1
Q
What are FRAX and QFracture scores?
A
- FRAX (fracture risk assessment tool) and QFracture scores estimate the liklihood of a fragility fracture (due to osteoporosis) within the next 10 years
- A FRAX score of 10% or greater warrants a DEXA scan
FRAX
- estimates the 10-year risk of fragility fracture
- valid for patients aged 40-90 years
- based on international data so use not limited to UK patients
- assesses the following factors: age, sex, weight, height, previous fracture, parental fracture, current smoking, glucocorticoids, rheumatoid arthritis, secondary osteoporosis, alcohol intake
- bone mineral density (BMD) is optional, but clearly improves the accuracy of the results. NICE recommend arranging a DEXA scan if FRAX (without BMD) shows an intermediate result
QFracture
- estimates the 10-year risk of fragility fracture
- developed in 2009 based on UK primary care dataset
can be used for patients aged 30-99 years (this is stated on the QFracture website, but other sources give a figure of 30-85 years)
- includes a larger group of risk factors e.g. cardiovascular disease, history of falls, chronic liver disease, rheumatoid arthritis, type 2 diabetes and tricyclic antidepressants
2
Q
Who should be assessed using the FRAX score? When should someone get a dexa scan?
A
All women aged >= 65 years and all men aged >= 75 years should be assessed. Younger patients should be assessed in the presence of risk factors, such as:
- previous fragility fracture
- current use or frequent recent use of oral or systemic glucocorticoid
- history of falls
- family history of hip fracture
- other causes of secondary osteoporosis
- low body mass index (BMI) (less than 18.5 kg/m²)
- smoking
- alcohol intake of more than 14 units per week for women and more than 14 units per week for men.
There are some situations where NICE recommend arranging BMD assessment (i.e. a DEXA scan) rather than using one of the clinical prediction tools:
- before starting treatments that may have a rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer).
- in people aged under 40 years who have a major risk factor, such as history of multiple fragility fracture, major osteoporotic fracture, or current or recent use of high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone or equivalent per day for 3 months or longer).
3
Q
What is a positive Froment’s sign?
A
Patient cannot grip paper placed between thumb and index finger. There is weakness of the adductor pollicus innervated by the ulnar nerve which would keep the IP joint relatively straight; instead, the FPL muscle which is innervated by the median nerve is substituted for the AP and will cause the IP joint to go into a hyperflexed position.
4
Q
Where is the ulnar nerve typically damaged?
A
elbow (cubital tunnel syndrome) or at the wrist (Guyons canal syndrome)
5
Q
Which nerve roots make up the tibial nerve?
A
L4-S3
6
Q
What is the function of the tibial nerve?
A
Sensory: Innervates the skin of the posterolateral side of the leg, lateral side of the foot, and the sole of the foot.In the popliteal fossa, the tibial nerve gives off cutaneous branches. These combine with branches from the common fibular nerve to form the sural nerve. This sensory nerve innervates the skin of the posterolateral side of the leg and the lateral side of the foot.
The tibial nerve also supplies all the sole of the foot via three branches:
- Medial calcaneal branches: These arise within the tarsal tunnel, and innervate the skin over the heel.
- Medial Plantar Nerve: Innervates the plantar surface of the medial three and a half digits, and the associated sole area.
- Lateral Plantar Nerve: Innervates the plantar surface of the lateral one and a half digits, and the associated sole area.
Motor: Innervates the posterior compartment of the leg:
Deep
- Popliteus – Laterally rotates the femur on the tibia to unlock the knee.
- Flexor Hallucis Longus – Flexes the big toe and plantar flexes the ankle.
- Flexor digitorum Longus – Flexes the other digits and plantar flexes the ankle.
- Tibialis Posterior – Inverts the foot and plantar flexes the ankle.
Superficial
- Plantaris – Plantar flexes the ankle.
- Soleus – Plantar flexes the ankle.
- Gastrocnemius – Plantar flexes the ankle and flexes the knee.
7
Q
What are the roots and functions of the obturator nerve?
A
Roots: L2, L3, L4.
Motor Functions: Innervates the muscles:
- obturator externus
- pectineus
- adductor longus
- adductor brevis
- adductor magnus
- gracilis
Sensory Functions: Innervates the skin over the medial thigh.
8
Q
What are the roots and functions of the femoral nerve?
A
Roots: L2, L3, L4.
Motor Functions: Innervates the muscles:
- Illiacus
- pectineus
- sartorius
- all the muscles of quadriceps femoris.
Sensory Functions: Innervates the skin on the anterior thigh and the medial leg.
9
Q
What are the branches of the sacral plexus?
A
A useful memory aid for the major branches of the sacral plexus is ‘Some Irish Sailor Pesters Polly’. This stands for:
- Superior Gluteal
- Inferior Gluteal
- Sciatic
- Posterior cutaneous nerve of thigh
- Pudendal
10
Q
What’s the course of the superior gluteal nerve? What are the roots, motor and sensory functions?
A
The superior gluteal nerve leaves the pelvis via the greater sciatic foramen, entering the gluteal region superiorly to the piriformis muscle. It is accompanied by the superior gluteal artery and vein for much of its course.
Roots: L4, L5, S1.
Motor Functions: Innervates the:
- gluteus minimus
- gluteus medius
- tensor fascia lata
Sensory Functions: None.
11
Q
What’s the course of the inferior gluteal nerve? What are the roots, motor and sensory functions?
A
The inferior gluteal nerve leaves the pelvis via the greater sciatic foramen, entering the gluteal region inferiorly to the piriformis muscle.
It is accompanied by the inferior gluteal artery and vein for much of its course.
Roots: L5, S1, S2.
Motor Functions: Innervates gluteus maximus.
Sensory Functions: None.
12
Q
What’s the course of the pudendal nerve? What are the roots, motor and sensory functions?
A
This nerve leaves the pelvis via the greater sciatic foramen, then re-enters via the lesser sciatic foramen. It moves anterosuperiorly along the lateral wall of the ischiorectal fossa, and terminates by dividing into several branches.
Roots: S2, S3, S4
Motor Functions: Innervates the skeletal muscles in the perineum, the external urethral sphincter, the external anal sphincter, levator ani.
Sensory Functions: Innervates the penis and the clitoris and most of the skin of the perineum.
(Tip – an easy way to remember the functions of the pudendal nerve is S2, S3, S4 keeps poo off the floor!)
13
Q
What are the roots, motor and sensory functions of the sciatic nerve?
A
Roots: L4, L5, S1, S2, S3
Motor Functions:
Tibial portion – Innervates the muscles in the posterior compartment of the thigh apart from the short head of the biceps femoris (biceps femoris, semimembranosus and semitendinosus), and the hamstring component of adductor magnus (remaining portion of which is supplied by the obturator nerve). Innervates all the muscles in the posterior compartment of the leg and sole of the foot.
Common fibular portion – Short head of biceps femoris, all muscles in the anterior and lateral compartments of the leg and extensor digitorum brevis.
Sensory Functions:
Tibial portion: Innervates the skin on the posterolateral and medial surfaces of the foot as well as the sole of the foot.
Common fibular portion: Innervates the skin on the anterolateral surface of the leg and the dorsal aspect of the foot.
14
Q
What are the sensory nerves of the sciatic nerve?
A
- Sural nerve (formed by branches of the common fibular and tibial nerves)- posterior/lateral lower leg and foot
- Deep fibular nerve (a branche of the common fibular nerve)- outer upper part of lower leg
- Superficial fibular nerve (a branch of the common fibular nerve)- lower lateral/anterior lower leg and dorsum of foot
- Medial calcaneal branches (branches of the tibial nerve)- back of heel
15
Q
What are the muscles within the foot and which nerves innervate them?
A
Dorsal aspect
- extensor digitorum brevis (deep fibular nerve)
- extensor hallucis brevis (deep fibular nerve)
Plantar side (medial plantar nerve or the lateral plantar nerve, which are both branches of the tibial nerve)
Layer 1 (most superficial)
- Abductor Hallucis (medial plantar nerve)
- Flexor Digitorum Brevis (medial plantar nerve)
- Abductor Digiti Minimi (lateral plantar nerve)
Layer 2
- Quadratus Plantae (lateral plantar nerve)
- Lumbricals ( most medial- medial plantar, lateral 3- lateral plantar)
Layer 3
- Flexor Hallucis Brevis (medial plantar)
- Adductor Hallucis (deep branch of lateral plantar)
- Flexor Digiti Minimi Brevis (superficial branch of lateral plantar)
Layer 4
- Plantar Interossei (lateral plantar nerve), unipennate
- Dorsal Interossei (lateral plantar nerve), bipennate
16
Q
What’s the medical name for club foot?
A
Talipes equinovarus
17
Q
Is talipes equinovarus more common in men or women? What’s the incidence? What’s it associated with?
A
- M:F 2:1
- 1 per 1,000 births. Around 50% of cases are bilateral.
Most commonly idiopathic. Associations include:
- spina bifida
- cerebral palsy
- Edward’s syndrome (trisomy 18)
- oligohydramnios
- arthrogryposis
18
Q
How do you diagnose and manage talipes equinovarus?
A
The diagnosis is clinical (the deformity is not passively correctable) and imaging is not normally needed.
Management
- in recent years there has been a move away from surgical intervention to more conservative methods such as the Ponseti method
- the Ponseti method consists of manipulation and progressive casting which starts soon after birth.
- The deformity is usually corrected after 6-10 weeks.
- An Achilles tenotomy is required in around 85% of cases but this can usually be done under local anaesthetic
- night-time braces should be applied until the child is aged 4 years.
- The relapse rate is 15%
19
Q
What is the pathophysiology of talipes equinovarus?
A
- contraction of achilles and tightness of skin and medial flexors.
- deformities:
CAVE
Cavus of midfoot
Adduction of forefoot
Varus of hindfoot
Equinus of hindfoot (plantarflexion)
20
Q
What is the most common cause of heel pain in an adult? Where is the pain worst?
A
Plantar fasciitis
The pain is usually worse around the medial calcaneal tuberosity.
21
Q
How do you manage plantar fasciitis?
A
- Plantar fasciitis is best managed initially with rest, stretching and weight loss if overweight
- wear shoes with good arch support and cushioned heels
- insoles and heel pads may be helpful
22
Q
What is trigger finger associated with?
A
Associations* (idiopathic in the majority)
- more common in women than men
- rheumatoid arthritis
- diabetes mellitus
*evidence for repetitive use is poor
23
Q
Which fingers is trigger finger most common in?
A
Thumb
Middle
Ring
24
Q
How do you treat trigger finger?
A
- immobilisation
- injection of steroid
- needling
- decompression
25
What are the featurs of meniscal tear and what imaging should you use?
Typically result from twisting injuries
Features
- pain worse on straightening the knee
- displaced meniscal tears may cause knee locking
- tenderness along the joint line
- Thessaly's test - weight bearing at 20 degrees of knee flexion, patient supported by doctor, postive if pain on twisting knee
MRI
26
What are the features of cauda equina?
- lower back pain
- urinary incontinence/retention
- reduced sensation in the perianal area
- decreased anal tone
27
When should you x-ray a suspected ankle injury?
Ottawa ankle rules to try and minimise the unnecessary use of x-rays.
An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:
1. 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)
2. 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)
3. inability to walk four weight bearing steps immediately after the injury and in the emergency department
Sensitivity nearly 100%
28
What are the different types of ankle fractures?
Unimalleolar 68%
Bimalleolar 25%
Trimalleolar 7%
Open 2%
29
What should the gap around the talus be on a mortise x-ray?
4mm
30
Which classification system is used to describe fibular breaks?
Weber classification
Related to the level of the fibular fracture.
- Type A is below the syndesmosis
- Type B fractures start at the level of the tibial plafond and may extend proximally to involve the syndesmosis
- Type C is above the syndesmosis which may itself be damaged
A subtype known as a Maisonneuve fracture may occur with spiral fibular fracture that leads to disruption of the syndesmosis with widening of the ankle joint, surgery is required.
The syndesmosis is the region between the distal tibia and fibula, between the top of the talus and 2.5cm proximal to that.
31
How do you treat ankle fractures?
Weber A or B, below knee cast 4-6 weeks, if they are diabetic tell them not to weight bear.
Weber C use syndesmosis screws
32
What is the recommended first line method of analgesia for NOF fractures?
Fascia iliaca compartment block
The Fascia iliaca compartment is an area of potential space that lies between the posterior surface of the fascia iliaca and the anterior surface of the iliacus and posts major muscles. Local anaesthetic injected into this potential space affects the femoral, obturator and lateral femoral cutaneous nerves. The aim of this is to reduce the use of opioids analgesics e.g. morphine, which is particularly helpful in elderly patients who are often more susceptible to their side effects.
33
What scale is used to classify the severity of open fractures?
Gustillo and Anderson
Type I
- wound ≤1 cm, minimal contamination or muscle damage
Type II
- wound 1-10 cm, moderate soft tissue injury
Type IIIA
- wound usually >10 cm, high energy, extensive soft-tissue damage, contaminated
- adequate tissue for flap coverage
- farm injuries are automatically at least Gustillo IIIA
Type IIIB
- extensive periosteal stripping, wound requires soft tissue coverage (rotational or free flap)
Type IIIC
- vascular injury requiring vascular repair, regardless of degree of soft tissue injury
34
How do you manage open fractures?
- Immobilise the fracture including the proximal and distal joints
- Carefully monitor and document neurovascular status, particularly following reduction and immobilisation
- Manage infection including tetanus prophylaxis (> chrs before surgery)
- IV broad spectrum antibiotics for open injuries
- As a general principle all open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution)
- Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury
- need definitive coverage (e.g flap) + fixation within 72 hours
35
What are the features of discitis?
- Back pain
- General features: pyrexia, rigors, sepsis
- Neurological features if epidural abscess develops
36
What are the causes of discitis?
- Bacterial: Staphylococcus aureus is the most common cause
- Viral
- TB
- Aseptic
37
How do you diagnose and treat a patient with discitis?
Diagnosis
Imaging:
- MRI has the highest sensitivity
- CT guided biopsy may be required to guide antimicrobial treatment
Treatment
- The standard therapy requires six to eight weeks of intravenous antibiotic therapy
- Choice of antibiotic is dependent on a variety of factors. The most important factor is to identify the organism with a positive culture (e.g. blood culture, or CT guided biopsy)
Further investigation:
Assess the patient for endocarditis e.g. with transthoracic echo or transesophageal echo. Discitis is usually due to haematogenous seeding of the vertebrae implying that the patient has had a bacteraemia and seeding could have occurred elsewhere
38
What's the pathology for lumbar spinal stenosis?
Degenerative disease is the commonest underlying cause. Degeneration is believed to begin in the intervertebral disk where biochemical changes such as cell death and loss of proteoglycan and water content lead to progressive disk bulging and collapse. This process leads to an increased stress transfer to the posterior facet joints, which accelerates cartilaginous degeneration, hypertrophy, and osteophyte formation; this is associated with thickening and distortion of the ligamentum flavum. The combination of the ventral disk bulging, osteophyte formation at the dorsal facet, and ligamentum flavum hyptertrophy combine to circumferentially narrow the spinal canal and the space available for the neural elements. The compression of the nerve roots of the cauda equina leads to the characteristic clinical signs and symptoms of lumbar spinal stenosis.`
39
How do you diagnose and treat lumbar spinal stenosis?
Diagnosis
MRI scanning is the best modality for demonstrating the canal narrowing. Historically a bicycle test was used as true vascular claudicants could not complete the test.
Treatment
Laminectomy
40
What's the condition and how do you test for it?
inflammation the tendons on the lateral aspect of the wrist and thumb
De Quervain's tenosynovitis
Finkelstein's test is can be used to make the diagnosis. The hand should be deviated medially rapidly with thumb flexed. If sharp pain occurs along the distal radius, de Quervain's tenosynovitis is likely.
41
What is De Quervain's tenosynovitis? Who does it typically affect?
- the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed
- typically affects females aged 30 - 50 years old
42
What are the symptoms of De Quervain's tenosynovitis?
- 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: with the thumb is flexed across the palm of the hand, pain is reproduced by movement of the wrist into flexion and ulnar deviation
43
How do you manage De Quervain's tenosynovitis?
- analgesia
- steroid injection
- immobilisation with a thumb splint (spica) may be effective
- surgical treatment is sometimes required
44
What's the diagnosis?
A 26-year-old man presents to the emergency department with a swelling over his left elbow after a fall on an outstretched hand. On examination, he has tenderness over the proximal part of his forearm, and has severely restricted supination and pronation movements.
Fracture of the radial head
45
What are the features of a fractured radial head?
- Fracture of the radial head is common in young adults.
- It is usually caused by a fall on the outstretched hand.
- On examination, there is marked local tenderness over the head of the radius (proximal part), impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination).
46
What movement aggravates subacromial impingement?
- A painful arc of abduction on examination - worse between 90 and 120 degrees.
- Tenderness over anterior acromion
47
What's the acute treatment for gout and how does it work?
Colchicine inhibits microtubule polymerization by binding tubulin. This impairs neutrophil chemotaxis and degranulation. In acute gout, monosodium urate crystals are deposited in joint generating an inflammatory response. Colchicine can therefore treat this condition by reducing inflammation by impairing neutrophil response. Other drugs used for acute treatment are glucocorticoids and NSAIDs e.g. naproxen.Allopurinol, febuxostat and probenecid are chronic gout drugs (preventative).
48
A patient presents with a heliotrope rash, a malar rash and Gottron's papules on the elbows and knees. She cannot comb her hair or climb the stairs due to muscle weakness. Lab results show an increased creatine kinase, positive antinuclear antibody (ANA) and anti-Jo-1 antibody. Biopsy reveals perimysial inflammation with perifascicular atrophy. She is treated with corticosteroids. What disease does the patient have?
Dermatomyositis
49
Synovial fluid was sampled for a joint condition and rhomboid shaped crystals with weak positive birefringence under polarised light were found. What joint disease is this an indicator of?
Pseudogout
Pseudogout has a similar presentation to gout clinically but it is due to deposition of calcium pyrophosphate dihydrate (CPPD) in tissues especially the joint, unlike the deposition of monosodium urate crystals seen in gout. Synovial fluid will show rhomboid crystals with weak positive birefringence under polarized light compared to gout for which there are needle shaped crystals with negative birefringence under polarised light ( yellow when parallel) in synovial fluid.
50
What type of injury would cause scapulothoracic dissociation and what are the complications?
- usually caused by a lateral traction injury to the shoulder girdle
- involves significant trauma to heart, chest wall and lungs
```
orthopaedic
- scapula fractures
- clavicle fractures
- AC dislocation/separation
- sternoclavicular dislocation
- flail extremity (52%)
complete loss of motor and sensory function rendering the extremity non-functional
```
vascular injury
- subclavian artery most commonly injured
- axillary artery
- neurologic injury (up to 90%)
- ipsilateral brachial plexus injury (often complete)
- neurologic injuries more common than vascular injuries
Prognosis
mortality rate of 10%
51
What is a lisfranc injury? How might it occur?
Tarsometatarsal fracture-dislocation
A condition characterized by disruption between the articulation of the medial cuneiform and base of the second metatarsal
- unifying factor is disruption of the TMT joint complex
- injuries can range from mild sprains to severe dislocations
- may take form of purely ligamentous injuries or fracture-dislocations
- ligamentous vs. bony injury pattern has treatment implications
causes include MVAs, falls from height, and athletic injuries
- mechanism is usually caused by indirect rotational forces and axial load through hyperplantar flexed forefoot
- hyperflexion/compression/abduction moment exerted on forefoot and transmitted to the TMT articulation
- metatarsals displaced in dorsal/lateral direction
52
Why is it important to diagnose lisfranc injuries?
missed injuries can result in progressive foot deformity, chronic pain and dysfunction
53
What x rays would you want to help diagnose a lisfranc injury?
- AP
- lateral
- oblique
- stress (may be helpful to show instability when non-weight bearing radiographs are normal and there is high suspicion)
- weight-bearing with comparison view (may be necessary to confirm diagnosis)
54
What radiographic findings would you see with a lisfranc injury?
- discontinuity of a line drawn from the medial base of the 2nd metatarsal to the medial side of the middle cuneiform (seen on AP view, diagnostic of Lisfranc injury)
- widening of the interval between the 1st and 2nd ray (seen on AP view)
- may see bony fragment (fleck sign) in 1st intermetatarsal space- represents avulsion of Lisfranc ligament from base of 2nd metatarsal (diagnostic of Lisfranc injury)
- dorsal displacement of the proximal base of the 1st or 2nd metatarsal (seen on lateral view)
- medial side of the base of the 4th metatarsal does not line up with medial side of cuboid (seen on oblique view)
- disruption of the medial column line (line tangential to the medial aspect of the navicular and the medial cuneiform) seen on oblique view
55
How do you treat a lisfranc injury?
8 weeks in a cast
56
Who normally gets a triplane ankle fracture and how is it normally caused?
Age 13-17, normally boys
- lateral triplane fractures results from supination-external rotation injury
- medial triplane fractures results from adduction injury
57
Who normally gets a medial epicondyle fracture? How do you treat it?
- third most common fracture seen in children and is usually seen in boys between the age of 9 and 14.
- treatment is controversial but is usually nonoperative unless the medial epicondyle is incarcerated in the joint (15% of cases)
Nonoperative
- immobilization (1-3 weeks) in a long arm cast with elbow flexed to 90 degrees
- indications (controversial):
- < 5mm displacement (amount of true displacement difficult to determine on plain radiographs)
- outcomes
- lower rate of osseous union rate compared to surgically treated patients
- radiographic nonunion (or fibrous union) often asymptomatic
Operative
- open reduction internal fixation
- indications
absolute
- displaced fx with entrapment of medial epicondyle fragment in joint
- extension to the articular surface with medial condyle involvement (articular surface)
- open fracture
relative
- ulnar nerve dysfunction
- > 2-15mm displacement, also controversial
- >2-5 mm in valgus stress athletes such as throwers or - gymnasts
- associated elbow dislocation (50-60%)
58
What is the most common type of bone tumour?
```
Metastatic
• Breast
• Prostate
• Renal Cell
• Thyroid
• Lung
```
Haemopoietic
• Leukaemia
• Lymphoma
• Multiple myeloma
59
What surgical staging is used to classify bone tumours?
* Histological grade G
* Site T
* Metastasis M
60
Give examples of stage 0 bone tumours
```
Osteoid osteoma (bone)
Enchondroma (cartilage)
Fibrous cortical defect (fibrous)
Eosinophilic
granuloma
```
61
Give examples of stage 1 bone tumours
```
< 15% chance of metastasis
Low grade osteosarcoma (bone)
Low grade chondrosarcoma (cartilage)
Adamantinoma (fibrous)
giant cell tumour
```
62
Give examples of stage 2 bone tumours
```
> 15% chance of mets
High grade osteosarcoma (bone)
High grade chondrosarcoma (cartilage)
Fibrosarcoma
Ewing's
```
63
What are the characteristic locations of bone tumours?
Central
• Enchondroma
Eccentric
• Giant Cell Tumour
• Osteosarcoma
• Chondromyxoid Fibroma
Cortical
• Non-Ossifying Fibroma
• Osteoid Osteoma
Parosteal
• Parosteal Osteosarcoma
• Osteochondroma (one that sticks out)
Epiphyseal
• Giant Cell Tumours
• Chondroblastomas
Metaphyseal
• Osteosarcoma
• Chondrosarcoma
• Osteomyelitis
Diaphyseal
• Round Cell Lesions
• Aneurysmal Bone Cysts
• Enchondromas
64
Where would you find a Chondroblastoma?
Epiphyses
65
Where would you find a Giant Cell Tumours?
Epiphyses
66
Where would you find a simple bone cyst?
Proximal humerus
67
Where would you find an Adamantinoma?
Tibia
68
Where would you find a Chordoma?
Sacrum
69
Where would you find a Osteoblastoma?
Posterior element of spine
70
Where would you find a Chondrosarcoma?
Pelvis
71
What bone tumours would you expect in someone less than 20?
Osteogenic Sarcoma
Ewings
Simple bone cysts
chondroblastomas
72
What bone tumours would you expect in someone in their 40s?
```
GCT
Chondrosarcoma
MFH (Malignant Fibrous Histiocytoma- a sarcoma that may arise in both soft tissue and bone)
Lymphoma
Mets
```
73
What bone tumours would you expect in someone in their 60s?
Mets
Myeloma
Chondrosarcoma
MFH
74
What x ray findings would you expect in a malignant bone tumour?
– Lamellated or onion peel
– Sunburst
– Codman’s triangle
– Spiculated
75
Multiple enchondromas are found in which diseases?
Ollier disease
| Maffucci syndrome
76
What is involucrum?
a layer of new bone growth outside existing bone (ossified lining of an osteomyelitis site)
77
What is a sequestrum?
a piece of dead bone tissue formed within a diseased or injured bone, typically in chronic osteomyelitis.
78
What's the tumour?
- Commoner in males
- Diaphyses of long bones or limb girdle
- Incidence of 0.3 / 1, 000, 000
- Onset typically between 10 and 20 years of age
- Location by femoral diaphysis is commonest site
- Histologically it is a small round tumour
- Blood borne metastasis is common and chemotherapy is often combined with surgery
- t11:22 translocation
- x-ray bone destruction and onion rings of new bone formation and soft tissue mass
Ewings sarcoma
79
What are the most common sites for bone metastases?
spine, femur, skull, humerus (not tibia)
80
What's the tumour?
- Mesenchymal cells with osteoblastic differentiation
- 20% of all primary bone tumours
- Incidence of 5 per 1,000,000
- Peak age 15-30, (later peak due to Paget's disease)
- commoner in males
- metaphyses of long bones esp knee
- x ray: sunray speculation, periosteal elevation (Codman's triangle)
- Limb preserving surgery may be possible and many patients will receive chemotherapy
- cure rate 60-70%
Osteosarcoma
81
What's the tumour?
- young male
- bone pain at night
- responds to NSAIDS
Osteoid osteoma
82
What's the diagnosis?
a child with an asymptomatic, fluctuant swelling behind the knee
Baker's cyst
83
What are Baker's cysts and what causes them?
Baker's cysts (also known as a popliteal cyst) are not true cysts but rather a distension of the gastrocnemius-semimembranosus bursa. They may be primary or secondary:
1. Primary: no underlying pathology, typically seen in children
2. Secondary: underlying condition such as osteoarthritis, typically seen in adults
84
What causes slow developing joint effusion and medial/lateral joint line tenderness?
MCL/LCL injury
85
What causes delayed knee swelling and joint locking?
meniscal injury
86
A 52-year-old male is referred to urology clinic with impotence. He is known to have hypertension. He does not have any morning erections. On further questioning the patient reports pain in his buttocks, this worsens on mobilising. On examination there is some muscle atrophy. The penis and scrotum are normal. What is the most likely diagnosis?
Leriche syndrome
Classically, it is described in male patients as a triad of symptoms:
1. Claudication of the buttocks and thighs
2. Atrophy of the musculature of the legs
3. Impotence (due to paralysis of the L1 nerve)
Leriche syndrome, is atherosclerotic occlusive disease involving the abdominal aorta and/or both of the iliac arteries. Management involves correcting underlying risk factors such as hypercholesterolaemia and stopping smoking. Investigation is usually with angiography.
87
What pain is characteristic for Ankylosing spondylitis?
lower back pain that is worse in the mornings and typically improved by exercise
88
How do you manage AC joint dislocation?
Grade I and II injuries are very common and are typically managed conservatively including resting the joint using a sling.
Grade IV, V and VI are rare and require surgical intervention.
89
When is the Stimson Maneuver used?
For reduction of dislocated shoulders
90
How do you investigate and manage osteomyelitis?
Investigations
- MRI is the imaging modality of choice, with a sensitivity of 90-100%
Management
- flucloxacillin for 6 weeks
- clindamycin if penicillin-allergic
91
What fundoscopic findings are associated with a fat embolus?
Retinal haemorrhages and intra-arterial fat globules
92
A 42-year-old netball coach presents to the general practitioner (GP) with a nine month history of right heel pain. She has previously visited the GP with the same complaint and over the past three months she has managed to lose 2 kg in weight and has performed daily stretching exercises. She has also been taking ibuprofen and has received a corticosteroid injection, which have not alleviated her pain. Her body mass index (BMI) is 23 kg/m². What should you do next?
Stop ibuprofen, refer to orthopaedics and refer to physiotherapy
Patients with persistent symptoms that have failed 6-12 months' worth of conservative management should be referred to orthopaedics for consideration of surgical intervention. Similarly, as physiotherapy input has not yet been sought, a referral would be appropriate.
93
What examination findings are consistent with a scaphoid fracture?
How do you treat it?
- tenderness in anatomical snuff box
- telescoping of thumb causes pain
- blood (haemarthrosis in wrist)- fullness of snuff box
- tender when radially deviated
4 x ray angles: AP, lateral, oblique, ulnar deviated view. Not seen? CT
undisplaced- plaster for 8 weeks
displaced- operative reduction and fixation
94
What is Kanavel signs?
Flexor tenosynovitis is diagnosed by Kanavel signs (the affected finger is held in slight flexion; there is uniform swelling over the affected tendon; there is tenderness over the affected tendon; there is pain on passive extension of the affected finger)
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What might you see on an x-ray of someone with supraspinus tendonitis?
Calcification of the supraspinatus tendon consistent with prolonged inflammation. This can look like a bit of bone.
96
What are the functions of the median nerve?
Motor functions
Anterior Forearm
In the forearm, the median nerve directly innervates muscles in the superficial and intermediate layers:
- Superficial layer: Pronator teres, flexor carpi radialis and palmaris longus.
- Intermediate layer: Flexor digitorum superficialis.
The median nerve also gives rise to the anterior interosseous nerve, which supplies the deep flexors:
- Deep layer: Flexor pollicis longus, pronator quadratus, and the lateral half of the flexor digitorum profundus (the medial half of the muscle is innervated by the ulnar nerve).
In general, these muscles perform pronation of the forearm, flexion of the wrist and flexion of the digits of the hand.
Hand
The median nerve innervates some of the muscles in the hand via two branches.
The recurrent branch of the median nerve innervates the thenar muscles – muscles associated with movements of the thumb. The palmar digital branch innervates the lateral two lumbricals – these muscles perform flexion at the metacarpophalangeal joints and extension at the interphalanageal joints of the index and middle fingers
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Sensory Functions
The median nerve is responsible for the cutaneous innervation of part of the hand. This is achieved via two branches:
Palmar cutaneous branch – arises in the forearm and travels into the hand. It innervates the lateral aspect of the palm. This nerve does not pass through the carpal tunnel, and is spared in carpal tunnel syndrome.
Palmar digital cutaneous branch – arises in the hand. Innervates the palmar surface and fingertips of the lateral three and half digits.
ORTEM
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