?

A

IV antibiotics

Joint washout

310
Q

Recall some risk factors for osteomyelitis

A

Vascular disease, trauma, SCD, immunosuppression

311
Q

What is the investigation of choice in suspected osteomyelitis?

A

MRI

312
Q

What is the management for osteomyelitis?

A

IV antibiotics and radical debridement to living bone

313
Q

What is the most likely pathogen in a prosthetic joint infection within 6 weeks of infection and after that?

A

<6 weeks: S. aureus

>6 weeks: S. epidermidis

314
Q

What is the gold-standard management of prosthetic joint infection?

A

Two-stage revision
Antibiotics whilst joint spacer is in
Re-implant with antibiotic-impregnated cement

315
Q

What are the 2 main types of non-neoplastic bone tumours?

A

Fibrous dysplasia

Simple bone cyst

316
Q

Which bone tumour produces a ‘shepherd’s crook deformity’ on X ray?

A

Fibrous dysplasia

317
Q

Recall the names of 3 types of benign cartilaginous neoplasms

A

Osteochondroma
Endochondroma
Chondroblastoma

318
Q

What is the most common benign bone tumour?

A

Osteochondroma

319
Q

What is the most likely location of an osteochondroma?

A

Knee

320
Q

What is a chondrosarcoma?

A

A malignant cartilaginous neoplasm

321
Q

What are the most common sites of chondrosarcomas?

A

Pelvis

Axial skeleton

322
Q

Which form of tumour produces the appearance of ‘popcorn calcification’ on x ray?

A

Chondrosarcoma

323
Q

Recall the 4 main different types of benign bone-forming neoplasms

A

Osteoma
Osteoid osteoma
Osteoblastoma
Osteoclastoma (giant cell tumour)

324
Q

Which bone tumour typically produces severe nocturnal pain in young adults?

A

Osteoid osteoma

325
Q

Which bone tumour produces a ‘soap bubble’ appearance on X ray?

A

Giant cell tumour/ osteoclastoma

326
Q

What are the 2 main forms of malignant bone-forming neoplasms?

A

Osteosarcoma

Ewing’s sarcoma

327
Q

What is the most common malignant primary bone tumour?

A

Osteosarcoma

328
Q

Which bone tumour is associated with onion-skinning of the periosteum on X ray?

A

Ewing’s sarcoma

329
Q

In which dermatomes is sensation lost in Erb’s palsy?

A

C5 C6

330
Q

In which dermatomes is sensation lost in Klumpke’s?

A

C8 T1

331
Q

What muscle groups would be paralysed in Erb’s palsy?

A

Abductors and external rotators –> waiter’s tip

332
Q

What muscle groups would be paralysed in Klumpke’s?

A

Small muscles of hand –> claw hand

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