1
Q
Describe the term arthritides.
A
Umbrella term for conditions causing inflammation and degradation of the joint which can include non-inflammatory (OA), inflammatory seropositive (RA) or inflammatory seronegative (psoriatic; crystal arthropathy; reactive; ankylosing spondylitis; enterohepatic arthritis)
2
Q
How can arthritides be broadly classified?
A
- Degenerative: Osteoarthritis (OA)
* Inflammatory: Rheumatoid Arthritis (RA); Ankylosing spondylitis; Crystal arthropathies; Psoriatic Arthropathy
3
Q
Outline the difference between articular and peri-articular pain.
A
- Articular pain = true joint pain
- Periarticular pain = pain in structures around a joint – e.g. tendonitis; bursitis; enthesitis
- Referred pain = pain referred from a distant site of pathology
4
Q
State 4 structures present at a joint.
A
- Bone
- Joint capsule
- Tendon
- Ligament and enthesis
- Articular cartilage
- Bursa
- Synovium
5
Q
Describe Osteoarthritis.
A
Degenerative joint disorder, a type of arthritide, caused by inflammation of the whole joint resulting in degradation of the articular cartilage, synovium and subchondral bone characterised by symptoms of joint pain, functional difficulties.
6
Q
State 3 RFs for OA.
A
- Advanced age: > 50 years
- Female sex
- Genetic factors
- Obesity
- Knee malalignment: Varus thrust
- Physically demanding sport
- Occupation
7
Q
How may osteoarthritis present?
A
• Joint pain: worse on movement; better on rest
• Functional difficulties: post-rest stiffness (‘gelling’)
• Swelling
- Heberden’s Nodes (DIP); Bouchard’s Nodes
Note: Heberden’s Nodes»_space;> Bouchard’s Nodes (common)
• Stiffness: Morning stiffness
• Antalgic gait
• Crepitus
• Effusion
• Bony deformities: Bouchard’s nodes (PIP)/Heberden’s nodes (DIP)
• Reduced range of movement
• Malalignment: genu valgum (knock-knees); genu varum (bow-legs)
Note: Varus thrust (worsening varus alignment when weight-bearing) = worsened medial knee OA
8
Q
Which finger swellings are more present in OA? Describe what joints are typically affected.
A
Heberden’s Nodes - swelling of the DIP
9
Q
What are the 4 radiographic signs seen in OA on XR.
A
Mnemonic: LOSS
- Loss of joint space (JSN)
- Osteophyte (bony spurs)
- Subchondral sclerosis (hardening of bone)
- Subchondral cysts (fluid filled spaces)
10
Q
What Grading System may be used to objectively measure OA on XR.
Outline the grades.
A
Kellgren-Lawrence Grading System
Grade 0 = no OA
Grade 1 = doubtful JSN and possible OPs
Grade 2 = OPs and possible JSN
Grade 3 = multiple OPs, definite JSN, cystic areas with sclerotic walls and possible bony contour deformity
Grade 4 = large OPs, multiple sclerotic areas and deformity of bone contour
11
Q
A XR-knee shows definite JSN loss and multiple OPs, what grade of KL is this?
A
Grade 3
12
Q
An XR-Hip shows doubtful JSN but some possible osteophytes. What KL grade is this?
A
Grade 1
13
Q
An XR-Knee shows definite osteophytes and possible JSN, it is unclear. What KL grade is this?
A
Grade 2
14
Q
An XR-Hip shows multiple large osteophytes, definite JSN and severe sclerosis.
What KL Grade is this?
A
Grade 4
15
Q
How do you manage patient with OA?
A
Supportive: education/ weight loss/ self-management/ exercise
Medical: analgesia (paracetamol/diclofenac/tramadol/co-codamol); Methylprednisolone IA
Surgery: Total knee arthroplasty
16
Q
Describe septic arthritis?
A
Infection of ≥ 1 joints caused by a pathogen either through direct inoculation or via haematogenous spread which is characterised by joint pain, fever and potential haemodynamic instability
17
Q
State 3 pathogens that may cause Septic Arthritis.
A
- S. aureus
- N. gonorrhoea
- N. meningitidis
- M. tuberculosis
18
Q
State 3 RFs for Septic Arthritis.
A
- Pre-existing joint disease – RA/OA
- Prosthetic joint
- IVDU
- Immunosuppressed
- Diabetes mellitus
- PMHx of IA corticosteroid injections/surgery
19
Q
What investigations would confirm a suspected case of septic arthritis?
A
• Arthrocentesis + Gram stain + White cell count: Pathogen present; Urate or pyrophosphate crystals may be present; Normal (≤ 3000 WCC/mm3)/ Inflammatory fluid (> 3000WCC/mm3)/ Septic fluid (up to 75 000 WCC/mm3)
-> Send to lab for urgent processing; Act on clinical suspicion at the time
• FBC: Leukocytosis perhaps
• CRP: Elevated
• Swab + Culture (Urethra/Cervix/Anorectum): Positive for gonococcal infection
20
Q
How would you manage a patient with septic arthritis of a native joint?
A
• ABX: Ceftriaxone (Meningococcal)/ Ceftriaxone + Azithromycin (Gonococcal)/ ∑ Rifampicin + Isoniazid + Pyrazinamide + Ethambutol (TB)/ Vancomycin (Gram Positive)
±
• Surgery: Joint aspiration
±
• Analgesia: Paracetamol/ Ibuprofen/ Diclofenac
21
Q
How do you manage a case of septic arthritis in a prosthetic joint without systemic involvement?
A
ABX
+
• Surgery: Arthrocentesis/Joint replacement
±
• Analgesia: Paracetamol/ Ibuprofen/ Diclofenac
22
Q
Describe osteomyelitis.
A
Infection of the bone caused by pathogen (commonly Staphylococcus spp.) transmitted by hematogenous spread or direct inoculation involving a single bone
23
Q
How may osteomyelitis present?
A
- Pain: at site of infection
- Fever
- Malaise
- Fatigue
- Inflammation
- Erythema
- Reduced range of movement
24
Q
What would an XR of a bone with osteomyelitis show?
A
• XR: Osteopenia; Bone destruction; Periosteal reaction; Cavities; Involucrum (thick sheath of periosteal bone surrounding sequestrum); Sequestrum (necrotic bone fragment); Cloacae (opening of involucrum)
25
What is the involucrum in osteomyelitis?
Periosteal thickened sheath of bone surrounding sequestrum
26
What is the sequestrum in osteomyelitis?
Necrotic bone fragment
27
What is the cloacae in osteomyelitis?
Opening of the involucrum - the thick sheath of periosteal bone
28
How would you manage osteomyelitis?
• Supportive: Analgesia/ Immobilisation/ Mobilisation/ Specialist referral
+
• ABX: Vancomycin; Pip/Taz
29
What is a soft tissue sarcoma?
Umbrella term for solid tumour of connective tissue (mesenchymal) which presents as soft-tissue swelling and diagnosed upon biopsy. Two main categories are sarcoma of bone or sarcoma of soft tissues.
30
What are the clinical features of a soft tissue sarcoma?
- Mass: no pain
- Weight loss
- Fatigue
- Anorexia
- Other Sx related to System affected: GI bleed; Rash; Acute abdomen
31
How may you manage a soft tissue sarcoma?
- MDT Referral: Surgical excision + radiotherapy + chemotherapy
32
What is an Ewing Sarcoma?
malignant bone tumour from neuroectodermal cells often present in the diaphyses of long bones and the pelvis present in young adults
33
Outline the clinical features of Ewing Sarcoma.
- Diaphyses of long bones and pelvis
- B symptoms
- Pain
- Hyperthermia
- Swelling after trauma (presents following trauma)
- In M and young adults
34
How may you manage an Ewing Sarcoma?
```
- Surgery: Resection
+
- Chemotherapy
+
- Radiotherapy
```
35
Describe what an Osteosarcoma is?
malignant, osteoid tumour from mesenchymal stem cells (Obs) in periosteum commonly in the metaphyses of long bones (femur and tibia) of young adults with progressive swelling and pain limiting ROM and gait
36
What is the term for the radiological feature showing a periosteal damage which lifts off the periosteum without replacement, leaving a triangular gap?
What bone cancer is this seen in?
Codman Triangle
Osteosarcoma
37
How do you manage Osteosarcoma?
- Surgery: Resection
+
- Chemotherapy
38
What is a chondrosarcoma?
malignant tumour arising from mesenchymal cells producing cartilage
39
What is the benign precursor to a chondrosarcoma?
Osteochondroma
40
How may a Chondrosarcoma present?
- Deep, dull pain
- Localised swelling
- Pathological fractures
- NV disturbance
- In 50+ y/o
41
What are the key radiological findings shown in a Chondrosarcoma.
Calcifications, Osteolysis, Endosteal scalloping
42
How do you manage a Chondrosarcoma?
```
- Surgery: Resection
+
- Chemotherapy
+
- Radiotherapy
```
43
Describe a Scoliosis.
A lateral curvature of the spine (and also a rotational deformity) which can be idiopathic or secondary to neuromuscular disease, tumour, skeletal dysplasia or infection. Painful scoliosis needs investigation (MRI for tumours, infections).
44
What are the clinical features of Scoliosis?
- Shoulder asymmetry
| - Asymmetry
45
What is the term for the angle used to quantify the curvature in the spine?
Cobb Angle
46
What is the threshold for spinal curvature to label a spine scoliotic?
Cobb angle > 10º
47
How do you manage Scoliosis?
Cobb angle ≤45º
- Supportive: Exercise; Physiotherapy
± (20º 45º)
- Surgery: Arthrodesis
48
What is a spondylolisthesis?
Slipping of one vertebra over another and usually occurs at L4/L5 and L5/S1. Associated with increased body weight or increased sporting activity.
49
How may a spondylolisthesis present?
* Lower back pain
* Radiculopathy
* Flat back- due to muscle spasm
50
How may a spondylolisthesis be managed?
* Minor- physio
| * Severe- stabilisation
51
What is mechanical back pain?
Recurrent relapsing and remitting back pain with no focal neurological symptoms, relieved by rest and in the absence of red flag symptoms
52
How may mechanical back pain be managed?
Supportive: simple analgesia; exercise; physiotherapy
Medical: Ibuprofen/Paracetamol; Co-codamol; Tramadol
Surgical: Spinal stabilisation; Decompression
53
What portion of the intervertebral disc is damaged in an acute disc tear?
Tear in AF with protruding NP
54
What augments the pain in an acute disc tear?
Movement
| Coughing
55
What effect will coughing have on the pain in an acute disc tear?
Worsens - raised intrathoracic pressure on disc
56
How may an acute disc tear be managed?
Analgesia and Physio
Surgery - stabilisation (discectomy and corpectomy with metallic cage, compressible or non-compressible)
57
What is Sciatica?
Disc material impinging on exiting spinal nerve root resulting in pain and altered motor/sensation in a dermatomal distribution
58
What clinical finds would be present if there is impingement at L3/L4 vertebral level?
L4 nerve affected
Pain down to the medial ankle (L4 dermatome)
Reduced quad power (extensor thigh compartment)
Reduced patellar tendon reflex
59
What clinical finds would be present if there is impingement at L4/L5 vertebral level?
L5 nerve affected
Pain affecting dorsum of foot and anterolateral leg.
Reduced power of EHL, EHL and TA (all supplied by deep peroneal nerve
60
What clinical finds would be present if there is impingement at L5/S1 vertebral level?
S1 nerve affected
Pain to the sole of the foot
Reduced plantarflexion and reduced ankle jerk tendon reflex
61
Which nerves does the Sciatic nerve give rise to?
Divides into:
Common fibular nerve
Sural nerve
Tibial nerve
62
Which nerves form the Sural Nerve?
Medial cutaneous branch of Tibial nerve and Lateral cutaneous branch from Common Peroneal Nerve
63
What is Bony Nerve Root Entrapment?
OA of facet joints leading to osteophyte formation hence impingement of exiting nerve roots
64
How is OA of facet joints managed?
Supportive - rest; exercise
Medical - analgesia
Surgery - decompression
65
Define spinal stenosis.
Reduced space within spinal canal which may compress multiple nerve roots
66
How may neurological claudication differ to vascular claudication?
Cause is neurological, not due to endothelial damage and subsequent atherosclerotic changes
Distance differs
Pain is burning
Pain is less severe walking up hill and bending forwards
Pedal pulses preserved
67
How may a spinal stenosis present?
* LBP: Neuropathic; insidious and duration; radiates down leg
* Claudication: neurogenic claudication; weakness in thighs; bend over to relieve; stooped posture;
* Leg weakness
68
How may spinal stenosis be treated?
* Physiotherapy
* Weight loss
* MRI evidence of stenosis may make patients candidates for
69
Define Cauda Equina syndrome.
Large central disc prolapse compressing all nerve roots of the cauda equina (below L2) resulting in altered perineal sensation, defeacation, urination and back pain
70
How may Cauda Equina present?
* Bilateral leg pain
* Paraesthesia or numbness- around sitting area and perineum
* Urinary retention
* Faecal incontinence and constipation
71
What investigation is required to diagnose Cauda Equina Syndrome?
• Urgent MRI to determine level of disc prolapse
72
How is Cauda Equina treated?
Surgical management - urgent discectomy
73
Define an Osteoporotic crush fracture.
With severe osteoporosis, spontaneous crush fractures of the vertebral body can occur
74
How may an Osteoporotic crush fracture be treated?
Conservative - analgesia and rest
Surgery - Vertebroplasty
75
Define Cervical Spondylosis.
This is a reduction in H20 content of the intervertebral discs leading to increased load on facet joints and accelerated OA.
76
Define Cervical Disc Prolapse.
erve root compression can cause shooting neuralgic pain in a dermatomal distribution with weakness and loss of reflexes. Typically involves the lower nerve root e.g. C5/C6 prolapse- C6 spinal nerve affected.
77
Give 3 conditions in which cervical spine instability may occur.
RA
Down Syndrome
Previous Injury
Chiari Malformation
Connective Tissue Diseases e.g. Ehler-Dahnloss Syndrome
78
What form of cervical spine instability may patients with Down Syndrome experience?
Atlanto-occipital instability - potential for subluxation
79
Define shoulder impingement.
This is when the tendons of the rotator cuff (predominantly supraspinous) are compressed in the sub acromial space.
80
State 3 causes of shoulder impingement.
Subacromial bursitis
AC OA
Hooked acromion rotator cuff tear
81
What are the clinical features of Shoulder Impingement?
* Painful arc between 60 and 120 degrees
* Pain radiates to deltoid and upper limb
* Tenderness may be felt below lateral edge of the acromion
* Hawkins kennedy test (Internal rotation of flexed shoulder) recreates the pain
82
How may you differentiate between shoulder impingement and a rotator cuff pathology?
Shoulder impingement may not be painful when movement is passive as the tendon is not engaged if muscle is not actively contracting
83
How may you manage a shoulder impingement?
* NSAIDs, analgesia and physio
* Subacromial steroid injection (up to three times)
* If it still doesn’t improve subarcomial decompression surgery is an option
84
Define a rotator cuff tear.
The tendons of the rotator cuff muscles (subscapularis, supraspinatous, infraspinatous and teres minor) can tear with minimal force. Classic Hx of sudden jerking motion in a patient >40 with subsequent pain and weakness. Tears can be partial or full thickness.
85
A jobe's test is used to ...
Test supraspinatus muscle
86
What does the painful arc test for?
Supraspinatus impingement
87
What does external rotation against resistance test for?
Infraspinatus and teres minor
88
The Gerber's lift-off test examines which muscle?
Subscapularis
89
The Scarf test examines the function of...
The AC Joint
90
What is the gold standard imaging to diagnose a rotator cuff tear?
MRI
or US if metal work in the body
91
How would you manage a rotator cuff injury?
Supportive: analgesia; physiotherapy
Medical: Steroid injection
Surgical: Subacromial decompression
92
# Define adhesive capsulitis?
Outline the 3 phases
Progressive pain and stiffness of the shoulder with global reduction in movement.
3 phases:
- Painful phase (2-9 mo)
- Frozen phase (4-12 mo)
- Thawing phase
93
How is frozen shoulder syndrome diagnosed?
Clinical diagnosis - potential XR-Shoulder to exclude any other pathology
94
How may adhesive capsulitis be managed?
Supportive: analgesia; physiotherapy; steroid injections
95
What is Acute Calcific Tendonitis?
Calcium deposition in a tendon causing acute onset severe shoulder pain which is exacerbated by activity
96
How may Acute Calcific Tendonitis be diagnosed?
XR-Shoulder - calcific area shown on superior aspect of greater tuberosity
97
How is acute calcific tendonitis managed?
Subacromial steroid injection
98
Define shoulder instability.
Shoulder disclocation/subluxation - often antero-inferiorly (90%)
99
What radiological sign is observed in a posterior shoulder dislocation?
Lightbulb sign
100
How may a shoulder subluxation be managed?
Analgesia
Reduction
Immobilise in a sling
If recurrent - surgery e.g. Bankart Repair
101
Define Tennis Elbow.
Lateral epicondylitis whereby the lateral epicondyle is inflamed due to RSI causing micro tears in the common extensor origin
102
How may Tennis Elbow present?
* Painful and tender lateral epicondyle
| * Pain on resisted middle finger and wrist extension
103
How is Tennis Elbow managed?
* Usually self limiting- period of rest from activities that exacerbate the pain
* Physio
* NSAIDs
* Steroid injections
* Brace use
104
What is Golfers Elbow?
RSI due to overuse causing micro tears in the common flexor origin at the median epicondyle
105
How is Golfers Elbow managed?
- Physio
| - NSAIDs
106
Define Carpal Tunnel Syndrome.
Median nerve compression when travelling through the wrist
The carpal tunnel is formed from the carpal bones and the flexor retinaculum. 10 structures pass through the carpal tunnel, four tendons of the flexor digitorum superficialis, four tendons of the flexor digitorum profundus, one tendon from the flexor pollicus longus and the median nerve. Any change in the carpal tunnel can cause compression of the median nerve.
107
State 3 causes of Carpal Tunnel Syndrome.
```
Pregnancy
RA
Wrist Fractures
Acromegaly
Neoplasm
Idiopathic
Diabetes
Oedema
Scar tissue
```
108
Outline the clinical features of carpal tunnel syndrome.
* Paraesthesia in the median nerve supplied area- the thumb, index and half of middle finger.
* Weakness of the thumb
* Muscle wasting of the thenar eminence.
* Tinels test- can reproduce symptoms by percussing over the median nerve.
* Phalens test- reproduce symptoms by holding the wrists hyperflexed
109
How may Carpal Tunnel Syndrome be managed?
* Non-operative- wrist splints at night to prevent flexion. Corticosteroid injection
* Carpal tunnel decompression- division of the transverse carpal ligament.
110
Define Cubital Tunnel Syndrome.
This is compression of the ulnar nerve at the medial epicondyle. Can be due to tightness in the Osbornes fascia or tightness in the intermuscular septum where the nerve passes through two heads of flexor carpi ulnaris
111
What is Osborne's Fascia?
Ligamentous tissue connecting Olecranon and Lateral Epicondyle - forming the cubital retinaculum
112
How may Cubital Tunnel Syndrome Present?
* Paraesthesia in the ulnar supplied areas- the little and ring finger plus half of the middle finger.
* Weakness of ulnar nerve supplied muscles
• Positive tinels test over cubital tunnel
113
What investigations may you order for Carpal Tunnel Syndrome?
```
FBC
TFTs
U+Es
Ca2+
HbA1c
```
Nerve conduction studies- slowed conduction
114
How may you manage Cubital Tunnel Syndrome?
Surgical decompression
115
Define Dupuytrens Contracture.
A proliferative connective tissue disease where the palmar fascia undergoes hyperplasia with normal fascial bands producing nodules and cords progressing to contractures at the MCP and PIP joints.
116
What cell type is responsible for Dupuytren's contracture?
Abnormal Collagen produced by myofibroblast cells
117
State 3 RFs for Dupuytrens Contracture.
FHx
Alcoholism
Diabetic
118
How may Dupuytren's contracture present?
* Puckered skin
* Palpable nodules
* Ring and little finger most commonly affected
* Half of cases are bilateral
119
How may Dupuytren's Contracture be managed?
* Mild contractures may be tolerated
* Surgery for contractures interfering with function. Fasciotomy- division of the cords. Fasciectomy- removal of diseased fascia.
120
Explain a trigger finger.
Tendonitis in a flexor tendon to a digit can result in nodular enlargement of the affected tendon- usually distal to a fascial pulley over the metacarpal neck (the A1 pulley). Movement of the finger produces a clicking sensation as the nodule catches then passes underneath the pulley, it cant go back to extension without help. Finger may lock in a flexed position. Most commonly affecting middle and ring finger.
121
Which fingers are most commonly affected in Trigger Finger?
Middle and Ring Finger
122
How may Trigger Finger be treated?
* Steroid injection around the tendon within the sheath
| * Surgery in recurrent and persistent cases
123
Define a Ganglion cyst.
These are common mucinous filled cysts found adjacent to a tendon or synovial joint
124
What are the clinical features of a ganglion cyst?
Firm, smooth and rubbery
Transilluminates
Not painful
125
How may a Ganglion Cyst be managed?
Needle aspiration
Surgical excision
126
Where may a Giant Cell Tumour of the Tendon Sheath be found?
What colour are they and why?
In the palmar surface of the hand.
Containing MGCs and heamosidirin gives them a brown appearance
127
What two questions must you always ask in a history?
Locking - functional locking or mechanical locking
Giving way
128
Rupture of which meniscus is more common and why?
Medial > Lateral due to Medial being more fixed and less mobile
129
What is the usual MOA of a meniscus injury?
Twisting injury on a planted foot
130
What are the clinical features of a meniscal injury?
* Pain localising to the medial or lateral compartment
* Joint effusion and swelling occurring a day or so after
* Locking and mechanical symptoms
131
How may you clinically suspect a meniscal tear?
McMurray test
132
What is the gold standard imaging test for a meniscal injury?
MRI
133
How may you manage meniscal injury?
Supportive: physio; analgesia; movement
Surgical: Repair; Partial meniscectomy
134
Define ACL rupture.
The anterior cruciate ligament runs from the medial anterior tibia to the lateral posterior femoral condyle. It prevents the femur from sliding posteriorly on the tibia (or the tibia sliding anteriorly on the femur).
135
Where does the ACL originate and insert?
posteromedial corner of lateral femoral condyle to the anterior intercondyloid eminence of the tibia
136
What is the function of the ACL?
Prevent anterior tibial translocation
137
Which MOA may cause an ACL rupture?
MOA- high impact twisting injury (e.g. turning the upper body on a planted foot)
Valgus moment at knee and adduction moment at hip upon landing
138
What are the clinical features of an ACL rupture?
* Audible pop
* Haemarthrosis (seen clinically as swelling)
* Deep knee pain
* Rotational instability
• Positive anterior draw test- trying to pull the tibia forward when the knee is flexed and planted. Positive if there is excessive anterior translation.
139
What is the gold standard imaging for an ACL rupture?
MRI
140
How may an ACL rupture be managed?
* Non-operative techniques for those with poor demand e.g. those not involved in sports
* Arthroscopic anterior cruciate repair with hamstring or patellar tendon graft- symptomatic knee instability. Professional sportsmen.
141
Which triad is commonly affected during a high-velocity pivot/ high-velocity lateral blow (valgus moment) of the knee?
ACL
MCL
Medial meniscus
142
What is the blood supply of the ACL?
Middle Geniculate Artery
143
What is the innervation of the ACL?
Posterior articular nerve (branch of Tibial nerve)
144
What fracture is pathognomonic of an ACL injury?
Segond Fracture - avulsion fracture of the proximal lateral tibia
145
What is the management for an ACL injury?
Non-operative: physio; lifestyle modifications
Operative: ACL repair
146
Define a PCL rupture.
High velocity/force causing posterior tibial translation when the knee is flexed resulting in tearing of the fibres
147
What is the origin and insertion of the PCL?
Anterolateral aspect of medial femoral condyle to posterior aspect of medial tibia plateau
148
Outline the clinical features of a PCL injury?
* Knee pain
* Swelling- can range from mild to severe
* Instability
149
How may you manage a PCL injury?
* Isolated PCL rupture is only repaired if there is severe laxity or recurrent instability with frequent hyperextension or feeling unstable going down stairs
* PCL construction is usually performed if there is multiple ligamentous injury.
150
What is the MOA of a MCL injury?
Excessive valgus stress on the knee
151
Clinical features of a MCL injury?
* Laxity
* Pain on valgus stress
* Tenderness over insertion of the MCL
152
Management of an MCL injury?
* Acute tears are treated with hinged knee braces
| * Chronic instability can be treated operatively with MCL tightening or reconstruction
153
How may you grade an MCL injury?
Grade 1 = minor sprain, high signal seen medial to ligament
Grade 2 = high signal medial to ligament and at ligament with slight tear
Grade 3 = complete disruption of the ligament
154
What is the origin and insertion of the MCL?
Medial aspect of distal femur to medial aspect of distal tibia
155
What is the origin and insertion of the LCL?
Lateral femoral condyle to fibular head
156
What are the clinical finds of a LCL tear?
* Marked instability on rotational movements
* Can have common peroneal nerve injury presenting with foot drop
* Vascular injury also common- affecting popliteal artery intimal
157
How may an LCL injury be managed?
Non-operative: physio; analgesia
Operative: reconstruction
158
Define an osteochondral lesion.
These are bony or cartilaginous injuries that can occur after direct blows to the knee or impaction of the articular surfaces. Any ongoing knee pain and effusion warrants further investigation.
159
How may you investigate a potential osteochondral lesion?
* X-ray
* MRI
* Arthroscopy
160
How may you manage an Osteochondral lesion?
Non-operative: Rest; NSAIDs; Physiotherapy; Exercise; Weight reduction
Operative: Surgery
- Debridement
- Mosaicplasty
- Chrondroplasty
- Microfracture
4cm is the threshold for debridement/microfracture/mosaicplasty vs MACI/ACI
161
What classification system may be used for an osteochondral lesion?
What components does it involve?
Outerbridge Scoring System
Grade 0 = normal
Grade 1 = softening and swelling (via probe)
Grade 2 = Partial thickness defect (<1.5cm)
Grade 3 = deep fissures of subchondral bone (>1.5cm diameter)
Grade 4 = exposed subchondral bone
162
What are the clinical features of an extensor mechanism rupture?
* Inability to straight leg raise
* Palpable gap in extensor tendon
* X-rays will show patellar shift. If the patellar is high a patellar tendon rupture has occurred, if low a quadriceps tendon rupture has occurred.
* Ultrasound can determine extent of partial tears
163
What investigations may you order in an extensor mechanism rupture? What will they show?
* X-rays will show patellar shift. If the patellar is high a patellar tendon rupture has occurred, if low a quadriceps tendon rupture has occurred.
* Ultrasound can determine extent of partial tears
164
How may you manage an extensor mechanism rupture?
• Surgical tendon-tendon repair
165
What are the clinical features of Patellofemoral Dysfunction?
* Anterior knee pain
* Worse on downhill
* Grinding or clicking sensation in the front of the knee
* Stiffness after prolonged sitting resulting in pseudolocking
166
How may you manage patellofemoral dysfunction?
* Physiotherapy aimed at rebalancing quads
| * Surgery is a last resort releasing the lateral retinaculum
167
Why is vastus medialis weakness a cause of patellofemoral dysfunction?
The pull of the quadriceps tendon pulls the patellar in a slight lateral direction. In some people excessive lateral forces produces anterior knee pain as the patella is compressed against the distal wall of the lateral femoral trochlear.
168
How may patellar instability be managed?
Treat with physio. If recurrently dislocates-need to reconstruct medial patellofemoral lig.
169
How is ankle OA managed?
Non-operative: NSAIDs; Analgesia; Exercise; Weight loss
Operative: Ankle arthroplasty; Arthrodesis
170
Describe a Hallux Valgus.
This is medial deviation of the MTP joint but lateral deviation of the toe itself. Aetiology is poorly understood however familial component.
171
What are the clinical features of a hallux valgus?
* May be painful due to joint malalignment or rubbing on shoes
* Ulceration and skin breakdown may occur from rubbing of toes
172
Define Hallux Rigidus.
This is OA of the first MTP joint.
173
How can Hallux Rigidus be managed?
* Conservative- A metal bar can be inserted into the sole of the shoe
* Surgical treatment- arthrodesis- fusion should alleviate pain with no motion (however little sacrifice as it doesn’t move much anyway
174
Define a Mortons Neuroma.
Swollen and irritated plantar (medial and lateral) nerves become swollen and inflamed, this is called a neuroma. Patients complain of burning pain and tingling radiaiting to the affected toes. More likely in women wearing high heels. Commonly found between the 3rd and 4th metatarsals.
175
What are the clinical features of a Mortons Neuroma?
Relief when removing shoes
Pain at the 3rd and 4th metatarsals (3rd webspace)
May be loss of sensation in the affected web space
Squeezing forefoot over MTPs may illicit pain
Mulder's test (squeezing metatarsals = click)
176
What imaging may you order for a suspected Morton's Neuroma?
US - hypoechoic mass parallel to metatarsal bones
XR - rule out pathology
MRI - rule out pathology
177
How do you manage a Morton's Neuroma?
Non-operative: wider shoes; steroid injection
Operative: neurectomy
178
What investigation may you order in a suspected metatarsal stress fracture?
* X-ray- may not show fracture until around 3 weeks as callus will grow.
* DEXA bone scan can be useful in diagnosis
179
How would you manage a metatarsal stress fracture?
• Prolonged rest for 6-12 weeks- rigid soled boot
180
How may Achilles Tendonopathy present?
Pain at the distal posterior leg; worse on activity; better on rest; tender on palpation
181
Which medications can increase the risk of Achilles tendon rupture?
Ciprofloxacin
Quinolones
Steroids
182
How do you manage Achilles Tendinopathy?
Treatment of tendonitis is rest, physio, use of heel raise to offload the tendon, splint or boot use. Usually self limiting
183
How may Achilles Rupture present?
* Sudden pain- like being kicked in the back of the leg
* Popping noise
* Difficulty weight bearing
* Weakness of plantarflexion
* Squeezing calf produces no plantarflexion
* Palpable gap
184
How would you manage Achilles Tendon Rupture?
* Non-operative has the same affects as operative at the 6 month period. Manage with serial plaster casts with foot in full equinous position (ankle plantarflexed- closes the gap).
* Surgical repair has lots of non-healing complications- suture repair. Need plaster cast for 8 weeks.
185
Describe plantar fasciitis.
Repetitive stress/overload condition of the foot. Pain with walking on the instep of the foot (the origin of the plantar fascia). Localised tenderness on palpation of the calcaneal tuberosity.
186
How may plantar fasciitis present?
Pain localised to calcaneal tuberosity (base of heel)
Worse when walking
Feels tight
187
How do you manage plantar fasciitis?
* Conservatively- rest, cushioning heel pads, Achilles and plantar fascia stretching exervises
* Corticosteroid injections may alleviate symptoms. Can take up to two years to resolve.
188
How do you manage Pes Cavus?
Treated with soft tissue release and tendon transfer.
189
How do you manage claw and hammer toes?
Management- can be painful so corn sleeves and support is conservative.
Surgical options include tenotomy (removal of overactive tendon), arthrodesis or amputation.
190
Outline the difference between a claw and hammer toe.
* Claw toe- hyperextension at MTP and hyperflexion at DIP
| * Hammer toe- hyperextension at MTP and hyperextension at DIP
191
Outline the process for interpreting an XR of bone.
- Details: Name, DOB; Date; Anatomical location and view (AP/PA/Lat)
- RPE: Rotation; Picture; Exposure
- Alignment and joint space
- Bone texture: density and trabeculae
- Cortices: Trace the cortex for lesion (location, shape, pieces, displacement)
- Soft tissue: ligament/cartilage; soft tissue
192
Outline the management of a fracture.
```
• Supportive: A-E assessment; admission; XR (2 planes); catastrophic haemorrhage management; Splintage; dressing + prophylactic ABX
+
• Analgesia: Morphine/ Entonox
+
• Definitive treatment:
If stable --> Cast/splint/traction
```
If unstable --> Surgical fixation
193
Outline the classification system for Paediatric Fractures at the Growth Plate.
Type 1 = transverse through physis – separating epiphysis and metaphysis
Type 2 = transverse through physis and metaphysis – separating triangular section of metaphysis
Type 3 = transverse fracture of physis and epiphysis
Type 4 = fracture through everything – metaphysis, physis and epiphysis
Type 5 = fracture characterised by impaction and disruption
```
Mnemonic: SALTeR
Straight across joint
Above joint
Lower
Through Everything
Rammed
```
194
What classification system is used to assess a patient's physiological status prior to surgery?
ASA
195
Outline the ASA classification.
- I = normal healthy patient
- II = Mild systemic disease
- III = Severe systemic disease
- IV = Severe systemic disease + threat to life
- V = Requires operation to survive
- VI – Brain-dead patient whose organs removed for donor purposes
196
How may you classify peripheral nerve injury?
Seddon Classification
197
What are the basic types of peripheral nerve injury?
1) Stretch related: traction force >>
2) Compression
3) Laceration
198
What are the two types of bone healing?
```
Primary: perfect opposition (0.1mm) and <2% strain; direct attempt by cortex to re-establish, without the formation of fracture callous.
Cutting cones (osteoclasts) cross fracture to generate cavities which are filled by Obs to re-establish osteon bridges and remodel into lamellar bone
```
Secondary: imperfect opposition and 2-10% strain resulting in injury, haemorrhage, inflammation and soft callus with mineralisation and remodelling
199
Outline the stages of secondary bone healing.
Injury: Traumatic fracture
Inflammation: haematoma forms, flooding with HSCs. HSCs secrete GFs; Macrophages, neutrophils and platelets secrete PDGF, TNF-a, TGF-ß, IL-1,6,10 and 12
Fibroblasts and mesenchymal cells migrate to fracture site
Repair: Primary callous forms within 2 weeks; mechanical environment drives differentiation with stable environment yielding osteoblastic lineage of cells. Endochondral ossification converts soft callus to hard callus of woven bone. Transition from type II (cartilage) collagen to type I (bone) collagen
Remodelling: chondrocytes undergo terminal differentiation via Ihh, PTHrP, FGF and BMP with type X collagen expressed by hypertrophic chondrocytes. Proteases degrade ECM and cartilaginous calcification occurs at junction between maturing chondrocytes - expression of TGF-ß, IGF, collagen I, V and XI.
Chondrocytes become apoptotic and VEGF production results in angiogenesis.
Newly formed bone remodelled via organised osteoblastic/osteoclastic activity
Bone is shaped through Wolff's law and Piezoelectric charges (tension = electropositive with osteoclasts cf compression = electronegative with osteoblasts)
200
How may variables influencing fracture healing be categorised? Give 2 examples of each.
Internal vs External
Internal:
- Blood supply
- Head injury
- Mechanical factors: stability; location; degree of loss; pattern
External:
- LIPUS (accelerates fracture healing and increases callus strength)
- Bone stimulators
- COX2
- Radiation
- Smoking
- Diabetes mellitus
- HIV (TNF-a deficiency, poor intraosseous circulation, poor nutritional intake)
- NSAIDs
- Quinolones (chondrotoxic)
201
What mode of bone healing does a compression plate encourage?
Compression plate
202
What is a nonunion fracture?
Failure to heal by 6 months
203
What are the types of non-union fracture?
Septic
Hypertrophic (abundant callous without bridging bone)
Atrophic nonunion (inadequate immobilisation and blood supply)
Oligotrophic nonunion (inadequate reduction with fracture fragment displacement)
204
What is the term for a fracture caused by a ruptured ACL?
Describe this type of fracture.
Segund fracture
Avulsion fracture of the proximal lateral tibia
205
What classification system is used in Chondral Lesions?
Outerbridge Classification
206
What classification system can be used to grade severity of hip OA.
Kellgren-Lawrence Scale
Grade 0 = normal
Grade 1 = possible JSN and subtle osteophytes
Grade 2 = definite JSN and defined osteophytes
Grade 3 = marked JSN, multiple small osteophytes, some sclerosis and subchondral bone cysts
Grade 4 = gross JSN, large osteophytes and increased deformity of femoral head and acetabulum
207
What is the MOA of a steroid injection indicated in OA?
Steroid (e.g. Triamcinolone) reduces COX and LOX to prevent biosynthesis of PGEs and leukotrienes thus anti-inflammatory effects.
Steroids inhibit macrophage and leukocyte migration site by reducing dilation and permeability thus reduced oedema, erythema and pruritus
Inhibits NF-kappa-S to reduce cytokine production of IL-6, IL-8, MCP-1 and COX-2.
208
What ASA classification is a healthy patient?
ASA 1
209
What ASA classification is a patient with moderate systemic disease that is well-controlled?
ASA 2
210
What ASA classification is a patient with severe disease limiting activity?
ASA 3
211
What ASA classification is a patient who is brain-dead?
ASA 6
212
What classification is a patient who has severe disease that threatens their life?
ASA 4
213
What ASA classification is a patient who requires the operation urgently, unable to survive 24 hours without an operation?
ASA 5
214
What is a Femoroacetabular Impingement?
extra bone grows along one or both of the bones that form the hip joint — giving the bones an irregular shape
215
What are the types of Femoroacetabular Impingement?
3 types: Pincer, CAM and Combined
Pincer: extra bone extends out over rim of acetabulum which may crush acetabulum
Cam: femoral head is not round, unable to rotate smoothly within the acetabulum which grinds cartilage inside the acetabulum.
Combined: Pincer and CAM deformity present
216
What are the guidelines regarding diagnosis of OA?
Clinical diagnosis may be made if patient is >45 years old, has typical pain and has no morning stiffness >30 minutes
217
How is OA managed?
Conservative: patient education; weight loss; physiotherapy; OT; orthotics; topical capsaicin
+
Medical: Oral Analgesia; Opiates; IA injections
±
Surgery: TO; HA; TKR
218
What are the potential adverse effects of NSAIDs?
Peptic ulcers
Gastritis
AKI
Worsening CKD
HTN
HF
MI
Stroke
Exacerbate asthma
219
What is the average life span of a replaced joint?
10-15 years
220
Outline a Total Hip Replacement.
Usually, a lateral incision over the outer aspect of the hip is used. The hip joint is dislocated (separated) to give access to both articular surfaces.
The head of the femur is removed. A metal or ceramic replacement head of femur, on a metal stem, is used to replace it. The stem can either be cemented into the shaft of the femur or carefully pushed into the shaft to make a tight enough fit to hold it securely in place. Uncemented stems have a rough surface that holds them tightly in place.
The acetabulum (socket) of the pelvis is hollowed out and replaced by a metal socket, which is cemented or screwed into place. A spacer is used between the new head and socket to complete the new artificial joint.
221
Outline the process of a Total Knee Replacement.
Usually, a vertical, anterior incision is made down the front of the knee. The patella is rotated out of the way to allow access to the knee joint.
The articular surfaces (the cartilage and some of the bone) of the femur and tibia are removed. A new metal surface replaces these. They can be either cemented or pushed tightly into place.
A spacer is added between the new articular surfaces of the femur and tibia to complete the new artificial joint.
222
Outline a total shoulder replacement.
Usually, an anterior incision is made down the front of the shoulder, along the deltoid. The shoulder joint is dislocated (separated) to give access to both articular surfaces.
The head of the humerus is removed and replaced with a metal or ceramic ball. This replacement head is attached to the humerus either by a metal stem or screws (stemless).
The glenoid (socket) is hollowed out and replaced by a metal socket. This completes the artificial shoulder joint.
223
Describe a Reverse Total Shoulder Replacement.
A reverse total shoulder replacement involves adding a sphere in place of the glenoid (socket) and a spacer with a cup to replace the head of the humerus. This reverses the normal ball-in-cup structure of the shoulder joint, but the joint function remains the same.
224
How long is the post-operative VTE prophylaxis for an elective hip replacement?
28 days
225
How long is the post-operative VTE prophylaxis for an elective knee replacement?
14 days
226
what percentage of prosthetic joints become infected?
1%
227
What is the most common pathogen to cause a prosthetic joint infection?
S aureus
228
How can you describe a fracture?
1) Describe the radiograph
2) Type of fracture (complete vs Incomplete vs Salter-Harris)
- Transverse
- Oblique
- Spiral
- Comminuted
- Bowing
- Buckle
- Greenstick
3) Site: Anatomical location and part of bone or bony Location
- Diaphysis
- Metaphysis
- Epiphysis
```
4) Is it displaced?
Angulation (axis of bone altered)
Translation (fractured bones move away)
Rotation (rotated on its axis)
Impaction
```
5) Joint involvement
229
A fracture to the distal radius resulting in dorsal angulation is termed?
What is the most common MOI for this?
Colle's Fracture - dinner fork deformity following FOOSH
230
A fracture of the distal radius resulting in volar displacement is termed?
What is the commonest MOI?
Smith's Fracture
231
A fracture which is involving the intra-articular surface of the distal radius is called?
Barton Fracture
232
What investigation would you wish to conduct in a suspected wrist fracture?
Wrist radiograph - PA and lateral (always 2 views)
233
How do you manage a non-displaced radius fracture?
Goal is to restore normal anatomical alignment, encouraging healing and preserved functionality
Tx depends on site, type and features of fracture
Acute:
- Analgesia
Non-displaced
Supportive: Analgesia; Immobilisation (splint/cast); Elevation using broad-arm sling; check for compartment syndrome; check for safeguarding
±
Immobilisation: Below-wrist cast (4-6wks) with 3 point fixation
--> Soft cast for Greenstick fractures
234
How do you manage a closed displaced radius fracture?
Supportive: Analgesia; Closed reduction + immobilisation (below elbow cast 4-6 weeks); check for compartment syndrome; review fracture within 72 hours (if IA) or 7 days if (EA)
235
How do you manage an open displaced fracture of the radius?
```
Supportive: Analgesia; Consider tetanus status; re-align and splint limb (A+E); check for compartment syndrome
+
Medical: Co-amoxiclav
+
Surgery: ORIF (0/12/24 rule)
```
operate immediately if contaminated
Open in 12 hours if high velocity injury and non-contaminated
Open in 24 hours for all other open displaced fractures
236
What are the complications of a distal radial fracture?
Neuropathy: median or ulnar nerve
Extensor pollicis longus/ flexor pollicis longus rupture
Compartment syndrome
```
OA
Non-union
Complex regional pain syndrome
Metal work infection
Metal work irritation
```
237
What classification system can be sued to describe lateral malleolus fractures?
Outline it
Weber classification - describes fracture in relation to the distal syndesmosis between tibia and fibula (tibiofibular syndesmosis)
A = below the ankle joint, syndesmosis in tact
B = level of ankle joint; synsesmosis intact or partially torn
C = above the ankle joint, syndesmosis disrupted
238
Which ligaments make up the deltoid ligament of the ankle?
Consists of superficial and deep part
Superficial portion:
Tibionavicular
Tibiocalcaneal
Superficial posterior tibiotalar ligament
Deep:
Anterior tibiotalar
Deep posterior tibiotalar ligament
239
What makes up the lateral collateral ligament?
ATFL
Calcaneofibular ligament
PTFL
240
What MOI tends to cause a weber type B ankle fracture?
Eversion ankle - can cause medial malleolus or deltoid ligament fracture - unstable
241
What MOI tends to cause a weber type A ankle fracture?
Inversion
242
What is a Maisonneuve fracture?
Sometimes considered a high Weber C, should not be missed! On occasion the energy from an ankle injury will pass through the ankle and syndesmosis and exit at the proximal fibula. This implies the energy has ruptured the syndesmosis resulting in an unstable ankle.
Always check for knee / proximal fibula pain. It may also be suspected after seeing widening of the mortise without obvious fracture on ankle views.
243
Which rules are used to help determine whether or not an ankle injury requires radiographic assessment?
Outline them
Ottawa ankle rules
Bony tenderness at lateral malleolus
Bony tenderness at medial malleolus
Inability to weight bear
244
What views should you order in an ankle injury?
AP, mortise and lateral
245
Why do you order a mortise view?
Evaluate talar shift (widening of medial clear space) - suggests instability with damage to syndesmosis
246
How is a Weber A fracture managed?
Supportive: Analgesia; RICE; Fx clinic FU; immobilisation with moon boot
247
How are Weber B and C fractures managed?
Supportive: Analgesia; reduce and cast (knee below backstab); VTE prophylaxis
± Instability
Surgery: ORIF
248
What are the most common cancers that metastasise to the bone?
```
Prostate
Breast
Liver
Thyroid
Kidney
Lung
```
249
What is a pathological fracture?
Fracture of bone secondary to underlying disease, in the absence of trauma
250
48 hours after a fracture, a patient presents with shortness of breath, a petechial rash and some confusion. They have a fever and their heart rate is elevated.
What are your potential differentials?
Sepsis
Fat embolism syndrome (use Gurd's major criteria)
251
Outline the blood supply to the femoral head.
Foveal artery (epiphysis supply in embryological development) -> ligamentum teres
Retinacular vessels - lateral and medial circumflex arteries
252
How do you classify a hip fracture?
Intra-articular or extra-articular relative to the inter-trochanteric line
253
How can you classify an intra-capsular fracture of the Hip?
Outline them
Garden's Classification
Type 1 = incomplete, impacted in valgus
Type 2 = complete, undisplaced
Type 3 = complete, partially displaced
Type 4 = complete, completely displaced
254
State 5 RFs for a hip fracture.
```
Increasing age
OP
Steroids
Smoking
Pathological fractures
Excess alcohol
Low muscle mass
```
255
How can you categorise falls broadly?
Mechanical - slips and trips
Precipitated - MI, stroke, UTI etc etc
256
What lines can be used to assess the pelvis and hips on an AP XR-Pelvis?
Shenton's line = curved line along superior ramus
Hilgenreiner's line = straight line between triradiate cartilages (forming acetabulum)
Perkin's line = straight line perpendicular to Hilgenreiner's line at acetabulum
257
What is the surgical management of a subtrochanteric fracture?
Intermedullary nail
258
What is the surgical management of an intertrochanteric fracture?
DHS
259
What are the NICE guidelines regarding surgical management of a hip fracture?
Operate within 48 hours of fracture
260
What is the clinical presentation of Compartment Syndrome?
P – Pain “disproportionate” to the underlying injury, worsened by passive stretching of the muscles
P – Paresthesia
P – Pale
P – Pressure (high)
P – Paralysis (a late and worrying feature)
Note: Pulseless is not a feature - differentiating it from ALI
261
What is the management of a Compartment Syndrome?
Surgical: Fasciotomy
262
What pathogen most commonly causes Osteomyelitis?
S aureus
263
What are the RFs for Osteomyelitis?
Open fractures
Orthopaedic operations, particularly with prosthetic joints
Diabetes, particularly with diabetic foot ulcers
Peripheral arterial disease
IV drug use
Immunosuppression
264
Which pathogen is more commonly associated with Osteomyelitis in IV drug uses?
P aeruginosa
265
Which pathogen is more commonly associated with Osteomyelitis with Sickle Cell Anaemia?
Salmonella spp.
266
Which pathogen is more commonly associated with Osteomyelitis with ulcers?
Polymicrobial
267
What radiographic features may you see in Osteomyelitis?
Sequestrum: dead piece of bone separated due to necrosis from surrounding bone
Involucrum: new growth of periosteal bone
Cloaca: opening in involucres allowing internal necrotic bone and pus to discharge out
268
How do you manage an Osteomyelitis?
A-E; Stabilisation
+
Medical: Co-amoxiclav; Ceftriaxone + Vancomycin
± Surgery (abscess/neuro deficit/failed ABX)
- Debridement
269
What are the red flags of back pain?
<40
Morning stiffness
Fever
Weight loss
Night sweats
Saddle anaesthesia
Urinary urinary retention
Incontinence
Bilateral neuro signs
Bony tenderness
270
What are the nerve roots of the Sciatic Nerve?
L4-S3
271
What are the main causes of sciatica?
```
Herniated disc
Facet joint hypertrophy
OA
Spondylolisthesis
Spinal stenosis
```
272
What are the main cancers that metastasise to bone?
```
Thyroid
Lung
Kidney
Breast
Prostate
```
273
What is the medical management for chronic sciatica?
Amitryptiline
or
Duloxetine
± epidural CSI
274
What are the red flags of Cauda Equina?
Saddle anaesthesia (loss of sensation in the perineum – around the genitals and anus)
Loss of sensation in the bladder and rectum (not knowing when they are full)
Urinary retention or incontinence
Faecal incontinence
Bilateral sciatica
Bilateral or severe motor weakness in the legs
Reduced anal tone on PR examination
275
What are the causes of Cauda Equina Syndrome?
Herniated disc (the most common cause)
Tumours, particularly metastasis
Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
Abscess (infection)
Trauma
276
What are the causes of spinal stenosis?
Congenital
Degenerative changes
Herniated discs
Thickening of posterior longitudinal ligament
Spinal fractures
Spondylolisthesis
Tumours
277
A 57 year old patient presents with leg weakness and leg pain every time they walk excessively. They have had lower back pain for the last 20 years.
They have a PMHx of Obesity; T2DM; Lap Cholecystectomy.
Their ABPI is normal.
What is your diagnosis?
Central spinal stenosis
278
What is the management of central spinal stenosis?
Supportive: exercise; weight loss; analgesia; physiotherapy
±
Surgery: Laminectomy
279
What type of neuropathy is Meralgia Paraesthetica?
Mononeuropathy of a sensory nerve
280
What are the nerve roots of the lateral femoral cutaneous nerve?
L1-L3
281
A 24 year old girl presents with a strange sensation of burning and numbness on the outer aspect of her thigh. She says she has experienced this for 3/52. The feeling is made worse by walking, improving when sat down.
There is no pain. She is generally well.
O/E no skin colour changes, tender to palpation; painful extension of the hip.
What is your diagnosis?
Meralgia paraesthetica
282
A 24 year old girl presents with a strange sensation of burning and numbness on the outer aspect of her thigh. She says she has experienced this for 3/52. The feeling is made worse by walking, improving when sat down.
There is no pain. She is generally well.
O/E no skin colour changes, tender to palpation; painful extension of the hip.
What is your management?
Supportive: Rest; Looser clothing; weight loss; Physiotherapy
+
Medical: Analgesia; CSI
±
Surgery: Decompression/Transection/Resection
283
A patient stands on their left leg whilst their right foot is lifted off the ground. The hip is seen to drop.
What sign is this?
Explain which muscle is affected.
Trendelenburg Sign
When standing, the contralateral gluteus medius stabilises the pelvis. Therefore when standing on the L leg, the L gluteus medius is weak, failing to stabilise the R pelvis
284
How long does it take to recover from trochanteric bursitis?
6-9 months
285
What clinical test is used to rule in or out a meniscal injury?
McMurray's Test - lay supine and flex knee with internal/external rotation whilst extending the leg at the knee.
Pain on internal rotation and varus deformity = lateral meniscus
Pain on external rotation and valgus deformity = medial meniscus
286
What rules may be used to decide if a patient needs a XR-Knee in an acute knee injury?
Age 55 <
Patella tenderness
Fibular head tenderness
Cannot flex knee to 90 degrees
Cannot weight bear
287
What is the management of a meniscal injury?
Supportive: RICE; NSAIDs; Physiotherapy
+
Surgery: Arthroscopy with repair or resection
288
Where do the ACL and PCL originate and insert?
Mnemonic: "LAMP"
ACL - lateral intercondylar area --> anterior intercondylar area of tibia
PCL - medial intercondylar area --> posterior intercondylar area of tibia
289
How is the ACL injured?
MOI is twisting
290
What is the MOI of PCL rupture?
Blunt trauma from posterior - e.g. car accident
291
What is the gold-standard to diagnose an ACL injury?
MRI-Knee
292
What type of fracture may be observed in an ACL rupture?
Segund fracture - avulsion fracture of tibial plateau
293
What type of fracture may be observed in an posterolateral ligamentous rupture?
Arcuate sign - avulsion fracture of proximal fibula
294
What is the name of the accessory ossicle found in the lateral head of gastrocnemius?
Fabella
295
Which ligaments make up the posterolateral ligamentous complex?
LCL
Arcuate Ligament
Popliteofemoral ligament
296
What is the management for a knee ligament injury?
Supportive: RICE; NSAIDs; Mobilisation
±
Surgery: Arthroscopic surgery grafting
297
What patient group is Osgood-Schlatter disease more common in?
10-15 years old
Males
Active
298
What is the pathophysiology of Osgood-Schlatter Disease?
The patella tendon inserts into the tibial tuberosity. In patients with Osgood-Schlatter disease, multiple minor avulsion fractures occur where the patella ligament pulls away tiny pieces of the bone. This leads to growth of the tibial tuberosity, causing a visible lump below the knee. Initially, this lump is tender due to inflammation. As the bone heals and inflammation settles, the lump becomes hard and non-tender.
299
What is the management of Osgood-Schlatter disease?
Supportive: RICE; limitation in activity; NSAIDs
300
What are the borders of the Popliteal fossa?
Semimembranosus + Semitendinosis
Biceps femoris
Medial + Lateral Gastrocnemius
301
What are Baker's Cysts associated with?
Degenerative changes in the knee
Meniscal tears (an important underlying cause)
Osteoarthritis
Knee injuries
Inflammatory arthritis (e.g., rheumatoid arthritis)
302
What is a Foucher's Sign?
Baker's cyst disappearing
The lump will get smaller or disappear when the knee is flexed to 45 degrees
303
A lump is found in the Popliteal fossa, what are your differentials?
```
DVT
Abscess
Baker's Cyst
Ganglion cyst
Lipoma
Tumour
```
304
What is the management for a Baker's Cyst?
Supportive: Reduce exacerbations; NSAIDs; Physiotherapy
±
Intervention: US-guided aspiration; CSI
305
State 3 RFs for Achille's Tendinopathy.
Sports that stress the Achilles (e.g., basketball, tennis and track athletics)
Inflammatory conditions (e.g., rheumatoid arthritis and ankylosing spondylitis)
Diabetes
Raised cholesterol
Fluoroquinolone antibiotics (e.g., ciprofloxacin and levofloxacin)
306
What test is clinical diagnostic of Achille's Tendinopathy?
Simmond's calf squeeze test
307
What imaging is used to visualise an Achille's Tendinopathy?
US
or
MRI
308
What is the management of Achille's Tendinopathy?
Supportive: RICE; weight loss; eccentric exercises; ESWT
±
Surgery: Removing nodules/adhesions
309
How may an Achille's Tendon rupture present?
MOI: force/snapping/pain
Dorsiflexed
Calor/Dolor/Pallor/Tumor
Palpable gap
Tenderness
Weakness in plantarflexion
Positive Simmonds' calf squeeze test
310
What imaging modality is used in a suspected Achille's Tendinopathy?
US-Achille's Tendon
311
How do you manage an Achille's Tendinopathy?
Supportive: RICE; Analgesia; moon boot (6-12 healing); physiotherapy
±
Surgery: Gastrocnemius recession; Debridement and Repair
312
A patient presents with gradual onset of pain at the heel. The pain is worse with pressure, better with rest.
It appears tender on palpation.
What is the diagnosis?
How would you manage this?
Plantar Fasciitis
Supportive: RICE; Analgesia; Physio
313
A patient presents with gradual onset of pain at the heel. The pain is worse with pressure, better with rest.
It appears tender on palpation. The entire plantar aspect of heel seems sore, worse when barefoot.
US-Foot shows reduced fat.
What is the diagnosis?
How would you manage this?
Fat pad atrophy
Supportive: RICE; weight loss; comfortable shoes
314
A 45 year old patient presents with a pain in their foot. The pain is between the 3rd and 4th metatarsal as they point towards it.
The pain is accompanied by a sensation of a lump in the shoe. They have a burning and numb feeling in the toes.
Squeezing the metatarsals elicits pain, as does deep pressure.
A click is felt when using two sites to force the metatarsals against the lesion.
What is your diagnosis?
What is the name of this sign for the audible click heard?
How do you manage this?
Morton's Neuroma
Mulder's Sign
Supportive: adapt activities; Analgesia; insoles; weight loss
±
Surgery: Excision
315
What joint is affected by a bunion?
MTP
316
What is the definitive treatment for a Hallux valgus?
Surgery: Bunienectomy
317
A fluid aspirat of the MTP joint shows needle shaped crystals which are negatively birefringent of polarised light.
What is your diagnosis?
How can you manage this?
Gout
```
Acute:
NSAIDs
or
Colchicine
or
Steroids
```
Chronic:
Allopurinol
/
Febuxostat
318
What are the phases of Adhesive Capsulitis?
Painful --> Stiff --> Thawing
319
Outline the pathophysiology of adhesive capsulitis.
In adhesive capsulitis, inflammation and fibrosis in the joint capsule lead to adhesions (scar tissue). The adhesions bind the capsule and cause it to tighten around the joint, restrict movement in the joint
320
What is the management for Adhesive Capsulitis?
Supportive: Analgesia; Exercise; IA-injections
321
Where do the rotator cuff muscles insert onto the humerus?
Mnemonic: SITS
Greater tubercle:
Supraspinatus: superior facet of greater tubercle
Infraspinatus: middle facet of greater tubercle
Teres minor: Inferior facet of the greater tubercle
Lesser tubercle: Subscapularis
322
What imaging modality can be used to diagnose a rotator cuff tear?
US-Shoulder
or
MRI-Shoulder
323
How do you manage a rotator cuff tear?
Supportive: RICE; Analgesia; Physiotherapy
±
Surgery: Arthroscopic rotator cuff repair
324
What is the most common type of GH dislocation?
Anterior (90%)
324
What is the most common type of GH dislocation?
Anterior (90%)
325
What is the MOI for a shoulder dislocation?
Humerus moves posteriorly when arm abducted and extended at shoulder
326
What is an anterior tear of the labrum called?
Bankart lesion
327
Following a shoulder dislocation, an XR-Shoulder shows a compression fracture of the posterolateral part of the humeral head.
What is this called?
Hill-Sachs lesion
328
What nerve palsy may occur following an anterior shoulder dislocation?
Axillary nerve damage
329
What imaging may you conduct in a shoulder anterior dislocation?
XR-Shoulder
MRI-Shoulder
Arthroscopy
330
How do you manage a shoulder dislocation?
Acute: Analgesia; Closed reduction; Post-reduction XR-Shoulder; broad arm sling
331
What surgical repair can be done to correct a Bankart lesion?
Latarhet procedure
332
What are the causes of olecranon bursitis?
RSI
Trauma
Inflammatory conditions
Infection
333
What investigation should be conducted in a suspected olecranon bursitis?
What may the different constituencies indicate?
Aspiration of fluid
Pus = infection
Straw-coloured = normal
Blood-stained = trauma or inflammation
Milky = gout/pseudogout
334
How do you manage an olecranon bursitis?
Supportive: RICE; Analgesia; Support; Aspiration; CSI
± Infection suspected
- ABX
335
Lateral epicondylitis is called?
Tennis elbow
336
Medial epicondylitis is called?
Golfer's elbow
337
How can you test clinically for lateral epicondylitis?
Cozen's test: elbow extended, make fist and pronate with radial deviation = pain = positive
338
How can you clinically test for Medial Epicondylitis?
Golfer's elbow test: elbow extender, forearm supinated and wrist extended
339
How do you manage a medial epicondylitis?
Supportive: RICE; Analgesia; Physio; Orthotics; CSI; ESWT
340
Which two tendons are affected in DeQuervain's Tenosyvitis?
APL tendon
| EPB tendon
341
What is the pathophysiology of DeQuervain's Tenosynovitis?
APL abducts thumb and wrist.
EPB extends the thumb but also abducts thumb and wrist.
Tendon sheaths can become inflamed due to RSI which cause swelling of tendon sheath, catching the extensor retinaculum
342
How can you clinically test for DeQuervain's Tenosynovitis?
Finkelstein's test: patient arm on table with wrist over edge, adduct wrist over edge = pain
Eichoff's test: patient makes fist then wrist adducted = pain
343
What is the management of DeQuervain's tenosynovitis?
Supportive: RICE; Analgesia; Physiotherapy; CSI
344
What is the pathophysiology of Trigger Finger?
Flexor tendons pass through sheaths along the lengths o the fingers but thickening of the sheath causes the tendon to catch when the finger is flexed and extended.
A1 pulley at the MCP joint most commonly affected
345
What is the management of a trigger finger?
Supportive: Rest; Analgesia; Splinting; CSI
±
Surgery: A1 pulley release
346
Outline the pathophysiology of Dupuytren's contracture.
Palmar fascia becomes thicker and tighter, developing nodules which pulls the fingers into flexure - causing a contracture
347
Give 5 RFs for Dupuytren's Contracture.
```
Age
FHx (AD inheritance)
Male
Manual labour
DM (1 > 2)
Epilepsy
Smoking
Alcohol
```
348
How can you clinically test for a Dupuytren's contracture?
table-top test is a straightforward test for Dupuytren’s contracture. The patient tries to position their hands flat on a table. If the hand cannot rest completely flat, the test is positive, indicating Dupuytren’s contracture
349
What is the management of a Dupuytren's Contracture?
Surgery: Needle fasciotomy; Limited fasciectomy; Dermofasciectomy
350
Which nerve is affected in Carpal Tunnel Syndrome?
Palmar digital cutaneous branch of median nerve
351
Give 5 RFs for Carpal Tunnel Syndrome.
```
Idiopathic
RSI
Diabetes
Pregnancy
Acromegaly
Hypothyroidism
Obesity
Perimenopause
Rheumatoid arthritis
```
352
How may you clinically test for Carpal Tunnel Syndrome?
Tinnel's test: Tap location of median nerve = numbness and paraesthesia
Phalen's Test: fully flex wrist and hold in position by putting backs of hands together = numbness and paraesthesia
353
What questionnaire may be used in the diagnosis of Carpal Tunnel Syndrome?
Kamath and Stothard questionnaire
- Symptoms at night
- Trick movements
- Little finger affected (less likely diagnosis)
354
What is the gold standard for diagnosis of CTS?
Nerve conduction studies - reduced electrical current/signal
355
How is CTS managed?
Supportive: Orthoses; Rest; CSI
±
Surgery: Carpal Tunnel Release
356
What are the clinical features of a ganglion?
Range in size from 0.5 to 5cm or more (most are 2cm or less)
Firm and non-tender on palpation
Well-circumscribed
Transilluminates (shining a torch into the cyst causes the whole lump to light up)
357
How are Ganglion cysts managed?
Supportive: Watch and wait (50% resolve spontaneously)
±
Intervention: Needle aspiration; Surgical excision
358
What is anaemia?
Reduced Hb concentration
359
What are the criteria for Anaemia?
State this for M, F and pregnant women.
360
Outline the knee Ottawa rules.
```
> 55 years old
Patella tenderness
Head of the fibula tenderness
Cannot flex knee 90 degrees
Cannot weight bear
```
361
How may you classify pelvic fractures?
Give the broad description.
Young-Burgess Classification of Pelvic Fracture
Split into three categories of Anterior Posterior Classification (APC), Lateral Compression (LC) and Vertical Shear (VS)
362
Outline the criteria in the Young-Burgess classification of pelvic fractures.
APC I: Symphysis > 2.5cm
APC II: Symphysis > 2.5cm; anterior SI diastasis; Posterior SI ligaments in tact; Disruption of SS and ST ligaments
APC III: SI dislocation; disruption of SS and ST ligaments
-> Related to vascular injury
LC I: Oblique or transverse ramus fracture + anterior sacral ala compression
LC II: Rami fracture + ipsilateral posterior ilium fracture dislocation
LC III: ipsilateral lateral compression and contralateral APC (windswept pelvis)
Vertical shear: Posterior and superior directed force
363
What are the cautions to consider in a haematoma block?
Do not inject an open fracture - require washout/debridement (I+D)
Do not use more than 15mL lidocaine - toxicity
Do not repeat injections - concern about compartment syndrome
364
What are the radiographic features of a Charcot joint?
Mnemonic: 5Ds
Density change (subchondral osteopenia or sclerosis)
Destruction (osseous fragmentation and resorption)
Debris (IA loose bodies)
Distension (joint effusion)
Disorganisation
Dislocation
365
What is the difference between Charcot Foot and Charcot-Marie-Tooth (CMT) disease?
Charcot Foot = charcot neuropathy due to impaired sensation (secondary to Diabetes), bones become weak and breakdown
CMT = inherited disorders of peripheral neuropathy with high arches and curled toes resulting in change shape due to atrophy.
```
Foot drop
Pes Cavus
Hammer toes
Distal muscle weakness
Distal muscle atrophy
Hyporeflexia
Stork leg deformity
```
366
A loss of vibration and proprioception indicates which of the following?
A. Dorsal column lesion
B. Spinothalamic tract lesion
C. Osteomyelitis
D. Infarction of spinal cord
A and D
367
Loss of pain, sensation and temperature is suggestive of what spinal disorder?
Spinothalamic tract lesion
368
In osteomyelitis of secondary to TB, what region of the spinal cord is affected?
Thoracic
369
What is Brown-Sequard syndrome?
Hemisection of the spinal cord
Ipsilateral paralysis and proprioception with loss of fine discrimination
Contralateral loss of pain and temperature
370
What myotome is involved in elbow flexion?
C5
371
What myotome is involved in elbow extension?
C7
372
What myotome is involved in wrist extension?
C6
373
What myotome is involved in finger flexion?
C8
374
What myotome is involved in finger abduction?
T1
375
What myotome is involved in hip flexion?
L1/L2
376
What myotome is involved in knee extension?
L3
377
Which myotome is involved in knee flexion?
L4
378
What myotome is involved in ankle dorsiflexion?
:4/:5
379
What myotome is involved in toe extension?
L5
380
What myotome is involved in plantarflexion?
S1
381
What are the two types of femoracetabular impingement?
Pincer lesion (acetabulum covers more of hip joint)
CAM lesion (loss of head sphericity at head-neck junction)
Mixed (combination of CAM and pincer)
382
State a hypothesis for the aetiology of Femoroacetabular impingement.
Critical development theory of the proximal femoral physics
10-14 boys
8-12 girls
Repetitive injury causes strain on the physio and subsequent deformity
383
What is the most common site of deformity in a CAM deformity?
Abnormal osseous prominence most significant anterior and lateral aspects of femoral neck
384
What is the pathophysiology of a CAM lesion?
Anterior and lateral aspects of the femoral neck tend to bear osseous prominence.
An irregularly shaped femoral head rotates within acetabulum during motion which contacts the anterosuperior aspect of the acetabulum resulting in delamination of the articular cartilage. Furthermore, the acetabular labrum is degenerated
Surgery
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