T&O

Question 1

A toddler of 3 years presents to the Emergency Department with swelling of his leg and is found to have a spiral fracture of the tibia. His mother reports that he had tripped and fallen the previous day but she had not noticed any sign of injury at the time. She is a single parent with little family support. The child is not on the child protection register.

Answer 1

Child physical abuse
It is imperative to determine whether the mechanism of injury is compatible with the history. There is delay in presentation and also spiral fracture indicates ‘twisting injury’ rather than falling over.

Question 2

An infant is admitted with symptoms and signs of respiratory infection and is found to have several posterior rib fractures on chest radiograph. He was born prematurely at 37 weeks’ gestation and was observed overnight on the special care baby unit for tachypnoea which settled by the following day. On assessment it is also apparent that his head circumference has increased at an excessive rate and has crossed 3 centiles since birth.

Answer 2

Child physical abuse
Posterior rib fractures are highly suggestive of non-accidental injury (NAI). The excessive head growth is likely to be secondary to a previous shaking injury which has resulted in an intracerebral bleed and hydrocephalus.

Question 3

A 4-month-old girl is presented with swelling of her right arm and is found to have a spiral fracture of the humerus. She had been in the care of her mother’s boyfriend who reported that he had nearly dropped her that day when reaching for her bottle and had inadvertently pulled on her arm to save her. She was immediately taken to the Emergency Department.

Answer 3

Accidental fracture

This history could be compatible with an accidental injury.

Question 4

A 32-year-old motor cyclist is brought to the emergency department with direct injury to his upper back when he was involved in a road traffic accident. He has tenderness over this region with bruising, and drooping of the shoulder and lengthening of the arm on the affected side.

Answer 4

Fracture neck of the scapula
Scapular fractures, though uncommon, are usually caused by direct trauma or due to road traffic accidents.
Patients present with drooping of the affected shoulder with apparent lengthening of the arm, particularly with fracture neck of the scapula. Most can be treated conservatively. Internal fixation is indicated for some articular fractures of the glenoid cavity.

Question 5

A 55-year-old man presents to the Emergency department after he fell nine foot off a step-ladder. On examination, there is a swelling in the deltopectoral groove with lowering of the anterior axillary fold and a prominent acromion process.

Answer 5

Anterior dislocation of the shoulder
Anterior (subcoracoid) dislocation is the commonest type of dislocation of the shoulder. It presents with a swelling in the deltopectoral groove, with an undue prominence of the acromion process. In addition, there is flattening and loss of contour of the shoulder just below the acromion process, and lowering of the anterior axillary fold. If the axillary nerve is damaged, patients may present with loss of sensation over the upper, outer aspect of the arm.

Question 6

A 79-year-old gentleman who is undergoing treatment for tertiary prostatic cancer presents with a swelling and tenderness over the proximal half of the arm after a fall.

Answer 6

Fracture of the shaft of humerus
Although, metastasis could affect any region, fractures of the proximal or mid half of the humerus are common sites in the upper limb for pathological fractures from carcinomatous metastases. Bony metastasis is seen with carcinomas of the prostate, breast, lung, bowel, kidney and thyroid.

Question 7

A 15-year-old boy presents to his GP with loss of weight, pain and fever. On examination, a soft tissue mass is palpable over the mid-thigh region.

Answer 7

Ewing’s sarcoma
Ewing’s sarcoma is a malignant round cell tumour occurring in the diaphysis of the long bones in children. These are not confined to the ends of long bones. x Rays often show a large soft-tissue mass with concentric layers of new bone formation - known as ‘onion-peel’ sign.

The erythrocyte sedimentation rate (ESR) may be elevated, thus suggesting an inflammatory or an infective cause such as osteomyelitis; although osteomyelitis usually affects the metaphyseal region in children.

Treatment modalities include chemotherapy and surgical excision.

Question 8

A 17-year-old girl presents with weight loss, fever and a swelling over her right knee. Movements of her knee are restricted. x Ray shows a soap bubble appearance.

Answer 8

Osteoclastoma
Osteoclastoma (giant cell tumour) is common in young adults. It is common around the knee and it affects the epiphysis of long bones. It is an osteolytic, slow growing tumour, sometimes resulting in pathological fractures.

x Ray shows the characteristic soap bubble appearance.

Question 9

A 76-year-old lady presents with weight loss, pain and a swelling over her left knee. She is undergoing treatment for Paget’s disease.

Answer 9

Osteosarcoma
Osteosarcoma affects typically the knee in the metaphyseal region. Secondary osteosarcoma may arise in the bones affected by Paget’s disease (in approximately 10% of patients affected for more than 10 years) or after irradiation.

x Ray shows bone destruction and new bone formation, often with marked periosteal elevation (sunray spiculation and Codman’s triangle respectively). It is usually treated by surgery.

Question 10

A 13-year-old boy who is small for his age presents to his GP with poor muscular development and hyper-mobile fingers. His x rays show multiple fractures of the long bones and irregular patches of ossification.

Answer 10

Osteogenesis imperfecta
Osteogenesis imperfecta is caused by defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid collagen and dentine. There is a failure of maturation of collagen in all the connective tissues. x Rays may reveal translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.

Question 11

A 16-year-old boy presents to the out-patient clinic with tiredness, recurrent throat and chest infections, and gradual loss of vision. x Rays shows brittle bones with no differentiation between the cortex and the medulla.

Answer 11

Osteopetrosis
Osteopetrosis is an autosomal recessive condition. The patient, usually a young adult, may present with symptoms of anaemia or thrombocytopaenia due to decreased marrow space. x Ray reveals a lack of differentiation between the cortex and the medulla described as marble bone. These bones are very dense and brittle.

Question 12

A 1-year-old infant is brought to the Emergency Department with a history of failure to thrive. On examination, the child is small for age and has a large head. x Rays show a cupped appearance of the epiphysis of the wrist.

Answer 12

Rickets
Rickets is the childhood form of osteomalacia. It is due to the failure of the osteoid to ossify due to vitamin D deficiency. Symptoms start about the age of one. The child is small for age and there is a history of failure to thrive.

Bony deformities include bowing of the femur and tibia, a large head, deformity of the chest wall with thickening of the costochondral junction (ricketty rosary), and a transverse sulcus in the chest caused by the pull of the diaphragm (Harrison’s sulcus). x Rays show widening and cupping of the epiphysis of the long bones, most noticeable in the wrist.

Question 13

A 28-year-old man presents to the emergency department with a swelling over his left elbow after a fall on the outstretched hand. On examination, he has tenderness over the proximal part of his forearm, and has severely restricted supination and pronation movements.

Answer 13

Fracture of the radial head
Fracture of the radial head is common in young adults. It is usually caused by a fall on the outstretched hand.

On examination, there is marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination)

Question 14

A 35-year-old man presents with a painful swelling over the volar aspect of his hand after receiving a hard blow to his palm. On examination, he experiences pain on moving the wrist and on longitudinal compression of the thumb.

Answer 14

Fracture of the scaphoid
Fractures of the scaphoid usually occur as a result of direct hard blow to the palm or following a fall on the outstretched hand. The main physical signs are swelling and tenderness in the anatomical snuff box, and pain on wrist movements and on longitudinal compression of the thumb.

Question 15

A 58-year-old lady presents with a painful swelling over the lower end of the forearm following a fall. x Ray reveals a distal radial fracture with disruption of the distal radio-ulnar joint.

Answer 15

Galeazzi fracture
Galeazzi fractures occur after a fall on the hand with a rotational force superimposed on it.

On examination, there is bruising, swelling and tenderness over the lower end of the forearm. x Rays reveal the displaced fracture of the radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint.

Question 16

A 23-year-old male builder presents with acute onset of bilateral sciatica. This occurred while attempting to lift a heavy beam. On closer questioning, he admits to being incontinent of urine. On examination he has poor anal tone, poor straight leg raise and an inability to dorsiflex either foot.

Answer 16

Central disc prolapse
Prolapse of the disc is more likely in a young person. Prolapsed intervertebral disc is a condition where the gelatinous nucleus pulposus squeezes through the annulus fibrosus and bulges in a posterior or posterolateral direction, beneath the posterior longitudinal ligament. A central disc protrusion may compress the cauda equine resulting in bladder involvement, conus compression or bilateral sciatica: this is a neurological emergency.

Question 17

A 45-year-old female presents to her general practitioner complaining of a three month history of lower back and right buttock pain, which is aggravated by coughing, sneezing and straining. On examination there is wasting and weakness of dorsiflexors of her right foot (with some degree of foot drop), extensor digitorum longus and extensor hallucis longus; wasting of extensor digitorum brevis; sensory impairment over lateral calf and dorsum of foot.

Answer 17

Lateral disc prolapse
Lateral disc protrusion typically only affects the nerve roots, about 70% of lumbar disc protrusions occur at the L5/S1 level, thus compressing the first sacral root, causing pressure symptoms on the root below the level of herniation.

Question 18

A 35-year-old male office worker presents to his general practitioner complaining of a one week history of acute onset left shoulder pain. The pain was initially intense but has now resolved, but he has been left with weakness in the shoulder. On examination there is a loss of sensation over the outer aspect of the shoulder, reflexes are absent in the left arm.

Answer 18

Neuralgic amyotrophy
Neuralgic amyotrophy is a relatively common disorder characterised by the acute onset of shoulder pain and weakness. Often, the pathology or site of the lesion is not known. It is most frequent in young males.

Question 19

A 5-year-old male child presents with a three month history of pain in the right foot. The foot is swollen and painful and there is tenderness over the medial longitudinal arch.

Answer 19

navicular bone
Osteochondroses such as Perthes’ disease or Kohler’s disease (osteochondritis of the navicular bone) result in an aseptic necrosis of bone. In this case the patient presents with typical bone pain which occurs in children 2-5 years of age and mostly males. The condition is unilateral, and comparative x rays of the unaffected side are valuable for assessment of progression.

Question 20

A 16-year-old male recruit attends for a medical with the Army. He is otherwise well but he is noticed to have a deformity of both feet, with clawing of his toes.

Answer 20

Pes cavus
Pes cavus is a deformity of the feet that results in clubbed feet and clawed toes. It is usually hereditary and can be associated with conditions such as Charcot-Marie-Tooth disease.

Question 21

A 45-year-old traffic warden presents with burning pain in the ball of his left foot radiating between the third and fourth toes.

Answer 21

Morton’s neuroma
Morton’s neuroma is a non-cancerous (benign) growth of nerve tissue. The condition does not involve a true tumour, but instead comprises a thickening of the tissue around one of the digital nerves between the third and fourth toes.

Clinical features include burning pain in the ball of the foot that may radiate into the toes or numbness in the toes. The pain typically worsens with activity such as prolonged standing or walking and the wearing of tight or narrow shoes.

Treatment involves changing footwear, using arch supports or pads to help take pressure off the area, and resting of feet. Some patients may require anti-inflammatory drugs, steroid injections or even surgery.

Question 22

A 46-year-old housewife has experienced dull ache and stiffness in her big toe. Her pain worsens with movement at the interphalangeal joint and the surrounding skin that feels swollen or warm to the touch.

Answer 22

Bursitis
Bursitis is inflammation of one of the fluid-filled sacs (bursae) which lubricates joints and tendon insertions. When inflamed, pressure on the joint or movement causes pain. Recurrent flare-ups are common.

Treatment for bursitis is usually simple and includes resting and immobilising the affected area, applying ice to reduce swelling and non-steroidal anti-inflammatory drugs (NSAIDs) to relieve pain and reduce inflammation. Bursitis usually disappears within a week or two.

Question 23

A 32-year-old parks attendant presents with a one year history of progressive lancinating pain in his right foot radiating in a straight line from the ankle to the bottom of foot arch. His symptoms are worsened by prolonged walking and standing. He has easily palpable foot pulses on palpation.

Answer 23

Tarsal tunnel syndrome
Tarsal tunnel syndrome is an entrapment neuropathy (pressure on nerve) of the tibial nerve as it courses through the inside aspect of the foot and ankle.

Factors that may cause tarsal tunnel syndrome include

Repetitive stress with activities
Flat feet
Excess weight
Any lesion which causes compression of tibial nerve within the tarsal tunnel region.
Diagnosis is supported by a positive Tinel’s test and nerve conduction studies.

Conservative treatment includes the use of

Non-steroidal anti-inflammatories
Ice
Physical therapy
Orthotic devices
Steroid injections
Cast immobilisation.
If unsuccessful then surgery, nerve release, may be required.

Question 24

A 60-year-old arthritis sufferer presents with a painful swelling at the base of her left big toe, progressive over the last 10 months and worse at the close of work and when wearing new shoes.

Answer 24

A bunion (hallux valgus) is a deformity caused by lateral deviation of the great toe. As the hallux turns into valgus the tissues surrounding the first metatarsal phalangeal joint may become swollen and tender.

The bunion is partly due to the swollen bursal sac. Symptoms are progressive and include painful swelling; they may be aggravated by the wearing of ill-fitting footwear.

Conservative treatment involves wearing the appropriate footwear with padding over the bunion, NSAIDs, ice and injections.

Surgery is indicated for variety of pathologies associated with the bunion:

Realignment of the first metatarsal, relative to adjacent metatarsals
Straightening of the hallux relative to the first metatarsal and adjacent toes
Realigning hallux cartilagenous surfaces
MTPj arthritis
Repositioning of the sesamoid, and
Shortening, lengthening, raising, or lowering the first MT.

Question 25

A 24-year-old swimmer known to have diabetes has developed a painful red swelling at the side of his right big toe toe nail. That toe nail is ingrowing and discoloured.

Answer 25

Paronychia
Paronychia is a superficial infection of the skin around the nails, most commonly caused by Staphylococcus bacteria or fungi. It results from picking the skin surrounding the nail, and is common in diabetics and those who stay in water for long periods.

Symptoms include a red painful localised swelling at the edge of the nail. The toe nail may be discoloured from fungal infection and ingrowing. Treatment is topical or oral antifungals or antibiotics.

Question 26

A 70-year-old woman has presented with a displaced intracapsular fracture of the femoral neck.

Answer 26

Arthroplasty - hemi
Arthroplasty - hemi. Intracapsular fractures can result in problems of non-union and late avascular necrosis due to disruption of the retinacular blood vessels, which cross the fracture to the femoral head. Patients with displaced fractures, that is, Garden’s grade III or IV are at higher risk of avascular necrosis. Therefore most surgeons advocate a prosthetic replacement of the head of the femur (Hemi- arthroplasty).

Question 27

A 30-year-old man has sustained a displaced closed fracture of the femoral shaft in the mid third while playing football.

Answer 27

Intra-medullary nail
Intra-medullary nail. These fractures are usually spiral, for example,fall or twisting force. A transverse fracture may result from a direct injury, for example, road traffic accident. The patient may be in hypovolaemic shock or have the symptoms of fat embolism. Initial management is fluid resuscitation and the application of a Thomas’ splint. Definitive treatment is either closed or open. An intramedullary nail is inserted ‘closed’ from the proximal end under x ray control. Locking screws are usually added proximally and distally to prevent movement.

Question 28

A 50-year-old man has sustained a stable extracapsular fracture of the femoral neck.

Answer 28

Dynamic hip screw
Dynamic hip screw. Extracapsular or intertrochanteric fractures of the femoral neck usually result in union of the fracture. This fracture is either stable (Type I - the fracture can be anatomically reduced by internal rotation of the leg. Type II - the proximal fragment is laterally rotated and the fracture can only be reduced by external rotation of the leg) or unstable (loss of continuity of bone cortex between the opposing surfaces of the fracture). Following accurate anatomical reduction, internal fixation is achieved with a dynamic hip screw.

Question 29

A 17-year old rugby player falls to the ground and lands on the posterior part of his outstretched arms. x Rays of his wrist reveals a fracture of the distal radius with a radial fragment angled forwards.

Answer 29

Smith’s fracture

The x ray findings suggest a diagnosis of Smith’s fracture. These fractures are often unstable and require fixation.

Question 30

An 18-year old goalkeeper tries to save a ball, which strikes his hand at high speed. He complains of pain in his right thumb and an x ray reveals a carpometacarpal fracture/dislocation of the thumb.

Answer 30

Bennets fracture

The x ray findings suggest a diagnosis of Bennett’s fracture. The fracture should be reduced and a plaster cast applied to the extended thumb for four to six weeks.

Question 31

A 74-year old lady falls at home on her outstretched hand. She has recently started taking Calcichew D3 Forte. She is in a lot of pain and on examination there is backward angulation and displacement producing a ‘dinner-fork’ wrist deformity when viewed in pronation.

Answer 31

Colles’ fracture
The appearance of the wrist and mechanism of injury suggest Colles’ fracture. If there is much displacement, reduction will be needed, particularly if there is backward and proximal shift of the distal fragment.

Question 32

A 22-year-old cricketer is fielding in the slips and the ball strikes him high on the forearm. He is in pain. On examination there is evidence of angulation and radial head sublaxation causing forced pronation. x Rays reveal a fracture of the proximal third of the ulna.

Answer 32

Monteggia fracture
The x rays and examination findings suggest a Monteggia fracture. Open reduction/plating is needed for good alignment so as not to impair pronation.

Question 33

A 68-year-old rambler presents to his GP complaining of pain in his left foot. x Rays show a fracture through the neck of both the second and third metatarsal bones.

Answer 33

March fracture
This patient has a March fracture. Treatment is expectant. If pain is severe, a plaster cast while awaiting healing may help.

Question 34

A 88-year-old man is being treated palliatively for renal cell carcinoma. He complains of a two month history of lower back pain. Serum biochemistry reveals a raised calcium and alkaline phosphatase.

Answer 34

Metastatic carcinoma

This man has vertebral metastatic disease. A bone scan will confirm this. Palliative radiotherapy may help.

Question 35

A 65-year-old lady presents to her GP with a four month history of pain in the back and buttocks typically coming on after a period of walking and easing with rest.

Answer 35

Spinal stenosis

This lady has spinal stenosis. CT and MRI will demonstrate cord compression and treatment is by surgical decompression.

Question 36

A 70-year-old man presents to his GP with a four month history of lethargy, lower back pain and bruising on minimal trauma. The GP arranges some blood tests, which show anaemia, thrombocytopenia, leucopenia and a high ESR.

Answer 36

Myeloma
The above findings are in keeping with a diagnosis of myeloma. He requires plasma electrophoresis and urinary Bence-Jones proteins to be sent.

Question 37

A 70-year-old man presents with a displaced intracapsular neck of femur fracture.

Answer 37

Hemiarthroplasty

Question 38

A 60-year-old man presents with a pertrochanteric neck of femur fracture.

Answer 38

Dynamic hip screw

Fractures of the proximal femur are subdivided into

Extracapsular
Intracapsular
Fractures of the femoral head.

Question 39

Intracapsular fractures

Answer 39

Intracapsular fractures are at greatest risk of non-union and avascular necrosis.

Intracapsular fractures are classified by Garden’s classification (stage I-IV with four having the greatest risk of avascular necrosis), which is based on the A-P radiograph. Intracapsular fractures have the greatest risk of avascular necrosis, as the high cervical fracture is most likely to interrupt the blood supply to the femoral head.

Non-displaced or impacted fractures in the elderly may be treated conservatively or with AO screws. However displaced fractures require prosthetic replacement (Thompson or Austin-Moore prosthesis) to achieve early mobilisation and to avoid fracture non-union.

Question 40

Extracapsular fractures

Answer 40

Extracapsular fractures are less likely to result in avascular necrosis as the blood supply to the femoral neck tends not to be affected.

Fracture non-healing is less of a problem as the surface areas of the fracture tend to be larger and there is less movement of the femoral head. They are classified by the Boyd-Griffin classification. This classification aims to identify those fractures which are unstable and more likely to collapse.

Question 41

Trochanteric fractures

Answer 41

Trochanteric fractures are divided into

Pertrochanteric (through both trochanters)
Intertrochanteric (between the trochanters)
Subtrochanteric or
Avulsion of the greater trochanter.
These fractures tend to be unstable and are not usually affected by non-union.

A dynamic hip screw and plate create compression between the two fracture surfaces (acts like a plaster cast). The patient requires protected weight bearing in the eight weeks following surgery.

Question 42

This type of joint is found in the proximal interphalangeal joints of the fingers.

Answer 42

Hinge

Interphangeal joints are hinge joints, with lateral and medial ligaments.

Question 43

This type of joint is found in the frontal coronal suture.

Answer 43

Fibrous

When two bones fuse to form one (as in the skull), the suture becomes fibrous.

Question 44

This joint is found between the dens of the axis and the atlas.

Answer 44

Pivot

The dens is the only pivot joint in the body.

Question 45

This joint type is found between the trapezium and first metacarpal.

Answer 45

Saddle
Saddle joints, are joints that can move in a range of directions by gliding over one another. For information about joints from Grey’s Anatomy, click here.

Question 46

This joint is found between the shafts of the radius and ulna.

Answer 46

Syndesmosis

Syndesmosis joints are sheets of ligaments found between the long bones of the forearm and leg.

Question 47

A 24-year-old man presents to the emergency department with an acutely swollen and painful right knee after awkwardly falling on this knee whilst playing rugby. There is tenderness on direct palpation over the medial joint line. There is no joint instability.

Answer 47

Medial meniscal tear
The history and clinical symptoms in this patient are suggestive of medial meniscal injury. This type of injury is caused due to twisting injury to the knee joint and is commonly seen in sports related trauma.

Patients present with pain (and direct tenderness) over the medial joint line. Effusion is commonly present. A plain x ray may be needed to rule out any associated fractures.

Question 48

A 24-year-old man is brought to the emergency department with a painful and swollen right knee after he was involved in a RTA. He is unable to weight bear and says that his knee feels unstable.
On examination, the tenderness in this knee extends from the tibial plateau to the lateral condyle of the femur. The pain is worsened with antero-posterior movements of the knee joint. Blood is drawn on joint aspiration.

Answer 48

Anterior cruciate ligament rupture
The anterior cruciate ligament runs upwards and backwards from the anterior part of the tibial plateau towards the lateral condyle of the femur. It prevents backward displacement of the femur on the tibial plateau. It also limits extension of the lateral condyle of the femur and causes medial rotation of the femur in the ‘screw-home’ position of full extension.

Cruciate ligament rupture characteristically produces swelling with one to two hours of injury. The pain is worsened with antero-posterior movements of the knee joint. Aspiration of blood suggests severe intra-articular damage. A plain x ray is mandatory to rule out any associated fractures.

Question 49

A 23-year-old football player presents to the emergency department with a 24 hour history of painful and swollen left knee after he sustained injury to that knee while involved in a tackle. There is severe tenderness along the lateral aspect of the knee joint and the pain is worsened with valgus and varus movements of the knee. The joint feels unstable but he is able to walk.

Answer 49

Lateral collateral ligament injury
This patient has an injury to the lateral collateral ligament. This ligament runs from the head of the fibula to the lateral condyle of the femur.

Collateral ligament injuries cause pain and discomfort with straining of the knee in the valgus and varus positions.