Orthopaedics

Question 1

Features of De Quervain’s tenosynovitis?

Answer 1

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.

• Pain on the radial side of the wrist
• Tenderness over the radial styloid process
• Abduction of the thumb against resistance is painful
• Finkelstein’s test: the examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction. In a patient with tenosynovitis this action causes pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus.

Question 2

Dx in burning sensation over the antero-lateral aspect of thigh?

Answer 2

Meralgia paraesthetica is a condition characterised by numbness, tingling and burning pain in the outer part of the thigh. It’s caused by compression of the lateral cutaneous nerve of the thigh (also called the lateral femoral cutaneous nerve) which supplies sensation to the skin’s surface on the upper thigh.

• Symptoms may be reproduced by deep palpation just below the ASIS (pelvic compression) and also by extension of the hip.
• There is altered sensation over the upper lateral aspect of the thigh.
• There is no motor weakness.

Question 3

McMurray’s test is used for?

Answer 3

Meniscal tears.

• Pain worse on straightening the knee
• Knee may ‘give way’
• Displaced meniscal tears may cause knee locking

Question 4

Features of Carpal Tunnel Syndrome?

Answer 4

• Pain/pins and needles in thumb, index, middle finger
• Patient shakes his hand to obtain relief, classically at night.
• Weakness of thumb abduction (abductor pollicis brevis).
• Wasting of thenar eminence (NOT hypothenar)
• Tinel’s sign: tapping causes paraesthesia
• Phalen’s sign: flexion of wrist causes symptoms

Question 5

Which finger commonly affected in Dupuytren’s contracture?

Answer 5

It is more common in older male patients and around 60-70% have a positive family history.

Specific causes include:
- manual labour
- Phenytoin treatment
- alcoholic liver disease
- diabetes mellitus
- trauma to the hand

• The ring finger and little finger are the fingers most commonly affected.

Question 6

Which nerve root for which reflex?

Answer 6

Buckle the shoe (ankle) (S1, S2)
Kick the door (Knee) (L3, L4)
Pick up sticks (Biceps) (C5, C6)
Lie them straight (triceps) (C7, C8)

Question 7

Features in Cubital Tunnel Syndrome?

Answer 7

Due to the compression of the ulnar nerve as it passes the cubital tunnel at the elbow.

• Initially intermittent tingling in the 4th and 5th finger
• May be worse when the elbow is resting on a firm surface or flexed for extended periods
• Later numbness in the 4th and 5th finger with associated weakness

Question 8

Features of lateral epicondylitis (tennis elbow)?

Answer 8

• Pain and tenderness localised to the lateral epicondyle.
• Pain worse on resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended.
• Episodes typically last between 6 months and 2 years. Patients tend to have acute pain for 6-12 weeks.

Question 9

Features of medial epicondylitis? (golfer’s elbow)

Answer 9

• Pain and tenderness localised to the medial epicondyle.
• Pain is aggravated by wrist flexion and pronation.
• Symptoms may be accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement

Question 10

Features of spinal stenosis?

Answer 10

Usually gradual onset.

Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down.

Relieved by sitting down, leaning forwards and crouching down

Clinical examination is often normal
Requires MRI to confirm diagnosis.

Lumbar spinal stenosis is a condition in which the central canal is narrowed by tumour, disk prolapse or other similar degenerative changes.

Patients may present with a combination of back pain, neuropathic pain and symptoms mimicking claudication. One of the main features that may help to differentiate it from true claudication in the history is the positional element to the pain. Sitting is better than standing and patients may find it easier to walk uphill rather than downhill.

Question 11

Ankle injury Ottawa Rules?

Answer 11

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.

Question 12

common cause of lateral knee pain in runners?

Answer 12

Iliotibial band syndrome.

Its an inflamed tendon running from your hip to the outside of your knee (laterally).

• Pain usually most severe where the tendon runs over lateral epicondyle of femur (any protrusion gives more friction and rub on the band).

Question 13

Non tender lump in popliteal fossa?

Answer 13

Baker’s cyst. They are more likely to develop in patients with arthritis or gout and following a minor trauma to the knee. Foucher’s sign describes the increase in tension of the Baker’s cyst on extension of the knee.

Question 14

Trigger finger most commonly affects which fingers?

Answer 14

• More common in the thumb, middle, or ring finger
• Initially stiffness and snapping (‘trigger’) when extending a flexed digit
• A nodule may be felt at the base of the affected finger

Question 15

Painful arc of abduction is seen in which condition?

Answer 15

Subacromial impingement often presents with a painful arc of abduction (classically causing pain between 60 to 120 degrees of abduction).

With rotator cuff tears the pain may be in the first 60 degrees!

Question 16

Fluctuant painful lump at elbow?

Answer 16

Olecranon bursitis describes inflammation of the olecranon bursa, the fluid-filled sac overlying the olecranon process at the proximal end of the ulna. . Inflammation may result from trauma, infection, or systemic conditions such as rheumatoid arthritis or gout. Olecranon bursitis is also known as ‘student’s elbow’ because the repetitive mild trauma of leaning on a desk using the elbows is a common cause.

• Swelling over the posterior aspect of the elbow, usually fluctuant and well-circumscribed, appearing over hours to days.
• Tenderness on palpation of the swollen area
• Redness and warmth of the overlying skin
• Fever
• Skin abrasion overlying the bursa
• Effusions in other joints if associated with rheumatoid arthritis
• Tophi if associated with gout

Question 17

Shortened, adducted and internally rotated leg?

Answer 17

Posterior dislocation of the hip.
In a posterior dislocation, the femoral head is now behind to the acetabulum, causing the leg to rotate internally to accommodate.

A reduction under general anaesthetic within 4 hours to reduce the risk of avascular necrosis.

Question 18

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

Answer 18

L3 Nerve root compression

Question 19

• Sensory loss anterior aspect of knee and medial malleolus
• Weak knee extension and hip adduction
• Reduced knee reflex

Answer 19

L4 Nerve root compression

Question 20

• Sensory loss dorsum of foot
• Weakness in foot and big toe Dorsiflexion
• Reflexes intact

Answer 20

L5 nerve root compression

Question 21

• Sensory loss posterolateral aspect of leg and lateral aspect of foot
• Weakness in plantar flexion of foot
• Reduced ankle reflex

Answer 21

S1 Nerve root compression

Question 22

Commonest cause of hip pain in children?

Answer 22

Transient synovitis (irritable hip)

Typical age group 2-10 years
Acute hip pain associated with viral infection

Question 23

Features of Perthes disease?

Answer 23

Perthes disease is a degenerative condition affecting the hip joints of children, typically between the ages of 4-8 years. It is due to avascular necrosis of the femoral head.

Perthes disease is 5 times more common in boys. Around 10% of cases are bilateral.

• Hip pain: develops progressively over a few weeks
• Limp
• Stiffness and reduced range of hip movement
  X-ray: early changes include widening of joint space, Later changes include decreased femoral head size/flattening

Question 24

Hip pain in obese children?

Answer 24

Slipped upper femoral epiphysis

Typical age group = 10-15 years

• More common in obese children and boys
  Displacement of the femoral head epiphysis postero-inferiorly.
  Bilateral slip in 20% of cases
• May present acutely following trauma or more commonly with chronic, persistent symptoms
• Knee or distal thigh pain is common
• Loss of internal rotation of the leg in flexion

Question 25

Imaging modality of choice for suspected Achilles tendon rupture?

Answer 25

Calf Ultrasound. Achilles tendon rupture should be suspected if the person describes the following whilst playing a sport or running; an audible 'pop' in the ankle, sudden onset significant pain in the calf or ankle or the inability to walk or continue the sport Patients with Achilles tendon rupture are unable to plantarflex the ankle. A positive Thompson's test is pathognomonic for Achilles tendon rupture; the patient lies prone and the calf muscle belly is squeezed. The test is positive if the squeezing of the calf does not cause plantarflexion of the calf.

Question 26

Housemaid's knee

Answer 26

Prepatellar bursitis Associated with more upright kneeling The prepatellar bursa lies anterior to the patella, and inflammation can be caused by excessive skin/patella friction, e.g. by working on one's knees.

Question 27

Clergyman's knee

Answer 27

Infrapatellar bursitis Associated with kneeling

Question 28

Pain in anatomical snuff box following a fall?

Answer 28

Scaphoid fracture. - Surface of scaphoid is covered by articular cartilage with small area available for blood vessels (fracture risks blood supply) - Risk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal 1/3) - The main physical signs are swelling and tenderness in the anatomical snuff box, and pain on wrist movements and on longitudinal compression of the thumb.

Question 29

Patellofemoral pain syndrome?

Answer 29

Patellofemoral pain syndrome is now the preferred term for chondromalacia patellae. Softening of the cartilage of the patella and worn with overuse, e.g. from athletics - causing pain anteriorly and medially over the knee joint. Common in teenage girls. Characteristically anterior knee pain on walking up and down stairs and rising from prolonged sitting.