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How do you read an X-ray?

  • Basic Information
    • Name / DOB
    • When it was taken/view/body part
      • Remember to always get 2 views
  • Problem
    • Fracture
      • Location
      • Displacement
      • Fracture Pattern
    • Dislocation
      • Direction / Rotation
    • Shadowing
      • Ca / Tumour / Infection / Cyst
    • Osteoarthritis
      • 4 key features


How would you describe the displacement of a fracture

  • Angulation (in degrees)
  • Direction
    • Superior / inferior / anterior / posterior / medial / lateral
    • Dorsal / Palmar (Volar) / radial / ulna
  • Translation (as a %)
    • if 100% then off ended
  • Shortening (Compaction)
    • estimate how much shorter in (cm)
  • Rotation
    • Medial / lateral


What are the different types of fracture patterns?

  • Transverse
  • Oblique
  • Spiral
  • Comminuted
  • Segmental
  • Impacted
  • Salter-harris (epiphyseal plate fracture)
  • Wedge
  • Greenstick
  • Torus / Buckle


What are the 4 signs of Osteoarthritis (OA) on Xray?

  • Loss of joint space
  • Osteophytes
  • Sclerosis
  • Subchondral cysts


What is a greenstick fracture and when does it occur?

When only 1 side of the cortex is broken the other is only bent

Occurs in children as their bones are softer and more malleable


What is a Torus / Buckle fracture

Axial pressure on a long bone leads to a buckle and a bulge in the cortex at the fracture site


What is a salter harris fracture and how are they classified?

Fracture involving the epiphyseal growth plate

5 types depending on location

  1. (S-straight) Transverse through physis
  2. (A-above) Through physis and metaphysis
  3. (L-lower) Through physis and epiphysis
  4. (T-through) Through all 3
  5. (ER-crush) Compression at physis


When are benign and aggresive periosteal reactions seen?

  • Benign
    • Callus formation in fractures
    • Slow growing tumours
  • Aggresive 
    • Infected bone
    • Eosinophillic granuloma
    • Malignant tumours
    • Osteoid osteoma
    • Bone cysts


What are the types of periosteal rection from least aggresive to most?

  • Solid
    • uniformly dense, single thin layer of new bone about 1-2 mm from the cortical surface.
  • Lamellated
    • multiple concentric parallel layers of new bone adjacent to the cortex, reminiscent of the layers on an onion
  • Spiculated 
    • represents spicules of new bone forming along vascular channels and the fibrous bands that anchor tendons to bone
  • Codman's 
    • the periosteum does not have time to ossify, so only the edge of the raised periosteum will ossify.


What things must you are generic to any joint examination?

  • Look
    • Swelling / brusing / discolouration
    • Scars (ask where they are from)
    • Asymmetry
  • Feel
    • Bony prominences
    • Muscle bulk (for wasting)
    • Tenderness
  • Move
    • Active + Passive movements
    • Resistence against power
  • Joint hypermobility
    • Beighton scoring (4/9 indictates hypermobility)


When observing during a spinal examination what must you look out for?

  • Asymmetry
    • Shoulder drop
    • Scapula protrussion
    • Unaligned iliac crests
  • Spine curvature
    • Scoliosis (sideways)
    • Kyphosis (hunchback)
    • Lordosis (big bum)
  • Gait
    • Normal walking
    • Test myotomes by getting patient to walk
      • on their tip toes (S1)
      • on their heels (L5)


What should you feel for during a spinal exam?

  • Down the spinous processes
    • feeling for tenderness
  • Paraspinal muscles
  • Scaro iliac joints
  • Verterbral Landmarks
    • Most prominant cervical vertebrate (C7)
    • Iliac crest (L4)
    • Posterior superior iliac spine (S2)


What movements should you do during a spine examination

  • Cervical
    • Flexion + Extension (C1) (chin to chest)
    • Rotation (C1/C2) (turn head)
    • Lateral Flexion (C2-7) (ears to shoulder)
  • Thoracic
    • Rotation (Siting and you hold hips straight)
  • Lumbar
    • Flexion + Extension (touch toes / lean back)
    • Later flexion (run arm down same leg)


What special tests are conducted in a spine examination

  • Schober's test
    • Mark skin at sacro iliac join
      • Mark skin 10cm above + 5cm below
      • Patient touch toes
      • 15cm gap should now be >20cm
    • Indicates restriction of lumber spine
      • Ankylosing spondylitis
  • Straight leg raise
    • Raise patient leg while knee is flexed
    • Extend the knee
      • If pain is present down the back of the leg sciatica is likely
      • Pain worsens during dorsiflexion (this is a +ve sciatic stretch test)
    • If pain is in opposite leg it will indicate a disc prolapse


When conducting a periheral neurological exam what are you looking for and feeling for?

  • Looking
    • Scarring 
    • Loss of muscle mass
    • Fasciculations
    • Gait (lower limb only)
    • Pronator drift (upper limb only)
  • Feeling
    • Muscle mass
    • Isolate movements of each joint and test them
    • Hypertonia (Rigidity)
      • Clasp knife (UMN lesion)
      • Leadpipe / Cogwheel (Parkinson's)
    • Hypotonia
      • LMN lesion


What do you look for in a patient's gait?

  • Parkinson's (Festinating) Gait
    • Stooped forward with no arm swing
    • Delayed initiation with festination
    • Pedestal turning
  • Trendelenburg Gait
    • Waddling gait with swinging hips
    • Dennervation to superior gluteal nerve due to damage in L4-S1
  • Stomping / Foot slapping gait
    • Loss of proprioception
    • Do romberg's test to verify
  • Scissoring gait
    • UMN lesion (cerberal palsy)
  • Cerebellar gait
    • Drunken walk staggering to side of lesion
  • Antalgic gait
    • Patient in pain


What do each of the myotomes in the upper limb do?

  • C5 - Elbow flexion
  • C6 - Wrist exension
  • C7 - Elbow extension
  • C8 - Finger flexion
  • T1 - Finger abduction


What do each of the myotomes in the lower limb do?

  • L2 - Hip flexion
  • L3 - Knee extension
  • L4 - Dorsiflexion of foot
  • L5 - Dorsiflexion of big toe
  • S1 - Plantarflexion of foot


Describe the MRC power grading

  1. No movement
  2. Flicker of contraction
  3. Active movement with no gravity
  4. Active movement against gravity
  5. Active movement against moderate resistance
  6. Normal Movement


What reflexes should you test in both the upper and lower limb

  • C5 Biceps brachii
  • C6 Brachioradialis
  • C7 Triceps brachii


  • L3/4 Patella tendon
  • S1/2 Calcaneal tendon


Special tests when examining the neurological function of the upper limb?

  • Cerebellar ataxia
    • Finger nose test for past pointing
    • Hand flipping for dysdiadochokinesia
  • UMN lesion
    • Hoffman's test
      • Hold middle finger at middle phalanx and flick distal phalanx
      • Thumb twitching indicated UMN lesion
    • Pronator drift


Special tests when examining the neurological function of the lower limb?

  • Cerebellar Ataxia
    • Heel to shin test
    • Tap feet against examiners hand as for as possible to assess dysdiadochokinesia
  • UMN lesion
    • Babinski's test
    • Clonus


Signs of an UMN lesion

  • Hyperreflexia
  • Hypertonia
  • Weakness
  • Special Tests
    • Babinski's Sign
    • Hoffman's Sign
    • Pronator Drift
    • Clonus


Signs of a LMN lesion

  • Hypotonia
  • Hyporeflexia / Areflexia
  • Weakness / Wasting
  • Fasciculations


Where is each dermatome situated on the upper limb

C5 - Regimental Badge Area

C6 - Thumb

C7 - Middle Finger

C8 - Little Finger

T1 - Medial Forearm

T2 - Medial Arm


Where is each dermatome situated on the lower limb

L1 - Groin

L2 - Anterior Thigh

L3 - Knee

L4 - Medial Malleolus

L5 - Big Toe

S1 - Heel

S2 - Popliteal Fossa


What do you use a DRE to asses

  • Anal Tone
    • S2,3,4 keeps your shit off the floor
    • Also check voluntary contraction
  • Stool Compaction
  • Perianal Sesation


What is spinal stenosis?

What are the complications?

What are the causes?

What are the risk factors?

  • Spinal stenosis is the narrowing of the spinal canal causing:
    • Nerve impingement
    • Cauda Equina
    • Neurogenic claudication
  • Caused by
    • Osteophytes
    • Hypertrophy of ligamentum flavum
  • RFs
    • Hyperparathyroidism 
    • Paget's
    • Ankylosing spondylitis
    • Cushing's
    • Acromegly


What is neurogenic intermittent claudication?

What causes it?

How do you differenciated it from vascualar claudication?

  • Pain pattern similiar to vascular claudication but caused by nerve impingment
  • Caused by spinal stenosis
  • Differenciate from vascular
    • Proximal pain in thigh rather than calf
    • No pain when cycling as no impingement when in bent position
    • Pain better going up hills as opposed to vascular.
    • Pain worsened by passive leg stretch test


How do you investigate neurogenic claudication?

How do you treat neurogenic claudication?

  • Investigations
    • X-ray / CT
      • Underlying abnormality such as
        • spina bifida occulta 
        • spondylolisthesis
    • MRI
  • Treatment
    • Conservative
      • NSAIDS / Parcetamol
      • Weight Reduction
      • Physio (Forward flexion)
      • Epidural steriod injections
    • Surgical
      • Decompression (Laminectomy)


What are the red flag symptoms for back pain? (Mneumonic)


  • Age <18 or >55
  • Trauma
  • Unexplained weight loss
  • Neurological symptoms
  • Atypical Pain
    • Thoracic
    • Pain when lying down
    • Non mechanical
  • Fever / Sweats / Rigors
  • Incontinence / Retention (Urinary)
  • Steriods
  • History of Ca.


Causes of back pain?

  • Trauma 
    • Fracture 
    • Sprain
  • Rhematoid
    • Ankylosing Spondylitis
    • Rheumatoid Arthritis
    • Polymyagia rheumatica
    • Osteoarthritis spondylosis
    • Septic arthritis
  • Osteomalacia
  • Refered Pain
    • Hip (tumour / athritis / ischeamia)
    • Sciatica 
  • Tumour
  • Intervertebral disc
    • Herniated nucleaus pulposus


What is cauda equina?

What are the red flag symptoms?

  • Medical Emergency involving the impingment of the cauda equina leading to paraplegia and incontinence
  • Red flag symptoms
    • Saddle paraesthesia
    • Faecal incontinence
    • Urinary retention + overflow incontinence


What are the causes of Cauda Equina

  • Herniation of lumber discs
  • Verterbrae tumours
  • Trauma
  • Infection
  • Congenital stenois (spina bifida)
  • Spondylolysis / Spondylolisthesis
  • Ankylosing spondylitis


What are the differential diagnosis for cauda equina

  • Conus medullaris syndrome (T12-L2 compression)
  • Mechanical back pain
  • Prolapsed lumber disc
  • Fractured lumber vertebrae
  • Spinal tumour
  • Spinal cord compression
  • peripheral neuropathy


What is the options for cauda equina?

  • Tumour cause
    • Surgical decompression
    • Radiotherapy
    • Chemotherapy
  • Inflamatory cause
    • NSAIDS
    • Steroid injections
  • Infectious cause
    • Antibiotics
  • General
    • Reduce weight
    • Physiotherapy


What is spina bifida?

What causes it?

What are the different types?

  • Failure of closure of the posterior neuropore
  • Folic Acid deficiency
  • Spina bifida
    • Occulta
      • Skin intact
      • Vertebral arch defect
    • Cystica (skin not intact)
      • Meningocele, protruding sac made of meninges
      • Myelomeningocele, neural tissue in protruding sac
    • Rachischisis
      • Cleft through the entire spine, leaving the spinal cord exposed


What is anencephaly

  • Failure of closure of the anterior neuopore
    • Brain does not develop
    • Not compatable with life


How can cases of spina bifida occulta be picked up on examination?

Spina bifida occulta leaves skin markings over the site of the defect such as increase hair growth, skin tags or discolouration.


What are the complications of spina bifida cystica

  • Developmental dysplasia of the hip
  • Scoliosis
  • Hyrocehpalus
  • Arnold chiari 2 malformation of the skull
  • Renal Impairment
    • Neurogenic bladding 
      • Overflow incontinence
      • Increased risk of UTIs
  • Spinal Cord tethering
  • Meningitis
  • Increased Risk of Latex allergy


What are the 2 ascending spinal tracts and what are they responsible for?

  • SPinoThalamic
    • Responsible for Pain and Temperature
  • Dorsal Column Medial Leminiscus Pathway
    • Responsible for fine touch, proprioception and vibration


What are the 2 descending spinal cord tracts and what are the responsible for?

  • Pyramidal Tracts (Corticospinal)
    • Pass through the medullary pyramid and innervate most motor function.
    • Damage leads to UMN lesion signs
      • Spasticity, Clasp Knife Rigidity
      • Hyperreflexia + Hypertonia
      • Muscle Weakness
  • Extrapyramidal Tracts
    • Rubrospinal, Tectospinal, Vestibulospinal, Reticulospinal
    • Damage leads to cerebellar signs (DANISH)
      • Dysdiadochokinesia, Ataxia, Nystagmus, Intention tremor, Slurred speech, Hypotonia


What are the symptoms of a central cord injury and what most commonly causes this.

  • Causes
    • Hyperextension injury (Whiplash)
    • Spinal cord ischaemia
    • Syringomyelia
      • Chiari malformation increases risk of cyst forming 
    • B12 deficiency
    • Cervical Stenosis
  • Symptoms
    • Motor and Sensory defecits, mostly in upper extremities
    • Hands affected with UMN lesion symptoms
    • Burning sensation in hands with cape distribution of sensory loss mostly affecting spinothalamic


What is chiari malformation?

A Chiari malformation is where the lower part of the brain pushes down into the spinal canal.


What are the causes and symptoms of an anterior cord injury?

  • Causes
    • Excessive flexion of C-spine causing anterior compression
    • Ischaemic damage due to thrombosis or trauma of the anterior spinal artery
  • Symptoms
    • Motor: Variable paralysis below the affected spinal level
    • Sensory: Only Spinothalamic pathway affected


What causes Brown-Sequard Syndrome and what are the symptoms?

  • Cause
    • Hemitransection of the cord usually from penetrating trauma
  • Symptoms
    • Ipsilateral loss of motor function
      • Decussates in medulla oblongata
    • psilateral loss of Dorsal column
      • Decussates in medulla oblongata
    • Contralateral loss of Spinothalamic pathway
      • Decussates at exit level


What are the causes and symptoms of a posterior spinal cord injury?

  • Causes
    • Penetrating injury to back
    • Hyperextension leading to vertebral arch fracture
  • Symtoms
    • Only dorsal column medial lemniscus pathway affected


What would be the most likely cause of spinothalamic sensation loss across the thumb and lateral 2.5 fingers?

Carpal Tunnel Syndrome


What would be the most likely cause of spinothalamic bilateral sensation loss at the level of the umbilicus with accompanying weakness across both lower limbs

Complete spinal cord injury


What would be the most likely cause of left sided spinothalamic sensation loss at the level of the umbilicus with accompanying weakness the right lower limb

Brown Sequard Syndrome


What would cause spinothalamic cape sensation loss (across the shoulders and up the neck)



What would right sided spinothalamic sensation loss from the nipple downwards and left sided facial sensation loss

Brain stem injury


What would cause entire left side spinothalamic sensation loss?

Thalamic or cerebral hemisphere injury


How do you investigate and manage a spinal cord injury?

  • Investigation
    • X-ray/Ct for vertebral fracture
    • MRI for soft tissue injury such as disc herniation or ligamentum damage
      • Could use a CT myelogram for this aswell (spinal cord contrast)
  • Managment
    • Support and maitain stability to prevent further damage
    • Refer to neurosurgeon as emergency spinal decompression maybe needed


What are the complications of a spinal cord injury?

  • Autonomic dysreflexia
    • Uncontrolled sympathetic stimulation causing
      • uncontrolled hypertension
        • increasing risk of stroke
      • severe headache
      • cold and clammy skin
      • dilated pupils
  • Aspiration
  • Chronic MSK pain
  • Limited regeneration of spinal cord leads to persitence of symptoms following treatment


What are you looking for during a hip examination?

  • Gait
    • Antalgic (pain)
    • Trendelenburg (superior gluteal nerve injury causing abductor weakness on contralateral side)
    • Parkinsonian (shuffling/festinating)
    • Ataxic (cerebellar)
    • Steppage (foot drop)
    • Stomping (loss of proprioceptive input)
  • Valgus/Varus
  • Muscle wasting
  • Swelling, bruising, discolouration, scarring
  • Leg length
    • Flex knees see if they are the same height
    • Extend legs match medial malleolus


What should you feel for during a hip exam?

What special tests can you do?

  • Landmarks
    • Great trochanter (trochanteric bursitis)
    • Ischial tuberosity (strained hamstrings)
  • Special test
    • Thomas' test (dont do in patients with hip replacments as you will dislocated the hip)
      • Place hand under patient's back and flex leg at hip + knee untill you feel back go down
      • Observe if contralateral leg is also flexed
      • Evidence of a fixed flexion deformity


do you like big butts

i cannot lie