Scenario 1



1Theme: Lower limb trauma?A Anterior compartment syndromeB Posterior compartment syndromeC Venous bleedD Traumatic nerve damageE Deep venous thrombosisF Lateral compartment syndromeFor each of the patients described below, select the single most likely diagnosis from the options listed above. Each option may be used once, more than once, or not at all.Scenario 1A motorcyclist rides into a lamppost and is unable to bear weight on his left leg. Lachman’s test is positive, there is no bony injury on X-ray, passive dorsiflexion of the ankle causes considerable pain and the foot is cold and numb on palpation.B - Posterior compartment syndrome?? CORRECT ANSWERThis patient is likely to have posterior compartment syndrome, as the muscles of the posterior compartment are stretched when the foot is passively dorsiflexed, thus eliciting pain.YOUR ANSWER WAS CORRECTScenario 2A patient suffers a displaced tibial fracture following a road traffic accident, is admitted and intramedullary nailing is done. You are on call and are asked to see him after he complains of severe pain in the leg that was operated on. He has severe pain on passive flexion of the toes, and also complains of paraesthesia in the first web space.A - Anterior compartment syndrome?? CORRECT ANSWERThis patient is likely to have an anterior compartment syndrome, especially due to the mechanism of injury (i.e. tibial fracture). The deep peroneal nerve which supplies the first web space runs in the extensor or anterior compartment of the leg. Passive stretching of the muscles of the anterior compartment (i.e. when passively flexing the toes) is responsible for the pain in this instance.YOUR ANSWER WAS CORRECT2Theme: Back painA Ankylosing spondylitisB Intervertebral disc herniationC Metastatic carcinomaD Multiple myelomaE OsteoporosisF OsteomyelitisG Scheuermann’s diseaseH Spinal stenosisI Spinal traumaJ SpondylolisthesisK SpondylosisL TuberculosisFrom the list above, select the most likely diagnosis for the following patients who all present with back pain. The items may be used once, more than once, or not at all.Scenario 1A 73-year-old diabetic man complains of severe back pain following an anterior resection. On examination, his temperature is 38.1°C, there is a limited range of spinal movements and marked lumbar muscle spasm. Neurological examination is normal.C - Metastatic carcinoma?? YOUR ANSWERF - Osteomyelitis?? CORRECT ANSWERF – OsteomyelitisIn approximately half of cases of osteomyelitis of the spine there is a history of:recent pelvic surgery, urinary tract infection, cutaneous sepsis, or diabetes mellitus. It is likely that haematogenous spread occurs via the vertebral venous plexus (Batson’s plexus) to the spine. The most common infecting organism is?Staphylococcus aureus, although Gram-negative organisms occur in association with urinary tract infection. The pain is usually worse in the recumbent position, and the patient is frequently pyrexial. White cell count, erythrocyte sedimentation rate and C-reactive protein are raised. Blood cultures, computed tomography, radioisotope or magnetic resonance scanning may all be helpful in making the diagnosis. Treatment is with rest, analgesia and appropriate antibiotics. Occasionally, surgery is required to ‘decompress’ the spine.YOUR ANSWER WAS INCORRECTScenario 2A 57-year-old woman with a past history of breast cancer presents to The Emergency Department with progressive severe thoracic back pain that has not responded to simple analgesics. The pain is now constant, and interrupts her sleep.C - Metastatic carcinoma?? CORRECT ANSWERC – Metastatic carcinomaThis case describes the disseminated presentation of carcinoma of the bronchus with secondary involvement of the lumbar spine. The majority of extradural spinal tumours are metastatic. The most common primary sites include the breast, bronchus, prostate, kidney, thyroid gland, or haemopoietic malignancies. The pain is non-mechanical (unrelated to physical activity), and is aggravated by recumbency. Occasionally, vertebral collapse may lead to presentation with profound neurological deficit. Plain radiographs may be normal early in the disease, and so isotope and magnetic resonance imaging may be more useful. Metastatic disease without clinical or radiological evidence of neurological compression is treated with:radiotherapy, chemotherapy, or hormone manipulation. Occasionally, anterior or posterior decompression surgery +/- fixation is required.YOUR ANSWER WAS CORRECTScenario 3A 65-year-old woman is referred for assessment of chronic lower back pain. Past history includes rheumatoid arthritis, for which she uses long-term steroids. She underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy at the age of 35 years. There is no neurological deficit on examination.K - Spondylosis?? YOUR ANSWERE - Osteoporosis?? CORRECT ANSWERE – OsteoporosisThis condition is defined by the World Health Organisation as ‘a progressive systemic skeletal disease characterised by low bone mass and microarchitectural deterioration of bone tissue with increased bone fragility and susceptibility to fracture’. Osteoporosis results in 200, 000 fractures per year (one-third of all women sustain one or more osteoporotic fractures), and leads to significant pain and individual disability. Bone density decreases with increasing age, immobility and postmenopausally in women. Conditions leading to secondary osteoporosis include: thyroid dysfunction, Cushing’s syndrome, premature (< 51 years)/iatrogenic (total abdominal hysterectomy with bilateral salpingo-oophorectomy) menopause, rheumatoid arthritis, drugs (corticosteroids, alcohol, anticonvulsants). Measurement of bone mineral density can be performed using dual energy X-ray absorptiometry scanning, and the hip is the site with the highest predictive value. Hormone replacement therapy, and bisphosphonates (etidronate/alendronate) prevent bone loss and decrease the risk of fractures; vitamin D and calcium supplements decrease the risk of hip and other fractures in the frail elderly.YOUR ANSWER WAS INCORRECT3A 35-year-old man presents to the emergency department with a 24-hour history of severe throbbing pain in the finger tip of his right index finger. He injured his hand whilst gardening 3 days before and thinks he cut his hand on a rose thorn. The fingertip is erythematous and swollen up to the DIP joint, but not proximal to it.What is the most likely diagnosis?Select one answer onlyApical infection?? YOUR ANSWERFelon?? CORRECT ANSWERHerpetic whitlowParonychiaFlexor tendon sheath infectionYOUR ANSWER WAS INCORRECTThe AnswerComment on this QuestionA felon is an abscess in the compartments of the pulp. This is usually more painful than a paronychia. The swelling doesn’t extend proximal to the distal interphalangeal joint. The infection often follows a penetrating trauma and is most common in the thumb and index finger.Paronychia occur between the tip of the nail and the cuticle. Apical infections occur between the top of the nail and the underlying nail bed. Herpetic whitlow is caused by the herpes simplex virus, small clear vesicles are seen. Flexor tendon sheath infection is a surgical emergency with a sausage shaped digit, flexed position, tenderness over the flexor tendon sheath and pain on passive extension.4Theme: OrthopaedicsA Medial plantar nerveB Femoral nerveC Common peroneal nerveD Deep peroneal nerve (old name anterior tibial nerve)E Saphenous nerveFor each of the scenarios match the appropriate nerve causing the palsy. Each option may be used once, more than once, or not at all.Scenario 1Compartment syndrome with paraesthesia of the first web space.D - Anterior tibial nerve?? CORRECT ANSWERThe deep peroneal nerve (old name anterior tibial nerve) supplies the first toe cleft. The skin of the sole of the foot is supplied by the medial and lateral plantar nerves. The plantar surfaces of the toes are supplied by the digital branches of the medial (three and a half) and lateral (one and a half) plantar nerves. They also supply the skin on the dorsum of each toe proximal to the nail bed.YOUR ANSWER WAS CORRECTScenario 2Paraesthesia of the ball of the big toe.A - Medial plantar nerve?? CORRECT ANSWERThe deep peroneal nerve (old name anterior tibial nerve) supplies the first toe cleft. The skin of the sole of the foot is supplied by the medial and lateral plantar nerves. The plantar surfaces of the toes are supplied by the digital branches of the medial (three and a half) and lateral (one and a half) plantar nerves. They also supply the skin on the dorsum of each toe proximal to the nail bed.YOUR ANSWER WAS INCORRECTThe AnswerComment on this QuestionThe deep peroneal nerve (old name anterior tibial nerve) supplies the first toe cleft. The skin of the sole of the foot is supplied by the medial and lateral plantar nerves. The plantar surfaces of the toes are supplied by the digital branches of the medial (three and a half) and lateral (one and a half) plantar nerves. They also supply the skin on the dorsum of each toe proximal to the nail bed.5Theme: Bone conditionsA OsteoporosisB Scheuermann's kyphosis?C Metastatic carcinomaD Osteoid osteomaE Giant cell tumourFor each of the patients described below, select the single most likely diagnosis from the options listed above. Each option may be used once, more than once, or not at all.Scenario 1A 68-year-old frail woman has suffered with back pain for 4 years and has developed slight kyphosis in the last year. She underwent a hysterectomy and bilateral salpingo-oophorectomy at the age of 35. She presents with a fracture of the left neck femur after slipping at home.A - Osteoporosis?? CORRECT ANSWEROsteoporosis can be caused by menopausal hormonal failure, Cushing’s disease, steroids, thyrotoxicosis and prolonged bed rest. Bone scan is diagnostic.YOUR ANSWER WAS CORRECTScenario 2A 30-year-old woman presents with pain and swelling in her thoracic region. Radiographs show a small lesion, with a well-demarcated central nidus surrounded by dense reactive bone in T6.D - Osteoid osteoma?? CORRECT ANSWEROsteiod osteomas are benign osteoblastic lesions. They typically occur in people between 5 and 30 years old.YOUR ANSWER WAS CORRECTScenario 3An x-ray shows a large radiolucent zone in the head of the right humerus extending to the subchondral plate in a 29-year-old man, with localised pain.E - Giant cell tumour?? CORRECT ANSWERGiant cell tumours typically affect patients between 20 and 60 years old. They occur more commonly in women then men.YOUR ANSWER WAS CORRECTScenario 4A 70-year-old presents with a large tumour in the left shoulder. He also complains of increasing difficulty in swallowing and most recently in breathing. On examination, he has a large hard irregular thyroid swelling.C - Metastatic carcinoma?? CORRECT ANSWERMetastatic carcinoma is the commonest malignancy in bone. The majority originate from the breast, prostate, lung, kidney and thyroid.YOUR ANSWER WAS CORRECT6Theme: Upper limb injuriesA Anterior dislocation of the shoulderB Acromioclavicular joint dislocationC Colles’ fractureD Fracture of the clavicleE Fracture dislocation of the elbowF Fracture of the distal humerusG Fracture of the proximal humerusH Fracture of the radial headI Fractured scapulaJ Fractured shaft of humerusK Olecranon fractureL Posterior dislocation of the shoulderM Scaphoid fractureN Smith’s fractureO Sternoclavicular dislocationP Supracondylar fracture of the humerusThe following patients have all fallen, injuring their upper limb. Please select the most appropriate fracture or dislocation from the above list. The items may be used once, more than once, or not at all.Scenario 1A 20-year-old epileptic presents to The Emergency Department following a seizure. On recovering from his seizure he complains of pain in his right arm. In addition, he is unable to move the affected limb. On examination his right arm is medially rotated at the shoulder. Active and passive movement is not possible at the shoulder joint. There is no obvious neurovascular deficit. A plain anteroposterior radiograph shows no obvious defect.A - Anterior dislocation of the shoulder?? YOUR ANSWERL - Posterior dislocation of the shoulder?? CORRECT ANSWERL – Posterior dislocation of the shoulderThis frequently missed injury should be suspected following a seizure or electric shock. The mechanism involves either a direct blow to the front of the shoulder or forced internal rotation when the arm is abducted. Clinical features are as described. In addition, the anterior contour of the shoulder may be flattened with prominence of the coracoid. Anteroposterior radiographs may look virtually normal, but the medially rotated humeral head appears globe-shaped (light bulb sign). Treatment involves closed reduction, which is maintained by a shoulder spica.YOUR ANSWER WAS INCORRECTScenario 2A 60-year-old woman has fallen onto her outstretched hand. On presentation she has marked bruising and tenderness of the upper arm. Neurovascular examination reveals wrist drop.J - Fractured shaft of humerus?? CORRECT ANSWERJ – Fractured shaft of humerusThis injury occurs at all ages but is most common in elderly osteoporotic individuals. The extensive bruising is characteristic. The diagnosis is supported in this case by the finding of a wrist drop, which has been caused by a radial nerve injury where it lies in the spiral groove of the humerus. Treatment is with a hanging cast, the weight of which maintains reduction. In closed injuries the nerve is seldom divided and the wrist may be splinted while the injury recovers. Fractures to the humeral shaft may be pathological and any occurring following minor trauma should be viewed with suspicion.YOUR ANSWER WAS CORRECTScenario 3A 24-year-old man presents after falling onto his outstretched hand. He complains of pain at the elbow. Examination reveals swelling around the elbow. Of note, the patient is unable to extend the elbow against resistance. There is no obvious neurovascular deficit.K - Olecranon fracture?? CORRECT ANSWERK – Olecranon fractureTwo types of injury are commonly seen. The first is a comminuted fracture following direct trauma to the point of the elbow. The second is a traction injury to the olecranon resulting in a transverse fracture. This typically occurs following a fall onto the hand with the triceps muscle contracted. Transverse fractures tend to cause disruption to the extensor mechanism of the elbow as in the case described. Displaced fractures may result in a palpable gap. Treatment of non-displaced fractures involves immobilisation in a cast followed by supervised mobilisation. Displaced fractures are treated by open reduction and internal fixation. Methods available include tension band wiring and plating.YOUR ANSWER WAS CORRECT7Theme: Complications of fracturesA Associated injury: nerveB Associated injury: vascularC Associated injury: visceralD Avascular necrosis (AVN)E Compartment syndromeF Complex regional pain syndrome (Sudeck’s atrophy)G Crush syndromeH Deep venous thrombosisI Delayed unionJ Fat embolismK Hypovolaemic shockL MalunionM Myositis ossificansN Non-unionO OsteomyelitisP Pulmonary embolusThe above list documents complications of fractures. Please pick the most appropriate complication for the following clinical scenarios. Each item may be used once, more than once, or not at all.Scenario 1A 35-year-old footballer has been admitted to the ward having sustained a spiral fracture to his right tibia. He is awaiting surgery and currently has a plaster backslab protecting his leg. The nurses on the ward have called you multiple times to ask for stronger analgesia, which apparently is still not settling his pain. When you assess him he is fidgeting in the bed. He complains of significant pain at the site of his fracture and some numbness between his great and second toe. He has warm, pink toes, and a dorsalis pedis pulse can just be palpated beneath the plaster and bandaging.E - Compartment syndrome?? CORRECT ANSWERE – Compartment syndromeThis is the typical description of compartment syndrome. This term refers to increased soft tissue pressure within an enclosed soft tissue compartment usually of the extremities (although it is possible to see abdominal compartment syndrome). Untreated it can lead to devastating muscle necrosis, contracture, nerve damage and ultimately severe functional impairment. Common causes of compartment syndrome include fractures (commonly tibial), soft tissue crush injuries, burns, gunshot wounds, surgery and vascular impairment. Clinical presentation, in a conscious patient, is severe pain, particularly on passive stretching of the muscle group involved. As time progresses paraesthesia, pallor, pulselessness and paralysis all begin to develop (the latter three at a stage where irreversible damage may already have occurred). Clinical suspicion with a relevant history should be enough to warrant surgical exploration and decompression via fasciotomy.YOUR ANSWER WAS CORRECTScenario 2A 29-year-old woman who dislocated her left elbow 4 weeks ago, during a strenuous martial arts training session, is being followed up in fracture clinic. (The elbow had been successfully re-located in a closed manoeuvre in Casualty). She tells you that after an initially good recovery, movement of the joint has suddenly become restricted and very painful. On closer questioning you determine that she has been rather actively mobilising the joint from an early stage to attempt to get back to her martial arts. An X-ray shows some calcification anterior to the joint.M - Myositis ossificans?? CORRECT ANSWERM – Myositis ossificansThis is a process whereby extraskeletal ossification occurs in muscle and soft tissue. Usually it arises after injury: commonly elbow fractures, elbow dislocations and injuries leading to large haematoma formation (eg soft tissue injuries of the thigh). It is thought to be related to joint mobilisation that is too early after injury, or too rigorous. Symptoms are as those described in the clinical scenario and treatment is rest, usually with immobilisation of the affected joint in a cast for a few weeks. In this way the accumulated calcification gradually reduces, and movement increases. Late excision may ultimately be required for non-resolution.YOUR ANSWER WAS CORRECTScenario 3A 45-year-old woman, who fell from her horse 3 months ago, returns for follow-up in orthopaedic outpatients. At the time her notes documented a dorsiflexion injury to her left wrist causing a scaphoid fracture that was treated in a scaphoid cast for 8 weeks. She continues to have pain and weakness in her left wrist despite a course of physiotherapy. The X-ray that you request shows increased density at the proximal pole of the scaphoid.D - Avascular necrosis (AVN)?? CORRECT ANSWERD – Avascular necrosis (AVN)Bone death (osteonecrosis) is usually the result of impaired blood supply. This can occur by two mechanisms: interruption of arterial inflow (eg after a fracture), or obstruction of venous outflow (eg by lesions that infiltrate and block the venous sinusoids). In this case a fracture to the scaphoid has disrupted the local blood supply. Other common sites that have a propensity to become ischaemic, and hence develop AVN, include the femoral head and the body of the talus. On X-ray the distinctive feature of AVN is increased bone density (as a result of new bone ingrowth in the necrotic segment with disuse osteoporosis in the surrounding regions).Scenario 4A 27-year-old rugby player presents to Casualty after being tackled to the ground during a match. His team-mates give an account of a forceful shoulder blow to his left chest. On examination he has significant bruising over his lower left chest and this region feels boggy. Clinically two ribs appear fractured. As you assess him further he starts to complain of severe shortness of breath and his breath sounds are diminished on the left side. Percussion note is hyper-resonant. SaO2: 89% on air, respiratory rate 35 breaths/min.C - Associated injury: visceral?? CORRECT ANSWERC – Associated injury: visceralFractures around the trunk can often be complicated by injuries to the underlying viscera. In this scenario blunt trauma to the chest with resultant rib fractures have led to a pneumothorax.YOUR ANSWER WAS CORRECT8Theme: Common disorders of the handA Carpal tunnel syndromeB Dupuytren’s diseaseC Extensor tendon injuryD Flexor tendon injuryE Gamekeeper’s thumbF GanglionG Heberden’s nodeH Mallet fingerI ParonychiaJ Phalangeal enchondromaK Pulp space infectionL Pyogenic granulomaM Rheumatoid arthritisN Trigger fingerThe following patients present with disorders of the hand. From the list above, select the most likely diagnosis. The items may be used once, more than once, or not at all.Scenario 1A 44-year-old man attends the clinic and reports that his index finger often gets stuck and ‘clicks’ when he straightens it. He denies any history of trauma. He has no relevant past medical history. On examination, the finger, and rest of the hand, appears normal. There is no contracture of the skin or subcutaneous tissues. Initially, the index finger is fixed in flexion, but it suddenly extends fully during active movement. There is no associated pain.N - Trigger finger?? CORRECT ANSWERN – Trigger fingerThis condition is caused by thickening of the flexor tendon, paratenon, or a narrowing of the flexor sheath. Consequently, the affected finger becomes locked in full flexion and will only extend after excessive voluntary effort, or assistance from the other hand. When extension begins it does so suddenly, and with a click, hence the name of the condition. The condition is usually painless. Steroid infiltration may be effective in mild cases, although surgical release of the proximal portion of the A1 pulley may be necessary.Scenario 2A 64-year-old woman attends The Emergency Department with a fracture of the distal phalanx of her left middle finger. She informs you that this finger has become increasingly painful over the last few months, and that she has been aware of a ‘bony swelling’ affecting this finger. She indicates that this was most marked on the volar aspect of the distal phalanx, close to the distal interphalangeal joint.J - Phalangeal enchondroma?? CORRECT ANSWERJ – Phalangeal enchondromaThis benign tumour is composed of mature, hyaline cartilage, and presents as a slow-growing mass within a phalanx. Pain, swelling or deformity of the affected finger may be evident. The presentation may be acute, with a ‘pathological’ fracture through the weakened cortex, as in the case described. There is a characteristic appearance on radiography. The usual opacity of the bony phalanx is lost, and the cavity of the mass appears radiolucent with stippled calcification. The cortex of the bone may be thinned as the internal mass expands. Treatment involves curettage followed by cancellous bone grafting.YOUR ANSWER WAS CORRECTScenario 3A 28-year-old manual labourer attends The Emergency Department with a painful left index finger. He sustained a minor abrasion to the palmar aspect of his left index finger at work 6 days ago. On examination, there is erythema and swelling affecting the distal aspect of the left index finger on the palmar surface.K - Pulp space infection?? CORRECT ANSWERK – Pulp space infectionPulp space infections usually arise from minor penetrating injuries. Pressure in the infected compartment causes marked pain. Infection may spread into adjacent compartments because of infarction of surrounding tissues secondary to rapidly increasing pressure. Occasionally, this may lead to rupture through the overlying skin, or into the distal phalanx. Treatment should involve early incision and drainage, to avoid permanent loss of pulp tissue, and subsequent reduction of cushioning of the distal phalanx.YOUR ANSWER WAS CORRECT9Theme: Painful conditions of the footA Claw toeB?Freiberg?’s diseaseC GoutD Hallux rigidusE Hallux valgusF Hammer toeG March fractureH Morton’s metatarsalgiaI Pes cavusJ Rheumatoid arthritisK Sever’s diseaseThe following descriptions are of patients who have presented with painful conditions of the foot. Please select the most appropriate diagnosis from the above list. The items may be used once, more than once, or not at all.Scenario 1A 45-year-old woman presents with a history of a sharp pain over the dorsum of the foot, which radiates into her toes. Examination reveals a fine point of tenderness in the cleft between the third and fourth toes.H - Morton’s metatarsalgia?? CORRECT ANSWERH – Morton’s metatarsalgiaThe description is a classical presentation of this condition. The exact aetiology is unclear; it is thought to occur following entrapment of a digital nerve between the metatarsal heads with secondary thickening and formation of a neuroma. The nerve most commonly affected lies between the third and fourth metatarsal heads. Pain is usually acute and may be associated with a sensory disturbance in the distribution of the nerve. If symptoms are troublesome treatment is by excision of the neuroma.Scenario 2A 25-year-old nurse asks for your opinion regarding her painful left foot. She qualified 5 months ago and has been working in The Emergency Department since. The pain started 1 week ago and causes her to limp. On examination she is tender over the second metatarsal, which feels unusually thick.G - March fracture?? CORRECT ANSWERG – March fractureThis is a metatarsal stress fracture, usually of the second or third metatarsal, which occurs in young adults after a period of unaccustomed walking. The initial complaint is that of pain in the forefoot and the affected bone feels thick and tender. The fracture may not be evident on initial X-rays of the foot but eventually reveals itself by the appearance of abundant callus. The condition is self limiting with no long-term sequelae. Treatment is symptomatic.Scenario 3A 42-year-old man complains of sudden onset of pain over the medial aspect of his right forefoot. Of note, he has recently returned from a ‘stag’ weekend in Dublin. On examination the base of his big toe is swollen, erythematous, hot and tender to touch.C - Gout?? CORRECT ANSWERC – GoutThis condition is the commonest form of inflammatory joint disease in men over 40 with the first metatarsophalangeal joint affected in over 90% of cases. The condition closely resembles septic arthritis; however, there is an absence of systemic features of infection. The primary cause is hyperuricaemia and there may be a precipitating cause such as alcohol excess or foods high in purines and diuretics. Treatment during the acute phase is with anti-inflammatory drugs followed by a xanthine oxidase inhibitor, eg allopurinol to prevent further episodes.Scenario 4A 23-year-old woman presents with a history of pain in the sole of her foot and on the dorsal aspect of her second toe. On examination there are callosities over the proximal interphalangeal joint of the second toe, which appears flexed and under the second metatarsal head. The second metatarsophalangeal and distal interphalangeal joints appear hyperextended.F - Hammer toe?? CORRECT ANSWERF – Hammer toeThe clinical findings are characteristic with pain occurring as a result of callosities forming over the pressure areas. This should not be confused with claw toes where there is hyperextension of the metatarsophalangeal joint and flexion of both the interphalangeal joints. If pain is severe, treatment is by excision arthrodesis.Scenario 5A 10 year-old boy presents with pain in his right heel. On examination, the foot appears grossly normal, however there is significant tenderness over the calcaneum close to the insertion of the Achilles tendon.K - Sever’s disease?? CORRECT ANSWERK – Sever’s diseaseThis condition is the most likely cause of a painful heel in a child and is a form of osteochondritis of the calcaneal epiphysis. Pain and tenderness occur close to the insertion of the Achilles tendon. Radiographs may demonstrate epiphyseal fragmentation or sclerosis. The condition is self limiting with symptoms controlled by means of a pressure-relieving pad.10Theme: Complications of orthopaedic surgeryA Aseptic looseningB ArthrofibrosisC Compartment syndromeD Deep venous thrombosisE Fat embolism syndromeF Delayed unionG Periprosthetic fractureH Pulmonary embolismI Septic arthritisFor each of the following clinical scenarios select the most likely diagnosis from the list above. Each option may be used once, more than once, or not at all.Scenario 1A 25-year-old male patient sustained a closed right femoral shaft fracture in a motorcycling accident 1 day previously. He now complains of difficulty breathing. On examination he is increasingly anxious, with a low-grade pyrexia, tachycardia and respiratory rate of 36 breaths/min. In the past few hours nursing staff have noted a declining urine output and a rash on his upper chest.E - Fat embolism syndrome?? CORRECT ANSWERFES?is a clinical diagnosis. Trauma to the long bone or pelvis accounts for ~90% of cases. The exact frequency is unknown, as the diagnosis is often missed or masked in the trauma patient. However it carries a mortality of 10–20% and must always be considered. Patients present with tachycardia, tachypnoea, pyrexia, reduced consciousness and hypoxia. They may develop petechial rash on the upper chest (<50%) and/or conjunctiae, oral mucosa and retinae. Searching for fat droplets in the urine, blood or cerebrospinal fluid (CSF) may help in confirming the diagnosis. Management is mainly supportive and consists primarily of maintaining good arterial oxygenation. Prompt surgical stabilization of fractures reduces the risk of occurrence. The pathophysiology is still debated, but it is thought to be caused by embolic marrow fat coalescing in pulmonary vasculature (and other areas of important microcirculation, eg cerebral) leading to pulmonary insufficiency and an acute respiratory distress syndrome?(ARDS)-like picture.YOUR ANSWER WAS CORRECTScenario 2A 47-year-old lady is admitted to the orthopaedic ward with a closed fractured tibia and fibula in her right leg. Whilst awaiting surgery the following day she complains of increasing pain in the right calf and knee preventing her from sleeping. This is unrelieved with analgesia and is sufficient to prevent flexion the ankle joint on the affected side.C - Compartment syndrome?? CORRECT ANSWERThis arises from swelling within a closed fascial compartment impairing capillary bed blood flow, in turn causing further swelling due to progressing ischaemia.?There should be a low index of suspicion for making this diagnosis, as irreversible ischaemia can rapidly develop. The initial swelling may result from fracture (commonly tibial or forearm), soft-tissue injury (crush, burns) or vascular insult (ischaemia-reperfusion injury). Clinical features include:·?excessive pain on passive movement of distal joints supplied by muscles of the affected compartment/s·?increasing pain despite immobilisation and analgesia·?altered sensation in the distribution of nerves passing through the affected compartment/s.Peripheral pulses may still be present as compartment pressure will rise high enough to occlude diastolic venous flow, but rarely systolic arterial flow. Diagnosis can be aided by measuring intracompartmental pressure. Definitive treatment is by prompt fasciotomy with the wound left open.YOUR ANSWER WAS CORRECTScenario 3Ten years following a left total-hip arthroplasty for osteoarthritis a 75-year-old lady is referred to orthopaedic out-patients clinic with worsening left hip pain and stiffness. This is worse on walking, when she feels this leg has become a little shorter. Inflammatory markers are normal.A - Aseptic loosening?? CORRECT ANSWERAseptic loosening means loosening of a prosthetic joint without the involvement of bacteria. It occurs as a late complication, affecting approximately 5–10% of total-hip arthroplasties. Foreign body components worn off the artificial surfaces initiate an inflammatory reaction involving macrophages, causing osteolysis of the surrounding bone. Patients present with pain and if the femoral component loosens, sinking further into the femoral shaft, a decreased leg length may ensue. It is important to exclude late infection as a cause of the pain. Diagnosis is aided by serial X-rays showing changing orientation of the components and progressive lines around the bone–prosthesis interface. Treatment is by revision of the joint.YOUR ANSWER WAS CORRECTScenario 4A teenage smoker suffers a closed right lateral malleolar fracture during a fall on an ice rink. The fracture is undisplaced and she is treated non-operatively in a plaster cast. Six weeks later she still feels severe pain on moving the ankle joint and attempting to weight bear, and there is continuing tenderness over the lateral malleolus.F - Delayed union?? CORRECT ANSWERThis is a failure of fractured bone-ends to form a bony union within the usual time period for that fracture and patient. There is no exactly defined time period that this can be diagnosed by. Typically the fracture site remains tender and may be mobile. It remains visible on X-rays with little callous formation. Causes include: infection, inadequate immobilization (allowing movement at the fracture site), poor blood supply. Smoking has been linked to delayed-union and non-union. If no union develops after an appropriate time period, internal fixation or bone grafting could be considered.11Theme: Treatment options in fracture managementA Broad arm sling (polysling)B Cast-braceC Cerclage wiresD Dynamic screw fixationE External fixationF Hanging castG HemiarthroplastyH Intramedullary nailingI K-wiresJ Plaster castK Plate and screw fixationL Screw fixationM Tension band wiringN TractionAll of the above are employed in the management of fractures. For the following fractures please choose the most appropriate method of fracture fixation from the list. Each item may be used once, more than once, or not at all.Scenario 1A closed, two-part fracture to the middle third of the clavicle (low-impact mechanism).A - Broad arm sling (polysling)?? CORRECT ANSWERA – Broad arm slingFractures of the clavicle, despite representing 5% of all fractures (and 44% of shoulder girdle fractures), seldom excite much interest. They are usually treated conservatively in a broad arm sling (or polysling), although surgical fixation may be indicated. Operative treatment is reserved for those patients with: open fractures, polytrauma, neurovascular injury (NB proximity of brachial plexus), compromise of the overlying skin, floating shoulder, symptomatic non-union and fractures of the lateral third proximal to, or between, the conoid and trapezoid ligaments.YOUR ANSWER WAS CORRECTScenario 2An inter-trochanteric fracture to the left neck of the femur in a 75-year-old woman.D - Dynamic screw fixation?? CORRECT ANSWERD – Dynamic screw fixationFor an extracapsular fracture, where blood supply to the femoral head isnot significantly compromised (such as that described in this scenario), theideal method of fixation is with dynamic screw fixation, specifically adynamic hip screw. This is a plate and sliding screw fixator that permitscompression at the fracture site. It allows good anatomical fixation of thefracture and early mobilisation of the patient.Scenario 3An isolated femoral shaft fracture in a 4-year-old boy.N - Traction?? CORRECT ANSWERN – TractionPaediatric femoral shaft fractures are commonly treated by skin or skeletal traction. This allows fracture union before the child then commences mobilisation in an appropriate cast. It is important to note that fixation of fractures in young children can disturb bone growth (particularly intramedullary nailing through an epiphyseal growth plate), leading to shortening and malformation of the affected limb. Hence it is restricted to the management of the polytraumatised child when plate fixation or external fixation may be used with care.Scenario 4A Gustilo III comminuted tibial fracture in a 35-year-old man.E - External fixation?? CORRECT ANSWERE – External fixationIndications for external fixation in trauma encompass: compound (open) long bone fractures with extensive tissue devitalisation (especially of the tibia), closed fractures with degloving skin injuries, ‘open book’ pelvic fractures, polytrauma, peri-articular and metaphyseal fractures. The unique characteristics of external fixation include: rapid skeletal stabilisation using connecting frames and percutaneous pins, remote from the site of injury; versatility (different injuries with differing anatomy); ability to adjust alignment and fixation during fracture healing; and ease of access to surrounding soft tissues.YOUR ANSWER WAS CORRECT12You are examining a 78-year-old lady with pain in both hands and difficulty with dropping objects. You note on examination that her middle finger PIP joint is fixed in flexion of approximately 300 and the DIP joint is fixed in hyperextension.How would you describe this finding?Select one answer onlyBouchard’s nodeBoutonniere deformity?? CORRECT ANSWERHeberden’s nodesMallet fingerSwan neck deformity?? YOUR ANSWERYOUR ANSWER WAS INCORRECTThe AnswerComment on this QuestionBouchard’s and Heberden’s nodes, Boutonniere and swan neck deformities are all features of arthritis of the hands. Bouchard’s and Heberden’s nodes are swellings over the dorsal surface, Bouchard’s at the PIP and Heberden’s at the DIP. In a Boutonniere deformity there is flexion of the PIP joint and extension of the DIP. In a swan neck deformity there is flexion of the DIP and extension of the PIP. A mallet finger is caused by rupture of the extensor tendon at the DIP joint resulting in flexion of the DIP.13Theme: MyotomesA C6 and C7B C7 and C8C C5 and C6D C6, C7 and C8E C6For each of the following movements, select the most likely answer from the above list. Each option may be used once, more than once, or not at all.Scenario 1The segmental innervation for pronation of the forearm.B - C7 and C8?? CORRECT ANSWERPronation of the forearm involves segments C7 and C8.Scenario 2The segmental innervation for supination of the forearm.E - C6?? CORRECT ANSWERSegment C6 is involved in supination of the forearm.Scenario 3The segmental innervation for elbow flexion.C - C5 and C6?? CORRECT ANSWERElbow flexion involves segments C5 and C6, whereas elbow extension involves segments C7 and C8.YOUR ANSWER WAS CORRECTScenario 4The segmental innervation for finger flexion.B - C7 and C8?? CORRECT ANSWERThe segmental innervation for finger and thumb flexion is C7 and C8, and also C7 and C8 for extension.14Theme: Leg PainA Acute limb ischaemiaB Superficial thrombophlebitisC Fractured tibiaD Ruptured Baker's cystE Gastrocnemius tearsF Complete Achilles' tendon ruptureG Chronic venous insufficiencyH Deep venous thrombosis (DVT)I Intervertebral disc (IVD) prolapseSelect the most appropriate diagnosis for each of the patients below. Each option may be used once, more than once, or not at all.Scenario 1A 65-year-old presented with a 3-day history of painful left leg and foot which is gradually worsening. On examination you see erythema over the dorsum of the foot extending to the shin of the leg; you also feel a firm tender cord-like vessel. There is an ulcer between the 3rd and 4th toes. The calf feels soft and not tender.B - Superficial thrombophlebitis?? CORRECT ANSWERSuperficial thrombophlebitis can occur spontaneously, but can also be associated with trauma, ulcers or even associated with a silent deep vein thrombosis (DVT).YOUR ANSWER WAS CORRECTScenario 2A 25-year-old male sustained a sudden painful left leg particularly on the back of the calf while playing badminton. On examination you find that plantar flexion power of the foot is only mildly affected; however it aggravates the pain. There is also a localised tenderness on the back of the leg approximately 5 cm below the knee joint.E - Gastrocnemius tears?? CORRECT ANSWERGastrocnemius tears are common sport injuries. Here plantar flexion is preserved so Achilles’ tendon rupture is ruled out (not partial ones though), and the localised muscular tenderness up the calf favours the diagnosis.YOUR ANSWER WAS CORRECTScenario 3A 76-year-old demented lady was referred from a residential home complaining of increasingly painful right leg over the last 3 days. She had bilateral hemiarthroplasty and her mobility is restricted to bed and chair. On examination her right leg is swollen, with shiny skin, erythematous, and tender, and dorsiflexion aggravates the pain. She also has a low-grade fever.H - Deep venous thrombosis (DVT)?? CORRECT ANSWERImmobility (bilateral hemiarthroplasty) is a major factor contributing to this lady’s DVT. Homan’s sign (pain on foot dorsiflexion) is said to be detrimental as it carries a theoretical risk of dislodging thrombi.YOUR ANSWER WAS CORRECTScenario 4An 83-year-old gentleman presented with an increasingly painful left leg over the last 5 hours and feeling weakness in that leg. On examination you find a pale, cold left leg, power 2/5 MRC (Medical Research Council grading system) but distal pulses are present.A - Acute limb ischaemia?? CORRECT ANSWERYou do not have to have all the Ps (pallor, paralysis, parasthesia, pain, pulsles) to diagnose acute limb ischaemia. Absent pulses is a very late sign. Muscle weakness is an important sign of critical ischaemia that needs urgent intervention.15Theme: Leg PainA Acute limb ischaemiaB Superficial thrombophlebitisC Fractured tibiaD Ruptured Baker's cystE Gastrocnemius tearsF Complete Achilles' tendon ruptureG Chronic venous insufficiencyH Deep venous thrombosis (DVT)I Intervertebral disc (IVD) prolapseSelect the most appropriate diagnosis for each of the patients below. Each option may be used once, more than once, or not at all.Scenario 1A 65-year-old presented with a 3-day history of painful left leg and foot which is gradually worsening. On examination you see erythema over the dorsum of the foot extending to the shin of the leg; you also feel a firm tender cord-like vessel. There is an ulcer between the 3rd and 4th toes. The calf feels soft and not tender.B - Superficial thrombophlebitis?? CORRECT ANSWERSuperficial thrombophlebitis can occur spontaneously, but can also be associated with trauma, ulcers or even associated with a silent deep vein thrombosis (DVT).YOUR ANSWER WAS CORRECTScenario 2A 25-year-old male sustained a sudden painful left leg particularly on the back of the calf while playing badminton. On examination you find that plantar flexion power of the foot is only mildly affected; however it aggravates the pain. There is also a localised tenderness on the back of the leg approximately 5 cm below the knee joint.E - Gastrocnemius tears?? CORRECT ANSWERGastrocnemius tears are common sport injuries. Here plantar flexion is preserved so Achilles’ tendon rupture is ruled out (not partial ones though), and the localised muscular tenderness up the calf favours the diagnosis.YOUR ANSWER WAS CORRECTScenario 3A 76-year-old demented lady was referred from a residential home complaining of increasingly painful right leg over the last 3 days. She had bilateral hemiarthroplasty and her mobility is restricted to bed and chair. On examination her right leg is swollen, with shiny skin, erythematous, and tender, and dorsiflexion aggravates the pain. She also has a low-grade fever.H - Deep venous thrombosis (DVT)?? CORRECT ANSWERImmobility (bilateral hemiarthroplasty) is a major factor contributing to this lady’s DVT. Homan’s sign (pain on foot dorsiflexion) is said to be detrimental as it carries a theoretical risk of dislodging thrombi.YOUR ANSWER WAS CORRECTScenario 4An 83-year-old gentleman presented with an increasingly painful left leg over the last 5 hours and feeling weakness in that leg. On examination you find a pale, cold left leg, power 2/5 MRC (Medical Research Council grading system) but distal pulses are present.D - Ruptured Baker's cyst?? YOUR ANSWERA - Acute limb ischaemia?? CORRECT ANSWERYou do not have to have all the Ps (pallor, paralysis, parasthesia, pain, pulsles) to diagnose acute limb ischaemia. Absent pulses is a very late sign. Muscle weakness is an important sign of critical ischaemia that needs urgent intervention.16Theme: Shoulder painA Acromioclavicular joint disruptionsB Biceps ruptureC Subacromial bursitisD Supraspinatus ruptureE Supraspinatus?tendonitisFor each of the patients described below, choose the most suitable diagnosis from the list of options above. Each option may be used once, more than once, or not at all.Scenario 1A 52-year-old plasterer complains of a 1-year history of shoulder pain and difficulty in lifting his arm up while performing his job. On examination, he had marked tenderness over the acromion. He has to bend over to the affected side to initiate shoulder abduction. He has no difficulty in passive abduction of his arm.D - Supraspinatus rupture?? CORRECT ANSWERD – Supraspinatus ruptureA complete tear of the supraspinatus tendon may occur after a long period of chronic tendonitis. Active abduction is impossible and attempting it produces a characteristic shrug; however, passive abduction is full and once the arm has been lifted to above a right angle the patient can keep it raised using the deltoid (abduction paradox).YOUR ANSWER WAS CORRECTScenario 2A 32-year-old man presents with a 1-month history of shoulder pain especially on lifting the arm. On examination he has marked tenderness lateral to the acromial process with a painful arc of 60–120°.E - Supraspinatus tendonitis?? CORRECT ANSWERE – Supraspinatus tendonitisSupraspinatus tendonitis usually occurs in patients < 40 years of age who develop shoulder pain after vigorous/strenuous exercise. On active abduction the scapulohumeral rhythm is disturbed and pain is aggravated as the arm traverses an arc between 60 and 120°.YOUR ANSWER WAS CORRECT17A 2-month-old boy presents with a 12-hour history of fever, vomiting and pain on movement s of the left hip. The ESR is 60, the CRP 120 and the WCC 30 x109/L.What is the most likely causative organism?Select one answer onlyGroup A streptococcusEnterobacteriaceaeNeisseria gonorrhoeaeStaphylococcus aureus?? YOUR ANSWERStreptococcus pneumoniaeYOUR ANSWER WAS CORRECTThe AnswerComment on this QuestionThe neonate in this scenario has septic arthritis of the hip, with raised inflammatory markers, white cell count, and a pyrexia. A child of this age would not be weight bearing. The commonest organism causing septic arthritis is staphylococcus aureus. There is some variation in causative organisms with age. Neisseria gonorrhoeae is more common in sexually active adults, and streptococcus pneumoniae and streptococcuspyogenes are more common in children between 3-months and 14-years, however, Staph aureus still remains the most common cause in these groups.18Theme: Nerve injuryA Axillary nerveB Intercostal nerveC Median nerveD Radial nerveE Ulnar nerveMatch the most appropriate site of damage from the list above to each clinical situation described below. Each option may be used once only, more than once or not at all.Scenario 1A rugby player who has some loss of sensation over the deltoid muscle following dislocation of his shoulder joint.A - Axillary nerve?? CORRECT ANSWERYOUR ANSWER WAS CORRECTScenario 2A teenager who has a fractured tibia and is experiencing increasing difficulty using her axilla crutch.D - Radial nerve?? CORRECT ANSWER?Scenario 3A child who has a weak grip and impaired sensation involving the ring and little fingers following dislocation of his elbow joint which was treated by manipulation.E - Ulnar nerve?? CORRECT ANSWERYOUR ANSWER WAS CORRECTScenario 4A child with a supracondylar fracture of his humerus who cannot oppose his thumb.C - Median nerve?? CORRECT ANSWERYOUR ANSWER WAS CORRECTThe AnswerComment on this QuestionThe axillary nerve lies close to the surgical neck of the neck of the humerus and may be damaged by dislocation of the shoulder joint. The nerve supplies skin over the lower part of the deltoid (the regimental badge area) as well as the deltoid muscle itself.Improper use of acilla crutches may damage the radial nerve in the axilla resulting in weakness of the triceps and of the muscles in the posterior compartment of the forearm, causing reduced power of extension at the elbow and instability at the wrist with impaired grip. Both the ulnar and median nerves may be damaged by a fracture or dislocation at the elbow joint.19A 7-year-old boy falls over sustaining a fractured right distal radius. On x-ray the fracture line passes through the epiphysis into the physis with separation of the fragment, the metaphysis is intact.How would you classify this fracture?Select one answer onlySalter Harris ISalter Harris II?? YOUR ANSWERSalter Harris III?? CORRECT ANSWERSalter Harris IVSalter Harris VYOUR ANSWER WAS INCORRECTThe AnswerComment on this QuestionThe Salter-Harris classification is a commonly used classification of epiphyseal injuries in children. There were 5 types originally described. Type II injuries are the most common type seen.The types are:Salter Harris I – Separation of the epiphysis from the metaphysisSalter Harris II – Fracture through the physis with a metaphyseal fragmentSalter Harris III – Fracture through the epiphysis and physisSalter Harris IV – Fracture through the epiphysis, physis and metaphysisSalter Harris V – Crush injury to the physis20An 8-year-old boy presents to the emergency department with pain in the left hip and limping. The symptoms have been present for 24 hours, but the boy has had previous episodes of hip pain intermittently for the past 3 months. He is small for his age, systemically well, does not recall any injury and his bloods are normal.What is the most likely diagnosis?Select one answer onlyDevelopmental dysplasia of the hipPerthes disease?? YOUR ANSWERSeptic arthritisSlipped upper femoral epiphysisTransient synovitisYOUR ANSWER WAS CORRECTThe AnswerLimping in children can be caused by a number of conditions including all those listed. The most likely condition varies with the patients’ age and symptoms. Developmental dysplasia of the hip is most commonly diagnosed in babies, and is screened for, but may present late usually when the child starts walking. Septic arthritis can occur at any age, but is more common in younger babies, it is generally associated with systemic upset and raised inflammatory markers.Transient synovitis is a diagnosis of exclusion. Perthes disease is a transient disruption in the blood supply to the femoral head, which is more common in boys, those who are small for their age and between the ages of 3-12 years. Slipped upper femoral epiphysis is also more common in boys, but tends to occur in older children, most commonly 11-16 years, at times of growth spurts.21THEME: SHOCKA Fat embolismB ThromboembolismC Cardiogenic shockD Hypovolaemic shockFor each of the patients described below, select the single most likely diagnosis from the options listed above. Each option may be used once, more than once, or not at all.Scenario 1A 26-year-old man with a comminuted closed fracture of the femur shaft undergoes intra-medullary nail fixation. Two days after the operation, he develops a pyrexia, shortness of breath, petechial haemorrhages on his chest and tachycardia.A - Fat embolism?? CORRECT ANSWERFat embolism occurs in patients with multiple closed fractures, but has been reported with other skeletal trauma, including burns. Fat embolism causes a temperature, tachycardia, shortness of breath, confusion and petechial haemorrhages, especially on the chest.YOUR ANSWER WAS CORRECTScenario 2A 72-year-old man with an underlying prostate carcinoma and a fractured femoral shaft undergoes intra-medullary nail fixation. Seven days after the operation, he develops shortness of breath, hypotension and tachycardia.B - Thromboembolism?? CORRECT ANSWERSeven days post-operation is the characteristic time for a thromboembolism.YOUR ANSWER WAS CORRECTScenario 3A 60-year-old man develops sudden back pain. He is brought to Accident and Emergency (A&E) with a swollen tense abdomen, tachycardia, low volume pulse and low BP.D - Hypovolaemic shock?? CORRECT ANSWERIn a patient with a sudden onset of back pain, a swollen tense abdomen and low BP, a ruptured aortic aneurysm is the most common diagnosis. This leads to hypovolaemic shock.YOUR ANSWER WAS CORRECT22Theme: DermatomesA C4B C5C C6D C7E C8For each of the following descriptions, select the most likely answer from the above list. Each option may be used once, more than once, or not at all.Scenario 1The area of the skin over the middle finger.D - C7?? CORRECT ANSWERThe thumb and index finger are supplied by C6, the middle finger by C7, and the ring and little fingers by C8.YOUR ANSWER WAS CORRECTScenario 2The area of the skin over the tip of the shoulder.A - C4?? CORRECT ANSWERC4 supplies the infraclavicular region to the tip of the shoulder and above the scapular spine.Scenario 3The area of the skin over the ring finger.E - C8?? CORRECT ANSWERC8 supplies the ring and little fingers, and distal medial forearm.YOUR ANSWER WAS CORRECTScenario 4The area of the skin over the little finger.E - C8?? CORRECT ANSWERC8 supplies the ring and little fingers, and the distal medial forearm.YOUR ANSWER WAS CORRECT23Theme: Shoulder painA Supraspinatus tendonitisB Supraspinatus ruptureC Subacromial burstisD Biceps ruptureE Acromioclavicular joint disruptionsScenario 1A 52-year-old billboard poster plasterer, with a 1-year history of shoulder pain and difficulty in lifting his arm up while performing his job. On examination he had marked tenderness over the acromion process. He is unable to initiate abduction of the arm. He has no difficulty adducting his arm.B - Supraspinatus rupture?? CORRECT ANSWERB - Supraspinatus ruptureYOUR ANSWER WAS CORRECTScenario 2A 32-year-old man presented with a 1-month history of shoulder pain especially on lifting his arm. On examination he had marked tenderness lateral to the acromion process with a painful arc of 60–120°.A - Supraspinatus tendonitis?? CORRECT ANSWERA - Supraspinatus tendonitisYOUR ANSWER WAS CORRECTThe AnswerComment on this QuestionA complete tear of the supraspinatus tendon may occur after a long period of chronic tendinitis. Active abduction is impossible and attempting it produces a characteristic shrug, although passive abduction is full and, once the arm has been lifted to above a right angle, the patient can keep it up using the deltoid (abduction paradox). Supraspinatus tendinitis usually occurs in a patient aged < 40 years who develops shoulder pain after vigorous/strenuous exercise. On active abduction scapulohumeral rhythm is disturbed and pain is aggravated as the arm traverses an arc between 60 and 120°.24Theme: Life-threatening chest injuriesA Traumatic aortic ruptureB Massive haemothorax (right)C Tension pneumothorax (left)D Cardiac tamponadeFor each of the physical signs described below, select the most likely diagnosis from the list of conditions above. Each option may be used once, more than once or not at all.Scenario 1Beck’s triadD - Cardiac tamponade?? CORRECT ANSWERCardiac tamponadeTension pneumothorax and cardiac tamponade produce similar signs, in that they cause distension of the neck veins (on inspiration = Kussmaul's sign), cyanosis and hypotension. Beck’s triad comprises hypotension, distended neck veins and muffled heart sounds and is characteristic of cardiac tamponade.YOUR ANSWER WAS CORRECTScenario 2Tracheal deviation to the rightC - Tension pneumothorax (left)?? CORRECT ANSWERTension pneumothorax (left)Tension pneumothorax causes tracheal deviation away from the side of the injury. Traumatic aortic rupture and massive haemothorax can cause tracheal deviation but these are uncommon signs.YOUR ANSWER WAS CORRECTScenario 3Most commonly caused by penetrating right chest injuryB - Massive haemothorax (right)?? CORRECT ANSWERMassive haemothorax (right)Tension pneumothorax and traumatic aortic rupture are usually due to blunt trauma. Cardiac tamponade can be due to penetrating trauma, but haemothorax is much more common as a result of penetrating trauma.YOUR ANSWER WAS CORRECT25Theme: The painful kneeA Anterior cruciate injuryB Chondromalacia patellaeC Infrapatellar bursitisD Lateral collateral injuryE Medial collateral injuryF Meniscal tearG Osgood–Schlatter diseaseH OsteoarthritisI Osteochondritis dissicansJ Pre-patellar bursitisK Recurrent dislocation of the patellaL Rheumatoid arthritisM Septic arthritisN TendinitisThe following are descriptions of patients with a painful knee(s). Please select the most appropriate diagnosis from the above list. The items may be used once, more than once, or not at all.Scenario 1A 43-year-old woman is seen with a history of chronic pain and swelling of the knee. On examination, flexion and extension of the knee are limited and a marked valgus deformity is noted. This is particularly apparent on standing.L - Rheumatoid arthritis?? CORRECT ANSWERL – Rheumatoid arthritisThis can occasionally start in the knee as a monoarticular synovitis. With chronicity, the joint may become increasingly deformed. Although deformity can also occur (with chronic pain and swelling) in osteoarthritis, a valgus deformity is characteristic of rheumatoid arthritis whereas a varus deformity is frequently seen with severe osteoarthritis.Scenario 2A 14-year-old girl is seen with a 3-month history of knee pain. There is no history of trauma. The pain is felt principally in front of the knee and is exacerbated on ascending and descending stairs.B - Chondromalacia patellae?? CORRECT ANSWERB – Chondromalacia patellaeSoftening of the articular cartilage of the patella is often associated with anterior knee pain in teenage girls. The exact aetiology is unknown, however, it is thought to result from overload of the patellar articular surface as a result of mal-tracking of the patella during flexion and extension. On clinical examination, pain can be elicited by the patella friction test. Treatment is rest, analgesia and physiotherapy.Scenario 3A 19-year-old man presents with a history of intermittent pain and swelling in his left knee. In addition, he complains of his knee locking, which he relieves by manoeuvring the leg. He also complains of his knee ‘giving way.’ There is no history of trauma. On examination a small effusion is noted and a small mobile ‘body’ is felt in the suprapatellar pouch.I - Osteochondritis dissicans?? CORRECT ANSWERI – Osteochondritis dissicansThis is a condition where a small osteocartilaginous fragment separates from one of the femoral condyles (usually the medial condyle) and is rendered avascular. Patients tend to be young and present with intermittent pain and swelling of the knee. Attacks of ‘locking’ may occur as the loose body becomes trapped between the joint surfaces. Between attacks the loose body may be palpable, particularly in the suprapatellar pouch. Treatment involves removal of the loose body if small. Large fragments may be fixed back into position, particularly if complete separation has not occurred.26Theme: Joint and back painA Ankylosing spondylitisB Intervertebral disc herniationC Metastatic diseaseD Multiple myelomaE OsteoarthritisF Paget’s diseaseG Reiter’s syndromeH Rheumatoid arthritisI Spinal stenosisJ SpondylolisthesisFor each of the following statements, select the most likely cause of joint/back pain from the above list. Each option may be used once, more than once, or not at all.Scenario 1A 25-year-old presents with an unstable fracture of the fourth lumbar vertebra following a fall. He is on long-term NSAIDs for a painful and stiff back. On examination, he has kyphosis and serology for human leukocyte antigen B27 (HLA-B27) is positive.A - Ankylosing spondylitis?? CORRECT ANSWERA – Ankylosing spondylitisAnkylosing spondylitis, predominantly seen in the young, affects more men than women (6 : 1). The patient presents with morning stiffness, backache, progressive loss of spinal movements leading to kyphosis, and hyperextension of the neck (question mark posture). Occasionally, patients may present with unstable fractures after minor trauma. X-rays show a ‘bamboo spine’ with squaring of the vertebrae. Blood test reveals raised ESR, normochromic anaemia and positive HLA-B27 antigen.Scenario 2A 33-year-old previously fit patient presents with an acute low backache, which commenced when he was lifting a heavy object at work. He also complains of shooting pain radiating down the back of his right thigh.B - Intervertebral disc herniation?? CORRECT ANSWERB – Intervertebral disc herniationLumbar disc herniation (prolapse) commonly occurs in fit young adults usually when lifting heavy weight or while straining. A sudden acute pain is felt in the lower back, and it may be accompanied by shooting pain radiating to the buttock or down the leg along the appropriate nerve roots. Examination reveals paravertebral muscle spasm, leading often to a ‘spinal tilt’ and a global reduction in spinal movements. Straight leg raise (SLR) is often restricted to < 50° and reproduces the radicular symptoms.YOUR ANSWER WAS CORRECTScenario 3A 25-year-old presents with a painful right knee, and vesicles and pustules over the soles of his feet. He also complains of soreness in his eyes and burning on micturition. He gives a history of unprotected sex 2 months ago.G - Reiter’s syndrome?? CORRECT ANSWERG – Reiter’s syndromeReiter’s syndrome (sexually acquired reactive arthritis) is a triad of urethritis, conjunctivitis and seronegative arthritis. The patient is usually young; the disease affects large joints and causes oligo- or mono-arthritis. Other features include iritis, keratoderma blenorrhagica (brown, aseptic abscesses on soles and palms), circinate balanitis (painless serpiginous penile rash), plantar fasciitis and Achilles tendonitis. Management includes NSAIDs, rest, and splintage of the affected joint.YOUR ANSWER WAS CORRECTScenario 4A 12-year-old gymnast is brought by her parents to the orthopaedic clinic with lower backache of 1-year duration. On examination, she has L5 root pain and a hamstring spasm. Straight leg raise is reduced.J - Spondylolisthesis?? CORRECT ANSWERJ – SpondylolisthesisSpondylolisthesis is the slipping forward of one vertebra in relation to another. Isthmic spondylolisthesis is one type (of five) and appears to be a form of repetitive stress fracture; the incidence is much higher in teenage gymnasts and other athletes. It commonly occurs between the ages of 7 and 10. The signs and symptoms include low backache, hamstring spasm, fifth lumbar nerve root pain, and disturbance in the sagittal profile of the spine with an acute kyphosis. In some cases, neurological symptoms may affect the legs. On examination, there may be a step in the line of the spinous processes; straight leg raising may be reduced because of hamstring spasm.27Theme: Peripheral nerve entrapmentA Ulnar nerveB Anterior interosseous nerveC Tibial nerveD Common peroneal nerveE Radial nerveF Median nerveG Femoral nerveH Lateral femoral cutaneous nerveI Axillary nerveSelect the nerve that is most likely to be involved in each of the patients below. Each option may be used once, more than once, or not at all.Scenario 1A 35-year-old pregnant lady in her third trimester presented with pain on the side of her left thigh. She noticed that the pain is worse on walking and is relieved by sitting. On examination you notice that motor power and tone of the left lower limb is not affected.H - Lateral femoral cutaneous nerve?? CORRECT ANSWERMeralgia paresthetica is entrapment of the lateral femoral cutaneous nerve (purely sensory) at the inguinal ligament especially in pregnant women and obese people.YOUR ANSWER WAS CORRECTScenario 2A 56-year-old lady with known rheumatoid arthritis complains of tingling sensation in her thumb and index finger especially at night. On examination you notice there is wasting of the thenar muscles.F - Median nerve?? CORRECT ANSWERCarpal tunnel syndrome (median nerve entrapment) is common in the hands of the rheumatoid arthritis population.YOUR ANSWER WAS CORRECTScenario 3A 30-year-old lady was put in a left below-knee cast for lateral malleolus fracture. Upon removal of the cast 4 weeks later you notice that there is a foot drop and anaesthesia of dorsum of the foot.D - Common peroneal nerve?? CORRECT ANSWERIn below-knee casts, care must be taken not trap the common peroneal nerve against the upper edge of the cast, because the nerve here is very superficial and lies against bone (neck of fibula).YOUR ANSWER WAS CORRECTScenario 4A 25-year-old male presented with weakness of his left hand grip. Past medical history revealed that he sustained an elbow fracture when he was a child. On examination you notice wasting of the dorsal interosseous muscles and altered sensation in the little and ring fingers.A - Ulnar nerve?? CORRECT ANSWERTardive ulnar nerve palsy can follow a fracture of the lateral epicondyle at the elbow during childhood that halts growth laterally, while the medial epicondyle will continue to grow causing the carrying angle to increase and ulnar nerve entrapment.YOUR ANSWER WAS CORRECT28Theme: Knee injuryA Medial meniscal tearB Lateral meniscal tearC Anterior cruciate ligament ruptureD Posterior cruciate ligament ruptureE Medial collateral ligament tearF Lateral collateral ligament tearG Knee effusionWhat is the injury in the following patients? Match the appropriate diagnosis for each scenario. Each option may be used once, more than once, or not at all.Scenario 1A 25-year-old man sustains injury to his right knee during a football tackle. However, he continues to play albeit with severe discomfort. He presents to the emergency department after 24 h with a swollen, tender right knee. He is unable to straighten the knee fully and tenderness is elicited over the anterior medial aspect of the knee at the level of the joint line.A - Medial meniscal tear?? CORRECT ANSWERScenario 2A 25-year-old man sustains severe injury to his left knee from an awkward fall while skiing. He reports hearing a pop and swelling in this knee was noticed immediately. There is no localised joint line tenderness, but he is unable to fully extend this knee.C - Anterior cruciate ligament rupture?? CORRECT ANSWERYOUR ANSWER WAS CORRECTThe AnswerComment on this QuestionA history of twisting injury and pain at the antero-medial aspect of the joint is indicative of a medial meniscal injury. If bleeding has occurred into the joint space, the knee swells within 1–2 h. This is usually suggestive of a serious intra-articular damage such as an anterior cruciate ligament rupture.If the knee swells over a 12–24 h period, the swelling is more likely to be due to a simple effusion. As fluid collects in the knee, movement becomes more restricted and painful and only a few degrees of movement may be possible. The knee is usually held in 10° of flexion. In collateral ligament injuries, the pain is usually localised; however, no clear tenderness can be elicited in cruciate ligament injuries.29Theme: Disorders of boneA AchondroplasiaB CraniocleidodysostosisC Diaphyseal aclasisD Ollier’s diseaseE OsteochondrodystrophyF Osteogenesis imperfectaG OsteopetrosisH Perthe’s diseaseI RicketsJ ScurvyFor each of the following situations, select the most appropriate cause for the presentation from the above list. Each option may be used once, more than once, or not at all.Scenario 1A 13-year-old boy is brought to the orthopaedic outpatient clinic with a history of tiredness, recurrent throat and chest infections and gradual loss of hearing. X-ray reveals a ‘marble bone’ appearance.G - Osteopetrosis?? CORRECT ANSWERG – OsteopetrosisOsteopetrosis is an autosomal recessive condition. The patient, usually a young adult, may present with symptoms of anaemia (tiredness) or thrombocytopenia (easy bruising) and leucopaenia (recurrent throat and chest infections) because of decreased marrow space. Deafness and optic atrophy can result from compression of the cranial nerves. Blood investigations may reveal a leukoerythroblastic picture. The bones are very dense and brittle, and X-ray reveals a lack of differentiation between the cortex and the medulla described as ‘marble bone’.YOUR ANSWER WAS CORRECTScenario 2A 14-year-old boy, who is small for age, is brought to his GP with loss of hearing in both ears. On examination, he has a blue sclera, knock-knees, and hypermobile fingers. X-rays show multiple fractures (old) of the long bones and irregular patches of ossification.F - Osteogenesis imperfecta?? CORRECT ANSWERF – Ostegenesis imperfectaOsteogenesis imperfecta (brittle bone disease) is defective osteoid formation due to the congenital inability to produce adequate intercellular substances, such as osteoid, collagen and dentine. In addition, there is a failure of maturation of collagen in all the connective tissues. Some typical clinical features of this condition include: a broad skull, blue sclera, premature deafness, scoliosis, ligament laxity, coxa vara and knock knees. X-rays may reveal translucent bones, multiple fractures particularly of the long bones, wormian bones (irregular patches of ossification), and a trefoil pelvis.YOUR ANSWER WAS CORRECTScenario 3A 3-year old boy is brought to the GP surgery with a swollen and painful right knee joint. The parents also say that they recently noticed some bleeding from his gums. He lies still and refuses to move the limb. X-ray shows generalised rarification of the bones in his legs.J - Scurvy?? CORRECT ANSWERJ – ScurvyScurvy (vitamin C deficiency) causes a failure of collagen synthesis and osteoid formation. The patient, usually a child or an infant, may present with swelling and tenderness near the large joints. There may be bleeding from the gums as they are spongy. Spontaneous bleeding may lead to subperiosteal haematoma and the child remains still (pseudoparalysis) as a result of subperiosteal bleeding. X-rays shows generalised bone rarefaction. The metaphysis may be deformed or fractured. Vitamin C in the form of ascorbic acid should be given in doses of 1 gm/day and the child should be encouraged to eat fresh fruit and vegetables.YOUR ANSWER WAS CORRECTScenario 4A 2-year-old infant is brought to the Emergency Department with convulsions. On examination, the child lies listless and flaccid, appears small for age and there is noticeable thickening of both wrists. X-ray shows an increase in the depth and width of the epiphysis of the lower ends of the radius and ulna.I - Rickets?? CORRECT ANSWERI – RicketsRickets is the childhood form of osteomalacia. Because of vitamin D deficiency osteoid fails to ossify. Symptoms start from about the age of 1 year. The child may present with tetany or convulsions. The child is small for age and there is a history of failure to thrive. Bony deformities include: bowing of the femur and tibia, deformity of the skull (craniotabes), deformity of the chest wall with thickening of the costochondral junction (ricketty rosary), and a transverse sulcus in the chest caused by the pull of the diaphragm (Harrison’s sulcus). The characteristic X-ray change is an increase in the depth and width of the epiphysis and the adjacent metaphysis has a ‘cupped’ appearance; these changes are most noticeable in the wrist.30Which of the following is a common childhood fracture (under 12 years)?Barton’s fractureColles’ fractureFracture of the femoral shaftHairline fracture of temporal boneSupracondylar fracture?? YOUR ANSWERYOUR ANSWER WAS CORRECTThe AnswerThe skull and long bones in young children are still ossifying and therefore more malleable than in adults. Fractures to these areas in young children should therefore be treated with suspicion and non-accidental injury considered. Colles’ fractures are classical, although not exclusive, to osteoporosis and therefore elderly adults. Barton’s fractures are intra-articular fractures of the distal radius in adults, similar fractures in children would be classified using the Salter Harris classification system.31Theme: Knee injuriesA Anterior cruciate ruptureB HaemarthrosisC Injury to the medial meniscusD Medial ligament ruptureE Patellar?fractureF Tibial plateau fractureFor each of the clinical situations described below, select the most likely diagnosis from the above list. Each option may be used once, more than once, or not at all.Scenario 1A 29-year-old man was hit by a car as he ran across the road. He was subsequently unable to weight-bear. His knee was bruised, swollen and tender.F - Tibial plateau fracture?? CORRECT ANSWERF – Tibial plateau fractureScenario 2A 45-year-old woman stumbled over an uneven paving stone and landed heavily on her knee. She walked aided into the Emergency Department with a swollen painful knee and was unable to straight leg raise.E - Patellar fracture?? CORRECT ANSWERE – Patellar fractureScenario 3A footballer sustained a twisting injury to his flexed knee while playing a game yesterday. He was unable to complete the game and by this morning his knee was very swollen. He was unable to fully flex or extend his knee.C - Injury to the medial meniscus?? CORRECT ANSWERC – Injury to the medial meniscusYOUR ANSWER WAS CORRECTScenario 4A 25-year-old man landed awkwardly having jumped for a ball in the line-out during a rugby match. He heard a pop and was unable to complete the game. He noticed his knee swell immediately.A - Anterior cruciate rupture?? CORRECT ANSWERA – Anterior cruciate ruptureYOUR ANSWER WAS CORRECTScenario 5A 25-year-old man was involved in a tackle during a football game today. A valgus force was applied to the knee – he fell to the ground and noted that his knee was at a ‘funny angle’. He has been unable to weight-bear and says that his knee feels ‘unsafe’. On examination, his knee is generally tender, there is significant laxity on valgus stress but no definite effusion.D - Medial ligament rupture?? CORRECT ANSWERD – Medial ligament ruptureYOUR ANSWER WAS CORRECTThe AnswerA valgus force to the knee produced by a car bumper is likely to result in bony damage (a tibial plateau fracture); a similarly directed force during a game of football is more likely to lead to rupture of the medial collateral ligament. Complete rupture of this ligament would lead to gross instability on weight-bearing at the time of injury. As the joint is disrupted, no discrete effusion is seen, although the area may be swollen and bruised. Swelling due to a medial meniscal injury usually takes some hours to become apparent. However, an anterior cruciate ligament rupture with the classical ‘pop’ produces a rapid haemarthrosis.32A 37-year-old man attends the emergency department having sustained a laceration to the left hand on a piece of broken glass. On examination there is a deep laceration on the volar surface lying 1cm proximal to the distal palmar crease.Which flexor tendon injury zone does this injury lie in?Select one answer onlyZone 1?? YOUR ANSWERZone 2Zone 3?? CORRECT ANSWERZone 4Zone 5YOUR ANSWER WAS INCORRECTThe AnswerThere are five zones of injury described by Verden for flexor tendons, based on anatomic factors and prognosis.?The five zones are:Zone 1 – Between the DIP and PIP joint creasesZone 2 – Between the mid point of the middle phalanx and distal palmar creaseZone 3 – Between the distal palmar crease and the distal margin of the carpal tunnelZone 4 – Overlying the carpal tunnelZone 5 – The forearm and wrist up to the proximal border of the carpal tunnel33Theme: Mono- and polyarthritisA Beh?et’s syndromeB Drug allergiesC GoutD OsteoarthritisE PseudogoutF PsoriasisG Reiter’s syndromeH Rheumatoid arthritisI Septic arthritisJ SpondyloarthritidesK Still’s diseaseL Systemic lupus erythematosusM TraumaN Viral illnessThe following patients all present with symptoms of arthritis. From the list above, select the most likely diagnosis. The items may be used once, more than once, or not at all.Scenario 1A 43-year-old man attends The Emergency Department with a painful right knee. He reports a sudden onset of severe, constant pain in the right knee, and that he is no longer able to mobilise. His temperature is 38.5°C. Examination of the knee reveals an increased temperature over the right knee, but no erythema. He is tender in the joint line, and he is unable to actively move the joint.I - Septic arthritis?? CORRECT ANSWERI – Septic arthritisJoints can become infected by direct extension from a wound, by direct introduction (joint injection/arthroscopy), or by spread from acute osteomyelitis or haematogenously. Staphylococci and?Haemophilus influenzae?predominate, although other Gram-positive cocci and Gramnegative bacilli may be implicated.The infection usually starts in the synovial membrane, and a seropurulent exudate develops in the synovial fluid. There is progressive destruction of the articular cartilage, and vascular damage may lead to death of epiphyseal bone; hence the need for urgent diagnosis and appropriate treatment. The classic clinical feature is reluctance to move the joint, but swelling and erythema are commonly present. The joint is the maximal site of tenderness (differentiating it from acute osteomyelitis), and all joint movements are restricted. White cell count and erythrocyte sedimentation rate/C-reactive protein are invariably raised. Radiography is often unremarkable in the early stages. Treatment involves analgesia, appropriate antibiotics, joint aspiration, or occasionally formal open drainage.YOUR ANSWER WAS CORRECTScenario 2A 52-year-old woman attends the clinic with a long history of intermittent pain and swelling affecting her left knee. Past history includes hypothyroidism. Examination is unremarkable. A plain radiograph reveals the presence of intra-articular calcium deposition, but no other abnormality.E - Pseudogout?? CORRECT ANSWERE – PseudogoutThis condition involves acute or chronic arthritis secondary to deposition of calcium pyrophosphate or basic calcium phosphates. Pyrophosphate is generated in cartilage by enzyme activity, and combines with calcium ions to form crystals. In many cases it is idiopathic, although it may occur in hyperparathyroidism, hypothyroidism, acromegaly, or haemochromatosis. The clinical presentation is less severe and usually more chronic than with gout (urate crystal arthropathy in patients with hyperuricaemia). The fibrocartilage of the knee, pubic symphysis and intervertebral discs are most commonly affected, particularly in women over the age of 60 years. Radiography reveals calcification that usually appears as a line across the joint, but the synovial capsule and surrounding tendons may be calcified. The diagnosis is confirmed by demonstrating weakly positive bi-refringent rhomboid crystals in plane-polarised light.Scenario 3A 13-year-old girl is referred with a 6-month history of pain and swelling affecting the joints of her upper limbs. Her mother also informs you that she also suffers with a ‘grumbling appendix’. On examination, there is bilateral involvement of the shoulder joints, elbows and wrists. Abdominal examination reveals splenomegaly.K - Still’s disease?? CORRECT ANSWERK – Still’s diseaseJuvenile chronic arthritis (Still’s disease) affects 1 in 1000 children, with 70% of those affected being female. At least two of joint pain, swelling, or limitation of movement, need to affect more than four joints for at least 3 months for the diagnosis to be accepted. Associated systemic symptoms of fever, macular rash and lymphadenopathy may predominate. Recurrent abdominal pain may occur secondary to bouts of mesenteric adenitis, as in the case presented. Hepatosplenomegaly, myocarditis and uveitis may complicate this condition. In 90% of cases the condition is seronegative and can only be confirmed by synovial biopsy. Chronic disease may lead to joint destruction, fibrosis and ankylosis, resulting in deformity. In addition, end-organ failure may supervene. It is differentiated from Reiter’s syndrome (polyarthritis, urethritis, conjunctivitis) on account of no urethral involvement.34Theme: Low back painA DiscitisB Facet joint arthrosisC Metastatic diseaseD Muscle strainE Osteoporotic collapseF Prolapsed intervertebral discG SpondylolisthesisFor each of the clinical situations described below, please select the most likely diagnosis from the above list. Each option may be used once, more than once, or not at all.Scenario 1A teenage boy presents to his GP with a 6-month history of increasing pain and stiffness in his lower lumbar spine. There is no history of trauma although he is an active sportsman. His lumbar spine is stiff on examination and there is bilateral limitation of straight leg raising with pain in the hamstring muscles.G - Spondylolisthesis?? CORRECT ANSWERG – SpondylolisthesisSpondylolisthesis commonly presents in the teenage years with pain and hamstring tightness. This is not the same as a limited straight leg raising where the ‘strain’ is on the sciatic nerve.YOUR ANSWER WAS CORRECTScenario 2A young man wakes up one morning complaining of pain in his lower back. The day before he had been redecorating his bedroom. There are no nerve root signs but his back is very stiff.D - Muscle strain?? CORRECT ANSWER2 D – Muscle strainMuscle strains are the most common cause of low back pain in fit young adults, particularly if there has been some ‘unaccustomed’ exercise. A slipped disc is more likely to be associated with radiation of the pain and symptoms of nerve root irritation.Scenario 3An active 88-year-old woman has had some back pain since she stumbled over her own doorstep 6 weeks ago. Her back was initially stiff but she feels there has been some improvement over the last 2 weeks.E - Osteoporotic collapse?? CORRECT ANSWERE – Osteoporotic collapseMany 88-year-olds have osteoporosis and a simple fall can cause an osteoporotic fracture with collapse. As the patient is improving, a more sinister explanation is unlikely.Scenario 4A 3-year-old baby girl refuses to walk. Her symptoms began last night and she is irritable and unwell. Examination of her lower limbs is entirely normal but percussion of her lumbar spine causes her to cry.A - Discitis?? CORRECT ANSWERA – DiscitisIn children who refuse to walk, a septic arthritis or osteomyelitis affecting the lower limbs must first be excluded; only then may a diagnosis of discitis be considered.YOUR ANSWER WAS CORRECTScenario 5A 45-year-old man gives a 3-month history of low back pain, which is worse at night and has become progressively worse such that he is now in agony and cannot get comfortable. The pain radiates to both buttocks. He also complains of feeling generally unwell and thinks that he has lost weight and neurological examination suggests there are problems with the sacral nerve roots.C - Metastatic disease?? CORRECT ANSWERC – Metastatic diseaseAlthough the gentleman here is relatively young, the history of progressive pain radiating to the buttocks with systemic symptoms and night pain must raise the concern of a metastatic lesion.35Theme: Joints of the upper limbA Saddle type of synovial jointB Pivot type of synovial jointC Condyloid synovial jointD Plane synovial jointE Hinge type of synovial jointFor each of the following joints, select the most likely answer from the above list. Each option may be used once, more than once, or not at all.Scenario 1Radioulnar jointB - Pivot type of synovial joint?? CORRECT ANSWERThe radius and ulna articulate with each other at their proximal and distal ends at synovial joints – proximal and distal radioulnar joints. These are the pivot type of synovial joint and produce pronation and supination of the forearm.Scenario 2Intercarpal jointsD - Plane synovial joint?? CORRECT ANSWERThese are the plane type of synovial joints which permit gliding and sliding movements.YOUR ANSWER WAS CORRECTScenario 3Metacarpophalangeal jointsC - Condyloid synovial joint?? CORRECT ANSWER3219450205740These joints are condyloid (knuckle-like) synovial joints and allow movement in two directions.Scenario 4Sternoclavicular jointA - Saddle type of synovial joint?? CORRECT ANSWERThis is a saddle type of synovial joint and is the only bony articulation between the axial skeleton and the upper limb.36Theme: Femoral neck fracture managementA Unipolar Austin Moore hemiarthroplastyB Bipolar Hastings hemiarthroplastyC Cannulated hip screwsD TractionE Intramedullary nailF Total hip replacementG Dynamic hip screwSelect the most appropriate treatment for each of the patients below. Each option may be used once, more than once, or not at all.Scenario 1A 66-year-old actively mobile lady fell whilst crossing the road sustaining an intracapsular right femoral neck fracture which appears to be completely displaced and detached from the neck (Garden IV).F - Total hip replacement?? CORRECT ANSWERGarden IV intracapsular neck of femur fractures will inevitably need removal of the head and arthroplasty. Scottish Intercollegiate Guidelines Network (SIGN) guidelines suggest that patients with displaced intracapsular femoral neck fractures who are relatively fit and mobile with reasonable life expectancy then total hip replacement is the option of choice.YOUR ANSWER WAS CORRECTScenario 2A 70-year-old demented lady in a nursing home falls out of bed complaining right hip pain. X-ray of the right hip shows an intracapsular completely detached and displaced fracture of the femoral neck (Garden IV).A - Unipolar Austin Moore hemiarthroplasty?? CORRECT ANSWERHere mobility is not an issue, so a hemiarthroplasty that will not erode into the acetabulum is justified. No benefit of bipolar has been shown over unipolar (as movement has been shown to occur at the outer articulation); although some surgeons prefer one to the other, there does not appear to be any good evidence to show any significant advantage from using bipolar hemiarthroplasty in favour of unipolar hemiarthroplasty (SIGN guidelines: Prevention and management of hip fracture on older people; section 7: surgical management).YOUR ANSWER WAS CORRECTScenario 3A 61-year-old lady fell on her right hip while watering the plants in the garden, sustaining pain and inability to weight bear. X-ray of the right hip shows a two-part intertrochanteric fracture of reverse obliquity.E - Intramedullary nail?? CORRECT ANSWERIntertrochanteric fractures with reverse obliquity will need intramedullary nailing as a dynamic hip screw (DHS) will fail because most of the weight will be transmitted through the DHS pin.Scenario 4A 77-year-old lady trips while walking and falls on her right hip sustaining a two-part intertrochanteric fracture of usual obliquity.G - Dynamic hip screw?? CORRECT ANSWERHere a dynamic hip screw to hold the two parts together will be justified (cf previous case).37Theme: Soft tissue injuries of the knee jointA Medial meniscal tearB Lateral meniscal tearC Supracondylar fracture of the femurD Fracture of the fibular headE Anterior cruciate ligament ruptureF Posterior cruciate ligament ruptureG Patellar fractureH Medial collateral ligamentI Lateral collateral ligamentSelect the most likely site of damage for the patients described below. Match the appropriate answer for each scenario. Each option may be used once, more than once, or not at all.Scenario 1A 20-year-old man present to the emergency department with an acutely swollen and painful left knee after falling awkwardly on this knee while playing football. There is tenderness over the medial joint line. There is no joint instability.A - Medial meniscal tear?? CORRECT ANSWERScenario 2A 66-year-old lady presents to the emergency department with a painful and swollen right knee after she tripped and fell over on the pavement. There is tenderness and crepitus on palpation over the patella. Aspiration of the knee joint reveals blood and fat globules.G - Patellar fracture?? CORRECT ANSWERYOUR ANSWER WAS CORRECTScenario 3A 19-year-old rugby player presents to the emergency department with a painful and swollen left knee after he sustained injury to that knee while involved in a scrum. There is severe tenderness along the lateral aspect of the knee joint and the pain is worsened with valgus and varus force. The joint feels unstable.I - Lateral collateral ligament?? CORRECT ANSWERYOUR ANSWER WAS CORRECTThe AnswerComment on this QuestionA history of twisting injury and pain at the antero-medial aspect of the joint is indicative of a medial meniscal injury. Cruciate ligament rupture characteristically produces swelling with 1–2 h of the injury. Aspiration of blood suggests severe intra-articular damage. The presence of fat globules usually signifies a fracture, such as fracture of the patella in this patient. In injuries secondary to trauma, plain radiography is needed to confirm or rule out associated fractures in patients presenting with swelling and tenderness of the knee joint, although they may manifest classical signs and symptoms of a soft tissue injury. Collateral ligament injuries cause pain and discomfort with straining of the knee in the valgus and varus positions.38Theme: Nerves of the upper limbA Radial nerveB Musculocutaneous nerveC Ulnar nerveD Median nerveE Axillary nerveFor each of the following descriptions, select the most likely answer from the above list. Each option may be used once, more than once, or not at all.Scenario 1This nerve is formed in the axilla by the union of the lateral root from the lateral cord and the medial root from the medial cord of the brachial plexus.D - Median nerve?? CORRECT ANSWERThe lateral root of the median nerve is the continuation of the lateral cord of the brachial plexus, and the lateral root is joined by the medial root of the median nerve, lateral to the axillary artery to form the median nerve.YOUR ANSWER WAS CORRECTScenario 2This nerve is the larger of the two terminal branches of the medial cord of the brachial plexus.C - Ulnar nerve?? CORRECT ANSWERThe ulnar nerve is the larger of the two terminal branches of the medial cord of the brachial plexus, the other terminal branch of the medial cord is the medial root of the median nerve.YOUR ANSWER WAS CORRECTScenario 3This nerve enters the arm posterior to the brachial artery, medial to the humerus, and anterior to the long head of triceps.A - Radial nerve?? CORRECT ANSWERThe radial nerve is the direct continuation of the posterior cord of the brachial plexus and is the largest branch of the brachial plexus. It enters the arm posterior to the brachial artery, medial to the humerus, and anterior to the long head of the triceps.YOUR ANSWER WAS CORRECTScenario 4This nerve becomes the lateral cutaneous nerve of the forearm at the lateral border of the tendon of the biceps brachii.B - Musculocutaneous nerve?? CORRECT ANSWERThe musculocutaneous nerve supplies the muscles of the anterior aspect of the arm and is one of the two terminal branches of the lateral cord of the brachial plexus. Just proximal to the elbow joint, the musculocutaneous nerve pierces the deep fascia and becomes superficial, being now known as the lateral cutaneous nerve of the forearm supplying the skin on the lateral aspect of the forearm.39Theme: Bone tumoursA Multiple myelomaB Non-ossifying fibromaC Metastatic malignancyD Ollier's diseaseE Giant cell tumourF OsteosarcomaG EnchondromaH Ewing sarcomaI Osteoid osteomaSelect the most appropriate diagnosis for each of the patients below. Each option may be used once, more than once, or not at all.Scenario 1A 19–year-old male complains of right thigh pain for the last 3 months especially at night which responds well to aspirin. X-ray of his right femur showed a translucent nidus in the diaphysis surrounded by an intense sclerotic reaction.I - Osteoid osteoma?? CORRECT ANSWEROsteoid osteoma can occur anywhere in the skeleton. The characteristic pain worse at night responding to aspirin is peculiar to this tumour.Scenario 2A 28-year-old female teacher presented with left knee pain and swelling for the last two weeks, otherwise she is fit and healthy. X-ray of the left knee showed a large translucent lesion in the proximal tibia with hazy margins extending into the epiphysis and eroding the articular cartilage.E - Giant cell tumour?? CORRECT ANSWERGiant cell tumours most commonly affect the epiphysis more than any other tumour in this age group. A non-ossifying fibroma can be included in the differential diagnosis but it will have a sclerotic margin.Scenario 3A 49-years-old female presented to the emergency department sustaining a right neck of femur following a trivial trauma. X-ray of the right hip also showed multiple lytic lesions. Past medical history reveals that she had a left mastectomy two years ago.C - Metastatic malignancy?? CORRECT ANSWERA history of previous malignancy with this characteristic appearance is strongly suggestive of metastatic malignancy even if the original tumour is not clinically evident yet. Multiple myeloma may be a differential diagnosis but it occurs in older age group.YOUR ANSWER WAS CORRECTScenario 4A 13 year-old-boy presented with a painful and swollen left leg for the last 3 weeks that is progressively worsening. On examination he is also febrile and blood investigations show leucocytosis. X-ray of the left leg shows a patchy density in the left fibula diaphysis surrounded by a lamellated periosteal reaction.H - Ewing sarcoma?? CORRECT ANSWEREwing sarcoma is common in this age group mainly confused with osteomyelitis. Onion skin appearance (lamellated periosteal reaction) is typical of this tumor.40Theme: Knee injuryA Anterior cruciate ligament (ACL) ruptureB Posterior cruciate ligament (PCL) ruptureC Medial meniscal injuryD Lateral meniscal injuryE Medial collateral ligament (MCL) injuryF Lateral collateral ligament (LCL) injuryG Patellar ligament tendonitisH Patellar tendon ruptureSelect the most appropriate diagnosis for each of the patients below. Each option may be used once, more than once, or not at all.Scenario 1A 29-year-old football player complains of anterior knee pain especially on extending the knee, relieved by rest. On examination there is tenderness below the patella and on the tibial tuberosity; however there are no other signs of knee injury.G - Patellar ligament tendonitis?? CORRECT ANSWERPatellar ligament tendonitis (so called jumper’s knee) is common in athletes due to repetitive microtrauma to the ligament. It is treated by non-steroidal anti-inflammatory drugs (NSAID) and rest, or steroid injection. The extensor mechanism is painful but NOT lost.YOUR ANSWER WAS CORRECTScenario 2A 28-year-old footballer presented to outpatients with a history of recurrent right knee pain and inability to extend the knee (he describes as if the knee locks). He sustained an injury to that knee 2 months ago with no mention of a significant swelling. On examination there is click and tenderness in the medial joint line when you extend the knee.C - Medial meniscal injury?? CORRECT ANSWERDue to relative avascularity of the menisci there is seldom a mention of significant swelling that classically accompanies anterior cruciate ligament (ACL) rupture (haemarthrosis); locking (inability to extend) of the knee and medial joint line tenderness all point to medial meniscal injury. Arthroscopy is indicated here.YOUR ANSWER WAS CORRECTScenario 3A 45-year-old man presented with his knee giving way when he climbs upstairs. He had sustained an injury to that knee few months ago when he was skiing in France where he describes a hyperextension injury of the knee which was followed rapidly by a tense knee effusion. On examination you can displace the tibia forward on the femur.A - Anterior cruciate ligament (ACL) rupture?? CORRECT ANSWERHyperextension injury and rapid swelling (haemarthrosis) point to cruciate injury. The fact that you can displace the tibia forward (Lachman test) favours ACL rupture.YOUR ANSWER WAS CORRECTScenario 4A 25-year-old rugby player presented with recurrent pain and giving way of his left knee. His knee was hit 2 months ago from the side in a tackle during a game sustaining swelling and pain. On examination you find that the joint opens on valgus stress.E - Medial collateral ligament (MCL) injury?? CORRECT ANSWERThis is a typical mechanism of sport injury to the medial collateral ligament MCL (lateral blow to the knee). Valgus stress confirms rupture of the ligament.YOUR ANSWER WAS CORRECTScenario 546-year-old male presented with inability to walk after he tripped on climbing the stairs. He suffers from brittle asthma for which he is on steroids. On examination of the knee there is mild swelling but no effusion. He also can’t extend his knee, and a gap is felt below the patella compared to the other side.H - Patellar tendon rupture?? CORRECT ANSWERThis is common in patients on steroid as it causes breakdown of collagen strength and organisation, thereby weakening tendons, ligaments, bones, skin etc.YOUR ANSWER WAS CORRECT41Theme: Bone and connective tissue tumoursA ChondrosarcomaB Ewing’s sarcomaC FibrosarcomaD LeiomyosarcomaE Malignant giant cell tumourF OsteochondromaG OsteoclastomaH Osteoid osteomaI OsteosarcomaJ RhabdomyosarcomaFor each of the following statements, select the most likely cause of pain/swelling from the above list. Each option may be used once, more than once, or not at all.Scenario 1A 65-year-old presents with a swelling and pain over her left proximal humerus. The pain is worse at night. She also gives a history of weight loss. She has a raised ESR and she is undergoing treatment for Paget’s disease.I - Osteosarcoma?? CORRECT ANSWERI – OsteosarcomaOsteosarcoma, the most frequently encountered malignant lesion of bone, is characterised by the direct formation of bone or osteoid tissue by a sarcomatous stroma. It typically affects the knee and the proximal humerus in the metaphyseal region. The incidence is highest in the 10–25-years age group. Secondary osteosarcoma, however, may arise in the bones of the elderly affected by Paget’s disease (in approximately 10% of patients affected for > 10 years) or after irradiation. The characteristic symptoms of pain, local tenderness, a soft tissue mass and a decreased function may be present for variable periods of time. On examination, the affected part is swollen and the overlying skin may be shiny and warm. The lump is tender and has irregular edges. The ESR may be raised. X-ray shows bone destruction and new bone formation, often with marked periosteal elevation (‘Sunray spiculation’ and ‘Codman’s triangle’, respectively). Surgical excision is the treatment of choice.YOUR ANSWER WAS CORRECTScenario 2A 13-year-old adolescent is brought by his parents to the GP with loss of weight, pain and fever. On examination, a soft but tender, ill-defined mass is palpable over his mid-thigh region.B - Ewing’s sarcoma?? CORRECT ANSWERB –?Ewing’s sarcomaEwing’s sarcoma is a malignant tumour arising from the vascular endothelium of the bone marrow. The tumour is common in the 10–20-years age group and occurs in the diaphysis of the long bones. Clinical features include pain and swelling; the lump is warm and tender, with ill-defined edges. The ESR may be elevated, thus spuriously suggesting an inflammatory or infective cause such as osteomyelitis, although osteomyelitis usually affects the metaphyseal region in children. X-rays often show a large soft-tissue mass with concentric layers of new bone formation – known as ‘onion-peel’ sign. Treatment includes chemotherapy and surgical excision.YOUR ANSWER WAS CORRECTScenario 3A 23-year-old presents with mild discomfort and a lump over his right knee. He accidentally discovered the lump one week ago. On examination, it is bony hard and non-tender. He is systemically well.F - Osteochondroma?? CORRECT ANSWERF – OsteochondromaOsteochondroma (cartilage-capped exostosis) is the most common benign tumour of the bone. The usual site for the tumour is the metaphysis of the long bones. The lesion may be single or multiple (hereditary multiple exostoses). The usual history is of a lump that is discovered accidentally. The lump is bony hard and non-tender. X-ray reveals a well-defined swelling; however, the swelling looks smaller than it feels because of the invisible cartilaginous cap.Scenario 4A 28-year-old lady presents with weight loss, fever and a swelling over her right knee of a few weeks duration. Movements of her knee are severely restricted. X-ray reveals thinning of the cortex and a fracture of the distal femur. An extraosseous soft tissue mass is seen on MRI scan.G - Osteoclastoma?? CORRECT ANSWERG – OsteoclastomaOsteoclastoma (giant cell tumour) is an uncommon, aggressive, locally destructive lesion seen in the metaphyseo-epiphyseal region of long bones. It frequently occurs in young adults 20–40 years of age and is more common in women. The principal sites are the distal femur, proximal tibia, proximal fibula, distal radius and proximal humerus. On examination, a vague swelling is felt at the end of long bones and the neighbouring joint is often inflamed. Although < 5% of these tumours metastasise, the lesions are extremely destructive, sometimes locally resulting in pathological fractures (approximately 10% of cases) as seen in this patient. X-ray shows thinning of the cortex giving it an expanded appearance – the characteristic ‘soap bubble’ appearance. Surgical excision is the treatment of choice, with concurrent bone grafting undertaken, if necessary. If this is not possible, radiotherapy may be attempted.42Theme: Swollen painful jointsA OsteoarthritisB GoutC Rheumatoid arthritisD Tuberculous arthritisE Neuropathic joint diseaseFor each of the patients described below, select the single most likely diagnosis from the options listed above each option may be used once more, than once or not at all.Scenario 1A 35-year-old woman progressively develops pain, swelling and stiffness of her hands. On examination, 2 years after the onset of her joint complaints, she is found to have swelling and tenderness in relation to the metacarpophalangeal joints. X-rays of the affected joints show diminution of joint space, as well as osteoporosis and marginal erosions of the articulating bones.C - Rheumatoid arthritis?? CORRECT ANSWERRheumatoid arthritis is associated with joint swelling, pain and stiffness. Common?X-ray changes include narrowing of joint space, marginal “mouse bite” erosions and cysts, as well as osteoporosis.Scenario 2A 60-year old woman complains of pain and swelling in both her knees of gradual onset over a period of 2 years. On examination there is evidence of excess synovial fluid and synovial thickening in both knee joints and local tenderness. Standing X-rays of her knees show diminution of joint space, sclerosis and cysts in the adjacent bones. Osteophytes are also seen at the articular margins.A - Osteoarthritis?? CORRECT ANSWERThis is typical of osteoarthritis, where you have joint tenderness, poor range of movements and effusions. Typically on?X-rays you will have loss of joint space, subchondral sclerosis and cysts and marginal osteophytes.43Theme: Nerve damageA Horner syndromeB Neurapraxia of the common peroneal nerveC Neurapraxia of the median nerveD Neurapraxia of the radial nerveE Neurotmesis?of the common peroneal nerveF Neurotmesis of the median nerveG Posterior interosseus nerve lesionH Sciatic nerve injuryFor each of the patients listed below, select the site and type of nerve damage that best explains the clinical situation from the above list. Each option may be used once, more than once, or not at all.Scenario 1A 21-year-old man sustained a comminuted fracture of the right femur and a fracture of the ipsilateral tibia and fibula. He was treated with skeletal traction and a below-knee plaster overnight. On review it was noticed that he could not dorsiflex his right toes.B - Neurapraxia of the common peroneal nerve?? CORRECT ANSWERThe peroneal nerve is very susceptible to pressure, and thus may result in a neurapraxia.Scenario 2A child falls on an outstretched hand and sustains a severely displaced supracondylar fracture of the humerus.C - Neurapraxia of the median nerve?? CORRECT ANSWERFollowing a supracondylar fracture of a child’s humerus, a neurapraxia of the median nerve (specifically, the anterior interosseous branch of the median nerve) is the most common neurological lesion but damage to the ulnar nerve is also not uncommon.Scenario 3Following a difficult elective plating of a non-union fracture of the humeral shaft, the patient was unable to extend his fingers and wrist. No nerves were visualised during the procedure.D - Neurapraxia of the radial nerve?? CORRECT ANSWERIf a surgical procedure is complicated by nerve injury, a transection (neurotmesis) must be considered – especially if the nerve has not been visualised.YOUR ANSWER WAS CORRECTScenario 4A motorcyclist came off his bike at considerable speed. Both he and his bike were then dragged down the road by a car. On examination he had a flail left upper limb. Secondary survey also reveals ocular ptosis and pupillary miosis on the ipsilateral side.A - Horner syndrome?? CORRECT ANSWERA flail upper limb suggests a brachial plexus lesion, which might well be associated with Horner syndrome if the sympathetic chain is involved.YOUR ANSWER WAS CORRECTScenario 5Following a total hip replacement performed via a posterior approach, the patient was noted to have a foot drop.H - Sciatic nerve injury?? CORRECT ANSWERDuring a hip replacement, two forms of nerve injury are well documented: direct damage to the sciatic nerve at the level of the hip joint (more common); and pressure on the peroneal nerve at the neck of the fibula. During a posterior approach to the hip, the sciatic nerve is in particular danger.YOUR ANSWER WAS CORRECT44Theme: Peripheral nerve anatomyA AxillaryB Long thoracicC Medial pectoralD MedianE MusculocutaneousF RadialG SuprascapularH ThoracodorsalI UlnarJ Upper subscapularFor each of the patients listed below, select the nerve most likely to be involved from the above list. Each option may be used once, more than once, or not at all.Scenario 1While playing football, a young man dislocates his right shoulder. The dislocation is reduced soon after. Once the shoulder is painfree, he notices that he cannot carry weights with his right arm and is unable to raise his arm from his side for more than a few degrees. Neurological examination reveals loss of abduction and blunted sensation over the skin covering the lateral part of the deltoid muscle. All reflexes are normal.A - Axillary?? CORRECT ANSWERA – AxillaryThe axillary nerve passes just below the capsule of the shoulder joint and is damaged here in about 5% of shoulder dislocations. The nerve gives off the upper lateral cutaneous nerve of the arm, and also motor branches to the deltoid and teres minor muscles. The multipennate fibres of the deltoid muscle contract isometrically when carrying weights in the hand. The strap/unipennate anterior and posterior slips of the muscle are used for flexion and extension and, when contracting together, take over from the supraspinatus muscle to abduct the arm beyond the first 15?.YOUR ANSWER WAS CORRECTScenario 2After a mastectomy, a 40-year-old woman loses the ability to fold her right arm behind her back and reach up to the opposite scapula.H - Thoracodorsal?? CORRECT ANSWERH – ThoracodorsalThe thoracodorsal nerve is most vulnerable to damage during axillary surgery, when the arm is laterally rotated and abducted, because it bows into the axilla from the posterior wall. Paralysis of the latissimus dorsi muscle is detected clinically if the patient is unable to fold the arm behind the back and reach up to the opposite scapula. The intercostobrachial (sensory) nerve is also vulnerable and, occasionally, has to be sacrificed.Scenario 3A 15-year-old boy riding in the passenger seat of a car escapes any apparent injury after a head-on collision because he was wearing a seat belt. However, after the accident he was unable to raise his arm easily and has visited the Emergency Department twice with spontaneous dislocation of the shoulder.G - Suprascapular?? CORRECT ANSWERG – SuprascapularThe suprascapular nerve, which is motor to the supraspinatus and infraspinatus muscles, may be damaged by sudden tightening of a car seatbelt (upper trunk injuries of the brachial plexus and clavicular fractures may also occur). Paralysis of both muscles weakens the rotator cuff, destabilising the shoulder joint. In addition, the supraspinatus abducts the arm from 0? to 15?, and the infraspinatus is a powerful lateral rotator of the humerus. Since the teres minor muscle is unaffected (axillary nerve), some lateral rotation is preserved after suprascapular nerve damage.YOUR ANSWER WAS CORRECTScenario 4A builder falls off a scaffolding on to his right side, fracturing his right humerus. Because of the patient’s shocked state and the pain, only a limited neurological examination is possible. This reveals an absence of the brachioradialis reflex, blunted cutaneous sensation over the first dorsal interosseous muscle and wrist drop.F - Radial?? CORRECT ANSWERF – RadialMid-shaft fractures of the humerus can damage the radial nerve in the spiral groove. The branches to the triceps are given off before the nerve enters the groove and so the muscle remains functional. All other extensors are paralysed, resulting in wrist drop. Although the cutaneous branches no longer conduct, compensatory overlap by adjacent nerves restricts the paraesthesia/anaesthesia to the dorsal skin over the first interosseous muscle. The brachioradialis reflex is mediated by the radial nerve and is thus lost. The triceps reflex remains intact for reasons explained above.YOUR ANSWER WAS CORRECTScenario 5After a radical mastectomy, a 41-year-old woman is unable to push a loaded supermarket trolley with her right arm. Her husband has noticed a deformity in her upper back on the right side that becomes more prominent when she pushes against resistance with the outstretched right arm.B - Long thoracic?? CORRECT ANSWERB – Long thoracicThe long thoracic nerve usually escapes damage during axillary surgery because it is bound to the serratus anterior muscle by overlying fascia on the medial wall, posterior to the mid-axillary line. When the nerve is injured, however, part or all of the serratus anterior muscle is paralysed, resulting in a ‘winged scapula’. There is loss of protraction and weakness of rotation of the scapula (the latter movement is, however, preserved by the action of the intact trapezius muscle – spinal accessory nerve).YOUR ANSWER WAS CORRECT45Theme: Orthopaedic traumaA Intramedullary nailB Traction (Thomas' splint)C Internal fixation with plate and screwsD Debridement and external fixationE Below-knee amputationF Repair of vessel and nervesG Above-knee amputationH Plaster of Paris castSelect the most appropriate treatment for the patients described below. Each option may be used once, more than once, or not at all.Scenario 1A 24-year-old male involved in a road traffic accident (RTA) is brought to the emergency department with head injury, flail chest and comminuted femoral shaft fracture. His Glasgow Coma Score is 8. He is intubated for his head injury and a chest drain is inserted. He is now stabilised. How is his fracture best treated?B - Traction (Thomas' splint)?? CORRECT ANSWERScenario 2A 30-year-old male involved in an RTA is brought to the emergency department with a Grade IIIC open tibial fracture, an insensate sole, and a pale and cold foot. A tyre mark is visible across his calf. His blood pressure is 90/66 mmHg and his pulse rate is 130/min. At surgery, the popliteal nerve is noticed to be crushed and divided. There is also injury to the popliteal artery.E - Below-knee amputation?? CORRECT ANSWERScenario 3A 25-year-old man fell from a height sustaining, a pneumo/haemothorax, fractured left humerus and a closed comminuted fracture to the mid-shaft of the left femur. The pneumo/haemothorax is treated with a chest drain and a collar and cuff is used to treat the humerus fracture. The patient is stable. How is the femoral fracture best treated?A - Intramedullary nail?? CORRECT ANSWERThe AnswerPatients with multisystem trauma and multiple fractures (of long bones) are best stabilised by having their fractures treated by internal fixation. This allows for more rapid improvement, reduction in incidence of acute respiratory distress syndrome and earlier mobilisation. However, in the first example, the 24-year-old man’s other injuries (chest and head) take precedence and the fracture should be initially treated with traction.In severe lower limb trauma, a careful evaluation of the extent of injury is needed. Reconstruction is determined by the nature and severity of the injuries. In the second example, there is gross soft tissue (muscle and nerve) and bony damage which precludes any possibility of limb salvage. In addition, the patient is also haemodynamically unstable, possibly due to blood loss from the fracture site and injury to the popliteal artery Hence below-knee amputation is the most appropriate treatment option.46Theme: Bone and soft tissue tumoursA Bone metastasesB ChondromaC ChondrosarcomaD?Ewing?’s sarcomaE FibromaF FibrosarcomaG LeiomyomaH LeiomyosarcomaI LipomaJ LiposarcomaK OsteomaL OsteoblastomaM OsteochondromaN Osteosarcoma (osteogenic sarcoma)O Osteoid osteomaP Simple bone cystThe following patients all present with bone or soft tissue tumours. From the list above, select the most likely diagnosis. The items may be used once, more than once, or not at all.Scenario 1A 15-year-old boy attends The Emergency Department. He describes pain affecting his left femur that was initially an ache but that has now become severe and constant. In addition, he reports generalised malaise and a persistent cough. On examination, he has an antalgic gait and there is asymmetrical swelling affecting the distal left femur. Radiology reveals breach of the periosteum, which is elevated, and a ‘sunray’ appearance affecting the distal femur.N - Osteosarcoma (osteogenic sarcoma)?? CORRECT ANSWERN – Osteosarcoma (osteogenic sarcoma)This is one of the commonest primary malignant bone tumours affecting the young with a slight male predominance. There is also a second peak in incidence in the elderly related to Paget’s disease. The long bone metaphyses are usually affected, most commonly around the knee. Bloodborne metastases develop early and spread to the lungs and other parts of the skeleton. Cortical penetration with peri-osteal elevation gives rise to ‘Codman’s triangle’ on X-ray. In addition, a characteristic sunray appearance may be evident on a plain radiograph as a result of new bone formation. In terms of histology, some may be largely fibroblastic, others are osteoblastic (with pleomorphic cells), some comprise chondroid osteoblasts, and they may even be highly vascular (telangiectatic). All form osteoid and/or bone-incorporating malignant cells. Computed tomography and magnetic resonance scanning are important in staging. Treatment involves chemotherapy combined with wide surgical excision (with limb salvage if possible). Five-year survival rates of 60% can be expected in those without distant metastases.Scenario 2A 51-year-old woman is referred urgently by her general practitioner with ‘a right upper quadrant mass, which he suspects is malignant’. On examination, there is no evidence of an abdominal mass but there is a tender swelling arising from the right costal margin. An X-ray of the lesion reveals a localised area of bone destruction with mottled appearances, affecting the ninth rib near the costal margin.C - Chondrosarcoma?? CORRECT ANSWERC – ChondrosarcomaThis is a malignant tumour of cartilage that affects the flat bones, vertebrae, girdles and the proximal limb bones in middle-aged patients. X-ray images may be diagnostic and reveal localised bone destruction, punctuated by mottled densities from calcification or ossification, as in the case described. Histological differentiation from enchondroma and osteosarcoma may be difficult. Treatment is similar to that for osteosarcomas, and 5-year survival rates are approximately 50%.Scenario 3A 12-year-old girl is referred with pain and swelling affecting her left lower leg. On examination, there is a tender, irregular swelling arising from the mid-tibia. X-ray reveals a destructive lesion, associated with a soft tissue mass, and peri-osteal ‘onion-skinning’. Biopsy demonstrates the presence of sheets of ‘small round cells’.D - Ewing’s sarcoma?? CORRECT ANSWERD –?Ewing’s sarcomaThis aggressive tumour is unusual in that it often affects the mid-diaphysis (shaft) of the bone, typically in children and adolescents. It is slightly less prevalent than osteosarcoma. It may masquerade as an osteomyelitis. Metastases arise in the liver, lung and other bones. Radiography reveals a characteristic ‘onion-skin’ appearance of the periosteum. Survival rates of 60% can be achieved at 5 years with the use of combined surgery, radiotherapy and chemotherapy.YOUR ANSWER WAS CORRECTThe AnswerPrimary tumours of bone and soft tissue are uncommon. They usually present with unremitting pain, swelling and loss of function. They may also present with a pathological fracture, a joint effusion or systemic symptoms when there is metastatic spread. In the diagnosis of bone tumours, the frequency of various tumours, the patient’s age, the bone affected and the location of the lesion within the bone, and its radiological appearances are all important.47THEME: UPPER-LIMB NERVE INJURIESA Posterior interosseous nerveB Upper roots of the brachial plexusC Musculocutaneous nerveD Lower roots of the brachial plexusE Anterior interosseous nerveF Radial nerveG Median nerveH Suprascapular nerveI Ulnar nerveJ Long thoracic nerveFor each of the case descriptions below, select from the above list the most likely upper-limb nerve injury. Each option may be used once, more than once, or not at all.Scenario 1A 25-year-old motorcyclist is brought to the Accident and Emergency Department following a road traffic accident (RTA). He complains of pain in the root of his neck. On examination, his right arm is adducted, internally rotated and extended at the elbow. He has loss of sensation along the outer aspects of the arm and the forearm.B - Upper roots of the brachial plexus?? CORRECT ANSWERUpper brachial plexus or supraclavicular plexus lesion (C5, C6) occurs due to excessive depression of the shoulder or displacement of the head that opens out the angle between the shoulder and the neck (Erb-Duchenne paralysis). In neonates, it may occur following traction on the shoulder girdle during difficult labour or in breech delivery. In adults, it may occur due to a fall exerting weight on the shoulder or to an RTA in which the head has been forcibly moved away from the shoulder. There is loss of shoulder abduction, elbow flexion and forearm supination. Consequently, the affected limb is internally rotated, extended at the elbow and pronated (porter’s tip position). There is sensory loss over the outer aspect of the arm and the outer aspect of the forearm.Scenario 2A 40-year-old woman presents to the Accident and Emergency Department with carpal dislocation (confirmed radiologically). On examination, she has loss of sensation over the thumb and the index and middle fingers.G - Median nerve?? CORRECT ANSWERIn adults, the median nerve (C5–T1) is commonly injured near the wrist, although it can be injured anywhere along the upper arm or the forearm. Distal lesions may be caused by lacerations to the front of the wrist or by carpal dislocation. In children, supracondylar fractures of the humerus may lead to median nerve injury at the elbow. Median nerve injuries at the wrist causes sensory loss over the thumb and the index and middle fingers and occasionally the lateral half of the ring finger; motor loss includes all thenar muscles except the adductor pollicis (which is supplied by the ulnar nerve) and the lateral two lumbricals. If the injury is at the level of the elbow, there is paralysis of the pronators of the forearm and the flexors of the wrist and fingers, with the exception of the flexor carpi ulnaris and the medial part of the flexor digitorum profundus.Scenario 3A 65-year-old man is brought to the Accident and Emergency Department with a wrist drop and sensory loss over a small patch at the base of the thumb. X-rays shows a mid-humerus fracture.F - Radial nerve?? CORRECT ANSWERThe radial nerve (C5–T1) is damaged at the mid-humerus level by fractures or pressure (eg prolonged tourniquet). Radial nerve damage is also seen in patients who fall asleep with an arm dangling over the back of a chair (Saturday night palsy). Radial nerve injury causes paralysis of the brachioradialis, the wrist extensors and the extensor digitorum, leading to wrist drop; there may be a small patch of sensory loss over the dorsum of the thumb and the first web space. With more proximal lesions, sensation is also lost over the dorsum of the forearm.YOUR ANSWER WAS CORRECTScenario 4A 30-year-old man presents to the Accident and Emergency Department with a deep laceration to his right wrist after he was involved in a fight in his local pub. On examination, he is unable to pinch and has loss of sensation over his little and ring fingers.I - Ulnar nerve?? CORRECT ANSWERThe ulnar nerve (C8, T1) is an important motor nerve of the hand. Pressure (eg from a deep ganglion) or laceration at the wrist may cause distal lesions. Injury to this nerve at the level of the wrist produces hypothenar wasting and clawing of the hand due to unopposed action of the long flexors; there is loss of sensation over the little and ring fingers. Finger abduction is weak and the loss of thumb adduction makes pinching difficult. This is due to paralysis of the adductor pollicis and the first palmar interosseous muscle causing flexion of the thumb (due to the flexor pollicis longus) when the patient is asked to grasp a card between their thumb and index finger (Froment’s paper sign).YOUR ANSWER WAS CORRECT48Theme: Knee injuriesA Medial meniscusB Lateral meniscusC Medial collateral ligamentD Lateral collateral ligamentE Patellar fractureF Anterior cruciate ligamentG Posterior cruciate ligamentScenario 1A young footballer injured his right knee in a tackle, and had swelling of the knee a few days later. He presented to A&E with tenderness in an area 2–3 cm above the joint line on the medial aspect. There is increased valgus deformity on examination.C - Medial collateral ligament?? CORRECT ANSWERYOUR ANSWER WAS CORRECTScenario 2A 60-year-old patient developed a painful left knee after a fall. On examination, swelling on the left knee was seen in the orthopaedic clinic a few days later. Flexion views of both knees showed that the left tibial plateau lay more posteriorly than that on the right.G - Posterior cruciate ligament?? CORRECT ANSWERYOUR ANSWER WAS CORRECTScenario 3A patient involved in a road traffic accident (RTA) hit his knee on the dashboard, producing an immediate haemarthrosis. The X-ray showed no bone injury, but he later experienced difficulty going downstairs.G - Posterior cruciate ligament?? CORRECT ANSWERThe AnswerComment on this QuestionThe history in the young footballer is most suggestive of a medial collateral ligament injury because there is a valgus deformity and tenderness above the joint line. Tenderness over the joint line is suggestive of meniscal injury. The posterior cruciate ligament prevents the femur from sliding forwards off the tibial plateau. In the weight-bearing flexed knee, it is the only stabilising factor for the femur and its attached quadriceps.?The most frequent injury mechanism in isolated posterior cruciate ligament (PCL) tears is a direct blow on the anterior tibia with the knee flexed thus driving the tibia posteriorly. Automobile accidents (in which the knee hits the dashboard) and soccer injuries (in which an athlete receives a blow to the anterior surface of the tibia during knee flexion) characteristically produce this type of injury. PCL tears may present as pain while walking down stairs due to anterior displacement of the femur over the tibia. On examination, the ‘posterior sag’ sign (i.e. as demonstrated in the second vignette) is suggestive of a PCL tear.49Theme: Glasgow Coma Score (GCS)A 10B 11C 12D 9E 8Pick the correct GCS for the patients described below. Each option may be used once only, more than once or not at all.Scenario 1A young child has fallen from a swing and hit his head. His eyes are opening to speech, localising to pain and he is mumbling incomprehensible sounds.D - 9?? YOUR ANSWERA - 10?? CORRECT ANSWERYOUR ANSWER WAS INCORRECTScenario 2A young man has been attacked with a baseball bat and has a palpable fracture through a wound in his scalp. His eyes are opening to pain, he is withdrawing to pain and saying inappropriate words.E - 8?? YOUR ANSWERD - 9?? CORRECT ANSWERYOUR ANSWER WAS INCORRECTThe AnswerComment on this QuestionThe Glasgow Coma Score (GCS) documents the depth of coma by assessment of the best verbal, motor and eye responses to stimulation.Eye opening: spontaneous (4), to speech (3), to pain (2) absent (1).Best motor response: obeys commands (6), localises to pain (5), withdraws to pain (4), abnormal flexion (3), extension (2), no response (1).Best verbal response: oriented (5) confused (4), inappropriate words (3), incomprehensible sounds (2), no verbal response (1).50Theme: Upper limb neurological injuriesA Ulnar nerveB Median nerveC Radial nerveD Axillary nerveMatch the nerve from the option list above which when injured would result in the clinical presentations described below. Each option may be used once only, more than once or not at all.Scenario 1Paraesthesia over first dorsal webspace of handC - Radial nerve?? CORRECT ANSWERRadial nerveYOUR ANSWER WAS CORRECTScenario 2Finger adduction weakenedA - Ulnar nerve?? CORRECT ANSWERUlnar nerveYOUR ANSWER WAS CORRECTScenario 3Paraesthesia over the deltoid muscleD - Axillary nerve?? CORRECT ANSWERAxillary nerveYOUR ANSWER WAS CORRECTScenario 4Anaesthesia of the little fingerA - Ulnar nerve?? CORRECT ANSWERUlnar nerveYOUR ANSWER WAS CORRECTScenario 5At risk from a fracture of the medial epicondyle of the humerusA - Ulnar nerve?? CORRECT ANSWERUlnar nerveYOUR ANSWER WAS CORRECTScenario 6Paralysis of the thenar musclesB - Median nerve?? CORRECT ANSWERMedian nerveYOUR ANSWER WAS CORRECTScenario 7At risk from cannulation of blood vessels in the antecubital fossaB - Median nerve?? CORRECT ANSWERMedian nerveYOUR ANSWER WAS CORRECTThe AnswerComment on this QuestionThe ulnar nerve innervates the intrinsic muscles of the hand and provides sensory innervation to the medial 1? fingers.The median nerve provides sensory innervation to the lateral 2? fingers (and thumb) of the hand and supplies most of the forearm flexor muscles and muscles of the thumb. The ulnar nerve passes over the medial epicondyle of the humerus and the median nerve in close proximity to the brachial artery51Theme: Cutaneous sensationA The median nerveB The radial nerveC The dorsal cutaneous branch of the ulnar nerveD The superficial branch of the ulnar nerveE The palmar cutaneous branch of the ulnar nerveFor each of the following anatomical position descriptions, select the most likely answer from the above list. Each option may be used once, more than once, or not at all.Scenario 1The sensory innervation of the nail bed of the index finger.A - The median nerve?? CORRECT ANSWERThe median nerve supplies the lateral 3? digits of the hand on both the anterior and posterior surfaces.Scenario 2The sensory innervation of the medial side of the palm.E - The palmar cutaneous branch of the ulnar nerve?? CORRECT ANSWERThe ulnar nerve enters the palm anterior to the flexor retinaculum, and as it crosses the flexor retinaculum it divides into a superficial and a deep terminal branch. The palmar cutaneous branch of the ulnar nerve is given off in the front of the forearm anterior to the flexor retinaculum, and supplies the skin over the medial aspect of the palm.YOUR ANSWER WAS CORRECTScenario 3The sensory innervation of the dorsal surface of the base of the thumb.B - The radial nerve?? CORRECT ANSWERThe superficial branch of the radial nerve descends over the extensor retinaculum and supplies the lateral two-thirds of the dorsum of the hand. It divides into a number of dorsal digital nerves which supply the dorsal surface of the thumb, the dorsal surface of the index finger and dorsal surface of the lateral side of the middle finger.Scenario 4The sensory innervation of the medial side of the palmar surface of the ring finger.D - The superficial branch of the ulnar nerve?? CORRECT ANSWERThe superficial branch of the ulnar nerve descends into the palm and gives off a muscular branch to the palmaris brevis, and cutaneous branches to the palmar aspect of the medial side of the little finger and the adjacent sides of the little and ring fingers.52Theme: Haemorrhagic shockA Blood loss of 2.3 litresB Blood loss of 1.7 litresC Blood loss of 2.5 litresD Blood loss of 0.5 litreE Blood loss of 1 litreFor each of the above volumes of blood loss, select the most appropriate physiological change in a 70kg adult male. Each option may be used once, more than once, or not at all.Scenario 1Normal heart rateD - Blood loss of 0.5 litre?? CORRECT ANSWERD – Blood loss of 0.5 litreYOUR ANSWER WAS CORRECTScenario 2UnconsciousC - Blood loss of 2.5 litres?? CORRECT ANSWERC – Blood loss of 2.5 litresYOUR ANSWER WAS CORRECTScenario 3Reduced systolic pressureB - Blood loss of 1.7 litres?? CORRECT ANSWERB – Blood loss of 1.7 litresScenario 4Confused and lethargicB - Blood loss of 1.7 litres?? CORRECT ANSWERB – Blood loss of 1.7 litresYOUR ANSWER WAS CORRECTScenario 5Respiratory rate 20 - 30 breaths/minE - Blood loss of 1 litre?? CORRECT ANSWERE – Blood loss of 1 litreYOUR ANSWER WAS CORRECTThe AnswerComment on this QuestionThe effects of blood loss can be monitored in terms of physiology, ie pulse rate/blood pressure/pulse pressure/respiratory rate/urine output/CNS or mental status. Shock is graded I–IV depending on the amount of blood loss, and each grade is associated with certain physiological changes. Class I shock occurs when up to 15% of the blood volume is lost (up to 750 ml in a 70-kg adult); class II between 15 and 30% (750–1500 ml); class III between 30 and 40% (1500–2000 ml), class IV > 40% (2000 ml). The percentages are best remembered as the scoring system in a tennis match.53Theme: Lower limb pathologiesA Ascending lymphangitisB Common peroneal nerve palsyC Compartment syndromeD Deep-vein thrombosisE ElephantiasisF Haemarthrosis of the knee jointG Milroy’s syndromeH Ruptured Achilles tendonI Superficial thrombophlebitisJ Torn calf muscleFor each of the following statements, select the most likely cause of limb pain from the above list. Each option may be used once, more than once, or not at all.Scenario 1A 37-year-old motorcyclist is brought to the Emergency Department following an RTA. He complains of numbness in his foot and unremitting pain in his right lower leg which is made worse by passive dorsiflexion of his ankle. X-ray reveals a closed fracture of the right tibia.C - Compartment syndrome?? CORRECT ANSWERC – Compartment syndromeCompartment syndrome may develop after trauma (accident) or surgery. It results from an increase in pressure within an osseofacial compartment, leading to compromise of the microcirculation and nerve and muscle damage. The microcirculation is compromised if compartment pressures rise above 30–40 mmHg (or the difference between the diastolic pressure and the compartment pressure is < 30 mmHg). With increasing compartment pressures, the capillary perfusion is inadequate to meet the metabolic demands of the intracompartmental tissues. The patient complains of unremitting pain that is not relieved by morphine. Loss of sensation in the early stages precedes motor loss – loss of peripheral pulses is usually a late, but sinister sign. Irreversible injury occurs with pressures as low as 30 mmHg for 6–8 hours.YOUR ANSWER WAS CORRECTScenario 2A 73-year-old patient presents with mild pyrexia, and pain and swelling in her left calf. She underwent total hip replacement 8 days ago.D - Deep-vein thrombosis?? CORRECT ANSWERD – Deep-vein thrombosisHospitalisation and immobility increase the incidence of deep-vein thrombosis. The other risk factors include: increasing age, pregnancy, oral contraceptive pill, surgery especially orthopaedic or pelvic, malignancy, past history of DVT and thrombophilia. In addition, any factor contributing to venous stasis, vein wall damage and increased coagulation of blood (known as Virchow’s triad) predisposes to formation of a clot. Clinical features of DVT include redness, swelling, pain, calf tenderness, dilated superficial veins (sometimes), and low-grade pyrexia. These signs and symptoms usually develop after 7–10 days post-operatively.YOUR ANSWER WAS CORRECTScenario 3A 13-year-old adolescent is brought to her GP with a swollen right leg; the swelling is extending up to the knee. It is painless and the parents say that the swelling was first noticed shortly after menarche. She is otherwise systemically well.G - Milroy’s syndrome?? CORRECT ANSWERG – Milroy’s syndromeThe peak age of onset of Milroy’s disease (primary lymphoedema; lymphoedema praecox) is 10–30 years, and it has a clear genetic predisposition in some patients. This condition is the result of congenital absence of the lymphatics. It is more common in females and is seen shortly after menarche. It is more likely to be unilateral. The swelling usually develops around the ankle and the dorsum of the foot which soon spreads proximally extending up to the knee. Occasionally, patients develop numerous vesicles in the skin which may leak clear lymph or, occasionally chyle. The swelling is worse during the day and decreases at night.YOUR ANSWER WAS CORRECTScenario 4A 42-year-old teacher is persuaded to take part in a staff–student tennis match. She has not done any exercise in the last 10 years. While running for a ball, she experiences sudden, severe pain in her right calf and is unable to play any longer. On examination, there is swelling and tenderness just above the heel, and she is unable to walk tiptoe.H - Ruptured Achilles tendon?? CORRECT ANSWERH– Ruptured Achilles tendonRupture of the Achilles tendon is common in patients over the age of 40, probably because the tendon is frayed. It usually occurs when the patient is involved in unaccustomed activities, such as running or jumping; sudden contraction of the calf muscle is resisted by the body weight and the tendon ruptures. The patient feels as if he or she has been struck just above the heel and is usually unable to continue with the involved activity. Soon after the tear, a gap can be felt about 5 cm above the insertion of the tendon. The patient is unable to tiptoe and plantar flexion of the ankle (or foot) is weak or lost. Simmond’s test is positive (reduced plantar flexion of the ankle on squeezing the calf muscle). The management is either conservative (using plaster casts) or surgical (with the foot plantar flexed, the cut ends are approximated and held in place using non-absorbable sutures 2/0 nylon). Following this, the ankle and the foot are immobilised in a below-knee plaster cast in equinus position for 6–8 weeks.YOUR ANSWER WAS CORRECT54Theme: Finger problemsA Trigger fingerB Volkmann's contractureC Dupuytren's contractureD Extensor pollicis longus (EPL) tendon ruptureE Abductor pollicis longus ruptureF Flexor pollicis tendon ruptureG de Quervain's diseaseSelect the most appropriate diagnosis for each of the patients below. Each option may be used once, more than once, or not at all.Scenario 1A 63-year-old man presented with painless inability to extend his thumb. He does not recall sustaining an injury to his thumb; however, he does recall having a Colles’ fracture treated 4 months ago.D - Extensor pollicis longus (EPL) tendon rupture?? CORRECT ANSWERDelayed rupture of the extensor pollicis longus (EPL) tendon is a recognised complication after Colles’ fracture due to attrition at the radial (lister) tubercle.YOUR ANSWER WAS CORRECTScenario 2A 35-year-old lady presented to the outpatient department complaining of pain and swelling in the anatomical snuff box with no history of trauma. On examination, flexion of her thumb is extremely painful and there is thickening of the tendons in the anatomical snuff box.G - de Quervain's disease?? CORRECT ANSWERDe Quervain's disease is a tenosynovitis of the extensor pollicis brevis and abductor pollicis longus which commonly affects middle-aged women, causing pain on flexion of the thumb (and ulnar deviation at the writs i.e. Finkelstein's test).YOUR ANSWER WAS CORRECTScenario 3A 55-year-old gentleman with a known history of alcohol abuse presented to you complaining of inability to extend his right ring and little fingers for the last 4 months that is progressively worsening. On examination you find painless nodules on the palmar aspect of the ring and little finger bases.C - Dupuytren's contracture?? CORRECT ANSWERThis is commonly idiopathic but may be attributed to alcohol abuse, trauma, diabetes and drugs.YOUR ANSWER WAS CORRECTScenario 4A 61-year-old lady known to have rheumatoid arthritis presented to the outpatient department complaining of pain and difficulty straightening her ring finger after making a fist; however, she manages to pull the finger straight but with pain. On examination you find a tender nodule on the palmar aspect of the ring finger.A - Trigger finger?? CORRECT ANSWERThis is tenosynovitis of the flexor tendon sheath which is trapped after flexion in the membranous sheath at the proximal phalanx (A1 pulley). When the patient attempts to straighten it, it is painful and snaps back once it passes the constrictive narrowing. Tenosynovitis is commonly found in rheumatoid arthritis; however, the trigger finger can also be associated with gout and diabetes.55Theme: The childhood limpA Acquired dislocation of the hipB Congenital dislocation of the hipC Congenital subluxationD Non-specific transient synovitisE Perthes’ diseaseF Pyogenic arthritisG Slipped upper femoral epiphysisH Still’s diseaseI Tuberculous synovitisThe following are descriptions of children who have presented with a limp. Please select the most appropriate diagnosis from the above list. The items may be used once, more than once, or not at all.Scenario 1A 14-year-old boy is brought to The Emergency Department by his mother. She is worried as he fell 4 days ago and has continued to limp since. He gives a 6-month history of pain in his right knee, which has worsened since falling over. On examination he is considerably overweight and has evidence of delayed puberty. His right leg is externally rotated and appears to be shorter than the left. Assessment of limb movements is not possible because of excessive pain in the limb.G - Slipped upper femoral epiphysis?? CORRECT ANSWERG – Slipped upper femoral epiphysisThis condition occurs during the pubertal growth spurt and the description of the patient is typical; an overweight boy, aged 13–15 who is sexually underdeveloped. The condition also occurs less commonly in unusually tall and thin children. The onset of pain may be either acute, chronic, or acute on chronic. Examination findings are as described. Treatment is by internal fixation of the slipped epiphysis with or without a corrective osteotomy.YOUR ANSWER WAS CORRECTScenario 2A 7-year-old boy is seen in clinic with a history of a limp and pain in the left groin. Initially the pain was severe and he was unable to move his left leg. The pain resolved spontaneously after bed rest. One month later his symptoms have now recurred with a similar, less severe pain, which causes him to limp. Examination of the left lower limb is normal except for limited abduction and internal rotation of the left hip.E - Perthes’ disease?? CORRECT ANSWERE – Perthes’ diseaseThe condition tends to occur between the ages of 4 and 7 when the blood supply is dependent on the lateral epiphyseal vessels, which run in the retinaculum. Trauma to the joint with a secondary effusion may compromise these vessels with consequent necrosis of the femoral head. Initial presentation is with symptoms and signs of an irritable hip; pain in the affected joint and a reduced range of movement. With time the pain subsides and movement returns; however, abduction and internal rotation remain limited. Changes may only become apparent on X-ray after several years and as such these patients need to be followed up carefully. Treatment is directed at ‘containment’, with the aim of ensuring the femoral head remains in the acetabulum by preventing lateral displacement of the femoral head. This is usually achieved by the use of an abduction splint.YOUR ANSWER WAS CORRECTScenario 3A 7-year-old girl is seen in the paediatric Emergency Department with a 1-day history of sudden onset of pain in the left hip and difficulty in ambulation. On examination she is apyrexial, appears well and is lying with her hip flexed and externally rotated. Palpation of her hip reveals tenderness over the anterior aspect. Extension, abduction and internal rotation lead to severe pain. Initial investigations include a full blood count, erythrocyte sedimentation rate and plain radiographs, all of which are normal.D - Non-specific transient synovitis?? CORRECT ANSWERD – Non-specific transient synovitisThis is the commonest cause of a limp with hip pain in a child and is self limiting in its natural history. Onset of pain tends to be sudden and of variable intensity. Examination findings are as described, and initial investigations tend to be normal. The condition tends to resolve after a few days of bed rest with analgesia and gentle traction applied to the affected limb.Scenario 4A 5-year-old girl is seen with a history of a limp. Her father says that she has been unwell recently with an intermittent fever. On examination she has an obvious limp when walking and is pyrexial (temperature 37.9°C). Examination reveals mild tenderness over the right hip, with a generalised reduction in movement. Her erythrocyte sedimentation rate is raised and her serum is positive for antinuclear antibodies.H - Still’s disease?? CORRECT ANSWERH – Still’s diseaseThe history is characteristic with an episodic fever associated with arthritis. Despite the presentation with a fever there are no other features to suggest a septic arthritis; pyogenic arthritis tends to occur at a younger age (usually less than 2), the child appears unwell and the affected joint is hot, swollen and held absolutely still. Rheumatoid factor is negative and antinuclear antibodies may be present. The erythrocyte sedimentation rate tends to be raised. Three types have been described, systemic, pauciarticular and polyarticular. Initial treatment is with non-steroidal anti-inflammatory drugs.56Theme: Lower limb nerve injuryA Common peroneal nerveB Femoral nerveC Lateral cutaneous nerve of thighD Lateral plantar nerveE Medial plantar nerveF Pudendal nerveG Saphenous nerveH Sciatic nerveI Sural nerveJ Tibial nerveFor each of the following statements, select the most likely cause of nerve injury from the above list. Each option may be used once, more than once, or not at all.Scenario 1A 28-year-old patient (37 weeks pregnant) presents to her GP with pain and paraesthesia over the upper outer aspect of her left thigh. She is able to walk and there is no restriction of movements in her hips or knees.C - Lateral cutaneous nerve of thigh?? CORRECT ANSWERC – Lateral cutaneous nerve of thighLateral cutaneous nerve of the thigh compression (meralgia paraesthetica) may cause pain and paraesthesia over the upper, lateral aspect of the thigh. Sensation may also be decreased over this area. It may be seen in pregnancy or any condition which causes a pressure on this nerve within the pelvis (eg tumours). The symptoms are usually self-limiting.Scenario 2A 32-year-old motorcyclist is brought to the Emergency Department after being involved in an RTA. He is unable to dorsiflex and evert his left foot. He has also reduced sensation over the lateral aspect of his lower leg and the dorsum of this foot. X-ray shows a fracture of the fibular neck.A - Common peroneal nerve?? CORRECT ANSWERA – Common peroneal nerveCommon peroneal nerve (lateral popliteal nerve; L4–S2) injury is common following fibular neck fractures since the nerve winds down the neck and is relatively superficial at this point. This nerve gives motor supply to the dorsiflexor and eversion muscles of the ankle and toes. Its sensory branches supply the anterior and lateral aspect of the leg and whole of the dorsum of the foot and toes, except the skin between the great and the second toe (supplied by deep peroneal nerve). Injuries result in foot drop and the patient is unable to dorsiflex or evert the foot. Sensory loss is over the anterior and lateral aspect of the leg, and dorsum of the foot and toes.YOUR ANSWER WAS CORRECTScenario 3A 27-year-old man is brought to the Emergency Department following a gunshot injury to his right thigh. He has numbness over the anterior thigh and medial aspect of his leg. He is unable to extent his knee and the knee jerk is diminished.B - Femoral nerve?? CORRECT ANSWERB – Femoral nerveThe femoral nerve (L2–4) may be injured by a gunshot wound, traction during surgery, injury to the femoral triangle or by massive haematoma within the thigh, and in patients with diabetes mellitus and lumbar spondylosis. There is weakness of the quadriceps muscle causing weak knee extension. Patients find that the knee gives way on walking and have difficulty climbing stairs. There is numbness over the anterior thigh and medial aspect of the leg. The knee jerk is depressed.YOUR ANSWER WAS CORRECTScenario 4A 75-year-old patient presents to the orthopaedic outpatient clinic with a right foot drop and decreased sensation below the knee on the lateral side. He had a right total hip replacement 8 weeks ago.H - Sciatic nerve?? CORRECT ANSWERH – Sciatic nerveSciatic nerve (L4–S3) injury is common following traumatic dislocations of the hip (posterior dislocation), total hip replacement and other traction injuries to the nerve. A complete lesion will affect all the muscles below the knee, leading to loss of knee flexion, foot drop and an inability to walk. Patients drag their feet behind them and are often unable to stand for prolonged periods. Calf muscle wasting is a long-term complication. There is loss of sensation below the knee on the lateral side (medial side is supplied by the saphenous nerve). The knee jerk is normal but the ankle jerk is lost.57A 25-year-old man who was playing football yesterday attends the emergency department, he sustained a blow to the lateral aspect of the tibia whilst his foot was planted and the knee flexed to about 20o. He was unable to play on or weight bear, and he developed a tense effusion in his knee within an hour.What is the most likely pattern of injury?Select one answer onlyLateral collateral ligament rupture, lateral meniscal tear, and anterior cruciate ligament ruptureLateral collateral ligament rupture, medial meniscal tear, and anterior cruciate ligament ruptureLateral meniscal tear, anterior cruciate ligament rupture and posterior cruciate ligament ruptureMedial collateral ligament rupture, lateral meniscal tear, and anterior cruciate ligament rupture?? YOUR ANSWERMedial collateral ligament rupture, medial meniscal tear, and anterior cruciate ligament rupture?? CORRECT ANSWERYOUR ANSWER WAS INCORRECTThe AnswerComment on this QuestionThe patient in this scenario has suffered a significant ligamentous injury to the knee as is evident from the rapid large haemarthrosis, and inability to weight bear immediately post-injury. An immediate tense haemarthrosis is most likely with anterior cruciate ligament rupture or fracture/dislocation. The medial collateral ligament is more commonly injured than the lateral, as lateral blows to the knee are more frequent than medial. When the medial collateral ligament ruptures, injury to the medial meniscus is commonly associated as the meniscus is attached to the medial collateral ligament. If the blow to the leg is severe the medial collateral ligament may completely rupture, the meniscus tear and the force continue to rupture the anterior cruciate ligament.58A 50-year-old man presents with pain in his right shoulder. The pain started 2 days ago, after he had painted a ceiling. The pain is present on forward flexion and abduction between 700-1200. Hawkin's test is positive, Jobe’s test, internal and external rotation lag signs, and Gerber’s lift-off tests are negative.What is the most likely diagnosis?Select one answer onlyAcromioclavicular joint arthritisAcute calcific tendonitisGlenohumeral joint arthritisRotator cuff tear?? YOUR ANSWERSubacromial impingement?? CORRECT ANSWERYOUR ANSWER WAS INCORRECTThe AnswerSubacromial impingement is most common between 40 and 50 years of age, it causes a painful arc of movement from 700-1200. It can be precipitated by unaccustomed overhead activity, e.g. painting a ceiling. Hawkin’s test is for subacromial impingement. Jobe’s test is for supraspinatus, the internal rotation lag sign and Greber’s lift-off test assess subscapularis, and the external rotation lag test assesses infraspinatus. Acute calcific tendonitis tends to present with sudden, acute, severe shoulder pain, with pain present even at rest and on all movements.59Theme: Knee injuriesA Medial meniscusB Lateral meniscusC Medial collateral ligamentD Lateral collateral ligamentE Patella fractureF Anterior cruciate ligamentG Posterior cruciate LigamentPick the most appropriate option from the above list. Each option may be used once only, more than once or not at all.Scenario 1A young footballer injures his right knee in a tackle and develops swelling of the knee a few days later. He presents to casualty with an area of tenderness 2–3 cm above the joint line on medial aspect. He has increased valgus deformity on examination.C - Medial collateral ligament?? CORRECT ANSWERThe history in the young footballer is most suggestive of a medial collateral ligament injury as there is a valgus deformity and tenderness above the joint line. Tenderness over the joint line is suggestive of meniscal injury.Scenario 2A 60-year-old develops a painful left knee following a fall. On examination in the orthopaedic clinic a few days later, swelling on the left knee is seen. Flexion views of both knees show that the left tibia plateau lies more anteriorly than on the right.F - Anterior cruciate ligament?? CORRECT ANSWERAnterior cruciate ligamentThe anterior cruciate ligament prevents backward displacement of the femur on the tibial plateau and limits extension of the lateral condyle of the femur.YOUR ANSWER WAS CORRECTScenario 3A patient involved in a road traffic accident hits his knee on the dashboard, producing an immediate haemarthrosis. X-ray shows no bony injury, but he later experiences difficulty walking down stairs.G - Posterior cruciate Ligament?? CORRECT ANSWERPosterior cruciate ligamentThe posterior cruciate ligament prevents the femur from sliding forwards off the tibial plateau. In the weight bearing flexed knee it is the only stabilising factor for the femur and its attached quadriceps. In walking down stairs, the upper knee is flexed and weight bearing, while the lower knee is straight. Immediate haemarthrosis is indicative of cruciate ligament rupture or fracture.YOUR ANSWER WAS CORRECT60Theme: Knee injuriesA Anterior cruciate ligament (ACL) injuryB Extensor mechanism disruptionC Knee dislocationD Lateral collateral ligament injuryE Medial collateral ligament injuryF Meniscal tearG Neck of fibular fractureH Patellar dislocationI Patellar fractureJ Posterior cruciate ligament (PCL) injuryK Proximal tibio-fibular dislocationL Supracondylar fractureM Tibial plateau fractureThe above are all descriptions of injuries to the knee. For the following scenarios please select the most appropriate answer from the list. The items may be used once, more than once, or not at all.Scenario 1A 30-year-old footballer, playing in the Sunday league, presents to The Emergency Department minors on Monday evening. He is complaining of a swollen right knee with pain, and an inability to completely straighten the joint. He describes the injury occurring as he tried to break into a run on the muddy pitch. His right thigh twisted but his leg remained fixed in the mud. At the time, although his knee was painful, he had not noticed any swelling and had continued to play. This morning he had observed that his right knee was much larger in size than the other. He has tenderness along the lateral joint line.F - Meniscal tear?? CORRECT ANSWERF – Meniscal tearMeniscal tears in the young adult typically result from a rotational stress upon the flexed weight-bearing knee joint. This mechanism of injury is often the same for anterior cruciate ligament (ACL) rupture (and frequently these injuries co-exist). The clues in this clinical scenario that point to meniscal damage, over ACL rupture, include: the symptom of locking (true locking is the inability to fully straighten the knee), which indicates a mechanical blockage within the knee; and the delayed onset of swelling (characteristically > 6 h after injury). The swelling is an effusion as a result of the synovial reaction, in contrast to the haemarthrosis seen in ACL rupture, which is an immediate phenomenon. Symptomatic meniscal tears warrant arthroscopic intervention.YOUR ANSWER WAS CORRECTScenario 2A 60-year-old grandfather presents acutely to the Casualty department complaining of severe pain in his left knee. He tells you that he was playing with his grandson who had unexpectedly jumped up on him from behind, causing him to stumble and lunge forward. As he lurched forward he noticed a sudden searing pain in his thigh and knee and was immediately unable to walk on the affected leg. On examination he is holding his knee in slight flexion and is unable to fully straighten the joint. He is incapable of performing a straight leg raise. An X-ray does not reveal any fracture.J - Posterior cruciate ligament (PCL) injury?? YOUR ANSWERB - Extensor mechanism disruption?? CORRECT ANSWERB – Extensor mechanism disruptionAny part of the extensor mechanism can be damaged at any age; however, there are common patterns of injury. In the middle-aged and elderly the quadriceps tendon and muscle tend to be compromised more readily. Patellar fractures are seen more often in the young and middle-aged, with tibial tuberosity avulsion occurring in younger age ranges. Patellar tendon rupture can happen at any age. In this scenario the man has ruptured his quadriceps tendon. This results from forced contraction of the extensor mechanism with the foot planted on the floor and can arise from a simple stumble or fall. Clinical examination may reveal a haemarthrosis and there is inevitably a palpable gap in the tendon at the site of rupture. The patient is unable to perform a straight leg raise (particularly against resistance) or to actively straighten the knee. Direct repair of the tendon using nonabsorbable material is required, because without intervention the extensor mechanism is severely compromised and the patient is unable to walk properly.YOUR ANSWER WAS INCORRECTScenario 3A 35-year-old skier has been flown back to the UK from the Alps after injuring himself on the slopes. He describes a ‘twisting’ injury to his left knee as his ski caught in some soft snow. Immediately he felt an agonising pain, heard a ‘pop’ and noticed instantaneous swelling, under his salopettes. He was unable to carry on skiing and after hobbling down the piste was seen by the resort doctor who has documented a positive Lachman test.A - Anterior cruciate ligament (ACL) injury?? CORRECT ANSWERA – Anterior cruciate ligament (ACL) injuryInjury to the ACL is fairly common. Patients often describe a non-contact, deceleration, twisting injury (although sometimes the mechanism is of hyperextension). In over 50% of cases the history will include hearing a ‘pop’ or feeling a sensation of something tearing inside the knee, with earlyonset swelling. (NB Up to 80% of patients attending Casualty with an acute haemarthrosis, have sustained an injury to their ACL and of these, 60% will have another associated pathology within the knee.) Specific examination of the ACL via the anterior draw and Lachman tests should be undertaken. Routine use of magnetic resonance imaging is probably unnecessary; however, it does have the advantage of delineating other associated ligamentous, meniscal, or bony damage. With regard to long-term management of ACL injuries there is still debate as to the necessity and timing of reconstructive surgery.YOUR ANSWER WAS CORRECTScenario 4A 28-year-old woman is brought into Casualty by ambulance following an accident while parachuting with the Territorial Army. She landed badly and forcefully on her left knee, which was flexed at the time. She complains of pain and tingling on the dorsum of her foot, and she cannot dorsiflex at the left ankle. X-ray of the knee does not clearly show any fracture.K - Proximal tibio-fibular dislocation?? CORRECT ANSWERK – Proximal tibio-fibular dislocationThis is an uncommon injury and tends to be caused by twisting of the weight-bearing flexed knee. It can occur as an isolated injury or in association with major trauma. Classically known as ‘horseback rider’s knee’, it is more commonly associated with parachute jumping (requiring a considerable amount of force). Hypermobile individuals (eg those with Ehlers–Danlos syndrome) are more susceptible. Examination reveals tenderness over the proximal tibio-fibular joint and movement of the ankle tends to cause pain in the knee. It is paramount to assess the integrity of the common peroneal nerve, as it passes close to the joint and can easily be injured. Reduction is effected by pressure over the fibular head with the knee flexed.YOUR ANSWER WAS INCORRECT61Theme: Multiple traumaA Cardiac tamponadeB Flail chestC HaemothoraxD Tension pneumothoraxE Aortic ruptureF Ruptured spleenFor each patient described below, select the most likely single diagnosis from the list of options above. Each option may be used once, more than once or not at all.Scenario 1A 57-year-old man is brought into the emergency department following a road traffic accident. He is conscious with an adequate airway. The Glasgow Coma Score (GCS) is 15. He is tachypnoeic (30 rpm). His pulse is 150 bpm and reduced in volume. The distal pulses are present. His blood pressure (BP) is 85/45 mm Hg. The chest X-ray shows multiple rib fractures on the left side (ribs 7, 8 and 9) and a small pneumothorax. A left chest drain is inserted and bubbles in the waterseal bottle. Pelvic X-ray is normal. Analysis of the diagnostic peritoneal lavage fluid reveals a white cell count (WCC) of 1000/mm3?, 200,000 RBCs/mm3 and an amylase of 400 units. He remains hypotensive (BP 90/55 mm Hg) despite 2 l of fluid resuscitation.F - Ruptured spleen?? CORRECT ANSWERRuptured spleenHypotension, tachycardia and low CVP suggest hypovolaemia. Multiple rib fractures on the left side and positive DPL support the diagnosis of splenic rupture.YOUR ANSWER WAS CORRECTScenario 2A 30-year-old man is brought into the emergency department following a road traffic accident. He is conscious. He has tachypnoea (46rpm), tachycardia (135 bpm) and distended neck veins. His systemic BP is 90/45 mmHg. His heart sounds are greatly diminished. A chest X-ray shows three fractured ribs (ribs 5, 6 and 7) on the left side and a small pneumothorax. A left chest drain drains air and no blood, the BP is 95/50 mmHg after 2 l of crystalloid infusion. The electrocardiogram (ECG) shows reduced voltage in QRS complexes.A - Cardiac tamponade?? CORRECT ANSWERCardiac tamponadeThe presence of distended neck veins, and failure to respond to fluid resuscitation strongly suggest the diagnosis of cardiac tamponade and exclude rupture of the aorta and the spleen as the possible cause of hypotension. Diminished heart sounds and reduced voltage of QRS complexes are recognised features of cardiac tamponade.YOUR ANSWER WAS CORRECT62Theme: Complications of rheumatoid arthritisA AnaemiaB Boutonnière’s deformityC Bronchiolitis obliteransD Carpal tunnel syndromeE Felty’s syndromeF Joint subluxationG MononeuritisH Ocular diseaseI PericarditisJ Peripheral neuropathyK Pleural effusionL Renal diseaseM Rheumatoid nodulesN Swan neck deformityO ThrombocytosisP Vascular lesionsQ Z deformity of the thumbAbove is a list of potential complications of rheumatoid arthritis. For the following scenarios please pick the most appropriate complication. Each item may be used once, more than once, or not at all.Scenario 1A 60-year-old woman presents with worsening deformity of her hands. On examination you note flexion at the proximal interphalangeal joint of the middle finger on her left hand, with hyperextension at the distal interphalangeal joint. Her metacarpophalangeal joint is extended.B - Boutonnière’s deformity?? CORRECT ANSWERB – Boutonnière deformityThis scenario describes the typical changes that occur with a Boutonnière deformity. These transformations occur as a result of rupture of the middle slip of the extensor tendon. At this stage there is no more than a failure to extend the proximal interphalangeal joint; however, if the tendon is not repaired the lateral slips slide down towards the volar surface allowing the knuckle to ‘buttonhole’ through the extensor hood, causing the distal interphalangeal joint to be drawn into hyperextension.Scenario 2A 64-year-old gentleman with a chronic history of rheumatoid arthritis presents to the elderly day ward with a history of malaise and lethargy. On examination he has splenomegaly with generalised lymphadenopathy; you also notice some weeping leg ulcers. A full blood count shows a pancytopenia (white cell count 2.4 x 109/litre, haemoglobin 10.5 g/dl, platelets 95 x 109/litre).E - Felty’s syndrome?? CORRECT ANSWERE – Felty’s syndromeThis haematological complication of rheumatoid arthritis was named after its pioneer: Augustus Felty (1934). The syndrome comprises seropositive (often high titres of rheumatoid factor) rheumatoid arthritis (frequently with relatively inactive synovitis), splenomegaly and neutropenia. It usually occurs in longstanding disease, and recurrent, severe infections are a common complication, as is vasculitis (leg ulcers and mononeuritis), lymphadenopathy and pigmentation. Resultant hypersplenism may require splenectomy.YOUR ANSWER WAS CORRECTScenario 3A 50-year-old man presents to The Emergency Department complaining of a progressive shortness of breath. Previously fit and well, he now describes dyspnoea on mild exertion. On examination he has decreased breath sounds at the left lung base and this region is dull to percussion.K - Pleural effusion?? CORRECT ANSWERK – Pleural effusionTypically, pleural effusion is unilateral and arises in seropositive men over the age of 45 years. It often precedes articular manifestations (arthritis), and unlike most other extra-articular complications, can occur early on in the disease. The effusion can be chronic and associated with significant pleural thickening. Other pulmonary manifestations include: rheumatoid nodules (less than 1% of cases) which can cavitate and need to be differentiated from primary and metastatic malignancy; and bronchiolitis obliterans, an illness characterised by rapid onset of breathlessness, progressing over a few months to complete incapacity or death. Pulmonary function tests show considerable reduction in vital capacity, with gross hyperinflation, although the chest X-ray is virtually normal. Interstitial disease occurs in 1–5% of patients and generally progresses slowly, but may remain stable or even regress over the years.Scenario 4A 48-year-old woman with known rheumatoid arthritis presents to outpatients complaining of pain and paraesthesia to her thumb, forefinger and middle finger of her right hand. The symptoms have been progressive and are worse at night. In clinic you are able to reproduce her symptoms using Phalen’s test.D - Carpal tunnel syndrome?? CORRECT ANSWERD – Carpal tunnel syndromeCarpal tunnel syndrome is a nerve compression syndrome that is frequently associated with rheumatoid arthritis. Swelling, inflammation and tenosynovitis of the anterior tendons as they pass under the flexor retinaculum cause compression of the median nerve with resultant tingling and pain in its region of distribution. Chronic pressure leads to wasting of the muscles supplied by the median nerve at this level (LOAF?– ie?Lumbricals (first two),?Opponens pollicis,?Abductor pollicis brevis and?Flexor pollicis brevis). The causes should also be memorised.YOUR ANSWER WAS CORRECT63Theme: Pelvic fractureA Rotationally and vertically stableB Rotationally unstable, vertically stable pelvic fractureC Rotationally unstable, vertically unstable pelvic fractureFor each of the pelvic injuries below, select the correct classification of pelvic fracture from the above list. Each option may be used once, more than once, or not at all.Scenario 1Lateral compression fractureB - Rotationally unstable, vertically stable pelvic fracture?? CORRECT ANSWERB – Rotationally unstable, vertically stable pelvic fractureRotationally unstable, vertically stable pelvic fractures include open-book fractures (pubic diastasis > 2.5 cm) and lateral compression fractures.YOUR ANSWER WAS CORRECTScenario 2Open-book fractureB - Rotationally unstable, vertically stable pelvic fracture?? CORRECT ANSWERB – Rotationally unstable, vertically stable pelvic fractureRotationally unstable, vertically stable pelvic fractures include open-book fractures (pubic diastasis >2.5 cm) and lateral compression fractures.Scenario 3Vertical shear injuriesC - Rotationally unstable, vertically unstable pelvic fracture?? CORRECT ANSWERC – Rotationally unstable, vertically unstable pelvic fractureRotationally and vertically unstable pelvic fractures usually result from vertical shear injuries.YOUR ANSWER WAS CORRECTScenario 4Isolated iliac wing fractureA - Rotationally and vertically stable?? CORRECT ANSWERA – Rotationally and vertically stableStable pelvic fractures include fractures not displacing the pelvic ring (such as:avulsion fractures and isolated fractures of the iliac wing or pubic ramus) or minimally displaced fractures of the pelvic ring.Scenario 5Isolated pubic ramus fractureA - Rotationally and vertically stable?? CORRECT ANSWERA – Rotationally and vertically stableStable pelvic fractures include fractures not displacing the pelvic ring (such as avulsion fractures and isolated fractures of the iliac wing or pubic ramus) or minimally displaced fractures of the pelvic ring.YOUR ANSWER WAS CORRECT64Theme: Common fracture eponymsA Barton’s fractureB Bennett’s fractureC Colles’ fractureD Galeazzi’s fracture dislocationE Garden II fractureF Garden III fractureG Garden IV fractureH Hill–Sachs fractureI Lisfranc fracture dislocationJ Monteggia’s fracture dislocationK Rolando’s fractureL Smith’s fractureM Weber A fractureN Weber B fractureO Weber C fractureThe following are descriptions of fractures. Please select the most appropriate fracture eponym from the above list. Each item may be used once, more than once, or not at all. These are all commonly used in current clinical practice (and so remain important).Scenario 1A comminuted, intra-articular fracture to the base of the first metacarpal.K - Rolando’s fracture?? CORRECT ANSWERK – Rolando’s fractureThis description could be one of a Bennett’s fracture, but the comminuted nature distinguishes it as a Rolando’s fracture. There are usually three fragments forming either a Y-shape or a T-shape on radiograph.Scenario 2A distal fibular fracture at the level of the syndesmosis, with or without a malleolar fracture.N - Weber B fracture?? CORRECT ANSWERN – Weber B fractureThe Weber (or Danis–Weber) classification describes the severity of tibio- fibular ligament injury by the level of fibular fracture. A Weber A fracture is infra-syndesmotic This is a Weber B fracture as it is sited at the level of the syndesmosis. while a Weber C fracture occurs above the level of the syndesmosis. The Lauge–Hansen classification is an alternative method of describing fractures of the distal tibia and fibular. It takes into account foot position and direction of deforming forces, and is preferred by senior orthopaedic surgeons. For your purposes the Weber system is sufficient as the Lauge–Hansen is complex and not all fractures fit the classical pattern.Scenario 3A complete fracture through the femoral neck, with rotation of the femoral head within the acetabulum, demonstrating minimal displacement.F - Garden III fracture?? CORRECT ANSWERF – Garden III fractureThe Garden classification is used to describe intra-capsular fractures of the neck of the femur. It is important to distinguish these from extra-capsular fractures, as there is a bearing on blood supply, and ultimately, treatment. The capsule contributes the majority of the blood supply to the head of the femur, via the medial and lateral circumflex arteries from the profunda femoris. A compromise in the blood supply can result in avascular necrosis. The Garden system consists of four grades (I–IV) as follows:Garden I – incomplete or impacted fractureGarden II – non-displaced fracture through both corticesGarden III – minimally displaced fracture with rotation of the femoral head in the acetabulumGarden IV – completely displaced fracture of the head of femur (no continuity between the proximal and distal fragments).YOUR ANSWER WAS CORRECTScenario 4An intra-articular fracture of the volar or dorsal margin of the distal radius. The fracture extends obliquely to the radio-carpal joint with a striking dislocation of the carpus.A - Barton’s fracture?? CORRECT ANSWERA – Barton’s fractureThis injury results from a fall onto an outstretched hand. The Barton fracture can be sub-divided into volar and dorsal types. It can be distinguished radiographically from Colles’ or Smith’s fractures by the presence of a dislocation or subluxation. This involves the rim of the distal radius, which can be dorsally or volarly displaced with the hand and carpus. The majority of these fractures require surgical reduction and fixation.YOUR ANSWER WAS CORRECT65Theme: Trauma procedures in the resuscitation roomA PericardiocentesisB Tube chest drainageC Needle thoracocentesisD Emergency thoracotomyE Venous cutdownF CricothyroidotomyG Diagnostic peritoneal lavageH Intraosseous infusionI Central line placementJ Passage of a nasogastric tubeK Endotracheal intubationMatch the most appropriate procedure from the list above to each clinical situation described below. Each option may be used once only, more than once or not at all.Scenario 1A patient with a systolic blood pressure of 60 mmHg following stab wound to chest, distended neck veins, reasonable bilateral air entry, central trachea.A - Pericardiocentesis?? CORRECT ANSWERPericardiocentesisA cardiac tamponade must be aspirated by pericardiocentesis with a large needle through a sub-xiphoid approach.YOUR ANSWER WAS CORRECTScenario 2A patient with a systolic blood pressure of 60 mmHg following blunt chest trauma, distended neck veins, no air entry on the right side, tracheal deviation to the left.C - Needle thoracocentesis?? CORRECT ANSWERNeedle thoracocentesisA tension pneumothorax is a clinical diagnosis and is treated initially by needle aspiration through the second intercostal space in the mid-clavicular line. Formal chest drainage is performed later towards the end of the primary survey.Scenario 3A prerequisite for diagnostic peritoneal lavage.J - Passage of a nasogastric tube?? CORRECT ANSWERPassage of a nasogastric tubeBefore diagnostic peritoneal lavage can be performed both a urinary catheter and a nasogastric tube must be in place.YOUR ANSWER WAS CORRECTScenario 4The recommended route for fluid replacement in children after peripheral cannulation fails.H - Intraosseous infusion?? CORRECT ANSWERIntraosseous infusionYOUR ANSWER WAS CORRECTScenario 5The recommended method for fluid replacement in adults after peripheral cannulation fails during the management of major traumatic injuries.H - Intraosseous infusion?? CORRECT ANSWERIntraosseous infusionAfter two attempts at peripheral cannulation in the child intraosseous infusion is recommended. Central lines should be avoided. This method is also recommended as the preferred means of achieving IV access in adults in whom peripheral cannulation is unsuccessful in the acute traumatic setting (i.e. where prompt and urgent fluid resuscitation is required).Scenario 6The first procedure in a pulseless apnoeic patient after a chest stabbing.K - Endotracheal intubation?? CORRECT ANSWEREndotracheal intubationYOUR ANSWER WAS CORRECTScenario 7The second procedure in a pulseless apnoeic patient after a chest stabbing.D - Emergency thoracotomy?? CORRECT ANSWEREmergency thoracotomyAccording to ATLS principles of ABCDE, securing the airway (A) would be the first consideration together with securing intravenous access using large bore simple intravenous cannulae (not an option here). Second to this, a thoracotomy to attempt to arrest the bleeding would be performed. In the case of open trauma, this would be of more use than inserting a chest drain.Scenario 8The procedure required for a large haemothorax.B - Tube chest drainage?? CORRECT ANSWERTube chest drainageIn all trauma, the first procedure is to secure the airway. In penetrating chest injury, up to 30% of pulseless patients can be saved by emergency thoracotomy if performed by a qualified operator when there is still some electrical cardiac activity.YOUR ANSWER WAS CORRECT66Theme: BackacheA Disc herniationB Sickle cell diseaseC Ankylosing spondylitisD TuberculosisE Psoriatic arthritisF Multiple myelomaG Paget's diseaseH OsteoporosisI Ruptured abdominal aortic aneurysmSelect the most appropriate diagnosis for each of the patients below. Each option may be used once, more than once, or not at all.Scenario 1A 70-year-old lady presented with low back pain, lethargy, malaise, fever and weight loss. On examination she appears to be anaemic. Blood investigations show a high erythrocyte sedimentation rate (95 mm/h), hypercalcaemia and anaemia. Urine analysis shows Bence–Jones proteins. X-ray of the lumbar spine shows multiple punched out lytic lesions which are also evident in both innominate bones.F - Multiple myeloma?? CORRECT ANSWERMultiple punched out lytic lesions are typical of multiple myeloma. Another place to look is the skull which also shows multiple round punched out lytic lesions. Plasma protein electrophoresis will show a prominent M-band.YOUR ANSWER WAS CORRECTScenario 2A 41-year-old lady presented with a low backache for the last 4 weeks. On examination you find that she has a goitre and exophthalmos. Blood investigations show thyrotoxicosis, normal plasma calcium, phosphate and alkaline phosphatase. Lumbar spine X-ray shows a compression fracture of L4.H - Osteoporosis?? CORRECT ANSWERThyrotoxicosis is an established cause of osteoporosis by increasing bone turnover. Serum alkaline phosphatase levels are typically normal in osteoporosis (as are serum calcium and serum phosphate levels).YOUR ANSWER WAS CORRECTScenario 3A 35-year-old male presents with low backache radiating to the left leg for the last 2 weeks after starting body-building exercises. On examination you notice he has scoliosis and left-sided weakness of ankle plantar flexion and hip extensionA - Disc herniation?? CORRECT ANSWERIntervertebral disc herniation is common in the young age group because the nucleus is still gelatinous, unlike in the elderly when it is degenerative. Commonly taking place at level L5/S1 it will affect the nerve root below i.e. S1 in this case hence the ipsilaleral weakness of ankle plantar flexion and hip extension.YOUR ANSWER WAS CORRECTScenario 4A 75-year-old grossly obese male presented with sudden onset of low backache associated with nausea, vomiting, palpitation and feeling clammy and sweaty. He has a long-standing history of ischaemic heart disease. On examination you notice pallor, tachycardia and hypotension. Abdominal examination is difficult due to body habitus.I - Ruptured abdominal aortic aneurysm?? CORRECT ANSWERIn an elderly patient presenting with sudden back pain associated with dynamic instability particularly with comorbidity suggestive of atherosclerosis, ruptured AAA should be ruled out first.YOUR ANSWER WAS CORRECT67Theme: Limping childA Septic arthritisB Femoral neck fractureC Slipped femoral capital epiphysisD Rheumatoid arthritisE Transient synovitisF Perthes' diseaseG Developmental dislocation of the hip (DDH)H Osteoid osteomaI Osteochondritis dessicansSelect the most appropriate diagnosis for each of the patients below. Each option may be used once, more than once, or not at all.Scenario 1A 3-year-old child has been having difficulty walking since his early steps. He walks with a waddling gait. On examination you notice that the child has an excessive lumbar lordosis. X-ray of the hip shows small femoral heads.G - Developmental dislocation of the hip (DDH)?? CORRECT ANSWERBilateral developmental dislocation of the hip will make the child lurch to both sides and will show lumbar lordosis to compensate for the hip flexion. Perthes’ disease is rare below the age of 4 years.Scenario 2A 6-year-old boy presented with a painful left hip that has been non-weight bearing for the last 24 h. He feels unwell and his mother says that he has been having a sore throat for the last week. On examination you note that he is pyrexial (38.5°C) and any movement in the left hip joint is restricted.A - Septic arthritis?? CORRECT ANSWERAn unwell pyrexial child with a splinted joint that does not allow movement in any direction without a history of trauma should always be considered as septic arthritis until proven otherwise. Septic arthritis of the hip joint is more common than of the knee in the paediatric age group.YOUR ANSWER WAS CORRECTScenario 3A 6-year-old child presented with a limp in his right leg. His mother reports that he has been having a sore throat for the last week. On examination he is afebrile and feels well. Right hip range of movement is only slightly affected. His white blood count and erythrocyte sedimentation rate are within the normal range. Upon follow-up five days later after being on simple analgesia he completely recovers.E - Transient synovitis?? CORRECT ANSWERThis is a diagnosis of exclusion. The history of a preceding upper respiratory infection, normal inflammatory markers and a self-limited course encourages the diagnosis.YOUR ANSWER WAS CORRECTScenario 4A 7-year-old child presented with a 5-week history of progressively worsening right hip pain. He has had previous episodes of similar hip pain. He does not complain of any constitutional symptoms (fever, nausea, anorexia etc) and on examination there is a limited abduction of the hip joint. X-ray of the hip shows increased bone density and flattening of the femoral head.F - Perthes' disease?? CORRECT ANSWERPerthes’ disease is common in the age group 4–10 years; it runs a chronic course and if missed then avascular necrosis of the femoral head will result in its collapse (flattening) and increased density as new bone is laid.68Theme: Cutaneous sensationA The median nerveB The radial nerveC The dorsal cutaneous branch of the ulnar nerveD The superficial branch of the ulnar nerveE The palmar cutaneous branch of the ulnar nerveFor each of the following descriptions, select the most likely answer from the above list. Each option may be used once, more than once, or not at all.Scenario 1The sensory innervation of the nail bed of the index finger.A - The median nerve?? CORRECT ANSWERThe median nerve supplies the lateral 3? digits of the hand on the palmar aspect, and the tips of the lateral 3 and a half digits on the dorsal aspect.YOUR ANSWER WAS CORRECTScenario 2The sensory innervation of the medial side of the palm.E - The palmar cutaneous branch of the ulnar nerve?? CORRECT ANSWERThe ulnar nerve enters the palm anterior to the flexor retinaculum, and as it crosses the flexor retinaculum it divides into a superficial and a deep terminal branch. The palmar cutaneous branch of the ulnar nerve is given off in the front of the forearm anterior to the flexor retinaculum, and supplies the skin over the medial aspect of the palm.YOUR ANSWER WAS CORRECTScenario 3The sensory innervation of the dorsal surface of the base of the thumb.B - The radial nerve?? CORRECT ANSWERThe superficial branch of the radial nerve descends over the extensor retinaculum and supplies the lateral two-thirds of the dorsum of the hand. It divides into a number of dorsal digital nerves which supply the dorsal surface of the thumb, the dorsal surface of the index finger and dorsal surface of the lateral side of the middle finger.YOUR ANSWER WAS CORRECTScenario 4The sensory innervation of the medial side of the palmar surface of the ring finger.D - The superficial branch of the ulnar nerve?? CORRECT ANSWERThe superficial branch of the ulnar nerve descends into the palm and gives off a muscular branch to the palmaris brevis, and cutaneous branches to the palmar aspect of the medial side of the little finger and the adjacent sides of the little and ring fingersYOUR ANSWER WAS CORRECT69Theme: ShockA Cardiogenic shockB Septic shockC Neurogenic shockD Hypovolaemic shock <15% volume lossE Hypovolaemic shock 15–30% volume lossF Hypovolaemic shock >40% volume lossFor each of the patients described below choose the most appropriate variety of shock from the list above. Each may be used once, more than once or not at all.Scenario 1A motorcyclist was admitted to the emergency department having been thrown a distance of 30 feet. He was wearing a helmet and had recovered consciousness at the scene. He remained confused. Pulse 40 bpm, respiratory rate 30/min, blood pressure (BP) 75/60 mmHg. Lateral cervical spine X-rays were suggestive of a fracture of C6.C - Neurogenic shock?? CORRECT ANSWERNeurogenic shockNeurogenic shock is due to the loss of sympathetic tone and combines the symptoms characteristic of hypovolaemic shock with a profound bradycardia.YOUR ANSWER WAS CORRECTScenario 2A 25-year-old marathon runner was involved in a road traffic accident while out training. She was admitted to the emergency department with a pulse of 100 bpm, BP 75/60 mmHg, respiratory rate 30/min. Her abdomen was generally tender, peritoneal lavage was positive. There was no urine output.F - Hypovolaemic shock >40% volume loss?? CORRECT ANSWERHypovolaemic shock >40% volume lossYOUR ANSWER WAS CORRECTScenario 3A homeless gentleman was found collapsed in a dark alleyway at 5am on New Year’s Day. He was unconscious and smelt of alcohol. On arrival in the emergency department his pulse was 110/min, BP 115/50 mmHg, he was apyrexial on admission, but his skin was noted to be flushed. During the secondary survey he was found to have sustained a penetrating abdominal injury, which looked a few days old.B - Septic shock?? CORRECT ANSWERSeptic shockGenerally in hypovolaemic shock <15% loss leads to anxiety, no change in pulse, blood pressure (BP) or respiratory rate, urine output is maintained; 15–30% loss leads to anxiety. The BP is maintained, the pulse generally 100 bpm and the pulse pressure reduced, urine output is maintained at 20–30 ml/h.; 40% loss causes confusion. The pulse is generally greater than 140/min, the BP and pulse pressure fall. There is no urine output. Fit athletic individuals may initially compensate for massive blood loss causing hypovolaemia maintaining pulse and BP, then rapidly decompensate. In cases of delayed presentation septic shock should be considered. This is similar in presentation to hypovolaemic shock but characterised by a wide pulse pressure. Patients who are hypothermic from exposure may initially appear to be apyrexial.YOUR ANSWER WAS CORRECT70Theme: Peripheral nerve injuryA Femoral nerveB Common peroneal nerveC Deep peroneal nerveD Superficial peroneal nerveE Sural nerveF Tibial nerveG Saphenous nervePick the most appropriate option from the above list. Each option may be used once only, more than once or not at all.Scenario 1A 28-year-old man sustains a varus injury to his left knee while skiing. He notes loss of sensation over the anterolateral aspect of the leg and dorsum of the foot, together with weakness of dorsiflexion and eversion of the foot.B - Common peroneal nerve?? CORRECT ANSWERCommon peroneal nerveDeep peroneal nerve injury may give rise to an anterior compartment syndrome and loss of sensation in the first web space between the first and second toes. The common peroneal nerve is often damaged at the level of the fibular neck by severe traction when the knee is forced into varus (eg lateral ligament injuries and fractures around the knee) or from pressure from a splint or plaster cast. The patient has foot drop and loss of sensation over the front and outer half of the leg and dorsum of the foot.YOUR ANSWER WAS CORRECTScenario 2A 32-year-old motorcyclist is involved in a road traffic accident and sustains a severe laceration 6 cm above the ankle on the lateral aspect of his leg. He is unable to evert his foot and has noted some numbness over the dorsum of foot and medial four toes.D - Superficial peroneal nerve?? CORRECT ANSWERSuperficial peroneal nerveThe superficial peroneal nerve innervates the peroneal muscles and emerges through the deep fascia 5-10 cm above the ankle to supply the skin over the dorsum of the foot and medial four toes.YOUR ANSWER WAS CORRECT71Theme: Fracture managementA Cannulated screwsB Dynamic hip screwC External fixatorD Fix with plate and screwsE Fix with screwsF Fix with wiresG HemiarthroplastyH Intramedullary nailI Manipulate under general anaesthesia (MUA)J Manipulation followed by plasterFor each of the following situations, select the most likely answer from the above list. Each option may be used once, more than once, or not at all.Scenario 1A 33-year-old lady sustains an inversion injury to her left ankle and presents with a bimalleolar fracture.D - Fix with plate and screws?? CORRECT ANSWERStable, undisplaced malleolar fractures can be treated with POP. Bimalleolar and trimalleolar fractures of the ankle are generally unstable injuries and require open reduction and internal fixation (ORIF) usually with plates and screws.YOUR ANSWER WAS CORRECTScenario 2An 88-year-old lady who lives in a nursing home falls onto her outstretched right hand. An X-ray reveals a fracture of the distal radius with dorsal and radial displacement.J - Manipulation followed by plaster?? CORRECT ANSWERThe most appropriate management for a patient in this situation would be to reduce the fracture by manipulation and apply a cast.YOUR ANSWER WAS CORRECTScenario 3A 23-year-old gentleman falls off his bicycle onto his left wrist. An X-ray reveals an intra-articular fracture of the distal radius with volar displacement.D - Fix with plate and screws?? CORRECT ANSWERIntra-articular fractures require accurate anatomical reduction and stabilisation. Distal radial fractures with volar displacement are usually unstable injuries. Therefore in this situation, the most appropriate management would be ORIF with a buttress plate and screws.Scenario 4A 55-year-old lady trips and falls onto her left hip. An X-ray shows an undisplaced intracapsular fracture of the femoral neck.A - Cannulated screws?? CORRECT ANSWERIntracapsular neck of femur fractures in young patients require anatomical reduction and fixation with cannulated screws as soon as possible to try and preserve the blood supply to the femoral head and therefore prevent avascular necrosis.Scenario 5A 76-year-old gentleman falls onto his right hip. An X-ray shows a displaced intracapsular fracture of the femoral neck.G - Hemiarthroplasty?? CORRECT ANSWERConversely, a hemiarthroplasty is used in older patients with intracapsular femoral fractures.YOUR ANSWER WAS CORRECTScenario 6An 81-year-old lady falls onto her right hip whilst getting out of the shower. On examination, the hip is short and externally rotated. An X-ray shows a three-part intertrochanteric fracture.B - Dynamic hip screw?? CORRECT ANSWERAn intertrochanteric fracture of the femoral neck is an example of an extracapsular fracture. The femoral head blood supply is usually preserved so the treatment of choice would be to reduce the fracture and fix it with a dynamic hip screw.YOUR ANSWER WAS CORRECTScenario 7A 37-year-old man twists his leg and falls over whilst skiing. His X-ray shows a spiral fracture of the midshaft of his left tibia.H - Intramedullary nail?? CORRECT ANSWERAn intramedullary nail is used to treat midshaft fractures of the femur and tibia. This allows optimal stabilisation and early mobilisation.YOUR ANSWER WAS CORRECT72Theme: Shoulder painA Clavicle fractureB Frozen shoulderC Septic arthritisD Anterior dislocationE Posterior dislocationF Acromioclavicular joint osteoarthritisG OsteoarthritisH Supraspinatous tendon ruptureI Supraspinatous tendonitisSelect the most appropriate diagnosis for each of the patients below. Each option may be used once, more than once, or not at all.Scenario 1A 65-year-old joiner presented with left shoulder pain especially at night, usually relieved by paracetamol. Movement is moderately restricted in all directions, however when he raises his arm above his head the shoulder is mainly painful during the last degrees of abduction. X-ray shows new bone formation at the glenoid edges.G - Osteoarthritis?? CORRECT ANSWERPain during the last degrees of shoulder abduction is typical of osteoarthritis, particularly in the presence of osteophytes on X-rays.YOUR ANSWER WAS CORRECTScenario 2A 45-year-old joiner presented with pain in his left shoulder which occasionally responds to simple analgesia. The pain bothers him mainly during work. On examination, abduction of the shoulder is painful during 60–120 degrees. When lowering the arm it suddenly drops halfway during adduction. X-rays are normal.I - Supraspinatous tendonitis?? CORRECT ANSWERSupraspinatous tendonitis, usually resulting occupations with shoulder overuse, is characterised by pain and impingement during 60–120 degrees of abduction.Scenario 3A 53-year-old lady suffering from NIDDM ( non-insulin-dependent diabetes mellitus) for the last 15 years presented with pain and stiffness in her right shoulder of few months duration. Examination reveals restriction of movement in all directions. Blood investigations show normal inflammatory markers. X-ray of the shoulder does not reveal any abnormality. Culture of joint aspirate did not grow any organisms.B - Frozen shoulder?? CORRECT ANSWERFrozen shoulder is common in middle-aged women especially diabetics. X-rays do not show any abnormality as the main pathology is adhesive capsulitis which can be released by arthroscopy. As septic arthritis still need to be excluded, where blood results can be unreliable then the gold standard is culture of joint aspirate.YOUR ANSWER WAS CORRECTScenario 4A 36-year-old electrician is an inpatient after sustaining an electric shock at work. He is complaining of left shoulder pain and stiffness. On examination you find any movement of the shoulder is not possible, and it is is held in adduction. AP view X-ray of the shoulder does not reveal any abnormality.E - Posterior dislocation?? CORRECT ANSWERLess common than anterior dislocation, posterior dislocation common takes place after seizures and electrocution. Anteroposterior view may not show any abnormality. A scapulohumeral view will show the posterior dislocation.YOUR ANSWER WAS CORRECT73Theme: Distal radial fracture managementA Closed reduction and plaster of paris (POP) castB POP cast without manipulationC Intramedullary nailingD Plate and screwsE K-wiresF External fixationSelect the most appropriate method of management for each of the patients below. Each option may be used once, more than once, or not at all.Scenario 1A 76-year-old lady fell on her right outstretched arm sustaining a non-comminuted Colles’ fracture with 20 degrees of dorsal tilt.A - Closed reduction and plaster of paris (POP) cast?? CORRECT ANSWERAny dorsal tilt in Colles’ fracture will need closed reduction if not comminuted to restore function.YOUR ANSWER WAS CORRECTScenario 2A 25-year-old male fell on the right outstretched hand while playing football sustaining a non-comminuted distal radial fracture with volar tilt.D - Plate and screws?? CORRECT ANSWERSmith fracture needs ORIF(open reduction and internal fixation) using a buttress plate because the distal fragment is unstable.YOUR ANSWER WAS CORRECTScenario 3A 55-year-old lady gets involved in a road traffic accident sustaining an open comminuted distal radial fracture with dorsal displacement.D - Plate and screws?? YOUR ANSWERF - External fixation?? CORRECT ANSWEREx-Fix will ease care of the wound which should not be closed as it may need debridement later; otherwise internal fixation will run the risk of implant infection and failure.YOUR ANSWER WAS INCORRECTScenario 4A 10-year-old girl falls on the outstretched arm sustaining a buckled fracture of the distal radius. No angulation is evident on X-ray.B - POP cast without manipulation?? CORRECT ANSWERBuckled and greenstick fractures are not manipulated if there is no angulation or tilt. Some surgeons don’t even manipulate it if the age is very young and there is no CLINICAL deformity despite a few degrees of tilt or angulation on the X-rays.YOUR ANSWER WAS CORRECT74Theme: Shoulder joint pathologiesA Acromioclavicular joint osteoarthritisB Acute supraspinatus tendonitisC Calcific tendonitisD Dislocated shoulderE Fracture of surgical neck of humerusF Frozen shoulderG Painful arc syndromeH Rotator cuff tearI Rupture of long head of bicepsJ Subdeltoid bursitisFor each of the following statements, select the most likely cause of shoulder pain from the above list. Each option may be used once, more than once, or not at all.Scenario 1A 47-year-old lady presents with a 3-month history of painful shoulder. The pain is worse during the mid-phase of abduction and when bringing the hand down. There is no pain during the two extremes of movement.G - Painful arc syndrome?? CORRECT ANSWERG – Painful arc syndromeIn painful arc syndrome (chronic supraspinatus tendonitis; impingement syndrome), there is pain on abduction 60–120° (middle 1/3 of the arc), but the extremes of movements are painless. The underlying pathology is the swelling of the tendon, and the pain is produced when it impinges on the undersurface of the acromial process during the mid-phase of abduction. Repeating the movement with the arm in full external rotation throughout may be much easier and relatively painless; this is virtually pathognomonic of painful arc syndrome.YOUR ANSWER WAS CORRECTScenario 2A 60-year-old presents with a painful right shoulder after he fell off a tree 2 days ago. He has suffered from chronic shoulder pain in the past. On examination, there is tenderness at the tip of his shoulder and underneath the acromial process. He is unable to lift his arm and there is hunching of the shoulder.E - Fracture of surgical neck of humerus?? YOUR ANSWERH - Rotator cuff tear?? CORRECT ANSWERH – Rotator cuff tearRotator cuff is a sheet of conjoint tendons (subscapularis, supraspinatus, infraspinatus and teres minor) closely applied to the shoulder capsule and inserting into the greater and lesser tubercle of the humerus. The differing clinical pictures stem from three basic pathological processes – degeneration, trauma and vascular lesion. The supraspinatus tendon is liable to injury when it contracts against firm resistance; this may occur when lifting a weight, or when the patient uses his or her arm to save themselves from falling. This is much more likely if the cuff is already degenerate. The clinical presentation reflects the loss of tendon function with weakness, a drop arm sign (characteristic hunching of the affected shoulder) and even inability to lift the arm. There is often relentless night pain. On local palpation, pain is felt at the shoulder-tip and upper arm and there is tenderness under the acromion.YOUR ANSWER WAS INCORRECTScenario 3A 68-year-old woman presents to her GP with an acutely painful left shoulder. There is no history of trauma. On examination, the shoulder joint is tender anterolaterally and there is restriction of all movements except external rotation. X-ray reveals radio-opaque deposits within the supraspinatus tendon.B - Acute supraspinatus tendonitis?? YOUR ANSWERC - Calcific tendonitis?? CORRECT ANSWERC – Calcific tendonitisCalcific tendonitis is a common disorder of unknown aetiology which results in an acutely painful shoulder joint. Frequently, there is no history of trauma. Calcium becomes deposited within the supraspinatus tendon and this may be part of a degenerative process. Clinical features include sudden onset of pain with no apparent precipitating cause. Pain in usually felt over the anterolateral aspect of the shoulder and is worse with overhead activities. On examination, the shoulder is tender anterolaterally, with some restriction of both active and passive movements. External rotation, however, is possible (this feature differentiates the condition from frozen shoulder). X-ray reveals calcific deposits within the supraspinatus tendon, inferior to the acromion and medial to the greater tibercle of the humerus.YOUR ANSWER WAS INCORRECTScenario 4A 23-year-old rugby player presents with sudden shoulder pain after being involved in a tackle during the game. On examination, there is loss of shoulder contour and a bulge is felt in the deltopectoral groove.D - Dislocated shoulder?? CORRECT ANSWERD – Dislocated shoulderShoulder dislocation is common after trauma. Anterior dislocation is the commonest type (in contrast to posterior dislocation in the hip joint). Shoulder dislocation may be associated with injury to the axillary nerve which causes loss of sensation over the upper outer aspect of the deltoid region (‘badge’ area). The round contour of the shoulder is lost because of the absence of the head of the humerus within the glenoid fossa – the head of humerus may be felt in the deltopectoral groove (in anterior dislocation). Even in clinically obvious dislocations, an X-ray should be performed to rule out an associated fracture.YOUR ANSWER WAS CORRECT75An 80-year-old lady is brought to the emergency department following a fall, her right leg is shortened and externally rotated. An AP x-ray shows an intracapsular fractured neck of femur which extends across the neck completely, the trabecular lines are interrupted, but they are not angulated.How would you classify this fracture?Select one answer onlyGarden IGarden II?? CORRECT ANSWERGarden III?? YOUR ANSWERGarden IVGarden VYOUR ANSWER WAS INCORRECTThe AnswerComment on this QuestionGarden classified intracapsular hip fractures based on the trabecular lines on the AP x-ray. The classification can be used to assist in guiding treatment, along with the patients’ age and physiological status. Garden described 4 types, I-IV, which are:Garden I – Incomplete fracture, impacted, medial cortex intact, trabecular lines angulatedGarden II – Complete fracture, undisplaced, trabecular lines interrupted but not angulatedGarden III – Complete fracture, partially displaced, trabeculae angulatedGarden IV – Complete fracture with complete displacement76A 70-year-old man presents with increasing pain in the lumbar spine for 3 months with night pain. He has no neurological signs or symptoms. X-rays reveal a sclerotic lesion in the L4 vertebra.What is the most likely primary diagnosis?Select one answer onlyBreast cancerLung cancerProstate cancer?? YOUR ANSWERRenal cancerThyroid cancerYOUR ANSWER WAS CORRECTThe AnswerComment on this QuestionThe five commonest tumours metastasizing to bone are breast, lung, prostate, renal and thyroid. A prostate cancer is most likely in a gentleman of this age, and prostate metastases tend to be sclerotic. Thyroid and renal metastases tend to be lytic, and breast and lung metastases tend to be mixed.77Theme: Upper limb nerve injuriesA Anterior interosseous nerveB Injury to the lower cord of brachial plexusC Injury to the upper cord of brachial plexusD Long thoracic nerveE Median nerveF Musculocutaneous nerveG Posterior interosseous nerveH Radial nerveI Suprascapular nerveJ Ulnar nerveFor each of the following statements, select the most likely cause of nerve injury from the above list. Each option may be used once, more than once, or not at all.Scenario 1A 25-year-old motorcyclist is brought to the Emergency Department after an RTA. He complains of pain in the root of his neck; on examination, his right arm is adducted, internally rotated and extended at the elbow. There is loss of sensation along the outer aspect of the arm and forearm.C - Injury to the upper cord of brachial plexus?? CORRECT ANSWERC – Injury to the upper cord of the brachial plexusUpper brachial plexus or supraclavicular plexus lesion (C5, C6) occurs because of excessive depression of the shoulder or displacement of the head that opens out the angle between the shoulder and the neck (Erb-Duchenne paralysis). In neonates, it may occur following traction on the shoulder girdle during difficult labour or in breech delivery. In adults, it may occur as a result of a fall of weight on the shoulder or an RTA where the head is moved away from the shoulder. There is loss of shoulder abduction, elbow flexion and forearm supination. Consequently, the affected limb is internally rotated, extended at the elbow and pronated. There is sensory loss over the outer aspect of the arm and forearm.YOUR ANSWER WAS CORRECTScenario 2A 40-year-old patient presents to the Emergency Department with carpal dislocation (confirmed radiologically). On examination, there is loss of sensation over the thumb, index and middle fingers.E - Median nerve?? CORRECT ANSWERE – Median nerveIn adults, the median nerve (C5–T1) is commonly injured near the wrist, although it can be injured anywhere along the arm or the forearm. Low lesions may be caused by lacerations in front of the wrist or by carpal dislocation. In children, supracondylar fractures of the humerus may lead to median nerve injury at the elbow. Median nerve injuries at the wrist cause sensory loss over the thumb, index, middle and occasionally ring finger (lateral half); motor loss includes all thenar muscles except adductor pollicis (supplied by ulnar nerve) and the lateral two lumbricals. If the injury is at the level of the elbow, there is paralysis of the pronators of the forearm and flexors of the wrist and fingers, with the exception of flexor carpi ulnaris and the medial part of flexor digitorum profundus.YOUR ANSWER WAS CORRECTScenario 3A 65-year-old is brought to the Emergency Department with a wrist drop and sensory loss over a small patch at the base of the thumb. X-ray shows a mid-humerus fracture.H - Radial nerve?? CORRECT ANSWERH – Radial nerveThe radial nerve (C5–T1) is damaged at the mid-humerus level by fractures or pressure (prolonged tourniquet). Damage is seen in patients who fall asleep with the arm dangling over the back of a chair (‘Saturday night palsy’). Radial nerve injury causes paralysis of the brachioradialis, the wrist extensors and extensor digitorum, leading to wrist-drop along with paralysis of extensors of the wrist, fingers and the thumb; there may be a small patch of sensory loss over the dorsum of the thumb and the first web space. In higher lesions, sensation is also lost on the dorsum of the forearm.YOUR ANSWER WAS CORRECTScenario 4A 30-year-old presents to the Emergency Department with a deep laceration to his right wrist after he was involved in a fight in a pub. On examination, he is unable to pinch and has got loss of sensation over his little and ring fingers.J - Ulnar nerve?? CORRECT ANSWERJ – Ulnar nerveThe ulnar nerve (C8, T1) is an important motor nerve of the hand. Pressure (from a deep ganglion) or lacerations at the wrist may cause low lesions. Lesion of this nerve at the wrist produces hypothenar wasting and clawing of the hand as a result of the action of unopposed long flexors; there is loss of sensation over the little and ring fingers. Finger abduction is weak and the loss of thumb adduction makes pinch difficult. Consequently, paralysis of the adductor pollicis and the first palmar interosseous causes flexion of the thumb (due to flexor pollicis longus) – when the patient is asked to grasp a card between his thumb and index finger (Froment’s sign).YOUR ANSWER WAS CORRECT ................
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