ORTHOPAEDICS – THE BASICS

Ruchir Shah FY1

Mr Alwyn Abraham Consultant Leicester

NEXT

INSTRUCTIONS

• Click NEXT to progress through slides
• Select your answer by clicking on it
• After being told if its correct or incorrect click GO BACK
• Some questions may require you to go back and select multiple answers

​

• There are 25 questions
• Good Luck!

NEXT

1. WHAT COMMON PROBLEM MUST ALL NEWBORNS BE EXAMINED FOR?

DDH using the Ortolani and Barlow tests

DDH by checking leg lengths

Perthes disease with an ultrasound

SUFE with an xray

NEXT

EXPLANATION

• Leg length discrepancy will be obvious 6mths upwards not in a tiny neonate (0-4 weeks). Perthes is common at junior school age and SUFE in adolescents (13+)

NEXT

Go Back

2. WHAT IS COMPARTMENT SYNDROME?

Most commonly with a compound tibial fracture

Most commonly with a femoral fracture

Also known as shin splints

NEXT

Increased pressure in a closed fascial space, most commonly with a tibial fracture

EXPLANATION

• Most commonly in tibial fractures, due to increasing pressure due to bleeding. A compound fracture decompresses the pressure. Shin splints is a chronic inflammation of the periosteum due to repetitive trauma.

NEXT

Go Back

3. ACUTE SEPTIC ARTHRITIS OF THE KNEE MAY BE DIFFERENTIATED FROM INFLAMMATORY ARTHRITIS BY WHICH LABORATORY TEST?

Gram stain, culture

CRP and WCC

MRI scan

Blood culture

NEXT

EXPLANATION

• CRP and WCC are non specific. A blood culture doesn’t identify the source. Aspiration and microscopy are the traditional tools but not always sensitive.

NEXT

Go Back

4. A PATIENT DISLOCATES HIS KNEE IN A CAR ACCIDENT. WHAT STRUCTURE(S) IS/ARE AT RISK FOR INJURY AND THEREFORE MUST BE EVALUATED IMMEDIATELY?

Tibial nerve

Peroneal nerve

Patella tendon

NEXT

Popliteal artery by checking for the 5 Ps

EXPLANATION

• Acute ischaemia post trauma = limb loss. It has to be identified and addressed. Nerve injuries are debilitating but don’t threaten the limb acutely.

NEXT

Go Back

5. A PATIENT PUNCHES HIS COMPANION IN THE FACE AND SUSTAINS A FRACTURE OF THE 5TH METACARPAL AND A 3 MM BREAK IN THE SKIN OVER THE FRACTURE.�WHAT IS THE CORRECT TREATMENT, AND WHY?

Antiseptic wipe

K wire fixation

irrigation and antibiotics in A&E

NEXT

Irrigation and debridement; risk of infection

EXPLANATION

• Also known as fight bite. Risk of septic arthritis is high. What might be the sequelae?

NEXT

Go Back

6. A PATIENT COMES TO THE OFFICE COMPLAINING OF LOW BACK PAIN THAT WAKES HIM UP FROM SLEEP.�WHAT TWO DIAGNOSES ARE YOU CONCERNED ABOUT?

Tumour

Ankylosing spondylitis

Mechanical back pain (non specific low back pain NSLBP)

Infection

NEXT

EXPLANATION

• A short history less than 6 weeks usually indicates an evolving process ie neoplasia or infection. NSLBP has a much longer history and is usually associated with yellow flags.

NEXT

Go Back

7. HOW IS COMPARTMENT SYNDROME TREATED?

observation

analgesia

Fracture fixation

NEXT

Fasciotomy

EXPLANATION

• Relieve the fascial pressure to prevent muscle death

NEXT

Go Back

8. A PATIENT LANDS ON HIS HAND AND IS TENDER TO PALPATION EXTENSOR AND ABDUCTOR POLLICIS TENDONS. INITIAL RADIOGRAPHS DO�NOT SHOW A FRACTURE. WHAT DIAGNOSIS MUST BE CONSIDERED?

Base of thumb OA

Fracture of thumb metacarpal

Trapezoid fracture

NEXT

Scaphoid fracture

EXPLANATION

• Classic fracture with pain and tenderness in the anatomical snuff box and on traction/compression at the thumb CMCJ

NEXT

Go Back

9. A 25-YEAR-OLD MAN IS INVOLVED IN A MOTOR VEHICLE�ACCIDENT. HIS LEFT LIMB IS IN A POSITION OF FLEXION AT THE�KNEE AND THE HIP, WITH INTERNAL ROTATION AND ADDUCTION�OF THE HIP. WHAT IS THE MOST LIKELY DIAGNOSIS?

Neck of femur fracture

Pelvic fracture

Sciatic nerve injury

NEXT

Hip dislocation

EXPLANATION

• The classic dashboard injury, hit the knee against the dashboard causing a posterior dislocation of the femoral head.

NEXT

Go Back

10. WHAT NERVE IS COMPRESSED IN CARPAL TUNNEL SYNDROME?

Ulnar nerve

Radial nerve

Sciatic nerve

NEXT

Median nerve

EXPLANATION

• The median nerve supplies the radial three and half digits. There is usually a very clear watershed on the ring finger, ulnar nerve supplies medial half and median nerve the lateral half

NEXT

Go Back

11. A PATIENT HAD A DISC HERNIATION PRESSING ON THE 5TH LUMBAR NERVE ROOT. HOW IS MOTOR FUNCTION OF THE 5TH LUMBAR NERVE ROOT TESTED?

Dorsiflexion of the great toe

Ankle dorsiflexion

Ankle plantarflexion

Big toe flexion

NEXT

EXPLANATION

• A prolapsed L4-L5 disc compresses the nerve root below ie L5 causing weakness in big toe dorsiflexion.

NEXT

Go Back

12. HOW IS MOTOR FUNCTION OF THE MEDIAN NERVE TESTED IN THE HAND?

metacarpophalangeal finger flexion thumb opposition, flexion, or abduction

Finger abduction

Finger adduction

Thumb adduction

NEXT

EXPLANATION

• LOAF – median nerve supplies later two lumbricals (flexion of MCP, extension of IPJs index and ring finger), oppones pollicis, abductor pollicis brevis and flexor pollicis brevis.

NEXT

Go Back

13. THE COMMON ORTHOPAEDIC INFECTIONS WHICH CAUSE RECENT ONSET PAIN, LOSS OF WEIGHT BEARING, INFLAMMATION AND SEPSIS DO NOT INCLUDE WHICH OF THE FOLLOWING?

Chronic osteomyelitis

Pyomyositis

Acute osteomyelitis

NEXT

Septic Arthrtis

EXPLANATION

• Chronic osteomyelitis is an infective necrotic sequelae of acute osteomyelitis. Patients are rarely unwell and in pain unlike the other diagnoses.

NEXT

Go Back

14. A PATIENT PRESENTS WITH NEW-ONSET LOW BACK PAIN. UNDER WHAT CONDITIONS ARE PLAIN RADIOGRAPHS INDICATED? PLEASE NAME 5

Night pain, short duration, history of cancer, systemic symptoms, no pain on weightbearing

Night pain, short duration, history of cancer, no systemic symptoms, pain on weightbearing

Night pain, short duration, history of diabetes, systemic symptoms, pain on weightbearing

NEXT

Night pain, short duration, history of cancer, systemic symptoms, pain on weightbearing

EXPLANATION

• We’re looking for infection or cancer. So the risk factors are Night pain, short duration, history of cancer, systemic symptoms, pain on weightbearing

​

NEXT

Go Back

15. A PATIENT HAS A DISPLACED FRACTURE NEAR THE FIBULAR NECK. �WHAT STRUCTURE IS AT RISK FOR INJURY?

Popliteal artery

Tibial nerve

Sciatic nerve

NEXT

Common peroneal nerve

EXPLANATION

NEXT

Go Back

16. A 20-YEAR-OLD INJURED HIS KNEE WHILE PLAYING FOOTBALL. �YOU SEE HIM ON THE SAME DAY, AND HE HAS A KNEE �EFFUSION. AN ASPIRATION SHOWS FRANK BLOOD. WHAT ARE THE�THREE MOST COMMON DIAGNOSES?

Osteochondral fracture

ACL injury

Meniscal detachment

Meniscal tear

NEXT

EXPLANATION

• It has to be a structure which is vascular and bleeds ir ACL, the periphery of the mensicus which is vascular and bone which might have fractured (no matter how minor)

NEXT

Go Back

17. WHAT ARE THE FIVE MOST COMMON SOURCES OF CANCER METASTASES TO BONE?

Lung, thyroid, kidneys, prostrate, parathyroid

Lung, thyroid, kidneys, colon, breast

Lung, thyroid, pancreas, prostrate, breast

NEXT

Lung, thyroid, kidneys, prostrate, breast

EXPLANATION

• Interestingly all the paired organs

NEXT

Go Back

18. NAME TWO DIFFERENCES BETWEEN RHEUMATOID ARTHRITIS AND OSTEOARTHRITIS.

One definitely genetic the other not

One age related familial the other not

RA has early morning stiffness OA doesn’t

OA pain is proportional to activity undertaken, RA isn’t

NEXT

EXPLANATION

• RA has early morning stiffness OA doesn’t because the inflammatory component causes stiffness relieved by stretching and use
• OA pain is proportional to activity undertaken, RA isn’t, so called mechanical pain

​

​

NEXT

Go Back

19. WHEN DIAGNOSING CES (CAUDA EQUINA SYNDROME) WHICH OF THE FOLLOWING ARE INCORRECT?

Severe acute back pain is strongly suggestive

Perianal numbness and loss of anal tone are indicative

Bilateral sciatica is indicative

​

Increased post void bladder volume is indicative

NEXT

EXPLANATION

CES is either CES S (suspected), CES I (incomplete) or CES R (retention). The sequence demonstrates increasing autonomic dysfunction due to compression from a large prolapsed intervertebral disc.

NEXT

Go Back

20. WHAT IS THE FUNCTION OF THE NORMAL ANTERIOR�CRUCIATE LIGAMENT AT THE KNEE?

To prevent a posterior drawer test

To allow anterior drawer test

To give a positive Lachman test

NEXT

To prevent anterior displacement of the tibia on the femur

EXPLANATION

• It prevent anterior translation of the tibia. When it is intact it prevent an anterior drawer test and the Lachman is negative

NEXT

Go Back

21. WHAT IS THE DIFFERENCE BETWEEN OSTEOPOROSIS AND OSTEOMALACIA?

One is genetic the other isn’t

One is acquired the other definitely isn’t

One is reduced bone density the other is abnormal bone calcification

Osteomalacia is the most common cause of hip fractures Osteoporosis isn’t

NEXT

EXPLANATION

• One is reduced bone density the other is abnormal bone calcification

​

NEXT

Go Back

22. IN ELDERLY PATIENTS, DISPLACED FRACTURES OF THE FEMORAL�NECK ARE TYPICALLY TREATED WITH JOINT REPLACEMENT, WHEREAS FRACTURES NEAR THE TROCHANTER ARE TREATED WITH�PLATES AND SCREWS. WHY?

Higher risk of osteorathritis

Loss of blood supply and risk of AVN

The screws might penetrate into the joint

To allow early full weight bearing

NEXT

EXPLANATION

• Because the risk of AVN is approx 30%
• In a younger patient we overlook the risk of AVN and do treat IC fractures with fixation because in a younger patient (under 50yr) avoiding a THR is a good thing

NEXT

Go Back

23. COMMON DEGENERATIVE TENDONOPATHIES DO NOT INCLUDE.

Traumatic rupture of the patellar tendon

Achilles tendinopathy

Lateral epicondylitis (tennis elbow)

Rotator cuff tears

NEXT

EXPLANATION

NEXT

Go Back

A good explanation of the aetiology of tendinopathy is here

The Tendinopathy Continuum

24. RUPTURE OF THE BICEPS AT THE ELBOW RESULTS IN WEAKNESS�OF BOTH ELBOW FLEXION AND _____?

pronation

Wrist flexion

Wrist extension

NEXT

Supination

EXPLANATION

NEXT

Go Back

25. WHAT MUSCLE(S) CONTROL(S) EXTERNAL ROTATION OF THE HUMERUS WITH THE ARM AT THE SIDE?

Infraspinatus and supraspinatus

suprasinatus and teres major

NEXT

Infraspinatus and teres minor

EXPLANATION

NEXT

Go Back

WELL DONE!

• How did you do???

I have mastered orthopaedics

I have more to learn

CORRECT !!!

Go Back

Incorrect ☹

Go Back