T&O II Flashcards
A 22-year-old male presents with a one day history of pain and swelling of the right knee which developed after he injured his right knee in a tackle whilst playing football three days earlier.
Originally he presented to the emergency department with an area of tenderness 2-3 cm above the joint line on the medial aspect. He has increased valgus deformity on examination.
Medial collateral ligament
The young footballer presents with a typical history of collateral ligament injury with valgus deformity, delayed swelling and tenderness above the joint. Tenderness over the joint line suggests meniscal injury.
A 24-year-old female basketball player complained of hearing a popping sound after landing and twisting her foot during a practice game. She was in immediate pain and her knee gave way when she tried to walk.
ACL
The anterior cruciate ligament prevents backward displacement of the femur on the tibial plateau and limits extension of the lateral condyle of the femur.
A 42-year-old male is admitted after a road traffic accident, where he hit his knee on the steering column, producing an immediate haemarthrosis.
An x ray showed no bony injury, but he has since had problems walking downstairs.
Posterior cruciate ligament
The posterior cruciate ligament is involved in retaining the femur in position preventing it from sliding over the tibial plateau. The history of problems walking downstairs suggests posterior cruciate injury.
Immediate haemarthrosis is indicative of cruciate ligament rupture or fracture.
During an orthopaedic examination of the hip you carry out the following examination:
The patient stands directly in front of you.
You place your hands on their anterior superior iliac spines.
You then ask them to lift their good leg off the floor so that their weight is on the bad leg that is being examined.
You note which way the pelvis tilts.
What is the name of this test?
(Please select 1 option)
Lachmann test
Macintosh test
McMurray test
Thomas test
Trendelenberg test
Trendelenberg test This is the correct answerThis is the correct answer
This is Trendelenberg’s test.
In a normal Trendelenberg test, when the patient stands on one leg, the abductors (gluteus medius and minimus) of the supporting leg would pull on the pelvis.
This means that the pelvis tilts and the opposite side of the pelvis rises.
A positive Trendelenberg’s test occurs when the opposite side of the pelvis falls.
Causes of a positive Trendelenberg test include:
Gluteal paralysis or weakness
Pain in the hip causing gluteal inhibition
Coxa vara and
Congenital dislocation of the hip.
A Thomas test is also used in the hip examination as a test of hip extension.
Lachmann’s, Macintosh’s and McMurray’s tests are used in the clinical examination of the knee.
During the anteriolateral (Hardinge) approach to the hip joint, after division of tensor fascia lata, which muscle is encountered before the hip joint is seen? (Please select 1 option) Gemellus Gluteus maximus Gluteus medius Gluteus minimus Sartorius
Gluteus medius
The three commonest approaches to the hip joint are the
Anterior
Anterolateral (Hardinge) and
Posterior
approaches.
In the Hardinge approach a skin incision is made from the greater trochanter. Tensor fascia lata is divided before gluteus medius is seen. Gluteus medius is then divided to reach the capsule.
In the posterior approach after skin and tensor fascia lata are divided the short external rotators are divided. There is an increased risk of dislocation with this approach.
A 27-year-old man attends the fracture clinic. He suffered an anterior dislocation of his shoulder whilst playing rugby three days before. This has been successfully manipulated back into joint in the emergency department. Since then his arm has been in a broad arm sling. When you examine him in the fracture clinic he is unable to abduct his shoulder and there is a numb patch over the lateral side of his arm. Which nerve has been affected? (Please select 1 option) Axillary nerve Musculocutaneous nerve Nerve to subscapularis Radial nerve Upper cord of brachial plexus
Axillary nerve
Common mechanisms of axillary nerve injury are
Following anterior dislocation of the shoulder
Proximal fracture of the humerus or
Injury during intramuscular injections into the deltoid muscle.
Injury to the axillary nerve will lead to paralsysis of the deltoid muscle which means that shoulder abduction will be virtually absent. There is also loss of sensation over an area of the upper limb which is also known as the ‘regimental badge’ area.
The deltoid muscle arises from the lateral third of the clavicle, the acromion and the spine of the scapula. It attaches into the deltoid tuberosity of the humerus.
A 23-year-old hairdresser presents with a history suggestive of subarachnoid haemorrhage on the emergency medical intake.
A CT scan is carried out and this is normal. To exclude a bleed, a lumbar puncture is carried out by the medical registrar.
After piercing the interspinous ligament with the spinal needle which of the following is the next structure to be passed through (next deepest structure)?
(Please select 1 option)
Arachnoid mater
Dura mater
Ligamentum flavum
Spinal cord
Supraspinous ligament
Ligamentum flavum
The landmarks for a lumbar puncture are the iliac crests.
The vertebra in the line with these is the fourth lumbar vertebra. The spinal cord ends at L1 level.
The different structures which a spinal needle would pass through are (most superficial to most deep)
Skin Fascia Supraspinous ligament Interspinous ligament Ligamentum flavum Areolar tissue Dura Arachnoid mater.
A 64-year-old lady is undergoing a right total hip replacement.
The surgeon’s preferred approach to the hip joint is the lateral approach. To reach the hip joint, he splits the tensor fascia lata, and then gluteus medius and minimus. During this approach, the nerve supply to the tensor fascia lata and gluteus medius is at risk.
What nerve innervates this muscle?
(Please select 1 option)
Femoral nerve
Lateral femoral cutaneous nerve of the thigh
Posterior branch of obturator nerve
Sciatic nerve
Superior gluteal nerve
Superior gluteal nerve This is the correct answerThis is the correct answer
The superior gluteal nerve arises from the ventral rami of L4- S1. It leaves the pelvis through the greater sciatic foramen. It supplies the gluteus medius, gluteus minimus and tensor fascia lata muscles.
There are several different approaches to the hip and different nerves may be damaged depending on which approach is used.
The posterior approach to the hip joint involves an incision through the deep fascia and gluteus maximus and then division of the external rotators. The sciatic nerve is in danger with this approach.
The anterior approach involves the planes between tensor fascia lata and sartorius and then rectus femoris and gluteus medius. The lateral femoral cutaneous nerve of the thigh is in danger with this approach.
A 71-year-old lady has a total hip replacement and post operatively develops a Trendelenburg gait. From the list below which structure is likely to have been damaged? (Please select 1 option) Femoral nerve Obturator nerve Psoas muscle Sciatic nerve Superior gluteal nerve
Superior gluteal nerve This is the correct answerThis is the correct answer
A Trendelenburg gait is caused by weakness of the hip abductors.
A superior gluteal nerve injury would paralyse the gluteus medius causing a Trendelenburg gait.
The femoral nerve supplies the anterior thigh muscles.
The obturator nerve supplies the hip adductors.
Injury to the psoas muscle would cause weakness of hip flexion.
The sciatic nerve supplies the hamstrings and other hip extensors.
A 23-year-old keen rugby player fractures his ankle whilst playing rugby and is then placed in a below knee plaster of Paris for six weeks.
After removal of the plaster he is noted to have quadriceps weakness of the affected limb.
What is the likely explanation for the quadriceps weakness?
(Please select 1 option)
Agenesis
Aplasia
Atrophy
Hyperplasia
Hypertrophy
Atrophy
Atrophy is defined as degeneration of an organ or tissue from its fully formed state.
Agenesis is complete failure of an organ or tissue to develop.
Aplasia is failure of an organ or tissue to attain its proper size.
Hyperplasia is an increase in the size of an organ or tissue because of an increase in the number of cells.
Hypertrophy is an increase in the size of an organ or tissue because of an increase in the size of its cells.
A 57-year-old male presents to the emergency department a few months after injuring his upper limb.
On examination the following are observed
Wasting of the interossei on the dorsum of the affected hand
Extension of the metocarpophalyngeal joints and
Marked flexion of the proximal and distal interphalyngeal joints.
There is no radial deviation.
Which of the following is the most likely mechanism of injury?
(Please select 1 option)
A laceration at the elbow
A laceration at the wrist
Fall from height and catching a ledge
Supracondylar fracture
Wrist fracture causing carpal tunnel syndrome
laceration in wrist
The description is of a true claw hand caused by injury to the ulnar nerve.
The injury is likely to be at the level of the wrist rather than the elbow as we are told the proximal and distal IP joints are flexed - due to flexor digitorum profundus being intact and there is no radial deviation.
You may expect radial deviation if the ulnar nerve is injured at the level of the elbow due to paralysis of flexor carpi ulnaris, which is also supplied by the ulnar nerve.
A fall from height and catching a ledge would typically cause a brachial plexus injury.
A supracondylar fracture can be complicated by ulnar nerve injury but this would cause signs of injury at the elbow.
Wrist fracture causing carpal tunnel syndrome would lead to signs of median nerve injury.
This film was taken on a 30-year-old male who originally presented to the orthopaedic surgeons six weeks ago with a fracture of the right tibia.
Following treatment he now complains of pain in the ankle. Which of the following options is the likely diagnosis? (Please select 1 option) Avascular necrosis Fractured talus Fractured tibia Osteoarthritis Reflex sympathetic dystrophy
AVN
There is avascular necrosis of the talus.
This is a complication of the initial fracture causing ischaemia of the talus. There is a sub-cortical fissure (lucency) related to the dome of the talus.
A 53-year-old pedestrian is brought to the Emergency department after he was hit on a crossing by a car travelling at about 30 mph. He has numerous bruises and lacerations over his left chest wall. On examination he appears pale and anxious. His blood pressure is 90/64 mmHg, heart rate is 116/min, respiratory rate is 20/min and his jugular venous pressure is elevated. Trachea is central and breath sounds are normal bilaterally but the heart sounds are muffled. A chest radiograph shows fractured 4th, 5th and 6th ribs on the left side and an enlarged cardiac silhouette. What is the most likely diagnosis? (Please select 1 option) Cardiac tamponade Diaphragmatic rupture Ruptured thoracic aorta Tension pneumothorax Traumatic haemothorax
Cardiac tamponade
Direct penetrating injury to the heart is the mostly likely aetiology for a cardiac tamponade although blunt injuries to the heart may also lead to this condition by injuring the pericardial vessels.
Likewise, high velocity injuries to the great vessels (for example, thoracic aorta) could result in pooling of blood in the pericardium leading to tamponade.
Apart from trauma it can occur following lung or breast carcinomas, myocardial infarctions, dissecting thoracic aneurysm and bacterial, viral or tuberculous pericarditis.
Cardiac tamponade can be difficult to detect clinically, especially in a trauma setting. The classic (and diagnostic) signs include:
A fall in blood pressure
Rising jugular venous pulse and
Muffled heart sounds (Beck’s triad).
Pulsus paradoxus may also be an associated finding (normally, there is a physiological decrease in systolic blood pressure during spontaneous inspiration. When this change exceeds 10 mmHg, it is termed pulsus paradoxus.).
In addition, the jugular venous pulse may paradoxically rise with inspiration (Kussmaul’s sign).
Chest radiograph may reveal a globular heart, a convex or straight left heart border, and a right cardiophrenic angle of
A 29-year-old motorcyclist is brought to the emergency department after he was involved in a high speed road traffic accident on the motorway. He was thrown off his bike onto the road.
On examination, severe bruising is noticed over his left antero-lateral chest wall. There is decreased air entry over the left lower lobe of lung and bowel sounds are heard in the chest. A chest x ray reveals fracture of the lower four ribs on the left side and a raised left dome of the diaphragm.
From the options below choose the one which you think is the most likely diagnosis in this patient.
(Please select 1 option)
Cardiac tamponade
Diaphragmatic rupture
Left basal pneumonia
Tension pneumothorax
Traumatic haemothorax
Diaphragmatic rupture
This patient is most likely to have a ruptured diaphragm. Direct penetrating injury to the thoraco-abdominal region is a common cause for diaphragmatic rupture. The injury could be at any level between the fourth and the tenth inter-costal space, depending on the patient’s respiratory pattern.
The other causes include rib fractures and a sudden increase in thoraco-abdominal pressure, as may occur when a patient with a closed glottis is hit in the abdomen.
The diaphragmatic rupture may present with signs and symptoms of cardiac and pulmonary compromise. The patient may or may not be haemodynamically compromised. Diaphragmatic rupture may be difficult to detect clinically, and thus may result in significant morbidity or sometimes mortality. Rupture may be seen on plain chest radiograph especially with the abnormal location of the naso-gastric tube; the accuracy of this method, however, is modest.
The differential diagnoses for a raised left hemidiaphragm, both clinically and in plain radiography, includes
Phrenic nerve palsy Atelectasis Diaphragmatic hernia Distended abdominal viscera. Conventional CT scan is not very accurate. Helical CT scan and multi-section CT scan identify most injuries in the trauma setting; they are thus the investigations of choice.
MR scanning, although very sensitive and specific, is not feasible in most trauma situations. However, they remain a useful tool to in stable patients to make a more accurate diagnosis and to delineate precisely the extent of anatomical damage.
An exploratory laparotomy or laparoscopy may be necessary to confirm or rule out the diagnosis of diaphragmatic rupture.
Diaphragmatic injury, secondary to high-impact trauma such as RTAs, is associated with a high proportion of associated injuries to the pelvis, thorax and abdomen, and to other visceral organs such as the lung, heart, spleen and liver. Thus a high index of suspicion should be maintained in patients with diaphragmatic injury, and injury to other anatomical structures and organs should be identified and treated.
A 7-year-old female presents with an angulated left elbow following a fall from a swing.
Examination reveals a cold left hand with no brachial, radial or ulnar pulses palpable. A plain radiograph of the elbow reveals a displaced left humeral supracondylar fracture.
Which of the following is the most appropriate initial management?
(Please select 1 option)
Backslab plaster and review in fracture clinic
Heparinisation
Manipulation of the fracture under anaesthetic
Open reduction and internal fixation of the fracture
Surgical exploration of the left brachial artery
Manipulation of the fracture under anaesthetic
Supracondylar fractures frequently result in complications, for example,
Vascular Nerve injury Compartment syndrome Malunion. Arterial injury occurs in 5% of fractures and results from the brachial artery becoming kinked over the anterior prominence of the proximal fragment or from laceration. The distal circulation should be checked carefully and recorded in the patient's notes.
Initial management includes analgesia and an emergency reduction of the fracture into a good anatomical position. This usually results in an unkinking of the brachial artery and restoration of the distal blood flow.
If blood flow is not restored a surgical exploration of the brachial artery should be performed by a vascular surgeon.
Lacerations of the artery are either repaired primarily (with sutures) or with a vein graft.
