ortho

Question 1

Mx of lumbar spinal stenosis

Answer 1

laminectomy - decompression of the spinal canal

Question 2

summarise Mx for #NOF

Answer 2

intracapsular NOF affects blood supply t4 risk of AVN of femur head

• ball on xray
• non-displaced fracture => internal fixation with screws
• displaced fracture => total hip replacement or hemiarthroplasty [ depending on pts mobility and lack of cognitive impairment.

extracapsular NOF - blood flow intact

• fish on xray
• intertrochateric => dynamic hip screw
• subtrochanteric =>intermedullary nail

Question 3

hemiarthroplasty vs total hip replacement

Answer 3

hemi replaces the femur head only
total replacement = replacement of the femoral head + the acetabulum

Question 4

FOOSH + pain in anatomical snuffbox
- main concern and mx

Answer 4

• scaphoid fracture
• if left untreated => risk of AVN of the scaphoid [bad]

mx =

• immobilisation with a Futuro splint or standard below-elbow backslab.
• Refer to ortho
• Further imaging needed in 7-10 days if initial Xray inconclusive.
• Undisplaced Fx => cast for 6-8 weeks
• Displaced Fx => surgical fixation
• proximal scaphoid pole fractures => surgical fixation

Question 5

signs of scaphoid fracture

Answer 5

Patients typically present with:

• Pain along the radial aspect of the wrist, at the base of the thumb
• Loss of grip / pinch strength

SIGNS
1. Point of maximal tenderness over the anatomical snuffbox
This is a highly sensitive (around 90-95%), but poorly specific test (<40%) in isolation
2. Wrist joint effusion
Hyperacute injuries (<4hrs old), and delayed presentations (>4days old) may not present with joint effusions.
3. Pain elicited by telescoping of the thumb (pain on longitudinal compression)
4. Tenderness of the scaphoid tubercle (on the volar aspect of the wrist)
5. Pain on ulnar deviation of the wrist

Question 6

which fractiures are associated with compartment syndrome

Answer 6

Compartment syndrome is most commonly associated with:

• supracondylar fractures in the arm
• tibial shaft fractures in the lower leg.

Question 7

DX and CFs of compartment syndrome

Answer 7

Dx
- Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic [intracompartmental pressure measured using a manometer]

CFs

• Pain, especially on movement (even passive)
  
  • excessive use of breakthrough analgesia should raise suspicion for compartment syndrome
• Parasthesia
• Pallor may be present
• Arterial pulsation may still be felt as the necrosis occurs as a result of microvascular compromise
• Paralysis of the muscle group may occur

Question 8

L3 nerve root compression

Answer 8

• Sensory loss over anterior thigh
• Weak hip flexion, knee extension and hip adduction
• Reduced knee reflex
• Positive femoral stretch test

Question 9

L4 nerve root compression

Answer 9

• Sensory loss over lower anterior aspect of knee and medial malleolus
• Weak knee extension and hip adduction
• Reduced knee reflex
• Positive femoral stretch test

Question 10

L5 nerve root compression

Answer 10

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

Question 11

S1 nerve root compression

Answer 11

• 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 12

IX and features of a meniscal tear

Answer 12

MRI imaging = 1st line. X-ray indicated if there is concurrent arthritis.

• pain worse on straightening the knee
• knee may ‘give way’
• displaced meniscal tears may cause knee locking
• tenderness along the joint line
• Thessaly’s test - weight bearing at 20 degrees of knee flexion, patient supported by doctor, postive if pain on twisting knee
• Typically result from twisting injuries.

Question 13

what is simmonds triad

Answer 13

Simmond’s triad diagnoses complete tendon rupture.

• Calf squeeze test +ve: squeeze the calf – no plantarflexion = +ve for total rupture
• Palpable gap in Achilles tendon
• Angle of dangle: prone pt with feet dangling off the bed. the injured foot hangs more dorsiflexed than the normal one = +ve

Question 14

Barton’s fracture =

Answer 14

Colle’s/ Smith’s fracture associated with radio-carpal dislocation

Question 15

Colle’s fracture =

Answer 15

DorsallyDisplacedDistal radius →Dinner forkDeformity

Question 16

Smith’s fracture =

Answer 16

AKA reverse Colle’s
Volar [forward] displacement of distal end of radius
Caused by falling with wrists flexed

Question 17

features of ACL injury

Answer 17

sudden ‘popping’ sound
knee swelling
instability, feeling that knee will give way
anterior draw test +ve
twisting injury or “landed funny”

Question 18

Trochanteric bursitis presents with…

Answer 18

isolated lateral hip/thigh pain with tenderness over the greater trochanter

Question 19

what are the ottowa rules

Answer 19

Ottawa rules are used to determine if an X-ray is needed:
X-ray after an ankle injury, if there is pain in the malleolar zone, + 1 of the following:

• Inability to bear weight (walk four steps) immediately after the injury and when examined.
• Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus.
• Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus

Question 20

carpal tunnel syndrome features on examination

Answer 20

• Weakness of thumb abduction (abductor pollicis brevis)
• Wasting of thenar eminence (NOT hypothenar)
• Tinel’s sign: tapping causes paraesthesia
• Phalen’s sign: flexion of wrist causes symptoms

Question 21

carpal tunnel syndrome Ix + Mx

Answer 21

• Electrophysiology => motor + sensory: prolongation of the action potential.

Mx

• • A 6-week trial of conservative treatments if the symptoms are mild-moderate
    
    • corticosteroid injection
    • wrist splints at night: particularly useful if transient factors present e.g. pregnancy
• if there are severe symptoms or symptoms persist with conservative management:
  
  • surgical decompression (flexor retinaculum division)

Question 22

Achilles tendonitis management:

Answer 22

• rest + NSAIDs,
• physio if symptoms persist beyond 7 days

Question 23

Weakness of hip abduction and foot drop, no specific reflex lost

Answer 23

L5 radiculopathy

Question 24

Pain on the radial side of the wrist/tenderness over the radial styloid process ?

Answer 24

De Quervain’s tenosynovitis

Question 25

De Quervain's tenosynovitis diagnostic examination / test

Answer 25

Finkelstein's test: the examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction. In a patient with tenosynovitis this action causes pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus

Question 26

sensory loss over anterior thigh, weak hip flexion, knee extension and hip adduction, reduced knee reflex

Answer 26

L3 nerve root compression

Question 27

MC cause of osteomyelitis

Answer 27

Staph. aureus is the most common cause except in patients with sickle-cell anaemia where Salmonella species predominate

Question 28

MC reason for total hip replacement revision

Answer 28

Aseptic loosening is the most common reason total hip replacements need to be revised

Question 29

CFs of OA of the hand

Answer 29

* Usually bilateral: Usually one joint at a time is affected over a period of several years. The carpometacarpal joints (CMCs), distal interphalangeal joints (DIPJs) are affected more than the proximal interphalangeal joints (PIPJs). * Episodic joint pain: An intermittent ache. Provoked by movement and relieved by resting the joint. * Stiffness * worse after long periods of inactivity e.g. waking up in the morning * stiffness lasts only a few minutes compared to the morning joint stiffness seen in rheumatoid arthritis. * Painless nodes (bony swellings) * Heberden's nodes at the DIP joints * Bouchard's Nodes at the PIP joints * these nodes are the result of osteophyte formation. * Squaring of the thumbs: Deformity of the carpometacarpal joint of the thumb resulting in fixed adduction of the thumb. * Functionally patients do not usually have any problems. If there is severe involvement of the DIPJs, there may be reduced grip strength which can result in disuse atrophy.

Question 30

Red Flags for back pain include -

Answer 30

Red Flags for back pain include: * Thoracic pain * Age <20 or >55 years * Non-mechanical pain * Pain worse when supine * Night pain * Weight loss * Pain associated with systemic illness * Presence of neurological signs * Past medical history of cancer or HIV * Immunosuppression or steroid use * IV drug use * Structural deformity

Question 31

OP risk assessment

Answer 31

QFracture * if the 10-year fracture risk is ≥ 10% then a DEXA scan should be arranged FRAX * a colour 'risk' is given by the calculator - green, orange or red * patients in the orange zone should have a DEXA scan if not already done to further refine their 10-year risk * patients in the red zone should also have a DEXA scan if not already done to act as a baseline and guide drug treatment

Question 32

OA hand findings

Answer 32

Signs of osteoarthritis on the hand can be remembered by "TBH" **T**:Thumb CMC squaring [squaring of the base of the thumb] **B**:Bouchard's nodes (affecting the proximal IPJ) **H**:Heberden's nodes (affecting distal IPJ) and if ur Arab u know HAB3D means i'll go far away rather than closer so Heberden's nodes (distal rather than proximal affected) !!

Question 33

OA xray findings

Answer 33

Question 34

RA x-ray findings

Answer 34

subluxation

Question 35

Lachman's test

Answer 35

Lachman's test is a special test used to identify ACL injuries. Lachman's test is more sensitive than the anterior draw test

Question 36

McMurray's test

Answer 36

McMurray's test is a special test used to identify a meniscal tear in the knee. While a meniscal tear can present similar to an ACL injury, you can differentiate the two by the timing of the swelling. ACL injuries swell immediately due to haemarthrosis, meniscal tears typically swell over time

Question 37

De Quervain's tenosynovitis is caused by

Answer 37

inflammation of the extensor pollicis brevis and abductor pollicis longus tendon sheath causing radial styloid process pain and painful abduction of the thumb against resistance

Question 38

ACJ injury Mx

Answer 38

based on degree of separation between the acromion and clavicle using a grading system from 1- 6 - 1 and 2 = conservative - sling and rest - 4 - 6 = surgical intervention. - 3 - clinical decision

Question 39

if you see a patient with bilateral carpal tunnel syndrome, look for features that might suggest underlying...

Answer 39

rheumatoid arthritis, diabetes, acromegaly hypothyroidism