1
Q
Which structure is diveded during carpal tunnel surgery?
A
The flexor retinaculum.
2
Q
Which nerve is affected in a condition that causes antero-lateral pain of the thigh?
What is the name of this syndrome?
A
This is meralgia paraesthetica - a syndrome due to compression of the lateral cutaneous nerve of the thigh.
Clinical features include:
- Burning, tingling, coldness, or shooting pain
- Numbness
- Deep muscle ache
- Symptoms are usually aggravated by standing, and relieved by sitting
- They can be mild and resolve spontaneously or may severely restrict the patient for many years.
3
Q
What are risk factors for meralgia paraesthetica?
A
- Obesity
- Pregnancy
- Diabetes
- Tight jeans/trousers
4
Q
What are the complications of bisphosphonates?
A
- Gastritis - this is a side effect of oral bisphosphonates. Can lead to gastric ulceration. Reason why they should be taken on an empty stomach and whilst sitting upright.
- Osteonecrosis of the jaw - uncommon. Patients should therefore seek advice before any dental procedure.
- Fevers/myalgia/arthralgia - common with IV infusion. Last 24-72 hours. Get progressively better with subsequent infusions.
5
Q
What is the management of bilateral talipes equinovarus?
A
The Ponseti method consists of manipulation and progressive casting which starts soon after birth. Deformity is usually corrected after 6-10 weeks. Achilles tenotomy is required in a majority of cases.
6
Q
Which nerve supplies the “regimental badge” area?
A
The axillary nerve.
7
Q
In what position would a leg be if the hip was dislocated anteriorly or posteriorly?
A
- Anteriorly: Leg would be externally rotated and NOT shortened
- Posteriorly: This would result in a shortened, internally rotated leg.
8
Q
In what position would a lef be if the hip was broken?
A
Leg is shortened and EXTERNALLY ROTATED with hip fracture
9
Q
What is the management of plantar fasciitis?
A
Conservative:
- Weight loss (If BMI >25)
- Tretch exercises (done 3x per day)
- Resting the heel
Medical: (if above fails)
- Orthotics such as insoles and heel pads
- NSAIDs
10
Q
Describe how you would carry out Simmonds test and what it tests for?
A
Get the patient to lie prone with feet hanging off end of bed. Then squeeze calfs. If the foot fails to plantarflex, the test is positive.
This tests for Achilles tendon rupture.
11
Q
What are the clinical features of compartment syndrome?
A
Clinical features:
- Severe, disproportionate pain
- Gets worse on passive movement of the leg
- Paraesthesia
- Pallor
- Pulses may still be present, as the pressure in the miccrovasculature is lower than arteries, so is suppressed quicker
- Paralysis of the muscle group may occur
12
Q
How is compartment syndrome diagnosed?
A
The diagnosis in most cases is clinical.
In some cases (e.g. unconscious patients) intracompartmental pressure measurements can be performed.
13
Q
What is the managment for compartment syndrome?
A
Fasciotomy performed promptly.
Due to the potential for myoglobinuria, aggressive IV fluid hydration is required to protect the kideys.
If necrosis is present, debribement may be required.
14
Q
How are fibular ankle fractures classified?
A
Fractures at the fibular ankle can be classified using the Weber classification:
- A: Below the syndesmosis
- B: fractures start at the level of the tibial plafond and.may extend proximally to involve the syndesmosis
- C: above the syndesmosis
Maisonneuve fracture is a subtype: spiral fracture of the fibula leading to disruption of the syndesmosis with widening at the ankle joint.
15
Q
What is a Maisonneuve fracture?
A
This descrives a spiral fracture of the fibula with tear of the interosseus membrane.
This usually requires surgical fixation.
16
Q
Try and summrise the management for ankle fractures.
A
Ankle fractures rqurie prompt reduction to remove pressure on the overlying skin and subsequent necrosis.
Young: surgical repair with fixation, often with a compression plate.
Old: conservative may be more appropriate.
17
Q
How lolng after a dynamic hip screw should patients mobilise?
A
After a dynamic hip screw patients should mobilise immediately post-OP.
18
Q
What is the classification used for epiphyseal fractures?
A
19
Q
What is “frozen shoulder”
A
Frozen shoulder, aka. adhesive capseolitis, is most common in middle-aged females. Features include:
- External rotation more affected than internal rotation
- Active and passove movements both affected
- Episodes last ~6 months - 2 years.
- Biltareal in 1/5th
Management is with NSAIDs, physiotherapy and steroids (oral or intra-articular)
20
Q
What neurovascular structure is most commonly damaged in a scaphoid fracture?
A
The dorsal carpal arch of the radial artery.
As the blood supply to the proximal scaphoid is a watershed area, there is concern regarding avascular necrosis of the scaphoid.
21
Q
What are the clinical features of a fat embolism?
A
Respiratory/CVS:
- Early, persistent tachycardia
- Tachypnoea, dyspnoea, hypoxia 72 hours following surgery
- Pyrexia (PE less associated with pyrexia)
Dermatological:
- Red/brown impalpable petichial rash
CNS:
- Confusion and agitation
- Retinal haemorrhages and intra-arterial fat globules on fundoscopy
22
Q
What syste is used to classify open fractures?
A
Gustilo and Anderson classification.
23
Q
How do you manage a fracture with vascular compromise?
A
Vascular impairment requires immediate surgery and restoration of circulation.
This should be done using: shunting, followed by temporary skeletal stabilisation, vascular reconstruction.
24
Q
What is a Ganglion?
A
- A ganglion presents as a painless cyst arising from a joint or tendon sheath.
- They are most common around the back of the wrist.
- They are 3 times more common in women than men, and are completely harmless. Typically disappear after several months.
25
How soon should you organise an MRI in a suspected cauda equina syndrome?
An MRI should be done ASAP, but at 6 hours latest.
26
What are the risk factors for congenital hip dysplasia?
* Female
* Breech
* First born
* Family History
* Oligohydramnios
27
What is the most important step in managing an ankle fracture?
With an ankle fracture, immediate closed reduction is improtant to prevent necrosis of the overlying skin.
28
How does a psoas abscess present?
What is the most common causative organism?
* Lumbar tenderness
* Pain eases when knees are slighly flexed
Most common causeative organism:
* S. aureus
* Streptococcus epidermidis
29
What investigations should you perform in a suspected psoas abscess?
Investigations should include:
* Bloods:
* FBC
* Blood cultures + full septic screen
* Imaging:
* Plain AXR - not good at diagnosing but can rule out other causes
* MRI - **gold standard**
30
Which nerve runs through the cubital tunnel?
The ulnar nerve - there is a **cubital tunnel syndrome** where patients complain of funny-bone sensation + tingling in the pinkie on the affected side.
31
What is the diagnosis of choice for a suspected achilles tendon rupture?
**Ultrasound is the initial imaging modality** of choice for suspected Achilles tendon rupture.
32
What are risk factors for achilles tendon rupture?
* Quinolone use (e.g. ciprofloxacin)
* Hypercholesterolaemia
* Steroids
33
What is Lachman test?
Lachman test checks for ACL rupture.
34
What is the treatment for adhesive capseolitis?
Aka. adhesive capsulitis is a painful stiff shoulder with restriction in all movements.
Aetiology:
* Not known, however associated with **diabetes mellitus** (up to 20% of DM patients may develop it)
Clinical features: (onset **over days**)
* External rotation is affected more than internal rotation
* active and passive movement both affected
* Bilateral in 20%
* Episodes last 6-24 months
Management:
* Nothing really helps. Try **NSAIDs**, **physio**, **steroids** (oral or intra-articular)
35
What is Kanave's sign?
Why is this significant?
This is a sign of **infective tenosinovitis** of the finger:
* Fixed Flexion
* Fusiform swelling
* Tenderness
* Pain on passive flexion
This is a **surgical emergency** as early management with **antibiotics** ± **surgical** **debridement** may be required.
36
What treatment should you NOT give in compartment syndrome?
**Anticoagulation** is contraindicated - this can lead to more bleeding into the compartment and therefore worsen it.
37
What does the FRAX score measure?
This measures the risk of suffering a fragility fracture within the next 10 years.
A risk of 10% warrants a DEXA scan.
38
What is discitis?
Discitis is an infection of the intervertebral disc space.
It can lead to **sepsis** or **epidural abscess**.
Causes include:
* S. aureus
* TB
* Viral
* Aseptic
39
What is the Ix and Rx for discitis?
Ix:
* MRI has the highest sensitivity
* CT-guided biopsy may be required to guie antibiotic treatment
* (Also consider echo, as haematogenous spread is common)
Rx:
* Standard therapy requires 6-8 weeks of IV ABx
40
How can you distinguish between a sciatic neuropathy and an L5 radiculopathy?
Sciatic neuropathy:
* **Loss of ankle jerk**
* Loss of plantar response
L5 radiculopathy:
* **Postiive straight leg raise**
* Normal reflexes
* Weakness of hip abduction
41
What is a Morton's neuroma?
What are the symptoms?
Morton's neuroma is a **benign neuroma** affecting the **intermetatarsal plantar nerve**. This occurs most commonly in the **third inter-metatarsophalangeal space**.
Symptoms include:
* Forefoot pain
* Worse on walking
* May have loss of sensation distally in the toes
42
What is the managment of a morton's neuroma?
Conservative:
* Avoid high-heels
* Metatarsal pad
* Orthotics: metatarsal dome
Medical:
* Corticosteroid injections
Surgical:
* Neurotomy
43
What does this X-ray show?
This X-ray shows an injruy in the acromio-clavicular joint (should be joined together).
This is common in falls on the shoulder or a fall on outstretched hand.
44
What are the causes for Dupuytren's contractures?
The most common cause is idiopathic. Specific causes include:
* Manual labour
* **Phenytoin**
* Alcoholic liver disease
* Diabetes mellitus
* Trauma to the hand
45
When should you refer a patient with Dupuytren's contractures for surgery?
When the MCP joints cannot be straightened and thus the hand cannot be placed flat on the table.
46
Which nerve is commonly damaged in supracondylar fractures?
Both the **ulnar** and the **median** **nerve** can be damaged in supracondylar fractures.
The radial is also sometimes injured, but less commonly.
47
What is trigger finger?
Trigger finger is a common condition associated with **abnormal flexion** of the digits. It is thought to be caused by a **disparity between the size of the tendon and pulley**s through which they pass. In simple terms the **tendon becomes 'stuck'** and cannot pass smoothly through the pulley.
48
What is the treatment for trigger finger?
* Steroid injection + Finger splint
* Srugery if above unsuccessul
49
What is a common causative organism of osteomyelitis in patients with sickle cell disease?
Non-typhi **Salmonella**
50
What type of fracture can you see here?
This is a **Buckle fracture**.
## Footnote
Torus fractures, also known as buckle fractures, are **incomplete fractures of the shaft** of a long bone that is characterised by **bulging of the cortex**. They result from trabecular compression due to an axial loading force along the long axis of the bone. They are usually seen in children, frequently involving the distal radial metaphysis.
51
Where would pain be most commonly reported with trochanteric bursitis?
Pain and tenderness over the **lateral side of thigh**
Aka. Greater trochanteric pain syndrome.
52
What is Finkelstein Test looking for and how is it carried out?
Finkelstein Test looks for DeQuervain's Tenosynovitis.
It is carried out: 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
53
What is DeQuervain's tenosynovitis?
De Quervain's tenosynovitis is a common condition in which the **sheath** **containing** the **extensor** **pollicis** **brevis** and **abductor** **pollicis** **longus** tendons is **inflamed**.
It typically affects females aged 30 - 50 years old.
54
How is DeQuervain'S tenosinovitis managed?
* Analgesia (NSAIDs, Paracetamol)
* Steroid injection
* Immobilisation with a thumb spling
* Surgical treatment (rarely done)
55
Which test checks for rupture of the Achilles Tendon?
Thompson's test.
aka Simmond's test
56
Summarise the management of osteoarthritis.
Conservative:
* Weight loss
* Physio for local muscle strengthening exercises
Medical:
* **Paracetamol** + **_topical_ NSAID** are first-line analgesics (latter for hands and feet only)
* NSAIDs, opioids, capsaicing cream + intraarticular corticosteroids are second-line
Mechanical/Surgical:
* Support braces, insoles
* Surgery (joint replacement)
57
Describe the deformity seen with clubfoot.
Inverted + plantar flexed foot. Not passively correctable
58
What are non-traumatic causes of avascular necrosis of the hip?
What are clinical features of AVN?
* Long-term steroid used
* Chemotherapy
* Alcohol excess
Initially this is asymptomatic, then presents with pain.
On plain X-ray, findings may be normal and then osteopenia and microfractures may be seen, ultimately leading to collapes.
**MRI is investigation of choice.**
59
Which nerve is commonly damaged in posterior hip dislocations=?
The sciatic nerve - predominantely the fibres affecting the peroneal nerve.
60
What is a Charcot joint?
Charcot joint - aka. neuropathic joint - describes a joint which has become badly disrupted and damaged secondary to a loss of sensation.
They are typically not or only mildly painful, and the joints are swollen, red and warm.
61
What is the most common site for osteomyelitis in childre, and what in adults?
Explain your answer.
The location of infection depends on the age due to the changing vascular supply. In children, it frequently affects the **metaphysis** as it is a highly vascular area. In adults it tends to be the **epiphysis**.
62
Name the parts of the bone.
63
What is a Hill-Sachs lesion?
Hill-Sachs lesions are a **posterolateral** **humeral** **head** **compression** **fracture**, typically **secondary** to **recurrent** **anterior** **shoulder** **dislocations**, as the humeral **head comes to rest against the anteroinferior part of the glenoid**.
64
Which bones are most commonly affected by Paget's disease?
The **skully, vertebral bones, pelvis, femur, tibia.**
65
What is iliotibial band syndrome?
This is inflamation of the iliotibial band due to friction with the. lateral epicondyle of the femur.
It is is a common cause of lateral knee pain in runners, occurring in around 1 in 10 people who run regularly.
Features
* tenderness 2-3cm above the lateral joint line
Management
* activity modification and iliotibial band stretches
* if not improving then physiotherapy referral
66
What does a positive straight leg raise test suggest as the underlying cause for someone's backpain?
This would suggest sciatica (pain shooting down the distribution of the sciatic nerve) - this is usually due to L5 (or L4 or S1) radiculopathy, i.e. compression of these nerveroots.
67
If the radiograph appears normalfor a suspected hip fracture, but clinically a fracture is still suspeced, which imaging should you get?
MRI is first line in occult hip fractures according to NICE.
In reality, a CT is often ordered before, however.
68
Which fractures commonly lead to compartment syndrome?
Compartment syndrome most commonly is associated with **supracondylar** **fractures** in the arm and **tibial** **shaft** **fractures** in the lower leg.
69
What is a fracture called that has Bimalleolar ankle fractures?
Pott's fractures.
70
What is a fracture called with intra-articular fractures of the first carpometacarpal joint?
Bennett's fracture - this is freqnetly caused by fist fights.
X-ray: triangular fragment at ulnar base of metacarpal
71
What are the Ottawa rules used for?
Line out the rules.
The Ottawa Rules are used to check whether an X-ray is needed after an ankle injury.
An ankle x-ray is required only if there is any **pain in the malleolar zone** and any one of the following findings:
* bony **tenderness at the lateral malleolar zone** (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)
* bony **tenderness at the medial malleolar zone** (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)
* **inability to walk four weight bearing steps immediately after the injury** and in the emergency department
72
What is the investigation of choice for suspected meniscus injueries?
MRI
73
What is the most common reason for THR revision surgeries?
Aseptic loosening is the most common reason total hip replacements need to be revised
74
What is epicondylitis?
Epicondylitis describes the syndrome seen with inflammation of the tendons inserting at the medial or lateral epicondyle.
**Medial epicondylitis: aka. Golfer's elbow**
* Pain aggrevated by **wrist flexion** and **pronation**
* Symptoms may be accompanied by **numbness/tingling** in 4th and 5th finger due to ulnar nerve involvement
**Lateral epicondylitis:**
* Pain worsened with **elbow extended** or **supination on extension**
75
What is cubital tunnel syndrome?
Cubital tunnel syndrome is a syndrome brough on by compression of the ulnar nerve in the cubital tunnel.
Features include:
* Intermittent tingling in 4th and 5th finger. Then numbness ± weakness
* Worse when elbow resting on firm surface or flexed for extended period
76
How does olecranon bursitis present?
This presents with swelling over the **posterior aspect** of the elbow. There may be associated pain, warmth and erythema.
Typically affects middle-aged men.
77
What is the common mode of injury for meniscal tears?
Typically result from **twisting** injuries, whilst the **knee is flexed**.
78
What are the features of a meniscal tear?
Features:
* Pain worse on straightening the knee
* Knee may **give way**
* Displaced meniscal tears may cause **knee locking**
* Tenderness along joint line
* Tested with Thessaly's test: weight bearing at 20° flexion, then twist. Positive if pain
79
What injury is usually associated with patella dislocation?
Direct trauma to the knee.
(tendency for dislocation can be tested with: patellar apprehension test.)
80
What is the problem with a scaphoid fracture?
80% of the scaphoid blood supply is derived from the **dorsal carpal branch** (branch of radial artery), in a **retrograde manner**. The blood supply is therfore at risk in a scaphoid fracture, leading to avascular necrosis - most commonly in **proximal scaphoid injuries**.
81
What are the main features of a scphoid fracture?
How would you investigate?
**Features**:
* Point of maximal tenderness in the **anatomical snuffbox**
* Wrist joint effusion
* Pain on ulnar deviation of the wrist
**Investigations**:
* **X-Ray** - repeat 2 weeks later is scaphoid fracture is suspected
* CT: superior to X-ray
* **MRI**: definitice investigation to exclude a diagnosis
82
What is a posterior shoulder dislocation typically associated with?
Posterior shoulder dislocations are associated with falls due to swizures and electric shock.
83
What is a Baker's Cyst?
This is a dorsal protrusion of the synovial membrane due to increased intra-articular pressure.
* Located between semimembranosus and medial gastrocnemius
84
What is subluxation of the radial head?
How is this managed?
This is also known as **pulled elbow**.
This is managed with **analgesia** and **passive subluxation of the elbow joint** whilst the elbow is **flexed to 90°.**
85
What test is used in the diagnosis of a meniscal tear?
Thessaly's test.
The patient is supported by doctor and is asked to stand on the affected leg, flexed to 20 degree. The test is positive if there is pain on twisting knee
McMurray's Test is also an option.
86
What are appropriate methods of analgesia for patients with an acute hip fracture?
All patients should receive paracetamol and opiods.
Also consider **iliofascial nerve blocks** - this can help reduce the need for opioids - now acutally **first-line** at many hopsitals.
87
What test can be used to see whether hip pain is acutally referred from the lumbar spine?
The **femoral nerve stretch test** - Lie patient **prone** and extend the hip joint with a straight leg, then bend the knee.
Positive if this causes pain.
88
What is Freiberg's disease?
Freibergs disease is an anterior **metatarsalgia** (pain in ball of foot) affecting the head of the second metarsal. It is due to **avascular necrosis of the matatrsal bone of the foot**.
It typically occurs in the pubertal growth spurt.
Freibergs disease the x-ray changes include; **joint space widening**, formation of **bony spurs**, **sclerosis** and **flattening of the metatarsal head**.
89
Explain the pathophsyiology behing the ulnar paradox.
The ulnar nerve supplies the palmer and dorsal interossei muscles and therefore finger abduction and adduction.
When the ulnar nerve is **damaged at the wrist**, the **medial two lumbrical muscles are affected** (the lateral two being supplied by the median nerve). Denervation of the lumbricals, which **flex the metacarpal phalangeal joints** (MCPJ) and **extend the interphalangeal joints** (IPJ), causes **unopposed extension of the MCPJ by extensor digitorum** and **flexion of the IPJ by flexor digitorum profundus and superficialis**. This gives the hand a claw like appearance.
When the ulnar nerve is damaged at the elbow, the **ulnar half of flexor digitorum profundus** is also affected resulting in a less marked clawing due to **reduced unopposed flexion at the IPJ.**
As the patient recovers, the deformity will get worse, as flexor digitorum is reinnervated, before getting better.
This is known as the **ulnar paradox,** as one would expect a more proximal lesion (and hence a larger section of ulnar nerve affected) to produce a more deformed appearance.
90
91
What are the features of obturator nerve injury?
Weakness in **hip adduction**, **numbness over the medial thigh.**
92
What are the features of **femoral nerve** injury?
Weakness in **knee extension**, **loss of patella reflex, numbness of the thigh.**
93
Other than dermatomyositis, what other condition are anti-Jo1 antibodies associated with?
**Antisynthetase Syndrome**.
This is where there is
* Myositis
* Interstitial lung disease
* Thickened and cracked skin of the hands (Mechanic's hands)
* Raynaud's phenomenon
94
What are the 4 muscles of the quadriceps?
95
What is osteogenesis imperfecta?
What are the features?
Aka. brittle bone disease, this is a group of collagen metabolism disorders resulting in bone fragility and fractures.
**Autosomal dominant**
**Features:**
* Fractures following minor trauma
* Blue sclera
* Deafness 2° to otosclerosis
* Denatl imperifecitons (e.g. karies) are common
96
Which tumour is commonly associated with
97
What classification system is used for acromioclavicular joint injuries?
What is the clinical implication of this classification?
The **Rockwood Classification**.
* 1-2 are managed conservatively, including joint rest + sling.
* 3 management unclear.
* 4-6 Surgical intervention requried.
98
Which X-Ray views do you want for ?ankle fractures?
* Mortise (slightly rotated)
* Lateral
Also get both in **weight bearing** and **non-weight bearing** when worried about ankle fracture, as it shows stability of the syndesmosis.
99
What are are the lesions associated with a shoulder dyslocation?
* **Bankart lesion**: this is **damage to the anteroinferior glenoid labrum**
* **Hill-Sachs Lesion**: **cortical depression** in the posterolateral part of the **humeral head** following impaction against the glenoid rim
100
How can you, based on clinical picture, differentiate a torn cruciate from a torn meniscus?
* Immediate swelling = torn cruciate vs swelling overnight = damaged meniscus
* Giving way = ligament injury, vs locking = damaged meniscus
101
How can menical tears be repaird?
Under athroscopy
* Direct vision of the injury
* If in the **red zone** or the **red-white zone** an be **repaired**
If in the **white zone** should usually be **trimmed** instead
Passmed Surgery
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