Trauma and Orthopaedics

Question 1

What is cervical spondylosis, its presentation and management?

Answer 1

Degenerative changes of the cervical spine (degeneration of the annulus fibrosus)

Presentation: - Men > 60 yrs, women > 50 yes. Usually asymptomatic but can cause neck and arm pain + paraesthesia
5-10% develop cervical myelopathy

Management - Acute presentation = neurosurgical referral

Question 2

Rotator cuff injury presentation, investigation and management

Answer 2

Shoulder pain and weakness, typically on abduction. Night pain. Typically >40 years old

US / MRI

Analgesia (maybe steroids but risks complete tear)
Surgery if complete, if incomplete then surgery if symptoms persist

Question 3

Adhesive capsulitis presentation and management

Answer 3

No obvious trigger. Very unusual in a younger person. Severe shoulder pain, typically worse at night. Active and passive movement range is reduced.

Management - Analgesia, NSAIDs and physiotherapy earlier. Corticosteroids may help in early stages
Oral steroids for short term (<6 weeks) but no benefit after that.

Surgical release with either manipulation under anaesthesia or arthroscopic arthrolysis is most effective.

Question 4

Pain in anterior shoulder on forced flexion of arm. Cause? Management?

Answer 4

Long head of biceps tendinopathy

Treatment - analgesia, corticosteroid injection (risks full rupture)

Question 5

Rupture of long head of biceps, presentation and treatment.

Answer 5

Discomfort after something pops after lifting or pulling. Ball appears like a muscle on flexion of arm

Treatment - repair rarely needed as function remains.

Question 6

Spinal stenosis cause and presentation

Answer 6

Generalised narrowing of the lumbar spinal canal

Causes - Facet joint OA and osteophytes that result in nerve compression

Presentation - Gradual onset unilateral or bilateral leg pain (with/out back pain). Resolves when sitting, crouching, leaning forward. Normal clinical examination, Pain on leg extension.

Question 7

Spinal stenosis investigation and management

Answer 7

Investigations - MRI needed to confirm diagnosis and rule out malignancy

Treatment - decompressive laminectomy. If not help: - NSAIDs, epidural steroid injections, corsets

Question 8

What is tennis elbow?

Answer 8

Lateral epicondylitis

Question 9

Presentation, investigation and management of lateral epicondylitis.

Answer 9

Presentation - Most common aged 45-55. History of repetitive strain. Unaccustomed activity like house painting or playing tennis (tennis elbow). Pain worse during resisted wrist and digit extension. and passive wrist flexion with elbow extended.

Investigations - Clinical diagnosis (ask patient to extent wrist and resist extension of the middle finger). Consider Elbow X-ray (for complex presentation), MRI of C-spine to rule out other causes

Management - Simple analgesia (NSAID, rest, ice, brace) Most are “watch and wait” - most recover within 6-24 months. Physio. Local anaesthetic injection sometimes used (lidocaine). Severe cases not cured with conservative management = surgery, extracorporeal shock wave therapy

Question 10

What is Golfer’s elbow?

Answer 10

Medial epicondylitis

Question 11

Medial Epicondylitis presentation

Answer 11

Usually 4th - 5th decade of life. Pain and tenderness localised to the medial epicondyle
Worse with wrist flexion and pronation. Can also be tingling in 4th/5th digit due to ulnar nerve which runs behind it.

Treatment same as lateral epicondylitis

Question 12

What is student’s elbow?

Answer 12

Olecranon Bursitis

Question 13

What is a bursa?

Answer 13

Sac containing a small amount of synovial fluid that lies between a tendon and either skin or bone to act as a friction buffer. They can be deep (subacromial bursa) or superficial (olecranon bursa)

Bursitis - thickening and proliferation of the synovial lining, bursal adhesions, tags, chalky deposits. May result from repetitive stress, infection, autoimmune disease or trauma.

Question 14

What is cubital tunnel syndrome?

Answer 14

Ulnar neuritis - Osteoarthritic or rheumatoid narrowing of ulnar groove and constriction of the ulnar nerve as it passes behind the medial epicondyle or friction of the ulnar nerve due to cubitus valgus can cause fibrosis (where arm is extended away from the body when elbow extended)

Question 15

Cubital tunnel presentation, investigation and management

Answer 15

Presentation - intermittent sensory symptoms in the 4th / 5th finger. Worse when elbow resting on a firm surface or flexed/extended for long periods of time.
Clumsiness of the hand, weakness of the small muscles of the hand innervated by the ulnar nerve

Tests - could consider nerve conduction studies

Treatment - Analgesia, avoid aggravating activity, physiotherapy Surgical decompression for nerve compression syndromes (resistant cases).

Question 16

What is pulled elbow, its presentation and treatment?

Answer 16

Sublaxation of the radial head

Typical patient - 1-4 year old who has been lifted by the arm during play causing the radial head to slip out of the annual ligament (arm is slightly flexed and twisted inwards)

Imaging not usually needed

Management - Reduction (cradling the elbow with thumb/forefingers over the radial head)

Question 17

Dupuytren’s Contracture presentation and management

Answer 17

Usually men aged >40 of European descent. Presents with a small lump or multiple with pits in the palm, progressing to contractures of the fingers.

Management:
Early disease - monitor 6 months. Adjunct - Corticosteroid injection (triamcinolone acetonide( - those with evidence of diease but no contractures yet

Other injections - clostridium histolyticum

Late disease - surgery - Fasciectomy (removal of fascia)

Question 18

L3 Nerve Compression Presentation

Answer 18

Sensory loss over anterior thigh.
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test

Question 19

L4 Nerve Compression Presentation

Answer 19

Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test

Question 20

L5 Nerve Compression Presentation

Answer 20

Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve root

Question 21

S1 Nerve Compression Presentation

Answer 21

Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test

Question 22

Management of a prolapsed disc

Answer 22

• Similar to that of other musculoskeletal lower back pain: analgesia (gabapentin, pregabalin or amitriptyline), physiotherapy, exercises
  
  • If symptoms persist (e.g.. after 4-6 weeks) then referral for consideration if appropriate
  • Urgent surgical referral - if bladder/bowel symptoms, weakness and cauda equina compression

Question 23

What is Charcot’s foot, presentations and risk factors for it

Answer 23

Also called neuropathic foot. Joints become damaged due to loss of sensation.

Most common in diabetics, also alcoholic neuropathy is associated

Joint typically warm, red and swollen but not as painful as expected

Question 24

Plantar Fasciitis, presentation and management

Answer 24

Common cause of heel pain in adults. Plantar fasciitis is what supports the arch of the foot. Arises due to microtrauma.

Pain usually worse around the medial calcaneal tuberosity. Risk factors - obesity, inactivity, excessive walking

Management - Mostly conservative - rest, appropriate footwear (shows with arch support) Analgesia, orthopaedics referral if conservative management fails

Question 25

Compartment syndrome presentation and diagnosis

Answer 25

Complication that occurs following fractures. Characterised by raised pressure within a closed anatomical space

Pain, particularly on movement. Paraesthesia, pallor, PULSE DOES NOT RULE OUT. Paralysis of muscle group can occur

Diagnosis - measurement of intracompartmental pressure (>20 mmHg is suggestive, >40 mmHg is diagnostic)

Question 26

Treatment of compartment syndrome

Answer 26

Prompt and extensive fasciotomies (deep muscles need deeper incisions)
Necrotic tissue = debrided
Myoglobinuria may occur following fasciotomy and can result in renal failure = may need aggressive IV fluids.

Question 27

What are stress fractures?

Answer 27

Tiny hairline fractures in a bone. Caused by repetitive force, often from overuse (jumping, immobilisation)

Question 28

What is tibial stress syndrome and what is an important differential?

Answer 28

Also called shin splints
Overuse injury (or repetitive-load injury) of the shin area. Leads to persistent dull anterior leg pain

Important differential = Stress fracture = do an X-ray to rule out

Question 29

Risk factors for Achilles disorders

Answer 29

Use of Quinolone (e.g. ciprofloxacin)

Hypercholesterolaemia (predisposes to tendon xanthomata)

Question 30

Achilles tendon rupture diagnosis

Answer 30

Sudden pop whilst running or playing support. Sudden onset of pain in the calf or ankle and inability to walk

Examination - Simmond’s triad (lying prone, feet hanging over the bed) Rupture leads to greater dorsiflexion of injured foot. Squeeze calf - ruptured foot will stay in neutral position

US for diagnosis
Acute referral to orthopaedics

Question 31

What is carpal tunnel syndrome?

Answer 31

Pressure on the median nerve, often cause to a tightening of the flexor retinaculum around the wrist

Question 32

Presentation of carpal tunnel

Answer 32

Pins and needles in the thumb, index and middle finger. Symptoms often at night. Patients shake to obtain relief. Symptoms can ascend proximally

Examination - weakness of thumb abduction, wasting of the thenar eminence. Tinels and phalens sign (worse on flexion of the wrist)

Question 33

Treatment of carpal tunnel syndrome

Answer 33

Corticosteroid injection
Wrist splints at night
Surgical decompression (flexor retinaculum division)

Question 34

What is trigger finger?

Answer 34

o Common condition associated with abnormal flexion of the digits
Thought to be caused by a disparity between the size of the tendon and pulleys through which they pass (tendon becomes stuck and cannot pass through the pully smoothly)

Question 35

Presentation of trigger finger

Answer 35

§ Swelling of the flexor tendon or tightening of the sheath
§ Ring and middle fingers commonly affected
§ Initially stiffness and snapping (trigger) when extending a flexed digit
§ A nodule at the base of the affected finger may be felt
Swelling of the tendon sheath along with nodule formation on the tendon proximal to A1 pulley prevents tendon sliding smoothly and instead ‘catches; causing the finger to lock in flexion

Question 36

Treatment of trigger finger

Answer 36

Simple rest and sometimes splinting

Steroid injections if pain severe

Question 37

Big risk factor for adhesive capsulitis?

Answer 37

Diabetes