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Phase 2 > MSK > Flashcards

MSK Flashcards

1
Q

What is a garden class I fracture?

A

Incomplete/impacted, valgus angulation of distal component

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2
Q

What is a garden class II fracture?

A

Complete fracture, undisplaced

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3
Q

What is a garden class III fracture?

A

Complete, partially displaced fracture

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4
Q

What is a garden class IV fracture?

A

Complete, totally displaced

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5
Q

What is the Weber classification used for?

A

Fibula fractures

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6
Q

What is a Weber class A fracture?

A

Distal to the ankle syndesmosis

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7
Q

What is a weber class B fracture?

A

At the level of the ankle syndesmosis

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8
Q

What is a weber class C fracture?

A

Proximal to the ankle syndesmosis

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9
Q

What is the Gustilo classification used for?

A

Open fractures

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10
Q

What is a Gustilo I fracture?

A

Low energy fracture

Small clean wound

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11
Q

What is a Gustilo II fracture?

A

Moderate energy, clean wound >1cm

Mild-moderate comminution

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12
Q

What is a Gustilo III fracture?

A

High energy
Extensive skin damage
Neurovascular damage and wound contamination

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13
Q

What is the Salter-Harris classification?

A

Physeal (growth plate) fractures

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14
Q

What is a Salter-Harris class I fracture?

A

Complete physeal fracture

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15
Q

What is a salter-Harris class II fracture?

A

Complete physeal fracture + chip of metaphysis

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16
Q

What is a salter-Harris III fracture?

A

Physeal fracture extending through epiphysis

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17
Q

What is a salter-Harris class IV fracture?

A

Physeal and epiphyseal and metaphyseal fractures

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18
Q

What is a salter-Harris class V fracture?

A

Compression fracture of growth plate

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19
Q

What do the increasing numbers in salter-Harris classification mean?

A

Increasing risk of growth arrest

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20
Q

What is the most common type of salter-Harris fracture?

A

II

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21
Q

What is the garden classification used for?

A

Intracapsular hip fractures

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22
Q

What is the common order for all MSK examinations?

A

Look
Feel
Move
Special tests

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23
Q

What do you look for from behind in a spinal examination?

A

Asymmetry - head, shoulders, pelvis
Scoliosis
Muscle wasting
Scars

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24
Q

What do you look for from the side in a spinal examination?

A

Kyphosis

Lordosis

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25
Q

What does asking a patient to walk on tip toes test?

A

S1

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26
Q

What does asking a patient to walk on their heels test?

A

L5

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27
Q

What do you feel for when palpating the spine?

A

Spinous processes
Paraspinal muscles
Start at occipital protuberance and move down to SI joints

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28
Q

What level is the iliac crest at?

A

L4

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29
Q

What level is the PSIS at?

A

S2

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30
Q

What movements of the cervical spine should you test?

A

Flexion/extension
Rotation
Lateral flexion

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31
Q

What movement of the thoracic spine should you test?

A

Rotation - hold pelvis still from behind and ask patient to turn to face you

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32
Q

What movements of the lumbar spine should you test?

A

Flexion/extension

Lateral flexion

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33
Q

What is the Schrober test?

A

Testing lumbar flexion

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34
Q

What are the 4 special tests for sciatica?

A

Straight leg raise
Save’s test - dorsiflex ankle, produces pain below knee (at full SLR)
Relax knee - pain goes away
Borg’s test - push in upper popliteal fossa

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35
Q

What is Spurling’s sign?

A

Laterally flex neck to side of pain

+ve = pain down arm

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36
Q

How do patients with spinal stenosis walk?

A

Flex forward

Widens gaps in spine to reduce pain

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37
Q

What are the components of a peripheral nerve examination?

A 
Inspection
Tone
Power
Reflexes
Sensation
Coordination
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38
Q

What does 0 on the ASIA chart mean?

A

Total paralysis

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39
Q

What does 1 on the ASIA chart mean?

A

Palpable or visible contraction

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40
Q

What does 2 on the ASIA chart mean?

A

Active movement, full ROM when gravity is eliminated

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41
Q

What does 3 on the ASIA chart mean?

A

Full ROM against gravity

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42
Q

What does 4 on the ASIA chart mean?

A

Full ROM against moderate resistance in a specific muscle position

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43
Q

What does 5 on the ASIA chart mean?

A

Full ROM against full resistance expected from an otherwise unimpaired person

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44
Q

How do you test the C5 myotome?

A

Elbow flexion

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45
Q

How do you test the C6 myotome?

A

Wrist extension

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46
Q

How do you test the C7 myotome?

A

Elbow extension

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47
Q

How do you test the C8 myotome?

A

Finger flexion

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48
Q

How do you test the T1 myotome?

A

Finger abduction

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49
Q

How do you test the L2 myotome?

A

Hip flexion

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50
Q

L3 myotome?

A

Knee extension

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51
Q

L4 myotome?

A

Ankle dorsiflexion

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52
Q

L5 myotome?

A

Extensor hallucis longus (big toe extension)

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53
Q

S1 myotome?

A

Ankle plantarflexion

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54
Q

What is the supply to the Biceps reflex?

A

C5

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55
Q

What is the supply to the brachioradialis/supinator reflex?

A

C6

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56
Q

What is the supply to the triceps reflex?

A

C7

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57
Q

What if Hoffman’s sign?

A

UMN sign
Click your finger with theirs in-between
Positive if the clasp their fingers
Analogous to clonus in lower limb

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58
Q

What is the nerve supply to the patella reflex?

A

L4

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59
Q

What is the nerve supply to the ankle reflex?

A

S1

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60
Q

What is babinski’s sign?

A

Stroke along metatarsal V then across to the big toe

First movement of big toe must be extension, followed by fanning of the other toes = UMN sign

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61
Q

How do you test for clonus?

A

Relax ankle by rolling it then sudden and sustained dorsiflexion
3-4 beats is normal, more than 5 is not - UMN sign

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62
Q

What dermatome do you test in the middle finger?

A

C7

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63
Q

Where is the L1 dermatome?

A

Groins

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64
Q

Where is the L2 dermatome?

A

Hands in pockets

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65
Q

Where is the L3 dermatome?

A

Knee

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66
Q

Where is the L4 dermatome?

A

Inside calf

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67
Q

Where is the L5 dermatome?

A

Outside calf

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68
Q

Where is the S1 dermatome?

A

Lateral foot and sole

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69
Q

What are the red flag symptoms for back pain?

A 
Age outside 18-55
Non-mechanical pain
Night pain
Thoracic pain
Systemic features: weight loss, night sweats
History of malignancy, infection or trauma
Steroid/drug abuse
Widespread neurology
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70
Q

Define widespread neurology

A

Neurological symptoms that can’t be explained by a single nerve root defect

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71
Q

What is cauda equina syndrome?

A

Compression, trauma, spinal stenosis or other damage to the cauda equina
I.e. The spinal cord after its termination at L2

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72
Q

What are the features of cauda equina syndrome?

A

Bilateral sciatica + perianal numbness (saddle anaesthesia)

Complete cauda equina = detrusor involvement - painless retention leading to incontinence

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73
Q

What is the treatment for cauda equina syndrome?

A

Surgical decompression within 48 hrs of sphincter dysfunction for good prognosis

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74
Q

What part of the vertebral body is commonly affected by tumours?

A

Pedicle

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75
Q

What colour is water on T2-weighted MRI?

A

White

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76
Q

What are the most common cancers found in the spine?

A

Mets

Lung, breast, kidney, prostate, thyroid

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77
Q

What primary tumour may appear in the spine?

A

Myeloma

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78
Q

What infections may be present in the spine?

A

Spondylo-discitis
Epidural abscess
Paravertebral abscess
TB

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79
Q

What are the features of neurological claudication?

A 
Proximal to distal
Variable distance
Sit to relieve (jelly legs)
Relieved in minutes
Associated pins and needles, numbness and weakness
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80
Q

What are the features of vascular claudication?

A

Distal to proximal
Fixed distance
Stand to relieve
Relieved in seconds

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81
Q

What is the management for spinal stenosis?

A

Physio
Pain relief
Injections
Surgical decompression

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82
Q

What is the conservative/medical management of sciatica?

A 
Short period of bed-rest
Analgesics
Muscle relaxant eg diazepam
Neuromodulating agents eg gabapentin
Physio once pain is under control
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83
Q

What surgery may be offered for sciatica?

A

Mini discectomy

Micro discectomy

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84
Q

What are the features of mechanical pain?

A

Varies with activity and time

Relieved by rest

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85
Q

What is the management of mechanical back pain?

A

Conservative with core stabilisation
Bed rest is bad
Aim for return to function ASAP
Simple analgesics and physio

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86
Q

What is referred pain?

A

Irritation of end place supplies felt in the whole area that the nerve supplies

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87
Q

What is the distinguishing feature of sciatica?

A

Must go below the knees

If it doesn’t, it is referred pain not sciatica

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88
Q

In the shoulder, if passive movement is greater than active, what does this suggest?

A

Nerve or tendon injury

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89
Q

What are the common shoulder problems in the 10-30 age group?

A

Instability

Muscle packing problem

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90
Q

What are the common shoulder problems in the 40-60 age group?

A

Impingement
Adhesive capsulitis (frozen shoulder)
Inflammatory Arthropathy

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91
Q

What are the common shoulder problems in 60-80 year olds?

A

Degenerative cuff tear
Osteoarthritis
Cuff arthropathy

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92
Q

What are the 4 articulations at the shoulder?

A

Glenohumeral
Sternoclavicular
Acromioclavicular
Scapulothoracic

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93
Q

What is the function of the glenoid labrum?

A

Increases depth of joint

Increases stability

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94
Q

What is the conjoined tendon?

A

Coracobrachialis + short head of biceps

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95
Q

What is the main surgical approach to the shoulder?

A

Deltopectoral

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96
Q

What are the stabilising factors of the shoulder joint?

A 
Labrum
Ligaments
Capsule
Muscles
Negative pressure
Contact
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97
Q

What is true singing of the scapula?

A

Long thoracic nerve damage

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98
Q

What is the most common cause of winged scapula?

A

Muscle imbalance

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99
Q

What is Popeye’s sign?

A

Rupture or adhesionary tear of biceps tendon

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100
Q

What nerve may be damaged in a posterior shoulder dislocation?

A

Axillary

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101
Q

How do you palpate the shoulder?

A

Use 2 fingers
One side at a time
Only palpate the affected shoulder but still look and move both

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102
Q

How do you feel the head of humerus?

A

Rotate shoulder internally and externally to feel the head moving in the sulcus

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103
Q

What movements do you test at the shoulder?

A

Forward elevation
Rotation: external and internal
Abduction: with palms facing up

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104
Q

How do you test internal rotation at the shoulder?

A

Put hands behind back, how high can their thumb reach? Should be mid-thoracic spine for full ROM

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105
Q

How do you test external rotation of the shoulder?

A

Lock elbows at side

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106
Q

What condition is suggested if both active and passive movements are restricted at the shoulder?

A

Frozen shoulder

Arthritis

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107
Q

Through what degrees of shoulder abduction is painful arc syndrome?

A

40-120

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108
Q

How do you test rotator cuff function?

A

Supraspinatous: abduction
Infraspinatous & teres minor: resist pressure when in full external rotation
Subscapularis: empty beer can

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109
Q

What is the Scarff test?

A

Put arm across neck

Pain = acromioclavicular joint pain

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110
Q

What are the causes of impingement at the shoulder?

A

Bursitis
Tendonitis (eg calcific)
Inflammation
Tear

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111
Q

What scoring system is used for hypermobility?

A

Beighton score

Ligamentous laxity

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112
Q

How do you finish a shoulder examination?

A

Neurological examination

Examination of cervical spine

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113
Q

What is the main clinical feature of a frozen shoulder?

A
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114
Q

How is a frozen shoulder managed?

A

1- NSAIDs, steroid injections
2- MUA, distension, arthrogram
3- leave it alone
Physio may make it worse

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115
Q

How do you manage shoulder impingement?

A

Physio
Steroid injections
USS/MRI to check for cuff tear
Su acromegaly decompression

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116
Q

How are steroid injections used in impingement syndrome?

A

Maximum 3
Each 6 weeks apart
Only give 2nd if the first gives sustained benefit

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117
Q

What is a Bankart lesion?

A

Shoulder dislocation causing tear of the glenoid labrum in the anteroinferior portion
Provides an area for the humeral head to dislocate into

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118
Q

What is a Hill-Sack’s lesion?

A

Impaction causes fracture of posterior humeral head

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119
Q

What are the common conditions of the elbow in children?

A

Pulled elbow
Fractures: supracondylar, epicondyles, radial neck
Infection

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120
Q

What are the common elbow conditions in older people?

A

Lateral epicondylitis
Medial epicondylitis
Osteoarthritis
Fractures: radial head, Olecranon, distal humerus
Nerve entrapment: ulnar, palmar interosseous, median

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121
Q

What do you look for in all MSK examinations?

A 
MRS SAD
Muscle wasting
Rash
Scars
Swelling
Asymmetry
Deformity
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122
Q

Which deformity of elbow alignment is a functional problem?

A

Valgus - can stretch the ulnar nerve, causing palsy

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123
Q

What is 3-point relation at the elbow?

A

Olecranon, medial and lateral epicondyles make an isosceles triangle when bent, and a straight line when extended

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124
Q

What movements do you test at the elbow?

A

Flexion/extension

Supination/pronation, with elbows bent at side

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125
Q

What are the special tests at the elbow?

A

Golfer’s elbow: flex wrist against resistance, palpate for tenderness
Tennis elbow: extend wrist against resistance, palpate lateral epicondyle for tenderness
Instability: test collateral ligaments

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126
Q

What is the most common elbow dislocation?

A

Posterolateral

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127
Q

What are the causes of a stiff elbow?

A

OA

RA

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128
Q

What is the volar surface of the hand?

A

Palmar surface

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129
Q

What is the relation of the MCPJ of the thumb and those of the other fingers?

A

Thumb MCPJ is at 90degrees to others

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130
Q

What is the normal resting posture of the hand?

A

Cascade: little finger is the most flexed at rest

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131
Q

What does a single palmar crease signify?

A

Simian crease

Seen in down’s and other congenital syndromes

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132
Q

What are Heberden’s nodes?

A

Swelling and deformity of distal IPJs

Classic of OA

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133
Q

What are the signs of RA in the hands?

A

Symmetrical swelling

Ulnar deviation of proximal finger joints

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134
Q

What are Dupuytren’s?

A

Contracture of fibrous bands in palmar fascia

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135
Q

What are the borders of the anatomical snuffbox?

A

Radial side: extensor pollicis brevis

Ulnar side: extensor pollicis longus + extensor digitorum

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136
Q

What does tenderness in the anatomical snuffbox suggest?

A

Scaphoid injury

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137
Q

What does tenderness at the tip of the radial styled process suggest?

A

deQuervain’s disease

= tenovaginitis of combined sheath of EPB and AbPL

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138
Q

What movements do you test in the hand?

A

Wrist flexion/extension
Ulnar/radial deviation
Pronation/supination

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139
Q

How do you test thumb movements?

A

Hold patient’s hand flat on the table dorsal surface down

  1. Stretch to the side (extension)
  2. Point to the ceiling (abduction)
  3. Pinch my finger (adduction)
  4. Touch your little finger (opposition)
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140
Q

How do you test flexor digitorum profundus?

A

Hold proximal IPJ extended and ask patient to bend finger

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141
Q

How do you test flexor digitorum superficialis?

A

Inactivate profundus by holding other fingers in extension and ask patient to flex finger to be tested

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142
Q

What are the differences in the tendons of FDS and FDP?

A

FDS has 4 separate muscle bellies

FDP has 1 belly then splits into 4 tendons

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143
Q

What is the Tonodesis test?

A

Flex wrist - fingers extend

Extend wrist - fingers flex

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144
Q

How do you test extensor digitorum/indicis?

A

Make fist and stretch out relevant finger

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145
Q

What is Allen’s test?

A

Compress both ulnar and radial arteries, get patient to make fist and clench
Open hand out and release first radial artery: how quickly does it go from white to red? Then repeat releasing ulnar first

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146
Q

How do you test interosseous muscle function?

A

Spread fingers and push little fingers against each other

If one is weaker, that hand’s fingers will collapse

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147
Q

What is Froment’s sign?

A

Grip card between thumb and index finger
If adductor pollicis is weak, the affected thumb will be flexed to bring FPL into action
Also tests ulnar nerve function

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148
Q

What is Tennell’s test?

A

Tap halfway between borders of wrist to stimulate median nerve
Causes tingling/shooting in median distribution

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149
Q

What are nerve symptoms?

A 
Tingling
Weakness
Numbness
Pain
Muscle wasting
Loss of dexterity
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150
Q

How do you test nerve function in children following fracture?

A

Thumbs up = radial
Make O = anterior interosseous
Cross fingers = ulnar

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151
Q

What is Phalen’s test?

A

Flex wrist

Causing pain within 1 min = carpal tunnel

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152
Q

What are the causes of carpal tunnel syndrome?

A 
Idiopathic
Hypothyroidism
Pregnancy
Wrist fracture
Work-related
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153
Q

What is the first part of the nerve affected when it is compressed?

A

Myelin, leading to decreased conduction velocity

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154
Q

Where are the majority of ulnar nerve compressions?

A

Cubical tunnel (elbow)

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155
Q

What digits are affected by ulnar nerve compression?

A

Ulnar 1.5 fingers

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156
Q

What muscles are affected by ulnar nerve compression?

A

Intrinsic muscles of hand
Adductor pollicis
FDP

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157
Q

What fracture can cause radial nerve damage?

A

Humeral shaft

Most commonly lower third of humerus

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158
Q

Where do you check sensory supply of the radial nerve?

A

1st dorsal webspace

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159
Q

What is the motor supply of the radial nerve?

A

Wrist extensors
Finger extensors
Extensor pollicis longus

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160
Q

What are the risk factors for Dupuytren’s contractures?

A

Family history
Alcoholism
Diabetes
Hand trauma

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161
Q

What is the threshold for intervention in Dupuytren’s?

A

When they can’t get their hand flat on the table

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162
Q

What is trigger finger?

A

Pulley that holds tendon against bone becomes thickened

Means the tendon gets stuck and doesn’t move smoothly

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163
Q

What is DeQuervain’s tenosynovitis?

A

Radial sided wrist pain

Swelling and tenderness over styloid

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164
Q

How do you test for flexor tendon injury?

A

Cascade
Tenodesis test
Squeeze test
FDS and FDP tests

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165
Q

What is tenosynovitis?

A

Chronic inflammation of a tendinous sheath

166
Q

How many extensor compartments are there in the wrist?

A

6

167
Q

What is the contents of the 1st extensor compartment of the wrist?

A

Abductor pollicis longus

Extensor pollicis brevis

168
Q

What joints in the hand are commonly affected by osteoarthritis?

A

DIPJ

MCPJ

169
Q

What are Bouchard’s nodes?

A

Swelling over PIPJs

170
Q

What are the differentials for a lump in the hand?

A

Endochondroma
Giant cell tumour
Malignant tumour
Cystic eg ganglion

171
Q

What type of scaphoid fracture takes longest to heal and why?

A

Tail

It is furthest from he blood supply (which is distal to proximal)

172
Q

What does an enlarged gap between carpal bones suggest?

A

Ligament rupture

173
Q

What is SNAC?

A

Scaphoid non-Union advanced collapse

174
Q

What is the main risk with scaphoid fractures?

A

Avacular necrosis due to disruption of the blood supply

175
Q

How are finger fractures stabilised?

A

Buddy strapping
Splintage
Internal fixation

176
Q

What are the risk factors for hand infections?

A 
Peripheral vascular disease
Diabetes
Immunocompromised
Innocuous injury eg gardening
Smoking
IVDU
177
Q

What are the feature of a flexor sheath infection?

A

Confines to digit affected
Tender on volar aspect

EMERGENCY

178
Q

What is pollicisation?

A

Turning a finger into thumb

May also use a big toe to make a thumb

179
Q

What is excision arthroplasty?

A

Removal of arthritic parts of the joint

180
Q

What is interposition?

A

Autograft

In the thumb, take part of flexor carpi radialis and use it as a sling to wrap around the joint

181
Q

Why do patients with arthritis get stiffness when starting walking after rest?

A

Normally cartilage creates a fluid film when you get up from a period of inactivity
Bone on bone in arthritis initially, as fluid takes longer to build up due to less cartilage being there

182
Q

What are the red flag symptoms for the hip?

A

Severe night pain
Inability to weight bear on limb
History of malignancy
Rapid deterioration of symptoms

183
Q

How do you do Trendelenburg’s test?

A

You’re testing the leg they’re standing on
Sit down and hold their pelvis, tell them to hold your elbows
If positive, you feel the pelvis drop and they push on your elbow (when they are stood on the bad leg)

184
Q

How do you position the patient to feel the hip joint?

A

Patient laid on side with knees to chest

185
Q

What bony prominences should you feel for in a hip examination?

A 
ASIS
PSIS
Greater Trochanter
Pubic Tubercle
Ischial Tuberosity
186
Q

What area is commonly tender in an arthritic hip?

A

Anterior groin

187
Q

Other than bony prominences, what else do you feel for in a hip examination?

A

Pulses

Leg length - thumbs behind each medial malleolus

188
Q

What movements should you test at the hip?

A

Flexion then…External and internal rotation
Ab and adduction
External and internal rotation with leg in extension

189
Q

What movement at the hip is most sensitive to arthritis?

A

Internal rotation

190
Q

What special tests do you do at the hip?

A

Leg length - pulses at the same time
Thomas’ test (fixed flexion deformity)
Trendelenburg

191
Q

What does the leg look like when the hip is fractured?

A

Externally rotated and shortened

192
Q

What are the features in a history that suggest OA?

A

Other joint involvement
Gradual onset, progressing over a long time
Pain, stiffness, loss of function
Family history

193
Q

What is GTPS?

A

Greater Trochanteric Pain Syndrome
Eg Trochanteric bursitis
Terrible pain there all the time, can’t sleep on affected side

194
Q

What is FAI?

A

Femoroacetabular impingement
Pre-arthritic hip, due to tearing of labrum
Common in sportsmen

195
Q

How do you test for FAI?

A

Flexion + adduction + internal rotation

196
Q

What are the causes of avascular necrosis of the head of femur?

A 
Alcohol
Steroid
Transplant
Liver disease
Trauma
197
Q

What does the head of femur look like in avascular necrosis?

A

White and sclerotic

198
Q

What are the signs of hip infection?

A

Severe pain and systemic sepsis
Common in children
Very stiff and unable to weight bear

199
Q

How do you manage hip infection?

A

USS shows fluid in hip

Urgent referral - needs decompression and cleaning early

200
Q

What is SUFE?

A

Slipped Upper Femoral Epiphysis

201
Q

When a lytic lesion has no clear edges, what does this suggest?

A

Aggressive tumour

No osteoblast activity

202
Q

What are the risk factors for #NOF?

A 
Caucasian
Female
70+ years
Osteoporosis, osteomalacia
Diabetes, stroke, alcoholism, chronic debilitating disease
Muscle weakness, poor balance
203
Q

What is the Garden classification of #NOF?

A
  1. Incomplete impacted fracture
  2. Complete undisplaced
  3. Complete with moderate displacement
  4. Severely displaced
204
Q

What is the blood supply to the head of femur?

A

Intramedullary vessels in femoral neck
Ascending branches of medial and lateral circumflex femoral arteries
Vessels of ligamentum teres - insufficient in adults

205
Q

What is the potential complication of displaced #NOF and why?

A

Avascular necrosis of femoral head

Tearing of ascending branches of medial and lateral circumflex arteries (found in capsule)

206
Q

How are elderly patients managed post-op hip fractures?

A

Early mobilisation

To prevent pulmonary complications and bed sores

207
Q

How are hip fractures managed in young people?

A

Reduce fracture and check with X-Ray
If satisfactory, fix with screws
Impacted fractures can be fixed as they lie

208
Q

What is hemiarthroplasty?

A

Only femoral part of hip joint replaced

209
Q

What are the indications for THR in hip fractures?

A

Acetabular damage

Metastatic or Paget’s disease

210
Q

What are the advantages of hemiarthroplasty vs THR in hip fractures?

A

Shorter operating time
Less blood loss
Lower infection rate

211
Q

What are the three types of proximal femur fracture?

A

Transcervical (neck of femur)
Intertrochanteric
Subtrochanteric

212
Q

How are intertrochanteric fractures managed?

A

Internal fixation - dynamic hip screw

213
Q

How do Subtrochanteric fractures compare to NOF fractures?

A

Blood loss greater in Subtrochanteric

214
Q

How are Subtrochanteric fractures managed?

A

Open reduction + internal fixation with intramedullary nails and locking screws into femoral head

215
Q

What is a common complication of Subtrochanteric fractures?

A

Malunion

216
Q

What are the common presenting complaints with the knee?

A 
Pain
Stiffness
Loss of function
Locking
Giving way
Swelling
Trauma
217
Q

What is locking of the knee?

A

Can’t be flexed

218
Q

What does the knee giving way going down stairs suggest?

A

PFJ problem

219
Q

What does the knee giving way on twisting/locking suggest?

A

Meniscus problem

Osteoarthritis

220
Q

What pain may be referred to the knee and why?

A

Hip

Femoral nerve innervation

221
Q

What is an antacid gait?

A

Hopping onto the good leg as soon as possible

To avoid pain

222
Q

What is a varus thrust?

A

Knee buckles to the side as it weight-bears

223
Q

What bony landmarks should you feel for in the knee?

A 
Femur
Tibia
Patella
Joint line
All done in 90degree flexion
224
Q

What is the sweep test?

A

Testing for effusion in the knee

Sweep fluid from medial side, then push back

225
Q

What special tests do you do for the knee?

A 
Sweep test
Collaterals
Anterior/posterior drawer
Lachman's
Straight leg raise
226
Q

How do you do anterior/posterior drawer tests?

A

Fix foot by sitting on it

Fingers either side of tibial tuberosity and rock back/forwards

227
Q

What is Lachman’s test?

A

For ACL
Pull tibia back/forward on femur
One hand on each bone at 30degrees

228
Q

What is the straight leg raise test for?

A

Shows extensor mechanism is intact

229
Q

What knee conditions are common in adolescents?

A 
Trauma/sporting injury eg meniscus, ACL, patella dislocation
PFJ pain
Osteochondritis dissecans
Inflammatory arthritis
Tumour
Infection
230
Q

What knee conditions are common in elderly patients?

A 
Osteoarthritis
Trauma
Crystal deposition
Infection
Secondary tumour
231
Q

What are the red flag symptoms for the knee?

A 
Inability to weight bear
Worsening pain
Acutely very stiff knee
Fever
Night pain
History of malignancy
232
Q

What are the functions of the menisci?

A

Improve articulate congruency and stability
Control rolling and gliding of knee
Distribute load during weight bearing

233
Q

Which meniscus is more liable to tearing and why?

A

Medial - less mobile than lateral meniscus

234
Q

What types of meniscal tear are there?

A

Bucket-handle
Anterior horn
Posterior horn
Horizontal tear

235
Q

What types of meniscal tear have worse healing?

A

Tears closer to the centre of the joint

This area is avascular

236
Q

What is the common presenting complaint of a meniscal tear?

A

Severe pain
Knee locked in flexion
Young patient following twisting injury to the knee

237
Q

What is the imaging of choice for meniscal tears?

A

MRI

White line through meniscus = tear

238
Q

What is osteochondritis dissecans?

A

Small fragment of avascular bone and overlying cartilage separates from femoral condyle
Later appears as a loose body in the joint
Intermittent pain and swelling

239
Q

What are the causes of loose bodies in the knee?

A 
Injury - chip of bone or cartilage
Osteochondritis dissecans
Osteoarthritis
Charcot's disease
Synovial chondromatosis
240
Q

What factors pre-dispose to OA of the knee?

A

Torn meniscus
Injury to articular surface
Ligament instability
Pre-existing deformity

241
Q

Where does cartilage breakdown most commonly start in the knee?

A

Area of greatest weight-bearing…medial compartment

242
Q

What may you observe in an osteoarthritic knee?

A

Swelling
Varus deformity
Quadriceps wasting

243
Q

What are the signs of OA on X-ray?

A

Loss of joint space
Subchondral sclerosis
Osteophytes
Sunchondral cysts

244
Q

What is the conservative management of osteoarthritis?

A

Analgesia
Apply warmth
Physio (quads)
Reduce joint load by sticks or weight loss

245
Q

What are the indications for knee surgery in OA?

A

Persistent, unresponsive pain

Progressive deformity and instability

246
Q

What happens in knee arthroscopy for OA?

A

Trim meniscal fragments/osteophytes and washout

Temporary relief, useful if reconstructive surgery is contraindicated

247
Q

When is realignment osteotomy used for OA?

A

Medial compartment disease in young people

248
Q

What are the sources of anterior knee pain?

A

Referred pain from the hip
Patellofemoral disorders
Knee joint disorders
Periarticular disorders

249
Q

What is Osgood-Schlatter’s disease?

A

Tibial tubercle apophysitis

250
Q

What patellofemoral disorders can cause anterior knee pain?

A

Patellar instability
Patellofemoral overload
Osteochondral injury
PFJ arthritis

251
Q

What is suggested by the feeling of the knee wanting to give way, or actually doing so, during weight-bearing activity?

A

Chronic ligamentous instability

252
Q

What are the types of tibiofemoral instability?

A 
Sideways tilt (varus or valgus)
Excessive glide (forwards or backwards)
Unstable rotation
253
Q

What are the indications for surgery in chronic ligamentous instability?

A

Intolerable giving way
Unacceptably reduced function
Associated internal injury eg torn meniscus
Symptomatic ligament injuries in adolescents

254
Q

What is Sinding-Larsen-Johansson syndrome?

A

Patellar tendinitis due to patellar ligament strain or partial rupture
Common in adolescent athletes
Repeated episodes of pain and local tenderness

255
Q

What is the function of the medial foot?

A

Stability and rigidity

256
Q

What is the function of the lateral foot?

A

Flexibility

257
Q

What is the function of the plantar fascia?

A

Helps support arch

Attaches skin to underlying tissue

258
Q

What is suggested by acute pain around the 1st MTPJ?

A

Gout

259
Q

What is metatarsalgia?

A

Diffuse ache across the forefoot

260
Q

Where is the subtalar gap?

A

In front of the lateral malleolus

261
Q

What is the nerve supply to the majority of the dorsum of the foot?

A

Superficial peroneal nerve

262
Q

What is the sensory supply to the lateral foot?

A

Sural nerve

263
Q

What should you look for when examining the foot?

A

Shoes
Whole leg: hip and knee
From front: alignment
Swelling, callosities, ulcers, vascularity
From behind: alignment, swelling, callosities, muscle bulk
Side: arches
Sole: plantar ulcer and callosities

264
Q

How many toes should you see from behind the foot?

A

2

More indicates a flat foot - too many toes sign

265
Q

What does walking on the outside of the feet test?

A

Tibialis posterior function

266
Q

What does deep pain and tenderness under the medial arch suggest?

A

Plantar fasciitis

267
Q

What movements should you test at the ankle?

A 
Dorsiflexion
Plantarflexion
Inversion
Eversion
Flexion and extension of toes
268
Q

What is the normal range of dorsiflexion at the ankle?

A

15 degrees

269
Q

What is the normal range of plantarflexion at the ankle?

A

40 degrees

270
Q

How do you test tibialis posterior function?

A

Point toes and push foot inwards while I resist

Tendon should stand out clearly behind medial malleolus

271
Q

What is Thomson’s test?

A

Squeeze calf and foot automatically plantarflexes

Doesn’t happen if Achilles has ruptured

272
Q

What happens to the heels when you stand on tiptoes?

A

Swing into valgus

Action of tibialis posterior

273
Q

How do you complete a foot and ankle examination?

A

Vascularity - pulses

Neuro: sensation and proprioception

274
Q

What is hallux valgus?

A

Bunion

275
Q

What happens in bunion surgery?

A

Metatarsal osteotomy - break and move metatarsal and put in screws/staples

276
Q

What is hallux rigidus?

A

Arthritis of 1st metatarsophalangeal joint

277
Q

What are the surgical options for hallux rigidus?

A

Osteotomy
Arthrodesis
Arthroplasty: excision/interposition/replacement

278
Q

What is planovalgus?

A

Flat foot

279
Q

What is the treatment of planovalgus?

A

Medial arch support
Physio
Can reconstruct tib post tendon

280
Q

What are the features of ankle arthritis?

A

Pain anteriorly over ankle

Stiffness

281
Q

How do you treat ankle arthritis?

A

Limit movement eg braces
Total ankle replacement
Osteotomy, arthrodesis, arthroplasty

282
Q

In what order are ankle ligaments commonly damaged?

A

Anterior talofibular
Calcaneofibular
Posterior talofibular

283
Q

What proportion of ankle sprains are associated with a fracture?

A

15%

284
Q

When is an X-ray indicated with ankle sprain?

A

Pain around the malleolus
Inability to weight bear/take 4 steps
Bone tenderness around base of metatarsal V

285
Q

How do you remember the structures passing anterior to the medial malleolus?

A

All Hospitals Are Not Very Dirty Places

286
Q

What else is commonly injured in ankle fractures?

A

Ligaments - invisible part of the injury

287
Q

What ankle fractures require internal fixation?

A

Displaced fractures and fracture-dislocations

288
Q

What are the complications of ankle fractures?

A

Joint stiffness
Complex regional pain syndrome
Osteoarthritis

289
Q

What is a Pilon fracture?

A

Tibial plafond fracture

Severe axial compression of ankle joint eg fall from height

290
Q

What is commonly associated with calcaneal fractures?

A

Spine, pelvis or hip injuries

291
Q

What are the common causes of metatarsal fractures?

A

Direct blow
Severe twisting
Repetitive stress

292
Q

What is the composition of bone extracellular matrix?

A

35% organic material: type I collagen, proteoglycans, glycosaminoglycans, lipids
65% inorganic material: hydroxyapatite

293
Q

What are cutting cones?

A

In bone formation

Osteoclasts remove bone at the front of the cone, osteoblasts follow behind producing new bone

294
Q

What is intramembranous ossification?

A

Preosteoblasts differentiate into osteoblasts which produce bone
This increases bone width

295
Q

What is endochondral ossification?

A

Pre-existing cartilage template is replaced by bone to increase bone length
Due to osteoblast activity

296
Q

Define fracture

A

Break in the structural continuity of bone

297
Q

What are the local complications of fracture?

A

Local oedema
Inflammatory reactions
Neurovascular impairment

298
Q

What is an open fracture?

A

Breach in skin or body cavity

299
Q

What is primary bone healing?

A

Minimal granulation tissue and no callus
Cutting cones form and cross the fracture site
Osteoclasts clear damaged bone and osteoblasts produce new bone
Happens if defect/gap is small

300
Q

What are the stages of secondary bone healing?

A

Haematoma formation
Fibrocartilaginous callus formation
Bony callus formation
Bone remodelling

301
Q

How does a haematoma form over a fracture site?

A

Fracture causes rupture of vessels
Damaged tissue and platelets release cytokines, vasomodulatory substances and growth factors
Causes clot to form

302
Q

What is Wolff’s law?

A

Bone can remodel and adapt to the loads placed on it

303
Q

What are BMPs?

A

Bone Morphogenic Proteins
I.e. Cytokines, metabolites
Induce formation of bone and cartilage

304
Q

How does PTH affect bones?

A

Stimulates osteoclasts

305
Q

What factors interrupt bone healing?

A

Movement of bony fragments
Soft tissue lying in between bony fragments
Misalignment
Infection
Bone disease
Surrounding soft tissue injury - damages blood supply

306
Q

What patient factors interrupt fracture healing?

A 
Poor general health
Malnutrition
Drug therapy
Age
Smoking
Diabetes
307
Q

How does diabetes affect fracture healing?

A

Defective collagen production

308
Q

How does smoking affect fracture healing?

A

Reduces osteoblast activity

Nicotine constricts vessels, reducing blood flow to fracture site

309
Q

What local patient factors affect fracture healing?

A

Blood supply
Soft tissue damage
Bone loss - need bone contact for Union

310
Q

What are the stages of fracture management?

A

Diagnosis
Reduction
Stabilisation
Rehabilitation

311
Q

What forms the physical examination of a fracture?

A

Deformity - open or closed?

Neurovascular status distal to fracture

312
Q

How do you describe displacement of a fracture?

A

Distal fragment relative to proximal fragment

313
Q

What is fracture translation?

A

% displacement

314
Q

What is anatomical reduction of a fracture?

A

To restore perfect bony anatomy and morphology

Required with joint fractures

315
Q

What is functional reduction of a fracture?

A

To restore relationship between proximal and distal bone fragments
Length, alignment and rotation restored
Needed for metaphyseal and diaphyseal fractures

316
Q

What is indirect reduction?

A

Closed reduction - lower infection risk

317
Q

What are the indications for open reduction?

A

Failure of closed reduction
Large articular fragments
Avulsion fractures
Associated injuries eg arterial damage

318
Q

What are the aims of fracture stabilisation?

A

Prevent fragment displacement
Alleviate pain
Allow soft tissue healing
Allow movement of unaffected joints

319
Q

What are the different methods used for fracture stabilisation?

A 
Sustained traction
Cast splintage
Functional bracing
Internal fixation
External fixation
320
Q

What are the risks associated with cast splintage?

A

Cast too tight - constricts blood supply causing diffuse pain
Pressure sores
Stuff joints
Loose cast

321
Q

What is functional bracing?

A

Segments of cast over bones, leaving joints exposed

Segments connected by hinges

322
Q

How may ultrasound be used in fracture healing?

A

Exogen ultrasound bone healing system
Treat non-union fractures of long bones
Stimulates production of growth factors and proteins to increase removal of old bone and production of new bone

323
Q

What are the indications for internal fixation?

A 
Can't be reduced with other techniques
Prone to displacement after reduction
Poor or slow fracture Union suspected
Pathological fractures
Multiple fractures
Patients with nursing difficulties
324
Q

What are the potential complications of internal fixation?

A

Inaction
Non-Union
Implant failure eg metal fatigue
Re-fracture if implants removed too soon

325
Q

What is external fixation?

A

Bone fixed above and below fracture site

Screws, pins and tension wires connected together by rigid bars or attached to a frame

326
Q

What are the complications of external fixation?

A

Soft tissue damage
Over-distraction
Pin-track infection

327
Q

What are the aims of early movement and weight-bearing following fracture?

A

Prevent oedema
Restore joint movement
Restore muscle power
Introduce patient back to normal activity

328
Q

How does exercise help fracture healing?

A

Stimulates blood flow
Prevents soft tissue adhesions
Promotes fracture healing

329
Q

What antibiotics do you give immediately once an open fracture has been diagnosed?

A

Co-amoxiclav or Cefuroxime

Clindamycin if penicillin allergic

330
Q

How do you inspect an open fracture?

A 
Clean or dirty
Gross contamination
Site and size
Tidy or ragged damage
Establish communication of wound with fracture
Condition of soft tissues
Neurovascular status
331
Q

What are the steps in managing an open fracture in A&E?

A 
ATLS assessment
Tetanus prophylaxis + Antibiotics
Inspect wound
Photograph
Revise splint from paramedics
X-ray or CT
Remove gross contamination and photograph again
Refer to ortho, plastics or vascular and transfer
332
Q

When is amputation indicated for open fractures?

A 
Uncontrollable haemorrhage
Incomplete traumatic amputation
4-6h of ischaemia
Segmental muscle loss of 2 compartments
Bone loss greater than 1/3 of the tibia
333
Q

What are the causes of pathological fractures?

A

Tumour: primary or secondary
Infection
Metabolic disease: osteoporosis, osteogenesis imperfecta

334
Q

What are the red flag symptoms for children?

A

Bone tenderness to palpation
Joint swelling
Muscle weakness
Fall in height or weight growth curve

335
Q

What 5 cancers commonly metastasise to bone?

A 
Kidney
Prostate
Thyroid
Breast
Lung
336
Q

What are the red flag symptoms for soft tissue lumps?

A

> 5cm
Deep to deep fascia
Painful
Enlarging

337
Q

What investigations should you do if pathological fracture is suspected?

A 
X-ray whole bone
CXR
PSA
Bence-Jones protein in urine (myeloma)
Isotope bone scan
CT chest
MRI lesion
338
Q

What are the treatment options for pathological fractures?

A

Intramedullary nail
Cement augmentation
Replacement
Consider excision if tumour is primary and prognosis good

339
Q

What are the three most common types of primary bone tumour?

A

Osteosarcoma
Chondrosarcoma
Ewing’s sarcoma

340
Q

Where do osteosarcomas commonly present?

A

Distal femur or proximal tibia

Young adult

341
Q

How do malignant bone tumours present?

A 
Mass - 80%
Discomfort/pain - 40%
Fracture
Mets
Systemic symptoms
342
Q

How do soft tissue sarcomas present?

A

Large mass
Deep to deep fascia
Rapidly growing
Calcification within mass on radiograph

343
Q

What are the urgent complications of a fracture?

A 
Vascular injury
Local visceral injury
Compartment syndrome
Haemarthrosis
Nerve injury
Infection
Gas gangrene
344
Q

What are the late complications of fracture?

A 
Malunion
Non-Union
Avascular necrosis
Muscle contracture
Joint instability
Regional pain syndrome
Osteoarthritis
345
Q

What vessel is commonly injured in 1st rib fracture?

A

Subclavian artery

346
Q

What vessel is commonly affected in shoulder dislocation?

A

Axillary artery

347
Q

What vessel is commonly damaged in humeral supracondylar fracture?

A

Brachial artery

348
Q

What vessel is commonly affected in knee dislocation?

A

Popliteal artery

349
Q

What nerve may be damaged in a humeral shaft fracture?

A

Radial

350
Q

What nerves may be damaged in humeral supracondylar fracture?

A

Radial

Median

351
Q

What nerve may be damaged in elbow dislocation?

A

Ulnar

352
Q

What nerve may be damaged in a monteggia fracture?

A

Posterior interosseous

353
Q

What nerve may be damaged in hip dislocation?

A

Sciatic

354
Q

What nerve may be damaged in knee dislocation?

A

Peroneal

355
Q

How may wrist fractures affect nerves?

A

Sometimes cause nerve compression

Median or ulnar nerve

356
Q

Define compartment syndrome

A

Raised pressure within an enclosed fascial space

Leading to localised tissue ischaemia

357
Q

What vessels are affected first in compartment syndrome?

A

Veins

358
Q

What are the causes of acute compartment syndrome?

A 
Fracture (70%)
Crush syndrome
Bleeding disorder / anticoagulants
Soft tissue injury without fracture
Reperfusion injury
Infection
Iatrogenic eg osteotomy, reduction
359
Q

Where is compartment syndrome most common?

A

Lower limb

Mainly due to tibial fractures

360
Q

What are the clinical features of compartment syndrome?

A

Pain: excessive or progressive, not relieved by analgesia
Tense, swollen compartment
Paraesthesiae
Pulses rarely absent

361
Q

What test can tell you which compartment is involved in compartment syndrome?

A

Passive stretch test

Pain

362
Q

How do you manage acute compartment syndrome?

A

Split circumferential dressings to skin
Single dose opiate
Reassessment
May need compartment pressure monitoring

363
Q

Who should have compartment pressure monitoring?

A 
Unconscious
Difficult to assess
Multiple injuries
Associated nerve injury
Young men
364
Q

What are the compartments of the lower leg?

A

Anterior
Lateral
Deep posterior
Superficial posterior

365
Q

How is fasciotomy of the lower leg performed?

A

2 incisions:

Medial and anterolateral

366
Q

What are the three compartments of the thigh?

A

Anterior
Medial
Posterior

367
Q

What are the three compartments of the forearm?

A

Palmar (flexor)
Dorsal (extensor)
Radial

368
Q

How is compartment syndrome managed post-op fasciotomy?

A 
Leave wounds open
Loose absorbent dressings
Gentle elevation
Fluid balance and analgesia
Re-inspection + debridement + delayed closure @ 2-5d
369
Q

What are the complications of compartment syndrome?

A 
Muscle necrosis
Joint stiffness
Nerve fibrosis
Delayed fracture union
Significant functional impairment
370
Q

What type of deformity is common following tibial fracture?

A

Ischaemic contractures

371
Q

How do microorganisms reach bones and joints?

A

Bloodstream

Direct invasion from skin puncture, operation or open fracture

372
Q

What can microbial invasion in bones and joints lead to?

A

Pyogenic osteomyelitis
Arthritis
Granulomatous reaction (chronic)

373
Q

Why does bone infection lead to necrosis more rapidly than soft tissue infection?

A

It is a rigid compartment so

More susceptible to cell death from pressure build-up in acute inflammation

374
Q

What factors increase susceptibility to infection of bone?

A

Local factors: trauma, poor circulation, chronic bone or joint disease and presence of foreign bodies
Systemic factors: malnutrition, general illness, diabetes, RA, steroid treatment
Very young or very old age

375
Q

What is the pathophysiology of acute pyogenic infection?

A

Pus formation = concentration of defunct leucocytes, dead bacteria and tissue debris
Often localised to form an abscess

376
Q

What are the principles of treatment for pyogenic bone infection?

A 
Analgesia and supportive measures
Rest affected area
Antibiotic or chemotherapy treatment
Evacuate pus and necrotic tissue
Stabilise bone if fractured
Maintain soft tissue and skin cover
377
Q

What organism is the most common cause of acute osteomyelitis?

A

Staph aureus

378
Q

Why does acute osteomyelitis lead to bone necrosis?

A

Rising intraosseus pressure
Vascular stasis
Compromise of blood supply to bone

379
Q

Where do children commonly get acute osteomyelitis?

A

Organisms settle in metaphysis of long bones

Commonly distal femur or proximal tibia

380
Q

How does acute osteomyelitis present?

A

Most commonly children under 4
Severe pain, malaise and fever
May be history of preceding skin lesion, injury or sore throat
Holding limb still, acutely tender over nearby joint, pseudoparalysis

381
Q

Where is the commonest site of acute osteomyelitis in adults?

A

Spine

382
Q

What are the differential diagnoses for acute osteomyelitis?

A

Cellulitis

Sickle cell crisis

383
Q

What are the complications of acute osteomyelitis?

A

Spread to joints or other bones
Pathological fracture
Growth disturbance
Persistent infection

384
Q

What is subacute haematogenous osteomyelitis?

A

Osteomyelitis in a relatively mild form

Due to less virulent organisms or a more resistant patient

385
Q

What is a Brodie’s abscess?

A

Small oval cavity surrounded by sclerotic bone

Classic of subacute haematogenous osteomyelitis

386
Q

What is the commonest cause of osteomyelitis in adults?

A

Post-traumatic (open fractures)

387
Q

How does chronic osteomyelitis present?

A

Following acute bone infection

Recurrent episodes of pain, redness, tenderness at affected site

388
Q

What organism commonly causes septic arthritis?

A

Staph aureus

389
Q

How do organisms get into a joint to cause septic arthritis?

A

Penetrating wound
Eruption of adjacent bone abscess
Blood spread from distant site

390
Q

What joints are most commonly affected by septic arthritis?

A

Hip in children

Knee in adults

391
Q

What does X-ray show in septic arthritis?

A

Soft tissue swelling
Widening of joint space due to effusion
Periarticular osteoporosis

392
Q

How do you investigate septic arthritis?

A

Joint aspiration and send for microbiology

393
Q

What are the differential diagnoses for an acute swollen joint?

A 
Septic arthritis
Osteomyelitis
Acute haemarthrosis
Transient synovitis
Gout or pseudogout
394
Q

What are the complications of septic arthritis?

A

Dislocation
Epiphyseal destruction
Growth disturbance
Ankylosis

395
Q

What is the management of septic arthritis?

A

Antibiotics
Splintage
Drainage

396
Q

What is NAI?

A

Non-accidental injury

397
Q

What is the cause of 90% of fractures before age 1?

A

Non-accidental injury

398
Q

What are Greenstick fractures?

A

One side of the periosteum stays intact when the bone is bent, so the fracture is not full thickness
Because periosteum is very thick in children

399
Q

Give a cause of a physeal fracture

A

Knee hyper extension injury

400
Q

What is the apophysis?

A

Centre of ossification where a tendon is inserting

401
Q

In what order to the ossification centres develop at the elbow?

A 
CRITOL
Capitulum
Radial head
Internal (medial) condyle
Trochlea
Olecranon
Lateral epicondyle
402
Q

What are the differential diagnoses for a limping child?

A 
Infection
Developmental Dysplasia of the hip
Perthes' disease
SUFE (adolescent)
Club foot
403
Q

How does hip infection present in children?

A

Unable to weight bear
Raised WCC and CRP
Fever over 38.5

404
Q

What are the risk factors for developmental dysplasia of the hip?

A

Female
Family history
Breach presentation at birth

405
Q

How do you test for developmental dysplasia of the hip?

A

Ortolani test: reduces dislocation

Abduct and lift, feel it clunking back into place

406
Q

How do you treat developmental dysplasia of the hip?

A

Frame to abduct and flex hip

407
Q

What is Perthes’ disease?

A

Avascular necrosis of the hip
Cause of loss of blood supply unknown
Causes deformity of the head of femur and predisposes to OA
Commonly presents in 4-8y, but can be other ages

408
Q

What is SUFE?

A

Slipped Upper Femoral Epiphysis

Neck of femur slipping and externally rotating can cause avascular necrosis, impingement or secondary OA

409
Q

What is the incidence of club foot?

A

1 in 1000

410
Q

How is club foot managed?

A

Slowly manipulating feet using plaster casts

Minor surgery may be required later on if the problem recurs

411
Q

How does foot alignment change during development?

A

Infant: geno varum
2-3y: geno valgum
7y: adult alignment (coronal)

Phase 2 (21 decks)

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