MSK Flashcards

Question

What causes SUFE?

Answer 1

Weakness in the growth plate caused by: * Stress on the growth plate due to obesity * Endocrine disorders - Pan-hypopituitarism/Hypothyroidism/Renal Osteodystrophy * Period of rapid grwoth in adolescence

Answer 2

* Stable - Patient can walk & Osteonecrosis is rare (Most common) * Unstable - Pt unable to walk + 50% risk of osteonecrosis

Answer 3

* Most commonly affects the hip * Common in teenage boys & girls * Risk factors - Obesity/Local trauma/Endocrine dysfunction

Answer 4

* Pain/discomfort in Hip/Referred pain to knee * Accentuated by activity * If acute - \<3wks of onset * If acute on chronic - Months of pain with sudden pain * Reduced hip movement - Internal rotation + Abduction due to pain * Leg length discrepancy * Trendelenberg gait

Answer 5

* SUFE * Hip # * Perthes disease * Osteomyelitis * Septic arthritis * Acute transient synovitis

Answer 6

* AP + Frog leg x-ray of Hip * Widening of epiphyseal line/Displacement of femoral head * Normal klein line * U&E - Normal. May have increased Cr if Renal Osteodystrophy * TFTs - Normal. May have Increased TSH if Hypothyroidism

Answer 7

* Limit mobility - No movement or rotation of leg * Analgesia - Paracetamol/Ibuprofen * If unstable * Open reduction + Internal fixation w/screws

Answer 8

* Chondrolysis - Degeneration of artciular cartilage * AVN of epiphysis

Answer 9

Any # distal to the femoral head + Proximal to 5cm below lesser trochanter Usually caused by falls from standing height in elderly pts, or high energy trauma in younger pts.

Answer 10

**Osteopenia** -- Decreased BMD due to increased osteoclast activity, and decreased osteoblast activity * BMD T score of -1 to -2.5 **Osteoporosis** -- Decreased BMD, and deterioration of bone due to increased osteoclast activity, and decreased osteoblast activity * BMD T score of \<-2.5

Answer 11

**Intracapsular** -- Within the hip capsule (Femoral neck to femoral head) * Can disrupt the blood supply to the femoral head leading to AVN **Extracapsular** -- After the line b/w the greater and lesser trochanter (Trochanteric or Subtrochanteric) * Less likely to disrupt femoral head blood supply

Answer 12

* Increasing age \>65yrs * Osteoporosis * Osteomalacia * Trauma * Post menopausal female * Falls

Answer 13

Softening of bone due to decreased vitamin D

Answer 14

Garden classification * **Garden 1** -- Undisplaced + Incomplete * **Garden 2** -- Undisplaced + Complete (# from superior - inferior cortex) * **Garden 3** -- Slightly Displaced + Complete (# from superior - inferior cortex) * **Garden 4** -- Completely displaced + Complete (# from superior - inferior cortex)

Answer 15

* Pain in upper thigh or groin, may radiate to the knee * Inability to weight bear * Hx of previous injury/trauma * If pathological # - Hx of previous aching pain * Increased pain on flexion/rotation of leg * Shortened/Adducted/Externally rotated leg

Answer 16

* Hip # * Acetabular # * Septic arthritis * Pubic rami #

Answer 17

* ABCDE assesment * AP + Lateral x-ray of Hip * Disruption of trabeculae, inferior±superior cortex # * Shentons line broken * If no # on x-ray but still suspecting a fracture - MRI/CT * FBC * Crossmatch blood * U&E * Glucose * ECG

Answer 18

Classify the # - Intracapsular v Extracapsular * Intracapsular: * Determine garden classification * Surgery within 24hrs of admission * **Garden 1 + 2** -- Internal fixation w/screws * If unfit -- Arthroplasty * **Garden 3 + 4** -- Replacement of femoral head w/Hemi-arthroplasty or Total hip replacement (If co-morbidities) * Extracapsular: * Surgical fixation unless C/I * Internal fixation - DHSS/Hip arthroplasty

Answer 19

* High mortality rate * Infection * Haemorrhage * AVN * Delayed union/Malunion * MI/PE/DVT

Answer 20

* Medial femoral circumflex artery * Lateral femoral circumflex artery * Ligamentum teres artery

Answer 21

**Spondylolisthesis** -- Movement of one vertebrae relative to others in Ant./Post. due to instability Stress # and sliding of vertebrae

Answer 22

* **Spondylolysis** -- Bony defect (Stress #) in pars interarticularis of vertebral arch * Can be unilateral/bilateral * Commonly affects L5 -- causing back pain

Answer 23

* **Spondylosis** -- Degenerative OA changes in the spine * Due to degeneration of IV discs, leading to narrow IV space * Osteophyte formation may lead to pressure on nerve roots -- Motor and sensory disturbance

Answer 24

Inflammation of the vertebrae

Answer 25

* Female gender * Young age * Presence of spina bifida * Positive FHx * High impact sport

Answer 26

* Aching pain with insidious onset * Low back pain & posterior thighs * Neurogenic claudication (Due to spinal stenosis) * Pain made worse by walking * Pain relieved by sitting in forward flexion/lying down * Chronic & progressive symptoms

Answer 27

* Asymptomatic * May be symptomatic: * Low back pain - provoked by lumbar extension * Paraspinal spasm * Tight hamstrings

Answer 28

* FBC -- Normal. Assess for infection/myeloma * Ca+ levels -- Normal. Assess for hyper/hypocalcaemia * x-ray -- Lateral + AP * MRI

Answer 29

Pain relief -- Paracetamol/NSAIDs/Codeine If stable: * Bed rest for 2-3 days * Sleep on side w/pillow b/w knees * Activity modification to prevent further injury * Physiotherapy If unstable: * Surgery -- Fuse affected vertebrae + Discectomy

Answer 30

* Neurosurgical emergency * Spinal cord is compressed due to trauma/tumour/prolapsed IV disc/Infection * Most common cause is malignancy

Answer 31

* Breast * Prostate * Lung * Bone tumour

Answer 32

* T or C spine pain * Severe unremitting or progressive spine pain * Spinal pain aggravated by straining -- Coughing/Sneezing/Passing stool * Nocturnal spinal pain preventing sleep * Localised spinal tenderness * Limb weakness * Loss of sexual/Bladder/bowel function

Answer 33

* **Spinal cord compression** * Transverse myelitis * GBS * MS * Diabetic neuropathy

Answer 34

* **Spinal cord compression** * Transverse myelitis * GBS * MS * Diabetic neuropathy

Answer 35

* FBC -- Check for infection * U&E * MRI Whole spine -- Assess for level of compression * Within 24hrs

Answer 36

* Nurse patient lying flat in neutral alignment * Dexamethasone IV * Insert catheter to manage bladder dysfunction * Pain control * Analgesia * Palliative radiotherapy - if malignant cause * May require spinal orthoses/vertebroplasty/kyphoplasty

Answer 37

* **MSK Back pain** * IV disc prolapse * Vertebral # * CES * Spinal metastases * Osteomyelitis

Answer 38

* **IV disc prolapse** * MSK Back pain * Vertebral # * CES * Spinal metastases * Osteomyelitis

Answer 39

* **IV disc prolapse** * MSK Back pain * Vertebral # * CES * Spinal metastases * Osteomyelitis

Answer 40

Cauda Equina Syndrome: * Saddle anaesthesia/parasthesia * Recent onset of bladder dysfunction/faecal incontinence * Perineal/perianal sensory loss * Severe/progressive neurological deficit in LL Spinal # * Sudden onset of severe central pain in spine, relieved by lying down * Major trauma - RTA/Fall from height * Minor trauma - strenuous lifting if patient has osteoporosis * Structural deformity of spine * Point tenderness over vertebral body Cancer * Pain that remains on lying down * Aching night time pain that disturbs sleep * Thoracic pain - consider thoracic aortic aneurysm * Hx of cancer * Unexplained weight loss Infection (Discitis/osteomyelitis) * Fever/Chills * Unexplained weight loss * Recent infection - UTI * IVDU * Immune suppression * Point tenderness over vertebral body

Answer 41

Signs which suggest that the patient is exaggerating their level of pain etc. * Superficial tenderness * Stimulation manoeuvres that are painful - e.g. axial loading of head/passively rotating shoulders/pelvis * No pain on distraction * Overreaction - disproportionate response to examination

Answer 42

If simple back pain - No investigations * Spine exam * Neurological exam If serious pathology likely e.g. red flags present * X-ray -\> Considering # or cancer * CT scan -\> Considering stress #/spondylolisthesis * FBC -\> Rule out cancer/infection/inflammation * ESR -\> Rule out cancer/infection/inflammation * CRP -\> Rule out cancer/infection/inflammation * Urinalysis -\> Rule out infection * LFTs -- ALP raised if metastatic disease/pagets disease of bone [Management] Conservative * Keep patient active * Give analgesia to facilitate increased activity if required * Paracetamol * NSAIDs - Ibuprofen/Naproxen * Codeine/Tramadol * If rest is suggested - only 48hrs * Physiotherapy Medical * Consider epidural corticosteroid injections - reduce nerve pain * If acute spasm -\> Diazepam * TENS machine * Trancutaneous Electrical Nerve Stimulation * Lumbar discectomy - if severe nerve compression or persistent symptoms despite conservative management

Answer 43

Where the cauda equina (Below L1) - nerve roots are compressed. **Medical EMERGENCY** Caused by: * Herniation of Lumbar IV disc - most commonly L4/5 or L5/S1 * Tumours - Metastases/lymphoma/spinal tumour * Trauma * Infection * Congenital - Congenital spinal stenosis/kyphoscoliosis/spina bifida * Spondylolisthesis * AS

Answer 44

* Not very common Symptoms/Signs: * Low back pain ± pain in unilateral/bilateral LL * Sudden onset of + Rapidly progressing: * Bladder ± bowel dysfunction * Urinary retention * Decreased bladder/urethral sensation * Faecal incontinence/Constipation * Reduced sensation in the saddle (Perineal) area * Sexual dysfunction * LMN Neurological signs

Answer 45

Investigations: * Neurological examination * DRE - Assess anal tone * Urgent MRI spine Management: * Immediate referral to neurosurgery * Spinal decompression * Immobilise spine if due to trauma

Answer 46

* Paralysis * Sensory abnormalities * Bladder/Bowel dysfunction * Sexual dysfunction

Answer 47

* Disc herniation -- Prolapsed IV disc * Common in younger pts \<40yrs * Degenerative disc disease * Common in older pts \>40yrs * Discitis

Answer 48

* Herniation of the nucleus pulposis in the IV disc, leads to: * Irritation of adjacent nerve root * Compression of adjacent nerve root e.g. Sciatica Caused by: * Trauma * Secondary to degenerative disc changes

Answer 49

Sciatica: * Pain + tingling + numbness - due to nerve root entrapment in lumbosacral spine * Usually caused by herniated IV disc * Most commonly L5/S1 level * Unilateral leg pain which radiates below knee to foot/toes * More severe than back pain * Numbness/parasthesia/weakness ± loss of tendon reflexes * Positive straight leg raise * Relieved on lying down * Exacerbated by long walks and prolonged sitting

Answer 50

* Pus forming infection of the spine, leads to inflammation of the vertebral disc space * Usually associated with infection, may have concurrent osteomyelitis (Spondylodiscitis) * Usually due to haematogenous spread of infection * Commonly caused by **Staph aureus**

Answer 51

* Males \> Females * Pts \>50yrs * IVDU * DM * Immunosuppression Symptoms/Signs: * Low back pain -- Pain worse on movement * Insidious onset - neck/back pain * Localised tenderness * Mobility restricted * Fever * Weight loss * May have neurological deficit

Answer 52

Investigations: * ESR - Raised * CRP - Raised * FBC - may be normal, or raised WCC * Blood cultures/sputum/urine culture - look for source of infection * X-ray of spine * Disc narrowing * End plate irregularities * Annulus calcification * MRI is most sensitive and specific Management: * CT guided or open biopsy of infected disc space area - allow for histology & culture * Surgical debridement * ABx * Based on local guidelines, adjusted based on culture results * May be required for 6-8 weeks * 2 weeks of bed rest - immobilisation by brace * Analgesia * Paracetamol/NSAIDs * Codeine/Tramadol

Answer 53

Treatment is an emergency! Manage with: * Adequate fluid/blood replacement * Analgesia * Splinting * ABx & Tetanus prophylaxis * IV Co-amoxiclav * Avoid handling wound unless to remove gross contaminants or obtain photographic evidence then to seal from environment Surgery only if: * Gross contamination * Compartment syndrome risk * Devascularised limb * Patient has multiple injuries * Debridement by orthopaedic & plastic surgeons (Remove non-viable tissue and stabilise #)

Answer 54

Layout: * Check what the patient knows * Brief history * Do they know what the drug is? * Indication & Action of the drug * Side effects * How to take it * Monitoring requirements [Indication & Action of the drug] Indication: * Mild to moderate pain - such as post-op pain * 2nd line for pain relief (WHO ladder) Action: * Codeine + Dihydrocodeine -\> Very weak opioids Metabolised by liver to produce small amounts of morphine (From codeine) or Dihydromorphine (From Dihydrocodeine) * Metabolites are stronger agonists of Mu opioid receptors * Work by activating Mu opioid receptors in the CNS * Activation -\> Leads to reduced neuronal excitability & pain transmission. In medulla * Blunt response to hypoxia & hypercapnia -\> Reduced respiratory drive and breathlessness * Also relieve pain and breathlessness and associated anxiety - reducing SNS activity (Fight or flight) * Reduce cardiac work and O2 demand -\> relieving symptoms in MI/Pulmonary oedema * Tramadol -\> Moderate opioid [Side effects] * Nausea * Constipation * Dizziness * Drowsiness * Neurological & Respiratory depression - In overdose Note: Tramadol may cause less constipation & respiratory depression * Codeine & Dihydrocodeine - Never to be given via IV -\> Cause Severe reaction similar to anaphylaxis Complications & CI Caution in: * Significant respiratory disease * Reduce doses in renal/hepatic impairment/Elderly * Tramadol lowers seizure threshold Avoid in: * Epilepsy [How to take it] * Orally as regular or PRN * Consider need for laxative if regular - Senna (Stimulant laxative) to mitigate constipation * Can be added to paracetamol -\> Co-codamol/Co-dyramol * Dose should be taken at regular intervals * Can be taken with or without food [Monitoring requirements] Information: * Constipation is very common - may require pre-emptive laxative use (Senna) along with hydration * Patient should NOT drive or operate heavy machinery if drowsy/confused * Review: * Acute pain - every 1hr * Assess for SE - respiratory depression * Chronic pain - Few weeks * Assess need to step up or step down pain relief or referral for specialist

Answer 55

Layout: * Check what the patient knows * Brief history * Do they know what the drug is? * Indication & Action of the drug * Side effects * How to take it * Monitoring requirements [Indication & Action of the drug] Indication: * Rapid relief of acute severe pain - post op pain/MI associated pain * Relief of chronic pain - when all other pain ladder drugs have been used * Relief of breathlessness in end of life care * Relief of breathlessness and anxiety due to acute pulmonary oedema Action: * Naturally occurring (Morphine) and synthetic (Oxycodone) opiates * Work by activating Mu opioid receptors in the CNS * Activation -\> Leads to reduced neuronal excitability & pain transmission * In medulla * Blunt response to hypoxia & hypercapnia -\> Reduced respiratory drive and breathlessness * Also relieve pain and breathlessness and associated anxiety - reducing SNS activity (Fight or flight) * Reduce cardiac work and O2 demand -\> relieving symptoms in MI/Pulmonary oedema [Side effects] * Respiratory depression * Reduce respitaroy drive * Euphoria * Detachment * Neurological depression * Activate chemoreceptor trigger zone -\> Nausea & Vomiting * Pupil constriction - stimulation of Erdinger-Westphal nucleus * In large intestine * Activation of Mu receptors -\> Smooth muscle tone + Reduced motility = Constipation * In skin * Histamine release -\> Itching + Urticaria + Vasodilation + Sweating * Continued use can lead to tolerance - dependence * Dependence is apparent as patient has withdrawal reaction on stopping Complications & CI Caution - reduce dose in: * Hepatic failure * Renal impairment * Elderly Avoid in: * Respiratory failure except in palliative situation * Biliary colic -\> Can cause spasm of sphincter of Oddi - Worsen pain [How to take it] * Acute severe pain -\> IV for rapid effect * If severe pain generally -\> IM/SC * Chronic pain -\> Orally Immediate release/Modified release * Immediate release -\> Oromorph * Modified release -\> MST every 12hrs May require breakthrough analgesia * 1/6 of total daily regular dose, immediate release (Oromorph) Information: * Nausea usually settles - but may need anti-emetic -\> Metoclopramide * Constipation is very common - may require pre-emptive laxative use (Senna) along with hydration * Patient should NOT drive or operate heavy machinery if drowsy/confused [Monitoring requirements] * Prescribe with BRAND NAME * Review:Acute pain - every 1hr * Assess for SE - respiratory depression * Chronic pain - Few weeks * Assess need to step up or step down pain relief or referral for specialist

Answer 56

Signs: * Loss of consciousness * Pinpoint pupils * Respiratory depression Management: * Naloxone prescription STAT * Stop any opioids on prescription chart * Prescribe paracetamol as baseline analgesia, until effects of overdose are gone

Answer 57

Colles # * Distal radius * Dorsal displacement of fragments Smiths # * Distal radius * Volar displacement of fragments

Answer 58

Some Lovers Try Positions That They Cant Handle Proximal row * (Lateral) Scaphoid - Lunate - Triquetrium - Pisiform (Medial) Distal row * (Lateral) Trapezium - Trapezoid - Capitate - Hamate (Medial)

Answer 59

* Fall/Trauma preceeding the # * Osteoporosis Hx * Pain * Difficulty weight bearing * May have open wound * May have loss of function * Tenderness over site * Deformity over site

Answer 60

Investigations: * Examination of the joint * Plain x ray of affected joint/bone (Joint above + below) Management: * ABCDE Assesment * Check for neurovascular compromise * Provide analgesia: * Paracetamol/Cocodamol/Morphine * Temporary splinting - Immobilise the joint * Open/Closed reduction * F/UP in # clinic

Answer 61

* Most common carpal bone # * Can be displaced or non-displaced * Vulnerable blood supply - so increased risk of AVN + Non union

Answer 62

**Galezzi:** * # of the distal 1/3 of the radius * Subluxation/dislocation of distal radio-ulnar joint **Monteggia:** * # of proximal 1/3 of Ulna * Dislocation of radial head

Answer 63

Infection producing inflammation in a native/prosthetic joint(s) * Can be acute/chronic Either caused by: * Direct innoculation * Haematogenous spread Most commonly caused by Staph Aureus/Group B Strep/Gonococcus (Sexually active)

Answer 64

Epidemiology: * Common in pts who are immunosuppressed/elderly * Can occur in pts with prosthetics * DM/IVDU/Prior joint damage Symptoms/Signs: * Single swollen joint with pain on movement * Fever/Rigors * Swollen + Red + Hot joint * Antalgic gait * Unwilling to weight bear * Tenderness in joint * Effusion

Answer 65

* **Septic Arthritis** * RA/OA * Gout * Reactive arthritis * Lyme disease * Cellulitis

Answer 66

* **Septic Arthritis** * RA/OA * Gout * Reactive arthritis * Lyme disease * Cellulitis

Answer 67

Investigations: * FBC -- Increased WCC * CRP + ESR -- Elevated * Blood culture -- Exclude systemic sepsis * Synovial fluid analysis + Culture -- WCC + Gram stain * X-ray of joint Management: * Surgical drainage + Lavage of joint (Aspiration) * High dose IV ABx: * IV Flucloxacillin/Clindamycin (If allergic) * 2-3 weeks then switch to oral for 2-4 weeks * If MRSA + then Vancomycin/Teicoplanin

Answer 68

Infection of the bone marrow, that can spread to the cortex + periosteum via the Haversian canals * Leads to inflammatory destruction of bone + necrosis Can be spread via: * Haematogenous -- Spread via blood from remote source, common in children * Direct contiguous -- From surgical procedure/trauma Typically caused by Staph Aureus/Haemophilus Influenzae/Streptococcus/E.Coli

Answer 69

Epidemiology: * Patients with DM/PAD * Everyone (Children + Adults) * Patients with trauma/previous joint surgery or prosthetic device * IVDU Symptoms/Signs: * Fever * Painful + Immobile limb * Made worse by movement * May also have Septic arthritis * Swelling + Tenderness * Erythema + Increased temperature * Localised oedema * Hx of accidental/surgical trauma (Dental procedures also) * May have had DM/PAD ulcer

Answer 70

* **Osteomyelitis** * Cellulitis * Gout * Acute sickle cell crisis * Trauma

Answer 71

* **Osteomyelitis** * Cellulitis * Gout * Acute sickle cell crisis * Trauma

Answer 72

Investigations: * FBC -- Increased WCC * CRP/ESR -- Increased * Blood culture -- May be positive * Bone culture -- Positive * Culture of expressed pus -- Positive * X-ray: * Patchy osteopenia * Signs of bone destruction Management: * Surgical debridement * Analgesia * ABx therapy for 4-6 weeks -- Flucloxacillin/Clindamycin (Allergic) * May require Fucidin/Rifampicin * If MRSA -- Vancomycin/Teicoplanin * If chronic infection/Prosthesis -- Contact Infectious diseases

Answer 73

* Vertebral Osteomyelitis from haematogenous spread of TB * Leads to damage to neighbouring verebrae -- Vertebral collapse + Abscess formation Pus can track to adjacent structures causing: * Night sweats * Malaise * Fever

Answer 74

Progressive systemic skeletal disease with: * Decreased bone mass * Microarchitectural deterioration of bone tissue * Bone = Increasingly fragile, increased risk of fragility #

Answer 75

* Osteocytes submit signals to Osteoclasts + Osteoblasts -- Bone remodelling Osteoclasts: * Resorb bone matric -- Apoptosis -- Signal osteoblasts Osteoblasts: * Synthesise bone matrix -- mineralisation Cytokines regulate the process * Ca+ Metabolism -- PTH + Vitamin D + Calcitonin + Oestrogen * Osteoclast function -- RANK + RANK Ligand + OPG * RANK L expressed by osteoblasts, RANK Receptors expressed by osteoclasts * OPG inhibits RANK Ligand (Lost in postmenopausal women)

Answer 76

* Women \> Men * Increased bone loss in older age + Post menopause * Corticosteroid use/Low BMI * Smoking Symptoms/Signs: * Asymptomatic * May have bone #

Answer 77

Using DEXA scan T score -- In relation to young health population Z - Score -- Age based Normal * Normal = T score \> -1 * Osteopenia = T score -1 to -2.5 * Osteoporosis = T score \< -2.5

Answer 78

Investigations: * Assess # risk, then DEXA if high risk * X-ray -- Detect # * LFTs + Albumin -- Normal. * Serum ca+ -- Normal * U&E -- Normal * Phosphate -- Normal * Vitamin D -- Normal. * Serum PTH -- Normal. * TFTs -- Normal Management: * Reduce polypharmacy * If postmenopausal w/o fragility #: * Bisphosphonates - Alendronate/Risendronate * Denosumab - 2nd line. Note risk of Osteonecrosis of jaw * Post-menopausal women with fragility #: * Alendronate * Ca+ & Vit D supplementation * Men + Pre-menopausal women: * Alendronate * HRT for pre-menopausal women

Answer 79

Q Fracture score If pt is: * Low risk -- No treatment or BMD measurement * Medium risk -- Arrange DEXA for BMD + Recalculate Q fracture score * High risk -- Treat + BMD Not essential

Answer 80

Destablised bone remodelling, leading to increased bone breakdown + decreased bone formation * Most common form of arthritis * Usually affects knees/hips/small joints of hands Characterised by: * Loss of cartilage * Remodelling of adjacent bone * Associated inflammation Can be: * Primary -- Idiopathic, no preceeding injury * Secondary -- Antecendent to insult to the joint

Answer 81

* Female \> Male * FHx of OA * Congenital deformities -- DDH * Patients with joint trauma/arthropathy * Age related \>50yrs * Obesity Symptoms/Signs: * Activity related joint pain * Joint stiffness \<30mins in morning * Pain exacerbated by exercise/use - Relieved by rest * Decreased joint function - ROM restriction * Joint swelling/synovitis (Increased Temp + Effusion) * Bony swelling + Deformity (Osteophyte formation)

Answer 82

* **Osteoarthritis** * Bursitis * Referred pain * Gout * RA * Septic arthritis

Answer 83

* **Osteoarthritis** * Bursitis * Referred pain * Gout * RA * Septic arthritis

Answer 84

Investigations: * Clinical diagnosis if: * Pt \>45yrs * Activity related joint pain * Morning joint stiffness \<30mins * x-ray - confirm diagnosis: * Loss of joint space * Osteophytes * Subchondral sclerosis * Subchondral cysts * BMI - Normal/Elevated * FBC -- Normal * U&E + Creatinine -- Normal * LFTs -- Normal * Joint aspiration if effusion -- Normal * CRP + ESR -- Normal * RF + Anti CCP -- Negative Management: * Assess QoL with the symptoms * Patient education * Weight loss advice * Exercise + Physiotherapy * Walking aids if required Medical management: * Paracetamol ± NSAIDs (Topical/Oral) * Topical capsacin * PPI for gastric protection -- Omeprazole * Intrarticular injections of steroid (Methylprednisolone) Surgery: * Arthroscopic lavage + Debridement * Joint replacement surgery

Answer 85

Layout: * Check what the patient knows * Brief history * Do they know what the drug is? * Indication & Action of the drug * Side effects * How to take it * Monitoring requirements [Indication & Action] Indications * Used as 1st line drug treatment for patients at risk of osteoporotic fragility # * Pamidronate + Zolendronic acid used for treatment of severe hypercalcaemia of malignancy after IV rehydration * Patients with myeloma and breast cancer with bone mets - reduce the risk of pathological #/cord compression/need for radiotherapy/surgery * Used as 1st line treatment for metabolically active Pagets disease - reduce bone turnover and pain Action * Aim: Help strengthen bones to prevent # and/or lower Ca+ levels in the blood * Inhibit action of osteoclasts - responsible for bone resorption * Similar structure to pyrophosphate (Naturally occurring) - so are readily incorporated into bone * As bone is resorbed - bisphosponates accumulate in osteoclasts * Inhibit activity * Promote apoptosis * Reduction of bone loss + improvement of bone mass [How to take it] * Take once a week * Note: They bind Ca+ so their absorption is reduced if taken with Calcium salts (Milk), and antacids and iron salts * Poorly absorbed orally * Enhance absorption by - Must take tablets whole at least 30mins before breakfast or other medications + Take with plenty of water * Remain upright for 30mins after taking to reduce oesophageal irritation * Long term [Important SE] * Oesophagitis when taken orally * Hypo-phosphataemia * Osteonecrosis of the jaw (Rare, but serious) * Ensure good dental care * Atypical femoral # (Rare) Complications/Contraindications Avoid in: * Severe renal impairment * Hypocalcaemia * Upper GI disorders * Pregnancy Caution in: * Due to risk of osteonecrosis * Smokers * Major dental disease [Monitoring requirements] * Patient should see dentist before starting treatment * Osteoporosis * Check and replace Ca+ and Vit D before treatment * Monitor efficacy with DEXA every 1-2yrs Monitor for SE: * Oesophagitis * Osteonecrosis of the jaw * Ca+ levels in serum * Phosphate levels in serum

Answer 86

* Sternoclavicular joint * Acromioclavicular joint * Glenohumeral joint -- Most commonly dislocated

Answer 87

SITS * Supraspinatus * Infraspinatus * Teres Minor * Subscapularis Joint together to form the rotator cuff tendon

Answer 88

Rotator cuff disorders * Rotator cuff tear * Impingement (Subacromial bursitis/tendonitis) Glenohumeral disorder * Frozen shoulder (Adhesive capsulitis) * Arthritis ACJ disorders Biceps tenonditis Shoulder instability -- Dislocation/Subluxation PMR

Answer 89

Supraspinatus Subacromial impingement

Answer 90

Investigations: * Shoulder exam * Full Hx * USS - if muscle pathology * x-ray if considering dislocation/arthritis Management: * Physiotherapy * Modification of activities * Analgesia: * Paracetamol - Codeine * NSAID * Subacromial steroid injection if limited function b/c of pain

Answer 91

Loss of congruity b/w head of humerus and glenoid fossa * Anterior most common, Posterior - rare - can be due to seizures/electrocution Symptoms/Signs: * Pain * Decreased range of movement * Prominent humeral head * Head in abducted + externally rotated Investigations: * x-ray -- AP + Lateral Management: * Closed reduction * Sling immobilisation * Analgesia

Answer 92

* Axillary nerve + Artery damage * Damage to brachial plexus * Increased risk of recurrence

Answer 93

Tear to the rotator cuff muscles (SITS) * Caused by -- Trauma/Degeneration/Weight lifting Symptoms/Signs: * Partial tear -- Painful arc syndrome * Complete tear -- Limited shoulder abduction * Pain * Shoulder tenderness on palpation * Weakness Investigations: * Shoulder exam * x-ray * MRI Management: * Rest + Physiotherapy * Analgesia * Arthroscopy ± repair

Answer 94

* Rotator cuff tear * Rotator cuff impingement * Subacromial bursitis * Humeral # * Bicep tendonitis

Answer 95

* Rotator cuff tear * Rotator cuff impingement * Subacromial bursitis * Humeral # * Bicep tendonitis * PMR

Answer 96

Chronic fibrosing condition -- Insidious + Progressive * Glenohumeral disorder - thickening & contraction of the glenohumeral capsule * Restriction of active + passive shoulder ROM * Self limiting - resolves in 2 yrs Who gets it: * Common \>40yrs * Women \> Men * Pts with DM/Thyroid disease Symptoms/Signs: * Stiffness in shoulder joint * Pain * Restriction in Active + Passive ROM * Impaired external rotation * Tenderness Investigations: * Clinical diagnosis * x-ray -- Normal Management: * Analgesia -- Paracetamol + NSAIDs * Maintain activity levels * Physiotherapy with joint mobilisation * Corticosteroid injections

Answer 97

Pain in the greater trochanter (Hip), due to stresses at muscle insertions on greater trochanter -- leading to inflammation * Painful bursa due to friction b/w trochanter and iliotibial band over it Who gets it: * Women \> Men * Runners * OA of the hips/back/knees * Degenerative disc disease of L spine * Obesity Symptoms/Signs: * Pain - Aching/burning * Tenderness over greater trochanter * Pain worse on lying on affected side * Snapping sound * Antalgic gait * Pain on resisted abduction + external rotation Investigations: * Clinical diagnosis: * Tenderness on palpation of greater trochanter * Pain on abduction + external rotation Management: * Rest + decrease activity * Self limiting (2-3 months) * Apply ice pack for 10-20 mins * NSAIDs for pain + inflammation * Weight loss * Physiotherapy Surgery: * Bursectomy/Release of iliotibial band

Answer 98

* **Adhesive capsulitis** * Glenohumeral dislocation * Rotator cuff tear * Rotator cuff impingement * Biceps tendonitis

Answer 99

* **Adhesive capsulitis** * Glenohumeral dislocation * Rotator cuff tear * Rotator cuff impingement * Biceps tendonitis

Answer 100

* Area of cartilage which proliferates/enlarges with the leading edge calcifying to form new bone in children * Can lead to cessation of growth + Limb shortening

Answer 101

* Type 1 -- # through the growth plate (Across) * Type 2 -- # through growth plate + metaphysis but not the epiphysis. Most common type * Type 3 # -- # through the growth plate leading to separation of epiphysis + growth plate from the metaphysis * Type 4 -- # through growth plate + metaphysis + epiphysis * Type 5 -- Compression # through growth plate. Poor prognosis

Answer 102

Inflammation of the patellar ligament at the tibial tuberosity Self limiting condition, typically during childhood

Answer 103

* Active children (Multiple avulsion # of tibial tuberosity) * During growth spurts (Strength of Quadriceps \> ability of tibial tuberosity to resist force) * Boys \> Girls * Common in teenagers Symptoms/Signs: * Gradual onset pain + Swelling below knee * Relieved by rest * Worse by activities * Tenderness/Swelling at tibial tuberosity * Pain on knee extension * Localised warmth * Prominent tibial tubercle

Answer 104

* **Osgood Schlatters disease** * Bone tumour * Septic arthritis/JIA * Hip pathology -- Perthes/SUFE/Transient synovitis * Knee injury

Answer 105

Investigations: * Clinical diagnosis * x-ray: * Irregular apophysis + seperation of tibial tuberosity Management: * Conservative treatment * Rest from painful activity * ICE * Physiotherapy * Paracetamol/Ibuprofen

Answer 106

Childhood condition with disruption of blood flow to the head of the femur, leading to avascular necrosis of the femoral head Not caused by trauma

Answer 107

* Boys \> Girls * Age 4-7yrs * White children Symptoms/Signs: * Pain in hip or referred to knee * Can be bilateral/asymmetrical * No Hx of trauma * Short stature * Antalgic gait * Hip effusion due to synovitis * All hip movements are limited

Answer 108

* **Perthes disease** * Septic arthritis * Transient synovitis * Hypothyroidism -- Bilateral * Sickle cell disease -- Bilateral

Answer 109

Investigations: * FBC -- Normal * CRP -- Normal/Reactive so Increased * ESR -- Normal * x-ray -- Frog lateral + AP * May be normal * Widening of joint space * Collapse + deformity of femoral head w/new bone formation * Subchondral # Management: * Aim to maintain shape of femoral head + prevent secondary arthritis * May not require treatment * Acute pain -- Paracetamol ± NSAIDs * Physiotherapy -- Muscle strengthening + stretching Surgery: * If Age \>6yrs + \>50% risk of femoral head necrosis * Proximal varus osteotomy * Arthrodesis at skeletal maturity

Answer 110

* Abnormality of the hip joint where the socket does not fully cover the ball, leading to increased risk of joint dislocation. * Congenital DDH -- Hip dysplasia at birth or early in life

Answer 111

* Newbowns/Young babies * L hip is more likely to be affected * Common if swaddled * FHx of DDH * Breech vaginal delivery/Breech position * Oligohydraminos * Girls \> Boys Symptoms/Signs: * Asymmetrical gluteal/thigh skin folds * Leg length discrepancy * Barlow + Ortlani -- Positive * Unilateral limitation + asymmetry of hip abduction * Unilateral femoral shortening * Waddling gait

Answer 112

Investigations: * Dynamic USS -- Assess hip stability + Acetabular development * Pelvic x-ray if older: * Once femoral head ossification has occured Management: * Usually stabilise spontenously at 2-6 weeks * If unstable/dislocatable -- treatment: * Bracing if \<6mo with Pavlik harness * If brace fails/\>6 mo: * Closed reduction of hip (Surgically) * + 3-4 months plaster cast/abduction brace

Answer 113

Inflammation of a joint, that commonly affects young people * Self limiting * Due to secondary temporary inflammation due to viral URTI * Most common cause of hip pain + limb in children Symptoms/Signs: * Limited ROM * Pain on movement * Fever * Tenderness on palpation * Antalgic gait Investigations: * FBC -- Normal or increased WCC * ESR -- Normal or Increased * CRP -- Normal or increased * x-ray: * Normal Management: * Activity restriction * Paracetamol * NSAIDs -- Ibuprofen/Naproxen

Answer 114

* **Transient synovitis** * Septic Arthritis * Osteomyelitis * Perthes disease * JIA

Answer 115

* Lateral deviation of the great toe (Valgus deformity of 1st MTP) * AKA Bunion * Can present with pain in the hallux MTP joint on walking

Answer 116

Acute/chronic pain in the inferior heel at the attachment of the plantar fascia to the medial calcaneal tubercle * Overuse injury Diagnosis -- Reproduction of pain by asking pt to stand on toes or passive dorsiflexion of toes Manage -- Rest + Physio + NSAIDs and Paracetamol

Answer 117

Compression of the median nerve as it travels through the carpal tunnel Symptoms/Signs: * Pain * Numbness * Paraesthesia in dristribution of median nerve (Thumb + Index + Middle finger) * Worse at night causes wakening -- Hanging it off the bed to ease pain * May have weakness * Positive Phalens + Tinnels test Management: * Observation * Splints * Steroid injections * Surgery - release the carpal tunnel

Answer 118

[Introduction] * Wash hands & Introduce self * Ask Patient name & DOB & Age * Today I am going to be examining your walking, your arms, legs, and spine as part of a screening exam to assess your bones and muscular system. is that ok? * I will need you to undress to your underwear and wear a robe, the examiner will act as a chaperone for both of us – is that ok? * Do you have any pain at the moment? Would you like some painkillers? [Screening Questions] * Do you have any pain in your muscles/joints/back? * Do you have any difficulty dressing yourself? * Do you have any difficulty walking up and down the stairs? [General Inspection] * Look at surrounding area for: * Walking aids * Specialist shoes * Assess patient for signs: * Pain * Body habitus * Systemic illness [Inspection] Can you please stand in the neutral position in front of me with your palms facing forward, assess: * Examine shoes for abnormal signs of wear * Overall alignment & willingness to weight bear * Limb alignment * Bulk & symmetry of * Shoulder * Gluteal muscles * Quadriceps * Calf muscles (Gastrocnemius & Soleus) * Alignment of the spine (From behind/sides) * Equal level of iliac crests * Ability to fully extend elbows & knees * Popliteal swelling * Excessively high or low foot arch profile * Skin changes - Rash/Erythema/Psoriatic plaques [Assess gait] Ask patient to walk from A to B, assess: * Symmetry * Smoothness * Normal heel strike & toe off * Ability to turn quickly * Gait * Antalgic gait * Trendelenberg gait * Foot drop * Toe walking [Assess spine] Ask patient to remain standing Inspection: * Normal Lordosis/kyphosis * C & L -\> Lordosis * T & S -\> Kyphosis * Any scoliosis * C spine Movements: * Lateral flexion -\> Can you please move your ear to your shoulder, repeat on other side * Flexion -\> Can you put your chin to your chest * Extension -\> Can you put your head back as far as possible * Rotation -\> Can you look over your shoulder, repeat on other side * L Spine Flexion -\> Place 2 fingers on L vertebrae, ask patient to bend forward and touch your toes * Fingers should move apart [Arms] Are you happy to remain standing or would you like to take a seat for me to examine your arms? * Shoulder & elbow Can you put your hands behind your head?Assess shoulder abduction & external rotation & elbow flexion * Restrictive movement -\> Elbow/shoulder pathology * Excessive movement -\> Hypermobility * Hands Assess for: * Swelling/deformity * Nails for psoriasis * Loss of muscle bulk - Thenar & Hypothenar eminence * Can you hold your hands in front of you, palms facing down, fingers outstretched * Assess Forward flexion of shoulder & Elbow extension & wrist extension & small joints of fingers extension * Can you turn your hands over (Supination) Assess Wrist & elbow supination * Ask the patient to make a fist * Assess flexion of small joints of fingers & hand function * Ask patient to squeeze my fingers to assess grip strength - compare R + L * Ask patient to touch each finger to their thumb (Opposition/precision grip) * Assess coordination of small joints - Fingers & thumb & manual dexterity * Squeeze each MCP joint on R+L hand, ask patient to splay out hand - squeeze both ends of MCP joints * Assess tenderness & symmetry of joint [Legs] Ask patient to lie down on the bed, check if any pain/comfortable * Assess the knee Flexion -\> Hold the knee with one hand on the patella to feel for crepitus * Flex the knee to bend to approx 130 deg * Assess for crepitus & asymmetry b/w R + L knee * Extension -\> Extend the knee back to the original position & further to determine if restricted movement/hypermobile * Patellar tap test * Milk the suprapatellar pouch from the thigh down to the knee. Hold at the patella * Push the patella down - Feel for tap of the patella due to Medium/Large effusion Assess the hip * Flex the hip & knee -\> Ask the patient to bring their hip towards their chin * Assess passive internal rotation of the hip Move foot OUTSIDE away from the other leg * Note asymmetry & range of movement on R + L Assess feet Assess * Swelling/Erythema * Deformity * Callus * Im going to be squeezing the small joints in your foot let me know if its tender Squeeze MTP joints all together [Present exam] * Wash hands & Thank patient * “This is patient x who is a x year old Male/Female with the following findings” * I would take a full Hx from the patient & Examine any joints which were problematic during the GALS exam * Consider differentials * Investigations * Observations * Bloods * Imaging * Management

Answer 119

[Introduction] * Wash hands & Introduce self * Ask Patient name & DOB & Age * Today I am going to be doing an examination on your spine today, as I believe you have had some issues. Is that what you were expecting? * So the examination will involve me having a look at you from the end of the bed/then closer at your spine/I will feel the spine/ and move it around and ask you to do some movements also * Does that all sound ok? * I will need you to remove your clothing down to your underwear for me so that I can see your whole spine, the examiner will act as a chaperone for both of us – is that ok? * Do you have any pain at the moment? Would you like some painkillers? [General Inspection] * Can you tell me where on your back is sore? Do you have any trouble walking? * To examiner: I will be assessing the whole spine, I will start by doing a general inspection * Assess the surrounding are * Walking aids * Specialist shoes * Back brace etc * Look at patient from end of the bed * Signs of pain * Body habitus * Systemically unwell [Close inspection/Look] I will need to have a look at what you look like when you are walking so can you walk up and down from me. Assess gait: * Antalgic * Foot drop * Trendelenberg * Stiff hip Next I would like to have a look more closely at your spine - Facing me/L/R/Facing the wall * Overall alignment * Willingness to weight bear * Scars * Spinal surgery * Deformity * Normal Lordosis/Kyphosis * Scoliosis * Any swellings/erythema * Any skin changes - colour/bruising * Muscle wasting * Paraspinal muscles * Gluteal muscles [Feel] Im just going to briefly feel your back and the structures there, let me know if you have any tenderness/if its too much I will stop Palpate the bones * C spine * T spine * L spine * Sacrum * Assess for any increased prominence & tenderness * Palpate sacro-iliac joints for tenderness * Palpate muscles/soft tissues * Trapezius muscle * Interscapular muscles * Paraspinal muscles [Move] C spine * Lateral flexion -\> Can you please move your ear to your shoulder, repeat on other side * Make sure its ear to shoulder not shoulder to the ear * Flexion -\> Can you put your chin to your chest * Extension -\> Can you put your head back as far as possible * Rotation -\> Can you look over your shoulder, repeat on other side * Any pain? Any difficulty? T spine * Rotation -\> Can you twist your body to your R, I will hold your hip so that you don’t move it * Next I need you to do the same with your other side so twist your body to your L as far as you can * Any pain? Any difficulty? L Spine * Flexion -\> Place 2 fingers on L vertebrae, ask patient to bend forward and touch your toes * Fingers should move apart * Any pain? Any difficulty? * Extension -\> Can you lean back as far as possible please, I will stand behind you to catch you if you are unsteady * Look to see if the movement is from the spine or the hips * Lateral flexion -\> I need you to slide your L hand down you L leg so I can see how far you can go * Can you do the same on the R side [Special tests] Schober’s test * Patient standing with back facing me * Find centre point of lumbosacral region (Above PSIS - Dimple of venus) * Mark area/put finger to mark it * Measure 10cm above this - Mark it with pen or use finger * Measure 5cm below the centre point - Mark it with pen or use finger * Ask patient to bend forward to touch their toes Measure increase in distance between the 2 marks * \>5cm = normal * \<5cm = Reduced range of flexion Straight leg raise * Can you please lie flat on your back on the bed * Can you keep your leg straight and relaxed * Let me raise your leg from the bed * Raise leg to 90 deg to assess for pain * Positive = pain in lower back/buttocks at 30-70 deg -\> Disc herniation/tight hamstrings/sciatic nerve entrapment * Assesses L4/5 and S1 nerve compression Femoral stretch test * Can you turn on your front and lie on the couch please * Flex knee to 90 deg * Extend hip by raising it off the bed Positive -\> Pain in lower back/buttocks/legs = disc herniation at femoral nerve roots * Assess L2/3/4 nerve compression Note: Waddells signs: * Superficial non-anatomical tenderness * overreaction * Pain on axial loading of skull/Pain on passive rotation of shoulder or pelvis * Non-dermatomal pattern of sensory loss [Complete examination] To complete the examination I would: * Examine the Joint Below -\> Hip * Internal rotation of Hip I would assess the Neurovascular status of the shoulder joint * Power – All LL myotomes * L2/3 Quadriceps * L3/4 Knee flexion * L4/5 Toe dorsiflexion * L5 Great toe dorsiflexion * S1 Plantarflexion * L5/S1 Knee extension * L4/L5 Hip extension * Sensation – All LL dermatomes * L2 Antero-medial thigh * L3 Medial knee * L4 Medial malleolus * L5 1st web space * S1 Lateral calcaneus * S2 Popliteal fossa * Reflexes * Knee * Ankle * Vascular * Dorsalis pedis * Posterior tibial [Present examination] * Wash hands & Thank patient * “This is patient x who is a x year old Male/Female with the following findings” * I would take a full Hx from the patient & Examine the joint below (Hip) * Consider differentials * Investigations * Observations * Bloods * Imaging * Management

Answer 120

[Introduction] * Wash hands & Introduce self * Ask Patient name & DOB & Age * Today I am going to be doing an examination on your shoulder, as I believe you have had some issues. Is that what you were expecting? * So the examination will involve me having a look at you from the end of the bed/then closer at your shoulder/I will feel the shoulder joint/ and move it around and ask you to do some movements also * Does that all sound ok? * I will need you to take your top off so that I can see your whole shoulder, the examiner will act as a chaperone for both of us – is that ok? * Do you have any pain at the moment? Would you like some painkillers? [General inspection] * Which shoulder is sore? Where is the pain? * Are you right/left handed? * To examiner: Would you like me to examine both shoulder joints or is one sufficient with the time allowed? * Look at the surrounding area around the patient * Any discarded slings? * Look at the patient * Could you stand up for me? * Any signs of pain? * Are they systemically unwell? * Body habitus [Close inspection] * Look at the shoulder for: * Overall alignment * Symmetry of the shoulder girdle * Obvious signs of trauma * Scoliosis * Deformity * Any steps in the clavicle * Any Dislocation? * Can you put your arms out against the wall, and push against the wall * Any winging of the scapula (From behind) -\> Due to Long thoracic nerve injury * Any scars? * From Arthroscopy * Any Shoulder surgery? * Muscle wasting * Trapezius muscle * Deltoid * Triceps * Biceps * Supraspinatus * Infraspinatus * Any swellings? * Inflammation/Bursitis * Skin changes * Bruising – Ecchymosis * Erythema * Check the axilla – Disease here can present as shoulder symptoms * Check for scars – Axillary clearance etc [Feel] Temperature * Using back of hands – feel temperature around the joint * Feel from Clavicle – Deltoid – Trapezius – Scapula * Compare both sides * If Warm -\> Inflammatory process Structures * SCJ – Clavicle – ACJ – Acromion – Coracoid process – Borders of the scapula – Supraspinatus – Infraspinatus – Deltoid muscle - Greater tubercle of humerus – Biceps tendon * Assess for swelling/Tenderness [Movement] Function * Can you put your hands behind your head (External rotation & abduction) * Can you put your hands behind your back (Internal rotation) * Can you put your R/L hand across your shoulder like you are putting on a scarf – Repeat for other hand Flexion * Can you stand with your palms facing me - Can you raise your arms above your head * Any pain on movement? * Record range of movement – as angle * Normal 150-180 deg Extension * Can you stand with your palms facing me – Can you move your arms behind you to try and touch the wall behind? * Any pain on movement? * Record range of movement – as angle * Normal 40deg Abduction * Can you put your arms by your sides + Palms facing forwards + Thumbs upwards * Raise your arms slowly out to the sides until they are above your head * Any pain on movement? * Record range of movement – as angle * Normal 180deg * Any Low arc pain – 80-90 deg = Supraspinatus impingement * Any High arc pain - \>120 deg = Suggestive of ACJ injury/pathology Adduction * Can you bring your arms across your body to cross your hands to opposite sides * Any pain on movement? * Record range of movement – as angle * Normal 30-40 deg External rotation * Can you put your arms by your sides + elbows flexed to 90deg + Fixed to your side (Tuck it into your hip) * Can you rotate your arm OUT * Record range of movement – as angle * Normal 80-90 deg * Loss of external rotation -\> Frozen shoulder Internal rotation * Can you put your hand behind your back as far as you can * Record range of movement Note: if range of movement is restricted or there is pain – Repeat movement passively [Special tests] **Rotator cuff – SITS (Supraspinatus/Infraspinatus/Teres Minor/Subscapularis** Supraspinatus – Abduction of humerus * Empty can test – Can you put your arms out at about 70deg + Point your thumb downwards * I’m going to push your forearms down – stop me from pushing it down Infraspinatus & Teres Minor – External rotation of humerus * Can you put your arms by your sides + elbows flexed to 90deg + Fixed to your side (Tuck it into your hip) * Can you rotate your arm OUT – Stop me from pushing it back IN Subscapularis – Internal Rotation * Gerbers lift off test – Can you put your hand behind your back as far as you can * Don’t let me push your hand into your back * Weakness in resistance -\> Tear in the specific muscle **Impignement testing** Hawkins-Kennedy * Can you move your upper arm out straight (Abduct shoulder to 90deg) + Bend your elbow so your hand is in front of you (Flexed to 90deg) + Palm facing down * Hold and support proximal wrist and elbow – stop me from rotating your arm down towards your body * Note: Pain -\> Supraspinatus impingement Scarf test * Can you touch your opposite shoulder with your R/L hand * Apply pressure on the elbow [Complete examination] To complete the examination I would: * Examine the joint above -\> C Spine & Joint Below -\> Elbow * C-Spine -- Flexion + Extension + Rotation + Lateral flexion * I would assess the Neurovascular status of the shoulder joint * Power – Deltoid -\> Axillary nerve * Sensation – Regimental Badge area -\> Axillary nerve * Vascular – Radial pulse [Present exam] * Wash hands & Thank patient * “This is patient x who is a x year old Male/Female with the following findings” * I would take a full Hx from the patient & Examine the joint above (C-spine) and below (Elbow) * Consider differentials * Investigations * Observations * Bloods * Imaging * Management

Answer 121

[Introduction] Wash hands & Introduce self * Ask Patient name & DOB & Age * Today I am going to be doing an examination on your elbow, as I believe you have had some issues. Is that what you were expecting? * So the examination will involve me having a look at you from the end of the bed/then closer at your elbow/I will feel the elbow joint/ and move it around and ask you to do some movements also * Does that all sound ok? * I will need you to remove your top or just move it so I can see the whole shoulder, the examiner will act as a chaperone for both of us – is that ok? * Do you have any pain at the moment? Would you like some painkillers? [General Inspection] - Sitting * Can you tell me which elbow is sore? Where on the elbow is painful? * Are you Right/Left handed? * To examiner - Ideally I would examine both elbows, but due to the time constraints I will only examine one, is that ok? * Assess the surrounding area: * Discarded slings * Casts * Painkillers * Look at the patient from the end of the bed: * Body habitus * Signs of pain * Are they systemically unwell? -\> The patient looks well at rest [Close inspection/Look] Inspect from the front to the back * Overall alignment * Symmetry of the joint * Normal -\> 10deg flexion at elbow when standing * Scars * Scar at medial epicondyle -\> Ulnar nerve surgery * Olecranon scar * Arthroscopy scar * Any obvious deformity * Dislocation * Swelling * Effusion/Olecranon bursitis * Fixed flexion deformity * Cubitus valgus deformity (\>15 deg)-\> Due to lateral epicondyle trauma * Cubitus varus deformity (\<5 deg) -\> Due to medial epicondyle trauma * Assess for muscle wasting * Forearm - Flexors/Extensors * Upper arm - Biceps/Triceps etc * Skin changes * Thickening * Nodules -\> Sign of RA * Psoriatic plaques -\> Sign of Psoriatic arthritis * Erythema/Ecchymosis [Feel] Assess temperature in the joint * Around the joint line/Medial aspect/Lateral aspect/Anterior/Posterior Assess the structures of the joint * Flex patients elbow at 90deg, Can you relax your arm and let me feel around the joint Assess: * Medial/Lateral epicondyles * Effusion behind radial head * Radial head + Radio-capitellar joint * Biceps tendon - within ante-cubital fossa * Olecranon process * Ulnar nerve - behind medial epicondyle [Move] Assess Function * Can you put your hands behind your head? * Can you put your hands to your mouth? Flexion * Can you bring your hands to touch your shoulders? * Record range of motion in deg * Normal -\> 0-145 degs Extension * Can you put your arms out straight to your sides? * Record range of motion in deg * Assess for hyperextension * Normal -\> 0 deg Pronation * Can you keep your arms to your sides, stick it in your hip/bend your elbows to 90deg/Fix them into your side * Can you rotate your arm so your palm is facing down? * Record range of motion in deg * Normal -\> 0-85 deg Supination * Can you keep your arms to your sides, stick it in your hip/bend your elbows to 90deg/ Fix them to your side * Can you rotate your arm so your palm is facing UP? * Record range of motion in deg * Normal -\> 0-90 deg Repeat all movements passively * Flexion/Extension/Pronation/Supination * Place hand over the joint to feel for crepitus [Special tests] Medial epicondylitis - Golfers elbow * Patient has a problem with resisted wrist flexion * Can you put your arm straight out in front of you/Elbow extended /Supinated - Palm UP * Let me take hold of your forearm * Palpate medial epicondyle with one hand/Hold pts wrist with other hand * Can you make a fist? and move it towards your body? * I’m going to try and push your wrist down, try and stop me (Resisted flexion) * Pain over medial epicondyle -\> Positive test for Epicondylitis * Note: Medial epicondyle is the attachment for all the forearm Flexors Lateral epicondylitis - Tennis elbow * Problem with resisted wrist extension * Can you put your arm straight out in front of you/Elbow extended /Pronation - Palm DOWN * Let me take hold of your forearm * Palpate lateral epicondyle with one hand/Hold pts wrist with other hand * Can you make a fist? and move it away from your body? * Im going to try and push your wrist UP, try and stop me (Resisted extension) * Pain over Lateral epicondyle -\> Positive test for epicondylitis * Note: Lateral epicondyle is the attachment for all the forearm Extensors [Complete examination] * I would examine the joint above (Shoulder) & Below (Wrist) * Hands behind head * I would assess the neuromuscular state of the limb Power * Ulnar nerve - Scissors * Median nerve - Stone * Anterior Osseous branch of medial - OK * Radial nerve - Wrist extension - Paper * Sensation * Ulnar nerve -\> Lateral aspect of little finger * Median nerve -\> Lateral aspect of index finger * Radial nerve -\> Dorsal 1st interosseous space * Vascular function * Radial/Ulnar pulse [Present examination] * Thank patient & Wash hands * “This is patient x who is a x year old Male/Female with the following findings” * I would take a full Hx + examine any other relevant joints and systems * I would consider the differentials * I would order relevant investigations * Observations * Bloods * Imaging * I would initiate management of the most likely differential

Answer 122

[Introduction] * Wash hands & Introduce self * Ask Patient name & DOB & Age * Today I am going to be doing an examination on your hand & wrist, as I believe you have had some issues. Is that what you were expecting? * So the examination will involve me having a look at you from the end of the bed/then closer at your hand & wrist/I will feel the hand & wrist joint/ and move it around and ask you to do some movements also * Does that all sound ok? * I will need you to remove your top or just move it so I can see the up to your elbow, the examiner will act as a chaperone for both of us – is that ok? * Do you have any pain at the moment? Would you like some painkillers? * You can remain seated for this exam with a pillow under your hand [General Inspection] * Can you tell me which hand is sore? Where on the hand is painful? * Are you Right/Left handed? * To examiner - Ideally I would examine both hands, but due to the time constraints I will only examine one, is that ok? * Assess the surrounding area: * Discarded slings/splints * Painkillers * Look at the patient from the end of the bed: * Body habitus * Signs of pain * Are they systemically unwell? -\> The patient looks well at rest [Close inspection/Look] Start by looking at the dorsum of the hand * Hand posture * Any abnormal posture - Contracture/ulnar deviation * Nail changes * Nailfold vasculitis -\> RA/Small vessel vasculitis * Nail pitting/Onycholysis -\> Psoriasis/Psoriatic Arthritis * Skin changes * Thinning/bruising -\> Steroid use/inflammatory arthritis * Psoriatic plaques -\> Psoriatic arthritis * Erythema -\> Cellulitis/Septic arthritis * Pallor of nail beds - CRT \<2s -\> PVD/Anaemia * Scars * Previous hand surgery * Swelling * Comparing R & L hands * Muscle wasting * 1st dorsal interossei -\> secondary to chronic joint pathology/LMN lesion e.g. carpal tunnel syndrome * Deformities * Herbedens nodes - DIPJ -\> OA sign * Bouchards nodes - PIPJ -\> OA sign * Boggy swelling -\> Synovitis/RA/Trama * Cystic swelling -\> Ganglion * Swan neck deformity -\> RA * DIPJ Flexion + PIPJ Hyperextension * Boutonnieres deformity -\> RA * PIPJ Flexion + DIPJ Hyperextension * Z thumb -\> RA * Hyperextension of IPJ + Fixed flexion + Subluxation of MCPJ * Ulnar deviation * MP joints deviate towards little finger (Ulna) * Mallet - DIP fixed flexion Assess the palmar surface of the hand * Hand posture * Asymmetry * Dupytrens contracture * Scars/Swelling * Scars from previous surgery * Compare R + L for swelling * Skin colour * Palmar erythema -\> RA * Hypothenar eminence * Deformity * Gouty tophi * Dupytrens contracture * Rheumatoid nodules * Assess the wrist Deformity * Subluxation * Deviation * Swelling * RA Nodules * Ganglion * Scars * Carpal tunnel release surgery * Scaphoid surgery * Assess the elbow Psoriatic rashes/lesions * If YES - Ask patient, do you have any other lesions anywhere on your body? * To examiner: I would also examine the ears/neck/scalp for plaques/tophi * Note: Tophi most likely at the ears [Feel] Temperature * Move distal to proximal & compare both sides * Increased warmth -\> Septic arthritis/inflammatory arthritis Pulses * Radial pulse * Ulnar pulse Muscle bulk * Thenar eminence (Median nerve) * Hypothenar eminence (Ulnar nerve) Palmar thickening * Palpate palms for palpmar thickening -\> Dupytrens contracture Nerve sensation * Ulnar nerve -\> Lateral little finger * Median nerve -\> Lateral index finger * Radial nerve -\> 1st dorsal web space Joint assessment MCP squeeze * Squeeze each MCPJ and look at patient for signs of pain * If tender -\> Inflammatory arthritis Bimanual palpation of ALL joints - thumb & index finger at sides & top * MCPJ/PIPJ/DIPJ/CMCJ of thumb * Anatomical snuffbox - get patient to abduct thumb * Tenderness -\> Scaphoid fracture Palpate wrist joint - irregularity/tenderness * Ulnar border * Radial styloid process * Ulnar head [Move] Assess function * Can you squeeze my fingers -\> Grip strength * Can you touch your thumb to all your fingers on that hand -\> Opposition * Are you able to do up your buttons/pick up a coin from a flat surface -\> Fine motor Fingers * Flexion -\> Can you make a fist * Extension -\> Open your fist and straighten your fingers out * Abduction -\> Can you spread your fingers wide apart * Adduction -\> Bring your fingers back together Thumb * Abduction -\> Can you move you thumb OUT to form an L * Adduction -\> Can you move it back towards your index * Flexion -\> Can you bring your thumb into your palm? Extension - And back out * Opposition -\> Can you touch each finger with your thumb Wrist * Extension -\> Put your palms together and push them together - Prayer sign * Flexion -\> Put the backs of your hands together and push them together - Reverse prayer * Pronation/Supination -\> Can you turn your wrist so your dorsum faces up/Palm [Special tests] Tinnels test * Tap over the carpal tunnel with finger * Ask patient to report any sensation * Positive -\> Tingling in thumb & radial 2.5 fingers -\> Median nerve irritation & compression (Carpal tunnel syndrome) Phalens test * Ask patient to hold wrists in reverse prayer sign * Hold it there for 60s * Tell me if you feel any change to your sensation * Positive -\> Patient should report change to sensation -\> Carpal tunnel syndrome symptoms - Burning/tingling/numb sensation in thumb/index/middle/ring fingers Froments test * Ask patient to hold paper b/w flat of thumb and index finger * Attempt to pull the paper out * Positive -\> Patient needs pinch grip to hold the paper [Complete examination] * I would examine the joint above (Elbow) * I would assess the neuromuscular status of the joint Motor * Radial nerve -\> Resisted wrist extension - don’t let me push your hand down * Ulnar nerve -\> Resisted little finger abduction - don’t let me push your little finger in * Median nerve -\> Resisted thumb opposition - thumb to little finger, don’t let me pull them apart Sensation * Ulnar nerve -\> Lateral little finger * Median nerve -\> Lateral index finger * Radial nerve -\> 1st dorsal web space Pulses * Capillary refill time * Radial/Ulnar pulse [Present examination] * Thank patient & Wash hands * “This is patient x who is a x year old Male/Female with the following findings” * I would take a full Hx + examine any other relevant joints and systems * I would consider the differentials * I would order relevant investigations * Observations * Bloods * Imaging * I would initiate management of the most likely differential

Answer 123

[Introduction] * Wash hands & Introduce self * Ask Patient name & DOB & Age * Today I am going to be doing an examination on your knee, as I believe you have had some issues. Is that what you were expecting? * So the examination will involve me having a look at you from the end of the bed/then closer at your knee/I will feel the knee joint/ and move it around and ask you to do some movements also * Does that all sound ok? * I will need you to remove your clothing from your bottom half or wear shorts so I can see the whole knee, the examiner will act as a chaperone for both of us – is that ok? * Do you have any pain at the moment? Would you like some painkillers? [General Inspection] * For the examination, I will need you standing up - can you do that? * Can you tell me which knee is sore? Where exactly is the pain? * To examiner: I would ordinarily examine both knees however due to the time constraints I will examine the knee that is affected, are you happy with that? * Assess the surrounding area: * Walking aids * Specialist shoes * Assess the patients shoes * Insole * Signs of uneven wear * Normal wear -\> Heel & 1st Metatarsal * Look at the patient and assess * Signs of pain * Body habitus * Are they systemically unwell? [Close inspection/Look] Gait * For the next part of the examination, I will need to have a look at you walking. Can you walk the wall A to wall B. * Assess gait looking for: * Normal gait - Stance & Swing phase * Antalgic gait -\> Decreased flexion of the knee, due to pain * Thrusting gait -\> Knee gives way as patient is walking * Foot drop -\> High stepping gait, due to Common Peroneal nerve injury Inspect the joint closely - Anterior/Lateral/Posterior/LateralSymmetry * Are the knees symmetrical? * Any Valgus/Varus deformity * Suggestive or OA/Rickets (Varus) & OA/RA (Valgus) * Look at feet & ankles for symmetry * Alignment of knees * Signs of Hyper-extension from the side * Is the patient willing to weight bear? Muscle wasting * Quadriceps (Anterior) * Gastrocnemius/Hamstrings (Posterior) Swellings * Effusion -\> Look for loss of medial knee dimple * Bakers cyst/Popliteal artery aneurysm (Posterior) * Note if it is pulsatile -\> Popliteal aneurysm Bursitis/Inflammation Fixed flexion deformity - (Lateral) * Sign of OA/Other knee pathology Scars * Arthroscopy * Knee replacement -\> Large Anterior crossing the joint Skin changes * Erythema * Brusing * Nodules [Feel] Temperature * Assess the temperature along the patella/medial/Lateral/Posterior joint line * Increased temp -\> Inflammation * Decreased temp -\> Vascular compromise Measure the thigh circumference * 10cm above the patella * Compare both sides Patellar tap test * Milk the suprapatellar pouch from the thigh down to the knee. Hold at the patella * Push the patella down - Feel for tap of the patella due to Medium/Large effusion Sweep/Bulge test * Sweep fluid UP from the medial/Lateral aspect of the patella x2 - then sweep down on the opposite side * Look for bulge on opposite side -\> Sign of small effusion Assess the structures of the knee * Can you please bend your knee, bringing your heel to your bottom (90 deg flexion) * Asses for:Local tenderness along the joint line (Anterior/Lateral/Posterior/Medial) * Lateral/Medial joint line tenderness -\> OA/Meniscal tear * Patella tendon * Insertion of patellar tendon (Tibial tuberosity) * Quadriceps tendon * Margins of the Patella * Medial/Lateral collateral ligaments * Hamstring tenderness (Posterior) * Swellings behind knee * Bakers cyst -\> Non pulsatile * Popliteal aneurysm -\> Pulsatile Feeling for: * Tenderness * Bony abnormality (Osteophyte) [Move] Function * Can I ask you to squat down * Do you have any pain or weakness? Flexion * Active - Can you bring your heel to your bottom - Assess range of motion * Passive - If you don’t mind i’m going to move your heel closer to your bottom, let me know if you feel any pain * Feel for crepitus & Look for pain * Normal - 140 deg Extension * Can you straighten your knee onto the bed, and then push the back of your knee into the bed * Hyper-extension * Can you please relax your leg and let me raise it off the bed, Raise leg by ankle/foot * Normal extension - \<10 deg * Hyper-extension - \>10 deg -\> Joint Hypermobility syndrome Straight leg raise * Can you keep your leg straight and let me raise your heel of the bed * To identify if Patellar tendon is intact (Extensor) [Special tests] Cruciate ligaments (ACL/PCL)Assess for posterior sag (PCL tear) * Ask pt to flex knee to 90 deg with feet flat on bed - can you bring your heel to your bottom * Look at the knee to see if there is a plateau before the tibia, caused by posterior sag * This could mean the pt has a false positive ACL drawer test ACL drawer test * Ask pt to flex knee to 90 deg with feet flat on bed - can you bring your heel to your bottom * I am going to sit on your feet just to fix it to the bed, is that ok? * Hold the leg below the knee & thumbs on the proximal tibia * Can you relax your leg for me, I’m going to pull your leg quite forcefully. Let me know if you have any pain * Pull tibia AWAY From patient * Normal - Little movement & firm end-point * If Lax - see/feel the tibia moving forward -\> ACL tear PCL drawer test * I’m just going to do the same thing as before but this time push your shin towards you, again let me know if you feel any pain * Push tibia TOWARDS patient * Normal - Little movement & firm end-point * If lax - see/feel the tibia moving backwards -\> PCL tear McMurrays test - Meniscal tear * Grasp sole of foot with one hand & on top of the knee with the other hand (Thumb feeling down one joint line & Index feeling down another) * Flex the knee and hip to 90deg * Slowly straighten the knee with the foot in external rotation - Lateral meniscus * Flex the knee again and hip to 90deg * Slowly straighten the knee with the foot in internal rotation - Medial meniscus * Feel over the knee for a click/grinding & Look at the patient for signs of pain/discomfort Collateral ligaments (LCL/MCL) * Hold the knee with one hand & the ankle with the other * Flex the knee to 30deg * For the MCL - Apply INWARD force on Knee + OUTWARD force on the ankle * For the LCL - Apply OUTWARD force on knee + INWARD force on ankle * Tear in ligament -\> pain or lack of firm end-point in movement Patellar apprehension test * Can you keep your legs straight * Apply lateral force to patella & Start to flex the knee * Watch patients face -\> Apprehension on face and doesn’t allow to move (Positive) * Apprehension -\> Previous patellar dislocation [Complete examination] * To complete the examination, I would assess the joint above (Hip) and the joint below (Ankle) * Internal rotation of Hip in flexion * I would also assess the neuromuscular function of the knee * Power * Extension of the toes -\> Common peroneal nerve * Plantarflexion of the foot -\> Tibial nerve * Sensation * Dorsum of the foot -\> Common peroneal nerve * Sole of the foot -\> Tibial nerve * Vascular * Posterior tibial pulse * Dorsalis pedis pulse * Capillary refill time at hallux [Present examination] * Thank patient & Wash hands * “This is patient x who is a x year old Male/Female with the following findings” * I would take a full Hx + examine any other relevant joints and systems * I would consider the differentials * I would order relevant investigations * Observations * Bloods * Imaging * I would initiate management of the most likely differential

Answer 124

[Introduction] * Wash hands & Introduce self * Ask Patient name & DOB & Age * Today I am going to be doing an examination on your hip, as I believe you have had some issues. Is that what you were expecting? * So the examination will involve me having a look at you from the end of the bed/then closer at your hip/I will feel the hip joint/ and move it around and ask you to do some movements also * Does that all sound ok? * I will need you to remove your clothing from your bottom half so I can see the whole hip, the examiner will act as a chaperone for both of us – is that ok? * Do you have any pain at the moment? Would you like some painkillers? * I’ll need you standing initially for the examination, then on the couch later [General Inspection] * Can you tell me which hip is sore? Where exactly is the pain? * To examiner: I would ordinarily examine both hip however due to the time constraints I will examine the hip that is affected, are you happy with that? * Assess the surrounding area: * Walking aids * Specialist shoes * Assess the patients shoes * Insole * Signs of uneven wear * Normal wear -\> Heel & 1st Metatarsal * Look at the patient and assess * Signs of pain * Body habitus * Are they systemically unwell? [Close inspection/Look] Gait * For the next part of the examination, I will need to have a look at you walking. Can you walk the wall A to wall B. * Assess gait looking for: * Normal gait - Stance & Swing phase * Antalgic gait * Stiff hip * Trendelenberg gait * Foot drop -\> High stepping gait, due to Common Peroneal nerve injury Trendelenberg test * Stand in front of patient with hands on iliac crest & patient hands on my forearms * Can you please stand on the abnormal leg? with other knee raised * Normal -\> Pelvis on raised knee side rises up * Positive pathology -\> Pelvis on raised knee side drops down * Caused by pain that inhibits muscles/muscle wasting/nerve damage Inspection whilst standing - Anterior/Left/Right/Posterior * Symmetry of the hip * Alignment * Willingness to weight bear * Deformity * Increased Lumbar lordosis * Scoliosis * Hip rotation * Knee flexion * Scars * Arthroscopy * Hip replacement * Muscle wasting * Quadriceps * Gluteal muscles * Swelling * Effusion * Inflammation * Bursitis * Skin changes * Erythema * Bruising [Feel] -- Supine position * Temperature - using back of hands * Palpation * Greater trochanter * ASIS [Move] * Ask patient to do a range of movements Flexion * Active - bring your knee to your chest * Passive - Push the hip further after active movement Rotation * Passive - With your knees still towards your chest, im going to move it in different directions, tell me if you feel any pain at all Internal rotation - Rotate leg OUT (Hip rotates IN) External rotation - Rotate leg IN (Hip rotates OUT) Abduction & Adduction Fix pelvis over iliac crest & Hold leg out at an angle * Abduction - Move leg OUT Feel for pelvis tilt at the iliac crest * Adduction - Move leg IN over other leg, feel for pelvis tilt Extension * Can you please roll over on your front fro me * Can you lift your leg off the bed for me, assist (Passive) Straight leg raise * Can you keep your knee straight and lift your leg off the bed * Assess spine [Special tests] Leg length - Ask patient to lie on front, bring ankles together * Check if medial malleoli meet -\> Unlikely leg length discrepancy * Measure Apparent leg length * Umbilicus -\> Medial malleolus * Repeat on other leg * Discrepancy -\> Pelvic deformity (Pelvic tilt) * Measure True leg length * ASIS -\> Medial malleolus * Repeat on other leg * Discrepancy -\> Bone deformity Thomas test * With patient supine, with legs hanging over the end of the bed * Place hand under L spine * Ask patient to flex non-painful or affected knee to their chest * Lumbar lordosis should be eliminated to 0 deg * If FFD -\> Abnormal, thigh raised off bed * Caused by FFD (Tightening/shortening of hip flexors) - OA * If normal -\> Abnormal Thigh stays on bed [Complete examination] * To complete the examination, I would assess the joint above (spine) and the joint below (knee) * Straight leg raise (Spine) * I would also assess the neuromuscular function of the knee * Power * Quadriceps -\> Femoral nerve * Toe extension -\> Common peroneal nerve * Plantar flexion of foot -\> Tibial nerve * Sensation * Anteromedial thigh -\> Femoral nerve * Dorsum of the foot -\> Common peroneal nerve * Sole of the foot -\> Tibial nerve * Vascular * Posterior tibial pulse * Dorsalis pedis pulse [Present examination] * Thank patient & Wash hands * “This is patient x who is a x year old Male/Female with the following findings” * I would take a full Hx + examine any other relevant joints and systems * I would consider the differentials * I would order relevant investigations * Observations * Bloods * Imaging * I would initiate management of the most likely differential

Answer 125

[Introduction] * Wash hands & Introduce self * Ask Patient name & DOB & Age * Today I am going to be doing an examination on your ankle & foot, as I believe you have had some issues. Is that what you were expecting? * So the examination will involve me having a look at you from the end of the bed/then closer at your ankle & foot/I will feel the ankle & foot joint/ and move it around and ask you to do some movements also * Does that all sound ok? * I will need you to remove your clothing and wear shorts so I can see the whole of your foot and ankle, and your knee the examiner will act as a chaperone for both of us – is that ok? * Do you have any pain at the moment? Would you like some painkillers? * I’ll need you standing initially for the examination, then on the couch later [General Inspection] * Can you tell me which ankle & foot is sore? Where exactly is the pain? * To examiner: I would ordinarily examine both ankles however due to the time constraints I will examine the ankle that is affected, are you happy with that? * Assess the surrounding area: * Walking aids * Specialist shoes * Assess the patients shoes * Insole * Signs of uneven wear * Normal wear -\> Heel & 1st Metatarsal * Look at the patient and assess * Signs of pain * Body habitus * Are they systemically unwell? [Close inspection/Look] Gait * For the next part of the examination, I will need to have a look at you walking. Can you walk the wall A to wall B. * Assess gait looking for: * Normal gait - Stance & Swing phase * Antalgic gait * Stiff ankle -\> Decreased dorsiflexion of ankle * Trendelenberg gait * Foot drop -\> High stepping gait, due to Common Peroneal nerve injury Assess function (Looking at ankle from behind and in front) * Can you walk on your tip toes, I will be around to support you * Can you walk on your heels Inspection of foot and ankle Front * Symmetry of feet & ankles * Toe alignment * May have Hallux valgus of big toe * Bunions - at 1st MTP joint * Deformity * Claw toe - Toes bend down like claw * Mallet toes - End joint only, mallet appearance at end * Hammer toe - Toe bent at middle joint -\> Curling of distal toe. Most common in 2nd toe * Scars * Previous injury * Surgery * Swelling/Erythema * Inflammatory arthritis/Septic arthritis/Cellulitis/injury * Calluses (Skin thickening) * Foot/Gait deformity or poorly fitting shoes * Normal at 1st MTP/Heel * Willingness to weight bear * Look b/w toast for ulcer/calluses * Look underneath foot at sole for ulcers/calluses * Side Foot arches * Pes planus -\> Flat feet Ask patient to stand on tip toes * If supple -\> Correction of pes planus * If rigid -\> No correction * Pes Cavus -\> High arched feet * Back/Behind Heel alignment * Valgus/varus deformity * Achilles tendon * Deformity * Swelling -\> Achilles tendonitis * Discontinuity * Erythema [Feel] Temperature * Forefoot * Midfoot * Ankle Palpate structures * Anterior ankle joint line * Distal fibula (Lateral) * Calcaneus * Medial malleoli * Lateral malleoli * Subtalar joint * Midtarsal joint * MTP joint squeeze Bimunual palpation of ALL toes Assess for * Tenderness * Swelling * Irregularity Palpate the achilles tendon * Position patient kneeling on a chair with feet handing off * Palpate gastrocnemius muscle + Achilles tendon * Note: * Focal tenderness/swelling -\> Achillies tendonitis * Apparent gaps in tendon -\> Rupture of achilles tendon [Move] * Foot plantar flexion -\> Push your feet down like you are pushing a pedal * 0-50 deg * Foot dorsiflexion -\> Point your foot towards your head * 0-20 * Toe flexion -\> Curl up your toes * Toe extension -\> Point your toes up towards your head * Ankle/Foot inversion -\> Stabilise above ankle, move your foot inside (Medial) * 0-35 deg * Ankle/foot eversion -\> stabilise above ankle, move your foot outside (Lateral) * 0-15 deg * Big toe - stabilise mid foot with hand - eliminate ankle movement * Dorsiflexion -\> move your big to up towards your head * Plantarflexion -\> Move your big toe down to the floor without using the other toes * Passive movement - feel for crepitus Mid-tarsal joint * Stabilise ankle w/L hand, grasp forefoot with R hand * Apply twisting motion between hands * Sub-talar joint * Stabilise foot above ankle joint with L hand grasping heel w/R hand * Invert/Evert the foot [Special tests] Simmonds test * Ask patient to kneel on a chair or lie on bed with foot handing over the edge * Squeeze the calf muscle/gastrocnemius * Normal -\> Plantarflexion of foot * Positive -\> Absence of plantar flexion of foot - Rupture of achilles tendon [Complete examination] * To complete the examination, I would assess the joint above (knee) * Flexion * Extension * I would also assess the neuromuscular function of the ankle & foot * Power * Toe extension -\> Common peroneal nerve * Plantar flexion of foot -\> Tibial nerve * Sensation * Dorsum of the foot -\> Common peroneal nerve * Sole of the foot -\> Tibial nerve * Reflex * Ankle jerk reflex * Vascular * Posterior tibial pulse * Dorsalis pedis pulse [Present examination] * Thank patient & Wash hands * “This is patient x who is a x year old Male/Female with the following findings” * I would take a full Hx + examine any other relevant joints and systems * I would consider the differentials * I would order relevant investigations * Observations * Bloods * Imaging * I would initiate management of the most likely differential

Answer 126

Antalgic gait * Limp/non weight bearing * b/c of pain * Can be due to: * Trauma e.g. fracture * Problems with appendix * Hernia * Testicular pathology Trendelenburg gait * Due to gluteal muscle weakness (Abductors) * Weight bearing on ipsilateral side -\> Pelvis drop on contralateral side * Note: Normal is for contralateral side to rise * If bilateral disease -\> Waddling gait * Caused Hip joint disease * Perthes/SUFE/DDH/JIA * Muscle disease * DMD/Metabolic muscle disease * Neurological conditions * Spina bifida/Cerebral palsy Circumduction gait * “Peg leg” - Due to excessive hip abduction * Legs swing forward -\> semi-circular movement of the leg * Caused by: * Restricted joint movement * JIA/Post trauma * Leg length discrepancy * Hemiplegic cerebral palsy Spastic gait * Flexion at hip + knees * Feet (Ankles) extended & internal rotation * Adduction of knees * Usually flexion of UL * Caused by: * UMNL * Cerebral palsy/Stroke Toe walking * Walking on tip toes w/lack of heel contact * Caused by: * Normal variant (If they can walk on heels on request) * UMNL * Cerebral palsy * DMD * ASD High stepping gait * Toes point down with foot hanging * Unable to dorsiflex foot * Caused by: * Damage to deep peroneal nerve

Answer 127

Increased pressure within a closed anatomical space, compromising circulation and function of tissues in that space * Can lead to damage to muscles + nerves * Acute -- Emergency * Chronic -- usually due to acvitity, stops at rest Commonly affects: * Anterior/Deep posterior compartment of the leg * Volar compartment of the forearm

Answer 128

Ventral: * Median nerve * Ulnar nerve * Radial artery * Ulnar artery Dorsal * Posterior interosseous nerve

Answer 129

* Fracture * Crush injury * Prolonged limb compression * Burns * Infection

Answer 130

* Within 48hrs of injury * Loss of muscle function -- may have muscle necrosis * Pain on passive stretching of muscles in the affected compartment * Disproportionate pain to severity of injury * Pressure in compartment * Parasthesia * Pulselessness * Pallor * Paralysis * Cool to touch * Loss of capillary refill

Answer 131

* **Acute compartment syndrome** * DVT * Infection * Acute ischaemia * Osteomyelitis

Answer 132

* **Acute compartment syndrome** * DVT * Infection * Acute ischaemia * Osteomyelitis

Answer 133

Investigations: * Clinical diagnosis * Compartment pressure measurment -- Differential pressure within 30mmHg of DBP * MRI - if unsure * Serum CK -- Increased if muscle necrosis * Urine myoglobin -- Increased if muscle necrosis Management: * Prompt diagnosis + Early surgery * Urgent decompression + Prevent severe ischaemia * Open fasciotomy + Wound left open * Debridement of muscle necrosis * Morphine for pain * If absence of muscle function in neurologically intact limb -- Amputation

Answer 134

Acute: * Neurovascular damage * Soft tissue damage * Blood loss * Local tissue contamination/infection * Fracture blisters * Compartment syndrome Delayed: * Delayed union * Malnunion -- # Doesnt heal in normal alignment * Non-union -- Doesnt heal at all * Osteomyelitis * AVN * Loss of function

Answer 135

* Inflammation with swelling lasting 2-3 wks * Soft callus formation * Hard callus formation * Bone remodelling

Answer 136

**Osteo arthritis in both R + L knees** * Loss of joint space * Osteophytes * Subchondral sclerosis * Subchondral cysts

Answer 137

**Inflammatory Arthritis (e.g. RA)** * Bone erosions * Ulnar deviation * Soft tissue swelling * Joint space narrowing * Osteopenia

Answer 138

**Gout** * Punched out erosions * Podagra * Joint effusion * No periarticular osteopenia

Answer 139

**Pathological fracture** * Low BMD -- Cortical thickness different to normal bone * Fracture through well defined lesion

Answer 140

**Fractured neck of femur** * Garden 2 * Shentons line disrupted

Answer 141

SUFE on the L hip (Right side of image)

Answer 142

Extracapsular hip fracture

Answer 143

Garden 4 - NOF fracture

Answer 144

Bilateral Perthes disease

Answer 145

Pes Cavus Normal arch Pes Planus

Answer 146

Mallet toe Hammer toe Claw toe

Answer 147

Tansverse Linear Oblique non-displaced Oblique displaced Spiral Greenstick Communinuted

MSK Flashcards

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